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Chandrasekar H, Kaufman BD, Beattie MJ, Ennis DB, Syed AB, Zucker EJ, Maskatia SA. Abbreviated cardiac magnetic resonance imaging versus echocardiography for interval assessment of systolic function in Duchenne muscular dystrophy: patient satisfaction, clinical utility, and image quality. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:157-165. [PMID: 37831292 DOI: 10.1007/s10554-023-02977-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/26/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE Poor acoustic windows make interval assessment of systolic function in patients with (Duchenne Muscular Dystrophy) DMD by echocardiography (echo) difficult. Cardiac magnetic resonance imaging (CMR) can be challenging in DMD patients due to study duration and patient discomfort. We developed an abbreviated CMR (aCMR) protocol and hypothesized that aCMR would compare favorably to echo in image quality and clinical utility without significant differences in exam duration, patient satisfaction, and functional measurements. METHODS DMD patients were recruited prospectively to undergo echo and aCMR. Modalities were compared with a global quality assessment score (GQAS), clinical utility score (CUS), and patient satisfaction score (PSS). Results were compared using Wilcoxon signed-rank tests, Spearman correlations, intraclass correlations, and Bland-Altman analyses. RESULTS Nineteen DMD patients were included. PSS scores and exam duration were equivalent between modalities, while CUS and GQAS scores favored aCMR. ACMR scored markedly higher than echo in RV visualization and assessment of atrial size. Older age was negatively correlated with echo GQAS and CUS scores, as well as aCMR PSS scores. Higher BMI was positively correlated with aCMR GQAS scores. Nighttime PPV requirement and non-ambulatory status were correlated with worse echo CUS scores. Poor image quality precluding quantification existed in five (26%) echo and zero (0%) aCMR studies. There was moderate correlation between aCMR and echo for global circumferential strain and left ventricular four chamber global longitudinal strain. CONCLUSION The aCMR protocol resulted in improved clinical relevance and quality scores relative to echo, without significant detriment to patient satisfaction or exam duration.
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Affiliation(s)
- Hamsika Chandrasekar
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Beth D Kaufman
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Meaghan J Beattie
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Daniel B Ennis
- Department of Radiology, Division of Pediatric Radiology and Cardiovascular Imaging, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ali B Syed
- Department of Radiology, Division of Pediatric Radiology and Cardiovascular Imaging, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Evan J Zucker
- Department of Radiology, Division of Pediatric Radiology and Cardiovascular Imaging, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Shiraz A Maskatia
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
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Morales Ciancio RA, Gagliardi MJ, Tucker S, Ember T, Harris M, Broomfield E, Craven CL. Distal fusion in Duchenne scoliosis: the relevance of preoperative pelvic obliquity. A case series study. Spine Deform 2023; 11:1261-1270. [PMID: 37280469 DOI: 10.1007/s43390-023-00689-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 04/08/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE The aim of this study was to determine clinical and radiographic outcomes for Duchenne Muscular Dystrophy (DMD) patients who underwent posterior spinal fusion from T2/3 to L5 (without pelvic fixation), at this single centre. METHODS From January 2012 to January 2020, 29 consecutive DMD scoliosis patients underwent posterior spinal fusion using pedicle screws from T2/3 to L5 in a single center with a minimum of 3 years follow-up (FU). Radiologic measurements and chart review were performed. RESULTS Twenty nine patients aged 14 ± 1.5 years were included. No patient was lost to FU. All patients had significant correction in Cobb angle, pelvic obliquity (PO) and lumbar lordosis (LL), without loss of correction at last FU. The mean values for preoperative, immediate postoperative and last FU were CA 62o, 15o and 17o, PO: 21o, 8o and 9o; and LL 10o, -41o and -41o respectively. Correction in CA was independent of any variable analysed including implant density, rod diameter, traction, or bone density. Regarding PO, it was inversely related to age and independent of all other variables. Factors associated with postoperative complications were age and respiratory function. CONCLUSIONS It appears from our results that pelvic fixation might not always be required in DMD scoliosis surgery, when using pedicle screws with lowest instrumented vertebra at L5. However, larger preoperative PO values can be related with residual PO. It seems that probably related to the underlying condition, early surgery may decrease incidence of complications. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | | | - Stewart Tucker
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Thomas Ember
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Mark Harris
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Edel Broomfield
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Claudia L Craven
- Orthopaedic and Spine Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
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3
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Soslow JH, Xu M, Slaughter JC, Crum K, Kaslow JA, George-Durrett K, Raucci FJ, Wilkinson JD, Cripe L, Hor K, Spurney CF, Markham LW. Cardiovascular Measures of All-Cause Mortality in Duchenne Muscular Dystrophy. Circ Heart Fail 2023; 16:e010040. [PMID: 37288563 PMCID: PMC10524475 DOI: 10.1161/circheartfailure.122.010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 03/30/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cardiopulmonary failure is the leading cause of death in Duchenne muscular dystrophy (DMD). Research into DMD-specific cardiovascular therapies is ongoing, but there are no Food and Drug Administration-approved cardiac end points. To adequately power a therapeutic trial, appropriate end points must be chosen and the rate of change for these end points reported. The objective of this study was to evaluate rate of change for cardiac magnetic resonance and blood biomarkers and to determine which measures associate with all-cause mortality in DMD. METHODS Seventy-eight DMD subjects underwent 211 cardiac magnetic resonance studies analyzed for left ventricular (LV) ejection fraction, indexed LV end diastolic and systolic volumes, circumferential strain, late gadolinium enhancement presence and severity (global severity score, and full width half maximum), native T1 mapping, T2 mapping, and extracellular volume. Blood samples were analyzed for BNP (brain natriuretic peptide), NT-proBNP (N-terminal pro-B-type natriuretic peptide), and troponin I. Cox proportional hazard regression modeling was performed with all-cause mortality as the outcome. RESULTS Fifteen subjects (19%) died. LV ejection fraction, indexed end systolic volumes, global severity score, and full width half maximum worsened at 1 and 2 years while circumferential strain and indexed LV end diastolic volumes worsened at 2 years. LV ejection fraction, indexed LV end diastolic and systolic volumes, late gadolinium enhancement full width half maximum, and circumferential strain associated with all-cause mortality (P<0.05). NT-proBNP was the only blood biomarker that associated with all-cause mortality (P<0.05). CONCLUSIONS LV ejection fraction, indexed LV volumes, circumferential strain, late gadolinium enhancement full width half maximum, and NT-proBNP are associated with all-cause mortality in DMD and may be the best end points for use in cardiovascular therapeutic trials. We also report change over time of cardiac magnetic resonance and blood biomarkers.
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Affiliation(s)
- Jonathan H Soslow
- Division or Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Kimberly Crum
- Division or Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Jacob A Kaslow
- Division of Pediatric Pulmonology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Kristen George-Durrett
- Division or Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Frank J Raucci
- Division of Pediatric Cardiology, Department of Pediatrics, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, VA 23298, USA
| | - James D Wilkinson
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Linda Cripe
- Division of Pediatric Cardiology, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH 43205 USA
| | - Kan Hor
- Division of Pediatric Cardiology, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH 43205 USA
| | - Christopher F Spurney
- Division of Cardiology, Children’s National Heart Institute, Children’s National Hospital, Washington, D.C. 20010, USA
| | - Larry W Markham
- Division of Cardiology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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Goebel J, Schult K, Schara U, Neudorf U, Forsting M, Schlosser T, Nassenstein K. Patterns of cardiac involvement in different muscular dystrophies assessed by magnetic resonance imaging. Acta Radiol 2023; 64:605-611. [PMID: 35147046 DOI: 10.1177/02841851221077402] [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: 11/15/2022]
Abstract
BACKGROUND In muscular dystrophies, it is not only skeletal muscles that can be affected, but also the myocardium. This cardiac involvement can represent a major cause of morbidity and mortality. PURPOSE To investigate cardiac involvement in Duchenne (DMD), Becker (BMD), and limb girdle muscular dystrophy (LGMD) patients, and carriers of DMD/BMD by cardiac magnetic resonance (CMR) imaging and to search for differences in the pattern of cardiac involvement. MATERIAL AND METHODS All patients with genetically or histologically proven DMD, BMD, and LGMD, or confirmed carriers of DMD/BMD who had undergone CMR at our clinic between January 2008 and November 2018 were retrospectively included and re-evaluated for regional and global left ventricular function, increased trabecularization, and late enhancement. RESULTS A total of 26 DMD, 10 BMD, 11 LGMD, and seven DMD/BMD carriers were included. Only one carrier of DMD presented with normal CMR results; all other participants showed cardiac abnormalities. Regional wall motion abnormalities (RWMA; prevalence in LGMD patients: 55%) and late enhancement (prevalence in LGMD patients: 82%) were frequent. RWMA were accentuated basal inferolateral in DMD/BMD carriers, while in LGMD they were accentuated apical. In all groups late enhancement was located mainly subepicardial/midmyocardial with a basal inferolateral accentuation. Apart from the different RWMA distribution, no further group-specific differences were found. CONCLUSION We found a high rate of cardiac involvement not only in DMD/BMD, but also in LGMD and DMD/BMD carriers with a different RWMA accentuation (apical in LGMD and basal inferolateral in DMD/BMD) as a single group-specific difference.
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Affiliation(s)
- Juliane Goebel
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
| | - Karolin Schult
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
| | - Ulrike Schara
- Department of Pediatric Neurology, 39081University Hospital Essen, Essen, Germany
| | - Ulrich Neudorf
- Department of Pediatric Cardiology, 39081University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
| | - Thomas Schlosser
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
| | - Kai Nassenstein
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
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Benvenuto S, Simonini G, Della Paolera S, Abu Rumeileh S, Mastrolia MV, Manerba A, Chicco D, Belgrano M, Caiffa T, Cattalini M, Taddio A. Cardiac MRI in midterm follow-up of MISC: a multicenter study. Eur J Pediatr 2023; 182:845-854. [PMID: 36484863 PMCID: PMC9734924 DOI: 10.1007/s00431-022-04748-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/25/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
UNLABELLED In this multicenter retrospective study we aimed to evaluate the outcome of cardiac involvement in children affected by multisystem inflammatory syndrome (MIS-C), assessed through cardiac magnetic resonance (CMR). Children referring to three Italian tertiary pediatric centers between February 2020 and November 2021 with a diagnosis of MIS-C, who underwent CMR during a follow-up visit, were enrolled. Demographic, clinical, laboratory, treatment, and outcome data were collected. Twenty MIS-C patients (aged 9-17, median 12 years) were included in the study. Heart involvement at onset was testified by hypotension/shock (55%), laboratory evidence of myocardial involvement (100%), reduced LV ejection fraction (EF) on echocardiography (83%), and/or need for inotrope agents (40%); they all presented good clinical, laboratory, and echocardiographic response to treatment. CMR was performed after a median interval of 3 months from discharge. Pericardial effusion and myocardial edema were found in 5% of patients. Mild residual left ventricular (LV) dysfunction was found in 20% of patients, all showing normal echocardiographic LVEF at discharge. Minimal myocardial scars were found in 25% by late gadolinium enhancement (LGE). One patient was evaluated at two consecutive time points, showing partial resolution of a myocardial scar after 7 months from its first finding. CONCLUSION Despite the severity of heart involvement in the acute MIS-C phase, the mid-term cardiac outcome is good. Direct cardiac tissue viral invasion may be involved in MIS-C pathogenesis. WHAT IS KNOWN • Heart involvement is common in MIS-C, but conflicting findings have been shown regarding cardiac outcome when assessed through cardiac MRI. WHAT IS NEW • Midterm cardiac MRI shows mild abnormalities in patients recovered from MIS-C with any grade of severity of cardiac involvement at presentation.
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Affiliation(s)
| | - Gabriele Simonini
- grid.8404.80000 0004 1757 2304NEUROFARBA Department, Rheumatology Unit, Anna Meyer Children’s Hospital, University of Florence, Florence, Italy
| | - Sara Della Paolera
- grid.418712.90000 0004 1760 7415Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Sarah Abu Rumeileh
- grid.413181.e0000 0004 1757 8562Rheumatology Unit, Meyer Children’s Hospital, University of Florence, Florence, Italy
| | - Maria Vincenza Mastrolia
- grid.8404.80000 0004 1757 2304NEUROFARBA Department, Rheumatology Unit, Anna Meyer Children’s Hospital, University of Florence, Florence, Italy
| | - Alessandra Manerba
- grid.412725.7Pediatric Cardiology, ASST Spedali Civili Di Brescia, Brescia, Italy
| | - Daniela Chicco
- grid.418712.90000 0004 1760 7415Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Manuel Belgrano
- grid.5133.40000 0001 1941 4308Department of Radiology, Azienda Sanitaria Universitaria Giuliano Isontina and University of Trieste, Trieste, Italy
| | - Thomas Caiffa
- grid.418712.90000 0004 1760 7415Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Marco Cattalini
- grid.7637.50000000417571846Pediatric Clinic, University of Brescia, ASST Spedali Civili Di Brescia, Brescia, Italy
| | - Andrea Taddio
- grid.5133.40000 0001 1941 4308University of Trieste, Via dell’Istria 65/1, Trieste, Italy ,grid.418712.90000 0004 1760 7415Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy
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Starnes JR, Crum K, George-Durrett K, Godown J, Parra DA, Markham LW, Soslow JH. Novel Cardiac Imaging Risk Score for Mortality Prediction in Duchenne Muscular Dystrophy. Pediatr Cardiol 2022:10.1007/s00246-022-03040-6. [PMID: 36322201 PMCID: PMC10151437 DOI: 10.1007/s00246-022-03040-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/22/2022] [Indexed: 01/04/2023]
Abstract
Cardiovascular disease is the leading cause of death in patients with Duchenne Muscular Dystrophy (DMD), but there is significant cardiomyopathy phenotypic variability. Some patients demonstrate rapidly progressive disease and die at a young age while others survive into the fourth decade. Criteria to identify DMD subjects at greatest risk for early mortality could allow for increased monitoring and more intensive therapy. A risk score was created describing the onset and progression of left ventricular dysfunction and late gadolinium enhancement in subjects with DMD. DMD subjects prospectively enrolled in ongoing observational studies (which included cardiac magnetic resonance [CMR]) were used to validate the risk score. A total of 69 subjects had calculable scores. During the study period, 12 (17%) died from complications of DMD. The median risk score was 3 (IQR [2,5]; range [0,9]). The overall risk score applied at the most recent imaging age was associated with mortality at a median age of 17 years (IQR [16,20]) (HR 2.028, p < 0.001). There were no deaths in subjects with a score of less than two. Scores were stable over time. An imaging-based risk score allows risk stratification of subjects with DMD. This can be quickly calculated during a clinic visit to identify subjects at greatest risk of early death.
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Affiliation(s)
- Joseph R Starnes
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37212, USA.
| | - Kimberly Crum
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37212, USA
| | - Kristen George-Durrett
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37212, USA
| | - Justin Godown
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37212, USA
| | - David A Parra
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37212, USA
| | - Larry W Markham
- Division of Cardiology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Jonathan H Soslow
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, 37212, USA
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7
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Neuromuscular diseases and their cardiac manifestations under the spectrum of cardiovascular imaging. Heart Fail Rev 2022; 27:2045-2058. [PMID: 35857244 DOI: 10.1007/s10741-022-10260-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 11/04/2022]
Abstract
Neuromuscular diseases (NMDs) include a broad spectrum of disorders that affect motor unit in every possible site, extending from the cell body of peripheral nerves to the muscle. The different lesion sites make this group of inherited disorders difficult to diagnose. Many NMDs, especially those involving skeletal muscles, can present significant cardiovascular complications, ranging from rhythm disturbances to the development of dilated or hypertrophic cardiomyopathy. Heart disease represents a major cause of morbidity and mortality among NMD patients, underlining the vital need for further familiarization with the pathogenesis and assessment of cardiac involvement. Cardiovascular imaging is the cornerstone for the evaluation of heart disorders in NMDs, with conventional echocardiography still offering a portable, affordable, and easily accessible solution. Meanwhile, newer echocardiographic techniques such as speckle tracking imaging in combination with cardiac magnetic resonance add new insights into further substrate characterization. The purpose of this review is to offer a brief presentation of the main NMDs and their cardiovascular complications, as well as the presentation of data that highlight the importance of cardiovascular imaging in early diagnosis, monitoring, and prognosis of these patients. Lastly, the authors provide a simple guide about which clinical features, imaging findings, and follow-up plan to adopt in each myopathic disorder.
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association. J Cardiovasc Magn Reson 2022; 24:37. [PMID: 35725473 PMCID: PMC9210755 DOI: 10.1186/s12968-022-00843-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA
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9
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association. Circ Cardiovasc Imaging 2022; 15:e014415. [PMID: 35727874 PMCID: PMC9213089 DOI: 10.1161/circimaging.122.014415] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA, (M.A.F.).,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, (M.A.F.)
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA, (S.A.)
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA, (C.B.)
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA, (L.B.)
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA, (T.C.)
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA, (T.J.)
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK, (V.M.)
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA, (M.T.)
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA (C.W.)
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10
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Yamaguchi H, Awano H, Yamamoto T, Nambu Y, Iijima K. Serum Cardiac Troponin I is a Candidate Biomarker for Cardiomyopathy in Duchenne and Becker Muscular Dystrophies. Muscle Nerve 2022; 65:521-530. [PMID: 35174514 DOI: 10.1002/mus.27522] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 02/04/2022] [Accepted: 02/12/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION/AIMS Serum cardiac troponin I (cTnI), its relation to cardiomyopathy, and the contribution of the ACTN3 genotype to serum levels of cTnI in Duchenne and Becker muscular dystrophy (DMD and BMD) remain unknown. This study aimed to reveal the characteristics of cTnI, assess whether cTnI is a biomarker for cardiomyopathy in these dystrophinopathies, and evaluate the contribution of the ACTN3 genotype to the serum levels of cTnI in DMD patients. METHODS Serum cTnI values obtained from 127 DMD and 47 BMD patients were retrospectively analyzed. The relationship between cTnI and echocardiography data or the ACTN3 XX genotype was assessed. RESULTS The cTnI levels and proportion of patients with abnormal cTnI levels were significantly higher among DMD patients than BMD, especially in the second decade of life. In DMD, the cTnI level reached a maximum at 13 years, and left ventricular ejection fraction (LVEF) became abnormal approximately 1 year subsequently. In BMD, the cTnI level peaked at the age of 14 years, and LVEF became abnormal 3 years later. Decreased LVEF was observed after cTnI elevation in both populations. cTnI levels by age in DMD patients with the ACTN3 XX genotype tended to increase significantly and early. DISCUSSION Myocardial injury indicated by cTnI elevation was more common and severe in DMD patients. cTnI elevation preceding cardiac dysfunction may represent an early phase of cardiomyopathy progression and may be a biomarker for early detection of cardiomyopathy in these dystrophinopathies. The ACTN3 XX genotype may be a risk factor for early myocardial injury. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hiroshi Yamaguchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Awano
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Yoshinori Nambu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan.,Director, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
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11
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Jariwala P, Jadhav K, Khetan S. Effectiveness and Safety of Sacubitril/Valsartan for Heart Failure with Reduced Ejection Fraction Secondary to Duchenne Muscular Dystrophy-Associated Cardiomyopathy. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2022. [DOI: 10.4103/jiae.jiae_17_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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12
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Cardiac Complications of Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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13
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Grigoratos C, Aimo A, Barison A, Castiglione V, Todiere G, Ricci G, Siciliano G, Emdin M. Cardiac magnetic resonance in patients with muscular dystrophies. Eur J Prev Cardiol 2021; 28:1526-1535. [PMID: 32418485 DOI: 10.1177/2047487320923052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/10/2020] [Indexed: 01/15/2023]
Abstract
Muscular dystrophies are inherited disorders sharing similar clinical features and dystrophic changes on muscle biopsy. Duchenne muscular dystrophy is the most common inherited muscle disease of childhood, and Becker muscular dystrophy is a milder allelic variant with a slightly lower prevalence. Myotonic dystrophy is the most frequent form in adults. Cardiac magnetic resonance is the gold standard technique for the quantification of cardiac chamber volumes and function, and also enables a characterisation of myocardial tissue. Most cardiac magnetic resonance studies in the setting of muscular dystrophy were carried out at single centres, evaluated small numbers of patients and used widely heterogeneous protocols. Even more importantly, those studies analysed more or less extensively the patterns of cardiac involvement, but usually did not try to establish the added value of cardiac magnetic resonance to standard echocardiography, the evolution of cardiac disease over time and the prognostic significance of cardiac magnetic resonance findings. As a result, the large and heterogeneous amount of information on cardiac involvement in muscular dystrophies cannot easily be translated into recommendations on the optimal use of cardiac magnetic resonance. In this review, whose targets are cardiologists and neurologists who manage patients with muscular dystrophy, we try to summarise cardiac magnetic resonance findings in patients with muscular dystrophy, and the results of studies evaluating the role of cardiac magnetic resonance as a tool for diagnosis, risk stratification and follow-up. Finally, we provide some practical recommendations about the need and timing of cardiac magnetic resonance examination for the management of patients with muscular dystrophy.
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Affiliation(s)
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | - Andrea Barison
- Fondazione Toscana Gabriele Monasterio, Italy
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | | | | | - Giulia Ricci
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Michele Emdin
- Fondazione Toscana Gabriele Monasterio, Italy
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
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14
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Szabo SM, Salhany RM, Deighton A, Harwood M, Mah J, Gooch KL. The clinical course of Duchenne muscular dystrophy in the corticosteroid treatment era: a systematic literature review. Orphanet J Rare Dis 2021; 16:237. [PMID: 34022943 PMCID: PMC8141220 DOI: 10.1186/s13023-021-01862-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/10/2021] [Indexed: 12/19/2022] Open
Abstract
Background Duchenne muscular dystrophy (DMD) is a severe rare progressive inherited neuromuscular disorder, leading to loss of ambulation (LOA) and premature mortality. The standard of care for patients with DMD has been treatment with corticosteroids for the past decade; however a synthesis of contemporary data describing the clinical course of DMD is lacking. The objective was to summarize age at key clinical milestones (loss of ambulation, scoliosis, ventilation, cardiomyopathy, and mortality) in the corticosteroid-treatment-era. Methods A systematic review was conducted using MEDLINE and EMBASE. The percentage experiencing key clinical milestones, and the mean or median age at those milestones, was synthesized from studies from North American populations, published between 2007 and 2018. Results From 5637 abstracts, 29 studies were included. Estimates of the percentage experiencing key clinical milestones, and age at those milestones, showed heterogeneity. Up to 30% of patients lost ambulation by age 10 years, and up to 90% by 15 years of age. The mean age at scoliosis onset was approximately 14 years. Ventilatory support began from 15 to 18 years, and up to half of patients required ventilation by 20 years of age. Registry-based estimates suggest that 70% had evidence of cardiomyopathy by 15 years and almost all by 20 years of age. Finally, mortality rates up to 16% by age 20 years were reported; among those surviving to adulthood mortality was up to 60% by age 30 years. Conclusions Contemporary natural history studies from North America report that LOA on average occurs in the early teens, need for ventilation and cardiomyopathy in the late teens, and death in the third or fourth decade of life. Variability in rates may be due to differences in study design, treatment with corticosteroids or other disease-modifying agents, variations in clinical practices, and dystrophin mutations. Despite challenges in synthesizing estimates, these findings help characterize disease progression among contemporary North American DMD patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01862-w.
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Affiliation(s)
- Shelagh M Szabo
- Broadstreet HEOR, 201 - 343 Railway St, Vancouver, BC, V6A 1A4, Canada.
| | - Renna M Salhany
- Sarepta Therapeutics, 215 First St, Cambridge, MA, 02142, USA
| | - Alison Deighton
- Broadstreet HEOR, 201 - 343 Railway St, Vancouver, BC, V6A 1A4, Canada
| | - Meagan Harwood
- Broadstreet HEOR, 201 - 343 Railway St, Vancouver, BC, V6A 1A4, Canada
| | - Jean Mah
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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15
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Bădilă E, Lungu II, Grumezescu AM, Scafa Udriște A. Diagnosis of Cardiac Abnormalities in Muscular Dystrophies. ACTA ACUST UNITED AC 2021; 57:medicina57050488. [PMID: 34066119 PMCID: PMC8151418 DOI: 10.3390/medicina57050488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 01/14/2023]
Abstract
Muscular disorders are mainly characterized by progressive skeletal muscle weakness. There are several aspects that can be monitored, which are used to differentiate between the types of muscular disorders, ranging from the targeted muscle up to the mutated gene. An aspect that holds critical importance when managing muscular dystrophies is that most of them exhibit cardiac abnormalities. Therefore, cardiac imaging is an essential part of muscular disorder monitoring and management. In the first section of the review, several cardiac abnormalities are introduced; afterward, different muscular dystrophies' pathogenesis is presented. Not all muscular dystrophies necessarily present cardiac involvement; however, the ones that do are linked with the cardiac abnormalities described in the first section. Moreover, studies from the last 3 years on muscular disorders are presented alongside imaging techniques used to determine cardiac abnormalities.
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Affiliation(s)
- Elisabeta Bădilă
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.B.); (A.S.U.)
- Internal Medicine Department, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania
| | - Iulia Ioana Lungu
- Faculty of Applied Chemistry and Materials Science, University Politehnica of Bucharest, 011061 Bucharest, Romania;
- Correspondence: ; Tel.: +40-21-402-39-97
| | - Alexandru Mihai Grumezescu
- Faculty of Applied Chemistry and Materials Science, University Politehnica of Bucharest, 011061 Bucharest, Romania;
- Research Institute of the University of Bucharest—ICUB, University of Bucharest, 050657 Bucharest, Romania
| | - Alexandru Scafa Udriște
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.B.); (A.S.U.)
- Cardiology Department, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania
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16
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Lee S, Lee M, Hor KN. The role of imaging in characterizing the cardiac natural history of Duchenne muscular dystrophy. Pediatr Pulmonol 2021; 56:766-781. [PMID: 33651923 DOI: 10.1002/ppul.25227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/19/2020] [Accepted: 11/12/2020] [Indexed: 01/11/2023]
Abstract
Duchene muscular dystrophy (DMD) is a rare but devastating disease resulting in progressive loss of ambulation, respiratory failure, DMD-associated cardiomyopathy (DMD-CM), and premature death. The use of corticosteroids and supportive respiratory care has improved outcomes, such that DMD-CM is now the leading cause of death. Historically, most programs have focused on skeletal myopathy with less attention to the cardiac phenotype. This omission is rather astonishing since patients with DMD possess an absolute genetic risk of developing cardiomyopathy. Unfortunately, heart failure signs and symptoms are vague due to skeletal muscle myopathy leading to limited ambulation. Traditional assessment of cardiac symptoms by the New York Heart Association American College of Cardiology/American Heart Association Staging (ACC/AHA) classification is of limited utility, even in advanced stages. Echocardiographic assessment can detect cardiac dysfunction late in the disease course, but this has proven to be a poor surrogate marker of early cardiovascular disease and an inadequate predictor of DMD-CM. Indeed, one explanation for the paucity of cardiac therapeutic trials for DMD-CM has been the lack of a suitable end-point. Improved outcomes require a better proactive treatment strategy; however, the barrier to treatment is the lack of a sensitive and specific tool to assess the efficacy of treatment. The use of cardiac imaging has evolved from echocardiography to cardiac magnetic resonance imaging to assess cardiac performance. The purpose of this article is to review the role of cardiac imaging in characterizing the cardiac natural history of DMD-CM, highlighting the prognostic implications and an outlook on how this field might evolve in the future.
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Affiliation(s)
- Simon Lee
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Marc Lee
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Kan N Hor
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
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17
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Kipke J, Birnkrant DJ, Jin JB, Aneja A, Bahler RC. A systematic review of pharmacologic therapies for the cardiomyopathy of Duchenne muscular dystrophy. Pediatr Pulmonol 2021; 56:782-795. [PMID: 33621446 DOI: 10.1002/ppul.25261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/09/2020] [Accepted: 12/29/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To perform a systematic review of studies evaluating pharmacologic therapies for the cardiomyopathy of Duchenne muscular dystrophy (DMD). METHODS PubMed, Google Scholar, and Embase were searched through October 8, 2020. Articles were selected using pre-determined criteria; 26 underwent detailed review by two co-authors. Study quality was assessed with the Newcastle-Ottawa scoring system (NOS); GRADE assessment evaluated their overall clinical importance. RESULTS There were few randomized controlled trials. Two of four trials of angiotensin converting enzyme inhibitors (ACEI) or ACEI plus beta-blockers (BB) found improved LV function. Two of two randomized trials of aldosterone antagonists (AA), when added to ACEI and BB therapy, demonstrated less decline of LV circumferential strain over 1 year of treatment. Observational studies of ACEI and BB had differing patient ages, symptomatology, cohort size, study duration and baseline heart function. LV function, assessed via unblinded imaging, was the most frequent outcome measure. LV dysfunction improved in some trials but was unconfirmed in others. Class IV heart failure patients had transient improvement of symptoms and LVEF. Most NOS scores reflected a low level of study quality. The Grade certainty rating, used for the summation of studies, was between "low" and "moderate." CONCLUSION Randomized trial evidence was inconsistent that either ACEI or BB or their combination improve LV function and/or alter progressive LV dysfunction. When ACEI and BB therapy are initiated for symptomatic Class IV heart failure, symptoms and LVEF improve transiently. AAs retard the rate of decline of LV function when initiated in younger DMD patients.
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Affiliation(s)
- Jasmine Kipke
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - David J Birnkrant
- Department of Pediatrics, Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Justin B Jin
- Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Pediatric Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ashish Aneja
- Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Robert C Bahler
- Case Western Reserve University School of Medicine at MetroHealth Medical Center, Cleveland, Ohio, USA
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18
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Abstract
Many neuromuscular disorders (NMD) are complicated by respiratory failure. These patients are best managed in a multidisciplinary outpatient clinic to provide timely access to the various disciplines they require. The key mainstay of treatment of respiratory failure in patients with NMD is noninvasive ventilation, supported by secretion clearance, speech and language therapy, optimisation of nutrition and the maintenance of mobility. Patients with specific conditions may also require cardiology, neurology, orthopaedics, urology and psychological services. The respiratory NMD multidisciplinary team should also provide access to palliative care, and caregiver health and wellbeing should also be reviewed at clinical reviews. The future of care for the respiratory NMD patient will increasingly involve home services and telehealth and the clinic should be equipped and resourced to deliver these. Although not all health systems will be able to provide all elements of the multidisciplinary team discussed here, this review provides the “ideal” recipe for the adult multidisciplinary team and the evidence base underpinning this from which a clinic can be developed. Care for neuromuscular-related respiratory failure is complex and is best delivered in a multidisciplinary context. The future will increasingly involve home services and telehealth, and their burden needs to be considered when establishing this service.https://bit.ly/33fNsMT
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Affiliation(s)
- Neeraj M Shah
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Patrick B Murphy
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Georgios Kaltsakas
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
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19
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Magrath P, Maforo N, Renella P, Nelson SF, Halnon N, Ennis DB. Cardiac MRI biomarkers for Duchenne muscular dystrophy. Biomark Med 2018; 12:1271-1289. [PMID: 30499689 PMCID: PMC6462870 DOI: 10.2217/bmm-2018-0125] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is a fatal inherited genetic disorder that results in progressive muscle weakness and ultimately loss of ambulation, respiratory failure and heart failure. Cardiac MRI (MRI) plays an increasingly important role in the diagnosis and clinical care of boys with DMD and associated cardiomyopathies. Conventional cardiac MRI biomarkers permit measurements of global cardiac function and presence of fibrosis, but changes in these measures are late manifestations. Emerging MRI biomarkers of myocardial function and structure include the estimation of rotational mechanics and regional strain using MRI tagging; T1-mapping; and T2-mapping, a marker of inflammation, edema and fat. These emerging biomarkers provide earlier insights into cardiac involvement in DMD, improving patient care and aiding the evaluation of emerging therapies.
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Affiliation(s)
- Patrick Magrath
- Department of Radiological Sciences, University of California, Los Angeles, CA 90024, USA.,Department of Bioengineering, University of California, Los Angeles, CA 90095, USA
| | - Nyasha Maforo
- Department of Radiological Sciences, University of California, Los Angeles, CA 90024, USA.,Physics & Biology in Medicine IDP, University of California, Los Angeles, CA 90095, USA
| | - Pierangelo Renella
- Department of Radiological Sciences, University of California, Los Angeles, CA 90024, USA.,Department of Medicine, Division of Pediatric Cardiology, CHOC Children's Hospital, Orange, CA 92868, USA
| | - Stanley F Nelson
- Center for Duchenne Muscular Dystrophy, Department of Human Genetics, University of California, Los Angeles, CA 90095, USA
| | - Nancy Halnon
- Department of Radiological Sciences, University of California, Los Angeles, CA 90024, USA.,Department of Medicine, Division of Pediatric Cardiology, University of California, Los Angeles, CA 90024, USA
| | - Daniel B Ennis
- Department of Radiological Sciences, University of California, Los Angeles, CA 90024, USA.,Department of Bioengineering, University of California, Los Angeles, CA 90095, USA.,Physics & Biology in Medicine IDP, University of California, Los Angeles, CA 90095, USA
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20
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Buddhe S, Cripe L, Friedland-Little J, Kertesz N, Eghtesady P, Finder J, Hor K, Judge DP, Kinnett K, McNally EM, Raman S, Thompson WR, Wagner KR, Olson AK. Cardiac Management of the Patient With Duchenne Muscular Dystrophy. Pediatrics 2018; 142:S72-S81. [PMID: 30275251 PMCID: PMC6566852 DOI: 10.1542/peds.2018-0333i] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 12/11/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) results in a progressive cardiomyopathy that produces significant morbidity and mortality. To improve the quality of life in patients with DMD, cardiac care is focused on surveillance and management, with the goal of slowing the onset and progression of heart failure complications. The current article is intended to be an expanded review on the cardiac management data used to inform the 2018 DMD Care Considerations recommendations as well as be a discussion on clinical controversies and future management directions. The new cardiac guidance includes changes regarding noninvasive imaging surveillance of cardiac function and pharmacologic therapy. Many emerging therapies lack sufficient evidence-based data to be recommended in the 2018 DMD Care Considerations. These are discussed in the present article as clinical controversies and future directions. Important emerging therapies include new heart failure medications, mechanical circulatory support with ventricular assist devices, heart transplantation, and internal cardiac defibrillators. Future research studies should be focused on the risks and benefits of these advanced therapies in patients with DMD. We conclude this review with a brief discussion on the relationship between the heart and the recently developed medications that are used to directly target the absence of dystrophin in DMD.
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Affiliation(s)
- Sujatha Buddhe
- Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Linda Cripe
- Nationwide Children’s Hospital, Columbus, Ohio;,The Ohio State University, Columbus, Ohio
| | - Joshua Friedland-Little
- Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Naomi Kertesz
- Nationwide Children’s Hospital, Columbus, Ohio;,The Ohio State University, Columbus, Ohio
| | - Pirooz Eghtesady
- St Louis Children’s Hospital and School of Medicine, Washington University, St Louis, Missouri
| | - Jonathan Finder
- Children’s Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kan Hor
- Nationwide Children’s Hospital, Columbus, Ohio;,The Ohio State University, Columbus, Ohio
| | - Daniel P. Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Kathi Kinnett
- Parent Project Muscular Dystrophy, Hackensack, New Jersey
| | | | | | | | - Kathryn R. Wagner
- Kennedy Krieger institute, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Aaron K. Olson
- Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
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21
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Shrader SM, Jung S, Denney TS, Smith BF. Characterization of Australian Labradoodle dystrophinopathy. Neuromuscul Disord 2018; 28:927-937. [PMID: 30286978 DOI: 10.1016/j.nmd.2018.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 08/05/2018] [Accepted: 08/23/2018] [Indexed: 12/22/2022]
Abstract
In humans, dystrophin mutations cause the X-linked recessive disorder known as Duchenne muscular dystrophy (DMD). These mutations result in skeletal and cardiac muscle damage with mortality increasingly associated with cardiomyopathy. We have identified a novel dystrophin mutation in exon 21 in a line of Australian Labradoodles; affected dogs develop progressive clinical signs including poor weight gain and weight loss, gait abnormalities, exercise intolerance, skeletal muscle atrophy, macroglossa, ptyalism, dysphagia, kyphosis, and a plantigrade stance. Echocardiographic abnormalities include hyperechoic foci in the left ventricular papillary muscles, septal hypokinesis, and decreased left ventricular systolic and diastolic volume and internal diameter. Holter recordings found a Mobitz type II second-degree atrioventricular (AV) block in one affected dog. Analysis of phosphocreatine-to-ATP ratios (PCr/ATP) (obtained via cardiac magnetic resonance imaging and spectroscopy evaluation), found no statistically significant difference in the mean PCr/ATP between groups. Histopathologic skeletal muscle changes included fibrofatty infiltration, myocyte degeneration, necrosis, and regeneration, lymphohistiocytic inflammation, and mineralization; cardiac changes were limited to a focal area of mineralization adjacent to the sinoatrial node in the dog with a second-degree AV block. Due to rapidly progressive clinical signs, a severe phenotype, and potential for cardiac involvement, Australian Labradoodle dystrophinopathy may be a useful model to further study DMD pathogenesis.
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Affiliation(s)
- Stephanie M Shrader
- Department of Pathobiology, Auburn University College of Veterinary Medicine, Auburn, AL 36849, USA.
| | - SeungWoo Jung
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, AL 36849, USA
| | - Thomas S Denney
- Department of Electrical and Computer Engineering, Auburn University, Auburn, AL 36849, USA; Auburn University MRI Research Center, Auburn, AL 36849, USA
| | - Bruce F Smith
- Department of Pathobiology, Auburn University College of Veterinary Medicine, Auburn, AL 36849, USA; Scott-Ritchey Research Center, Auburn University College of Veterinary Medicine, Auburn, AL 36849, USA
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22
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Hor KN, Mah ML, Johnston P, Cripe TP, Cripe LH. Advances in the diagnosis and management of cardiomyopathy in Duchenne muscular dystrophy. Neuromuscul Disord 2018; 28:711-716. [PMID: 30064893 DOI: 10.1016/j.nmd.2018.06.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 02/07/2023]
Abstract
Patients with Duchenne muscular dystrophy suffer debilitating muscle destruction, resulting in loss of ambulation, diminished respiratory function, gastrointestinal disturbances and cardiomyopathy. Although it is the most common cause of death in these patients, cardiomyopathy is poorly understood in terms of distinct pathogenesis, natural history, and specific, effective therapeutic interventions. We review the state-of-the-art knowledge of Duchenne muscular dystrophy-associated cardiomyopathy including clinical evaluation, imaging, medical and perioperative management, and prospects for gene therapy. We also review cardiomyopathy in heterozygote carriers. By describing our current understanding and best practices, we hope to improve harmonization of care across institutions and identify collective knowledge gaps to guide future research efforts.
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Affiliation(s)
- Kan N Hor
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - May Ling Mah
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Pace Johnston
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Timothy P Cripe
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Linda H Cripe
- The Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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23
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Power LC, O'Grady GL, Hornung TS, Jefferies C, Gusso S, Hofman PL. Imaging the heart to detect cardiomyopathy in Duchenne muscular dystrophy: A review. Neuromuscul Disord 2018; 28:717-730. [PMID: 30119965 DOI: 10.1016/j.nmd.2018.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 05/24/2018] [Accepted: 05/29/2018] [Indexed: 01/16/2023]
Abstract
Duchenne Muscular Dystrophy is the most common paediatric neuromuscular disorder. Mutations in the DMD gene on the X-chromosome result in progressive skeletal muscle weakness as the main clinical manifestation. However, cardiac muscle is also affected, with cardiomyopathy becoming an increasingly recognised cause of morbidity, and now the leading cause of mortality in this group. The diagnosis of cardiomyopathy has often been made late due to technical limitations in transthoracic echocardiograms and delayed symptomatology in less mobile patients. Increasingly, evidence supports earlier pharmacological intervention in cardiomyopathy to improve outcomes. However, the optimal timing of initiation remains uncertain, and the benefits of prophylactic therapy are unproven. Current treatment guidelines suggest initiation of therapy once cardiac dysfunction is detected. This review focuses on new and evolving techniques for earlier detection of Duchenne muscular dystrophy-associated cardiomyopathy. Transthoracic echocardiography or cardiac magnetic resonance imaging performed under physiological stress (dobutamine or exercise), can unmask early cardiac dysfunction. Cardiac magnetic resonance imaging can define cardiac function with greater accuracy and reliability than an echocardiogram, and is not limited by body habitus. Improved imaging techniques, used in a timely fashion, offer the potential for early detection of cardiomyopathy and improved long-term outcomes.
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Affiliation(s)
- Lisa C Power
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand; Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gina L O'Grady
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand.
| | - Tim S Hornung
- Paediatric Cardiology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Craig Jefferies
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Silmara Gusso
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Paul L Hofman
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
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24
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Kamimura D, Cain LR, Mentz RJ, White WB, Blaha MJ, DeFilippis AP, Fox ER, Rodriguez CJ, Keith RJ, Benjamin EJ, Butler J, Bhatnagar A, Robertson RM, Winniford MD, Correa A, Hall ME. Cigarette Smoking and Incident Heart Failure: Insights From the Jackson Heart Study. Circulation 2018; 137:2572-2582. [PMID: 29661945 DOI: 10.1161/circulationaha.117.031912] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/15/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cigarette smoking has been linked with several factors associated with cardiac dysfunction. We hypothesized that cigarette smoking is associated with left ventricular (LV) structure and function, and incident heart failure (HF) hospitalization. METHODS We investigated 4129 (never smoker n=2884, current smoker n=503, and former smoker n=742) black participants (mean age, 54 years; 63% women) without a history of HF or coronary heart disease at baseline in the Jackson Heart Study. We examined the relationships between cigarette smoking and LV structure and function by using cardiac magnetic resonance imaging among 1092 participants, cigarette smoking and brain natriuretic peptide levels among 3325 participants, and incident HF hospitalization among 3633 participants with complete data. RESULTS After adjustment for confounding factors, current smoking was associated with higher mean LV mass index and lower mean LV circumferential strain (P<0.05, for both) in comparison with never smoking. Smoking status, intensity, and burden were associated with higher mean brain natriuretic peptide levels (all P<0.05). Over 8.0 years (7.7-8.0) median follow-up, there were 147 incident HF hospitalizations. After adjustment for traditional risk factors and incident coronary heart disease, current smoking (hazard ratio, 2.82; 95% confidence interval, 1.71-4.64), smoking intensity among current smokers (≥20 cigarettes/d: hazard ratio, 3.48; 95% confidence interval, 1.65-7.32), and smoking burden among ever smokers (≥15 pack-years: hazard ratio, 2.06; 95% confidence interval, 1.29-3.3) were significantly associated with incident HF hospitalization in comparison with never smoking. CONCLUSIONS In blacks, cigarette smoking is an important risk factor for LV hypertrophy, systolic dysfunction, and incident HF hospitalization even after adjusting for effects on coronary heart disease.
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Affiliation(s)
- Daisuke Kamimura
- Department of Medicine (D.K., E.R.F., J.B., M.D.W., A.C., M.E.H.)
| | - Loretta R Cain
- Department of Data Sciences (L.R.C.), University of Mississippi Medical Center, Jackson
| | - Robert J Mentz
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC (R.J.M.)
| | - Wendy B White
- Tougaloo College, MS (W.B.W.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease and Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (M.J.B.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Andrew P DeFilippis
- Division of Cardiovascular Medicine, University of Louisville, KY (A.P.D., A.B.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Ervin R Fox
- Department of Medicine (D.K., E.R.F., J.B., M.D.W., A.C., M.E.H.)
| | - Carlos J Rodriguez
- Department of Medicine and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (C.J.R.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Rachel J Keith
- Diabetes and Obesity Center, University of Louisville School of Medicine, KY (R.J.K., A.B.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Emelia J Benjamin
- Department of Medicine, Boston University School of Medicine and Department of Epidemiology, Boston University School of Public Health, MA (E.J.B.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Javed Butler
- Department of Medicine (D.K., E.R.F., J.B., M.D.W., A.C., M.E.H.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Aruni Bhatnagar
- Division of Cardiovascular Medicine, University of Louisville, KY (A.P.D., A.B.).,Diabetes and Obesity Center, University of Louisville School of Medicine, KY (R.J.K., A.B.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Rose M Robertson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (R.M.R.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Michael D Winniford
- Department of Medicine (D.K., E.R.F., J.B., M.D.W., A.C., M.E.H.).,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
| | - Adolfo Correa
- Department of Medicine (D.K., E.R.F., J.B., M.D.W., A.C., M.E.H.)
| | - Michael E Hall
- Department of Medicine (D.K., E.R.F., J.B., M.D.W., A.C., M.E.H.) .,American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX (W.B.W., M.J.B., A.P.D., C.J.R., R.J.K., E.J.B., J.B., A.B., R.M.R., M.D.W., M.E.H.)
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Danilov VV, Skirnevskiy IP, Gerget OM, Shelomentcev EE, Kolpashchikov DY, Vasilyev NV. Efficient workflow for automatic segmentation of the right heart based on 2D echocardiography. Int J Cardiovasc Imaging 2018; 34:1041-1055. [PMID: 29428969 DOI: 10.1007/s10554-018-1314-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 02/02/2018] [Indexed: 12/01/2022]
Abstract
The present study aimed to present a workflow algorithm for automatic processing of 2D echocardiography images. The workflow was based on several sequential steps. For each step, we compared different approaches. Epicardial 2D echocardiography datasets were acquired during various open-chest beating-heart surgical procedures in three porcine hearts. We proposed a metric called the global index that is a weighted average of several accuracy coefficients, indices and the mean processing time. This metric allows the estimation of the speed and accuracy for processing each image. The global index ranges from 0 to 1, which facilitates comparison between different approaches. The second step involved comparison among filtering, sharpening and segmentation techniques. During the noise reduction step, we compared the median filter, total variation filter, bilateral filter, curvature flow filter, non-local means filter and mean shift filter. To clarify the endocardium borders of the right heart, we used the linear sharpen. Lastly, we applied watershed segmentation, clusterisation, region-growing, morphological segmentation, image foresting segmentation and isoline delineation. We assessed all the techniques and identified the most appropriate workflow for echocardiography image segmentation of the right heart. For successful processing and segmentation of echocardiography images with minimal error, we found that the workflow should include the total variation filter/bilateral filter, linear sharpen technique, isoline delineation/region-growing segmentation and morphological post-processing. We presented an efficient and accurate workflow for the precise diagnosis of cardiovascular diseases. We introduced the global index metric for image pre-processing and segmentation estimation.
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Affiliation(s)
- Viacheslav V Danilov
- Medical Devices Design Laboratory, RASA Center in Tomsk, Tomsk Polytechnic University, Tomsk, Russia
| | - Igor P Skirnevskiy
- Medical Devices Design Laboratory, RASA Center in Tomsk, Tomsk Polytechnic University, Tomsk, Russia
| | - Olga M Gerget
- Medical Devices Design Laboratory, RASA Center in Tomsk, Tomsk Polytechnic University, Tomsk, Russia
| | - Egor E Shelomentcev
- Medical Devices Design Laboratory, RASA Center in Tomsk, Tomsk Polytechnic University, Tomsk, Russia
| | - Dmitrii Yu Kolpashchikov
- Medical Devices Design Laboratory, RASA Center in Tomsk, Tomsk Polytechnic University, Tomsk, Russia
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Boivin A, Antonelli R, Sethna NF. Perioperative management of gastrostomy tube placement in Duchenne muscular dystrophy adolescent and young adult patients: A role for a perioperative surgical home. Paediatr Anaesth 2018; 28:127-133. [PMID: 29205678 DOI: 10.1111/pan.13295] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND In past decades, Duchenne muscular dystrophy patients have been living longer and as the disease advances, patients experience multisystemic deterioration. Older patients often require gastrostomy tube placement for nutritional support. For optimizing the perioperative care, a practice of multidisciplinary team can better anticipate, prevent, and manage possible complications and reduce the overall perioperative morbidity and mortality. AIMS The aim of this study was to review our experience with perioperative care of adolescent and young adults with Duchenne muscular dystrophy undergoing gastrostomy by various surgical approaches in order to identify challenges and improve future perioperative care coordination to reduce morbidity. METHODS We retrospectively examined cases of gastrostomy tube placement in patients of ages 15 years and older between 2005 and 2016. We reviewed preoperative evaluation, anesthetic and surgical management, and postoperative complications. RESULTS Twelve patients were identified; 1 had open gastrostomy, 3 laparoscopic gastrostomies, 5 percutaneous endoscopic guided, and 3 radiologically inserted gastrostomy tubes. All patients had preoperative cardiac evaluation with 6 patients demonstrating cardiomyopathy. Nine patients had preoperative pulmonary consultations and the pulmonary function tests reported forced vital capacity of ≤36% of predicted. Eight patients were noninvasive positive pressure ventilation dependent. General anesthesia with tracheal intubation was administered in 8 patients, and intravenous sedation in 4 patients; 1 received sedation supplemented with regional anesthesia and 3 received deep sedation. One patient had a difficult intubation that resulted in trauma and prolonged tracheal intubation. Three patients developed postoperative respiratory complications. Two patients' procedures were postponed due to inadequate preoperative evaluation and 1 because of disagreement between anesthesia and procedural services as to the optimal approach for airway management. CONCULSION Optimal management of the perioperative care of Duchenne muscular dystrophy patients requires input from relevant medical specialists, proceduralist and anesthesiologist. This complexity of care coordination presents an opportunity for anesthesiologists to lead a collaborative perioperative team in management of advanced Duchenne patients coming for gastrostomy.
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Affiliation(s)
- Ariane Boivin
- Department of Anesthesiology, CHUL - Centre Mère-Enfant du CHU de Québec, Québec City, QC, Canada
| | - Richard Antonelli
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Navil F Sethna
- Department of Anesthesiology, Pain and Perioperative Medicine, Boston Children's Hospital, Boston, MA, USA
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Mavrogeni S, Papavasiliou A, Giannakopoulou K, Markousis-Mavrogenis G, Pons MR, Karanasios E, Nikas I, Papadopoulos G, Kolovou G, Chrousos GP. Oedema-fibrosis in Duchenne Muscular Dystrophy: Role of cardiovascular magnetic resonance imaging. Eur J Clin Invest 2017; 47. [PMID: 29027210 DOI: 10.1111/eci.12843] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 10/09/2017] [Indexed: 12/13/2022]
Abstract
Duchenne muscular dystrophy (DMD) is an X-linked muscle disorder characterized by progressive, irreversible loss of cardiac and skeletal muscular function. Muscular enlargement in DMD is attributed to oedema, due to the increased cytoplasmic Na+ concentration. The aim of this review was to present the current experience and emphasize the role of cardiovascular magnetic resonance (CMR) in the diagnosis of this condition. DMD patients' survival depends on ventilatory assistance, as respiratory muscle dysfunction was the most common cause of death in the past. Currently, due to improved ventilatory assistance, cardiomyopathy has become the main cause of death, even though clinically overt heart failure may be absent. CMR is the technique of choice to assess the pathophysiologic phenomena taking place in DMD, such as myocardial oedema and subepicardial fibrosis. The classic index to assess oedema is the T2-weighted short-tau inversion recovery (T2w-STIR), as it suppresses the signal from flowing blood and resident fat and enhances sensitivity to tissue fluid. Furthermore, CMR is the most reliable technique to detect and quantify fibrosis in DMD. Recently, the new indices T2, T1 mapping (native and postcontrast) and the extracellular volume (ECV) allow a more accurate approach of myocardial oedema and fibrosis. To conclude, the assessment of cardiac oedema and subepicardial fibrosis in the inferolateral wall of the left heart ventricle are the most important early finding in DMD with preserved ventricular function, and CMR, using both the classic and the new indices, is the best technique to detect and monitor these lesions.
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Affiliation(s)
| | | | - Katerina Giannakopoulou
- First Dept of Paediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | | | - Maria Roser Pons
- First Dept of Paediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Evangelos Karanasios
- First Dept of Paediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Ioannis Nikas
- First Dept of Paediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - George Papadopoulos
- First Dept of Paediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | | | - George P Chrousos
- First Dept of Paediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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Feingold B, Mahle WT, Auerbach S, Clemens P, Domenighetti AA, Jefferies JL, Judge DP, Lal AK, Markham LW, Parks WJ, Tsuda T, Wang PJ, Yoo SJ. Management of Cardiac Involvement Associated With Neuromuscular Diseases: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e200-e231. [DOI: 10.1161/cir.0000000000000526] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Cardiac profile of asymptomatic children with Becker and Duchenne muscular dystrophy under treatment with steroids and with/without perindopril. BMC Cardiovasc Disord 2017; 17:197. [PMID: 28738778 PMCID: PMC5525273 DOI: 10.1186/s12872-017-0627-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/12/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To evaluate cardiovascular function in boys with Duchenne (DMD) and Becker (BMD) muscular dystrophy, using cardiac magnetic resonance (CMR). METHODS This is a single point cross sectional study of twenty-four boys with genetically ascertained DMD, and 10 with BMD, aged 10.5 ± 1.5 years (range 9-13), were prospectively evaluated by a 1.5 T system and compared with those of age-sex matched controls. The DMD patients were divided in 2 groups. Group A (N = 12) were under treatment with both deflazacort and perindopril, while Group B (n = 12) were under treatment with deflazacort, only. BMD patients did not take any medication. Biventricular function was assessed using a standard SSFP sequence. Late gadolinium enhancement (LGE) was assessed from T1 images taken 15 min after injection of 0.2 mg/Kg gadolinium DTPA using a 3D-T1-TFE sequence. RESULTS Group A and BMDs were asymptomatic with normal ECG, 24 h ECG recording and echocardiogram. Group B were asymptomatic but 6/12 had abnormal ECG and mildly impaired LVEF. Their 24 h ECG recording revealed supraventricular and ventricular extrasystoles (all at 12-13 yrs). LV indices in Group A and BMD did not differ from those of controls. However, LV indices in Group B were significantly impaired compared with controls, Group A and BMDs (p < 0.001). An epicardial LGE area = 3 ± 0.5% of LV mass was identified in the posterolateral wall of LV only in 6/12 patients of Group B, but in not in any BMD or Group A. CONCLUSION Children with either BMD or DMD under treatment with both deflazacort and perindopril present preserved LV function and lack of LGE. However, further large scale multicenter studies are warranted to confirm these data, including further CMR mapping approaches.
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McKane M, Soslow JH, Xu M, Saville BR, Slaughter JC, Burnette WB, Markham LW. Does Body Mass Index Predict Premature Cardiomyopathy Onset for Duchenne Muscular Dystrophy? J Child Neurol 2017; 32:499-504. [PMID: 28084148 PMCID: PMC5352486 DOI: 10.1177/0883073816687422] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Duchenne muscular dystrophy leads to cardiomyopathy. The objective of this study was to estimate the association of body mass index with cardiomyopathy onset. Cardiomyopathy was defined as left ventricular ejection fraction <55% or left ventricular fractional shortening <28%. Overall, 48% met the criteria for cardiomyopathy. We were unable to demonstrate an association between body mass index Z score and age of cardiomyopathy onset (hazard ratio 0.79, 95% confidence interval 0.57-1.11, P = .17) after adjusting for covariates. Duration of corticosteroid use ( P = .01), but not loss of ambulatory ability ( P = .47), was associated with age of cardiomyopathy onset. We were unable to detect a significant difference in median body mass index Z scores in corticosteroid-treated boys compared with corticosteroid-naïve boys (1.11, 95% confidence interval 0.25-1.95, vs 1.05, 95% confidence interval 0.01-1.86, P = .69). No association was detected between the body mass index Z scores of Duchenne muscular dystrophy subjects and age of cardiomyopathy onset.
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Affiliation(s)
- Meghann McKane
- 1 Thomas P. Graham Division of Pediatric Cardiology Monroe Carell Jr Children's Hospital at Vanderbilt University, Nashville, TN, USA
| | - Jonathan H Soslow
- 1 Thomas P. Graham Division of Pediatric Cardiology Monroe Carell Jr Children's Hospital at Vanderbilt University, Nashville, TN, USA
| | - Meng Xu
- 2 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Benjamin R Saville
- 2 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - James C Slaughter
- 2 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - W Bryan Burnette
- 3 Division of Neurology, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Larry W Markham
- 1 Thomas P. Graham Division of Pediatric Cardiology Monroe Carell Jr Children's Hospital at Vanderbilt University, Nashville, TN, USA
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Comparison of left ventricular function assessment between echocardiography and MRI in Duchenne muscular dystrophy. Pediatr Radiol 2016; 46:1399-408. [PMID: 27173979 DOI: 10.1007/s00247-016-3622-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/23/2016] [Accepted: 03/30/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cardiomyopathy in Duchenne muscular dystrophy (DMD) is associated with death in approximately 40% of patients. Echocardiography is routinely used to assess left ventricular (LV) function; however, it has limitations in these patients. OBJECTIVE We compared echocardiographic measures of cardiac function assessment to cardiac MRI. MATERIALS AND METHODS We included children and young adults with DMD who had MRI performed between January 2010 and July 2015. We measured echocardiographic and MRI parameters of function assessment, including strain. Presence of late gadolinium enhancement (LGE) was assessed by MRI. Subjects were divided into two groups based on MRI left ventricular ejection fraction (LVEF): group I, LVEF ≥55% and group II, LVEF <55%. RESULTS We included 41 studies in 33 subjects, with 25 in group I and 16 in group II. Mean age of subjects was 13.6 ± 2.8 years and mean duration between echocardiogram and MRI was 7.6 ± 4.1 months. Only 8 of 16 (50%) patients in group II had diminished function on echocardiogram. Echocardiographic images were suboptimal in 16 subjects (39%). Overall, echocardiographic parameters had weak correlation with MRI-derived ejection fraction percentage. MRI-derived myocardial strain assessment has better correlation with MRI ejection fraction as compared to echocardiography-derived strain parameters. CONCLUSION Echocardiography-based ventricular functional assessment has weak correlation with MRI parameters in children and young adults with Duchenne muscular dystrophy. While this correlation improves in the subset of subjects with adequate echocardiographic image quality, it remains modest and potentially suboptimal for clinical management. Accordingly, we conclude that MRI should be performed routinely and early in children with DMD, not only for LGE imaging but also for functional assessment.
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Soslow JH, Xu M, Slaughter JC, Stanley M, Crum K, Markham LW, Parra DA. Evaluation of Echocardiographic Measures of Left Ventricular Function in Patients with Duchenne Muscular Dystrophy: Assessment of Reproducibility and Comparison to Cardiac Magnetic Resonance Imaging. J Am Soc Echocardiogr 2016; 29:983-991. [PMID: 27544870 DOI: 10.1016/j.echo.2016.07.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Patients with Duchenne muscular dystrophy (DMD) require frequent imaging to assess left ventricular (LV) function. Poor imaging windows can limit the diagnostic utility of echocardiography. Cardiac magnetic resonance imaging (CMR) is the gold standard for the assessment of LV function but has not been universally adopted in patients with DMD. The study objectives were (1) to evaluate the reproducibility of echocardiographic measures of LV function, (2) to evaluate which echocardiographic methods correlate best with CMR LV ejection fraction (LVEF), and (3) to evaluate whether CMR provides additional value compared with echocardiography. METHODS Twenty-eight participants with DMD prospectively underwent echocardiography and CMR. Two blinded readers measured fractional shortening from M-mode and two-dimensional images and LVEF using four-chamber, biplane Simpson, 5/6 area-length, and three-dimensional methods. Speckle-tracking echocardiography was used to analyze circumferential strain. Readers subjectively rated function and segmental wall motion. Agreement was assessed using intraclass correlation coefficients, Bland-Altman plots, Spearman correlation, and weighted κ. RESULTS Two-dimensional fractional shortening and 5/6 area-length LVEF had the best combination of reproducibility and correlation with CMR LVEF, though both misclassified approximately 20% as either normal or abnormal function. Other measures of LV function were less reproducible, with worse correlations with CMR LVEF. Thirty-seven percent of segments not visible on echocardiography were believed to have wall motion abnormalities by CMR. CONCLUSIONS Two-dimensional fractional shortening and 5/6 area-length LVEF represent the most accurate and reproducible echocardiographic measures of LV function in patients with DMD. CMR should be considered when neither of these techniques is measurable or when it is necessary to detect more subtle cardiovascular changes.
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Affiliation(s)
- Jonathan H Soslow
- Thomas P. Graham Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Stanley
- Thomas P. Graham Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kimberly Crum
- Thomas P. Graham Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Larry W Markham
- Thomas P. Graham Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A Parra
- Thomas P. Graham Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Circulating miRNAs are generic and versatile therapeutic monitoring biomarkers in muscular dystrophies. Sci Rep 2016; 6:28097. [PMID: 27323895 PMCID: PMC4914855 DOI: 10.1038/srep28097] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/26/2016] [Indexed: 12/29/2022] Open
Abstract
The development of medical approaches requires preclinical and clinical trials for assessment of therapeutic efficacy. Such evaluation entails the use of biomarkers, which provide information on the response to the therapeutic intervention. One newly-proposed class of biomarkers is the microRNA (miRNA) molecules. In muscular dystrophies (MD), the dysregulation of miRNAs was initially observed in muscle biopsy and later extended to plasma samples, suggesting that they may be of interest as biomarkers. First, we demonstrated that dystromiRs dysregulation occurs in MD with either preserved or disrupted expression of the dystrophin-associated glycoprotein complex, supporting the utilization of dystromiRs as generic biomarkers in MD. Then, we aimed at evaluation of the capacity of miRNAs as monitoring biomarkers for experimental therapeutic approach in MD. To this end, we took advantage of our previously characterized gene therapy approach in a mouse model for α-sarcoglycanopathy. We identified a dose-response correlation between the expression of miRNAs on both muscle tissue and blood serum and the therapeutic benefit as evaluated by a set of new and classically-used evaluation methods. This study supports the utility of profiling circulating miRNAs for the evaluation of therapeutic outcome in medical approaches for MD.
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Finsterer J, Stöllberger C. Heart Disease in Disorders of Muscle, Neuromuscular Transmission, and the Nerves. Korean Circ J 2016; 46:117-34. [PMID: 27014341 PMCID: PMC4805555 DOI: 10.4070/kcj.2016.46.2.117] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/30/2015] [Accepted: 11/24/2015] [Indexed: 12/31/2022] Open
Abstract
Little is known regarding cardiac involvement (CI) by neuromuscular disorders (NMDs). The purpose of this review is to summarise and discuss the major findings concerning the types, frequency, and severity of cardiac disorders in NMDs as well as their diagnosis, treatment, and overall outcome. CI in NMDs is characterized by pathologic involvement of the myocardium or cardiac conduction system. Less commonly, additional critical anatomic structures, such as the valves, coronary arteries, endocardium, pericardium, and even the aortic root may be involved. Involvement of the myocardium manifests most frequently as hypertrophic or dilated cardiomyopathy and less frequently as restrictive cardiomyopathy, non-compaction, arrhythmogenic right-ventricular dysplasia, or Takotsubo-syndrome. Cardiac conduction defects and supraventricular and ventricular arrhythmias are common cardiac manifestations of NMDs. Arrhythmias may evolve into life-threatening ventricular tachycardias, asystole, or even sudden cardiac death. CI is common and carries great prognostic significance on the outcome of dystrophinopathies, laminopathies, desminopathies, nemaline myopathy, myotonias, metabolic myopathies, Danon disease, and Barth-syndrome. The diagnosis and treatment of CI in NMDs follows established guidelines for the management of cardiac disease, but cardiotoxic medications should be avoided. CI in NMDs is relatively common and requires complete work-up following the establishment of a neurological diagnosis. Appropriate cardiac treatment significantly improves the overall long-term outcome of NMDs.
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Affiliation(s)
| | - Claudia Stöllberger
- 2 Medical Department with Cardiology and Intensive Care Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Posner AD, Soslow JH, Burnette WB, Bian A, Shintani A, Sawyer DB, Markham LW. The Correlation of Skeletal and Cardiac Muscle Dysfunction in Duchenne Muscular Dystrophy. J Neuromuscul Dis 2016; 3:91-99. [PMID: 27182492 DOI: 10.3233/jnd-150132] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is characterized by progressive skeletal muscle and cardiac dysfunction. While skeletal muscle dysfunction precedes cardiomyopathy, the relationship between the progressive decline in skeletal and cardiac muscle function is unclear. This relationship is especially important given that the myocardial effects of many developing DMD therapies are largely unknown. OBJECTIVE Our objective was to assess the relationship between progression of skeletal muscle weakness and onset of cardiac dysfunction in DMD. METHODS A total of 77 DMD subjects treated at a single referral center were included. Demographic information, quantitative muscle testing (QMT), subjective muscle strength, cardiac function, and current and retrospective medications were collected. A Spearman rank correlation was used to evaluate for an association between subjective strength and fractional shortening. The effects of total QMT and arm QMT on fractional shortening were examined in generalized least square with and without adjustments for age, ambulatory status, and duration of corticosteroids and cardiac specific medications. RESULTS We found a significant correlation between maintained subjective skeletal muscle arm and leg strength and maintained cardiac function as defined by fractional shortening (rho=0.47, p=0.004 and rho=0.48, p=0.003, respectively). We also found a significant association between QMT and fractional shortening among non-ambulatory DMD subjects (p=0.03), while this association was not significant in ambulatory subjects. CONCLUSIONS Our findings allow us to conclude that in this population, there exists a significant relationship between skeletal muscle and cardiac function in non-ambulatory DMD patients. While this does not imply a causal relationship, a possible association between skeletal and cardiac muscle function suggests that researchers should carefully monitor cardiac function, even when the primary outcome measures are not cardiac in nature.
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Affiliation(s)
| | - Jonathan H Soslow
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, United States
| | - W Bryan Burnette
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Douglas B Sawyer
- Department of Medicine, Division of Cardiovascular Services, Maine Medical Center, Portland, ME, United States
| | - Larry W Markham
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, 2200 Children's Way, Suite 5230 DOT, Nashville, TN, United States
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Zuberi SM. Editorial note. Eur J Paediatr Neurol 2015; 19:389. [PMID: 26043359 DOI: 10.1016/j.ejpn.2015.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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