(Circulation. 2002;106:69.)
© 2002 American Heart Association, Inc.
Clinical Investigation and Reports |
From Molecular Cardiology (S.G.P., C.N., M.M., B.C., R.B.), IRCCS Fondazione S. Maugeri, University of Pavia, Pavia, Italy; Cardiologia Pediatrica, Ospedale Bambin Gesù (F.D.), Roma, Italy; Unità Operativa di Elettrofisiologia (M.G., F.C.), Istituto Clinico Humanitas, Rozzano, Italy; Cardiologia Pediatrica (L.D.), Ospedale Meyer, Firenze, Italy; Servicio de Cardiología (R.K.), HIGA Dr. José Penna, Bahía Blanca, Argentina; Instituto de Cardiologia Laranjeiras, Ministry of Health of Brazil (F.E.S.C.F.), Rio de Janeiro, Brazil; Cardiologia Pediatrica (G.V.), Ospedale Niguarda, Milano, Italy; Pediatric Cardiology (A.B.), Academic Hospital VUB, Brussels, Belgium; and Cardiologia Pediatrica (A.D.), Policlinico Gemelli, Roma, Italy.
Correspondence to Silvia G. Priori, MD, PhD, Molecular Cardiology, IRCCS Fondazione Salvatore Maugeri, Via Ferrata 8, 27100 Pavia, Italy. E-mail spriori{at}fsm.it
| Abstract |
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Methods and Results Patients with documented polymorphic ventricular arrhythmias occurring during physical or emotional stress with a normal heart entered the study. The clinical phenotype of the 30 probands and of 118 family members was evaluated, and mutation screening on the RyR2 gene was performed. Arrhythmias documented in probands were: 14 of 30 bidirectional ventricular tachycardia, 12 of 30 polymorphic ventricular tachycardia, and 4 of 30 catecholaminergic idiopathic ventricular fibrillation; RyR2 mutations were identified in 14 of 30 probands (36% bidirectional ventricular tachycardia, 58% polymorphic ventricular tachycardia, 50% catecholaminergic idiopathic ventricular fibrillation) and in 9 family members (4 silent gene carriers). Genotype-phenotype analysis showed that patients with RyR2 CPVT have events at a younger age than do patients with nongenotyped CPVT and that male sex is a risk factor for syncope in RyR2-CPVT (relative risk=4.2).
Conclusions CPVT is a clinically and genetically heterogeneous disease manifesting beyond pediatric age with a spectrum of polymorphic arrhythmias. ß-Blockers reduce arrhythmias, but in 30% of patients an implantable defibrillator may be required. Genetic analysis identifies two groups of patients: Patients with nongenotyped CPVT are predominantly women and become symptomatic later in life; patients with RyR2 CPVT become symptomatic earlier, and men are at higher risk of cardiac events. These data provide a rationale for prompt evaluation and treatment of young men with RyR2 mutations.
Key Words: death, sudden genetics arrhythmia catecholamines
| Introduction |
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See p 8
genetic bases of inherited arrhythmogenic syndromes have been discovered, providing novel insights for the understanding and treatment of diseases predisposing to SCD.2,3 On the basis of this novel knowledge, it has become apparent that "idiopathic cardiac arrest" may be caused by subclinical or misdiagnosed forms of arrhythmogenic diseases that elude clinical diagnosis until they unexpectedly manifest with SCD.4 We have recently demonstrated5 that the cardiac ryanodine receptor gene (RyR2) is responsible for catecholaminergic bidirectional ventricular tachycardia (CPVT), an uncommon form of arrhythmogenic disease occurring in children and adolescents with a structurally intact heart. We conducted clinical and genetic characterization of the largest group of patients with CPVT reported thus far with the end point of assessing the clinical features, the response to therapy, and the genotype-phenotype correlation of this disease.
| Methods |
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One hundred eighteen family members were evaluated by standard ECG, exercise stress testing, and Holter recording. Programmed electrical stimulation was performed to assess inducibility of life-threatening arrhythmias. DNA for genetic analyses was obtained from proband and family members. In all patients and affected family members, clinical follow-up was performed every 6 to 12 months as clinically required.
All probands and family members provided informed consent for clinical and genetic evaluation. The institutional review boards approved the protocols.
Genetic Evaluation
Mutation screening was performed on genomic DNA samples, extracted from peripheral blood lymphocytes. Intronic primers amplifying the RyR2 coding region were used for polymerase chain reaction amplifications. polymerase chain reaction products (120 to 300 bp) were analyzed by single-strand conformation polymorphisms and denaturating high-performance liquid chromatography (DHPLC) (Wave, Transgenomic Inc). Abnormal conformers were sequenced with an ABI310 genetic analyzer. A control group of 350 healthy and unrelated subjects (700 alleles) was used to exclude DNA polymorphisms. Additionally, in all probands, the entire coding sequences of KCNQ1, KCNH2, SCN5A, KCNE1, and KCNE2 genes were screened as previously described8 to exclude the presence of long QT syndrome genetic defects.
Definitions
Bidirectional VT is a ventricular tachycardia characterized by a beat-to-beat alternation of the QRS axis present in at least 1 lead and in most of the documented runs of ventricular tachycardia (salvos
4 beats) (Figure 1A).
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Polymorphic ventricular tachycardia with an irregularly variable axis of the QRS is classified as pVT (Figure 1B).
Catecholaminergic idiopathic ventricular fibrillation is defined as ventricular fibrillation elicited by physical or emotional stress in the absence of identifiable precipitating factors and in the absence of ventricular tachycardia documented at Holter and/or exercise stress testing.
Statistical Analysis
Data are presented as mean±SD. An unpaired t test was used to assess the differences of means between groups. Fishers exact test was used to assess statistical difference in the frequency of events between groups. A probability value of <.05 was considered statistically significant. The arrhythmia-free interval and the syncopal-free interval were determined with the use of the life-table method of Kaplan-Meier.9 Results were compared by means of the log-rank test.
| Results |
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In 16 of 26 patients with syncope as the first manifestation, CPVT diagnosis was established after a mean delay of 2±0.8 years because syncope was initially attributed to vasovagal events or to neurologic factors. Even when the cardiac origin of symptoms was identified, the diagnosis was missed in 9 of 30 patients in whom the diagnosis of "LQTS with normal QT interval"10 was suspected because of the occurrence of syncope during emotion and exercise.
Clinical Evaluation of Family Members
One hundred eighteen living and asymptomatic family members were evaluated with ECG recording, exercise stress testing, and Holter monitoring. Ventricular tachyarrhythmias were documented in 9 individuals (8 female subjects; mean age, 31±19 years; range, 4 to 59 years) of 3 different families. In each of these clinically affected individuals, the arrhythmic events were induced during exercise stress testing and had a pattern similar to that observed in the proband. Exercise/emotion syncopal events occurred in 3 of 9 family members. Programmed electrical stimulation was offered to all and was accepted by 2 of 9 subjects who were not inducible.
Genetic Evaluation of Probands and Family Members
Genetic analysis demonstrated the presence of 12 RyR2 mutations (Figure 2) in 14 probands: In 10 of them the genetic defect occurred as a de novo mutation, whereas it was inherited in 4. All the mutations identified occurred in highly conserved amino acids (Figure 3) Remarkably, 3 of 4 genetically affected parents of the probands transmitted the disease but were asymptomatic for syncope or palpitations. Mutations were present in a similar proportion of probands with all 3 types of adrenergically mediated arrhythmias. RyR2 mutations were in fact identified in 5 of 14 (36%) patients with bVT, in 7 of 12 (58%) with pVT, and in 2 of 4 (50%) survivors of stress-related c-IVF. Nine gene carriers were identified among family members (Figure 4): Five had exercise-induced arrhythmias at clinical evaluation, whereas the remaining 4 (3 female subjects) were phenotypically silent (incomplete penetrance). No mutations in the LQTS-related genes were identified.
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Juvenile SCD in Affected Families
A history of juvenile (
40 years) unexplained SCD was present in 10 of 30 (33%) families (5 in Ryr2 CPVT and 5 nongenotyped CPVT), and a total of 19 lethal events (7 in female subjects; mean age, 18±8 years; range, 5 to 38 years) were reported. Eight (42%) individuals had a personal history positive for syncope and 1 subject had a documented run of pVT during exercise stress testing. Autopsy performed in 11 of 19 subjects who died failed to identify the cause of death, which was therefore attributed to a "primary electrical event." Seven juvenile SCDs occurred in 5 of 14 genotyped families. No difference was observed in the occurrence of sudden death between RyR2 CPVT and nongenotyped CPVT.
Clinical Characteristics of RyR2 CPVT and Patients With Nongenotyped CPVT
Overall, 43 clinically and genetically affected individuals are included in study. Clinical characteristics of Ryr2 CPVT and of patients with nongenotyped CPVT are presented in Table 2. No statistically significant differences were observed in demographic characteristics and clinical parameters when patients with RyR2 CPVT were grouped on the basis of the type of arrhythmia identified in the probands/symptomatic patients. On the contrary, when we compared patients with RyR2 CPVT and patients with nongenotyped CPVT, demographic characteristics were remarkably different. Female sex was predominant among nongenotyped CPVT (18 of 20 female subjects versus 10 of 23 among genotyped RyR2 CPVT; P<0.004). The sex difference between the two groups remained statistically significant, even when only symptomatic patients were included in the analysis (18 of 20 versus 7 of 19 female subjects; P<0.002). The first syncope occurred at a younger age among patients with RyR2 CPVT compared with patients with nongenotyped CPVT (8±2 versus 20±12 years; P<0.001). The patients with RyR2 CPVT with syncope were predominantly male (11 of 13 male subjects versus 2 of 10 female subjects; P<0.004). Male sex in RyR2 CPVT is associated with a relative risk of 4.2 (95% CI, 1.2 to 15) of developing syncope as compared with female subjects (Figure 5).
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Ventricular arrhythmias, the number of juvenile sudden deaths, and the response to antiadrenergic therapy did not differ between RyR2 CPVT and nongenotyped-CPVT.
All 39 clinically affected patients were treated with ß-blockers (1 to 2 mg/kg per day nadolol, 1 to 3 mg/kg per day metoprolol, 3 to 4 mg/kg per day propranolol); however, antiadrenergic drugs provided only incomplete protection from recurrence of sustained ventricular tachycardia and ventricular fibrillation. No difference in the response to ß-blockers at follow-up was observed between RyR2 CPVT and nongenotyped CPVT. As shown in Table 3, 18 of 39 patients treated with ß-blockers (7 RyR2 CPVT and 11 nongenotyped CPVT) had cardiac arrhythmias. An implantable cardioverter-defibrillator (ICD) was recommended to these patients, and 12 of 18 (6 RyR2 CPVT and 6 nongenotyped CPVT) accepted our advice and received an ICD. Over a follow-up of
2 years, 50% of patients with the ICD received an appropriate shock to terminate ventricular tachyarrhythmias (Table 3).
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Study Limitations
Genetic analysis was performed by single strand conformational polymorphism and DHPLC, which represent standard methods used for mutation analysis worldwide. Nonetheless, it is fair to mention that these methods are <100% sensitive; therefore, our study as well as similar studies performed in patients affected by inherited arrhythmogenic diseases may underestimate the number of genotyped patients.
| Discussion |
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The clinical description of CPVT is still based on the 21 patients described by Leenhardt et al12 in 1995. As a consequence, CPVT is a diagnosis almost exclusively established in children with stress- or emotion-related ventricular arrhythmias mainly presenting with the pattern of bidirectional ventricular tachycardia in the absence of structural heart disease.
We provide evidence that the diagnosis of CPVT extends beyond this profile. Our population included patients with the typical pattern of bVT described by Coumel et al13 and by Leenhardt et al12 but also patients with pVT, similar to those described by Laitinen et al7 and even individuals who had unexplained cardiac arrest during physical or emotional stress without arrhythmias inducible at exercise stress testing or Holter monitoring. The phenotype that we observed therefore includes patients with arrhythmias resembling the autosomal recessive variant of pVT described by Lahat et al14 and mapped to chromosome 1; however, pedigree analysis of nongenotyped CPVT in our series did not suggest a recessive pattern of transmission.
RyR2 mutations were identified in a similar proportion of patients with bVT (36%), pVT (58%), and cIVF (50%), suggesting that the diagnosis of CPVT extends to all patients with pVT or polymorphic ventricular fibrillation occurring in the structurally intact heart in the absence of prolonged QT interval.
At variance with current view considering CPVT as a disease manifesting only during childhood, in our patients the age of first manifestation of the disease extended into adulthood, suggesting that the diagnosis of CPVT should include individuals of any age with adrenergically mediated asymptomatic ventricular tachycardias occurring in the structurally intact heart. Interestingly, the age of onset of syncope was significantly lower in patients with RyR2 CPVT than in patients with nongenotyped-CPVT; however, the mean age of sudden death among individuals in families with RyR2 CPVT suggests that if not identified and treated during childhood, the disease becomes lethal in early adulthood.
A strong predominance of symptomatic female subjects was observed among patients with nongenotyped CPVT, whereas male sex was a strong risk factor (relative risk, 4.2) for syncope in patients with RyR2 CPVT. These data support the use of prophylactic antiadrenergic treatment in all male children who are carriers of RyR2 mutations and highlight the importance of early genotyping of all children who may have inherited the RyR2 defect from gene-carrier parents.
The mutations identified in patients with RyR2 CPVT were clustered within three functionally interesting regions of RyR2: the binding site for the FKBP12.6 protein that stabilizes the RyR2 channel, the calcium binding site, and the channel-forming transmembrane domains (Figure 2). The morphology of the ventricular arrhythmias is independent from the genetic defect, as demonstrated by the presence of discordant phenotypes in individuals with the same mutation (Figure 2). The S2246L mutation was present in two sporadic cases: one manifesting typical and reproducible bVT that never degenerated into ventricular fibrillation, the other manifesting ventricular fibrillation in the absence of arrhythmias at ECG monitoring. The G3946S mutation was present in two sporadic cases and manifested with a typical bVT in one patient and a pVT in the other. The variable expressivity of RyR2 mutations is further highlighted by the evidence that 4 of 23 (17%) of gene carriers had no phenotype demonstrating that in analogy with other inherited arrhythmogenic diseases,2 RyR2 CPVT has incomplete penetrance.
A remarkable feature of CPVT is its high lethality, demonstrated by the occurrence of 19 juvenile SCDs in 10 affected families and by the occurrence of appropriate ICD shocks in 6 of 12 patients implanted with an ICD (Table 3). The lethality of the RyR2 CPVT and nongenotyped CPVT presented no difference. Because in most of the patients who died of cardiac arrest and in the survivors syncope or documented rapid ventricular arrhythmias preceded the event, it is important to extend clinical and genetic evaluation to all asymptomatic family members of CPVT probands both with RyR2 CPVT and nongenotyped CPVT. In this respect, exercise stress testing is extremely useful to provoke arrhythmias in RyR2 CPVT and nongenotyped CPVT, whereas in both forms of CPVT invasive evaluation with programmed electrical stimulation and isoprenaline infusion adds little to the diagnosis of the disease.
Interestingly, in 30% of the patients, clinical symptoms were considered typical of the long-QT syndrome, and patients were diagnosed as having "long QT-syndrome with normal QT interval."15 However, in light of the incomplete protection afforded by ß-blockers in CPVT, its distinction from long-QT syndrome is clinically relevant.
Clinical Implications
Documentation of ventricular tachyarrhythmias in the structurally intact heart leads to the diagnosis of "idiopathic ventricular tachyarrhythmia," which may be considered a nonmalignant condition.16,17 We demonstrated that CPVT is a highly lethal disease unless it is recognized and treated. This diagnosis should be considered in subjects of all ages with idiopathic polymorphic ventricular arrhythmias occurring during exercise or emotion in the absence of structural abnormalities and of prolonged QT interval.
The presence of RyR2 mutations identifies a subset of patients with early onset of symptoms, with a higher risk of cardiac events associated with male sex. On the basis of these observations, we recommend early genetic screening in all children within families with RyR2 and support prompt evaluation and treatment of male carriers of RYR2 mutations for primary prevention of SCD.
| Acknowledgments |
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Received February 25, 2002; revision received April 12, 2002; accepted April 13, 2002.
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W. Creighton, R. Virmani, R. Kutys, and A. Burke Identification of Novel Missense Mutations of Cardiac Ryanodine Receptor Gene in Exercise-Induced Sudden Death at Autopsy J. Mol. Diagn., February 1, 2006; 8(1): 62 - 67. [Abstract] [Full Text] [PDF] |
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C. H. George, H. Jundi, N. Walters, N. L. Thomas, R. R. West, and F. A. Lai Arrhythmogenic Mutation-Linked Defects in Ryanodine Receptor Autoregulation Reveal a Novel Mechanism of Ca2+ Release Channel Dysfunction Circ. Res., January 6, 2006; 98(1): 88 - 97. [Abstract] [Full Text] [PDF] |
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S. G. Priori and C. Napolitano Intracellular Calcium Handling Dysfunction and Arrhythmogenesis: A New Challenge for the Electrophysiologist Circ. Res., November 25, 2005; 97(11): 1077 - 1079. [Full Text] [PDF] |
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D. Jiang, R. Wang, B. Xiao, H. Kong, D. J. Hunt, P. Choi, L. Zhang, and S. R. W. Chen Enhanced Store Overload-Induced Ca2+ Release and Channel Sensitivity to Luminal Ca2+ Activation Are Common Defects of RyR2 Mutations Linked to Ventricular Tachycardia and Sudden Death Circ. Res., November 25, 2005; 97(11): 1173 - 1181. [Abstract] [Full Text] [PDF] |
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Z. Liu, R. Wang, J. Zhang, S. R. W. Chen, and T. Wagenknecht Localization of a Disease-associated Mutation Site in the Three-dimensional Structure of the Cardiac Muscle Ryanodine Receptor J. Biol. Chem., November 11, 2005; 280(45): 37941 - 37947. [Abstract] [Full Text] [PDF] |
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A V Postma, I Denjoy, J Kamblock, M Alders, J-M Lupoglazoff, G Vaksmann, L Dubosq-Bidot, P Sebillon, M M A M Mannens, P Guicheney, et al. Catecholaminergic polymorphic ventricular tachycardia: RYR2 mutations, bradycardia, and follow up of the patients J. Med. Genet., November 1, 2005; 42(11): 863 - 870. [Abstract] [Full Text] [PDF] |
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M. Shah, F. G. Akar, and G. F. Tomaselli Molecular Basis of Arrhythmias Circulation, October 18, 2005; 112(16): 2517 - 2529. [Abstract] [Full Text] [PDF] |
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A. D. Krahn, M. Gollob, R. Yee, L. J. Gula, A. C. Skanes, B. D. Walker, and G. J. Klein Diagnosis of Unexplained Cardiac Arrest: Role of Adrenaline and Procainamide Infusion Circulation, October 11, 2005; 112(15): 2228 - 2234. [Abstract] [Full Text] [PDF] |
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S. Brunet, T. Scheuer, R. Klevit, and W. A. Catterall Modulation of CaV1.2 Channels by Mg2+ Acting at an EF-hand Motif in the COOH-terminal Domain J. Gen. Physiol., September 26, 2005; 126(4): 311 - 323. [Abstract] [Full Text] [PDF] |
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K. Kontula, P. J. Laitinen, A. Lehtonen, L. Toivonen, M. Viitasalo, and H. Swan Catecholaminergic polymorphic ventricular tachycardia: Recent mechanistic insights Cardiovasc Res, August 15, 2005; 67(3): 379 - 387. [Abstract] [Full Text] [PDF] |
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S. Kaab and E. Schulze-Bahr Susceptibility genes and modifiers for cardiac arrhythmias Cardiovasc Res, August 15, 2005; 67(3): 397 - 413. [Abstract] [Full Text] [PDF] |
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D. M. Roden Proarrhythmia as a pharmacogenomic entity: A critical review and formulation of a unifying hypothesis Cardiovasc Res, August 15, 2005; 67(3): 419 - 425. [Abstract] [Full Text] [PDF] |
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P. Brugada, R. Brugada, J. Brugada, S. G. Priori, C. Napolitano, P. Brugada, R. Brugada, J. Brugada, S. G. Priori, and C. Napolitano Should patients with an asymptomatic Brugada electrocardiogram undergo pharmacological and electrophysiological testing? Circulation, July 12, 2005; 112(2): 279 - 292. [Full Text] [PDF] |
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H. L. Tan, N. Hofman, I. M. van Langen, A. C. van der Wal, and A. A.M. Wilde Sudden Unexplained Death: Heritability and Diagnostic Yield of Cardiological and Genetic Examination in Surviving Relatives Circulation, July 12, 2005; 112(2): 207 - 213. [Abstract] [Full Text] [PDF] |
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A. Kadish and M. Mehra Heart Failure Devices: Implantable Cardioverter-Defibrillators and Biventricular Pacing Therapy Circulation, June 21, 2005; 111(24): 3327 - 3335. [Full Text] [PDF] |
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G.-B. Nam, A. Burashnikov, and C. Antzelevitch Cellular Mechanisms Underlying the Development of Catecholaminergic Ventricular Tachycardia Circulation, May 31, 2005; 111(21): 2727 - 2733. [Abstract] [Full Text] [PDF] |
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S. R. Houser Can Novel Therapies for Arrhythmias Caused by Spontaneous Sarcoplasmic Reticulum Ca2+ Release be Developed Using Mouse Models? Circ. Res., May 27, 2005; 96(10): 1031 - 1032. [Full Text] [PDF] |
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M. Cerrone, B. Colombi, M. Santoro, M. R. di Barletta, M. Scelsi, L. Villani, C. Napolitano, and S. G Priori Bidirectional Ventricular Tachycardia and Fibrillation Elicited in a Knock-In Mouse Model Carrier of a Mutation in the Cardiac Ryanodine Receptor Circ. Res., May 27, 2005; 96(10): e77 - e82. [Abstract] [Full Text] [PDF] |
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T. T. Beery The Genetics of Cardiac Arrhythmias Biol Res Nurs, April 1, 2005; 6(4): 249 - 261. [Abstract] [PDF] |
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M. Morad, L. Cleemann, and B. C. Knollmann Triadin: The New Player on Excitation-Contraction Coupling Block Circ. Res., April 1, 2005; 96(6): 607 - 609. [Full Text] [PDF] |
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A Farzaneh-Far and B B Lerman Idiopathic ventricular outflow tract tachycardia Heart, February 1, 2005; 91(2): 136 - 138. [Abstract] [Full Text] [PDF] |
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C. Antzelevitch Cardiac repolarization. The long and short of it Europace, January 1, 2005; 7(s2): S3 - S9. [Abstract] [Full Text] [PDF] |
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X. H. T. Wehrens and A. R. Marks Sudden Unexplained Death Caused by Cardiac Ryanodine Receptor (RyR2) Mutations Mayo Clin. Proc., November 1, 2004; 79(11): 1367 - 1371. [PDF] |
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D. J. Tester, D. B. Spoon, H. H. Valdivia, J. C. Makielski, and M. J. Ackerman Targeted Mutational Analysis of the RyR2-Encoded Cardiac Ryanodine Receptor in Sudden Unexplained Death: A Molecular Autopsy of 49 Medical Examiner/Coroner's Cases Mayo Clin. Proc., November 1, 2004; 79(11): 1380 - 1384. [Abstract] [PDF] |
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G. F. Tomaselli and D. P. Zipes What Causes Sudden Death in Heart Failure? Circ. Res., October 15, 2004; 95(8): 754 - 763. [Abstract] [Full Text] [PDF] |
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G. Choi, L. J. Kopplin, D. J. Tester, M. L. Will, C. M. Haglund, and M. J. Ackerman Spectrum and Frequency of Cardiac Channel Defects in Swimming-Triggered Arrhythmia Syndromes Circulation, October 12, 2004; 110(15): 2119 - 2124. [Abstract] [Full Text] [PDF] |
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N. Lowri Thomas, C. H. George, and F. Anthony Lai Functional heterogeneity of ryanodine receptor mutations associated with sudden cardiac death Cardiovasc Res, October 1, 2004; 64(1): 52 - 60. [Abstract] [Full Text] [PDF] |
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D. Jiang, B. Xiao, D. Yang, R. Wang, P. Choi, L. Zhang, H. Cheng, and S. R. W. Chen RyR2 mutations linked to ventricular tachycardia and sudden death reduce the threshold for store-overload-induced Ca2+ release (SOICR) PNAS, August 31, 2004; 101(35): 13062 - 13067. [Abstract] [Full Text] [PDF] |
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A. Bagattin, C. Veronese, B. Bauce, W. Wuyts, L. Settimo, A. Nava, A. Rampazzo, and G. A. Danieli Denaturing HPLC-Based Approach for Detecting RYR2 Mutations Involved in Malignant Arrhythmias Clin. Chem., July 1, 2004; 50(7): 1148 - 1155. [Abstract] [Full Text] [PDF] |
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D. Stilli, R. Berni, L. Bocchi, M. Zaniboni, F. Cacciani, A. Sgoifo, and E. Musso Vulnerability to ventricular arrhthmias and heterogeneity of action potential duration in normal rats Exp Physiol, July 1, 2004; 89(4): 387 - 396. [Abstract] [Full Text] [PDF] |
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B. J. Maron, B. R. Chaitman, M. J. Ackerman, A. Bayes de Luna, D. Corrado, J. E. Crosson, B. J. Deal, D. J. Driscoll, N.A. M. Estes III, C. G. S. Araujo, et al. Recommendations for Physical Activity and Recreational Sports Participation for Young Patients With Genetic Cardiovascular Diseases Circulation, June 8, 2004; 109(22): 2807 - 2816. [Abstract] [Full Text] [PDF] |
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C. H. George, H. Jundi, N. L. Thomas, M. Scoote, N. Walters, A. J. Williams, and F. A. Lai Ryanodine Receptor Regulation by Intramolecular Interaction between Cytoplasmic and Transmembrane Domains Mol. Biol. Cell, June 1, 2004; 15(6): 2627 - 2638. [Abstract] [Full Text] [PDF] |
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B. Xiao, C. Sutherland, M. P. Walsh, and S.R. W. Chen Protein Kinase A Phosphorylation at Serine-2808 of the Cardiac Ca2+-Release Channel (Ryanodine Receptor) Does Not Dissociate 12.6-kDa FK506-Binding Protein (FKBP12.6) Circ. Res., March 5, 2004; 94(4): 487 - 495. [Abstract] [Full Text] [PDF] |
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S. G. Priori Inherited Arrhythmogenic Diseases: The Complexity Beyond Monogenic Disorders Circ. Res., February 6, 2004; 94(2): 140 - 145. [Abstract] [Full Text] [PDF] |
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P.D. Allen Not All Sudden Death Is the Same Circ. Res., September 19, 2003; 93(6): 484 - 486. [Full Text] [PDF] |
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C. H. George, G. V. Higgs, and F. A. Lai Ryanodine Receptor Mutations Associated With Stress-Induced Ventricular Tachycardia Mediate Increased Calcium Release in Stimulated Cardiomyocytes Circ. Res., September 19, 2003; 93(6): 531 - 540. [Abstract] [Full Text] [PDF] |
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M. N. Obreztchikova, E. A. Sosunov, E. P. Anyukhovsky, N. S. Moise, R. B. Robinson, and M. R. Rosen Heterogeneous Ventricular Repolarization Provides a Substrate for Arrhythmias in a German Shepherd Model of Spontaneous Arrhythmic Death Circulation, September 16, 2003; 108(11): 1389 - 1394. [Abstract] [Full Text] [PDF] |
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B. J. Maron Sudden Death in Young Athletes N. Engl. J. Med., September 11, 2003; 349(11): 1064 - 1075. [Full Text] [PDF] |
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H. Honjo, M. R. Boyett, R. Niwa, S. Inada, M. Yamamoto, K. Mitsui, T. Horiuchi, N. Shibata, K. Kamiya, and I. Kodama Pacing-Induced Spontaneous Activity in Myocardial Sleeves of Pulmonary Veins After Treatment With Ryanodine Circulation, April 15, 2003; 107(14): 1937 - 1943. [Abstract] [Full Text] [PDF] |
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H. Lahat, E. Pras, M. Eldar, S. G. Priori, R. Bolise, M. Memmi, B. Colombi, C. Napolitano, F. Coltorti, M. Gasparini, et al. RYR2 and CASQ2 Mutations in Patients Suffering From Catecholaminergic Polymorphic Ventricular Tachycardia * Response Circulation, January 28, 2003; 107 (3): e29 - e29. [Full Text] [PDF] |
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Z. Liu, J. Zhang, P. Li, S. R. W. Chen, and T. Wagenknecht Three-dimensional Reconstruction of the Recombinant Type 2 Ryanodine Receptor and Localization of Its Divergent Region 1 J. Biol. Chem., November 22, 2002; 277(48): 46712 - 46719. [Abstract] [Full Text] [PDF] |
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A. V. Postma, I. Denjoy, T. M. Hoorntje, J.-M. Lupoglazoff, A. Da Costa, P. Sebillon, M. M.A.M. Mannens, A. A.M. Wilde, and P. Guicheney Absence of Calsequestrin 2 Causes Severe Forms of Catecholaminergic Polymorphic Ventricular Tachycardia Circ. Res., October 18, 2002; 91 (8): e21 - e26. [Abstract] [Full Text] [PDF] |
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A. R. Marks Clinical Implications of Cardiac Ryanodine Receptor/Calcium Release Channel Mutations Linked to Sudden Cardiac Death Circulation, July 2, 2002; 106(1): 8 - 10. [Full Text] [PDF] |
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