Left ventricular mechanics in adolescents and young adults with a history of kawasaki disease: analysis by three-dimensional speckle tracking echocardiography

The long-term vascular and myocardial outcomes in selected Kawasaki disease patients with regression of giant coronary artery aneurysms

BACKGROUND

Giant coronary artery aneurysms and myocardial fibrosis after Kawasaki disease may lead to devastating cardiovascular outcomes. We characterised the vascular and myocardial outcomes in five selected Kawasaki disease patients with a history of giant coronary artery aneurysms that completely regressed.

METHODS

Five patients were selected who had giant coronary artery aneurysm in early childhood that regressed when studied 12-33 years after Kawasaki disease onset. Coronary arteries were imaged by coronary CT angiography, and coronary artery calcium volume scores were determined. We used endocardial strain measurements from CT imaging to assess myocardial regional wall function. Calprotectin and galectin-3 (gal-3) as biomarkers of inflammation and myocardial fibrosis were measured by enzyme-linked immunosorbent assay.

RESULTS

The five selected patients with regressed giant coronary artery aneurysms had calcium scores of zero, normal levels of calprotectin and gal-3, and normal appearance of the coronary arteries by coronary computed tomography angiography. CT strain demonstrated normal peak systolic and diastolic strain patterns in four of five patients. In one patient with a myocardial infarction at the time of Kawasaki disease diagnosis at the age of 10 months, CT strain showed altered global longitudinal strain, reduced segmental peak strain, and reduced diastolic relaxation patterns in multiple left ventricle segments.

CONCLUSIONS

These patients illustrate that regression of giant aneurysms after Kawasaki disease is possible with no detectable calcium, normal biomarkers of inflammation and fibrosis, and normal myocardial function. Individuals with regressed giant coronary artery aneurysm still require longitudinal surveillance to assess the durability of this favourable outcome.

Evaluation of subclinical left ventricular systolic dysfunction in patients with acute-phase Kawasaki disease by hematological indices, layer-specific left ventricular longitudinal strain and global myocardial work

PURPOSE

To evaluate subclinical LV systolic dysfunction in aKD patients by hematological indices, global layer-specific LV longitudinal strain and myocardial work (MW).

METHODS

Forty-three normal controls and 42 aKD patients were enrolled in the present study. The peak systolic epimyocardial (GLSEpi), middle layer (GLSMid) and endomyocardial (GLSEndo) longitudinal strain, global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW) and myocardial work efficiency (GWE) were measured by two-dimensional speckle-tracking echocardiography in apical three-chamber, four-chamber, and two-chamber views.

RESULTS

The absolute values of GLSEpi, GLSMid, and GLSEndo in aKD patients were significantly lower than those in normal controls (p < .01). The values of GCW and GWE were significantly lower than those of normal controls (p < .05). There were no significant differences among the AUCs of layer-specific LV GLS and global MW (p > .05). The correlation test showed that layer-specific LV GLS showed a good correlation with GCW. Multivariable analysis showed that Hb and LVEF were independent factors for GCW.

CONCLUSION

In this research, we found that subclinical LV systolic dysfunction was detected by layer-specific GLS and MW in aKD patients. GCW has the same diagnostic value as layer-specific LV GLS. Hb and LVEF are independent factors of LV myocardial function.

Imaging the delayed complications of childhood Kawasaki disease

This review will discuss the long-term complications of Kawasaki disease with a particular focus on imaging surveillance of the coronary arteries in adolescence and adult life. The relative advantages and disadvantages of each modality will be illustrated with practical examples, demonstrating that, in many cases, a multimodality imaging strategy may be required.

Global Myocardial Strain in Multisystem Inflammatory Syndrome in Children, Kawasaki Disease, and Healthy Children: A Network Meta-Analysis

BACKGROUND

Nearly 6,000 multisystem inflammatory syndrome in children (MIS-C) have been reported in the United States by November 2021. Left ventricular global myocardial strain has been proved to be one of the best evidence of the diagnostic and prognostic implications for cardiac dysfunction. The global myocardial strain change of MIS-C in the acute phase was still unclear.

METHODS

PubMed and other sources were searched. A network meta-analysis was conducted. MIS-C was divided into two groups according to left ventricular ejection fraction (LVEF): MIS-C with depressed ejection fraction (MIS-C dEF) and MIS-C with preserved ejection fraction (MIS-C pEF). Global longitudinal strain (GLS) and global circumferential strain (GCS) were compared among MIS-C, Kawasaki disease (KD), and healthy children.

RESULTS

In total, nine case-control studies were included, published between 2014 and 2021. These studies involved 107 patients with MIS-C, 188 patients with KD, and 356 healthy children. After Bayesian analysis, MIS-C dEF group was found to have a lower LVEF, higher GLS and GCS than the KD groups. Both MIS-C pEF and KD had similar GLS and GCS, which were higher than healthy controls. There was no difference of LVEF among MIS-C pEF, KD, and healthy controls.

CONCLUSION

MIS-C dEF was more severe than KD, both in LVEF and global myocardial strain. MIS-C pEF and KD were similar with mild impaired left ventricular myocardial strain compared with the healthy children. Global myocardial strain may be a monitoring index for MIS-C.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021264760].

Coronary artery vasculitis: a review of current literature

Cardiac vasculitis is recognized as a heterogeneous disease process with a wide spectrum of manifestations including pericarditis, myocarditis, valvular heart disease and less frequently, coronary artery vasculitis (CAV). CAV encompasses an emerging field of diseases which differ from conventional atherosclerotic disease and have a proclivity for the younger population groups. CAV portends multiple complications including the development of coronary artery aneurysms, coronary stenotic lesions, and thrombosis, all which may result in acute coronary syndromes. There are several aetiologies for CAV; with Kawasaki's disease, Takayasu's arteritis, Polyarteritis Nodosa, and Giant-Cell Arteritis more frequently described clinically, and in literature. There is a growing role for multi-modality imaging in assisting the diagnostic process; including transthoracic echocardiography, cardiac magnetic resonance imaging, computed tomography coronary angiography, fluorodeoxyglucose-positron emission tomography and conventional coronary angiogram with intravascular ultrasound. Whilst the treatment paradigms fundamentally vary between different aetiologies, there are overlaps with pharmacological regimes in immunosuppressive agents and anti-platelet therapies. Interventional and surgical management are is a consideration in select populations groups, within a multi-disciplinary context. Further large-scale studies are required to better appropriately outline management protocols in this niche population.

Speckle tracking echocardiography as a new diagnostic tool for an assessment of cardiovascular disease in rheumatic patients

Chronic inflammation represents the cornerstone of the raised cardiovascular (CV) risk in patients with inflammatory rheumatic diseases (IRD). Standardized mortality ratios are increased in these patients compared to the general population, which can be explained by premature mortality associated with early atherosclerotic events. Thus, IRD patients need appropriate CV risk management in view of this CV disease (CVD) burden. Currently, optimal CV risk management is still lacking in usual care, and early diagnosis of silent and subclinical CVD involvement is mandatory to improve the long-term prognosis of those patients. Although CV involvement in such patients is highly heterogeneous and may affect various structures of the heart, it can now be diagnosed earlier and promptly treated. CV imaging provides valuable information as a reliable diagnostic tool. Currently, different techniques are employed to evaluate CV risk, including transthoracic or trans-esophageal echocardiography, magnetic resonance imaging, or computed tomography, to investigate valve abnormalities, pericardial disease, and ventricular wall motion defects. All the above methods are reliable in investigating CV involvement, but more recently, Speckle Tracking Echocardiography (STE) has been suggested to be diagnostically more accurate. In recent years, the role of left ventricular ejection fraction (LVEF) as the gold standard parameter for the evaluation of systolic function has been debated, and many efforts have been focused on the clinical validation of new non-invasive tools for the study of myocardial contractility as well as to characterize the subclinical alterations of the myocardial function. Improvement in the accuracy of STE has resulted in a large amount of research showing the ability of STE to overcome LVEF limitations in the majority of primary and secondary heart diseases. This review summarizes the additional value that STE measurement can provide in the setting of IRD, with a focus in the different clinical stages.

Assessing left ventricular systolic function in children with a history of Kawasaki disease

BACKGROUND

The incidence of Kawasaki disease (KD) is increasing. Indeed, KD has become the most common cause of acquired heart disease in children. Previous studies have well summarized the acute phase left ventricular (LV) systolic dysfunction using speckle tracking echocardiography (STE); however, changes in LV systolic function after long-term follow-up remain unclear.

METHODS

One hundred children with a history of KD, but without coronary artery aneurysms, were enrolled. These children were divided into two subgroups based on the presence or absence of coronary artery dilatation (CAD). The duration of follow-up was > 7 years. The control group consisted of 51 healthy children. The LV myocardial strain were measured by two- and three-dimensional STE.

RESULTS

Two-dimensional STE not only revealed that LV longitudinal strain decreased in part of segments in both KD groups, but also showed that global strain decreased in the KD group with CAD compared to the controls (P < 0.05). Global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) were obtained by 3D STE. Compared to the controls, GLS and GAS decreased in both KD groups (P < 0.05). GCS and GRS decreased in the KD group with CAD, but was unchanged in the KD group without CAD (P < 0.05).

CONCLUSIONS

LV systolic dysfunction in children with KD and CAD was more severe than KD children without CAD compared to healthy children. This dysfunction can be assessed by LV regional and global myocardial strain using two- and three-dimensional STE.

Comprehensive left ventricular myocardial deformation assessment in children with Kawasaki disease

OBJECTIVE

Children with Kawasaki disease (KD) with persistent coronary artery aneurysms (CAAs) can develop chronic vasculopathy and subsequent myocardial ischemia. Early detection of this process is challenging. Myocardial deformation analysis can detect early alterations in myocardial performance. We aim to determine whether there are differences in myocardial deformation between KD patients with and without CAAs.

DESIGN

This is a cross-sectional study of 123 echocardiograms performed on 103 children with KD. Myocardial deformation was measured with two-dimensional speckle tracking (2DSTE). The echocardiograms were divided into groups according to the KD phase in which they were performed: acute, subacute, and convalescent/chronic. The convalescent/chronic phase group was then divided based on the presence or absence of CAAs. Left ventricular (LV) global longitudinal strain (GLS), global longitudinal strain rate (GLSSR), global circumferential strain (GCS), global circumferential systolic strain rate (GCSSR), peak torsion, and torsion rate were measured.

RESULTS

The numbers of echocardiograms analyzed in each of the KD phase groups were: 31 acute, 25 subacute, and 67 convalescent/chronic. Myocardial deformation was within normal limits in all groups. However, GLSSR, GCSSR, peak torsion, and torsion rate were lower in the convalescent/chronic phase group than in the acute phase group (mean, -1.37 ± 0.24 vs -1.55 ± 0.21 1/s; -1.63 ± 0.27 vs -1.84 ± 0.35 1/s; 2.49 ± 1.13 vs 3.41 ± 2.60 °/cm, and 21.97 ± 8.36 vs 26.69 ± 10.86 °/cm/s; P < .05 for all). The convalescent/chronic phase subgroup with CAAs had lower GLSSR and GCSSR than the subgroup without CAAs (mean, -1.23 ± 0.22 vs -1.42 ± 0.22 1/s; -1.46 ± 0.25 vs -1.68 ± 0.26 1/s, P < .05 for both).

CONCLUSIONS

Children in the convalescent/chronic phase of KD have a subtle decrease in strain rate when compared to the acute phase, although within the normal range. This decrease is more pronounced in children with CAAs than those without CAAs. Longitudinal studies are needed to discern whether low-normal strain rate predicts decreased myocardial function in the long term.

Initial application of three-dimensional speckle-tracking echocardiography to detect subclinical left ventricular dysfunction and stratify cardiomyopathy associated with Duchenne muscular dystrophy in children

Three-dimensional (3D) speckle-tracking echocardiography (STE) is a new imaging modality used for quantitative analysis of left ventricular (LV) function. The aim of this study is to assess the value of 3D STE in early detection of subclinical myocardial involvement in children with Duchenne muscular dystrophy (DMD). Fifty-six children with DMD (mean age, 8.8 ± 1.9 years) and 31 age-matched control subjects were studied. Patients were subdivided into two groups by age: ≤ 8 or > 8 years. Standard echocardiography examinations were performed to measure LV size and ejection fraction (EF). 3D STE was performed to assess LV 3D global strain and LV end-diastolic volume (EDV), end-systolic volume (ESV), and EF. Standard and 3D echocardiography measures were compared between children with DMD and those in the control group as well as between different patient groups. The areas under the receiver-operating characteristic (ROC) curve were calculated to determine the capability of 3D global strain indices to discriminate between patients and control subjects. No significant difference was detected in either LVEF derived from M-mode or 3D echocardiography between the two groups, and they were both within the normal range. Compared with control subjects, children with DMD had significantly reduced LV 3D global longitudinal strain (GLS; - 16.6 ± 4.7 vs. - 19.5 ± 3.7, p = 0.003), global circumferential strain (GCS; - 13.7 ± 2.9 vs. - 15.8 ± 2.6, p = 0.001), global radial strain (GRS; 42.5 ± 9.7 vs. 50.3 ± 10.4, p = 0.001), and global area strain (GAS; - 25.3 ± 4.9 vs. - 30.7 ± 4.1, p = 0.000). The older DMD children (age > 8 years) had lower GLS (- 15.1 ± 4.43 vs. - 18.6 ± 4.35, p < 0.05), GCS (- 12.8 ± 3.48 vs. - 14.8 ± 2.83, p < 0.001), GAS (- 23.8 ± 4.7 vs. - 29.0 ± 5.4, p < 0.001), and GRS (40.7 ± 8.8 vs. 47.3 ± 11.5, p < 0.05) than younger patients (age ≤ 8 years). The AUC of GAS was 0.80, and the cutoff value of - 29.5 had a sensitivity of 85.7% and a specificity of 71.0% for differentiating DMD patients from control. 3D speckle-tracking echocardiography is useful for detecting subclinical myocardial dysfunction and stratifying cardiomyopathy in children with DMD.

Cardiac function on 3-D speckle tracking imaging and cytokines in Kawasaki disease

BACKGROUND

Serum N-terminal pro-brain natriuretic peptide (NT-proBNP) tends to rise in acute phase Kawasaki disease (KD), but the cause of NT-proBNP elevation has not been clarified. In a previous study, cardiac function evaluated on 2-D echocardiography (2D-E) such as ejection fraction was normal, but this does not reflect subtle changes in cardiac dysfunction, and hence the association between cardiac function and NT-proBNP elevation is still controversial. The aim of this study was therefore to elucidate the influence of cardiac function on NT-proBNP elevation, by evaluating cardiac function via strain on 3-D speckle tracking imaging (3D-STI), in acute and subacute KD patients. Given that cytokines are also thought to induce NT-proBNP in acute phase KD, serum cytokines and cytokine receptors were measured at the same time.

METHODS

Laboratory data and echocardiography in 52 KD patients in the acute and subacute phases were reviewed.

RESULTS

Median NT-proBNP was significantly elevated in the acute phase compared with the subacute phase (356.5 pg/mL; IQR, 145-904 pg/mL vs 103.5 pg/mL; IQR, 59-150 pg/mL, P < 0.01). All cytokines were also significantly elevated in the acute phase compared with the subacute phase. Tumor necrosis factor (TNF)-α, soluble TNF receptor (sTNFR)1, and sTNFR2 concentration were all significantly higher in the acute phase. Indices of cardiac function were not significant different between phases. NT-proBNP in the acute and subacute phases correlated with sTNFR1 (r = 0.63/0.43, P < 0.01), sTNFR2 (r = 0.50/0.31, P < 0.05), and interleukin-6 (r = 0.58/0.43, P < 0.01). NT-proBNP did not correlate with global longitudinal strain (GLS) on 3D-STI.

CONCLUSION

Although no correlation was seen between NT-proBNP and GLS on 3D-STI, correlations between NT-proBNP and cytokines were clear. NT-proBNP might be a marker of inflammation in KD, but is not a marker of cardiac function.

Evaluation of myocardial deformation in patients with Kawasaki disease using speckle-tracking echocardiography during mid-term follow-up

Speckle-tracking echocardiography is a recently developed technique for the evaluation of myocardial deformation or strain. Our objective was to examine strain through a mid-term follow-up of patients with Kawasaki disease.

METHODS

We explored left ventricular mechanics using speckle-tracking echocardiography in 35 patients with a history of Kawasaki disease at least 6 months after the acute phase. We also included 30 healthy children as controls. Strain data sets were acquired for the quantification of left ventricular global strain, segmental strain, and left ventricular ejection fraction.

RESULTS

The mean age of our patients was 25.6±15.4 months. At a median follow-up of 57.5 months (16.5-98.2), although both values were in the normal range, the mean left ventricular ejection proportion of patients (57.3%) was a little lower than that of controls (p⩽0.05). Patient strain values at the basal inferoseptal (20.0), basal anterolateral (19.5), apical septal (23.3), and apical inferior (24.0) segments were lower compared with controls. In all, seven patients had coronary aneurysms during follow-up. Kawasaki disease patients with pyuria had lower left ventricular strain at the mid anterior, mid anteroseptal, apical anterior, and apical inferior segments and global longitudinal strain compared with patients with no pyuria (p⩽0.05).

CONCLUSION

In children with a history of Kawasaki disease, impairment of left ventricular mechanics occurs especially within the left anterior descending artery territories.

Mechanical Dyssynchrony and Abnormal Regional Strain Promote Erroneous Measurement of Systolic Function in Pediatric Heart Transplantation

BACKGROUND

Clinical experience suggests that measurement of left ventricular (LV) ejection fraction (EF) using two-dimensional echocardiography (2DE) is often at variance with results of three-dimensional echocardiography (3DE) in patients who have undergone heart transplantation (HT). The aim of this study was to test the hypothesis that LV mechanical dyssynchrony and abnormal regional strain are present in asymptomatic pediatric HT patients and that they promote errors in the measurement of LV function when 2DE is used.

METHODS

HT subjects and normal volunteer children were prospectively enrolled. All had normal estimated right ventricular systolic pressure and function. LV EF, global and regional strain, and systolic dyssynchrony index (SDI) were quantified using real time 3DE. SDI was determined from volume-time curves of the 16 LV segments and expressed as the standard deviation of the heart rate-corrected time to reach minimal segmental systolic volume. Septal strain was defined as the average of five segments in the interventricular septum. In addition to 3DE, the Teichholz, biplane Simpson, and bullet (5/6 area-length) methods were used to measure EF using 2DE in each subject. Ninety-three examinations were done: 40 in the 40 normal control subjects (mean age, 14.6 ± 10.6 years; 10 male) and 53 in 36 HT subjects (mean age, 10.3 ± 6.2 years; 21 male).

RESULTS

SDI was greater in HT patients (mean, 6.2 ± 4.3%) than in normal controls (mean, 2.2 ± 1.1%) (P < .0001). Global and septal strain was lower in HT patients than in normal controls. EF divergence (absolute difference between two- and three-dimensional EFs) was greater in HT patients (mean, 3.8 ± 2.2%) than in normal controls (mean, 0.7 ± 0.5%) (P < .0001). EF divergence had a strong positive correlation with SDI (adjusted r² = 0.46, P < .001) and negative correlations with all measures of strain (range of adjusted r² values, 0.13-0.32). SDI had no particular relation to LV mass or to QRS duration.

CONCLUSIONS

Children after HT have abnormal LV mechanics characterized by greater dyssynchrony and lower strain. These features correlate with, and possibly contribute to differences between measurements by 2DE and 3DE. EF should be calculated using 3DE in this population and others with dyssynchrony and regional strain abnormalities.

Cardiovascular status after Kawasaki disease in the UK

OBJECTIVE

Kawasaki disease (KD) is an acute vasculitis that causes coronary artery aneurysms (CAA) in young children. Previous studies have emphasised poor long-term outcomes for those with severe CAA. Little is known about the fate of those without CAA or patients with regressed CAA. We aimed to study long-term cardiovascular status after KD by examining the relationship between coronary artery (CA) status, endothelial injury, systemic inflammatory markers, cardiovascular risk factors (CRF), pulse-wave velocity (PWV) and carotid intima media thickness (cIMT) after KD.

METHODS

Circulating endothelial cells (CECs), endothelial microparticles (EMPs), soluble cell-adhesion molecules cytokines, CRF, PWV and cIMT were compared between patients with KD and healthy controls (HC). CA status of the patients with KD was classified as CAA present (CAA+) or absent (CAA-) according to their worst-ever CA status. Data are median (range).

RESULTS

Ninety-two KD subjects were studied, aged 11.9 years (4.3-32.2), 8.3 years (1.0-30.7) from KD diagnosis. 54 (59%) were CAA-, and 38 (41%) were CAA+. There were 51 demographically similar HC. Patients with KD had higher CECs than HC (p=0.00003), most evident in the CAA+ group (p=0.00009), but also higher in the CAA- group than HC (p=0.0010). Patients with persistent CAA had the highest CECs, but even those with regressed CAA had higher CECs than HC (p=0.011). CD105 EMPs were also higher in the KD group versus HC (p=0.04), particularly in the CAA+ group (p=0.02), with similar findings for soluble vascular cell adhesion molecule 1 and soluble intercellular adhesion molecule 1. There was no difference in PWV, cIMT, CRF or in markers of systemic inflammation in the patients with KD (CAA+ or CAA-) compared with HC.

CONCLUSIONS

Markers of endothelial injury persist for years after KD, including in a subset of patients without CAA.

Vascular health late after Kawasaki disease: implications for accelerated atherosclerosis

Kawasaki disease (KD), an acute vasculitis that primarily affects young children, is the most common acquired paediatric cardiovascular disease in developed countries. While sequelae of arterial inflammation in the acute phase of KD are well documented, its late effects on vascular health are increasingly unveiled. Late vascular dysfunction is characterized by structural alterations and functional impairment in term of arterial stiffening and endothelial dysfunction and shown to involve both coronary and systemic arteries. Further evidence suggests that continuous low grade inflammation and ongoing active remodeling of coronary arterial lesions occur late after acute illness and may play a role in structural and functional alterations of the arteries. Potential importance of genetic modulation on vascular health late after KD is implicated by associations between mannose binding lectin and inflammatory gene polymorphisms with severity of peripheral arterial stiffening and carotid intima-media thickening. The changes in cholesterol and lipoproteins levels late after KD further appear similar to those proposed to be atherogenic. While data on adverse vascular health are less controversial in patients with persistent or regressed coronary arterial aneurysms, data appear conflicting in individuals with no coronary arterial involvements or only transient coronary ectasia. Notwithstanding, concerns have been raised with regard to predisposition of KD in childhood to accelerated atherosclerosis in adulthood. Until further evidence-based data are available, however, it remains important to assess and monitor cardiovascular risk factors and to promote cardiovascular health in children with a history of KD in the long term.