Transcript Research Template - UMKC School of Medicine

Comparison of Echocardiographic Methods to
Cardiac Magnetic Resonance Imaging in Survivors of Pediatric Cancer
Jeet Mehta1, Sanket Shah1,2
Introduction
Wendy McClellan2, Joy M. Fulbright2, Jignesh D. Dalal1,2, Joshua Q. Knowlton1,2, Ashley K. Sherman2, Anitha Parthiban1,2, Girish Shirali1,2
1UMKC School of Medicine, 2Children’s Mercy Hospital
• Pediatric echocardiogram labs report left ventricle
[LV] ejection fraction [EF] using either M-mode [MM]
or 2D echo [2DE] for cancer patients. In adults, 3D
echo [3DE] measurement of LV volume and function
is now rapid, more accurate and reproducible than
2DE and MM.
• Our study aims to show the feasibility and validity of
3DE measurements in pediatric cancer patients in
comparison to cardiac MRI as gold standard, and to
compare with other methods, including MM and
2DE.
Results
Methods
• The study population consisted of children and young
adults being followed up after cancer remission at
Children’s Mercy Hospital. Families with children older
than 10 years of age who have survived > 2 years after
completion of cancer treatment were enrolled to
participate in the study.
• An MRI was performed the same day as clinicallyindicated echocardiograms wherein LV function was
quantified using MM and 2DE. Additional 3DE images
were acquired from the apical window.
• MM, 2DE and 3DE ventricular volume and function
analysis was performed offline using programs such as
Xcelera and QLab (Philips) and blinded to MRI
measurements.
• The study is approved by the institutional review
board [IRB] of Children’s Mercy Hospital.
Summary
Figure 2. 2D Echocardiogram (Apical chamber view)
Figure 3. 3D Echo (4ch and 2ch view; arrow at LV volume measurement)
• For the 41 subjects studied, age ranged from 10 to 22 years, with
a median duration of cancer remission of 10 years.
• Forty had received anthracyclines [median dose of 175 mg/m2 of
body surface area and 9 subjects receiving dosage of ≥300
mg/m2], 32 had received alkylating agents, 20 had radiation
therapy; 20 were girls and 39 were Caucasians.
• Satisfactory 3DE images were obtained in 37/41 subjects; MRI
was obtained in all 41. LV end-diastolic volume by 3DE had a
stronger correlation with MRI (gold standard) [r=0.71, p<0.01] as
compared to 2DE [r=0.59, p<0.01] and MM [r=0.64, p<0.01].
• Six subjects had mild LV dysfunction [defined as] Cardiac
Magnetic Resonance LV EF of <55%; none had EF <50%.
• 3DE had higher sensitivity [40%], specificity [100%], positive
predictive value [100%] and negative predictive value [91%] for
detecting LV dysfunction when compared with MM and 2DE (See
Table below).
• No subjects had notable valvular dysfunction and all subjects
were asymptomatic from a cardiovascular standpoint [New York
Heart Association class I].
Echocardiogram
Method
Sensitivity %
Specificity %
%
Positive %
Negative
predictive vale
predictive value
MM
17
97
50
87
2DE
17
89
20
86
3DE
40
100
100
91
All combined
50
87.5
42.9
90.3
Conclusion
• 3DE measurement of LV volumetrics is feasible and correlates
better with MRI than do MM and 2DE.
• This modality should be considered for routine usage in
pediatric cancer patients following completion of therapy.
Figure 1. M-mode image parasternal short axis of the heart
Figure 4. Cardiac MRI (Short axis SSFP image)
• We performed extensive cardiac imaging of 41 pediatric cancer
survivors using various methods.
• Left ventricular ejection fraction <55 % is widely considered as
abnormal systolic function and it has been validated in multiple
outcome studies to correlate with higher cardiovascular
morbidity and mortality.
• With a median duration of remission of 10 years, there were 6
subjects with mild LV dysfunction [defined as] CMR LV EF of
<55% but none had EF <50% and none had cardiovascular
symptoms.
• It is possible that their cardiac function may decline and they
may become symptomatic. However, it appears at this point,
that the careful dose selection by the oncologists has reduced
the prevalence of symptomatic or overt heart failure.
• 2D Echocardiography remains the mainstay of cardiac function
evaluation, but now, 3D echocardiography is widely available
from all manufacturers of echocardiography machines.
• The table on left shows the sensitivity, specificity, and
predictive values of the various echocardiography methods.
When compared to cardiac MRI as gold standard, 3D
echocardiography was very specific in identifying those with
MRI LV EF of <55%. Also, M-mode and 2D echocardiography
had an additive effect in accurately identifying those with MRI
LV EF of <55%.
References
1.Steinherz LJ, et al. Cardiac toxicity 4 to 20 years after completing anthracycline
therapy. JAMA. 1991;266:1672-7.
2.Alvarez JA, et al. Long-term effects of treatments for childhood cancers. Curr Opin
Pediatr. 2007;19:23-31.
3.Oeffinger KC, et al. Chronic health conditions in adult survivors of childhood cancer. N
Engl J Med. 2006;355:1572-82.
4.Nousiainen T, et al. Early decline in left ventricular ejection fraction predicts
doxorubicin cardiotoxicity in lymphoma patients. Br J Cancer. 2002;86:1697-1700.
5.Kronik G, et al. Comparative value of eight M-mode echocardiographic formulas for
determining left ventricular stroke volume. Circulation. 1979;60(6):1308-16.
6.Feigenbaum H AW, Ryan T, ed Feigenbaum’s echocardiography. Philadelphia:
Lippincott Williams & Wilkins; 2005. Feigenbaum H AW, Ryan T, ed. Evaluation of
systolic and diastolic function of the left ventricle.
7.Lopez L, et al. Recommendations for quantification methods during the performance
of a pediatric echocardiogram: a report from the Pediatric Measurements Writing
Group of the American Society of Echocardiography Pediatric and Congenital Heart
Disease Council. J Am Soc Echocardiogr. 2010;23:465-95
8.Lipshultz SE, et al. Late cardiac effects of doxorubicin therapy for acute lymphoblastic
leukemia in childhood. N Engl J Med. 1991;324:808-15.