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. 2026 Jan 8;26:115. doi: 10.1186/s12872-025-05497-8

Left ventricular geometric patterns and systolic myocardial performance in Nigerian children with homozygous sickle cell anaemia

Igoche D Peter 1,, Mustafa O Asani 2,3, Shehu U Abdullahi 2,3, Ibrahim Aliyu 2,3, Josephat M Chinawa 4,5, Stephen K Obaro 6,7, Fidelia Bode-Thomas 8,9
PMCID: PMC12870735  PMID: 41501639

Abstract

Background

Cardiac complications contribute significantly to morbidity in children with sickle cell anaemia (SCA). Little is known about the geometry and contractile function of the left ventricle (LV) of affected children in sub-Saharan Africa, which has the greatest burden of this disease.

Objective

To compare the LV systolic function of children with SCA in the steady state with that of matched haemoglobin AA controls.

Methods

Clinical, laboratory and LV M-mode echocardiographic parameters of 120 steady-state SCA patients aged 3–14 years were compared with those of matched Hb AA controls. Univariate and multivariate analyses were performed using SPSS software, version 22 (IBM, Armonk, NY, USA).

Results

The median ejection fraction of 62.00 (IQR = 55.0–67.0) for the subjects was significantly less than that of 68.00 (IQR = 65.8–73.0) for the controls (p < 0.001) and correlated negatively with age (ρ=-0.25, p = 0.006), BSA (ρ=-0.24, p = 0.008), systolic BP (ρ=-0.23, p = 0.022), and diastolic BP (ρ=-0.31, p = 0.002). Left ventricular systolic dysfunction (LVSD) was present in 27% of the SCA patients but only in 1% of the controls (χ² = 26.5, p < 0.001). The odds of having LVSD decreased by 0.9 for every 1% increase in HbF level (CI = 0.82–0.99, p = 0.03). Abnormal LV geometry, detected in 52% of the subjects, was associated with the presence of LVSD (Fisher’s exact test, p < 0.001). The odds of having abnormal LV geometry decreased by 0.5 for every 1 g increase in Hb level (CI = 0.27–0.87, p = 0.02).

Conclusions

LVSD is more common in SCA patients than in controls and is less likely to occur in patients with higher HbF levels. Approximately one in every two children with SCA have abnormal LV geometry, which is less likely to occur at higher Hb levels.

Keywords: Children, Sickle cell anaemia, Ejection fraction, Left ventricular hypertrophy, Left ventricular systolic dysfunction

Introduction

Sickle cell anaemia (SCA) is recognized by the World Health Organization (WHO) as a global public health problem with sub-Saharan Africa as its epicentre [1, 2]. Together with the reduced haemoglobin content causing chronic arterial hypoxaemia, the characteristic recurrent red cell selection impedes microcirculation, which results in tissue and organ injury [2]. The clinical manifestations of SCA are protean with multiorgan effects, including cardiovascular complications, which are recognized as significant contributors to morbidity in these children [3, 4]. The structural integrity and contractile function of the left ventricle in children with SCA have received little research attention, and conflicting findings have been reported as the few available studies with rather small sample sizes disagree as to whether there exists left ventricular systolic dysfunction [47]. Furthermore, Rees et al. [8] reported a significantly reduced left ventricular ejection fraction (LVEF) in children with SCA compared with controls in the USA, Chung et al. [9] in Jamaica, and Bamigboye-Taiwo et al. [10] in Nigeria found no significant difference between the two groups with respect to LVEF. Additionally, the relationship between haemoglobin and foetal haemoglobin levels and left ventricular systolic function and geometric patterns in paediatric SCA patients has remained largely unexplored.

This study was designed to determine and compare the LV systolic function of children with SCA in the steady state with that of matched haemoglobin AA controls and to determine the prevalence and factors associated with LV systolic dysfunction (LVSD) and abnormal geometry in Nigerian paediatric SCA patients.

Methods

This was an observational, descriptive, cross-sectional comparative study

The study population comprised 120 paediatric SCA subjects and matched haemoglobin AA controls aged 3–14 years who were systematically sampled over a period of 8 months from the population of children attending the Sickle Cell Clinic of Aminu Kano Teaching Hospital, Kano. Every fourth eligible subject whose haemoglobin phenotype had been confirmed by high-performance liquid chromatography (HPLC) who was admitted to the clinic was enrolled in the study. These patients were hydroxyurea naïve and were crisis-free for at least 3 weeks, with no history of blood transfusion in the preceding 3 months. Patients who were sickle cell carriers on chronic transfusion therapy or who had any chronic or recent (within the preceding 3 weeks) respiratory illness, human immunodeficiency virus (HIV) infection, renal disease or any congenital/acquired heart disease were excluded from the study. An equal number of age- and sex-matched apparently healthy children with an HPLC-confirmed Hb AA phenotype without congenital or acquired heart disease or any other chronic medical illnesses were recruited from the Paediatric Outpatient Department. Recruitment of controls was done by intentional matching with already selected cases, and not by systematic sampling.

A pretested interviewer-administered questionnaire was used to collect information (biodata, clinical history and physical examination, including anthropometry, laboratory, and echocardiography findings) from both the subjects and controls. Echocardiography was performed by one of the authors (IDP) using an SSI-8000 cardiac ultrasound system (SonoScape, Shenzhen, China). For quality control, 10% of the echocardiograms were independently validated by the second author (MOA). Left ventricular dimensions in systole and diastole (including LVID, IVST, and PWT) were measured according to the American Society of Echocardiography paediatric echocardiography guidelines [1113]. The percentage of fractional shortening (FS) and the ejection fraction (EF) were derived from these dimensions and calculated automatically by the machine, and left ventricular systolic dysfunction (LVSD) was considered present if the EF was less than 55% [12, 13]. Left ventricular mass (LVM) was calculated using the following formula: [11]. 

graphic file with name d33e405.gif

The LVM index was calculated by dividing the LVM by the body surface area (BSA) and compared with published normative values [14].

The relative wall thickness (RWT) was derived from [Inline graphic]-obtained values and compared with published cut-off values [15], and the left ventricular geometry was classified as follows: [16] normal LV geometry; normal RWT and normal LVMI; eccentric LVH; high LVMI and low RWT (< 0.45); dilated internal ventricular dimensions; concentric LVH; high LVMI; and high RWT (> 0.45). In this patient, wall thickness increased in the presence of a normal internal ventricular diameter, concentric LV remodelling, a high RWT and a normal LVMI.

Laboratory investigations

Haemoglobin levels were determined from venous blood samples using the Swelab Alpha Automated haematology system (Boule Medical, Stockholm, Sweden), while the Hb phenotypes and foetal haemoglobin (HbF) levels of all study participants were determined using the Variant II Haemoglobin Testing System (Bio-Rad, Hercules, CA, USA).

Statistical analysis

The data were analysed using the Statistical Package for Social Sciences (SPSS) software, version 22 (IBM, Armonk, NY, USA). Continuous variables were assessed for normality using the Kolmogorov‒Smirnov test. Descriptive statistics, including the mean (standard deviation) and median (interquartile range), were used to summarize continuous and normally or nonnormally distributed data, respectively. Student’s t test (for normally distributed data) or the Mann‒Whitney U test (for nonnormally distributed data) were used for comparisons. The correlation of the ejection fraction with clinical and laboratory parameters was examined using Spearman rank order correlation (as these data were all nonnormally distributed). Multiple logistic regression analysis using the backward elimination process was used to determine predictors of LV systolic dysfunction and the presence of abnormal LV geometry. A p value < 0.05 was considered significant.

Results

Baseline characteristics of the subjects and controls

A total of 120 children with SCA and an equal number of age- and sex-matched controls were enrolled in this study. There were 67 male and 53 female subjects and controls, for a male: female ratio of 1.3:1. The respondents’ median age was 7 years (IQR 5.0–11.0). Both subjects were similar with respect to body surface area and diastolic blood pressure. However, SCA patients had higher systolic BP and lower oxygen saturation (Table 1).

Table 1.

Comparison of General Characteristics of SCA Subjects with Age- and Sex-Matched Controls

Parameter Median (IQR) SCA subjects Hb AA controls p- value
Pallor <0.001* j
 Yes 57 (57.0) 0 (0.0)
 No 43 (43.0) 100 (100.0)
Jaundice
 Yes 37 (37.0) 0 (0.0)
 No 63 (63.0) 100 (0.0)  <0.001* j
Digital clubbing 1.00f
 Yes 1 (1.0) 0 (0.0)
 No 99 (99.0) 100 (100.0)
Systolic BP (mmHg) 100.0 (90-110) 90.0 (80-100) 0.003*
Sat O2 (%) 97.0 (93-98) 99.0 (98-99) <0.001*
Diastolic BP (mmHg) 60.0 (50-70) 60.0 (50-70) 0.13
BSA (/m2) 0.8 (0.7-1.0) 0.9 (0.7-1.0) 0.34
Weight (Kg) 20.0 (18.0-27.0) 21.0 (17.0-28.3) 0.65

Height (cm)

Mean (±SD)

118.6±16.0 121.4±19.7 0.28
Hb F (%)  9.5 (5.1-14.4) 0.6 (0.4-1.0) <0.001*
Hb (g/dl) 7.9 (7.2-8.6) 11.0 (10.3-11.7) <0.001*

Keys: IQR Interquartile range, SCA Sickle cell anaemia, Hb Haemoglobin, Hb F Foetal haemoglobin, BP Blood pressure, mmHg millimetres of mercury, Kg Kilogram, g/dl grams per decilitre, f- Fisher exact, j- Chi square, BSA Body surface area, m2- meter squared

*Statistically significant (based on Mann-Whitney U test done for all except Weight which had Student T test done)

Children with SCA were significantly different from the controls with respect to the presence of jaundice (83.3%) and pallor (60.0%) (p < 0.001).

SCA patients had significantly lower median haemoglobin and foetal haemoglobin levels than controls (Table 1).

LV dimensions and functional parameters

The left ventricular internal dimensions were significantly greater in the systole- 2.8 cm (IQR 2.4–3.0.4.0) for the SCA group than in the control- 2.2 cm (IQR 2.0–2.4.0.4) group (p < 0.001) and in the diastole- 4.0 ± 0.5 cm for the SCA group when compared with the control group (3.6 ± 0.5 cm; p < 0.001). While the interventricular septum in systole was significantly thinner in SCA subjects, the LV posterior wall was significantly thicker in diastole but not significantly thicker in systole (Table 2).

Table 2.

LV Dimensions and Functional Parameters in Subjects and Controls

Parameter SCA subjects Hb AA controls p- value

LVMI (g/m2)

Median (IQR)

71.7 (56.7-91.7) 41.9(35.8-54.1) <0.001*

EF (%)

Median (IQR)

62.0 (55.0-67.0) 68.0 (65.8-73.0) <0.001*

FS (%)

Median (IQR)

33.0 (27.3-36.8) 37.0 (35.0-41.0) <0.001*

LVIDd (cm)

Mean (±SD)

4.0 (±0.5) 3.6 (±0.5) <0.001*

LVIDs (cm)

Median (IQR)

2.8 (2.4-3.0) 2.2 (2.0-2.4) <0.001*

LVPWTs (cm)

Median (IQR)

0.9 (0.7-1.0) 0.8 (0.7-0.9) 0.41

LVPWTd (cm)

Median (IQR)

0.6 (0.5-0.7) 0.6 (0.5-0.7) 0.02*

IVSTs (cm)

Median (IQR)

0.5 (0.4-0.6) 0.6 (0.5-0.7) <0.001*

IVSTd (cm)

Median (IQR)

0.4 (0.4-0.6) 0.3 (0.3-0.5) <0.001*

RWT (cm)

Median (IQR)

0.3 (0.2-0.3) 0.3 (0.2-0.3) 0.95

Keys: SCA Sickle cell anaemia, Hb Haemoglobin, LVMI Left ventricular mass index, EF Ejection fraction, FS Fractional shortening

*Statistically significant (based on Mannn-Whitney U test done for all except LVIDd which had Student T test done done), LVIDd- Left ventricular internal dimension in diastole, LVIDs Left ventricular internal dimension in systole, LVPWTs Left ventricular posterior wall thickness in systole, LVPWTd Left ventricular posterior wall thickness in diastole, IVSTs Interventricular septum thickness in systole, IVSTd Interventricular septum thickness in diastole, RWT Relative wall thickness

LV systolic dysfunction

The median ejection fraction and fractional shortening were also significantly lower in the subjects than in the controls, with values of 62.0% (IQR 55.0–67.0) and 33.00% (IQR 27.3–36.8), respectively, in the subjects and 68.0% (IQR 65.8–73.0) and 37.0% (IQR 35.0–41.0), respectively, in the controls (p < 0.001) (Table 2). Left ventricular systolic dysfunction was therefore present in 27% of the SCA patients but only in 1% of the controls (χ² = 26.5, p < 0.001).

Patient characteristics in relation to LV dysfunction

Spearman’s rank correlation showed a significant negative relationship between EF with age (ρ=−0.25, p = 0.006), BSA (ρ=−0.24, p = 0.008), systolic (ρ=−0.23, p = 0.022) and diastolic (ρ=−0.31, p = 0.002) BP i.e., EF declines significantly with increasing in these variables (Table 3).

Table 3.

Correlation of EF with Clinico-laboratory parameters

Parameter Spearman’s rho p- value
Age −0.25 0.006*
Body surface area −0.24 0.008*
Haemoglobin −0.12 0.184
% Foetal haemoglobin 0.09 0.336
Oxygen saturation −0.02 0.871
Systolic blood pressure −0.23 0.022*
Diastolic blood pressure −0.31 0.002*

Although SCA patients with LVSD were older (8.5 years, IQR 7.0–12.0) than those without this abnormality (7.0 years, IQR 5.0–10.0), this difference was not statistically significant (p = 0.34). Subjects with LVSD had a significantly greater diastolic BP (70 mmHg; IQR 60–70) than did those without this abnormality (60 mmHg; IQR 50–70) (p = 0.04).

The odds of having LVSD decreased by 0.9 for every 1% increase in HbF level (CI = 0.82–0.99, p = 0.03) (Table 4).

Table 4.

Adjusted odds ratios with 95% confidence intervals for multiple logistic regression analysis to determine predictors of LV systolic dysfunction

Parameters Adjusted odds ratio (95% Confidence interval) p- value
HbF (%) 0.9 (0.82–0.99) 0.03*
Hb (g/dl) 1.7 (0.94–3.17) 0.80
Systolic BP (mmHg) 0.9 (0.92–1.06) 0.69
Diastolic BP (mmHg) 1.3 (0.96–1.12) 0.37
Abnormal LV geometry 1.1 (0.53–4.13) 0.45

*Statistically significant

LV geometric patterns

Of the 120 SCA patients studied, 48% had normal LV geometry, and 52% had abnormal LV geometry. Eccentric LVH was the predominant abnormal pattern and was present in 50%, concentric LVH was present in 2%, and none had concentric remodelling (Fig. 1).

Fig. 1.

Fig. 1

Left ventricular geometric patterns of 120 SCA patients

The presence of abnormal LV geometry was associated with LVSD (Fisher’s exact test, p < 0.001). The odds of having abnormal LV geometry decreased by 0.5 for every 1 g increase in Hb level (CI = 0.27–0.87, p = 0.02), as shown in Table 5.

Table 5.

Adjusted odds ratios with 95% confidence intervals for multiple logistic regression analysis to determine predictors of abnormal LV geometry

Parameters Adjusted odds ratio (95% Confidence interval) p- value
Hb (g/dl) 0.5 (0.27–0.87) 0.02*
HbF (%) 0.9 (0.89–1.05) 0.39
Systolic BP (mmHg) 1.0 (0.97–1.09) 0.30
Diastolic BP (mmHg) 0.98 (0.92–1.06) 0.64

*Statistically significant

Discussion

The present study confirmed that LV systolic function is significantly lower in children with SCA, as they were found to have a significantly lower median ejection fraction; hence, the prevalence of LV systolic dysfunction was 27% greater in these patients than in their Hb AA counterparts. This difference in ejection fraction is in tandem with the observations made by Rees et al. [8] and Animasahun et al. [17]. Other investigators, however, have reported contrary observations, which may be due to several factors, including their smaller sample size and possibility of interobserver variability in echo measurements performed by different sonographers. Chung et al. [9] reported a sample size 5 times smaller than ours, possibly obscuring the true picture. Similarly, Bamigboye-Taiwo et al. [10], who also found no statistically significant difference between the two groups for ejection fraction, not only had a sample size of up to 70 subjects less than that in the present study but also had different echocardiographers who took measurements; however, they did not account for the reliability of the measurements. Our observation of impaired LV systolic function in SCA patients is conceivable from the significantly increased dimensions of the left ventricle in both phases of the cardiac cycle in our SCA cohort. Since the ejection fraction is an index of fibre shortening, dilatation of the left ventricular chamber contributes to a reduction in the ejection fraction [18]. In such hearts, there is “functional apical dead space”, as the apex empties poorly, as explained by the results of layered dissections of such hearts, which demonstrate that the middle circumferentially oriented muscle bundles, which normally cover only the upper 60% of the ventricular chamber, in chamber dilatation, extend to the apex, which ordinarily should be covered with spirally directed fibres [19].

The ejection fraction decreased significantly with age, BSA, and systolic and diastolic BP in children with SCA. Although Animasahun et al. [17] and Bamigboye-Taiwo et al. [10] did not observe any correlation between EF and age or between EF and BSA, Balfour et al. [20] showed that LV function deteriorates with age. The latter report had a sample size of 124 children with SCA, similar to our study, whereas the former two studies had a much smaller sample size than our study. Therefore, there is a need to monitor left ventricular functional parameters as these subjects grow older.

Our data has established the role of HbF in LVSD as we found that higher HbF levels were protective against LV systolic dysfunction, as every 1% increase in HbF decreased the risk of LV systolic dysfunction by a small but significant extent, almost 1%. More data will be necessary to validate this concept, which should be of therapeutic importance which to the best of the authors’ knowledge, this has not been previously reported. Foetal haemoglobin has long been known to be beneficial for some complications of SCA, and the present study has established its role in preserving LV systolic function [21]. Further studies are recommended to validate our observation of the protective role of HbF against LV systolic dysfunction in SCA patients, with a focus on therapeutic implications.

More than half of our SCA patients had LV hypertrophy, and this observation is similar to that of Bamigboye-Taiwo et al. [10]. Similarly, in the aforementioned study, Johnson et al. [22] and our group reported that eccentric LVH was the most common type among SCA patients, and this was associated with an intermediate risk for cardiovascular outcomes. Furthermore, we showed that the odds of having abnormal LV geometry decreased by 0.5 times with every 1 g increase in haemoglobin. Therefore, measures to optimize haemoglobin levels should be strictly adhered to in children with SCA, as this will be valuable in maintaining a normal LV geometry and hence good cardiovascular health.

Conclusion

LVSD is more common in SCA patients than in controls and is less likely to occur in patients with higher HbF levels. Approximately one in every two children with SCA have abnormal LV geometry, which is less likely to occur at higher Hb levels.

Acknowledgements

Not applicable.

Abbreviations

HbF

Foetal haemoglobin

LVEF

Left ventricular ejection fraction

LVSD

Left ventricular systolic dysfunction

SCA

Sickle cell anaemia

Authors’ contributions

I.D.P., M.O.A, S.U.A. and F.B. conceived the study; I.D.P., F.B. and I.A. designed the study protocol; I.D.P. and M.O.A. carried out the clinical assessment and I.D.P. carried out echocardiography; I.D.P., M.O.A., S.U.A., F.B. and S.K.O. drafted the manuscript; M.O.A., S.U.A., F.B., J.M.C. I.A. and S.K.O. critically revised the manuscript for intellectual content. All authors re and approved the final manuscript.

Funding

Nil.

Data availability

The data that support the findings of this study are available from [P.I.D.], but restrictions apply to the availability of these data, which were used under licence for the current study and so are not publicly available. The data are, however, available from the authors upon reasonable request and with permission from [P.I.D.].

Declarations

Ethics approval and consent to participate

Approval from the Ethics and Research Committee of Aminu Kano Teaching Hospital, Kano, was obtained for this study (NHREC/21/08/2008/AKTH/EC/1296). Written informed consent was obtained from the parents of the subjects prior to enrolment in the study, in addition to obtaining assent from the children aged 7 years and older.

Consent for publication

Granted.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from [P.I.D.], but restrictions apply to the availability of these data, which were used under licence for the current study and so are not publicly available. The data are, however, available from the authors upon reasonable request and with permission from [P.I.D.].


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