Reference intervals for the echocardiographic measurements of the right heart in children and adolescents: a systematic review

M-Mode Echocardiographic Measurements of Interventricular Septum, Left Ventricular Internal Diameter, and Left Ventricular Free-Wall Thickness in Normal Horses-A Meta-Analytical Study

The purpose of this study was to provide a systematic meta-analysis on echocardiographic measurements in normal Thoroughbred and Standardbred horses. The current systematic meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). All the available published papers on the reference values of echocardiographic assessment via M-mode echocardiography were searched, and fifteen studies were finally selected for analysis. In both fixed and random effect, the confidence interval (CI) for the interventricular septum (IVS) was 2.8-3.1 and 4.7-7.5; for the left ventricular free-wall (LVFW) thickness, it was 2.9-3.2 and 4.2-6.7; and for the left ventricular internal diameter (LVID), it was -5.0-4.6 and -10.0--6.7, respectively. For IVS, the Q statistic, I-squared, and tau-squared were 925.3, 98.1, and 7.9, respectively. Similarly, for LVFW, all the effects were on the positive side of zero, with a range of 1.3-68.1. The CI indicated a significant variation among the studies (fixed, 2.9-3.2; random, 4.2-6.7). The z-values of LVFW for fixed and random effects were, respectively, 41.1 (p < 0.001) and 8.5 (p < 0.001). However, the Q statistic was 886.6 (p < 0.001). Moreover, the I-squared was 98.08, and the tau-squared was 6.6. By contrast, the effects of LVID fell on the negative side of zero, (2.8-83.9). The present meta-analysis provides an overview of the echocardiographic measurements of cardiac diameters in healthy Thoroughbred and Standardbred horses. The meta-analysis indicates variations in results among different studies. This result should be considered when evaluating a horse for heart disease and each case should be evaluated independently.

Investigating the Accuracy of Quantitative Echocardiographic-Modified Task Force Criteria for Arrhythmogenic Ventricular Cardiomyopathy in Adolescent Male Elite Athletes

Athlete preparticipation screening focuses on preventing sudden cardiac death (SCD) by detecting diseases such as arrhythmogenic ventricular cardiomyopathy (AVC), which affects primarily the right ventricular myocardium. Diagnosis may be obscured by physiological remodeling of the athlete heart. Healthy athletes may meet the 2010 Task Force Criteria right ventricular outflow tract (RVOT) dimension cut-offs, questioning the suitability of the modified Task Force Criteria (mTFC) in adolescent athletes. In this study, 67 male adolescent footballers undergoing preparticipation screening were reviewed. All athletes underwent a screening for resting ECG and echocardiogram according to the English FA protocol, as well as cardiopulmonary exercise testing, stress ECG, and exercise echocardiography. Athletes' right ventricular outflow tract (RVOT) that met the major AVC diagnostic criteria for dilatation were identified. Of 67 evaluated athletes, 7 had RVOT dilatation that met the major criteria, all in the long axis parasternal view measurement. All had normal right ventricular systolic function, including normal free-wall longitudinal strain (ranging from - 21.5 to - 32.7%). Left ventricular ejection fraction ranged from 52 to 67%, without evidence of structural changes. Resting ECGs and cardiopulmonary exercise tests were normal in all individuals. In a series of healthy athletes meeting the major AVC diagnostic criteria for RVOT dilatation, none had any other pathological changes on a detailed screening including ECG, exercise testing, and echocardiography. This report highlights that current AVC echocardiographic diagnosis criteria have limitations in this population.

Echocardiography for the Assessment of Pulmonary Hypertension and Congenital Heart Disease in the Young

While invasive assessment of hemodynamics and testing of acute vasoreactivity in the catheterization laboratory is the gold standard for diagnosing pulmonary hypertension (PH) and pulmonary vascular disease (PVD) in children, transthoracic echocardiography (TTE) serves as the initial diagnostic tool. International guidelines suggest several key echocardiographic variables and indices for the screening studies when PH is suspected. However, due to the complex anatomy and special physiological considerations, these may not apply to patients with congenital heart disease (CHD). Misinterpretation of TTE variables can lead to delayed diagnosis and therapy, with fatal consequences, or–on the other hand-unnecessary invasive diagnostic procedures that have relevant risks, especially in the pediatric age group. We herein provide an overview of the echocardiographic workup of children and adolescents with PH with a special focus on children with CHD, such as ventricular/atrial septal defects, tetralogy of Fallot or univentricular physiology. In addition, we address the use of echocardiography as a tool to assess eligibility for exercise and sports, a major determinant of quality of life and outcome in patients with PH associated with CHD.

Lipid Biomarkers as Predictors of Diastolic Dysfunction in Diabetes with Poor Glycemic Control

Uncontrolled type-1 diabetes (T1DM) can lead to dyslipidaemia and albuminuria, which may promote cardiovascular injuries. However, some lipidemic factors could be useful in predicting cardiac dysfunction. Seventy-eight adolescents under insulin treatment due to a 6-year history of T1DM and were retrospectively examined. Glycemia, lipidemia, and albuminuria were measured in addition to development of cardiovascular abnormalities Both girls and boys showed higher HbA1c and fasting blood glucose and 27.1% females and 33.3% males exhibited microalbuminuria though their plasma levels of total cholesterol (TC), triglycerides (TG), and low-density lipoproteins (LDL) and high-density lipoproteins (HDL lipoproteins were in the normal range. They exhibited a preserved systolic function, but 50% of females and 66.6% of males had developed diastolic failures. Interestingly, girls with diastolic dysfunction showed significantly lower concentrations of HDL and higher TC/HDL and TG/HDL ratios. In fact, low HDL levels (OR 0.93; 95% CI 0.88-0.99; p = 0.029) and high TC/HDL (OR 2.55; 95% CI 1.9-5.45; p = 0.016) and TG/HDL (OR 2.74; 95% CI 1.12-6.71; p = 0.028) ratios associated with the development of diastolic complications. The cut-off values for HDL, TC/HDL, and TG/HDL were 49 mg/dL, 3.0 and 1.85, respectively. HDL and TC/HDL and TG/HDL ratios may be useful for predicting diastolic dysfunction in girls with uncontrolled T1DM.

[Reference values (Z-score) of inlet and trabecular portion diameters of the right ventricle: First description in Spanish healthy children]

INTRODUCTION AND OBJECTIVES

Right ventricle (RV) measurements are crucial for certain congenital heart diseases and various cardiovascular conditions. Echocardiographic RV diameters are especially useful for its assessment. Paediatric echocardiographic data standardisation in normal subjects is complex, scarce, and heterogeneous. The aim of this study was to establish reliable and reproducible echocardiographic reference values (Z-score) of RV diameters in a healthy Spanish paediatric cohort.

METHODS

A multicentre study was conducted on 661 healthy subjects (age range 0-18 years, 43.5% female). Several regression models were tested to examine the relationship between RV diameters and biometric variables. Heteroscedasticity and residual associations (Shapiro-Wilk and Breusch-Pagan tests) and confounding factors (gender, age, inter/intraobserver agreement) were considered for an unbiased standardisation.

RESULTS

Structured Z-scores were computed for each RV diameter. Predicted mean value for each diameter was determined according to age, weight, height, and different body surface area. The Haycock formula provided the best fit for basal, midcavity, and longitudinal diameters (R² 0.81; 0.82; 0.9). Confounders were not significant, and therefore not included in final models (inter/intraobserver agreement > 0.9).

CONCLUSIONS

This study reports reference values for echocardiographic RV diameters from a Spanish healthy paediatric cohort using a rigorous statistical design. These Z-scores partly cover a gap in current paediatric cardiology and represent a relevant diagnostic tool for clinical practice, as well as a useful guide to decision making at any paediatric stage.

Early assessment of right ventricular systolic function after pediatric heart transplant

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.

How should we determine normal echocardiographic right ventricle function reference values in pediatrics?

Several models have been used to establish pediatric Z-scores for echocardiographic right ventricle (RV) variables. This study aimed to determine the most appropriate mathematical model for RV function reference values in pediatrics. Prospective cross-sectional study among 314 healthy children ages 2 days to 18 years (46% female, 88 infants, 26 neonates, 226 children). RV parameters (S', E', A' waves, TEI index, TAPSE) were modelized with four explanatory variables: age, height, weight and body surface area. Four mathematical models were applied: a linear model, a polynomial model of degree 2, a linear regression model by spline with free knot, and a polynomial regression model of degree 2 by spline with a free knot. The choice of the best method used the adjusted coefficient of determination (aR²). The modelization of RV variables did not follow a linear model. A single explanatory variable could not determine all Z-scores, as specific and independent variables were required for each parameter. The quadratic spline model best adjusted the modelization of RV variables. The S' wave was best modelized by the spline model with the weight (knot at 6.86 kg). The E' wave was best modelized by the spline model with the age (knot at 0.29 years). The A' wave was best modelized by the model with the height (knot at 81 cm). The TAPSE was best modelized by the spline model with the weight (knot at 9.04 kg). The spline regression models best applies to echocardiographic RV reference values in pediatrics.

Nomograms for echocardiographic right ventricular sub-costal view dimensions in healthy Caucasian children: A new approach to measure the right ventricle

BACKGROUND

The sub-costal examination of the heart is part of routine examination in pediatric echocardiography, and has the advantage to visualize also the infundibulum part of the right ventricle (RV). Despite this fact, currently nomograms for sub-costal RV dimensions are lacking.

METHODS

We prospectively studied healthy Caucasian Italian children by two-dimensional echocardiography. Measurements included: sub-costal end diastolic basal-apical and latero-lateral diameters, end diastolic and end systolic area, 4 chamber end diastolic and end systolic area and length, end diastolic basal (RV1) and mid-cavity (RV2) diameters. Age, weight, height, heart rate (HR), and body surface area (BSA) were used as independent variables in different analyses to predict the mean values of each measurement. Structured Z scores were then computed. Agreement of RV diameters and areas in subcostal view and 4-chamber view were investigated.

RESULTS

732 subjects (age 0 days-17 years; 48% female; BSA 0.12-2.12 m2) were studied. The Haycock formula was used when presenting data as predicted values (mean ± 2 SDs) for a given BSA and within equations relating echocardiographic measurements to BSA. The predicted values and Z-score boundaries for all measurements are presented. Excellent correlations were found among two-dimensional diameters and area calculated in sub-costal view with those evaluated in 4-chamber view.

CONCLUSIONS

We report echocardiographic nomograms for RV diameters and areas measured in the sub-costal view. Our data may implement normative data for 2D echocardiography evaluation of the RV in children.

Velocity vector imaging shows normal cardiac systolic function in survivors of severe bronchopulmonary dysplasia at six to 16 years of age

AIM

This study evaluated global myocardial function and associations between cardiac function and lung function in very low birth weight (VLBW) children, with and without severe radiographic bronchopulmonary dysplasia (BPD), at six to 14 years of age.

METHODS

We studied 34 VLBW and 19 term-born controls, and the VLBW group was further divided into a BPD group with severe radiographic BPD and those without radiographic BPD in infancy. Detailed right and left ventricular myocardial functions were analysed by velocity vector imaging, and the left ventricular mass was calculated. The associations between cardiac function and lung function were assessed by impulse oscillometry.

RESULTS

The right and left ventricular myocardial systolic functions and the left ventricular mass were similar in the three groups. Lung function was not associated with cardiac systolic function. Neonatal exposure to dexamethasone treatment was negatively associated with right ventricular function, as measured by the automated fractional area change, with an odds ratio of 7.9 and 95% confidence interval of 1.9-33.5 (p = 0.005).

CONCLUSION

Lung function measurements were not associated with cardiac systolic function in preterm infants at six to 14 years of age. Neonatal exposure to dexamethasone, used for weaning from the ventilator, was negatively associated with right ventricular function.

Two-dimensional echocardiographic right ventricle measurements adjusted to body mass index and surface area in a normal population

BACKGROUND

To determine reference echocardiographic values in a normal population and assess their correlation with body mass index (BMI) and body surface area.

METHODS

An expert cardiologist performed two-dimensional echocardiography with triplicate right ventricle (RV) size measurements in 80 subjects with normal heart condition. Results were correlated with anthropometric data.

RESULTS

Base-to-apex length in four-chamber view (RVD3) and above-pulmonic valve in short-axis view in males, as well as mid-RV diameter in standard four-chamber view (RVD), basal RV diameter, and mid RV diameter in RV-focused four-chamber view in females, were significantly correlated with BMI. All RV variables were significantly correlated with BMI in 20-30-year-old subjects. All RV variables except RVD3 and above-aortic valve in short-axis view (proximal) were significantly correlated with BMI in 35-55-year-old subjects. All RV parameters were significantly correlated with body surface area, except for RVD and in 20-35-year-old subjects.

CONCLUSIONS

RV echocardiographic values must be adjusted to anthropometric characteristics for proper diagnosis and management of cardiac disorders. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:204-210, 2017.

Freshwater drowning in a child: A case study demonstrating the role of post-mortem computed tomography

In recent years, modern imaging techniques have gained ground in forensics. A crucial question is whether virtual autopsy is capable of replacing traditional autopsy. Forensic diagnosis of freshwater drowning (FWD) is based on the evidence of findings from external inspection (e.g. frothy fluid exuding from the mouth and nostrils), internal examination (e.g. pulmonary congestion, enlargement of heart chambers) and biochemical analysis (haemodilution), findings which are non-specific. The detection of diatoms in organs of the systemic circulation may be of some assistance, but this analysis is rarely performed and is of debatable validity. An 18-month-old child was found dead at home in a swimming pool. Considering the family's wishes to avoid autopsy, the district attorney authorised a whole-body post-mortem computed tomography scan (PMCT). The main imaging findings were frothy fluid in the upper airways, fluid in the trachea and main bronchi, many pulmonary nodular ground glass opacities (GGO) in non-dependent regions and haemodilution. CT imaging did not show any other forensically relevant abnormality.A high concordance was found between the CT findings reported in the literature in cases of FWD and the imaging results. Thus, after the exclusion of other causes of death, advised by the forensic pathologist, the district attorney closed the case and the death was attributed to FWD. This case report demonstrates that PMCT imaging in cases of suspected FWD can provide some important findings for the diagnosis of FWD as the cause of death.