Anne-Marie Koop

298 In this study, a concept of a multi-biomarker approach has been outlined by assessing plasma levels of a panel of eight biomarkers in order to guide follow-up and eventually treatment strategies including optimization of timing of surgical or medicinal interventions. This serves the goal to prevent adverse processes of RV remodelling, such as metabolic and neuro-endocrine dysregulation, oxidative stress injury and fibrosis, and by that preserve RV function in time. The authors emphasize that an algorithmas shown in figure 3 is conceptual and hypothetical, requires further validation before clinical use and here solely serves the purpose of illustrating the potential value of blood-derived multi-biomarker profiles in children with CHD and abnormal RV loading conditions. Data regarding these biomarkers are still sparse and future research is needed to further elucidate the role of such multi-biomarkers profiles in pediatric heart disease. Since the current cohort predominantly included children with preserved functional class, this algorithm focuses on early detection of RV disease in this group of patients. Once validated, an algorithm like this may offer advances for children with CHD in remote areas, where advanced diagnostic tools to evaluate cardiac function are not available. Eventually, integrating the use of plasma biomarkers with the characterization of RV remodelling and metabolic processes in the RV by advanced imaging techniques, including single photon emission computed tomography, may further improve the clinical assessment of adaptive and mal-adaptive RV-responses to chronic abnormal loading conditions. LIMITATIONS This prospective study contains the completeness of both clinical and echocardiographic data in a relatively large pediatric cohort. However, the number of children per group for different types of RV overloadwas still modest which limited multivariate analyses. As this was a cross-sectional study, the prognostic value of the multi-biomarker approach on outcome and the use of the biomarker profile for treatment decisions could not be assessed. Larger, prospective cohort studies with longer follow-up are needed to investigate these additional and important questions. CONCLUSION In this pediatric cohort consisting of childrenwith a(n) (history of) abnormal RV loading conditions due to CHD or PH and with predominantly preserved functional status, plasma levels of NT-proBNP and ET-1 were increased in RV pressure overload in general, whereas hsTnT was identified as a marker for severe RV pressure overload. RVH was accompanied by increased levels of hsTnT, NT-proBNP, MR-proADM, GDF-15, MPO and ET-1, suggesting accompany of neuro-endocrine, inflammatory and metabolic processes. This study illustrates the potential use of an accessible,