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Current Concepts in Arrhythmogenic Cardiomyopathy
Second Edition Corrinna Brunckhorst Digital Instant
Download
Author(s): Corrinna Brunckhorst, Ardan M. Saguner, Firat Duru
ISBN(s): 9781942909507, 1942909500
Edition: Second
File Details: PDF, 11.98 MB
Year: 2021
Language: english
Current Concepts in

BRUNCKHORST • SAGUNER • DURU

Current Concepts in
Arrhythmogenic Cardiomyopathy
Arrhythmogenic
Current Thinking on
Second Edition
Editors
Prof. Dr. Corinna Brunkhorst • PD Dr. Ardan M. Saguner • Prof. Dr. Firat Duru
—University Heart Center, Zurich, Switzerland
Cardiomyopathy
Second Edition
Current Concepts in Arrhythmogenic Cardiomyopathy, Second Edition

Arrhythmogenic Cardiomyopathy
presents essential insights into all aspects of this complex disease and will serve as
a valuable guide to help readers provide the best possible care for their patients. Editors
CORINNA BRUNCKHORST  ARDAN M. SAGUNER  FIRAT DURU

Discussion by internationally recognized authorities includes:

• Increasing evidence that arrhythmogenic cardiomyopathy is not
necessarily confined to the RV, but often involves both ventricles
• Basic and clinical science of arrhythmogenic cardiomyopathy
• Pathophysiology, molecular mechanisms, and genetic background
• The mechanisms of disease progression leading to a diversity of
disease phenotypes
• Guidance in the clinical setting for diagnosis, risk stratification, and therapy

The Zurich ARVC Program was established in 2011 at the University Heart
Center in Zurich, Switzerland, to increase awareness of the challenging entity
of arrhythmogenic cardiomyopathies. Supported by the Georg and Bertha
Schwyzer-Winiker Foundation, Baugarten Foundation, Dr. Hans-Peter
Wild / USZ Foundation, Swiss Heart Foundation, and Swiss National

Second Edition
Science Foundation (SNF), the program focuses on providing clinical
excellence for the care of patients with arrhythmogenic cardiomyopathy
along with promoting basic and clinical research for this condition.

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Current Concepts in Arrhythmogenic Cardiomyopathy

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 ONLINE ACCESS
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 Current Concepts in Arrhythmogenic Cardiomyopathy

Second Edition

Editors:

Prof. Dr. CORINNA BRUNCKHORST

Co-Director, Cardiac Arrhythmia Service
University Heart Center, Zurich, Switzerland

PD Dr. ARDAN M. SAGUNER

Senior Consultant, Cardiac Arrhythmia Service
University Heart Center, Zurich, Switzerland

Prof. Dr. FIRAT DURU

Director, Cardiac Arrhythmia Service
University Heart Center, Zurich, Switzerland
Second Edition

First Edition © 2014 Corinna Brunckhorst, Firat Duru

Second Edition © 2021 Corinna Brunckhorst, Ardan M. Saguner, Firat Duru

The first edition of this book is entitled Current Concepts in Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia.

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1234567 25 24 23 22 21
 Dedication
We sincerely thank all patients with arrhythmogenic cardiomyopathy who agreed to be enrolled
in clinical research studies and have helped to substantially advance our understanding of this
challenging disease. It is a tremendous privilege to interact with our collaborators and friends
around the globe in an attempt to advance this field to new frontiers. Furthermore, we are
immensely thankful for the invaluable endorsement of our sponsors, as it is only due to their
enormous generosity that our work is rendered possible. In addition, we are greatly indebted to
our exceptional mentors, who have paved the way for us to follow their paths.

We are more than grateful for the affection and support of our families who help us main-
tain our rhythm. Ultimately, this book is dedicated, in love and gratitude, to the memory of
our dear parents Sieglinde Brunckhorst, Oylar Saguner, and Nurettin Duru. They will always
remain in our hearts.

v
 Table of Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Chapter 1 The History of Naxos Disease: Landmarks in the History of the Disorder . . . . . . . . . . . . . 1
Alexandros Protonotarios, Adalena Tsatsopoulou

Chapter 2 Metabolic Deregulation in Arrhythmogenic Cardiomyopathy:

Novel Pathogenic Insights and Their Clinical Application . . . . . . . . . . . . . . . . . . . . . . 11
Shing Fai Chan, Liang Chen, Chuan-yu Wei, Jiangping Song, Huei-sheng Vincent Chen

Chapter 3 Pleiotropic Functions of Plakophilin-2 and Arrhythmia Mechanisms . . . . . . . . . . . . . . . . 25

Marina Cerrone, Chantal J. M. van Opbergen, Mario Delmar

Chapter 4 Immune Signaling in Arrhythmogenic Cardiomyopathy. . . . . . . . . . . . . . . . . . . . . . . . . . 37

Stephen P. Chelko, Angeliki Asimaki, Justin Lowenthal, Carlos Bueno-Beti,
Alexandros Protonotarios, Leslie Tung, Jeffrey E. Saffitz

Chapter 5 Studying Arrhythmogenic Cardiomyopathy Under the Microscope . . . . . . . . . . . . . . . . . 49

Monica De Gaspari, Stefania Rizzo, Gaetano Thiene, Cristina Basso

Chapter 6 Genetic Contributions to Arrhythmogenic Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . 59

Daniel P. Judge, J. Peter van Tintelen

Chapter 7 Current Challenges in the Diagnosis of Arrhythmogenic Cardiomyopathies . . . . . . . . . . 73

Mimount Bourfiss, Richard Hauer

Chapter 8 Differential Diagnosis of Phenotypic Variants of Arrhythmogenic Cardiomyopathy . . . . . 87

Hugh Calkins

Chapter 9 Life-Threatening Arrhythmias Without Overt Clinical Disease:

“Concealed” Arrhythmogenic Right Ventricular Cardiomyopathy. . . . . . . . . . . . . . . . . 93
Christopher Semsarian, Jodie Ingles

vii
viii Current Concepts in Arrhythmogenic Cardiomyopathy

Chapter 10 Genotype-Phenotype Correlations in ACM: The Chinese Experience. . . . . . . . . . . . . . . 101

Liang Chen, Jiangping Song

Chapter 11 Biomarkers in Inherited Arrhythmias: Arrhythmogenic Right Ventricular

Cardiomyopathy and Beyond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111
Robert M. Hamilton

Chapter 12 Atrial Fibrillation and ECG Markers of Atrial Involvement in Arrhythmogenic

Right Ventricular Cardiomyopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Maria A. Baturova, Pyotr G. Platonov

Chapter 13 Medical Therapy in Arrhythmogenic Right Ventricular Cardiomyopathy. . . . . . . . . . . . . 127

Laura Sommerfeld, Areej Aljehani, Manish Kalla, Larissa Fabritz

Chapter 14 Role of Catheter Ablation in Arrhythmogenic Right Ventricular Cardiomyopathy . . . . . . 135

Fabrizio R. Assis, Harikrishna Tandri

Chapter 15 Arrhythmogenic Right Ventricular Cardiomyopathy Research: Better Together . . . . . . . 147

Anneline S. J. M. te Riele, Laurens P. Bosman, Julia Cadrin-Tourigny, Cynthia A. James

Chapter 16 The Role of Protein Redistribution in the Diagnosis of Arrhythmogenic

Cardiomyopathy: A Translational Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Carlos Bueno-Beti; Angeliki Asimaki

Chapter 17 The Zurich ARVC Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Deniz Akdis, Ardan M. Saguner, Corinna Brunckhorst, Firat Duru

Impressions from the Zurich International Symposium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

on Arrhythmogenic Cardiomyopathies, 2019

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
 Contributors

Editors
CORINNA BRUNCKHORST, MD
Co-Director, Cardiac Arrhythmia Service, University Heart Center, Zurich, Switzerland

ARDAN M. SAGUNER, MD
Senior Consultant, Cardiac Arrhythmia Service, University Heart Center, Zurich, Switzerland

FIRAT DURU, MD
Director, Cardiac Arrhythmia Service, University Heart Center, Zurich, Switzerland

Contributors
Deniz Akdis, MD Laurens P. Bosman, MD
Cardiology Resident/ARVC Fellow, Cardiac Department of Cardiology, University Medical
Arrhythmia Service, University Heart Center, Center, University of Utrecht; Netherlands
Zurich, Switzerland Heart Institute, Utrecht, The Netherlands

Areej Aljehani, MSc Mimount Bourfiss, MD

Institute of Cardiovascular Sciences, University Department of Cardiology, University Medical
of Birmingham, Department of Cardiology, Center Utrecht, Utrecht, The Netherlands
University Hospital Birmingham,
Carlos Bueno-Beti, PhD
Birmingham, UK
St. George’s, University of London, London, UK
Angeliki Asimaki, PhD
Julia Cadrin-Tourigny, MD
St. George’s, University of London, London, UK
Department of Medicine and Cardiovascular
Fabrizio R. Assis, MD Genetics Center, Montreal Heart Institute,
ARVC Program, Division of Cardiology, Université de Montréal, Montréal, Canada;
Johns Hopkins University School of Medicine, Johns Hopkins ARVC Program, Johns Hopkins
Baltimore, Maryland, USA Division of Cardiology, Department of
Medicine, Johns Hopkins University, Baltimore,
Cristina Basso, MD, PhD
Maryland, USA
Department of Cardiac, Thoracic and Vascular
Sciences and Public Health, University of Padua Hugh Calkins, MD
Medical School, Padua, Italy Division of Cardiology, Johns Hopkins Medical
Institutions, Baltimore, Maryland, USA
Maria A. Baturova, MD, PhD
Department of Cardiology, Lund University, Marina Cerrone, MD
Lund, Sweden; Research Park, Saint Petersburg Inherited Arrhythmias Clinic, Heart Rhythm
State University, Saint Petersburg, Russia Center, Leon H. Charney Division of
Cardiology, New York University School of
Medicine, New York, New York, USA

ix
x Current Concepts in Arrhythmogenic Cardiomyopathy

Shing Fai Chan, PhD Richard Hauer, MD, PhD

Krannert Institute of Cardiology, Indiana Department of Cardiology, University Medical
University, Indianapolis, Indiana, USA Center Utrecht; Netherlands Heart Institute,
Utrecht, The Netherlands
Stephen P. Chelko, PhD
Department of Biomedical Sciences, Florida Cynthia A. James, PhD, ScM
State University College of Medicine, Johns Hopkins ARVC Program, Johns Hopkins
Tallahassee, Florida, USA Division of Cardiology, Department of
Medicine, Johns Hopkins University, Baltimore,
Huei-sheng Vincent Chen, MD, PhD
Maryland, USA
Krannert Institute of Cardiology, Indiana
University, Indianapolis, Indiana, USA Daniel P. Judge, MD
Medical University of South Carolina;
Liang Chen, MD, PhD
Fellowship Program Director, Cardiology;
State Key Laboratory of Cardiovascular
Director of Cardiovascular Genetics,
Disease, Fuwai Hospital; National Center for
Section of Advanced Heart Failure &
Cardiovascular Diseases, Chinese Academy of
Transplant, Charleston, South Carolina, USA
Medical Sciences (CAMS) and Peking Union
Medical College (PUMC), Beijing, P. R. China Manish Kalla, MD
Department of Cardiology, University Hospital
Monica De Gaspari, MD
Birmingham, Institute of Cardiovascular
Department of Cardiac, Thoracic and Vascular
Sciences, University of Birmingham,
Sciences and Public Health, University of Padua
Birmingham, UK
Medical School, Padua, Italy
Justin Lowenthal, BS
Mario Delmar, MD, PhD
Department of Biomedical Engineering,
Leon H. Charney Division of Cardiology, New
Johns Hopkins School of Medicine, Baltimore,
York University School of Medicine, New York,
Maryland, USA
New York, USA
Frank I. Marcus, MD
Larissa Fabritz, MD
Professor Emeritus, Department of Cardiology,
Institute of Cardiovascular Sciences, University
Sarver Heart Center, University of Arizona
of Birmingham; Department of Cardiology,
Health Science Center, Tucson, Arizona, USA
University Hospital Birmingham,
Birmingham, UK Pyotr G. Platonov, MD, PhD
Department of Cardiology, Lund University,
Jodie Ingles, GradDipGenCouns, PhD, MPH
Lund, Sweden
Agnes Ginges Centre for Molecular Cardiology,
Centenary Institute, Sydney; Alexandros Protonotarios, MD
Sydney Medical School, Faculty of Medicine Institute of Cardiovascular Science, University
and Health, University of Sydney; College London, London, UK
Department of Cardiology, Royal Prince Alfred
Hospital, Sydney, Australia Stefania Rizzo, MD, PhD
Department of Cardiac, Thoracic and Vascular
Robert M. Hamilton, MD, MHSc, FRCP(C) Sciences and Public Health, University of Padua
The Labatt Family Heart Centre and Division Medical School, Padua, Italy
of Cardiology Department of Pediatrics, and
Translational Medicine Program, The Hospital Jeffrey E. Saffitz, MD, PhD
for Sick Children and University of Toronto, Department of Pathology, Beth Israel Deaconess
Toronto, Ontario, Canada Medical Center, Boston, Massachusetts, USA
 Contributors xi

Christopher Semsarian, MBBS, PhD, MPH Gaetano Thiene, MD

Agnes Ginges Centre for Molecular Cardiology, Department of Cardiac, Thoracic and Vascular
Centenary Institute, Sydney; Sciences and Public Health, University of Padua
Sydney Medical School, Faculty of Medicine Medical School, Padua, Italy
and Health, University of Sydney;
Adalena Tsatsopoulou, MD
Department of Cardiology, Royal Prince Alfred
Naxos General Hospital, Naxos, Greece
Hospital, Sydney, Australia
Leslie Tung, PhD
Laura Sommerfeld, MSc
Department of Biomedical Engineering,
Institute of Cardiovascular Sciences, University
Johns Hopkins School of Medicine, Baltimore,
of Birmingham, Birmingham, UK
Maryland, USA
Jiangping Song, MD, PhD
Chantal J. M. van Opbergen, PhD
State Key Laboratory of Cardiovascular
Leon H. Charney Division of Cardiology, New
Disease, Fuwai Hospital; National Center for
York University School of Medicine, New York,
Cardiovascular Diseases, Chinese Academy of
New York, USA
Medical Sciences (CAMS) and Peking Union
Medical College (PUMC), Beijing, P. R. China J. Peter van Tintelen, MD, PhD
Department of Medical Genetics, University
Harikrishna Tandri, MD
Medical Center Utrecht, University of Utrecht,
ARVC Program, Division of Cardiology,
Utrecht, The Netherlands
Johns Hopkins University School of Medicine,
Baltimore, Maryland, USA Chuan-yu Wei, PhD
Krannert Institute of Cardiology, Indiana
Anneline S. J. M. te Riele, MD, PhD
University, Indianapolis, Indiana, USA
Department of Cardiology, University Medical
Center, University of Utrecht; Netherlands
Heart Institute, Utrecht, The Netherlands
 Preface
Arrhythmogenic cardiomyopathy continues to be a challenging clinical entity, for which the
diagnosis, risk stratification, and therapy have evolved over the last three decades. When we
published the first edition of this book in 2014, our primary focus was on arrhythmogenic
right ventricular cardiomyopathy (ARVC), which is the most common and typical form of
arrhythmogenic cardiomyopathy. In recent years, there has been mounting evidence that the
disease is not confined to the right ventricle, but in most cases, it involves both ventricles.
Therefore, we have adapted the title of this edition to be Current Concepts in Arrhythmogenic
Cardiomyopathy, Second Edition.
All cardiomyopathies can predispose the affected patients to the occurrence of ventricular
arrhythmias. The main difference between arrhythmogenic cardiomyopathy and other forms
of cardiomyopathies is that, in the former, life-threatening arrhythmias may occur early and
out of proportion to the degree of the underlying myocardial substrate. This poses the patients
who are typically young and athletic at high risk for sudden cardiac death. When we estab-
lished the Zurich ARVC Program in 2011, our primary aim was to increase awareness for this
challenging disease. Our program, which was initially supported by the Georg and Bertha
Schwyzer-Winiker Foundation, has received other generous support and research funds from
the Baugarten Foundation, Dr. Hans-Peter Wild / USZ Foundation, Swiss Heart Foundation,
and Swiss National Science Foundation (SNF). Therefore, we were fortunate to focus our
efforts on providing clinical excellence for the care of these patients and promoting in-depth
basic and clinical research for this disease. Moreover, in the course of this decade, we were able
to organize four international symposia to create a platform for exchange of knowledge and ini-
tiate global collaboration by convening key opinion leaders for arrhythmogenic cardiomyopathy
from around the world in Zurich.
Current Concepts in Arrhythmogenic Cardiomyopathy, Second Edition includes 16 chapters
on various basic and clinical science aspects of arrhythmogenic cardiomyopathy. It includes
a broad spectrum of topics, including pathophysiology, molecular mechanisms, and genetic
background of disease, as well as its clinical presentation, diagnosis, risk stratification, and
therapy. Our ultimate goal is to offer a useful guide to help medical caregivers provide the best
possible care for their patients and update them with state-of-the-art knowledge on this disease.
We sincerely hope that Current Concepts in Arrhythmogenic Cardiomyopathy, Second Edition
fulfills this purpose.
We wish to thank all the contributing authors for their invaluable collaborations and for
being part of this project.
—The Editors

xiii
 Abbreviations
ACE angiotensin-converting enzyme LGE late gadolinium enhancement
ACM arrhythmogenic cardiomyopathy LV left ventricle; left ventricular
AF atrial fibrillation LVEF left ventricular ejection fraction
ALVC arrhythmogenic left ventricular MACE major adverse cardiovascular events
cardiomyopathy MCFA medium-chain fatty acids
APC adenomatous polyposis coli MMP matrix metalloproteinase
ARVC arrhythmogenic right ventricular MRI magnetic resonance imaging
cardiomyopathy NCAD N-cadherin
AV atrioventricular NFκB nuclear factor κB
β-OHB β-hydroxybutyrate NGS next-generation sequencing
BCDS bilateral cardiac sympathetic NIPS noninvasive programmed stimulation
denervation NLVS nonischemic left ventricular scar
BrS Brugada syndrome NRVMs neonatal rat ventricular myocytes
CAAR chimeric autoantibody receptor NSVT nonsustained ventricular tachycardia
CMR cardiac magnetic resonance Nt-BNP N-terminal pro-brain natriuretic
CMs cardiomyocytes peptide
CPVT catecholaminergic polymorphic PKC protein kinase C
ventricular tachycardia PKP2 plakophilin-2
Cx43 connexin43 PLN phospholamban
DCM dilated cardiomyopathy PPAR peroxisome proliferator-activated
DPI days postinjection receptor
DSC2 desmocollin-2 PTF-V1 P-terminal negative force in lead V1
DSG2 desmoglein-2 PVC premature ventricular contraction
DSP desmoplakin RAAS renin-angiotensin-aldosterone system
EC4 extracellular cadherin 4 ROS reactive oxygen species
EC5/EA extracellular cadherin 5/extracellular RV right ventricular
articulating RyR ryanodine receptors
ECG electrocardiogram SAECGs signal-averaged electrocardiograms
ELISA enzyme-linked immunosorbent assay SAP97 synapse-associated protein 97
EP electrophysiology SCD sudden cardiac death
FAO fatty acid oxidation shRNA short hairpin RNA
HCM hypertrophic cardiomyopathy TAD terminal activation duration/delay
HTx heart transplant/heart transplantation TFC Task Force Criteria
ICD implantable cardioverter-defibrillator TTE transthoracic echocardiography
iPSC induced pluripotent stem cells VA ventricular arrhythmia
iPSC-CMs induced pluripotent stem cell-derived VF ventricular fibrillation
cardiomyocytes VT ventricular tachycardia
JUP plakoglobin WES whole exome sequencing
KO knockout WT wildtype
LCFA long-chain fatty acids

xv
 Introduction
Right ventricular cardiomyopathy/dysplasia (ARVC/D) is considered to be a newly identified,
rare disease. However, it is neither. It has been a well-recognized entity since the publication
of 24 cases in 1982.1 Subsequently, there have been a plethora of articles describing the various
aspects of ARVC/D including ECG characteristics, frequent involvement of the left ventricle,
and recognition of familial inheritance. It is now recognized that it is not rare, as shown by a
recent report of 1001 patients and family members with this disease.2
ARVC/D was recognized several hundred years ago, as documented by Gaetano Thiene.3
He noted that the first report of ARVC/D was published by Lancisi in 1736.4 The first detailed
pathological description was published by Laennec in 1819.5 There followed a lack of reports of
ARVC/D until 1961 when Dalla Volta et al. published observations of patients with “auricular-
ization of the right ventricle.”6 Dalla Volta emphasized the hemodynamic dysfunction of the
right ventricle. Recognition of the disease as a distinct entity was made by Guy Fontaine in the
1970s from patients who were referred for treatment of ventricular tachycardia but did not have
ischemic heart disease or congestive heart failure.7 The ventricular tachycardia was initiated
from the right ventricle with a left bundle branch block morphology. There were 24 patients
with similar morphologies in their ECGs during ventricular tachycardia, and these patients had
similar diagnostic criteria that was described as a syndrome and published by Marcus et al. in
1982.1 A familial inheritance was also observed. Once these observations were published, the
disease became well recognized as a frequent cause of ventricular tachycardia and became a
disease entity.
What does this sequence of the discovery of ARVC/D indicate? How many disease entities
are still undiscovered? The answer to this question is unknown, but the sequence of the recogni-
tion of the discovery of ARVC/D indicates that there may be a number of diseases that are yet to
be uncovered. The availability of genetics should assist in the discovery of new diseases.

—Frank Marcus, MD

xvii
References
1. Marcus FI, Fontaine GH, Guiraudon G, et al. Right ventricular dysplasia: A report of 24 cases. Cir-
culation. 1982;65:384–398.
2. Groeneweg JA, Bhonsale A, James CA, et al. Clinical presentation, long term follow-up, and outcomes
of 1001 arrhythmogenic right ventricular dysplasia/cardiomyopathy patients and family members. Circ
Cardiovascular Genet. 2015;8:437–446.
3. Thiene G. The research venture in arrhythmogenic right ventricular cardiomyopathy: A paradigm of
translational medicine. Eur Heart J. 2015;36:837–846.
4. Lancisi GM. De motu cardis et aneuysmatibus. Caput V. Naples: excedebat. Felix-Carolus Musca,
1936.
5. Laennec RTH. De l’ausutation mediate au trané du diagnostic des maladies des poumons et du Coeur.
Paris: Brosson & Chaudé, 1819.
6. Dalla Volta S, Farneli O, Maschio G. Le syndrome clinique et hemodynamique de l’auricularisation
du ventricule droit. Arch Mal Coeur. 1965;58:1129–1143.
7. Fontaine G, Frank R, Vedel J, Grosgogeat Y, Carbrol C, Facquet J. Stimulation studies and epicardial
mapping in ventricular tachycardia: study of mechanisms and selection for surgery. In: Kulbertus HE
(ed). Reentrant Arrhythmias. Lancaster, PA: MTPP Publishing, 1977:334–350.
 1

The History of Naxos Disease: Landmarks in

the History of the Disorder

Alexandros Protonotarios, MD; Adalena Tsatsopoulou, MD

“The whole art of medicine is in observation.”

–William Osler
“The Hospital as a College,” Aequanimitas

Clinical Observations QRS prolongation, and repolarization abnor-

malities, while his chest x-ray showed huge
In the winter of 1984, in a mountain village cardiomegaly attributed to extreme right ven-
of Naxos, a 24-year-old male presented to the tricular outflow tract (RVOT) dilatation. That
rural surgery with an episode of sustained episode of sustained VT was as the previous
ventricular tachycardia (VT). His previous ones: unresponsive to medical treatment and
history of arrhythmia had started 7 years ago terminated by defibrillation in an Athens ter-
with syncope followed by a burst of episodes tiary hospital, where the patient was trans-
of VT. Following the diagnosis of Ebstein’s ported by a helicopter.
anomaly, the patient had undergone a tricus- Naxos, the biggest of the Cyclades islands
pid valve replacement in an Athens hospital. in Greece, is located at the middle of the
Since then, he suffered one or two episodes of Aegean Sea and has 20,000 inhabitants. In the
sustained VT each year, presenting with vom- early 1980s, the only connection from Naxos
iting; the episodes were well tolerated, and he to Athens was an 8- to 10-hour trip by boat to
was defibrillated to restore the sinus rhythm the Athenian port of Piraeus, scheduled every
on all occasions. Interestingly, this young man other day. There was neither a hospital nor a
had severe hyperkeratotic lesions on his palms primary health center on the island. A pair of
and soles, causing him suffering as he worked young, married doctors, Nikos Protonotarios
in his agricultural activities, and extremely and Adalena Tsatsopoulou, had chosen Naxos,
woolly hair unlike his other family members. as Nikos’ homeland, to serve their obligatory
The patient’s electrocardiogram (ECG) was rural service in order to achieve a license to
quite abnormal with low voltages, precordial practice. On that case, their first impression

Current Concepts in Arrhythmogenic Cardiomyopathy, Second Edition

© 2021 Corinna Brunckhorst, Ardan M. Saguner, Firat Duru, Editors. Cardiotext Publishing. ISBN: 978-1-942909-50-7 1
2 Current Concepts in Arrhythmogenic Cardiomyopathy

was that an association of severe ventricular tainous region of Naxos) warranted further
arrhythmias (VAs) with palmoplantar kerato- investigation. The three patients were appar-
derma in a young person was likely a syndromic ently not related. However, the two doctors
defect, since two rare phenotypes coexisted.1 suspected familial occurrence of the defects,
Nevertheless, such an association did not exist so they decided to visit the family of the girl.
in their medical textbooks at the time. A few There were two older siblings with woolly
months later, during a social event, they were hair and palmoplantar keratoderma. The
extremely surprised to meet a 32-year-old pro- eldest brother at 26 years old had already suf-
fessional photographer with the same hair and fered episodes of syncope and, after complete
cutaneous features, who discussed with them physical examination, 12-lead resting ECG,
his problem of chest discomfort and recurrent and chest x-ray, could be suspected of having
VA episodes; after extensive evaluation, he DCM (Figure 1.2). The younger brother, who
had already been given a diagnosis of dilated was 17 years old, was asymptomatic but had
cardiomyopathy (DCM). The patient’s ECG abnormal ECG findings (Figure 1.3).
showed intraventricular conduction delay and On a warm, sunny day by the seashore, Drs
precordial repolarization changes. Protonotarios and Tsatsopoulou noticed a well-
Later in the same year, a 17-year-old girl developed young boy with woolly hair enjoying
from a different village on the island died sud- the sea. On a closer look, keratoses on palms
denly while at school. She had the same cuta- and soles were obvious. Carefully approach-
neous phenotype as the two other patients. ing the family, they were given permission to
Interestingly, a couple of years previously, she do an evaluation of the boy, and the 12-lead
had been diagnosed with DCM after an epi- resting ECG was consistent with a myocardial
sode of syncope (Figure 1.1). The incidence of defect (Figure 1.4). The increasing data of a
three young patients presenting an extremely syndromic potentially lethal cardiac disorder
rare skin condition also associated with rare running in those families challenged the physi-
events of severe VAs or sudden death and cians to make a thorough investigation of other
belonging to a population pool of around 4,000 families with this cutaneous condition. This
(all residents of villages occupying the moun- study was ultimately designed and performed

FIGURE 1.1 Resting 12-lead ECG (A) and M-mode echocardiography (B) of the 17-year-old girl as were recorded in a clinic
visit prior to her suffering sudden cardiac death (SCD), are presented. Right and left ventricular dilatation and hypokinesia as
well as paradoxical interventricular septal motion are observed. An echodense muscular type band (white arrow) is obvious
in the right ventricle. Abbreviations: IVS, interventricular septum; LV, left ventricle; RV, right ventricle. (Figure reproduced from
Protonotarios et al., Cardiovasc Pathol. 2014;13(4),185–194.1)
 The History of Naxos Disease: Landmarks in the History of the Disorder 3

FIGURE 1.2 Recording from baseline 12-lead ECG (A) and chest x-ray (B) in a 26-year-old man with Naxos disease and severe
biventricular involvement are presented. (Figure reproduced from Protonotarios et al., Cardiovasc Pathol. 2014;13(4),185–194.1)

FIGURE 1.3 Resting 12-lead ECG of the asymptomatic 17-year-old man showing QRS of right bundle branch block
morphology with inferior and extensive precordial T-wave inversions is presented. Right-sided precordial leads are also
presented (V1ʹ, V2ʹ, V3ʹ).

on the whole island by Drs. Protonotarios and persistent and continuous searching for a
Tsatsopoulou. The investigation went on to whole month into myriad lemmas embedded
reveal more families living in Naxos, as well into thin and densely written pages, the two
as others in Athens but of Naxian origin, with doctors were convinced that the observed syn-
the affected persons being closely related. An dromic association had not been described in
autosomal recessive, inherited disorder could any publications since 1895.
be postulated. All but one young boy, age 6, The permission Dr. Protonotarios gained
presented similar cardiac findings. by the 401 Army Hospital to perform echocar-
diographic evaluations for all of the patients
Description of a New himself was critical to the whole investigation.
Syndrome Impressed by the kinetic abnormalities of the
RV (Figure 1.5), he focused on a detailed
In those pre-internet times, researching the evaluation of RV structure and function and
scientific literature in Greece was only avail- performed the echocardiographic evaluation
able by looking up studies in the printed Index and follow-up in all patients himself, follow-
Medicus volumes in Athens. Therefore, after ing standard protocols.2 The common find-
4 Current Concepts in Arrhythmogenic Cardiomyopathy

FIGURE 1.4 Representative photographs demonstrating the woolly hair and palmoplantar keratoderma (top). Resting 12-lead
ECG is shown in bottom left and an episode of sustained VT in bottom right.

ings of RVOT dilatation and localized kinetic Following the breakthrough publication
abnormalities of the RV free wall together in The New England Journal of Medicine by
with the precordial repolarization changes the Padua group,5 the 2 doctors sent a letter to
led the doctors to notice in the Index Medicus the editor of the NEJM stressing the presenta-
a publication in Circulation by Frank Marcus tion of a broad clinical spectrum of ARVC in
and Guy Fontaine from 2 years earlier.3 Even- the Naxos series and an observation of inflam-
tually, the condition called “arrhythmogenic matory findings in myocardial specimens.6
RV dysplasia” (now referred to as arrhythmo- They also postulated a potential relationship
genic RV cardiomyopathy or ARVC) was the between Veneto and Naxos patients, due to the
closest description to the cardiomyopathy long-standing occupation of Naxos island after
their patients presented with. The first obser- the 13th century. That letter would initiate the
vations in 9 patients belonging to 4 families link between their research and the ARVC
were submitted to the British Heart Journal community of London and Padua later on.
in February 1986 and published without Within 4 years, 14 more patients of Nax-
any revision just 4 months later.4 Alongside ian origin situated in Athens and Frankfurt who
the initial report in Circulation in 1982, it had the combination of palmoplantar keratosis,
was one of the first descriptions of ARVC woolly hair, and ARVC had been identified.
patients. Notably, both left ventricular (LV) They were fully investigated and put in a stan-
involvement and atrial fibrillation (AF) were dard prospective follow-up protocol designed by
described in these patients, features that were the two doctors. Heart biopsy specimens were
not linked to ARVC until much later on. consistent with ARVC (Figure 1.6). Electro-
 The History of Naxos Disease: Landmarks in the History of the Disorder 5

A B

FIGURE 1.5 Two-dimensional echocardiographic images recorded from a patient with Naxos disease (Panel A). An
aneurysm of the RV outflow tract (white arrows) is exhibited by a modified parasternal long-axis view (Panel B). An
aneurysm of posterior wall of the RV just below the tricuspid valve (white arrows) is exhibited by a subcostal four-chamber
view. Abbreviations: LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract;
TV, tricuspid valve. (Figure reproduced from Protonotarios et al., J Am Coll Cardiol. 2001;38:1477–1484.2)

FIGURE 1.6 Hematoxylin-eosin stained section of the anterior wall of the RV shows fibrofatty replacement of cardiac
myocytes in the mediomural layers. (Figure reproduced from McKoy et al., Lancet. 2000;355:2119–2124.10)
6 Current Concepts in Arrhythmogenic Cardiomyopathy

physiological investigations had been performed disorder was named and first presented to an
in Guy’s Hospital, London and in Jean Rostand international audience. Names of diseases
Hospital, Paris by Dr. Guy Fontaine. should be short and easy to pronounce; both
It is a universal truth that life is mostly doctors were against the idea of giving one
unexpectable and inexplicable. A devastat- of their names to the disorder. They agreed
ing event in their family caused Drs. Protono- to “Naxos syndrome,” as they were confident
tarios and Tsatsopoulou to leave Athens. The that the people of Naxos would never misin-
city where they both had studied and worked terpret this nomenclature.
turned against them and became their nemesis. The key point of presentation in Warsaw
Moreover, no one among their peers within the was the co-segregation of cutaneous abnor-
Athenian academic community seemed to be malities with ARVC and the implication of
interested in supporting the studies of the new a common, potentially genetic mechanism
syndrome. They moved back to Naxos, where underlying the apparently different manifes-
they worked in private practice self-supporting tations of the skin and the heart. Drs. Proto-
their clinical investigations on families with notarios and Tsatsopoulou were always firm
the new syndrome. They also managed to in medically thinking, that “entities should
trace inheritance of the affected families 6 gen- not be multiplied without necessity”; in other
erations back, detecting relationships that con- words, all symptoms and signs of a patient’s
firmed the recessive type of inheritance. illness should be attributed to the same
pathogenetic background, unless proven oth-
Nomenclature and Genetic erwise.7 Hence, the Naxos syndrome would
Studies be an ideal model for linkage analysis and
identification of the pathogenic mutation.
The World Congress of Cardiomyopathies That was the basis for the fruitful collabora-
held in Warsaw at the end of September 1993 tion with Professor McKenna and the London
was a key occasion, as it was there that this group, which was initiated on the occasion

FIGURE 1.7 Scanned copy of the letter from Professor McKenna to Drs. Protonotarios and Tsatsopoulou following the initial
meetup in Warsaw in 1993 that set the basis for the further collaboration that led to the discovery of the variant causing
Naxos disease.
 The History of Naxos Disease: Landmarks in the History of the Disorder 7

of a Warsaw meeting in 1993 (Figure 1.7). a broad spectrum of the cardiomyopathy phe-
The project, apart from sampling the affected notype. The disease potential to affect the LV
persons, included screening of a large num- was also revealed; LV involvement detected on
ber of normal population and family mem- echocardiography was documented in 27% of
bers; people from Naxos and a nearby island, adult patients with Naxos disease.2 Overcom-
Milos, willingly participated. The gene locus ing conflicts and collaborating is always the
was mapped to 17q21.8 In the refined region key to enable scientists to work together to
of homozygosity delineating the disease locus, advance knowledge and discovery in the life
the gene for plakoglobin was located. sciences. Dr. Protonotarios’ priority was shar-
A defect in plakoglobin, a constituent pro- ing data, evaluating patients together with
tein of desmosomes and adherens junctions, other European experts in ARVC, and design-
might explain both skin and heart abnor- ing clinical collaborative studies. So, the clini-
malities since both tissues are subjected to a cal expression of PKP2 and JUP mutations was
constant mechanical stress. The fact that the studied in 187 mutation carriers.11 The two
keratoderma of palms and soles was becom- cardiac phenotypes proved to be quite similar,
ing apparent when the affected children apart from the depolarization changes being
started to use their hands and feet supported more common among patients with Naxos dis-
the candidacy of plakoglobin. Additionally, ease, i.e., JUP homozygotes. The same study
null plakoglobin mice showed heart and skin revealed the high sensitivity of precordial
abnormalities analogous to Naxos disease.9 repolarization changes and frequent ventricu-
Eventually, a deletion mutation, Pk2157del2, lar extrasystoles to clinically detect mutation
was identified to co-segregate with the dis- carriers while it showed the tendency of LV
ease. The mutant protein was also confirmed involvement in predisposing to SCD.11
in cardiac tissue, using a postmortem car- Immunohistology demonstrated gap
diac biopsy sample, by Western blot analysis junction remodeling in a collaborative study
using an antiplakoglobin antibody. The find- between Washington University in St. Louis,
ings were published in The Lancet in 2000.10 Missouri, Yannis Protonotarios Medical Cen-
The Naxos syndrome would ultimately be tre in Naxos, the University of Athens, the
renamed Naxos disease. It was the first time Heart Hospital in London, and Hôpital de la
that an inherited cardiac condition was attrib- Pitie Salpetriere in Paris. In that study, it was
uted to a defect in desmosomes. The identifi- also confirmed for the first time that myocar-
cation of the JUP mutation in Naxos ARVC dial gap junction remodeling might exist in
was a breakthrough in cardiomyopathies, ARVC even when no other abnormality on
since it paved the way for identification of gross pathology or histology can be detected.
other desmosomal mutations that underlie Furthermore, the abnormal distribution of
the most common nonsyndromic ARVC. plakoglobin was the only subcellular defect to
underlie the clinical appearance of frequent
Clinical Projects and ventricular ectopics that a child with Naxos
Collaborations cutaneous phenotype presented already at the
age of 5 years (Figure 1.8).12
In Naxos disease, the first genotype-phenotype The long and close clinical follow-up
study on ARVC was performed and published of families with Naxos disease and the exis-
in 2001.2 It was quite clear that Naxos ARVC tence of cutaneous characteristics from the
showed 100% penetrance by adolescence, first year of life permitted early identification
and as a recessive disorder, it was expressing of cardiac abnormalities and observation of
8 Current Concepts in Arrhythmogenic Cardiomyopathy

FIGURE 1.8 Histology of the heart showing panoramic transverse sections of the LV and RV, without evidence of fibrofatty
replacement (top). Representative confocal microscopy images of left ventricle from control and Naxos disease stained with
specific antibodies against selected intercellular junction proteins (bottom). Cx43 = connexin43. (Figure reproduced from
Kaplan et al., Heart Rhythm. 2004;1:3–11.11)

the way that the cardiomyopathy might ini- is increasingly recognized all over the world.
tiate and progress. Episodes with elevation Checking the patient’s hands, feet, and hair
of cardiac enzymes and documentation of besides a pure cardiac evaluation brings the
cardiac magnetic resonance late gadolinium patient’s care to an improved personalized
enhancement findings suggestive of myocar- level. A “hard” feeling while shaking hands
ditis were described as the first clinical pre- with a patient has been established as a warn-
sentation or inducing a hot phase in ARVC ing sign for an underlying arrhythmogenic
evolution.13,14 The reduced arrhythmic poten- cardiomyopathy, prompting a more detailed
tial that advanced ARVC with biventricu- cardiac evaluation of the patient.
lar dilatation and heart failure might show
was demonstrated in a patient with Naxos References
disease whose heart was also extensively
1. Protonotarios N, Tsatsopoulou A. Naxos dis-
evaluated by the top experts, the team of Pro-
ease and Carvajal syndrome: Cardiocutane-
fessors Gaetano Theine and Cristina Basso
ous disorders that highlight the pathogenesis
in Padua.15 and broaden the spectrum of arrhythmogenic
In this chapter, only the landmarks in the right ventricular cardiomyopathy. Cardio-
history of this disorder are described, which is vasc Pathol. 2004;13(4):185–194. https://doi.
part of the story. The Naxos syndromic asso- org/10.1016/j.carpath.2004.03.609.
ciation of arrhythmogenic cardiomyopathy 2. Protonotarios N, Tsatsopoulou A, Anastasa-
with woolly hair and palmoplantar keratoses kis A, et al. Genotype-phenotype assessment
 The History of Naxos Disease: Landmarks in the History of the Disorder 9

in autosomal recessive arrhythmogenic right 10. McKoy G, Protonotarios N, Crosby A, et al.

ventricular cardiomyopathy (Naxos disease) Identification of a deletion in plakoglobin
caused by a deletion in plakoglobin. J Am Coll in arrhythmogenic right ventricular cardio-
Cardiol. 2001;38:1477–1484. myopathy with palmoplantar keratoderma
3. Marcus FI, Fontaine GH, Guiraudon G, Frank and woolly hair (Naxos disease). Lancet.
R, Laurenceau JL, Malergue C, Grosgogeat Y. 2000;355:2119–2124.
Right ventricular dysplasia: A report of 24 adult 11. Antoniades L, Tsatsopoulou A, Anastasakis
cases. Circulation. 1982;65:384–398. A, et al. Arrhythmogenic right ventricular
4. Protonotarios N, Tsatsopoulou A, Patsoura- cardiomyopathy caused by deletions in pla-
kos P, Alexopoulos D, Gezerlis P, Simitsis S, kophilin-2 and plakoglobin (Naxos disease) in
Scampardonis G. Cardiac abnormalities in families from Greece and Cyprus: Genotype-
familial palmoplantar keratosis. Br Heart J. phenotype relations, diagnostic features and
1986;56:321–326. prognosis. Eur Heart J. 2006;27:2208–2216.
5. Thiene G, Nava A, Corrado D, Rossi L, Pen- 12. Kaplan SR, Gard JJ, Protonotarios N, et al.
nelli N. Right ventricular cardiomyopathy and Remodeling of myocyte gap junctions in
sudden death in young people. N Engl J Med. arrhythmogenic right ventricular cardiomyop-
1988;318:129–133. athy due to a deletion in plakoglobin (Naxos
6. Thiene G, Nava A, Corrado D, Rossi, L, disease). Heart Rhythm. 2004;1:3–11.
Pennelli N. Right ventricular cardiomyopa- 13. Mavrogeni S, Protonotarios N, Tsatsopoulou
thy and sudden death in young people [let- A, Papachristou P, Sfendouraki E, Papado-
ter]. N Engl J Med. 1988;319(3):174–176. poulos G. Naxos disease evolution mimicking
doi: 10.1056/NEJM198807213190312. acute myocarditis: The role of cardiovascular
7. Knowles E. The Oxford dictionary of phrase magnetic resonance imaging. Int J Cardiol.
and fable. New York: Oxford University Press, 2013;166:e14–e15.
2005. 14. Patrianakos AP, Protonotarios N, Nyktari E,
8. Coonar AS, Protonotarios N, Tsatsopoulou A, Pagonidis K, Tsatsopoulou A, Parthenakis FI,
et al. Gene for arrhythmogenic right ventricu- Vardas PE. Arrhythmogenic right ventricu-
lar cardiomyopathy with diffuse nonepider- lar cardiomyopathy/dysplasia and troponin
molytic palmoplantar keratoderma and woolly release. Myocarditis or the “hot phase” of the
hair (Naxos disease) maps to 17q21. Circula- disease? Int J Cardiol. 2012;157:e26–e28.
tion. 1998;97:2049–2058. 15. Basso C, Tsatsopoulou A, Thiene G, Anasta-
9. Ruiz P, Brinkmann V, Ledermann B, et sakis A, Valente M, Protonotarios N. “Petri-
al. Targeted mutation of plakoglobin in fied” right ventricle in long-standing Naxos
mice reveals essential functions of desmo- arrhythmogenic right ventricular cardiomy-
somes in the embryonic heart. J Cell Biol. opathy. Circulation. 2001;104:e132–e133.
1996;135:215–225.
 2
Metabolic Deregulation in Arrhythmogenic
Cardiomyopathy: Novel Pathogenic
Insights and Their Clinical Application

Shing Fai Chan, PhD; Liang Chen, MD, PhD; Chuan-yu Wei, PhD;
Jiangping Song, MD, PhD; Huei-sheng Vincent Chen, MD, PhD

Introduction Pathologies and

Pathogenic Mechanisms
Cardiovascular diseases remain the major
cause of death in the world.1 Recent advances of Arrhythmogenic Right
in cellular reprogramming of somatic cells2–4 Ventricular Cardiomyopathy
from patients with inherited heart diseases
(ARVC)
into induced pluripotent stem cells (iPSCs)
have enabled the generation of cardiomyo- ARVC is an inherited cardiomyopathy with
cytes (CMs) for myocardial repair5–7 and most identified mutations in genes that encode
in vitro modeling of human inherited car- cardiac desmosomes, which include plakoglo-
diac diseases.8–13 However, most published bin (JUP), plakophilin-2 (PKP2), desmoplakin
iPSC-based cardiac disease models showed (DSP), desmoglein-2 (DSG2), and desmocol-
rapid-onset pathologies and exaggerated lin-2 (DSC2).17–21 Pathological hallmarks of
arrhythmias, frequently occurring sponta- ARVC are progressive fibrofatty replacement
neously within 30 days in culture, that devi- of CMs with increased CM apoptosis primar-
ated greatly from the clinical course of these ily in the right ventricle (RV), leading to heart
cardiac diseases.14–16 Thus, there is a tremen- failure and/or lethal arrhythmias. Clinical cri-
dous need to develop more clinically relevant teria to diagnose ARVC are well established,22
iPSC-CM–based in vitro models for better but pathogenic mechanisms of ARVC are
pathogenic and therapeutic investigations. difficult to study because obtaining cardiac

Current Concepts in Arrhythmogenic Cardiomyopathy, Second Edition

© 2021 Corinna Brunckhorst, Ardan M. Saguner, Firat Duru, Editors. Cardiotext Publishing. ISBN: 978-1-942909-50-7 11
12 Current Concepts in Arrhythmogenic Cardiomyopathy

samples from early stages of human ARVC Moreover, using genetic fate mapping
hearts is rarely possible due to ARVC being techniques in mouse ARVC models, islet-1–
commonly diagnosed at advanced disease positive cardiac progenitor cells of the second
stages or postmortem. Additionally, primary heart field have been implicated as the source
cardiac tissues are difficult to biopsy safely of adipocytes in ARVC hearts.29 However, the
from symptomatic ARVC patients due to the incorrect use of activation of PPARγ and its
risk of cardiac perforation. These limiting fac- target genes as the markers for adipogenesis
tors impose significant constraints in develop- (adipocyte formation) likely accounted for
ing therapies for human ARVC. Currently, no this misleading interpretation.23,29 In fact,
pathogenesis-guided therapy is available to PPARγ and its target genes are normally acti-
curtail the progression of ARVC pathologies vated in several nonadipocyte tissues (e.g.,
except standard heart failure therapy, antiar- endothelial cells and macrophages)30 and
rhythmic medications and ablation to reduce could be abnormally activated by pathologi-
arrhythmia burden, and inserting implant- cal conditions in hepatocytes (obesity)31 and
able cardioverter defibrillators (ICDs) to pre- CMs (diabetic cardiomyopathy).32 Therefore,
vent sudden cardiac death (SCD).22 activation of PPARγ and its target genes indi-
How desmosomal mutations could cause cates the active “de novo lipogenesis (DNL)”
CM loss, fibrofatty infiltration, and lethal rather than cell transdifferentiation toward
arrhythmia remains poorly understood. adipocytes. More importantly, the proper lin-
Experimental data from animal and cultured eage marker to identify adipocyte formation
cell line models have led to confusing and (adipogenesis) is perilipin-1 (PLIN1) that is
conflicting results.23–28 Early experiments with only expressed in adipocytes.33 Also, mesen-
DSP knockdown in murine HL-1 atrial tumor chymal stromal cells (MSCs) isolated from
CMs and cardiac-specific DSP knockout (KO) human ARVC hearts have been shown to be
mice suggested that DSP deficits resulted in the true source of aggressive adipogenesis in
aggressive lipogenesis in CMs and nuclear ARVC hearts.34 In addition, aggressive fibro-
translocation of plakoglobin proteins (JUP). sis is found in most ARVC hearts and cardiac
This abnormal JUP nuclear localization was MSCs are also the main source for aggressive
suggested to compete with and decrease the fibrosis in pathological hearts.35 Thus, the key
binding of β-catenin to the TCF/LEF tran-
pathogenic mechanism for exaggerated adip-
scription factor complexes (gain of function
ogenic and/or fibrogenic potential of ARVC
hypothesis), leading to low β-catenin activities
MSCs remains unresolved.
and adipogenic transdifferentiation of CMs.23
However, the majority of human ARVC heart
tissues demonstrated significant downregula-
Establishing iPSCs from
tion of JUP without abnormal nuclear trans- Patients with Clinical ARVC
location,24,25 and cardiac-specific KO of JUP and Desmosome Gene
can reproduce ARVC pathologies in mouse
hearts,26,27 indicating that loss of JUP function,
Mutations
rather than JUP competition with β-catenin, To further explore the pathogenic mecha-
is responsible for eliciting ARVC patholo- nisms of human ARVC hearts, we first gener-
gies.28 Moreover, JUP overexpression can res- ated and fully characterized two sets of ARVC
cue ARVC heart pathologies with JUP deficits, PKP2 mutant iPSC lines from two unrelated
further supporting that loss of JUP function is ARVC patients.11 The first ARVC patient has
the pathogenic mechanism for ARVC hearts.28 homozygous PKP2 c.2484C>T mutations36
 Metabolic Deregulation in Arrhythmogenic Cardiomyopathy 13

with frame-shifted C-terminals that fail to published in detail.38 PPARγ is the major tran-
anchor JUP (JK lines), and the other has a het- scriptional regulator of fatty-acid metabolism
erozygous PKP2 c.2013delC mutation (delC in normal adult CMs.40 In contrast, PPARγ
lines) that causes premature termination should be minimally activated in normal
codons (leading to a PKP2 haplo-insufficiency CMs. However, the PPARγ pathway has been
phenotype).37 We also generated several iPSC reported to be abnormally hyperactivated
lines from normal subjects (CF and WS lines) in RV tissue samples of ARVC hearts,41 and
without any known cardiac disease. First, we transgene-induced overexpression of PPARγ
find that abnormal nuclear translocation of in mouse CMs could lead to dilated cardi-
JUP occurred only in the ARVC iPSC-CMs omyopathy.42 As such, we added to 3F either
contacting the rigid plastic culture surface an endogenous PPARγ agonist 13-hydroxyoc-
(> 6 gigapascal), indicating that apparent ta-decadienoic acid (13-HODE, termed 3F+13
JUP nuclear localization is a culture-induced HODE) or two strong PPARγ chemical activa-
phenomenon and not a clinically relevant tors (5F protocol = 3F + 5 µM indomethacin
pathological finding.38 We also find that low and 200 µM rosiglitazone) to activate PPARγ
β-catenin activity in both PKP2 mutant ARVC after inducing FAO-dependent metabo-
iPSC-CMs at baseline is insufficient for gen- lism. We found that mutant ARVC iPSC-
erating ARVC pathologies. Moreover, we did CMs manifested ARVC pathologies only
not observe any CM transdifferentiation from after induction of adult-like metabolism and
human ARVC iPSCs in any culture condi- abnormal activation of the PPARγ pathway.
tion. These results are consistent with the loss- Coactivation of normal PPAR and abnor-
of-function role of JUP in the pathogenesis of mal PPARγ pathways resulted in exaggerated
ARVC hearts.28 We now have generated iPSC- lipogenesis, apoptosis, further Na+ channel
CM with mutations in DSP or DSC2 respec- downregulation,11,43 and defective intracellular
tively for further pathogenic studies. calcium (Ca2+) handling capability in ARVC
iPSC-CMs, recapitulating the pathological
Metabolic Maturation-based signatures of ARVC (Figure 2.1 and see Refer-
Pathogenic Induction of ence 11), which could be prevented by PPARγ
antagonists or overexpression of wildtype
ARVC Pathologies (WT) PKP2 in ARVC iPSC-CMs.11
The major metabolic differences between Moreover, based on our functional assays
embryonic and adult CMs are (1) embryonic using the Seahorse XF96 Extracellular Flux
CMs use mainly glycolysis and lactate for Analyzer, we observed that the absolute levels
energy production, and (2) adult CMs produce of FAO in ARVC iPSC-CMs are always 1.5-
most energy via fatty-acid oxidation (FAO) but to 2-fold higher than those of normal iPSC-
retain the ability to readily switch to glucose CMs after 3F metabolic maturation induction
or other substrate utilization when fatty acid (Figure 2.2). This higher FAO flux in ARVC
is not available or FAO is compromised.39,40 iPSC-CMs might explain why many patients
We first developed a 3-factor (3F) protocol with desmosomal mutations participated and
[steroid, insulin, and 3-Isobutyl-1-methylxan- excelled in endurance sports at younger ages
thine (IBMX)] to induce PPARα-dependent, prior to the pathological processes that kicked
adult-like metabolism of cultured iPSC-CMs in at adulthood. However, endurance exer-
with significant capacity of FAO but no ARVC cises are known to accelerate the pathological
pathology. The rationales for designing this phenotypes of ARVC.44 The elevated cyclic
3F metabolic induction protocol had been adenosine monophosphate (cAMP) levels
14 Current Concepts in Arrhythmogenic Cardiomyopathy

FIGURE 2.1 Metabolic maturation and pathogenic induction of ARVC iPSC-CMs and potential therapeutic strategies.
Panel A: Protocols for metabolic maturation (3F) and pathogenic (5F) induction. Panel B: 3F induced PPARa expression
and 5F induced abnormal PPAR activation only in ARVC iPSC-CMs (relative to GAPDH by quantitative RT-PCR). Panels C
and D: Degrees of CM apoptosis (TUNEL-positive, Panel C) and percentage of lipid-laden (Nile-red positive, Panel D) CMs
after 0F (Con), 3F, or 5F treatment for 4 weeks. Panels E and F: Summary of (Panel E) degrees of apoptosis and (Panel F)
lipid-laden CMs in beating embryoid bodies (EBs) is shown here. 13-HODE can replace the indomethacin and rosiglitazone in
the 5F protocol to induce ARVC pathologies, which could be prevented by PPAR antagonists, 3 µM GW9662 (GW), or 0.5 µM
T0070907 (T007); ROS scavengers, 1 mM N-acetyl-cysteine (NAC), or ascorbic acid (AA; Panel G); or scaling down FAO by
2 µM Etomoxir (ETO) or 5 µM 4-bromocrotonic acid (4-BCA; Panel H). The number in each column represents the number of
biological replicates tested. Asterisks indicate P < 0.05 and NS, no significant difference by analysis of variance (ANOVA). All
data are shown as mean ± SEM. (This figure is adapted from Kim et al., Nature. 2013;494:105–110.11)

from the continuous presence of IBMX in our result strongly supports the use of β-blockers
3F or 5F protocols likely simulate endurance and the recommendation of avoidance of
exercise in real life. We therefore hypoth- endurance or competitive sports22 so as to
esized that this high FAO flux might also reduce the metabolic flux and the progression
account for the high reactive oxygen species of ARVC phenotypes.
(ROS) production in ARVC iPSC-CMs and
is required to drive them toward the apoptotic Plasma β-OHB Levels Predict Adverse
state after PPARa/PPARγ coactivation. As Outcomes and Pathological Disease
such, we toned down FAO hyper-flux by add- Progression in ARVC
ing an EC50 dose of either etomoxir (ETO,
to block CPT-1) or 4-bromocrotonic acid The onset of clinical symptoms/signs of ARVC
(4BCA, to block β-oxidation), which reduced is usually unpredictable. The clinically con-
CM apoptosis (Figure 2.1, Panel H). This cealed phase of ARVC, even in individuals
 Metabolic Deregulation in Arrhythmogenic Cardiomyopathy 15

FIGURE 2.2 Functional assays of glucose utilization versus FAO in PKP2 mutant iPSC-CMs after various treatments. Using
a Seahorse XF96 Extracellular Flux Analyzer, we determined the degree of FAO by measuring the etomoxir (100 µM ETO, a
specific CPT-1 inhibitor) blocked components of OCR, and glycolysis by measuring 2-deoxyglucose (50 mM 2-DG) blocked
components of ECAR (see Reference 11 for detailed methods). Absolute values of OCR and ECAR are expressed as pmol/
min/106 cells and mpH/min/106 cells, respectively. Panel A: Real-time measurement of OCR showed that ETO blocked 14.4
± 10.2 (0F), 53.9 ± 8.2 (3F), and 15.3 ± 8.5% (5F) of baseline OCR (red arrow) for ARVC iPSC-CMs. Panel B: ETO-blocked
absolute OCR (white boxes) for ARVC iPSC-CMs are 85.2 ± 196.6 (0F), 1865.3 ± 383.5 (3F), and 254.5 ± 115.4 (5F).
Panel C: ECAR measurement after ETO inhibition of β-oxidation showed a rapid ~21% compensatory increase of glycolysis
only in the 3F condition (a switch in energy substrates); yet, after 5F, ETO transiently decreased ECAR by ~45% (green arrow)
followed by ~28% compensatory increase in ECAR (glycolysis). Panel D: 2DG-blocked absolute ECAR (glycolysis) for ARVC
iPSC-CMs after 0F, 3F or 5F are 1353.0 ± 313.6, 1766.0 ± 579.7, and 457.2 ± 211.0, respectively. Comparable patterns in
absolute and relative OCR or ECAR in normal hS-iPSC-CMs (WS#4) are shown (Panel E–H). For normal iPSC-CMs, ETO-
blocked FAO after 0F, 3F, or 5F are (Panel E) (relative) 21.8 ± 24.8%, 42.6 ± 6.6%, and 50.5 ± 4.06%; or (Panel F) (absolute)
329.4 ± 235.8, 1114.5 ± 316.6, and 807.8 ± 196.4, respectively. 2DG-blocked glycolysis after 0F, 3F, or 5F are (Panel G)
(relative) 65.5 ± 5.3%, 54.9 ± 3.8%, and 58.8 ± 4.8%; or (Panel H) (absolute) 915.3 ± 270.6, 929.4 ± 314.3, and 556.8
± 217.9, respectively. Panel I: A simple diagram to illustrate substrate utilization pathways in CMs. These results (Panels
A–H) support that both normal and ARVC iPSC-CMs 1) display embryonic metabolism at baseline, and 2) show significantly
increases FAO after 3F with ability to switch between FAO and glucose utilization (an adult-like metabolic pattern). ARVC iPSC-
CMs after 5F behave like failing CMs with pathological burnt-out metabolism. Single asterisk indicates p < 0.05 and NS, no
significant difference by ANOVA. P values are shown when unpaired t-test was performed. (This figure is adapted from Kim et
al., Nature. 2013;494:105–110.11)
16 Current Concepts in Arrhythmogenic Cardiomyopathy

with known mutations, could last 20 to 40 intermediate pathological stage when CMs
years, and some patients’ relatives could be started showing apoptosis and impaired FAO
asymptomatic carriers. Unfortunately, SCD at 2.5 weeks (Figure 2.3, Panels C and D).
could be the first symptom of patients with Seahorse metabolic assays showed that ARVC
ARVC. The progression of ARVC is not pre- iPSC-CMs at 2 weeks after pathological
dictable and could have flares of “hot” phases induction already displayed decreased over-
with malignant ventricular arrhythmias (VAs) all oxidative phosphorylation, and at 4 weeks
and heart failure.17–22 Thus, establishing a of pathological induction they had very low
biomarker for early diagnosis and better risk long-chain fatty acid (LCFA) oxidation with
stratification45 of ARVC patients and their rel- increased utilization of other metabolic sub-
atives46 is quintessential for preventing SCD strates for oxidative phosphorylation (Figure
in patients with ARVC. Current diagnosis 2.3, Panels C and D). The ketogenesis process
and risk stratification have focused largely on after 2 weeks of 5F treatment was significantly
clinically detectable changes in arrhythmia diminished owing to the decreased FAO of
burden and abnormalities of cardiac struc- LCFA shown by Seahorse metabolic assays.
ture and function.45–47 Serum markers, such The results in Figure 2.3 support that
as C-reactive protein and N-terminal pro-B ARVC CMs likely are ketogenic from high
type natriuretic peptide, have been reported FAO at early prepathological stages in vitro.
to associate with ARVC. However, these Thus, we measured the plasma β-OHB lev-
serum markers are routinely used for general els of the first- and second-degree relatives
evaluation of cardiac dysfunction and are not of 65 ARVC probands. We classified ARVC
specific for ARVC or predictive of malignant probands’ relatives who had syncope or were
arrhythmias in patients with ARVC.48,49 positive for at least one of the ARVC Task
Since ARVC iPSC-CMs displayed higher Force Criteria (TFC) in echocardiography
levels of FAO than normal iPSC-CMs (Fig- or electrocardiography (ECG) studies as sus-
ure 2.2) at mature and prediseased states, pected ARVC relatives or early-phase patients
we hypothesized that metabolic markers of (n = 25). We found that plasma β-OHB levels
increased FAO in early-stage ARVC hearts of suspected ARVC relatives are higher than
may provide clues for early diagnosis of ARVC those of unaffected relatives (n = 69; fold
and that markers of FAO-related metabolic change = 1.52, P < 0.001; Figure 2.4, Panel
abnormalities may be used as predictors for A), whereas unaffected relatives had the same
adverse disease progression of ARVC hearts. plasma β-OHB levels as healthy volunteers.
Because ketone production and utilization are A receiver-operating characteristic (ROC)
closely associated with high FAO and extra- curve analysis showed that plasma β-OHB
hepatic lipogenesis,50 we measured β-hydrox- could distinguish suspected ARVC relatives
ybutyrate (β-OHB, a major form of ketones in from unaffected relatives with a sensitivity
human plasma) concentrations from culture of 56.00% and a specificity of 93.94% using a
media and CM lysates of ARVC iPSC-CMs cutoff value of 30.76 M (AUC = 0.783, P <
after 3F metabolic maturation induction 0.001). Thus, plasma β-OHB levels could be
and 5F pathological induction (Figure 2.3, used as an early diagnostic marker of adverse
Panels A and B).51 The assays demonstrated disease progression in relatively asymptomatic
a significant increase in β-OHB production ARVC relatives with excellent specificity.
from pathological ARVC CMs and release We next investigated whether the pres-
into culture medium at early stages (1 week, ence of heart failure or history of arrhyth-
P < 0.05) and returned to baseline levels at an mia correlated with plasma β-OHB levels in
 Metabolic Deregulation in Arrhythmogenic Cardiomyopathy 17

FIGURE 2.3 Increased ketone (β-OHB) production (ketogenesis) with high FAO at early stages, and later decreased FAO with
no more ketone production at intermediate to advanced stages after pathogenic induction by 5F in ARVC CMs, is presented.
ARVC iPSC-CMs treated with 5F showed increased β-OHB levels in both culture media (Panel A) and CMs (Panel B) at 1–2
weeks, preceding the irreversible ARVC pathologies at 2.5–4 weeks. Panel C: Using real-time Seahorse XF96 metabolic
flux measurement, 5F treated ARVC iPSC-CMs at 2 weeks show decreased overall oxidative phosphorylation, and the small
compensatory increases of OCR after ETO and 2-DG treatment indicate the compensatory increases in utilization of other
metabolic substrates for oxidative phosphorylation. Panel D: 5F treated ARVC iPSC-CMs at 4 weeks are at a metabolic burnt-
out state and rely on other metabolic substrates for oxidative phosphorylation. (This figure is adapted from Kim et al., Nature.
2013;494:105–11011 and Song et al., Sci Transl Med. 2020;12:eaay8329.51)

patients with ARVC. In 65 ARVC probands, results support that plasma β-OHB levels in
plasma β-OHB levels of patients with biven- patients with ARVC are elevated early and
tricular heart failure (n = 12), with isolated before RV or left ventricular (LV) failure
RV failure (n = 30), or with only VAs (n = 23) and that elevation of plasma β-OHB levels is
are higher than those of 56 healthy volun- not a compensatory response of heart failure
teers (Figure 2.4, Panel B). Thirty-four of 65 but rather a specific metabolic signature in
ARVC patients had major adverse cardiovas- patients with ARVC. Thus, plasma β-OHB
cular events (MACE), defined as those who levels in patients with ARVC and their rela-
had syncope, sustained VA, appropriate ICD tives might be an early biomarker of adverse
shocks, or heart transplant (HTx), and their pathological progression in ARVC. To
plasma β-OHB levels are higher than those of explore whether plasma β-OHB levels could
ARVC patients without MACE (Figure 2.4, serve as an indicator of disease progression
Panel C). Of note, no cardiac dysfunction- over the entire ARVC disease spectrum, we
dependent elevation of β-OHB was observed categorized ARVC pathological progression
(see Reference 51 for detailed data). These and corresponding plasma β-OHB levels into
18 Current Concepts in Arrhythmogenic Cardiomyopathy

FIGURE 2.4 Plasma β-OHB levels rise with the adverse progression of the ARVC pathological processes. Panel A: Plasma
β-OHB levels are higher in ARVC relatives with some ARVC diagnostic criteria than those of completely unaffected relatives.
Panel B: In general, ARVC probands have higher plasma β-OHB levels than healthy controls. Panel C: In ARVC probands,
patients with major adverse cardiac events (MACE) have higher plasma β-OHB levels than probands without MACE.
Panel D: Progressive increases in plasma β-OHB levels stratified by five progressively worsening stages of ARVC according
to clinical presentation and MACE events [unaffected relatives, suspected ARVC, ARVC without MACE, ARVC with MACE, and
ARVC patients requiring HTx].

5 progressively worsening stages according the disease (Figure 2.4, Panel D), supporting
to clinical presentation and MACE events, that progressively rising plasma β-OHB lev-
from completely unaffected relatives (24.04 els in patients with ARVC and their relatives
± 2.00 M, n = 69), suspected ARVC (36.47 indicate underlying adverse disease progres-
± 2.98 M, n = 25), early ARVC [ARVC sion. Thus, we demonstrate that cardiac keto-
patients without MACE (35.48 ± 4.11 M, genesis occurs in early ARVC CMs. Plasma
n = 31)], advanced ARVC [ARVC probands β-OHB levels could be used as a potential
with MACE but no need for HTx, 89.82 ± biomarker to predict not only MACE in
.43 M, n = 26], to end-stage ARVC who ARVC probands but also disease progression
received HTx during follow-up (165.60 ± in ARVC patients and their family members,
30.23 M, n = 21). Plasma β-OHB levels particularly useful for individuals at the con-
increased progressively with the severity of cealed phase.
 Metabolic Deregulation in Arrhythmogenic Cardiomyopathy 19

Distinct Metabolic Phenotypes an adult-onset cardiac disease. We demon-

of Immature, Mature, and strate the importance of PPAR-dependent/
Pathological ARVC CMs adult-like metabolism, PPARγ coactivation,
ROS production, and high flux of fatty acid
Using the Seahorse XF96 Extracellular Flux oxidation in the pathogenesis of ARVC.11 This
Analyzer,52 functional assays of FAO and gly- efficient in vitro iPSC-CM–based model
colysis in live cells revealed that normal and recapitulates the pathognomonic features of
ARVC iPSC-CMs had dominant glycolytic ARVC hearts and enables pathogenic inves-
energetics (an embryonic pattern) at baseline tigation and therapeutic screens. Future
(Figure 2.2, Panels A–H). After activation research to elucidate how mutant PKP2 leads
of PPAR by 3F, mutant and normal iPSC- to abnormal PPARγ activation in ARVC CMs
CMs displayed slightly higher levels of gly- would further deepen our understanding of
colysis but significant activation of FAO (an this unfortunate disease and pave the way for
adult-like pattern) when compared to the developing novel therapeutics.
un-induced, baseline conditions [zero factor Furthermore, we observed increased keto-
(0F)]. Compared to 3F induction, mutant genesis in early ARVC CMs that could be used
PKP2 iPSC-CMs treated with 5F for 4 weeks, to diagnose adverse pathological progression
demonstrated overall depressed energy of ARVC relatives in the fairly asymptomatic
metabolism with more FAO reduction (from stages. More importantly, we find that plasma
using LCFA) than the reduction in glycoly- β-OHB levels in ARVC probands correlate
sis, resulting in a fuel shift from using both well with the adverse disease progressions.
fatty acids and glucose to primarily glucose Finally, metabolic and metabolomic assays
utilization (including glycolysis and pyru- show that both end-stage explanted ARVC
vate oxidation) and other substrate oxidation, hearts and pathological ARVC iPSC-CMs are
much like the so-called metabolic burnt-out in a metabolic burnt-out state with MCFAs
state observed in failing hearts (Figure 2.5).53 as the main energy fuel. Thus, using in vitro
More importantly, our metabolomic analysis51 iPSC-CM model and in vivo explanted ARVC
indicates that the end-stage ARVC human diseased hearts, we reveal that metabolic
hearts depict impaired LCFA utilization and derangement is the main pathogenic mecha-
elevated utilization of medium-chain fatty nism of ARVC hearts. Future prospective
acid (MCFA) without increased ketone utili- clinical trials using plasma β-OHB (ketones)
zation, an unique metabolic pattern that dif- levels to diagnose adverse disease progression
fers from metabolic burnt-out phenotypes in in asymptomatic ARVC relatives, and ARVC
other types of dilated cardiomyopathy.51 probands are needed to support our patho-
genic findings and to confirm the usefulness
Conclusions and Future of plasma β-OHB (ketones) levels as the diag-
Perspective nostic marker for adverse disease progression
in ARVC. Also, we must devote effort and time
Using patient-specific mutant PKP2 iPSC- into studying the mechanisms of CM matura-
CMs grown in a 3D beating EB format and tion so as to build better and more clinically
induced by various maturation/pathogenic relevant in-vitro models before an applicable
conditions, we accelerate the pathogenesis of therapeutic screen can be pursued.
20 Current Concepts in Arrhythmogenic Cardiomyopathy

FIGURE 2.5 Summary scheme for ketone body metabolism and metabolic deregulations in early and advanced stages of
ARVC. In early or relatively asymptomatic stages of ARVC, ARVC CMs are ketogenic and producing β-OHB that could be used
to diagnose adverse disease progression in ARVC relatives. In the intermediate and late stages of ARVC, ARVC CMs show
decreased FAO and no ketone production, leading to progressive accumulation of plasma ketones (produced by the liver)
that could be used to predict MACE in ARVC probands.
 Metabolic Deregulation in Arrhythmogenic Cardiomyopathy 21

Acknowledgments 9. Itzhaki I, Maizels L, Huber I, et al. Modelling

the long QT syndrome with induced pluripo-
We thank the patients for their participa-
tent stem cells. Nature. 2011;471:225–229.
tion, microarray core facilities at Sanford- 10. Moretti A, Laugwitz KL, Dorn T, Sinnecker
Burnham-Prebys Medical Discovery Institute D, Mummery C. Pluripotent stem cell models
(SBP) for their support, the Johns Hopkins of human heart disease. Cold Spring Harbor
ARVC registry for their valuable support, and Persp Med. 2013;3(11).
George W. Rogers from Seahorse Bioscience 11. Kim C, Wong J, Wen J, et al. Studying arrhyth-
for assistance in metabolic assays. Huei-sheng mogenic right ventricular dysplasia with
Vincent Chen was supported by grants from patient-specific iPSCs. Nature. 2013;494:105–
the National Institutes of Health and Kran- 110.
nert Institute of Cardiology Start-up Funds. 12. Mercola M, Colas A, Willems E. Induced
The authors report no conflicts of interest pluripotent stem cells in cardiovascular drug
discovery. Circ Res. 2013;112:534–548.
in relation to this article.
13. Shinnawi R, Gepstein L. iPSC cell modeling
of inherited cardiac arrhythmias. Curr Treat
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 3

Pleiotropic Functions of Plakophilin-2 and

Arrhythmia Mechanisms

Marina Cerrone, MD; Chantal J. M. van Opbergen, PhD;

Mario Delmar, MD, PhD

Introduction strate, with the gene PKP2, coding for pla-

kophilin-2 (PKP2), being the most commonly
Arrhythmogenic cardiomyopathy (ACM, also involved.6,7 Desmosomal proteins have a clear
referred to as arrhythmogenic right ventricular role in cell–cell adhesion; hence it has been
cardiomyopathy, or ARVC) is an inheritable postulated that defective desmosomes could
condition characterized by a fibrofatty infiltra- promote fibrosis by weakening intercellular
tion of the heart muscle, as well as increased adhesion strength between cardiomyocytes
risk of ventricular arrhythmias (VAs) and (CMs).8,9 However, this hypothesis could not
sudden cardiac death (SCD).1–3 The disease easily justify some other aspects of ACM, such
phenotype progresses over time, with lethal as the known adipose infiltration of the car-
arrhythmias often observed in the early stages diac tissue or the arrhythmogenic phenotype
before the onset of the cardiomyopathy. The observed in the precardiomyopathic stages.
structural disease most commonly (though Recent data from our group and others10–12
not always) starts in the right ventricular (RV) have shown that defective or deficient PKP2
free wall, later involving the left ventricle in the context of ACM can alter multiple
(LV) and ultimately resulting in biventricular molecular pathways and lead to transcrip-
heart failure.1,3 Its prevalence is estimated at tional modifications, thus encompassing a
around 1:2000–1:5000 and it is considered wider spectrum of functions in addition to
one of the predominant causes of unexpected the one related to cell–cell adhesion. In this
SCD in athletes.4,5 Mutations in genes coding chapter we will review the pleiotropic aspects
for cardiac desmosomal proteins account for of PKP2 loss at the molecular level and their
most familial cases with known genetic sub- relation to the ACM phenotype.

Current Concepts in Arrhythmogenic Cardiomyopathy, Second Edition

© 2021 Corinna Brunckhorst, Ardan M. Saguner, Firat Duru, Editors. Cardiotext Publishing. ISBN: 978-1-942909-50-7 25
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is a counsel of perfection to suggest providing against contingencies
on this lavish scale; but it is well to bear in mind the ideal. And there
is, besides, a precaution which surely can and will be taken: to take
a supply of oxygen for restorative purposes. The value of oxygen for
restoring exhausted and warming cold men was sufficiently well
illustrated during the second attempt in 1922.
 Chang La and North-east Shoulder of Mount Everest

The question as to whether the use of oxygen will otherwise help

or hinder climbers is one about which opinions may be expected to
disagree. Anyone who thinks that it is impossible to get up without
oxygen can claim that nothing has shown it to be impossible to get
up with its aid. For my part, I don’t think it impossible to get up
without oxygen. The difference of atmospheric pressure between
27,000 feet and the summit is small, and it is safe to conclude that
men who have exerted themselves at 27,000 feet could live without
difficulty for a number of hours on the summit. As to whether their
power of progress would give out before reaching 29,000 feet, it is
impossible to dogmatise. I can only say that nothing in the
experience of the first attempt has led me to suppose that those last
2,000 feet cannot be climbed in a day. I am not competent to sift
and weigh all the evidence as to whether, how much, and with what
consumption of gas it was easier to proceed up the slopes of Mount
Everest with oxygen so far as Finch and Bruce went on that
memorable day. But I do venture to combat the suggestion that it is
necessarily easier to reach the top in that manner. I think no one will
dispute the statement that the final camp for the second attempt
was too low, as it had been for the first, to enable the oxygen party
to reach the summit. With the same apparatus it will be necessary in
this case also to provide a second camp above the North Col. And
the question for the moment will ultimately be, is it possible to add
to that immense burden of transport to 27,000 feet the weight of the
oxygen cylinders required?
The weather in all probability will have something to say to this
problem. The Expedition of 1922 was certainly not favoured by the
weather. There was no continuous spell of calm fine days, and the
summer snows began a week earlier than the most usual date. One
wonders what sort of weather is to be expected with the most
favourable conditions on Mount Everest. It is conceivable that a
series of calm fine days sometimes precede the monsoon. But when
we consider the perpetual winds of Tibet at all seasons, it seems
unlikely that Mount Everest is often immune from this abominable
visitation. It is far more likely that the calm day is a rare exception,
and only to be expected when the north-westerly current is
neutralised by the monsoon from the South-east. The ill-luck of 1922
may probably be computed as no more than those seven days by
which the monsoon preceded expectation. With so short a time for
preparations and advance, we were indeed unfortunate in meeting
an early monsoon. And it is hardly possible considerably to extend
the available time by starting earlier. There was only the barest
trickle of water at the Base Camp on May 1, 1922, and the
complications involved by the necessity of melting snow for water,
both here and at all higher stages, for any considerable time, would
be a severe handicap. But it must be remembered that the second
attempt was made a week before the monsoon broke. Time
appeared short on the mountain chiefly from the threat of bad
weather and the signs showing that the majority of days were, to
say the least, extremely disagreeable for climbing high on the
mountain. If others are confronted by similar conditions, they too
will probably feel that each fine day must be utilised and the attack
must be pressed on; for the fine days past will not come back, and
ahead is the uncertain monsoon.
A final question may now be asked: What advantages will another
Expedition have which we did not have in 1922? In one small and in
one large matter the next Expedition may be better equipped. It was
disappointing, after so much time and thought had been expended
upon the problem of foot-gear, that nothing was evolved in 1922
which succeeded in taking the place of Alpine boots of well-known
patterns. The great disadvantage of these sorts of boot is that one
cannot wear crampons with them at these high altitudes, for the
strap bound tightly round the foot will almost certainly cause
frostbite; either different boots or different spikes must be invented
if the climbers are to have crampons or their equivalent. It is
essential that they should be so equipped to avoid the labour of
step-cutting, and the lack of this equipment might well rob them of
victory on the steep final slopes below the summit. This matter of
foot-gear is not so very small, after all. But a still more important
one is the oxygen apparatus. It is conceivable, and I believe by no
means unlikely, that a different type of cylinder may be used in the
future, and capable of containing more oxygen, compared with the
same weight, than those of 1922. A 50 per cent. improvement in this
direction should alter the whole problem of using oxygen. With this
advantage it might well be possible to go to the top and back with
the four cylinders which a man may be expected to carry from a
height of 25,000 feet or little higher. If a second camp above the
North Col becomes unnecessary in this way, the whole effort
required, and especially the effort of transport, will be reduced to
the scale of what has already been accomplished, and can no doubt
be accomplished again.
The further advantage of a future Expedition is simply that of
experience. It amounts to something, one cannot say how much. In
small ways a number of mistakes may be avoided. The provision of
this and that may be more accurately calculated according to tried
values. The whole organisation of life in high camps should be rather
more efficient. Beyond all this, the experience of 1922 should help
when the moment comes towards the making of a right plan; and a
party which chooses rightly what to do and when to do it, and can
so exclude other possibilities as to be certain that no better way
could be chosen, has a great advantage. But, when all is said as to
experience and equipment, it still remains true that success requires
a quality. History repeats itself, perhaps, but in a vague and general
fashion only where mountains are concerned. The problem of
reaching the summit is every time a fresh one. The keen eye for a
fair opportunity and resource in grave emergencies are no less
necessary to the mountaineer everywhere, and not least upon Mount
Everest, than determination to carry through the high project, the
simple will to conquer in the struggle.
 NOTES
By
T. HOWARD SOMERVELL
on

ACCLIMATISATION AT HIGH
ALTITUDES
COLOUR IN TIBET
TIBETAN CULTURE
 CHAPTER XII

ACCLIMATISATION AT HIGH ALTITUDES

The Everest Expedition of 1922 had no preconceived programme

of scientific investigation, and was first and foremost an attempt to
get up the mountain; though, as I had been connected with
physiological research for some years, I was naturally anxious to
make observations on the effect of altitude on the human frame.
These observations were rather subjective, and were
unaccompanied by any accurate data—in other words, the reader
will be relieved to hear that there are no tables of figures to be
reproduced. Barcroft and others were in the course of their
Expedition to the Andes, and I knew full well their results would
supply more accurate information on the exact process of
acclimatisation at high altitudes than anything we could do with our
simpler apparatus. We left it to this other Expedition, therefore, to
supply the figures, while our observations were exclusively on the
practical side; that is to say, we observed the rapidity and effect of
acclimatisation, while not investigating exactly how it is brought
about.
The first effect of altitude, in such moderate degree as we
encountered it on the plains of Tibet, was almost entirely a mere
breathlessness, which limited our rate of walking, and increased the
popularity of our uncomfortable Tibetan saddles when travelling
uphill. A few of us had severe headaches from time to time; at the
modest height of 17,000 feet I noticed Cheyne-Stokes respiration at
night when lying down, though never when sitting or standing; and I
remember being distinctly amused at the fact that one was unable to
control it.[7] A few of the party had a single attack of vomiting, but
no permanent effect was noticed, and by the time we had lived on
the Tibetan Plateau for a few weeks we had lost all ill effects save
only breathlessness, which, of course, persisted to some extent until
we reached comparatively low elevations. Further effect at these
heights was not noticed save in the case of some of the older
members of the party, who suffered from a considerable loss of
appetite while at the Base Camp at 16,000 feet; this effect on
appetite did not improve as time went on.
7. For the benefit of the non-medical reader, Cheyne-Stokes breathing is the
gradual alternation of shallow and deep respirations: usually about ten
shallow breaths are followed by respirations which get gradually deeper;
then by three or four really deep ones, which become shallower until the
cycle recommences.
It was when we began the more serious work on the mountain
that we made the most interesting observations on acclimatisation,
and proved both its rapidity (which was known before) and its
persistence to great heights. Scientists of various schools had,
before the start of the Expedition, predicted that acclimatisation
would be impossible above the height of 20,000 feet. Why they had
done so will always remain a mystery to me; but possibly they were
misled by the fact that so many climbing expeditions in the past
have failed somewhere in the region of 23,000 feet above sea-level.
We were enabled, however, to prove conclusively that acclimatisation
does go on to greater heights; in fact, I do not see a theoretical limit
to it at any elevation below the top of Mount Everest. Our
observations were largely subjective, but for that reason they are
perhaps all the more to be appreciated by the general reader; and in
view of their subjective nature I may perhaps be pardoned in
substituting “feelings” for figures and putting information in the form
of a personal experience.
When Mallory and I arrived at Camp III and established it on the
site chosen by the reconnaissance party, our first concern was the
preparation of another camp at the North Col. I shall never forget
our first ascent up that accursed slope of snow and ice, each step a
hardship, every foot a fight; until at last we lay almost exhausted on
the top. After a day or two at Camp III below, we went up again to
the col, this time with Strutt and Morshead, and I think Norton. The
ascent of the col this time was hard work, but not more than that;
and after the col had been reached Morshead and I were sufficiently
cheerful to explore the way leading up to Everest. A day or two later
we again ascended the North Col, and never really noticed more
discomfort than was occasioned by breathlessness. Though not
possessing the scientific data which explained this change in our
condition, yet in those few days of life at 21,000 feet we had
become acclimatised to our altitude to a very remarkable degree;
what had previously been a hard struggle had now become a
comparatively easy job. By this rapid change in our constitution we
had not only proved the predictions of scientists to be wrong, but
had gained the physical power which took us without artificial
oxygen supply to 27,000 feet, and we had determined that
acclimatisation is not only possible but is also quite rapid at these
high altitudes.
Thus, by sojourn and exercise for a week above 20,000 feet, we
obtained the physiological equipment necessary for an attempt on
the mountain, and at this point some personal experiences may be
of interest, though possibly of no great importance. We found that,
as we ascended, we fell into an automatic rate of breathing; Mallory
preferred to breathe slowly and deeply, while rapid and shallower
respirations appealed to me; but we all walked upwards at almost
exactly the same rate at any given height. Below the North Col, I
took three breaths to a step, while at 26,000 feet I was taking five
complete respirations; but as long as I was walking slowly enough I
experienced no distress or discomfort. If one hurried for a short
distance, one was forced to rest for a few seconds—a rest was
imperative, and one felt it were impossible to do without it; but as
long as an even pace was kept up, one had no desire to stop, nor to
make one’s admiration of the landscape an excuse for delaying one’s
comrades. At the height of 26,000 feet, I took my pulse (which was
180) and my respirations (which were 50 to 55 to the minute); but
withal one felt perfectly comfortable even though these abnormal
physiological conditions were present. No doubt the heart must be
young to stand this rate of beating for many hours; yet not too
young, or it will easily become enlarged and permanently damaged.
In view of our experiences it seems justifiable to predict that
acclimatisation at 23,000 feet will be sufficient for the attainment of
the summit of Mount Everest, if indeed a sojourn at 21,000 feet is
insufficient—which is to my mind more than doubtful. The other
important practical observation we made is less encouraging:
namely, that we all varied in our rate of acclimatisation, and in fact
some of our number (especially the older ones among us) actually
seemed to deteriorate in condition while staying at a great height.
But I think we proved that it is possible to climb to the summit of
Everest without the use of oxygen, though the selection of men who
are able to do so is very difficult until those heights are actually
reached at which acclimatisation becomes established. Personally I
felt perfectly well at 27,000 feet, and my condition seemed no
different at that height from what it had been at 25,000 feet, or
even lower; and I have no doubt there are many people, if only they
can be found, who can get to the top of Everest unaided save by
their own physiological reaction to a life at 21,000 feet for a few
days. If a number of such people were allowed to live at a height
corresponding to our Camp III for a fortnight or so, making perhaps
a few minor excursions to 23,000 or 24,000 feet, then I have no
doubt from the physiological point of view that they will be able to
climb Mount Everest, provided the weather is fine and the wind not
too violent. Without allowing time for acclimatisation to take place, it
is probable that nobody—that is, unless some lusus naturæ exists—
will reach the summit; if artificially supplied oxygen be used, the
acclimatisation may not be necessary; but the danger of an attempt
by non-acclimatised men with oxygen apparatus is that a breakdown
of the apparatus might lead to serious consequences, while a fully
acclimatised man is probably just as capable of standing a height of
29,000 feet, unaided, as you or I would be able to stand the height
of Mount Blanc to-morrow. When the Expedition of 1922 started I
was personally of opinion that nobody could exist at a height about
25,000 or 26,000 feet without oxygen; but since we have proved
that this can be done, it seems that the chances of climbing the
mountain are probably greater if oxygen be not used. For the
apparatus, and the spare cylinders required, necessitate the use of a
large number of coolies; while in an attempt without oxygen only
three or four coolies are required for the camping equipment and the
food at the highest camp. Therefore it seems that the best chance of
getting to the top of Mount Everest lies in the sending out of some
nine or ten climbers, who can remain at a high camp, become
thoroughly acclimatised, and then make a series of expeditions up
the mountain, three or so at a time, as continuously as weather
conditions will allow. By adopting these tactics the number of
possible attempts up the mountain can be increased; and it seems
to me that the chances of climbing to the summit lie in the
multiplicity of possible attempts rather than in any other direction. It
were better to prepare for a number of attempts each by a small but
acclimatised party, rather than to stake all on one or two highly
organised endeavours, in which oxygen, and a large number of
coolies, are used. It is only a small proportion of coolies who can get
up to the heights of 25,000 or 27,000 feet, and they should be used
for any one attempt as sparingly as possible. During the war we all
had our ideas of how it should be run, and they were generally
wrong; the above plan is the writer’s idea of how to climb Mount
Everest, and may or may not be right, but is enunciated for what it
is worth.
Among subsidiary effects of extreme altitudes, were those upon
appetite, temper, and mental condition generally. Most of us will
admit a good deal of peevishness and irritability while at a level of
22,000 feet and more; for the altitude undoubtedly makes one lose
to some extent one’s mental balance, and the first way in which this
appears on the surface is by a ruffling of the temper. In addition,
one has a certain lack of determination, and when at a height
approaching 27,000 feet I remember distinctly that I cared very little
whether we reached the top of Everest or not. A good instance of
this altered attitude of mind is provided by the fact that Finch and
Bruce took a camera with them on their ascent, and forgot to take
any photographs of their last day’s climbing.
I have mentioned the deleterious effect of altitude on the appetite
of some of our older members; but the same was to some extent
true of us all. I have the most vivid recollection of distaste for food
during our first few days at Camp III, and especially of the way one
had almost to push a prune down one’s throat on the way up to the
North Col; but with the majority of us this distaste for food
(especially for meat and the slowly-digested foods) diminished
during our sojourn at great heights, though our appetites never
became quite normal until we reached one of the lower camps.
Those who had oxygen reported that they had large appetites above
the North Col; and there is no doubt that it is the rarefaction of the
air that causes this alteration of the appetite. One may perhaps be
justified in assuming that the secretion of gastric juice is diminished
while air that is poor in oxygen is inhaled, though it is rather hard to
understand how this is brought about.
Although acclimatisation is not entirely connected with the actual
increase in the number of blood corpuscles (as has been proved by
Barcroft in 1922), yet this is still recognised as one of the important
factors in its production. But this increase in the concentration of the
blood must be associated with a great increase in its viscosity, and
when that is combined with intense cold with its accompanying
constriction of all the smaller blood-vessels, there are present all the
conditions necessary for the production of frostbite. Therefore
acclimatisation with all its benefits probably increases the risk of
frostbite; hence one who is acclimatised must be especially careful
of feet and hands and their coverings. It is hard to put on too many
clothes at a great altitude, and very easy to put on too few.
The chief point still remaining to be mentioned concerns the after-
effects of the climbing of Everest; but these varied so much that
they give us little or no scientific information. Some of us were tired
for twenty-four hours only, some for many days; some were
reported to have enlarged hearts, while in some the heart was
normal; some were incapacitated by frostbite, though their general
physical condition was very probably good. One therefore cannot
generalise about after-effects, but as a medical man I felt strongly
(by observation on myself and my companions on the Expedition)
that if one is to “live to fight another day” and to require the
minimum recuperation period after an attempt on the mountain, it is
essential during the attempt to keep oneself well within one’s
powers. One is tempted to go too hard, and to exert one’s strength
to its limits; but it is just the last few ounces of strength which call
forth the greatest effort and make the maximum demands on one’s
resources; and if these resources are to be used to their full extent
they should be continuously conserved by an avoidance of definite
hurry. Personally I am of opinion that exercise before the climbing
begins is of great value. Mallory and I were the only ones whom
Longstaff allowed to make two attempts on Everest; and we were
probably rendered fit in this way by the subsidiary expeditions we
had made on the way to Mount Everest and by our preliminary work
in getting the camp ready on the North Col. It is, however, hard to
generalise on a point like this, but each man knows the
idiosyncrasies of his own constitution, and it should be left to
individuals to a great extent to see that their condition on arrival at
the foot of the mountain is the best that is possible.
 CHAPTER XIII

COLOUR IN TIBET

In order to bring before the reader a vivid picture of Tibet, and

especially of the region around Mount Everest, a comparison
between Tibet and other better-known countries is almost inevitable.
The Expedition of 1922 took with them no official artist, or no doubt
he would have been deputed to write this section of the book; there
were, however, two people who tried to paint pictures of the
country, Major Norton and myself; and though I realise how
inadequate our efforts were, perhaps those of an official artist might
have been almost as bad. However, as one who looks on the world
with an eye for its beauty, although lacking the ability to transfer
that beauty to canvas, one may perhaps be pardoned for
endeavouring to describe certain general impressions of the scenery
encountered by the Expedition.
In the course of our journey we passed through a great variety of
landscape; in Sikkim, for instance, we found a land of steep slopes
and dense forests, while Tibet is almost a desert country. We
experienced the clear air of the winter, and the mists and storm-
clouds of the monsoon. While we were on the rolling plains of the
Tibetan Plateau, only a few miles away were the snow-covered
summits of the highest mountains in the world.
Sikkim is a country of deep valleys and of luxurious vegetation;
the air is generally damp and the skies cloudy, and there is often a
beautiful blue haze that gives atmosphere to the distance. Sikkim is
not unlike the Italian side of the Alps, in many ways. True, its scale
is larger, and it possesses some of the most beautiful and impressive
peaks in the world (for no Alpine peak can vie with Siniolchum or
Pandim for sheer beauty of form and surface), but on the whole the
scenery of Sikkim is of the same general build as the valleys and
peaks of Northern Italy. In this sense Sikkim did not offer to the
new-comer anything entirely different from what he had seen
before. But Tibet and Everest certainly did; and the difference
between Sikkim and Tibet is twofold—first, Tibet is almost uniformly
over 13,000 feet above sea-level, and therefore bears no trees at all;
second, Tibet is almost free from rainfall and is, in consequence, a
desert country. One’s eye travelled, for mile after mile, over red-
brown sand and red-brown limestone hills, finally to rest on the blue
and white of the distant snows. The air, before the monsoon
commences, is almost always clear—clear to an extent unimagined
by a European, clearer even than the air of an Alpine winter. So
peaks and ridges 30 or 40 miles away are often almost in the same
visual plane as the foreground of the landscape. In some extensive
views, such as we had from the hills above Tinki Dzong, one came to
look upon hills 30 miles away as the middle distance of one’s picture,
while the background was formed of mountains a hundred miles
from the point of view. It is this lack of atmosphere which makes
pictorial representation of these Tibetan scenes so very difficult; the
pictures I made on the course of the Expedition have all had one
criticism from many different people—“there is no atmosphere.”
Many as are the demerits of these pictures, this is the one merit they
have; and if they had an “atmosphere” they would cease to be
truthful. In the Alps one has often seen mountains with extreme
clearness at a great distance, but I never remember having viewed
an Alpine landscape in which there was practically no effect of
distance, and practicably no blueness of the more distant shadows.
Yet that is precisely what obtains in Tibet before the month of June.
And then, with startling suddenness, comes the monsoon, with its
damp air; for some months the landscape is entirely altered, and
also much beautified. The blue haze of the monsoon converts the
distant shadows from their crude purple-brown to the most
magnificent and sometimes brilliant blue. Once or twice one looked
in vain on one’s palette for a blue of sufficient brilliance and intensity
to reproduce the colour of the shadows 20 or 30 miles away. Then
the monsoon brings clouds and rain-storms, all of which tend to give
variety to the scene, and to endue the distant peaks with that effect
of mystery which renders them so alluring and so beautiful.
As far as the scenery among the higher mountains is concerned,
the comparison of photographs of the Everest group of peaks with
those of the Alps will give one more idea of the differences between
the two districts than can a mere verbal description, save in the
matter of scale and colour. In colour, the Alps are more varied and
the rock is, as a rule, a darker brown; the snow-shadows are more
blue and the outlines less clear; while Alpine foregrounds so often
contain trees which are totally absent from the foregrounds of Tibet.
There both rocks and stones, scree and valley-bed are of a light
reddish-brown, almost uniform in tone from near foreground to
extreme distance; Makalu, for example, is a colossal rock-pyramid of
quite a light ochre colour; the rocks of Everest are of a light amber
brown relieved in the neighbourhood of 27,000 feet by a lighter
yellowish band of quartzite. The snow of the range on its northern
side resembles that of Alpine peaks, but on the southern face the
festoons and grooves of ice, so well known to many from
photographs of Himalayan mountains, decorate the much steeper
and more uncompromising slopes. Most of the higher peaks are
swept by continual gusts of wind which whirl clouds of snow from
the topmost ridges into the sky.
 CHAPTER XIV

TIBETAN CULTURE

The Tibetans are a very simple folk, though not without a very
definite civilisation of their own. Art and music exist in all nations, if
the art be merely the fashioning of utensils, and the music be the
crudest of rhythms played on a tom-tom. Yet in Tibet the
rudimentary music and art associated with so many Eastern races is
carried a stage farther, and what is in wilder people merely natural
instinct has become in Tibet a definite culture. For I presume that
culture is merely organised art, and certainly on that criterion the
Tibetan is to some extent cultured.
He is a fine architect, and many of his houses have a simple
stateliness which raises them in artistic value high above the average
dwelling-house of most other Oriental countries, to say nothing of
our own garden suburbs. The Monasteries of Tibet are still more
imposing, and some of them are real objects of beauty, for the
dignified simplicity of the buildings themselves is combined with an
elaborate and often beautiful decoration of windows and cornices.
The Tibetans have learned the true principles of decoration—they do
not cover the surfaces of their buildings with unnecessary ornament,
but reserve the wooden parts alone for elaboration. The cornices are
often intricate in workmanship, but throughout the great principle of
design is carried to perfection—the principle that all ornament should
be founded on utility. Thus economy in the use of scrolls is combined
with the multiplication of brackets, supports, and rafter-ends, so that
the whole is satisfying to the eye as being beautiful, rather than
useless. Considerable Chinese influence is shown in their decorative
art, but the Tibetans have a personal, or rather national, touch
which distinguishes their work in all branches of art from the
Chinese. In painting, too, the influence of China, and very
occasionally of India, is felt: though through it all the refined
austerity of the better-class Tibetan shines unmistakably. The older
pictures, nearly always of sacred subjects, are drawn with
consummate skill, coloured with great taste, and in the matter of
design rank much higher than the contemporary art of India. But,
alas! the story of painting in Tibet is the same as it is everywhere in
this commercial world of ours; the modern Tibetan picture is
worthless, careless and meretricious. No doubt the demand for
“native art” at the bazaars of Darjeeling and other places around has
caused this deterioration of what was once a fine and noble art;
pictures which used to be the life-work of devoted lamas and
conscientious hermits are now “dashed off” to satisfy the capacious
maw of the tasteless traveller. Though Tibet is still in measure “The
Forbidden Land,” yet the tentacles of commercialism cannot but
penetrate between its bars, and the same thing is now happening to
Tibet as happened to Europe last century and produced oleographs
and official artists. It seems almost as if man by nature does bad
work only when he is working for reward.
 Religious Banners in Shekar Monastery.

This is a mere flashlight sketch of the art of Tibet, for details of

which other books must be consulted; but the music of Tibet will be
described more fully, for two reasons—first, that no accurate record
of it has to my knowledge been obtained until now, and second, that
the writer is himself particularly fond of music, which he believes to
be the highest of the arts.
Just as in Europe to-day we have both the traditional folk-song
and the highly organised orchestral music, so in Tibet both these
forms of the art exist. The two are also more or less interdependent
in Tibet, while in Western nations each often goes its own way
without the other.
The airs sung by the Tibetan people are usually simple, short, and
oft-repeated. They are nearly always in the pentatonic scale,
represented best to the general reader by the black notes of the
piano. Most isolated races evolve this scale at some time during their
history, and the tunes of the Highlands of Scotland, the Forests of
Central Africa, the Appalachians of America, and the Tibetans are all
in this scale.[8]
8. Sir Walford Davies has pointed out that, starting (on the black notes) from A
flat, and using only the perfect fifth, this scale is very soon developed. From
A flat one gets E flat and D flat, each a fifth away; from D flat one obtains G
flat, a fifth down, and from E flat a fifth upwards gives us B flat. Thus we get
the five notes of the scale by a simple series of fifths, the fifth being the
most perfect interval in music, and the one which will appeal most readily to
a primitive people.
A typical well-known pentatonic tune is “Over the Sea to Skye.”
Those who know, for instance, the songs of the Western Highlands,
will be able to appreciate the cheerful and non-Oriental character of
the tunes of Tibet, which are more akin to those of Russia and
Eastern Europe than to the music of China or India. This general
spirit of the music which the Tibetans play or sing points to a
common origin of the folk-tunes of Tibet and Russia. It seems
probable that in Turkestan was the real origin of this music, which
very likely spread eastwards into Tibet and westwards into Russia; or
if Turkestan is not the country of origin of the music, it may be the
musical link between Russia and Tibet. The tunes of Nepal, as sung
by our coolies, are many of them of a similar nature to those of
Tibet, though more often the whole major or minor scale is used,
giving them often a strangely European sound; some of the
Nepalese airs have a jolly lilt and swing; others in the minor key
have quite a haunting beauty; and they too are quite unlike the
music of the plains of India with its rather pointless wailing
characteristics.[9]
9. A more technical article on the subject of Tibetan Music, with musical
quotations, will be found in the Musical Times for February 1, 1923.
In Tibet, then, the folk-tunes are simple, short, and emphatically
not such “good tunes” as the airs of Nepal. But, in addition to the
songs of the peasants and beggars, there is the more highly-
organised and orchestrated music of the monasteries. This is usually
played with three groups of instruments—first and foremost the
percussion; drums of all sizes from those made of a human skull to
others 3 and 4 feet in diameter, and cymbals of great resonance and
good tone, coming often from China. The cymbals are taken very
seriously, and each different way of clashing them has a special
name and a special religious significance. The hard-worked
percussion department keeps up a continuous rhythm throughout
the performance of a devil-dance or other musical festival; and to its
strenuous and often sinister efforts are added from time to time the
sounds of the two groups of wind instruments. The first of these,
playing airs which often possess great charm, are the double-reed
oboes, about twice as long as our European oboe, and very often
provided with equidistant holes, rendering them incapable of playing
save in the scale of whole tones (or a close approximation to it). The
second and larger wind instrument is the long straight trumpet, 8 to
12 feet long, of which the fundamental note is almost continuously
blown. Most monasteries have two of these, about one tone apart in
pitch; but as the longer of the two is blown so as to play its first
overtone, while the fundamental note is played on the other, a drone
bass of a minor seventh is the resulting sound. This adds to the
sinister impressiveness of the music, and provides an effective
accompaniment to the quaint tunes of the oboe-like instruments. At
a devil-dance performance, the orchestra plays for a whole day, or
perhaps two, almost without rest either for itself or for its listeners.
In addition to these instruments, a fairly civilised violin is used in
Tibet, especially by wandering beggar minstrels. This is about two-
thirds as long as our violin, and has four strings, tuned A,D,A,D, in
that order. The bow has two hanks of hair, one of which passes
between the first and second strings, while the other goes between
the third and fourth. Thus, by pressing the bow in one direction the
two A strings are sounded, producing a reinforced note (i.e. two
notes in unison); by pressing the bow in the other direction the
sound of the D strings is obtained. The strings converge towards the
top of the instrument, so that they can all be fingered at once. The
Tibetans become very agile with their fingers, and I have heard very
skilful performances of rapid, jolly dance-tunes by wandering
minstrels; these tunes, like the songs of the peasants, are usually in
the pentatonic scale.
One more instrument must be mentioned—the trumpet made
from a human thigh-bone. This is not very commonly used in the
larger monasteries, but occasionally sounds a note in the ritual of
the worship of smaller villages.
NATURAL HISTORY
By
T. G. LONGSTAFF, M.D.
 CHAPTER XV

NATURAL HISTORY

Previous experience of the conditions of Tibetan travel had taught

me that collection and observation was a task requiring complete
immunity from other duties; but to the doctor of such an Expedition
this condition was not attainable. In the collection of specimens we
were, however, fortunate in obtaining the assistance of several other
members of the Expedition. But it is especially to Major Norton that
the thanks of the Everest Committee are due, for in addition to his
other duties, he took over the whole of the botanical work and
worked equally with myself in all other branches of Zoology. His gift
of painting was particularly valuable in leading to the certain
identification of birds in districts where collecting was prohibited. At
the time of writing he is on duty at Chanak, and the following notes
lose half their value through lack of his promised collaboration,
which I had anticipated with particular pleasure.
In his absence I must omit all reference to botany, for personally,
owing to the wintry conditions during our outward march and to the
speed of my journey back with the invalids, I saw nothing that has
not been already better described by Wollaston. But Norton, with our
Lepcha collector Rumoo, obtained some 350 flowering plants in
Kharta, and we also sent back samples of agricultural seeds.
It must be remembered that it was the constant aim of General
Bruce to render it easier for any subsequent party to pass through
the country. The objection of the Tibetans to the taking of any wild
life is almost universal amongst the clerics and is devoutly shared by
the lay population in certain localities. These considerations
unfortunately applied particularly to the districts of Tengkye, Shelkar
Dzong and Rombuk, where the killing of even domestic animals is
prohibited.
There are, however, other parts of Tibet where the same restraint
is unnecessary, and even where hunting is habitually practised by
the semi-nomadic population. This immunity in our case applied
especially to the Chumbi Valley and the country round Phari, and in
consequence we have been able to bring back some material which
it is hoped will add to the value of the larger collections brought
back last year by Dr. Wollaston.
That portion of Tibet visited by the Expedition, and indeed it is
typical of most of its provinces, is a region of bare uplands and
naked mountains. Such physical conditions combine with a violent
type of radiation in the thin dry air to evolve a daily strife of winds,
ceaselessly seeking to rectify the balance of atmospheric stability;
this continual wind is indeed the foundation of the traveller’s
discomfort and the worst enemy of the mountaineer.
Romoo, the Lepcha Collector, who assisted
Dr. Longstaff and Major Norton.