Sequential evaluation of left ventricular myocardial performance in children after anthracycline therapy

Acute and early-onset cardiotoxicity in children and adolescents with cancer: a systematic review

BACKGROUND

Cardiotoxicity is among the most important adverse effects of childhood cancer treatment. Anthracyclines, mitoxantrone and radiotherapy involving the heart are its main causes. Subclinical cardiac dysfunction may over time progress to clinical heart failure. The majority of previous studies have focused on late-onset cardiotoxicity. In this systematic review, we discuss the prevalence and risk factors for acute and early-onset cardiotoxicity in children and adolescents with cancer treated with anthracyclines, mitoxantrone or radiotherapy involving the heart.

METHODS

A literature search was performed within PubMed and reference lists of relevant studies. Studies were eligible if they reported on cardiotoxicity measured by clinical, echocardiographic and biochemical parameters routinely used in clinical practice during or within one year after the start of cancer treatment in ≥ 25 children and adolescents with cancer. Information about study population, treatment, outcomes of diagnostic tests used for cardiotoxicity assessment and risk factors was extracted and risk of bias was assessed.

RESULTS

Our PubMed search yielded 3649 unique publications, 44 of which fulfilled the inclusion criteria. One additional study was identified by scanning the reference lists of relevant studies. In these 45 studies, acute and early-onset cardiotoxicity was studied in 7797 children and adolescents. Definitions of acute and early-onset cardiotoxicity prove to be highly heterogeneous. Prevalence rates varied for different cardiotoxicity definitions: systolic dysfunction (0.0-56.4%), diastolic dysfunction (30.0-100%), combinations of echocardiography and/or clinical parameters (0.0-38.1%), clinical symptoms (0.0-25.5%) and biomarker levels (0.0-37.5%). Shortening fraction and ejection fraction significantly decreased during treatment. Cumulative anthracycline dose proves to be an important risk factor.

CONCLUSIONS

Various definitions have been used to describe acute and early-onset cardiotoxicity due to childhood cancer treatment, complicating the establishment of its exact prevalence. Our findings underscore the importance of uniform international guidelines for the monitoring of cardiac function during and shortly after childhood cancer treatment.

Echocardiography Monitoring during Anthracycline Administration in Hodgkin and Non-Hodgkin’s Lymphoma: The Tei Index Evaluation

Anthracyclines are widely employed in lymphoma’s chemotherapy and has been shown to induce heart failure. Echocardiographic parameters of left ventricular (LV) systolic function are usually used to monitor the cardiac side effects during and after anthracyclines treatment. The measurement of theTei index could anticipate the onset of LV dysfunction. The aim of this study was to evaluate the performance of the delta Tei index for the early detection of cardiac toxicity in a prospective population of anthracycline-treated lymphoma patients. Our preliminary data suggest that the Tei index may predict the risk for cardiotoxicity in this subset of patients earlier than LV ejection fraction alteration.

Longitudinal Changes in Echocardiographic Parameters of Cardiac Function in Pediatric Cancer Survivors

Objectives

The purpose of this study was to assess the timing of changes in serial echocardiographic parameters in pediatric cancer survivors and to evaluate their associations with cardiomyopathy development.

Background

Pediatric cancer survivors undergo serial echocardiograms to screen for cardiotoxicity. It is not clear whether small longitudinal changes in functional or structural parameters over time have clinical significance.

Methods

This is a multicenter, retrospective, case-control study of ≥1-year survivors following the end of cancer therapy. Cardiomyopathy cases (fractional shortening [FS] ≤28% or ejection fraction [EF] ≤50% on ≥2 occasions) were matched to control subjects (FS ≥30%, EF ≥55%, not on cardiac medications) by cumulative anthracycline and chest radiation dose, follow-up duration, and age at diagnosis. Digitally archived clinical surveillance echocardiograms were quantified in a central core laboratory, blinded to patient characteristics. Using mixed models with interaction terms between time and case status, we estimated the least square mean differences of 2-dimensional, M-mode, pulsed wave Doppler, and tissue Doppler imaging–derived parameters over time between cases and control subjects.

Results

We identified 50 matched case-control pairs from 5 centers. Analysis of 412 echocardiograms (cases, n = 181; control subjects, n = 231) determined that indices of left ventricular systolic function (FS, biplane EF), diastolic function (mitral E/A ratio), and left ventricular size (end-diastolic dimension z-scores) were significantly different between cases and control subjects, even 4 years prior to the development of cardiomyopathy.

Conclusions

Longitudinal changes in cardiac functional parameters can occur relatively early in pediatric cancer survivors and are associated with the development of cardiomyopathy.

Echocardiography Imaging of Cardiotoxicity

Heart disease is the most important cause of non-cancer death for patients with cancer. Addressing the cardiotoxic effects of anticancer therapies to prevent increased cardiovascular risk in this population is crucial. Echocardiography plays a big role in monitoring cardiotoxicity induced by cancer treatment. Many emerging modalities, including tissue Doppler imaging measures, speckle tracking imaging, and three-dimensional echocardiography, may provide improved sensitivity and specificity to detect cancer treatment-induced cardiotoxicity. Additional research is critical to define the value of both conventional and novel indices in guiding the clinical management of cancer treatment-induced cardiotoxicity.

Cardiovascular imaging in the diagnosis and monitoring of cardiotoxicity: role of echocardiography

The evaluation by cardiovascular imaging of chemotherapy patients became a central topic in the last several years. The use of drugs for the treatment of cancers increased, and new molecules and protocols were developed to improve outcomes in these patients. Although, these novel approaches also produced a progressive increase in side effects, particularly myocardial dysfunction. Imaging of the heart was highly accurate in the early diagnosis of cancer therapeutics related-cardiac dysfunction. Echocardiography is the first-line method to assess ventricular function alterations, and it is required to satisfy the need for an early, easy and accurate diagnosis to stratify the risk of heart failure and manage treatments. A careful monitoring of cardiac function during the course of therapy should prevent the onset of severe heart impairment. This review provides an overview of the most important findings of the role of echocardiography in the management of chemotherapy-treated patients to create a clear and complete description of the efficacy of conventional measurements, the importance of comprehensive heart evaluations, the additional role of new echocardiographic techniques, the utility of integrated studies using other imaging tools and the positions of the most important international societies on this topic.

Sürücü index and others

BACKGROUND

In this study, we have aimed to evaluate the correlation between echocardiographic parameters that test systolic and diastolic function together.

METHOD

The study population was divided into two groups according to Vp. Group-1 (n = 103) represented the control group (Vp > 50 cm/s) and group-2 (n = 86) represented patients with systolic and diastolic dysfunctions together (Vp ≤ 50 cm/s). The echocardiographic parameters that evaluate systolic and diastolic function together, such as the Tei and the Sürücü indices, were compared between the groups.

RESULTS

In group-2, the Tei index was higher (p = 0.001) and the Sürücü index was lower (p < 0.001). We also showed that the Tei and Sürücü indices were significantly and negatively correlated. That is, as the Sürücü index decreases, the Tei index increases (p = 0.001).

CONCLUSION

Vp is an index more affected by diastolic parameters but rarely by systolic parameters because it is measured at diastolic period. The Tei index, on the other hand, is affected by preload variables and needs two different heart cycles for calculation. The Modified Tei index, however, has limited diagnostic value because of high inter-observer variability. In this study, the usability of the Sürücü index is shown in comparison with other indices used for this purpose. Considering that it is less affected by preload variables, can be calculated over a single heart cycle, and has the ability to test variables of both systolic and diastolic periods unlike Vp. We postulate that the Sürücü index is more usable and reliable.

The (Pulsed-Wave) Doppler Fetal Myocardial Performance Index: Technical Challenges, Clinical Applications and Future Research

Functional cardiovascular assessment is becoming an increasingly important tool in the study of fetal pathology. The myocardial performance index (MPI) is a parameter measuring global myocardial function. Since its introduction, several studies have proposed methods to improve its reproducibility and have constructed normative reference ranges. Fetal heart evaluation using the MPI is technically challenging, requiring specific training and expertise, and a consensus has yet to be reached on the method of delineating the time periods used to calculate the index. Despite these limitations, it has been shown to be a useful and highly sensitive parameter of dysfunction in a number of fetal pathologies. Further research is warranted into the effect of pathology on MPI, parameters of unilateral cardiac strain that utilise MPI, and automation of the MPI to encourage incorporation of the MPI as a useful tool in clinical practice.

Imaging of early modification in cardiomyopathy: the doxorubicin-induced model

Doxorubicin chemotherapy is effective and widely used to treat acute lymphoblastic leukemia. However, its effectiveness is hampered by a wide spectrum of dose-dependent cardiotoxicity including both morphological and functional changes, affecting primarily the myocardium. Non-invasive imaging techniques are used for the diagnosis and monitoring of these cardiotoxic effects. The purpose of this review is to summarize and compare the most common imaging techniques used in early detection and therapeutic monitoring of doxorubicin-induced cardiotoxicity and the suggested mechanisms of such side effects. Imaging techniques using echocardiography including conventional 2D and 3D echocardiography along with MRI sequences including Tagging, Cine, and quantitative MRI in detecting early myocardial damage are also reviewed. As there is a multitude of reported indices and imaging methods to assess particular functional alterations, we limit this review to the most relevant techniques based on their clinical application and their potential to early detection of doxorubicin-induced cardiotoxic effects.

Myocardial performance index and biochemical markers for early detection of doxorubicin-induced cardiotoxicity in children with acute lymphoblastic leukaemia

BACKGROUND

Despite significant improvements in the prognosis of childhood acute lymphoblastic leukaemia (ALL), the risk of anthracycline-induced cardiovascular disease remains a major concern. This study was designed to investigate the role of the myocardial performance index (MPI) and serum concentrations of biomarkers (cTnT and NT-pro-BNP) in the early detection of subclinical anthracycline-induced functional alterations in children with ALL.

METHODS

All children consecutively admitted to our Pediatric Oncologic Department from January 2009 to October 2010 with a diagnosis of ALL were enrolled in this study. cTnT and NT-pro-BNP were evaluated in all patients at diagnosis, before doxorubicin therapy and 2 and 24 h following each anthracycline administration. ECG and echocardiography were performed at diagnosis and 24 h after each anthracycline course.

RESULTS

Nineteen children with standard-risk ALL were evaluated. The mean age was 6 years. The cumulative doxorubicin dosage was 240 mg/m(2) according to the AIEOP (Associazione Italiana Ematologia Oncologia Pediatrica) ALL 2000 protocol. None of the 19 patients developed congestive heart failure. With increasing cumulative dosages of anthracyclines a significant increase was observed in MPI. This increase was statistically significant starting from the cumulative dosage of 120 mg/m(2) compared to baseline, while the median NT-pro-BNP level did not change significantly during treatment and cTnT levels never exceeded the cut-off value for cardiac injury.

CONCLUSION

MPI value is a sensitive and accurate parameter, allowing subclinical cardiac dysfunction to be detected in children receiving anthracyclines. Lifelong cardiac surveillance of these patients is warranted in order to determine the clinical implications of increased MPI on long-term cardiac status.

Time intervals and myocardial performance index by tissue Doppler imaging

The application of tissue Doppler imaging (TDI) has shown remarkable growth in clinical practice during the past few years, especially, in risk stratification of patients with coronary heart disease or heart failure (systolic and diastolic). Myocardial performance index (MPI) is a Doppler echocardiographic parameter defined as the sum of the isovolemic contraction and relaxation times divided by the ejection time. It is considered as a reliable parameter to assess global left ventricular function. Cardiac time intervals and MPI have also been found as new applications in diagnosing cardiotoxicity from chemotherapy, COPD, valvular heart disease, pulmonary hypertension and endocrinopathies.

Evaluation of myocardial function using the Tei index in patients with Kawasaki disease

Myocarditis is a well-recognized component of Kawasaki disease, with left ventricular dysfunction occurring in more than half of the patients during the acute phase of the disease. The purpose of our study was to evaluate myocardial function in these patients using the myocardial performance index, also known as the Tei index. In a prospective study, 14 patients underwent echocardiographic evaluation, first at the time of diagnosis of the disease, in its acute phase before treatment with intravenous immunoglobulin and then 2 weeks later after treatment with immunoglobulin. We assessed the Tei-index, the ejection fraction, shortening fraction, and the presence of valvar regurgitation, pericardial effusion, or coronary arterial involvement. As a control, we also assessed 22 healthy children, matched for age and sex with the study population. Of the patients, half had an increased left ventricular Tei-index in the acute phase, as compared with the data obtained after treatment, the index changing from 0.43 +/- 0.08 to 0.35 +/- 0.06 (p equal to 0.003). An increased index for the right ventricle was found in 5 patients (36%), values being 0.30 +/- 0.05 as opposed to 0.26 +/- 0.04 (p equal to 0.009). Of the patients, 5 (35.7%) also had decreased ejection fractions and proportional shortening fractions during the acute phase, confirming left ventricular dysfunction. We concluded that the Tei-index, which measures combined systolic and diastolic function, is a simple, sensitive, and accurate tool for estimating global myocardial dysfunction in patients with Kawasaki disease.

Usefulness of myocardial performance index and biochemical markers for early detection of anthracycline-induced cardiotoxicity in adults

BACKGROUND

Anthracycline therapy is limited by cardiotoxicity. Currently no diagnostic parameter is available allowing ubiquitous and reliable detection of preclinical anthracycline cardiomyopathy and prediction of prognosis.

PATIENTS AND METHODS

In 100 consecutive patients receiving anthracycline-based chemotherapy serial measurements of left ventricular systolic and diastolic function, Tei index (a Doppler echocardiographic parameter of global ventricular function), cardiac troponin T (cTnT) and NT-probrain natriuretic peptides (BNP) at baseline and during 1-year follow-up were performed.

RESULTS

Mean ejection fraction (LVEF) significantly decreased immediately after completion of anthracycline therapy (mean dose 226.1 +/- 8.3 mg/m(2)) und further declined during follow-up (65.9 +/- 0.6% Vs. 61.6 +/- 0.7%; P < 0.001), while mean E/A ratio decreased after 6 months (P = 0.05). No patient presented with cardiac symptoms. The Tei index increased after therapy in the majority of patients (78.8%) compared with pre-therapy values indicating myocardial alteration in more patients than previously recognized. cTnT levels did not exceed the upper limit of the normal range in any patient. Seven patients had low-level elevations of cTnT. Only one of these patients developed a concomitant decrease in LVEF. Mean N-terminal-pro-BNP (NT-proBNP) levels did not significantly change after anthracycline administration. However, in 13 patients (15.3%) a marked, transient increase of NT-proBNP was obtained after the first anthracycline cycle without cardiac dysfunction presumably due to altered cardiac loading conditions during chemotherapy.

CONCLUSION

Low to moderate doses of anthracyclines resulted in subclinical myocardial alteration in more patients than so far noticed. Clinical implications of increased Tei index remain to be determined in long-term. Our results do not support that assessment of cTnT or BNP levels may safely replace serial echocardiographic evaluation of systolic and diastolic function for the monitoring of anthracycline cardiotoxicity.

Assessment of variables affecting flow propagation velocity of the left ventricle in healthy children

BACKGROUND

The purpose of the present study was to establish the normal values of flow propagation velocity (FPV) in healthy children and examine the variables that affect FPV in clinical situations.

METHODS

Two hundred and thirty- five healthy children and adolescents were assessed (aged 0-22.6 years, mean age 7.4 +/- 5.4 years; male, n = 142; female, n = 93). FPV was obtained from an apical four-chamber view and determined as the slope of aliasing velocity of early diastolic transmitral flow on the color M-mode using Aloka SSD-5500 with 5.0 MHz transducer. Aliasing velocity was set at 50-70% of the peak transmitral flow velocity. Peak transmitral flow velocities in early diastole (E) and during atrial contraction (A), and the ratio of early to late peak velocity (E/A) were obtained. Tei index was also measured for analysis of general left ventricular performance. Left ventricular mass index (LVMI) was obtained from conventional echo measurement. E, E/A, Tei index and LVMI were compared with FPV in healthy subjects.

RESULTS

FPV obtained from all subjects ranged from 23.7 to 96.0 cm/s (61.3 +/- 13.6 cm/s). Normal value of FPV was less dependent on age, body size, heart rate and left ventricular dimension. In contrast, although there was no significant correlation between FPV and ejection fraction, statistically significant correlation was found between FPV, LVMI (P = 0.0008) and Tei index (P = 0.025).

CONCLUSIONS

FPV is independent of age, body size and heart rate and is useful to assess left ventricular relaxation in children.

Assessment of left ventricular dysfunction in children undergoing chemotherapy

BACKGROUND

In Taiwan, children with malignancies are treated under the protocols of the Taiwan Pediatric Oncology Group (TPOG). The purpose of this study was to determine the change in left ventricular (LV) function in pediatric patients undergoing chemotherapy.

METHODS

A total of 19 pediatric patients (mean age, 12.5 +/- 4.6 years; 11 males, 8 females) were enrolled. We divided the patients into 2 groups: (1) osteogenic sarcoma (OGS) group (n = 12; Group I); and (2) non-osteogenic sarcoma (non-OGS) group (n = 7; Group II). The accumulated dosages of anthracycline in Group I and II patients were 144.3 +/- 56.4 mg/M2 and 131.7 +/- 105.5 mg/M2 (p = 0.735), respectively. The children received echocardiography to investigate the parameters of LV systolic function, LV diastolic function, and myocardial performance index (MPI) after the entire chemotherapy course.

RESULTS

Higher E/A ratio (1.71 +/- 0.37), shorter isovolumic relaxation time (IRT, 42 +/- 19.14 ms), and shorter deceleration time (DT, 140.3 +/- 40.6 ms) were demonstrated in these patients. There was no statistically significant difference in the E/A ratio and DT between the 2 groups. Group I children were older (14.4 +/- 3.7 vs. 9.3 +/- 4.5 years; p = 0.015) and had lower MPI (0.20 +/- 0.02 vs. 0.28 +/- 0.07; p = 0.031) than Group II children.

CONCLUSION

The children treated with chemotherapy using the TPOG protocol had a shorter IRT, higher E/A ratio and shorter DT. No significant evidence of anthracycline-related cardiotoxicity was found in any of the children in this study undergoing chemotherapy with the TPOG protocol.

Monitoring left ventricular function in adults receiving anthracycline-containing chemotherapy

AIMS

To assess prospectively (1) the incidence of early anthracycline-induced cardiotoxicity; (2) the best predictor for identifying individuals at risk of developing functional cardiotoxicity; and (3) the most sensitive standard echocardiographic measure for the detection of anthracycline-induced changes in left ventricular (LV) function.

METHODS

Sixty-seven consecutive patients (45 male, mean age 50+/-18 years) requiring doxorubicin-containing chemotherapy were enrolled. Clinical and echocardiographic assessments occurred before they received any anthracycline, after low-dose anthracyclines and 1-3 months after completion of their chemotherapy.

RESULTS

Twenty six percent of patients without significant pre-existing cardiac disease developed cardiotoxicity. The parameter that best predicted the development of functional cardiotoxicity was the change in EF between baseline and low dose with an area under the curve of 0.92. The Tei index detected declines in LV function earlier in the course of treatment with anthracyclines and to a greater significance than any other standard echocardiographic measurement but did not predict functional cardiotoxicity.

CONCLUSIONS

All patients receiving potential cardiotoxic chemotherapy should be under the care of a cardiologist and have their EF monitored closely.

Tei index in adult patients submitted to adriamycin chemotherapy: failure to predict early systolic dysfunction

AIMS

This study prospectively assessed whether Tei index is predictive of early systolic dysfunction in adults undergoing adriamycin treatment.

METHODS AND RESULTS

Left ventricular ejection fraction (LVEF) was obtained by radionuclide ventriculography at baseline and after treatment. Tei index was evaluated by echocardiography at baseline, at an intermediary cycle and at the end of chemotherapy. Fifty-five predominantly female patients (91%) with breast cancer (80%) and without known cardiac disease were evaluated. After treatment (adriamycin dose of 304 +/- 47 mg/m(2)), systolic dysfunction (final LVEF < 50%) occurred in eight patients (14%). Baseline, intermediate or variation of Tei index were not accurate to predict early systolic dysfunction ("c" statistics < or = 0.60). Baseline Tei index > 0.39, for example, had a sensitivity of 75%, specificity of 55%, positive predictive value of 22% and negative predictive value of 93%.

CONCLUSION

Tei index does not appear to be a useful tool for detection of early adriamycin cardiotoxicity in adults.

The Tei index identifies a differential effect on left and right ventricular function with low-dose anthracycline chemotherapy

OBJECTIVE

We sought to study the relative effect on left ventricular (LV) and right ventricular (RV) function of low-dose anthracycline-containing chemotherapy regimes.

METHODS

A total of 23 patients (mean age 48 +/- 20 years) underwent echocardiographic examinations before any anthracycline had been administered and then after low-dose anthracycline (doxorubicin 50-125 mg/m2). The Tei index was used to compare the relative effects on RV and LV function.

RESULTS

Anthracycline administration was significantly associated with an increase in the LV Tei index (0.38 +/- 0.12 vs 0.46 +/- 0.16, P = .02). There was no significant change in the RV Tei index (0.19 +/- 0.10 vs 0.20 +/- 0.10, P = .72). Comparing the relative effect on global LV and RV function the change in LV Tei was significantly greater than the change in RV Tei (0.07 +/- 0.13 vs 0.01 +/- 0.09, P = .044).

CONCLUSIONS

Low-dose anthracycline administration has a significant negative impact on LV function but does not affect RV function.

Increased Tei index suggests absence of adequate coronary reperfusion in patients with first anteroseptal acute myocardial infarction

BACKGROUND

The estimation of coronary reperfusion in acute myocardial infarction (AMI) is important. The left ventricular (LV) Tei index is a noninvasive and sensitive parameter expressing overall LV function. We hypothesized that patients without good coronary reperfusion have worse LV function with a higher or worse Tei index compared to those with good reperfusion.

METHODS AND RESULTS

In 85 patients with first anteroseptal AMI, without other cardiac lesions such as prior myocardial infarction, LV hypertrophy or valvular disease, the Tei index was measured using Doppler echocardiography immediately after patients' arrival to the hospital, and the Thrombolysis in Myocardial Infarction (TIMI) grade was evaluated through subsequent coronary angiography. The Tei index was significantly greater in patients who did not have TIMI score of 3 compared to those with a TIMI of 3 (0.60+/-0.13 vs 0.46+/-0.06, p<0.0001). A Tei index >0.50 as the criteria for the absence of TIMI 3 had the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 75, 86, 94, 54 and 78%, respectively.

CONCLUSION

An increased Tei index suggests the absence of adequate coronary reperfusion in patients with first anterior AMI without other lesion.

Cardioprotective effect of dexrazoxane during treatment with doxorubicin: a study using low-dose dobutamine stress echocardiography

AIM

To assess the late cardioprotective effect of dexrazoxane associated with doxorubicin during treatment of osteosarcoma by means of low-dose dobutamine stress echocardiography (LDDSE) in non-relapsed asymptomatic children and teenagers.

PATIENTS AND METHODS

The study population included 58 patients with osteosarcoma divided in three groups, with equivalent age range, gender proportion and body surface area. Group I (21 patients, 14 males, 15 +/- 4 years) was analyzed before chemotherapy and considered the control group; Group II (19 patients, 11 males, 19.7 +/- 4 years) was treated with 348.4 +/- 18 mg/m2 of doxorubicin only and Group III (18 patients, 14 male, 16.8 +/- 5 years) treated with 396.5 +/- 55 mg/m2 of doxorubicin with dexrazoxane in the ratio 10:1. The patients were submitted to LDDSE (maximal dose 5 microg/kg/min). No major side effects were observed. Heart rate, blood pressure, left ventricular diameters, end systolic wall stress (ESWS), and other diastolic and systolic function indexes were assessed at rest conditions and during LDDSE and compared between the three groups.

RESULTS

Group III received a doxorubicin dose significantly greater than Group II (P = 0.001). During LDDSE there were no significant changes in the diastolic function indexes in any of the groups, but there was a significant increase of systolic indexes and a decrease of ESWS in Group III compared to group II. There was no significant difference of any systolic functional parameters between Group I and III. Considering the ejection fraction (EF) at rest or at LDDSE, 13 patients (69.4%) in Group II and 5 patients (27.7%) in Group III were considered to have systolic dysfunction. (P = 0.02).

CONCLUSION

Myocardial response to LDDSE in patients treated with doxorubicin and dexrazoxane was similar to patients without chemotherapy and better than those treated with doxorubicin only, suggesting less cardiotoxicity.

Quantitative assessment of ventricular function in sickle cell disease: effect of long-term erythrocytapheresis

BACKGROUND

Previous studies on cardiac function in patients with sickle cell disease (SCD) demonstrated abnormalities of systolic and diastolic function including elevated left ventricular myocardial performance index (LVMPI) on chronic transfusion protocols. LVMPI has been validated as a useful and easy non-invasive measure of overall cardiac function. Up to now, there are no reported studies on cardiac function in patients with SCD maintained on long-term erythrocytapheresis (LTE).

PROCEDURES

We recorded LVMPI in 22 patients with SCD aged 3-20 years and we compared the results between non-transfused patients (NT-SCD) and patients on LTE (T-SCD).

RESULTS

Males with SCD had higher mean LVMPI than females (P = 0.04). There were significant differences among T-SCD, severe NT-SCD, and mild NT-SCD patients with respect to hemoglobin (Hb) levels (P = .003) and TR velocity (P = .03). T-SCD patients showed elevated LVMPI compared to NT-SCD patients with severe and mild disease (P = 0.002). Pair-wise comparisons demonstrated that T-SCD patients had LVMPI that was significantly higher than NT-SCD (mild) patients (P = 0.01).

CONCLUSIONS

Our study demonstrates that patients SCD on LTE have cardiac dysfunction based on elevated LVMPI. This may be a reflection of the global severity of disease. Our findings merit further investigation with serial monitoring of LVMPI on a larger number of patients with SCD.

Evaluation of left ventricular function in long-term survivors of childhood Hodgkin disease

BACKGROUND

Data on the presence of myocardial abnormalities in long-term Hodgkin disease survivors are contradictory. The purpose of this study was to determine if myocardial performance index (MPI) was capable of discovering cardiac abnormalities.

PROCEDURE

Echocardiographic evaluation was performed in 31 survivors of Hodgkin disease (mean age 17.0 years), who received doxorubicin as part of chemotherapeutic treatment (median dose 164.8 +/- 42.5 mg/m(2)). Control group comprised 22 healthy subjects (mean age 16.7 years).

RESULTS

Peak A velocity was increased (P = 0.004) and peak E/A velocity ratio was lower (P = 0.002) in patients compared to controls. Mean isovolumetric contraction time was longer in patients than in controls (P = 0.0001). Ejection time was significantly shorter in patients than in the controls (P = 0.001). Consequently, the MPI was significantly greater in the patients than in the controls (P = 0.0001). Abnormal MPI was found in 25/31 patients (83%).

CONCLUSIONS

The Doppler-derived index of combined systolic and diastolic myocardial performance demonstrates the presence of subtle cardiac abnormalities in the majority of Hodgkin disease survivors.

Quantitative assessment of right ventricular function using doppler tissue imaging in fetuses with and without heart failure

BACKGROUND

Previous reports have established the use of Doppler tissue imaging (DTI) for noninvasive assessment of ventricular function, but the technique has not been validated for diagnosis of fetal cardiac failure.

OBJECTIVE

The purpose of this study was to assess right ventricular (RV) function in fetuses with heart failure using DTI.

METHODS

In all, 43 fetuses (36 control, 7 heart failure) were assessed using pulsed Doppler echocardiography combined with DTI. RV peak myocardial velocities during early diastole (Ea), atrial contraction, and systole were measured; and tricuspid peak velocities during early diastole (E) and atrial contraction. The ratio of E/Ea was used as an index of filling pressure were measured. From DTI, a Doppler-derived index of combined systolic/diastolic myocardial performance (DTI-Tei index) was measured.

RESULTS

Compared with control fetuses, the mean Ea was significantly lower and the mean E was significantly higher in fetuses with heart failure, although these parameters did overlap between the 2 groups. The mean RV myocardial wall-motion velocity during atrial contraction, ratio of Ea/RV myocardial wall-motion velocity during atrial contraction, and RV myocardial wall-motion velocity during systole did not differ between the 2 groups. Compared with control fetuses, the mean E/Ea was significantly higher (9.71 +/- 0.91 vs 6.20 +/- 0.97; P <.0001) and the mean DTI-Tei index was significantly greater (0.79 +/- 0.11 vs 0.55 +/- 0.05; P <.0001) in fetuses with heart failure. In addition, the DTI-Tei index z score was >2 in all fetuses with heart failure.

CONCLUSIONS

This study demonstrated a clinically important application of DTI-derived tricuspid annular velocities in fetuses with heart failure. Although DTI velocities were not sufficiently sensitive to identify fetuses with heart failure versus control fetuses, DTI-Tei index and E/Ea were useful and sensitive indicators of global RV dysfunction.

Noninvasive differentiation of pseudonormal/restrictive from normal mitral flow by Tei index: a simultaneous echocardiography-catheterization study in patients with acute anteroseptal myocardial infarction

BACKGROUND

Differentiation of pseudonormal/restrictive from normal mitral flow is still clinically problematic. Pseudonormal/restrictive flow is usually associated with left ventricular dysfunction, which can be detected by Doppler Tei index, combining systolic and diastolic function. Therefore, the purpose of this study was to test the feasibility of the Tei index to differentiate pseudonormal/restrictive from normal mitral flow.

METHODS

In 26 patients with anteroseptal acute myocardial infarction and early diastolic mitral flow velocity (E) to late diastolic mitral flow velocity (A) ratio (E/A) > or = 1, left ventricular volumes; E and A; deceleration time of E; and the Tei index, defined as the sum of the isovolumic contraction and relaxation time divided by ejection time, were evaluated by Doppler echocardiography, and pulmonary capillary wedge pressure was measured by catheterization. Pseudonormal/restrictive mitral flow was defined as E/A > or = 1 associated with pulmonary capillary wedge pressure > 12 mm Hg.

RESULTS

There were 19 and 7 patients with pseudonormal/restrictive and normal mitral flow, respectively. Among the indices of left ventricular function, the Tei index achieved the best correlation with pulmonary capillary wedge pressure (r(2) = 0.66, P <.0001). By setting the Tei index > or = 0.55 as the criteria for pseudonormal/restrictive mitral flow, this diagnosis had the sensitivity, specificity, and accuracy of 84%, 100%, and 88%, respectively.

CONCLUSION

The Tei index allows noninvasive differentiation of pseudonormal/restrictive from normal mitral flow.

Non-Invasive Functional and Biochemical Assessment of Mitoxantrone Cardiotoxicity in Patients with Multiple Sclerosis

As mitoxantrone is a recently approved immunosuppressant for managing multiple sclerosis, the number of patients treated with this effective but potentially cardiotoxic anthracenedione derivative will increase substantially. To detect subclinical mitoxantrone-induced cardiotoxicity, sensitive non-invasive diagnostic tools are required. Assuming that changes in myocardial high-energy phosphate metabolism and alterations in left ventricular (LV) diastolic performance might be early markers of mitoxantrone-induced cardiotoxicity we examined fifteen MS patients treated with mitoxantrone up to 100 mg/m2 compared with 15 matched control MS patients. 31P-magnetic resonance (MR) spectroscopy was employed to measure myocardial high-energy phosphate metabolism, MR imaging for morphometric evaluation of changes in LV geometry. Indices of diastolic performance were assessed by Doppler echocardiography. In this exploratory study, phosphocreatine/ATP ratios were comparable between mitoxantrone-treated and control patients (1.48 +/- 0.23 and 1.43 +/- 0.41). LV mass, LV end-diastolic and systolic volumes, wall motion score, EF and cardiac output did not differ between both groups. All parameters of diastolic performance (E/A-ratio, isovolumic relaxation time, and E-wave deceleration time) were not different and within normal limits.In conclusion, using advanced diagnostic methodology, including functional, morphometric, and biochemical measurements no cardiotoxic effect of mitoxantrone up to a cumulative dose range of 100 mg/m2 could be detected.

Pseudonormalized Doppler total ejection isovolume (Tei) index in patients with right ventricular acute myocardial infarction

The Doppler total ejection isovolume (Tei) index is useful for estimating global cardiac function. However, the relation between the right ventricular (RV) Tei index and RV infarction has not been investigated. The relation between the RV Tei index and severity of RV infarction was evaluated in 25 patients with inferior wall acute myocardial infarction (13 with and 12 without RV infarction). RV infarction was diagnosed when right atrial pressure was > or = 10 mm Hg or when right atrial pressure/pulmonary capillary wedge pressure was >0.8 by catheterization. The RV Tei index was significantly increased in patients with RV infarction compared with those without (0.53 +/- 0.15 vs 0.38 +/- 0.14, p <0.05). The RV Tei index in patients with severe RV infarction (right atrial pressure > or = 15 mm Hg) was significantly smaller compared with those with mild/moderate RV infarction (right atrial pressure <15 mm Hg) and showed no significant difference in patients with myocardial infarction but without RV infarction (0.44 +/- 0.09 vs 0.61 +/- 0.16 vs 0.38 +/- 0.14, severe RV infarction vs mild/moderate RV infarction vs no RV infarction, p <0.01). The RV Tei index is generally increased in patients with RV infarction; however, severe RV infarction can be manifested with limited or no increase in the Tei index (pseudonormalization).

Fetal cardiac function assessed by Doppler myocardial performance index (Tei Index)

OBJECTIVES

The Tei Index (TI) is a useful, non-invasive, Doppler-derived myocardial performance tool which can be used to assess aspects of systolic and diastolic function. The aim of this study was to determine normal values of fetal left ventricular (LV) TI in second- and third- trimester fetuses and to compare these to other values reported in the literature.

METHODS

Doppler waveforms of the LV outflow tracts were obtained in 74 second- and early third-trimester fetuses. The LV isovolumic contraction time (ICT), isovolumic relaxation time (IRT) and ejection time (ET) were measured and the TI calculated using the formula (ICT + IRT)/ET. The literature on LV myocardial function in the fetus was also reviewed.

RESULTS

The normal TI in second- and early third-trimester fetuses (18-31 weeks' gestation) was 0.53 +/- 0.13. The ICT was 43 +/- 14 ms, the ET was 173 +/- 16 ms and the IRT was 48 +/- 13 ms.

CONCLUSION

The TI can be easily obtained in the fetus without the need for precise anatomic imaging. The TI may be a useful tool to explore fetal myocardial function in different clinical situations.

Automated calculation of the Tei index from signal averaged left ventricular acoustic quantification wave forms

The Tei index is a combined measurement of systolic and diastolic left ventricular (LV) performance and may be more useful for the diagnosis of global cardiac dysfunction than either systolic or diastolic measures alone. We sought to determine whether the Tei index could be accurately calculated from LV area waveforms generated with automated border detection. Twenty-four patients were studied in 3 groups: systolic dysfunction, diastolic dysfunction, and normal. The Tei index was calculated both from Doppler tracings and from analysis of LV area waveforms. Excellent agreement was found between Doppler-derived timing intervals and the Tei index with those obtained from averaged LV area waveforms. A significant difference was seen in the Tei index, computed with both Doppler and automated border detection techniques, between the normal group and those with LV systolic dysfunction and subjects with isolated diastolic dysfunction. This study validates the use of LV area waveforms for the automated calculation of the Tei index.

Noninvasive differentiation of normal from pseudonormal/restrictive mitral flow using TEI index combining systolic and diastolic function

Differentiation of normal from pseudonorma/restrictive mitral flow is not necessarily easy. Pseudonormal/restrictive flow is usually associated with left ventricular (LV) dysfunction, which can be detected using the TEI index, combining systolic and diastolic function. The purpose of this study was to test the feasibility of using the TEI index to differentiate pseudonormal/restrictive from normal mitral flow. In 33 patients with mitral flow E/A > or = 1 and LV mid-diastolic pressure measured by catheterization, the LV volumes, mitral E and A velocity, deceleration time of the E velocity, and the TEI index, defined as the sum of the isovolumic contraction and relaxation time divided by ejection time, were evaluated using Doppler echocardiography. Pseudonormal/restrictive mitral flow was defined as mitral flow E/A > or = 1 associated with LV mid-diastolic pressure > 12 mmHg. There were 22 and 11 patients with normal and pseudonorma/restrictive mitral flow, respectively. Among the indices of LV function, the TEI index achieved the best correlation with LV mid-diastolic pressures (r2 = 0.63, p < 0.0001). By setting the TEI index > or = 0.65 as the criteria for pseudonormal/restrictive mitral flow, this diagnosis had sensitivity, specificity, and accuracy of 82%, 96%, and 91%, respectively. TEI index allows noninvasive differentiation of pseudonormal /restrictive from normal mitral flow.

Evaluation of a novel doppler index of combined systolic and diastolic myocardial performance in Newfoundland dogs with familial prevalence of dilated cardiomyopathy

A Doppler index of myocardial performance (IMP) has been recently proposed in human cardiology, which is calculated from the isovolumic contraction time (ICT), isovolumic relaxation time (IRT), and the ejection time (ET) using the following formula: (ICT+IRT)/ET. In this study, IMP was measured and evaluated in Newfoundland dogs categorized in four groups: Normal dogs (n = 31), dilated cardiomyopathy (DCM) (n = 34), depressed fractional shortening (dFS) (n = 27), and left ventricular enlargement (LVE) (n = 7). IMP was found to be independent of age, sex, body surface area, and the R-R interval in the Normal group. There were significant differences in IMP between the DCM group and the Normal and dFS groups (P < 0.05) and between Newfoundlands with overt vs. occult DCM. IMP is a Doppler index which appears to correlate with severity of disease and may be of use in the early diagnosis of affected dogs during screening for the presence of DCM.