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Ji X, Zhang J, Xie Y, Wang W, Zhang Y, Xie M, Zhang L. Speckle-Tracking Echocardiography in Right Ventricular Function of Clinically Well Patients with Heart Transplantation. Diagnostics (Basel) 2024; 14:1305. [PMID: 38928720 PMCID: PMC11203351 DOI: 10.3390/diagnostics14121305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 05/31/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Heart transplantation (HT) is the mainstream therapy for end-stage heart disease. However, the cardiac graft function can be affected by several factors. It is important to monitor HT patients for signs of graft dysfunction. Transthoracic echocardiography is a simple, first-line, and non-invasive method for the assessment of cardiac function. The emerging speckle-tracking echocardiography (STE) could quickly and easily provide additive information over traditional echocardiography. STE longitudinal deformation parameters are markers of early impairment of ventricular function. Although once called the "forgotten ventricle", right ventricular (RV) assessment has gained attention in recent years. This review highlights the potentially favorable role of STE in assessing RV systolic function in clinically well HT patients.
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Affiliation(s)
- Xiang Ji
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (X.J.); (J.Z.)
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Junmin Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (X.J.); (J.Z.)
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yuji Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (X.J.); (J.Z.)
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Wenyuan Wang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (X.J.); (J.Z.)
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yiwei Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (X.J.); (J.Z.)
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (X.J.); (J.Z.)
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Li Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (X.J.); (J.Z.)
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
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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 2024:10.1007/s10554-024-03143-6. [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] [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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Sun Z, Cai Y, Yang Y, Huang L, Xie Y, Zhu S, Wu C, Sun W, Zhang Z, Li Y, Wang J, Fang L, Yang Y, Lv Q, Dong N, Zhang L, Gu H, Xie M. Early left ventricular systolic function is a more sensitive predictor of adverse events after heart transplant. Int J Cardiol 2024; 398:131620. [PMID: 38036269 DOI: 10.1016/j.ijcard.2023.131620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/30/2023] [Accepted: 11/26/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND First-phase ejection fraction (EF1) is a novel measure of early changes in left ventricular systolic function. This study was to investigate the prognostic value of EF1 in heart transplant recipients. METHODS Heart transplant recipients were prospectively recruited at the Union Hospital, Wuhan, China between January 2015 and December 2019. All patients underwent clinical examination, biochemistry measures [brain natriuretic peptide (BNP) and creatinine] and transthoracic echocardiography. The primary endpoint was a combined event of all-cause mortality and graft rejection. RESULTS In 277 patients (aged 48.6 ± 12.5 years) followed for a median of 38.7 [26.8-45.0] months, there were 35 (12.6%) patients had adverse events including 20 deaths and 15 rejections. EF1 was negatively associated with BNP (β = -0.220, p < 0.001) and was significantly lower in patients with events compared to those without. EF1 had the largest area under the curve in ROC analysis compared to other measures. An optimal cut-off value of 25.8% for EF1 had a sensitivity of 96.3% and a specificity of 97.1% for prediction of events. EF1 was the most powerful predictor of events with hazard ratio per 1% change in EF1: 0.628 (95%CI: 0.555-0.710, p < 0.001) after adjustment for left ventricular ejection fraction and global longitudinal strain. CONCLUSIONS Early left ventricular systolic function as measured by EF1 is a powerful predictor of adverse outcomes after heart transplant. EF1 may be useful in risk stratification and management of heart transplant recipients.
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Affiliation(s)
- Zhenxing Sun
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yu Cai
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yujia Yang
- British Heart Foundation Centre of Research Excellence, King's College London, UK
| | - Lei Huang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yuji Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Shuangshuang Zhu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Chun Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Wei Sun
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Ziming Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Jing Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Lingyun Fang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yali Yang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Qing Lv
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China.
| | - Haotian Gu
- British Heart Foundation Centre of Research Excellence, King's College London, UK.
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China.
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The predictive value of deep learning-based cardiac ultrasound flow imaging for hypertrophic cardiomyopathy complicating arrhythmias. Eur J Med Res 2023; 28:36. [PMID: 36658623 PMCID: PMC9850559 DOI: 10.1186/s40001-022-00975-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/29/2022] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To investigate the predictive value of deep learning-based cardiac ultrasound flow imaging for hypertrophic cardiomyopathy (HCM) complicated by arrhythmias. METHODS The clinical data of 158 patients with hypertrophic cardiomyopathy were retrospectively collected from July 2019 to December 2021, and additionally divided into training group 106 cases, validation group 26 cases and test group 26 cases according to the ratio of 4:1:1, and divided into concurrent and non-concurrent groups according to whether they were complicated by arrhythmia or not, respectively. General data of patients (age, gender, BMI, systolic blood pressure, diastolic blood pressure, HR) were collected, a deep learning model for cardiac ultrasound flow imaging was established, and image data, LVEF, LAVI, E/e', vortex area change rate, circulation intensity change rate, mean blood flow velocity, and mean EL value were extracted. RESULTS The differences in general data (age, gender, BMI, systolic blood pressure, diastolic blood pressure, HR) between the three groups were not statistically significant, P > 0.05. The differences in age, gender, BMI, systolic blood pressure, diastolic blood pressure, HR between the patients in the concurrent and non-concurrent groups in the training group were not statistically significant, P > 0.05. CONCLUSIONS Deep learning-based cardiac ultrasound flow imaging can identify cardiac ultrasound images more accurately and has a high predictive value for arrhythmias complicating hypertrophic cardiomyopathy, and vortex area change rate, circulation intensity change rate, mean flow velocity, mean EL, LAVI, and E/e' are all risk factors for arrhythmias complicating hypertrophic cardiomyopathy.
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Yang Y, Li T, Zhou X, Tan Z, Chen R, Xiao Z, Li X, Luo W, Xu H, Ye W, Liu E, Wu Z, Wu M, Liu H. Multiparametric cardiovascular magnetic resonance characteristics and dynamic changes in asymptomatic heart-transplanted patients. Eur Radiol 2022:10.1007/s00330-022-09358-2. [PMID: 36571606 DOI: 10.1007/s00330-022-09358-2] [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: 09/22/2022] [Revised: 09/22/2022] [Accepted: 11/30/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To describe the dynamic changes in cardiac deformation and tissue characteristics using cardiac magnetic resonance (CMR) in asymptomatic patients during 12 months after heart transplantation (HT). METHODS From April 2020 to January 2021, 21 consecutive HT patients without clinical symptoms were included in this prospective study. Multiparametric CMR was performed at 3, 6, and 12 months after HT. Twenty-five healthy volunteers served as controls. RESULTS During follow-up, a decline in left ventricular (LV) global radial strain (GRS) (p = 0.020) and right ventricular (RV) global longitudinal strain (GLS) (p < 0.001) and an increase in post-contrast T1 (p = 0.024) and T2 (p < 0.001) in asymptomatic HT patients occurred at 3 months, which normalized at 6 months postoperatively, compared with those in healthy controls. A decline in LVGLS (p < 0.001) and LV global circumferential strain (GCS) (p < 0.001) and an increase in native T1 (p < 0.001), T2 (p < 0.001), and extracellular volume (ECV) (p < 0.001) occurred at 3 months. Although most parameters improved gradually, LVGLS, native T1, and ECV remained abnormal compared with those in healthy controls at 12 months; only T2 and LVGCS were normalized at 6 months and 12 months, respectively. ECV was significantly correlated with LVGLS, LVGCS, and LVGRS. CONCLUSION Cardiac deformation and tissue characteristics were abnormal early after HT, although the patients were clinically asymptomatic. The dynamic changes in CMR characteristics demonstrate a gradual recovery of myocardial injury associated with transplantation during the first 12 months after HT. KEY POINTS • Multiparametric CMR can detect the dynamic changes of transplantation-associated myocardial injury. • Post-contrast T1, T2, LVGRS, and RVGLS values are normalized at 6 months after HT. • Native T1, ECV, and LVGLS values remain abnormal compared with those in healthy controls at 12 months after HT.
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Affiliation(s)
- Yuelong Yang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.,Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Tingyu Li
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Xiaobing Zhou
- Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, 519000, China
| | - Zekun Tan
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Rui Chen
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Zebin Xiao
- Department of Pathology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Xiaodan Li
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Wei Luo
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Huanwen Xu
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Weitao Ye
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Entao Liu
- WeiLun PET Center, Department of Nuclear Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Zhigang Wu
- Philips Healthcare China, Shenzhen, 518000, China
| | - Min Wu
- Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China.
| | - Hui Liu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China. .,Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China. .,Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China.
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da Costa RCPL, Rodrigues ACT, Vieira MLC, Fischer CH, Monaco CG, Filho EBL, Bacal F, Caixeta A, Morhy SS. Evaluation of the myocardial deformation in the diagnosis of rejection after heart transplantation. Front Cardiovasc Med 2022; 9:991016. [PMID: 36312230 PMCID: PMC9606419 DOI: 10.3389/fcvm.2022.991016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/05/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction Heart transplantation represents main therapy for end-stage heart failure. However, survival after transplantation is limited by development of graft rejection. Endomyocardial biopsy, an invasive and expensive procedure, is gold standard technique for diagnosis of rejection. Most of biopsy complications are observed using echocardiography. Novel echocardiographic techniques, such as myocardial strain and three-dimensional reconstruction, can be useful in heart transplant patients. Purpose To evaluate ventricular strain in heart transplant patients and association with rejection, cellular or humoral, as well as two- and three-dimensional echocardiographic parameters. Methods Cohort of patients from heart transplant program taken to echocardiography after endomyocardial biopsy, from December 2017 to January 2020. Ventricular strain and three-dimensional left ventricle parameters were studied. Rejection results were retrieved from medical record. Qualitative variables were expressed by absolute frequency and percentages, while continuous variables by means and standard deviations. Association between rejection and variables of interest was measured by odds ratio and confidence interval of 95%, with p-value < 0.05. Results 123 post-endomyocardial biopsy echocardiographic exams were performed in 54 patients. Eighteen exams were excluded, lasting 105 exams to be evaluated for conventional and advanced echocardiographic parameters. Male patients were 60.4%. Prevalence of cellular rejection was 8.6%, humoral rejection 12.4%, and rejection of any type 20%. There was no association between right ventricular strain and rejection, whether cellular (p = 0.118 and p = 0.227 for septum and free wall, respectively), humoral (p = 0.845 and p = 0.283, respectively), or of any type (0.504 and 0.446). There was no correlation between rejection and left ventricle global longitudinal strain, three-dimensional ejection fraction or desynchrony index. Conventional parameters associated to rejection were left ventricle posterior wall thickness [OR 1.660 (1.163; 2.370), p = 0.005] and left ventricle mass index [OR 1.027 (1.011; 1.139), p = 0.001]. Left ventricle posterior wall thickness remained significant after analysis of cellular and humoral rejection separately [OR 1.825 (1.097; 3.036), p = 0.021 and OR 1.650 (1.028; 2.648), p = 0.038, respectively]. Conclusions There was no association between ventricular strain, three-dimensional left ventricular ejection fraction and the desynchrony index and rejection, cellular or humoral. Evidence of association of graft rejection with left ventricle posterior wall thickness and left ventricle mass index was observed.
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The Role of Nutrition in Primary and Secondary Prevention of Cardiovascular Damage in Childhood Cancer Survivors. Nutrients 2022; 14:nu14163279. [PMID: 36014785 PMCID: PMC9415958 DOI: 10.3390/nu14163279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/05/2022] [Accepted: 08/07/2022] [Indexed: 12/03/2022] Open
Abstract
Innovative therapeutic strategies in childhood cancer led to a significant reduction in cancer-related mortality. Cancer survivors are a growing fragile population, at risk of long-term side effects of cancer treatments, thus requiring customized clinical attention. Antineoplastic drugs have a wide toxicity profile that can limit their clinical usage and spoil patients’ life, even years after the end of treatment. The cardiovascular system is a well-known target of antineoplastic treatments, including anthracyclines, chest radiotherapy and new molecules, such as tyrosine kinase inhibitors. We investigated nutritional changes in children with cancer from the diagnosis to the end of treatment and dietary habits in cancer survivors. At diagnosis, children with cancer may present variable degrees of malnutrition, potentially affecting drug tolerability and prognosis. During cancer treatment, the usage of corticosteroids can lead to rapid weight gain, exposing children to overweight and obesity. Moreover, dietary habits and lifestyle often dramatically change in cancer survivors, who acquire sedentary behavior and weak adherence to dietary guidelines. Furthermore, we speculated on the role of nutrition in the primary prevention of cardiac damage, investigating the potential cardioprotective role of diet-derived compounds with antioxidative properties. Finally, we summarized practical advice to improve the dietary habits of cancer survivors and their families.
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Husain N, Watanabe K, Berhane H, Gupta A, Markl M, Rigsby CK, Robinson JD. Multi-parametric cardiovascular magnetic resonance with regadenoson stress perfusion is safe following pediatric heart transplantation and identifies history of rejection and cardiac allograft vasculopathy. J Cardiovasc Magn Reson 2021; 23:135. [PMID: 34809650 PMCID: PMC8607604 DOI: 10.1186/s12968-021-00803-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/10/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The progressive risk of graft failure in pediatric heart transplantation (PHT) necessitates close surveillance for rejection and coronary allograft vasculopathy (CAV). The current gold standard of surveillance via invasive coronary angiography is costly, imperfect and associated with complications. Our goal was to assess the safety and feasibility of a comprehensive multi-parametric CMR protocol with regadenoson stress perfusion in PHT and evaluate for associations with clinical history of rejection and CAV. METHODS We performed a retrospective review of 26 PHT recipients who underwent stress CMR with tissue characterization and compared with 18 age-matched healthy controls. CMR protocol included myocardial T2, T1 and extracellular volume (ECV) mapping, late gadolinium enhancement (LGE), qualitative and semi-quantitative stress perfusion (myocardial perfusion reserve index; MPRI) and strain imaging. Clinical, demographics, rejection score and CAV history were recorded and correlated with CMR parameters. RESULTS Mean age at transplant was 9.3 ± 5.5 years and median duration since transplant was 5.1 years (IQR 7.5 years). One patient had active rejection at the time of CMR, 11/26 (42%) had CAV 1 and 1/26 (4%) had CAV 2. Biventricular volumes were smaller and cardiac output higher in PHT vs. healthy controls. Global T1 (1053 ± 42 ms vs 986 ± 42 ms; p < 0.001) and ECV (26.5 ± 4.0% vs 24.0 ± 2.7%; p = 0.017) were higher in PHT compared to helathy controls. Significant relationships between changes in myocardial tissue structure and function were noted in PHT: increased T2 correlated with reduced LVEF (r = - 0.57, p = 0.005), reduced global circumferential strain (r = - 0.73, p < 0.001) and reduced global longitudinal strain (r = - 0.49, p = 0.03). In addition, significant relationships were noted between higher rejection score and global T1 (r = 0.38, p = 0.05), T2 (r = 0.39, p = 0.058) and ECV (r = 0.68, p < 0.001). The presence of even low-grade CAV was associated with higher global T1, global ECV and maximum segmental T2. No major side effects were noted with stress testing. MPRI was analyzed with good interobserver reliability and was lower in PHT compared to healthy controls (0.69 ± - 0.21 vs 0.94 ± 0.22; p < 0.001). CONCLUSION In a PHT population with low incidence of rejection or high-grade CAV, CMR demonstrates important differences in myocardial structure, function and perfusion compared to age-matched healthy controls. Regadenoson stress perfusion CMR could be safely and reliably performed. Increasing T2 values were associated with worsening left ventricular function and increasing T1/ECV values were associated with rejection history and low-grade CAV. These findings warrant larger prospective studies to further define the role of CMR in PHT graft surveillance.
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Affiliation(s)
- Nazia Husain
- Department of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Kae Watanabe
- Department of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Haben Berhane
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, USA
| | - Aditi Gupta
- Lincoln Medical and Mental Health Center, Bronx, NY USA
| | - Michael Markl
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, USA
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Cynthia K. Rigsby
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, USA
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, USA
- Department of Medical Imaging, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
| | - Joshua D. Robinson
- Department of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, USA
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, USA
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9
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Niemelä J, Ylänen K, Suominen A, Pushparajah K, Mathur S, Sarkola T, Jahnukainen K, Eerola A, Poutanen T, Vettenranta K, Ojala T. Cardiac Function After Cardiotoxic Treatments for Childhood Cancer-Left Ventricular Longitudinal Strain in Screening. Front Cardiovasc Med 2021; 8:715953. [PMID: 34733890 PMCID: PMC8558299 DOI: 10.3389/fcvm.2021.715953] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The majority of childhood cancer survivors (CCSs) have been exposed to cardiotoxic treatments and often present with modifiable cardiovascular risk factors. Our aim was to evaluate the value of left ventricular (LV) longitudinal strain for increasing the sensitivity of cardiac dysfunction detection among CCSs. Methods: We combined two national cohorts: neuroblastoma and other childhood cancer survivors treated with anthracyclines. The final data consisted of 90 long-term CCSs exposed to anthracyclines and/or high-dose chemotherapy with autologous stem cell rescue and followed up for > 5 years and their controls (n = 86). LV longitudinal strain was assessed with speckle tracking (Qlab) and LV ejection fraction (EF) by three-dimensional echocardiography (3DE). Results: Of the CCSs, 11% (10/90) had abnormal LV longitudinal strain (i.e., < -17.5%); of those, 70% (7/10) had normal 3DE LV EF. Multivariable linear model analysis demonstrated that follow-up time (p = 0.027), sex (p = 0.020), and BMI (p = 0.002) were significantly associated with LV longitudinal strain. Conversely, cardiac risk group, hypertension, age, cumulative anthracycline dose or exposure to chest radiation were not. Conclusion: LV longitudinal strain is a more sensitive method than LV EF for the detection of cardiac dysfunction among CCSs. Therefore, LV longitudinal strain should be added to the screening panel, especially for those with modifiable cardiovascular risk factors.
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Affiliation(s)
- Jussi Niemelä
- Department of Pediatric Cardiology, Pediatric Research Center, New Children's Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland.,Department of Pediatrics and Adolescent Medicine, Turku University Hospital, University of Turku, Turku, Finland
| | - Kaisa Ylänen
- Department of Pediatric Cardiology, Pediatric Research Center, New Children's Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland.,Center for Child Health Research, Tampere, Finland.,Department of Pediatrics, Faculty of Medicine and Health Technology, Tampere University Hospital, Tampere University, Tampere, Finland
| | - Anu Suominen
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children's Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Kuberan Pushparajah
- Department of Paediatric Cardiology, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Trust, London, United Kingdom.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Sujeev Mathur
- Department of Paediatric Cardiology, Evelina London Children's Hospital, Guy's & St. Thomas' NHS Trust, London, United Kingdom.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Taisto Sarkola
- Department of Pediatric Cardiology, Pediatric Research Center, New Children's Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland.,Minerva Foundation Institute for Medical Research, Biomedicum Helsinki, Helsinki, Finland
| | - Kirsi Jahnukainen
- Division of Hematology-Oncology and Stem Cell Transplantation, New Children's Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Anneli Eerola
- Center for Child Health Research, Tampere, Finland.,Department of Pediatrics, Faculty of Medicine and Health Technology, Tampere University Hospital, Tampere University, Tampere, Finland
| | - Tuija Poutanen
- Center for Child Health Research, Tampere, Finland.,Department of Pediatrics, Faculty of Medicine and Health Technology, Tampere University Hospital, Tampere University, Tampere, Finland
| | - Kim Vettenranta
- Department of Pediatrics, New Children's Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Tiina Ojala
- Department of Pediatric Cardiology, Pediatric Research Center, New Children's Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
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10
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Lv Q, Li M, Li H, Wu C, Dong N, Li Y, Zhang L, Xie M. Assessment of biventricular function by three-dimensional speckle-tracking echocardiography in clinically well pediatric heart transplantation patients. Echocardiography 2020; 37:2107-2115. [PMID: 33078446 DOI: 10.1111/echo.14893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/08/2020] [Accepted: 09/25/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The biventricular function plays an important role in the prognosis of pediatric heart transplantation (HTx) patients. Therefore, in this study, we aimed to evaluate the biventricular function of pediatric HTx patients by three-dimensional (3D) speckle-tracking echocardiography (3D-STE). METHODS We enrolled 30 clinically well pediatric HTx patients and 30 healthy controls with a similar distribution of sex and age to the HTx. All participants underwent comprehensive two-dimensional (2D) and 3D echocardiography. Left ventricular (LV) global longitudinal strain (GLS), global circumferential strain (GCS), left and right ventricular ejection fraction (LVEF and RVEF, respectively), and right ventricular free wall longitudinal strain (RV FWLS) were acquired by 3D-STE. Moreover, the correlations between strains and clinical data were explored. RESULTS Compared with controls, LV GLS was decreased in pediatric HTx patients (P < .05), while LV GCS and LVEF showed no difference. LV GLS showed a weak correlation with cold ischemic time in HTx group (r = 0.396, P < .05). Meanwhile, RVEF and RV FWLS were significantly lower in the HTx group (P < .05). In the HTx group, RV FWLS showed a weak correlation with the preoperative mean pulmonary artery pressure (r = 0.420, P < .05) and postoperative pulmonary artery systolic pressure (r = 0.465, P < .05). CONCLUSION The 3D-biventricular mechanical functions were decreased in clinically well pediatric HTx patients. The provided characteristics and appropriate normal values of biventricular mechanical functions can be the basis in subsequent studies in the pediatric HTx patients.
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Affiliation(s)
- Qing Lv
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Meng Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - He Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chun Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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11
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Li M, Lv Q, Wang S, Zhu S, Li H, Wu C, Dong N, Li Y, Zhang L, Xie M. Assessment of biatrial function in clinically well pediatric bicaval heart transplantation patients by three-dimensional echocardiography. Int J Cardiovasc Imaging 2020; 37:921-929. [PMID: 33048269 DOI: 10.1007/s10554-020-02067-1] [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] [Received: 05/23/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
Atrial size and function are closely correlated with atrial contributions to cardiovascular performance. Therefore, in this study, we aimed to assess atrial size and function in pediatric heart transplantation (HTx) patients using three-dimensional echocardiography (3DE). We enrolled 33 clinically well pediatric HTx patients and 33 healthy controls with a similar distribution of sex and age to the HTx patients. All patients underwent two-dimensional echocardiography (2DE) and 3DE. 2DE- and 3DE-derived biatrial maximal volume (Vmax), minimal volume (Vmin), ejection volume (EV), ejection fraction (EF), volume before atrial contraciton (VpreA), passive EV, passive EF, active EV and active EF were obtained in all patients. The 3D left atrail (LA) Vmax, Vmin and VpreA increased significantly in HTx patients after being indexed by BSA, while 3D LAEV and passive EV decreased significantly (P < 0.05). Moreover, the 3D LAEF, LA passive EF, and LA active EF all decreased significantly in HTx patients (P < 0.05). The 3D right atrial (RA) Vmax, Vmin, and VpreA increased significantly in HTx patients (P < 0.05), while the 3D RAEF and RA passive EF decreased significantly in HTx patients (P < 0.05). 3DE-derived LAVmax, LAVpreA, LA passive EV, LAEF, and LA passive EF were all lower than the corresponding 2D parameters. 3DE-derived RAVpreA, RA passive EV and RAEF were all lower than the corresponding 2D parameters. Atrial sizes and function assessed by 3DE- and 2DE-derived parameters, yield significantly discordant results in pediatric HTx patients. 3DE confirms significantly enlarged atrial sizes and decreased atrial functions in pediatric HTx patients.
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Affiliation(s)
- Meng Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Qing Lv
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Shuyuan Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Shuangshuang Zhu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - He Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chun Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China. .,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China. .,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
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12
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Lv Q, Sun W, Wang J, Wu C, Li H, Shen X, Liang B, Dong N, Li Y, Zhang L, Xie M. Evaluation of Biventricular Functions in Transplanted Hearts Using 3-Dimensional Speckle-Tracking Echocardiography. J Am Heart Assoc 2020; 9:e015742. [PMID: 32370590 PMCID: PMC7660853 DOI: 10.1161/jaha.119.015742] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The current study aims to validate the accuracy of 3-dimensional speckle-tracking echocardiography (3D-STE) in evaluating biventricular functions against the accuracy of cardiac magnetic resonance (CMR) and to explore the comprehensive characteristics and normal values for 3D-biventricular functions in transplanted hearts. Methods and Results A cohort of 35 heart transplant (HT) patients underwent both 3D echocardiography and CMR examination to validate the accuracy of 3D-STE in evaluating biventricular functions (Protocol 1). Then, 3D-STE derived biventricular functions were compared between 46 HT patients and 46 non-HT controls (Protocol 2). Protocol 1, validated that 3D-STE showed excellent accuracy in evaluating biventricular functions of transplanted hearts against CMR. Protocol 2, revealed lower (normal range) 3D-biventricular ejection fractions in HT patients than in controls (P<0.001). 3D-left ventricular global longitudinal strain, left ventricular-global circumferential strain, left ventricular-global radial strain, left ventricular-global performance index and right ventricular free-wall longitudinal strain were all lower in the HT patients than in healthy controls (P<0.001). Further, these strain values were all good for differentiating between groups (areas under the curve: 0.80-0.94, P<0.001). Moreover, left ventricular-lateral-wall radial displacement was higher and septal-wall radial displacement was lower in the HT group than in control group (P<0.001). Conclusions Compared with cardiac magnetic resonance, 3D-STE can evaluate biventricular functions of transplanted hearts accurately; 3D-biventricular mechanical functions are reduced even in clinically well HT patients. The provided characteristics and appropriate normal values of biventricular functions can be the basis for detection of ventricular dysfunction during follow-ups and further studies on transplanted hearts.
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Affiliation(s)
- Qing Lv
- Department of Ultrasound Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China.,Hubei Province Key Laboratory of Molecular Imaging Wuhan China
| | - Wei Sun
- Department of Ultrasound Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China.,Hubei Province Key Laboratory of Molecular Imaging Wuhan China
| | - Jing Wang
- Department of Ultrasound Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China.,Hubei Province Key Laboratory of Molecular Imaging Wuhan China
| | - Chun Wu
- Department of Ultrasound Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China.,Hubei Province Key Laboratory of Molecular Imaging Wuhan China
| | - He Li
- Department of Ultrasound Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China.,Hubei Province Key Laboratory of Molecular Imaging Wuhan China
| | - Xuehua Shen
- Department of Radiology Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Bo Liang
- Department of Radiology Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Nianguo Dong
- Department of Cardiovascular Surgery Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Yuman Li
- Department of Ultrasound Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China.,Hubei Province Key Laboratory of Molecular Imaging Wuhan China
| | - Li Zhang
- Department of Ultrasound Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China.,Hubei Province Key Laboratory of Molecular Imaging Wuhan China
| | - Mingxing Xie
- Department of Ultrasound Union Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China.,Hubei Province Key Laboratory of Molecular Imaging Wuhan China
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13
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Cardiovascular magnetic resonance-derived myocardial strain in asymptomatic heart transplanted patients and its correlation with late gadolinium enhancement. Eur Radiol 2020; 30:4337-4346. [PMID: 32232791 DOI: 10.1007/s00330-020-06763-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/16/2020] [Accepted: 02/19/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To investigate whether cardiovascular magnetic resonance (CMR)-derived myocardial strains were abnormal in asymptomatic heart transplant (HT) patients with normal left ventricular ejection fraction (LVEF) and to detect the relationship between CMR-derived myocardial strain parameters and late gadolinium enhancement (LGE) in asymptomatic HT patients. METHODS A total of 72 HT patients and 35 healthy volunteers underwent 1.5-T MR scanning. The examination protocol included basic cine imaging and LGE. The deformation registration algorithm (DRA) and feature tracking (FT) software were used for the strain analyses. Myocardial strain measurements included left ventricular global longitudinal strain (LVGLS), LV global circumferential strain (LVGCS), LV global radial strain (LVGRS) and right ventricular longitudinal strain (RVLS). RESULTS Compared with healthy volunteers, HT patients had significantly decreased DRA- and FT- derived myocardial strain measurements (all p < 0.05). There was a significant correlation and high reproducibility between the DRA- and FT-derived strain parameters. Both CMR-derived LVGLS and LVGRS were significantly related to the presence of LGE, and multivariate logistic regression analyses showed that the LVGLS measurement obtained from both techniques was independently associated with the presence of LGE. The odds ratios (ORs) for DRA- and FT-LVGLS were 1.340 and 1.342, respectively. CONCLUSIONS Asymptomatic HT patients with preserved LVEF exhibited reduced myocardial strain parameters. The CMR-derived LVGLS was independently related to the presence of LGE in HT patients. KEY POINTS • Reduced myocardial strain parameters were found in asymptomatic heart transplanted (HT) patients with normal left ventricular ejection fraction (LVEF). • The deformation registration algorithm (DRA) and feature tracking (FT)-derived strains in asymptomatic HT patients had high reproducibility. • DRA- and FT-derived LVGLS had an independent relationship with late gadolinium enhancement (LGE) in asymptomatic HT patients.
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14
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Zhu S, Li M, Tian F, Wang S, Li Y, Yin P, Zhang L, Xie M. Diagnostic value of myocardial strain using two-dimensional speckle-tracking echocardiography in acute cardiac allograft rejection: A systematic review and meta-analysis. Echocardiography 2020; 37:561-569. [PMID: 32200582 DOI: 10.1111/echo.14637] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/06/2020] [Accepted: 03/01/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Two-dimensional speckle-tracking echocardiography (2D STE) has been demonstrated to have certain diagnostic utility in heart transplantation (HTX) patients with acute cardiac allograft rejection (ACAR). The aim of the systematic review and meta-analysis was to evaluate the diagnostic value of common strain parameters for ACAR in HTX patients. METHODS After conducting a database search, we selected studies evaluating left ventricular global longitudinal strain (GLS), circumferential strain (CS), radial strain (RS), and free wall right ventricular longitudinal strain (RV FW) in rejection group vs rejection-free group. RESULTS After reviewing 886 publications, seven studies were finally included in the meta-analysis, representing the data of 1173 pairs of endomyocardial biopsy and echocardiographic examination. Heart transplantation patients with rejection had significantly lower GLS than rejection-free subjects (weighted mean difference -2.32 (95% CI, -3.41 to -1.23; P < .001). Heart transplantation patients with rejection had significantly lower CS than rejection-free subjects (weighted mean difference -2.49 (95% CI, -4.05 to -0.91; P = .0019). In addition, HTX patients with rejection also had significantly lower RV FW (weighted mean difference -4.90 (95% CI, -6.15 to -3.65; P < .001). CONCLUSIONS The meta-analysis and systematic review demonstrate that myocardial strain parameters derived from 2D STE may be useful in detecting ACAR in HTX patients. The present results provide encouraging evidence to consider the routine use of GLS, CS, and RV FW as markers of graft function involvement during ACAR.
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Affiliation(s)
- Shuangshuang Zhu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Meng Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Fangyan Tian
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Shuyuan Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Ping Yin
- Epidemiology and Health Statistics, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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15
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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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16
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Berhane H, Ruh A, Husain N, Robinson JD, Rigsby CK, Markl M. Myocardial velocity, intra-, and interventricular dyssynchrony evaluated by tissue phase mapping in pediatric heart transplant recipients. J Magn Reson Imaging 2019; 51:1212-1222. [PMID: 31515865 DOI: 10.1002/jmri.26916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Endomyocardial biopsy (EMB) is the standard method for detecting allograft rejection in pediatric heart transplants (Htx). As EMB is invasive and carries a risk of complications, there is a need for a noninvasive alternative for allograft monitoring. PURPOSE To quantify left and right ventricular (LV & RV) peak velocities, velocity twist, and intra-/interventricular dyssynchrony using tissue phase mapping (TPM) in pediatric Htx compared with controls, and to explore the relationship between global cardiac function parameters and the number of rejection episodes to these velocities and intra-/interventricular dyssynchrony. STUDY TYPE Prospective. SUBJECTS Twenty Htx patients (age: 16.0 ± 3.1 years, 11 males) and 18 age- and sex-matched controls (age: 15.5 ± 4.3 years, nine males). FIELD STRENGTH/SEQUENCE 5T; 2D balanced cine steady-state free-precession (bSSFP), TPM (2D cine phase contrast with three-directional velocity encoding). ASSESSMENT LV and RV circumferential, radial, and long-axis velocity-time curves, global and segmental peak velocities were measured using TPM. Short-axis bSSFP images were used to measure global LV and RV function parameters. STATISTICAL TESTS A normality test (Lilliefors test) was performed on all data. For comparisons, a t-test was used for normally distributed data or a Wilcoxon rank-sum test otherwise. Correlations were determined by a Pearson correlation. RESULTS Htx patients had significantly reduced LV (P < 0.05-0.001) and RV (P < 0.05-0.001) systolic and diastolic global and segmental long-axis velocities, reduced RV diastolic peak twist (P < 0.01), and presented with higher interventricular dyssynchrony for long-axis and circumferential motions (P < 0.05-0.001). LV diastolic long-axis dyssynchrony (r = 0.48, P = 0.03) and RV diastolic peak twist (r = -0.64, P = 0.004) significantly correlated with the total number of rejection episodes. DATA CONCLUSION TPM detected differences in biventricular myocardial velocities in pediatric Htx patients compared with controls and indicated a relationship between Htx myocardial velocities and rejection history. LEVEL OF EVIDENCE 2 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:1212-1222.
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Affiliation(s)
- Haben Berhane
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Alexander Ruh
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nazia Husain
- Department of Pediatrics, Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Joshua D Robinson
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Cynthia K Rigsby
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, Illinois, USA
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17
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Uysal C, Arslan D, Buyukinan M, Gederet YT, Vatansev H, Ozcelik HS. Growth Differentiation Factor-15 Level and Tissue Doppler Echocardiography as a Tool in Identification of Cardiac Effects in the Children with Type 1 Diabetes Mellitus. Exp Clin Endocrinol Diabetes 2019; 129:574-580. [PMID: 31426113 DOI: 10.1055/a-0983-1673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the importance of growth-differentiation factor-15 level and tissue Doppler imaging in the detection of cardiomyopathy in children who have type 1 diabetes mellitus. MATERIALS AND METHODS Thirty-eight patients (11 males and 27 females) with type 1 diabetes mellitus were included in this study. The control group consisted of 40 age- and gender-matched healthy volunteers. All children underwent a detailed echocardiography, which contained an m-mode, pulse Doppler and tissue Doppler imaging; and growth-differentiation factor-15 level was measured. RESULTS In this study, there were significant differences between diastolic function parameters of the heart. The mitral isovolumic contraction time, contraction time, and isovolumic relaxation time values were different in the patients than in the controls (p<0.01, p<0.01, p<0.01, respectively). Also, the tricuspid isovolumic contraction time, contraction time, and isovolumic relaxation time values were different in the patients than in the controls (p<0.01, p=0.01, p<0.01, respectively). No statistically significant difference was found between the other M-mode parameters. Mean plasma growth-differentiation factor-15 level was significantly higher in patients than in healthy controls (p<0.01). CONCLUSION The follow-up of children with type 1 diabetes mellitus in terms of cardiomyopathy and the use of tissue Doppler imaging and growth differentiation factor-15 levels may be useful.
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Affiliation(s)
- Celil Uysal
- Department of Pediatrics, Patnos State Hospital, Agri, Turkey
| | - Derya Arslan
- Department of Pediatric Cardiology, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey
| | - Muammer Buyukinan
- Department of Pediatric Endocrinology, Konya Training and Research Hospital, Konya, Turkey
| | | | - Husamettin Vatansev
- Department of Biochemistry, Selcuk University Medical Faculty, Konya, Turkey
| | - Huseyin Samet Ozcelik
- Department of Pediatrics, Dr. Ali Kemal Belviranli Obstetrics and Gynecology Hospital, Konya, Turkey
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Harrington JK, Richmond ME, Woldu KL, Pasumarti N, Kobsa S, Freud LR. Serial Changes in Right Ventricular Systolic Function Among Rejection-Free Children and Young Adults After Heart Transplantation. J Am Soc Echocardiogr 2019; 32:1027-1035.e2. [PMID: 31202590 DOI: 10.1016/j.echo.2019.04.413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evolution of right ventricular (RV) systolic function after pediatric heart transplantation (HT) has not been well described. METHODS We analyzed echocardiograms performed over the first year after HT among children and young adults who remained rejection-free. Ninety-six patients (median age 7.1 [0.1-24.4] years at HT) were included: 22 infants (≤1 year) and 74 noninfants (>1 year). Two-dimensional tricuspid annular plane systolic excursion (TAPSE), tissue Doppler-derived tricuspid annular systolic velocity (S'), fractional area change (FAC), myocardial performance index (MPI), and two-dimensional speckle-tracking-derived RV global longitudinal (GLS) and free wall strain (FWS) were assessed. RESULTS All measures of RV function were impaired immediately after HT and significantly improved over the first year: TAPSE z-score (-8.15 ± 1.88 to -3.94 ± 1.65, P < .0001), S' z-score (-4.30 ± 1.36 to -2.28 ± 1.33, P < .0001), FAC (24.37% ± 7.71% to 42.02% ± 7.09%, P < .0001), MPI (0.96 ± 0.47 to 0.41 ± 0.22, P < .0001), GLS (-10.37% ± 3.86% to -21.05% ± 3.41%, P < .0001), and FWS (-11.2% ± 4.08% to -23.66% ± 4.13%, P < .0001). By 1 year post-HT, TAPSE, S', GLS, and FWS, remained abnormal, whereas FAC and MPI nearly normalized. Patients transplanted during infancy demonstrated better recovery of RV systolic function. CONCLUSIONS Although RV systolic function improved over the first year after HT in children and young adults without rejection, measures that assess longitudinal contractility remained abnormal at 1 year post-HT. These findings contribute to our understanding of RV myocardial contractility after HT in children and young adults and improve our ability to assess function quantitatively in this population.
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Affiliation(s)
- Jamie K Harrington
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Marc E Richmond
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Kristal L Woldu
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Nikhil Pasumarti
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Serge Kobsa
- Department of Surgery, Division of Cardiothoracic Surgery, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Lindsay R Freud
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York.
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Reduced Biventricular Volumes and Myocardial Dysfunction Long-term After Pediatric Heart Transplantation Assessed by CMR. Transplantation 2019; 103:2682-2691. [PMID: 30964835 DOI: 10.1097/tp.0000000000002738] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Long-term cardiac remodeling after heart transplantation (HT) in children has been insufficiently characterized. The aim of our study was to evaluate ventricular size in HT patients using cardiovascular magnetic resonance (CMR) imaging, to find underlying factors related to potentially abnormal cardiac dimensions and to study its impact on functional class and ventricular function. METHODS Seventy-five pediatric HT recipients (age 14.0 ± 4.2 y) were assessed by using CMR 11.2 ± 5.4 years after HT. Right ventricular (RV) and left ventricular (LV) volumes and mass were derived from short-axis cine images and myocardial strain/strain rate was assessed using myocardial feature tracking technique. Results were compared with a healthy reference population (n = 79, age 13.7 ± 3.7 y). RESULTS LV end-diastolic ventricular volumes were smaller (64 ± 12 versus 84 ± 12 mL/m; P < 0.001) while mass-to-volume ratio (0.86 ± 0.18 versus 0.65 ± 0.11; P < 0.001) and heart rate (92 ± 14 versus 78 ± 13 beats/min; P < 0.001) were higher in HT patients. LV-ejection fraction (EF) was preserved (66% ± 8% versus 64% ± 6%; P = 0.18) but RV-EF (58 ± 7 versus 62% ± 4%, P = 0.004), LV systolic longitudinal strain (-12 ± 6 versus -15% ± 5%; P = 0.05), diastolic strain rate (1.2 ± 0.6 versus 1.5 ± 0.6 1/s; P = 0.03), and intra and interventricular synchrony were lower in the HT group. Smaller LV dimensions were primarily related to longer follow-up time since HT (β = -0.38; P < 0.001) and were associated with worse functional class and impaired ventricular systolic and diastolic performance. CONCLUSIONS Cardiac remodeling after pediatric HT is characterized by reduced biventricular size and increased mass-to-volume ratio. These adverse changes evolve gradually and are associated with impaired functional class and ventricular dysfunction suggesting chronic maladaptive processes affecting allograft health.
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Harrington JK, Freud LR, Woldu KL, Joong A, Richmond ME. Early assessment of right ventricular systolic function after pediatric heart transplant. Pediatr Transplant 2018; 22:e13286. [PMID: 30178513 DOI: 10.1111/petr.13286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/08/2018] [Accepted: 07/31/2018] [Indexed: 11/27/2022]
Abstract
RV systolic function is important early after HT; however, it has not been critically assessed in children using quantitative measures. The aim of this study was to describe the most validated and commonly used quantitative echocardiographic measures of RV systolic function early after pediatric HT and to assess associations with qualitative function evaluation and clinical factors. RV systolic function was quantified on the first post-HT echocardiogram >24 hours after cardiopulmonary bypass using two-dimensional TAPSE, Tricuspid annular S', FAC, and MPI. In 145 patients (median age 7.6 years), quantitative RV systolic function was markedly abnormal: mean TAPSE z-score -8.43 ± 1.89; S' z-score -4.36 ± 1.22; FAC 24.4 ± 8.34%; and MPI 0.86 ± 0.51. Few patients had normal quantitative function: TAPSE (0%), S' (1.2%), FAC (9.4%), and MPI (28.4%). In contrast, 48.3% were observed as normal by qualitative assessment. Most clinical factors, including diagnosis, pulmonary vascular resistance, posttransplant hemodynamics, inotropic support, and rejection, were not associated with RV function. In this large pediatric HT population, TAPSE, S', FAC, and MPI were strikingly abnormal early post-HT despite reassuring qualitative assessment and no significant association with clinical factors. This suggests that the accepted normal values of these quantitative measures may not apply in the early post-HT period to accurately grade RV systolic function, and there may be utility in adapting a concept of normal reference values after pediatric HT.
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Affiliation(s)
- Jamie K Harrington
- Division of Pediatric Cardiology, Department of Pediatrics, College of Physicians & Surgeons, Columbia University Medical Center, New York, New York
| | - Lindsay R Freud
- Division of Pediatric Cardiology, Department of Pediatrics, College of Physicians & Surgeons, Columbia University Medical Center, New York, New York
| | - Kristal L Woldu
- Division of Pediatric Cardiology, Department of Pediatrics, College of Physicians & Surgeons, Columbia University Medical Center, New York, New York
| | - Anna Joong
- Division of Pediatric Cardiology, Department of Pediatrics, College of Physicians & Surgeons, Columbia University Medical Center, New York, New York
| | - Marc E Richmond
- Division of Pediatric Cardiology, Department of Pediatrics, College of Physicians & Surgeons, Columbia University Medical Center, New York, New York
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Pediatric Fontan patients are at risk for myocardial fibrotic remodeling and dysfunction. Int J Cardiol 2017; 240:172-177. [DOI: 10.1016/j.ijcard.2017.04.073] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/26/2017] [Accepted: 04/20/2017] [Indexed: 11/19/2022]
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