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Greiner E, Breaux A, Kasten J, Seo J, Ollberding NJ, Spar D, Ryan TD, Lang SM, Tian C, Sawnani H, Villa CR. Cardiac atrial pathology in Duchenne muscular dystrophy. Muscle Nerve 2024; 69:572-579. [PMID: 38426616 DOI: 10.1002/mus.28072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 02/17/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION/AIMS Duchenne muscular dystrophy (DMD) is characterized by fibrofatty replacement of muscle. This has been documented in the ventricular myocardium of DMD patients, but there is limited description of atrial involvement. The purpose of this study is to examine the arrhythmia and ectopy burden in patients with DMD and non-DMD dilated cardiomyopathy (DCM) and to characterize the cardiac histopathologic changes in DMD patients across the disease spectrum. METHODS This was a retrospective analysis of age-matched patients with DMD and non-DMD DCM who received a Holter monitor and cardiac imaging within 100 days of each other between 2010 and 2020. Twenty-four-hour Holter monitors were classified based on the most recent left ventricular ejection fraction at the time of monitoring. Cardiac histopathologic specimens from whole-heart examinations at the time of autopsy from three DMD patients and one DCM patient were reviewed. RESULTS A total of 367 patients with 1299 Holter monitor recordings were included over the study period, with 94% representing DMD patients and 6% non-DMD DCM. Patients with DMD had more atrial ectopy across the cardiac function spectrum (p < 0.05). There was no difference in ventricular ectopy. Four DMD patients developed symptomatic atrial arrhythmias. Autopsy specimens from DMD patients demonstrated fibrofatty infiltration of both atrial and ventricular myocardium. DISCUSSION The atrial myocardium in patients with DMD is unique. Autopsy specimens reveal fibofatty replacement of the atrial myocardium, which may be a nidus for both ectopy and arrhythmias in DMD patients.
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Affiliation(s)
- Eleanor Greiner
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Andrea Breaux
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jennifer Kasten
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - JangDong Seo
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David Spar
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sean M Lang
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Cuixia Tian
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center & University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Hemant Sawnani
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pediatric Pulmonology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Chet R Villa
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Ryan TD, Ryan JB. Differences in life expectancy within and between countries: implications for domestic TAVI guidelines in Australia and Aotearoa New Zealand. N Z Med J 2024; 137:75-80. [PMID: 38603789 DOI: 10.26635/6965.6402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
The advent of transcatheter aortic valve implantation (TAVI) has caused a paradigm shift in the management of aortic stenosis away from traditional surgical aortic valve replacement (SAVR). However, uncertainty remains about the long-term (>10 year) durability of TAVI valves, especially in younger patients. This viewpoint collates life expectancy data from Australia and Aotearoa New Zealand to propose sex-specific age-based recommendations for choice of SAVR versus TAVI in their respective general populations and among Aboriginal and Torres Strait Islander people in Australia and both Māori and Pacific peoples living in Aotearoa New Zealand.
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Affiliation(s)
- Thomas D Ryan
- Graduate Medical Student, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Jonathon B Ryan
- Conjoint Senior Lecturer, Discipline of Surgery, Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, Australia; Cardiothoracic Surgeon, Prince of Wales Hospital, Sydney, NSW, Australia
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Rigter PMF, de Konink C, Dunn MJ, Proietti Onori M, Humberson JB, Thomas M, Barnes C, Prada CE, Weaver KN, Ryan TD, Caluseriu O, Conway J, Calamaro E, Fong CT, Wuyts W, Meuwissen M, Hordijk E, Jonkers CN, Anderson L, Yuseinova B, Polonia S, Beysen D, Stark Z, Savva E, Poulton C, McKenzie F, Bhoj E, Bupp CP, Bézieau S, Mercier S, Blevins A, Wentzensen IM, Xia F, Rosenfeld JA, Hsieh TC, Krawitz PM, Elbracht M, Veenma DCM, Schulman H, Stratton MM, Küry S, van Woerden GM. Role of CAMK2D in neurodevelopment and associated conditions. Am J Hum Genet 2024; 111:364-382. [PMID: 38272033 PMCID: PMC10870144 DOI: 10.1016/j.ajhg.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 01/27/2024] Open
Abstract
The calcium/calmodulin-dependent protein kinase type 2 (CAMK2) family consists of four different isozymes, encoded by four different genes-CAMK2A, CAMK2B, CAMK2G, and CAMK2D-of which the first three have been associated recently with neurodevelopmental disorders. CAMK2D is one of the major CAMK2 proteins expressed in the heart and has been associated with cardiac anomalies. Although this CAMK2 isoform is also known to be one of the major CAMK2 subtypes expressed during early brain development, it has never been linked with neurodevelopmental disorders until now. Here we show that CAMK2D plays an important role in neurodevelopment not only in mice but also in humans. We identified eight individuals harboring heterozygous variants in CAMK2D who display symptoms of intellectual disability, delayed speech, behavioral problems, and dilated cardiomyopathy. The majority of the variants tested lead to a gain of function (GoF), which appears to cause both neurological problems and dilated cardiomyopathy. In contrast, loss-of-function (LoF) variants appear to induce only neurological symptoms. Together, we describe a cohort of individuals with neurodevelopmental disorders and cardiac anomalies, harboring pathogenic variants in CAMK2D, confirming an important role for the CAMK2D isozyme in both heart and brain function.
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Affiliation(s)
- Pomme M F Rigter
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands; ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands
| | - Charlotte de Konink
- ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands; Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands
| | - Matthew J Dunn
- Department of Biochemistry and Molecular Biology, University of Massachusetts, Amherst, MA 01003, USA
| | - Martina Proietti Onori
- ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands; Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands
| | - Jennifer B Humberson
- Pediatric Specialty Care, University of Virginia Health, Charlottesville, VA 22903, USA
| | - Matthew Thomas
- Division of Genetics, Department of Pediatrics, University of Virginia Children's, Charlottesville, VA 22903, USA
| | - Caitlin Barnes
- Division of Genetics, Department of Pediatrics, University of Virginia Children's, Charlottesville, VA 22903, USA
| | - Carlos E Prada
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; Division of Genetics, Genomics, and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA; Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia
| | - K Nicole Weaver
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Oana Caluseriu
- Department of Medical Genetics, University of Alberta, Edmonton, AB T6G 2H7, Canada; Stollery Children's Hospital, Department of Medical Genetics, University of Alberta, Edmonton, AB T6G 2B7, Canada
| | - Jennifer Conway
- Stollery Children's Hospital, Department of Pediatrics, Division of Pediatric Cardiology, University of Alberta, Edmonton, AB T6G 2B7, Canada
| | - Emily Calamaro
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
| | - Chin-To Fong
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
| | - Wim Wuyts
- Department of Medical Genetics, University of Antwerp and University Hospital of Antwerp, 2650 Edegem, Belgium
| | - Marije Meuwissen
- Department of Medical Genetics, University of Antwerp and University Hospital of Antwerp, 2650 Edegem, Belgium
| | - Eva Hordijk
- Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands
| | - Carsten N Jonkers
- Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands
| | - Lucas Anderson
- Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands
| | - Berfin Yuseinova
- Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands
| | - Sarah Polonia
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands
| | - Diane Beysen
- Department of Paediatric Neurology, University Hospital of Antwerp, 2650 Edegem, Belgium; Department of Translational Neurosciences, University of Antwerp, 2650 Edegem, Belgium
| | - Zornitza Stark
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, VIC 3052, Australia; Australian Genomics, Melbourne, VIC 3052, Australia
| | - Elena Savva
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, VIC 3052, Australia
| | - Cathryn Poulton
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, WA 6008, Australia
| | - Fiona McKenzie
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, WA 6008, Australia; School of Paediatrics and Child Health, University of Western Australia, Perth, WA 6009, Australia
| | - Elizabeth Bhoj
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Caleb P Bupp
- Corewell Health & Helen DeVos Children's Hospital, Grand Rapids, MI 49503, USA
| | - Stéphane Bézieau
- Nantes Université, CHU Nantes, Service de Génétique Médicale, 44000 Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, 44000 Nantes, France
| | - Sandra Mercier
- Nantes Université, CHU Nantes, Service de Génétique Médicale, 44000 Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, 44000 Nantes, France
| | | | - Ingrid M Wentzensen
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Fan Xia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jill A Rosenfeld
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA; Baylor Genetics Laboratories, Houston, TX 77021, USA
| | - Tzung-Chien Hsieh
- Institute for Genomic Statistics and Bioinformatics, University of Bonn, 53127 Bonn, Germany
| | - Peter M Krawitz
- Institute for Genomic Statistics and Bioinformatics, University of Bonn, 53127 Bonn, Germany
| | - Miriam Elbracht
- Institute for Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Danielle C M Veenma
- ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands; Sophia Children's Hospital, Erasmus Medical Center, Rotterdam 3015 CN, the Netherlands
| | - Howard Schulman
- Department of Neurobiology, Stanford University, School of Medicine, Stanford, CA 94305, USA; Panorama Research Institute, Sunnyvale, CA 94089, USA
| | - Margaret M Stratton
- Department of Biochemistry and Molecular Biology, University of Massachusetts, Amherst, MA 01003, USA
| | - Sébastien Küry
- Corewell Health & Helen DeVos Children's Hospital, Grand Rapids, MI 49503, USA; Nantes Université, CHU Nantes, Service de Génétique Médicale, 44000 Nantes, France.
| | - Geeske M van Woerden
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands; ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands; Department of Neuroscience, Erasmus Medical Center, Rotterdam 3015 GD, the Netherlands.
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Brown SA, Beavers C, Bauer B, Cheng RK, Berman G, Marshall CH, Guha A, Jain P, Steward A, DeCara JM, Olaye IM, Hansen K, Logan J, Bergom C, Glide-Hurst C, Loh I, Gambril JA, MacLeod J, Maddula R, McGranaghan PJ, Batra A, Campbell C, Hamid A, Gunturkun F, Davis R, Jefferies J, Fradley M, Albert K, Blaes A, Choudhuri I, Ghosh AK, Ryan TD, Ezeoke O, Leedy DJ, Williams W, Roman S, Lehmann L, Sarkar A, Sadler D, Polter E, Ruddy KJ, Bansal N, Yang E, Patel B, Cho D, Bailey A, Addison D, Rao V, Levenson JE, Itchhaporia D, Watson K, Gulati M, Williams K, Lloyd-Jones D, Michos E, Gralow J, Martinez H. Advancing the care of individuals with cancer through innovation & technology: Proceedings from the cardiology oncology innovation summit 2020 and 2021. Am Heart J Plus 2024; 38:100354. [PMID: 38510746 PMCID: PMC10945974 DOI: 10.1016/j.ahjo.2023.100354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 03/22/2024]
Abstract
As cancer therapies increase in effectiveness and patients' life expectancies improve, balancing oncologic efficacy while reducing acute and long-term cardiovascular toxicities has become of paramount importance. To address this pressing need, the Cardiology Oncology Innovation Network (COIN) was formed to bring together domain experts with the overarching goal of collaboratively investigating, applying, and educating widely on various forms of innovation to improve the quality of life and cardiovascular healthcare of patients undergoing and surviving cancer therapies. The COIN mission pillars of innovation, collaboration, and education have been implemented with cross-collaboration among academic institutions, private and public establishments, and industry and technology companies. In this report, we summarize proceedings from the first two annual COIN summits (inaugural in 2020 and subsequent in 2021) including educational sessions on technological innovations for establishing best practices and aligning resources. Herein, we highlight emerging areas for innovation and defining unmet needs to further improve the outcome for cancer patients and survivors of all ages. Additionally, we provide actionable suggestions for advancing innovation, collaboration, and education in cardio-oncology in the digital era.
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Affiliation(s)
- Sherry-Ann Brown
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Brenton Bauer
- COR Healthcare Associates, Torrance Memorial Medical Center, Torrance, CA, USA
| | - Richard K. Cheng
- Cardio-Oncology Program, Division of Cardiology, University of Washington, Seattle, WA, USA
| | | | - Catherine H. Marshall
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Avirup Guha
- Cardio-Oncology Program, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Prantesh Jain
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | | | - Jeanne M. DeCara
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Iredia M. Olaye
- Division of Clinical Epidemiology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | | | - Jim Logan
- University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, MO, USA
| | - Carri Glide-Hurst
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
| | - Irving Loh
- Ventura Heart Institute, Thousand Oaks, CA, USA
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John Alan Gambril
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
| | | | | | - Peter J. McGranaghan
- Department of Cardiothoracic Surgery, German Heart Center, Berlin, Germany
- Department of Internal Medicine and Cardiology, Charité Campus Virchow-Klinikum, Berlin, Germany
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Akshee Batra
- Department of Medicine, University of Vermont Medical Center, Burlington, VT, USA
| | - Courtney Campbell
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Fatma Gunturkun
- Center for Biomedical Informatics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert Davis
- Center for Biomedical Informatics, University of Tennessee Health Science Center, Memphis, TN, USA
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | - John Jefferies
- Center for Biomedical Informatics, University of Tennessee Health Science Center, Memphis, TN, USA
- St. Jude Children's Research Hospital, Memphis, TN, USA
- The Heart Institute at Le Bonheur Children's Hospital, University of Tennessee Health and Science Center, Memphis, TN, USA
| | - Michael Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine Albert
- Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences, University of Colorado at Colorado Springs, Denver, CO, USA
| | - Anne Blaes
- Division of Hematology/Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Indrajit Choudhuri
- Department of Electrophysiology, Froedtert South Hospital, Milwaukee, WI, USA
| | - Arjun K. Ghosh
- Cardio-Oncology Service, Barts Heart Centre and University College London Hospital, London, UK
| | - Thomas D. Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine; Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ogochukwu Ezeoke
- Department of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Douglas J. Leedy
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | | | - Sebastian Roman
- Department of Internal Medicine III: Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Lorenz Lehmann
- Department of Internal Medicine III: Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Abdullah Sarkar
- Department of Medicine, Cleveland Clinic Florida, Weston, FL, USA
| | - Diego Sadler
- Department of Medicine, Cleveland Clinic Florida, Weston, FL, USA
| | - Elizabeth Polter
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Neha Bansal
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eric Yang
- Cardio-Oncology Program, University of California, Los Angeles, Los Angeles, CA, USA
| | - Brijesh Patel
- Division of Cardiology, West Virginia University Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - David Cho
- Division of Cardiovascular Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Alison Bailey
- Center for Heart, Lung, and Vascular Health at Parkridge, HCA Healthcare, Chattanooga, TN, USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Vijay Rao
- Indiana Heart Physicians, Franciscan Health, Indianapolis, IN, USA
| | - Joshua E. Levenson
- Division of Cardiology, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dipti Itchhaporia
- Cardiology, University of California Irvine, Hoag Hospital Newport Beach, Newport Beach, CA, USA
| | - Karol Watson
- Division of Cardiovascular Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Kim Williams
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Donald Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Erin Michos
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Julie Gralow
- American Society of Clinical Oncology, Alexandria, VA, USA
| | - Hugo Martinez
- St. Jude Children's Research Hospital, Memphis, TN, USA
- The Heart Institute at Le Bonheur Children's Hospital, University of Tennessee Health and Science Center, Memphis, TN, USA
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Zhao J, Setchell KD, Zhao X, Galandi S, Garr BN, Gao Z, Chin C, Stark S, Steele PE, Ryan TD. Use of volumetric absorptive microsampling and parallel reaction monitoring mass spectrometry for tacrolimus blood trough measurements at home in pediatric heart transplant patients. J Mass Spectrom Adv Clin Lab 2024; 31:1-7. [PMID: 38163003 PMCID: PMC10755538 DOI: 10.1016/j.jmsacl.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/22/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Background Measurement of trough levels for calcineurin inhibitors by venipuncture sampling is a mainstay of patient management in solid organ transplant recipients but challenging in pediatric patients. Volumetric Absorptive Microsampling (VAMS) is a patient-friendly, minimally invasive sampling technique to accurately collect blood. An assay for measurement of tacrolimus in blood using VAMS, coupled with parallel reaction monitoring (PRM) mass spectrometry, was validated in pediatric heart transplant patients. Methods Tacrolimus was measured by a newly developed high-resolution PRM assay and compared with low-resolution tandem mass spectrometry (MRM). Dried blood samples were collected from pediatric heart transplant patients (n = 35) using VAMS devices and a satisfaction survey was completed by patients/guardians. Tacrolimus concentrations were compared across whole liquid blood, dried blood spots, and capillary blood, and shipping stability determined. Results The PRM assay was linear over a range 1-50 ng/mL, similar to MRM but had greater specificity due to reduced background noise. No significant differences in tacrolimus concentrations were observed between VAMS and venous blood. Tacrolimus dried on VAM tips was stable for 14 days and concentrations were unaffected by postal shipping. The variability in two simultaneously collected at-home patient samples was minimal - average concentration difference was 0.12 ± 0.94 ng/mL (p = 0.6) between paired samples. Conclusion A high resolution PRM mass spectrometry assay was developed for home-based dried blood collections for therapeutic monitoring of tacrolimus. The advantage of PRM was enhanced specificity and the VAMS devices provided a simple and convenient approach to blood sampling at home in pediatric heart transplant patients.
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Affiliation(s)
- Junfang Zhao
- Division of Pathology & Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kenneth D.R. Setchell
- Division of Pathology & Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Xueheng Zhao
- Division of Pathology & Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stephanie Galandi
- Division of Pathology & Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - BreAnn N Garr
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Zhiqian Gao
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Clifford Chin
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shelly Stark
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Paul E. Steele
- Division of Pathology & Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas D. Ryan
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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6
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Perry T, Greenberg JW, Cooper DS, Smith R, Benscoter AL, Koh W, Ryan TD, Lehenbauer DG, Brown TN, Zafar F, Thiagarajan RR, Sweberg TM, Morales DL. Balloon atrial septostomy versus left atrial cannulation for left heart decompression in children with dilated cardiomyopathy and myocarditis on extracorporeal membrane oxygenation: An ELSO registry analysis. Perfusion 2023:2676591231220816. [PMID: 38053305 DOI: 10.1177/02676591231220816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
INTRODUCTION In children with myocarditis or dilated cardiomyopathy (DCM) on extracorporeal membrane oxygenation (ECMO) for cardiogenic shock, it is often necessary to decompress the left heart to minimize distension and promote myocardial recovery. We compare outcomes in those who underwent balloon atrial septostomy (BAS) versus direct left atrial (LA) drainage for left heart decompression in this population. METHODS Retrospective study of the Extracorporeal Life Support Organization (ELSO) multicenter registry of patients ≤ 18 years with myocarditis or DCM on ECMO who underwent LA decompression. Descriptive and univariate statistics assessed association of patient factors with decompression type. Multivariable logistic regression sought independent associations with outcomes. RESULTS 369 pediatric ECMO runs were identified. 52% myocarditis, 48% DCM, overall survival 74%. 65% underwent BAS and 35% LA drainage. Patient demographics including age, weight, gender, race/ethnicity, diagnosis, pre-ECMO pH, mean airway pressure, and arrest status were similar. 89% in the BAS group were peripherally cannulated onto ECMO, versus 3% in the LA drainage group (p < .001). On multivariable analysis, LA drainage (OR 3.96; 95% CI, 1.47-10.711; p = .007), renal complication (OR 2.37; 95% CI, 1.41-4.01; p = .001), cardiac complication (OR 3.14; 95% CI, 1.70-5.82; p < .001), and non-white race/ethnicity (OR 1.75; 95% CI, 1.04-2.94; p = .035) were associated with greater odds of mortality. There was a trend toward more episodes of pulmonary hemorrhage in BAS (n = 17) versus LA drainage group (n = 3), p = .08. Comparing only those with central cannulation, LA drainage group was more likely to be discontinued from ECMO due to recovery (72%) versus the BAS group (48%), p = .032. CONCLUSIONS In children with myocarditis or DCM, there was a three times greater likelihood for mortality with LA drainage versus BAS for LA decompression. When adjusted for central cannulation groups only, there was better recovery in the LA drainage group and no difference in mortality. Further prospective evaluation is warranted.
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Affiliation(s)
- Tanya Perry
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jason W Greenberg
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Reanna Smith
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexis L Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Wonshill Koh
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David G Lehenbauer
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tyler N Brown
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Farhan Zafar
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Todd M Sweberg
- Department of Pediatric Critical Care, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - David Ls Morales
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Abou Alaiwi S, Roston TM, Marstrand P, Claggett BL, Parikh VN, Helms AS, Ingles J, Lampert R, Lakdawala NK, Michels M, Owens AT, Rossano JW, Saberi S, Abrams DJ, Ashley EA, Semsarian C, Stendahl JC, Ware JS, Miller E, Ryan TD, Russell MW, Day SM, Olivotto I, Vissing CR, Ho CY. Left Ventricular Systolic Dysfunction in Patients Diagnosed With Hypertrophic Cardiomyopathy During Childhood: Insights From the SHaRe Registry. Circulation 2023; 148:394-404. [PMID: 37226762 PMCID: PMC10373850 DOI: 10.1161/circulationaha.122.062517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 05/09/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The development of left ventricular systolic dysfunction (LVSD) in hypertrophic cardiomyopathy (HCM) is rare but serious and associated with poor outcomes in adults. Little is known about the prevalence, predictors, and prognosis of LVSD in patients diagnosed with HCM as children. METHODS Data from patients with HCM in the international, multicenter SHaRe (Sarcomeric Human Cardiomyopathy Registry) were analyzed. LVSD was defined as left ventricular ejection fraction <50% on echocardiographic reports. Prognosis was assessed by a composite of death, cardiac transplantation, and left ventricular assist device implantation. Predictors of developing incident LVSD and subsequent prognosis with LVSD were assessed using Cox proportional hazards models. RESULTS We studied 1010 patients diagnosed with HCM during childhood (<18 years of age) and compared them with 6741 patients with HCM diagnosed as adults. In the pediatric HCM cohort, median age at HCM diagnosis was 12.7 years (interquartile range, 8.0-15.3), and 393 (36%) patients were female. At initial SHaRe site evaluation, 56 (5.5%) patients with childhood-diagnosed HCM had prevalent LVSD, and 92 (9.1%) developed incident LVSD during a median follow-up of 5.5 years. Overall LVSD prevalence was 14.7% compared with 8.7% in patients with adult-diagnosed HCM. Median age at incident LVSD was 32.6 years (interquartile range, 21.3-41.6) for the pediatric cohort and 57.2 years (interquartile range, 47.3-66.5) for the adult cohort. Predictors of developing incident LVSD in childhood-diagnosed HCM included age <12 years at HCM diagnosis (hazard ratio [HR], 1.72 [CI, 1.13-2.62), male sex (HR, 3.1 [CI, 1.88-5.2), carrying a pathogenic sarcomere variant (HR, 2.19 [CI, 1.08-4.4]), previous septal reduction therapy (HR, 2.34 [CI, 1.42-3.9]), and lower initial left ventricular ejection fraction (HR, 1.53 [CI, 1.38-1.69] per 5% decrease). Forty percent of patients with LVSD and HCM diagnosed during childhood met the composite outcome, with higher rates in female participants (HR, 2.60 [CI, 1.41-4.78]) and patients with a left ventricular ejection fraction <35% (HR, 3.76 [2.16-6.52]). CONCLUSIONS Patients with childhood-diagnosed HCM have a significantly higher lifetime risk of developing LVSD, and LVSD emerges earlier than for patients with adult-diagnosed HCM. Regardless of age at diagnosis with HCM or LVSD, the prognosis with LVSD is poor, warranting careful surveillance for LVSD, especially as children with HCM transition to adult care.
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Affiliation(s)
- Sarah Abou Alaiwi
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA (S.A.A., T.M.R., B.L.C., N.K.L., C.Y.H.)
| | - Thomas M. Roston
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA (S.A.A., T.M.R., B.L.C., N.K.L., C.Y.H.)
- University of British Columbia, Vancouver, Canada (T.M.R.)
| | - Peter Marstrand
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Denmark (P.M.)
| | - Brian Lee Claggett
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA (S.A.A., T.M.R., B.L.C., N.K.L., C.Y.H.)
| | - Victoria N. Parikh
- Center for Inherited Cardiovascular Disease, Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (V.N.P., E.A.A.)
| | - Adam S. Helms
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (A.S.H., S.S., M.W.R.)
| | - Jodie Ingles
- Centre for Population Genomics, Garvan Institute of Medical Research and University of New South Wales, Sydney, Australia (J.I.)
| | - Rachel Lampert
- Department of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (R.L., J.C.S.)
| | - Neal K. Lakdawala
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA (S.A.A., T.M.R., B.L.C., N.K.L., C.Y.H.)
| | - Michelle Michels
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, the Netherlands (M.M.)
| | - Anjali T. Owens
- Division of Cardiology, University of Pennsylvania, Philadelphia (A.T.O., S.M.D.)
| | - Joseph W. Rossano
- Division of Cardiology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (J.W.R.)
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (A.S.H., S.S., M.W.R.)
| | - Dominic J. Abrams
- Center for Cardiovascular Genetics, Department of Cardiology, Boston Children’s Hospital & Harvard Medical School, MA (D.J.A.)
| | - Euan A. Ashley
- Center for Inherited Cardiovascular Disease, Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (V.N.P., E.A.A.)
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Australia (C.S.)
| | - John C. Stendahl
- Department of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT (R.L., J.C.S.)
| | - James S. Ware
- Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK (J.S.W.)
| | - Erin Miller
- Department of Pediatrics, University of Cincinnati College of Medicine, OH (E.M., T.D.R.)
- Division of Cardiology, The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (E.M., T.D.R.)
| | - Thomas D. Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, OH (E.M., T.D.R.)
- Division of Cardiology, The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (E.M., T.D.R.)
| | - Mark W. Russell
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (A.S.H., S.S., M.W.R.)
| | - Sharlene M. Day
- Division of Cardiology, University of Pennsylvania, Philadelphia (A.T.O., S.M.D.)
| | - Iacopo Olivotto
- Meyer Children Hospital, Department of Experimental and Clinical Medicine, University of Florence, Italy (I.O.)
| | - Christoffer R. Vissing
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (C.R.V.)
| | - Carolyn Y. Ho
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA (S.A.A., T.M.R., B.L.C., N.K.L., C.Y.H.)
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Dani A, Price N, Thangappan K, Ryan TD, Hooper DK, Cooper DS, Lehenbauer DG, Chin C, Zafar F, Morales DLS. Heart-kidney listing is better than isolated heart listing for pediatric heart transplant candidates with significant renal insufficiency. J Thorac Cardiovasc Surg 2022; 164:2019-2031. [PMID: 35331555 PMCID: PMC9433468 DOI: 10.1016/j.jtcvs.2021.10.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Significant renal insufficiency is identified as a risk factor for post-transplantation mortality in pediatric heart transplant recipients. This study evaluates simultaneous heart-kidney transplantation listing outcomes compared with heart transplant for pediatric candidates with significant renal insufficiency. METHODS The United Network for Organ Sharing registry was searched for patients (January 1987 to March 2020) who were simultaneously listed for a heart-kidney transplantation or for heart transplant with significant renal insufficiency at the time of listing. Significant renal insufficiency was defined as needing dialysis or having a low estimated glomerular filtration rate (<40 mL/min). Survival was calculated using Kaplan-Meier analysis. RESULTS A total of 427 cases were identified; 109 were listed for heart-kidney transplantation, and 318 were listed for heart transplant alone. Median time on the waitlist was 101 days (interquartile range, 28-238) for heart-kidney transplantation listings compared with 39 days (14-86) and 23.5 days (6-51) for heart transplant recipients with a low estimated glomerular filtration rate (P = .002) or on dialysis (P < .001), respectively. Of all heart-kidney transplantation listings, 66% (n = 71) received a transplant compared with 54% (n = 173) of heart transplantation with significant renal insufficiency (P = .005) with a mean survival of 14.6 years (12.7-16.4 years) for heart transplant without significant renal insufficiency at transplantation and 7.6 years (5.4-9.9 years) for heart transplant with significant renal insufficiency at transplantation. At 1 year after listing, 69% of heart-kidney transplantation listed recipients were alive, compared with 51% of heart transplant listed recipients (P = .029). Heart-kidney transplantation recipients had better 1-year post-transplantation survival (86%) than heart transplantation with significant renal insufficiency at transplant (66%) (P = .001). There was no significant difference in the 1- and 5-year survivals of those undergoing heart transplantation listed with significant renal insufficiency but no significant renal insufficiency at the time of transplant (89% and 78%) and heart-kidney transplantation recipients (86% and 81%; P = .436). CONCLUSIONS Pediatric candidates with significant renal insufficiency listed for heart-kidney transplantation have superior waitlist and post-transplantation outcomes compared with those listed for heart transplant alone. Patients with significant renal insufficiency should be listed for heart-kidney transplantation, however; if their renal function improves significantly, heart transplant alone appears judicious.
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Affiliation(s)
- Alia Dani
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nina Price
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karthik Thangappan
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Thomas D Ryan
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David K Hooper
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David S Cooper
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David G Lehenbauer
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Clifford Chin
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Farhan Zafar
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L S Morales
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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9
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Ryan TD, Rainusso NC. Consensus-Based Cardiomyopathy Care in Childhood Cancer Survivors. JACC CardioOncol 2022; 4:368-370. [PMID: 36213356 PMCID: PMC9537069 DOI: 10.1016/j.jaccao.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Thomas D. Ryan
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Address for correspondence: Dr Thomas D. Ryan, Heart Institute, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2003, Cincinnati, Ohio 45229, USA. @DrThomasRyan
| | - Nino C. Rainusso
- Texas Children’s Cancer and Hematology Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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10
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Perl E, Ravisankar P, Beerens ME, Mulahasanovic L, Smallwood K, Sasso MB, Wenzel C, Ryan TD, Komár M, Bove KE, MacRae CA, Weaver KN, Prada CE, Waxman JS. Stx4 is required to regulate cardiomyocyte Ca 2+ handling during vertebrate cardiac development. HGG Adv 2022; 3:100115. [PMID: 35599850 PMCID: PMC9114686 DOI: 10.1016/j.xhgg.2022.100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/22/2022] [Indexed: 12/16/2022] Open
Abstract
Requirements for vesicle fusion within the heart remain poorly understood, despite the multitude of processes that necessitate proper intracellular trafficking within cardiomyocytes. Here, we show that Syntaxin 4 (STX4), a target-Soluble N-ethylmaleimide sensitive factor attachment receptor (t-SNARE) protein, is required for normal vertebrate cardiac conduction and vesicular transport. Two patients were identified with damaging variants in STX4. A patient with a homozygous R240W missense variant displayed biventricular dilated cardiomyopathy, ectopy, and runs of non-sustained ventricular tachycardia, sensorineural hearing loss, global developmental delay, and hypotonia, while a second patient displayed severe pleiotropic abnormalities and perinatal lethality. CRISPR/Cas9-generated stx4 mutant zebrafish exhibited defects reminiscent of these patients' clinical presentations, including linearized hearts, bradycardia, otic vesicle dysgenesis, neuronal atrophy, and touch insensitivity by 3 days post fertilization. Imaging of Vamp2+ vesicles within stx4 mutant zebrafish hearts showed reduced docking to the cardiomyocyte sarcolemma. Optical mapping of the embryonic hearts coupled with pharmacological modulation of Ca2+ handling together support that zebrafish stx4 mutants have a reduction in L-type Ca2+ channel modulation. Transgenic overexpression of zebrafish Stx4R241W, analogous to the first patient's STX4R240W variant, indicated that the variant is hypomorphic. Thus, these data show an in vivo requirement for SNAREs in regulating normal embryonic cardiac function and that variants in STX4 are associated with pleiotropic human disease, including cardiomyopathy.
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Affiliation(s)
- Eliyahu Perl
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Molecular and Developmental Biology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Division of Molecular Cardiovascular Biology, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Padmapriyadarshini Ravisankar
- Division of Molecular Cardiovascular Biology, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Manu E. Beerens
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lejla Mulahasanovic
- Praxis für Humangenetik, Tübingen, Baden-Württemberg, Germany,CeGaT GmbH, Tübingen, Baden-Württemberg, Germany
| | - Kelly Smallwood
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Marion Bermúdez Sasso
- Institute for Clinical Genetics, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Saxony, Germany
| | - Carina Wenzel
- Institute of Pathology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Thomas D. Ryan
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA,Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Matej Komár
- Department of Gynecology and Obstetrics, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Saxony, Germany
| | - Kevin E. Bove
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA,Division of Pathology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pathology and Laboratory Medicine, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Calum A. MacRae
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Genetics and Network Medicine Divisions, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Harvard Stem Cell Institute, Boston, MA, USA
| | - K. Nicole Weaver
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Carlos E. Prada
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Joshua S. Waxman
- Division of Molecular Cardiovascular Biology, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA,Division of Developmental Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Corresponding author
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11
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Jodele S, Dandoy CE, Sabulski A, Koo J, Lane A, Myers KC, Wallace G, Chima RS, Teusink-Cross A, Hirsch R, Ryan TD, Benoit S, Davies SM. TA-TMA risk stratification: is there a window of opportunity to improve outcomes? Transplant Cell Ther 2022; 28:392.e1-392.e9. [DOI: 10.1016/j.jtct.2022.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 10/18/2022]
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12
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Powell AW, Urbina EM, Madueme P, Rotz S, Chin C, Taylor MD, Mays WA, Davies SM, Lane A, Berger S, Jodele S, Dandoy CE, Ryan TD. Abnormal maximal and submaximal cardiopulmonary exercise capacity in pediatric stem cell transplant recipients despite normal standard echocardiographic parameters: a pilot study. Transplant Cell Ther 2022; 28:263.e1-263.e5. [PMID: 35219851 DOI: 10.1016/j.jtct.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/10/2022] [Accepted: 02/20/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Left ventricular systolic dysfunction is a known complication of stem cell transplant (SCT). There has been minimal research to determine if subclinical cardiac dysfunction exists in SCT patients utilizing tools other than standard echocardiography, such as maximal and submaximal effort cardiopulmonary exercise testing (CPET) and vascular function studies. OBJECTIVE The objective of this study was to determine the rate of subclinical cardiac dysfunction in patients with normal ejection fraction after SCT, identified by abnormal values by CPET, tissue-Doppler imaging, and arterial stiffness measurements and to further describe submaximal exercise test measures in this population. STUDY DESIGN A prospective cohort study of SCT survivors who were at least three years post-SCT without prior anthracycline or radiation exposure and with preserved systolic function (LV ejection fraction > 50%) was performed to evaluate for abnormalities in exercise, vascular function, and diastolic function in an effort to detect subclinical dysfunction in SCT patients. RESULTS There were 11 patients (12.4±3.8-years-old) included in the study. No patients had diastolic dysfunction. All patients completed a maximal effort exercise test, and 73% (8/11) had abnormal peak oxygen consumption (VO2peak), which is a measure of aerobic fitness. However, during submaximal effort CPET, 45% (5/11) had an abnormal VO2 at anaerobic threshold (i.e. the point in exercise where aerobic transitions to anaerobic metabolism and fatigue starts), and 64% (7/11) had an abnormal oxygen uptake efficiency slope (a measure that relates VO2peak to total ventilation). 86% (6/7) of the patients with an abnormal oxygen uptake efficiency slope ultimately had an abnormal VO2peak. There were no vascular function abnormalities. CONCLUSION Pediatric survivors of SCT often have abnormal maximal and submaximal exercise capacity without vascular or cardiac dysfunction.
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Affiliation(s)
- Adam W Powell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Elaine M Urbina
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Peace Madueme
- The Division of Pediatric Cardiology, Nemours Children's Hospital, Orlando, FL
| | - Seth Rotz
- The Division of Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH
| | - Clifford Chin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael D Taylor
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Wayne A Mays
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stella M Davies
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adam Lane
- The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Suzanne Berger
- The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sonata Jodele
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Christopher E Dandoy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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13
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Brickler M, Raskin A, Ryan TD. Current State of Pediatric Cardio-Oncology: A Review. Children 2022; 9:children9020127. [PMID: 35204848 PMCID: PMC8870613 DOI: 10.3390/children9020127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/23/2021] [Accepted: 11/30/2021] [Indexed: 01/03/2023]
Abstract
The landscape of pediatric oncology has dramatically changed over the course of the past several decades with five-year survival rates surpassing 80%. Anthracycline therapy has been the cornerstone of many chemotherapy regimens for pediatric patients since its introduction in the 1960s, and recent improved survival has been in large part due to advancements in chemotherapy, refinement of supportive care treatments, and development of novel therapeutics such as small molecule inhibitors, chimeric antigen receptor T-cell therapy, and immune checkpoint inhibitors. Unfortunately, many cancer-targeted therapies can lead to acute and chronic cardiovascular pathologies. The range of cardiotoxicity can vary but includes symptomatic or asymptotic heart failure, arrhythmias, coronary artery disease, valvar disease, pericardial disease, hypertension, and peripheral vascular disease. There is lack of data guiding primary prevention and treatment strategies in the pediatric population, which leads to substantial practice variability. Several important future research directions have been identified, including as they relate to cardiac disease, prevention strategies, management of cardiovascular risk factors, risk prediction, early detection, and the role of genetic susceptibility in development of cardiotoxicity. Continued collaborative research will be key in advancing the field. The ideal model for pediatric cardio-oncology is a proactive partnership between pediatric cardiologists and oncologists in order to better understand, treat, and ideally prevent cardiac disease in pediatric oncology patients.
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Affiliation(s)
| | | | - Thomas D. Ryan
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
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14
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Abstract
OBJECTIVES Sepsis-associated myocardial dysfunction is common in pediatric septic shock and negatively impacts outcomes. Early estimation of sepsis-associated myocardial dysfunction risk has the potential to inform clinical care and improve clinical trial design. The Pediatric Sepsis Biomarker Risk Model II is validated as a biomarker-based enrichment algorithm to discriminate children with septic shock with high baseline mortality probability. The objectives were to determine if Pediatric Sepsis Biomarker Risk Model biomarkers are associated with risk for sepsis-associated myocardial dysfunction in pediatric septic shock and to develop a biomarker-based model to reliably estimate sepsis-associated myocardial dysfunction risk. DESIGN Secondary analysis of prospective cohort study. SETTING Single-center, quaternary-care PICU. PATIENTS Children less than 18 years old admitted to the PICU from 2003 to 2018 who had Pediatric Sepsis Biomarker Risk Model biomarkers measured for determination of Pediatric Sepsis Biomarker Risk Model II mortality probability and an echocardiogram performed within 48 hours of septic shock identification. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pediatric Sepsis Biomarker Risk Model II mortality probability was calculated from serum biomarker concentrations and admission platelet count. Echocardiograms were reread by a single cardiologist blinded to Pediatric Sepsis Biomarker Risk Model II data, and sepsis-associated myocardial dysfunction was defined as left ventricular ejection fraction less than 45% for primary analyses. Multivariable logistic regression analyzed the association of Pediatric Sepsis Biomarker Risk Model II mortality probability with sepsis-associated myocardial dysfunction. Classification and regression tree methodology was employed to derive a Pediatric Sepsis Biomarker Risk Model biomarker-based model for sepsis-associated myocardial dysfunction. Thirty-two of 181 children with septic shock demonstrated sepsis-associated myocardial dysfunction. Pediatric Sepsis Biomarker Risk Model II mortality probability was independently associated with sepsis-associated myocardial dysfunction (odds ratio, 1.45; 95% CI, 1.17-1.81; p = 0.001). Modeling with Pediatric Sepsis Biomarker Risk Model biomarkers estimated sepsis-associated myocardial dysfunction risk with an area under the receiver operating characteristic curve of 0.90 (95% CI, 0.85-0.95). Upon 10-fold cross-validation, the derived model had a summary area under the receiver operating characteristic curve of 0.74. Model characteristics were similar when sepsis-associated myocardial dysfunction was defined by both low left ventricular ejection fraction and abnormal global longitudinal strain. CONCLUSIONS A newly derived Pediatric Sepsis Biomarker Risk Model biomarker-based model reliably estimates risk of sepsis-associated myocardial dysfunction in pediatric septic shock, but independent prospective validation is needed.
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Affiliation(s)
- Andrew J. Lautz
- University of Cincinnati College of Medicine, Department of Pediatrics
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine
| | - Hector R. Wong
- University of Cincinnati College of Medicine, Department of Pediatrics
- Cincinnati Children’s Hospital Medical Center, Division of Critical Care Medicine
| | - Thomas D. Ryan
- University of Cincinnati College of Medicine, Department of Pediatrics
- Cincinnati Children’s Hospital Medical Center, Division of Cardiology
| | - Christopher J. Statile
- University of Cincinnati College of Medicine, Department of Pediatrics
- Cincinnati Children’s Hospital Medical Center, Division of Cardiology
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15
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Henson SE, Lang SM, Khoury PR, Tian C, Rutter MM, Urbina EM, Ryan TD, Taylor MD, Alsaied T. The Effect of Adiposity on Cardiovascular Function and Myocardial Fibrosis in Patients With Duchenne Muscular Dystrophy. J Am Heart Assoc 2021; 10:e021037. [PMID: 34569261 PMCID: PMC8649129 DOI: 10.1161/jaha.121.021037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Patients with Duchenne muscular dystrophy (DMD) develop cardiomyopathy because of a dystrophin deficiency causing fibrofatty replacement of the myocardium. Corticosteroid use and mobility limitations place these patients at risk for increased adiposity. We sought to determine the association of adiposity with cardiovascular dysfunction in patients with DMD. Methods and Results This was a retrospective review of patients with DMD who underwent both cardiac magnetic resonance imaging and dual‐energy x‐ray absorptiometry within 1 year. The cardiac magnetic resonance imaging parameters included left ventricular ejection fraction and the presence of late gadolinium enhancement (LGE positive [LGE+]). The adiposity indices, measured by dual‐energy x‐ray absorptiometry, included percentage of body fat, whole body fat mass indexed to height, and body mass index. A total of 324 patients were identified. Fifty‐two percent had LGE+, and 36% had cardiac dysfunction (left ventricular ejection fraction <55%). Patients with cardiac dysfunction had higher whole body fat mass indexed to height and body mass index on univariate analysis (mean difference between patients with and without cardiac dysfunction: +2.9 kg/m, P=0.001; and +1.5 kg/m2, P=0.03, respectively). whole body fat mass indexed to height remained independently associated with cardiac dysfunction on multivariable analysis after adjusting for age, LGE+, and corticosteroid duration. High whole body fat mass indexed to height and percentage of body fat were associated with LGE+ on univariate analysis (mean difference between patients with and without LGE+: +2.0 kg/m, P=0.02; and +2.4%, P=0.02, respectively). Using multivariable analysis, including age and cardiac dysfunction, high percentage of body fat remained independently associated with LGE+. Conclusions This study demonstrates an independent association of adiposity with cardiac dysfunction and LGE+ in patients with DMD. Preventing adiposity may mitigate the later development of ventricular dysfunction in DMD.
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Affiliation(s)
- Sarah E Henson
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Sean M Lang
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Philip R Khoury
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Heart Institute Research Core Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Cuixia Tian
- Neurology, Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Meilan M Rutter
- Endocrinology, Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Elaine M Urbina
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Thomas D Ryan
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Michael D Taylor
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Tarek Alsaied
- Pediatric Cardiology and Heart Institute, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh Pittsburgh PA
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16
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Ryan TD. The future is now! A supplemental webinar series to the First International Pediatric Cardio-Oncology Meeting. Prog Pediatr Cardiol 2021; 61:101362. [PMID: 36570378 PMCID: PMC9759962 DOI: 10.1016/j.ppedcard.2021.101362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 12/27/2022]
Abstract
Planning for the First International Pediatric Cardio-Oncology Meeting has been underway since early 2019, with the original date in October 2020 delayed due to the COVID-19 pandemic. But patients continue to need care, research carries on, and the ability to learn from our colleagues remains one of the most important tools in our collective ability to advance the field. Through collaboration with Heart University (www.heartuniversity.org), a free web-based global education resource and training tool with an emphasis on acquired and congenital heart disease, we are able to provide colleagues around the world with focused sessions similar to those that will be expanded at the in-person meeting. The first such two-hour webinar was presented live online on December 16, 2020, and moving forward similar webinars will be offered approximately every other month for the next year leading up to the in-person meeting in 2022, with all sessions available online afterward for on-demand viewing. Although we are excited to get together with our colleagues in person, why wait until then to share what we know? The future is now!
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Affiliation(s)
- Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital Medical Center, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, United States of America
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17
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Agresta L, O'Brien MM, O'Brien EJ, Norris RE, Breese EH, Burns KC, Mizukawa B, Ryan TD, Desai PB, Vinks A, Grimes HL, Absalon M, Perentesis JP. V2 Trial: A phase I study of venetoclax and CPX-351 for young patients with relapsed/refractory acute leukemia. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.tps7052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS7052 Background: Despite significant advances in therapy for acute myeloid leukemia (AML), 30-40% of young patients will relapse, after which prognosis is poor. In young patients, curative-intent salvage therapy involves intensive re-induction followed by hematopoietic stem cell transplant. Recently, the COG Phase II study of CPX-351 (liposomal cytarabine:daunorubicin, Vyxeos™) in pediatric patients with AML in first relapse (NCT02642965) demonstrated a CR/CRi rate of 81.3%. Separately, our first-in-pediatrics CPX-351 Phase I (NCT01943682) showed 48% in a heavily pre-treated pediatric cohort with multiply relapsed and refractory (R/R) AML. Our integrated pilot study of single cell RNA sequencing (scRNA-seq) done before, during, and after CPX-351 showed p53 targets over time with enrichment for genes regulating apoptosis (ex.: FAS, BAX), suggesting blasts may be primed for apoptosis following CPX-351. Venetoclax is a small molecule inhibitor of the anti-apoptotic protein BCL-2, a regulator of apoptotic balance in some leukemias. Based on our preclinical data, we developed a Phase I study to investigate venetoclax with CPX-351 for the treatment of young patients with R/R acute leukemias. Methods: The V2 Trial (NCT03826992) is a single-institution Phase I study to evaluate the safety and tolerability of venetoclax with CPX-351 in patients ages 1-39 years with R/R acute leukemias. Inclusion diagnoses include AML, mixed phenotype acute leukemia (MPAL), KMT2A-rearranged acute lymphoblastic leukemia (ALL), and T-ALL. Exclusion criteria include CNS status 3, bone marrow failure syndromes, and prior cardiotoxic exposures above acceptable risk thresholds. Subjects receive a single course of CPX-351 at the FDA approved adult dose on Days 1, 3, 5 with concurrent daily venetoclax. In the dose exploration phase, venetoclax dosing is 400 mg daily (or allometrically-scaled equivalent) for 21 (Dose Level 0) or 14 days (Dose Level -1) using a rolling 6 design. Primary endpoints are determination of the recommended phase 2 dose of venetoclax in combination with CPX-351 and description of toxicities. Secondary endpoints include estimations of CR/CRp/CRi +/- MRD negativity in the context of a phase I study and evaluation of therapy-related cardiac dysfunction. Correlative studies include analysis of venetoclax pharmacokinetics with concomitant CPX-351. At the initial dose level, DLT were encountered and the study is now continuing enrollment at Dose Level -1. Clinical trial information: NCT03826992.
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Affiliation(s)
- Laura Agresta
- Michigan State University College of Human Medicine, East Lansing, MI
| | | | | | | | | | | | | | - Thomas D Ryan
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Pankaj B Desai
- University of Cincinnati, College of Pharmacy, Cincinnati, OH
| | - A.a. Vinks
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Michael Absalon
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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18
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Rotz SJ, Ryan TD, Hayek SS. Cardiovascular disease and its management in children and adults undergoing hematopoietic stem cell transplantation. J Thromb Thrombolysis 2021; 51:854-869. [PMID: 33230704 PMCID: PMC8085022 DOI: 10.1007/s11239-020-02344-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2020] [Indexed: 02/07/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for many malignancies, hemoglobinopathies, metabolic diseases, bone marrow failure syndromes, and primary immune deficiencies. Despite the significant improvement in survival afforded by HSCT, the therapy is associated with major short and long-term morbidity and mortality. Cardiovascular complications such as cardiomyopathy, arrhythmias, pulmonary hypertension, and pericardial effusions are increasingly recognized as potential outcomes following HSCT. The incidence of cardiac complications is related to various factors such as age, co-morbid medical conditions, whether patients received cardiotoxic chemotherapy prior to HSCT, the type of HSCT (autologous versus allogeneic), and the specific conditioning regimen. Thus, the cardiovascular evaluation has become a core component of the pre-transplant assessment, however, the practice differs from center to center as national guidelines and contemporary high-quality studies are lacking. We review the incidence of cardiotoxicity in pediatric and adult HSCT, potential mechanisms of injury, and effects on long-term outcomes. We also discuss the possible therapeutic approaches when disease arises, as well as the indications and need for surveillance before, during, and after transplantation.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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19
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Martinez HR, Salloum R, Wright E, Bueche L, Khoury PR, Tretter JT, Ryan TD. Echocardiographic myocardial strain analysis describes subclinical cardiac dysfunction after craniospinal irradiation in pediatric and young adult patients with central nervous system tumors. Cardiooncology 2021; 7:5. [PMID: 33531084 PMCID: PMC7856804 DOI: 10.1186/s40959-021-00093-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/25/2021] [Indexed: 11/26/2022]
Abstract
Background Craniospinal irradiation (CSI) is part of the treatment of central nervous system (CNS) tumors and is associated with cardiovascular disease in adults. Global myocardial strain analysis including longitudinal peak systolic strain (GLS), circumferential peak systolic strain (GCS), and radial peak systolic strain (GRS) can reveal subclinical cardiac dysfunction. Methods Retrospective, single-center study in patients managed with CSI vs. age-matched controls. Clinical data and echocardiography, including myocardial strain analysis, were collected at early (< 12 months) and late (≥ 12 months) time points after completion of CSI. Results Echocardiograms were available at 20 early and 34 late time points. Patients at the late time point were older (21.7 ± 10.4 vs. 13.3 ± 9.6 years) and further out from CSI (13.1 ± 8.8 vs. 0.2 ± 0.3 years). Standard echocardiographic parameters were normal for both groups. For early, CSI vs. control: GLS was − 16.8 ± 3.6% vs. -21.3 ± 4.0% (p = 0.0002), GCS was − 22.5 ± 5.2% vs. -21.3 ± 3.4% (p = 0.28), and GRS was 21.8 ± 11.0% vs. 26.9 ± 7.7% (p = 0.07). For late, CSI vs. control: GLS was − 16.2 ± 5.4% vs. -21.6 ± 3.7% (p < 0.0001), GCS was − 20.9 ± 6.8% vs. -21.9 ± 3.5% (p = 0.42), and GRS was 22.5 ± 10.0% vs. 27.3 ± 8.3% (p = 0.03). Radiation type (proton vs. photon), and radiation dose (< 30 Gy vs. ≥ 30 Gy) did not impact any parameter, although numbers were small. Conclusions Subclinical cardiac systolic dysfunction by GLS is present both early and late after CSI. These results argue for future studies to determine baseline cardiovascular status and the need for early initiation of longitudinal follow-up post CSI.
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Affiliation(s)
- Hugo R Martinez
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA.,Present address: Division of Pediatric Cardiology, Heart Institute, Le Bonheur Children's Hospital, University of Tennessee Health and Science Center, Memphis, TN, USA
| | - Ralph Salloum
- Division of Oncology, Department of Pediatrics, University of Cincinnati College of Medicine, and Cancer and Blood Disorders Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Present address: Division of Hematology/Oncology/Bone Marrow Transplant Nationwide Children's Hospital Columbus, Columbus, OH, USA
| | - Erin Wright
- Present address: Division of Pediatric Cardiology, Heart Institute, Le Bonheur Children's Hospital, University of Tennessee Health and Science Center, Memphis, TN, USA.,Present address: Division of Hematology and Oncology, Showers Family Center for Childhood Cancer and Blood Disorders, Akron Children's Hospital, Akron, OH, USA
| | - Lauren Bueche
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Philip R Khoury
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Justin T Tretter
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA
| | - Thomas D Ryan
- Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA.
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20
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Siddiqui S, Alsaied T, Henson SE, Gandhi J, Patel P, Khoury P, Villa C, Ryan TD, Wittekind SG, Lang SM, Taylor MD. Left Ventricular Magnetic Resonance Imaging Strain Predicts the Onset of Duchenne Muscular Dystrophy-Associated Cardiomyopathy. Circ Cardiovasc Imaging 2020; 13:e011526. [PMID: 33190531 DOI: 10.1161/circimaging.120.011526] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Early detection of left ventricular (LV) dysfunction before the onset of overt Duchenne muscular dystrophy-associated cardiomyopathy (DMDAC) may direct clinical management to slow onset of dysfunction. We aimed to assess whether LV strain will predict those who develop DMDAC. METHODS We performed a single center retrospective case control study of patients with Duchenne muscular dystrophy who underwent serial cardiac magnetic resonance between 2006 and 2019. Patients with Duchenne muscular dystrophy with an LV ejection fraction ≥55% on ≥1 cardiac magnetic resonance were identified and grouped into age-matched +DMDAC and -DMDAC. Within 3 years, +DMDAC had a subsequent cardiac magnetic resonance with a decline in LV ejection fraction ≥10% and absolute LV ejection fraction ≤50%. -DMDAC maintained an LV ejection fraction ≥55% on serial cardiac magnetic resonances. Two-dimensional and 3-dimensional global radial strain, global circumferential strain (GCS), and global longitudinal strain were measured using tissue tracking software and their ability to predict DMDAC onset was assessed. Multivariable analysis adjusted for late gadolinium enhancement. RESULTS Thirty +DMDAC and 30 age-matched -DMDAC patients were included with a total of 164 studies analyzed. Before DMDAC onset, 2-dimensional global radial strain and GCS were significantly worse in +DMDAC compared with -DMDAC (25.1±6.0 versus 29.0±6.3, P=0.011; -15.4%±2.4 versus -17.3%±2.6, P=0.003). Three-dimensional GCS and global radial strain had similar findings. Among strain measures, 3-dimensional GCS had the highest area under the curve to predict DMDAC in our cohort. These findings persisted after adjusting for the presence of late gadolinium enhancement. CONCLUSIONS Reduced global radial strain and GCS may predict those at risk for developing DMDAC before onset of LV dysfunction and its clinical utility warrants further exploration.
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Affiliation(s)
- Saira Siddiqui
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH
| | - Tarek Alsaied
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Sarah E Henson
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH
| | | | | | - Philip Khoury
- Heart Institute Research Core (P.K.), Cincinnati Children's Hospital Medical Center, OH
| | - Chet Villa
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Thomas D Ryan
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Samuel G Wittekind
- Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Sean M Lang
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
| | - Michael D Taylor
- The Heart Institute (S.S., T.A., S.E.H., C.V., T.D.R., S.W., S.M.L., M.D.T.), Cincinnati Children's Hospital Medical Center, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, OH (T.A., C.V., T.D.R., S.G.W., S.M.L., M.D.T.)
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21
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Lang SM, Alsaied T, Khoury PR, Ryan TD, Taylor MD. Variations in native T1 values in patients with Duchenne muscular dystrophy with and without late gadolinium enhancement. Int J Cardiovasc Imaging 2020; 37:635-642. [PMID: 32951096 DOI: 10.1007/s10554-020-02031-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/17/2020] [Indexed: 12/14/2022]
Abstract
Duchenne muscular dystrophy (DMD) is an X-linked genetic disorder leading to progressive skeletal and cardiac myopathy. Elevated myocardial T1 values correlate with fibrosis in most disease processes, but DMD skeletal and cardiac histopathology is defined by fibrofatty replacement that may result in a decrease in T1 values, due to the low T1 of fat. The study goal was to assess myocardial T1 values in DMD patients with and without late gadolinium enhancement (LGE). A retrospective analysis was performed on all patients with DMD referred for CMR at our institution from 7/5/2017 to 10/24/2018. T1 measurements were performed using breath-held modified Look Locker inversion recovery (MOLLI) sequences at the basal and mid-ventricular levels. The cohort was separated into patients without the presence of LGE (LGE-) and patients with current or previous LGE (LGE+). A total of 207 CMR studies were analyzed. The LGE- group comprised 88 patients while 119 patients were in the LGE+ group. The LGE+ group was older, had larger indexed LV end-diastolic volume and lower LV ejection fraction (LVEF) compared to the LGE- group. T1 values in the LGE+ group were lower compared to the LGE- group (mid T1 1012 ms vs. 1035 ms; p = 0.002), with 5 CMR studies demonstrating mid T1 values < 900 ms. There was no correlation between mid T1 and LVEF in the LGE- group. In the LGE+ cohort, lower T1 values correlated with worse LVEF (r = 0.34, p = 0.0002). The association between mid T1 values and LVEF remained statistically significant on multivariable analysis when accounting for number of LGE segments, LVEDVi, and age (p = 0.009). This is the largest study assessing native T1 values in patients with DMD. The results demonstrate that patients with LGE had lower T1 values than patients without LGE. In the LGE+ group, lower T1 values correlated with worse LV systolic function. These results are consistent with the evolving recognition of fibrofatty replacement in advanced stages of DMD myopathy. Furthermore, our study supports that there is not a simple linear relationship between increasing T1 values and advancing disease progression reported in most other cardiomyopathies.
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Affiliation(s)
- Sean M Lang
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA.
| | - Tarek Alsaied
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
| | - Philip R Khoury
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA.,Heart Institute Research Core, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
| | - Michael D Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
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22
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Ryan TD, Hayek SS. New perspectives in cardio-oncology. J Thromb Thrombolysis 2020; 51:835-836. [PMID: 32880797 DOI: 10.1007/s11239-020-02267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine; Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA.
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan Frankel Cardiovascular Center, University of Michigan, 1500 E Medical Center Dr, CVC #2709, Ann Arbor, MI, 48109, USA.
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23
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Bottinor WJ, Friedman DL, Ryan TD, Wang L, Yu C, Borinstein SC, Godown J. Cardiovascular disease and asymptomatic childhood cancer survivors: Current clinical practice. Cancer Med 2020; 9:5500-5508. [PMID: 32558321 PMCID: PMC7402829 DOI: 10.1002/cam4.3190] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/19/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND It is poorly understood how cardiovascular screening in asymptomatic childhood cancer survivors (CCS) is applied to and impacts clinical care. OBJECTIVES To describe the current role of cardiovascular screening in the clinical care of asymptomatic CCS. METHODS At 50 pediatric academic medical centers, a childhood cancer survivorship clinic director, pediatric cardiologist, and adult cardiologist with a focus on CCS were identified and invited to participate in a survey. Surveys were managed electronically. Categorical data were analyzed using nonparametric methods. RESULTS Of the 95 (63%) respondents, 39% were survivorship practitioners, and 61% were cardiologists. Eighty-eight percent of survivorship practitioners reported that greater than half of CCS received cardiovascular screening. CCS followed by adult cardiology were more likely to be seen by a cardio-oncologist. Those followed by pediatric cardiology were more likely to be seen by a heart failure/transplant specialist. Common reasons for referral to cardiology were abnormal cardiovascular imaging or concerns a CCS was at high risk for cardiovascular disease. Ninety-two percent of cardiologists initiated angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapy for mild systolic dysfunction. Adult cardiologists initiated beta-blocker therapy for less severe systolic dysfunction compared to pediatric cardiologists (P < .001). Pediatric cardiologists initiated mineralocorticoid therapy for less severe systolic dysfunction compared to adult cardiologists (P = .025). Practitioners (93%) support a multi-institutional collaboration to standardize cardiovascular care for CCS. CONCLUSIONS While there is much common ground in the clinical approach to CCS, heterogeneity is evident. This highlights the need for cohesive, multi-institutional, standardized approaches to cardiovascular management in CCS.
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Affiliation(s)
- Wendy J Bottinor
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Debra L Friedman
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine; Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott C Borinstein
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Justin Godown
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Brosbe MS, Wright LK, Cantor R, Dreyer WJ, Kirmani S, Knight M, Nakano SJ, Kindel SJ, Ryan TD, Kirklin JK, Deshpande SR. Educational and learning morbidity in pediatric heart transplant recipients: A pediatric heart transplant society study. Pediatr Transplant 2020; 24:e13711. [PMID: 32320118 DOI: 10.1111/petr.13711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/28/2020] [Accepted: 03/20/2020] [Indexed: 11/29/2022]
Abstract
Educational development is an important component of quality of life for children with heart transplant. Aims include determining prevalence of and risk factors for modified education placement in a large representative sample of pediatric heart transplant recipients. Participants included 1495 patients (age 6-18 years) from the PHTS database. Data on education placement and clinical predictors were collected at listing and at 1 and 3 years post-transplant. At listing, 88% of patients were in typical education placement, while 12% were in modified education. Males (P = .02), those with CHD (P < .0001), those with non-private insurance (P < .0001), and those with longer hospital stay (P = .001) were more likely to be in a modified education placement at time of listing. Age, race, listing status, mechanical support, and waitlist time were not significantly associated with placement. The prevalence of typical education placement was similar (87% at 1-year and 86% at 3-year) post-transplant. Predictors of modified education placement at 3-year follow-up included placement at listing (OR = 12.9 [95% CI 7.6-21.9], P < .0001), non-private insurance (OR = 2.0 [95% CI 1.3-3.2], P = .001), CHD (OR = 1.8 [95% CI 1.1-2.7, P = .01), history of post-transplant infection (OR = 1.9 [95% CI 1.2-2.9, P = .007), and number of post-transplant infections (OR = 1.3 [95% CI 1.1-1.5, P = .002). Among pediatric heart transplant recipients, males, those with non-private insurance, those with CHD, and those who experience post-transplant infections are at greatest risk for modified academic placement, which persists for several years post-transplant and deserves targeted intervention.
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Affiliation(s)
| | | | - Ryan Cantor
- University of Alabama at Birmingham, Birmingham, Alabama
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25
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Wells D, Rizwan R, Jefferies JL, Bryant R, Ryan TD, Lorts A, Chin C, Zafar F, Morales DL. Heart Transplantation in Muscular Dystrophy Patients: Is it a Viable Option? Circ Heart Fail 2020; 13:e005447. [PMID: 32216460 DOI: 10.1161/circheartfailure.118.005447] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cardiomyopathy is a common complication among muscular dystrophy (MD) patients and often results in advanced heart failure and premature death. In spite of this, there is hesitancy to consider heart transplantation (HTx). This study describes the HTx outcomes in patients with MD in the United States. METHODS AND RESULTS All HTx in the United Network for Organ Sharing database from October 1, 1987, to March 31, 2016, were identified. Two patient groups were created: MD cohort (n=81), and a cohort of all other cardiomyopathies, called cardiomyopathy-unmatched (n=41 317). Propensity score matching (ratio 1:2) was performed on transplant age, gender transplant year, renal function, and inotropic support at transplant to form a cardiomyopathy-matched cohort (n=162). Patient characteristics and posttransplant outcomes were compared. In the 81 patients with MD, Becker was the most common type (42%-52%). All the analyzed preoperative characteristics did not statistically differ between the MD and cardiomyopathy-matched cohorts except ventricular assist device use (16% versus 30%; P=0.017), ventilator support (0% versus 6%; P=0.031), and donor race mismatch (30% versus 55%; P<0.001). Median time on waitlist was not statistically different between the 2 groups (52 versus 59 days; P=0.12). Posttransplant survival of MD cohort was not statistically different compared with cardiomyopathy-matched cohort (P=0.18; hazard ratio [95% CI], 0.71 [0.42-1.18]) and was better than the cardiomyopathy-unmatched cohort (P=0.004; hazard ratio [95% CI], 0.53 [0.34-0.82]). Among the types of MD, no statistical difference was observed in posttransplant survival of Becker MD versus non-Becker MD (P=0.12; hazard ratio [95% CI], 2.17 [0.79-6.01]). CONCLUSIONS Patients with MD undergoing HTx had similar long-term posttransplant survival compared with matched cardiomyopathy-related HTx recipients. HTx appears to be an effective treatment for a select group of muscular dystrophy patients with end-stage heart failure.
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Affiliation(s)
- Dennis Wells
- From the Department of Cardiothoracic Surgery (D.W.), University of Cincinnati College of Medicine, OH
| | - Raheel Rizwan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (R.R., J.L.J., R.B., T.D.R., A.L., C.C., F.Z., D.L.M.)
| | - John L Jefferies
- Department of Pediatrics (J.L.J., R.B., A.L., C.C., D.L.M.), University of Cincinnati College of Medicine, OH.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (R.R., J.L.J., R.B., T.D.R., A.L., C.C., F.Z., D.L.M.)
| | - Roosevelt Bryant
- Department of Pediatrics (J.L.J., R.B., A.L., C.C., D.L.M.), University of Cincinnati College of Medicine, OH.,Department of Surgery (R.B., F.Z., D.L.M.), University of Cincinnati College of Medicine, OH.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (R.R., J.L.J., R.B., T.D.R., A.L., C.C., F.Z., D.L.M.)
| | - Thomas D Ryan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (R.R., J.L.J., R.B., T.D.R., A.L., C.C., F.Z., D.L.M.)
| | - Angela Lorts
- Department of Pediatrics (J.L.J., R.B., A.L., C.C., D.L.M.), University of Cincinnati College of Medicine, OH.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (R.R., J.L.J., R.B., T.D.R., A.L., C.C., F.Z., D.L.M.)
| | - Clifford Chin
- Department of Pediatrics (J.L.J., R.B., A.L., C.C., D.L.M.), University of Cincinnati College of Medicine, OH.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (R.R., J.L.J., R.B., T.D.R., A.L., C.C., F.Z., D.L.M.)
| | - Farhan Zafar
- Department of Surgery (R.B., F.Z., D.L.M.), University of Cincinnati College of Medicine, OH.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (R.R., J.L.J., R.B., T.D.R., A.L., C.C., F.Z., D.L.M.)
| | - David L Morales
- Department of Pediatrics (J.L.J., R.B., A.L., C.C., D.L.M.), University of Cincinnati College of Medicine, OH.,Department of Surgery (R.B., F.Z., D.L.M.), University of Cincinnati College of Medicine, OH.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (R.R., J.L.J., R.B., T.D.R., A.L., C.C., F.Z., D.L.M.)
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26
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He Q, Wang F, Ryan TD, Chalasani M, Redington AN. Repeated Remote Ischemic Conditioning Reduces Doxorubicin-Induced Cardiotoxicity. JACC CardioOncol 2020; 2:41-52. [PMID: 34396208 PMCID: PMC8352345 DOI: 10.1016/j.jaccao.2020.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 02/06/2023]
Abstract
Objectives This study investigated the cardioprotective effect of repeated remote ischemic preconditioning (rRIC) on doxorubicin-induced cardiotoxicity in mice. Background Doxorubicin is an effective chemotherapeutic agent for a wide range of tumor types but its use and dosing are limited by acute and chronic cardiotoxicity. Remote ischemic conditioning (RIC) is cardioprotective in multiple cardiovascular injury models, but the effectiveness of rRIC in doxorubicin-induced cardiotoxicity has not been fully elucidated. Methods rRIC was performed on mice before and after doxorubicin administration. Cardiac function was assessed by echocardiography and myocardial biology was tested by molecular approaches. Results Doxorubicin administration induced acute cardiotoxicity, as indicated by reduced cardiac function, reduced myocyte cross-section area and increased extracellular collagen deposition, increased circulating cardiac muscle damage markers, and decreased heart weight. Doxorubicin also adversely affected other organs, including the kidney, liver, and spleen, as evaluated by circulating markers or organ weight loss. rRIC not only abrogated doxorubicin-induced cardiotoxicity (left ventricular ejection fraction, doxorubicin 47.5 ± 1.1%, doxorubicin + rRIC 51.6 ± 0.7%, p = 0.017), but also was associated with multiorgan protection. Within the myocardium, rRIC attenuated doxorubicin-induced cardiomyocyte apoptosis, reduced inflammation, and increased autophagy signaling. Conclusions rRIC may be a promising approach to reduce doxorubicin-induced cardiotoxicity.
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Affiliation(s)
- Quan He
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Fangfei Wang
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Thomas D Ryan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Meghana Chalasani
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew N Redington
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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27
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Camors EM, Purevjav E, Jefferies JL, Saffitz JE, Gong N, Ryan TD, Lucky AW, Taylor MD, Sullivan LM, Mestroni L, Towbin JA. Early Lethality Due to a Novel Desmoplakin Variant Causing Infantile Epidermolysis Bullosa Simplex With Fragile Skin, Aplasia Cutis Congenita, and Arrhythmogenic Cardiomyopathy. Circ Genom Precis Med 2020; 13:e002800. [PMID: 32164419 DOI: 10.1161/circgen.119.002800] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Emmanuel M Camors
- Department of Pediatrics, The Heart Institute (E.M.C., E.P., J.L.J., N.G., T.D.R., M.D.T., J.A.T.), Cincinnati Children's Hospital Medical Center, OH.,The Division of Cardiology, Department of Pediatrics, University of Tennessee Health Science Center and the Heart Institute, Le Bonheur Children's Hospital Research Center, Memphis, TN (E.M.C., E.P., J.A.T.)
| | - Enkhsaikhan Purevjav
- Department of Pediatrics, The Heart Institute (E.M.C., E.P., J.L.J., N.G., T.D.R., M.D.T., J.A.T.), Cincinnati Children's Hospital Medical Center, OH.,The Division of Cardiology, Department of Pediatrics, University of Tennessee Health Science Center and the Heart Institute, Le Bonheur Children's Hospital Research Center, Memphis, TN (E.M.C., E.P., J.A.T.)
| | - John L Jefferies
- Department of Pediatrics, The Heart Institute (E.M.C., E.P., J.L.J., N.G., T.D.R., M.D.T., J.A.T.), Cincinnati Children's Hospital Medical Center, OH
| | - Jeffrey E Saffitz
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA (J.E.S.)
| | - Nan Gong
- Department of Pediatrics, The Heart Institute (E.M.C., E.P., J.L.J., N.G., T.D.R., M.D.T., J.A.T.), Cincinnati Children's Hospital Medical Center, OH
| | - Thomas D Ryan
- Department of Pediatrics, The Heart Institute (E.M.C., E.P., J.L.J., N.G., T.D.R., M.D.T., J.A.T.), Cincinnati Children's Hospital Medical Center, OH
| | - Anne W Lucky
- The Division of Dermatology, Department of Pediatrics (A.W.L.), Cincinnati Children's Hospital Medical Center, OH
| | - Michael D Taylor
- Department of Pediatrics, The Heart Institute (E.M.C., E.P., J.L.J., N.G., T.D.R., M.D.T., J.A.T.), Cincinnati Children's Hospital Medical Center, OH
| | - Lisa M Sullivan
- Department of Pathology, University of Mississippi Medical Center, Jackson (L.M.S.)
| | - Luisa Mestroni
- The Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Denver Anschutz Medical Campus, Aurora (L.M.)
| | - Jeffrey A Towbin
- Department of Pediatrics, The Heart Institute (E.M.C., E.P., J.L.J., N.G., T.D.R., M.D.T., J.A.T.), Cincinnati Children's Hospital Medical Center, OH.,The Division of Cardiology, Department of Pediatrics, University of Tennessee Health Science Center and the Heart Institute, Le Bonheur Children's Hospital Research Center, Memphis, TN (E.M.C., E.P., J.A.T.)
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28
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Hayek SS, Ganatra S, Lenneman C, Scherrer-Crosbie M, Leja M, Lenihan DJ, Yang E, Ryan TD, Liu J, Carver J, Mousavi N, O'Quinn R, Arnold A, Banchs J, Barac A, Ky B. Preparing the Cardiovascular Workforce to Care for Oncology Patients: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 73:2226-2235. [PMID: 31047011 DOI: 10.1016/j.jacc.2019.02.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/04/2019] [Indexed: 10/26/2022]
Abstract
Cardiovascular disease and cancer are the 2 main causes of death in the United States. They intersect on multiple levels, sharing common causal mechanisms and epidemiological risk factors. The growing prevalence and complexity of cardiovascular disease and cancer have resulted in the development of the discipline of cardio-oncology. Preparing the cardiovascular workforce for the care of a growing population of cancer patients is necessary to enhance the delivery of high-quality cardiovascular care for patients with cancer. The goal of this review is to present the dedicated efforts of the cardio-oncology community to meet the growing need for education and training of cardiovascular practitioners providing care to cancer patients and survivors. Integration in general cardiology training programs and the efforts of the stakeholder organizations serve as an example of how a multidimensional, innovative approach can address provider education and training needs in a relatively new discipline.
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Affiliation(s)
- Salim S Hayek
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Sarju Ganatra
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Carrie Lenneman
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Monika Leja
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Daniel J Lenihan
- Division of Cardiology, Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, Missouri
| | - Eric Yang
- Division of Cardiology, University of California at Los Angeles, Los Angeles, California
| | - Thomas D Ryan
- Department of Pediatrics, University College of Medicine and Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer Liu
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical Center, New York, New York
| | - Joseph Carver
- Division of Cardiology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Negareh Mousavi
- Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Rupal O'Quinn
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anita Arnold
- Division of Cardiology, Florida State University, Tallahassee, Florida
| | - Jose Banchs
- Division of Cardiology, MD Anderson Cancer Center, Houston, Texas
| | - Ana Barac
- MedStar Heart and Vascular Institute, Washington, DC.
| | - Bonnie Ky
- Department of Epidemiology, Biostatistics and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania.
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29
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Jodele S, Dandoy CE, Lane A, Laskin B, Teusink-Cross A, Myers KC, Wallace G, Nelson AS, Bleesing JJ, Chima R, Hirsch R, Ryan TD, Benoit SW, Mizuno K, Warren M, Davies SM. Complement Blockade for TA-TMA: Lessons Learned from Large Pediatric Cohort Treated with Eculizumab. Biol Blood Marrow Transplant 2020. [DOI: 10.1016/j.bbmt.2019.12.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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30
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Abstract
Advances in cancer therapies have significantly improved patient outcomes. However, with improvements in survival, the toxicities associated with cancer therapy have become of paramount importance and oncologists are faced with the challenge of establishing therapeutic efficacy while minimizing toxicity. Cardiovascular disease represents a significant risk to survivors of childhood cancer and is a major cause of morbidity and mortality. This article outlines the current state of knowledge regarding cardiotoxicity in children undergoing cancer therapies, including the impact of specific oncologic therapies, recommendations for cardiovascular screening, the management of established cardiac disease, and the evolving field of pediatric cardio-oncology.
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Affiliation(s)
- Thomas D Ryan
- Department of Pediatrics, Division of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229, USA.
| | - Rajaram Nagarajan
- Department of Pediatrics, Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7018, Cincinnati, OH 45229, USA
| | - Justin Godown
- Department of Pediatrics, Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Suite 5230 DOT, Nashville, TN 37232, USA
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31
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Ganatra S, Carver JR, Hayek SS, Ky B, Leja MJ, Lenihan DJ, Lenneman C, Mousavi N, Park JH, Perales MA, Ryan TD, Scherrer-Crosbie M, Steingart RM, Yang EH, Zaha V, Barac A, Liu JE. Chimeric Antigen Receptor T-Cell Therapy for Cancer and Heart: JACC Council Perspectives. J Am Coll Cardiol 2019; 74:3153-3163. [PMID: 31856973 PMCID: PMC8211027 DOI: 10.1016/j.jacc.2019.10.049] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 10/09/2019] [Accepted: 10/31/2019] [Indexed: 12/23/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has significantly advanced the treatment of patients with relapsed and refractory hematologic malignancies and is increasingly investigated as a therapeutic option of other malignancies. The main adverse effect of CAR T-cell therapy is potentially life-threatening cytokine release syndrome (CRS). Clinical cardiovascular (CV) manifestations of CRS include tachycardia, hypotension, troponin elevation, reduced left ventricular ejection fraction, pulmonary edema, and cardiogenic shock. Although insults related to CRS toxicity might be transient and reversible in most instances in patients with adequate CV reserve, they can be particularly challenging in higher-risk, often elderly patients with pre-existing CV disease. As the use of CAR T-cell therapy expands to include a wider patient population, careful patient selection, pre-treatment cardiac evaluation, and CV risk stratification should be considered within the CAR T-cell treatment protocol. Early diagnosis and management of CV complications in patients with CRS require awareness and multidisciplinary collaboration.
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Affiliation(s)
- Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts; Cardio-Oncology and Adult Cancer Survivorship Program, Dana Farber Cancer Institute, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joseph R Carver
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Salim S Hayek
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Bonnie Ky
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monika J Leja
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Daniel J Lenihan
- Cardio-Oncology Center of Excellence, Division of Cardiovascular Medicine, Department of Medicine, Washington University, St. Louis, Missouri
| | - Carrie Lenneman
- Division of Cardiovascular Medicine, Department of Medicine, University of Alabama, Birmingham, Alabama
| | - Negaresh Mousavi
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Jae H Park
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Miguel Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplant, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marielle Scherrer-Crosbie
- Cardio-Oncology Program and Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard M Steingart
- Department of Medicine, Weill Cornell Medical College, New York, New York; Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric H Yang
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Ronald Reagan University of California Los Angeles Medical Center, Los Angeles, California
| | - Vlad Zaha
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Divison of Cardiovascular Medicine, Department of Medicine, Dallas, Texas
| | - Ana Barac
- Cardio-Oncology Program, Department of Cardiology, MedStar Washington Hospital Center, MedStar Heart and Vascular Institute, Washington, DC.
| | - Jennifer E Liu
- Department of Medicine, Weill Cornell Medical College, New York, New York; Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
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32
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Ryan TD, Border WL, Baker-Smith C, Barac A, Bock MJ, Canobbio MM, Choueiter NF, Chowdhury D, Gambetta KE, Glickstein JS, Kondapalli L, Mital S, Peiris V, Schiff RJ, Spicer RL, Towbin JA, Chen MH. The landscape of cardiovascular care in pediatric cancer patients and survivors: a survey by the ACC Pediatric Cardio-Oncology Work Group. Cardiooncology 2019; 5:16. [PMID: 32154022 PMCID: PMC7048086 DOI: 10.1186/s40959-019-0051-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/03/2019] [Indexed: 12/12/2022]
Abstract
Objective To enhance the understanding of cardiovascular care delivery in childhood cancer patients and survivors. Study design A 20-question survey was created by the Pediatric Cardio-oncology Work Group of the American College of Cardiology (ACC) Cardio-oncology Section to assess the care, management, and surveillance tools utilized to manage pediatric/young adult cardio-oncology patients. The survey distribution was a collaborative effort between Cardio-oncology Section and membership of the Adult Congenital and Pediatric Cardiology Section (ACPC) of the ACC. Results Sixty-five individuals, all self-identified as physicians, responded to the survey. Most respondents (n = 58,89%) indicated childhood cancer patients are regularly screened prior to and during cancer therapy at their centers, predominantly by electrocardiogram (75%), standard echocardiogram (58%) and advanced echocardiogram (50%) (i.e. strain, stress echo). Evaluation by a cardiologist prior to/during therapy was reported by only 8(12%) respondents, as compared to post-therapy which was reported by 28 (43%, p < 0.01). The most common indications for referral to cardiology at pediatric centers were abnormal test results (n = 31,48%) and history of chemotherapy exposure (n = 27,42%). Of note, during post-treatment counseling, common cardiovascular risk-factors like blood pressure (31,48%), lipid control (22,34%), obesity & smoking (30,46%) and diet/exercise/weight loss (30,46%) were addressed by fewer respondents than was LV function (72%). Conclusions The survey data demonstrates that pediatric cancer patients are being screened by EKG and/or imaging prior to/during therapy at most centers. Our data, however, highlight the potential for greater involvement of a cardiovascular specialist for pre-treatment evaluation process, and for more systematic cardiac risk factor counseling in posttreatment cancer survivors.
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Affiliation(s)
- Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH 45229 USA
| | - William L Border
- 2Children's Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, GA USA
| | - Carissa Baker-Smith
- 3Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD USA
| | - Ana Barac
- 4MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Matthew J Bock
- 5Loma Linda University Children's Hospital, Loma Linda, CA USA
| | - Mary M Canobbio
- 6Ahmanson/UCLA ACHD Center, UCLA Health, Los Angeles, CA USA
| | - Nadine F Choueiter
- 7The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY USA
| | | | | | - Julie S Glickstein
- 10Morgan Stanley Children's Hospital of New York, Columbia University Vagelos College of Physicians and Surgeons, New York, NY USA
| | - Lavanya Kondapalli
- 11UC Health Heart & Vascular Center - Anschutz, University of Colorado School of Medicine, Aurora, CO USA
| | - Seema Mital
- 12The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Vasum Peiris
- Department of Health and Human Services, Food and Drug Administration Center for Devices and Radiological Health, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Russell J Schiff
- Cohen Children's Medical Center of New York - Northwell Health, New Hyde Park and Huntington, NY USA
| | - Robert L Spicer
- 15Children's Hospital and Medical Center, University of Nebraska Medical Center, Omaha, NE USA
| | - Jeffrey A Towbin
- Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, St. Jude Children's Research Hospital, Memphis, TN USA
| | - Ming Hui Chen
- Departments of Cardiology and Pediatrics, Boston Children's Hospital, Dana-Farber Cancer Institute/Harvard Cancer Center, and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 USA
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Abstract
There are approximately 450,000 survivors of childhood cancer due, in large part, to successes of therapeutic regimens. With this success comes an increase in the number of patients developing cardiotoxicity as a result of cancer therapies. In certain cases, this includes heart failure recalcitrant to medical therapy, and consideration for heart transplantation may be necessary. However, this group of patients has unique comorbidities that may affect outcomes. Despite this, available data show that complications and overall survival are similar for patients transplanted for anthracycline-induced cardiomyopathy compared to those with other cardiomyopathies, demonstrating that this is a viable treatment option for this population. As other cancer therapies become more common, new cardiovascular toxicities are recognized. Whether heart transplantation will be appropriate for all patients with cancer-therapy related cardiotoxicity (CTRC) will require demonstration of similarly good outcomes to ensure proper allocation of organs.
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Affiliation(s)
- Svetlana B Shugh
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Evers PD, Anderson JB, Ryan TD, Czosek RJ, Knilans TK, Spar DS. Wearable cardioverter-defibrillators in pediatric cardiomyopathy: A cost-utility analysis. Heart Rhythm 2019; 17:287-293. [PMID: 31476408 DOI: 10.1016/j.hrthm.2019.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Dilated cardiomyopathy (DCM) is the most common cardiomyopathy in children. Patients with severe cardiac dysfunction are thought to be at risk of sudden cardiac arrest (SCA). After diagnosis, a period of medical optimization is recommended before permanent implantable cardioverter-defibrillator (ICD) implantation. Wearable cardioverter-defibrillators (WCDs) provide an option for arrhythmia protection as an outpatient during this optimization. OBJECTIVE The purpose of this study was to determine the strategy that optimizes cost and survival during medical optimization of a patient with DCM before ICD placement. METHODS A Markov state transition model was constructed for the 3 clinical approaches to compare costs, clinical outcomes, and quality of life: (1) "Inpatient," (2) "Home-WCD," and (3) "Home-No WCD." Transitional probabilities, costs, and utility metrics were extracted from the existing literature. Cost-effectiveness was assessed comparing each paradigm's incremental cost-effectiveness ratio against a societal willingness-to-pay threshold of $50,000 per quality-adjusted life year. RESULTS The cost-utility analysis illustrated that Home-WCD met the willingness-to-pay threshold with an incremental cost-effectiveness ratio of $20,103 per quality-adjusted life year and 4 mortalities prevented per 100 patients as compared with Home-No WCD. One-way sensitivity analyses demonstrated that Home-No WCD became the most cost-effective solution when the probability of SCA fell below 0.2% per week, the probability of SCA survival with a WCD fell below 9.8%, or the probability of SCA survival with Home-No WCD quadrupled from base-case assumptions. CONCLUSION Based on the existing literature probabilities of SCA in pediatric patients with DCM undergoing medical optimization before ICD implantation, sending a patient home with a WCD may be a cost-effective strategy.
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Affiliation(s)
- Patrick D Evers
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey B Anderson
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Thomas D Ryan
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Richard J Czosek
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Timothy K Knilans
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S Spar
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Sparks JD, Cantor RS, Pruitt E, Kirklin JK, Carboni M, Dreyer W, Kindel S, Ryan TD, Morrow WR. New-onset diabetes after pediatric heart transplantation: A review of the Pediatric Heart Transplant Study. Pediatr Transplant 2019; 23:e13476. [PMID: 31124221 DOI: 10.1111/petr.13476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 01/25/2019] [Accepted: 02/16/2019] [Indexed: 11/30/2022]
Abstract
NDT is a well-defined complication after solid organ transplantation. Little has been published describing the incidence, risk factors, and effect on outcome after pediatric heart transplantation. We performed a retrospective evaluation of pediatric patients from the PHTS registry from 2004 to 2014. Group comparison, associated factors, incidence using Kaplan-Meier method, and risk factor and outcome analysis for NDT at 1 year post-transplant. Of the 2185 recipients, 1756 were alive and followed at 1 year. Overall freedom from NDT was 98.9%, 94.7%, and 92.6% at 1, 5, and 10 years, respectively. Patients with NDT were more likely to be black (non-Hispanic; P = 0.002), older at time of transplant (P < 0.0001), and have a higher BMI percentile at time of transplant (P < 0.0001). Adjusted risk factors for NDT at 1 year were older age at transplant (years; >12 years, OR: 8.8 and 5-12 years, HR: 8.0), obese BMI percentile at time of transplant (OR: 3.8), and steroid use at 30 days after transplant (OR: 4.7). Though uncommon, NDT occurs with a constant hazard after pediatric heart transplant; it occurs more often in older patients at transplant, those who are of black race, those who are obese, and those who use steroids. Therefore, targeted weight reduction and selective steroid use in at-risk populations could reduce the incidence of early NDT. Further data are needed to determine the risk imparted by transplantation, factors that predict late-onset NDT, and whether NDT alters the outcome after transplant.
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Affiliation(s)
| | - Ryan S Cantor
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | | | - Steven Kindel
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Thomas D Ryan
- University Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Lang SM, Alsaied T, Moore RA, Rattan M, Ryan TD, Taylor MD. Conservative gadolinium administration to patients with Duchenne muscular dystrophy: decreasing exposure, cost, and time, without change in medical management. Int J Cardiovasc Imaging 2019; 35:2213-2219. [DOI: 10.1007/s10554-019-01670-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/13/2019] [Indexed: 01/16/2023]
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Lesmana H, Dyer L, Morales DL, Ryan TD, Hopkin RJ. Neonatal myocardial infarction in Williams–Beuren syndrome. Progress in Pediatric Cardiology 2019. [DOI: 10.1016/j.ppedcard.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Wittekind SG, Ryan TD, Gao Z, Zafar F, Czosek RJ, Chin CW, Jefferies JL. Contemporary Outcomes of Pediatric Restrictive Cardiomyopathy: A Single-Center Experience. Pediatr Cardiol 2019; 40:694-704. [PMID: 30542921 DOI: 10.1007/s00246-018-2043-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pediatric restrictive cardiomyopathy (RCM) has high mortality in historical cohorts, and traditional management often involves early referral for heart transplantation (HTx). This study sought to determine outcomes of pediatric RCM at a center that has favored medical management over early listing for HTx. METHODS All patients (N = 43) with pure RCM phenotype (RCM, N = 26) and hypertrophic cardiomyopathy with restrictive physiology (RCM/HCM, N = 17) managed at our center over a 15-year period were investigated. Outcomes of those listed for HTx (N = 18) were compared to a benchmark of contemporaneous pediatric RCM patients in the UNOS database (N = 377). Proportional hazards models were used to determine predictors of adverse outcomes. RESULTS The mean age was 11 ± 9 years and 49% were male. 14 of 18 patients listed received HTx. Overall mortality (12%) was identical between the phenotypes; however, RCM patients were more likely to be listed (P = 0.001) and receive HTx (P = 0.02) compared to RCM/HCM. Prior to HTx, 60% had documented arrhythmia, 16% had cardiac arrest, and 7% required mechanical circulatory support. 4 of 17 patients with an ICD/PM received device therapies (four of five shocks appropriate for VT/VF, and two effective anti-tachycardia pacing interventions). Outcomes of those listed for HTx at our center were similar to the UNOS benchmark. In multivariate analysis, markers of congestive heart failure were associated with adverse outcomes. CONCLUSION Heart failure and arrhythmia treatments can delay or possibly prevent the need for HTx in some cases of pediatric RCM. Survival post-HTx is not compromised using this approach.
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Affiliation(s)
- Samuel G Wittekind
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA. .,Cincinnati Children's Hospital Medical Center, Heart Institute, Heart Failure/Transplant Program, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229-3026, USA.
| | - Thomas D Ryan
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Zhiqian Gao
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA
| | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA
| | - Richard J Czosek
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Clifford W Chin
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA
| | - John L Jefferies
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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39
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Ryan TD. Letter Regarding: "Evaluation of Early Left Ventricular Dysfunction in Patients with Duchenne Muscular Dystrophy Using Two-Dimensional Speckle Tracking Echocardiography and Tissue Doppler Imaging," Cho et al., Pediatric Cardiology ePub July 2018. Pediatr Cardiol 2018; 39:1719-1720. [PMID: 30238136 DOI: 10.1007/s00246-018-1983-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 09/03/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA.
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Armenian SH, Armstrong GT, Aune G, Chow EJ, Ehrhardt MJ, Ky B, Moslehi J, Mulrooney DA, Nathan PC, Ryan TD, van der Pal HJ, van Dalen EC, Kremer LCM. Cardiovascular Disease in Survivors of Childhood Cancer: Insights Into Epidemiology, Pathophysiology, and Prevention. J Clin Oncol 2018; 36:2135-2144. [PMID: 29874141 DOI: 10.1200/jco.2017.76.3920] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease (CVD), which includes cardiomyopathy/heart failure, coronary artery disease, stroke, pericardial disease, arrhythmias, and valvular and vascular dysfunction, is a major concern for long-term survivors of childhood cancer. There is clear evidence of increased risk of CVD largely attributable to treatment exposures at a young age, most notably anthracycline chemotherapy and chest-directed radiation therapy, and compounded by traditional cardiovascular risk factors accrued during decades after treatment exposure. Preclinical studies are limited; thus, it is a high priority to understand the pathophysiology of CVD as a result of anticancer treatments, taking into consideration the growing and developing heart. Recently developed personalized risk prediction models can provide decision support before initiation of anticancer therapy or facilitate implementation of screening strategies in at-risk survivors of cancer. Although consensus-based screening guidelines exist for the application of blood and imaging biomarkers of CVD, the most appropriate timing and frequency of these measures in survivors of childhood cancer are not yet fully elucidated. Longitudinal studies are needed to characterize the prognostic importance of subclinical markers of cardiovascular injury on long-term CVD risk. A number of prevention trials across the survivorship spectrum are under way, which include primary prevention (before or during cancer treatment), secondary prevention (after completion of treatment), and integrated approaches to manage modifiable cardiovascular risk factors. Ongoing multidisciplinary collaborations between the oncology, cardiology, primary care, and other subspecialty communities are essential to reduce therapeutic exposures and improve surveillance, prevention, and treatment of CVD in this high-risk population.
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Affiliation(s)
- Saro H Armenian
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Gregory T Armstrong
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Gregory Aune
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Eric J Chow
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Matthew J Ehrhardt
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Bonnie Ky
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Javid Moslehi
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Daniel A Mulrooney
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Paul C Nathan
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Thomas D Ryan
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Helena J van der Pal
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Elvira C van Dalen
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Leontien C M Kremer
- Saro H. Armenian, City of Hope, Duarte, CA; Gregory T. Armstrong, Matthew J. Ehrhardt, and Daniel A. Mulrooney, St Jude Children's Research Hospital, Memphis; Javid Moslehi, Vanderbilt School of Medicine, Nashville, TN; Gregory Aune, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, TX; Eric J. Chow, Fred Hutchinson Cancer Research Center, Seattle, WA; Bonnie Ky, University of Pennsylvania, Philadelphia, PA; Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada; Thomas D. Ryan, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Helena J. van der Pal and Leontien C.M. Kremer, Princess Máxima Center for Pediatric Oncology, Utrecht; and Elvira C. van Dalen and Leontien C.M. Kremer, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
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Ryan TD, Zafar F, Siegel RM, Villa CR, Bryant R, Chin C. Obesity class does not further stratify outcome in overweight and obese pediatric patients after heart transplantation. Pediatr Transplant 2018; 22. [PMID: 29377429 DOI: 10.1111/petr.13161] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2018] [Indexed: 11/28/2022]
Abstract
The effect of obesity stratification on pediatric heart transplant outcomes is unknown. The UNOS database was queried for patients ≥2-<18 years listed for heart transplant and stratified by BMI: normal (BMI>5%-≤85 percentile), overweight (BMI=86%-95 percentile), class 1 (BMI=100%-120% of 95 percentile), class 2 (BMI=121%-140% of 95 percentile), and class 3 obesity (BMI>140% of 95 percentile). A total of 5056 individuals were listed for transplant, with 71% normal, 13% overweight, 10% class 1, 4% class 2, and 2% class 3 obesity. Waitlist survival was not different between groups. Post-transplant survival was decreased in overweight and combined obese groups vs normal, with no further difference between overweight and obese classes. Overweight and obese patients had higher listing status and were more likely to have ventilator, inotrope, and mechanical circulatory support at listing. After transplant, there was an association of overweight-obese patients with diabetes and rejection requiring hospitalization. Stricter definition of normal weight reveals overweight-obese status was an independent risk factor for poorer post-transplant survival, without further effect by stratification of weight class. However, because there is no difference in waitlist survival, this study does not allow the selection of absolute weight-based criteria regarding transplant listing and suggests the need to look further for modifiable risk factors post-transplant.
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Affiliation(s)
- Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Farhan Zafar
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robert M Siegel
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Chet R Villa
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Roosevelt Bryant
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Clifford Chin
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Rotz SJ, Ryan TD, Hlavaty J, George SA, El-Bietar J, Dandoy CE. Cardiotoxicity and cardiomyopathy in children and young adult survivors of hematopoietic stem cell transplant. Pediatr Blood Cancer 2017; 64. [PMID: 28453909 DOI: 10.1002/pbc.26600] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/26/2017] [Accepted: 03/21/2017] [Indexed: 01/23/2023]
Abstract
Cardiomyopathy is common in long-term survivors of pediatric hematopoietic stem cell transplant (HSCT). Events occurring before and after HSCT when combined with specific insults during HSCT likely contribute to long-term risk. Strategies for detecting subclinical cardiomyopathy prior to patients developing overt heart failure are under investigation. Changes in HSCT preparative regimens and cardioprotective medications administered during chemotherapy may alter the risk for cardiomyopathy. Interventions in long-term survivors such as lifestyle modification and cardioactive medications are of increasing importance. Herein we review the causes of cardiac injury, discuss strategies for detection of cardiomyopathy, and evaluate therapeutic options for long-term HSCT survivors.
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Affiliation(s)
- Seth J Rotz
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Thomas D Ryan
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joel Hlavaty
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen A George
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Javier El-Bietar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Ryan TD, Absalon MJ, de Alarcon A, Gupta A, Peters AL, Lorts A, Danziger-Isakov LA, Chin C. Airway plaque presenting after alteration of immunosuppression in a pediatric patient remote from heart transplantation. Pediatr Transplant 2017; 21. [PMID: 28836710 DOI: 10.1111/petr.13046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 11/30/2022]
Abstract
Success after solid organ transplantation is dependent on the proper balance of immunosuppression to prevent rejection of the allograft while limiting the risk of developing infections and malignancy. We present a 9-year-old girl, remote from transplant, who presented with airway plaque after a change in immunosuppression to include the mTOR inhibitor sirolimus. Differential diagnosis included direct medication side effect, infection, and neoplasia.
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Affiliation(s)
- Thomas D Ryan
- The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Michael J Absalon
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Alessandro de Alarcon
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Anita Gupta
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Anna L Peters
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | - Clifford Chin
- The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Dandoy CE, Jodele S, Paff Z, Hirsch R, Ryan TD, Jefferies JL, Cash M, Rotz S, Pate A, Taylor MD, El-Bietar J, Myers KC, Wallace G, Nelson A, Grimley M, Pfeiffer T, Lane A, Davies SM, Chima RS. Team-based approach to identify cardiac toxicity in critically ill hematopoietic stem cell transplant recipients. Pediatr Blood Cancer 2017; 64. [PMID: 28271596 DOI: 10.1002/pbc.26513] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 02/06/2017] [Accepted: 02/13/2017] [Indexed: 01/13/2023]
Abstract
INTRODUCTION We observed pulmonary hypertension (PH), pericardial effusions, and left ventricular systolic dysfunction (LVSD) in multiple critically ill hematopoietic stem cell transplant (HSCT) recipients. We implemented routine structured echocardiography screening for HSCT recipients admitted to the pediatric intensive care unit (PICU) using a standardized multidisciplinary process. METHODS HSCT recipients admitted to the PICU with respiratory distress, hypoxia, shock, and complications related to transplant-associated thrombotic microangiopathy were screened on admission and every 1-2 weeks thereafter. Echocardiography findings requiring intervention and/or further screening included elevated right ventricular pressure, LVSD, and moderate to large pericardial effusions. All echocardiograms were compared to the patient's routine pretransplant echocardiogram. RESULTS Seventy HSCT recipients required echocardiography screening over a 3-year period. Echo abnormalities requiring intervention and/or further screening were found in 35 (50%) patients. Twenty-four (34%) patients were noted to have elevated right ventricular pressure; 14 (20%) were at risk for PH, while 10 (14%) had PH. All patients with PH were treated with pulmonary vasodilators. LVSD was noted in 22 (31%) patients; 15/22 (68%) received inotropic support. Moderate to large pericardial effusions were present in nine (13%) patients, with six needing pericardial drain placement. DISCUSSION Echocardiographic abnormalities are common in critically ill HSCT recipients. Utilization of echocardiogram screening may allow for early detection and timely intervention for cardiac complications in this high-risk cohort.
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Affiliation(s)
- Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Zachary Paff
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Russel Hirsch
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Thomas D Ryan
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John L Jefferies
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michelle Cash
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Seth Rotz
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Abigail Pate
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael D Taylor
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Javier El-Bietar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gregory Wallace
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adam Nelson
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael Grimley
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Thomas Pfeiffer
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adam Lane
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ranjit S Chima
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Armenian SH, Ryan TD, Khouri MG. Cardiac Dysfunction and Heart Failure in Hematopoietic Cell Transplantation Survivors: Emerging Paradigms in Pathophysiology, Screening, and Prevention. Heart Fail Clin 2017; 13:337-345. [PMID: 28279419 DOI: 10.1016/j.hfc.2016.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hematopoietic cell transplantation (HCT) has been used for curative intent in patients with hematologic and nonhematologic malignancies, resulting in an increasing number of HCT survivors. These survivors are at risk for serious and life-threatening complications, including cardiovascular disease (CVD). This article provides an overview of CVD in HCT survivors, describing the pathophysiology of disease, with a special emphasis on therapeutic exposures and comorbidities unique to this population. This article also discusses novel screening and prevention strategies that have shown promise in non-HCT cancer populations, emphasizing opportunities for collaboration between cardiologists and hematologists to improve the cardiovascular health of HCT survivors.
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Affiliation(s)
- Saro H Armenian
- Division of Outcomes Research, Department of Population Sciences, Comprehensive Cancer Center, City of Hope, 1500 East Duarte Road, Duarte, CA 91010-3000, USA.
| | - Thomas D Ryan
- Department of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Michel G Khouri
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
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Ryan TD, Parent JJ, Gao Z, Khoury PR, Dupont E, Smith JN, Wong B, Urbina EM, Jefferies JL. Central Arterial Function Measured by Non-invasive Pulse Wave Analysis is Abnormal in Patients with Duchenne Muscular Dystrophy. Pediatr Cardiol 2017. [PMID: 28639151 DOI: 10.1007/s00246-017-1657-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder caused by mutation of dystrophin. Cardiovascular involvement includes dilated cardiomyopathy. Non-invasive assessment of vascular function has not been evaluated in DMD. We hypothesize arterial wave reflection is abnormal in patients with DMD. Pulse wave analysis was performed on DMD patients with a SphygmoCor SCOR-PVx System to determine central blood pressure and augmentation index (AIx) as an assessment of arterial wave reflection. Results were compared to a control group. A total of 43 patients with DMD were enrolled, and compared to 43 normal controls. Central systolic blood pressure was lower, while both AIx-75 (7.8 ± 9.6% vs. 2.1 ± 10.4%, p 0.01, DMD vs. normal) and AIx-not corrected (16.8 ± 10.1% vs. -3.6 ± 10.9, p < 0.001, DMD vs. normal) were higher in the DMD compared to control. Using multivariable linear regression model, the variables found to have a significant effect on AIx-not corrected included diagnosis of DMD, height, and heart rate (r 2 = 0.257). The current data suggest that, despite lower central systolic blood pressure, patients with DMD have higher wave reflection when compared to normal controls, which may represent increased arterial stiffness. Overall there appears to be no effect on ventricular systolic function, however the long-term consequence in this group is unknown. Further study is required to determine the mechanism of these differences, which may be related to the effects of systemic steroids or the role of dystrophin in vascular function.
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Affiliation(s)
- Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45220, USA.
| | - John J Parent
- Division of Pediatric Cardiology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Zhiqian Gao
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45220, USA
| | - Philip R Khoury
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45220, USA
| | - Elizabeth Dupont
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45220, USA
| | - Jennifer N Smith
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45220, USA
| | - Brenda Wong
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elaine M Urbina
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45220, USA
| | - John L Jefferies
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45220, USA
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Abstract
Heart transplantation in pediatric patients generally arises as a treatment option of last resort, that is, the indication is for patients with heart failure of various etiologies, with potential or actual end-organ dysfunction, in whom there are no reasonable, long-term options for life-prolonging therapy. The concept of heart failure is complex in a pediatric population, particularly those with congenital heart disease. While heart failure may refer simply to systolic dysfunction leading to low cardiac output, it can also encompass: diastolic dysfunction in restrictive cardiomyopathy; single ventricle physiology without an option for stable palliation. A good candidate should have a predicted life expectancy less than the median lifetime of a transplanted heart. Significant improvement in survival has been observed over time with 1- and 5-year survival approximately 90% and 80% in the contemporary era.
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Affiliation(s)
- Thomas D Ryan
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave-MLC 2003, Cincinnati, Ohio 45229
| | - Clifford Chin
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave-MLC 2003, Cincinnati, Ohio 45229.
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Rotz SJ, Ryan TD, Jodele S, Jefferies JL, Lane A, Pate A, Hirsch R, Hlavaty J, Levesque AE, Taylor MD, Cash M, Myers KC, El-Bietar JA, Davies SM, Dandoy CE. The injured heart: early cardiac effects of hematopoietic stem cell transplantation in children and young adults. Bone Marrow Transplant 2017; 52:1171-1179. [PMID: 28394368 DOI: 10.1038/bmt.2017.62] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/12/2017] [Accepted: 02/13/2017] [Indexed: 12/25/2022]
Abstract
We hypothesized that subclinical cardiac injury in the peri-transplant period is more frequent than currently appreciated in children and young adults. We performed echocardiographic screening on 227 consecutive patients prior to hematopoietic stem cell transplantation (HSCT), and 7, 30 and 100 days after transplant. We measured cardiac biomarkers cardiac troponin-I (cTn-I), and soluble suppressor of tumorigenicity 2 (sST2) prior to transplant, during conditioning, and days +7, +14, +28 and +49 in 26 patients. We subsequently analyzed levels of cTn-I every 48-72 h in 15 consecutive children during conditioning. Thirty-two percent (73/227) of patients had a new abnormality on echocardiogram. New left ventricular systolic dysfunction (LVSD) occurred in 6.2% of subjects and new pericardial effusion in 27.3%. Eight of 227 (3.5%) patients underwent pericardial drain placement, and 5 (2.2%) received medical therapy for clinically occult LVSD. cTn-I was elevated in 53.0% of all samples and sST2 in 38.2%. At least one sample had a detectable cTn-I in 84.6% of patients and an elevated sST2 in 76.9%. Thirteen of fifteen patients monitored frequently during condition had elevation of cTn-I. Echocardiographic and biochemical abnormalities are frequent in the peri-HSCT period. Echocardiogram does not detect all subclinical cardiac injuries that may become clinically relevant over longer periods.
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Affiliation(s)
- S J Rotz
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - T D Ryan
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J L Jefferies
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A Lane
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A Pate
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - R Hirsch
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Hlavaty
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A E Levesque
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - M D Taylor
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - M Cash
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J A El-Bietar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - C E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Rotz SJ, Ryan TD, Jodele S, Wilkey A, Lane A, Pate AR, Jefferies JL, Taylor MD, Powell A, Lake KE, Davies SM, Dandoy CE. Echocardiographic Abnormalities in Long-Term Survivors of Pediatric HSCT. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2016.12.478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pfeiffer TM, Rotz SJ, Ryan TD, Hirsch R, Taylor M, Chima R, Pate A, Hlavaty J, Grimley M, Myers K, El-Bietar J, Davies SM, Jodele S, Dandoy C. Pericardial effusion requiring surgical intervention after stem cell transplantation: a case series. Bone Marrow Transplant 2016; 52:630-633. [PMID: 27991890 DOI: 10.1038/bmt.2016.331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- T M Pfeiffer
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S J Rotz
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - T D Ryan
- Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - R Hirsch
- Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - M Taylor
- Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - R Chima
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A Pate
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Hlavaty
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - M Grimley
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J El-Bietar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - C Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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