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Echocardiographic Follow-up of Perinatally
HIV-infected Children and Adolescents
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Results From a Single-center Retrospective Cohort Study in Brazil
Vallilo, Nathália Gaspar MD*; Durigon, Giuliana Stravinskas MD, PhD*; Lianza, Alessandro Cavalcanti MD, PhD†; de Fátima Rodrigues Diniz, Maria MD†; Shiraishi Sawamura, Karen Saori MD†; Brito, Carolina Rocha MD†; de Souza Marques, Heloisa Helena MD, PhD*; Ferraro, Alexandre Archanjo MD, PhD‡; Leal, Gabriela Nunes MD, PhD†
Conclusions:
Echocardiograms identified cardiac abnormalities among children with perinatally acquired HIV infection, and data suggest that immunologic status and therapeutic strategies throughout development can influence cardiac disease burden in this population.
Objectives:
To determine the prevalence of cardiac abnormalities in a retrospective cohort of perinatally HIV-infected patients and to investigate associations between echocardiographic and clinical data during their follow-up.
Methods:
Review of medical records and echocardiogram reports of 148 perinatally HIV-infected patients between January 1991 and December 2015.
Results:
Four hundred and eighty echocardiograms were analyzed and 46 (31%) patients showed cardiac abnormalities, frequently subclinical and transient. Nadir CD4 count was higher in patients with consistently normal echocardiogram: 263 (4-1480) versus 202 (5-1746) cells/μL, P = 0.021. Right ventricular (RV) dilation was detected in 18.9%, left ventricular (LV) dilation in 21.6%, septal hypertrophy in 12.2%, LV posterior wall hypertrophy in 6%, LV systolic dysfunction in 8% and pulmonary hypertension in 8.7% of patients. Opportunistic infections were associated with RV dilation [odds ratio (OR = 4.34; 1.78-10.53; P < 0.01)], pulmonary hypertension (OR = 8.78; 2.80-27.51; P < 0.01) and LV systolic dysfunction (OR = 5.38; 1.55-18.71; P < 0.01). Longer duration of highly active antiretroviral therapy was associated with reduced risk of LV dilation (OR = 0.91; 0.85-0.97; P < 0.01) and systolic dysfunction (OR = 0.71; 0.59-0.85; P < 0.01). Protease inhibitors use was associated with reduced risk of RV dilation (OR = 0.54; 0.30-0.97; P < 0.05), LV dilation (OR = 0.35; 0.21-0.60; P < 0.01) and LV systolic dysfunction (OR = 0.07; 0.02-0.31; P < 0.01). Higher CD4 count was associated with lower risk of LV systolic dysfunction (OR = 0.82; 0.69-0.98; P < 0.05).
DISCUSSION
The present study stands out for the serial echocardiographic evaluation of a cohort of pediatric patients with perinatal HIV infection, enabling determination of the frequency and course of cardiac impairment throughout their development. Furthermore, it revealed significant associations between echocardiographic abnormalities and clinical, immunologic and therapeutic parameters in this particular population.
Similarly to Patel et al,28 an association between lower CD4 values at nadir and the occurrence of cardiac compromise was detected. In fact, this was the only parameter that differed significantly between those with consistently normal and ever abnormal echocardiograms.
RV impairment in perinatally HIV-infected patients has not been extensively investigated since most studies focused exclusively on LV abnormalities. Moreover, RV dilation or systolic dysfunction is frequently attributed to PH in this population. The frequency of RV dilatation (18.9%) among our patients was higher than the frequency of PH (8.7%). Consequently, RV enlargement could not be interpreted solely as a consequence of an increased afterload. In fact, Simon et al29 proposed that RV compromise in HIV may represent an independent entity from PH and also from LV cardiomyopathy. In agreement with our results, those authors pointed out opportunistic infections and HAART toxicity as possible contributors to RV myocardial impairment. The use of non-nucleoside reverse transcriptase inhibitors, recently associated with LV dilation in HIV-infected patients,30 was otherwise associated with RV dilation in our cohort. The absence of PI in the antiretroviral regimen, previously related only to the LV dilation in children with HIV,30 was also associated with the presence of RV dilation in our patients. Similar to what was described for the LV in the AMP study,17 more severe HIV infection (CDC clinical classification C) was associated with greater RV compromise.
CONCLUSIONS
Echocardiograms identified subclinical cardiac abnormalities in perinatally HIV-infected patients, which were transient in a significant number of cases. Immunologic status and therapeutic strategies can influence cardiac outcomes in perinatally HIV-infected patients. Further prospective studies should be held to define which strategies adopted throughout childhood will reduce cardiovascular risk in adult life.
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