Cardiomyopathy With Restrictive Physiology in Sickle Cell Disease

• Published in: JACC. Cardiovascular imaging 2016-03, Vol.9 (3), p.243-252
• Main Authors: Niss, Omar, MD, Quinn, Charles T., MD, MS, Lane, Adam, PhD, Daily, Joshua, MD, Khoury, Philip R., MS, Bakeer, Nihal, MD, Kimball, Thomas R., MD, Towbin, Jeffrey A., MD, Malik, Punam, MD, Taylor, Michael D., MD, PhD
• Format: Article
• Language: English
• Subjects: Adolescent; Anemia, Sickle Cell - complications; Anemia, Sickle Cell - diagnosis; Anemia, Sickle Cell - mortality; Arterial Pressure; Atrial Function, Left; Cardiomyopathies - diagnostic imaging; Cardiomyopathies - etiology; Cardiomyopathies - mortality; Cardiomyopathies - physiopathology; cardiomyopathy; Cardiovascular; Child; Echocardiography, Doppler; Female; Humans; Hypertension, Pulmonary - etiology; Hypertension, Pulmonary - physiopathology; Hypertrophy, Left Ventricular - etiology; Hypertrophy, Left Ventricular - physiopathology; Male; Predictive Value of Tests; Prognosis; pulmonary hypertension; Pulmonary Veins - physiopathology; restrictive physiology; Retrospective Studies; Risk Factors; sickle cell disease; Tricuspid Valve - physiopathology; Venous Pressure; Ventricular Dysfunction, Left - etiology; Ventricular Dysfunction, Left - physiopathology; Ventricular Function, Right
• ISSN: 1936-878X; 1876-7591
• DOI: 10.1016/j.jcmg.2015.05.013

Abstract Objectives The aim of this study was to identify a unifying cardiac pathophysiology that explains the cardiac pathological features in sickle cell disease (SCD). Background Cardiopulmonary complications, the leading cause of adult death in SCD, are associated with heart chamber dilation, diastolic dysfunction, elevated tricuspid regurgitant jet velocity (TRV), and pulmonary hypertension. However, no unifying cardiac pathophysiology has been identified to explain these findings. Methods In a 2-part study, we first examined patients with SCD who underwent screening echocardiography during steady state at our institution. We then conducted a meta-analysis of cardiac studies in SCD. Results In the 134 patients with SCD studied (median age 11 years), significant enlargement of the left atrial volume was present ( z -score 3.1, p = 0.002), shortening fraction was normal (37.6 ± 4.7%), and lateral and septal ratios of mitral velocity to early diastolic velocity of the mitral annulus (E/e′) were severely abnormal in 8% and 14% of patients, respectively, indicating impaired diastolic function. Both TRV and lateral E/e′ correlated with enlarged left atrial volume in SCD (p = 0.003 and p = 0.006, respectively). Meta-analysis of 68 studies confirmed significant left atrial diameter enlargement in patients with SCD compared with controls, evidence of diastolic dysfunction and enlarged left ventricular end-diastolic dimension with normal shortening fraction. The majority of patients with catheter-confirmed pulmonary hypertension had mild pulmonary venous hypertension consistent with restrictive cardiac physiology. Conclusions Patients with SCD have a unique form of cardiomyopathy with restrictive physiology that is superimposed on hyperdynamic physiology and is characterized by diastolic dysfunction, left atrial dilation, and normal systolic function. This combination results in mild, secondary, pulmonary venous hypertension and elevated TRV. Sudden death is common in other forms of restrictive cardiomyopathy. Our finding of this unique restrictive cardiomyopathy may explain the increased mortality rates and sudden death seen in patients with SCD with mildly elevated TRV.