Combined use of voltage mapping and speckle tracking echocardiography for the early diagnosis of ARVC/D: a case report

Abstract A 38 years-old man was admitted to our hospital after ventricular tachycardia with left-bundle-branch block and inferior axis morphology. After undergoing different examinations the criteria for the diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) were met. An electrophysiological study was then performed together with endocardial bipolar and unipolar voltage map. Unipolar and bipolar voltage mapping of the right ventricle showed low voltage areas and corresponding fragmented potentials from the tricuspid annulus to the inferior apex. On the right ventricular outer tract (RVOT), the bipolar voltage mapping was normal while the unipolar mapping showed low-voltage areas in the antero-septal outer tract. An off-line map was used to perform speckle tracking analysis on intracardiac echocardiography (ICE) clips of right ventricle and standard echocardiography. A reduction of the strain analysis was stored in correspondence of the fragmented electrograms area, in particular, speckle tracking analysis on ICE views showed a reduction of the RV LS in the segments below tricuspid valve, in the three different myocardial layers. The endocardial longitudinal strain was reduced from sub-tricuspidalic segments to the RV apex in accordance with the fragmentated potentials stored during voltage mapping. On the contrary, at anterior RVOT wall, the unipolar voltage mapping showed fragmented potentials and the STE analysis revealed a reduced epicardial LS. This case report lays emphasis on the importance of the integration of ICE-derived right ventricular strain and voltage mapping in the improvement of the sensibility of an early diagnosis of the ARVC.