Arrhythmogenic right ventricular cardiomyopathy (ARVC)
Please send 10mls of EDTA blood or DNA to: Molecular Genetics Laboratory, The Churchill Hospital, Headington, OXFORD, OX3 7LJ.
Contact: Clinical:
Dr Ed Blair
Ed.Blair@orh.nhs.uk
01865 226008
Laboratory: Kate Thomson Kate.Thomson’orh.nhs.uk
01865 225586
Referrals will only be accepted from the following:
PLEASE SELECT
REFERRER
Consultant Clinical Geneticist
Consultant Cardiologist from Cardiovascular Genetics Unit in liaison with a Clinical
Geneticist (N.B. A copy of results reports will be issued to a Clinical Geneticist, please provide contact details below)
Consultant Pathologist in liaison with a Clinical Genetics Department
(N.B. A copy of results reports will be issued to a Clinical Geneticist, please provide contact details below)
Coroner
Minimum criteria required for testing:
PLEASE SELECT
CRITERIA
Individuals who fulfill Task Force criteria for diagnosis of ARVC.
McKenna et al, Br. Heart J. 1994 Mar;71(3):215-8.
Individuals who fulfill modified Task Force criteria for diagnosis of familial ARVC.
Hamid et al, J Am Coll Cardiol. 2002 Oct 16;40(8):1445-50.
Test for Familial Variant
Genetic testing is not recommended for diagnosis of ARVC outside the setting of expert clinical and
detailed family assessment. If the sample does not fulfill the above criteria and you still feel that
testing should be performed please contact Dr Ed Blair (details above) to discuss testing of the
sample.
Referral Details:
REFERRER DETAILS 1
Name:
Address for report: -
Specialty: - (please circle)
Genetics
Cardiology
Post code: Address for Invoice:
Post code: Telephone: -
Fax No: -
E-mail: -
REFERRER DETAILS 2
Name:
Address for report: -
Specialty: - (please circle)
Genetics
Cardiology
Post code: Telephone: -
Fax No: -
E-mail: -
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Patient Details:
Forename:
D.O.B: Address: -
Surname: NHS No.:
Your Ref. No.: Post Code: -
Additional Information: -
FAMILY HISTORY DETAILS
Is there a Family history of: ARVC
Other cardiomyopathies
SCD
Pedigree Details (please state name and D.O.B where known)
In submitting this sample the clinician confirms that genetic counseling has been undertaken and consent for
testing has been obtained.
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