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Schäfer M, Miyamoto SD, Jaggers J, Everitt MD, von Alvensleben JC, Campbell DN, Mitchell MB, Stone ML. Non-invasive myocardial tissue deformation and discoordination indices predict cardiac allograft vasculopathy in pediatric heart transplantation patients. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1565-1574. [PMID: 38780709 DOI: 10.1007/s10554-024-03143-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
There is an urgent need for non-invasive imaging-based biomarkers suitable for diagnostic surveillance of cardiac allograft vasculopathy (CAV) in pediatric heart transplant (PHT) patients. The purpose of this study was to comprehensively investigate left ventricular (LV) myocardial deformation in conjunction with electromechanical discoordination in PHT. PHT patients with and without CAV were evaluated for echocardiography derived global longitudinal strain (GLS) and electromechanical discoordination indices including systolic stretch fraction (SSF) and diastolic relaxation fraction (DRF). SSF was increased in CAV(+) patients at the time of CAV diagnosis (median CAV(+) 5.0 vs. median CAV(-) 0.0, P = 0.008) and in the echocardiogram preceding the CAV diagnosis (median CAV(+) 29.0 vs. median CAV(-) 0.0, P < 0.001). DRF was also increased in the echocardiogram that preceded CAV diagnosis in CAV(+) patients (0.31 ± 0.08 vs. 0.25 ± 0.05, P = 0.008). The final model using indices 6-12 months prior to CAV diagnosis included GLS, SSF, and DRF providing AUC of 0.94 with sensitivity 98.5%, specificity 80.0%, positive predictive value 85.0%, and negative predictive value 94.1%. Systolic and diastolic electro-mechanical discoordination indices are significantly worse in PHT patients experiencing CAV. Non-invasive imaging guided surveillance using echocardiographic myocardial deformation indices can be improved by adding SSF and DRF to standard GLS measurements.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA.
- Heart Institute, Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO, 80045-2560, USA.
| | - Shelley D Miyamoto
- Division of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - James Jaggers
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Melanie D Everitt
- Division of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Johannes C von Alvensleben
- Division of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - David N Campbell
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Max B Mitchell
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew L Stone
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
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Romanowicz J, Ferraro AM, Harrington JK, Sleeper LA, Adar A, Levy PT, Powell AJ, Harrild DM. Pediatric Normal Values and Z Score Equations for Left and Right Ventricular Strain by Two-Dimensional Speckle-Tracking Echocardiography Derived from a Large Cohort of Healthy Children. J Am Soc Echocardiogr 2023; 36:310-323. [PMID: 36414123 DOI: 10.1016/j.echo.2022.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Strain values vary with age in children and are both vendor and platform specific. Philips QLAB 10.8 and TomTec AutoSTRAIN are two widely used strain analysis platforms, and both incorporate recent European Association of Cardiovascular Imaging/American Society of Echocardiography/Industry Task Force to Standardize Deformation Imaging guidelines. The aims of this study were to establish normal strain values and Z scores for both platforms using a large data set of healthy children and to compare values among these two platforms and a previous version, QLAB 10.5, which predated the task force guidelines. METHODS Echocardiograms from 1,032 subjects <21 years old with structurally and functionally normal hearts were included. Images were obtained on the Philips EPIQ platform. Left ventricular (LV) and right ventricular (RV) strain was analyzed using QLAB 10.8 and AutoSTRAIN, and measurement reliability was assessed. Z score equations were derived as a function of age for QLAB 10.8 (LV longitudinal and circumferential strain) and AutoSTRAIN (LV and RV longitudinal strain). A subset (n = 309) was analyzed using QLAB 10.5. Strain values were compared among the three platforms. RESULTS For both of the newer platforms, strain varied with age, with magnitude reaching a maximum at 4 to 5 years. For LV longitudinal strain, the largest differences in value were observed in the youngest patients when using QLAB 10.5; the other two platforms were similar. LV circumferential strain measurements (QLAB 10.5 vs QLAB 10.8) were different for all ages, as were measurements of RV longitudinal strain (QLAB 10.8 vs AutoSTRAIN). Reliability was greater for AutoSTRAIN than for QLAB 10.8 and greater for LV than for RV strain. CONCLUSIONS Normal RV and LV strain values and Z scores were generated from a large cohort of children for two commonly used platforms in pediatric echocardiography laboratories. Following the incorporation of task force guidelines, the greatest improvement in standardization was seen in infants. Small differences persist between modern platforms; however, these results support the cautious consideration of comparing interplatform measurements.
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Affiliation(s)
- Jennifer Romanowicz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | - Alessandra M Ferraro
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jamie K Harrington
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Adi Adar
- Pediatric Cardiology Institute, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Philip T Levy
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - David M Harrild
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Paediatric heart transplantation recipients ≥7 years of age receiving donors with pre-existing coronary atherosclerosis showed progressive coronary artery disease. Cardiol Young 2022; 32:1104-1111. [PMID: 34565492 DOI: 10.1017/s1047951121003784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study aimed to determine the effect of donor-transmitted atherosclerosis on the late aggravation of cardiac allograft vasculopathy in paediatric heart recipients aged ≥7 years. METHODS In total, 48 patients were included and 23 had donor-transmitted atherosclerosis (baseline maximal intimal thickness of >0.5 mm on intravascular ultrasonography). Logistic regression analyses were performed to identify risk factors for donor-transmitted atherosclerosis. Rates of survival free from the late aggravation of cardiac allograft vasculopathy (new or worsening cardiac allograft vasculopathy on following angiograms, starting 1 year after transplantation) in each patient group were estimated using the Kaplan-Meier method and compared using the log-rank test. The effect of the results of intravascular ultrasonography at 1 year after transplantation on the late aggravation of cardiac allograft vasculopathy, correcting for possible covariates including donor-transmitted atherosclerosis, was examined using the Cox proportional hazards model. RESULTS The mean follow-up duration after transplantation was 5.97 ± 3.58 years. The log-rank test showed that patients with donor-transmitted atherosclerosis had worse survival outcomes than those without (p = 0.008). Per the multivariate model considering the difference of maximal intimal thickness between baseline and 1 year following transplantation (hazard ratio, 22.985; 95% confidence interval, 1.948-271.250; p = 0.013), donor-transmitted atherosclerosis was a significant covariate (hazard ratio, 4.013; 95% confidence interval, 1.047-15.376; p = 0.043). CONCLUSION Paediatric heart transplantation recipients with donor-transmitted atherosclerosis aged ≥7 years had worse late cardiac allograft vasculopathy aggravation-free survival outcomes.
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Laks JA, Dipchand AI. Cardiac allograft vasculopathy: A review. Pediatr Transplant 2022; 26:e14218. [PMID: 34985793 DOI: 10.1111/petr.14218] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/11/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease, and outcomes have consistently improved over the last few decades. CAV, however, remains a leading cause of morbidity and mortality in heart transplantation and is the leading cause of death beyond 3 years post-transplantation. We sought out to provide an in-depth overview of CAV in the pediatric heart transplant population. METHODS Database searches were conducted in both Medline and Embase on the topic of cardiac vasculopathy in pediatric heart transplant recipients. The search used five broad concept terms: heart transplant; pediatric; CAV; diagnosis, prognosis, and risk factors; and guidelines and reviews. References were captured if there was at least one term in each of the concepts. The search was limited to articles in the English language. RESULTS A total of 148 articles were identified via the literature search with further articles identified via review of references. Pediatric data regarding the etiology and development of CAV remain limited although knowledge about the immune and non-immune factors playing a role are increasing. CAV continues to be difficult to detect with many invasive and non-invasive methods available, yet their effectiveness in the detection of CAV remains suboptimal. There remains no proven medical intervention to treat or reverse established CAV disease, and CAV is associated with high rates of graft loss once detected. However, several medications are used in hopes of preventing, slowing progression, or modifying the outcomes. CONCLUSION This review provides a comprehensive overview of CAV, discusses its clinical presentation, risk factors, diagnostic tools used to identify CAV in the pediatric population, and highlights the current therapeutic options and the need for ongoing research.
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Affiliation(s)
- Jessica A Laks
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Anne I Dipchand
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
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Pradhan S, Mullikin A, Zang H, Ollberding NJ, Stark S, Hill GD, Chin C, Tretter JT. Decreased Global Myocardial Work Efficiency Correlates with Coronary Vasculopathy in Pediatric Heart Transplant Patients. Pediatr Cardiol 2022; 43:515-524. [PMID: 34651198 DOI: 10.1007/s00246-021-02748-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/30/2021] [Indexed: 11/29/2022]
Abstract
Coronary angiography remains the standard for diagnosis of cardiac transplant vasculopathy (CAV), but it is invasive. Non-invasively derived left ventricle (LV) global myocardial work (GMW) indices have not been evaluated. We aimed to assess for correlations between LV GMW and the presence of CAV in a pediatric population. 24 heart transplant patients and 24 normal controls were prospectively enrolled. Patients were age-matched into groups with: orthotopic heart transplant and CAV (OHT-CAV; 6 patients, 33% male, mean age 13.5 years [SD 4.2]), orthotopic heart transplant without CAV (OHT; 18 patients, 67% male, mean age 11.1 years [SD 4.8]), and normal healthy controls (42% male, mean age 12.8 years [SD 5.0]). Transplant patients underwent cardiac catheterization with coronary angiography within 3 months of echocardiogram. Post-processing of echocardiograms with speckle-tracking echocardiography and derivation of GMW indices was performed. OHT-CAV patients had decreased global work efficiency (GWE) compared to OHT (mean difference = 7.01 [1.76, 12.25], adjusted p < 0.01). LV global longitudinal strain (GLS) and LV ejection fraction were not different between groups. Both global work index and GWE were decreased in OHT-CAV and OHT when compared to normal controls (OHT-CAV 1311.23 mmHg% vs OHT 1426.22 mmHg% vs controls 1802.81 mmHg%, adjusted p < 0.01; OHT-CAV 83.87% vs. OHT 90.87% vs. controls 95.41%, adjusted p < 0.01). GWE correlated negatively with the presence of CAV (r = - 0.44 [- 0.72, - 0.05]). This pilot study demonstrates decreased GWE correlates with pediatric CAV. This supports the need for further investigation of this promising diagnostic tool.
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Affiliation(s)
- Sarah Pradhan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Anna Mullikin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Huaiyu Zang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shelly Stark
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Garick D Hill
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Clifford Chin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Justin T Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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You J, Yu JJ, Kim MJ, Cha S, Baek JS, Choi ES, Kwon BS, Park CS, Yun TJ, Kim YH. Predictive Parameters of Decreased Left Ventricular Global Longitudinal Strain at 1 Month After Pediatric Heart Transplantation. Pediatr Cardiol 2021; 42:784-792. [PMID: 33464371 PMCID: PMC7814263 DOI: 10.1007/s00246-021-02542-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/05/2021] [Indexed: 11/27/2022]
Abstract
Previous reports indicate that the decreased left ventricular global longitudinal strain (LVGLS) seen in the early postoperative period of pediatric heart transplant patients generally recovers over the course of 1-2 years. In this study, we investigate the predictive capacity of preoperative parameters on the LVGLS decline seen at 1 month post transplant. Forty-six transplant subjects with 2D echocardiographic images sufficient for speckle tracking echocardiography were enrolled. We excluded patients diagnosed with cardiac allograft vasculopathy or with an episode of rejection 1 month before or after their echocardiographic examinations. The mean LVGLS was significantly reduced at 1 month when compared to 1 year following transplant (- 15.5% vs. - 19.4%, respectively, p < 0.001). The predictors of LVGLS that decline at 1 month were the LV mass z-score [odds ratio (OR) 1.452; 95% confidence interval (CI) 1.007-2.095, p = 0.046], recipient age (OR 1.124; 95% CI 1.015-1.245, p = 0.025), and donor age (OR 1.081; 95% CI 1.028-1.136, p = 0.002) in the univariate logistic regression analyses. Although multivariate analysis yielded no significant predictors, higher LV mass z-scores showed a trend associated with the decline of LVGLS (p = 0.087). The donor/recipient weight ratio was associated with the LV mass z-score (R2 = 0.412, p < 0.001).
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Affiliation(s)
- Jihye You
- Department of Pediatrics, Sejong General Hospital, Bucheon, Republic of Korea
| | - Jeong Jin Yu
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul, 138-736, Republic of Korea.
| | - Mi Jin Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul, 138-736 Republic of Korea
| | - Seulgi Cha
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul, 138-736 Republic of Korea
| | - Jae Suk Baek
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul, 138-736 Republic of Korea
| | - Eun Seok Choi
- Department of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bo Sang Kwon
- Department of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chun Soo Park
- Department of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Jin Yun
- Department of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Hwue Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul, 138-736 Republic of Korea
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Engelhardt K, Das B, Sorensen M, Malik S, Zellers T, Lemler M. Two-dimensional systolic speckle tracking echocardiography provides a noninvasive aid in the identification of acute pediatric heart transplant rejection. Echocardiography 2019; 36:1876-1883. [PMID: 31573720 DOI: 10.1111/echo.14481] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/02/2019] [Accepted: 08/23/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Acute rejection is an important cause of morbidity and mortality in the pediatric heart transplant (HT) population. A reliable noninvasive method for diagnosis of clinical rejection could substantially reduce these negative outcomes. OBJECTIVE Evaluate left ventricular (LV) global longitudinal strain (GLS), and global circumferential strain (GCS) as early noninvasive indicators of acute pediatric HT rejection. METHODS An 18-month prospective cohort study involving 61 patients evaluated absolute change in peak global systolic strain (GLS and GCS) from enrollment (baseline) to next planned clinical encounter (follow-up) or rejection. Acute rejection defined as a biopsy of grade ≥ 2R or treatment with enhanced immunosuppression by the transplant team, blinded to strain analysis. Two patient cohorts three months post HT without evidence of rejection at enrollment were identified. The study cohort experienced rejection. The control cohort remained free from rejection on follow-up. Two-way analysis of variance (ANOVA) models evaluated change in GLS and GCS by cohort group and time. RESULTS Applying exclusion criteria, 51 patients enrolled in the control cohort and 10 in the study cohort. The study cohort's mean GLS declined 33% from baseline to rejection (P < .001) and mean GCS declined 16.6% (P = .021). No significant change from baseline to follow-up was seen in the control cohort. A threshold absolute GLS value of 16.1% identified acute rejection with 100% sensitivity and 98% specificity (Likelihood Ratio, [LR] 51). CONCLUSION Noninvasive global longitudinal strain was sensitive and specific in the identification of acute clinical rejection in pediatric HT recipients.
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Affiliation(s)
- Kevin Engelhardt
- Department of Child Health, Division of Cardiac Intensive Care, Phoenix Children's Hospital, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Bibhuti Das
- Department of Pediatrics, Division of Cardiology, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Matthew Sorensen
- Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sadia Malik
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Health Dallas, University of Texas Southwestern (UTSW), Dallas, TX, USA
| | - Thomas Zellers
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Health Dallas, University of Texas Southwestern (UTSW), Dallas, TX, USA
| | - Matthew Lemler
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Health Dallas, University of Texas Southwestern (UTSW), Dallas, TX, USA
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Abstract
The assessment of pediatric patients after orthotropic heart transplantation (OHT) relies heavily on non-invasive imaging. Because of the potential risks associated with cardiac catheterization, expanding the role of non-invasive imaging is appealing. Echocardiography is fast, widely available, and can provide an accurate assessment of chamber sizes and function. Advanced echocardiographic methods, such as myocardial deformation, have potential to assess for acute rejection or cardiac allograft vasculopathy (CAV). While not currently part of routine care, cardiac magnetic resonance imaging (CMR) and computed tomography may potentially aid in the detection of graft complications following OHT. In particular, CMR tissue characterization holds promise for diagnosing rejection, while quantitative perfusion and myocardial late gadolinium enhancement may have a role in the detection of CAV. This review will evaluate standard and novel methods for non-invasive assessment of pediatric patients after OHT.
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Affiliation(s)
- Jonathan H Soslow
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Margaret M Samyn
- Medical College of Wisconsin, Pediatrics (Cardiology), Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Sahewalla R, Sehgal S, Blake J, Aggarwal S. Left ventricular adaptation following orthotopic heart transplantation in children: A speckle tracking echocardiographic imaging study. Clin Transplant 2019; 33:e13632. [PMID: 31309613 DOI: 10.1111/ctr.13632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/31/2019] [Accepted: 06/05/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evolution of left ventricle (LV) function in the pediatric OHT population has not been well described. Our hypothesis was that, in children following OHT without any rejection, there would be progressive normalization of LV size and function over 2 years. METHODS LV function was evaluated using STE and conventional echo parameters at five time points in pediatric OHT patients without any rejection in the first 2 years following OHT and normal controls. LV global peak systolic longitudinal strain (LVPLS) and strain rate, LV peak systolic radial and circumferential strain (LVRS and LVCS), and strain rate were analyzed. RESULTS We had twenty two patients with median age at OHT of 1.27 years ( IQR 0.19, 5.6 years). The LVPLS (mean ± SD) was abnormal in the post-OHT echocardiograms at 1 week (-12.4 ± 3.7) and 1 month (-13.9 ± 3.7) and significantly improved at 6 months (-15.8 ± 3.2), 1 year (-15.7 ± 3.1), and 2 years (-17.8 ± 2.8). However, LVPLS remained below the normal group even at 2 years following OHT (-21.3 ± 1.76). CONCLUSION In children following OHT, despite the absence of rejection, strain values are significantly impaired in the initial months, improve progressively over the first 2 years but remain abnormal compared with healthy controls.
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Affiliation(s)
- Rini Sahewalla
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Swati Sehgal
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Jennifer Blake
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Sanjeev Aggarwal
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA
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Temporal changes in left ventricular strain with the development of rejection in paediatric heart transplant recipients. Cardiol Young 2019; 29:954-959. [PMID: 31204638 PMCID: PMC6715531 DOI: 10.1017/s1047951119001185] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Myocardial strain measurements are increasingly used to detect complications following heart transplantation. However, the temporal association of these changes with allograft rejection is not well defined. The aim of this study was to describe the evolution of strain measurements prior to the diagnosis of rejection in paediatric heart transplant recipients. METHODS All paediatric heart transplant recipients (2004-2015) with at least one episode of acute rejection were identified. Longitudinal and circumferential strain measurements were assessed at the time of rejection and retrospectively on all echocardiograms until the most recent negative biopsy. Smoothing technique (LOESS) was used to visualise the changes of each variable over time and estimate the time preceding rejection at which alterations are first detectable. RESULTS A total of 58 rejection episodes were included from 37 unique patients. In the presence of rejection, there were decrements from baseline in global longitudinal strain (-18.2 versus -14.1), global circumferential strain (-24.1 versus -19.6), longitudinal strain rate (-1 versus -0.8), circumferential strain rate (-1.3 versus -1.1), peak longitudinal early diastolic strain rate (1.3 versus 1), and peak circumferential early diastolic strain rate (1.5 versus 1.3) (p<0.01 for all). The earliest detectable changes occurred 45 days prior to rejection with simultaneous alterations in myocardial strain and ejection fraction. CONCLUSIONS Changes in graft function can be detected non-invasively prior to the diagnosis of rejection. However, changes in strain occur concurrently with a decline in ejection fraction. Strain measurements aid in the non-invasive detection of rejection, but may not facilitate earlier diagnosis compared to more traditional measures of ventricular function.
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11
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Watanabe K, Schäfer M, Cassidy C, Miyamoto SD, Jone PN. Right atrial function in pediatric heart transplant patients by echocardiographic strain measurements. Pediatr Transplant 2019; 23:e13383. [PMID: 30866164 DOI: 10.1111/petr.13383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/13/2018] [Accepted: 01/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND CAV is a major cause of mortality in PHTx patients. Research on echocardiographic indices to detect CAV focuses primarily on ventricular function and less is known about RAF. Thus, we primarily sought to evaluate RAF in PHTx patients with CAV. For secondary analysis, we compared RAF between PHTx patients and control patients and evaluated RAF with respect to rejection and surgical type. METHODS We retrospectively evaluated echocardiography derived RA strain indices in recipients <18 years old and >1 year from time of transplant. The RA strain phases included, reservoir (εs), conduit (εe), pump (εa), and respective strain rate indices (SRs, SRe, SRa). RESULTS There were 36 PHTx patients and 14 age-, sex-matched control patients. There was a significant reduction in εs, εe, SRs, and SRe (P < 0.001) in the PHTx patients when compared to controls. There was no difference between the CAV (+) and CAV (-) patients with respect to RAF indices. Furthermore, εs, εe, and SRe (P < 0.05) were lower in patients with acute rejection (n = 7) compared to those without (n = 26). Patients with a bi-atrial anastomosis (n = 14) had decreased εs, εa, SRs, SRa (P < 0.05), compared to bi-caval anastomosis (n = 24). CONCLUSION PHTx patients have decreased RAF compared to healthy children. RAF does not differentiate PHTx patients based on the presence of CAV. RAF is also decreased in PHTx patients with rejection and in those transplanted with a bi-atrial anastomosis.
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Affiliation(s)
- Kae Watanabe
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado.,Division of Cardiology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michal Schäfer
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Courtney Cassidy
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Shelley D Miyamoto
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Pei-Ni Jone
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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12
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Echocardiographic Measurements of Right Ventricular Mechanics in Infants with Bronchopulmonary Dysplasia at 36 Weeks Postmenstrual Age. J Pediatr 2018; 203:210-217.e1. [PMID: 30244987 PMCID: PMC6252141 DOI: 10.1016/j.jpeds.2018.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/19/2018] [Accepted: 08/06/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To test the hypothesis that specific echocardiographic measurements of right ventricular (RV) mechanics at 36 weeks postmenstrual age (PMA) are associated with the severity of bronchopulmonary dysplasia (BPD). STUDY DESIGN A subset of 93 preterm infants (born between 27 and 29 weeks of gestation) was selected retrospectively from a prospectively enrolled cohort. BPD was defined using the National Institutes of Health workshop definition, with modifications for oxygen reduction testing and altitude. The cohort was divided into no-BPD and BPD groups using previously published methodology for analyses. Echocardiographic measurements of RV function (ie, tricuspid annular plane systolic excursion, fractional area of change, systolic-to-diastolic ratio, tissue Doppler myocardial performance index, and RV strain), RV remodeling/morphology (end-systolic left ventricular eccentricity index), and RV afterload (pulmonary artery acceleration time measure) were evaluated at 36 weeks PMA. Multivariable logistic regression determined associations between RV measurements and BPD severity. RESULTS Compared with the no-BPD cohort, the BPD group had lower birth weight z-scores (P = .04) and trended toward a male predominance (P = .08). After adjusting for birth weight z-score, gestational age, and sex, there were no between-group differences in echocardiographic measurements except for the eccentricity index (scaled OR [0.1-unit increase], 1.49; 95% CI, 1.13-2.12; P = .01). CONCLUSIONS Among conventional and emerging echocardiographic measurements of RV mechanics, eccentricity index was the sole variable independently associated with BPD severity in this study. The eccentricity index may be a useful echocardiographic measurement for characterizing RV mechanics in patients with BPD at 36 weeks PMA.
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Cote AT, Hosking M, Voss C, Human DG, Sandor GGS, Harris KC. Coronary artery intimal thickening and ventricular dynamics in pediatric heart transplant recipients. CONGENIT HEART DIS 2018; 13:663-670. [DOI: 10.1111/chd.12629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Anita T. Cote
- Department of Pediatrics; University of British Columbia & British Columbia Children’s Hospital Research Institute; Vancouver Canada
- School of Human Kinetics; Trinity Western University; Langley Canada
| | - Martin Hosking
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
| | - Christine Voss
- Department of Pediatrics; University of British Columbia & British Columbia Children’s Hospital Research Institute; Vancouver Canada
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
| | - Derek G Human
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
| | - George G. S. Sandor
- Department of Pediatrics; University of British Columbia & British Columbia Children’s Hospital Research Institute; Vancouver Canada
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
| | - Kevin C. Harris
- Department of Pediatrics; University of British Columbia & British Columbia Children’s Hospital Research Institute; Vancouver Canada
- British Columbia Children’s Hospital, Children’s Heart Centre; Vancouver Canada
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Watanabe K, Karimpour-Fard A, Michael A, Miyamoto SD, Nakano SJ. Elevated serum vascular endothelial growth factor and development of cardiac allograft vasculopathy in children. J Heart Lung Transplant 2018; 37:1075-1082. [PMID: 29954686 PMCID: PMC6261433 DOI: 10.1016/j.healun.2018.04.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/19/2018] [Accepted: 04/25/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a leading cause of retransplantation and death in pediatric heart transplant recipients. Our aim was to evaluate the association between serum vascular endothelial growth factor-A (VEGF) and CAV development in the pediatric heart transplant population. METHODS In this retrospective study performed at a university hospital, VEGF concentrations were measured by enzyme-linked immunosorbent assay in banked serum from pediatric heart transplant recipients undergoing routine cardiac catheterization. In subjects with CAV (n = 29), samples were obtained at 2 time-points: before CAV diagnosis (pre-CAV) and at the time of initial CAV diagnosis (CAV). In subjects without CAV (no-CAV, n = 16), only 1 time-point was used. VEGF concentrations (n = 74) were assayed in duplicate. RESULTS Serum VEGF is elevated in pediatric heart transplant recipients before catheter-based diagnosis of CAV (no-CAV mean: 144.0 ± 89.05 pg/ml; pre-CAV mean: 316.2 ± 118.3 pg/ml; p = 0.0002). Receiver-operating characteristic curve analysis of pre-CAV VEGF levels demonstrated an area under the curve of 87.7% (p = 0.0002), with a VEGF level of 226.3 pg/ml predicting CAV development with 77.8% sensitivity and 91.7% specificity. VEGF is similarly elevated in subjects with angiographically diagnosed CAV and in those with normal angiography but intravascular ultrasound (IVUS) evidence of CAV. CONCLUSIONS The increase in serum VEGF before onset of detectable CAV is fundamental to its utility as a predictive biomarker and suggests further investigations of VEGF in the pathogenesis of CAV are warranted in the pediatric heart transplant population.
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Affiliation(s)
- Kae Watanabe
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Anis Karimpour-Fard
- Department of Pharmacology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Alix Michael
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Shelley D Miyamoto
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Stephanie J Nakano
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.
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Godown J, Dodd DA, Stanley M, Havens C, Xu M, Slaughter JC, Bearl DW, Soslow JH. Changes in left ventricular strain parameters following pediatric heart transplantation. Pediatr Transplant 2018; 22:e13166. [PMID: 29575396 PMCID: PMC6047919 DOI: 10.1111/petr.13166] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2018] [Indexed: 11/30/2022]
Abstract
STE is increasingly utilized to assess strain in a variety of pathologies. Strain measurements have demonstrated utility following HTx and may aid in the detection of rejection and CAV. Strain parameters have not been well defined in the pediatric HTx population. This study aimed to describe strain in pediatric HTx recipients compared to controls and assess changes over time. All pediatric HTx recipients with available echocardiograms (2004-2015) without rejection or CAV were identified. Longitudinal and circumferential strain was measured at <1 month, 1 year, 3 years, and 5 years post-transplant and compared to controls. A total of 218 echocardiograms were analyzed in 79 HTx recipients. At <1 month post-transplant, there was a significant decrement in longitudinal strain (GLS -14.6 vs -19.2, P < .001) with concurrent augmentation of circumferential strain (GCS -27.3 vs -24.3, P = .005). By 1 year post-HTx, all strain parameters normalized and were not significantly different from the control population. In the absence of graft complications, strain parameters did not change up to 5 years post-transplant. Abnormal longitudinal strain parameters are present in the early post-HTx period with a compensatory increase in circumferential strain. These changes normalize by 1 year post-transplant and do not change over time in the absence of graft complications.
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Affiliation(s)
- Justin Godown
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Debra A. Dodd
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Michael Stanley
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Corey Havens
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - James C. Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - David W. Bearl
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN
| | - Jonathan H. Soslow
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN
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Worsening in Longitudinal Strain and Strain Rate Anticipates Development of Pediatric Transplant Coronary Artery Vasculopathy as Soon as One Year Following Transplant. Pediatr Cardiol 2018; 39:129-139. [PMID: 28948364 DOI: 10.1007/s00246-017-1737-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
Abstract
Transplant coronary artery vasculopathy (TCAV) following orthotopic heart transplantation (OHT) continues to be the primary reason for late graft failure in children. The current gold standard of diagnosis of TCAV is coronary angiography with or without intravascular ultrasound. This study investigates the longitudinal use of speckle-tracking echocardiographic strain imaging as an early non-invasive marker to screen for development of TCAV. Echocardiograms from patients who underwent OHT between 2006 and 2010 at Children's Hospital Colorado (n = 50) were retrospectively assessed. Studies were evaluated at baseline (within a month of transplant), then at each annual clinical follow-up for peak longitudinal (LS) and circumferential (CS) strain, systolic strain rate, and diastolic strain rate using Siemens Velocity Vector Imaging software. Comparisons were made between subjects who did and did not develop TCAV. Mean time to TCAV diagnosis following OHT was 3.2 years (range 1-5.1 years). One year after transplant, significant differences were seen between groups in LS (non-TCAV mean -19.6%, TCAV mean -17.3%, p = 0.03) and longitudinal strain rate (non-TCAV mean -1.7%/s, TCAV mean -1.4%/s, p = 0.04). These differences persisted in subsequent years. Differences in LS preceded the catheterization-based diagnosis of TCAV in pediatric heart recipients and were noted as early as one year post transplant. Additionally, within-subject LS changes may have utility as a non-invasive screening tool to predict those patients at increased risk for development of TCAV.
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