Open Access

Tissue doppler echocardiography detects preclinical markers of cardiac lesion in MDS patients

  • Cláudio César Monteiro de Castro2,
  • Carlos Bellini Gondim Gomes1,
  • Manoel Ricardo Alves Martins1,
  • Juliana Cordeiro de Sousa1,
  • Silvia MM Magalhaes1 and
  • Ronald F Pinheiro1, 2, 3Email author
Journal of Hematology & Oncology20125:30

DOI: 10.1186/1756-8722-5-30

Received: 23 May 2012

Accepted: 7 June 2012

Published: 18 June 2012

Abstract

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.

Keywords

Myelodysplastic syndrome Comorbidity Cardiac 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.

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 (m 2 )

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/m 2 )

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/m 2 )

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/m 2 )

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.

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.

Abbreviation

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.

Declarations

Acknowledgements

Support by CAPES CNPq and FUNCAP.

Authors’ Affiliations

(1)
Post-Graduate Program in Medical Sciences, Federal University of Ceará
(2)
Post-Graduate Program of Pathology- Federal University of Ceará
(3)
R. Pereira Valente

References

  1. Cazzola M, Della Porta MG, Travaglino E, Malcovati L: Classification and prognostic evaluation of myelodysplastic syndromes. Semin Oncol. 2011, 38 (Suppl 5): 627-634.View ArticlePubMedGoogle Scholar
  2. Naqvi K, Garcia-Manero G, Sardesai S, Oh J, Vigil CE, Pierce S, Lei X, Shan J, Kantarjian HM, Suarez-Almazor ME: Association of comorbidities with overall survival in myelodysplastic syndrome: development of a prognostic model. J Clin Oncol. 2011, 29: 2240-2246. 10.1200/JCO.2010.31.3353.PubMed CentralView ArticlePubMedGoogle Scholar
  3. Malcovati L, Porta MG, Pascutto C, Invernizzi R, Boni M, Travaglino E, Passamonti F, Arcaini L, Maffioli M, Bernasconi P, Lazzarino : Prognostic factors and life expectancy in myelodysplastic syndromes classified according to WHO criteria: a basis for clinical decision making. J Clin Oncol. 2005, 20 (Suppl 30): 7594-7603.View ArticleGoogle Scholar
  4. Carmer R: Anemia and aging: an overview of clinical, diagnostic and biological issues. Blood Rev. 2001, 15: 9-18. 10.1054/blre.2001.0146.View ArticleGoogle Scholar

Copyright

© de Castro et al.; licensee BioMed Central Ltd. 2012

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement