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Meloni A, Parravano M, Pistoia L, Cossu A, Grassedonio E, Renne S, Fina P, Spasiano A, Salvo A, Bagnato S, Gerardi C, Borsellino Z, Cademartiri F, Positano V. Phenotypic Clustering of Beta-Thalassemia Intermedia Patients Using Cardiovascular Magnetic Resonance. J Clin Med 2023; 12:6706. [PMID: 37959172 PMCID: PMC10647397 DOI: 10.3390/jcm12216706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/15/2023] Open
Abstract
We employed an unsupervised clustering method that integrated demographic, clinical, and cardiac magnetic resonance (CMR) data to identify distinct phenogroups (PGs) of patients with beta-thalassemia intermedia (β-TI). We considered 138 β-TI patients consecutively enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) Network who underwent MR for the quantification of hepatic and cardiac iron overload (T2* technique), the assessment of biventricular size and function and atrial dimensions (cine images), and the detection of replacement myocardial fibrosis (late gadolinium enhancement technique). Three mutually exclusive phenogroups were identified based on unsupervised hierarchical clustering of principal components: PG1, women; PG2, patients with replacement myocardial fibrosis, increased biventricular volumes and masses, and lower left ventricular ejection fraction; and PG3, men without replacement myocardial fibrosis, but with increased biventricular volumes and masses and lower left ventricular ejection fraction. The hematochemical parameters and the hepatic and cardiac iron levels did not contribute to the PG definition. PG2 exhibited a significantly higher risk of future cardiovascular events (heart failure, arrhythmias, and pulmonary hypertension) than PG1 (hazard ratio-HR = 10.5; p = 0.027) and PG3 (HR = 9.0; p = 0.038). Clustering emerged as a useful tool for risk stratification in TI, enabling the identification of three phenogroups with distinct clinical and prognostic characteristics.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy; (L.P.); (F.C.); (V.P.)
- Unità Operativa Complessa Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy;
| | - Michela Parravano
- Unità Operativa Complessa Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy;
- Dipartimento di Ingegneria dell’Informazione, Università degli Studi di Pisa, 56122 Pisa, PI, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy; (L.P.); (F.C.); (V.P.)
- Unità Operativa Complessa Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy
| | - Alberto Cossu
- Unità Operativa Radiologia Universitaria, Azienda Ospedaliero-Universitaria “S. Anna”, 44124 Cona, FE, Italy;
| | - Emanuele Grassedonio
- Sezione di Scienze Radiologiche, Dipartimento di Biopatologia e Biotecnologie Mediche, Policlinico “Paolo Giaccone”, 90127 Palermo, PA, Italy;
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero “Giovanni Paolo II”, 88046 Lamezia Terme, CZ, Italy;
| | - Priscilla Fina
- Unità Operativa Complessa Diagnostica per Immagini, Ospedale “Sandro Pertini”, 00157 Roma, RM, Italy;
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, 80131 Napoli, NA, Italy;
| | - Alessandra Salvo
- Unità Operativa Semplice Talassemia, Presidio Ospedaliero “Umberto I”, 96100 Siracusa, SR, Italy;
| | - Sergio Bagnato
- Ematologia Microcitemia, Ospedale San Giovanni di Dio—ASP Crotone, 88900 Crotone, KR, Italy;
| | - Calogera Gerardi
- Unità Operativa Semplice Dipartimentale di Talassemia, Presidio Ospedaliero “Giovanni Paolo II”—Distretto AG2 di Sciacca, 92019 Sciacca, AG, Italy;
| | - Zelia Borsellino
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico “Benfratelli-Di Cristina”, 90134 Palermo, PA, Italy;
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy; (L.P.); (F.C.); (V.P.)
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy; (L.P.); (F.C.); (V.P.)
- Unità Operativa Complessa Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy;
- Dipartimento di Ingegneria dell’Informazione, Università degli Studi di Pisa, 56122 Pisa, PI, Italy
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Stenger E, Xiang Y, Wetzel M, Gillespie S, Chellapandian D, Shah R, Arnold SD, Bhatia M, Chaudhury S, Eckrich MJ, Kanter J, Kasow KA, Krajewski J, Nickel RS, Ngwube AI, Olson TS, Rangarajan HG, Wobma H, Guilcher GMT, Horan JT, Krishnamurti L, Shenoy S, Abraham A. Long-Term Organ Function After HCT for SCD: A Report From the Sickle Cell Transplant Advocacy and Research Alliance. Transplant Cell Ther 2023; 29:47.e1-47.e10. [PMID: 36273784 DOI: 10.1016/j.jtct.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/21/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
Abstract
Hematopoietic cell transplantation (HCT) is an established cure for sickle cell disease (SCD) supported by long-term survival, but long-term organ function data are lacking. We sought to describe organ function and assess predictors for dysfunction in a retrospective cohort (n = 247) through the Sickle cell Transplant Advocacy and Research alliance. Patients with <1-year follow-up or graft rejection/second HCT were excluded. Organ function data were collected from last follow-up. Primary measures were organ function, comparing pre- and post-HCT. Bivariable and multivariable analyses were performed for predictors of dysfunction. Median age at HCT was 9.4 years; the majority had HbSS (88.2%) and severe clinical phenotype (65.4%). Most received matched related (76.9%) bone marrow (83.3%) with myeloablative conditioning (MAC; 57.1%). Acute and chronic graft-versus-host disease (GVHD) developed in 24.0% and 24.8%. Thirteen patients (5.3%) died ≥1 year after HCT, primarily from GVHD or infection. More post-HCT patients had low ejection or shortening fractions than pre-HCT (0.6% → 6.0%, P = .007 and 0% → 4.6%, P = .003). The proportion with lung disease remained stable. Eight patients (3.2%) had overt stroke; most had normal (28.3%) or stable (50.3%) brain magnetic resonance imaging. On multivariable analysis, cardiac dysfunction was associated with MAC (odds ratio [OR] = 2.71; 95% confidence interval [CI], 1.09-6.77; P = .033) and severe acute GVHD (OR = 2.41; 95% CI, 1.04-5.62; P = .041). Neurologic events were associated with central nervous system indication (OR = 2.88; 95% CI, 2.00-4.12; P < .001). Overall organ dysfunction was associated with age ≥16 years (OR = 2.26; 95% CI, 1.35-3.78; P = .002) and clinically severe disease (OR = 1.64; 95% CI, 1.02-2.63; P = .043). In conclusion, our results support consideration of HCT at younger age and use of less intense conditioning.
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Affiliation(s)
- Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, Georgia.
| | - Yijin Xiang
- Biostatistics Core, Department of Pediatrics, Emory School of Medicine, Atlanta, Georgia
| | - Martha Wetzel
- Biostatistics Core, Department of Pediatrics, Emory School of Medicine, Atlanta, Georgia
| | - Scott Gillespie
- Biostatistics Core, Department of Pediatrics, Emory School of Medicine, Atlanta, Georgia
| | | | - Rikin Shah
- Orlando Health - Arnold Palmer Hospital for Children, Orlando, Florida
| | - Staci D Arnold
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, Georgia
| | - Monica Bhatia
- Columbia University Irving Medical Center, New York, New York
| | | | | | - Julie Kanter
- University of Alabama Birmingham; Birmingham, Alabama
| | | | | | - Robert S Nickel
- Division of Blood and Marrow Transplantation, Center for Cancer and Immunology Research, Children's National Hospital, Washington, District of Columbia
| | | | - Tim S Olson
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Holly Wobma
- Boston Children's Hospital, Boston, Massachusetts
| | - Gregory M T Guilcher
- Section of Pediatric Hematology, Oncology and BMT, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - John T Horan
- Boston Children's Hospital, Boston, Massachusetts
| | | | - Shalini Shenoy
- Washington University Medical Center, St. Louis, Missouri
| | - Allistair Abraham
- Division of Blood and Marrow Transplantation, Center for Cancer and Immunology Research, Children's National Hospital, Washington, District of Columbia
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Oni OO, Adebiyi AA, Aje A, Akingbola TS. Left ventricular geometry and electrocardiographic criteria in assessing left ventricular hypertrophy in sickle cell anemia patients. J Natl Med Assoc 2022; 114:504-511. [PMID: 35803775 DOI: 10.1016/j.jnma.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 05/20/2022] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) is recognized as a cardiovascular risk factor and is a known consequence of sickle cell anemia (SCA). Abnormal left ventricular geometric patterns have been described but the determinants have not been well elucidated. METHOD Electrocardiography (ECG) and Echocardiography (ECHO) was done on subjects with SCA and hemoglobin A(HBA). Those with systemic hypertension were excluded. Voltages, durations, and intervals were measured as appropriate and recorded in a standard proforma. Analysis was made using a standard statistical software. RESULTS Eighty four people with SCA and 91 with HBA were recruited as cases and controls respectively. Subjects with SCA have more abnormal LV geometric patterns than those with HBA(p=0.000). Eccentric LVH(p=0.000) was more in SCA subjects while concentric LVH(p=0.054) and concentric remodeling(p=0.319) were not. Forty-one and fifty-two subjects with SCA and HBA respectively did ECGs. . Subjects with eccentric LVH had lower hip circumference, higher left atrial diameter, right atrial area, higher sokolow-lyon voltage sum, stroke volume and cardiac output. The Sokolow-Lyon voltage criteria at the traditional cut off point was not different between those with and without eccentric LVH. However, Sokolow-Lyon voltage criteria at a cut-off of ≥4.7mV detected eccentric LVH with a sensitivity of 60% and specificity of 83.3%.While Sokolow-Lyon voltage sum, stroke volume, right atrial area, and left atrial diameter correlated positively, pulse rate and hip circumference correlated inversely with eccentric LVH. Sokolow Lyon voltage sum was the independent determinant of eccentric LVH in this study. CONCLUSION Sickle cell anemia predisposes to abnormal LV geometric patterns, especially eccentric LVH. There may be a need to review the electrocardiographic cut off points for defining eccentric LVH in the SCA populace.
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Affiliation(s)
- Opeyemi O Oni
- Department of Medicine, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria.
| | - Adewole A Adebiyi
- Department of Medicine, University College Hospital, Ibadan. Oyo state, Nigeria.
| | - Akinyemi Aje
- Department of Medicine, University College Hospital, Ibadan. Oyo state, Nigeria.
| | - Titilola S Akingbola
- Department of Haematology, University College Hospital, Ibadan, Oyo state, Nigeria.
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Niazi MRK, Chukkalore D, Jahangir A, Sahra S, Macdougall K, Rehan M, Odaimi M. Management of acute chest syndrome in patients with sickle cell disease: a systematic review of randomized clinical trials. Expert Rev Hematol 2022; 15:547-558. [PMID: 35666654 DOI: 10.1080/17474086.2022.2085089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Acute chest syndrome (ACS) accounts for the highest mortality in Sickle cell disease patients. Early diagnosis and timely management of ACS results in better outcomes. However, the effectiveness of most treatment modalities for ACS management has not been established. AREAS COVERED To review the treatment modalities management protocols and highlight the effectiveness of each option a literature search was done. Randomized controlled trials that assessed the efficacy of different treatment modalities in ACS management in SCD patients were chosen and reviewed. EXPERT OPINION 11 randomized controlled trials were found that evaluated the efficacy of incentive spirometry, positive expiratory pressure device, intravenous dexamethasone, oral vs. intravenous morphine, inhaled nitric oxide, unfractionated heparin, and blood transfusion in the prevention or treatment of ACS. Although there are guidelines for ACS treatment, the available evidence is very limited to delineating the effectiveness of various interventions in ACS management. More high-quality studies and trials with a larger patient population can benefit this area to support the recommendations with stronger evidence.
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Affiliation(s)
- Muhammad Rafay Khan Niazi
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Divya Chukkalore
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Abdullah Jahangir
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Syeda Sahra
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Kira Macdougall
- Department of Hematology and Medical Oncology, Oklahoma University of Health and Science, Oklahoma, OK, USA
| | - Maryam Rehan
- Department of Hematology and Medical Oncology, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Marcel Odaimi
- Department of Hematology and Medical Oncology, Staten Island University Hospital/Northwell Health, New York, NY, USA
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Meloni A, Righi R, Missere M, Renne S, Schicchi N, Gamberini MR, Cuccia L, Lisi R, Spasiano A, Roberti MG, Zuccarelli A, Ait-Ali L, Festa P, Aquaro GD, Mangione M, Barra V, Positano V, Pepe A. Biventricular Reference Values by Body Surface Area, Age, and Gender in a Large Cohort of Well-Treated Thalassemia Major Patients Without Heart Damage Using a Multiparametric CMR Approach. J Magn Reson Imaging 2020; 53:61-70. [PMID: 32311193 DOI: 10.1002/jmri.27169] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cardiac MRI plays a critical role in the management of thalassemic patients. No accurate biventricular reference values are available. PURPOSE To establish the ranges for normal left ventricular (LV) and right ventricular (RV) volumes and ejection fraction (EF) and LV mass normalized to body surface area (BSA), age, and gender in a large cohort of well-treated beta-thalassemia major (β-TM) patients without heart damage using a multiparametric MRI. STUDY TYPE Retrospective/cohort study. POPULATION In all, 251 β-TM patients with no known risk factors or cardiac disease, normal electrocardiogram, no macroscopic myocardial fibrosis, and all cardiac segments with T2 * ≥20 msec, and 246 healthy subjects. FIELD STRENGTH/SEQUENCE 1.5T/cine steady-state free precession (SSFP), gradient-echo T2 *, late gadolinium enhancement (LGE) images. ASSESSMENT Biventricular end-diastolic volume, end-systolic volume, stroke volume, and LV mass were normalized to BSA (EDVI, ESVI, SVI). STATISTICAL TESTS Comparisons between the two groups was performed with two-samples t-test or Wilcoxon's signed rank test. For more than two groups, one-way analysis of variance (ANOVA) or a Kruskal-Wallis test were applied. RESULTS Compared to controls, males with β-TM showed significantlt higher LVEDVI in all the age groups, while for the other volumes the difference was significant only within one or more age groups. In females the volumes were comparable between β-TM patients and healthy subjects in all the age groups. In the male β-TM population we found a significant effect of age on LVEDVI (P = 0.017), LVESVI (P = 0.001), RVESVI (P = 0.029), and RVEF (P = 0.031), while for females none of the biventricular parameters were significantly different among the age groups (LVEDVI: P = 0.614; LVESVI: P = 0.449; LVSVI: P = 0.186; LV mass index: P = 0.071; LVEF: P = 0.059; RVEDVI: P = 0.374; RVESVI: P = 0.180; RVSVI: P = 0.206; RVEF: P = 0.057). In β-TM patients all biventricular volume indexes as well as the LV mass index were significantly larger in males than in females (P < 0.0001 in all cases). The LV and the RV EF were comparable between the sexes (P = 0.568 and P = 0.268, respectively). DATA CONCLUSION Appropriate "normal" reference ranges normalized to BSA, sex, and age are recommended to avoid misdiagnosis of cardiomyopathy in β-TM patients. LEVEL OF EVIDENCE 4 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Antonella Meloni
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, Lagosanto, Italy
| | - Massimiliano Missere
- Dipartimento di Immagini, Fondazione di Ricerca e Cura "Giovanni Paolo II", Campobasso, Italy
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II", Lamezia Terme, Italy
| | - Nicolò Schicchi
- Dipartimento di Radiologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti "Umberto I-Lancisi-Salesi", Ancona, Italy
| | - Maria Rita Gamberini
- Dipartimento della Riproduzione e dell'Accrescimento Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria Arcispedale "S. Anna", Ferrara, Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico "Benfratelli-Di Cristina", Palermo, Italy
| | - Roberto Lisi
- Unità Operativa Dipartimentale Talassemia, Presidio Ospedaliero Garibaldi-Centro-ARNAS Garibaldi, Catania, Italy
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Maria Grazia Roberti
- Servizio Trasfusionale, Azienda Ospedaliero-Universitaria OO.RR. Foggia, Foggia, Italy
| | - Angelo Zuccarelli
- U.O. Medicina trasfusionale, Presidio Ospedaliero Sirai, Carbonia, Italy
| | - Lamia Ait-Ali
- Institute of Clinical Physiology, National Research Council, Massa, Italy
| | - Pierluigi Festa
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy.,Pediatric Cardiology and GUCH Unit, Fondazione G. Monasterio CNR-Regione Toscana, Massa, Italy
| | - Giovanni Donato Aquaro
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Maurizio Mangione
- U.O.S. Sistemi informativi (UOSI), Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Valerio Barra
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Vincenzo Positano
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Alessia Pepe
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
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Prospective CMR Survey in Children With Thalassemia Major: Insights From a National Network. JACC Cardiovasc Imaging 2020; 13:1284-1286. [PMID: 32061556 DOI: 10.1016/j.jcmg.2019.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 01/24/2023]
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Betts M, Flight PA, Paramore LC, Tian L, Milenković D, Sheth S. Systematic Literature Review of the Burden of Disease and Treatment for Transfusion-dependent β-Thalassemia. Clin Ther 2019; 42:322-337.e2. [PMID: 31882227 DOI: 10.1016/j.clinthera.2019.12.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/25/2019] [Accepted: 12/04/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE β-Thalassemia is an inherited blood disorder characterized by reduced or no production of adult hemoglobin. Systematic identification of the burden of β-thalassemia with contemporary treatments is lacking in published literature. Thus, a gap exists in understanding the baseline burden on which to assess future treatments. Therefore, a systematic literature review (SLR) was performed to assess management and outcomes in patients with transfusion-dependent β-thalassemia (TDT) who received long-term transfusion regimens. METHODS Searches of MEDLINE, EMBASE, and 5 conference websites were conducted to identify clinical-practice studies in Italy, France, Germany, Greece, the United States, and the United Kingdom, published since January 2007. The review found 135 articles meeting the SLR criteria. FINDINGS Among patients carrying 2 β-thalassemia mutations, 64%-89% underwent regular transfusions at intervals of between 2 and 4 weeks. Transfusion-associated complications that were reported included iron overload, transfusion reactions, alloimmunization, and infections. Analyses of 42, 25, and 73 studies reporting liver iron concentration (median, 8.5 mg/g of dry weight [dw]; interquartile range [IQR], 4.5-11.0 mg/g dw), cardiac T2* magnetic resonance imaging (median, 27.4 ms; IQR, 26.0-30.2 ms), and serum ferritin (median, 1465.0 ng/mL; IQR, 1238.2-1797.0 ng/mL), respectively, showed wide ranges in iron levels and a general trend toward improved iron control in recent years. Adverse transfusion reactions and alloimmunization were reported in ~50% and 10%-20% in patients, respectively. Rates of transfusion-transmitted infections were highly variable by study but were lower in more recent cohorts. Complications stemming from iron overload and underlying disease captured in this SLR included cardiac disease, liver disease, and endocrine and musculoskeletal disorders. Approximately 10% of patients were diagnosed with heart failure, with rates ranging from 2.9% to 20.9% across 6 studies. Other significant complications reported with β-thalassemia included pain (25%-69%), psychiatric disorders (25%-30%), and reduced health-related quality of life. Despite substantial improvements in survival, patients with TDT remained at an increased risk for early mortality. IMPLICATIONS Consistent with improvements in transfusion practices and iron monitoring and management, outcomes in patients with TDT have improved. However, iron overload and disease-associated complications remain a challenge in this population. This review supports the burden of disease affecting patients with β-thalassemia and provides a baseline health status against which to assess future improvements in care.
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Affiliation(s)
| | | | | | | | | | - Sujit Sheth
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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Johnson A, Yang F, Gollarahalli S, Banerjee T, Abrams D, Jonassaint J, Jonassaint C, Shah N. Use of Mobile Health Apps and Wearable Technology to Assess Changes and Predict Pain During Treatment of Acute Pain in Sickle Cell Disease: Feasibility Study. JMIR Mhealth Uhealth 2019; 7:e13671. [PMID: 31789599 PMCID: PMC6915456 DOI: 10.2196/13671] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 06/22/2019] [Accepted: 07/19/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Sickle cell disease (SCD) is an inherited red blood cell disorder affecting millions worldwide, and it results in many potential medical complications throughout the life course. The hallmark of SCD is pain. Many patients experience daily chronic pain as well as intermittent, unpredictable acute vaso-occlusive painful episodes called pain crises. These pain crises often require acute medical care through the day hospital or emergency department. Following presentation, a number of these patients are subsequently admitted with continued efforts of treatment focused on palliative pain control and hydration for management. Mitigating pain crises is challenging for both the patients and their providers, given the perceived unpredictability and subjective nature of pain. OBJECTIVE The objective of this study was to show the feasibility of using objective, physiologic measurements obtained from a wearable device during an acute pain crisis to predict patient-reported pain scores (in an app and to nursing staff) using machine learning techniques. METHODS For this feasibility study, we enrolled 27 adult patients presenting to the day hospital with acute pain. At the beginning of pain treatment, each participant was given a wearable device (Microsoft Band 2) that collected physiologic measurements. Pain scores from our mobile app, Technology Resources to Understand Pain Assessment in Patients with Pain, and those obtained by nursing staff were both used with wearable signals to complete time stamp matching and feature extraction and selection. Following this, we constructed regression and classification machine learning algorithms to build between-subject pain prediction models. RESULTS Patients were monitored for an average of 3.79 (SD 2.23) hours, with an average of 5826 (SD 2667) objective data values per patient. As expected, we found that pain scores and heart rate decreased for most patients during the course of their stay. Using the wearable sensor data and pain scores, we were able to create a regression model to predict subjective pain scores with a root mean square error of 1.430 and correlation between observations and predictions of 0.706. Furthermore, we verified the hypothesis that the regression model outperformed the classification model by comparing the performances of the support vector machines (SVM) and the SVM for regression. CONCLUSIONS The Microsoft Band 2 allowed easy collection of objective, physiologic markers during an acute pain crisis in adults with SCD. Features can be extracted from these data signals and matched with pain scores. Machine learning models can then use these features to feasibly predict patient pain scores.
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Affiliation(s)
- Amanda Johnson
- Department of Pediatrics, Duke University, Durham, NC, United States
| | - Fan Yang
- Department of Computer Science & Engineering, Wright State University, Dayton, OH, United States
| | | | - Tanvi Banerjee
- Department of Computer Science & Engineering, Wright State University, Dayton, OH, United States
| | - Daniel Abrams
- Engineering Sciences and Applied Mathematics, Northwestern University, Chicago, IL, United States
| | - Jude Jonassaint
- Social Work and Clinical and Translational Science, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Charles Jonassaint
- Social Work and Clinical and Translational Science, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Nirmish Shah
- Division of Hematology, Department of Medicine, Duke University, Durham, NC, United States
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Novelli EM, Gladwin MT. Crises in Sickle Cell Disease. Chest 2015; 149:1082-93. [PMID: 26836899 DOI: 10.1016/j.chest.2015.12.016] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/04/2015] [Accepted: 12/11/2015] [Indexed: 12/16/2022] Open
Abstract
In spite of significant strides in the treatment of sickle cell disease (SCD), SCD crises are still responsible for high morbidity and early mortality. While most patients initially seek care in the acute setting for a seemingly uncomplicated pain episode (pain crisis or vaso-occlusive crisis), this initial event is the primary risk factor for potentially life-threatening complications. The pathophysiological basis of these illnesses is end-organ ischemia and infarction combined with the downstream effects of hemolysis that results from red blood cell sickling. These pathological changes can occur acutely and lead to a dramatic clinical presentation, but are frequently superimposed over a milieu of chronic vasculopathy, immune dysregulation, and decreased functional reserve. In the lungs, acute chest syndrome is a particularly ominous lung injury syndrome with a complex pathogenesis and potentially devastating sequelae, but all organ systems can be affected. It is, therefore, critical to understand the SCD patients' susceptibility to acute complications and their risk factors so that they can be recognized promptly and managed effectively. Blood transfusions remain the mainstay of therapy for all severe acute crises. Recommendations and indications for the safest and most efficient implementation of transfusion strategies in the critical care setting are therefore presented and discussed, together with their pitfalls and potential future therapeutic alternatives. In particular, the importance of extended phenotypic red blood cell matching cannot be overemphasized, due to the high prevalence of severe complications from red cell alloimmunization in SCD.
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Affiliation(s)
- Enrico M Novelli
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Mechanisms linking red blood cell disorders and cardiovascular diseases. BIOMED RESEARCH INTERNATIONAL 2015; 2015:682054. [PMID: 25710019 PMCID: PMC4331396 DOI: 10.1155/2015/682054] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 11/14/2014] [Accepted: 11/23/2014] [Indexed: 01/07/2023]
Abstract
The present paper aims to review the main pathophysiological links between red blood cell disorders and cardiovascular diseases, provides a brief description of the latest studies in this area, and considers implications for clinical practice and therapy. Anemia is associated with a special risk in proatherosclerotic conditions and heart disease and became a new therapeutic target. Guidelines must be updated for the management of patients with red blood cell disorders and cardiovascular diseases, and targets for hemoglobin level should be established. Risk scores in several cardiovascular diseases should include red blood cell count and RDW. Complete blood count and hemorheological parameters represent useful, inexpensive, widely available tools for the management and prognosis of patients with coronary heart disease, heart failure, hypertension, arrhythmias, and stroke. Hypoxia and iron accumulation cause the most important cardiovascular effects of sickle cell disease and thalassemia. Patients with congenital chronic hemolytic anemia undergoing splenectomy should be monitored, considering thromboembolic and cardiovascular risk.
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Johnson MC, Johnikin MJ, Euteneuer JC, DeBaun MR, Hildebolt C. Coronary artery dilation and left ventricular hypertrophy do not predict morbidity in children with sickle cell disease. Pediatr Blood Cancer 2015; 62:115-9. [PMID: 25264310 DOI: 10.1002/pbc.25239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 08/06/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Little is known about the clinical significance of coronary artery dilation (CAD) and left ventricular hypertrophy (LVH) in patients with sickle cell disease (SCD). PROCEDURE In a retrospective cohort, we studied the prevalence of CAD and LVH in 101 children with SCD in comparison to 93 healthy African-American patients without SCD. Hospital days, number of admissions, and intensive care unit admission after the echocardiogram were assessed as measures of morbidity. RESULTS Multivariable analysis of echocardiographic measures of LVH and CAD did not predict subsequent intensive care unit admission, hospital days/year or number of hospital admissions/year during a median follow-up time of 6.1 years. LVH as measured by left ventricular mass index was present in 46% of children with SCD and was inversely related to age (P = 0.0004). Height-indexed dimensions in children with SCD demonstrated that the prevalence of dilation was 49% for the left main coronary artery (LMCA), 29% for the left anterior descending (LAD), and 6% for the right coronary artery (RCA). LMCA dilation was related to relative wall thickness (P = 0.006), inversely to age (P < 0.0006) and weakly to disease severity as determined by hemoglobin (P = 0.03). CAD and LVH were not related to a clinical history of vaso-occlusive pain episode, acute chest syndrome, or cerebrovascular accident. CONCLUSION LVH and CAD are common findings in children with SCD; however, they are not associated with need for subsequent hospital or intensive care unit admission.
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Affiliation(s)
- Mark C Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, St. Louis, Missouri
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12
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Meloni A, Detterich J, Pepe A, Harmatz P, Coates TD, Wood JC. Pulmonary hypertension in well-transfused thalassemia major patients. Blood Cells Mol Dis 2014; 54:189-94. [PMID: 25488617 DOI: 10.1016/j.bcmd.2014.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 11/13/2014] [Indexed: 02/09/2023]
Abstract
The risk for pulmonary hypertension (PH) in thalassemia major (TM) patients remains controversial. We report echocardiography results from 60 TM patients: we evaluated the association between tricuspid regurgitation velocities (TRV), iron stores, and serologic markers of hemolysis and arginine dysregulation. Patients were enrolled from August 2004 until May 2009. All parameters were inversely weighted by the number of exams. TRV was comparable between sexes and it was uncorrelated with age. At the first exam, TR velocities at the upper limits of normal (2.5-2.7m/s) were observed in 8 patients. An abnormal TRV (2.9m/s) was found in 1 patient. Borderline increases in TRV were associated with a reduced global arginine bioavailability (R=-0.399 P=0.005), increased anemia (hemoglobin: R=-0.219 P=0.0461), cardiac index (R=0.223 P=0.0481), and diastolic dysfunction (E/A: R=0.289 P=0.0088; E/E': R=0.223 P=0.0453), but not hemolysis, iron overload and systolic function evaluated by Magnetic Resonance Imaging, and splenectomy. Well-transfused TM patients have a lower risk for PH than thalassemia intermedia patients. However, they do have vascular stressors that raise their lifetime PH risk to levels higher than for the general population. Consequently, we support recommendations for annual echocardiographic screening and cardiac catheterization for persistent TRV above 3m/s.
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Affiliation(s)
- Antonella Meloni
- CMR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy; Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jon Detterich
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Alessia Pepe
- CMR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Paul Harmatz
- Division of Gastroenterology, Children's Hospital Oakland, Oakland, CA, USA
| | - Tom D Coates
- Section of Hematology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Wood
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA, USA.
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Meloni A, Puliyel M, Pepe A, Berdoukas V, Coates TD, Wood JC. Cardiac iron overload in sickle-cell disease. Am J Hematol 2014; 89:678-83. [PMID: 24664847 DOI: 10.1002/ajh.23721] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 03/19/2014] [Accepted: 03/21/2014] [Indexed: 12/15/2022]
Abstract
Chronically transfused sickle cell disease (SCD) patients have lower risk of myocardial iron overload (MIO) than comparably transfused thalassemia major (TM) patients. However, cardioprotection is incomplete. We present the clinical characteristics of six patients who have prospectively developed MIO, to identify potential risk factors for cardiac iron accumulation. From 2002 to 2011, cardiac, hepatic, and pancreatic iron overload were assessed by R2 and R2 * magnetic resonance imaging techniques in 201 chronic transfused SCD patients as part of their clinical care. At the time, they developed MIO, five of six patients had been on chronic transfusion for more than 11 years; only one was on exchange transfusion. The time to MIO was correlated with reticulocyte and hemoglobin S percentages. All patients had qualitatively poor chelation compliance (<50%). All patients had serum ferritin levels >4600 ng/ml and liver iron concentration >22 mg/g. Pancreatic R2 * was >100 Hz in every patient studied (5/6). Cardiac iron rose proportionally to pancreas R2 *, with all patients having pancreas R2 *>100 Hz when cardiac iron was present. MIO had a threshold relationship with liver iron that was higher than observed in TM patients. In conclusion, MIO occurs in a small percentage of chronically transfused SCD patients and is only associated with exceptionally poor control of total body iron stores. Duration of chronic transfusion is clearly important but other factors, such as levels of effective erythropoiesis, appear to contribute to cardiac risk. Pancreas R2 * can serve as a valuable screening tool for cardiac iron in SCD patients.
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Affiliation(s)
- Antonella Meloni
- CMR Unit; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
- Division of Cardiology; Children's Hospital Los Angeles; Los Angeles California
| | - Mammen Puliyel
- Division of Hematology-Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - Alessia Pepe
- CMR Unit; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Vasili Berdoukas
- Division of Hematology-Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - Thomas D. Coates
- Division of Hematology-Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - John C. Wood
- Division of Cardiology; Children's Hospital Los Angeles; Los Angeles California
- Department of Radiology; Children's Hospital Los Angeles; Los Angeles California
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Kostopoulou AG, Tsiapras DP, Chaidaroglou AS, De giannis DE, Farmakis D, Kremastinos DT. The pathophysiological relationship and clinical significance of left atrial function and left ventricular diastolic dysfunction in β-thalassemia major. Am J Hematol 2014; 89:13-8. [PMID: 24038100 DOI: 10.1002/ajh.23581] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 08/13/2013] [Accepted: 08/21/2013] [Indexed: 01/26/2023]
Abstract
Iron deposition in combination with inflammatory and immunogenetic factors is involved in the pathophysiology of cardiac dysfunction in β-thalassemia major. We investigated the mechanical and endocrine function of the left atrium and ventricle to identify early signs of dysfunction. We studied 90 patients (mean age: 29 ± 11 years) with β-thalassemia and normal left ventricular function and 90 age and sex-matched healthy controls. Patients and controls underwent a thorough cardiac echocardiographic study and measurements of the b-type (NT-proBNP) and atrial natriuretic peptides (proANP). Patients underwent 24-hr Holter recordings for arrhythmia monitoring. In the patient group, atria were affected early during the course of the disease, prior to diastolic and systolic left ventricular dysfunction. The E/E'ratio (E Doppler mitral fast inflow to the corresponding tissue Doppler E) continually increased with age (P < 0.05) and reached levels indicating left ventricular diastolic dysfunction (E/E' > 15) in the third decade whereas indexes of active and passive atrial function decreased gradually throughout life. In controls, the E/E' ratio continually increased with age but with later (fifth decade) appearance of diastolic dysfunction and a compensatory increase in atrial active function. Both natriuretic peptides were significantly increased in patients compared to controls (558 ± 141 and 2,580 ± 1,830 fmol/mL for NT-proBNP and proANP versus 332 ± 106 and 1,331 ± 1,134 fmol/mL, respectively). Atrial fibrillation was found in a subgroup of 23 (26%) patients, older in age with mild diastolic function and enlarged, depressed atria. In conclusion, atrial mechanical depression seems to be a very early sign of cardiac damage. It may become echocardiographically evident even before diastolic and systolic dysfunction and is associated to supraventricular arrhythmias.
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Affiliation(s)
| | - Dimitrios P. Tsiapras
- Laboratory of Molecular Immunology and Histocompatibility; Onassis Cardiac Surgery Center; Athens Greece
| | - Antigoni S. Chaidaroglou
- Laboratory of Molecular Immunology and Histocompatibility; Onassis Cardiac Surgery Center; Athens Greece
| | - Dimitrios E. De giannis
- Laboratory of Molecular Immunology and Histocompatibility; Onassis Cardiac Surgery Center; Athens Greece
| | - Dimitrios Farmakis
- First Department of Internal Medicine; University of Athens Medical School; Laiko Hospital Athens Greece
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Pennell DJ, Udelson JE, Arai AE, Bozkurt B, Cohen AR, Galanello R, Hoffman TM, Kiernan MS, Lerakis S, Piga A, Porter JB, Walker JM, Wood J. Cardiovascular function and treatment in β-thalassemia major: a consensus statement from the American Heart Association. Circulation 2013; 128:281-308. [PMID: 23775258 DOI: 10.1161/cir.0b013e31829b2be6] [Citation(s) in RCA: 261] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This aim of this statement is to report an expert consensus on the diagnosis and treatment of cardiac dysfunction in β-thalassemia major (TM). This consensus statement does not cover other hemoglobinopathies, including thalassemia intermedia and sickle cell anemia, in which a different spectrum of cardiovascular complications is typical. There are considerable uncertainties in this field, with a few randomized controlled trials relating to treatment of chronic myocardial siderosis but none relating to treatment of acute heart failure. The principles of diagnosis and treatment of cardiac iron loading in TM are directly relevant to other iron-overload conditions, including in particular Diamond-Blackfan anemia, sideroblastic anemia, and hereditary hemochromatosis. Heart failure is the most common cause of death in TM and primarily results from cardiac iron accumulation. The diagnosis of ventricular dysfunction in TM patients differs from that in nonanemic patients because of the cardiovascular adaptation to chronic anemia in non-cardiac-loaded TM patients, which includes resting tachycardia, low blood pressure, enlarged end-diastolic volume, high ejection fraction, and high cardiac output. Chronic anemia also leads to background symptomatology such as dyspnea, which can mask the clinical diagnosis of cardiac dysfunction. Central to early identification of cardiac iron overload in TM is the estimation of cardiac iron by cardiac T2* magnetic resonance. Cardiac T2* <10 ms is the most important predictor of development of heart failure. Serum ferritin and liver iron concentration are not adequate surrogates for cardiac iron measurement. Assessment of cardiac function by noninvasive techniques can also be valuable clinically, but serial measurements to establish trends are usually required because interpretation of single absolute values is complicated by the abnormal cardiovascular hemodynamics in TM and measurement imprecision. Acute decompensated heart failure is a medical emergency and requires urgent consultation with a center with expertise in its management. The first principle of management of acute heart failure is control of cardiac toxicity related to free iron by urgent commencement of a continuous, uninterrupted infusion of high-dose intravenous deferoxamine, augmented by oral deferiprone. Considerable care is required to not exacerbate cardiovascular problems from overuse of diuretics or inotropes because of the unusual loading conditions in TM. The current knowledge on the efficacy of removal of cardiac iron by the 3 commercially available iron chelators is summarized for cardiac iron overload without overt cardiac dysfunction. Evidence from well-conducted randomized controlled trials shows superior efficacy of deferiprone versus deferoxamine, the superiority of combined deferiprone with deferoxamine versus deferoxamine alone, and the equivalence of deferasirox versus deferoxamine.
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Saravi M, Tamadoni A, Jalalian R, Mahmoodi-Nesheli H, Hojati M, Ramezani S. Evaluation of tissue doppler echocardiography and T2* magnetic resonance imaging in iron load of patients with thalassemia major. CASPIAN JOURNAL OF INTERNAL MEDICINE 2013; 4:692-697. [PMID: 24009962 PMCID: PMC3755834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 05/12/2013] [Accepted: 05/14/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND Iron-mediated cardiomyopathy is the main complication of thalassemia major (TM) patients. Therefore, there is an important clinical need in the early diagnosis and risk stratification of patients. The aim of this study was to evaluate the efficacy of tissue doppler imaging (TDI) to study cardiac iron overload in patients with TM using T2* magnetic resonance (MR) as the gold-standard non-invasive diagnostic test. METHODS A total of 100 TM patients with the mean age of 19±7 years and 100 healthy controls 18.8±7 years were evaluated. Conventional echocardiography, TDI, and cardiac MRI T2* were performed in all subjects. TDI measures included myocardial systolic (Sm), early (Em) and late (Am) diastolic velocities at basal and middle segments of septal and lateral LV wall. The TM patients were also subgrouped according to those with iron load (T2* ≤ 20 ms) and those without (T2* > 20 ms), and also severe (T2* ≤ 10 ms) versus the non-severe (T2* ≤ 10 ms). RESULTS Using T2* cardiovascular MR, abnormal myocardial iron load (T2* ≤ 20 ms) was detected in 84% of the patients and among these, 50% (42/84) had severe (T2* ≤ 10 ms) iron load. The mean T2* was 11.6±8.6 ms (5-36.7). A negative linear correlation existed between transfusion period of patients and T2* levels (r = -0.53, p=0.02). The following TDI measures were lower in patients than in controls: basal septal Am (p<0.05), mid-septal Em and Am (p<0.05), basal lateral Am (p<0.05), mid-lateral LV wall Sm (p<0.05) and Am (p<0.05). CONCLUSION Tissue doppler imaging is helpful in predicting the presence of myocardial iron load in Thalassemia patients. Therefore, it can be used for screening of thalassemia major patients.
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Affiliation(s)
- Mehrdad Saravi
- Department of Cardiology, Babol University of Medical Sciences, Babol, Iran
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