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Mattia D, Matney C, Zangwill S, Wisotzkey B, Rhee E, Knoll C. Prinzmetal angina in a child with actin gene ACTC1 mutation. Cardiol Young 2023; 33:2440-2442. [PMID: 37489518 DOI: 10.1017/s1047951123002640] [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] [Indexed: 07/26/2023]
Abstract
Prinzmetal angina is a rare cause of intermittent chest pain in paediatrics. Here, we report the case of a 2-year-old female who presented with episodic chest pain, malaise, diaphoresis, fatigue, and poor perfusion on exam. During her hospitalisation, these episodes were associated with significant low cardiac output as evidenced by lactic acidosis and low mixed venous oxygen saturations. Her workup revealed an actin alpha cardiac muscle 1 (ACTC1) gene mutation and associated left ventricular non-compaction with decreased systolic function. She was started on oral heart failure medications as well as a calcium channel blocker but continued to have episodes which were found to promptly resolve with nitroglycerine. She was ultimately listed for cardiac transplant given her perceived risk of sudden death.
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Affiliation(s)
- Donald Mattia
- Phoenix Children's Center for Heart Care, Phoenix, AZ, USA
| | - Chelsea Matney
- Phoenix Children's Center for Heart Care, Phoenix, AZ, USA
| | | | | | - Edward Rhee
- Phoenix Children's Center for Heart Care, Phoenix, AZ, USA
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Dorfman AL, Geva T, Samyn MM, Greil G, Krishnamurthy R, Messroghli D, Festa P, Secinaro A, Soriano B, Taylor A, Taylor MD, Botnar RM, Lai WW. SCMR expert consensus statement for cardiovascular magnetic resonance of acquired and non-structural pediatric heart disease. J Cardiovasc Magn Reson 2022; 24:44. [PMID: 35864534 PMCID: PMC9302232 DOI: 10.1186/s12968-022-00873-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/24/2022] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) is widely used for diagnostic imaging in the pediatric population. In addition to structural congenital heart disease (CHD), for which published guidelines are available, CMR is also performed for non-structural pediatric heart disease, for which guidelines are not available. This article provides guidelines for the performance and reporting of CMR in the pediatric population for non-structural ("non-congenital") heart disease, including cardiomyopathies, myocarditis, Kawasaki disease and systemic vasculitides, cardiac tumors, pericardial disease, pulmonary hypertension, heart transplant, and aortopathies. Given important differences in disease pathophysiology and clinical manifestations as well as unique technical challenges related to body size, heart rate, and sedation needs, these guidelines focus on optimization of the CMR examination in infants and children compared to adults. Disease states are discussed, including the goals of CMR examination, disease-specific protocols, and limitations and pitfalls, as well as newer techniques that remain under development.
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Affiliation(s)
- Adam L. Dorfman
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan C.S. Mott Children’s Hospital, 1540 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Tal Geva
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 USA
| | - Margaret M. Samyn
- Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin/Herma Heart Institute, Children’s Wisconsin, Milwaukee, WI 53226 USA
| | - Gerald Greil
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas, TX 75235 USA
| | - Rajesh Krishnamurthy
- Department of Radiology, Nationwide Children’s Hospital, 700 Children’s Dr. E4A, Columbus, OH 43205 USA
| | - Daniel Messroghli
- Department of Internal Medicine-Cardiology, Deutsches Herzzentrum Berlin and Charité-University Medicine Berlin, Berlin, Germany
| | - Pierluigi Festa
- Department of Cardiology, Fondazione Toscana G. Monasterio, Massa, Italy
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Department of Imaging, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Brian Soriano
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
| | - Andrew Taylor
- Department of Cardiovascular Imaging, Great Ormond Street Hospital for Sick Children, University College London, London, UK
| | - Michael D. Taylor
- Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children’s Hospital, 3333 Burnet Ave #2129, Cincinnati, OH 45229 USA
| | - René M. Botnar
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Wyman W. Lai
- CHOC Children’s, 1201 W. La Veta Avenue, Orange, CA 92868 USA
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Wang AP, Homme JL, Qureshi MY, Sandoval Y, Jaffe AS. High-Sensitivity Troponin T Testing for Pediatric Patients in the Emergency Department. Pediatr Cardiol 2022; 43:350-359. [PMID: 34787696 DOI: 10.1007/s00246-021-02726-7] [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: 06/23/2021] [Accepted: 09/01/2021] [Indexed: 01/19/2023]
Abstract
Debate exists on the usefulness of high-sensitivity cardiac troponin (hs-cTn) testing in pediatric patients due to the perceived low incidence of myocardial injury and lack of data concerning its efficacy. We evaluated the contribution of an increased hs-cTnT above the 99th percentile upper-reference limit (URL) to clinical diagnoses made in pediatric patients presenting to the emergency department (ED). Retrospective cohort study including patients aged 0-18 years presenting to the ED from 2018 to 2020 where hs-cTnT was measured. Sex-specific 99th percentile URLs of 15 and 10 ng/L for males and females, respectively, were used, with concentrations above these thresholds considered indicative of myocardial injury. Overall, 356 patients were identified in whom hs-cTnT concentrations were measured during ED clinical evaluation. Hs-cTnT was increased above the 99th percentile on presentation in 36 patients (10.1%). Twelve patients (3.4%) had a clinical cardiac diagnosis made. Hs-cTnT was increased in 6 of these (50.0%). Serial hs-cTnT from 106 patients with an initial hs-cTnT < 99th percentile was subsequently elevated in 5 (4.6%); none of whom had a final clinical cardiac diagnosis. Hs-cTnT has high specificity, but low sensitivity when used as a screening tool for myocardial injury when the gold standard is mostly clinical assessment. In present practice, however, they do not appear to track well with clinical diagnoses. Further studies are needed to more clearly define the role of hs-cTnT in this patient population.
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Affiliation(s)
- Alan P Wang
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - James L Homme
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Yasir Qureshi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pediatric Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Brancato F, De Rosa G, Gambacorta A, Nunziata A, Ferrara P, Buonsenso D, Covino M, Chiaretti A. Role of Troponin Determination to Diagnose Chest Pain in the Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:e1589-e1592. [PMID: 32541399 DOI: 10.1097/pec.0000000000002123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Chest pain is a common cause to admission to the pediatric emergency department and often leads to an extensive cardiac evaluation. The objective of this study was to evaluate the usefulness of the troponin (TN) plasma level determination in the initial phase of the differential diagnosis of chest pain in children. METHODS This is a retrospective observational study on 107 patients, aged 0 to 19 years, admitted for chest pain to the pediatric emergency department of our institution. Demographics, clinical data, and patient outcomes were analyzed. Troponin values of >0.03 ng/mL but <0.1 ng/mL were considered suspected for cardiac pathology, whereas levels of >0.1 ng/mL were indicative of cardiac pathology. In these latter patients, an echocardiographic examination was also performed. RESULTS Only 99 patients were evaluated with electrocardiogram (ECG). In 91 of 99 patients of our series, both TN determination and ECG recording were performed. Troponin was higher than the cutoff value (0.03 ng/mL) in 9 patients (9.1%). Only 2 of the 9 patients who presented high TN values showed a nonpathological ECG, whereas 16 (17.5%) of 91 patients in whom both ECG and TN determination were performed had ECG abnormalities without a simultaneous elevation of TN. Of the 26 patients who had medical history and suggestive targets of cardiac pathology, only in 6 (23.1%) of them the diagnosis was confirmed. The final diagnosis of the 99 patients was idiopathic chest pain in 45.4% of cases. CONCLUSIONS Even with the low cost and the relatively easiness for the plasma level determination, TN should be measured only in children with chest pain associated to familiar history suggestive of cardiovascular disease and/or clinical symptoms and/or ECG alterations.
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Affiliation(s)
| | | | | | | | | | | | - Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario Agostino Gemelli, Istituti di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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Barfuss SB, Butts R, Knecht KR, Prada-Ruiz A, Lal AK. Outcomes of Myocarditis in Patients with Normal Left Ventricular Systolic Function on Admission. Pediatr Cardiol 2019; 40:1171-1174. [PMID: 31177303 DOI: 10.1007/s00246-019-02127-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
The objective of this study was to describe a cohort of patients with clinical myocarditis and normal left ventricular (LV) systolic function on admission. A retrospective chart review at seven tertiary pediatric hospitals identified patients aged < 19 years admitted with an ICD-9 code of myocarditis between 2008 and 2012. Patients were excluded if admission LV systolic ejection fraction was < 50%, fractional shortening (FS) was < 28% or if the admitting or consulting cardiologist did not suspect myocarditis. A total of 75 patients met inclusion criteria. The median age was 15.5 years with an Interquartile Range (IQR) of 13.6-16.6. 33% were female. Patients presented most commonly with chest pain (75%) and dyspnea (24%). On admission, median B-type natriuretic peptide (BNP) was 132 pg/mL (IQR 57-689) and median troponin I (TnI) was 8.4 ng/mL (IQR 2.0-20.3). Electrocardiogram revealed ST elevation in the majority (55%). Magnetic resonance imaging was obtained on 40%, with 63% of those showing evidence of inflammation. Therapies included inotropic support (15%), mechanical ventilation (12%), antiarrhythmic medications (9%), and Extracorporeal Membrane Oxygenation (5%). Those with poor outcomes were noted to have significantly higher BNP, TnI, and creatine kinase levels on presentation. One patient was transplanted and 35% were discharged on heart failure medications. At one year follow-up one patient had died of unspecified causes, 15% required readmission for cardiac reasons, and 21% continued on heart failure medications. The risk associated with clinical myocarditis in the setting of normal ventricular function at presentation may be higher than previously suspected.
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Affiliation(s)
- Spencer B Barfuss
- Pediatrics, Primary Children's Hospital, University of Utah, 81 Mario Capecchi Dr, Salt Lake City, UT, 84112, USA.
| | - Ryan Butts
- Pediatric Cardiology, Children's Medical Center Dallas, UT Southwestern, Dallas, TX, USA
| | - Kenneth R Knecht
- Pediatric Cardiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adriana Prada-Ruiz
- Pediatric Cardiology, Nemours Children's Health System, Wilmington, DE, USA
| | - Ashwin K Lal
- Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
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Analysis of clinical parameters and echocardiography as predictors of fatal pediatric myocarditis. PLoS One 2019; 14:e0214087. [PMID: 30893383 PMCID: PMC6426257 DOI: 10.1371/journal.pone.0214087] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/06/2019] [Indexed: 12/21/2022] Open
Abstract
Pediatric myocarditis symptoms can be mild or as extreme as sudden cardiac arrest. Early identification of the severity of illness and timely provision of critical care is helpful; however, the risk factors associated with mortality remain unclear and controversial. We undertook a retrospective review of the medical records of pediatric patients with myocarditis in a tertiary care referral hospital for over 12 years to identify the predictive factors of mortality. Demographics, presentation, laboratory test results, echocardiography findings, and treatment outcomes were obtained. Regression analyses revealed the clinical parameters for predicting mortality. During the 12-year period, 94 patients with myocarditis were included. Of these, 16 (17%) patients died, with 12 succumbing in the first 72 hours after admission. Fatal cases more commonly presented with arrhythmia, hypotension, acidosis, gastrointestinal symptoms, decreased left ventricular ejection fraction, and elevated isoenzyme of creatine kinase and troponin I levels than nonfatal cases. In multivariate analysis, troponin I > 45 ng/mL and left ventricular ejection fraction < 42% were significantly associated with mortality. Pediatric myocarditis had a high mortality rate, much of which was concentrated in the first 72 hours after hospitalization. Children with very high troponin levels or reduced ejection fraction in the first 24 hours were at higher risk of mortality, and targeting these individuals for more intensive therapies may be warranted.
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Baskar S, Betancor J, Patel K, El Yaman M, Cremer PC, Zeft AS, Klein AL. Cardiac MRI in evaluation and management of pediatric pericarditis. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Elevated Troponin in the First 72 h of Hospitalization for Pediatric Viral Myocarditis is Associated with ECMO: An Analysis of the PHIS+ Database. Pediatr Cardiol 2018; 39:1139-1143. [PMID: 29654450 DOI: 10.1007/s00246-018-1871-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
Abstract
Serum troponin (Tn) is often elevated in viral myocarditis; however, its prognostic significance is unknown. We tested the hypothesis that abnormal serum Tn is associated with mortality in children hospitalized with myocarditis. We retrospectively studied data from six large children's hospitals participating in the Pediatric Health Information System Plus (PHIS+) database. Analysis was performed on patients hospitalized with viral myocarditis between 2007 and 2013, in whom at least one Tn was recorded within 72 h of admission. Abnormal baseline Tn was defined as any value outside the upper limit of normal within the first 72 h. Primary outcome was mortality. Secondary outcomes included mechanical support, defined as use of extracorporeal membrane oxygenation (ECMO) or a ventricular assist device (VAD), cardiac transplantation, intravenous immunoglobulin (IVIg), mechanical ventilation, and inotrope use. A total of 149 patients with myocarditis (61% male, 48% adolescents) across all PHIS+ centers had TnI (n = 113) or TnT (n = 36) recorded. At least one abnormal Tn was present in 81% of cases. Overall mortality was 7.3% and was not associated with abnormal baseline Tn. Abnormal baseline Tn was associated with ECMO (7.1 vs. 25.6%, p = 0.03) and IVIg (46.4 vs. 83.5%, p < 0.001). Abnormal baseline Tn was not associated with transplantation, mechanical ventilation or inotrope use. Abnormal Tn in the first 72 h of hospitalization for myocarditis was associated with the use of ECMO and IVIg, but was not associated with mortality. This finding may help risk stratify this population if it can be prospectively validated.
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Wu C, Singh A, Collins B, Fatima A, Qamar A, Gupta A, Hainer J, Klein J, Jarolim P, Di Carli M, Nasir K, Bhatt DL, Blankstein R. Causes of Troponin Elevation and Associated Mortality in Young Patients. Am J Med 2018; 131:284-292.e1. [PMID: 29106977 PMCID: PMC5817012 DOI: 10.1016/j.amjmed.2017.10.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 10/06/2017] [Accepted: 10/06/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND While increased serum troponin levels are often due to myocardial infarction, increased levels may also be found in a variety of other clinical scenarios. Although these causes of troponin elevation have been characterized in several studies in older adults, they have not been well characterized in younger individuals. METHODS We conducted a retrospective review of patients 50 years of age or younger who presented with elevated serum troponin levels to 2 large tertiary care centers between January 2000 and April 2016. Patients with prior known coronary artery disease were excluded. The cause of troponin elevation was adjudicated via review of electronic medical records. All-cause death was determined using the Social Security Administration's death master file. RESULTS Of the 6081 cases meeting inclusion criteria, 3574 (58.8%) patients had a myocardial infarction, while 2507 (41.2%) had another cause of troponin elevation. Over a median follow-up of 8.7 years, all-cause mortality was higher in patients with nonmyocardial infarction causes of troponin elevation compared with those with myocardial infarction (adjusted hazard ratio [HR] 1.30; 95% confidence interval [CI], 1.15-1.46; P < .001). Specifically, mortality was higher in those with central nervous system pathologies (adjusted HR 2.21; 95% CI, 1.85-2.63; P < .001), nonischemic cardiomyopathies (adjusted HR 1.66; 95% CI, 1.37-2.02; P < .001), and end-stage renal disease (adjusted HR 1.36; 95% CI, 1.07-1.73; P = .013). However, mortality was lower in patients with myocarditis compared with those with an acute myocardial infarction (adjusted HR 0.43; 95% CI:, 0.31-0.59; P < .001). CONCLUSION There is a broad differential for troponin elevation in young patients, which differs based on demographic features. Most nonmyocardial infarction causes of troponin elevation are associated with higher all-cause mortality compared with acute myocardial infarction.
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Affiliation(s)
- Candace Wu
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass
| | - Avinainder Singh
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass
| | - Bradley Collins
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass
| | - Amber Fatima
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass
| | - Arman Qamar
- Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, Mass
| | - Ankur Gupta
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass
| | - Josh Klein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Marcelo Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass
| | - Khurram Nasir
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Fla
| | - Deepak L Bhatt
- Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, Mass
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass.
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Affiliation(s)
- Benson S Hsu
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD
| | - Mary Guillot
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD
| | - Jennifer Mosher
- Department of Pediatrics, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | - Theresa Stamato
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD
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