Supplementary Material
Supplementary Table 1. Definitions of clinical and ECG variables employed in this study.
Term
Definition
Sudden cardiac death
Death of cardiac origin that occurred unexpectedly within 1
hour of the onset of new symptoms or a death that was
unwitnessed and unexpected
An event as described above, that is reversed, usually by
cardio-pulmonary resuscitation and/or defibrillation or
cardioversion
Ventricular tachycardia which lasts 30 s or more, or less than
30 s when terminated electrically or pharmacologically
ICD shock or anti-tachycardia overdrive pacing delivered in
response to a ventricular tachyarrhythmia and documented by
stored intracardiac ECG data
Distinct waves of small amplitude within the ST segment in the
right precordial leads and are distinct from the QRS complex
The longest value in V1–V3, from the nadir of the S wave to the
end of all depolarization deflections. Considered abnormal
when ≥55 msec
QRS duration ≥0.12 s, secondary R wave in right precordial
leads, and wide S wave in leads I and V6
Sudden cardiac arrest
Sustained ventricular tachycardia
Appropriate ICD Therapy
Epsilon wave
Terminal activation duration
Complete right bundle branch block
Proven or definite ARVD/C (Diagnostic
terminology as per 2010 revised Task
Force Criteria)
2 major or 1 major and 2 minor criteria or 4 minor from
different categories
Heart failure
Stage C heart failure was defined using the American College of
Cardiology/American Heart Association heart failure staging
system, but required both evidence of structural heart disease
including RV abnormalities and symptoms directly attributed
to heart failure.
Nonsense, frame shift, splice site mutations and exon deletions
were all considered to be proven pathogenic mutations unless
previously identified as polymorphism or non-pathogenic.
Missense mutations were considered pathogenic when: 1) the
minor allele frequency in the Exome Sequencing Project (ESP)
dataset was ≤0.05% (NHLBI 6500 Exome data sets; EVS;
http://evs.gs.washington.edu/EVS/) and 2) in silico predictive
programs (SIFT) and Polymorphism Phenotyping-2
(PolyPhen-2) both predicted the genetic variants to affect
protein function by a tolerance index score of <0.02 (SIFT) and
>0.900 (PolyPhen-2), respectively.
The proband (index patient) was the first affected family
member seeking medical attention for ARVD/C in whom the
diagnosis was confirmed (i.e. an affected person ascertained
independently of family history of ARVD/C and in whom DNA
analysis was started)
Pathogenic Mutation
Proband (index patient)
Family members
Individuals ascertained through family screening.
Abbreviations: ICD= Implantable Cardioverter-Defibrillator; VT= Ventricular tachycardia; VF= Ventricular fibrillation;
ARVD/C= Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy
Supplementary Table 2. List of 322 mutations identified in the study population.
Gene; n (%)
Amino Acid Change
Nucleotide Change
PKP2
Abnormal splice product
p.(Arg79*)
p.(Val406fs)
p.(Trp538*)
p.(His733fs)
Abnormal splice product
Abnormal splice product
p.(Cys796Arg)
p.(Gly548fs)
p.(Thr50fs)
Abnormal splice product
p.(Gln133*)
p.(Asn456fs)
p.(Ser837fs)
p.(Arg413*)
Abnormal splice product
Abnormal splice product
c.2146-1G>C
c.235C>T
c.1211-1212insT
c.1613G>A
c.2197_2202delinsG
c.2489+1G>A
c.1171-2A>G
c.2386T>C
c.1643delG
c.148_151delACAG
c.2489+4A>C
c.397C>T
c.1368delA
c.2509delA
c.1237C>T
c.337-2A>T
c.224-3C>G
Deletion exon 1-14
c.1821dupT
c.1767T>G
c.1307_1315insATTTA
c.390C>T
c.2145+1G>A
c.2013delC
c.1271T>C
c.1369_1372delCAAA
c.368G>C
c.1759delG
c.218dupG
c.1132C>T
c.968_971delAGGC
c.1848C>A
c.1849C>T
c.2169_2172dupAGTT
c.2174T>A
c.253_256delGAGT
c.517C>T
c.663C>A
c.1378+1G>C
c.1760delT
c.2544G>A
c.1844C>T
c.451delT
c.14delG
p.(Val608fs)
p.(Tyr589*)
p.(His436fs)
p.(Tyr130*)
Abnormal splice product
p.(Lys672fs)
p.(Phe424Ser)
p.(Gln457*)
p.(Trp123*)
p.(Val587fs)
p.(Asn74fs)
p.(Gln378*)
p.(Gln323fs)
p.(Tyr616*)
p.(Gln617*)
p.(Val725fs)
p.(Val725Asp)
p.(Glu85fs)
p.(Gln173*)
p.(Tyr221*)
Abnormal splice product
p.(Val587fs)
p.(Trp848*)
p.(Ser615Phe)
p.(Ser151fs)
p.(Gly5fs)
Pediatric
n
5
1
3
2
5
5
0
1
0
1
1
0
1
1
1
1
1
0
1
1
0
1
0
0
1
0
0
1
2
1
1
0
1
0
0
1
0
1
1
0
1
0
0
0
Adult
n
28
21
10
9
17
16
2
4
2
13
4
4
0
8
4
1
0
5
1
0
1
0
1
5
2
3
1
0
0
3
1
1
4
2
1
2
1
2
3
3
1
1
1
1
p.(Glu601fs)
p.(Lys258*)
p.(Arg651*)
p.(Asn480fs)
p.(Asn759fs)
p.(Pro716fs)
DSG2
PLN
DSP
DSC2
JUP
TMEM43
Compound/
Digenic
Heterozygote
p.(Arg292Cys)
p.(Arg46Gln)
p.(Arg46Trp)
p.(Cys507Tyr)
p.(Glu156fs)
p.(Gln812Cys)
p.(Asp297Asn)
p.(Arg49His)
p.(Tyr1047Arg)
p.(Lys346del)
p.(Arg14del)
p.(Arg2160*)
p.(Arg2166*)
p.(Arg160*)
p.(Arg1738*)
p.(Gln51*)
p.(Glu422Lys)
p.(Ile445Val)
p.(Lys1054fs)
p.(Gly220Arg)
p.(Gly863fs)
Abnormal splice product
p.(Thr275Lys)
p.(Thr19Ile)
p.(Val159Leu)
p.(Ser358Leu)
p.(Val406fs) (PKP2) +
p.(Gln90Arg) (DSP)
p.(Gln133*) (PKP2) +
p.(Thr872Ile) (PKP2)
p.(Ala358Thr) (DSG2)
p.(Glu426Lys) (DSC2) +
p.(Pro1565Ala) (RYR2)
p.(Arg203His) (DSC2)
p.(Arg2160*) (DSP) +
p.(Arg315Cys) (DSP)
c.1803delC
c.722A>T
c.1951C>T
c.1440_1444delTCCCA
c.2274delG
c.2146-1G>C
Deletion exon 10
Deletion exon 7-14
Deletion exon 1-4
c.874C>T
c.137G>A
c.136C>T
c.1520G>A
c.464_465insT
c.2434G>T
c.889G>A
c.146G>A
c.3140C>G
c.1038_1040delGAA
c.40_42delAGA
c.6478C>T
c.6496C>T
c.478C>T
c.5212C>T
c.151C>T
c.1264G>A
c.1333A>G
c.3160_3169del
c.658G>A
c.2582_2585dupGAAG
c.154+G>A
c.824C>A
c.56C>T
c.475G>T
c.1073C>T
0
0
0
0
1
0
0
1
0
0
3
1
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
0
1
0
1
1
1
0
0
1
1
3
1
0
1
2
0
2
2
2
0
1
1
2
1
2
1
1
23
1
2
2
1
1
0
1
1
0
1
0
0
0
1
1
c.1211_1212insT (PKP2) +
c.269A>G (DSP)
c.397C>T (PKP2) +
c.2615C>T (PKP2)
Deletion exon 1-14 (PKP2) +
c.1072G>A (DSG2)
c.1276G>A (DSC2) +
c.4693C>G (RYR2)
c.608G>A homozygosity
(DSC2)
c.6478C>T (DSP) +
c.943C>T (DSP)
0
1
0
5
1
0
0
1
1
0
0
1
Abnormal splice product
(PKP2)
Mutant splice product
(PKP2) + p.(Asn661Ile)
(DSP)
p.(Arg413*) (PKP2) +
p.(Leu277_Met280del)
(DSG2)
p.(Lys346del) (DSG2) +
p.(Ala358Thr) (DSG2)
Abnormal splice product
(DSG2) + (Lys346del)
(DSG2)
p.(Arg79*) (PKP2) +
p.(Phe829fs) (PKP2)
p.(Trp306*) (DSG2) +
p.(Arg49His) (DSG2)
p.(Glu2313fs) (DSP) +
p.(Ser800Cys) (DSG2)
c.2484C>T homozygosity
(PKP2)
c.2489+4A>C (PKP2) +
c.1982A>T (DSP)
1
0
0
1
c.1237C>T (PKP2) +
c.824_840del (DSG2)
0
1
c.1038_1040delGAA (DSG2)
+ c.1072G>A (DSG2)
c.523+2T>C (DSG2) +
c.1038_1040delGAA (DSG2)
1
0
1
0
c.235C>T (PKP2),
c.2487delT (PKP2)
c.918G>A (DSG2) +
c.146G>A (DSG2)
c.6937delG (DSP) +
c.2399C>G (DSG2)
0
2
0
1
0
1
Abbreviations: DSC2: desmocollin-2; DSG2: desmoglein-2; DSP: desmoplakin; JUP: plakoglobin; PKP2:
plakophilin-2; PLN: phospholamban; RYR2: Ryanodine Receptor-2; TMEM43: transmembrane protein 43.
Supplementary Table 3. Demographic Details of 11 Children Who Presented With A Sudden Death. For the purpose of this study,
the cause of death was defined as ARVD/C only if children were confirmed to harbor a pathogenic ARVD/C-causing mutation, or had a
positive family history of ARVD/C. Single sudden death cases with questionable autopsy findings were excluded.
Sex
Age at
SCD
Family status
Circumstance
of SCD
Prior medical
evaluation
Mutation*
Autopsy findings
Symptoms
prior to SCD
1
Female
15
Proband
No
PKP2; p.Q74fsX84
No records
None
2
Male
17
Proband
Playing
basketball
Playing hockey
No
PKP2; p.A733fsX740
“Chest
discomfort”
3
Male
16
Proband
No
PKP2; p.IVS10-1G>C
4
Male
16
Proband
Playing
basketball
Playing
basketball
No
PKP2; p.IVS12+1G>A
5
Female
13
Proband
Rest
No
None
6
Male
15
Hunting
No
PKP2, p.A733fxX740
7
Male
16
PKP2; p.Q74fsX84
No records
None
Female
14
Getting up to go
to bathroom
Playing
basketball
No
8
Family member
(brother of proband)
Family member
(brother of proband)
Family member
(sister of proband)
Biventricular hypertrophy,
fibrofatty RV replacement,
aneurysm RV free wall
Biventricular dilatation with
fatty infiltration RV>LV
Macroscopic fatty infiltration
of basal anterior and inferior
RV and posterolateral LV
Fatty infiltration of RV
subepicardial until
endocardium, with areas of
fibrosis and strands of normal
heart tissue
Inflammatory changes in RV
No
PKP2: mutant splice
product
No records
9
Female
16
In bed
No
None
RV dilatation with wall
thinning and fibrofatty
replacement
No records
10
Male
14
Playing soccer
No
PKP2; p.IVS12+1G>A
No records
11
Male
17
Fibrofatty RV (and to lesser
extent, LV) infiltration with
focal absence of myocardium
No records
Family member
(sister of proband)
Family member
(son of proband)
No records
No records
None
No records
None
Family member
Gym class
No
PKP2; p.V406SfsX4
Presyncope
(brother of proband)
during exercise
* SCD cases who did not have genotype studies were assumed to have the same mutation as other genetically affected first-degree relatives of their
respective family.
Supplementary Table 4. Ascertainment of pediatric and adult ARVD/C subjects, and
fulfillment of 2010 Task Force Criteria in the “family history” category. Pediatric and adult
ARVD/C cases are ascertained similarly, resulting in a similar proportion of probands and family
members in the two groups. In addition, pediatric ARVD/C cases do not rely on family history
criteria more often than adults. Abbreviations as in text.
Ascertainment
Relative coming to attention by
family screening
2010 TFC for Family History
Mutation carrier
1st degree affected relative per TFC
1st degree affected relative autopsy
Possible ARVD/C in 1st degree
relative but impossible to
determine TFC
Premature SCD <35yo due to
suspected ARVD/C
2010 TFC without family history
Relying on Family History criteria
for definite diagnosis
Overall
(n=468)
Pediatric
(n=64)
Adult
(n=404)
P-value
139 (30)
14 (22)
125 (31)
0.140
275 (59)
142 (31)
40 (9)
23 (5)
51 (80)
17 (26)
3 (5)
3 (5)
224 (55)
125 (31)
37 (9)
20 (5)
<0.001
0.457
0.229
0.918
38 (8)
3 (5)
35 (9)
0.273
5 (IQR 4-6)
94 (20)
5 (IQR 4-6)
12 (19)
5 (IQR 4-6)
82 (21)
0.242
0.776
Supplementary Table 5. Clinical phenotype and outcome among 346 probands. Abbreviations
as in text.
Overall
(n=346)
Male
207 (60)
Age at presentation (yrs)
34.8 ± 14.8
Proband
346 (100)
Mutation carrier
197 (57)
Clinical phenotype and Disease Course*
Duration of follow-up (yrs)
8.9 ± 7.9
Repolarization criteria
302 (92)
Negative T-wave V1-3
269 (82)
Negative T-wave V1-2
16 (5)
Negative T-wave V4-6
10 (3)
Negative T-wave V1-4 w/ CRBBB
26 (8)
Depolarization criteria
207 (64)
Epsilon wave
42 (13)
>TAD
140 (43)
Late potentials
124/273 (45)
Arrhythmia criteria
309 (94)
LBBB superior axis VT
169 (52)
LBBB VT
233 (71)
Holter monitor >500 PVC/24hrs
195/243 (80)
Pediatric
(n=55)
32 (58)
15.5 ± 1.9
55 (100)
43 (78)
Adult
(n=291)
175 (60)
38.4 ± 13.2
291 (100)
154 (53)
P-value
9.8 ± 8.6
48 (96)
45 (90)
2 (4)
1 (2)
4 (8)
30 (60)
6 (12)
21 (42)
15/42 (36)
265 (95)
24 (48)
34 (68)
35/37 (95)
8.7 ± 7.8
254 (92)
224 (81)
14 (5)
9 (3)
22 (8)
177 (64)
36 (13)
119 (43)
109/231 (47)
44 (88)
145 (52)
199 (72)
160/206 (78)
0.565
0.292
0.120
0.750
0.637
0.989
0.577
0.832
0.851
0.170
0.041
0.588
0.607
0.017
3015
5027
2587
(IQR 1003-7185) (IQR 2347-10907) (IQR 951-6444)
Imaging abnormal
261 (80)
44 (88)
217 (79)
Major
230 (71)
40 (80)
190 (69)
Minor
31 (10)
4 (8)
27 (10)
Major adverse clinical event
279 (85)
40 (80)
239 (86)
Life-threatening arrhythmia
308 (66)
39 (78)
239 (86)
Cardiac transplantation
18 (6)
2 (4)
16 (6)
Cardiac death
18 (6)
4 (8)
14 (5)
* Among 329 probands presenting alive.
0.001
PVC count/24hrs
0.786
<0.001
<0.001
0.129
0.304
0.168
0.619
0.393
Supplementary Table 6. Clinical phenotype and outcome among 156 family members.
Abbreviations as in text.
Overall
(n=156)
Male
57 (37)
Age at presentation (yrs)
35.7 ± 15.3
Proband
0 (0)
Mutation carrier
125 (80)
Clinical phenotype and Disease Course*
Duration of follow-up (yrs)
7.1 ± 6.3
Repolarization criteria
112 (82)
Negative T-wave V1-3
80 (58)
Negative T-wave V1-2
20 (15)
Negative T-wave V4-6
9 (7)
Negative T-wave V1-4 w/ CRBBB
4 (3)
Depolarization criteria
75 (55)
Epsilon wave
8 (6)
>TAD
46 (34)
Late potentials
47/107 (44)
Arrhythmia criteria
92 (67)
LBBB superior axis VT
14 (10)
LBBB VT
31 (23)
Holter monitor >500 PVC/24hrs
77/123 (63)
PVC count/24hrs
1017
(IQR 181-3843)
Imaging abnormal
78/136 (57)
Major
45 (33)
Minor
33 (24)
Major adverse clinical event
30 (22)
Life-threatening arrhythmia
30 (22)
Cardiac transplantation
1 (1)
Cardiac death
1 (1)
* Among 139 family members presenting alive.
Pediatric
(n=20)
9 (45)
14.9 ± 3.4
0 (0)
17 (85)
Adult
(n=136)
48 (35)
38.8 ± 13.9
0 (0)
108 (79)
P-value
6.3 ± 5.9
10 (71)
8 (57)
2 (14)
0 (0)
0 (0)
9 (64)
0 (0)
5 (36)
5/12 (42)
7 (50)
0 (0)
0 (0)
7/14 (50)
7.2 ± 6.3
102 (83)
72 (59)
18 (15)
9 (7)
4 (3)
66 (54)
8 (7)
41 (33)
42/95 (44)
85 (69)
14 (11)
31 (25)
70/109 (64)
0.513
0.291
0.920
0.972
0.295
0.493
0.449
0.325
0.858
0.867
0.163
0.185
0.034
0.301
1473
(IQR 204-4594)
8/14 (57)
5 (36)
3 (21)
1 (7)
1 (7)
0 (0)
0 (0)
1006
(IQR 178-3784)
70/122 (57)
40 (33)
30 (25)
29 (23)
29 (23)
1 (1)
1 (1)
0.763
0.400
<0.001
0.559
0.987
0.166
0.166
0.737
0.737
Supplementary Table 7. Clinical phenotype and outcome in pediatric ARVD/C vs. adult
ARVD/C corrected for proband status. Odds ratios did not change >10% in multivariate analyses
correcting for proband status, justifying a combination of proband and family members in the
manuscript. Abbreviations as in text.
Odds ratio*
Male
1.06 (9.64-1.75)
Mutation carrier
2.72 (1.48-5.00)
Clinical phenotype and Disease Course
Duration of follow-up (yrs)
1.01 (0.98-1.05)
Repolarization criteria
1.08 (0.44-2.69)
Negative T-wave V1-3
1.54 (0.76-3.12)
Negative T-wave V1-2
0.87 (0.29-2.57)
Negative T-wave V4-6
0.36 (0.05-2.78)
Negative T-wave V1-4 w/ CRBBB
0.89 (0.30-2.65)
Depolarization criteria
0.97 (0.56-1.67)
Epsilon wave
0.78 (0.32-1.92)
>TAD
0.98 (0.57-1.68)
Late potentials
0.68 (0.37-1.23)
Arrhythmia criteria
0.40 (0.19-0.86)
LBBB superior axis VT
0.76 (0.43-1.36)
LBBB VT
0.66 (0.37-1.18)
Holter monitor >500 PVC/24hrs
1.64 (0.76-3.56)
Imaging abnormal
1.54 (0.78-3.04)
Major adverse clinical event
0.58 (0.29-1.13)
Life-threatening arrhythmia
0.53 (0.27-1.02)
Cardiac transplantation
0.66 (0.15-2.93)
Cardiac death
1.56 (0.50-4.89)
p-value
0.827
0.001
0.538
0.864
0.227
0.795
0.329
0.836
0.909
0.585
0.933
0.200
0.019
0.354
0.159
0.210
0.211
0.110
0.059
0.583
0.448
* Odds ratio denotes adult ARVD/C vs. pediatric (i.e. value >1 signifies higher odds in pediatric patients)