Echo Assessment of LV diastolic function in Children

CIRCULATION: CARDIOVASCULAR IMAGING


Published online before print January 23, 2013,

doi: 10.1161/​CIRCIMAGING.112.000175

Interpretation of Left Ventricular Diastolic Dysfunction in Children with Cardiomyopathy by Echocardiography: Problems and Limitations

Andreea Dragulescu, Luc Mertens and Mark K. Friedberg (Toronto)

Background:
Left ventricular diastolic dysfunction(DD) is a key determinant of outcomes in pediatric cardiomyopathy(CM), but remains very challenging to diagnose and classify. Adult paradigms and guidelines relating to DD are currently applied in children. However, it is unknown whether these are applicable to children with CM. We investigated the assessment of DD in children with CM using adult and pediatric echocardiographic criteria and tested whether recent adult guidelines are applicable to this population.

Methods and Results:
Three investigators independently classified diastolic function in 4 study groups: controls; dilated(DCM), hypertrophic(HCM) and restrictive(RCM) cardiomyopathy. Agreement between investigators, failure to classify DD and the reasons for diagnostic failure were determined. The usefulness of individual echo parameters to diagnose and classify DD was assessed. 175 children (0-18yrs) were studied. DD diagnostic criteria were discrepant in the majority of patients. Delayed relaxation was diagnosed in only 14% of HCM patients and never in DCM and RCM, with 50% of those patients having co-existing findings of elevated filling pressures. Many key parameters, such as mitral and pulmonary venous Doppler were not informative. Agreement between investigators for grading of diastolic dysfunction was poor (36% of CM patients).

Conclusions:
Assessment of DD in childhood cardiomyopathy seems inadequate using current guidelines. The large range of normal pediatric reference values allows diagnosis of diastolic dysfunction in only a small proportion of patients. Key echo parameters to assess DF are not sufficiently discriminatory in this population and discrepancies between criteria within individuals prevent further classification and result in poor inter-observer agreement.