Speckle tracking echocardiography detects decreased cardiac longitudinal function in anthracycline-exposed survivors of childhood cancer

Can acute high-altitude sickness be predicted in advance?

In high-altitude environments, the oxygen and air density are decreased, and the temperature and humidity are low. When individuals enter high-altitude areas, they are prone to suffering from acute mountain sickness (AMS) because they cannot tolerate hypoxia. Headache, fatigue, dizziness, and gastrointestinal reactions are the main symptoms of AMS. When these symptoms cannot be effectively alleviated, they can progress to life-threatening high-altitude pulmonary edema or high-altitude cerebral edema. If the risk of AMS can be effectively assessed before people enter high-altitude areas, then the high-risk population can be promptly discouraged from entering the area, or drug intervention can be established in advance to prevent AMS occurrence and avoid serious outcomes. This article reviews recent studies related to the early-warning biological indicators of AMS to provide a new perspective on the prevention of AMS.

Assessment of left and right ventricular systolic function in dogs with multicentric lymphoma

OBJECTIVE

Myocardial dysfunction in cardio-oncology is generally thought to be related to the cardiotoxicity of chemotherapy treatment. However, it is known that some tumors have direct effects on myocardial function. These effects have already been studied in man, but there are no publications of these of the effects in dogs. Novel advanced echocardiographic techniques may allow early detection of myocardial dysfunction when compared to conventional echocardiographic techniques. This study aims to assess myocardial systolic function in dogs with multicentric lymphoma prior to initiation of chemotherapy.

ANIMALS

Fifteen dogs with multicentric lymphoma and nineteen healthy dogs.

METHODS

Case-control study. Dogs with multicentric lymphoma and healthy control dogs underwent physical examination, electrocardiography, systolic blood pressure measurement, standard and speckle tracking echocardiography to assess biventricular systolic function.

RESULTS

There were no differences between groups in terms of ejection fraction, fractional shortening, left ventricular systolic and diastolic diameter, tricuspid annular plane systolic excursion, mitral annular plane systolic excursion and fractional area change of the right ventricle (RV). However, there was a reduction in the values of global circumferential strain (p = 0.0003), RV strain (p = 0.01) and RV tissue motion annular displacement (p < 0.05) in the dogs with lymphoma when compared to the control group.

CONCLUSIONS

Speckle tracking techniques appear to demonstrate early systolic dysfunction, primarily affecting the RV, in dogs with lymphoma prior to chemotherapy treatment.

The effects of obesity on longitudinal ventricular and atrial strain in a rural population of Spanish children and adolescents, evaluated by a new strain software

BACKGROUND AND OBJECTIVES

Research on the relationship between body mass index (BMI) and strain values in children and adolescents is limited. Our aim was to analyse the relationship between BMI and strain values of both ventricles and left atrium in children and adolescents.

METHODS

Both ventricles and left atrial strain values were compared among different BMI categories in children and adolescents from a town in the South of Spain.

RESULTS

Of the 198 subjects, aged 6-17 years, 53% were of normal weight, 26% were overweight and 21% had obesity. Lower absolute values of left ventricular global longitudinal strain (25.9 ± 2.0% vs. 26.9 ± 2.2%, p = 0.002) and right ventricular free wall longitudinal strain (29.5 ± 4.2% vs. 30.8 ± 4.5%, p = 0.04) were found in subjects with obesity and overweight versus subjects with normal weight. A lower right ventricular four-chamber longitudinal strain was also observed in males with obesity and overweight (24.8 ± 3.3% vs. 26.4 ± 3.6%, p = 0.03). Statistically significant negative correlations of BMI were found for all ventricular, but not atrial, strain values in univariate analysis. This association turned non-significant for right ventricular four-chamber longitudinal strain in multivariate analysis.

CONCLUSIONS

Utilizing this new strain software, children and adolescents with high BMI were associated with significantly lower values for left and right ventricular free wall longitudinal strain, without impact in left atrial strain.

Impaired right ventricular function in long-term survivors of allogeneic haematopoietic stem-cell transplantation

AIMS

Survivors of allogeneic haematopoietic stem-cell transplantation (allo-HSCT) are at higher risk of cardiovascular disease. We aimed to describe right ventricular (RV) systolic function and risk factors for RV dysfunction in long-term survivors of allo-HSCT performed in their youth.

METHODS AND RESULTS

This cohort included 103 survivors (53% female), aged (mean±SD) 17.6±9.5 years at allo-HSCT, with a follow-up time of 17.2±5.5 years. Anthracyclines were used as first-line therapy for 44.7% of the survivors. The RV was evaluated with echocardiography, and found survivors to have reduced RV function in comparison to a group of healthy control subjects: Tricuspid annular plane systolic excursion, (TAPSE, 20.8±3.7 mm vs 24.6±3.8 mm, p<0.001), RV peak systolic velocity (RV-s', 11.2±2.3 cm/s vs 12.3±2.3 cm/s, p=0.001), fractional area change (FAC, 41.0±5.2% vs 42.2±5.1%, p=0.047) and RV free-wall strain (RVFWS, -27.1±4.2% vs -28.5±3.3%, p=0.043). RV systolic dysfunction (RVSD) was diagnosed in 14 (13.6%), and was strongly associated with progressive left ventricular systolic dysfunction (LVSD). High dosages of anthracyclines were associated with greater reductions in RV and LV function. Multivariable linear regressions confirmed global longitudinal strain to be a significant independent predictor for reduced RV function.

CONCLUSION

Impaired RV function was found in long-term survivors of allo-HSCT who were treated in their youth. This was associated with progressive left ventricle dysfunction, and pretransplant therapies with anthracyclines. The occurrence of RVSD was less frequent and was milder than coexisting LVSD in this cohort.

Assessment of longitudinal systolic function using tissue motion annular displacement in dogs with degenerative mitral valve disease

INTRODUCTION

Although degenerative mitral valve disease (DMVD) is essentially a disorder of the valve, the progression of the disease leads to structural myocardial changes that may compromise left ventricular systolic function. Tissue motion annular displacement (TMAD) is a surrogate for longitudinal fiber function based on speckle tracking assessment of the movement of the mitral annulus toward the apex during systole. The aim of this study was to evaluate longitudinal systolic function with TMAD in dogs with DMVD.

ANIMALS

Ninety-four dogs with DMVD and 32 healthy dogs.

METHODS

Prospective cross-sectional observational study. Dogs with DMVD of various American College of Veterinary Internal Medicine classification stages and healthy control dogs underwent physical examination, electrocardiography, systolic blood pressure measurement, as well as a standard and speckle tracking echocardiography. Global longitudinal strain (GLS) and TMAD were used to assess longitudinal systolic function.

RESULTS

The global TMAD_mm and global TMAD_% were higher in American College of Veterinary Internal Medicine B2 animals than in the stage CD. Global TMAD _(mm/kg,_mm/bodyweight3, _mm/m²) were correlated with GLS and ejection fraction. Global TMAD _(mm/kg,_mm/m²,%) and GLS were influenced by sex. In addition, systolic blood pressure influenced GLS (P < 0.01; r = -0.23), global TMAD_mm/kg (P = 0.017; r = -0.21) and global TMAD_mm/m² (P = 0.031; r = -0.19). Tissue motion annular displacement was fast to be performed and produced good repeatability in dogs with DMVD.

CONCLUSIONS

Global TMAD _(mm,%), was reduced in DMVD dogs with clinical signs of heart failure compared with stage B2. Tissue motion annular displacement was shown to be a repeatable technique for evaluation of longitudinal systolic function in dogs with DMVD.

Cardiac Function After Cardiotoxic Treatments for Childhood Cancer-Left Ventricular Longitudinal Strain in Screening

Background: The majority of childhood cancer survivors (CCSs) have been exposed to cardiotoxic treatments and often present with modifiable cardiovascular risk factors. Our aim was to evaluate the value of left ventricular (LV) longitudinal strain for increasing the sensitivity of cardiac dysfunction detection among CCSs. Methods: We combined two national cohorts: neuroblastoma and other childhood cancer survivors treated with anthracyclines. The final data consisted of 90 long-term CCSs exposed to anthracyclines and/or high-dose chemotherapy with autologous stem cell rescue and followed up for > 5 years and their controls (n = 86). LV longitudinal strain was assessed with speckle tracking (Qlab) and LV ejection fraction (EF) by three-dimensional echocardiography (3DE). Results: Of the CCSs, 11% (10/90) had abnormal LV longitudinal strain (i.e., < -17.5%); of those, 70% (7/10) had normal 3DE LV EF. Multivariable linear model analysis demonstrated that follow-up time (p = 0.027), sex (p = 0.020), and BMI (p = 0.002) were significantly associated with LV longitudinal strain. Conversely, cardiac risk group, hypertension, age, cumulative anthracycline dose or exposure to chest radiation were not. Conclusion: LV longitudinal strain is a more sensitive method than LV EF for the detection of cardiac dysfunction among CCSs. Therefore, LV longitudinal strain should be added to the screening panel, especially for those with modifiable cardiovascular risk factors.

A novel echocardiographic parameter to identify individuals susceptible to acute mountain sickness

BACKGROUND

Acute mountain sickness (AMS) may cause life-threatening conditions. This study aimed to screen echocardiographic parameters at sea level (SL) to identify predictors of AMS development.

METHODS

Overall, 106 healthy men were recruited at SL and ascended to 4100 m within 7 days by bus. Basic characteristics, physiological data, and echocardiographic parameters were collected both at SL and 4100 m above SL. AMS was identified by 2018 Lake Louise Questionnaire Score.

RESULTS

After acute high altitude exposure (AHAE), 33 subjects were diagnosed with AMS and exhibited lower lateral mitral valve tissue motion annular displacement (MV TMAD_lateral) at SL than AMS-free subjects (13.09 vs. 13.89 mm, p = 0.022). MV TMAD_lateral at SL was significantly correlated with AMS occurrence (OR = 0.717, 95% CI: 0.534-0.964, p = 0.028). The MV TMAD_lateral<13.30-mm group showed over 4-fold risk for AMS development versus the MV TMAD_lateral≥13.30-mm group. After AHAE, the MV TMAD_lateral<13.30-mm group had increased HR (64 vs. 74 bpm, p = 0.001) and right-ventricular myocardial performance index (0.54 vs. 0.69, p = 0.009) and decreased left ventricular global longitudinal strain (-21.50 vs. -20.23%, p = 0.002), tricuspid valve E/A ratio (2.11 vs. 1.89, p = 0.019), and MV E-wave deceleration time (169.60 vs. 156.90 ms, p = 0.035).

CONCLUSION

MV TMAD_lateral at SL was a potential predictor of AMS occurrence and might be associated with differential alterations of ventricular systolic and diastolic functions in subjects with different MV TMAD_lateral levels at SL after AHAE.

Validation of estimating left ventricular ejection fraction by mitral annular displacement derived from speckle-tracking echocardiography: A neglected method for evaluating left ventricular systolic function

PURPOSE

The echocardiographic measurement of left ventricular (LV) ejection fraction (EF) is dependent on professional experience and adequate visualization. Tissue motion of mitral annular displacement (TMAD) can be easily assessed using speckle-tracking echocardiography (STE), even in patients with poor acoustic windows. Therefore, this study aimed to assess whether left ventricular ejection fraction (LVEF) can be estimated using STE-derived TMAD when LVEF is not available.

METHODS

Four-hundred fifty-six outpatients were enrolled after excluding the patients whose LVEF measurements remained challenging or TMAD value could be confounded. An optimized regression model for LVEF-TMAD was developed in the derivation set (n = 287), and its reliability was verified in the validation set (n = 123) and regional wall motion abnormalities (RWMA) set (n = 46).

RESULTS

In the derivation set, the power models had the highest F-value. Therefore, the power equations were chosen to estimate LVEF by TMAD in the validation set. There was a near-zero bias and a narrow range between the observed and estimated LVEF. The highest intra-class correlation coefficient was found between the observed and the estimated LVEF by normalized TMAD at the midpoint of mitral annular (nTMADmid). Moreover, there were no significant differences between the observed and the estimated LVEF in the RWMA set.

CONCLUSION

The LVEF can be estimated with STE-derived TMAD, even for patients with RWMA, and nTMADmid may be the optimal parameter.

Cardiac Surveillance for Early Detection of Late Subclinical Cardiac Dysfunction in Childhood Cancer Survivors After Anthracycline Therapy

BACKGROUND

In childhood cancer survivors (CCSs) anthracycline-related cardiotoxicity is an important cause of morbidity and late mortality, but the optimal modality of cardiac surveillance still remains to be defined. The aim of this study was to assess whether non-invasive echocardiography-based functional cardiac measures can detect early subclinical myocardial changes in long-term pediatric cancer survivors who received anthracycline therapy.

METHODS

Twenty anthracycline-treated long-term CCSs and 20 age, sex, and body surface area matched healthy controls were enrolled in this study. Among cancer survivors, mean age at diagnosis was 6.5 ± 4.4 years, and the mean cumulative anthracycline dose was 234.5 ± 87.4 mg/m2. All subjects underwent a comprehensive functional echocardiographic protocol study including two-dimensional echocardiography (2D Echo), tissue Doppler imaging (TDI), speckle tracking (STE) and three-dimensional echocardiography (3D Echo). Patients were studied at a mean follow-up time of 6.5 ± 2.8 years from the end of therapy.

RESULTS

No significant differences in two-dimensional left ventricle ejection fraction (LVEF), diastolic parameters and speckle tracking (STE)-derived myocardial strain were observed between patients treated with anthracyclines and controls. Myocardial performance index was significantly prolonged (p = 0.005) and three-dimensional LVEF was significantly reduced (p = 0.002) in CCSs compared to controls, even though most values were within the normal range. There were no significant correlations between 2D, STE, and 3D echocardiographic parameters and age at diagnosis or duration of follow-up. No significant differences in echocardiographic parameters were found when stratifying cancer patients according to established risk factors for anthracycline cardiomyopathy.

CONCLUSIONS

This study found significantly reduced three-dimensional LVEF in CCSs compared with controls, despite no significant differences in two-dimensional LVEF and longitudinal strain values. These findings suggest that long-term CCSs who had received anthracycline therapy may be found to have subclinical features of myocardial dysfunction. However, further studies are needed to demonstrate the validity of new imaging techniques, including STE and 3D Echo, to identify patients at risk for cardiomyopathy in the long-term follow-up of CCSs.

Paediatric cardio-oncology: epidemiology, screening, prevention, and treatment

With 5-year survival of children with cancer exceeding 80% in developed countries, premature cardiovascular disease is now a major cause of early morbidity and mortality. In addition to the acute and chronic cardiotoxic effects of anthracyclines, related chemotherapeutics, and radiation, a growing number of new molecular targeted agents may also have detrimental effects on the cardiovascular system. Survivors of childhood cancer also may have earlier development of conventional cardiovascular risk factors such as hypertension, dyslipidaemia, and diabetes, which further increase their risk of serious cardiovascular disease. This review will examine the epidemiology of acute and chronic cardiotoxicity relevant to paediatric cancer patients, including genetic risk factors. We will also provide an overview of current screening recommendations, including the evidence regarding both imaging (e.g. echocardiography and magnetic resonance imaging) and blood-based biomarkers. Various primary and secondary prevention strategies will also be discussed, primarily in relation to anthracycline-related cardiomyopathy. Finally, we review the available evidence related to the management of systolic and diastolic dysfunction in paediatric cancer patients and childhood cancer survivors.

Diastolic Dysfunction is Common in Survivors of Pediatric Differentiated Thyroid Carcinoma

INTRODUCTION

Whether pediatric patients with differentiated thyroid carcinoma (DTC) are at risk of developing treatment-related adverse effects on cardiac function is unknown. We therefore studied in long-term survivors of pediatric DTC the prevalence of cardiac dysfunction and atrial fibrillation in relation to treatment variables, and the association between cardiac dysfunction and plasma biomarkers.

METHODS

In this nationwide prospective multicenter study, cardiac assessments were performed in 66 adult survivors of pediatric DTC (age at diagnosis ≤18 years and follow-up ≥5 years after diagnosis) treated in the Netherlands between 1970 and 2009. Assessment included echocardiography, plasma biomarkers (N-terminal pro-brain natriuretic peptide, high-sensitive troponin-T, galectin-3), and 24-hour Holter electrocardiography. Echocardiographic measurements were compared with retrospective data of 66 sex- and age-matched unaffected Dutch controls. Diastolic dysfunction was defined as an early diastolic septal and/or lateral tissue velocity (e') less than 2 SD of mean age-adjusted reference data.

RESULTS

The survivors (86.4% women) had at DTC diagnosis a median age of 16 years. Median follow-up was 17 years. Left ventricular ejection fraction <50% was found in one survivor, and median global longitudinal systolic strain was near normal. Diastolic dysfunction was present in 14 asymptomatic survivors (21.2%). Overall, diastolic function of survivors was lower compared with controls (e'mean 14.5 versus 15.8 cm/s, P = 0.006). Older attained age and higher waist circumference were associated with decreased diastolic function, whereas thyrotropin levels and cumulative administered radioiodine dose were not. In survivors, biomarkers were not associated with diastolic dysfunction; atrial fibrillation was not observed.

CONCLUSION

While systolic function is unaffected, diastolic dysfunction is frequently observed in asymptomatic long-term survivors of pediatric DTC, which may suggest early cardiac aging.