Cardiac Dysfunction In Children Research Articles

Protective Role of Silymarin in Early Doxorubicin-induced Cardiac Dysfunction in Children with Acute Lymphoblastic Leukemia.

Doxorubicin is a well-established chemotherapeutic agent for the treatment of childhood acute lymphoblastic leukemia (ALL), but its efficacy is often limited by its related cardiotoxicity. Protection against doxorubicin-induced cardiotoxicity can be of great value, especially for children. Silymarin has a potent antioxidant property that can be helpful in preventing cardio-toxicity. 'To assess the possible protective role of silymarin against early doxorubicin-induced cardiotoxicity in children with ALL'. This study was conducted on 80 children with ALL, including 40 patients under doxorubicin therapy and silymarin 420 mg/day for one week after each doxorubicin dose starting from the day of doxorubicin infusion (Group I) and 40 patients under doxorubicin therapy and placebo (Group II). 'Conventional echo-Doppler measures of left ventricular systolic and diastolic functions and pulsed wave tissue Doppler of lateral mitral annulus were done for all patients'. After doxorubicin therapy, there was a significant higher reduction of systolic function [ejection fraction (EF), fraction shortening (FS) and s wave] in Group II compared with Group I and non-significant reduction of diastolic function [E/A ratio or e/a ratio] in both Groups. Although serum troponin increases in both groups after doxorubicin therapy, the increase of troponin is significantly lower in group I compared with group II. Silymarin decreased early Doxorubicin-induced left ventricular systolic function disturbances and can be recommended as an adjuvant drug in patients with ALL under doxorubicin therapy. 'Multicenter studies on a large number of patients with longer follow up' periods to prove the protective role of silymarin in early and late Doxorubicin-induced cardiotoxicity.

Cardiac function in children with premature ventricular contractions: the effect of omega-3 polyunsaturated fatty acid supplementation.

Premature ventricular contractions are accepted as benign in structurally normal hearts. However, reversible cardiomyopathy can sometimes develop. Omega-3 polyunsaturated fatty acids have anti-arrhythmic properties in animals and humans.AimWe evaluated left ventricular function in children with premature ventricular contractions with normal cardiac anatomy and assessed the impact of omega-3 fatty acid supplementation on left ventricular function in a prospective trial. A total of 25 patients with premature ventricular contraction, with more than 2% premature ventricular contractions on 24-hour Holter electrocardiography, and 30 healthy patients were included into study. All patients underwent electrocardiography, left ventricular M-mode echocardiography, and myocardial performance index testing. Patients with premature ventricular contraction were given omega-3 fatty acids at a dose of 1 g/day for 3 months, and control echocardiography and 24-hour Holter electrocardiography were performed. Neither placebo nor omega-3 fatty acids were given to the control group. Compared with the values of the control group, the patients with premature ventricular contraction had significantly lower fractional shortening. The myocardial performance index decreased markedly in the patient groups. The mean heart rate and mean premature ventricular contraction percentage of Group 2 significantly decreased in comparison with their baseline values after the omega-3 supplementation. In conclusion, premature ventricular contractions can lead to systolic cardiac dysfunction in children. Omega-3 supplementation may improve cardiac function in children with premature ventricular contractions. This is the first study conducted in children to investigate the possible role of omega-3 fatty acid supplementation on treatment of premature ventricular contractions.

Biochemical markers of cardiac dysfunction in children with obstructive sleep apnoea (OSA).

We explored relationships between biochemical markers and cardiac responses of children with and without obstructive sleep apnoea (OSA) during exercise. We hypothesised that serum markers of sympathetic nervous system activity and low-grade inflammation would correlate with cardiac responses to exercise in children with or without OSA. The study included 40 of 71 children with previously characterised responses to cardiopulmonary exercise testing. Measures included serum cytokine levels using a multiplex bead-based assay (interleukins IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, TNF-α and IFN-γ). Serum amyloid A (SAA) was quantified by nephelometry, and metanephrine/normetanephrine levels were measured by liquid chromatography, mass-spectroscopy. Comparisons were made between children with and without OSA, and with and without obesity. Relationships between biomarkers and various cardiac parameters were explored by linear regression. Amongst the 40 children in this study, OSA was present in 23. Compared to the 17 children without OSA, those with OSA had higher resting serum IL-6 levels compared to those without (median 3.22pg/ml vs. 2.31, p < 0.05). Regarding correlations with cardiac function after adjusting for OSA, IL-8 negatively correlated to heart rate (HR) response following exercise (p = 0.03) and IFN-γ negatively correlated with Stroke Volume Index (SVI) (p = 0.03). Both metanephrine and normetanephrine levels positively correlated with SVI (p = 0.04, p = 0.047; respectively) and QI (p = 0.04, p = 0.04; respectively) during exercise when adjusting for OSA. Children with OSA have raised morning levels of serum IL-6. Separately, higher levels of IFN-γ and IL-8 and lower levels of metanephrine and normetanephrine related to poorer cardiac function during exercise.

Cardiac dysfunction in children and young adults with heart transplantation: A comprehensive echocardiography study

Transplanted heart dysfunction is a serious life-threatening condition in pediatric transplant recipients. Several studies have focused on echocardiographic detection of early signs of cardiac dysfunction in this population. We evaluated advanced echocardiographic indices of cardiac function in a large sample of children and young adults with heart transplants with apparently normal cardiac function. The study included 60 patients with normal ejection fraction with transplantation performed at pediatric age between 1986 and 2014 and 60 healthy control subjects. All patients and control subjects underwent a complete transthoracic echocardiographic examination including tissue Doppler analysis, 2-dimensional speckle tracking, and 3-dimensional echocardiography. Two-dimensional speckle tracking analysis was used to obtain measures of left ventricular (LV) radial, circumferential, and longitudinal strain and to derive LV twist and torsion from basal and apical rotation. Three-dimensional echocardiography was used to measure LV volumes and ejection fraction and to evaluate LV systolic synchrony. No differences were observed between groups in LV volumes, left atrial diameters, LV ejection fraction, or right ventricular fractional area change. However, patients showed lower values of longitudinal systolic excursion of valvular planes at both the mitral and the tricuspid valve level as well as higher mitral E/E' ratio. Cardiac radial strain was similar between groups; a significant net reduction in both global left and right ventricular longitudinal strain and LV global circumferential strain could be observed between the 2 groups (all p < 0.05). In addition, reduced LV twist and torsion was found in patients compared with healthy control subjects (p < 0.01) mainly owing to a significant reduction in basal rotation (-2.4° vs -3.8°; p < 0.05). none of the control subjects demonstrated LV dyssynchrony, whereas systolic dyssynchrony was observed in 20% of heart transplant recipients. Even in the absence of signs of graft failure and in the presence of a normal ejection fraction, transplanted hearts show a significant reduction in biventricular function. Additional prognostic studies are needed to establish whether these abnormalities predict development of overt heart failure.

Advances in diagnosis and mechanisms of septic cardiac dysfunction in children

Septic cardiac dysfunction is very common in children with sever sepsis and septic shock, and the diagnosis mainly depends on echocardiography.In this article, we reviewed the diagnosis of septic cardiac dysfunction and its relation with prognosis.Meanwhile, we showed the hot spot and controversy on potential mechanisms of septic cardiomyopathy. Key words: Septic cardiac dysfunction; Diagnosis; Septic cardiomyopathy; Echocardiography; Mechanism

Oxidative stress and cardiac dysfunction in children with chronic renal failure on regular hemodialysis

The objective of this study was to evaluate cardiac function in children with end-stage renal disease (ESRD) on regular hemodialysis using speckle tracking echocardiography (STE) and correlate results with plasma glutathione level as a marker of oxidative stress. The study involved 30 children with ESRD and 30 healthy controls. The plasma glutathione and C-reactive protein (CRP) levels were measured, and cardiac function was evaluated using conventional echocardiography and STE. Plasma glutathione levels were significantly lower and CRP significantly higher in patients than in controls. Children with ESRD had significant systolic and diastolic cardiac dysfunctions detected by STE compared with controls. Conventional echocardiography failed to detect these dysfunctions. There was significant increase in left-ventricular relative wall thickness (LV-RWT) in patients, especially those with hypertension, compared with the control group. There was also significant impairment of LV and right-ventricular (RV) global longitudinal strain (GLS) and torsion; however, LV-GLS was significantly better in hypertensive than in normotensive patients. The degree of impairment in GLS and cardiac torsion negatively correlated with plasma glutathione levels. Significant oxidative stress was present in children with ESRD and was correlated with the degree of cardiac dysfunction detected early using the new cardiac imaging modality, STE.

Rigid Body Rotation Is a Robust and Highly Reproducible Marker of Cardiac Dysfunction in Children and Young Adults with Heart Disease

Objective: Reversed left ventricular (LV) twist, so-called rigid body rotation (RBR), is a marker of cardiac dysfunction. Speckle tracking echocardiography (STE) is commonly used for the assessment of LV twist mechanics. Region of interest (ROI) width variability affects the reproducibility of strain measurements. The aim of this study was to investigate the effect of ROI width variability on the reproducibility of RBR patterns in children and young adults.

CARDIAC COMPLICATIONS IN DUCHENNE MUSCULAR DYSTROPHY IN CHILDREN

Cardiac complications are frequently diagnosed in Duchenne muscular dystrophy (DMD), clinical manifestations generally appear after age 10. ECG recordings objectified various changes in these patients, the most common being represented by extensive R waves in V1, left deep Q waves, conduction abnormalities and arrhythmias. Echocardiographic examination may objective the presence of subclinical cardiac dysfunction in children under 12 years old diagnosed with DMD. In patients where standard echocardiographic examination is normal, myocardial performance index is a parameter useful in early detection of asymptomatic cardiac abnormalities. Cardiovascular magnetic resonance provides information both on left ventricular systolic function and myocardial tissue changes and occurrence of fibrosis, lesions rarely objectified before the age of 10 years. All these explorations should be considered in children with DMD at the end of a complete neurological exam.

Cardiac dysfunction following brain death in children: prevalence, normalization, and transplantation.

Cardiac dysfunction has been reported to occur in as much as 42% of adults with brain death, and may limit cardiac donation after brain death. Knowledge of the prevalence and natural course of cardiac dysfunction after brain death may help to improve screening and transplant practices but adequately sized studies in pediatric brain death are lacking. The aims of our study are to describe the prevalence and course of cardiac dysfunction after pediatric brain death. Cross-sectional study. We examined an organ procurement organization database (Life Center Northwest) of potential pediatric cardiac donors diagnosed with brain death between January 2011 and November 2013. Transthoracic echocardiograms were reviewed for cardiac dysfunction (defined as ejection fraction <50% or the presence of regional wall motion abnormalities). Descriptive statistics were used to analyze clinical characteristics and describe longitudinal echocardiogram findings in a subgroup of patients. We examined for heterogeneity between cardiac dysfunction with respect to cause of brain death. We identified 60 potential pediatric cardiac donors (age ≤ 18 yr) with at least one transthoracic echocardiogram following brain death. Cardiac dysfunction was present in 23 patients (38%) with brain death. Mean ejection fraction (37.6% vs 62.2%) and proportion of procured hearts (56.5% vs 83.8%) differed significantly between the groups with and without cardiac dysfunction, respectively. Of the 11 subjects with serial transthoracic echocardiogram data, the majority of patients with cardiac dysfunction (73%) improved over time, leading to organ procurement. No heterogeneity between cardiac dysfunction and particular causes of brain death was observed. The frequency of cardiac dysfunction in children with brain death is high. Serial transthoracic echocardiograms in patients with cardiac dysfunction showed improvement of cardiac function in most patients, suggesting that initial decisions to procure should not solely depend on the initial transthoracic echocardiogram examination results.

Anthracycline-related cardiotoxicity in childhood cancer survivors

Anthracyclines have markedly improved the survival rates of children with cancer. However, anthracycline-related cardiotoxicity is also well recognized and can compromise the long-term outcome in some patients. The challenge remains of how to balance the chemotherapeutic effects of anthracycline treatment with its potentially serious cardiovascular complications. Here, we review the pathophysiology, risk factors, clinical manifestations, prevention, and treatment of anthracycline-related cardiotoxicity. Some risk factors and biomarkers associated with an increased probability of anthracycline-related cardiotoxicity have been identified. Modifying the structural forms and dosages of anthracyclines and coadministering cardioprotective agents may prevent some of these cardiotoxic effects. Cardiovascular complications have also been treated with angiotensin-converting enzyme inhibitors, β-blockers, and growth hormone replacement therapy. Cardiac transplantation remains the treatment of last resort. Despite major advances in cancer treatment, anthracycline-related cardiotoxicity remains a major cause of morbidity and mortality in survivors of childhood cancer. Promising areas of research include: use of biomarkers for early recognition of cardiac injury in children receiving chemotherapy, development and application of cardioprotective agents for prevention of cardiotoxicity, and advancements in therapies for cardiac dysfunction in children after anthracycline treatment.

Subclinical Cardiac Dysfunction in Children with Coeliac Disease: Is the Gluten-Free Diet Effective?

Objectives. The aim of this study is to investigate the effects of coeliac disease on cardiac function in children using conventional transthoracic echocardiography (TTE) and tissue Doppler echocardiography (TDE). Methods. Coeliac disease patients were evaluated in two different groups based on serum endomysial antibody (EmA) titers (EmA (+) and EmA (−)), and the data obtained by conventional and TDE studies were compared between the patient groups and healthy controls. Results. There was no significant difference between EmA (+) and EmA (−) groups in terms of the conventional TTE parameters, including ejection fraction (EF), fractional shortening (FS), and left ventricle end diastolic diameter (LVEDD), that show the left ventricular systolic function (P = 0.727, P = 0.317, P = 0.118). TDE showed a significant difference in left ventricle (LV) isovolumic relaxation time (LV IVRT) and LV myocardial performance index (LV MPI) parameters between EmA (+) and EmA (−) patient groups (P < 0.0001). Conclusion. The measurement of LV MPI and LV IVRT parameters by TDE would be beneficial in early determination of the cardiac involvement and establishing appropriate treatment and followup of patients with coeliac disease as well as in making distinction between EmA (+) and EmA (−) patients.

Early Detection of Cardiac Dysfunction by Strain and Strain Rate Imaging in Children and Young Adults With Marfan Syndrome

Strain and strain rate imaging have been reported to detect cardiac dysfunction more accurately than conventional methods in adults with Marfan syndrome, but their utility has not been proven in younger patients. We sought to determine whether strain and strain rate imaging would allow early detection of cardiac dysfunction in children and young adults with Marfan syndrome. Unoperated patients (<30 years) with Marfan syndrome and healthy control participants were prospectively enrolled. Patients with greater than mild mitral or aortic insufficiency were excluded. Left ventricular systolic function was assessed by standard M-mode imaging. The strain and strain rate values were obtained from apical 4-chamber (longitudinal) and parasternal short-axis views at basal and midventricular levels (radial and circumferential). Data from the two groups were compared by a t test. Sixteen patients with Marfan syndrome (mean age ± SD, 14.4 ± 6.4 years; range, 5.8-28.9 years) and 26 controls (mean age, 12.4 + 4.4 year; range, 4.1-18.1 years) were enrolled. Demographics and left ventricular end-diastolic dimensions were similar between the patients with Marfan syndrome and the controls. The M-mode-derived shortening fraction was significantly lower in the patients with Marfan syndrome compared to the controls, even though the values were within normal limits. The patients with Marfan syndrome had lower regional radial and circumferential strain rates, but there were no significant difference in strain between the groups. Strain rate imaging may be useful in detection of subclinical changes in cardiac function in patients with Marfan syndrome when conventional echocardiographic parameters are within normal limits. These findings may be clinically important and warrant closer follow-up of these patients to monitor for cardiac dysfunction.

Comparison of the Clinical Presentation, Treatment, and Outcome of Fulminant and Acute Myocarditis in Children

Myocarditis (MC) is an important cause of cardiac dysfunction in children. Fulminant MC is sometimes fatal, and sequelae may develop during follow-up. We conducted a nationwide survey to determine the clinico-epidemiological features of MC in Japanese children and adolescents. Survey questionnaires were mailed to 627 hospitals, which were asked if they had treated MC patients aged between 1 month and 17 years during the period from January 1997 through December 2002. Responses were collected until December 2005, and data were collected and analyzed until January 2008. A total of 169 patients were reported: 64 fulminant cases, 89 acute cases, and 8 chronic cases. Incidence was 43.5 cases/year and 0.26 cases/100,000. Pathogens were identified in 37 patients; coxsackie virus accounted for 60%. Major cardiovascular manifestations at onset were congestive heart failure, refractory arrhythmia, and syncope in 70, 37, and 17 patients, respectively. Intravenous immunoglobulin was administered to 73 patients. Mechanical support seemed to be effective and life-saving. Among the 169 patients, 123 survived. Cardiovascular sequelae were reported in 49 patients. The survival rate for children with fulminant MC was disappointing. Overall, two-thirds of survivors had no sequelae. Mechanical support may reduce the mortality and the risk of clinical worsening.

Body mass index is directly associated with biomarkers of angiogenesis and inflammation in children and adolescents

ObjectivesChildhood obesity is associated with an increased risk of atherosclerosis, which can be mediated by an increase in angiogenesis and inflammation. The objective was to investigate the association between body mass index (BMI) and circulating biomarkers of angiogenesis, inflammation, and cardiac dysfunction in children and adolescents. MethodsThe Genetic Park Study is a highly inclusive survey conducted in three isolated villages of southern Italy. One hundred fifty-one children and adolescents (age range 5–17 y, 45% male) were included and categorized as obese (BMI z-score ≥ 1.64, n = 38) or non-obese (n = 113). Metabolic and cardiovascular biomarkers included glucose, triacylglycerol, total cholesterol, high-density lipoprotein, vascular endothelial growth factor (VEGF), placental growth factor, soluble feline sarcoma virus (fms)-like tyrosine kinase-1, highly sensitive C reactive protein (hs-CRP), highly sensitive troponin T (hs-TnT), and N-terminal prohormone brain natriuretic peptide (NT-proBNP). ResultsObese subjects had higher levels of triacylglycerol (P = 0.03) and hs-CRP (P = 0.02) after adjustment for age and gender. Circulating levels of VEGF were directly associated with BMI z-score (r = 0.22, P = 0.007) and hs-CRP (r = 0.33, P < 0.001). BMI z-score was not associated with biomarkers of cardiac dysfunction (hs-TnT and NT-proBNP). ConclusionIncreasing BMI was associated with plasma levels hs-CRP and VEGF, which are involved in the initiation and progression of atherosclerosis. The lack of association between BMI and markers of cardiac damage (hs-TnT) or ventricular volume overload (NT-proBNP) suggest that atherosclerotic risk may still at a preclinical stage in this population of obese but otherwise healthy young individuals. Collectively, this suite of biomarkers could provide mechanistic insights into the physiopathologic progression of cardiovascular risk associated with childhood obesity.

Risk factors for cardiac dysfunction in children on treatment for cancer at Kenyatta National Hospital, Nairobi

To determine the point prevalence of abnormal cardiac function and to assess the risk factors for cardiac dysfunction in paediatric oncology patients on treatment at Kenyatta National Hospital. Descriptive cross-sectional study with a nested case control. Kenyatta National Hospital between February and April 2006. Left ventricular dysfunction if ejection fraction (EF) <55% or fractional shortening (FS) <29% defined cases. Controls had EF >55% or FS >29%. One hundred and eleven patients were enrolled of whom 32 had abnormal cardiac function and were classified as cases while 79 had normal cardiac function. About a third, point prevalence 29% (95% CI 21.2-37.9), had cardiac dysfunction. Cumulative anthracycline dose was a risk factor for cardiac dysfunction in this population. Above 200 mg/m2 the attributable risk percentage of cardiac dysfunction was 77%. Serial echocardiography should be performed to identify patients at risk. Alternative treatment protocols should be used when the cumulative anthracycline dose exceeds 200 mg/m2 due to the high attributable risk. Studies to further assess the other associated risk factors and long term effects of anthracycline are recommended.

Circulating cardiac troponins levels and cardiac dysfunction in children with acute and fulminant viral myocarditis

To study the correlation between cardiac troponins blood levels and degrees of cardiac dysfunction in children with acute and fulminant viral myocarditis and to study their prognostic role in predicting the outcomes and risk of having dilated cardiomyopathy. Troponin I & T blood levels were measured in 65 children with acute or fulminant viral myocarditis. The cardiac functions of RV & LV were assessed by Doppler echocardiography. The levels of cTnI & CTnT were significantly higher in patients with fulminant myocarditis than in controls and children with acute myocarditis (p < 0.05 & <0.001* respectively). The cardiac functions were significantly impaired in fulminant myocarditis than in acute myocarditis (p < 0.001*). There were negative correlations between the cardiac troponins levels and the cardiac functions measured by echocardiography in children with acute and fulminant myocarditis. There were 3 deaths (7.5%), and 10 (25%) children developed dilated cardiomyopathy in acute myocarditis while there were eight deaths (32%) and one patient (4%) who developed dilated cardiomyopathy in fulminant myocarditis group. Cardiac troponins levels can predict the severity of myocarditis and the prognosis on the short-term level. Fulminant myocarditis was associated with higher levels of both cTn I & cTn T than acute myocarditis. Despite that fulminant myocarditis has a more aggressive course, the risk of developing cardiomyopathy was less than in acute myocarditis.

Elevated Brain Natriuretic Peptide Is Associated with Abnormal Heart Geometry in Children with Chronic Kidney Disease

Aim: It was to establish whether brain natriuretic peptide (BNP) might predict cardiac dysfunction in children with chronic kidney disease (CKD). Methods: The relation between BNP, echocardiography and risk factors (hypertension, anemia, lipids, CRP, hyperparathyroidism) was investigated in 46 children (10 pre-dialysis patients, 14 on dialysis, 11 children with kidney transplants, and 11 healthy controls). Data on BNP were transformed into common logarithms (log₁₀ BNP, log BNP). Results: log BNP was significantly higher in dialysis patients when compared to controls (2.09 ± 0.78 vs. 1.43 ± 0.34 pg/ml, p = 0.012) and patients in the pre-dialysis stage (2.09 ± 0.78 vs. 1.52 ± 0.42 pg/ml, p = 0.039). log BNP in transplanted children was not significantly different from healthy children (2.09 ± 0.78 vs. 1.71 ± 0.46 pg/ml, p = 0.19). Abnormal heart geometry (concentric and eccentric hypertrophy, concentric remodeling) was found in 19 patients (54.28%). A significant correlation was observed between log BNP and ventricular hypertrophy (r = 0.515, p = 0.001). Compared to controls higher log BNP was seen in children with eccentric hypertrophy than in children with concentric hypertrophy (2.178 ± 0.956 vs. 1.496 ± 0.395 pg/ml, p = 0.05, or 1.982 ± 0.618 vs. 1.496 ± 0.395, p = 0.04). Conclusions: BNP might predict an abnormal geometry in children with CKD.

N-Terminal-ProB-Type Natriuretic Peptide as a Marker for Anthracycline Cardiotoxicity in Children with Acute Lymphoblastic Leukaemia

Background: Anthracyclines (ANTR) are very effective agents in treatment of acute lymphoblastic leukaemia (ALL). However, a potential heart damage caused by ANTR in patients who have been cured of ALL may lessen the success of this cure. Plasma brain B-type natriuretic peptide (BNP) levels are highly sensitive biochemical markers for myocardial damage.Objectives of the study: Our purpose was to evaluate N-terminal proBNP (Nt-proBNP) as a screening test for detecting cardiac dysfunction in children with ALL.Subjects: 156 asymptomatic children (72 girls and 84 boys) who had received ANTR during treatment for ALL were evaluated. They had received ANTR doses of 180 to 480mg/m2 (according to the protocol treatment) at median age of 6.6 years at diagnosis. 47 healthy children constituted the control group.Methods: Concentration of plasma N-terminal proBNP was measured in 420 samples by enzyme immunoassay (Biomedica) before treatment, after 6 months, 2 and 4 years and longer than 5 years after ANTR therapy. 261 echocardiograms (ECHO) were performed in 128 children. Nt-proBNP was measured at the same time. Shortening fraction (%SF) and ejection fraction (%EF) were determined as systolic left ventricular function.Results: Mean Nt-proBNP plasma levels in children with ALL were higher in comparison with the control group (90.7 and 66.2pg/ml respectively) but the difference was not significant (p=0.2). The levels of Nt-proBNP before ALL treatment were significantly the lowest (51.5pg/ml). Later, they were respectively: 108.3pg/ml after 6 months, 97.4pg/ml after 2 years and 92.9pg/ml after 4 years (p=0.0019). The highest levels of NT-proBNP were observed in children with cumulative ANTR doses of 240, 330 and 480mg/m2 (98.8pg/ml, 102.8pg/ml, 86.1pg/ml respectively) (p=0.0008). The lowest levels were observed with the cumulative doses of 180mg/m2 and 300mg/m2 (60.7pg/ml and 58.8pg/ml respectively). The average value of %SF in children with ALL was 39.4% (26 to 52%) and the average value of %EF was 69.95% (51.1 do 83.4%). In children with %SF and %EF lower than the average in both study and control group Nt-proBNP was insignificantly higher than in children whose %SF and %EF were higher than the average in both groups (respectively for %SF: 107.1pg/ml and 97.3pg/ml and for %EF: 106.3pg/ml and 98.8pg/ml).Conclusion: Increased Nt-proBNP levels were observed more often in children who received higher doses of ANTR and in all children after the end of treatment. Independently of ECHO assessment of the left ventricular function, the Nt-proBNP is of value in the detection of subclinical left ventricular dysfunction in children with ALL who were treated with ANTR therapy.

Myocardial depression in dengue hemorrhagic fever: Prevalence and clinical description*

To determine the prevalence of myocardial depression and its effect on the clinical severity in patients with dengue hemorrhagic fever. Clinical study. King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Ninety-one children (age 10.5 +/- 2.9 yrs, male/female = 52/39) with serologically or polymerase chain reaction-proven dengue virus infection. Left ventricular ejection fraction (EF) was measured. The proportions of patients with EF <50% were identified in patients with dengue fever (DF, n = 30), dengue hemorrhagic fever without shock (DHF, n = 36), and dengue shock syndrome (DSS, n = 25). Comparisons of clinical findings were made among DSS patients with depressed ventricular function (EF <50%), fair ventricular function (EF > or =50% and <60%), and good ventricular function (EF > or = 60%). Serum troponin T was analyzed in nine patients. EF during toxic stage was significantly lower in patients with DSS than DHF, and lower in DHF than DF (p = .05) with rapid recovery within 24-48 hrs. EF <50% was found in 6.7%, 13.8%, and 36% of patients with DF, DHF, and DSS during the toxic stage, respectively (p = .01). DSS patients with poor ventricular function had significantly more tachycardia and hepatomegaly. While end-diastolic volumes were similarly reduced, patients with lower EF tended to have lower cardiac output, required more aggressive intravenous fluid resuscitation, developed larger pleural effusion, and had higher incidence of respiratory embarrassment. No patient had elevated troponin T level. Transient myocardial depression is not uncommon in patients with DSS. Cardiac dysfunction in children with DSS may contribute to the clinical severity and the degree of fluid overload in these patients.

N-Terminal-proB-Type Natriuretic Peptide as a Marker for Acute Anthracycline Cardiotoxicity in Children

Anthracyclines are widely used in the treatment of pediatric cancer but their use is associated with cardiotoxicity. The cardiotoxic effect may become clinically apparent many years after therapy, and no reliable method exists for early detection of cardiac damage while the patient is receiving the drug. The natriuretic peptides have been established as markers for anthracycline-induced cardiotoxicity in adults and markers for cardiac dysfunction in children. We examined whether N-terminal proB-type natriuretic peptide (NT-proBNP) may be used as a marker for anthracycline-induced cardiotoxicity in children. Twenty-three consecutive pediatric patients with newly diagnosed cancer were enrolled in this study. All patients received anthracycline-containing chemotherapy. Fifty-four age-matched children served as controls. Serial measurements of plasma NT-proBNP levels were taken before and after each anthracycline-containing course. Echocardiograms were performed before initiation of treatment and at the end of the study. Plasma levels of NT-proBNP were within normal limits before treatment and increased significantly only after the first anthracycline dose (from 150+/-112 to 327+/-321 pg/mL, mean+/-SD, P=0.02) and not after subsequent doses. This increase was attributed mainly to a subgroup of patients who received more than 25 mg/m of doxorubicin. In 14 patients (61%), the highest NT-proBNP level occurred after the first anthracycline dose. All patients had normal echocardiograms and none developed heart failure. NT-proBNP increases significantly after the first anthracycline course in a subset of pediatric cancer patients. This increase is not associated with clinical or echocardiographic evidence of cardiac dysfunction. Anthracyclines may be more cardiotoxic in the first course than in subsequent courses. Longer follow-up of these patients is necessary to determine whether NT-proBNP can be used as an early marker for anthracycline-induced cardiotoxicity.