Echocardiographic predictors of adverse clinical events in children with dilated cardiomyopathy: a prospective clinical study

The Relationship Between Global Left Ventricular Function, as Indicated by the Tei Index, and Long-Term Survival in Patients With Non-Ischemic, Dilated Cardiomyopathy

AIM

Idiopathic dilated cardiomyopathy (DCM) is one of the leading causes of low ejection fraction (EF) heart failure (HF). The Tei index is a reliable marker that reflects both left ventricular (LV) systolic and diastolic function, and it has prognostic value in patients with DCM. We aimed to investigate the relationship between the Tei index and long-term survival in non-ischemic, DCM patients.

MATERIAL AND METHODS

The present study included 98 patients with non-ischemic DCM. The mean survival time of the patients was 59 mos.

RESULTS

The Tei index was prominently higher in patients who died (0.64±0.08 vs 0.71±0.12, respectively; p=0.01). LV end-systolic volume and LV ejection fraction (LVEF) were independent prognostic factors and predicted worse long-term survival. Additionally, the patients with LVEF ≥32.7 % and the Tei index ≤0.76 had significantly longer survival.

CONCLUSION

The present study showed that the Tei index was significantly associated with mortality and the patients with both low LVEF (≤32.7 %) and high Tei index (≥0.76) values had a shorter life expectancy. As a result, we suggest that the Tei index may be a useful echocardiographic marker to predict long-term survival in DCM patients.

Screening left ventricular systolic dysfunction in children using intrinsic frequencies of carotid pressure waveforms measured by a novel smartphone-based device

Objective.Children with heart failure have higher rates of emergency department utilization, health care expenditure, and hospitalization. Therefore, a need exists for a simple, non-invasive, and inexpensive method of screening for left ventricular (LV) dysfunction. We recently demonstrated the practicality and reliability of a wireless smartphone-based handheld device in capturing carotid pressure waveforms and deriving cardiovascular intrinsic frequencies (IFs) in children with normal LV function. Our goal in this study was to demonstrate that an IF-based machine learning method (IF-ML) applied to noninvasive carotid pressure waveforms can distinguish between normal and abnormal LV ejection fraction (LVEF) in pediatric patients.Approach. Fifty patients ages 0 to 21 years underwent LVEF measurement by echocardiogram or cardiac magnetic resonance imaging. On the same day, patients had carotid waveforms recorded using Vivio. The exclusion criterion was known vascular disease that would interfere with obtaining a carotid artery pulse. We adopted a hybrid IF- Machine Learning (IF-ML) method by applying physiologically relevant IF parameters as inputs to Decision Tree classifiers. The threshold for low LVEF was chosen as <50%.Main results.The proposed IF-ML method was able to detect an abnormal LVEF with an accuracy of 92% (sensitivity = 100%, specificity = 89%, area under the curve (AUC) = 0.95). Consistent with previous clinical studies, the IF parameterω1was elevated among patients with reduced LVEF.Significance.A hybrid IF-ML method applied on a carotid waveform recorded by a hand-held smartphone-based device can differentiate between normal and abnormal LV systolic function in children with normal cardiac anatomy.

Exploring the Possible Impact of Echocardiographic Diastolic Function Parameters on Outcome in Paediatric Dilated Cardiomyopathy

Diastolic dysfunction is an important determinant for prognosis and survival in several paediatric heart diseases. We aimed to explore its possible impact on outcome in children with dilated cardiomyopathy. From 2006 to 2016, children less than 18 years old with dilated cardiomyopathy were retrospectively enrolled. Echocardiographic diastolic function parameters and child outcomes were analysed. Of 43 children aged 0.2 to 16.1 years old referred with dilated cardiomyopathy, 8 patients required cardiac transplant or mechanical assist devices (18%), 24 had persistently abnormal left ventricular function and/or dilatation (56%) and 11 patients recovered (26%). There was no significant difference in mitral velocities on Tissue Doppler Imaging, mitral valve inflow velocities, isovolumic relaxation time, left atrial area z-score and mitral lateral E/e' ratios between patients with recovery and patients with disease progression or persistently abnormal ventricular function and/or dilation. This is the first study on childhood dilated cardiomyopathy to address individual echocardiographic diastolic function parameters and their association to recovery. In this study, echocardiographic parameters for diastolic function did not predict recovery.

Peri-operative changes in diastolic function and outcomes in congenital aortic valve surgery

Background

The ratio of early diastolic mitral inflow velocity (E) to early diastolic mitral annular tissue velocity (e’), or E/e’, is an echocardiographic measure of left ventricular filling pressure. Peri‐operative changes in E/e’ and association with outcomes have been demonstrated in adults undergoing surgery for aortic stenosis (AS). We sought to explore changes in E/e’ and other diastolic indices in the setting of congenital AS surgery and to assess for association with post‐operative outcomes among children and young adults.

Methods

A retrospective, single‐center study was performed among patients 6 months to 30 years of age who underwent congenital AS surgery from 2006 to 2018. Tissue Doppler indices were collected from pre‐ and post‐operative echocardiograms. Post‐operative outcomes were reviewed.

Results

Sixty‐six subjects with subvalvar (45%), valvar (47%), and supravalvar (8%) AS underwent surgery at a median age of 9.5 years (IQR: 4.0–14.8). Pre‐operatively, the lateral E/e’ ratio was 8.6 (6.7–11.0); 33% had E/e’≥10. Post‐operatively, the lateral e’ decreased to 9.9 cm/s (8.0–11.4), the E/e’ ratio increased to 10.4 (8.3–13.1); and 53% had E/e’≥10 (p‐values < 0.0001, 0.0072, and < 0.001, respectively). Pre‐operative lateral e’ correlated modestly with duration of intubation (ρ = −0.24, p‐value 0.048) and post‐operative lateral e’ correlated modestly with duration of intubation and length of hospital stay (ρ = −0.28 and −0.26, p‐values = 0.02 and 0.04, respectively).

Conclusions

Children and young adults who underwent congenital AS surgery had echocardiographic evidence of diastolic dysfunction pre‐operatively that worsened post‐operatively. Lateral e’ may be a sensitive indicator of impaired ventricular relaxation in these patients and may impact duration of intubation and hospital stay.

Tissue Doppler, speckling tracking and four-dimensional echocardiographic assessment of right ventricular function in children with dilated cardiomyopathy

BACKGROUND

Right ventricular (RV) function is frequently overlooked during dilated cardiomyopathy (DCM) evaluation.

AIM

To evaluate RV function in children with idiopathic DCM using relatively recent echocardiographic modalities.

METHODS

We prospectively studied the cardiac function in 50 children with idiopathic DCM and 50 healthy children as a control group, using four-dimensional echocardiography (4-DE), Tissue Doppler Imaging (TDI), and two-dimensional-speckles tracking echocardiography (2-D-STE). RV EF was measured by 4-DE.

RESULTS

The auto left (LV) ejection fractions (EF) measured by 2-D-STE were significantly lower in the patients' group than in the control. The sphericity index was also significantly lower in children with DCM than in the control. RV EF measured by 4-DE was significantly lower in the patient's group than the control. RV S wave, e´/a' ratio, myocardial performance index (MPI), and tricuspid annular plane systolic excursion (TAPSE) were significantly impaired in children with DCM than in control. Both LV and RV global longitudinal strains (GLS) were significantly reduced in children with DCM than in control. RVGLS was significantly associated with the duration since diagnosis, tricuspid annulus S wave, RV MPI, and TAPSE, but not with the age of the patients, RV EF, or e´/a' ratio.

CONCLUSION

There was impairment of the RV LGS and other systolic and diastolic parameters in children with DCM. STE and TDI can help to detect the early decline of RV function.

Anorexia nervosa-related cardiopathy in children with physical instability: prevalence, echocardiographic characteristics and reversibility at mid-term follow-up

Prompt detection of cardiovascular abnormalities in children with anorexia nervosa and physical instability requiring hospitalization is essential to identify patients at higher cardiovascular risk. We studied all anorexia nervosa children requiring admission at Paediatric Institute in the period 2015-2019. Anorexia nervosa cardiopathy at admission was defined by the presence of at least two of the following clinical findings: pericardial effusion, mitral regurgitation, bradycardia, mitral billowing, aortic regurgitation, altered LV morphology and ECG abnormalities. Echocardiographic data were compared with those registered at 3-8-month follow-up and with data from a healthy population. Thirty-eight anorexia nervosa children were examined. Prevalence of anorexia nervosa cardiopathy at admission was 63% (24 patients). Pericardial effusion, bradycardia and mitral regurgitation were present together in 26% of patients. Most cardiovascular changes recovered at follow-up. Anorexia nervosa cardiopathy was associated with significantly lower left ventricle end-diastolic diameters and mass, and higher E wave, E/A and E/e' ratios and left ventricle sphericity index values vs healthy population and vs anorexia nervosa children without cardiopathy (p<0.05). Left ventricle global longitudinal strain was significantly reduced only in anorexia nervosa cardiopathy patients but recovered, whereas end-diastolic diameters, E/A ratio and sphericity index values remained impaired.Conclusion: Among anorexia nervosa children requiring hospitalization, those presenting several cardiac findings together express an acute anorexia nervosa cardiopathy which is characterized by worse LV filling, geometry and subclinical myocardial deformation impairment. Despite treatment, in those patients, some alterations persist at mid-term follow-up. What is Known: • Cardiac and electrocardiographic changes are present in anorexia nervosa children at diagnosis or during stable disease, and most recover after body-weight treatment. • It is unknown if anorexia nervosa children with more severe cardiac impairment during hospitalization present higher cardiovascular-risk profile despite treatment. What is New: • In anorexia nervosa children needing hospitalization for physical reasons, prevalence of acute anorexia nervosa cardiopathy at admission is high, around 60%. • By advanced echocardiography, children with anorexia nervosa cardiopathy at admission have a worse cardiac filling, impaired cardiac geometry and systolic deformation that only partially recover at mid-term follow-up.

Parameters affecting outcome of paediatric cardiomyopathies in the intensive care unit: experience of an Egyptian tertiary centre over 7 years

Introduction: Paediatric cardiomyopathies are rare but serious and often life-threatening conditions. In the absence of cardiac transplant and ventricular assist device as treatment options in our region, it is very important to identify patients at higher risk. The aim of this study was to determine the outcome of patients diagnosed with cardiomyopathies and their prognostic indicators. Patients and methods: This study included 92 cases representing all patients diagnosed with cardiomyopathy who were admitted into the pediatric cardiac intensive care unit during the period from January 2012 to September 2018. The patients were classified into two groups according to the outcome: the first group comprised 69 patients who survived, and the second group comprised 23 patients who died. All medical records were reviewed, and data were recorded and analysed. Results: Patients with cardiomyopathies represented 8.6% (92/1071) of all patients with cardiac diseases who were admitted in the study period and in the target age group (0.5-12 years). Dilated cardiomyopathy (DCM) was the most frequent type of cardiomyopathy among the admitted patients (80 patients), while 6 patients were diagnosed with hypertrophic cardiomyopathy (HCM), 4 were diagnosed with restrictive cardiomyopathy (RCM), and only 2 were diagnosed with mixed DCM-RCM. Seventy patients required inotropic support (76.1%). Assisted mechanical ventilation was used on 15 patients (16.3%). Twenty-three patients (25.0%) died during the 7-year study period. Conclusions Conclusions The occurrence of hypotension, abnormally high liver enzymes, the need for mechanical ventilation and the need for multiple inotropic drugs were found to be statistically significant predictors of mortality, while age, sex, fractional shortening, ejection fraction, presence of mitral regurgitation, mural thrombus, electrolyte disturbance and arrhythmias did not predict or affect patients' outcomes.

Longitudinal Prediction of Transplant-Free Survival by Echocardiography in Pediatric Dilated Cardiomyopathy

BACKGROUND

The prognostic significance of serial echocardiography and its rate of change in children with dilated cardiomyopathy (DCM) is incompletely defined.

METHODS

We retrospectively analysed up to 4 serial echocardiograms. Associations between mortality/transplant and echocardiographic parameters over time and between outcomes and the rate of change of echocardiographic parameters were analysed. Estimation of patient-specific intercepts and slopes was done using linear regression models.

RESULTS

Fifty-seven DCM children were studied (50% male; median age, 0.6 year; average follow-up, 2.1 ± 2.4 years). The median time to transplant or death was 2.0 years. Increased left ventricular (LV) diastolic (LVEDD) and systolic (LVESD) dimensions and myocardial performance index (MPI) were associated with increased mortality and transplant risk. Increased LV ejection fraction, mitral E-deceleration time, right ventricular (RV) fractional area change, and tricuspid annular plane systolic excursion were associated with reduced mortality and transplant risk. Transplant/mortality likelihood increased by 41.6% and 19.8% for each unit increase in LVEDD and LVESD z scores, respectively (LVEDD: hazard ratio [HR], 1.416; 95% confidence interval [CI], 1.285-1.560; P < 0.001; LVESD: HR, 1.198; 95% CI, 1.147-1.251; P < 0.001). A higher monthly change in LVESD z score increased transplant/mortality likelihood by 85.6% (HR, 1.856; 95% CI, 1.572-2.191; P = 0.015). Greater changes in mitral E/e' (HR, 0.707; 95% CI, 0.636-0.786; P < 0.001) and RV MPI (HR, 0.412; 95% CI, 0.277-0.613; P < 0.001) were associated with reduced mortality and transplant risk.

CONCLUSIONS

LV and RV systolic and diastolic dimensions and function over time and their rate of change are associated with risk for transplant and mortality in childhood DCM. Serial changes in these parameters may be useful to predict clinical outcomes.

Left ventricular diastolic dysfunction in HIV-uninfected infants exposed in utero to antiretroviral therapy

OBJECTIVES

To longitudinally measure LV diastolic function in HIV-exposed but uninfected (HEU) children perinatally exposed to ART.

DESIGN

HEU children who were perinatally exposed to antiretroviral therapy (ART) may be at risk for adverse cardiac effects. We have previously reported that those children have decreased left ventricular (LV) mass, dimension, and septal thickness with increased contractility.

METHODS

Serial echocardiograms were obtained at specific times from birth to 48 months from two groups of HIV-uninfected children: 148 HIV-negative children who were perinatally exposed to ART and 130 non-ART-exposed HIV-unexposed healthy controls. The following LV diastolic indices were obtained: mitral valve early and late diastolic velocity (E and A), tissue Doppler-derived LV-free wall and septal early diastolic velocity (LV e' and sep e').

RESULTS

All echocardiographic indices were significantly different in ART-exposed children compared with ART-unexposed healthy controls. Both E and A were overall lower at all ages by 8.28 cm/s (P = 0.0002) and 13.46 cm/s (P < 0.0001) respectively. E/A ratio was higher by 0.27, 0.46, and 0.28 units at birth, 1 year and 2 years of age, respectively (all P ≤ 0.01). Moreover, LV e' and sep e' were overall lower at all ages by 0.84 cm/s (P = 0.01) and 0.47 cm/s (P = 0.02), respectively.

CONCLUSION

Children who were exposed to ART in utero have subclinical yet significant differences in specific LV diastolic indices. Follow-up with serial echocardiograms are recommended in this population to further assess the potential cardiac toxicity of perinatal exposure to ART.

Prognostic significance of tissue Doppler imaging-derived myocardial performance index in pediatric patients with dilated cardiomyopathy

TDI-MPI has been shown to predict cardiovascular mortality in adults; there are a paucity of data on its use in children. We sought to determine the prognostic significance of TDI-MPI at time of DCM diagnosis in children. Patients aged ≤18 years diagnosed with DCM were included along with age- and sex-matched controls. Echo at diagnosis was analyzed to obtain standard measures of LV function, PW-MPI, and septal and LV free wall TDI-MPI. Survival analysis was used to assess the time to composite outcome of death, VAD, or transplant, stratified by TDI-MPI z-score. The study included 79 patients with DCM and 79 controls. During a median follow-up of 182 days (IQR 41-815 days), 16 underwent VAD placement, 21 underwent cardiac transplant, 6 died, and 36 had event-free survival. The median septal TDI-MPI for cases was 0.70 for patients with DCM vs 0.45 for controls (P < .001). Those with septal TDI-MPI z-scores ≥2 develop events significantly earlier than those with z-score <2 (P = .014). In multivariable analysis, TDI-MPI z-score ≥2 was significantly associated with poor outcomes (HR 2.12, 95% CI 1.06-4.23). TDI-MPI can be reliably performed in pediatric patients with DCM. A TDI-MPI z-score ≥2 at diagnosis may be associated with earlier poor outcome. Further studies evaluating the use of TDI-MPI in longitudinal follow-up of patients with DCM may be helpful in refining its clinical use.

Left Atrial Strain to Identify Diastolic Dysfunction in Children with Cardiomyopathies

Background: Left ventricular (LV) diastolic dysfunction (DD) carries worse prognosis in childhood. 2-dimensional (2-D) left atrial (LA) strain accurately categorizes DD in adults but its role in children is unknown. Thus, the aim of this study is to investigate whether LA strain and strain rate could diagnose and classify DD in children with dilated (CMD), hypertrophic (HCM) and restrictive (RCM) cardiomyopathies (CM). Methods and Results: The study includes 136 children (aged 8.8 ± 6 years): 44 with DCM, 40 with HCM, 7 with RCM and 45 healthy controls (CTRL). They underwent standard echocardiographic examination and 2-D speckle-tracking analyses (LV longitudinal peak systolic strain (LS), LA peak systolic strain and strain rate). No significant differences in mitral E/A and pulmonary S/D ratios were observed among the four groups. Although E/E’ and indexed left atrial volumes were found to be significantly higher in HCM, DCM and RCM compared to CTRL (p < 0.001), they showed no significant difference among the three CM groups. LV LS values were significantly reduced in CM vs CTRL (p < 0.001) and in DCM vs HCM (p < 0.01), with no other differences between the remaining groups. LA peak systolic strain and strain rate values showed a steady and significant decrease with worsening of DD. Receiver Operating Characteristics (ROC) curves showed area under the curve of 0.976 (p < 0.001) for LA strain and 0.946 (p < 0.001) for LA strain rate, to distinguish CTRL from CMs. Conclusions: LA strain and strain rate could be a promising tool to better understand and classify DD in children with cardiomyopathies, opening the way to its clinical use.

Ventricular Arterial Coupling: A Novel Echocardiographic Risk Factor for Disease Progression in Pediatric Dilated Cardiomyopathy

In adult heart failure (HF) patients, a higher ventricular arterial (VA) coupling ratio measured non-invasively is associated with worse HF prognosis and response to treatment. There are no data regarding the relationship of VA coupling to outcome in pediatric dilated cardiomyopathy (DCM) patients. We investigated the association of VA coupling ratio with worse outcome (mechanical circulatory support, transplant, or death) in 48 children with DCM and 97 age-gender matched controls. Mean age at presentation was 9 ± 7 years; DCM patients had a higher arterial elastance (3.8 ± 1.7 vs 2.7 ± 0.7 respectively p = 0.001), a lower LV elastance (1.1 ± 0.65 vs 4.5 ± 1.4, respectively p = 0.001) and higher VA coupling ratio (5.0 ± 3.9 vs 0.34 ± 0.14, respectively p = 0.001). Outcome events occurred in 27/48 (56%) patients. Patients with an outcome event had a higher NYHA class (p = 0.001), lower LV elastance (0.8 ± 0.47 vs 1.6 ± 0.57, respectively p = 0.001), higher arterial elastance (4.5 ± 1.8 vs 2.9 ± 1.1, respectively p = 0.002), and a higher VA coupling ratio (7.1 ± 3.8 vs 2.2 ± 1.5, respectively p = 0.001) compared to those without. In a multivariate CART analysis, VA coupling was the top and only discriminator of poor outcome. In conclusion, a higher VA coupling ratio is associated with worse outcome in pediatric patients with DCM. VA coupling is promising as a bedside analysis tool that may provide insight into the mechanisms of HF in pediatric DCM and identify potential targets for therapy.

Neutrophil-to-lymphocyte ratio used as prognostic factor marker for dilated cardiomyopathy in childhood and adolescence

Objective

The objective of this study is to evaluate the neutrophil-to-lymphocyte ratio (NLR) and platelet-lymphocyte ratio, from the hemograms obtained from children and adolescents with dilated cardiomyopathy (DCM), and to correlate them with the levels of B-type natriuretic peptide (BNP) and with the clinical evolution of these patients in the long term.

Materials and Methods

Follow-up of 57 patients with DCM was made retrospectively, with hemogram and BNP level determination being performed after optimized therapy for heart failure. We compared the findings of the patients' examinations that progressed with stability in relation to the occurrence of transplant listing, cardiac transplantation, or evolution to death.

Results

The average age was 48 months, and the follow-up was 64 months. The average of the levels of neutrophils was greater in poor evolution group (7026 vs. 3903; P = 0.011) as well as the average of NLR (5.5 vs. 1.9; P = 0.034). The averages of hemoglobin, total leukocytes, lymphocytes, and platelets were similar in the groups. The area under the receiver operating characteristic curve for NLR in relation to the poor evolution was of 72.9%, being the best cutoff point of NLR ≥5.2 (sensitivity: 93.8% and specificity: 87.8%). Kaplan-Meier curves demonstrate that patients with NLR ≤5.2 (P = 0.001) and BNP <1000 pg/dl (P < 0.0001) presented greater survival.

Conclusions

NLR (≥5.2) and lymphopenia (≤1000 lymphocyte/μL) were associated with a poor prognosis and a higher chance of evolution to death or cardiac transplant, similar to the findings for BNP.

Forgotten Right Ventricle in Pediatric Dilated Cardiomyopathy

To evaluate the right ventricular (RV) function in relation to that of the left ventricle (LV) in patients with dilated cardiomyopathy (DCM). Echocardiographic examination was done using tissue Doppler imaging (TDI) and two-dimensional speckle tracking echocardiography (2D-STE) for 32 pediatric patients with DCM comparing them to another 32 normal matched controls. The global longitudinal strain (GLS) derived from 2D-STE was used to reflect the LV systolic function. Tricuspid annular plan systolic excursion (TAPSE) and the following RV TDI derived indexes: peak systolic velocity (S'), peak early diastolic velocity E', peak late diastolic velocity A', isovolumic acceleration (IVA) and myocardial performance index (MPI) were measured. RV had significant systolic and diastolic dysfunction; TAPSE, S' velocity, IVA, peak early diastolic velocity (E') and peak early diastolic velocity/peak late diastolic velocity (E'/A') ratio were significantly decreased while MPI was significantly prolonged compared to controls. Moreover, TAPSE, S', IVA, E', E'/A' and RV MPI were significantly correlated to LV GLS. For prediction of LV dysfunction among patients, the area under the receiver operating characteristic curve was 0.98 for RV MPI, 0.906 for RV IVA. For identifying severe LV dysfunction; RV MPI  > 0.29 had 100% sensitivity and 93.7% specificity, while the RV IVA  ≤ 3 had 84.4% sensitivity and 90.6% specificity. In pediatric patients with DCM the RV systolic and diastolic functions are affected beside the LV dysfunction. Non-conventional echocardiographic evaluation of RV function is recommended in among this cohort.

Six-Minute Walk Test as a Predictor for Outcome in Children with Dilated Cardiomyopathy and Chronic Stable Heart Failure

Cardiopulmonary exercise testing is an important tool to predict prognosis in children and adults with heart failure. A much less sophisticated exercise test is the 6 min walk test, which has been shown an independent predictor for morbidity and mortality in adults with heart failure. Therefore, we hypothesized that the 6 min walk test could be predictive for outcome in children with dilated cardiomyopathy. We prospectively included 49 children with dilated cardiomyopathy ≥6 years who performed a 6 min walk test. Median age was 11.9 years (interquartile range [IQR] 7.4-15.1), median time after diagnosis was 3.6 years (IQR 0.6-7.4). The 6 min walk distance was transformed to a percentage of predicted, using age- and gender-specific norm values (6MWD%). For all patients, mean 6MWD% was 70 ± 21%. Median follow-up was 33 months (IQR 14-50). Ten patients reached the combined endpoint of death or heart transplantation. Using univariable Cox regression, a higher 6MWD% resulted in a lower risk of death or transplantation (hazard ratio 0.95 per percentage increase, p = 0.006). A receiver operating characteristic curve was generated to define the optimal threshold to identify patients at highest risk for an endpoint. Patients with a 6MWD% < 63% had a 2 year transplant-free survival of 73%, in contrast to a transplant-free survival of 92% in patients with a 6MWD% ≥ 63% (p = 0.003). In children with dilated cardiomyopathy, the 6 min walk test is a simple and feasible tool to identify children with a higher risk of death or heart transplantation.

Impact of Interatrial Communication on Left Ventricle Performance in Patients with Significant Post-tricuspid Shunt

Infants with post-tricuspid valve shunts (PTS) may benefit from interatrial communication (IAC). The effect of IAC on left ventricular (LV) performance in these patients was studied. IAC was documented prospectively in 55 patients with PTS. Clinical status, echocardiographic dimensions of LV, mitral inflow Doppler, tissue Doppler velocities and time intervals were measured. Creatinine kinase (CK), CKMB, troponin-I and NT pro-brain natriuretic peptide (NT pro-BNP) were measured. Patients were divided into four groups: (A) PTS but no IAC (n = 32); (B) PTS and IAC (n = 23); (C) VSD but no IAC (n = 16); and (D) VSD and IAC (n = 19). Group A had more frequent mitral regurgitation (p = 0.041), larger mitral annulus (1.80 vs. 1.30 cm, p < 0.0001) and larger LV systolic and diastolic dimensions (2.01 vs. 1.40 and 3.28 vs. 2.35 cm, p < 0.001) than group B. The E-wave deceleration time tended to be longer in group A (121.0 vs. 106.8 ms, p = 0.06). By tissue Doppler, group A had E'- and S-waves significantly taller (15.51 vs. 13.14 and 7.69 vs. 6.72 cm, p = 0.04 and p = 0.005, respectively) than group B. Also, NT pro-BNP was significantly higher in group A (1116.15 vs. 458.73 pg/ml, p = 0.028). Group C had significant larger mitral z-score values (1.2 vs. 0.01, p < 0.001), larger LV diameter z-score (p = 0.001) and higher NT pro-BNP level (1477.37 vs. 451.66 pg/ml, p = 0.001) than group D. There was no significant difference in the clinical status between the groups. In children with PTS, the presence of IAC could be beneficial. Their echocardiographic parameters and biomarker show better systolic and diastolic LV performance.

Biomarkers in pediatric heart disease

A biomarker is a characteristic that can be used as an indicator of a biological state. A biomarker can be a clinical observation, laboratory test or an imaging parameter. In this review, we discuss the use of biomarkers in differentiating cardiac from noncardiac disease; predicting the prognosis of patients with heart failure, pulmonary hypertension and dilated cardiomyopathy; diagnosing subclinical cardiac involvement in muscular dystrophy and postchemotherapy cancer patients; detecting acute rejection following heart transplantation; diagnosing Kawasaki disease; aiding the management of postoperative cardiac patients; and managing both common (tetralogy of Fallot) and complex (single-ventricle physiology) congenital heart diseases.

Does surgically induced right bundle branch block really effect ventricular function in children after ventricular septal defect closure?

In this prospective study, we aimed to assess left and right ventricular function in terms of the presence of right bundle branch block (RBBB) in the cases with repaired ventricular septal defect (VSD). Fifty-three patients who had VSD surgery at least 1-year preceding admission and 52 healthy controls were enrolled into the study. All the participants underwent electrocardiographic and echocardiographic examination. The cases with RBBB were determined. The conventional and tissue Doppler echocardiographic measurements of the patients with and without RBBB were compared with each other and healthy controls. Twenty-eight of VSD repair groups were male and 25 were female. Control group consisted of 30 males and 22 females. The mean age of the study and control groups was 7.5 ± 5.0 and 6.9 ± 4.3 years, respectively. RBBB was detected in 20 of 53 (37.7 %) operated patients. The only significant difference between the cases with and without RBBB was decreased right ventricular fractional area change (%) in the former group (33 ± 7 vs. 39 ± 5 p < 0.05). When compared to controls, operated group had statistically lower [corrected] tricuspid annular plane systolic excursion (p < 0.05), lower systolic, early diastolic, and late diastolic myocardial velocities, higher left and right ventricular myocardial performance indices, irrespective of the presence of RBBB. The ratios of mitral or tricuspid inflow to left or right ventricular myocardial in early diastolic velocities measured from lateral annular levels were increased in operated group (all p values <0.05). In conclusion, RBBB in the cases with surgical VSD repair might be associated with right ventricular dysfunction. Biventricular systolic and diastolic dysfunction may develop following VSD repair irrespective of the presence of RBBB. Tissue Doppler-derived myocardial performance indices are useful in detection of those subclinical dysfunctions.

Circulating microRNA as a biomarker for recovery in pediatric dilated cardiomyopathy

BACKGROUND

MicroRNAs (miRNAs) are short regulatory RNAs that control gene expression through interacting with the 3'UTR of target messenger RNAs. The purpose of this study was to determine if circulating miRNAs are useful biomarkers of outcome in children with dilated cardiomyopathy (DCM).

METHODS

An array for 754 miRNAs and real time polymerase chain reaction confirmation of select miRNAs were performed. Serum from 55 children <18 years old with DCM was analyzed. Samples were drawn from all patients with DCM when undergoing heart transplant evaluation and/or at the time of transplantation. Patients with DCM were categorized based on when their blood was drawn (Pre-Transplant or Transplant) and outcome (Transplant/died or Recovered).

RESULTS

Two miRNAs were significantly up-regulated (hsa-miR-155 and hsa-miR-636) and 2 miRNAs were down-regulated (hsa-miR-646 and hsa-miR-639) in patients with DCM who were transplanted or died compared with patients with DCM who recovered their ventricular function. Receiver operator curves, performed for differences in any 1 of these 4 differentially regulated miRNAs in patients who were transplanted or died compared with patients who recovered, resulted in an area under the receiver operating characteristic curve of 0.875 for the Pre-Transplant blood draw time point and an area under the receiver operating characteristic curve of 0.93 for the day of Transplant time point.

CONCLUSIONS

We identified specific miRNAs that are differentially regulated between children with DCM who need a transplant compared with children with DCM who recover. A unique biomarker signature of miRNAs that are specific to children with DCM who have the potential to recover would be valuable in risk stratification of this challenging patient population.

Left ventricular diastolic function in hypertension: methodological considerations and clinical implications

The assessment of left ventricular (LV) diastolic function should be an integral part of a routine examination of hypertensive patient; indeed when LV diastolic function is impaired, it is possible to have heart failure even with preserved LV ejection fraction. Left ventricular diastolic dysfunction (LVDD) occurs frequently and is associated to heart disease. Doppler echocardiography is the best tool for early LVDD diagnosis. Hypertension affects LV relaxation and when left ventricular hypertrophy (LVH) occurs, it decreases compliance too, so it is important to calculate Doppler echocardiography parameters, for diastolic function evaluation, in all hypertensive patients. The purpose of our review was to discuss about the strong relationship between LVDD and hypertension, and their relationship with LV systolic function. Furthermore, we aimed to assess the relationship between the arterial stiffness and LV structure and function in hypertensive patients.

Predictors of disease progression in pediatric dilated cardiomyopathy

BACKGROUND

Despite medical advances, children with dilated cardiomyopathy (DCM) remain at high risk of death or need for cardiac transplantation. We sought to identify predictors of disease progression in pediatric DCM.

METHODS AND RESULTS

The Pediatric Heart Network evaluated chronic DCM patients with prospective echocardiographic and clinical data collection during an 18-month follow-up. Inclusion criteria were age <22 years and DCM disease duration >2 months. Patients requiring intravenous inotropic/mechanical support or listed status 1A/1B for transplant were excluded. Disease progression was defined as an increase in transplant listing status, hospitalization for heart failure, intravenous inotropes, mechanical support, or death. Predictors of disease progression were identified using Cox proportional hazards modeling and classification and regression tree analysis. Of the 127 patients, 28 (22%) had disease progression during the 18-month follow-up. Multivariable analysis identified older age at diagnosis (hazard ratio=1.14 per year; P<0.001), larger left ventricular (LV) end-diastolic M-mode dimension z-score (hazard ratio=1.49; P<0.001), and lower septal peak systolic tissue Doppler velocity z-score (hazard ratio=0.81; P=0.01) as independent predictors of disease progression. Classification and regression tree analysis stratified patients at risk of disease progression with 89% sensitivity and 94% specificity based on LV end-diastolic M-mode dimension z-score ≥7.7, LV ejection fraction <39%, LV inflow propagation velocity (color M-mode) z-score <-0.28, and age at diagnosis ≥8.5 months.

CONCLUSIONS

In children with chronic stable DCM, a combination of diagnosis after late infancy and echocardiographic parameters of larger LV size and systolic and diastolic function predicted disease progression.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00123071.

Preoperative regional left ventricular wall thickening determined by quantitative gated SPECT as a predictor of mid-term surgical results for ischemic and nonischemic cardiomyopathy

BACKGROUND

This study aimed to elucidate whether regional left ventricular wall thickening (LVWT) determined by quantitative gated SPECT (QGS) is useful in predicting surgical outcomes for ischemic (ICM) and nonischemic cardiomyopathy (NICM).

METHODS AND RESULTS

The study group comprised 53 patients with either ICM (n=30, left ventricular ejection fraction (LVEF)=24.7±7.1%) or NICM (n=23, LVEF=24.0±6.3%) scheduled for surgical repair underwent preoperative QGS to evaluate regional LV function. LVWT of 20 segments derived from QGS was normalized by being divided by the normal value of each LV level. Normalized values of the segments were summed to be representative of each area. For 16 of the 30 patients with ICM and 17 of the 23 patients with NICM, surgical ventricular restoration and papillary muscle approximation (PMA) were performed for surgical repair and, for the rest, PMA alone was done for both ICM and NICM patients. Adjunctive coronary artery bypass grafting for ICM patients was added when necessary. Mean follow-up periods were 2.5±1.8 years for ICM and 2.2±2.4 years for NICM. Posterior regional LVWT in NICM (normalized sum value <0.61 n=7, ROC: AUC=0.80) predicted cardiac events (chronic heart failure and cardiac-caused death). The one-year cardiac event-free rates were 22.2% and 85.1% and the 2 years rates were 11.1% and 48.6% for the lower posterior WT group and higher posterior WT group respectively (P=0.003).

CONCLUSIONS

Posterior LVWT can be a predictor for postoperative cardiac events in patients with NICM.

Cardiac effects in perinatally HIV-infected and HIV-exposed but uninfected children and adolescents: a view from the United States of America

Introduction

Human immunodeficiency virus (HIV) infection is a primary cause of acquired heart disease, particularly of accelerated atherosclerosis, symptomatic heart failure, and pulmonary arterial hypertension. Cardiac complications often occur in late-stage HIV infections as prolonged viral infection is becoming more relevant as longevity improves. Thus, multi-agent HIV therapies that help sustain life may also increase the risk of cardiovascular events and accelerated atherosclerosis.

Discussion

Before highly active antiretroviral therapy (HAART), the two-to-five-year incidence of symptomatic heart failure ranged from 4 to 28% in HIV patients. Patients both before and after HAART also frequently have asymptomatic abnormalities in cardiovascular structure. Echocardiographic measurements indicate left ventricular (LV) systolic dysfunction in 18%, LV hypertrophy in 6.5%, and left atrial dilation in 40% of patients followed on HAART therapy. Diastolic dysfunction is also common in long-term survivors of HIV infection. Accelerated atherosclerosis has been found in HIV-infected young adults and children without traditional coronary risk factors. Infective endocarditis, although rare in children, has high mortality in late-stage AIDS patients with poor nutritional status and severely compromised immune systems. Although lymphomas have been found in HIV-infected children, the incidence is low and cardiac malignancy is rare. Rates of congenital cardiovascular malformations range from 5.6 to 8.9% in cohorts of HIV-uninfected and HIV-infected children with HIV-infected mothers. In non-HIV-infected infants born to HIV-infected mothers, foetal exposure to ART is associated with reduced LV dimension, LV mass, and septal wall thickness and with higher LV fractional shortening and contractility during the first two years of life.

Conclusions

Routine, systematic, and comprehensive cardiac evaluation, including a thorough history and directed laboratory assays, is essential for the care of HIV-infected adults and children as cardiovascular illness has become a part of care for long-term survivors of HIV infection. The history should include traditional risk factors for atherosclerosis, prior opportunistic infections, environmental exposures, and therapeutic and illicit drug use. Laboratory tests should include a lipid profile, fasting glucose, and HIV viral load. Asymptomatic cardiac disease related to HIV can be fatal, and secondary effects of HIV infection often disguise cardiac symptoms, so systematic echocardiographic monitoring is warranted.

The role of right ventricular function in paediatric idiopathic dilated cardiomyopathy

INTRODUCTION

The prevalence of right ventricular dysfunction in idiopathic dilated cardiomyopathy is incompletely studied in children. Furthermore, right ventricular function may signal worse outcomes. We evaluated recently published right ventricular function echocardiographic indices in identifying dysfunction in children with idiopathic dilated cardiomyopathy and the impact of right ventricular dysfunction on long-term prognosis.

METHODS

A retrospective database review of right ventricular function indices in 30 patients with idiopathic dilated cardiomyopathy was compared with 60 age- and sex-matched controls from January, 2001 until December, 2010. Right ventricular function was assessed by Doppler tissue peak systolic S', early and late diastolic E' and A' waves and isovolumic acceleration at the tricuspid valve annulus; pulsed wave Doppler tricuspid valve inflow E and A waves; right ventricular myocardial performance index; tricuspid annular plane systolic excursion; right ventricular fractional area change.

RESULTS

Right ventricular systolic and diastolic function in idiopathic dilated cardiomyopathy was significantly impaired. All measured indices except for isovolumic acceleration and fractional area change were significantly reduced, with a p-value less than 0.05. There was no right ventricular index predictive of death or transplantation. Patients with poor outcome were significantly more likely to need inotropic support (p-value equal to 0.018), be placed on a ventricular assist device (p equal to 0.005), and have a worse left ventricular ejection fraction z-score (p-value equal to 0.002).

CONCLUSION

Right ventricular dysfunction is under-recognised in children presenting with idiopathic dilated cardiomyopathy. The need for clinical circulatory support and left ventricular ejection fraction z-score less than minus 8 were primary determinants of outcome, independent of the degree of derangement in right ventricular function.

Effects of carvedilol therapy on cardiac autonomic control, QT dispersion, and ventricular arrhythmias in children with dilated cardiomyopathy

BACKGROUND

The purpose of this study was to examine the effects of carvedilol therapy on autonomic control of the heart and QT-interval dispersion (QTd) among children with idiopathic dilated cardiomyopathy (DCM) whose symptoms were not adequately controlled with standard congestive heart failure therapy.

MATERIAL AND METHODS

Patients with DCM who were treated with carvedilol were enrolled in the study. All patients had undergone carvedilol therapy in addition to standard therapy for at least 6 months. Clinical, echocardiographic, and electrocardiographic parameters, and 24-h Holter records of patients were retrospectively evaluated before and after carvedilol treatment.

RESULTS

A total 34 patients (mean age: 7.4 ± 4.3 years) with DCM were analyzed in the study. The median follow-up period was 9.5 months. After the 6 months of carvedilol therapy the clinical score significantly improved, left ventricular ejection fraction (LVEF) and fractional shortening (LVFS) significantly increased, and left ventricle end-diastolic dimensions and end-systolic dimensions significantly decreased. There were statistically significant increases in mean SDNN, SDANN, rMSSD, and pNN50 (p = 0.002, p = 0.001, p = 0.008, and p = 0.026, respectively). After the carvedilol therapy, SDNN was correlated with the clinical score, heart rate, LVEF, LVFS, and total premature ventricular contractions (PVCs). In addition, rMSSD and pNN50 were correlated with heart rate, LVEF and LVFS. A significant reduction was observed in QTc-minimum, QTc-maximum, and QTd values (434.9 ± 40.7 vs. 416.1 ± 36.5, 497.8 ± 43.6 vs. 456.3 ± 41.7, 58.6 ± 17.1 vs. 49.3 ± 15.6; p < 0.001, p = 0.001, and p = 0.008, respectively). QTd was significantly related to PVCs (r = 0.62, p = 0.02).

CONCLUSIONS

We conclude that the addition of carvedilol to standard therapy can improve clinical symptoms and heart rate variability, and reduce in arrhythmia markers in children with DCM.

Effects of omega-3 polyunsaturated Fatty acids on heart function and oxidative stress biomarkers in pediatric patients with dilated cardiomyopathy

OBJECTIVES

Dilated cardiomyopathy is the most prevalent type of cardiomyopathy in children, which results in congestive heart failure and causes significant morbidity and mortality. This study, aims to investigate the effect of supplementation with omega-3 polyunsaturated fatty acids (n-3 PUFA) on heart function and oxidative stress biomarkers in these patients.

METHODS

The present research was a case-control study on pediatric patients with dilated cardiomyopathy, who received n-3 PUFA and anti-failure therapy for 6 months (group 1, n = 6), or anti-failure therapy alone for 6 months (group 2, n = 6), as well as age matched normal individuals (group 3, n = 6), and evaluated the cardiac function and biomarkers of oxidative stress.

RESULTS

Echocardiographic parameters, such as left ventricular ejection fraction, shortening fraction, tissue Doppler Ea and Aa waves of lateral annulus of tricuspid valve, and Ea and S wave of septum, were significantly improved in group 1 after n-3 PUFA compared to pre- treatment status, while they were not changed after treatment in group 2. Antioxidant enzymes, including catalase and glutathione peroxidase activities in erythrocytes were slightly decreased, while plasma 8-iso-prostaglandin F2α concentrations were somewhat increased in group 1 compared to groups 2 and 3, however these changes were not statistically significant. Total antioxidant capacity of plasma was similar in all 3 groups.

CONCLUSIONS

The results indicate that some echocardiographic parameters were significantly improved in patients receiving omega-3 fish oil. However, omega-3 had no significant effect on oxidative stress biomarkers.

Interpretation of left ventricular diastolic dysfunction in children with cardiomyopathy by echocardiography: problems and limitations

BACKGROUND

Left ventricular diastolic dysfunction (DD) is a key determinant of outcomes in pediatric cardiomyopathy (CM), but remains very challenging to diagnose and classify. Adult paradigms and guidelines relating to DD are currently applied in children. However, it is unknown whether these are applicable to children with CM. We investigated the assessment of DD in children with CM using adult and pediatric echocardiographic criteria and tested whether recent adult guidelines are applicable to this population.

METHODS AND RESULTS

Three investigators independently classified diastolic function in 4 study groups: controls, dilated, hypertrophic, and restrictive CM. Agreement among investigators, failure to classify DD, and the reasons for diagnostic failure were determined. The usefulness of individual echo parameters to diagnose and classify DD was assessed. One hundred seventy-five children (aged 0-18 years) were studied. DD diagnostic criteria were discrepant in the majority of patients. Delayed relaxation was diagnosed in only 14% of hypertrophic CM patients and never in dilated CM and restrictive CM, with 50% of those patients having coexisting findings of elevated filling pressures. Many key parameters, such as mitral and pulmonary venous Doppler, were not informative. Agreement among investigators for grading of DD was poor (36% of CM patients).

CONCLUSIONS

Assessment of DD in childhood CM seems inadequate using current guidelines. The large range of normal pediatric reference values allows diagnosis of DD in only a small proportion of patients. Key echo parameters to assess DF are not sufficiently discriminatory in this population, and discrepancies between criteria within individuals prevent further classification and result in poor interobserver agreement.

Reduced diastolic function and left ventricular mass in HIV-negative preadolescent children exposed to antiretroviral therapy in utero

OBJECTIVE

Abnormalities in left ventricular morphology and function have been reported in HIV-negative infants exposed to antiretroviral therapy (ART) in utero that persists throughout preschool age. The objective of this study was to determine if these abnormalities persist, resolve, or worsen during preadolescence.

DESIGN

Cross-sectional observation study.

METHODS

Thirty HIV-negative children born to HIV-positive women and exposed to ART in utero (mean age 8 ± 2 years, 37% female, 74% African-American) and 30 HIV-negative children born to HIV-negative women (mean age 8 ± 3 years, 37% female, 76% African-American) underwent two-dimensional Doppler, tissue Doppler, and strain echocardiography to evaluate left ventricular systolic and diastolic function.

RESULTS

Weight, body surface area, heart rate and blood pressure were similar between groups. For the ART-exposed group, left ventricular mass index was lower (60 ± 9 vs. 67 ± 12 g/m, P < 0.02) and early diastolic annular velocity was lower (15.0 ± 2.2 vs. 16.3 ± 2.5 cm/s, P < 0.03) compared to controls. Left ventricular systolic function did not differ between groups. Lower maternal third trimester CD4 count was associated with lower early diastolic annular velocity; other non-HIV-related variables including cocaine use and increased maternal age correlated with lower left ventricular mass index.

CONCLUSIONS

Abnormalities in left ventricular systolic performance previously reported in HIV-negative infants and preschool aged children exposed to ART in utero were not apparent in preadolescent children. Left ventricular diastolic relaxation was reduced compared with controls suggesting residual effects of ART exposure on left ventricular diastolic function. Larger, longitudinal studies are necessary to confirm these observations.

Outcomes of children following a first hospitalization for dilated cardiomyopathy

BACKGROUND

We hypothesized that children with dilated cardiomyopathy who require hospital admission are at increased risk for death or transplantation during their first hospitalization and in the first year that follows. We also assessed the value of routine data collected during that time to predict death or the need for transplantation prior to discharge and within 1 year of admission.

METHODS AND RESULTS

We conducted a retrospective review of 83 pediatric patients with dilated cardiomyopathy whose initial hospitalization fell between 2004 and 2009. The mean age at hospitalization was 7 years. The majority of patients demonstrated moderate or severe left ventricular dysfunction on initial echocardiogram (80%) and/or the need for intravenous inotropes within 7 days of hospital admission (69%). Five patients (6%) died, and 15 (18%) were transplanted in the initial hospitalization. At 1 year, 11/71 (15%) had died, and 27/71 (38%) were transplanted. The overall freedom from death, transplantation, or rehospitalization at 1 year following admission was 21%. Fractional shortening, left ventricular ejection fraction, serum cholesterol, uric acid, mixed venous saturation, and atrial filling pressures were all predictive of death or transplantation during the initial hospitalization. Left ventricular ejection fraction was predictive of death or transplantation at 1 year.

CONCLUSIONS

The first hospitalization for dilated cardiomyopathy marks a period of high risk for clinical decline, end stage heart failure, and the need for cardiac transplantation. Echocardiographic function and hemodynamic and serum measurements may aid in predicting outcomes. Despite medical management, most patients will be rehospitalized and/or require cardiac transplantation within 1 year of admission.

The clinical value of the Tei index among Nigerians with hypertensive heart failure: correlation with other conventional indices

BACKGROUND

Various conventional methods are used for functional evaluation and risk stratification in heart failure. A combined index of global myocardial performance called the Tei index has been described. The aim of this study was to evaluate the correlation of the Tei index with other conventional indices of systolic and diastolic function among Nigerians with hypertensive heart failure.

METHODS

Fifty-five subjects with hypertensive heart failure and 30 controls were examined, a clinical history was taken, and echocardiography was performed on them. The subjects were categorised into four groups based on their ejection fraction (normal ejection fraction, mild, moderate and severe heart failure). The Tei index was calculated as the sum of the isovolumic relaxation and contraction time, divided by the ejection time. Statistical analysis was done using SPSS 16.0.

RESULTS

The Tei index was significantly higher among subjects with hypertensive heart failure compared with the controls (0.91 ± 0.33 vs 0.28 ± 0.16, p < 0.005). The Tei index also increased with the severity of the heart failure and was inversely correlated with ejection fraction (r = -0.697, p < 0.001) and fractional shortening (r = -0.580, p = 0.001). It was directly correlated with mitral E/A ratio (r = 0.246, p = 0.030), left ventricular internal diastolic dimension (r = 0.414, p = 0.002), left ventricular internal systolic dimension (r = 0.596, p < 0.001) and deceleration time (r = 0.219, p = 0.032).

CONCLUSION

The Tei index correlated significantly with other conventional indices of systolic and diastolic function among Nigerians with hypertensive heart failure. It can be used as a risk-stratification index similar to other traditional indices of systolic and diastolic function.

Myocardial function in offspring 5-8years after pregnancy complicated by preeclampsia

INTRODUCTION

Preeclampsia and diabetic pregnancies share pathophysiological features suggested to influence epigenetic changes during foetal life with importance for later development and metabolic and cardiovascular diseases.

AIM

Our objective was to study the myocardium in offspring after pregnancy complications.

METHODS

Forty-five children (age 5-8 years) delivered from pregnancies complicated by preeclampsia (n = 25), diabetes mellitus type 1 (n = 8) or gestational diabetes mellitus (n = 12) were included. Fifteen children from uneventful pregnancies served as controls. Myocardial functions of right and left ventricle were examined by conventional Doppler and tissue Doppler imaging (TDI).

RESULTS

No major differences were found in the myocardial function between offspring of pregnancy complications and control group. However, the preeclampsia group had smaller hearts, increased heart rate and increased late diastolic velocity (A'-wave) at mitral valve attachments shown by both pulsed wave and colour TDI compared to the control and diabetic groups together (p ≤ 0.01).

CONCLUSION

Children born after preeclampsia may show effects of a negative impact on the heart already at the age of 5 to 8 years. The numbers of examined children were, however, limited.

Relationship of brain natriuretic peptide concentrations to left ventricular function and adverse outcomes in children with end-stage renal disease undergoing hemodialysis

B-type natriuretic peptide (BNP) is a biomarker of cardiovascular disease that is common in adults with chronic kidney disease (CKD). However, in children with CKD, the range and predictive power of BNP concentrations are not known. We aimed to determine the effect of HD on BNP, as well as the prognostic impact of BNP, in end-stage renal disease (ESRD) children undergoing hemodialysis (HD). Thirty-five children with chronic renal failure (16 boys age 12.1 ± 3.7 years) on maintenance HD were included. BNP level was measured, and Doppler echocardiography was performed 30 min before (pre-HD BNP) and 30 min after (post-HD BNP) HD in each patient. An adverse event was defined as all-cause death and heart failure hospitalization. The median pre-HD BNP, the post-HD BNP, and the change in BNP were, respectively, 240 pg/ml (72 to 3346), 318 pg/ml (79 to 3788), and 9 pg/ml (-442 to 1889). Pre-HD BNP concentration was negatively correlated with left ventricular (LV) ejection fraction (r = -0.41, P = 0.018). During a mean follow-up of 39 ± 14 months, 6 patients died, and 3 were hospitalized for heart failure. Using univariate analysis, BNP before and after HD as well as Doppler tissue imaging velocities had a strong graded relationship with adverse events. Cox proportional hazards model demonstrated that pre-HD body weight (P = 0.008), pre-HD BNP (P = 0.011), and post-HD BNP (P = 0.038) remained independent predictors of adverse outcome. Even in case of ESRD, BNP still strongly correlated with LV systolic and diastolic dysfunction and was associated with mortality in HD children.

Usefulness of mitral regurgitation as a marker of increased risk for death or cardiac transplantation in idiopathic dilated cardiomyopathy in children

In adults with idiopathic dilated cardiomyopathy (IDC), mitral regurgitation (MR) is associated with adverse prognosis and is often addressed by surgery or intervention. MR is commonly found in children with IDC, but its prognostic relevance has not been defined, and interventions to reduce MR are not routinely performed in this population. In this study, it was hypothesized that MR is an independent risk factor for death or transplantation. This was a single-center, retrospective study of sequential patients with IDC or familial IDC (left ventricular end-diastolic dimension z score >2 and ejection fraction <50%). Patients with acute myocarditis or previous mitral surgery were excluded. MR severity was graded according to American Society of Echocardiography guidelines as mild, moderate, or severe on the basis of MR jet vena contracta width. Left ventricular end-diastolic volume, end-systolic volume, and ejection fraction were measured by biplane Simpson's method. Forty-two children with IDC were studied. The mean follow-up period was 25 months. At initial assessment, 34 children (82%) were taking angiotensin-converting enzyme inhibitors, 25 (60%) furosemide, 27 (65%) β blockers, and 7 (17%) intravenous inotropes. The mean indexed end-systolic volume was 91 ± 51 ml/m(2). The mean ejection fraction was 27 ± 16%. MR was mild in 42%, moderate in 19%, severe in 2%, and absent in 35% of patients. MR severity progressed from initial to last evaluation. MR severity was an independent risk factor for lower freedom from death or transplantation. Progression in MR severity increased the annual hazard of death or transplantation by a factor of 2.4 (p = 0.003). In conclusion, MR severity is independently associated with worse clinical status and decreased freedom from death or transplantation in children with IDC.

Pediatric cardiomyopathies over the last decade: a retrospective observational epidemiology study in a tertiary institute, Egypt

BACKGROUND

Pediatric cardiomyopathy (CM) is a rare, life-threatening disorder of unknown etiology. Data on CM in Egypt are scarce as there is no national registry. This study was an effort to understand the demographic features, clinical presentation, and frequency of different types of childhood CM in Egypt.

MATERIALS AND METHODS

Medical files of all children diagnosed with CM in the last decade (1997-2007) and referred to the Pediatric Cardiology Clinic at Ain Shams University, Children's Hospital (Cairo, Egypt), were reviewed. This study included 124 (6.6%) cardiomyopathic patient files from a total of 1876 cardiac patients that were followed up at the Pediatric Cardiology Clinic during the 10-year study period.

RESULTS

In the last decade (1997-2007), children with CM represented 6.6% of all children with cardiovascular diseases followed at the Pediatric Cardiology Clinic; 73 were boys (58.9%) and 51 were girls (41.1%), with a mean age of 3.82±3.99 years. Parental consanguinity was positive in 19.4% of patients and a history of preceding viral infection was present in one patient (0.8%). Eight patients had a similarly affected sibling (6.5%).

CONCLUSION AND RECOMMENDATIONS

Data on CM in Egypt are scarce, highlighting the urgent need for a national registry for CM (a) to allow more accurate assessment of the size of this problem, especially in children; (b) to minimize loss of follow-up data when patients move from one region to another; and (c) to allow screening of family members of a proband case.

Dilated cardiomyopathy presenting in childhood: aetiology, diagnostic approach, and clinical course

OBJECTIVE

To determine the outcome of dilated cardiomyopathy presenting in childhood and the features that might be useful for prognostic stratification.

METHODS

Retrospective study of 41 consecutive children affected by dilated cardiomyopathy - aged 0-14 years; median 33.4 plus or minus 49.25 - between 1993 and 2008. We reviewed the medical history to determine age at diagnosis, family history, previous viral illness, aetiology, symptoms and signs at presentation, treatment, and outcome. The diagnosis was made on the basis of cardiomegaly and evidence of poor left ventricular function by echocardiography. We also carried out a metabolic evaluation including blood lactate, pyruvate, carnitine, amino acids, urine organic acids, assessment of respiratory chain enzymes, and analysis of histopathological material. Survival curves were constructed by the Kaplan-Meier method.

RESULTS

Follow-up ranged from 10 days to 162 months - median 45.25 plus or minus 41.15 months. Freedom from death or cardiac transplantation was 68.3% at 5 years. The primary end-point of death/cardiac transplantation was associated with the need for intravenous inotropic support. A trend towards a poorer prognosis was found for age at diagnosis of more than 5 years and for a metabolic aetiology of dilated cardiomyopathy. For the children affected by cardiomyopathy as part of a multi-system involvement, mortality was 50%.

CONCLUSIONS

In children, dilated cardiomyopathy is a diverse disorder with outcomes that depend on cause, age, and cardiac failure status at presentation. Overt cardiac failure at presentation is a major prognostic factor for death or cardiac transplantation. Older age at presentation and metabolic aetiology may be associated with a poorer prognosis.

Diastolic dysfunction in pediatric cardiac patients: evaluation and management

OPINION STATEMENT

The heart is a complex and sophisticated pump that cycles between two phases: diastole, during which a compliant chamber (ventricle) allows the blood to fill from a reservoir chamber (atrium) of low pressure, and systole, during which a stiff chamber with rapidly rising pressure ejects the blood into an arterial circuit of high pressure. However, the systolic and diastolic cycles are not dichotomous. They have complex interactions with interrelated segments of the cardiac cycle. Although the entity of "diastolic heart failure with preserved systolic function" has been applied in adult patients, a discrete diagnosis of systolic and diastolic heart failure may be difficult to apply in pediatric patients. Advances in echocardiography have helped decipher the morphologic and physiologic expression of congenital and acquired heart disease and have increased our understanding the diastolic function and dysfunction. The evolving concept of systolic and diastolic heart failure is helping us develop a strategy for its management in pediatric patients with complex heart diseases.

Echocardiographic evaluation of children with systemic ventricular dysfunction treated with carvedilol

Echocardiography is used to measure the therapeutic effectiveness of heart failure therapy in adults and children. The purposes of this study were (1) to assess baseline echocardiographic predictors of clinical outcome, (2) to investigate changes in echocardiographic parameters, and (3) to compare these echocardiographic changes with changes in plasma levels of b-type natriuretic peptide (BNP) in a population of children with systemic ventricular dysfunction and symptomatic heart failure treated with carvedilol or placebo. All available baseline and 6-month echocardiograms from Pediatric Carvedilol Trial (PCT) participants (carvedilol n = 161; placebo n = 55) were reviewed. Systolic and diastolic sphericity index (SI; n = 110), TEI index (n = 145), and systemic ventricular dP/dt (n = 70) were measured. The PCT composite definition of clinical outcome (i.e., worsened, improved, or unchanged) was used. For all patients, baseline TEI index was a predictor of worsened outcome. Only children treated with carvedilol showed a significant decrease in systolic SI (P B 0.0001), diastolic SI (P B 0.0001), and TEI index (P = 0.02). An inverse correlation between changes in BNP and changes in dP/dt (r = -0.45, P = 0.04) was found only in the carvedilol group. In conclusion, TEI index predicted outcome in children with systemic ventricular dysfunction and heart failure. Carvedilol may have a beneficial effect on reversal of left ventricular remodeling and global ventricular function in pediatric heart failure.