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Cardiac changes in pediatric cancer survivors
  1. Deepa Mokshagundam1,
  2. Laura J Olivieri2,
  3. Robert McCarter3,
  4. Aerang Kim4,
  5. Craig A Sable2,
  6. Christopher F Spurney2,
  7. Niti Dham2
  1. 1 Washington University in Saint Louis, Saint Louis, Missouri, USA
  2. 2 Cardiology, Children's National Health System, Washington, DC, USA
  3. 3 Biostatistics and Study Methodology, Children's National Health System, Washington, DC, USA
  4. 4 Oncology, Children's National Health System, Washington, DC, USA
  1. Correspondence to Dr Niti Dham, Cardiology, Children's National Health System, Washington, DC 20010, USA; ndham{at}


Cardiac damage from chemotherapy is a known phenomenon leading to significant morbidity and mortality in the cancer surviving population, and identifying high-risk pediatric patients early is challenging. The purpose of this pilot study was to evaluate whether echo strain, cardiac MRI (CMR), and serum biomarkers are more sensitive methods for detecting cardiac toxicity than standard echo and to examine the relationship between biomarkers in patients without decreased systolic function as determined by standard echo. In this pilot study, we prospectively enrolled pediatric subjects after completion of anthracycline inclusive chemotherapy. Each subject underwent a post-treatment echocardiogram (standard with strain), serum biomarkers (N-terminal brain natriuretic peptide (NT-pro-BNP) and interleukin 1 receptor-like 1 protein (ST2)), and CMR (standard and extracellular volumes (ECVs)). We correlated the markers using Pearson correlation. We enrolled 30 subjects, 11F/19M, aged 8–21 years. Cumulative anthracycline dose (CAD) correlated with BNP (p=0.06), CMR ECV 4-chamber (p=0.05) and sagittal (p=0.01), and mitral valve E/A (p=0.02). BNP correlated with CMR ECV 4-chamber (p=0.001) and sagittal (p=0.001) and with echo average longitudinal strain (ALS) (p=0.05). This study demonstrated a significant correlation of CAD with BNP and CMR ECV. There was also a significant correlation of NT-pro-BNP with CMR ECV and ALS. Combining these parameters with standard echo has the potential to identify high-risk patients early. Further studies are needed for long-term follow-up and management in this vulnerable population.

  • cardiomyopathies
  • echocardiography
  • drug-related side effects and adverse reactions
  • biomarkers
  • leukemia

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  • Contributors DM—acquisition, analysis and interpretation of data. LJO—concept of design and planning, acquisition and interpretation of data. RM—design of the work, analysis and interpretation of data. AK—concept and design of the work, acquisition of data. CAS—analysis and interpretation of data. CFS—design of study, analysis and interpretation of data. ND—concept and design of work; acquisition, analysis, and interpretation of data. Drafting the work or revising it critically for important intellectual content—all authors. Final approval of the version to be published—all authors. Agreement to be accountable for all aspects of the work—all authors.

  • Funding This study was funded by a Pilot Award Grant from the Clinical and Translational Science Institute at Children’s National Medical Center and in part by the National Institute of Health (NHLBI, Prime Award No. R01HL125918-01).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This prospective observational study was approved by the Institutional Review Board at Children’s National Medical Center.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. The deidentified data that support the findings on this study are available on request from the corresponding author, ND ( The data are not publicly available due to privacy or ethical reasons.