Tissue doppler echocardiography detects preclinical markers of cardiac lesion in MDS patients
verfasst von:
Cláudio César Monteiro de Castro, Carlos Bellini Gondim Gomes, Manoel Ricardo Alves Martins, Juliana Cordeiro de Sousa, Silvia MM Magalhaes, Ronald F Pinheiro
Myelodysplastic syndrome (MDS) is a clonal hematopoietic stem cell disorder of elderly people. Cardiac dysfunction is a marker of grim prognosis in MDS. We evaluated cardiac dysfunction of MDS patients with or without transfusion dependency by tissue doppler echocardiography. We found the average values of ventricular end-systolic and end-diastolic volumes in transfusion dependency MDS group higher than others. These results were strongly correlated to hemoglobin levels. Tissue Doppler Echocardiography should be routinely performed in MDS patients to detect preclinical cardiac alterations and prevent more heart insults in this group of chronic anemic aged patients.
The online version of this article (doi:10.1186/1756-8722-5-30) contains supplementary material, which is available to authorized users.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
CCMC was the principal investigator and takes primary responsibility for the paper. CBGG provide technical support. MRAM participated in the statistical analysis. JCS performed the laboratory work for this study and edited the manuscript. SMMM provided critical revision. RFP coordinated the research and wrote the paper.
Abkürzungen
NT-MDS
Non-transfused patients
T-MDS
Transfused patients
LVDD
Left ventricular diastolic diameter
LVSD
Left ventricular systolic diameter
IVS
Inter-ventricular septum
LVPW
Left ventricular posterior wall
LVEDV
Left ventricular end-diastolic volume
LVESV
Left ventricular end-systolic volume
LAV
Left atrial volume
RCC
Red cell concentrate
VD
Ventricular dysfunction.
To the Editor
Myelodysplastic syndrome (MDS) is a clonal hematopoietic stem cell disorder and anemia with transfusion dependency is detected in up to 60% of patients [1]. Early recognition of patients at risk of heart failure is difficult because global ventricular function and exercise capacity in chronically transfused patients may remain normal until late in the disease [2].
We evaluated three groups of MDS patients: cases with transfusion dependency (T-MDS), patients without transfusion dependency (NT-MDS) and age-matched controls. Transfusion dependency was considered as reported by Malcovati et al. [3]. Echo-Doppler, tissue velocity imaging and strain measures were obtained using General Electric-Healthcare (GE, Vivid-7) system with a matrix probe M3S.
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Parametric data were analyzed by “one-way” analyzes of variance (ANOVA) with Bonferroni’s Multiple Comparison as a post-test. Non-parametric data were analyzed by Kruskal-Wallis. The studies of correlation was assessed by Pearson’s correlation coefficient (r).
The three groups were composed of 13 T-MDS, 21 NT-MDS and 14 controls. There were no significant differences between groups. See Table 1. Table 2 presents the echocardiographic parameters. The average values of ventricular end-systolic and end-diastolic volumes in T-MDS group were significantly higher than NT-MDS and controls (p <0.05 and p <0.04 respectively). The left atrial volume indexed (LAV index) was significantly larger in patients of T-MDS group than NT-MDS and controls (35.9 ± 15 mL/m2, 26.6 ± 5,2 mL/m2, 22.8 ± 8 mL/m2 respectively) (p <0.004.). A strong correlation between hemoglobin levels and LVEDV (left ventricular end-diastolic volume), LVESV (left ventricular end-systolic volume), LAV (left atrial volume) and LAV index was observed, with r values of −0.4, -0.4, -0.53 and 0.51 respectively (p <0.02, p <0.02, p <0.002 and p <0.002 respectively). See Figure 1. Otherwise, we found no correlation between ferritin levels and echocardiographic parameters.
Table 1
Patients were diagnosed and classified according to WHO, IPSS and WPSS criteria
Patient
WHO
IPSS
Serum Ferritin
Transfusion therapy
Transfusional dependent
WPSS
1
RA
NA
288,8
No transfusion therapy
NO
NA
2
RAEB 2
INT 1
94,7
No transfusion therapy
NO
HIGH
3
RCMD
INT 1
416,5
14 RCC
NO
LOW
4
RARS
INT 1
1.994,0
69 RCC
Yes
LOW
5
RA
NA
826,0
No transfusion therapy
NO
NA
6
RA
LOW
22,4
No transfusion therapy
NO
LOW
7
MDS-T
NA
3.484,0
42 RCC
Yes
NA
8
RARS
NA
1.399,0
64 RCC
Yes
NA
9
RCMD
NA
7.107,0
81 RCC
Yes
NA
10
RARS
LOW
1.587,0
20 RCC
Yes
LOW
11
RARS
INT 1
132,0
04 RCC
NO
INT
12
RARS
LOW
1.937,8
82 RCC
Yes
LOW
13
RARS
NA
541,0
No transfusion therapy
NO
NA
14
RA
LOW
307,0
No transfusion therapy
NO
VERY LOW
15
RCMD
INT 1
5.113,1
96 RCC
Yes
INT
16
RCMD
LOW
38,0
No transfusion therapy
NO
LOW
17
RCMD
NA
98,0
03 RCC
NO
NA
18
RARS
LOW
318,0
No transfusion therapy
NO
VERY LOW
19
RCMD
LOW
87,0
No transfusion therapy
NO
LOW
20
RCMD
NA
765,0
38 RCC
Yes
NA
21
RCMD
INT 1
780,0
17 RCC
Yes
HIGH
22
RARS
LOW
356,2
No transfusion therapy
NO
VERY LOW
23
RCMD
INT 1
298,4
No transfusion therapy
NO
LOW
24
RCMD
INT 1
2.160,0
24 RCC
Yes
HIGH
25
RA
LOW
86,4
No transfusion therapy
NO
VERY LOW
26
RCMD
NA
276,0
No transfusion therapy
NO
NA
27
RCMD
NA
1.922,3
24 RCC
Yes
NA
28
RAEB 2
INT 2
1.022,0
42 RCC
Yes
VERY HIGH
29
RARS
NA
321,0
No transfusion therapy
NO
NA
30
RCMD
NA
223,0
12 RCC
Yes
NA
31
RAEB 1
INT 1
229,0
03 RCC
NO
VERY LOW
32
RCMD
INT 1
132,4
No transfusion therapy
NO
INT
33
RCMD
NA
556,0
04 RCC
NO
NA
34
RCMD
NA
850,0
10 RCC
NO
NA
Legend. MDS unclassifiable; RA, refractory anemia; RAEB, RA with excess of blasts; RARS, RA with ringed sideroblasts; RCMD, refractory cytopenia with multilineage dysplasia; t-MDS, therapy-related MDS; WHO, World Health Organization. red cell concentrate – RCC. NA -Not applicable, due to cytogenetics by G-banding without metaphases).
Table 2
Echocardiographic parameters of patients and controls
Controls(14)
NT-MDS(21)
T-MDS(13)
P value
Baseline demographics and characteristics
Age (year)
72.4 ± 8 (58–84)
70.3 ± 14 (47–88)
65.2 ± 20 (27–90)
NS
Gender (m/f)
(6/8)
(7/14)
(6/7)
Body weigth (kg)
66.0 ± 11.9 (46 – 83)
63.7 ± 10.1 (43.6 – 91.3)
64.9 ± 10.1 (49.3 – 90)
NS
Height (m)
1.59 ± 0.09 (1.45 – 1.75)
1.57 ± 0.07 (1.46 – 1.72)
1.59 ± 0.08 (1.45 – 1.70)
NS
BSA (m2)
1.68 ± 0.16 (1.42 – 1.98)
1.64 ± 0.15 (1.33 – 2.01)
1.67 ± 0.15 (1.4 – 2.01)
NS
BMI (kg/m2)
26.2 ± 5.7 (19.1 – 36.9)
25.8 ± 2.9 (20.5 – 32.3)
25.5 ± 3.7 (21.4 – 32.7)
NS
HR (bpm)
75.8 ± 5.4 (66–83)
77.6 ± 1.4 (66–88)
78.4 ± 2.2(65–90)
NS
SBP (mmHg)
139.2 ± 19 (110–180)
121.8 ± 16 (100–150)
<0.02
DBP (mmHg)
77.9 ± 12 (60–108)
70 ± 9.6 (60–90)
NS
Hb (g/dL)
9.85 ± 1.8 (6.6 - 12.7)
6.5 ± 1.7 (3.8 - 9.9)
<0.001
Ferritin (ng/mL)
298.8 ± 234 (22.4 a 850)
2269 ± 1931 (223 a 7101)
<0.001
Chamber quantification and ejection fraction of patients and controls
LVDD (mm)
46.0 ± 4.7 (40–57)
48.5 ± 3.9 (41–56)
49.3 ± 6.6 (40–64)
NS
LVSD (mm)
26.9 ± 4.9 (19–39)
27.7 ± 3.7 (22–37)
29.5 ± 6.8 (23–50)
NS
IVS (mm)
8.9 ± 2.3 (6–16)
8.5 ± 0.9 (7–11)
8.9 ± 1.4 (7–12)
NS
LVPW (mm)
8.5 ± 1.7 (6–13)
8.4 ± 0.7 (7–10)
8.8 ± 1.4 (7–12)
NS
MASS (g)
165.9 ± 61,0 (79–326)
173.8 ± 34.1 (116–249)
165.9 ± 61.0 (90–321)
NS
MASS index (g/m2)
101.3 ± 37 (55.6 - 185)
106 ± 18 (73–140.7)
110 ± 37.1 (56.2 - 198)
NS
EF%TEI
71.8 ± 7.6 (58.2 - 89)
71.9 ± 6.5 (58.8 - 80.1)
69.8 ± 9.3 (43.6 - 83.9)
NS
FS (%)
41.4 ± 6.8 (31.2 - 58)
41.6 ± 5.7 (31–48.7)
39.4 ± 7.2 (22–53)
NS
LA (mm)
32 ± 4.2 (27–44)
33.4 ± 4.2 (28–43)
36.5 ± 4.9 (31–46)
<0.04*
EF%SIM
67.7 ± 7.3 (50.1 - 81.3)
66.2 ± 4.8 (55.2 - 76.1)
64.7 ± 5.4 (50.7 - 70.8)
NS
LVEDV (ml)
65.5 ± 18 (37–105)
85.1 ± 29.9 (44–169)
92.8 ± 36.1 (49–189)
<0.05*
LVESV (ml)
20.5 ± 6.2 (10–28)
28.7 ± 11.9 (12.5 - 65)
33.8 ± 19.7 (15–93)
<0.04*
LAV (ml)
39.1 ± 14.5 (17–69)
43.5 ± 10.3 (25–64)
59.8 ± 24.8 (29–120)
<0.006**
LAV index (mL/m2)
22.8 ± 8 (10.5 - 39.6)
26.5 ± 5.2 (15.9 - 34.8)
35.9 ± 15 (18.8 - 70.9)
<0.004**
Doppler parameters (transmitral and myocardial tissue) and strain of patients and controls
Evel(cm/s)
77.2 ± 13.2 (55.4 - 105)
89.6 ± 20 (63–128)
96.6 ± 14.2 (68.5 - 116)
<0.02*
Avel(cm/s)
94.3 ± 18 (68.6 - 137.3)
100.2 ± 19 (68.5 - 131)
100.6 ± 27 (52.8 - 145)
NS
E/A
0.83 ± 0.2 (0.6 - 1.2)
0.9 ± 0.2 (0.6 - 1.4)
1.0 ± 0.26 (0.64 - 1,6)
NS
Em(cm/s)
8.6 ± 3.2 (4.1 - 14)
9.3 ± 2.4 (5.4 - 14)
10.4 ± 2.5 (7.5 a 14.8)
NS
E/Em
10 ± 3.4 (5.3 - 16.2)
10.3 ± 3,9 (5.6 - 20)
9.7 ± 2.9 (5.9 - 14.4)
NS
LV-Sm(cm/s)
6.5 ± 1.3 (5.1 - 9.5)
7.9 ± 1.3 (5.5 - 10.8)
7.8 ± 1.3 (6–10,3)
<0.02*
RV-Sm(cm/s)
10.1 ± 0.7 (9.1 - 11)
11.4 ± 3.3 (7.6 - 19)
12.3 ± 1,5 (9.8 - 14,7)
NS
TAPSE(mm)
24.9 ± 4.2 (20–33)
28.2 ± 5.3 (21–39)
28.9 ± 5 (22–40)
NS
VD basal(mm)
30.1 ± 6.4 (22–48)
31.7 ± 4 (24–41)
31.5 ± 4 (23–39)
NS
ST2DL (%)
−19.9 ± 2.7 (−24 to −13)
−20.7 ± 2.5 (−25 to −16,8)
−20.9 ± 1.4 (−23 to - 18,6)
NS
Legend. NT-MDS: non-transfused patients; T-MDS: transfused patients; LVDD: left ventricular diastolic diameter; LVSD: left ventricular systolic diameter; IVS: inter-ventricular septum; LVPW: left ventricular posterior wall; MASS: left ventricular mass; EF%TEI: ejection fraction Teicholz; FS: fractional shortening; LA: left atrial diameter; EF%SIM: ejection fraction Simpson; LVEDV: left ventricular end-diastolic volume; LVESV: left ventricular end-systolic volume; LAV: left atrial volume.
Figure 1
Linear correlation between left cardiac volumes and values of hemoglobin. A.LAV: left atrial volume.B.LVEDV: left ventricular end-diastolic volume;C.LAV index : left atrial volume index.D.LVESV: left ventricular end-systolic volume.
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The reduction of blood viscosity in severe anemia increases blood return [4] and ventricular preload which lead to atrial and ventricular enlargement observed in T-MDS patients. Confirming this hypothesis, these results are correlated to hemoglobin levels.
The T-MDS group showed no clinical sign of cardiac dysfunction. Otherwise, cardiac alterations were detected by tissue-doppler echocardiography, a relative fast and cheap bedside method to evaluate heart function. Echocardiography should be routinely performed in MDS patients to detect preclinical cardiac alterations and prevent more heart insults in these group of chronic anemic aged patients.
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Acknowledgements
Support by CAPES CNPq and FUNCAP.
Open Access
This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution License (
https://creativecommons.org/licenses/by/2.0
), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
CCMC was the principal investigator and takes primary responsibility for the paper. CBGG provide technical support. MRAM participated in the statistical analysis. JCS performed the laboratory work for this study and edited the manuscript. SMMM provided critical revision. RFP coordinated the research and wrote the paper.
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Tissue doppler echocardiography detects preclinical markers of cardiac lesion in MDS patients
verfasst von
Cláudio César Monteiro de Castro Carlos Bellini Gondim Gomes Manoel Ricardo Alves Martins Juliana Cordeiro de Sousa Silvia MM Magalhaes Ronald F Pinheiro
