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1.
Echocardiography ; 41(8): e15910, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-39189828

RESUMEN

BACKGROUND: The atrium augments ventricular function, but the significance of atrial function in hypoplastic left heart syndrome (HLHS) has not been well evaluated. OBJECTIVE: We investigated the association of atrial reservoir strain (common atrial strain [CAS]) to death or need for transplantation in patients with HLHS. METHODS: In this retrospective single-center study, echocardiograms from three timepoints (pre-stage 1 palliation [S1P], 4-8 weeks post-S1P, and pre-Glenn) were analyzed in infants with classic HLHS. Patients were separated based on transplant-free survival to Fontan (survivors) versus death or heart transplant prior to Fontan (composite outcome). Echocardiographic parameters evaluated included CAS, right ventricle (RV) global longitudinal strain (RVGLS), RV fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE). An equal variance t-test, regression, and receiver operating characteristic (ROC) analyses were performed. RESULTS: A total of 45 HLHS patients (25 survivors, 20 patients meeting endpoint) were included in this study. There were no significant differences in any of the functional parameters during the pre-stage 1 or post-stage 1 timepoints. Pre-Glenn CAS and RVGLS were significantly worse in those meeting composite endpoint compared to survivors. CAS was significantly correlated to RVGLS during the pre-S1P and pre-Glenn timepoints. A pre-Glenn CAS < 19.5 had an area under the curve of  .78 and a 75% sensitivity and 83% specificity for death or need for transplantation. CONCLUSION: Pre-Glenn CAS is significantly lower in patients with mortality or need for the transplantation prior to Fontan completion and may carry prognostic significance in patients with HLHS.


Asunto(s)
Ecocardiografía , Procedimiento de Fontan , Atrios Cardíacos , Síndrome del Corazón Izquierdo Hipoplásico , Humanos , Síndrome del Corazón Izquierdo Hipoplásico/cirugía , Síndrome del Corazón Izquierdo Hipoplásico/fisiopatología , Síndrome del Corazón Izquierdo Hipoplásico/diagnóstico por imagen , Masculino , Estudios Retrospectivos , Femenino , Ecocardiografía/métodos , Lactante , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/fisiopatología , Resultado del Tratamiento , Pronóstico
3.
Pediatr Transplant ; 28(5): e14828, 2024 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-39030991

RESUMEN

BACKGROUND: Pulmonary vein stenosis (PVS) is a rare condition in which neointimal proliferation leads to venous and arterial hypertension. Little is known about PVS after heart transplant (HTx) in children. We sought to describe the characteristics and outcomes of children who develop PVS after HTx. METHODS: We performed a retrospective review of patients ≤18 years old who underwent HTx at two HTx centers between April 2012 and October 2023. Patients with PVS were identified via database queries. Cardiac diagnosis, PVS location and extent, and outcomes were recorded. RESULTS: Over 11.5 years, 422 patients underwent HTx across both centers. Nineteen patients with PVS (10 male) were identified, 15 with de novo PVS. Sixteen had underlying congenital heart disease (CHD), two with anomalous pulmonary venous return. PVS was diagnosed at a median of 2 months (range 2 weeks to 14 years) after HTx. At time of initial diagnosis, 13 patients had one-vessel PVS. At final follow-up, 7/19 (37%) had increases in the number of vessels involved. Six patients underwent surgery, and nine patients had stent or balloon angioplasty. Two patients were treated for pulmonary hypertension following PVS diagnosis. Three patients died from right heart failure secondary to PVS. CONCLUSIONS: This is the largest study to describe the characteristics of post-HTx PVS in children. PVS occurs in 4.5% of HTx, and underlying CHD is a strong risk factor. Multiple vessels can be involved and may require catheter-based or surgical intervention. Clinicians must be vigilant in monitoring the development of PVS in this population.


Asunto(s)
Trasplante de Corazón , Complicaciones Posoperatorias , Estenosis de Vena Pulmonar , Humanos , Estudios Retrospectivos , Masculino , Trasplante de Corazón/efectos adversos , Femenino , Niño , Preescolar , Estenosis de Vena Pulmonar/etiología , Lactante , Adolescente , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Recién Nacido , Progresión de la Enfermedad , Cardiopatías Congénitas/cirugía , Cardiopatías Congénitas/complicaciones , Estudios de Seguimiento
4.
Pediatr Cardiol ; 2024 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-38822853

RESUMEN

We present the clinical course of an 8-month-old infant with a giant cutaneous hemangioma resulting in high-output heart failure and pulmonary hypertension. The lesion was successfully embolized and excised, with rapid resolution of heart failure and improvement in pulmonary hypertension.

6.
Pediatr Cardiol ; 45(5): 1120-1128, 2024 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-38519623

RESUMEN

Cardiac dysfunction is associated with mortality in children with hypoplastic left heart syndrome (HLHS). We evaluated the ability of qualitative and quantitative RV functional parameters to predict outcomes in HLHS patients. In this retrospective, single-center study, echocardiograms from 3 timepoints (pre-stage 1 palliation, 4-8 weeks post-stage 1 palliation, and pre-Glenn) were analyzed in infants with HLHS. Patients were stratified into two groups based on outcome of transplant-free survival post-Glenn (survivors) versus mortality or transplantation prior to Fontan (non-survivors). Images were retrospectively reviewed to obtain RV global longitudinal strain (RVGLS), RV-free wall strain (RVFWS), fractional area change (FAC), tricuspid annular systolic plane excursion (TAPSE), tissue motion annular displacement of the tricuspid valve (TMAD-TV) and qualitative systolic function assessment during the predetermined timepoints. An equal variance t-test and chi-square were used to determine significant differences and ROC curve analysis was performed to derive optimal cutoff values to predict mortality/transplant. A total of 47 patients met inclusion criteria, of which, 21 patients met composite endpoint. There were no significant differences in any RV functional parameter during the pre- or post-stage 1 palliation timepoints. The absolute values of RVFWS, RVGLS, and TMAD-TV were significantly greater in survivors than non-survivors during the pre-Glenn timepoint. A pre-Glenn RVGLS > -15.6 (AUC 0.79), RVFWS > -18.6 (AUC 0.75), and TMAD-TV < 12.6% (AUC 0.82) were sensitive and specific for predicting death or need for transplantation prior to Fontan completion. RVGLS, RVFWS, and TMAD-TV may help identify higher-risk HLHS patients during the interstage period.


Asunto(s)
Ecocardiografía , Procedimiento de Fontan , Síndrome del Corazón Izquierdo Hipoplásico , Humanos , Síndrome del Corazón Izquierdo Hipoplásico/cirugía , Síndrome del Corazón Izquierdo Hipoplásico/mortalidad , Síndrome del Corazón Izquierdo Hipoplásico/fisiopatología , Masculino , Estudios Retrospectivos , Femenino , Pronóstico , Lactante , Trasplante de Corazón , Función Ventricular Derecha/fisiología , Recién Nacido , Ventrículos Cardíacos/fisiopatología , Ventrículos Cardíacos/diagnóstico por imagen , Curva ROC
7.
Circ Heart Fail ; 16(7): e00080, 2023 07.
Artículo en Inglés | MEDLINE | ID: mdl-37357777

RESUMEN

Patients with pulmonary hypertension associated with congenital heart disease make up an increasing proportion of the total pulmonary hypertension population who bring with them added complexity because of underlying anatomical and hemodynamic abnormalities. Currently, no consensus recommendations are available on how to best manage this group of patients for either the primary cardiologist or pulmonary hypertension subspecialist, including timing of referral. The purposes of this document are (1) to describe the various pulmonary hypertension groups and subgroups associated with congenital heart disease, (2) to describe imaging modalities used in patient evaluation, (3) to elucidate medical and surgical management considerations, (4) to highlight disparities within this population, and (5) to identify gaps and future research needs of patients with pulmonary hypertension associated with congenital heart disease.


Asunto(s)
Cardiopatías Congénitas , Insuficiencia Cardíaca , Hipertensión Pulmonar , Estados Unidos/epidemiología , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/terapia , American Heart Association , Insuficiencia Cardíaca/complicaciones , Cardiopatías Congénitas/complicaciones , Cardiopatías Congénitas/diagnóstico , Hemodinámica
8.
Pediatr Cardiol ; 44(3): 572-578, 2023 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-35767021

RESUMEN

Transesophageal echocardiography (TEE) education is part of pediatric cardiology fellow training. Simulation-based mastery learning (SBML) is an efficient and valuable education experience. The aim of this project was to equip trainees with the basic knowledge and skill required to perform a pediatric TEE. The secondary aim was to assess the utility of using SBML for pediatric TEE training. The target group is trainees from pediatric cardiology and cardiac anesthesia who participated in a TEE bootcamp. A baseline knowledge pretest was obtained. The knowledge session consisted of preparation via reading material, viewing recorded lectures and completing an iterative multiple-choice examination, which was repeated until a minimum passing score of 90% was achieved. The skills session involved a review of TEE probe manipulation and image acquisition, followed by rapid cycle deliberate practice using simulation to acquire TEE skills at 3 levels, advancing in complexity from level 1 to level 3. Eight individuals (7 pediatric cardiology fellows at varying training levels and one anesthesia attending) participated in the TEE bootcamp. All reached a minimum knowledge post test score of at least 90% before the skills session. All subjects reached mastery in TEE probe manipulation. All reached mastery in image acquisition for the skill level that they attempted (level 1-8/8, level 2-8/8, level 3-4/4, with 4 participants not attempting level 3). A TEE bootcamp using SBML is a powerful medical education strategy. SBML is a rigorous approach that can be used to achieve high and uniform TEE learning outcomes among trainees of different training levels and backgrounds.


Asunto(s)
Anestesia , Cardiología , Educación Médica , Niño , Humanos , Cardiología/educación , Competencia Clínica , Simulación por Computador , Curriculum , Ecocardiografía Transesofágica
9.
Pediatr Cardiol ; 2022 Oct 19.
Artículo en Inglés | MEDLINE | ID: mdl-36260103

RESUMEN

Multisystem Inflammatory Syndrome in Children (MIS-C) often involves a post-viral myocarditis and associated left ventricular dysfunction. We aimed to assess myocardial function by strain echocardiography after hospital discharge and to identify risk factors for subacute myocardial dysfunction. We conducted a retrospective single-center study of MIS-C patients admitted between 03/2020 and 03/2021. Global longitudinal strain (GLS), 4-chamber longitudinal strain (4C-LS), mid-ventricular circumferential strain (CS), and left atrial strain (LAS) were measured on echocardiograms performed 3-10 weeks after discharge and compared with controls. Among 60 MIS-C patients, hypotension (65%), ICU admission (57%), and vasopressor support (45%) were common, with no mortality. LVEF was abnormal (< 55%) in 29% during hospitalization but only 4% at follow-up. Follow-up strain abnormalities were prevalent (GLS abnormal in 13%, 4C-LS in 18%, CS in 16%, LAS in 5%). Hypotension, ICU admission, ICU and hospital length of stay, and any LVEF < 55% during hospitalization were factors associated with lower strain at follow-up. Higher peak C-reactive protein (CRP) was associated with hypotension, ICU admission, total ICU days, and with lower follow-up GLS (r = - 0.55; p = 0.01) and CS (r = 0.41; p = 0.02). Peak CRP < 18 mg/dL had negative predictive values of 100% and 88% for normal follow-up GLS and CS, respectively. A subset of MIS-C patients demonstrate subclinical systolic and diastolic function abnormalities at subacute follow-up. Peak CRP during hospitalization may be a useful marker for outpatient cardiac risk stratification. MIS-C patients with hypotension, ICU admission, any LVEF < 55% during hospitalization, or a peak CRP > 18 mg/dL may warrant closer monitoring than those without these risk factors.

10.
J Perinatol ; 42(6): 788-795, 2022 06.
Artículo en Inglés | MEDLINE | ID: mdl-35397644

RESUMEN

OBJECTIVE: To describe the association between echocardiographic measures of pulmonary vascular disease and time to respiratory improvement among infants with Type I severe bronchopulmonary dysplasia (sBPD). STUDY DESIGN: We measured the pulmonary artery acceleration time indexed to the right ventricular ejection time (PAAT/RVET) and right ventricular free wall longitudinal strain (RVFWLS) at 34-41 weeks' postmenstrual age. Cox-proportional hazards models were used to estimate the relationship between the PAAT/RVET, RVFWLS, and the outcome: days from 36 weeks' postmenstrual age to room-air or discharge with oxygen (≤0.5 L/min). RESULT: For 102 infants, the mean PAAT/RVET and RVFWLS were 0.27 ± 0.06 and -22.63 ± 4.23%. An abnormal measurement was associated with an increased time to achieve the outcome (PAAT/RVET: 51v24, p < 0.0001; RVFWLS; 62v38, p = 0.0006). A normal PAAT/RVET was independently associated with a shorter time to outcome (aHR = 2.04, 1.11-3.76, p = 0.02). CONCLUSION: The PAAT/RVET may aid in anticipating timing of discharge in patients with type I severe BPD.


Asunto(s)
Displasia Broncopulmonar , Hipertensión Pulmonar , Enfermedades Vasculares , Displasia Broncopulmonar/complicaciones , Ecocardiografía , Humanos , Hipertensión Pulmonar/complicaciones , Lactante , Recién Nacido , Arteria Pulmonar/diagnóstico por imagen , Enfermedades Vasculares/complicaciones
13.
Pacing Clin Electrophysiol ; 43(10): 1213-1216, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32885843

RESUMEN

An infant with transposition of the great arteries was paced for postoperative heart block (single-site, right ventricular [RV] epicardial). She developed severe left ventricular (LV) dysfunction and septal dyskinesis. Resynchronization was performed at the age of 4 with an LV epicardial lead and an RV septal endocardial lead. The endocardial lead was affixed to the interventricular septum, then tunneled through the RV free wall and attached to an abdominal pulse generator. QRS duration decreased (176 to 122 ms) and LV ejection fraction improved (26 to 61%) and remained stable for 8 years. We present a case of successful resynchronization in congenital heart disease using a transmural RV septal lead.


Asunto(s)
Terapia de Resincronización Cardíaca/métodos , Bloqueo Cardíaco/fisiopatología , Bloqueo Cardíaco/terapia , Transposición de los Grandes Vasos/fisiopatología , Niño , Femenino , Defectos del Tabique Interventricular/fisiopatología , Humanos
14.
Circ Cardiovasc Imaging ; 13(3): e009717, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-32178537

RESUMEN

BACKGROUND: Bicuspid aortic valve (BAV) is the most prevalent congenital heart defect affecting 1% to 2% of the population. It is associated with ascending aorta dilatation. Valve morphology, aortic stenosis (AS), and aortic insufficiency (AI) have been proposed as potential risk factors; however, evaluating their role is difficult, as these factors are inherently related. The aim of this study was to determine whether BAV morphology and dysfunction are independent determinants for ascending aorta dilatation in pediatric patients. METHODS: A multicenter, retrospective, cross-sectional study of pediatric BAV patients followed since 2004 was performed. Imaging data were assessed for BAV morphology, severity of AS and AI, history of coarctation, and aortic dimensions. Associations were determined using multivariable regression analysis. A subset of patients undergoing aortic interventions (balloon dilation or Ross) were assessed longitudinally. RESULTS: Data were obtained from 2122 patients (68% male; median age 10.2 years). Fifty percent of patients had ascending aorta dilatation. Right and noncoronary cusp fusion, increasing AS and AI, and older age were independently associated with ascending aorta dilatation. A history of coarctation was associated with less ascending aorta dilatation. In patients with neither AS nor AI, 37% had ascending aorta dilatation (4% severe). No complications related to aortic dilatation occurred in this cohort. Aortic Z scores were determined, and a Z-score calculator was created for this population. CONCLUSIONS: In this large pediatric cohort of patients with BAV, valve morphology, AS, and AI are independently associated with ascending aorta dilatation, suggesting that hemodynamic factors influence aortopathy. However, even in BAVs with no AS or AI, there is significant ascending aorta dilatation independent of valve morphology. Interventions that led to changes in degree of AI and AS did not seem to influence change in aortic dimensions. The current BAV cohort can be used as a reference group for expected changes in aortic dimensions during childhood.


Asunto(s)
Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico , Válvula Aórtica/anomalías , Ecocardiografía/métodos , Enfermedades de las Válvulas Cardíacas/complicaciones , Adolescente , Aneurisma de la Aorta Torácica/etiología , Enfermedad de la Válvula Aórtica Bicúspide , Niño , Preescolar , Estudios Transversales , Progresión de la Enfermedad , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico , Humanos , Lactante , Recién Nacido , Masculino , Pronóstico , Estudios Retrospectivos , Factores de Riesgo
15.
Pediatr Cardiol ; 41(1): 209-212, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31522266

RESUMEN

Anomalous origin of the left anterior descending coronary artery from the pulmonary artery is a rare variant of anomalous origin of the left main coronary artery from the pulmonary artery. We report on a seemingly asymptomatic patient with ALADCAPA and a small restrictive muscular ventricular septal defect diagnosed by echocardiogram in the neonatal period. Our patient underwent elective repair at 3.5 months of age after which feeding and growth improved dramatically. Multimodality imaging is helpful to confirm this rare anomaly; however, echocardiographic clues including lack of left coronary branching or an abnormal coronary course should raise suspicion for ALADCAPA. This case provides support for early repair in children with an incidental finding of this anomaly as subclinical ischemia may be under-recognized by available testing but may lead to symptoms later in life.


Asunto(s)
Anomalías de los Vasos Coronarios/diagnóstico por imagen , Defectos del Tabique Interventricular/diagnóstico , Arteria Pulmonar/diagnóstico por imagen , Angiografía por Tomografía Computarizada/métodos , Angiografía Coronaria , Ecocardiografía/métodos , Femenino , Defectos del Tabique Interventricular/cirugía , Humanos , Hallazgos Incidentales , Recién Nacido , Imagen Multimodal
16.
Vet Pathol ; 57(1): 147-150, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31551010

RESUMEN

Odontomas are variably differentiated, hamartoma-like proliferations of odontogenic epithelium, pulp ectomesenchyme (odontoblasts), and dental matrix. Frogs are polyphyodont and homodont. Their teeth also differ from mammals in that they are restricted to the upper jaw in adults and lack a periodontal ligament and cementum, attaching directly to the underlying bone. Odontomas were identified in an African clawed frog (Xenopus laevis), a false tomato frog (Dyscophus guineti), and a tomato frog of unknown species (Dyscophus sp.). All of the examined odontomas were composed of numerous tooth-like structures comprising an arc of dentinal matrix lined on the convex surface by ameloblasts and on the concave surface by odontoblasts. Masson's trichrome and immunohistochemistry with pan-cytokeratin supported these findings. The pathogenesis of these lesions may be displacement of the dental lamina, which has been shown in research studies to lead to de novo proliferation of dental elements in frogs.


Asunto(s)
Anuros , Hamartoma/veterinaria , Neoplasias de la Boca/veterinaria , Tumores Odontogénicos/veterinaria , Odontoma/veterinaria , Animales , Hamartoma/diagnóstico , Hamartoma/patología , Inmunohistoquímica/veterinaria , Neoplasias de la Boca/diagnóstico , Neoplasias de la Boca/patología , Tumores Odontogénicos/diagnóstico , Tumores Odontogénicos/patología , Odontoma/diagnóstico , Odontoma/patología
17.
World J Pediatr Congenit Heart Surg ; 10(2): 235-238, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30841833

RESUMEN

Utilization of the Melody valve for mitral valve replacement has been previously reported; however, left ventricular outflow tract obstruction is a frequent concern. In this report, a technique for supra-annular placement of the Melody valve in the mitral position is described which will minimize the risk of left ventricular outflow tract obstruction.


Asunto(s)
Cardiopatías Congénitas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Obstrucción del Flujo Ventricular Externo/prevención & control , Ecocardiografía , Femenino , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Humanos , Lactante , Válvula Mitral/diagnóstico por imagen , Diseño de Prótesis
18.
World J Pediatr Congenit Heart Surg ; 10(1): 111-115, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30799720

RESUMEN

Left mainstem bronchial compression by a midline descending thoracic aorta is a rare anatomic variant. Translocation of the descending thoracic aorta to the ascending aorta has recently been described to treat this condition. We performed an aortic translocation and right pulmonary artery reimplantation in a 4-month-old infant with severe pulmonary hypertension secondary to right pulmonary artery stenosis and left bronchial compression by a midline descending thoracic aorta. The procedure was successful in ameliorating the patient's left mainstem bronchial compression and pulmonary hypertension. Descending aortic translocation should be considered when the left bronchus is compressed causing respiratory symptoms.


Asunto(s)
Aorta/cirugía , Enfermedades Bronquiales/cirugía , Constricción Patológica/cirugía , Arteria Pulmonar/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Aorta/anomalías , Aorta/diagnóstico por imagen , Enfermedades Bronquiales/congénito , Enfermedades Bronquiales/diagnóstico , Constricción Patológica/congénito , Constricción Patológica/diagnóstico , Humanos , Lactante , Masculino , Arteria Pulmonar/anomalías , Arteria Pulmonar/diagnóstico por imagen , Reimplantación , Tomografía Computarizada por Rayos X
19.
Cardiooncology ; 5: 10, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-32154016

RESUMEN

BACKGROUND: Early recognition of anthracycline-induced cardiomyopathy may reduce morbidity and mortality in children, but risk stratification tools are lacking. This study evaluates whether electrocardiogram (ECG) changes precede echocardiographic abnormalities in children with anthracycline-induced cardiomyopathy. METHODS: We performed a retrospective analysis of 589 pediatric cancer patients who received anthracyclines at a tertiary referral center. ECG endpoints were sum of absolute QRS amplitudes in the 6 limb leads (ΣQRS(6 L)) and corrected QT interval (QTc). Cardiomyopathy was defined by echocardiogram as ejection fraction < 50%, shortening fraction < 26%, or left ventricular end-diastolic diameter z-score > 2.5. RESULTS: Median age at start of therapy was 7.8 years (IQR 3.7-13.6); median follow-up time was 3.6 years (IQR 1.1-5.8). 19.5% of patients met criteria for cardiomyopathy. Male sex, race, older age at first dose, and larger body surface area were associated with development of cardiomyopathy. A 0.6 mV decrease in ΣQRS(6 L) and 10 ms increase in QTc were associated with an increased risk of developing cardiomyopathy with hazard ratios of 1.174 (95% CI = 1.057-1.304, p = 0.003) and 1.098 (95%CI = 1.027-1.173, p = 0.006) respectively. Kaplan-Meier estimates showed a lower chance of cardiomyopathy-free survival for QTc ≥ 440 ms and ΣQRS(6 L) ≤ 3.2 mV over time. After controlling for confounders, total anthracycline dose predicted a decrease in ΣQRS(6 L) and an increase in QTc independent of cardiomyopathy status (p = 0.01 and p < 0.001 respectively). Cardiotoxic radiation did not predict changes in ECG parameters. Cardiomyopathy was associated with increased mortality (34% versus 12%, p < 0.001). CONCLUSION: In children receiving anthracyclines, decrease in ΣQRS(6 L) and QTc prolongation are associated with increased risk of developing cardiomyopathy. ECG is a potential non-invasive risk stratification tool for prediction of anthracycline-induced cardiomyopathy and requires prospective validation.

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