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Musallam KM, Barella S, Origa R, Ferrero GB, Lisi R, Pasanisi A, Longo F, Gianesin B, Forni GL. Revisiting iron overload status and change thresholds as predictors of mortality in transfusion-dependent β-thalassemia: a 10-year cohort study. Ann Hematol 2024; 103:2283-2297. [PMID: 38503936 DOI: 10.1007/s00277-024-05715-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/15/2024] [Indexed: 03/21/2024]
Abstract
Data on iron overload status and change thresholds that can predict mortality in patients with transfusion-dependent β-thalassemia (TDT) are limited. This was a retrospective cohort study of 912 TDT patients followed for up to 10 years at treatment centers in Italy (median age 32 years, 51.6% female). The crude mortality rate was 2.9%. Following best-predictive threshold identification through receiver operating characteristic curve analyses, data from multivariate Cox-regression models showed that patients with Period Average Serum Ferritin (SF) > 2145 vs ≤ 2145 ng/mL were 7.1-fold (P < 0.001) or with Absolute Change SF > 1330 vs ≤ 1330 ng/mL increase were 21.5-fold (P < 0.001) more likely to die from any cause. Patients with Period Average Liver Iron Concentration (LIC) > 8 vs ≤ 8 mg/g were 20.2-fold (P < 0.001) or with Absolute Change LIC > 1.4 vs ≤ 1.4 mg/g increase were 27.6-fold (P < 0.001) more likely to die from any cause. Patients with Index (first) cardiac T2* (cT2*) < 27 vs ≥ 27 ms were 8.6-fold (P < 0.001) more likely to die from any cause. Similarly, results at varying thresholds were identified for death from cardiovascular disease. These findings should support decisions on iron chelation therapy by establishing treatment targets, including safe iron levels and clinically meaningful changes over time.
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Affiliation(s)
- Khaled M Musallam
- Center for Research On Rare Blood Disorders (CR-RBD), Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Susanna Barella
- S.C. Centro Delle Microcitemie E Anemie Rare, ASL Cagliari, Cagliari, Italy
| | - Raffaella Origa
- Università Di Cagliari, S.C. Centro Delle Microcitemie E Anemie Rare, ASL Cagliari, Cagliari, Italy
| | - Giovanni Battista Ferrero
- Hemoglobinopathies and Rare Anemia Reference Center, Department of Biological and Clinical Sciences, San Luigi Gonzaga University Hospital, University of Turin, Turin, Italy
| | - Roberto Lisi
- Thalassemia Unit, ARNAS Garibaldi, Catania, Italy
| | - Annamaria Pasanisi
- Centro Della Microcitemia A.Quarta, Hematology Unit, A. Perrino Hospital, Brindisi, Italy
| | - Filomena Longo
- Day Hospital Della Talassemia E Delle Emoglobinopatie, Azienda Ospedaliero Universitaria S. Anna, Ferrara, Italy
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Akca T, Ozdemir GN, Aycicek A, Ozkaya G. Long-term Results of Splenectomy in Transfusion-dependent Thalassemia. J Pediatr Hematol Oncol 2023; 45:143-148. [PMID: 35446800 DOI: 10.1097/mph.0000000000002468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
Splenectomy is indicated in transfusion-dependent thalassemia (TDT) only in certain situations. This study aimed to present the effectiveness, complications, and long-term follow-up results of splenectomy in children with TDT. We performed a 30-year single-institution analysis of cases of splenectomy for TDT between 1987 and 2017 and their follow-up until 2021. A total of 39 children (female/male: 24/15) were included. The mean age at splenectomy was 11.2±3.2 years, and their mean follow-up duration after splenectomy was 21.5±6.4 years. Response was defined according to the patient's annual transfusion requirement in the first year postsplenectomy and on the last follow-up year. Complete response was not seen in any of the cases; partial response was observed in 32.3% and no response in 67.6%. Thrombocytosis was seen in 87% of the patients. The platelet counts of 7 (17.9%) patients were >1000 (10 9 /L), and aspirin prophylaxis was given to 22 (56.4%) patients. Complications were thrombosis in 2 (5.1%) patients, infections in 11 (28.2%) patients, and pulmonary hypertension in 4 (10.2%) patients. Our study showed that after splenectomy, the need for transfusion only partially decreased in a small number of TDT patients. We think splenectomy can be delayed with appropriate chelation therapy up to higher annual transfusion requirement values.
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Affiliation(s)
- Tugberk Akca
- Departments of Pediatrics
- Departments of Pediatric Cardiology
| | - Gul N Ozdemir
- Pediatric Hematology and Oncology, Kanuni Sultan Suleyman Training and Research Hospital
- Department of Pediatric Hematology and Oncology, Istinye University Faculty of Medicine, Istanbul
| | - Ali Aycicek
- Pediatric Hematology and Oncology, Kanuni Sultan Suleyman Training and Research Hospital
- Department of Hematology and Oncology, Basaksehir Cam Sakura City Hospital, University of Health Sciences
| | - Guven Ozkaya
- Biostatistics, Bursa Uludag University Faculty of Medicine, Bursa, Turkey
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Bayraktaroglu S, Karadas N, Onen S, Karapinar DY, Aydinok Y. Modern management of iron overload in thalassemia major patients guided by MRI techniques: real-world data from a long-term cohort study. Ann Hematol 2022; 101:521-529. [DOI: 10.1007/s00277-021-04748-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/15/2021] [Indexed: 01/19/2023]
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Kumar I, Aggarwal P, Gupta V, Verma A, Kumar S, Shukla RC. Cardiac T2* magnetic resonance analysis of membranous interventricular septum in assessment of cardiac iron overload in pediatric thalassemia patients: A pilot study. Indian J Radiol Imaging 2021; 29:33-39. [PMID: 31000939 PMCID: PMC6467041 DOI: 10.4103/ijri.ijri_395_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Cardiac iron deposition in transfusion-dependent thalassemia patients is patchy in distribution. Purpose: The purpose of this study is to assess the correlation between T2* matrices of membranous interventricular septum (MIVS) and T2* values of muscular interventricular septum (IVS) on magnetic resonance imaging (MRI) and to evaluate the relationship of myocardial T2* at these two locations with MRI-estimated liver iron concentrations (LIC) and electrocardiographic (ECG) parameters. Material and Methods: MRI of heart and liver was performed in 16 consecutive pediatric patients of transfusion-dependent thalassemia major to calculate liver iron concentration and T2* time of membranous and muscular IVS. ECG parameters of these patients were charted and correlated with MRI parameters. Results: No significant correlation between T2* values of muscular IVS and MIVS was observed. Mean T2* of MIVS (9.8 ms) was significantly lower than that of muscular IVS (26.9 ms). T2* of MIVS correlated strongly with LIC where as a weak correlation was observed between T2* of IVS and LIC. Significantly higher mean QTc (corrected QT interval) value (439.86 ms) was seen in patients with T2* IVS <20 ms. Conclusion: Addition of T2* analysis of MIVS to the existing MRI protocol, consisting of muscular IVS analysis, may offer a more sensitive estimation of cardiac iron overload.
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Affiliation(s)
- Ishan Kumar
- Department of Radiodiagnosis, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Priyanka Aggarwal
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Vineeta Gupta
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Ashish Verma
- Department of Radiodiagnosis, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Suwen Kumar
- Department of Cardiology, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Ram C Shukla
- Department of Radiodiagnosis, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Daniłowicz-Szymanowicz L, Świątczak M, Sikorska K, Starzyński RR, Raczak A, Lipiński P. Pathogenesis, Diagnosis, and Clinical Implications of Hereditary Hemochromatosis-The Cardiological Point of View. Diagnostics (Basel) 2021; 11:diagnostics11071279. [PMID: 34359361 PMCID: PMC8304945 DOI: 10.3390/diagnostics11071279] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 01/25/2023] Open
Abstract
Hereditary hemochromatosis (HH) is a genetic disease leading to excessive iron absorption, its accumulation, and oxidative stress induction causing different organ damage, including the heart. The process of cardiac involvement is slow and lasts for years. Cardiac pathology manifests as an impaired diastolic function and cardiac hypertrophy at first and as dilatative cardiomyopathy and heart failure with time. From the moment of heart failure appearance, the prognosis is poor. Therefore, it is crucial to prevent those lesions by upfront therapy at the preclinical phase of the disease. The most useful diagnostic tool for detecting cardiac involvement is echocardiography. However, during an early phase of the disease, when patients do not present severe abnormalities in serum iron parameters and severe symptoms of other organ involvement, heart damage may be overlooked due to the lack of evident signs of cardiac dysfunction. Considerable advancement in echocardiography, with particular attention to speckle tracking echocardiography, allows detecting discrete myocardial abnormalities and planning strategy for further clinical management before the occurrence of substantial heart damage. The review aims to present the current state of knowledge concerning cardiac involvement in HH. In addition, it could help cardiologists and other physicians in their everyday practice with HH patients.
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Affiliation(s)
- Ludmiła Daniłowicz-Szymanowicz
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Dębinki 7 St., 80-211 Gdańsk, Poland;
- Correspondence: ; Tel.: +48-349-39-10
| | - Michał Świątczak
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Dębinki 7 St., 80-211 Gdańsk, Poland;
| | - Katarzyna Sikorska
- Department of Tropical Medicine and Epidemiology, Medical University of Gdańsk, Dębinki 7 St., 80-211 Gdańsk, Poland;
| | - Rafał R. Starzyński
- Department of Molecular Biology, Institute of Genetics and Animal Breeding, Polish Academy of Sciences, Wólka Kosowska, 05-552 Jastrzębiec, Poland; (R.R.S.); (P.L.)
| | - Alicja Raczak
- Clinical Psychology Department, Faculty of Health Sciences, Medical University of Gdańsk, 80-211 Gdańsk, Poland;
| | - Paweł Lipiński
- Department of Molecular Biology, Institute of Genetics and Animal Breeding, Polish Academy of Sciences, Wólka Kosowska, 05-552 Jastrzębiec, Poland; (R.R.S.); (P.L.)
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Khafagy RTM, El Mozy W, Hamed E, ElKhalek YIA, Tantawy W. Prognostic value of microvascular occlusion MRI quantification in assessment of reperfused myocardial infarction. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00202-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Reperfusion therapy in patients with acute myocardial infarction (AMI) can salvage the myocardium; however, successful restoration of the coronary artery patency is not always associated with adequate perfusion at the level of microvasculature, known as the no-reflow or microvascular occlusion (MVO). The primary objective of our prospective study was to assess, by cardiac magnetic resonance (CMR), the prognostic value of MVO size, and its impact on left ventricular (LV) remodeling in cases of reperfused AMI.
Thirty-three patients with AMI underwent cardiac MRI at 1.5-T scanner within 7 days (baseline) and 3 months (follow-up) after reperfusion. Patients with MVO were included where early gadolinium enhancement (EGE), late gadolinium enhancement (LGE), and cine sequences were acquired. The impact of MVO size on LV ejection fraction (EF%) and LV volumes was quantitively analyzed.
Results
There was a significant inverse correlation between the MVO size % of the LV mass (LVM) and the EF% values measured at follow-up with a P value of 0.000, while a significant positive correlation was encountered between the MVO% of LVM and both indexed end-systolic volume (ESVI) and indexed end-diastolic volume (EDVI) values measured at follow-up with P values of 0.438 and 0.389, respectively. MVO size was found to be a significant factor affecting the patient’s outcome (P = 0.000) where MVO size of > 10% of the total LVM can be a predictor of a worse outcome and reduced EF% at follow-up.
Conclusion
The prognostic value of MVO could be statistically determined with a cut off value to predict a possible good outcome using CMR.
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Ghanavat M, Haybar H, Pezeshki SMS, Shahjahani M, Jodat H, Elyasi M, Saki N. Cardiomyopathy in Thalassemia: Quick Review from Cellular Aspects to Diagnosis and Current Treatments. Lab Med 2020; 51:143-150. [PMID: 32155272 DOI: 10.1093/labmed/lmz052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cardiomyopathic manifestations induced by continuous blood transfusion are the leading cause of death among patients with thalassemia major (TM). Despite introduction of chelation therapy, heart failure after cardiomyopathic manifestations is still a major threat to patients. METHODS We performed a search of relevant English-language literature, retrieving publications from the PubMed database and the Google Scholar search engine (2005-2018). We used "thalassemia major", "cardiomyopathy", "iron overload", "cardiac magnetic resonance T2" "chelation therapy", and "iron burden" as keywords. RESULTS The results of the studies we found suggest that cardiac hepcidin is a major regulator of iron homeostasis in cardiac tissue. Unlike previous assumptions, the heart appears to have a limited regeneration capability, originating from a small population of hypoxic cardiomyocytes. CONCLUSIONS Oxygen levels determine cardiomyocyte gene-expression patterns. Upregulation of cardiac hepcidin in hypoxia preserves cardiomyocytes from forming out of reactive oxygen species catalyzed by free cellular iron in cardiomyocytes. Using the limited regeneration capacity of cardiac cells and gaining further understanding of the cellular aspects of cardiomyopathic manifestations may help health care professionals to develop new therapeutic strategies.
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Affiliation(s)
- Majid Ghanavat
- Child Growth & Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Habib Haybar
- Atherosclerosis Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyed Mohammad Sadegh Pezeshki
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Shahjahani
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hosein Jodat
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Milad Elyasi
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Najmaldin Saki
- Child Growth & Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.,Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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8
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Shehata SM, Amin MI, Zidan ESH. MRI evaluation of hepatic and cardiac iron burden in pediatric thalassemia major patients: spectrum of findings by T2*. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0044-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Iron deposition distorts the local magnetic field exerting T2* signal decay. Biopsy, serum ferritin, echocardiography are not reliable to adjust iron chelation therapy. Quantified MRI signal decay can replace biopsy to diagnose iron burden, guide treatment, and follow up. The objective of this study is to evaluate the role of T2* in quantification of the liver and heart iron burden in thalassemia major patients. This cross-sectional study included 44 thalassemia patients who were referred to MRI unit, underwent T2* MRI.
Results
Twenty-one male (47.7%) and 23 female (52.3%) were included (age range 6–15 years, mean age 10.9 ± 2.9 years). Patients with excess hepatic iron show the following: 11/40 (27.5%) mild, (13/40) 32.5% moderate, and (14/40) 35% severe liver iron overload. High statistical significance regarding association between LIC and liver T2* (p = 0.000) encountered. Cardiac T2* values showed no relationship with age (p = 0.6).
Conclusion
T2* is a good method to quantify, monitor hepatic and myocardial iron burden, guiding chelation therapy and prevent iron-induced cardiac complications.
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Woei-A-Jin FJSH, Zheng SZ, Kiliçsoy I, Hudig F, Luelmo SAC, Kroep JR, Lamb HJ, Osanto S. Lifetime Transfusion Burden and Transfusion-Related Iron Overload in Adult Survivors of Solid Malignancies. Oncologist 2019; 25:e341-e350. [PMID: 32043782 DOI: 10.1634/theoncologist.2019-0222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 07/31/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Limited data exist on transfusion burden and transfusion-related iron overload in adult survivors of solid malignancies. METHODS Hospital-specific cancer registry data of patients with solid tumor receiving systemic anticancer treatment between January 2008 and September 2009 at the Oncology Department of the Leiden University Medical Center (The Netherlands) were retrieved and cross-referenced with red blood cell (RBC) transfusion records. Individual lifetime transfusion burden was captured in April 2015. Multitransfused long-term survivors with serum ferritin >500 μg/L were subsequently screened for hepatic and cardiac iron overload using 1.5 Tesla magnetic resonance imaging. RESULTS The study population consisted of 775 adult patients with solid cancer (45.2% male; median age, 58 years; >75% chemotherapy-treated), 423 (54.6%) of whom were transfused with a median of 6.0 RBC units (range 1-67). Transfusion triggers were symptomatic anemia or hemoglobin <8.1-8.9 g/dL prior to each myelosuppressive chemotherapy cycle. We identified 123 (15.9%) patients across all tumor types with a lifetime transfusion burden of ≥10 RBC units. In the absence of a hemovigilance program, none of these multitransfused patients was screened for iron overload despite a median survival of 4.6 years. In 2015 at disclosure of transfusion burden, 26 multitransfused patients were alive. Six (23.1%) had hepatic iron overload: 3.9-11.2 mg Fe/g dry weight. No cardiac iron depositions were found. CONCLUSION Patients with solid malignancies are at risk for multitransfusion and iron overload even when adhering to restrictive RBC transfusion policies. With improved long-term cancer survivorship, increased awareness of iatrogenic side effects of supportive therapy and development of evidence-based guidelines are essential. IMPLICATIONS FOR PRACTICE In the presence of a restrictive transfusion policy, ∼30% of transfused adult patients with solid cancer are multitransfused and ∼50% become long-term survivors, underscoring the need for evidence-based guidelines for the detection and management of transfusion-related iron overload in this group of patients. In each institution, a hemovigilance program should be implemented that captures the lifetime cumulative transfusion burden in all patients with cancer, irrespective of tumor type. This instrument will allow timely assessment and treatment of iron overload in cancer survivors, thus preventing organ dysfunction and decreased quality of life.
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Affiliation(s)
- F J Sherida H Woei-A-Jin
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Laboratory of Clinical Chemistry and Hematology, Haga Hospital, The Hague, The Netherlands
| | - Shu Zhen Zheng
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Inci Kiliçsoy
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Francisca Hudig
- Department of Laboratory of Clinical Chemistry and Hematology, Haga Hospital, The Hague, The Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Susanne Osanto
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Khaled A, Ezzat DA, Salem HA, Seif HM, Rabee H. Effective method of evaluating myocardial iron concentration in pediatric patients with thalassemia major. J Blood Med 2019; 10:227-233. [PMID: 31372080 PMCID: PMC6636185 DOI: 10.2147/jbm.s204848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/08/2019] [Indexed: 12/02/2022] Open
Abstract
Background The use of T2* magnetic resonance imaging (MRI) has been promoted by recent studies as a noninvasive method for the detection of iron overload in thalassemia major patients. This study aims to estimate the iron load in the heart and liver of thalassemia major patients using T2* MRI and to determine its correlation with the left ventricle ejection fraction and serum ferritin level. Methods Forty β-Thalassemia major patients were included in the study. We evaluated the serum ferritin level, echocardiography, cardiac T2*, myocardial iron concentration (MIC), liver iron concentration (LIC) and hepatic T2* in all patients. CMR T2* findings were categorized as normal cardiac T2* (T2* >20 ms) or abnormal cardiac T2* (T2* <20 ms). Results The study found that 85% of patients had a normal cardiac T2* value. The median serum ferritin level was 2189. A significant inverse correlation was found between the serum ferritin level and the cardiac T2* (r=−0.381, =0.015); however, the correlations between serum ferritin and the hepatic T2* and liver iron concentration were statistically non-significant (P=0.539 and P=0.637, respectively). Additionally, the LVEF correlation was statistically non-significant with SF, hepatic T2* and cardiac T2*. Conclusion Regardless of the serum ferritin level or left ventricle function, a cardiac T2* MRI should be done for all patients with β-Thalassemia major in order to estimate the myocardial iron concentration.
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Affiliation(s)
- Arwa Khaled
- Department Of Clinical Pharmacy, Beni-Suef University Hospital, Beni-Suef University, Beni Suef, Egypt
| | - Dina A Ezzat
- Department of Pediatrics and Pediatric Hematology, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt
| | - Hoda A Salem
- Department of Clinical Pharmacy, Faculty of Pharmacy, Al - Azhar University, Girl Branch, Cairo, Egypt
| | - Hadeel M Seif
- Department of Radiology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hoda Rabee
- Department of Clinical Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni Suef, Egypt
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Ngim CF, Lee MY, Othman N, Lim SM, Ng CS, Ramadas A. Prevalence and Risk Factors for Cardiac and Liver Iron Overload in Adults with Thalassemia in Malaysia. Hemoglobin 2019; 43:95-100. [PMID: 31179787 DOI: 10.1080/03630269.2019.1599906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We explored the severity and risk factors for cardiac and liver iron overload (IOL) in 69 thalassemia patients who underwent T2* magnetic resonance imaging (T2* MRI) in a Malaysian tertiary hospital from 2011 to 2015. Fifty-three patients (76.8%) had transfusion-dependent thalassemia (TDT) and 16 (23.2%) had non transfusion-dependent thalassemia (NTDT). Median serum ferritin prior to T2* MRI was 3848.0 μg/L (TDT) and 3971.0 μg/L (NTDT). Cardiac IOL was present in 16 (30.2%) TDT patients and two (12.5%) NTDT patients, in whom severe cardiac IOL defined as T2* <10 ms affected six (11.3%) TDT patients. Liver IOL was present in 51 (96.2%) TDT and 16 (100%) NTDT patients, 37 (69.8%) TDT and 13 (81.3%) NTDT patients were in the most severe category (>15 mgFe/gm dry weight). Serum ferritin showed a significantly strong negative correlation with liver T2* in both TDT (rs = -0.507, p = 0.001) and NTDT (r = -0.762, p = 0.002) but no correlation to cardiac T2* in TDT (r = -0.252, p = 0.099) as well as NTDT (r = -0.457, p = 0.100). For the TDT group, regression analysis showed that cardiac IOL was more severe in males (p = 0.022) and liver IOL was more severe in the Malay ethnic group (p = 0.028) and those with higher serum ferritin levels (p = 0.030). The high prevalence of IOL in our study and the poor correlation between serum ferritin and cardiac T2* underline the need to routinely screen thalassemia patients using T2* MRI to enable the early detection of cardiac IOL.
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Affiliation(s)
- Chin F Ngim
- a Jeffrey Cheah School of Medicine and Health Sciences , Monash University Malaysia , Johor Bahru , Malaysia
| | - Mei Y Lee
- a Jeffrey Cheah School of Medicine and Health Sciences , Monash University Malaysia , Johor Bahru , Malaysia
| | - Norliza Othman
- b Department of Radiology , Hospital Sultanah Aminah Johor Bahru , Johor Bahru , Malaysia
| | - Soo M Lim
- c Haematology Unit, Department of Medicine , Hospital Sultanah Aminah Johor Bahru , Johor Bahru , Malaysia
| | - Chen S Ng
- d Department of Nuclear Medicine , Hospital Sultanah Aminah Johor Bahru , Johor Bahru , Malaysia
| | - Amutha Ramadas
- a Jeffrey Cheah School of Medicine and Health Sciences , Monash University Malaysia , Johor Bahru , Malaysia
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12
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Patel H. Presidential address. Indian J Radiol Imaging 2019; 29:4-5. [PMID: 31000934 PMCID: PMC6467027 DOI: 10.4103/ijri.ijri_73_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hemant Patel
- President Elect, Indian Radiological and Imaging Association (IRIA), Consultant & Director, Gujarat Imaging Centre, Postgraduate Institute of Radiology and Imaging, Samved Hospital, Navarangpura, Ahmedabad - 380 009, Gujarat, India
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13
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Affiliation(s)
- Robert C Hider
- From the Institute of Pharmaceutical Science, King's College London (R.C.H.), and the Department of Haematology, Royal Free Hospital (A.V.H.) - both in London
| | - A Victor Hoffbrand
- From the Institute of Pharmaceutical Science, King's College London (R.C.H.), and the Department of Haematology, Royal Free Hospital (A.V.H.) - both in London
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14
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Werner S, Krauss B, Haberland U, Bongers M, Starke U, Bakchoul T, Enkel S, Nikolaou K, Horger M. Dual-energy CT for liver iron quantification in patients with haematological disorders. Eur Radiol 2018; 29:2868-2877. [DOI: 10.1007/s00330-018-5785-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/28/2018] [Accepted: 09/20/2018] [Indexed: 12/22/2022]
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Mancuso L, Vitrano A, Mancuso A, Sacco M, Ledda A, Maggio A. Left Ventricular Diastolic Dysfunction in β-Thalassemia Major with Heart Failure. Hemoglobin 2018; 42:68-71. [PMID: 29633668 DOI: 10.1080/03630269.2018.1451341] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
We studied the clinical, electrocardiographic, echocardiographic, Doppler and T2* cardiac magnetic resonance (CMR) data of all adult β-thalassemia major (β-TM) patients with heart failure (HF) consecutively observed at our referral center of the Sicilian region between 2008 and 2016. There were 16 patients enrolled in the study. Echocardiographic examination showed that only one patient had HF with systolic dysfunction of the left ventricle (HFrEF), whereas the others had HF with preserved systolic function of the left ventricle (HFpEF). Systolic dysfunction of the right ventricle (RV) was observed in 13 cases. Furthermore, 30.0% of the patients presented T2* CMR values consistent with intermediate risk of systolic dysfunction of the left ventricle (LV) due to iron overload, whereas 70.0% had normal values. Typical electrocardiographic abnormalities (wide T wave inversion and low voltages) were observed in 11 out of 16 patients. In conclusion, in the adult β-TM patients with HF recently observed at our center, the predominant form was that with diastolic dysfunction of the LV, and with systolic dysfunction of the RV. Only 30.0% had low values of T2* CMR. Typical electrocardiographic abnormalities were found in 69.0%.
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Affiliation(s)
- Luigi Mancuso
- a Franco and Piera Cutino Campus di Ematologia , Ospedali Riuniti Villa Sofia-V. Cervello , Palermo Italia
| | - Angela Vitrano
- a Franco and Piera Cutino Campus di Ematologia , Ospedali Riuniti Villa Sofia-V. Cervello , Palermo Italia
| | - Andrea Mancuso
- b Medicina Interna, Azienda di Rilievo Nazionale ad Alta Specializzazione (ARNAS) Civico , Palermo , Italia.,c Epatologia e Gastroenterologia, Ospedale Niguarda Ca' Granda , Milano , Italia
| | - Massimiliano Sacco
- a Franco and Piera Cutino Campus di Ematologia , Ospedali Riuniti Villa Sofia-V. Cervello , Palermo Italia
| | - Antonietta Ledda
- d Cardiologia, Ospedali Riuniti Villa Sofia-V. Cervello , Palermo , Italia
| | - Aurelio Maggio
- a Franco and Piera Cutino Campus di Ematologia , Ospedali Riuniti Villa Sofia-V. Cervello , Palermo Italia
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Siri-Angkul N, Chattipakorn SC, Chattipakorn N. Diagnosis and treatment of cardiac iron overload in transfusion-dependent thalassemia patients. Expert Rev Hematol 2018; 11:471-479. [DOI: 10.1080/17474086.2018.1476134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Natthaphat Siri-Angkul
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
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Saunthararajah Y, Vichinsky EP. Sickle Cell Disease. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00042-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Paisant A, d'Assignies G, Bannier E, Bardou-Jacquet E, Gandon Y. MRI for the measurement of liver iron content, and for the diagnosis and follow-up of iron overload disorders. Presse Med 2017; 46:e279-e287. [PMID: 29133084 DOI: 10.1016/j.lpm.2017.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 10/04/2017] [Accepted: 10/04/2017] [Indexed: 01/19/2023] Open
Abstract
MRI is now the reference method for detecting and quantifying hepatic and extrahepatic iron overload, regardless of its cause. The decrease of the hepatic signal is proportional to the amount of iron in the tissues. It is more pronounced with T2*-weighted gradient echo sequences. It increases proportionally with the strength of the magnetic field. Thus a 3-T MRI is be more sensitive and probably more accurate to detect a slight iron overload, as seen in dysmetabolic hepatosiderosis. Conversely, a 1.5-T MRI better estimates a high overload. Quantification can be done with the calculation of T2* (or R2*) or by using the liver to muscle signal intensity ratio (SIR). Today with a single multi-echo gradient-echo sequence, obtained in a unique apnea, the two methods can be used simultaneously. An associated quantification of steatosis is also obtained. This same type of sequence is proposed for quantification of iron in other tissues and in particular for the myocardium.
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Affiliation(s)
- Anita Paisant
- CHU de Rennes, service de radiologie, 35033 Rennes, France
| | | | - Elise Bannier
- CHU de Rennes, service de radiologie, 35033 Rennes, France
| | | | - Yves Gandon
- CHU de Rennes, service de radiologie, 35033 Rennes, France.
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Wahidiyat PA, Liauw F, Sekarsari D, Putriasih SA, Berdoukas V, Pennell DJ. Evaluation of cardiac and hepatic iron overload in thalassemia major patients with T2* magnetic resonance imaging. Hematology 2017; 22:501-507. [PMID: 28218005 DOI: 10.1080/10245332.2017.1292614] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES Recent advancements have promoted the use of T2* magnetic resonance imaging (MRI) in the non-invasive detection of iron overload in various organs for thalassemia major patients. This study aims to determine the iron load in the heart and liver of patients with thalassemia major using T2* MRI and to evaluate its correlation with serum ferritin level and iron chelation therapy. METHODS This cross-sectional study included 162 subjects diagnosed with thalassemia major, who were classified into acceptable, mild, moderate, or severe cardiac and hepatic iron overload following their T2* MRI results, respectively, and these were correlated to their serum ferritin levels and iron chelation therapy. RESULTS The study found that 85.2% of the subjects had normal cardiac iron stores. In contrast, 70.4% of the subjects had severe liver iron overload. A significant but weak correlation (r = -0.28) was found between cardiac T2* MRI and serum ferritin, and a slightly more significant correlation (r = 0.37) was found between liver iron concentration (LIC) and serum ferritin. DISCUSSION The findings of this study are consistent with several other studies, which show that patients generally manifest with liver iron overload prior to cardiac iron overload. Moreover, iron accumulation demonstrated by T2* MRI results also show a significant correlation to serum ferritin levels. CONCLUSION This is the first study of its kind conducted in Indonesia, which supports the fact that T2* MRI is undoubtedly valuable in the early detection of cardiac and hepatic iron overload in thalassemia major patients.
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Affiliation(s)
- Pustika Amalia Wahidiyat
- a Pediatric Hematology-Oncology Division, Department of Child Health, Faculty of Medicine , Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital , Jakarta , Indonesia
| | - Felix Liauw
- b Department of Child Health, Faculty of Medicine , Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital , Jakarta , Indonesia
| | - Damayanti Sekarsari
- c Department of Radiology, Faculty of Medicine , Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital , Jakarta , Indonesia
| | - Siti Ayu Putriasih
- b Department of Child Health, Faculty of Medicine , Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital , Jakarta , Indonesia
| | - Vasili Berdoukas
- d University of Southern California, Keck School of Medicine Children's Hospital , Los Angeles , USA
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Black-blood T2* mapping with delay alternating with nutation for tailored excitation. Magn Reson Imaging 2017; 40:91-97. [DOI: 10.1016/j.mri.2017.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 04/17/2017] [Accepted: 04/20/2017] [Indexed: 02/05/2023]
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Hasiloglu ZI, Asik M, Ure E, Ertem F, Apak H, Albayram S. The utility of susceptibility-weighted imaging to evaluate the extent of iron accumulation in the choroid plexus of patients with β-thalassaemia major. Clin Radiol 2017; 72:903.e1-903.e7. [PMID: 28502664 DOI: 10.1016/j.crad.2017.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 12/20/2016] [Accepted: 04/11/2017] [Indexed: 01/09/2023]
Abstract
AIM To assess iron accumulation in the choroid plexus of β-thalassaemia patients using fast spin echo (FSE) T2-weighted, gradient echo (GRE) T2*-weighted, susceptibility-weighted imaging (SWI) and compare the results. MATERIALS AND METHODS Eighteen patients with transfusion-dependent β-thalassaemia and the control group underwent magnetic resonance imaging (MRI) examinations. Signal intensities were separately evaluated using a "number of hypointensity in the choroid plexus" (NHICP) grading system on axial FSE T2-weighted, GRE T2*-weighted, and SWI images. The NHICP grading system scores were compared using the chi-squared test. Spearman's correlation analysis was used to explore relationships between the variables and NHICP grading system scores. RESULTS The sensitivity of each technique was calculated: FSE T2-weighted imaging=0.17, GRE T2*-weighted imaging=0.48, and SWI=0.81. Three-sample test for equality of proportions showed that chi-squared=74.85, df=2, p<0.0001. All of the FSE T2-weighted, GRE T2*-weighted, and SWI images differed significantly in terms of their capacity to reveal iron accumulation in the choroid plexus. Of the three methods, SWI was the most sensitive. CONCLUSIONS SWI is useful for revealing iron deposition in the brains of β-thalassaemia patients, especially those in the early stages of disease, and it can be used to predict disease prognosis. The present study contributes to an understanding of the important role played by the choroid plexus in brain iron metabolism.
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Affiliation(s)
- Z I Hasiloglu
- Department of Radiology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey.
| | - M Asik
- Department of Radiology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey
| | - E Ure
- Department of Radiology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey
| | - F Ertem
- Istanbul University, Istanbul Medical School, Fatih, Istanbul, Turkey
| | - H Apak
- Department of Pediatrics, Division of Haematology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey
| | - S Albayram
- Department of Radiology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey
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Guzelbey T, Gurses B, Ozturk E, Ozveren O, Sarsilmaz A, Karasu E. Evaluation of Iron Deposition in the Adrenal Glands of β Thalassemia Major Patients Using 3-Tesla MRI. IRANIAN JOURNAL OF RADIOLOGY 2016; 13:e36375. [PMID: 27853501 PMCID: PMC5107262 DOI: 10.5812/iranjradiol.36375] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 02/25/2016] [Accepted: 03/29/2016] [Indexed: 11/16/2022]
Abstract
Background Beta-thalassemia major (β-TM) patients need blood transfusions, which result in iron deposition. To regulate chelation therapy, iron load has to be measured. With MRI, the amount of signal loss and T2* decay time shortening are used for iron quantification. Objectives The aim was to measure adrenal iron load with T2* relaxometry using MRI, and to compare it with liver and cardiac iron and serum ferritin, and to find out whether adrenal iron could be predicted from those parameters. Patients and Methods Between October 2014 and March 2015, MRI was performed in 21 patients with β-TM, recieving blood transfusions and chelation therapy. The control group (n = 11) included healthy volunteers with no known history of adrenal, hematologic, chronic disease, and blood transfusion. Results Among patients, there was no significant correlation between plasma ferritin and adrenal T2*. Significant difference was detected among T2* values of adrenals between the patient and control groups. There was no significant correlation between adrenal gland and liver T2* in β-TM patients, moderate correlation was detected between adrenal T2* and cardiac T2*. Conclusion Adrenal iron in β-TM can be reliably measured in 3 Tesla MRI. The results highlight the absence of correlation between adrenal iron deposition both with serum ferritin and hepatic iron.
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Affiliation(s)
- Tevfik Guzelbey
- Department of Radiology, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Bengi Gurses
- Department of Radiology, School of Medicine, Koc University, Istanbul, Turkey
- Corresponding author: Bengi Gurses, Department of Radiology, School of Medicine, Koc University, Istanbul, Turkey, E-mail:
| | - Erman Ozturk
- Department of Hematology, School of Medicine, Koc University, Istanbul, Turkey
| | - Olcay Ozveren
- Department of Cardiology, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Aysegul Sarsilmaz
- Department of Radiology, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Ebru Karasu
- Department of Radiology, School of Medicine, Yeditepe University, Istanbul, Turkey
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Myocardial and liver iron overload, assessed using T2* magnetic resonance imaging with an excel spreadsheet for post processing in Tunisian thalassemia major patients. Ann Hematol 2016; 96:133-139. [PMID: 27730342 DOI: 10.1007/s00277-016-2841-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
Thalassemia is a common genetic disorder in Tunisia. Early iron concentration assessment is a crucial and challenging issue. Most of annual deaths due to iron overload occurred in underdeveloped regions of the world. Limited access to liver and heart MRI monitoring might partially explain these poor prognostic results. Standard software programs are not available in Tunisia. This study is the first to evaluate iron overload in heart and liver using the MRI T2* with excel spreadsheet for post processing. Association of this MRI tool results to serum ferritin level, and echocardiography was also investigated. One hundred Tunisian-transfused thalassemia patients older than 10 years (16.1 ± 5.2) were enrolled in the study. The mean myocardial iron concentration (MIC) was 1.26 ± 1.65 mg/g dw (0.06-8.32). Cardiac T2* (CT2*) was under 20 ms in 30 % of patients and under 10 ms in 21 % of patients. Left ventricular ejection function was significantly lower in patients with CT2* <10 ms. Abnormal liver iron concentration (LIC >3 mg/g dw) was found in 95 % of patients. LIC was over 15 mg/g dw in 25 % of patients. MIC was more correlated than CT2* to LIC and serum ferritin. Among patients with SF <1000 μg/l, 13 % had CT2* <20 ms. Our data showed that 30 % of the Tunisian thalassemia major patients enrolled in this cohort had myocardial iron overload despite being treated by iron chelators. SF could not reliably predict iron overload in all thalassemia patients. MRI T2* using excel spreadsheet for routine follow-up of iron overload might improve the prognosis of thalassemia major patients in developing countries, such as Tunisia, where standard MRI tools are not available or expensive.
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Petrakos G, Andriopoulos P, Tsironi M. Pregnancy in women with thalassemia: challenges and solutions. Int J Womens Health 2016; 8:441-51. [PMID: 27660493 PMCID: PMC5019437 DOI: 10.2147/ijwh.s89308] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Advances in treatment of thalassemia have led to the aging of thalassemic patients, and consequently concern about successful reproductive outcome is augmented. Although women with thalassemia intermedia only were considered competent of achieving pregnancy, case series reveal the willingness of both thalassemia major and thalassemia intermedia women to have a family. Pregnancy in general is characterized by dynamic multiple-system changes and increased susceptibility to oxidative stress, while homozygous, transfusion-dependent, β-thalassemia patients manifest cardiac, hepatic, endocrine, and metabolic disorders attributable to chronic anoxia and iron overload and thalassemia intermedia, usually nontransfused, is associated with augmented risk of thromboembolic events. Pregnancy in thalassemia should be considered a high risk for both mother and fetus, and favorable outcomes are the result of continuous preconception, antenatal, and postpartum assessment and management by a team of thalassemia experts.
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Affiliation(s)
- George Petrakos
- Department of Nursing, University of Peloponnese, Sparta, Greece
| | | | - Maria Tsironi
- Department of Nursing, University of Peloponnese, Sparta, Greece
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Martin M, Haines D. Clinical Management of Patients With Thalassemia Syndromes. Clin J Oncol Nurs 2016; 20:310-7. [DOI: 10.1188/16.cjon.310-317] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Correlation of N-terminal pro-B-type natriuretic peptide levels and cardiac magnetic resonance imaging T2* in patients with β-thalassaemia major. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:516-520. [PMID: 27136436 DOI: 10.2450/2016.0120-15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cardiac death secondary to myocardial iron toxicity occurs in 50% of patients with transfusion-dependent β-thalassaemia major. N-terminal pro-B-type natriuretic peptide (NT-proBNP) seems to be a useful tool for early detection of cardiac haemosiderosis. We designed this study to determine whether plasma NT-proBNP levels are predictive of cardiac iron concentration, based on heart T2* assessment by magnetic resonance imaging (MRI). MATERIALS AND METHODS We evaluated plasma NT-proBNP levels in 50 patients with β-thalassaemia major, aged 18 to 46 years, with preserved left ventricular systolic function, all of whom had undergone cardiac MRI within 3 months before the study. Next, three groups were defined based on heart T2* value as: group A, patients without evidence of cardiac iron overload (T2*>20 ms); group B, patients with mild to moderate cardiac iron overload (10 ms<T2*<20 ms); group C, patients with severe cardiac iron overload (T2*<10 ms). RESULTS NT-proBNP level was not similar among the three groups (p=0.03), being significantly higher in patients in group C (1,104.2±350.5 pg/mL) than in patients in group B (565.9±116.9 pg/mL, p=0.03) or group A (563.5±162.5 pg/mL, p=0.04). The analyses indicate that NT-proBNP levels did not correlate with cardiac iron concentrations (r=0.152, p=0.148). DISCUSSION Based on our study, measurements of NT-proBNP levels are not sufficient for early detection of cardiac iron overload. However, NT-proBNP measurements might be used as a tool to guide iron chelation therapy in patients with severe cardiac iron overload. The determination of their clinical use still requires multicentre studies.
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Quinn CT, St Pierre TG. MRI Measurements of Iron Load in Transfusion-Dependent Patients: Implementation, Challenges, and Pitfalls. Pediatr Blood Cancer 2016; 63:773-80. [PMID: 26713769 PMCID: PMC5064750 DOI: 10.1002/pbc.25882] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 01/19/2023]
Abstract
Magnetic resonance imaging (MRI) has played a key role in studies of iron overload in transfusion-dependent patients, providing insights into the relations among liver and cardiac iron loading, iron chelator dose, and morbidity. Currently, there is rapid uptake of these methods into routine clinical practice as part of the management strategy for iron overload in regularly transfused patients. Given the manifold methods of data acquisition and analysis, there are several potential pitfalls that may result in inappropriate decision making. Herein, we review the challenges of establishing suitable MRI techniques for tissue iron measurement in regularly transfused patients.
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Affiliation(s)
- Charles T. Quinn
- Division of HematologyCincinnati Children's Hospital Medical CenterCincinnatiOhio
| | - Tim G. St Pierre
- School of PhysicsThe University of Western AustraliaCrawleyAustralia
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Yuksel IO, Koklu E, Kurtoglu E, Arslan S, Cagirci G, Karakus V, Kus G, Cay S, Kucukseymen S. The Association between Serum Ferritin Level, Tissue Doppler Echocardiography, Cardiac T2* MRI, and Heart Rate Recovery in Patients with Beta Thalassemia Major. ACTA CARDIOLOGICA SINICA 2016; 32:231-8. [PMID: 27122954 DOI: 10.6515/acs20150824a] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND It is generally well-understood that iron-mediated cardiomyopathy is the major complication that can arise from beta thalassemia major (TM). Therefore, early diagnosis, risk stratification, and the effective treatment of beta TM patients are clinically important to optimize long-term positive outcomes. METHODS This study included 57 beta TM patients with a mean age of 25 ± 7 years. We determined the serum ferritin level, echocardiography, heart rate recovery (HRR), and cardiac magnetic resonance (CMR) T2* in all patients. CMR T2* findings were categorized as normal myocardium (T2* > 20 ms), and myocardial involvement (T2* ≤ 20 ms). HRR values at 1-5 min (HRR1-5) were recorded; Subsequently. HRR was calculated by subtracting the heart rate at each time point from the heart rate at peak exercise. RESULTS There was a significant negative correlation between the serum ferritin level and the cardiac T2* MRI findings (r = -0.34, p = 0.009). A similar result was found in the negative correlation between serum ferritin and all heart rate recovery values. There was a significant positive correlation between HRR1, HRR2, and HRR3 values, and CMR T2* (T2* heart rate recovery (HRR)1: r = 0.51, p < 0.001; T2* HRR2: r = 0.48, p < 0.001; T2* HRR3: r = 0.47, p < 0.001, respectively). CONCLUSIONS The serum ferritin level and echocardiography can be used to predict the presence of myocardial iron load in beta TM patients. Therefore, HRR can be used to screen beta TM patients, and the clinical use of HRR can be a predictive marker for autonomic dysfunction in beta TM patients. KEY WORDS Beta thalassemia major • Cardiac magnetic resonance T2* • Heart rate recovery • Iron overload • Serum ferritin level • Tissue Doppler imaging.
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Affiliation(s)
| | | | - Erdal Kurtoglu
- Department of Haematology, Antalya Education and Research Hospital
| | | | | | - Volkan Karakus
- Department of Haematology, Antalya Education and Research Hospital
| | | | - Serkan Cay
- Department of Cardiology, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
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Chen X, Zhang H, Yang Q, Luo Z, Zhang Z, Cheng Z, Mao J, Chan Q, Xu H, Liang B, Guo H. Value of severe liver iron overload for assessing heart iron levels in thalassemia major patients. J Magn Reson Imaging 2016; 44:880-9. [PMID: 27038128 DOI: 10.1002/jmri.25238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/29/2016] [Indexed: 11/11/2022] Open
Abstract
PURPOSE The relationship between severe liver iron overload (LIO) and heart iron overload (HIO) in transfusion-dependent patients with thalassemia major (TM) is uncertain. Whether severe LIO can serve as an index for assessing heart iron deposition has vital clinical significance. Therefore, our aim is to determine if a close relationship exists between severe LIO and HIO. MATERIALS AND METHODS We examined 110 TM patients who underwent T2* measurement in the liver and heart on a 1.5 Tesla MRI scanner. Various statistical analysis methods were used to assess the relationship. RESULTS Most of these patients suffered from severe LIO (58.18%, liver T2* < 1.4 ms). Both Pearson's and Spearman's tests showed a significant correlation between liver T2* and heart T2* values (with a correlation coefficient of 0.408 and 0.550, respectively, both P < 0.0001). A nonlinear model, with the equation of Heart T2* = 37.974-17.684 / Liver T2*, was found to be the best model to indicate the relationship between liver T2* and heart T2*. Receiver operating characteristic (ROC) analysis showed the area under the ROC curve of liver T2* and serum ferritin for predicting HIO was 0.812 (95% confidence interval [CI]: 0.731-0.892; P < 0.0001) and 0.69 (95% CI: 0.585-0.795; P = 0.001), respectively. CONCLUSION Our preliminary data suggest the existence of a close relationship between severe LIO and HIO. High liver iron levels appear to increase the risk of heart iron deposition. This further supports the concept of critical liver iron concentration, above which elevated heart iron is present. J. MAGN. RESON. IMAGING 2016;44:880-889.
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Affiliation(s)
- Xiaodong Chen
- Department of Radiology, Affiliated hospital of Guangdong Medical College, Guangdong, China.,Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Hui Zhang
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Qihua Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zebin Luo
- Department of Radiology, Affiliated hospital of Guangdong Medical College, Guangdong, China
| | - Zuoquan Zhang
- Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-Sen University, Guangdong, China
| | - Ziliang Cheng
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jiaji Mao
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | | | - Honggui Xu
- Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Biling Liang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Hua Guo
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China.
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De Sanctis V, Soliman AT, Elsedfy H, Pepe A, Kattamis C, El Kholy M, Yassin M. Diabetes and Glucose Metabolism in Thalassemia Major: An Update. Expert Rev Hematol 2016; 9:401-8. [DOI: 10.1586/17474086.2016.1136209] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Ricchi P, Meloni A, Spasiano A, Neri MG, Gamberini MR, Cuccia L, Caruso V, Gerardi C, D'Ascola DG, Rosso R, Campisi S, Rizzo M, Terrazzino F, Vangosa AB, Chiodi E, Missere M, Mangione M, Positano V, Pepe A. Extramedullary hematopoiesis is associated with lower cardiac iron loading in chronically transfused thalassemia patients. Am J Hematol 2015; 90:1008-12. [PMID: 26228763 DOI: 10.1002/ajh.24139] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/22/2015] [Accepted: 07/27/2015] [Indexed: 02/02/2023]
Abstract
The aim of this study was to evaluate, in a large cohort of chronically transfused patients, whether the presence of extramedullary hematopoiesis (EMH) accounts for the typical patterns of cardiac iron distribution and/or cardiac function parameters. We retrospectively selected 1,266 thalassemia major patients who had undergone regular transfusions (611 men and 655 women; mean age: 31.3 ± 8.9 years, range: 4.2-66.6 years) and were consecutively enrolled within the Myocardial Iron Overload in Thalassemia network. The presence of EMH was evaluated based on steady-state free precession sequences; cardiac and liver iron overloads were quantified using a multiecho T2* approach; cardiac function parameters and pulmonary diameter were quantified using the steady-state free precession sequences; and myocardial fibrosis was evaluated using the late gadolinium enhancement technique. EMH was detected in 167 (13.2%) patients. The EMH+ patients had significantly lower cardiac iron overload than that of the EMH- patients (P = 0.003). The patterns of cardiac iron distribution were significantly different in the EMH+ and EMH- patients (P < 0.0001), with a higher prevalence of patients with no myocardial iron overload and heterogeneous myocardial iron overload and no significant global heart iron in the EMH+ group EMH+ patients had a significantly higher left ventricle mass index (P = 0.001) and a significantly higher pulmonary artery diameter (P = 0.002). In conclusion, in regularly transfused thalassemia patients, EMH was common and was associated with a thalassemia intermedia-like pattern of cardiac iron deposition despite regular transfusion therapy.
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Affiliation(s)
- Paolo Ricchi
- Unità Operativa Semplice Dipartimentale Malattie Rare Del Globulo Rosso; Azienda Ospedaliera Di Rilievo Nazionale “a. Cardarelli,”; Napoli Italy
| | - Antonella Meloni
- CMR Unit, Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
- U.O.C. Bioingegneria E Ingegneria Clinica, Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare Del Globulo Rosso; Azienda Ospedaliera Di Rilievo Nazionale “a. Cardarelli,”; Napoli Italy
| | | | - Maria Rita Gamberini
- Dipartimento Della Riproduzione E Dell'accrescimento; Day Hospital Della Talassemia E Delle Emoglobinopatie, Azienda Ospedaliero-Universitaria Arcispedale “S. Anna,”; Ferrara Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia Con Talassemia; ARNAS Civico “Benfratelli-Di Cristina,”; Palermo Italy
| | - Vincenzo Caruso
- Unità Operativa Dipartimentale Talassemia; Presidio Ospedaliero Garibaldi-Centro - ARNAS Garibaldi; Catania Italy
| | - Calogera Gerardi
- Presidio Ospedaliero “Giovanni Paolo II,”; Distretto AG2 Di Sciacca, Sciacca (AG); Italy
| | | | - Rosamaria Rosso
- Unità Operativa Talassemie Ed Emoglobinopatie; Ospedale “Ferrarotto” - Azienda Ospedaliero-Universitaria Policlinico “Vittorio Emanuele,”; Catania Italy
| | - Saveria Campisi
- Unità Operativa Semplice Talassemia; Presidio Ospedaliero “Umberto I,”; Siracusa Italy
| | - Michele Rizzo
- Reparto Di Ematologia; Ospedale “Sant'elia,”; altanisetta Italy
| | | | - Alessandra Briatico Vangosa
- Institute of Radiology; Department of Neuroscience and Imaging; Section of Diagnostic Imaging and Therapy-Radiology Division; “G. D'Annunzio” University; Chieti Italy
| | - Elisabetta Chiodi
- Dipartimento Di Diagnostica per Immagini E Medicina Di Laboratorio; Struttura Complessa Di Radiologia Diagnostica E Interventistica Interaziendale, Azienda Ospedaliero-Universitaria Arcispedale “S. Anna-Cona,”; Cona (FE) Italy
| | - Massimiliano Missere
- Dipartimento Di Immagini; Fondazione Di Ricerca E Cura “Giovanni Paolo II,”; Campobasso Italy
| | - Maurizio Mangione
- U.O.S. Sistemi Informatici, Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Vincenzo Positano
- CMR Unit, Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
- U.O.C. Bioingegneria E Ingegneria Clinica, Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Alessia Pepe
- CMR Unit, Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
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Abstract
With repeated blood transfusions, patients with thalassemia major rapidly become loaded with iron, often surpassing hepatic metal accumulation capacity within ferritin shells and infiltrating heart and endocrine organs. That pathological scenario contrasts with the physiological one, which is characterized by an efficient maintenance of all plasma iron bound to circulating transferrin, due to a tight control of iron ingress into plasma by the hormone hepcidin. Within cells, most of the acquired iron becomes protein-associated, as once released from endocytosed transferrin, it is used within mitochondria for the synthesis of protein prosthetic groups or it is incorporated into enzyme active centers or alternatively sequestered within ferritin shells. A few cell types also express the iron extrusion transporter ferroportin, which is under the negative control of circulating hepcidin. However, that system only backs up the major cell regulated iron uptake/storage machinery that is poised to maintain a basal level of labile cellular iron for metabolic purposes without incurring potentially toxic scenarios. In thalassemia and other transfusion iron-loading conditions, once transferrin saturation exceeds about 70%, labile forms of iron enter the circulation and can gain access to various types of cells via resident transporters or channels. Within cells, they can attain levels that exceed their ability to chemically cope with labile iron, which has a propensity for generating reactive oxygen species (ROS), thereby inducing oxidative damage. This scenario occurs in the heart of hypertransfused thalassemia major patients who do not receive adequate iron-chelation therapy. Iron that accumulates in cardiomyocytes forms agglomerates that are detected by T2* MRI. The labile forms of iron infiltrate the mitochondria and damage cells by inducing noxious ROS formation, resulting in heart failure. The very rapid relief of cardiac dysfunction seen after intensive iron-chelation therapy in some patients with thalassemia major is thought to be due to the relief of the cardiac mitochondrial dysfunction caused by oxidative stress or to the removal of labile iron interference with calcium fluxes through cardiac calcium channels. In fact, improvement occurs well before there is any significant improvement in the total level of cardiac iron loading. The oral iron chelator deferiprone, because of its small size and neutral charge, demonstrably enters cells and chelates labile iron, thereby rapidly reducing ROS formation, allowing better mitochondrial activity and improved cardiac function. Deferiprone may also rapidly improve arrhythmias in patients who do not have excessive cardiac iron. It maintains the flux of iron in the direction hemosiderin to ferritin to free iron, and it allows clearance of cardiac iron in the presence of other iron chelators or when used alone. To date, the most commonly used chelator combination therapy is deferoxamine plus deferiprone, whereas other combinations are in the process of assessment. In summary, it is imperative that patients with thalassemia major have iron chelators continuously present in their circulation to prevent exposure of the heart to labile iron, reduce cardiac toxicity, and improve cardiac function.
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Affiliation(s)
- Vasilios Berdoukas
- Section of Hematology, Division of Hematology, Oncology, and Blood & Marrow Transplantation, Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA.
| | - Thomas D Coates
- Section of Hematology, Division of Hematology, Oncology, and Blood & Marrow Transplantation, Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA
| | - Zvi Ioav Cabantchik
- Alexander Silberman Institute of Life Science, Hebrew University of Jerusalem, E Safra Campus at Givat Ram, Jerusalem 91904, Israel
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Borgna-Pignatti C, Marsella M. Iron Chelation in Thalassemia Major. Clin Ther 2015; 37:2866-77. [PMID: 26519233 DOI: 10.1016/j.clinthera.2015.10.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 01/19/2023]
Abstract
PURPOSE Iron chelation has improved survival and quality of life of patients with thalassemia major. there are currently 3 commercially available iron-chelating drugs with different pharmacokinetic and pharmacodynamic activity. The choice of adequate chelation treatment should be tailored to patient needs and based on up-to-date scientific evidence. METHODS A review of the most recent literature was performed. FINDINGS The ability of the chelators to bind the redox active component of iron, labile plasma iron, is crucial for protecting the cells. Chelation therapy should be guided by magnetic resonance imaging that permits the tailoring of therapy according to the needs of the patient because different chelators preferentially clear iron from different sites. Normal levels of body iron seem to decrease the need for hormonal and cardiac therapy. IMPLICATIONS The 3 chelators currently available have different benefits, different safety profiles, and different acceptance on the part of the patients. Good-quality, well-designed, randomized, long-term clinical trials continue to be needed.
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Affiliation(s)
| | - Maria Marsella
- Pediatrics and Adolescentology Unit, Maternal and Child Health Department, "G. Rummo" Hospital, Benevento, Italy
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Mokhtar GM, Sherif EM, Habeeb NM, Abdelmaksoud AA, El-Ghoroury EA, Ibrahim AS, Hamed EM. Glutathione S-transferase gene polymorphism: Relation to cardiac iron overload in Egyptian patients with Beta Thalassemia Major. ACTA ACUST UNITED AC 2015; 21:46-53. [PMID: 26288192 DOI: 10.1179/1607845415y.0000000046] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Estimating the prevalence of glutathione S-transferase gene polymorphism (GSTM1) null genotype among patients with beta thalassemia major (β-TM) in relation to myocardial status assessed by tissue Doppler and cardiac siderosis assessed by cardiac magnetic resonance imaging (MRI) T2*. METHODS Hundred patients with β-TM and 100 healthy controls were enrolled. Complete blood count (CBC), mean serum ferritin and GSTM1 genotyping, echocardiography, tissue Doppler, and cardiac MRI T2* were done. RESULTS Serum ferritin ranged from 1200 to 8000 ng/ml, and mean T2* value was 27.10 ± 11.20 ms. Of patients, 68 (68%) had no cardiac siderosis, while 24 (24%) with mild to moderate, and 8 (8%) with sever cardiac siderosis. T2* values were not correlated with serum ferritin (r = -0.09, P = 0.50). GSTM1 null genotype was prevalent in 46% of patients and 40% of controls (P = 0.69). Patients with null genotype had significantly shorter T2* (P = 0.001), higher left ventricular end-diastolic diameter (P = 0.002), and shorter ejection time (P = 0.005) with no significant relation to serum ferritin (P = 0.122). GSTM1 null genotype was the only predictor for cardiac iron overload (P = 0.002). DISCUSSION Serum ferritin concentrations have been shown to correlate poorly with all stages of cardiac dysfunction. Low cardiac MRI T2* values occur in patients with β-TM despite good chelation therapy, suggesting a possible role of genetic factors in cardiac siderosis. CONCLUSION GSTM1 null genotype is significantly associated with cardiac iron overload independent of serum ferritin in Egyptian patients with β-TM.
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Casale M, Meloni A, Filosa A, Cuccia L, Caruso V, Palazzi G, Rita Gamberini M, Pitrolo L, Caterina Putti M, Giuseppe D’Ascola D, Casini T, Quarta A, Maggio A, Giovanna Neri M, Positano V, Salvatori C, Toia P, Valeri G, Midiri M, Pepe A. Multiparametric Cardiac Magnetic Resonance Survey in Children With Thalassemia Major. Circ Cardiovasc Imaging 2015; 8:e003230. [DOI: 10.1161/circimaging.115.003230] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background—
Cardiovascular magnetic resonance (CMR) plays a key role in the management of thalassemia major patients, but few data are available in pediatric population. This study aims at a retrospective multiparametric CMR assessment of myocardial iron overload, function, and fibrosis in a cohort of pediatric thalassemia major patients.
Methods and Results—
We studied 107 pediatric thalassemia major patients (61 boys, median age 14.4 years). Myocardial and liver iron overload were measured by T2* multiecho technique. Atrial dimensions and biventricular function were quantified by cine images. Late gadolinium enhancement images were acquired to detect myocardial fibrosis. All scans were performed without sedation. The 21.4% of the patients showed a significant myocardial iron overload correlated with lower compliance to chelation therapy (
P
<0.013). Serum ferritin ≥2000 ng/mL and liver iron concentration ≥14 mg/g/dw were detected as the best threshold for predicting cardiac iron overload (
P
=0.001 and
P
<0.0001, respectively). A homogeneous pattern of myocardial iron overload was associated with a negative cardiac remodeling and significant higher liver iron concentration (
P
<0.0001). Myocardial fibrosis by late gadolinium enhancement was detected in 15.8% of the patients (youngest children 13 years old). It was correlated with significant lower heart T2* values (
P
=0.022) and negative cardiac remodeling indexes. A pathological magnetic resonance imaging liver iron concentration was found in the 77.6% of the patients.
Conclusions—
Cardiac damage detectable by a multiparametric CMR approach can occur early in thalassemia major patients. So, the first T2* CMR assessment should be performed as early as feasible without sedation to tailor the chelation treatment. Conversely, late gadolinium enhancement CMR should be postponed in the teenager age.
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Affiliation(s)
- Maddalena Casale
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Antonella Meloni
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Aldo Filosa
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Liana Cuccia
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Vincenzo Caruso
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Giovanni Palazzi
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Maria Rita Gamberini
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Lorella Pitrolo
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Maria Caterina Putti
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Domenico Giuseppe D’Ascola
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Tommaso Casini
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Antonella Quarta
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Aurelio Maggio
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Maria Giovanna Neri
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Vincenzo Positano
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Cristina Salvatori
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Patrizia Toia
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Gianluca Valeri
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Massimo Midiri
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
| | - Alessia Pepe
- From the Centro per la Cura delle Microcitemie, Cardarelli Hospital, Napoli, Italy (M.C., A.F.); Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Università di Napoli, Napoli, Italy (M.C.); Cardiovascular MR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy (A.M., M.G.N., V.P., A.P.); Ematologia-Emoglobinopatie, Civico Hospital-ARNAS, Palermo, Italy (L.C.); Centro Microcitemia, “Garibaldi” Hospital, Catania, Italy (V.C.); Oncoematologia Pediatrica,
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Chen X, Zhang Z, Zhong J, Yang Q, Yu T, Cheng Z, Chan Q, Guo H, Liang B. MRI assessment of excess cardiac iron in thalassemia major: When to initiate? J Magn Reson Imaging 2015; 42:737-45. [PMID: 26154874 DOI: 10.1002/jmri.24781] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 09/29/2014] [Indexed: 11/10/2022] Open
Affiliation(s)
- Xiaodong Chen
- Sun Yat-Sen Memorial Hospital; Guang Zhou Guang Dong China
- Guangdong Medical College; Guangdong China
| | - Zuoquan Zhang
- The Fifth Affiliated Hospital of Sun Yat-Sen University; Guangdong China
| | - Jinglian Zhong
- Sun Yat-Sen Memorial Hospital; Guang Zhou Guang Dong China
| | - Qihua Yang
- Sun Yat-Sen Memorial Hospital; Guang Zhou Guang Dong China
| | - Taihui Yu
- Sun Yat-Sen Memorial Hospital; Guang Zhou Guang Dong China
| | - Ziliang Cheng
- Sun Yat-Sen Memorial Hospital; Guang Zhou Guang Dong China
| | | | - Hua Guo
- Center for Biomedical Imaging Research, Department of Biomedical Engineering; Tsinghua University; Beijing China
| | - Biling Liang
- Sun Yat-Sen Memorial Hospital; Guang Zhou Guang Dong China
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Dessì C, Leoni G, Moi P, Danjou F, Follesa I, Foschini ML, Morittu M, Zappu A, Defraia E, Bina P, Cunico A, Civolani A, Podda RA, Origa R. Thalassemia major between liver and heart: Where we are now. Blood Cells Mol Dis 2015; 55:82-8. [DOI: 10.1016/j.bcmd.2015.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 03/29/2015] [Indexed: 02/08/2023]
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Danjou F, Cabantchik ZI, Origa R, Moi P, Marcias M, Barella S, Defraia E, Dessì C, Foschini ML, Giagu N, Leoni GB, Morittu M, Galanello R. A decisional algorithm to start iron chelation in patients with beta thalassemia. Haematologica 2015; 99:e38-40. [PMID: 24598857 DOI: 10.3324/haematol.2013.098202] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Aydinok Y, Porter JB, Piga A, Elalfy M, El-Beshlawy A, Kilinç Y, Viprakasit V, Yesilipek A, Habr D, Quebe-Fehling E, Pennell DJ. Prevalence and distribution of iron overload in patients with transfusion-dependent anemias differs across geographic regions: results from the CORDELIA study. Eur J Haematol 2015; 95:244-53. [PMID: 25418187 DOI: 10.1111/ejh.12487] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The randomized comparison of deferasirox to deferoxamine for myocardial iron removal in patients with transfusion-dependent anemias (CORDELIA) gave the opportunity to assess relative prevalence and body distribution of iron overload in screened patients. METHODS Patients aged ≥ 10 yr with transfusion-dependent anemias from 11 countries were screened. Data were summarized descriptively, overall and across regions. RESULTS Among 925 patients (99.1% with β-thalassemia major; 98.5% receiving prior chelation; mean age 19.2 yr), 36.7% had myocardial iron overload (myocardial T2* ≤ 20 ms), 12.1% had low left ventricular ejection fraction. Liver iron concentration (LIC) (mean 25.8 mg Fe/g dw) and serum ferritin (median 3702 ng/mL) were high. Fewer patients in the Middle East (ME; 28.5%) had myocardial T2* ≤ 20 ms vs. patients in the West (45.9%) and Far East (FE, 40.9%). Patients in the West had highest myocardial iron burden, but lowest LIC (26.9% with LIC < 7 mg Fe/g dw) and serum ferritin. Among patients with normal myocardial iron, a higher proportion of patients from the ME and FE had LIC ≥ 15 than < 7 mg Fe/g dw (ME, 56.7% vs. 17.2%; FE, 78.6% vs. 7.8%, respectively), a trend which was less evident in the West (44.6% vs. 33.9%, respectively). Transfusion and chelation practices differed between regions. CONCLUSIONS Evidence of substantial myocardial and liver iron burden across regions revealed a need for optimization of effective, convenient iron chelation regimens. Significant regional variation exists in myocardial and liver iron loading that are not well explained; improved understanding of factors contributing to differences in body iron distribution may be of clinical benefit.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Dany Habr
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | | | - Dudley J Pennell
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
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He T. Cardiovascular magnetic resonance T2* for tissue iron assessment in the heart. Quant Imaging Med Surg 2014; 4:407-12. [PMID: 25392825 DOI: 10.3978/j.issn.2223-4292.2014.10.05] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/06/2014] [Indexed: 01/21/2023]
Abstract
Until recently, even in Europe and the US, iron induced cardiomyopathy was the most common cause of death for patients with thalassemia major (TM). In order to prevent deaths from this potentially reversible condition, accurate measurement of myocardial iron is needed to detect iron early and guide chelation therapy. Cardiovascular magnetic resonance (CMR) T2* is the method of choice for the assessment of cardiac iron and in the UK, where it was first introduced clinically, 60% reductions in overall mortality for TM have been observed. The history of T2* development is described in this article. T2* image acquisition and post processing techniques are reviewed. Remaining challenges and emerging techniques to potentially improve characterization of tissue iron are also discussed.
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Affiliation(s)
- Taigang He
- Cardiovascular Science Research Centre, St George's, University of London, London, UK
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41
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Yetimakman AF, Oztarhan K, Aydogan G. Comparison of tissue Doppler imaging with MRI t2* and 24-hour rhythm holter heart rate variability for diagnosing early cardiac impairment in thalassemia major patients. Pediatr Hematol Oncol 2014; 31:597-606. [PMID: 24684386 DOI: 10.3109/08880018.2014.891681] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Cardiology follow up is important in thalassemia major patients. The object of this study is to define parameters which can be used in the early detection of cardiac impairment. MATERIAL AND METHODS Forty seven beta thalassemia major patients (mean age 16.3 ± 4.47 years; 22 boys, 25 girls) whose left ventricular systolic functions were normal and a healthy control group of fifty age and gender matched children were included in the study. M-mode echocardiographic measurements, systolic and diastolic functions with PW and tissue Doppler and heart rate variabilities (HRVs) were compared between the two groups. The patients were also grouped according to MRT2*, ferritin and left ventricular diastolic diameters (LVDds) to compare the echocardiographic and Holter parameters among them. RESULTS None of the children in the study group had symptomatic congestive heart failure. PW Doppler late diastolic forward flow in pulmonary artery was higher in the thalassemia group when compared with the control group (P = 0.01) indicating decreased compliance of the right ventricle. While the systolic and diastolic functions were normal, all the HRV parameters in the thalassemia group were significantly lower than the control group (P = 0.005). CONCLUSIONS Significant decrease in HRV and increase in PW late diastolic forward flow in pulmonary artery in the absence of systolic or diastolic dysfunction, points out that these parameters can be useful in detection of early cardiac impairment.
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Affiliation(s)
- Ayse Filiz Yetimakman
- 1Department of Pediatrics, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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42
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Moussavi F, Ghasabeh MA, Roodpeyma S, Alavi S, Shakiba M, Gheiratmand R, Omidghaemi M. Optimal method for early detection of cardiac disorders in thalassemia major patients: magnetic resonance imaging or echocardiography? Blood Res 2014; 49:182-6. [PMID: 25325038 PMCID: PMC4188784 DOI: 10.5045/br.2014.49.3.182] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 07/14/2014] [Accepted: 08/18/2014] [Indexed: 11/18/2022] Open
Abstract
Background Heart failure resulting from myocardial iron deposition is the most important cause of death in β-thalassemia major (TM) patients. Cardiac T2*magnetic resonance imaging (MRI), echocardiography, and serum ferritin level serve as diagnostic methods for detecting myocardial iron overload. In this study, we aimed to evaluate the relationship between the above-mentioned methods. Methods T2*MRI and echocardiographic measurement of left ventricular (LV) systolic and diastolic function were performed in 63 patients. Serum ferritin level was measured. The relationships between all assessments were evaluated. Results There were 40 women and 23 men with a mean age of 23.7±5.1 years (range, 15-35 years). There was no statistically significant correlation between serum ferritin level and LV systolic and diastolic function (P=0.994 and P=0.475, respectively). T2*MRI results had a significant correlation with ferritin level; 63.6% of patients with serum ferritin level >2,000 ng/mL had abnormal cardiac MRI, while none of the patients with ferritin level <1,000 ng/mL had abnormal cardiac MRI (P=0.001). There was no significant correlation between MRI findings and LV systolic function (P=1.00). However, we detected a significant difference between LV diastolic function and cardiac siderosis (P=0.03) Conclusion MRI findings are a good predictor of future cardiac dysfunction, even in asymptomatic TM patients; however, diastolic dysfunction may happen prior to cardiac siderosis in some patients, and echocardiography is able to diagnose this diastolic dysfunction while T2*MRI shows normal findings.
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Affiliation(s)
- Farideh Moussavi
- Department of Pediatric Hematology, Shohada Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mounes Aliyari Ghasabeh
- Advanced Diagnostic and Interventional Radiology Research Center, Imam Khomeini Hospital, Keshavarz Boulevard, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahla Roodpeyma
- Pediatric cardiology division, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samin Alavi
- Department of Pediatric Hematology, Mofid Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Shakiba
- Advanced Diagnostic and Interventional Radiology Research Center, Imam Khomeini Hospital, Keshavarz Boulevard, Tehran University of Medical Sciences, Tehran, Iran
| | - Riaz Gheiratmand
- Department of Pediatric Hematology, Shohada Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Omidghaemi
- Department of Pediatric Hematology, Shohada Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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43
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Nichols-Vinueza DX, White MT, Powell AJ, Banka P, Neufeld EJ. MRI guided iron assessment and oral chelator use improve iron status in thalassemia major patients. Am J Hematol 2014; 89:684-8. [PMID: 24652616 DOI: 10.1002/ajh.23715] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 03/14/2014] [Accepted: 03/18/2014] [Indexed: 01/19/2023]
Abstract
Oral iron chelators and magnetic resonance imaging (MRI) assessment of heart and liver iron burden have become widely available since the mid 2000s, allowing for improved patient compliance with chelation and noninvasive monitoring of iron levels for titration of therapy. We evaluated the impact of these changes in our center for patients with thalassemia major and transfusional iron overload. This single center, retrospective observational study covered the period from 2005 through 2012. Liver iron content (LIC) was estimated both by a T2* method and by R2 (Ferriscan® ) technique. Cardiac iron was assessed as cT2*. Forty-two patients (55% male) with transfused thalassemia and at least two MRIs were included (median age at first MRI, 17.5 y). Over a mean follow-up period of 5.2 ± 1.9 y, 190 MRIs were performed (median 4.5 per patient). Comparing baseline to last MRI, 63% of patients remained within target ranges for cT2* and LIC, and 13% improved from high values to the target range. Both the median LIC and cT2* (cR2* = 1000/cT2*) status improved over time: LIC 7.3 to 4.5 mg/g dry weight, P = 0.0004; cR2* 33.4 to 28.3 Hz, P = 0.01. Individual responses varied widely. Two patients died of heart failure during the study period. Annual MRI iron assessments and availability of oral chelators both facilitate changes in chelation dose and strategies to optimize care.
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Affiliation(s)
- Diana X. Nichols-Vinueza
- Division of Hematology/Oncology; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
| | - Matthew T. White
- Clinical Research Center and Department of Psychiatry; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
| | - Andrew J. Powell
- Department of Cardiology; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
| | - Puja Banka
- Department of Cardiology; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
| | - Ellis J. Neufeld
- Division of Hematology/Oncology; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
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Lee TA, von Riedemann S, Tricta F. Cost-utility of chelators in transfusion-dependent β-thalassemia major patients: a review of the pharmacoeconomic literature. Expert Rev Pharmacoecon Outcomes Res 2014; 14:651-60. [PMID: 24918168 DOI: 10.1586/14737167.2014.927314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In the inherited hematologic disorder β-thalassemia major, patients receive regular, lifelong blood transfusions, which carry excess iron that the body is unable to eliminate. Chelation therapy (deferoxamine, deferiprone, deferasirox or deferoxamine-deferiprone combination) is required to reduce iron accumulation in target organs and the associated morbidity and mortality. Each chelation regimen has a distinct safety/efficacy profile and particular costs associated with its use. This review aims to provide an overview of published cost-utility analyses of currently used chelation regimens, and to comment on the potential relevance of their findings in the USA market, where deferiprone has recently been introduced.
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Affiliation(s)
- Todd A Lee
- University of Illinois at Chicago, 833 South Wood Street, RM164 MC886, Chicago, IL 60612, USA
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45
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Akcay A, Salcioglu Z, Oztarhan K, Tugcu D, Aydogan G, Ayaz NA, Bornaun H, Sen HS, Akici F, Akdana B. Cardiac T2* MRI assessment in patients with thalassaemia major and its effect on the preference of chelation therapy. Int J Hematol 2014; 99:706-13. [PMID: 24719246 DOI: 10.1007/s12185-014-1575-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 03/18/2014] [Accepted: 03/18/2014] [Indexed: 11/26/2022]
Abstract
The aim of the study is to assess the relationship between T2* magnetic resonance imaging (MRI) values and age, serum ferritin level, left ventricular ejection fraction (LVEF), splenectomy status, and to identify appropriate modifications to chelation therapy based on T2* MRI results of children with thalassaemia major. Sixty-four patients with thalassaemia major (37 girls/27 boys) older than 8 years of age were enrolled in the study. Based on the first T2* MRI, the patients' myocardial iron depositions were classified into three groups: T2* MRI <10 ms (high risk group), T2* MRI 10-20 ms (medium-risk group) and T2* MRI >20 ms (low-risk group). There was no significant relationship between T2* MRI value and ages, serum ferritin levels and splenectomy status of thalassaemia major patients. The mean LVEFs were 60, 75, and 72.5 % in the high-, medium-, and low-risk groups, respectively (P = 0.006). The mean cardiac iron concentrations calculated from the T2* MRI values were 4.96 ± 1.93, 1.65 ± 0.37, and 0.81 ± 0.27 mg/g in the high-, medium-, and low-risk groups, respectively. Chelation therapies were re-designed in 24 (37.5 %) patients according to cardiac risk as assessed by cardiac T2* MRI. In conclusion, until recently, T2* MRI has been employed to demonstrate cardiac siderosis without a direct relationship with the markers used in follow-up of patients with thalassaemia. However, modifications of chelation therapies could reliably be planned according to severity of iron load displayed by T2* MRI.
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Affiliation(s)
- Arzu Akcay
- Pediatric Hematology-Oncology, Department of Pediatrics, Istanbul Kanuni Sultan Suleyman Education and Research Hospital, Turgut Ozal cad No. 1, Halkali, 34306, Istanbul, Turkey,
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46
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Chen MR, Ko HS, Chao TF, Liu HC, Kuo JY, Bulwer BE, Yeh HI, Hung CL. Relation of Myocardial Systolic Mechanics to Serum Ferritin Level as a Prognosticator in Thalassemia Patients Undergoing Repeated Transfusion. Echocardiography 2014; 32:79-88. [DOI: 10.1111/echo.12590] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ming-Ren Chen
- Department of Pediatrics; Mackay Memorial Hospital; Taipei Taiwan
- Mackay Junior College of Medicine Nursing and Management; Taipei Taiwan
- Mackay Medical College; Taipei Taiwan
| | - Ho-Shun Ko
- Departments of Pediatrics; Shuang Ho Hospital; Taipei Medical University; Taipei Taiwan
| | - Tze-Fan Chao
- Division of Cardiology; Department of Medicine; Taipei Veterans General Hospital; Taipei Taiwan
- Institute of Clinical Medicine; Cardiovascular Research Center; National Yang-Ming University; Taipei Taiwan
| | - Hsi-Che Liu
- Department of Pediatrics; Mackay Memorial Hospital; Taipei Taiwan
- Mackay Junior College of Medicine Nursing and Management; Taipei Taiwan
| | - Jen-Yuan Kuo
- Division of Cardiology; Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
- Mackay Medical College; New Taipei County Taiwan
| | - Bernard E. Bulwer
- Noninvasive Cardiovascular Research; Cardiovascular Division; Brigham and Women's Hospital; Boston Massachusetts
| | - Hung-I Yeh
- Division of Cardiology; Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
- Mackay Medical College; New Taipei County Taiwan
| | - Chung-Lieh Hung
- Division of Cardiology; Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
- Mackay Medical College; New Taipei County Taiwan
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47
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Carson SM, Martin MB. Effective Iron Chelation Practice for Patients With β-Thalassemia Major. Clin J Oncol Nurs 2014; 18:102-11. [DOI: 10.1188/14.cjon.102-111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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48
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Yang G, Liu R, Peng P, Long L, Zhang X, Yang W, Tan S, Pan H, Long X, He T, Anderson L, Lai Y. How early can myocardial iron overload occur in beta thalassemia major? PLoS One 2014; 9:e85379. [PMID: 24465548 PMCID: PMC3899006 DOI: 10.1371/journal.pone.0085379] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 11/25/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Myocardial siderosis is the most common cause of death in patients with beta thalassemia major(TM). This study aimed at investigating the occurrence, prevalence and severity of cardiac iron overload in a young Chinese population with beta TM. METHODS AND RESULTS We analyzed T2* cardiac magnetic resonance (CMR), left ventricular ejection fraction (LVEF) and serum ferritin (SF) in 201 beta TM patients. The median age was 9 years old. Patients received an average of 13 units of blood per year. The median SF level was 4536 ng/ml and 165 patients (82.1%) had SF>2500 ng/ml. Myocardial iron overload was detected in 68 patients (33.8%) and severe myocardial iron overload was detected in 26 patients (12.6%). Twenty-two patients ≤10 years old had myocardial iron overload, three of whom were only 6 years old. No myocardial iron overload was detected under the age of 6 years. Median LVEF was 64% (measured by CMR in 175 patients). Five of 6 patients with a LVEF<56% and 8 of 10 patients with cardiac disease had myocardial iron overload. CONCLUSIONS The TM patients under follow-up at this regional centre in China patients are younger than other reported cohorts, more poorly-chelated, and have a high burden of iron overload. Myocardial siderosis occurred in patients younger than previously reported, and was strongly associated with impaired LVEF and cardiac disease. For such poorly-chelated TM patients, our data shows that the first assessment of cardiac T2* should be performed as early as 6 years old.
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Affiliation(s)
- Gaohui Yang
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Rongrong Liu
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Peng Peng
- Department of Radiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liling Long
- Department of Radiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xinhua Zhang
- Department of Hematology, 303rd Hospital of People's Liberation Army, Nanning, China
| | - Weijia Yang
- Department of Pediatrics, Women and Children Hospital of Guilin, Guilin, China
| | - Shaohong Tan
- Department of Pediatrics, Women and Children Hospital of Yulin, Yulin, China
| | - Hongfei Pan
- Department of Pediatrics, Affiliated Hospital of Youjiang Medical University for Nationality, Baise, China
| | - Xingjiang Long
- Department of Pediatrics, The People's Hospital of Liuzhou, Liuzhou, China
| | - Taigang He
- Cardiovascular Sciences Research Centre, St George's University of London, London, United Kingdom
- Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom
| | - Lisa Anderson
- Cardiovascular Sciences Research Centre, St George's University of London, London, United Kingdom
| | - Yongrong Lai
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
- * E-mail:
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Koonrungsesomboon N, Chattipakorn SC, Fucharoen S, Chattipakorn N. Early detection of cardiac involvement in thalassemia: From bench to bedside perspective. World J Cardiol 2013; 5:270-279. [PMID: 24009816 PMCID: PMC3761180 DOI: 10.4330/wjc.v5.i8.270] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 07/31/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
Myocardial siderosis is known as the major cause of death in thalassemia major (TM) patients since it can lead to iron overload cardiomyopathy. Although this condition can be prevented if timely effective intensive chelation is given to patients, the mortality rate of iron overload cardiomyopathy still remains high due to late detection of this condition. Various direct and indirect methods of iron assessment, including serum ferritin level, echocardiogram, non-transferrin-bound iron, cardiac magnetic resonance T2*, heart rate variability, and liver biopsy and myocardial biopsy, have been proposed for early detection of cardiac iron overload in TM patients. However, controversial evidence and limitations of their use in clinical practice exist. In this review article, all of these iron assessment methods that have been proposed or used to directly or indirectly determine the cardiac iron status in TM reported from both basic and clinical studies are comprehensively summarized and presented. Since there has been growing evidence in the past decades that cardiac magnetic resonance imaging as well as cardiac autonomic status known as the heart rate variability can provide early detection of cardiac involvement in TM patients, these two methods are also presented and discussed. The existing controversy regarding the assessment of cardiac involvement in thalassemia is also discussed.
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50
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Low prevalence of cardiac siderosis in heavily iron loaded Egyptian thalassemia major patients. Ann Hematol 2013; 93:375-9. [PMID: 23949317 DOI: 10.1007/s00277-013-1876-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 08/04/2013] [Indexed: 01/19/2023]
Abstract
Myocardial siderosis in thalassemia major remains the leading cause of death in developing countries. Once heart failure develops, the outlook is usually poor with precipitous deterioration and death. Cardiovascular magnetic resonance (CMR) can measure cardiac iron deposition directly using the magnetic relaxation time T2*. This allows earlier diagnosis and treatment and helps to reduce mortality from this cardiac affection. This study aims to determine the prevalence of cardiac siderosis in Egyptian patients who are heavily iron loaded and its relation to liver iron concentration, serum ferritin, and left ventricular ejection fraction. Eighty-nine β-thalassemia patients receiving chelation therapy (mean age of 20.8 ± 6.4 years) were recruited in this study. Tissue iron levels were determined by CMR with cardiac T2* and liver R2*. The mean ± standard deviation (range) of cardiac T2* was 28.5 ± 11.7 ms (4.3 to 53.8 ms), the left ventricular ejection fraction (LVEF) was 67.7 ± 4.7 % (55 to 78 %), and the liver iron concentration (LIC) was 26.1 ± 13.4 mg Fe/g dry weight (dw) (1.5 to 56 mg Fe/g dw). The mean serum ferritin was 4,510 ± 2,847 ng/ml (533 to 22,360 ng/ml), and in 83.2 %, the serum ferritin was >2,500 ng/ml. The prevalence of myocardial siderosis (T2* of <20 ms) was 24.7 % (mean age 20.9 ± 7.5 years), with mean T2* of 12.7 ± 4.4 ms, mean LVEF of 68.6 ±5.8 %, mean LIC of 30.9 ± 13 mg Fe/g dw, and median serum ferritin of 4,996 ng/ml. There was no correlation between T2* and age, LVEF, LIC, and serum ferritin (P = 0.65, P = 0.085, P = 0.99, and P = 0.63, respectively). Severe cardiac siderosis (T2* of <10 ms) was present in 7.9 %, with a mean age of 18.4 ± 4.4 years. Although these patients had a mean T2* of 7.8 ± 1.7 ms, the LVEF was 65.1 ± 6.2 %, and only one patient had heart failure (T2* of 4.3 ms and LVEF of 55 %). LIC and serum ferritin results were 29.8 ± 17.0 mg/g and 7,200 ± 6,950 ng/ml, respectively. In this group of severe cardiac siderosis, T2* was also not correlated to age (P = 0.5), LVEF (P = 0.14), LIC (P = 0.97), or serum ferritin (P = 0.82). There was a low prevalence of myocardial siderosis in the Egyptian thalassemia patients in spite of very high serum ferritin and high LIC. T2* is the best test that can identify at-risk patients who can be managed with optimization of their chelation therapy. The possibility of a genetic component for the resistance to cardiac iron loading in our population should be considered.
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