Skip to main content
SpringerLink
Log in

Cardiac Involvements in Myotonic Dystrophy

  • Chapter
  • First Online:
Myotonic Dystrophy

Abstract

For the management of myotonic dystrophy, cardiac involvements should be treated as being important as same as the treatment of respiratory failure at the aspect of prognosis particularly in patients with myotonic dystrophy type 1 (DM1). The most critical cardiac involvement is cardiac conduction diseases including sick sinus syndrome and AV block to be cared with cardiac pacemakers. The progressive cardiac conduction disease has been reported to be associated with sudden death in DM1 patients, and physicians need to manage when cardiac devices should be implanted in DM1 patients on the results by noninvasive or invasive cardiac tests, e.g., electrocardiogram, 24-h Holter monitoring, or electrophysiological study. Ventricular tachyarrhythmias should be also monitored for DM1 patients, and implanted cardioverter defibrillator but not pacemakers may be suitable especially for DM1 patients with severe conduction diseases. Atrial fibrillation has been reported to be common and a clinical marker to be associated with sudden death in DM1 patients. We regularly need to care whether these arrhythmias appear on electrocardiograms. As shown in the recent guideline in American Heart Association, neurologists are required to care DM1 patients with cardiologists.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Abbreviations

ACEI:

Angiotensin-converting enzyme inhibitor

ARB:

Angiotensin receptor blocker

AV:

Atrioventricular

CRT:

Cardiac resynchronization therapy

DM:

Myotonic dystrophy

DM1:

Myotonic dystrophy type 1

DM2:

Myotonic dystrophy type 2

DMPK:

Myotonin-protein kinase

ICD:

Implantable cardioverter defibrillator

LVEF:

Left ventricular ejection fraction

MMRGlu:

Myocardial metabolic rate for glucose

References

  1. Turner C, Hilton-Jones D. The myotonic dystrophies: diagnosis and management. J Neurol Neurosurg Psychiatry. 2010;81:358–67.

    Article  Google Scholar 

  2. Udd B, Krahe R. The myotonic dystrophies: molecular, clinical, and therapeutic challenges. Lancet Neurol. 2012;11:891–905.

    Article  CAS  Google Scholar 

  3. Steinert H. Myopathologische Beitraege 1. Ueber das klinische und anatomische Bild des Muskelschwunds der Myotoniker. Dtsch Z Nervenheilkd. 1909;37:58–10.

    Article  Google Scholar 

  4. Ricker K, Koch MC, Lehmann-Horn F, Pongratz D, Otto M, Heine R, Moxley RT III. Proximal myotonic myopathy: a new dominant disorder with myotonia, muscle weakness, and cataracts. Neurology. 1994;44:1448–52.

    Article  CAS  Google Scholar 

  5. Lund M, Diaz LJ, Ranthe MF, Petri H, Duno M, Juncker I, Eiberg H, Vissing J, Bundgaard H, Wohlfahrt J, Melbye M. Cardiac involvement in myotonic dystrophy: a nationwide cohort study. Eur Heart J. 2014;35:2158–64.

    Article  Google Scholar 

  6. Petri H, Vissing J, Witting N, Bundgaard H, Køber L. Cardiac manifestations of myotonic dystrophy type 1. Int J Cardiol. 2012;160:82–8.

    Article  Google Scholar 

  7. Dello Russo A, Pace M, Bellocci F. Sudden death in myotonic dystrophy. N Engl J Med. 2008;359:1626.

    Google Scholar 

  8. Sansone VA, Brigonzi E, Schoser B, Villani S, Gaeta M, De Ambroggi G, Bandera F, De Ambroggi L, Meola G. The frequency and severity of cardiac involvement in myotonic dystrophy type 2 (DM2): long-term outcomes. Int J Cardiol. 2013;168:1147–53.

    Article  CAS  Google Scholar 

  9. Buxton J, Shelbourne P, Davies J, Jones C, Van Tongeren T, Aslanidis C, de Jong P, Jansen G, Anvret M, Riley B, Williamson R, Johnson K. Detection of an unstable fragment of DNA specific to individuals with myotonic dystrophy. Nature. 1992;355:547–8.

    Article  CAS  Google Scholar 

  10. Fu YH, Pizzuti A, Fenwick RG Jr, King J, Rajnarayan S, Dunne PW, Dubel J, Nasser GA, Ashizawa T, de Jong P, et al. An unstable triplet repeat in a gene related to myotonic muscular dystrophy. Science. 1992;255:1256–8.

    Article  CAS  Google Scholar 

  11. Mahadevan M, Tsilfidis C, Sabourin L, Shutler G, Amemiya C, Jansen G, Neville C, Narang M, Barceló J, O’Hoy K, et al. Myotonic dystrophy mutation: an unstable CTG repeat in the 3′ untranslated region of the gene. Science. 1992;255:1253–5.

    Article  CAS  Google Scholar 

  12. Brook JD, McCurrach ME, Harley HG, Buckler AJ, Church D, Aburatani H, Hunter K, Stanton VP, Thirion JP, Hudson T, et al. Molecular basis of myotonic dystrophy: expansion of a trinucleotide (CTG) repeat at the 3′ end of a transcript encoding a protein kinase family member. Cell. 1992;69:799–808.

    Article  Google Scholar 

  13. Annane D, Duboc D, Mazoyer B, Merlet P, Fiorelli M, Eymard B, Radvanyi H, Junien C, Fardeau M, Gajdos P, et al. Correlation between decreased myocardial glucose phosphorylation and the DNA mutation size in myotonic dystrophy. Circulation. 1994;90:2629–34.

    Article  CAS  Google Scholar 

  14. Berul CI, Maguire CT, Aronovitz MJ, Greenwood J, Miller C, Gehrmann J, Housman D, Mendelsohn ME, Reddy S. DMPK dosage alterations result in atrioventricular conduction abnormalities in a mouse myotonic dystrophy model. J Clin Invest. 1999;103:R1–7.

    Article  CAS  Google Scholar 

  15. Lee HC, Patel MK, Mistry DJ, Wang Q, Reddy S, Moorman JR, Mounsey JP. Abnormal Na channel gating in murine cardiac myocytes deficient in myotonic dystrophy protein kinase. Physiol Genomics. 2003;12:147–57.

    Article  CAS  Google Scholar 

  16. Philips AV, Timchenko LT, Cooper TA. Disruption of splicing regulated by a CUG-binding protein in myotonic dystrophy. Science. 1998;280:737–41.

    Article  CAS  Google Scholar 

  17. Mankodi A, Lin X, Blaxall BC, Swanson MS, Thornton CA. Nuclear RNA foci in the heart in myotonic dystrophy. Circ Res. 2005;97:1152–5.

    Article  CAS  Google Scholar 

  18. Nakamori M, Kimura T, Fujimura H, Takahashi MP, Sakoda S. Altered mRNA splicing of dystrophin in type 1 myotonic dystrophy. Muscle Nerve. 2007;36:251–7.

    Article  CAS  Google Scholar 

  19. Nakamori M, Kimura T, Kubota T, Matsumura T, Sumi H, Fujimura H, Takahashi MP, Sakoda S. Aberrantly spliced alpha-dystrobrevin alters alpha-syntrophin binding in myotonic dystrophy type 1. Neurology. 2008;70:677–85.

    Article  CAS  Google Scholar 

  20. Wahbi K, Algalarrondo V, Bécane HM, Fressart V, Beldjord C, Azibi K, Lazarus A, Berber N, Radvanyi-Hoffman H, Stojkovic T, Béhin A, Laforêt P, Eymard B, Hatem S, Duboc D. Brugada syndrome and abnormal splicing of SCN5A in myotonic dystrophy type 1. Arch Cardiovasc Dis. 2013;106:635–43.

    Article  Google Scholar 

  21. Freyermuth F, Rau F, Kokunai Y, Linke T, Sellier C, Nakamori M, Kino Y, Arandel L, Jollet A, Thibault C, Philipps M, Vicaire S, Jost B, Udd B, Day JW, Duboc D, Wahbi K, Matsumura T, Fujimura H, Mochizuki H, Deryckere F, Kimura T, Nukina N, Ishiura S, Lacroix V, Campan-Fournier A, Navratil V, Chautard E, Auboeuf D, Horie M, Imoto K, Lee KY, Swanson MS, Lopez de Munain A, Inada S, Itoh H, Nakazawa K, Ashihara T, Wang E, Zimmer T, Furling D, Takahashi MP, Charlet-Berguerand N. Splicing misregulation of SCN5A contributes to cardiac-conduction delay and heart arrhythmia in myotonic dystrophy. Nat Commun. 2016;7:11067.

    Article  CAS  Google Scholar 

  22. Adsit GS, Vaidyanathan R, Galler CM, Kyle JW, Makielski JC. Channelopathies from mutations in the cardiac sodium channel protein complex. J Mol Cell Cardiol. 2013;61:34–43.

    Article  CAS  Google Scholar 

  23. Tan HL, Bink-Boelkens MT, Bezzina CR, Viswanathan PC, Beaufort-Krol GC, van Tintelen PJ, van den Berg MP, Wilde AA, Balser JR. A sodium-channel mutation causes isolated cardiac conduction disease. Nature. 2001;409:1043–7.

    Article  CAS  Google Scholar 

  24. Makiyama T, Akao M, Tsuji K, Doi T, Ohno S, Takenaka K, Kobori A, Ninomiya T, Yoshida H, Takano M, Makita N, Yanagisawa F, Higashi Y, Takeyama Y, Kita T, Horie M. High risk for bradyarrhythmic complications in patients with Brugada syndrome caused by SCN5A gene mutations. J Am Coll Cardiol. 2005;46:2100–6.

    Article  CAS  Google Scholar 

  25. Chen Q, Kirsch GE, Zhang D, Brugada R, Brugada J, Brugada P, Potenza D, Moya A, Borggrefe M, Breithardt G, Ortiz-Lopez R, Wang Z, Antzelevitch C, O'Brien RE, Schulze-Bahr E, Keating MT, Towbin JA, Wang Q. Genetic basis and molecular mechanism for idiopathic ventricular fibrillation. Nature. 1998;392:293–6.

    Article  CAS  Google Scholar 

  26. Baroudi G, Pouliot V, Denjoy I, Guicheney P, Shrier A, Chahine M. Novel mechanism for Brugada syndrome: defective surface localization of an SCN5A mutant (R1432G). Circ Res. 2001;88:E78–83.

    Article  CAS  Google Scholar 

  27. Itoh H, Shimizu M, Takata S, Mabuchi H, Imoto K. A novel missense mutation in the SCN5A gene associated with Brugada syndrome bidirectionally affecting blocking actions of antiarrhythmic drugs. J Cardiovasc Electrophysiol. 2005;16:486–93.

    Article  Google Scholar 

  28. Itoh H, Shimizu M, Mabuchi H, Imoto K. Clinical and electrophysiological characteristics of Brugada syndrome caused by a missense mutation in the S5-pore site of SCN5A. J Cardiovasc Electrophysiol. 2005;16:378–83.

    Article  CAS  Google Scholar 

  29. Amin AS, Boink GJ, Atrafi F, Spanjaart AM, Asghari-Roodsari A, Molenaar RJ, Ruijter JM, Wilde AA, Tan HL. Facilitatory and inhibitory effects of SCN5A mutations on atrial fibrillation in Brugada syndrome. Europace. 2011;13:968–75.

    Article  Google Scholar 

  30. Watanabe H, Darbar D, Kaiser DW, Jiramongkolchai K, Chopra S, Donahue BS, Kannankeril PJ, Roden DM. Mutations in sodium channel β1- and β2-subunits associated with atrial fibrillation. Circ Arrhythm Electrophysiol. 2009;2:268–75.

    Article  CAS  Google Scholar 

  31. Ziyadeh-Isleem A, Clatot J, Duchatelet S, Gandjbakhch E, Denjoy I, Hidden-Lucet F, Hatem S, Deschênes I, Coulombe A, Neyroud N, Guicheney P. A truncating SCN5A mutation combined with genetic variability causes sick sinus syndrome and early atrial fibrillation. Heart Rhythm. 2014;11:1015–23.

    Article  Google Scholar 

  32. Chong-Nguyen C, Wahbi K, Algalarrondo V, Bécane HM, Radvanyi-Hoffman H, Arnaud P, Furling D, Lazarus A, Bassez G, Béhin A, Fayssoil A, Laforêt P, Stojkovic T, Eymard B, Duboc D. Association between mutation size and cardiac involvement in myotonic dystrophy type 1: an analysis of the DM1-Heart Registry. Circ Cardiovasc Genet. 2017;10:e001526.

    Article  CAS  Google Scholar 

  33. Chou T. Electrocardiography in clinical practice: adult and pediatric. 4th ed. Philadelphia: W.B. Saunders; 1996.

    Google Scholar 

  34. Groh WJ, Groh MR, Saha C, Kincaid JC, Simmons Z, Ciafaloni E, Pourmand R, Otten RF, Bhakta D, Nair GV, Marashdeh MM, Zipes DP, Pascuzzi RM. Electrocardiographic abnormalities and sudden death in myotonic dystrophy type 1. N Engl J Med. 2008;358:2688–97.

    Article  CAS  Google Scholar 

  35. Pambrun T, Mercier A, Chatelier A, Patri S, Schott JJ, Le Scouarnec S, Chahine M, Degand B, Bois P. Myotonic dystrophy type 1 mimics and exacerbates Brugada phenotype induced by Nav1.5 sodium channel loss-of-function mutation. Heart Rhythm. 2014;11:1393–400.

    Article  Google Scholar 

  36. Maury P, Audoubert M, Cintas P, Rollin A, Duparc A, Mondoly P, Chiriac AM, Acket B, Zhao X, Pasquié JL, Cardin C, Delay M, Sadron M, Carrié D, Galinier M, Davy JM, Arne-Bès MC, Raczka F. Prevalence of type 1 Brugada ECG pattern after administration of Class 1C drugs in patients with type 1 myotonic dystrophy: myotonic dystrophy as a part of the Brugada syndrome. Heart Rhythm. 2014;11:1721–7.

    Article  Google Scholar 

  37. Wilde AA, Antzelevitch C, Borggrefe M, Brugada J, Brugada R, Brugada P, Corrado D, Hauer RN, Kass RS, Nademanee K, Priori SG, Towbin JA, Study Group on the Molecular Basis of Arrhythmias of the European Society of Cardiology. Proposed diagnostic criteria for the Brugada syndrome: consensus report. Circulation. 2002;106:2514–9.

    Article  Google Scholar 

  38. Juang JJ, Horie M. Genetics of Brugada syndrome. J Arrhythm. 2016;32:418–25.

    Article  Google Scholar 

  39. Brugada R, Brugada J, Antzelevitch C, Kirsch GE, Potenza D, Towbin JA, Brugada P. Sodium channel blockers identify risk for sudden death in patients with ST-segment elevation and right bundle branch block but structurally normal hearts. Circulation. 2000;101:510–5.

    Article  CAS  Google Scholar 

  40. Turker I, Ai T, Itoh H, Horie M. Drug-induced fatal arrhythmias: acquired long QT and Brugada syndromes. Pharmacol Ther. 2017;176:48–59.

    Article  CAS  Google Scholar 

  41. Lenègre J, Moreau PH. Le bloc auriculo-ventriculaire chronique: etude anatomique, clinique et histologique. Arch Mal Cœur. 1963;56:867–88.

    PubMed  Google Scholar 

  42. Lev M. Anatomic basis for atrioventricular block. Am J Med. 1964;37:742–8.

    Article  CAS  Google Scholar 

  43. Baruteau AE, Probst V, Abriel H. Inherited progressive cardiac conduction disorders. Curr Opin Cardiol. 2015;30:33–9.

    Article  Google Scholar 

  44. Wahbi K, Babuty D, Probst V, Wissocque L, Labombarda F, Porcher R, Bécane HM, Lazarus A, Béhin A, Laforêt P, Stojkovic T, Clementy N, Dussauge AP, Gourraud JB, Pereon Y, Lacour A, Chapon F, Milliez P, Klug D, Eymard B, Duboc D. Incidence and predictors of sudden death, major conduction defects and sustained ventricular tachyarrhythmias in 1388 patients with myotonic dystrophy type 1. Eur Heart J. 2017;38:751–8.

    PubMed  Google Scholar 

  45. Nguyen HH, Wolfe JT 3rd, Holmes DR Jr, Edwards WD. Pathology of the cardiac conduction system in myotonic dystrophy: a study of 12 cases. J Am Coll Cardiol. 1988;11:662–71.

    Article  CAS  Google Scholar 

  46. Segawa I, Kikuchi M, Tashiro A, Hiramori K, Sato M, Satodate R. Association of myotonic dystrophy and sick sinus syndrome, with special reference to electrophysiological and histological examinations. Intern Med. 1996;35:185–8.

    Article  CAS  Google Scholar 

  47. Brembilla-Perrot B, Schwartz J, Huttin O, Frikha Z, Sellal JM, Sadoul N, Blangy H, Olivier A, Louis S, Kaminsky P. Atrial flutter or fibrillation is the most frequent and life-threatening arrhythmia in myotonic dystrophy. Pacing Clin Electrophysiol. 2014;37:329–35.

    Article  Google Scholar 

  48. Merino JL, Peinado R, Sobrino JA. Sudden death in myotonic dystrophy: the potential role of bundle-branch reentry. Circulation. 2000;101:E73.

    Article  CAS  Google Scholar 

  49. Merino JL, Carmona JR, Fernández-Lozano I, Peinado R, Basterra N, Sobrino JA. Mechanisms of sustained ventricular tachycardia in myotonic dystrophy: implications for catheter ablation. Circulation. 1998;98(6):541.

    Article  CAS  Google Scholar 

  50. Bhakta D, Groh MR, Shen C, Pascuzzi RM, Groh WJ. Increased mortality with left ventricular systolic dysfunction and heart failure in adults with myotonic dystrophy type 1. Am Heart J. 2010;160:1137–41.

    Article  Google Scholar 

  51. Lindqvist P, Mörner S, Olofsson BO, Backman C, Lundblad D, Forsberg H, Henein MY. Ventricular dysfunction in type 1 myotonic dystrophy: electrical, mechanical, or both? Int J Cardiol. 2010;143:378–84.

    Article  CAS  Google Scholar 

  52. Feingold B, Mahle WT, Auerbach S, Clemens P, Domenighetti AA, Jefferies JL, Judge DP, Lal AK, Markham LW, Parks WJ, Tsuda T, Wang PJ, Yoo SJ, American Heart Association Pediatric Heart Failure Committee of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Radiology and Intervention, Council on Functional Genomics and Translational Biology; and Stroke Council. Management of cardiac involvement associated with neuromuscular diseases: a scientific statement from the American Heart Association. Circulation. 2017;136:e200–31.

    Article  Google Scholar 

  53. Berger RD, Orias D, Kasper EK, Calkins H. Catheter ablation of coexistent bundle branch and interfascicular reentrant ventricular tachycardias. J Cardiovasc Electrophysiol. 1996;7:341–7.

    Article  CAS  Google Scholar 

  54. Shiraishi H, Shirayama T, Inoue K, Tanaka H, Kuwabara H, Inoue D, Nakagawa M. Successful catheter ablation against ventricular tachycardia associated with myotonic dystrophy. Intern Med. 2000;39:39–44.

    Article  CAS  Google Scholar 

  55. Halawa A, Iskandar SB, Brahmbhatt V, Fahrig SA. Atrial flutter and myotonic dystrophy in a male adolescent treated with radiofrequency catheter ablation. Rev Cardiovasc Med. 2007;8:118–22.

    Article  Google Scholar 

  56. Wahbi K, Sebag FA, Lellouche N, Lazarus A, Bécane HM, Bassez G, Stojkovic T, Fayssoil A, Laforêt P, Béhin A, Meune C, Eymard B, Duboc D. Atrial flutter in myotonic dystrophy type 1: patient characteristics and clinical outcome. Neuromuscul Disord. 2016;26:227–33.

    Article  Google Scholar 

  57. Wahbi K, Meune C, Porcher R, Bécane HM, Lazarus A, Laforêt P, Stojkovic T, Béhin A, Radvanyi-Hoffmann H, Eymard B, Duboc D. Electrophysiological study with prophylactic pacing and survival in adults with myotonic dystrophy and conduction system disease. JAMA. 2012;307:1292–301.

    Article  CAS  Google Scholar 

  58. Lazarus A, Varin J, Babuty D, Anselme F, Coste J, Duboc D. Long-term follow-up of arrhythmia in patients with myotonic dystrophy treated by pacing—a multicenter diagnostic pacemaker study. J Am Coll Cardiol. 2002;40:1645–52.

    Article  Google Scholar 

  59. Laurent V, Pellieux S, Corcia P, Magro P, Pierre B, Fauchier L, Raynaud M, Babuty D. Mortality in myotonic dystrophy patients in the area of prophylactic pacing devices. Int J Cardiol. 2011;150:54–8.

    Article  Google Scholar 

  60. Bhakta D, Shen C, Kron J, Epstein AE, Pascuzzi RM, Groh WJ. Pacemaker and implantable cardioverter-defibrillator use in a US myotonic dystrophy type 1 population. J Cardiovasc Electrophysiol. 2011;22:1369–75.

    Article  Google Scholar 

  61. Benhayon D, Lugo R, Patel R, Carballeira L, Elman L, Cooper JM. Long-term arrhythmia follow-up of patients with myotonic dystrophy. J Cardiovasc Electrophysiol. 2015;26:305–10.

    Article  Google Scholar 

  62. Sochala M, Wahbi K, Sorbets E, Lazarus A, Bécane HM, Stojkovic T, Fayssoil A, Laforêt P, Béhin A, Sroussi M, Eymard B, Duboc D, Meune C. Risk for complications after pacemaker or cardioverter defibrillator implantations in patients with myotonic dystrophy type 1. J Neuromuscul Dis. 2017;4:175–81.

    Article  Google Scholar 

  63. Russo V, Rago A, Antonio Papa A, Nigro G. Cardiac resynchronization improves heart failure in one patient with myotonic dystrophy type 1. A case report. Acta Myol. 2012;31(2):154–5.

    PubMed  PubMed Central  Google Scholar 

  64. Kilic T, Vural A, Ural D, Sahin T, Agacdiken A, Ertas G, Yildiz Y, Komsuoglu B. Cardiac resynchronization therapy in a case of myotonic dystrophy (Steinert’s disease) and dilated cardiomyopathy. Pacing Clin Electrophysiol. 2007;30(7):916–20.

    Article  Google Scholar 

Download references

Acknowledgment

Authors thank Drs. Kazuhiko Segawa, Satoshi Kuru, Shugo Suwazono, Shingo Sasaki, Minoru Horie, Tsuyoshi Matsumura, and Masanori Takahashi for clinical data and valuable comments. This work was partly supported by grants from the Ministry of Health, Labour and Welfare of Japan (H28-Nanchitou(Nan)-Ippan-030) and Japan Agency for Medical Research and Development (AMED) (17ek0109259).

Disclosures. None.

Author information

Authors and Affiliations

  1. Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan

    Hideki Itoh

  2. Department of Neurology, National Hospital Organization Higashisaitama National Hospital, Saitama, Japan

    Takuhisa Tamura

Authors
  1. Hideki Itoh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Takuhisa Tamura
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hideki Itoh .

Editor information

Editors and Affiliations

  1. Department of Functional Diagnostic Science, Osaka University Graduate School of Medicine, Osaka, Japan

    Masanori P. Takahashi

  2. Department of Neurology, National Hospital Organization Toneyama National Hospital, Osaka, Japan

    Tsuyoshi Matsumura

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer Nature Singapore Pte Ltd.

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Itoh, H., Tamura, T. (2018). Cardiac Involvements in Myotonic Dystrophy. In: Takahashi, M., Matsumura, T. (eds) Myotonic Dystrophy. Springer, Singapore. https://doi.org/10.1007/978-981-13-0508-5_4

Download citation

  • DOI: https://doi.org/10.1007/978-981-13-0508-5_4

  • Published:

  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-13-0507-8

  • Online ISBN: 978-981-13-0508-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation