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Meloni A, Pistoia L, Ricchi P, Bagnato S, Longo F, Messina G, Bagnato S, Rossi V, Renne S, Righi R, Fina P, Positano V, Cademartiri F. Impact of genotype on multi-organ iron and complications in patients with non-transfusion-dependent β-thalassemia intermedia. Ann Hematol 2024; 103:1887-1896. [PMID: 38581547 DOI: 10.1007/s00277-024-05741-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 03/30/2024] [Indexed: 04/08/2024]
Abstract
We evaluated the impact of the genotype on clinical and hematochemical features, hepatic and cardiac iron levels, and endocrine, hepatic, and cardiovascular complications in non-transfusion-dependent (NTD) β-thalassemia intermedia (TI) patients. Sixty patients (39.09 ± 11.11 years, 29 females) consecutively enrolled in the Myocardial Iron Overload in Thalassemia project underwent Magnetic Resonance Imaging to quantify iron overload, biventricular function parameters, and atrial areas and to detect replacement myocardial fibrosis. Three groups of patients were identified: homozygous β+ (N = 18), heterozygous β0β+ (N = 22), and homozygous β0 (N = 20). The groups were homogeneous for sex, age, splenectomy, hematochemical parameters, chelation therapy, and iron levels. The homozygous β° genotype was associated with significantly higher biventricular end-diastolic and end-systolic volume indexes and bi-atrial area indexes. No difference was detected in biventricular ejection fractions or myocardial fibrosis. Extramedullary hematopoiesis and leg ulcers were significantly more frequent in the homozygous β° group compared to the homozygous β+ group. No association was detected between genotype and liver cirrhosis, hypogonadism, hypothyroidism, osteoporosis, heart failure, arrhythmias, and pulmonary hypertension. Heart remodelling related to a high cardiac output state cardiomyopathy, extramedullary hematopoiesis, and leg ulcers were more pronounced in patients with the homozygous β° genotype compared to the other genotypes analyzed. The knowledge of the genotype can assist in the clinical management of NTD β-TI patients.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Paolo Ricchi
- U.O.S.D. Malattie Rare del Globulo Rosso, Azienda Ospedaliera Di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Sergio Bagnato
- Ematologia Microcitemia, Ospedale San Giovanni di Dio - ASP Crotone, Crotone, Italy
| | - Filomena Longo
- Unità Operativa Day Hospital Della Talassemia E Delle Emoglobinopatie, Azienda Ospedaliero-Universitaria "S. Anna", Cona, FE, Italy
| | - Giuseppe Messina
- Centro Microcitemie, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Sabrina Bagnato
- U.O.S. Di Talassemia, Presidio Ospedaliero Lentini - ASP 8 Siracusa, Lentini, SR, Italy
| | | | - Stefania Renne
- Struttura Complessa Di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II", Lamezia Terme, Italy
| | - Riccardo Righi
- Diagnostica Per Immagini E Radiologia Interventistica, Ospedale del Delta, Lagosanto, FE, Italy
| | - Priscilla Fina
- Unità Operativa Complessa Diagnostica Per Immagini, Ospedale "Sandro Pertini", Rome, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy.
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Truby LK, Michelis K, Grodin JL. More Than Meets the Eye: Defining the Prevalence, Pathophysiology, and Approach to Myocardial Iron Overload. Am J Cardiol 2024; 219:38-43. [PMID: 38461925 DOI: 10.1016/j.amjcard.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/05/2024] [Accepted: 01/19/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Lauren K Truby
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katherine Michelis
- University of Texas Southwestern Medical Center, Dallas, Texas; Dallas VA Medical Center, Dallas, Texas
| | - Justin L Grodin
- University of Texas Southwestern Medical Center, Dallas, Texas.
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Wlodarski MW, Vlachos A, Farrar JE, Da Costa LM, Kattamis A, Dianzani I, Belendez C, Unal S, Tamary H, Pasauliene R, Pospisilova D, de la Fuente J, Iskander D, Wolfe L, Liu JM, Shimamura A, Albrecht K, Lausen B, Bechensteen AG, Tedgard U, Puzik A, Quarello P, Ramenghi U, Bartels M, Hengartner H, Farah RA, Al Saleh M, Hamidieh AA, Yang W, Ito E, Kook H, Ovsyannikova G, Kager L, Gleizes PE, Dalle JH, Strahm B, Niemeyer CM, Lipton JM, Leblanc TM. Diagnosis, treatment, and surveillance of Diamond-Blackfan anaemia syndrome: international consensus statement. Lancet Haematol 2024; 11:e368-e382. [PMID: 38697731 DOI: 10.1016/s2352-3026(24)00063-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/08/2024] [Accepted: 02/16/2024] [Indexed: 05/05/2024]
Abstract
Diamond-Blackfan anaemia (DBA), first described over 80 years ago, is a congenital disorder of erythropoiesis with a predilection for birth defects and cancer. Despite scientific advances, this chronic, debilitating, and life-limiting disorder continues to cause a substantial physical, psychological, and financial toll on patients and their families. The highly complex medical needs of affected patients require specialised expertise and multidisciplinary care. However, gaps remain in effectively bridging scientific discoveries to clinical practice and disseminating the latest knowledge and best practices to providers. Following the publication of the first international consensus in 2008, advances in our understanding of the genetics, natural history, and clinical management of DBA have strongly supported the need for new consensus recommendations. In 2014 in Freiburg, Germany, a panel of 53 experts including clinicians, diagnosticians, and researchers from 27 countries convened. With support from patient advocates, the panel met repeatedly over subsequent years, engaging in ongoing discussions. These meetings led to the development of new consensus recommendations in 2024, replacing the previous guidelines. To account for the diverse phenotypes including presentation without anaemia, the panel agreed to adopt the term DBA syndrome. We propose new simplified diagnostic criteria, describe the genetics of DBA syndrome and its phenocopies, and introduce major changes in therapeutic standards. These changes include lowering the prednisone maintenance dose to maximum 0·3 mg/kg per day, raising the pre-transfusion haemoglobin to 9-10 g/dL independent of age, recommending early aggressive chelation, broadening indications for haematopoietic stem-cell transplantation, and recommending systematic clinical surveillance including early colorectal cancer screening. In summary, the current practice guidelines standardise the diagnostics, treatment, and long-term surveillance of patients with DBA syndrome of all ages worldwide.
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Affiliation(s)
- Marcin W Wlodarski
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, USA; Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Adrianna Vlachos
- Cohen Children's Medical Center, Hematology/Oncology and Stem Cell Transplantation, Hew Hyde Park, NY, USA; Feinstein Institutes for Medical Research, Manhasset, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jason E Farrar
- Arkansas Children's Research Institute and Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lydie M Da Costa
- Hôpital R. DEBRE, Groupe Hospitalier Universitaire, Assistance Publique-Hôpitaux de Paris Nord, Université de Paris Cité, Paris, France; HEMATIM, EA4666, UPJV, Amiens, France; Le LabEx Gr-Ex - Biogénèse et Pathologies du Globule Rouge, Paris, France
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Irma Dianzani
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Cristina Belendez
- Pediatric Hematology and Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Sule Unal
- Hacettepe University, Department of Pediatric Hematology and Research Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey
| | - Hannah Tamary
- The Rina Zaizov Hematology-Oncology Division, Schneider Children's Medical Center of Israel, Peta Tikvah, Israel; Felsenstein Medical Research Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | - Dagmar Pospisilova
- Department of Pediatrics, Faculty Hospital of Palacky University, Olomouc, Czech Republic
| | - Josu de la Fuente
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Deena Iskander
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Lawrence Wolfe
- Cohen Children's Medical Center, Hematology/Oncology and Stem Cell Transplantation, Hew Hyde Park, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Johnson M Liu
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, The Tisch Cancer Institute, New York, NY, USA
| | - Akiko Shimamura
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Katarzyna Albrecht
- Department of Oncology, Paediatric Haematology, Clinical Transplantology and Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Birgitte Lausen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Ulf Tedgard
- Department of Pediatric Hematology and Oncology, Skåne University Hospital, Lund, Sweden
| | - Alexander Puzik
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paola Quarello
- Department of Pediatric and Public Health Sciences, University of Turin, Turin, Italy
| | - Ugo Ramenghi
- Department of Pediatric and Public Health Sciences, University of Turin, Turin, Italy
| | - Marije Bartels
- Pediatric Hematology Department, University Medical Center Utrecht, Utrecht, Netherlands
| | - Heinz Hengartner
- Pediatric Hospital of Eastern Switzerland St Gallen, St Gallen, Switzerland
| | - Roula A Farah
- Department of Pediatrics, LAU Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Mahasen Al Saleh
- King Faisal Hospital and Research Center Riyadh, Riyadh, Saudi Arabia
| | - Amir Ali Hamidieh
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Wan Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Etsuro Ito
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hoon Kook
- Chonnam National University Hwasun Hospital, Gwangju, South Korea
| | - Galina Ovsyannikova
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Leo Kager
- St. Anna Children's Hospital, Department of Pediatrics, Medical University Vienna, Vienna, Austria; Children's Cancer Research Institute, Vienna, Austria
| | | | - Jean-Hugues Dalle
- Pediatric Immunology and Hematology Department and CRMR aplasies médullaires, Robert Debré Hospital, Groupe Hospitalier Universitaire, Assistance Publique-Hôpitaux de Paris Nord, Université de Paris Cité, Paris, France
| | - Brigitte Strahm
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Charlotte M Niemeyer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium, Freiburg, Germany; German Cancer Research Center, Heidelberg, Germany
| | - Jeffrey M Lipton
- Cohen Children's Medical Center, Hematology/Oncology and Stem Cell Transplantation, Hew Hyde Park, NY, USA; Feinstein Institutes for Medical Research, Manhasset, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Thierry M Leblanc
- Pediatric Immunology and Hematology Department and CRMR aplasies médullaires, Robert Debré Hospital, Groupe Hospitalier Universitaire, Assistance Publique-Hôpitaux de Paris Nord, Université de Paris Cité, Paris, France
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Meloni A, Pistoia L, Ricchi P, Longo F, Cecinati V, Sorrentino F, Cuccia L, Corigliano E, Rossi V, Righi R, Fina P, Renne S, Barbuto L, Positano V, Cademartiri F. Multiparametric cardiac magnetic resonance in patients with thalassemia intermedia: new insights from the E-MIOT network. LA RADIOLOGIA MEDICA 2024:10.1007/s11547-024-01821-y. [PMID: 38683500 DOI: 10.1007/s11547-024-01821-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 04/16/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE In a relatively large cohort of thalassemia intermedia (TI) patients, we systematically investigated myocardial iron overload (MIO), function, and replacement fibrosis using cardiac magnetic resonance (CMR), we assessed the clinical determinants of global heart T2* values, and we explored the association between multiparametric CMR findings and cardiac complications. MATERIALS AND METHODS We considered 254 beta-TI patients (43.14 ± 13.69 years, 138 females) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia project. MIO was quantified by T2* technique and biventricular function and atrial areas by cine images. Macroscopic myocardial fibrosis was detected by late gadolinium enhancement technique. RESULTS Compared to never/sporadically transfused patients, regularly transfused (RT)-TI patients exhibited significantly lower global heart T2* values, biventricular end-diastolic volume indexes, left ventricular mass index, and cardiac index. In RT-TI patients, age and serum ferritin levels were the strongest predictors of global heart T2* values. Independently from the transfusional state, cardiac T2* values were not associated with biventricular function. Of the 103 (40.6%) patients in whom the contrast medium was administrated, 27 (26.2%) had replacement myocardial fibrosis. Age, sex distribution, cardiac iron, and biventricular function parameters were comparable between patients without and without replacement myocardial fibrosis. Twenty-five (9.8%) patients had a history of cardiac complications (heart failure and arrhythmias). Increased age and replacement myocardial fibrosis emerged as significant risk markers for cardiac complications. CONCLUSIONS In TI, regular transfusions are associated with less pronounced cardiac remodeling but increase the risk of MIO. Replacement myocardial fibrosis is a frequent finding associated with cardiac complications.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Paolo Ricchi
- U.O.S.D. Malattie Rare del Globulo Rosso, Azienda Ospedaliera Di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Filomena Longo
- Unità Operativa Day Hospital Della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria ''S. Anna'', Cona, FE, Italy
| | - Valerio Cecinati
- Struttura Semplice di Microcitemia, Ospedale "SS. Annunziata" ASL Taranto, Taranto, Italy
| | | | - Liana Cuccia
- Unità Operativa Complessa di Radiologia, ''ARNAS'' Civico, Di Cristina Benfratelli, Palermo, Italy
| | | | | | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, Lagosanto, FE, Italy
| | - Priscilla Fina
- Unità Operativa Complessa Diagnostica per Immagini, Ospedale ''Sandro Pertini'', Rome, Italy
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II", Lamezia Terme, Italy
| | - Luigi Barbuto
- U.O.C. Radiologia Generale e di Pronto Soccorso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy.
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Liao F, Yang W, Long L, Yu R, Qu H, Peng Y, Lu J, Ren C, Wang Y, Fu C. Elucidating Iron Metabolism through Molecular Imaging. Curr Issues Mol Biol 2024; 46:2798-2818. [PMID: 38666905 PMCID: PMC11049567 DOI: 10.3390/cimb46040175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Iron is essential for many physiological processes, and the dysregulation of its metabolism is implicated in the pathogenesis of various diseases. Recent advances in iron metabolism research have revealed multiple complex pathways critical for maintaining iron homeostasis. Molecular imaging, an interdisciplinary imaging technique, has shown considerable promise in advancing research on iron metabolism. Here, we comprehensively review the multifaceted roles of iron at the cellular and systemic levels (along with the complex regulatory mechanisms of iron metabolism), elucidate appropriate imaging methods, and summarize their utility and fundamental principles in diagnosing and treating diseases related to iron metabolism. Utilizing molecular imaging technology to deeply understand the complexities of iron metabolism and its critical role in physiological and pathological processes offers new possibilities for early disease diagnosis, treatment monitoring, and the development of novel therapies. Despite technological limitations and the need to ensure the biological relevance and clinical applicability of imaging results, molecular imaging technology's potential to reveal the iron metabolic process is unparalleled, providing new insights into the link between iron metabolism abnormalities and various diseases.
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Affiliation(s)
- Feifei Liao
- Beijing University of Traditional Chinese Medicine Graduate School, Beijing University of Chinese Medicine, Beijing 100105, China; (F.L.); (R.Y.); (Y.P.); (J.L.); (C.R.)
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100091, China; (W.Y.); (L.L.); (H.Q.)
| | - Wenwen Yang
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100091, China; (W.Y.); (L.L.); (H.Q.)
- CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China
| | - Linzi Long
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100091, China; (W.Y.); (L.L.); (H.Q.)
| | - Ruotong Yu
- Beijing University of Traditional Chinese Medicine Graduate School, Beijing University of Chinese Medicine, Beijing 100105, China; (F.L.); (R.Y.); (Y.P.); (J.L.); (C.R.)
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100091, China; (W.Y.); (L.L.); (H.Q.)
| | - Hua Qu
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100091, China; (W.Y.); (L.L.); (H.Q.)
| | - Yuxuan Peng
- Beijing University of Traditional Chinese Medicine Graduate School, Beijing University of Chinese Medicine, Beijing 100105, China; (F.L.); (R.Y.); (Y.P.); (J.L.); (C.R.)
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100091, China; (W.Y.); (L.L.); (H.Q.)
| | - Jieming Lu
- Beijing University of Traditional Chinese Medicine Graduate School, Beijing University of Chinese Medicine, Beijing 100105, China; (F.L.); (R.Y.); (Y.P.); (J.L.); (C.R.)
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100091, China; (W.Y.); (L.L.); (H.Q.)
| | - Chenghuan Ren
- Beijing University of Traditional Chinese Medicine Graduate School, Beijing University of Chinese Medicine, Beijing 100105, China; (F.L.); (R.Y.); (Y.P.); (J.L.); (C.R.)
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100091, China; (W.Y.); (L.L.); (H.Q.)
| | - Yueqi Wang
- CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China
| | - Changgeng Fu
- Graduate School, China Academy of Chinese Medical Sciences, Beijing 100091, China; (W.Y.); (L.L.); (H.Q.)
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Musallam KM, Barella S, Origa R, Ferrero GB, Lisi R, Pasanisi A, Longo F, Gianesin B, Forni GL. Revisiting iron overload status and change thresholds as predictors of mortality in transfusion-dependent β-thalassemia: a 10-year cohort study. Ann Hematol 2024:10.1007/s00277-024-05715-x. [PMID: 38503936 DOI: 10.1007/s00277-024-05715-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/15/2024] [Indexed: 03/21/2024]
Abstract
Data on iron overload status and change thresholds that can predict mortality in patients with transfusion-dependent β-thalassemia (TDT) are limited. This was a retrospective cohort study of 912 TDT patients followed for up to 10 years at treatment centers in Italy (median age 32 years, 51.6% female). The crude mortality rate was 2.9%. Following best-predictive threshold identification through receiver operating characteristic curve analyses, data from multivariate Cox-regression models showed that patients with Period Average Serum Ferritin (SF) > 2145 vs ≤ 2145 ng/mL were 7.1-fold (P < 0.001) or with Absolute Change SF > 1330 vs ≤ 1330 ng/mL increase were 21.5-fold (P < 0.001) more likely to die from any cause. Patients with Period Average Liver Iron Concentration (LIC) > 8 vs ≤ 8 mg/g were 20.2-fold (P < 0.001) or with Absolute Change LIC > 1.4 vs ≤ 1.4 mg/g increase were 27.6-fold (P < 0.001) more likely to die from any cause. Patients with Index (first) cardiac T2* (cT2*) < 27 vs ≥ 27 ms were 8.6-fold (P < 0.001) more likely to die from any cause. Similarly, results at varying thresholds were identified for death from cardiovascular disease. These findings should support decisions on iron chelation therapy by establishing treatment targets, including safe iron levels and clinically meaningful changes over time.
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Affiliation(s)
- Khaled M Musallam
- Center for Research On Rare Blood Disorders (CR-RBD), Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Susanna Barella
- S.C. Centro Delle Microcitemie E Anemie Rare, ASL Cagliari, Cagliari, Italy
| | - Raffaella Origa
- Università Di Cagliari, S.C. Centro Delle Microcitemie E Anemie Rare, ASL Cagliari, Cagliari, Italy
| | - Giovanni Battista Ferrero
- Hemoglobinopathies and Rare Anemia Reference Center, Department of Biological and Clinical Sciences, San Luigi Gonzaga University Hospital, University of Turin, Turin, Italy
| | - Roberto Lisi
- Thalassemia Unit, ARNAS Garibaldi, Catania, Italy
| | - Annamaria Pasanisi
- Centro Della Microcitemia A.Quarta, Hematology Unit, A. Perrino Hospital, Brindisi, Italy
| | - Filomena Longo
- Day Hospital Della Talassemia E Delle Emoglobinopatie, Azienda Ospedaliero Universitaria S. Anna, Ferrara, Italy
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7
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Meloni A, Pistoia L, Ricchi P, Maggio A, Cecinati V, Longo F, Sorrentino F, Borsellino Z, Salvo A, Rossi V, Grassedonio E, Restaino G, Renne S, Righi R, Positano V, Cademartiri F. Prognostic Role of Multiparametric Cardiac Magnetic Resonance in Neo Transfusion-Dependent Thalassemia. J Clin Med 2024; 13:1281. [PMID: 38592121 PMCID: PMC10931742 DOI: 10.3390/jcm13051281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND We prospectively evaluated the predictive value of multiparametric cardiac magnetic resonance (CMR) for cardiovascular complications in non-transfusion-dependent β-thalassemia (β-NTDT) patients who started regular transfusions in late childhood/adulthood (neo β-TDT). METHODS We considered 180 patients (38.25 ± 11.24 years; 106 females). CMR was used to quantify cardiac iron overload, biventricular function, and atrial dimensions, and to detect left ventricular (LV) replacement fibrosis. RESULTS During a mean follow-up of 76.87 ± 41.60 months, 18 (10.0%) cardiovascular events were recorded: 2 heart failures, 13 arrhythmias (10 supraventricular), and 3 cases of pulmonary hypertension. Right ventricular (RV) end-diastolic volume index (EDVI), RV mass index (MI), LV replacement fibrosis, and right atrial (RA) area index emerged as significant univariate prognosticators of cardiovascular complications. The low number of events prevented us from performing a multivariable analysis including all univariable predictors simultaneously. Firstly, a multivariable analysis including the two RV size parameters (mass and volume) was carried out, and only the RV MI was proven to independently predict cardiovascular diseases. Then, a multivariable analysis, including RV MI, RA atrial area, and LV replacement fibrosis, was conducted. In this model, RV MI and LV replacement fibrosis emerged as independent predictors of cardiovascular outcomes (RV MI: hazard ratio (HR) = 1.18; LV replacement fibrosis: HR = 6.26). CONCLUSIONS Our results highlight the importance of CMR in cardiovascular risk stratification.
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Affiliation(s)
- Antonella Meloni
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy;
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy;
- Unità Operativa Complessa Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Paolo Ricchi
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, 80131 Napoli, Italy;
| | - Aurelio Maggio
- Ematologia II con Talassemia, Ospedale “V. Cervello”, 90100 Palermo, Italy;
| | - Valerio Cecinati
- Struttura Semplice di Microcitemia, Ospedale “SS. Annunziata”, 74123 Taranto, Italy;
| | - Filomena Longo
- Unità Operativa Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria “S. Anna”, 44124 Cona, FE, Italy;
| | - Francesco Sorrentino
- Unità Operativa Semplice Dipartimentale Day Hospital Talassemici, Ospedale “Sant’Eugenio”, 00143 Rome, Italy;
| | - Zelia Borsellino
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico “Benfratelli-Di Cristina”, 90134 Palermo, Italy;
| | - Alessandra Salvo
- Operativa Semplice Talassemia, Presidio Ospedaliero “Umberto I”, 96100 Siracusa, Italy;
| | - Vincenza Rossi
- Unità Operativa Complessa Ematologia, Ospedale di Cosenza, 87100 Cosenza, Italy;
| | - Emanuele Grassedonio
- Sezione di Scienze Radiologiche, Dipartimento di Biopatologia e Biotecnologie Mediche, Policlinico “Paolo Giaccone”, 90127 Palermo, Italy;
| | - Gennaro Restaino
- Unità Operativa Complessa Radiodiagnostica, Gemelli Molise SpA, Fondazione di Ricerca e Cura “Giovanni Paolo II”, 86100 Campobasso, Italy;
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero “Giovanni Paolo II”, 88046 Lamezia Terme, CZ, Italy;
| | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, 44023 Lagosanto, FE, Italy;
| | - Vincenzo Positano
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy;
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy;
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8
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Zhou Y, Cao Y, Fang Z, Huang K, Yang M, Pang G, Zhao J, Liu Y, Luo J. Research on the clinical factors of cardiac iron deposition in children with beta-thalassemia major. Eur J Pediatr 2024; 183:875-882. [PMID: 37938353 PMCID: PMC10912130 DOI: 10.1007/s00431-023-05300-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/09/2023] [Accepted: 10/19/2023] [Indexed: 11/09/2023]
Abstract
Magnetic resonance imaging (MRI) T2* is the gold standard for detecting iron deposition in cardiac tissue, but the technique has limitations and cannot be fully performed in paediatric thalassemia patients. The aim of this study was to analyse clinical data to identify other predictors of cardiac iron deposition. A retrospective analysis was performed on 370 children with β-TM. According to the cardiac MRI results, patients were allocated to a cardiac deposition group and noncardiac deposition group. Multivariate analysis revealed that genotype and corrected QT interval were associated with cardiac iron deposition, indicating that the-β0/β0 genotype conferred greater susceptibility to cardiac iron deposition. Receiver operating characteristic curve (ROC) analysis was performed, and the area under the curve (AUC) of genotype was 0.651. The AUC for the corrected QT interval was 0.711, at a cut-off value of 418.5 ms. ROC analysis of the combined genotype and corrected QT interval showed an AUC of 0.762 with 81.3% sensitivity and 64.7% specificity. Compared to patients with the β+/β+ and β0β+ genotypes, β0β0 children with β-TM were more likely to have cardiac iron deposition. Conclusion: The genotype and QTc interval can be used to predict cardiac iron deposition in children with β-TM who are unable to undergo MRI T2 testing.
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Affiliation(s)
- Yuhang Zhou
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Yaxuan Cao
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Zhenhua Fang
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Ken Huang
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Mengxin Yang
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Guanxiu Pang
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Jie Zhao
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Yang Liu
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Jianming Luo
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China.
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9
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Petronek MS, Monga V, Bodeker KL, Kwofie M, Lee CY, Mapuskar KA, Stolwijk JM, Zaher A, Wagner BA, Smith MC, Vollstedt S, Brown H, Chandler ML, Lorack AC, Wulfekuhle JS, Sarkaria JN, Flynn RT, Greenlee JD, Howard MA, Smith BJ, Jones KA, Buettner GR, Cullen JJ, St-Aubin J, Buatti JM, Magnotta VA, Spitz DR, Allen BG. Magnetic Resonance Imaging of Iron Metabolism with T2* Mapping Predicts an Enhanced Clinical Response to Pharmacologic Ascorbate in Patients with GBM. Clin Cancer Res 2024; 30:283-293. [PMID: 37773633 PMCID: PMC10841843 DOI: 10.1158/1078-0432.ccr-22-3952] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/22/2023] [Accepted: 09/27/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE Pharmacologic ascorbate (P-AscH-) is hypothesized to be an iron (Fe)-dependent tumor-specific adjuvant to chemoradiation in treating glioblastoma (GBM). This study determined the efficacy of combining P-AscH- with radiation and temozolomide in a phase II clinical trial while simultaneously investigating a mechanism-based, noninvasive biomarker in T2* mapping to predict GBM response to P-AscH- in humans. PATIENTS AND METHODS The single-arm phase II clinical trial (NCT02344355) enrolled 55 subjects, with analysis performed 12 months following the completion of treatment. Overall survival (OS) and progression-free survival (PFS) were estimated with the Kaplan-Meier method and compared across patient subgroups with log-rank tests. Forty-nine of 55 subjects were evaluated using T2*-based MRI to assess its utility as an Fe-dependent biomarker. RESULTS Median OS was estimated to be 19.6 months [90% confidence interval (CI), 15.7-26.5 months], a statistically significant increase compared with historic control patients (14.6 months). Subjects with initial T2* relaxation < 50 ms were associated with a significant increase in PFS compared with T2*-high subjects (11.2 months vs. 5.7 months, P < 0.05) and a trend toward increased OS (26.5 months vs. 17.5 months). These results were validated in preclinical in vitro and in vivo model systems. CONCLUSIONS P-AscH- combined with temozolomide and radiotherapy has the potential to significantly enhance GBM survival. T2*-based MRI assessment of tumor iron content is a prognostic biomarker for GBM clinical outcomes. See related commentary by Nabavizadeh and Bagley, p. 255.
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Affiliation(s)
| | - Varun Monga
- Department of Internal Medicine, Division of Hematology and Oncology, University of Iowa; Iowa City, IA, USA
| | - Kellie L. Bodeker
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | - Michael Kwofie
- Department of Radiology, University of Iowa; Iowa City, IA, USA
| | - Chu-Yu Lee
- Department of Radiology, University of Iowa; Iowa City, IA, USA
| | - Kranti A. Mapuskar
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | | | - Amira Zaher
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | - Brett A. Wagner
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | - Mark C. Smith
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | - Sandy Vollstedt
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | - Heather Brown
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | - Meghan L. Chandler
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | - Amanda C. Lorack
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | | | - Jann N. Sarkaria
- Department of Radiation Oncology, Mayo Clinic; Rochester, MN, USA
| | - Ryan T. Flynn
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | | | | | - Brian J. Smith
- Department of Biostatistics, University of Iowa; Iowa City, IA, USA
| | - Karra A. Jones
- Department of Pathology, Division of Neuropathology, Duke University; Durham, NC, USA
| | - Garry R. Buettner
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | | | - Joel St-Aubin
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | - John M. Buatti
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | | | - Douglas R. Spitz
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
| | - Bryan G. Allen
- Department of Radiation Oncology, University of Iowa; Iowa City, IA, USA
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10
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Feng XL, Qi WY, Xiao ZY, Zheng X, Zhang XY, Liu T, Kou XY, Chen J. Assessment of early anthracycline-induced cardiotoxicity and liver injury with T2 and T2* mapping in rabbit models. Eur Radiol 2024; 34:226-235. [PMID: 37552260 DOI: 10.1007/s00330-023-10027-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/09/2023] [Accepted: 06/13/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVES To evaluate the early prevalence of anthracycline-induced cardiotoxicity (AIC) and anthracycline-induced liver injury (AILI) using T2 and T2* mapping and to explore their correlations. MATERIALS AND METHODS The study included 17 cardiotoxic rabbits that received weekly injections of doxorubicin and magnetic resonance imaging (MRI) every 2 weeks for 10 weeks. Cardiac function and T2 and T2* values were measured on each period. Histopathological examinations for two to five rabbits were performed after each MRI scan. The earliest sensitive time and the threshold of MRI parameters for detecting AIC and AILI based on these MRI parameters were obtained. Moreover, the relationship between myocardial and liver damage was assessed. RESULTS Early AIC could be detected by T2 mapping as early as the second week and focused on the 7th, 11th, and 12th segments of left ventricle. The cutoff value of 46.64 for the 7th segment had the best diagnostic value, with an area under the curve (of 0.767, sensitivity of 100%, and specificity of 52%. T2* mapping could detect the change in iron content for early AIC at the middle interventricular septum and AILI as early as the sixth week (p = 0.014, p = 0.027). The T2* values of the middle interventricular septum showed a significant positive association with the T2* values of the liver (r = 0.39, p = 0.002). CONCLUSION T2 and T2* mapping showed value one-stop assessment of AIC and AILI and could obtain the earliest MRI diagnosis point and optimal parameter thresholds for these conditions. CLINICAL RELEVANCE STATEMENT Anthracycline-induced cardiotoxicity could be detected by T2 mapping as earlier as the second week, mainly focusing on the 7th, 11th, and 12th segments of left ventricle. Combined with T2* mapping, hepatoxicity and supplementary cardiotoxicity were assessed by one-stop scan. KEY POINTS • MRI screening time of cardiotoxicity was as early as the second week with focusing on T2 values of the 7th, 11th, and 12th segments of left ventricle. • T2* mapping could be used as a complement to T2 mapping to evaluate cardiotoxicity and as an effective index to detect iron change in the early stages of chemotherapy. • The T2* values of the middle interventricular septum showed a significant positive association with the T2* values of the liver, indicating that iron content in the liver and heart increased with an increase in the chemotherapeutic drugs.
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Affiliation(s)
- Xiao-Lan Feng
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, 646000, Sichuan, China
| | - Wan-Yin Qi
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, 646000, Sichuan, China
| | - Zheng-Yuan Xiao
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, 646000, Sichuan, China
| | - Xue Zheng
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, 646000, Sichuan, China
| | - Xiao-Yong Zhang
- Department of Clinical Science, Philips Healthcare, Chengdu, 610000, China
| | - Tao Liu
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, 646000, Sichuan, China
| | - Xing-Yuan Kou
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, 646000, Sichuan, China
| | - Jing Chen
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, 646000, Sichuan, China.
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11
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Houshmand G, Parsaee M, Najmafshar L, Rajablou N, Golroudbari HT, Hosseini R, Omidi N. Role of feature tracking cardiac magnetic resonance imaging in early detection of cardiac dysfunction in β-thalassemia patients recovered from COVID-19: A cross-sectional study. Health Sci Rep 2024; 7:e1783. [PMID: 38186932 PMCID: PMC10765551 DOI: 10.1002/hsr2.1783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Background and Aims β-Thalassemia patients may have cardiac complications due to iron overload, which puts them at higher risk of cardiac complications induced by coronavirus disease 2019 (COVID-19) compared with the normal population. The present study aims to evaluate early cardiovascular complications following iron overload in β-thalassemia patients who had early recovery from COVID-19 by cardiac magnetic resonance imaging (MRI) and feature-tracking technique. Methods Thirty-two confirmed COVID-19-recovered β-thalassemia cases were evaluated within 3 weeks to 3 months after a positive reverse-transcriptase polymerase chain reaction COVID-19 test. Both the heart and liver of all patients were examined using cardiac MRI. Results We analyzed 32 patients with mean age of 32.84 ± 6.45 years at baseline. Left ventricular global strain values were significantly associated with myocardial T2*. A cut-off value of -15.08% for global longitudinal strain (GLS) with sensitivity and specificity of 90% and 61.1% (p = 0.017), 32.33% for global radial strain (GRS) with sensitivity and specificity of 80% and 94.4% (p = 0.001) and -16.21 for global circumferential strain (GCS), with sensitivity and specificity of 80% and 89.9% (p = 0.013) may indicate cardiac iron overload. Conclusion GLS, GRS, and GCS were significantly decreased in patients with myocardial T2* <20 ms (iron overload), while no significant change was observed in the right and left ventricular ejection fraction (RV- and LVEF). Cardiac MRI feature-tracking may be helpful in the early detection of cardiac complications resulting from iron overload in β-thalassemia patients who had early recovery from COVID-19.
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Affiliation(s)
- Golnaz Houshmand
- Rajaie Cardiovascular, Medical and Research CenterIran University of Medical SciencesTehranIran
| | - Mozhgan Parsaee
- Rajaie Cardiovascular, Medical and Research CenterIran University of Medical SciencesTehranIran
| | - Leila Najmafshar
- Rajaie Cardiovascular, Medical and Research CenterIran University of Medical SciencesTehranIran
| | - Nadia Rajablou
- School of MedicineTehran University of Medical SciencesTehranIran
| | | | - Rana Hosseini
- Social Determinants of Health Research Center, Clinical Research InstituteUrmia University of Medical SciencesUrmiaIran
| | - Negar Omidi
- Cardiovascular Disease Research Institute, Tehran Heart CenterTehran University of Medical SciencesTehranIran
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12
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Liu H, Naser JA, Lin G, Lee SS. Cardiomyopathy in cirrhosis: From pathophysiology to clinical care. JHEP Rep 2024; 6:100911. [PMID: 38089549 PMCID: PMC10711481 DOI: 10.1016/j.jhepr.2023.100911] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 01/12/2024] Open
Abstract
Cirrhotic cardiomyopathy (CCM) is defined as systolic or diastolic dysfunction in the absence of prior heart disease or another identifiable cause in patients with cirrhosis, in whom it is an important determinant of outcome. Its underlying pathogenic/pathophysiological mechanisms are rooted in two distinct pathways: 1) factors associated with portal hypertension, hyperdynamic circulation, gut bacterial/endotoxin translocation and the resultant inflammatory phenotype; 2) hepatocellular insufficiency with altered synthesis or metabolism of substances such as proteins, lipids, carbohydrates, bile acids and hormones. Different criteria have been proposed to diagnose CCM; the first in 2005 by the World Congress of Gastroenterology, and more recently in 2019 by the Cirrhotic Cardiomyopathy Consortium. These criteria mainly utilised echocardiographic evaluation, with the latter refining the evaluation of diastolic function and integrating global longitudinal strain into the evaluation of systolic function, an important addition since the haemodynamic changes that occur in advanced cirrhosis may lead to overestimation of systolic function by left ventricular ejection fraction. Advances in cardiac imaging, such as cardiac magnetic resonance imaging and the incorporation of an exercise challenge, may help further refine the diagnosis of CCM. Over recent years, CCM has been shown to contribute to increased mortality and morbidity after major interventions, such as liver transplantation and transjugular intrahepatic portosystemic shunt insertion, and to play a pathophysiologic role in the genesis of hepatorenal syndrome. In this review, we discuss the pathogenesis/pathophysiology of CCM, its clinical implications, and the role of cardiac imaging modalities including MRI. We also compare diagnostic criteria and review the potential diagnostic role of electrocardiographic QT prolongation. At present, no definitive medical therapy exists, but some promising potential treatment strategies for CCM are reviewed.
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Affiliation(s)
- Hongqun Liu
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Jwan A. Naser
- Division of Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Grace Lin
- Division of Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Samuel S. Lee
- Liver Unit, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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13
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Mousavi-Aghdas SA, Farashi E, Naderi N. Iron Dyshomeostasis and Mitochondrial Function in the Failing Heart: A Review of the Literature. Am J Cardiovasc Drugs 2024; 24:19-37. [PMID: 38157159 DOI: 10.1007/s40256-023-00619-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 01/03/2024]
Abstract
Cardiac contraction and relaxation require a substantial amount of energy provided by the mitochondria. The failing heart is adenosine triphosphate (ATP)- and creatine-depleted. Studies have found iron is involved in almost every aspect of mitochondrial function, and previous studies have shown myocardial iron deficiency in heart failure (HF). Many clinicians advocated intravenous iron repletion for HF patients meeting the conventional criteria for systemic iron deficiency. While clinical trials showed improved quality of life, iron repletion failed to significantly impact survival or significant cardiovascular adverse events. There is evidence that in HF, labile iron is trapped inside the mitochondria causing oxidative stress and lipid peroxidation. There is also compelling preclinical evidence demonstrating the detrimental effects of both iron overload and depletion on cardiomyocyte function. We reviewed the mechanisms governing myocardial and mitochondrial iron content. Mitochondrial dynamics (i.e., fusion, fission, mitophagy) and the role of iron were also investigated. Ferroptosis, as an important regulated cell death mechanism involved in cardiomyocyte loss, was reviewed along with agents used to manipulate it. The membrane stability and iron content of mitochondria can be altered by many agents. Some studies are showing promising improvement in the cardiomyocyte function after iron chelation by deferiprone; however, whether the in vitro and in vivo findings will be reflected on on clinical grounds is still unclear. Finally, we briefly reviewed the clinical trials on intravenous iron repletion. There is a need for more well-simulated animal studies to shed light on the safety and efficacy of chelation agents and pave the road for clinical studies.
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Affiliation(s)
- Seyed Ali Mousavi-Aghdas
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Rajaie Cardiovascular, Medical, and Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ebrahim Farashi
- Department of Cardiothoracic Surgery, Imam Reza Medical Research & Training Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
- Rajaie Cardiovascular, Medical, and Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nasim Naderi
- Department of Cardiothoracic Surgery, Imam Reza Medical Research & Training Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
- Rajaie Cardiovascular, Medical, and Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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14
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Padhani ZA, Gangwani MK, Sadaf A, Hasan B, Colan S, Alvi N, Das JK. Calcium channel blockers for preventing cardiomyopathy due to iron overload in people with transfusion-dependent beta thalassaemia. Cochrane Database Syst Rev 2023; 11:CD011626. [PMID: 37975597 PMCID: PMC10655499 DOI: 10.1002/14651858.cd011626.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Beta-thalassaemia is an inherited blood disorder that reduces the production of haemoglobin. The most severe form requires recurrent blood transfusions, which can lead to iron overload. Cardiovascular dysfunction caused by iron overload is the leading cause of morbidity and mortality in people with transfusion-dependent beta-thalassaemia. Iron chelation therapy has reduced the severity of systemic iron overload, but removal of iron from the myocardium requires a very proactive preventive strategy. There is evidence that calcium channel blockers may reduce myocardial iron deposition. This is an update of a Cochrane Review first published in 2018. OBJECTIVES To assess the effects of calcium channel blockers plus standard iron chelation therapy, compared with standard iron chelation therapy (alone or with a placebo), on cardiomyopathy due to iron overload in people with transfusion-dependent beta thalassaemia. SEARCH METHODS We searched the Cochrane Haemoglobinopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books, to 13 January 2022. We also searched ongoing trials databases and the reference lists of relevant articles and reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs) of calcium channel blockers combined with standard chelation therapy versus standard chelation therapy alone or combined with placebo in people with transfusion-dependent beta thalassaemia. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. We used GRADE to assess certainty of evidence. MAIN RESULTS We included six RCTs (five parallel-group trials and one cross-over trial) with 253 participants; there were 126 participants in the amlodipine arms and 127 in the control arms. The certainty of the evidence was low for most outcomes at 12 months; the evidence for liver iron concentration was of moderate certainty, and the evidence for adverse events was of very low certainty. Amlodipine plus standard iron chelation compared with standard iron chelation (alone or with placebo) may have little or no effect on cardiac T2* values at 12 months (mean difference (MD) 1.30 ms, 95% confidence interval (CI) -0.53 to 3.14; 4 trials, 191 participants; low-certainty evidence) and left ventricular ejection fraction (LVEF) at 12 months (MD 0.81%, 95% CI -0.92% to 2.54%; 3 trials, 136 participants; low-certainty evidence). Amlodipine plus standard iron chelation compared with standard iron chelation (alone or with placebo) may reduce myocardial iron concentration (MIC) after 12 months (MD -0.27 mg/g, 95% CI -0.46 to -0.08; 3 trials, 138 participants; low-certainty evidence). The results of our analysis suggest that amlodipine has little or no effect on heart T2*, MIC, or LVEF after six months, but the evidence is very uncertain. Amlodipine plus standard iron chelation compared with standard iron chelation (alone or with placebo) may increase liver T2* values after 12 months (MD 1.48 ms, 95% CI 0.27 to 2.69; 3 trials, 127 participants; low-certainty evidence), but may have little or no effect on serum ferritin at 12 months (MD 0.07 μg/mL, 95% CI -0.20 to 0.35; 4 trials, 187 participants; low-certainty evidence), and probably has little or no effect on liver iron concentration (LIC) after 12 months (MD -0.86 mg/g, 95% CI -4.39 to 2.66; 2 trials, 123 participants; moderate-certainty evidence). The results of our analysis suggest that amlodipine has little or no effect on serum ferritin, liver T2* values, or LIC after six months, but the evidence is very uncertain. The included trials did not report any serious adverse events at six or 12 months of intervention. The studies did report mild adverse effects such as oedema, dizziness, mild cutaneous allergy, joint swelling, and mild gastrointestinal symptoms. Amlodipine may be associated with a higher risk of oedema (risk ratio (RR) 5.54, 95% CI 1.24 to 24.76; 4 trials, 167 participants; very low-certainty evidence). We found no difference between the groups in the occurrence of other adverse events, but the evidence was very uncertain. No trials reported mortality, cardiac function assessments other than echocardiographic estimation of LVEF, electrocardiographic abnormalities, quality of life, compliance with treatment, or cost of interventions. AUTHORS' CONCLUSIONS The available evidence suggests that calcium channel blockers may reduce MIC and may increase liver T2* values in people with transfusion-dependent beta thalassaemia. Longer-term multicentre RCTs are needed to assess the efficacy and safety of calcium channel blockers for myocardial iron overload, especially in younger children. Future trials should also investigate the role of baseline MIC in the response to calcium channel blockers, and include a cost-effectiveness analysis.
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Affiliation(s)
- Zahra Ali Padhani
- Institute for Global Health and Development, Aga Khan University, Karachi, Pakistan
- Robinson Research Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Karachi, Pakistan
| | | | - Alina Sadaf
- Department of Paediatric Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Babar Hasan
- Division of Cardiothoracic Sciences, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Steven Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Najveen Alvi
- Department of Pediatrics, Aga Khan University, Karachi, Pakistan
| | - Jai K Das
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
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15
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Lian Z, Lu Q, Lin B, Chen L, Peng P, Feng Y. MRI Deep Learning-Based Automatic Segmentation of Interventricular Septum for Black-Blood Myocardial T2* Measurement in Thalassemia. J Magn Reson Imaging 2023. [PMID: 37941460 DOI: 10.1002/jmri.29113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND The T2* value of interventricular septum is routinely reported for grading myocardial iron load in thalassemia major, and automatic segmentation of septum could shorten analysis time and reduce interobserver variability. PURPOSE To develop a deep learning-based method for automatic septum segmentation from black-blood MR images for the myocardial T2* measurement of thalassemia patients. STUDY TYPE Retrospective. POPULATION/SUBJECTS One hundred forty-six transfusion-dependent thalassemia patients with cardiac MR examinations from two centers. Data from Center 1 (1.5 T) were assigned to the training (100 examinations) and internal testing (20 examinations) sets; data from Center 2 were assigned to the external testing set (26 examinations; 10 at 1.5 T and 16 at 3.0 T). FIELD STRENGTH/SEQUENCE 1.5 T and 3.0 T, multiecho gradient-echo sequence. ASSESSMENT A modified attention U-Net for septum segmentation was constructed and trained, and its performance evaluated on unseen internal and external datasets. T2* was measured by fitting the average septum signal, separately segmented by automatic and manual methods. STATISTICAL TESTS Agreement between manual and automatic septum segmentations was assessed with the Dice coefficient, and T2* agreement was assessed using the Bland-Altman plot and the coefficient of variation (CoV). RESULTS The median Dice coefficient of deep network-based septum segmentation was 0.90 [0.05] on the internal dataset, 0.82 [0.10] on the external 1.5 T dataset, and 0.86 [0.14] on the external 3.0 T dataset. T2* measurements using automatic segmentation corresponded with those from manual segmentation, with a mean difference of 0.02 (95% LoA: -0.74 to 0.79) msec, 0.43 (95% LoA: -2.1 to 3.0) msec, and 0.36 (95% LoA: -0.72 to 1.4) msec on the three datasets. The CoVs between the two methods were 3.1%, 7.0%, and 6.1% on the internal and two external datasets, respectively. DATA CONCLUSIONS The proposed septum segmentation yielded myocardial T2* measurements which were highly consistent with those obtained by manual segmentation. This automatic approach may facilitate data processing and avoid operator-dependent variability in practice. EVIDENCE LEVEL 4 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Zifeng Lian
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Medical Image Processing & Guangdong Province Engineering Laboratory for Medical Imaging and Diagnostic Technology, Southern Medical University, Guangzhou, China
- Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence & Key Laboratory of Mental Health of the Ministry of Education, Southern Medical University, Guangzhou, China
| | - Qiqi Lu
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Medical Image Processing & Guangdong Province Engineering Laboratory for Medical Imaging and Diagnostic Technology, Southern Medical University, Guangzhou, China
- Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence & Key Laboratory of Mental Health of the Ministry of Education, Southern Medical University, Guangzhou, China
| | - Bingquan Lin
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lingjian Chen
- Department of Equipment, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde, Foshan), Foshan, China
| | - Peng Peng
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- NHC Key Laboratory of Thalassemia Medicine and Guangxi Key Laboratory of Thalassemia Research, Nanning, China
| | - Yanqiu Feng
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Medical Image Processing & Guangdong Province Engineering Laboratory for Medical Imaging and Diagnostic Technology, Southern Medical University, Guangzhou, China
- Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence & Key Laboratory of Mental Health of the Ministry of Education, Southern Medical University, Guangzhou, China
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16
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Pascal L. [Transfusions and iron chelation in myelodysplastic syndromes]. Bull Cancer 2023; 110:1176-1182. [PMID: 37543453 DOI: 10.1016/j.bulcan.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 08/07/2023]
Abstract
Iron overload (IO) is probably as toxic in elderly patients with low-risk myelodysplastic syndromes (MDS) as in young thalassemic patients. This impact is more difficult to demonstrate because of associated comorbidities. Cardiovascular disease increases vulnerability to the toxic effects of IO. In recent years, registry studies have shown a survival benefit of Iron Chelation Therapy (ICT) in these patients. These findings are now corroborated by an improvement in event-free survival in a single randomized study: the Telesto study. The EFS curves separate after two years of follow-up. This indicates inertia in the occurrence of complications. The benefits of ICT are also very slowly being revealed. It is possible to offer ICT to patients with transfusion-dependent MDS with a life expectancy of at least two years. In Telesto, patients had a serum ferritin (F) level of at least 1000ng/mL, recommendations using this F threshold as a trigger for chelation seem to be reinforced. It remains an open question whether chelation should be started earlier for effective suppression of IO-related oxidative stress. ICTs could be used in transfusion-dependent MDS patients with life expectancy greater than two years. including possibly higher risk patients responding to hypomethylating agents.
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Affiliation(s)
- Laurent Pascal
- Hôpital Saint-Vincent-de-Paul, service d'hématologie et de thérapie cellulaire, boulevard de Belfort, 59000 Lille, France.
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17
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Brendel JM, Kratzenstein A, Berger J, Hagen F, Nikolaou K, Gawaz M, Greulich S, Krumm P. T2* map at cardiac MRI reveals incidental hepatic and cardiac iron overload. Diagn Interv Imaging 2023; 104:552-559. [PMID: 37550171 DOI: 10.1016/j.diii.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE The purpose of this study was to assess the diagnostic capabilities of cardiac magnetic resonance (CMR) T2* mapping in detecting incidental hepatic and cardiac iron overload. MATERIALS AND METHODS Patients with various clinical indications for CMR examination were consecutively included at a single center from January 2019 to April 2023. All patients underwent T2* mapping at 1.5 T in a single mid-ventricular short-axis as part of a comprehensive routine CMR protocol. T2* measurements were performed of the heart (using a region-of-interest in the interventricular septum) and the liver, categorized according to the severity of iron overload. The degree of cardiac iron overload was categorized as mild (15 ms < T2* < 20 ms), moderate (10 ms < T2* < 15 ms) and severe (T2* < 10 ms). The degree of hepatic iron overload was categorized as mild (4 ms < T2* < 8 ms), moderate (2 ms < T2* < 4 ms), severe (T2* < 2 ms). Image quality and inter-reader agreement were assessed using intraclass correlation coefficient (ICC). RESULTS CMR examinations from 614 patients (374 men, 240 women) with a mean age of 50 ± 18 (standard deviation) years were fully evaluable. A total of 24/614 patients (3.9%) demonstrated incidental hepatic iron overload; of these, 22/614 patients (3.6%) had mild hepatic iron overload, and 2/614 patients (0.3%) had moderate hepatic iron overload. Seven out of 614 patients (1.1%) had incidental cardiac iron overload; of these, 5/614 patients (0.8%) had mild iron overload, 1/614 patients (0.2%) had moderate iron overload, and 1/614 patients (0.2%) had severe iron overload. Good to excellent inter-reader agreement was observed for the assessment of T2* values (ICC, 0.90 for heart [95% confidence interval: 0.88-0.91]; ICC, 0.91 for liver [95% confidence interval: 0.89-0.92]). CONCLUSION Analysis of standard CMR T2* maps detects incidental cardiac and hepatic iron overload in 1.1% and 3.9% of patients, respectively, which may have implications for further patient management. Therefore, despite an overall low number of incidental abnormal findings, T2* imaging may be included in a standardized comprehensive CMR protocol.
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Affiliation(s)
- Jan M Brendel
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Alina Kratzenstein
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Josephine Berger
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Florian Hagen
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Konstantin Nikolaou
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
| | - Meinrad Gawaz
- Department of Internal Medicine III, Cardiology and Angiology, University of Tübingen, 72076 Germany
| | - Simon Greulich
- Department of Internal Medicine III, Cardiology and Angiology, University of Tübingen, 72076 Germany.
| | - Patrick Krumm
- Department of Radiology, Diagnostic and Interventional Radiology, University of Tübingen, 72076 Germany
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Kottam A, Hanneman K, Schenone A, Daubert MA, Sidhu GD, Gropler RJ, Garcia MJ. State-of-the-Art Imaging of Infiltrative Cardiomyopathies: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2023; 16:e000081. [PMID: 37916407 DOI: 10.1161/hci.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Infiltrative cardiomyopathies comprise a broad spectrum of inherited or acquired conditions caused by deposition of abnormal substances within the myocardium. Increased wall thickness, inflammation, microvascular dysfunction, and fibrosis are the common pathological processes that lead to abnormal myocardial filling, chamber dilation, and disruption of conduction system. Advanced disease presents as heart failure and cardiac arrhythmias conferring poor prognosis. Infiltrative cardiomyopathies are often diagnosed late or misclassified as other more common conditions, such as hypertrophic cardiomyopathy, hypertensive heart disease, ischemic or other forms of nonischemic cardiomyopathies. Accurate diagnosis is also critical because clinical features, testing methodologies, and approach to treatment vary significantly even within the different types of infiltrative cardiomyopathies on the basis of the type of substance deposited. Substantial advances in noninvasive cardiac imaging have enabled accurate and early diagnosis. thereby eliminating the need for endomyocardial biopsy in most cases. This scientific statement discusses the role of contemporary multimodality imaging of infiltrative cardiomyopathies, including echocardiography, nuclear and cardiac magnetic resonance imaging in the diagnosis, prognostication, and assessment of response to treatment.
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19
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Sayed SZ, Abd El-Hafez AH, Abu El-Ela MA, Mourad MAF, Mousa SO. OPG/RANK/RANKL axis relation to cardiac iron-overload in children with transfusion-dependent thalassemia. Sci Rep 2023; 13:12568. [PMID: 37532711 PMCID: PMC10397306 DOI: 10.1038/s41598-023-39596-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/27/2023] [Indexed: 08/04/2023] Open
Abstract
OPG/RANK/RANKL axis was reportedly involved in initiating various diseases, especially bone and cardiovascular diseases. This study aimed to assess the relationship between some OPG, RANK, and RANKL polymorphisms and alleles and iron-overload-induced cardiomyopathy in children with transfusion-dependent thalassemia (TDT). This study included 80 TDT children and 80 age and sex-matched controls. Real-time PCR was done for rs207318 polymorphism for the OPG gene and rs1805034, rs1245811, and rs75404003 polymorphisms for the RANK gene, and rs9594782 and rs2277438 polymorphisms for the RANKL gene. Cardiac T2* MRI and ejection fraction (EF) were done to assess the myocardial iron status and cardiac function. In this study, there were no significant differences in frequencies of the studied polymorphisms between cases and controls (p > 0.05 in all). In TDT children, OPG rs2073618 (G > C) had a significant relation to myocardial iron overload (p = 0.02). Its C allele had significantly more frequent normal EF than its G allele (p = 0.04). RANK rs75404403 (C > DEL) had a significant relation to cardiac dysfunction (p = 0.02). Moreover, the C allele of that gene had significantly more frequent affected EF than its DEL allele (p = 0.02). The A allele of RANKL rs2277438 (G > A) had significantly less frequent severe cardiac iron overload than the G allele (p = 0.04). In conclusion, the OPG/ RANK/RANKL genes may act as genetic markers for iron-induced cardiomyopathy in TDT children. Some of the studied genes' polymorphisms and alleles were significantly related to myocardial iron overload and cardiac dysfunction in TDT children.
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Affiliation(s)
- Samira Zein Sayed
- Department of Pediatrics, Faculty of Medicine, Minia University, El Minya, Egypt
| | | | | | | | - Suzan Omar Mousa
- Department of Pediatrics, Faculty of Medicine, Minia University, El Minya, Egypt.
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20
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Ebeid FSE. The implementation of automated red blood cell exchange (erythrocytapheresis) as a treatment modality in sickle cell disease patients: Single center experience. Transfus Apher Sci 2023; 62:103719. [PMID: 37147250 DOI: 10.1016/j.transci.2023.103719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Improvements of health infrastructure, preventive care and clinical management is important to reduce the morbidity and mortality of sickle cell disease (SCD). OBJECTIVE This prospective, investigator-initiated non-randomized open-label intervention, single centre study describes the implementation of the automated erythrocytapheresis in low-middle income country as a treatment modality for SCD patients to improve the standard of care and highlights its benefits and challenges. METHODOLOGY Eligible patients with SCD who had overt stroke, abnormal/conditional transcranial doppler (TCD), or other indications were subjected to regular automated erythrocytapheresis program. RESULTS From 18th Dec 2017 till 17th Dec 2022, 21 subjects were enrolled; seventeen (80.9 %) were Egyptian and four (19.1 %) were non-Egyptian (three Sudanese and one Nigerian). Totalling 133 sessions had been performed mainly in working hours with fluctuating frequency per month. All sessions maintained isovolumic status and were performed using central venous access. The target HbS concentration was set from the start; the mean final FCR % fraction was 51, most of the session (n = 78, 58.7 %) were able to achieve target FCR. The majority of session pass smoothly with no adverse event (n = 81, 60.9 %), except for certain challenges as shortage of the required blood (n = 38), hypotension (n = 2), hypocalcaemia (n = 2). CONCLUSION Automated erythrocytapheresis is safe and effective modality for management of patients with sickle cell disease.
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Affiliation(s)
- Fatma Soliman Elsayed Ebeid
- Pediatric Hematology Oncology and BMT, Ain Shams University, Cairo, Egypt; Faculty of Medicine, Ain Shams University Research Institute-Clinical Research Center, Egypt.
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21
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Xu F, Luo C, Li M, Guan K, Peng F, Yang G, Peng P. Quantification of cardiac iron in patients with thalassemia with 3-T MRI calibrated by 1.5-T MRI. Acta Radiol 2023; 64:2096-2103. [PMID: 37032518 DOI: 10.1177/02841851231165283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
BACKGROUND Due to the small sample size of many studies, it remained unclear what standardized reference range the T2* cutoff at 3 T would be used to assess the severity of cardiac iron load. In addition, the number of patients with moderate to severe cardiac iron load was small in some studies, especially the sample of patients with severe cardiac iron load. PURPOSE To explore the feasibility, reproducibility, and reliability of using T2* values in quantifying cardiac iron load in patients with thalassemia at 3 T. MATERIAL AND METHODS A total of 122 patients with thalassemia underwent cardiac T2* imaging at both 1.5 T and 3 T. Cardiac R2* (1000/T2*) values of the 100 patients at 3 T were fitted against the values at 1.5 T using linear regression and the prediction equation was derived. The remaining 22 cases were used to test the prediction accuracy of the equation. RESULTS The combined R2* values exhibited a strong linear relationship between 1.5 T and 3 T (r = 0.830,P<0.001). At the center, it had a slope of 1.348 and an intercept of 37.279. According to the equation, the truncated T2* values of cardiac iron overload and cardiac heavy iron overload at 3 T were <10 ms and <6 ms, respectively. The two truncated T2* values were used to diagnose different levels of cardiac iron overloaded of 22 patients at 3 T; the accuracy rates were 95.5% and 100.0%, respectively. CONCLUSION T2* quantification of cardiac iron load at 3 T MRI resulted to be feasible, reproducible, and reliable.
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Affiliation(s)
- Fengming Xu
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, PR China
- NHC Key Laboratory of Thalassemia Medicine (Guangxi Medical University), Nanning, Guangxi Zhuang Autonomous Region, PR China
| | - Chaotian Luo
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, PR China
- NHC Key Laboratory of Thalassemia Medicine (Guangxi Medical University), Nanning, Guangxi Zhuang Autonomous Region, PR China
| | - Meicheng Li
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, PR China
- NHC Key Laboratory of Thalassemia Medicine (Guangxi Medical University), Nanning, Guangxi Zhuang Autonomous Region, PR China
| | - Kaiming Guan
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, PR China
- NHC Key Laboratory of Thalassemia Medicine (Guangxi Medical University), Nanning, Guangxi Zhuang Autonomous Region, PR China
| | - Fei Peng
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, PR China
- NHC Key Laboratory of Thalassemia Medicine (Guangxi Medical University), Nanning, Guangxi Zhuang Autonomous Region, PR China
| | - Gaohui Yang
- NHC Key Laboratory of Thalassemia Medicine (Guangxi Medical University), Nanning, Guangxi Zhuang Autonomous Region, PR China
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, PR China
| | - Peng Peng
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, PR China
- NHC Key Laboratory of Thalassemia Medicine (Guangxi Medical University), Nanning, Guangxi Zhuang Autonomous Region, PR China
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22
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Bou-Fakhredin R, Motta I, Cappellini MD, Taher AT. Clinical Complications and Their Management. Hematol Oncol Clin North Am 2023; 37:365-378. [PMID: 36907609 DOI: 10.1016/j.hoc.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
The diversity of disease-related complications among patients with β-thalassemia is complicated by the wide spectrum of genotypes and clinical risk factors. The authors herein present the different complications seen in patients with β-thalassemia, the pathophysiology underlying these complications and their management.
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Affiliation(s)
- Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Irene Motta
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; UOC General Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; UOC General Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ali T Taher
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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23
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Gertler C, Jauert N, Freyhardt P, Valentova M, Aland SC, Walter-Rittel TC, Unterberg-Buchwald C, Placzek M, Ding-Reinelt V, Bekfani T, Doehner W, Hasenfuß G, Hamm B, Sandek A. Magnetic resonance imaging of organ iron before and after correction of iron deficiency in patients with heart failure. ESC Heart Fail 2023; 10:1847-1859. [PMID: 36907649 DOI: 10.1002/ehf2.14329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/29/2022] [Accepted: 02/06/2023] [Indexed: 03/14/2023] Open
Abstract
AIMS Intravenous iron therapy (IVIT) is known to improve functional status in chronic heart failure (CHF) patients. The exact mechanism is not completely understood. We correlated magnetic resonance imaging (MRI) patterns of T2* iron signal in various organs to systemic iron and exercise capacity (EC) in CHF before and after IVIT. METHODS AND RESULTS We prospectively analysed 24 patients with systolic CHF for T2* MRI pattern of the left ventricle (LV), small and large intestines, spleen, liver, skeletal muscle, and brain for iron. In 12 patients with iron deficiency (ID), we restored iron deficit by IVIT using ferric carboxymaltose. The effects after 3 months were analysed by spiroergometry and MRI. Patients with vs. without ID showed lower blood ferritin, haemoglobin (76 ± 63 vs. 196 ± 82 μg/L and 12.3 ± 1.1 vs. 14.2 ± 1.1 g/dL, all P < 0.002), and in trend a lower transferrin saturation (TSAT) (19.1 [13.1; 28.2] vs. 25.1 [21.3; 29.1] %, P = 0.05). Spleen and liver iron was lower as expressed by higher T2* value (71.8 [66.4; 93.1] vs. 36.9 [32.9; 51.7] ms, P < 0.002 and 33.5 ± 5.9 vs. 28.8 ± 3.9 ms, and P < 0.03). There was a strong trend for a lower cardiac septal iron content in ID (40.6 [33.0; 57.3] vs. 33.7 [31.3; 40.2] ms, P = 0.07). After IVIT, ferritin, TSAT, and haemoglobin increased (54 [30; 104] vs. 235 [185; 339] μg/L, 19.1 [13.1; 28.2] vs. 25.0 [21.0; 33.7] %, 12.3 ± 1.1 vs. 13.3 ± 1.3 g/L, all P < 0.04). Peak VO2 improved (18.2 ± 4.2 vs. 20.9 ± 3.8 mL/min/kg-1 , P = 0.05). Higher peak VO2 at anaerobic threshold was associated with higher blood ferritin, reflecting higher metabolic exercise capacity after therapy (r = 0.9, P = 0.0009). Increase in EC was associated with haemoglobin increase (r = 0.7, P = 0.034). LV iron increased by 25.4% (48.5 [36.2; 64.8] vs. 36.2 [32.9; 41.9] ms, P < 0.04). Spleen and liver iron increased by 46.4 and 18.2%, respectively (71.8 [66.4; 93.1] vs. 38.5 [22.4; 76.9] ms, P < 0.04 and 33.5 ± 5.9 vs. 27.4 ± 8.6 ms, P < 0.007). Iron in skeletal muscle, brain, intestine, and bone marrow remained unchanged (29.6 [28.6; 31.2] vs. 30.4 [29.7; 30.7] ms, P = 0.7, 81.0 ± 6.3 vs. 82.9 ± 9.9 ms, P = 0.6, 34.3 ± 21.4 vs. 25.3 ± 14.1 ms, P = 0.2, 9.4 [7.5; 21.8] vs. 10.3 [6.7; 15.7] ms, P = 0.5 and 9.8 ± 1.5 vs. 13.7 ± 8.9 ms, P = 0.1). CONCLUSIONS CHF patients with ID showed lower spleen, liver, and in trend lower cardiac septal iron. After IVIT, iron signal of the left ventricle as well as spleen and liver increased. Improvement in EC was associated with increase in haemoglobin after IVIT. In ID, liver, spleen, and brain but not heart iron were associated with markers of systemic ID.
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Affiliation(s)
- Christoph Gertler
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner site Göttingen, Göttingen, Germany
| | - Nadja Jauert
- BIH Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Patrick Freyhardt
- Department of Diagnostic and Interventional Radiology, Helios Hospital Krefeld, Krefeld, Germany.,School of Medicine, Faculty of Health, University Witten-Herdecke, Witten, Germany
| | - Miroslava Valentova
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner site Göttingen, Göttingen, Germany
| | - Sven Christopher Aland
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner site Göttingen, Göttingen, Germany
| | | | - Christina Unterberg-Buchwald
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner site Göttingen, Göttingen, Germany.,Institute for Diagnostic and Interventional Radiology, University of Göttingen Medical Center, Göttingen, Germany
| | - Marius Placzek
- Department of Medical Statistics, University of Göttingen, Göttingen, Germany
| | | | - Tarek Bekfani
- Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Magdeburg, Otto von Guericke-University, Magdeburg, Germany
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gerd Hasenfuß
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner site Göttingen, Göttingen, Germany
| | - Bernd Hamm
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anja Sandek
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner site Göttingen, Göttingen, Germany
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24
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Kurban LA, Almarri BK, Alshamsi MH, Abdelrahman SS, Alwahshi SG, Alhorani Q, Syed R, Bakoush O. Optimized serum ferritin prediction of iron overload in transfusion-dependent thalassemia: likelihood ratio and age-adjustment approach. Ann Saudi Med 2023; 43:90-96. [PMID: 37031371 PMCID: PMC10082945 DOI: 10.5144/0256-4947.2023.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2023] Open
Abstract
BACKGROUND Early detection of iron overload in transfusion-dependent thalassemia (TDT) patients is critical to prevent complications and improve survival. OBJECTIVES Evaluate the utility of serum ferritin (SF) in the prediction of hepatic and myocardial iron overload (HIO and MIO) compared to T2*-MRI. DESIGN Retrospective SETTINGS: Governmental hospitals. PATIENTS AND METHODS Patients with TDT who had T2*-MRI examinations between January 2016 to October 2019 were included. The predictive value of SF for detection of HIO and MIO was assessed by measuring area under the curve (AUC). A sample size of 123 cases was calculated to detect a correlation of 0.25 with 90% power and a two-sided type I error of 0.05. MAIN OUTCOME MEASURES The correlation between SF and estimated hepatic iron concentration. SAMPLE SIZE 137 TDT patients who required regular blood transfusions. RESULTS The predictive value of SF was excellent for detection of HIO (AUC=0.83-0.87) but fair for detection of MIO (AUC=0.67). The two independent predictors of MIO were age and SF. The log of (age × SF) enhanced the SF predictive value for MIO (AUC=0.78). SF values of 700 and 1250 mg/L effectively excluded mild and moderate HIO with a sensitivity of 97.8% and 94.2%, respectively (LR-=0.1). While SF values of 1640 and 2150 mg/L accurately diagnosed mild and moderate HIO with a specificity of 95.55% and 96.4%, respectively (LR+>10). A log of (age × SF) cut-off value of 4.15 effectively excluded MIO (LR-=0.1), while a value of 4.65 moderately confirmed MIO (LR+=3.2). CONCLUSIONS SF is an excellent predictor of hepatic IO in TDT. Age adjustment enhanced its myocardial IO predictive accuracy. Likelihood ratio-based SF cut-off values may help clinicians in risk stratification and treatment decision-making. LIMITATIONS The laboratory data were gathered retrospectively and although the risk of selection bias for T2*-MRI examination is thought to be low, it cannot be ignored. CONFLICT OF INTEREST None.
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Affiliation(s)
- Lutfi Ali Kurban
- From the Department of Radiology, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Bashayer Khamis Almarri
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Maitha Helal Alshamsi
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Shahid Shehadeh Abdelrahman
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Sara Ghumail Alwahshi
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Qays Alhorani
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Rizwan Syed
- From the Department of Radiology, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Omran Bakoush
- From the Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
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Meloni A, Pistoia L, Quota A, Messina G, Ricchi P, Bagnato S, Gerardi C, Lisi R, Cuccia L, Renne S, Vallone A, Righi R, Positano V, Pepe A, Cademartiri F. Prognostic value of multiparametric cardiac magnetic resonance in sickle cell patients. Ann Hematol 2023; 102:261-270. [PMID: 36459182 DOI: 10.1007/s00277-022-05057-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
The aim of this multicenter study was to prospectively assess the predictive value of multiparametric cardiac magnetic resonance (CMR) for cardiovascular complications in sickle cell disease (SCD) patients. Among all patients with hemoglobinopathies consecutively enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) Network, we selected 102 SCD patients (34.38 ± 12.67 years, 49 females). Myocardial iron overload (MIO) was measured by the multislice multiecho T2* technique. Atrial dimensions and biventricular function parameters were quantified by cine images. Late gadolinium enhancement (LGE) images were acquired to detect focal myocardial fibrosis. At baseline CMR, only two patients had significant MIO (global heart T2* < 20 ms). During a mean follow-up of 63.01 ± 24.95 months, 11 cardiovascular events (10.8%) were registered: 3 pulmonary hypertension, 2 supraventricular arrhythmias, 1 heart failure, 1 death for heart failure, 1 pulmonary embolism, 1 peripheral vascular disease, 1 transient ischemic attack, and 1 death after acute chest syndrome. In the multivariate analysis, the independent CMR predictors of cardiovascular events were left ventricular (LV) ejection fraction (hazard ratio-HR = 0.88; p = 0.025) and right ventricular (RV) mass index (HR = 1.09; p = 0.047). According to the receiver-operating characteristic curve analysis for adverse events, an LV ejection fraction < 58.9% and an RV mass index > 31 g/m2 were optimal cut-off values. Reduced left ventricular ejection fraction and increased right ventricular mass index showed a significant prognostic value in patients with SCD. Our data seem to suggest that CMR may be added as a screening tool for identifying SCD patients at high risk for cardiopulmonary and vascular diseases.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1 - 56124, Pisa, Italy.,U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1 - 56124, Pisa, Italy
| | - Alessandra Quota
- Servizio Di Talassemia, Ospedale V. Emanuele III, Gela, CL, Italy
| | - Giuseppe Messina
- Centro Microcitemie, Grande Ospedale Metropolitano Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Paolo Ricchi
- U.O.S.D. Malattie Rare del Globulo Rosso, Azienda Ospedaliera Di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Sergio Bagnato
- Ematologia Microcitemia, Ospedale San Giovanni di Dio - ASP Crotone, Crotone, Italy
| | - Calogera Gerardi
- Unità Operativa Semplice Di Talassemia, Presidio Ospedaliero Giovanni Paolo II - Distretto AG2 Di Sciacca, Sciacca, AG, Italy
| | - Roberto Lisi
- Unità Operativa Dipartimentale Talassemia, Azienda Ospedaliera Garibaldi Presidio Ospedaliero Garibaldi-Centro, Catania, Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia Con Talassemia, ARNAS Civico Benfratelli-Di Cristina, Palermo, Italy
| | - Stefania Renne
- Struttura Complessa Di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II", Lamezia Terme, Italy
| | - Antonino Vallone
- Reparto Di Radiologia, Azienda Ospedaliera Garibaldi Presidio Ospedaliero Nesima, Catania, Italy
| | - Riccardo Righi
- Diagnostica Per Immagini e Radiologia Interventistica, Ospedale del Delta, Lagosanto, FE, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1 - 56124, Pisa, Italy.,U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1 - 56124, Pisa, Italy.
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Meloni A, Pistoia L, Positano V, De Luca A, Martini N, Spasiano A, Fotzi I, Bitti PP, Visceglie D, Alberini G, Sinagra G, Pepe A, Cademartiri F. Increased myocardial extracellular volume is associated with myocardial iron overload and heart failure in thalassemia major. Eur Radiol 2023; 33:1266-1276. [PMID: 36066735 DOI: 10.1007/s00330-022-09120-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/27/2022] [Accepted: 08/18/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Myocardial extracellular volume (ECV) by cardiovascular magnetic resonance (CMR) is a surrogate marker of diffuse fibrosis. We evaluated the association between ECV and demographics, CMR findings, and cardiac involvement in patients with thalassemia major (TM). METHODS A total of 108 β-TM patients (62 females, 40.16 ± 8.83 years), consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network, and 16 healthy subjects (6 females, 37.12 ± 16.13 years) underwent CMR. The protocol included assessment of T2*, native T1, and T2 values in all 16 myocardial segments for myocardial iron overload (MIO) quantification, cine images for left ventricular (LV) function quantification, post-contrast T1 mapping for ECV calculation, and late gadolinium enhancement (LGE) technique for replacement myocardial fibrosis detection. RESULTS Global ECV values were significantly higher in females than in males. Global ECV values were significantly higher in patients with significant MIO (global heart T2* < 20 ms) than in patients without significant MIO, and both groups exhibited higher global ECV values than healthy subjects. No association was detected between native T1 and ECV values, while patients with reduced global heart T2 values showed significantly higher global ECV values than patients with normal and increased global heart T2. Global ECV values were not correlated with LV function/size and were comparable between patients with and without LGE. Compared to patients without heart failure, patients with a history of heart failure (N = 10) showed significantly higher global heart ECV values. CONCLUSION In TM, increased myocardial ECV, potentially reflecting diffuse interstitial fibrosis, is associated with MIO and heart failure. KEY POINTS • CMR-derived myocardial extracellular volume is increased in thalassemia major patients, irrespective of the presence of late gadolinium enhancement. • In thalassemia major, myocardial iron overload contributes to the increase in myocardial ECV, which potentially reflects diffuse interstitial fibrosis and is significantly associated with a history of heart failure.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1 -, 56124, Pisa, Italy.,U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1 -, 56124, Pisa, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1 -, 56124, Pisa, Italy.,U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Antonio De Luca
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Nicola Martini
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1 -, 56124, Pisa, Italy.,U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Napoli, Italy
| | - Ilaria Fotzi
- Centro Talassemie ed Emoglobinopatie, Ospedale "Meyer", Firenze, Italy
| | - Pier Paolo Bitti
- Servizio Immunoematologia e Medicina Trasfusionale - Dipartimento dei Servizi, Presidio Ospedaliero "San Francesco" ASL Nuoro, Nuoro, Italy
| | - Domenico Visceglie
- Servizio di Immunoematologia e Medicina Trasfusionale, A.S.L. di Bari, Ospedale "Di Venere", Bari, Italy
| | - Gianna Alberini
- U.O.C. INFOTEL Translational BioInformatics and eHealth, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | | | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1 -, 56124, Pisa, Italy.
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Left ventricular global function index is associated with myocardial iron overload and heart failure in thalassemia major patients. Int J Cardiovasc Imaging 2023; 39:991-999. [PMID: 36637709 DOI: 10.1007/s10554-023-02792-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/02/2023] [Indexed: 01/14/2023]
Abstract
PURPOSE The left ventricular global function index (LVGFI) is a comprehensive marker of cardiac performance, integrating LV morphology with global function. We explored the cross-sectional association of LVGFI with myocardial iron overload (MIO), LV ejection fraction (LVEF), myocardial fibrosis, and heart failure (HF) in β-thalassemia major (TM) patients. METHODS We considered 1352 adult TM patients (708 females, 32.79 ± 7.16years) enrolled in the Myocardial Iron Overload in Thalassemia Network and 112 healthy subjects (50 females, 32.09 ± 6.08years). LVGFI and LVEF were assessed by cine images and MIO by multislice multiecho T2* technique. Replacement myocardial fibrosis was detected by late gadolinium enhancement technique. RESULTS LVGFI and LVEF were significantly lower in patients with significant MIO (global heart T2*<20ms) than in patients without MIO and in healthy subjects but were comparable between TM patients without MIO and healthy subjects. In TM, LVGFI was significantly associated with LVEF (R = 0.733; p < 0.0001). Global heart T2* values were significantly associated with both LVGFI and LVEF, but the correlation with LVGFI was significantly stronger (p = 0.0001). Male sex, diabetes mellitus, significant MIO, and replacement myocardial fibrosis were the strongest predictors of LVGFI. Eighty-six patients had a history of HF and showed significantly lower global heart T2* values, LVEF, and LVGFI than HF-free patients. A LVGFI ≤ 44.9% predicted the presence of HF. The LVGFI showed a diagnostic performance superior to that of LVEF (area under the curve: 0.67 vs. 0.62; p = 0.039). CONCLUSION In TM patients the LVGFI correlates with MIO and provides incremental diagnostic value for HF detection compared with LVEF.
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Chapchap EC, Silva MMA, de Assis RA, Kerbauy LN, Diniz MDS, Rosemberg LA, Loggetto SR, Araujo ADS, Fabron Junior A, Verissimo MPDA, Baldanzi GR, Esposito BP, Tricta F, Steagall MEA, Vellozo CÂGDS, Fertrin KY, Baroni RH, Hamerschlak N. Cardiac iron overload evaluation in thalassaemic patients using T2* magnetic resonance imaging following chelation therapy: a multicentre cross-sectional study. Hematol Transfus Cell Ther 2023; 45:7-15. [PMID: 34090847 PMCID: PMC9938451 DOI: 10.1016/j.htct.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/28/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) T2* technique is used to assess iron overload in the heart, liver and pancreas of thalassaemic patients. Optimal iron chelation and expected tissue iron response rates remain under investigation. The objective of this study was to analyse serum ferritin and the iron concentration in the heart, liver and pancreas measured by MRI T2*/R2* during regular chelation therapy in a real-world cohort of patients with thalassemia. METHODS We evaluated thalassaemic patients ≥ 7 years old undergoing chelation/transfusion therapy by MRI and assessed serum ferritin at baseline and follow-up from 2004-2011. RESULTS We evaluated 136 patients, 92% major thalassaemic, with a median age of 18 years, and median baseline ferritin 2.033ng/ml (range: 59-14,123). Iron overload distribution was: liver (99%), pancreas (74%) and heart (36%). After a median of 1.2 years of follow-up, the iron overload in the myocardium reduced from 2,63 Fe mg/g to 2,05 (p 0.003). The optimal R2* pancreas cut-off was 148 Hertz, achieving 78% sensitivity and 73% specificity. However, when combining the R2* pancreas cut off ≤ 50 Hertz and a ferritin ≤ 1222 ng/ml, we could reach a negative predictive value (NPV) of 98% for cardiac siderosis. Only 28% were undergoing combined chelation at baseline assessment, which increased up to 50% on follow up evaluation. CONCLUSIONS Chelation therapy significantly reduced cardiac siderosis in thalassaemic patients. In patients with moderate/severe liver iron concentration undergoing chelation therapy, ferritin levels and myocardium iron improved earlier than the liver siderosis.
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Rao S, Hasan BS, Hoodbhoy Z, Habib I, Mohsin S, Tomredle R, Ashiqali S, Tipoo FA, Cartoski MJ, Bijnens B, Chowdhury D. Role of myocardial deformation imaging in transfusion-dependent thalassemia—Correlation with severity of myocardial siderosis. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Left Ventricular Function and Iron Loading Status in a Tertiary Center Hemochromatosis Cohort-A Cardiac Magnetic Resonance Study. Diagnostics (Basel) 2022; 12:diagnostics12112620. [PMID: 36359463 PMCID: PMC9689750 DOI: 10.3390/diagnostics12112620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Haemochromatosis (HCH), a common genetic disorder with variable penetrance, results in progressive but understudied iron overload. We prospectively evaluated organ iron loading and cardiac function in a tertiary center HCH cohort. Methods: 42 HCH patients (47 ± 14 years) and 36 controls underwent laboratory workup and cardiac magnetic resonance (CMR), including T1 and T2* mapping. Results: Myocardial T2* (myoT2*), myocardial T1 (myoT1) and liver T2* (livT2*) were lower in patients compared to controls (33 ± 4 ms vs. 36 ± 3 ms [p = 0.004], 964 ± 33 ms vs. 979 ± 25 ms [p = 0.028] and 21 ± 10 ms vs. 30 ± 5 ms [p < 0.001], respectively). MyoT2* did not reach the threshold of clinically significant iron overload (<20 ms), in any of the patients. In 22 (52.4%) patients, at least one of the tissue parameters was reduced. Reduced myocardial T2* and/or T1 were found in 10 (23.8%) patients, including 4 pts with normal livT2*. LivT2* was reduced in 18 (42.9%) patients. MyoT1 and livT2* inversely correlated with ferritin (rs = −0.351 [p = 0.028] and rs = −0.602 [p < 0.001], respectively). LivT2* by a dedicated sequence and livT2* by cardiac T2* mapping showed good agreement (ICC = 0.876 p < 0.001). Conclusions: In contemporary hemochromatosis, significant myocardial iron overload is rare. Low myocardial T2* and/or T1 values may warrant closer follow-up for accelerated myocardial iron overload even in patients without overt liver overload. Cardiac T2* mapping sequence allows for liver screening at the time of CMR.
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Hoe HG, Git KA, Loh CK, Abdul Latiff Z, Hong J, Abdul Hamid H, Wan Sulaiman WNA, Mohd Zaki F. Magnetic resonance imaging T2 * of the pancreas value using an online software tool and correlate with T2 * value of myocardium and liver among patients with transfusion-dependent thalassemia major. FRONTIERS IN RADIOLOGY 2022; 2:943102. [PMID: 37492672 PMCID: PMC10365003 DOI: 10.3389/fradi.2022.943102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/28/2022] [Indexed: 07/27/2023]
Abstract
Objective Patients with thalassemia major do require lifetime blood transfusions that eventually result in iron accumulation in different organs. We described the usefulness of using magnetic resonance imaging (MRI) T2*imaging values for the evaluation of pancreatic iron load in these patients, and we correlated it with MRI T2* haemosiderosis of the myocardium and liver that has been recognized as a non-invasive assessment of iron overload among patients with thalassemia major. Materials and methods We conducted a cross-sectional study on 39 patients with thalassemia major in one of the tertiary university hospitals for a 1-year period. Demographic data were collected from the patient's history. MRI T2* of the pancreas, liver, and heart were executed on all patients in the same setting. Objective values of iron overload in these organs were obtained using the MRI post-processing software from online software. Results A total of 32 (82.1%) patients had pancreatic iron overload including 2 patients (5.1%) with severe iron overload and 15 patients (38.5%) with moderate and mild iron overload, respectively. Nine patients (23.1%) had myocardial iron overload, which included 3 patients (7.7%) who had severe cardiac haemosiderosis. Notably, 37 patients (94.9%) had liver iron overload, which included 15 patients (38.5%) who had severe liver haemosiderosis. There was a moderate positive correlation between the relaxation time of the pancreas and heart haemosiderosis (r = 0.504, P < 0.001). No significant correlation was found between the relaxation time of the pancreas with the liver and the heart with the liver. Conclusion Pancreatic haemosiderosis precedes cardiac haemosiderosis, which establishes a basis for initiating earlier iron chelation therapy to patients with thalassemia major.
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Affiliation(s)
- Han Guan Hoe
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Kim-Ann Git
- Department of Radiology, Hospital Selayang, Batu Caves, Malaysia
| | - C-Khai Loh
- Paediatric Oncology and Haematology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Zarina Abdul Latiff
- Paediatric Oncology and Haematology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Joyce Hong
- Paediatric Endocrinology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Hamzaini Abdul Hamid
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | | | - Faizah Mohd Zaki
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
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Raief Mosaad BM, Ibrahim AS, Mansour MG, ElAlfy MS, Ebeid FSE, Abdeldayem EH. The role of MRI-R2* in the detection of subclinical pancreatic iron loading among transfusion-dependent sickle cell disease patients and correlation with hepatic and cardiac iron loading. Insights Imaging 2022; 13:140. [PMID: 36057708 PMCID: PMC9440968 DOI: 10.1186/s13244-022-01280-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/01/2022] [Indexed: 11/11/2022] Open
Abstract
Objectives Pancreatic reserve could be preserved by early assessment of pancreatic iron overload among transfusion-dependent sickle cell disease (SCD) patients. This study aimed to measure pancreatic iron load and correlate its value with patients’ laboratory and radiological markers of iron overload. Materials and methods Sixty-six SCD children and young adults underwent MRI T2* relaxometry using a simple mathematical spreadsheet and laboratory assessment. Results The results indicated moderate-to-severe hepatic iron overload among 65.2% of studied cases. None had cardiac iron overload. Normal-to-mild iron overload was present in the pancreas in 86% of cases, and 50% had elevated serum ferritin > 2500 ug/L. There was no significant correlation between pancreatic R2* level, serum ferritin, and hepatic iron overload. Patients with higher levels of hemolysis markers and lower pre-transfusion hemoglobin levels showed moderate-to-severe pancreatic iron overload. Conclusion Chronically transfused patients with SCD have a high frequency of iron overload complications including pancreatic iron deposition, thereby necessitating proper monitoring of the body’s overall iron balance as well as detection of extrahepatic iron depositions.
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Affiliation(s)
| | - Ahmed Samir Ibrahim
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed G Mansour
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohsen Saleh ElAlfy
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Emad H Abdeldayem
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Cardiac Magnetic Resonance at 3.0 T in Patients With C282Y Homozygous Hereditary Hemochromatosis: Superiority of Radial and Circumferential Strain Over Cardiac T2* Measurements at Baseline and at Post Venesection Follow-up. J Thorac Imaging 2022; 37:300-306. [PMID: 35426858 DOI: 10.1097/rti.0000000000000645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Iron-overload cardiomyopathy initially manifests with diastolic dysfunction and can progress to dilated cardiomyopathy if untreated. Previous studies have shown that patients with primary and secondary hemochromatosis can have subclinical left ventricle dysfunction with abnormalities on strain imaging. This study aimed to evaluate the relationship between cardiac T2* values and myocardial-wall strain in patients with hereditary hemochromatosis (HH) at the time of diagnosis and after a course of venesection treatment. MATERIALS AND METHODS Baseline cardiac magnetic resonance (CMR) at 3 T was performed in 19 patients with newly diagnosed HH with elevated serum ferritin levels and repeated after a course of treatment with venesection. Quantitative T2* mapping and strain analysis were performed offline using dedicated relaxometry fitting and feature-tracking software. RESULTS The majority (84%) of patients had normal baseline myocardial T2* values (mean 19.3 ms, range 8.9 to 31.2 ms), which improved significantly after venesection (mean 24.1 ms, range 11 to 38.1 ms) ( P =0.021). Mean global radial strain significantly improved from 25.0 (range: 15.6 to 32.9) to 28.3 (range: 19.8 to 35.8) ( P =0.001) and mean global circumferential strain improved, decreasing from -15.7 (range: -11.1 to -19.2) to -17.1 (range: -13.0 to -20.1) ( P =0.001). CONCLUSION Patients with HH may have normal T2* values in the presence of subclinical left ventricle dysfunction, which can be detected by abnormal radial and circumferential strain. As strain imaging improves following venesection in HH, it may serve as a useful biomarker to guide treatment.
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Mavrogeni S, Pepe A, Nijveldt R, Ntusi N, Sierra-Galan LM, Bratis K, Wei J, Mukherjee M, Markousis-Mavrogenis G, Gargani L, Sade LE, Ajmone-Marsan N, Seferovic P, Donal E, Nurmohamed M, Cerinic MM, Sfikakis P, Kitas G, Schwitter J, Lima JAC, Dawson D, Dweck M, Haugaa KH, Keenan N, Moon J, Stankovic I, Donal E, Cosyns B. Cardiovascular magnetic resonance in autoimmune rheumatic diseases: a clinical consensus document by the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2022; 23:e308-e322. [PMID: 35808990 DOI: 10.1093/ehjci/jeac134] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 11/12/2022] Open
Abstract
Autoimmune rheumatic diseases (ARDs) involve multiple organs including the heart and vasculature. Despite novel treatments, patients with ARDs still experience a reduced life expectancy, partly caused by the higher prevalence of cardiovascular disease (CVD). This includes CV inflammation, rhythm disturbances, perfusion abnormalities (ischaemia/infarction), dysregulation of vasoreactivity, myocardial fibrosis, coagulation abnormalities, pulmonary hypertension, valvular disease, and side-effects of immunomodulatory therapy. Currently, the evaluation of CV involvement in patients with ARDs is based on the assessment of cardiac symptoms, coupled with electrocardiography, blood testing, and echocardiography. However, CVD may not become overt until late in the course of the disease, thus potentially limiting the therapeutic window for intervention. More recently, cardiovascular magnetic resonance (CMR) has allowed for the early identification of pathophysiologic structural/functional alterations that take place before the onset of clinically overt CVD. CMR allows for detailed evaluation of biventricular function together with tissue characterization of vessels/myocardium in the same examination, yielding a reliable assessment of disease activity that might not be mirrored by blood biomarkers and other imaging modalities. Therefore, CMR provides diagnostic information that enables timely clinical decision-making and facilitates the tailoring of treatment to individual patients. Here we review the role of CMR in the early and accurate diagnosis of CVD in patients with ARDs compared with other non-invasive imaging modalities. Furthermore, we present a consensus-based decision algorithm for when a CMR study could be considered in patients with ARDs, together with a standardized study protocol. Lastly, we discuss the clinical implications of findings from a CMR examination.
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Affiliation(s)
- S Mavrogeni
- Onassis Cardiac Surgery Center, Leof. Andrea Siggrou 356, Kallithea 176 74, Greece.,Exercise Physiology and Sport Medicine Clinic, Center for Adolescent Medicine and UNESCO Chair in Adolescent Health Care, First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, 115 27 Athens, Greece
| | - A Pepe
- Institute of Radiology, Department of Medicine, University of Padua, 35122 Padua, Italy
| | - R Nijveldt
- Department of Cardiology, Radboud University Medical Center, 6525 GA, Nijmegen, the Netherlands
| | - N Ntusi
- University of Cape Town & Groote Schuur Hospital, City of Cape Town, 7700 Western Cape, South Africa
| | - L M Sierra-Galan
- Department of Cardiology, American British Cowdray Medical Center, 05330 Mexico City, Mexico
| | - K Bratis
- Department of Cardiology, Manchester Royal Infirmary, Manchester M13 9WL, UK
| | - J Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA 90048, USA.,Preventive and Rehabilitative Cardiac Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA 90048, USA
| | - M Mukherjee
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | - L Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - L E Sade
- University of Pittsburgh, University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA 15260, USA.,Department of Cardiology, Baskent University, 06790 Ankara, Turkey
| | - N Ajmone-Marsan
- Department of Cardiology, Leiden University Medical Center, 2311 EZ Leiden, the Netherlands
| | - P Seferovic
- Department of Cardiology, Belgrade University, 11000 Belgrade, Serbia
| | - E Donal
- Université RENNES-1, CHU, 35000 Rennes, France
| | - M Nurmohamed
- Amsterdam Rheumatology Immunology Center, Amsterdam University Medical Centers, 1105 AZ, Amsterdam, the Netherlands
| | - M Matucci Cerinic
- Experimental and Clinical Medicine, Division of Internal Medicine and Rheumatology, Azienda Ospedaliera Universitaria Careggi, University of Florence, 50121 Florence, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS, San Raffaele Hospital, 20132 Milan, Italy
| | - P Sfikakis
- First Department of Propeudeutic and Internal medicine, Laikon Hospital, Athens University Medical School, 115 27 Athens, Greece
| | - G Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester M13 9PL, UK
| | - J Schwitter
- Lausanne University Hospital, CHUV, CH-1011 Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, 1015 UniL, Switzerland.,Director CMR Center of the University Hospital Lausanne, CHUV, CH-1011 Lausanne, Switzerland
| | - J A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Chang S, Park J, Yang YJ, Beck KS, Kim PK, Choi BW, Jung JI. Myocardial T2* Imaging at 3T and 1.5T: A Pilot Study with Phantom and Normal Myocardium. J Cardiovasc Dev Dis 2022; 9:jcdd9080271. [PMID: 36005435 PMCID: PMC9410052 DOI: 10.3390/jcdd9080271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/06/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Myocardial T2* mapping at 1.5T remains the gold standard, but the use of 3T scanners is increasing. We aimed to determine the conversion equations in different scanners with clinically available, vendor-provided T2* mapping sequences using a phantom and evaluated the feasibility of the phantom-based conversion method. Methods: T2* of a phantom with FeCl3 (five samples, 3.53–20.09 mM) were measured with 1.5T (MR-A1) and 3T scanners (MR-A2, A3, B), and the site-specific equation was determined. T2* was measured in the interventricular septum of three healthy volunteers at 1.5T (T2*1.5T, MR-A1) and 3T (T2*3.0T, MR-B). T2*3.0T was converted based on the equation derived from the phantom (T2*eq). Results: R2* at 1.5T and 3T showed linear association, but a different relationship was observed according to the scanners (MR-A2, R2*1.5T = 0.76 × R2*3.0T − 2.23, R2 = 0.999; MR-A3, R2*1.5T = 0.95 × R2*3.0T − 34.28, R2 = 0.973; MR-B, R2*1.5T = 0.76 × R2*3.0T − 3.02, R2 = 0.999). In the normal myocardium, T2*eq and T2*1.5T showed no significant difference (35.5 ± 3.5 vs. 34.5 ± 1.2, p = 0.340). The mean squared error between T2*eq and T2*1.5T was 16.33, and Bland–Altman plots revealed a small bias (−0.94, 95% limits of agreement: −8.86–6.99). Conclusions: a phantom-based, site-specific equation can be utilized to estimate T2* values at 1.5T in centers where only 3T scanners are available.
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Affiliation(s)
- Suyon Chang
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | | | | | - Kyongmin Sarah Beck
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | | | - Byoung Wook Choi
- Phantomics, Inc., Seoul 07803, Korea
- Department of Radiology, Center for Clinical Imaging Data Science, Research Institute of Radiological Sciences, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jung Im Jung
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
- Correspondence: ; Tel.: +82-2-2258-1431
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Das KM, Baskaki UMA, Pulinchani A, Ali HM, Almanssori TM, Gorkom KV, Das A, Dewedar H, Sharma S. Significance of Cardiac Magnetic Resonance Feature Tracking of the Right Ventricle in Predicting Subclinical Dysfunction in Patients with Thalassemia Major. Diagnostics (Basel) 2022; 12:diagnostics12081920. [PMID: 36010270 PMCID: PMC9406855 DOI: 10.3390/diagnostics12081920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 01/19/2023] Open
Abstract
In patients with thalassemia major (TM), cardiac magnetic resonance feature-tracking (CMR-FT) has been shown to be an effective method for diagnosing subclinical left ventricular (LV) dysfunction. This study aimed to determine whether CMR-FT could detect abnormal RV dysfunction in patients with a normal right ventricular ejection fraction (RVEF). We performed a retrospective analysis of TM patients admitted to Dubai’s Rashid Hospital between July 2019 and March 2021. The inclusion criteria were TM patients with SSFP cine with T2* (T2*-weighted imaging), while exclusion criteria included any other cardiovascular disease. When there was no myocardial iron overload (MIO) (T2* ≥ 20 ms) and when there was significant MIO (T2* < 20 ms), the CMR-FT was used to correlate with EF. Among the 89 participants, there were 46 men (51.7%) and 43 women (48.3%), with a mean age of 26.14 ± 7.4 years (range from 10 to 48 years). Forty-six patients (51.69%) did not have MIO, while 43 individuals did (48.31%). Thirty-nine patients (32.6%) were diagnosed with severe MIO, while seventeen (19.1%) were diagnosed with mild to moderate MIO. A significant correlation existed between RVEF and T2* values (r = 0.274, p = 0.014) and between left ventricular ejection fraction (LVEF) and T2* values (r = 0.256, p = 0.022). Using a multiple logistic regression model with predictors such as right ventricular longitudinal strain (RVGLS), LV ejection fraction (LV EF), and hemoglobin, abnormal myocardial iron overload can be predicted. This model demonstrates an AUC of 78.3%, a sensitivity of 72%, and a specificity of 76%. In the group with preserved RVEF > 53%, the left ventricular radial strain (LVGRS) (p = 0.001), right ventricular radial strain (RVGRS) (p = 0.000), and right ventricular basal circumferential strain (RVGCS-basal) (p = 0.000) CMR-FT strain values are significantly lower than those of the control group (p > 0.05). There was no significant correlation between the LVGLS and T2*. RVGLS was ranked among the most accurate predictors of abnormal myocardial iron overload. The LVGRS, RVGRS, and RVGCS-basal CMR-FT strain values were the best predictors of subclinical RV dysfunction in the group with preserved RVEF. The most accurate way to diagnose MIO is still T2*, but FT-strain can help us figure out how MIO affects the myocardium from a pathophysiological point of view.
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Affiliation(s)
- Karuna M. Das
- College of Medicine & Health Sciences, United Arab Emirates University, Al Ain P.O. Box 17666, United Arab Emirates
- Correspondence:
| | | | - Anisha Pulinchani
- Department of Data Science, PSPH, Manipal Academy of Higher Education, Manipal 576104, India
| | | | - Taleb M. Almanssori
- College of Medicine & Health Sciences, United Arab Emirates University, Al Ain P.O. Box 17666, United Arab Emirates
| | - Klaus Van Gorkom
- College of Medicine & Health Sciences, United Arab Emirates University, Al Ain P.O. Box 17666, United Arab Emirates
| | - Amrita Das
- Brighton College, Al Ain P.O. Box 17666, United Arab Emirates
| | - Hany Dewedar
- Thalassemia Center, Dubai P.O. Box 9115, United Arab Emirates
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Quarello P, Ramenghi U, Fagioli F. Diamond-Blackfan anaemia with iron overload: A serious issue. Br J Haematol 2022; 199:171-172. [PMID: 35929529 DOI: 10.1111/bjh.18393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022]
Abstract
Transfusion-dependent Diamond-Blackfan anaemia (DBA) patients rapidly develop iron overload and frequently experience cardiac complications. The report by Lecornec and colleagues offers useful details on indications and the management of deferiprone, a highly efficient chelator in removing excess cardiac iron but associated with a high risk of agranulocytosis in DBA patients. Commentary on: Nicolas Lecornec and colleagues: Agranulocytosis in patients with Diamond-Blackfan anaemia treated with deferiprone for post-transfusion iron overload: A retrospective study of the French DBA cohort. British Journal of Haematology 2022.
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Affiliation(s)
- Paola Quarello
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Ugo Ramenghi
- Department of Pediatric and Public Health Sciences, University of Turin, Turin, Italy
| | - Franca Fagioli
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, University of Torino, Torino, Italy
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Gayathri N, Kumar MV, Vinoth T, Prabhu R, Krishnabharath S. Correlation of Liver and Myocardium Iron Concentration Determined by Magnetic Resonance Imaging With Serum Ferritin in Non-Transfusion-Dependent Thalassemia Patients. Cureus 2022; 14:e27467. [PMID: 36060401 PMCID: PMC9420837 DOI: 10.7759/cureus.27467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/05/2022] Open
Abstract
Background The primary factor associated with fatality in thalassemia patients is heavy cardiac complications. Currently, magnetic resonance imaging (MRI) is accepted as the non-invasive modality of choice for diagnosing iron overload in the liver. This study aimed to correlate liver iron concentration (LIC) and myocardium iron concentration (MIC) determined by MRI and clinical and biochemical parameters in non-transfusion-dependent thalassemia (NTDT) patients. Methodology This prospective study was conducted in the radiology department from October 2016 to September 2018. A total of 30 patients were included. Using Siemens MAGNETOM® Avanto 1.5T, iron was quantified with a body matrix coil. Sequences performed were gradient-echo 8 and 12 for the myocardium and liver, respectively. Dual-echo fast spoiled gradient-echo in/out phase and diffusion-weighted images were used. Iron values were calculated using T2* spreadsheet analysis software version 3.1. Data were analyzed using coGuide software V.1.03. Results The mean age of the participants was 24.9 ± 12.6 years. There was a very strong positive correlation between LIC and serum ferritin. There was a strong negative correlation between LIC and hemoglobin. Between LIC and MIC, there was a marginally favorable relationship (rs value = 0.077, p-value = 0.985). Conclusions When MRI is not available, serum ferritin can be used as an alternative to diagnose iron overload in patients with NTDT.
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Munikoty V, Sodhi KS, Bhatia A, Bhatia P, Verma Attri S, Rohit MK, Trehan A, Khandelwal N, Bansal D. Estimation of iron overload with T2*MRI in children treated for hematological malignancies. Pediatr Hematol Oncol 2022; 40:315-325. [PMID: 35833695 DOI: 10.1080/08880018.2022.2098436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Iron overload may contribute to long-term complications in childhood cancer survivors. There are limited reports of assessment of tissue iron overload in childhood leukemia by magnetic resonance imaging (MRI). A cross-sectional, observational study in children treated for hematological malignancy was undertaken. Patients ≥6 months from the end of therapy who had received ≥5 red-cell transfusions were included. Iron overload was estimated by serum ferritin (SF) and T2*MRI. Forty-five survivors were enrolled among 431 treated for hematological malignancies. The median age at diagnosis was 7-years. A median of 8 red-cell units was transfused. The median duration from the end of treatment was 15 months. An elevated SF (>1,000 ng/ml), elevated liver iron concentration (LIC) and myocardial iron concentration (MIC) were observed in 5 (11.1%), 20 (45.4%), and 2 (4.5%) patients, respectively. All survivors with SF >1,000 ng/ml had elevated LIC. The LIC correlated with SF (p < 0.001). MIC lacked correlation with SF or LIC. Factors including the number of red-cell units transfused and duration from the last transfusion were associated with elevated SF (p = 0.001, 0.002) and elevated LIC (p = 0.012, 0.005) in multiple linear regression. SF >595 ng/ml predicted elevated LIC with a sensitivity of 85% and specificity of 91.6% (AUC 91.2%). A cutoff >9 units of red cell transfusions had poor sensitivity and specificity of 70% and 75% (AUC 76.6%) to predict abnormal LIC. SF >600 ng/ml is a robust tool to predict iron overload, and T2*MRI should be considered in childhood cancer survivors with SF exceeding 600 ng/ml.
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Affiliation(s)
- Vinay Munikoty
- Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kushaljit Singh Sodhi
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anmol Bhatia
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prateek Bhatia
- Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Savita Verma Attri
- Pediatric Biochemistry Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj K Rohit
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Trehan
- Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Dissanayake R, Samarasinghe N, Waidyanatha S, Pathirana S, Neththikumara N, Dissanayake VHW, Wetthasinghe K, Gooneratne L, Wickramasinghe P. Assessment of iron overload in a cohort of Sri Lankan patients with transfusion dependent beta thalassaemia and its correlation with pathogenic variants in HBB, HFE, SLC40A1, and TFR2 genes. BMC Pediatr 2022; 22:344. [PMID: 35705926 PMCID: PMC9199146 DOI: 10.1186/s12887-022-03191-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 02/22/2022] [Indexed: 01/21/2023] Open
Abstract
Background Iron overload (IO) is a complication in transfusion dependent beta thalassaemia (TDT). Pathogenic variants in genes involving iron metabolism may confer increased risk of IO. The objective of this study was to determine the magnitude of the cardiac and hepatic IO and determine whether pathogenic variants in HFE, SLC40A1 and TFR2 genes increase the risk of IO in a cohort of TDT patients in Sri Lanka. Materials and Methods Fifty-seven (57) patients with TDT were recruited for this study. Serum ferritin was done once in 3 months for a period of one year in all. Those who were ≥ 8 years of age (40 patients) underwent T2* MRI of the liver and heart. Fifty-two (52) patients underwent next generation sequencing (NGS) to identify pathogenic variants in HBB, HFE, SLC40A1 and TFR2 genes. Results The median age of the patients of this cohort was 10 years. It comprised of 30 (52.6%) boys and 27 (47.4%) girls. The median level of serum ferritin was 2452 ng/dl. Hepatic IO was seen in 37 (92.5%) patients and cardiac IO was seen in 17 (42.5%) patients. There was no statistically significant correlation between serum ferritin and hepatic or cardiac IO. Thirty-two (61.5%), 18 (34.6%), 2 (3.8%) of patients were homozygotes, compound heterozygotes and heterozygotes for pathogenic variants in the HBB gene. Eight (15.4%) and 1 (1.9%) patients were heterozygotes for pathogenic and likely pathogenic variants of HFE genes respectively. There were no pathogenic variants for the TfR2 and SLC40A1 genes. The heterozygotes of the pathogenic variants of the HFE were not at increased risk of IO. Conclusions Cardiac T2* MRI helps to detect cardiac IO in asymptomatic patients. It is important to perform hepatic and cardiac T2* MRI to detect IO in patients with TDT. There was no statistically significant correlation between pathogenic variants of HBB and HFE genes with hepatic and cardiac IO in this cohort of patients.
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Affiliation(s)
- Ruwangi Dissanayake
- Department of Paediatrics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka. .,Lady Ridgeway Hospital for Children, Colombo, Sri Lanka.
| | | | | | - Sajeewani Pathirana
- Human Genetics Unit, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | | | - Kalum Wetthasinghe
- Human Genetics Unit, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Lallindra Gooneratne
- Department of Pathology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Pujitha Wickramasinghe
- Department of Paediatrics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.,Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
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O'Brien AT, Gil KE, Varghese J, Simonetti OP, Zareba KM. T2 mapping in myocardial disease: a comprehensive review. J Cardiovasc Magn Reson 2022; 24:33. [PMID: 35659266 PMCID: PMC9167641 DOI: 10.1186/s12968-022-00866-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 04/27/2022] [Indexed: 12/20/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) is considered the gold standard imaging modality for myocardial tissue characterization. Elevated transverse relaxation time (T2) is specific for increased myocardial water content, increased free water, and is used as an index of myocardial edema. The strengths of quantitative T2 mapping lie in the accurate characterization of myocardial edema, and the early detection of reversible myocardial disease without the use of contrast agents or ionizing radiation. Quantitative T2 mapping overcomes the limitations of T2-weighted imaging for reliable assessment of diffuse myocardial edema and can be used to diagnose, stage, and monitor myocardial injury. Strong evidence supports the clinical use of T2 mapping in acute myocardial infarction, myocarditis, heart transplant rejection, and dilated cardiomyopathy. Accumulating data support the utility of T2 mapping for the assessment of other cardiomyopathies, rheumatologic conditions with cardiac involvement, and monitoring for cancer therapy-related cardiac injury. Importantly, elevated T2 relaxation time may be the first sign of myocardial injury in many diseases and oftentimes precedes symptoms, changes in ejection fraction, and irreversible myocardial remodeling. This comprehensive review discusses the technical considerations and clinical roles of myocardial T2 mapping with an emphasis on expanding the impact of this unique, noninvasive tissue parameter.
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Affiliation(s)
- Aaron T O'Brien
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio, USA
| | - Katarzyna E Gil
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Juliet Varghese
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Orlando P Simonetti
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA
- Department of Radiology, The Ohio State University, Columbus, Ohio, USA
| | - Karolina M Zareba
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA.
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Zhang H, Jamieson KL, Grenier J, Nikhanj A, Tang Z, Wang F, Wang S, Seidman JG, Seidman CE, Thompson R, Seubert JM, Oudit GY. Myocardial Iron Deficiency and Mitochondrial Dysfunction in Advanced Heart Failure in Humans. J Am Heart Assoc 2022; 11:e022853. [PMID: 35656974 PMCID: PMC9238720 DOI: 10.1161/jaha.121.022853] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Myocardial iron deficiency (MID) in heart failure (HF) remains largely unexplored. We aim to establish defining criterion for MID, evaluate its pathophysiological role, and evaluate the applicability of monitoring it non‐invasively in human explanted hearts. Methods and Results Biventricular tissue iron levels were measured in both failing (n=138) and non‐failing control (NFC, n=46) explanted human hearts. Clinical phenotyping was complemented with comprehensive assessment of myocardial remodeling and mitochondrial functional profiles, including metabolic and oxidative stress. Myocardial iron status was further investigated by cardiac magnetic resonance imaging. Myocardial iron content in the left ventricle was lower in HF versus NFC (121.4 [88.1–150.3] versus 137.4 [109.2–165.9] μg/g dry weight), which was absent in the right ventricle. With a priori cutoff of 86.1 μg/g d.w. in left ventricle, we identified 23% of HF patients with MID (HF‐MID) associated with higher NYHA class and worsened left ventricle function. Respiratory chain and Krebs cycle enzymatic activities were suppressed and strongly correlated with depleted iron stores in HF‐MID hearts. Defenses against oxidative stress were severely impaired in association with worsened adverse remodeling in iron‐deficient hearts. Mechanistically, iron uptake pathways were impeded in HF‐MID including decreased translocation to the sarcolemma, while transmembrane fraction of ferroportin positively correlated with MID. Cardiac magnetic resonance with T2* effectively captured myocardial iron levels in failing hearts. Conclusions MID is highly prevalent in advanced human HF and exacerbates pathological remodeling in HF driven primarily by dysfunctional mitochondria and increased oxidative stress in the left ventricle. Cardiac magnetic resonance demonstrates clinical potential to non‐invasively monitor MID.
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Affiliation(s)
- Hao Zhang
- Division of Cardiology Department of Medicine Faculty of Medicine and DentistryEdmonton Alberta Canada.,Mazankowski Alberta Heart Institute Edmonton Alberta Canada
| | - K Lockhart Jamieson
- Department of Pharmacology Faculty of Medicine and DentistryEdmonton Alberta Canada
| | - Justin Grenier
- Mazankowski Alberta Heart Institute Edmonton Alberta Canada.,Department of Biomedical Engineering Faculty of Medicine and DentistryEdmonton Alberta Canada
| | - Anish Nikhanj
- Division of Cardiology Department of Medicine Faculty of Medicine and DentistryEdmonton Alberta Canada.,Mazankowski Alberta Heart Institute Edmonton Alberta Canada
| | - Zeyu Tang
- Division of Cardiology Department of Medicine Faculty of Medicine and DentistryEdmonton Alberta Canada.,Mazankowski Alberta Heart Institute Edmonton Alberta Canada
| | - Faqi Wang
- Division of Cardiology Department of Medicine Faculty of Medicine and DentistryEdmonton Alberta Canada.,Mazankowski Alberta Heart Institute Edmonton Alberta Canada
| | - Shaohua Wang
- Mazankowski Alberta Heart Institute Edmonton Alberta Canada.,Division of Cardiac Surgery Department of Surgery Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada
| | | | - Christine E Seidman
- Department of Genetics Harvard Medical School Boston MA.,Cardiovascular Division Brigham and Women's Hospital Boston MA
| | - Richard Thompson
- Mazankowski Alberta Heart Institute Edmonton Alberta Canada.,Department of Biomedical Engineering Faculty of Medicine and DentistryEdmonton Alberta Canada
| | - John M Seubert
- Mazankowski Alberta Heart Institute Edmonton Alberta Canada.,Department of Pharmacology Faculty of Medicine and DentistryEdmonton Alberta Canada
| | - Gavin Y Oudit
- Division of Cardiology Department of Medicine Faculty of Medicine and DentistryEdmonton Alberta Canada.,Mazankowski Alberta Heart Institute Edmonton Alberta Canada
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Finelli C, Parisi S, Paolini S. Exploring the rationale for red cell transfusion in myelodysplastic syndrome patients: emerging data and future insights. Expert Rev Hematol 2022; 15:411-421. [PMID: 35549626 DOI: 10.1080/17474086.2022.2077721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Anemia is often present in mostly elderly patients with myelodysplastic syndromes (MDS), and is associated with a poorer outcome. Although Red blood cell (RBC) transfusions are the most immediate treatment, waiting for the response to disease-specific therapy, or in case of non-response, the choice of the optimal transfusion regimen is still controversial. AREAS COVERED The main objectives of RBC transfusion are the control of anemia-related symptoms and complications and the improvement of functional status and of health-related quality of life (HRQoL). However, RBC transfusions are associated with several negative clinical consequences, mainly adverse transfusion reactions and iron overload, which can be counteracted by iron chelation therapy. Recent few pilot prospective trials have shown a benefit, in terms of HRQoL, of more liberal transfusion regimens, with higher haemoglobin (Hb) targets, compared to conventional restrictive regimens, but these results need confirmation by larger studies. EXPERT OPINION : A patient-oriented RBC transfusion therapy in MDS patients must take into account several laboratory (Hb), clinical (age, comorbidities), psychological, family and social factors, and evaluation of HRQoL should become a fundamental parameter in assessing the clinical benefit of therapy. Many questions remain to be clarified, including why some patients report little benefit from transfusions.
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Affiliation(s)
- Carlo Finelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Sarah Parisi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Stefania Paolini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
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Ogier AC, Bustin A, Cochet H, Schwitter J, van Heeswijk RB. The Road Toward Reproducibility of Parametric Mapping of the Heart: A Technical Review. Front Cardiovasc Med 2022; 9:876475. [PMID: 35600490 PMCID: PMC9120534 DOI: 10.3389/fcvm.2022.876475] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/11/2022] [Indexed: 01/02/2023] Open
Abstract
Parametric mapping of the heart has become an essential part of many cardiovascular magnetic resonance imaging exams, and is used for tissue characterization and diagnosis in a broad range of cardiovascular diseases. These pulse sequences are used to quantify the myocardial T1, T2, T2*, and T1ρ relaxation times, which are unique surrogate indices of fibrosis, edema and iron deposition that can be used to monitor a disease over time or to compare patients to one another. Parametric mapping is now well-accepted in the clinical setting, but its wider dissemination is hindered by limited inter-center reproducibility and relatively long acquisition times. Recently, several new parametric mapping techniques have appeared that address both of these problems, but substantial hurdles remain for widespread clinical adoption. This review serves both as a primer for newcomers to the field of parametric mapping and as a technical update for those already well at home in it. It aims to establish what is currently needed to improve the reproducibility of parametric mapping of the heart. To this end, we first give an overview of the metrics by which a mapping technique can be assessed, such as bias and variability, as well as the basic physics behind the relaxation times themselves and what their relevance is in the prospect of myocardial tissue characterization. This is followed by a summary of routine mapping techniques and their variations. The problems in reproducibility and the sources of bias and variability of these techniques are reviewed. Subsequently, novel fast, whole-heart, and multi-parametric techniques and their merits are treated in the light of their reproducibility. This includes state of the art segmentation techniques applied to parametric maps, and how artificial intelligence is being harnessed to solve this long-standing conundrum. We finish up by sketching an outlook on the road toward inter-center reproducibility, and what to expect in the future.
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Affiliation(s)
- Augustin C. Ogier
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Aurelien Bustin
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Université de Bordeaux, INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, France
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Pessac, France
| | - Hubert Cochet
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Université de Bordeaux, INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, France
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Pessac, France
| | - Juerg Schwitter
- Cardiac MR Center, Cardiology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Ruud B. van Heeswijk
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- *Correspondence: Ruud B. van Heeswijk
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Salama K, Khaled HZ, El Dien HMS, Afifi RARAA, Shaheen NMM, El Wahab MAMA. Assessment of Cardiac Functions and Arrhythmia in Children with Beta-Thalassemia Major and Beta-Thalassemia Intermedia. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Heart disease is a major complication in thalassemic patients. Heart injuries in iron overload cases include arrhythmia, pulmonary hypertension, systolic/diastolic dysfunction, and heart failure.
AIM: This study aimed to assess cardiac functions and arrhythmia in children with β-thalassemia major (TM) and β-thalassemia intermedia (TI) and its relation to cardiac iron overload.
METHODS: Thirty β-TM patients and 30 β-TI patients were evaluated using echocardiography and 24-h ambulatory electrocardiogram monitoring (Holter). Among these patients, 15 β-TM and 15 β-TI patients were evaluated using cardiac magnetic resonance imaging T2* by single breath-hold multi-echo technique.
RESULTS: Arrhythmia was detected significantly more in β-TM patients than β-TI (p = 0.049). Nine (30%) β-TM and five (16.6%) β-TI patients had Sinus tachycardia. Two (6.7%) β-TM patients compared to one (3.33%) β-TI patient had supraventricular tachycardia runs. Three (10%) β-TM and one (3.33%) β-TI patient had extreme sinus tachycardia. Two (3.3%) β-TI patients had sinus bradycardia, while two (3.3%) β-TM patients had incomplete Right bundle branch block. Regarding echo parameters: Isovolumic relaxation time (IVRT), Left ventricle myocardial performance index (MPI LV), Right ventricle myocardial performance index (MPI RV) and end systolic pulmonary artery pressure, were significantly higher in β-TM than TI group (p < 0.05). Fractional shortening, Ejection fraction were significantly lower in β-TM than TI group (p < 0.001). A statistically significant negative correlation was found between cardiac T2* and each of (IVRT, MPI LV, MPI RV) (p ˂ 0.05).
CONCLUSION: Arrhythmias are more common in the β-TM group. Systolic, diastolic dysfunction and high pulmonary pressure are more prevalent in TM than in TI. Global myocardial performance is more impaired in TM than in TI patients. Iron overload has a deleterious effect on cardiac function.
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Reid A, Dweck MR. Let there be light! The meteoric rise of cardiac imaging. BRITISH HEART JOURNAL 2022; 108:780-786. [PMID: 35459728 DOI: 10.1136/heartjnl-2021-320147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/02/2022] [Indexed: 11/04/2022]
Abstract
Imaging plays a central role in modern cardiovascular practice. It is a field characterised by exciting technological advances that have shaped our understanding of pathology and led to major improvements in patient diagnosis and care. The UK has played a key international role in the development of this subspecialty and is the current home to many of the leading global centres in multimodality cardiovascular imaging. In this short review, we will outline some of the key contributions of the British Cardiovascular Society and its members to this rapidly evolving field and look at how this relationship may continue to shape future cardiovascular practice.
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Affiliation(s)
- Anna Reid
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Marc Richard Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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Triadyaksa P, Overbosch J, Oudkerk M, Sijens PE. T2* assessment of the three coronary artery territories of the left ventricular wall by different monoexponential truncation methods. MAGNETIC RESONANCE MATERIALS IN PHYSICS, BIOLOGY AND MEDICINE 2022; 35:749-763. [PMID: 35437686 PMCID: PMC9463254 DOI: 10.1007/s10334-022-01008-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/04/2022] [Accepted: 03/18/2022] [Indexed: 11/28/2022]
Abstract
Abstract
Objectives
This study aimed at evaluating left ventricular myocardial pixel-wise T2* using two truncation methods for different iron deposition T2* ranges and comparison of segmental T2* in different coronary artery territories.
Material and methods
Bright blood multi-gradient echo data of 30 patients were quantified by pixel-wise monoexponential T2* fitting with its R2 and SNR truncation. T2* was analyzed at different iron classifications. At low iron classification, T2* values were also analyzed by coronary artery territories.
Results
The right coronary artery has a significantly higher T2* value than the other coronary artery territories. No significant difference was found in classifying severe iron by the two truncation methods in any myocardial region, whereas in moderate iron, it is only apparent at septal segments. The R2 truncation produces a significantly higher T2* value than the SNR method when low iron is indicated.
Conclusion
Clear T2* differentiation between the three coronary territories by the two truncation methods is demonstrated. The two truncation methods can be used interchangeably in classifying severe and moderate iron deposition at the recommended septal region. However, in patients with low iron indication, different results by the two truncation methods can mislead the investigation of early iron level progression.
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Affiliation(s)
- Pandji Triadyaksa
- University of Groningen, 9700 RB, Groningen, The Netherlands.
- Departemen Fisika, Universitas Diponegoro, Fakultas Sains Dan Matematika, Prof. Sudharto street, Semarang, 50275, Indonesia.
| | - Jelle Overbosch
- Department of Radiology, University of Groningen, University Medical Center Groningen, EB45, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Matthijs Oudkerk
- University of Groningen, 9700 RB, Groningen, The Netherlands
- Institute for Diagnostic Accuracy, Groningen, The Netherlands
| | - Paul Eduard Sijens
- University of Groningen, 9700 RB, Groningen, The Netherlands
- Department of Radiology, University of Groningen, University Medical Center Groningen, EB45, PO Box 30001, 9700 RB, Groningen, The Netherlands
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Ruscogenin Alleviates Myocardial Ischemia-Induced Ferroptosis through the Activation of BCAT1/BCAT2. Antioxidants (Basel) 2022; 11:antiox11030583. [PMID: 35326233 PMCID: PMC8945524 DOI: 10.3390/antiox11030583] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 02/04/2023] Open
Abstract
Ruscogenin (RUS), a natural steroidal sapogenin, exerts various biological activities. However, its effectiveness for preventing myocardial ischemia (MI) and its molecular mechanisms need further clarification. The model of MI mice and oxygen-glucose deprivation-induced cardiomyocytes injury was performed. RUS significantly alleviated MI, as evidenced by decreased infarct size, ameliorated biochemical indicators and cardiac pathological features, and markedly inhibited ferroptosis by means of the up-regulation of GPX4 and down-regulation of ACSL4 and FLC. Simultaneously, RUS notably mitigated cell injury and oxidative stress, and ameliorated ferroptosis in vitro. Subsequently, HPLC-Q-TOF/MS-based metabolomics identified BCAT1/BCAT2 as possible regulatory enzymes responsible for the cardioprotection of RUS. Importantly, RUS treatment significantly increased the expression of BCAT1 and BCAT2 in MI. Furthermore, we found that BCAT1 or BCAT2 siRNA significantly decreased cell viability, promoted ferroptosis, and increased Keap1 expression, and induced Nrf2 and HO-1 degradation in cardiomyocytes. Conversely, cardiac overexpression of BCAT1 or BCAT2 in MI mice activated the Keap1/Nrf2/HO-1 pathway. Moreover, RUS significantly activated the Keap1/Nrf2/HO-1 pathway in MI, whereas BCAT1 or BCAT2 siRNA partially weakened the protective effects of RUS, suggesting that RUS might suppress myocardial injury through BCAT1 and BCAT2. Overall, this study demonstrated that BCAT1/BCAT2 could alleviate MI-induced ferroptosis through the activation of the Keap1/Nrf2/HO-1 pathway and RUS exerted cardioprotective effects via BCAT1/BCAT2.
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Link between Genotype and Multi-Organ Iron and Complications in Children with Transfusion-Dependent Thalassemia. J Pers Med 2022; 12:jpm12030400. [PMID: 35330400 PMCID: PMC8950605 DOI: 10.3390/jpm12030400] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 01/27/2023] Open
Abstract
We evaluated the impact of the genotype on hepatic, pancreatic and myocardial iron content, and on hepatic, cardiac and endocrine complications in children with transfusion-dependent β-thalassemia (β-TDT). We considered 68 β-TDT patients (11.98 ± 3.67 years, 51.5% females) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia network. Iron overload was quantified by T2* technique and biventricular function by cine images. Replacement myocardial fibrosis was evaluated by late gadolinium enhancement technique. Three groups of patients were identified: homozygous β+ (N = 19), compound heterozygous β0β+ (N = 24), and homozygous β0 (N = 25). The homozygous β0 group showed significantly lower global heart and pancreas T2* values than the homozygous β+ group. Compared to patients with homozygous β+ genotype, β0β+ as well as β0β0 patients were more likely to have pancreatic iron overload (odds ratio = 6.53 and 10.08, respectively). No difference was detected in biventricular function parameters and frequency of replacement fibrosis. No patient had cirrhosis/fibrosis, diabetes or heart failure, and the frequency of endocrinopathies was comparable among the groups. In pediatric β-TDT patients, there is an association between genotype and cardiac and pancreatic iron overload. The knowledge of patients’ genotype can be valuable in predicting some patients’ phenotypic features and in helping the clinical management of β-TDT patients.
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50
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Menacho KD, Ramirez S, Perez A, Dragonetti L, Perez de Arenaza D, Katekaru D, Illatopa V, Munive S, Rodriguez B, Shimabukuro A, Cupe K, Bansal R, Bhargava V, Rodriguez I, Seraphim A, Knott K, Abdel-Gadir A, Guerrero S, Lazo M, Uscamaita D, Rivero M, Amaya N, Sharma S, Peix A, Treibel T, Manisty C, Mohiddin S, Litt H, Han Y, Fernandes J, Jacob R, Westwood M, Ntusi N, Herrey A, Walker JM, Moon J. Improving cardiovascular magnetic resonance access in low- and middle-income countries for cardiomyopathy assessment: rapid cardiovascular magnetic resonance. Eur Heart J 2022; 43:2496-2507. [PMID: 35139531 PMCID: PMC9259377 DOI: 10.1093/eurheartj/ehac035] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/30/2021] [Accepted: 01/18/2022] [Indexed: 02/01/2023] Open
Abstract
AIMS To evaluate the impact of a simplified, rapid cardiovascular magnetic resonance (CMR) protocol embedded in care and supported by a partner education programme on the management of cardiomyopathy (CMP) in low- and middle-income countries (LMICs). METHODS AND RESULTS Rapid CMR focused particularly on CMP was implemented in 11 centres, 7 cities, 5 countries, and 3 continents linked to training courses for local professionals. Patients were followed up for 24 months to assess impact. The rate of subsequent adoption was tracked. Five CMR conferences were delivered (920 attendees-potential referrers, radiographers, reporting cardiologists, or radiologists) and five new centres starting CMR. Six hundred and one patients were scanned. Cardiovascular magnetic resonance indications were 24% non-contrast T2* scans [myocardial iron overload (MIO)] and 72% suspected/known cardiomyopathies (including ischaemic and viability). Ninety-eighty per cent of studies were of diagnostic quality. The average scan time was 22 ± 6 min (contrast) and 12 ± 4 min (non-contrast), a potential cost/throughput reduction of between 30 and 60%. Cardiovascular magnetic resonance findings impacted management in 62%, including a new diagnosis in 22% and MIO detected in 30% of non-contrast scans. Nine centres continued using rapid CMR 2 years later (typically 1-2 days per week, 30 min slots). CONCLUSIONS Rapid CMR of diagnostic quality can be delivered using available technology in LMICs. When embedded in care and a training programme, costs are lower, care is improved, and services can be sustained over time.
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Affiliation(s)
- Katia Devorha Menacho
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | | | - Aylen Perez
- Cardiology and Cardiovascular Surgery National Institute, La Havana, Cuba
| | | | | | - Diana Katekaru
- Military National Hospital, Cardiac Imaging Department, Lima, Peru
| | | | - Sara Munive
- National Cardiovascular Institute—INCOR, Lima, Peru
| | | | - Ana Shimabukuro
- Guillermo Almenara Irigoyen Hospital, National Hospital, Lima, Peru
| | - Kelly Cupe
- Guillermo Almenara Irigoyen Hospital, National Hospital, Lima, Peru
| | - Rajiv Bansal
- Santokba Durlabhji Memorial Hospital Cum Medical Research Institute, Jaipur, India
| | | | | | - Andreas Seraphim
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Kris Knott
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Amna Abdel-Gadir
- Institute of Cardiovascular Science, University College London, London, UK
| | | | - Marco Lazo
- Ramiro Priale National Hospital, Huancayo, Peru
| | - David Uscamaita
- Edgardo Rebagliati Hospital, MRI and CT Department, Lima, Peru
| | | | - Neil Amaya
- Edgardo Rebagliati Hospital, MRI and CT Department, Lima, Peru
| | - Sanjiv Sharma
- AlI India Institute of Medical Sciences, New Delhi, India
| | - Amelia Peix
- Cardiology and Cardiovascular Surgery National Institute, La Havana, Cuba
| | - Thomas Treibel
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Sam Mohiddin
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Harold Litt
- Department of Medicine (Cardiovascular Division), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yuchi Han
- Department of Medicine (Cardiovascular Division), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Ron Jacob
- Lancaster General Health Hospital, Lancaster, USA
| | - Mark Westwood
- St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Ntobeko Ntusi
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anna Herrey
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - John Malcolm Walker
- Institute of Cardiovascular Science, University College London, London, UK,The Hatter Cardiovascular Institute, University College London Hospital, London, UK
| | - James Moon
- Corresponding author. Tel: +44 203 8870566,
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