Three-directional phase velocity mapping (PVM) is capable of measuring longitudinal, radial and circumferential regional myocardial velocities. Current techniques use Cartesian k-space coverage and navigator-gated high spatial and high temporal resolution acquisitions are long. In addition, prospective ECG-gating means that analysis of the full cardiac cycle is not possible. The aim of this study is to develop a high temporal and high spatial resolution PVM technique using efficient spiral k-space coverage and retrospective ECG-gating. Detailed analysis of regional motion over the entire cardiac cycle, including atrial systole for the first time using MR, is presented in 10 healthy volunteers together with a comprehensive assessment of reproducibility.A navigator-gated high temporal (21 ms) and spatial (1.4 × 1.4 mm) resolution spiral PVM sequence was developed, acquiring three-directional velocities in 53 heartbeats (100% respiratory-gating efficiency). Basal, mid and apical short-axis slices were acquired in 10 healthy volunteers on two occasions. Regional and transmural early systolic, early diastolic and atrial systolic peak longitudinal, radial and circumferential velocities were measured, together with the times to those peaks (TTPs). Reproducibilities were determined as mean ± SD of the signed differences between measurements made from acquisitions performed on the two days.All slices were acquired in all volunteers on both occasions with good image quality. The high temporal resolution allowed consistent detection of fine features of motion, while the high spatial resolution allowed the detection of statistically significant regional and transmural differences in motion. Colour plots showing the regional variations in velocity over the entire cardiac cycle enable rapid interpretation of the regional motion within any given slice. The reproducibility of peak velocities was high with the reproducibility of early systolic, early diastolic and atrial systolic peak radial velocities in the mid slice (for example) being −0.01 ± 0.36, 0.20 ± 0.56 and 0.14 ± 0.42 cm/s respectively. Reproducibility of the corresponding TTP values, when normalised to a fixed systolic and diastolic length, was also high .Retrospectively gated spiral PVM is an efficient and reproducible method of acquiring 3-directional, high resolution velocity data throughout the entire cardiac cycle, including atrial systole. Cardiovascular Magnetic Resonance (CMR) is a well established tool for measuring cardiac function. Global parameters of function such as ejection fraction and ventricular volumes are routinely used clinically as predictors of prognosis , howeverPVM does not suffer from tag fading and several studies have used PVM to assess regional myocardial motion. Early work measured only longitudinal velocities, but established that the technique was capable of characterising global and regional myocardial motion and detecting abnormal motion in patients with infarcts. However, the long scan times – even though respiratory gating was not used - meant application of the technique was unfeasible in clinical practice . The devImproved temporal and spatial resolution may be achieved by acquiring data during free-breathing with diaphragmatic navigators limiting the motion to a small range  around the end expiratory pause position . NavigatOne approach to speeding up MR acquisitions is to use a more efficient k-space trajectory, such as spirals . Using sProspective cardiac gating has been used in all previous PVM studies of the myocardium which limits data acquisition to approximately 90% of the cardiac cycle. In contrast, applying retrospective cardiac gating to PVM of the myocardium would allow the analysis of 100% of the cardiac cycle, including atrial systole, a feature of cardiac motion that to our knowledge has not previously been shown with MR studies. In healthy motion atrial systole accounts for 20–30% of LV filling, but in diseases where diastolic function is impaired, atrial systole can become more important to allow preservation of LV function . AnalysiThe aim of this work is to develop a spiral trajectory phase velocity mapping sequence allowing the acquisition of high temporal and spatial resolution data in a reasonable time period. The sequence is implemented with retrospective cardiac gating to allow analysis of the entire cardiac cycle. Data are acquired in 10 healthy subjects and global, regional and transmural motion characterised in terms of systolic and early diastolic peak velocities and their timings. In addition, repeat scanning of the ten subjects on a second occasion enables a comprehensive assessment of the inter-study reproducibilities of the global and regional parameters characterising myocardial motion.A retro-gated phase velocity mapping sequence with three orthogonal directions of velocity encoding was developed using spiral readout gradients. K-space was covered using 13 spiral interleaves of 12 ms duration. To improve the temporal resolution of the sequence, reference and velocity encoded data were acquired on consecutive cardiac cycles following a single dummy cardiac cycle. The total acquisition duration for the four datasets making up a single acquisition (reference and 3-velocity encoded) was therefore 53 cardiac cycles (assuming 100% respiratory efficiency). Bipolar velocity encoding gradients prior to the spiral readouts resulted in velocity sensitivities of 30 cm/s through-plane and 20 cm/s in-plane. A black blood pulse of duration 6 ms .A 1–1 binomial water excitation pulse (flip angle = 15 degrees) was implemented to reduce off-resonance blurring of fat. The acquired temporal resolution was 21 ms. The retrospective reconstruction mode available on the scanner was used to interpolate linearly between the acquired time points to produce 60 equally spaced phases through the heart cycle, leading to a reconstructed temporal resolution of 14–20 ms depending on heart-rate. A field of view of 360 mm was used and the spiral data re-gridded onto a 256 × 256 matrix using a standard gridding technique  leading in vivo studies showed that a simple accept/reject algorithm based on this single navigator did not provide good respiratory motion compensation throughout the entire cardiac cycle (as discussed later). Instead, the algorithm implemented ensured that data acquired within a given cardiac cycle was only accepted if both the navigators immediately before and after that data acquisition were within the acceptance window. This stricter acceptance criterion - requiring the navigators on two consecutive cardiac cycles to be within the acceptance window - results in markedly reduced scan efficiency and so a guided breathing technique was introduced to ensure reasonable scan duration. During the data acquisition, the respiratory trace was displayed in real-time on a screen visible to the subject in the scanner. The subject could then use this visual feedback to guide their breathing, completing the scan in a series of breath-holds or by slow and steady breathing, or by a combination of the two.A 90°/180° crossed-pair navigator   in 10 healthy volunteers . In all 10 subjects, all three acquisitions were repeated on a second occasion (on average 9.7 days later) in order to assess inter-study reproducibility. The two studies were carried out at similar times of day. Heart rates were noted for each acquisition. The study was in compliance with the Helsinki Declaration and was approved by an institutional review committee (East London REC 3). All subjects gave written informed consent.The retrogated spiral phase velocity mapping sequence was implemented on a clinical scanner  equipped with an anterior cardiac 18-element matrix coil and a 48 element spine array. 6 elements of the cardiac coil and 6 of the spine coil were used for all Background phase errors were determined for each acquired dataset by scanning a large homogeneous stationary phantom  using the same sequence parameters and the same slice positions as in the volunteer study. A simulated ECG with the same heart-rate as the subject was used to trigger the acquisitions. The velocity maps from these phantom acquisitions were smoothed using a median filtering technique to reduce noise and then subtracted from the volunteer data on a pixel-by-pixel basis .Custom software programmed using MATLAB  was used to analyse the images. The myocardium was manually segmented in each frame with a spline drawing algorithm. Both the magnitude images and the velocity maps were used to locate the position of the endo- and epicardial borders by eye. Background corrected velocities were transformed into a cylindrical system of co-ordinates natural to the LV anatomy (with a polar axis defined by the anterior LV-RV meeting point and the centre of mass of the slice at each time-point) and the slices were segmented according to the AHA 17 segment model , resultiL, SR) and diastolic  velocities were determined together with the times to those peaks (TTP (ms)) from the R-wave. The longitudinal and radial velocity-time curves also show a late peak in atrial systole  which was recorded along with the TTP ASL and TTP ASR. In the circumferential velocity-time curves, two early systolic peaks (C1 and C2) were recorded in all three slices along with their TTP values. In the basal and apical slices a third peak (C3) was also seen in early diastole. All TTP values were recorded in ms (from the R-wave) and also as percentages of the length of systole or diastole as appropriate. The length of systole was determined as the time from the R-wave to the first negative radial peak which represented end systole and which could be seen in all scans [Calculated global and segmental parameters are labelled on example basal short-axis longitudinal (a), radial (b) and circumferential (c) velocity-time curves in Figure ll scans .In addition, the ratio of the early diastolic peak to the atrial systolic peak in longitudinal and radial directions was calculated for both regional and global velocity-time curves. This is analogous to the parameter E/A (the ratio of peak early (E) filling and late diastolic filling (A) measured at the level of the mitral valve in echocardiography to assess diastolic function .Statistical testing was performed using SPSS . All parameters were checked for normality using the Shapiro-Wilk test. The mean ± standard deviation (SD) of global longitudinal, radial and circumferential parameters was determined for each slice . Repeated measures analysis of variance (with Greenhouse-Geisser correction in the case of non-sphericity) and paired t-testing (with Bonferroni correction for multiple testing) were used to compare parameters between slices. Differences between endo, mid and epi-cardium velocities were similarly analysed.As well as segmenting the myocardium according to the 17-segment model for the analyses described above, each slice was also segmented into 24 equal angle segments. Regional velocities in these segments were normalised to a fixed RR interval and averaged over the ten healthy volunteers. This normalisation was performed independently for systole, early diastole, diastasis and atrial systole, as discussed later. The velocities were colour coded and displayed in a grid with circumferential position in the myocardium  plotted along the vertical axis and time from the R-wave along the horizontal axis. These 2D colour plots effectively summarise normal regional velocity-time patterns through the entire cardiac cycle.Inter-study reproducibility of all parameters  was determined as the mean +/− SD of the signed differences between repeat acquisitions, together with Bland-Altman analysis . The intData were successfully acquired from the basal, mid and apical slices on two separate occasions for all ten healthy volunteers. Figure Figure Mean ± SD of all measured and derived velocity parameters can be found in Table As expected the peak systolic and diastolic velocities in the longitudinal direction are higher at base than apex . In 1 apical velocity-time curve, atrial systole was not clearly shown but in the remaining cases, peak longitudinal atrial systolic velocities also showed a significant decrease from base to apex .Radial velocities do not show any trend when moving from base to apex, with similar peak systolic, diastolic and atrial systolic velocity values at all levels. Atrial systole is seen clearly in all cases.Circumferential velocity-time curves show two peaks (C1 and C2) in opposite directions in rapid succession at the beginning of systole at all 3 levels. Both C1 and C2 are higher at base than apex . The opposite directions of circumferential motion in early diastole (C3 at base vs C3 at apex) indicate the characteristic untwisting of the ventricle during relaxation. In the mid-slice there is no consistent peak in global velocities at early diastole and so no values for C3 in the mid-slice are shown.L, SR, C1 and C2) but increases for early diastolic parameters  and increases further for late diastolic parameters . This is clearly seen in Figure L is 858.5 ± 137.5 ms from the R-wave but 869.4 ± 30.6 ms when expressed in terms of the average systolic and diastolic length.Table Average longitudinal regional velocity-time curves  for the 6 AHA segments of the mid short-axis slice are shown in Figure The same data can also be shown in a 2D colour plot  immediately after the R-wave. At base and mid levels this first peak is followed by a second peak in the opposite direction (C2) (which is strongest at base). C2 is also present at apical levels, although it can be either positive or negative, depending on the exact slice position. During early diastole the motion is highly dependent on slice position. At basal level, C3 is a sharp negative peak which shows some regional variation in timing, whereas at apex the peak is broader but positive, leading to the characteristic wringing motion of the heart. C3 is not present in the global velocity-time curves of the mid slice, however a small negative peak with highly regional timing can be seen on the colour plots in early diastole.Table Longitudinal peak velocities show no difference between endocardium and mid myocardium, however for both systolic and diastolic peaks there is a significant difference between mid-wall and epicardium (P = <0.05 for both). Circumferential velocities show significant differences in C1 between endocardium and mid (P < 0.05) and between all layers for C2 (P < 0.05 and P < 0.001 respectively).L) to 1.54 cm/s (mid DL) in the longitudinal direction, 0.27 cm/s  to 0.96 cm/s  in the radial direction and 0.38 cm/s  to 0.64 cm/s  in the circumferential direction. Peak atrial systolic velocities also show small standard deviations of signed differences, particularly in the radial direction , 0.43 cm/s (mid) and 0.45 cm/s ). E/A is more reproducible in the radial direction than in the longitudinal direction at all levels.The inter-study reproducibilities of retrospective spiral phase velocity mapping for measuring peak systolic and diastolic velocities are shown in Table L, SR, C1 and C2) is high at all slice levels , while that of later peaks  is reduced. When expressed in terms of percentages of systole or diastole as appropriate, the reproducibility is high for all TTP values. This improvement can best be seen by converting the percentages of systole or diastole into milliseconds based on the average length of systole or diastole: these values are shown in the last two columns of Table The inter-study reproducibilities of TTPs are shown in Table An efficient method for acquiring three directional velocities over the entire cardiac cycle using spiral k-space trajectories has been developed and is capable of acquiring high resolution images in a relatively short time. The implementation of retrospective cardiac gating has enabled analysis of myocardial mechanics through the entire cardiac cycle, including atrial systole which has not previously been seen with MR PVM techniques. We have presented global, regional and transmural data in the basal, mid and apical short-axis slices of 10 healthy volunteers together with a detailed analysis of the inter study reproducibility of systolic, early diastolic and late-diastolic peaks and their timings.The use of spirals has allowed the acquisition of images with high spatial (1.4 mm × 1.4 mm) and temporal 21 ms) resolution in a short time (53 cardiac cycles) which compares favourably with previous Cartesian schemes  in 128 cardiac cycles  or 2.6 ×1 ms resoA previous study found that simple accept/reject navigator algorithms using a single navigator per cardiac cycle are not sufficient to deal with respiratory motion for prospectively gated PVM of the myocardium . SimilarDuring navigator output and feedback, no image data may be acquired. For prospective cardiac gating this means that no velocity information is available during this time, whereas for retrospective gating it results in decreased accuracy in the retrospective data interpolation close to the navigator. In this study, the navigator duration (9 ms) and feedback time (10 ms) were reduced as much as possible to minimise this problem. However, the retrospective cardiac gating allows us to calculate average velocities for the entire cardiac cycle, and, because they are close to zero (see Results), we can be confident that the accuracy of the technique overall is very good. An acceptance window of 5 mm has been used – as is conventional in high resolution coronary artery studies - which allows good suppression of respiratory artefact while ensuring that the scan efficiency is not too low.Global longitudinal peak systolic and early diastolic velocities show the expected reductions from base to apex and this pattern is also seen in the atrial systolic peak velocities. The atrial systolic peak in longitudinal velocity measures the passive motion of the ventricle as the atria contract, pulling the base of the ventricle towards them. The peak velocity is therefore larger at base (−2.62 ± 0.99 cm/s) than at apex (−0.81 ± 0.29 cm/s) and was not seen in 3 (out of the 20) apical acquisitions, perhaps because atrial systole is not sufficiently strong in some patients to allow passive longitudinal motion to be detected at the apical level. Atrial systole also causes passive radial motion in the left ventricle at all levels, caused by blood being forced into the LV by the contraction of the atria: reduced radial peak velocity in atrial systole could therefore indicate reduced LV compliance. As expected, in the radial direction, there were no changes in the magnitude of any of the peak velocities from base to apex while in the circumferential direction, the characteristic wringing of the heart was clearly apparent through the opposite polarity of the C3 peaks at the basal and apical levels. The circumferential motion is most complicated and agrees well with previously published results .In addition to the quantification of peak velocities, the retrospective cardiac gating has enabled us to determine the ratio of peak diastolic velocity and peak atrial systolic velocity  in healthy subjects. In echocardiography blood flow velocities at the mitral valve are measured at early diastolic filling (the E-wave) and during atrial systole (the A-wave). The blood velocity is well established to reflect the LA-LV pressure gradient and hence these measurements can give important information about preload, alterations in LV relaxation, LV compliance and LA contractile function: mitral annular velocities are also used to give similar information . The ratTime to peak (TTP) velocities have also been investigated and normal values are shown in Figure The high spatial resolution of our technique also allows detailed analysis of regional variations of myocardial motion. Regional myocardial velocity information has been displayed on colour plots. These are analogous to bulls eye plots which show all of the velocity information for the complete myocardium at a single time point in the cardiac cycle , but insR in the mid slice was −0.01 ± 0.36 cm/s compared with −0.12 ± 0.84 cm/s with 37–87 ms temporal resolution [L compared with −0.51 ± 2.1 cm/s in a navigator study with 35 ms resolution [The inter-study reproducibilities of peak velocity data are high and are better than those obtained with lower temporal resolution sequences, both using breath-holding techniques (eg Ssolution ) and navsolution , the repA Cartesian trajectory PVM technique has been used previously to assess healthy motion in subjects and in several patients ,35, howeBy using spiral k-space trajectories, high temporal and spatial resolution PVM images can be acquired in a much reduced time when compared with conventional imaging techniques. Fine regional and temporal variation in velocities can be seen, and retrospective cardiac gating enables the assessment of atrial systole. The 2D colour plots clearly and effectively depict regional velocities allowing easy assessment of myocardial motion over the entire cardiac cycle. The reproducibility of the technique has been comprehensively assessed. Spiral PVM has the potential to be a useful and reproducible clinical tool for assessing regional myocardial motion.CMR: Cardiovascular magnetic resonance; DENSE: Displacement encoding with stimulated echoes; LV: Left ventricle; PVM: Phase velocity mapping; SD: Standard deviation; SENC: Strain encoded imaging; SNR: Signal to noise; TTP: Time to peak.The authors declare that they have no competing interests.RS was involved in developing the sequence, collecting and analysing the data and drafting the manuscript. JK was involved in designing the study, developing the sequence and revising the manuscript. DF was involved in designing the study and revising the manuscript. All authors have read and approved the final manuscript.Jennifer Keegan and David Firmin are joint senior authors.


In cardiovascular research, there is an increasing interest in high-field MRI to characterize cardiac anatomy and function in small rodents. However, data on reproducibility of the method are scarce. Our aim was to evaluate the intra-observer, inter-experiment and inter-observer variability of left ventricular (LV) mass and volumes measurements in mice using an 11.7T MRI scanner.Seven 10 weeks-old C57Bl6J male mice were studied, including 4 animals with a surgical transverse aortic constriction in order to produce cardiac hypertrophy. 3 were sham (control) mice.During the entire procedure, animals were anaesthetized with Isoflurane 1-3%, in a temperature-controlled setting. Scan were retrospectively gated for electrocardiogram (ECG) and respiration. Imaging was performed on a 11.7 Tesla Bruker MR scanner. Cardiac scout images were obtained in the conventional planes with a tripilot sequence. A 2D cine FLASH sequence was applied to acquire a set of 7 contiguous short axis images covering the entire ventricles, perpendicular to the LV long axis. One day after the procedure, mice were scanned again under the same conditions.The LV systolic function was assessed from each stack of images by tracing epicardial and endocardial borders, including papillary muscles, on the Segment software . End-diastolic (EDV), end-systolic (ESV) and stroke volume (SV) were determined (µl). LV ejection fraction  and LV mass (mg) were subsequently deduced. One stack of images was analyzed twice by the same person, and once by an independent observer.Accurate quantitative data were obtained in all animals. The Table In our hands, reproducibility was excellent for LV mass and EDV, good for ESV and EF to a lesser extent, and more limited for the stroke volume, with a bad inter-observer correlation. This highlights the need to interpret our results by taking into account these limitations, focusing on more reproducible parameters when interpreting data.This work was supported by grants from the Fonds de la Recherche Scientifique FRS-FNRS.


Acute myocarditis clinical onset can span from subclinical disease to acute heart failure, fatal arrhythmias or sudden cardiac death. Patients with more severe clinical onset have larger areas of inflammation and contrast enhancement which are directly correlated with left ventricular systolic function.acute myocarditis (AM) clinical onset can span from subclinical disease to acute heart failure (AHF) ventricular fibrillation (VF) or sudden cardiac death in young adults. Myocarditis can underly the aetiology of other cardiomyopathies (CM) such as dilated CM arrhythmogenic left or right ventricle CM. Aim of the study was to evaluate the relationship between myocardial oedema and late enhancement (LGE) extension and clinical presenting patterns of acute myocarditis by means of cardiac magnetic resonance imaging (CMR).Eighty-two consecutive patients (pts) referred for suspected myocarditis from 2007 to 2010 were retrospectively analyzed. Symptoms, ECG changes, reduced myocardial function, elevated creatine kinase, positive troponin T, suggested AM. Coronary artery disease was excluded at angiography. Patients were studied on days x±y after the onset of symptoms The diagnosis was confirmed by CMR (Siemens Avanto 1.5 Tesla) according to the presence of typical signal hyperintensity at Short Tau Inversion Recovery (STIR) images, associated with concordant LGE (0.1mmol/Kg gadobutrol) distribution . The area of enhancement on STIR and CE-IR images were measured by commercial software and expressed as percentage of the LV. Data are x±SD, significant difference p<0.05.According to the initial clinical picture pts were divided into two groups: group 1 , presenting with chest pain; group 2 , presenting with AHF or VF. Haemodynamic and functional parameters were similar in the 2 groups (Table), in G2 EF was slightly lower. G2 showed a larger area of oedema on STIR images and LGE distribution. LVEF was significantly correlated both to STIR (R= 0.49 p<0.0001) and LGE (R= 0.4 p<0.0006) percentages.Pts with AM presenting with AHF or VF at admission showed significantly larger percentage of oedema and of LGE. Our data suggest a direct relationship between the severity of clinical presentation and the extension of myocardial damage.Department of Cardiology, Niguarda Ca’Granda Hospital, Milan, Italy.


Cardiac MRI (CMR) is commonly used for serial monitoring of right ventricular (RV) size and function in patients with repaired tetralogy of Fallot (TOF). However, the inter-study variability of these measurements is not known, which hinders accurate interpretation of serial changes. In this study we prospectively assessed the inter-study variability of CMR measurements of RV size and function in TOF patients.Patients with repaired TOF referred for a clinically indicated CMR examination at our institution were prospectively enrolled. ECG-gated steady-state free precession cine imaging of ventricular long- and short-axis planes was obtained on a 1.5 T scanner. Immediately after the conclusion of the examination, patients returned for a second study performed by a different technologist. Ventricular size and function data from both short-axis image sets were analyzed by a single observer and compared using Bland-Altman analysis with calculation of a repeatability coefficient (2SD of difference between studies), and intra-class correlation coefficient (ICC).Between March 2009 and April 2010, 30 patients with repaired TOF  were enrolled. Mean RV end-diastolic volume was 158.1±48 ml and mean RV ejection fraction was 57.1±6. Estimates of repeatability coefficient and ICC are summarized in the table. CMR measurements were highly reproducible between studies for quantification of RV end-diastolic volume , ejection fraction , and mass . ICC values were not different between RV and LV for most parameters except mass, for which they were higher for the LV . ICC values for all the CMR parameters were not influenced by the presence of a transannular patch.CMR measurements of RV and LV size and function in repaired TOF patients are highly reproducible between studies. These data will aid in interpretation of serial changes and may be useful for sample size calculation in clinical trials.None.


Left ventricular aneurysm (LVA) is one of the most important complications of myocardial infarction LVA is strictly defined as a distinct area of abnormal left ventricular diastolic contour with systolic dyskinesia or paradoxical bulging. LVA usually results from myocardial infarction. Other rare aetiologies of LVA include hypertrophic cardiomyopathy, Chagas' disease, sarcoidosis, congenital LVA, and idiopathic However, LVA formation in patients with idiopathic dilated cardiomyopathy is rarely reported, and the incidence, clinical features, and pathogenesis of LVA formation in patients with idiopathic dilated cardiomyopathy is not well understood. Here, we present a 45 years old, idiopathic dilated cardiomyopathy patient with LVA and normal coronary arteries The pathogenesis of LVA formation in patients with idiopathic dilated cardiomyopathy is not clear. One acceptable hypothesis is that coronary artery emboli originate from mural thrombi, present in some patients with idiopathic dilated cardiomyopathy, which develop due to local wall infarction and fibrosis. The local myocardial perfusion differences could be seen in idiopathic dilated cardiomyopathy and predominantly found in the anteroposterior axis of the left ventricle. Local fibrosis occurs more frequently on the anterior wall or posterior wall, and less frequently on the lateral or septal wall. In our patient, LVA existed in the septal segments.We could not define the exact mechanism of the septal aneurysm in our patient but we decided to present this abnormal case, which is different from cases thus far reported in the literature. Left ventricular aneurysm (LVA) is one of the most important complications of myocardial infarction and is thought to develop in five to ten percent of all patients with acute myocardial infarction . Left veLeft ventricular aneurysms are generally related to myocardial infarction or coronary artery malformations but can also be associated with other rare causes, such as hypertrophic cardiomyopathy, Chagas' disease, sarcoidosis, and congenital or other idiopathic conditions. However, LVA formation in patients with idiopathic dilated cardiomyopathy is rarely reported, and the incidence, clinical features, and pathogenesis of LVA formation in patients with idiopathic dilated cardiomyopathy are not well understood . Here, wA 45-year-old male was admitted to our cardiology clinic with exertional dyspnea and atypical chest pain complaints. He had no systemic diseases, no smoking history, and no family history of cardiovascular diseases. He had New York Heart Association (NYHA) Class II exertional dyspnea which had worsened over the course of two months. His blood pressure was 140/80 mmHg, and his pulse was 55 bpm. Upon cardiovascular examination, a third-degree systolic murmur was heard at apical and pulmonary foci. The rest of the systemic examination was normal. On his electrocardiography, 55 beats per minute sinus rhythm inferolateral nonspecific ST-segment depressions were detected. No Q wave was observed. On echocardiographic examination, his left ventricular ejection fraction was 31 percent, and the ventricle was severely and globally hypokinetic. The left heart cavities and ascending aorta were dilated. Aneurysmatic dilatation of the interventricular septum was observed . CoronarLeft ventricular aneurysm is strictly defined as a distinct area of abnormal left ventricular diastolic contour with systolic dyskinesia or paradoxical bulging. LVA usually results from myocardial infarction. Other rare aetiologies of LVA include hypertrophic cardiomyopathy, Chagas' disease, sarcoidosis, congenital LVA, and idiopathic LVA . HoweverJuillière et al. defined the local myocardial perfusion differences seen in NIDCM and found that they are predominant in the anteroposterior axis of the left ventricle. Local fibrosis occurs more frequently on the anterior wall or posterior wall, and less frequently on the lateral or septal wall . Hayashi


Tandem autologous hematopoietic stem cell transplantation (ta-HSCT) is a standard treatment for multiple myeloma (MM). Patients receive a high-dose cyclophosphamide (CY), followed by two myeloablative cycles of melphalan (MEL). There are scarce data about long term cardiotoxicity.We studied 12 patients (62.25 ± 8.55 years) six years after the completion of MM treatment with ta-HCST. Late cardiotoxic effects were evaluated clinically and echocardiographically.m  and Sm velocities . The E/Em values were in an abnormal range .None of the patients developed clinical signs of heart failure, all were in sinus rhythm and NT-pro BNP concentration was elevated (778 ± 902.76 pg/mL). The left ventricular (LV) size remained normal. The LV ejection fraction did not decrease . The LV diastolic function parameters  did not change significantly. In tissue Doppler parameters we observed a nonsignificant decrease in EThe treatment of MM with ta-HSCT, during which patients receive a high dose CY followed by two myeloablative cycles of MEL, causes mild, chronic, partially reversible and clinically silent cardiotoxic side-effects. However, ta-HSCT in patients with MM is a safe regarding cardiotoxic side effects, but, because of increasing life expectancy needs long term attention. Autologous hematopoietic stem cell transplantation (HSCT) is one of the most efficient therapies for patients with multiple myeloma (MM).2). Patients who did not respond completely underwent a second ta-HSCT with the same dosage of melphalan within the next few months. They, thus, received a high dose cyclophosphamide and two myeloablative dosages of melphalan during a short period of time. Both chemotherapeutic agents may exert cardiotoxic side effects.Because our study started in the era before novel agents were available, included patients received vincristine, epirubicin, dexamethasone (VED) induction chemotherapy, followed by cyclophosphamide with granulocyte colonies stimulating factor (G-CSF) as part of the stem cell mobilization and collection regimen and first myeloablative cycle of melphalan  six years after successful autologous HSCT because of MM: 7 men and 5 women, aged 53 to 75 (62.25 ± 8.55). None of them had at presentation, nor later on in the course of the disease, the extramedullary form of MM involving the chest, cervical or thoracic spine that would require the treatment by irradiation of the thoracic cavity.i.e. prior to the administration of cyclophosphamide at a dose of 4 g/m2 as a part of the stem cell mobilization/collection regimen. Prior to the initiation of cyclophosphamide therapy, physical examination and baseline echocardiography (phase 0) were carried out. Two months after the cyclophosphamide therapy, the administration of the first myeloablative cycle of melphalan (200 mg/m2) was administered. Four months after the administration of the first cycle of melphalan, the patients received the second myeloablative cycle of melphalan (200 mg/m2) as a part of the ta-HSCT. Three months after the patients had received the second cycle of melphalan, we made the final assessment of cardiac toxicity of cyclophosphamide and two successive myeloablative dosages of melphalan, based on the last physical examination and echocardiography (phase 1). In the year 2007, two years after the completion of autologous HSCT, the echocardiographic study was repeated (phase 2) and in the year 2011, six years after double autologous HSCT, we finished the trial with the fourth echocardiographic follow up (phase 3). At each step of the study we examined the patients regarding clinical signs and symptoms of heart failure and performed ECG. N-terminal prohormone of brain natriuretic peptide (NT-proBNP) serum concentrations were measured at the very end of the study.During the year 2005, thirty patients with MM underwent ta-HSCT. The trial started four weeks after the completion of the last out of three cycles of VAD chemotherapy, m) and early mitral annulus diastolic tissue velocity (Em) were measured. The E/Em index was calculated as a marker of increased left atrial pressure. We used the mean value of three consecutive measurements for each of the parameters examined. Each examination included the evaluation for potential mitral regurgitation and pericardial effusion.Each patient was evaluated at each phase with two-dimensional, conventional Doppler and tissue Doppler echocardiographic studies. All examinations at all times were carried out by the same examiner. We determined left ventricular end-diastolic (LV EDD), left ventricular systolic diameter (LV ESD), calculated the left ventricular ejection fraction (LV EF), and assessed the left atrial transversal and longitudinal diameters. The systolic function of the left ventricle was assessed also by the velocity time integral of the left outflow tract (VTI). The left ventricular diastolic function was assessed by measuring diastolic mitral inflow velocities (E and A-wave), pulmonary vein systolic (s-wave), diastolic (d-wave) and atrial reversal (a-wave) velocities. The E/A velocities index and A/a duration ratio were calculated as markers of the diastolic left ventricular function. In addition, tissue Doppler echocardiography of the mitral annulus was used for assessing the left ventricular systolic and diastolic function. Mitral annulus systolic  with Bonferroni’s multiple comparisons test was used to assess the possible significance of changes in each echocardiographic parameter in successive time points. A p value of 0.05 or less was considered statistically significant. Statistical analyses were performed with the SPSS software package (version 13.0).The study included 12 surviving patients with MM (7 men and 5 women) after successful double autologous HSCT. Eighteen out of 30 patients initially included in the study died because of MM progression during the period of six years. None of them complained of heart failure symptoms, nor did they manifest signs of it during the period mentioned.All 12 enrolled surviving patients had normal baseline cardiovascular status. None of them developed clinically overt heart failure at any point in the study and electrocardiographic recordings disclosed no dynamic changes or rhythm abnormalities. In phase 3, the average value of NT-proBNP was 778 ± 902.76 pg/mL (range 124 – 2724 pg/mL).m, a very sensitive tissue Doppler parameter, mildly decreased throughout the study and finally the values dropped under the lowest reference values.The echocardiographic parameters are indicated in m velocities without statistical significance. The E/Em values were in an abnormal range for this age group from the phase 1 on. The E/Em ratio showed the gradual increase during all phases with statistical significance (p=0.01) and was in an abnormal range from phase 1 on. The only positive correlation was found between serum NT-proBNP concentration and E/Em (p = 0.009).The standard parameters identifying the diastolic left ventricular function by mitral flow velocities  did not change significantly during the six years of observation. Nevertheless, the E/A ratio reached the criteria of the abnormal relaxation in phases 1 and 2 and was restored in the phase 3. The duration of a wave in pulmonary vein flow decreased from phase 1 to 2 significantly (p = 0.04). The ratio A/a improved from phase 1 to 2 significantly (p = 0.001). No statistical differences regarding the baseline values could be found in other pulmonary vein parameters. In tissue Doppler parameters we observed a mild progressive decrease of EThe frequency of mitral regurgitation and pericardial effusion did not reach statistically significant difference between the baseline study and phase 2 or 3.There were no statistically significant differences between results of the baseline study (phase 0) and the results of the long term study in any of the observed parameters.Ta-HSCT is an efficient and frequently used treatment modality regimen for patients with MM. Patients treated with ta-HSCT develop immediate but transient, mostly reversible and clinically non-overt neurohormonal activation of heart failure in each phase of their treatment. Early post-treatment abnormalities including diastolic dysfunction with abnormal left ventricular relaxation, elevated left atrial pressure and functional mitral regurgitation are detected echocardiographicaly.In this long term study, we followed up 12 survivors out of 30 treated MM patients with ta-HSCT. The rest, 18 out of 30 patients initially included, died of MM progression and did not suffer from symptoms of heart failure at any time. In the 12 currently alive MM patients, the clinical examination did not reveal any signs of heart failure.m; the values did not reach normal range even after the completion of the therapy. The Sm decrease was not statistically significant, probably because of the small number of patients. Therefore, we can conclude that there are some indices for a mild systolic dysfunction at long term follow-up. We suggest that stress echocardiography may be helpful in solving this question.ECG did not show any rhythm disturbances. They were all in sinus rhythm. The left atrial and ventricular size and left ventricular ejection fraction did not show any significant changes in a period of six years after the completion of therapy and all parameters were in the range of normal values. This result is as expected, because these are rather nonsensitive parameters of cardiotoxicity. The VTI, Doppler echocardiographic marker of systolic left ventricular function, was in the range of normal values as well, although it showed a mild decrease for the period of the follow-up but recovered to baseline values within six years. The tissue Doppler parameters are more sensitive and we noticed a gradual decrease in Sm velocities from the completion of therapy on and further on the values reached neither normal nor baseline levels at the end of the study. We believe that the decrease of Em velocities did not reach statistical significance because of the small number of patients. The E/Em ratio, a marker of elevated filling pressure of the left ventricle, was increasing throughout the follow-up and at the end of the study exceeded the value immediately after the completion of the therapy; it was in the abnormal range.m supports this fact. The highest values of NT-proBNP were present in two patients with the lowest E/Em.Diastolic dysfunction parameters are much more reliable and sensitive markers of cardiotoxicity than parameters of the left ventricular systolic function, as has been proven for acute cardiotoxicity in many Doppler echocardiographic studies.We conclude that the treatment of patients with MM with ta-HSCT, in which the patients receive a high dose cyclophosphamide and two myeloablative dosages of melphalan, causes mild, chronic, partially reversible, but clinically silent cardiotoxic side effects. The most reliable parameters were NT-proBNP and tissue Doppler parameters of diastolic function of the left ventricle. To determine this with certainty, we need studies with a greater number of patients and stress echocardiographic studies. Long term studies with a longer period of observational time would not improve our knowledge of long term side effects because of the influence of age on Doppler and especially on tissue Doppler parameters.However, our study shows that ta-HSCT in patients with MM represents a safe treatment modality regarding cardiotoxic side effects, but because life expectancy in these patients is increasing, needs a long term follow up.


T2-weighted cardiovascular magnetic resonance (CMR) is clinically-useful for imaging the ischemic area-at-risk and amount of salvageable myocardium in patients with acute myocardial infarction (MI). However, to date, quantification of oedema is user-defined and potentially subjective.We describe a highly automatic framework for quantifying myocardial oedema from bright blood T2-weighted CMR in patients with acute MI. Our approach retains user input  to confirm the presence of oedema on an image which is then subjected to an automatic analysis. The new method was tested on 25 consecutive acute MI patients who had a CMR within 48 hours of hospital admission. Left ventricular wall boundaries were delineated automatically by variational level set methods followed by automatic detection of myocardial oedema by fitting a Rayleigh-Gaussian mixture statistical model. These data were compared with results from manual segmentation of the left ventricular wall and oedema, the current standard approach.The mean perpendicular distances between automatically detected left ventricular boundaries and corresponding manual delineated boundaries were in the range of 1-2 mm. Dice similarity coefficients for agreement  between manual delineation and automatic segmentation of the left ventricular wall boundaries and oedema regions were 0.86 and 0.74, respectively.Compared to standard manual approaches, the new highly automatic method for estimating myocardial oedema is accurate and straightforward. It has potential as a generic software tool for physicians to use in clinical practice. The ischemic area-at-risk and myocardial salvage are determinants of prognosis in patients with recent myocardial infarction (MI) and potentially useful for risk stratification . MyocardAssessment of myocardial oedema in a T2-weighted CMR scan requires judgment in order to interpret the presence and distribution of a hyperintense myocardial region in relation to the clinical history and other CMR findings. Beyond the initial clinical interpretation of the T2-weighted CMR scan, reliable quantification of oedema is challenging and time-consuming. The current manual approach for estimating myocardial oedema as a percentage of left ventricular (LV) mass initially involves delineation of the LV boundaries on each short axial scan from a stack of images extending from the base to the apex of the heart . SubsequAccurate LV boundary segmentation is the first essential step for computerized oedema quantification. A comprehensive review of these methods has been written by Petitjean et al. . AlthougDelineation of injured myocardium is the second essential step after LV segmentation. Even though LGE CMR and T2-weighted CMR both reveal myocardial injury  with regional hyperenhancement, the segmentation challenges based on T2-weighted CMR are technically more demanding, particularly because of the comparatively reduced signal to noise levels associated with this method. LGE CMR has high diagnostic utility and is well established in clinical practice. Interpretation of LGE CMR by physicians has been facilitated by the development of computerized intensity thresholding techniques based on the standard deviation (SD) of healthy myocardial signal intensity -16. HoweKadir et al.  in our gUntil now, a robust and automatic approach involving LV boundary segmentation and delineation of area-at-risk has not been reported. Most studies have involved manual segmentation of LV boundaries ,19,21,22The strategy for the proposed oedema quantification scheme mainly includes CMR image acquisition and initial clinical interpretation, LV wall boundary segmentation, and oedema region delineation. Figure CMR scans were performed on 25 consecutive patients  age 55(12) years) within 48 hours of primary percutaneous coronary intervention (PPCI) for acute ST elevation myocardial infarction (STEMI). The study protocol was approved by the local ethics committee and all patients gave written informed consent. CMR was carried out on a Siemens MAGNETOM Avanto  1.5-Tesla scanner with an 8-element phased array cardiac surface coil. The CMR protocol included breath-hold steady state free precession (SSFP) cine MRI and myocardial oedema imaging with bright blood turbo T2-weighted turbo spin echo steady state free precession  , and LGE3. Twenty nine coherent spin echoes (echo train length) were obtained per heartbeat and the time interval (echo spacing) between the 180° inversion pulses was 3.4 ms. The trigger pulse was 2 such that the data were acquired every second R-R interval. The ACUT2E method incorporated automated surface coil intensity correction by acquisition of a proton density gradient echo image interleaved with the T2-weighted acquisition every other heart beat. This image served as a proton density field map, which was used for surface coil intensity correction.The ACUT2E acquisition involved the following parameters: acquisition time 7-12 s, matrix 192×192, flip angle 180°, echo time (TE) = 1.69 ms, bandwidth=789 Hz/pixel, slice thickness=6 mm with 4 mm gap, the voxel size was 1.9×1.9×6 mm3. Figure Myocardial infarction was imaged with a segmented PSIR turbo fast low-angle shot (PSIR-FLASH) ,25 startTwo cardiologists  undertook the MRI analyses on a Siemens workstation with Syngo software. The MRI scans were obtained during usual patient care and the diagnostic reports were drafted by A.P., reviewed and verified by C.B. The window and level settings were also established at this time. The workstation allows user-defined selection of the level of the image display. Initial review of the ACUT2E scans involved standard adjustment of window and level signal intensity settings as previously described ,8  slices from the base were excluded if the circumference of the heart included the mitral valve orifice or LV outflow tract; (2) the most apical slices were excluded if the endocardial border of the LV cavity was unclear. According to these criteria, of 221 images, 171 short axis T2-weighted MR images from 25 patients were suitable for analysis (approximately 7 slices per patient), of which 142 slices with visual evidence of myocardial oedema, and 11All analyses were performed using in-house Matlab programs. The signal intensity of all MR slices was re-scaled and standardized in the range 0–255 as done by Syngo software in the Siemens workstation according to Eq. 1.I stands for the original pixel intensity, Ic and Iw are the centre and width of the intensity window, which are available from the DICOM header.where Manual contouring of the LV wall and oedema was carried out by a Matlab program to provide the reference dataset. Firstly, LV wall boundaries on bright blood T2-weighted CMR were manual delineated by H.G. (3 years in CMR image processing) on 171 slices in total; secondly, C.B. performed the manual oedema quantification for all the 25 patients with super-imposed LV wall boundaries from H.G., which was the reference data for the proposed automatic approach. Separately, A.P. did the manual oedema quantification for 16 patients and the results of this analysis were used for the inter-observer study. LGE and cine MRI scans were available if necessary to aid the segmentation of oedema by providing improved anatomical and functional information and care was taken to exclude blood pool signal adjacent to the sub-endocardium. For each patient, voxels in oedematous regions from base to apex were counted for oedema mass, and then oedema extent in each patient was defined as the percentage of the whole LV mass calculated from the T2-weighted slices from base to apex. The manual oedema delineation method by C.B. and A.P. has been validated and routinely performed in the clinical settings ,27.The same short axis bright blood T2-weighted MR images were used for the proposed automatic approach. There were two main stages. Stage 1: automatic LV wall segmentation on all short axis images; Stage 2: automatic oedema quantification with the inputs from stage 1 on the slices with oedema presence. Since the windowing process was involved before exporting these DICOM images (the human inputs), while the other steps were fully automatic, therefore the proposed approach was considered to be highly automatic.The LV endocardial and epicardial wall boundaries were defined for each slice by using an automatic approach based on a variational level set method. A detailed theoretical description of the approach is provided in Additional file i) automatic LV centre point detection in each slice  andii) variational level set method without re-initialization  for LV wThe automatic method for myocardial oedema delineation consists of four main steps:i) Rayleigh-Gaussian mixture model fitting for the intensity histogram of LV wall;ii) Thresholding operation;iii) Morphological filtering;iv) Oedema region feature analysis.Step 1: Rayleigh-Gaussian mixture model fitting: The widely used simple xSD thresholding, methods used by Kadir [fmyoc of myocardium is defined as follows [by Kadir  and Johnby Kadir  are baseby Kadir . Image i follows :an and ae are the weighting parameters for the two models; σn is the Rayleigh distribution parameter; μe and σe are the mean and standard deviation of the Gaussian distribution; I stands for myocardium intensity in LV wall. αshift represents the intensity shift during MR image windowing and intensity adjustments. In a similar manner to the signal processing during LGE CMR acquisition used by Elagouni et al’s study [Eq. 2 is the Rayleigh-Gaussian mixture model, Eq. 3 and Eq. 4 represent the Rayleigh and Gaussian distributions respectively. In Eq.1 ’s study , this sh’s study . Figure Step 2: Thresholding operation: a threshold value was defined to classify healthy and pathological tissues after the fitting process. The mean of the Rayleigh distribution isImap was defined according to μn and μe as,A fuzzy membership map I is less than μn, then the pixel is classified as unaffected myocardium, and Imap=0; if I is greater than μe, then it is classified as oedema tissue, and Imap=1; Imap varies linearly from μn to μe. In this study, a membership value of Imap ≥ 0.7 was defined as the thresholding value for the regions of oedema. The value of 0.7 was chosen based on a pilot study of 4 patients by maximizing the agreement with manual delineations. Furthermore a parameter study by varying the thresholding value from 0.6 to 0.9 is summarized in the result section, which confirms 0.7 is optimal for this study.For each pixel, if intensity value Step 3: Morphological Filtering: After thresholding, segmented regions of myocardial oedema were processed using an alternative sequential morphological filtering which is a robust approach to preserve topology [topology . Sequenti) a morphological closing operation with a small kernel (disk shape with size of 2 pixels) for removing the noise and false positives;ii) an opening process with the same kernel as in the first step;iii) a closing process with a bigger kernel (disk shape with size of 5 pixels) is applied to connect isolated regions if close enough.Since a region of myocardial oedema may also include dark zones of reduced signal, such as arising from myocardial haemorrhage , the cloStep 4: Oedema region feature analysis: Given the regional location of myocardial infarction following coronary artery occlusion, a short axis slice typically has one area of oedema  The region is considered to be oedema if the area of the region is greater than two fifths of the main oedema region;ii) The region is considered to be oedema if the area of the region lies in the range from one fifth to two fifths of the main oedema region, and the arc distance from the region to the main oedema region is less than 20 degrees;iii) The region is taken to be oedema if the area of the region is less than one fifth of the main oedema region, and the arc distance from the region to the main oedema region is less than 10 degrees.Figure In order to study inter-operator variations in manual oedema quantification, 16 out of 25 patients were manual segmented again by A.P., and compared with manual results from C.B. Furthermore, because the manual windowing of oedema images after CMR acquisition could cause variations on the final oedema results, therefore the same 16 patients were re-evaluated by K.K.  blinded to the previous dataset for the variation assessment on the effects resulting from the windowing process, followed by automatic LV boundary segmentation and oedema delineation, finally the newly obtained oedema results were compared with the results from the windowing process done by A.P.The segmented regions were categorized as either oedematous or healthy. The spatial overlap between the results from the proposed approach and manual segmentations was assessed using the Dice similarity coefficient (Dsc), defined asA+B represents the sum of the areas/volumes. Dsc=1 indicates a perfect overlap (agreement) between A and B and Dsc=0 means no overlap between A and B. Zijdenbos et al. [where ∩ represents the intersection of the two regions and s et al.  suggestss et al.  and Dice3. Furthermore, quantification of oedema by Kadir’s method [The agreement for oedema quantification was done by comparing oedema extent (counting oedema from base to apex in each patient) with manual oedema segmentations. Oedema extent was defined as% of LV mass for each patient, in which the LV mass was calculated by reconstructing 3D LV wall geometry from corresponding boundaries on those T2-weighted images, with a density of 1.05 g/cms method  was implFigure Imap from 0.6 to 0.9 (Eq. 5), the results are summarized in Table Since the actual amount of oedematous myocardium for each patient was not available, a standard validated approach for estimating the extent of myocardial oedema was adopted ,8,27 forp=0.07), with an absolute difference of 3±3%. The mean Dice similarity coefficient based on oedema volume overlap is 0.74±0.06. Figure r=-0.4, p=0.03), indicating the automatic approach tends to overestimate oedema region when reference oedema region is small, and underestimate vice versa.Hyperintense oedematous regions of interest were successfully quantified in 142 oedema MR images. The mean oedema extent from the automatic approach is 28±8%, close to the results from manual quantification (C.B. 27±10% (p=0.02) with Dice similarity coefficient of 0.7; while the new automatic approach generates the closest results compared to the manual oedema delineation.The results of the comparison of the volumetric extent of oedema by manual segmentation (C.B.) and the automatic approach using Kadir’s method  are summp=0.9) with an averaged Dice similarity coefficient of 0.84±0.07, close to the average value between A.P. and B.C. (0.85±0.03 from the inter-observer study). The difference in the extent of oedema from the two independent windowing processes is 3±3%, which is close to the difference between A.P. and C.B. for the 16 patients (3±2%) from the inter-observer study.In the inter-observer study of manual oedema quantification with same computed LV wall boundaries, the averaged difference in the volumetric extent of oedema (% of LV) between A.P. and C.B. is 3±2%, and the mean Dice similarity coefficient between A.P. and C.B. is 0.85±0.03. Table The averaged processing time for one patient is 40±6 seconds on a laptop , compared to the processing time for manual oedema quantification (range 360 to 420 seconds for an experienced cardiologist). In the proposed approach, the total average times for LV segmentation and oedema delineation are 34±6 and 6±0.9 seconds for each patient, less than one minute overall.We have developed and tested a highly automatic method for estimating the extent of myocardial oedema by using bright blood T2-weighted CMR in patients with acute myocardial infarction. Physician judgment is retained as the initial step in image analysis and following this initial evaluation, images are subjected to automatic segmentation of the LV wall and oedema territory. High levels of agreement for the proposed approach are found when compared to a standardized and validated manual approach for myocardial oedema analysis on T2-weighted CMR (Dice similarity coefficient >0.7). Furthermore our new approach is also seen to outperform two other computerized methods ,21. AlthLV wall boundary segmentation (semi-/fully automatic) with CMR has been extensively studied -37. HoweM in oedema regions was 103, and 3.85 in unaffected regions. Then SNR for oedema regions was A/σ=0.98. The analysis indicates Rayleigh-Gaussian distribution is applicable in this study. Furthermore, the comparison with Kadir’s method [Gudbjartsson et al.  suggestes method  shows ths method  used a GBy incorporating a prior model of the maximal extent of user defined culprit, Sjogren et al  improved3. In oedema region feature analysis in our study, approximately one-fifth of the main oedema area was considered to be a critical threshold for discrimination from noise. This threshold area corresponds to an average mass of 1.2 g. To improve the post-processing, minimum distance constraint criteria with the main oedema region was applied. By increasing the degree to 20 in the third step of feature analysis, and in the second step, the degree was changed to 40 at the same time. The result showed that the oedema extent was 27±8% with a mean Dsc of 0.73±0.06 related to the manual quantification. This analysis indicates that the oedema extent may not be sensitive to the choice of the minimum distance constraint. If no any feature analysis was applied, then the mean oedema extent was 30±8% (Dsc: 0.7±0.06), suggesting that oedema feature analysis is essential. Another potential source of error for overestimation of the oedema area is incorrect placement of the endocardial border within the bright LV cavity blood pool. In future a dark blood T2-prepared CMR method with steady state free precession readout might overcome this problem.After thresholding, alternate morphological filtering was applied to produce smoothed oedema regions without changing the overall shape. A kernel size of 2 pixels was used in the beginning for the closing and opening process followed by a kernel size of 5 pixels for the closing process. The kernel size of 5 pixels for the last closing process is in line with the approach by Hsu et al. (5 mm) . The morIn this study, we intended to minimize user-inputs for oedema quantification, therefore there is no manual correction for automatic LV boundary segmentations and oedema delineations. As shown in Figure In order to use our method attention is needed for: (1) the windowing process, which could introduce variability due to the observer’s experience. Our sensitivity study of the windowing process shows that the automatic approach is able to quantify oedema region consistently if the observer is trained properly on T2-weighted oedema images. (2) The definition of optimal threshold value, which might be different from 0.7 when actual oedematous regions are available for comparison, thus it needs to be carefully selected for different studies. (3) The oedema region feature analysis, which may not be applied to patients such as with myocarditis. Other limitations: (1) the manual input in our method involves user-defined adjustment of the greyscale level. Potentially, future technical developments may enable this step to be removed. Secondly there is no automatic decision making step for the presence of oedema. However, we suggest this aspect should be considered a strength of the method since physicians’ judgment is still retained; (2) Improvement in methods for automatic LV boundary segmentation and dark zones detection (such as haemorrhage) within the oedema regions are needed for more accurate oedema quantification; (3) 3D anatomical structure information of oedema, culprit coronary artery assignment  and myocA highly automatic scheme has been developed for oedema quantification based on bright blood T2-weighted CMR. The method includes a level set model for automatic left ventricular wall segmentation and oedema delineation by using a Rayleigh-Gaussian statistical mixture model. The results show that the method could produce accurate delineation of oedema regions on bright blood T2-weighted CMR compared with manual oedema quantification. The method has some user-involvement and can be rapidly performed. We have also shown that reliable and accurate left ventricular wall boundary segmentation is essential.CMR: Cardiac Magnetic Resonance; MI: Myocardial infarction; SDs: Standard deviations; LGE: Late Gadolinium Enhancement; pPCI: Primary percutaneous coronary intervention; STEMI: ST elevation myocardial infarction; SSFP: Steady state free precession; TSE-SSFP: Turbo spin echo steady state free precession; PSIR: Phase sensitive inversion recovery; MRI: Magnetic resonance imaging; PSIR-FLASH: PSIR turbo fast low-angle shot; Dsc: Dice similarity coefficientThe authors declare that they have no competing interests.HG performed the study design, algorithm development, result analysis and drafted the manuscript. KK participated in the study design, algorithm development  and data analysis. AP scanned the patients, contributed to the data analysis. JS participated in the study design and revised manuscript. CB participated in the study design, patient scan, and manual quantification and revised manuscript. All authors read and approved the final manuscript.Appendix 1. The left ventricular (lv) endocardial and epicardial wall boundaries were segmented by using an automatic approach based on a variational level set method (vlsm), including lv centre definition for level set initialisation and boundary detections by vlsm. Click here for file


Cardiac Magnetic Resonance Imaging (CMR) provides reliable estimation of the extent of necrosis after acute myocardial infarction (AMI). Nevertheless usual quantification methods are time consuming and subjective. We sought to assess necrosis extent with a new method (fuzzy c-means clustering), compared to usual methods, applied on Late Gadolinium Enhancement (LGE) sequences. Results were compared to biochemical markers of necrosis and LV functional parameters.CMR was performed 50±21 hours after AMI in 52 consecutive patients. We quantified the amount of necrosis using three approaches: 1) automated fuzzy c-means clustering method, 2) +2SD thresholding approach with manually defined remote myocardium, 3) +2SD thresholding approach with automated definition of the remote myocardium. Results were compared with biochemical marker-estimated necrosis amount and left ventricular (LV) functional parameters.Although the 3 methods strongly correlated , the quantified amount of necrosis was significantly different between methods. Manual quantification reported highest (20.5±17.6%), whereas fuzzy c-means clustering reported lowest (12.5±12.1 %) values. Strongest correlations were found between fuzzy c-means and both biochemical quantification of necrosis (r 0.61 to 0.80) and LV functional parameters (r 0.55 to 0.71).The fuzzy c-means-assessed amount of necrosis on CMR images shows higher correlation with biochemical infarct size quantification as well as left ventricular global and regional function than usual methods. This method may be clinically useful in the evaluation of patients with AMI.


Data from large epidemiological studies suggest that elevated heart rate is independently associated with cardiovascular and all-cause mortality in patients with hypertension and in those with established cardiovascular disease. Clinical trial findings also suggest that the favorable effects of beta-blockers and other heart rate–lowering agents in patients with acute myocardial infarction and congestive heart failure may be, at least in part, due to their heart rate–lowering effects. Contemporary clinical outcome prediction models such as the Global Registry of Acute Coronary Events (GRACE) score include admission heart rate as an independent risk factor.This article critically reviews the key epidemiology concerning heart rate and cardiovascular risk, potential mechanisms through which an elevated resting heart rate may be disadvantageous and evaluates clinical trial outcomes associated with pharmacological reduction in resting heart rate.Prospective randomised data from patients with significant coronary heart disease or heart failure suggest that intervention to reduce heart rate in those with a resting heart rate >70 bpm may reduce cardiovascular risk. Given the established observational data and randomised trial evidence, it now appears appropriate to include reduction of elevated resting heart rate by lifestyle +/− pharmacological therapy as part of a secondary prevention strategy in patients with cardiovascular disease. Epidemiological data over the last six decades have found that elevated resting heart rate (RHR) may be associated with increased risk of all-cause mortality and cardiovascular (CV) mortality, both in the general population (with or without risk factors) P < 0.001). In women , RHR >100 bpm versus <60 bpm was associated with a modest increase in CV mortality that was not significant  but a trend to increase stroke mortality  An early description of the association between elevated RHR and mortality in hypertension was described in the Framingham Study dataset. During 36-year follow-up of those with any blood pressure >140/90 mmHg but not on antihypertensive treatment (n = 4530), the adjusted odds of all-cause mortality for a RHR increment of 40 bpm was 1.98 for men and 1.87 for women P = 0.035). The LIFE study In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Increased RHR in patients with acute myocardial infarction (MI) is an important predictor of subsequent death, independent of the presence of heart failure, hypotension/shock, and other clinical variables. In the pre-thrombolytic era, Hjalmarson et al. In the thrombolytic era, among 11 267 post-MI patients in the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico-3(GISSI-3) trial, admission RHR 81–100 bpm compared with RHR <60 bpm was associated with double the in-hospital mortality (6.3% vs. 3.3%) and discharge RHR 81–100 bpm was associated with fourfold higher mortality at 6 months (9.3% vs. 1.9%) In 9461 patients with non-ST elevation acute coronary syndrome in the Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (eptifibatide) Therapy (PURSUIT) trial, admission RHR  was the second strongest predictor of 30-day mortality In 1453 patients undergoing primary angioplasty for ST elevation MI, Antoni et al. reported that discharge heart rate ≥70 bpm (vs. <70 bpm) was independently associated with a twofold increase in risk of CV mortality at 1- and 4-year follow-up Registry data from 135 164 non-ST-elevation acute coronary syndrome patients enrolled in CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) P < 0.0001). A RHR of ≥83 bpm, compared with <62 bpm, was associated with 32% increase in total mortality and 31% increase in CV mortality even after adjustment for multiple potentially confounding clinical variables.Heart rate may also be a prognostic factor in patients with stable coronary heart disease (CHD). Diaz et al. P = 0.04), with a trend to all-cause mortality .Frank et al. In the Angina and Silent Ischaemia Study (ASIS), a rise in RHR of at least 5 bpm preceded 81% of ischemic episodes recorded during 48-h ambulatory ECG monitoring The importance of baseline and on-treatment RHR was evaluated in 22 576 patients with stable CHD plus hypertension enrolled in the INternational VErapamil-SR/trandolapril STudy (INVEST), f inhibitor ivabradine in patients with coronary disease and left ventricULar dysfunction) trial, P = 0.0041), MI , coronary revascularization , or admission with heart failure . Each 5 bpm increment in RHR was associated with approximately 8% increase in CV death, 7% increase in MI, 8% increase in coronary revascularization, and 16% increase in admission with heart failure .In the placebo arm of the large randomized BEAUTIfUL , CV mortality (P = 0.006), and worsening heart failure (P < 0.0001). Those with RHR in the highest (>90 bpm) versus lower 4 quintiles had 51% increased all-cause mortality, 90% increased heart failure mortality, and 78% increased hospitalization for worsening heart failure. In the Cardiac Insufficiency BIsoprolol Study-II (CIBIS-II), which assessed bisoprolol in 2647 patients with symptomatic chronic heart failure, baseline RHR independently predicted mortality and hospitalization for worsening heart failure P < 0.005; nine trials, n = 19 537) and the amount of change in RHR correlated with change in ejection fraction . While some of the benefit of beta-blockers maybe attributed to prevention of dysrhythmias, reduction of free fatty acid use in favor of glucose and reduced cardiac myocyte apoptosis, RHR reduction appeared the predominant mechanism of benefit f inhibitor ivabradine Trial (SHIFT), patients with RHR in the highest versus lowest quintile (≥87 bpm vs. 70 to <72 bpm) were over twice as likely to have a CV death or hospitalization for worsening heart failure , the risk increasing by 16% for every 5 bpm increase in RHR Resting heart rate is also an independent predictor of mortality in patients with heart failure. In the placebo arm of Metoprolol controlled release/Extended Release randomized Intervention Trial in Heart Failure (MERIT-HF) The precise pathophysiological mechanisms that link RHR and CV outcomes are not fully defined. However, this link appears independent of lifestyle and other conditions that may contribute to elevated RHR Elevated RHR per se may have direct adverse impact on CV risk and CV function . AlteredMore detailed examination of pathophysiological mechanisms including ambulatory assessment is discussed elsewhere While epidemiological and preclinical data support the hypothesis that elevated RHR is a risk marker for adverse CV outcome, the clinical value (or otherwise) and the mechanisms of benefit of intervention to lower elevated RHR is a separate and more challenging question because the benefits of some heart rate–lowering agents may be mediated via nonheart rate mechanisms.P < 0.001), a ≥15 bpm RHR reduction being associated with 25–30% reduction in infarct size P < 0.05) and recurrent MI , benefits being most marked in those with higher RHR. In contrast, beta-blockers with intrinsic sympathomimetic activity showed limited reduction in RHR and no significant effect on mortality Multiple trials have shown that beta-blockers improve outcomes in patients with acute MI The Euro Heart survey of stable angina suggested that use of beta-blockers may be suboptimal. Although beta-blockers were the most commonly added treatment, mean doses used were relatively low compared with clinical trials. While a high baseline heart rate (>83 bpm) was more often noted in patients with chronic respiratory disease (23.1%) and diabetes (22.6%), beta-blockers were less likely to be added in these patients In heart failure, the CIBIS-II study , patients with the lowest baseline RHR or greatest decrease in RHR during treatment had the lowest mortality and lowest risk of readmission. A reduction of >10 bpm was associated with the best chance of survival, provided systolic blood pressure did not fall excessively It is noteworthy that in CIBIS-II, patients with no change in RHR still derived some benefit from bisoprolol treatment, Nevertheless, in a small but intriguing study of 49 pacemaker-dependent patients with heart failure, reversal of the apparent benefit of the beta-blocker-induced bradycardia on left ventricular volume and systolic function occurred in those randomized to a high-pacing rate (80 bpm) versus those paced at 60 bpm, supporting RHR reduction as an important mechanism by which beta-blockers improve heart failure outcomes P = 0.1052), with significant reductions in secondary endpoints, including all-cause mortality , total CV events and procedures , fatal and nonfatal stroke , and incidence of new-onset diabetes . However, the authors noted that approximately half of the difference in outcome may be accounted for by a lower on-treatment blood pressure in the amlodipine-based arm  and emergence in the atenolol arm of higher BMI, fasting glucose, creatinine, triglycerides, and lower HDL-cholesterol By contrast, in the setting of hypertension, despite observational studies showing the typical association between elevated RHR and adverse outcome, the value of beta-blockers appears lower than might be expected. The ASCOT trial P = 0.11), and a significant reduction in the composite of cardiac death/MI  P = 0.02) and reinfarction . By contrast, in those with heart failure (n = 614), verapamil showed a slight, nonsignificant excess in death (17.9% vs. 17.5%) and reinfarction (14.3% vs. 14.2%). The Multicenter Diltiazem Post-Infarction Trial (MDPIT) randomized 2466 patients with acute MI  to diltiazem (60 mg qid) or placebo, for 12–52 months. Over half were also receiving beta-blockers Nondihydropyridine calcium channel blockers, which lower heart rate, have been shown to reduce the risk of cardiac events in post-MI patients P < 0.001), all-cause death (P = 0.008), sudden death (P = 0.015), and nonfatal reinfarction (P = 0.024). Larger RHR reduction was associated with greater improvement in outcome—each 10 bpm reduction in RHR reduced the risk of cardiac death by approximately 30%. Heterogeneity analysis found outcome differences between trials were fully explained by achieved RHR reduction, rather than drug class. In particular, the absence of mortality reduction with calcium channel blockers appeared entirely because of their minimal reduction in RHR.An important recent meta-regression analysis of 17 randomized controlled studies  assessed whether improvements in outcome following MI were related to RHR reduction f channel. This channel is an inward-mixed sodium and potassium current, directly regulated by intracellular cyclic adenosine monophosphate (excitatory) and muscarinic (inhibitory) receptors. The If current is a key determinant of the slope and duration of diastolic depolarization and thus of overall heart rate. Early If channel inhibitors were too nonselective to be of clinical value. However, the highly selective If channel blocker ivabradine has good tolerability, with a mean reduction in RHR of 8–10 bpm at usual doses and similar anti-ischemic benefits to atenolol Several ion channels or currents control sino-atrial node pacemaker activity, including the IP = 0.05) and a 42% reduction in hospitalization for MI . Further reductions in coronary endpoints were seen in the subgroup with limiting angina plus RHR ≥70 bpm (n = 712) albeit with wide confidence intervals due to the smaller subgroup numbers. Given the neutral primary endpoint in BEAUTIfUL, such coronary endpoint reductions can only be considered as hypothesis generating, and thus, a prospective clinical trial is currently being undertaken .In BEAUTIfUL, 10 917 patients with CHD and left ventricular ejection fraction <40% were randomized to ivabradine (5–7.5 mg bid) or placebo, for a median of 19 months P < 0·0001), mainly driven by a reduction in hospital admission for heart failure and deaths caused by heart failure. Event rates were lowest in those achieving a 28-day RHR <60 bpm. The event reduction with ivabradine was greatest in patients with highest baseline heart rates  driven, like SHIFT, by a significant reduction in heart failure hospitalization . Of note, patients in DIG were not treated with a beta-blocker and such a combination can infrequently lead to atrioventricular block. However, unlike ivabradine, digoxin is beneficial in the setting of atrial fibrillation. While prospective data are needed Digoxin reduces RHR mainly by enhancing parasympathetic activity nervous system although it probably also inhibits the sympathetic nervous system. Its use in heart failure declined after its failure to reduce all-cause mortality in the Digitalis Investigation Group (DIG) Trial f channel inhibitor) A number of new specific heart rate–lowering agents with potential value for treatment of angina are currently in development, including YM 758 (another IMultiple studies, in those with established CV disease, with CV risk factors, and even apparently healthy subjects, have shown elevated RHR is a marker of increased risk. Increased risk has been well described in many studies for RHR >80 bpm, with newer data demonstrating increased risk >70 bpm. In the setting of coronary artery disease


Left atrial (LA) size as assessed by echocardiography has been shown to have prognostic value in patients with dilated cardiomyopathy (DCM). More recently cardiac magnetic resonance (CMR) imaging studies have reported that the presence of left ventricular mid-wall late gadolinium enhancement (LGE), a marker of myocardial fibrosis, also predicts adverse outcome in DCM.The biplane area-length method has been validated as an accurate method for assessment of LA volumes, which echocardiography may underestimate by up to 47% compared with CMR.We sought to establish whether LA volume as assessed by CMR was associated with the presence of mid-wall LGE in DCM patients.DCM patients were studied between Jan 2006-Aug 2008. Patients with coronary artery disease were excluded. All patients underwent a comprehensive CMR study which included acquisition of LGE images in 2 separate phase-encoding directions to exclude artefact. LA area and length were traced at end-ventricular systole and diastole in both horizontal and vertical long axis images. Maximum (LA max) and minimum (LA min) LA volumes were then calculated using the biplane area-length method for ellipsoid bodies and indexed to BSA. A separate cardiologist who was blinded to the results of the LA area determined the presence of mid-wall LGE.One hundred and ninety two patients ; LV EF 40% ± 15%, were recruited to the study. The overall mean indexed LA max was 54.5 (95% CI: 51.7-57.5) and mean indexed LA min 29.8 (95%CI: 23.7-27.1).Patients with concurrent mid-wall LGE had significantly larger indexed LA max volumes than those without LGE (56.2 ml (25.6 ml - 60.9 ml) vs. 49.7 ml (45.5 ml -54.2 ml) (mean (95%CI), p = 0.03)). Patients with concurrent LGE also had significantly larger indexed LA min volumes than those without (31.9 ml (28.6 ml - 35.7 ml) vs. 24.3 ml (20.7 ml - 28.5 ml) respectively; p < 0.01). The differences remained statistically significant when patients with atrial fibrillation were excluded from analysis.LA volumes were significantly greater in DCM patients with left ventricular mid-wall LGE compared to those with no LGE. The presence of mid-wall LGE may therefore be associated with increased left atrial pressures in DCM patients. Further studies are therefore required to evaluate whether LA size has incremental prognostic value to midwall LGE in DCM.


To define sensitivity and specificity of thresholded myocardial transmural perfusion gradients in the diagnosis of coronary artery stenosis and to describe the characteristics of perfusion gradients using novel indexes of myocardial perfusion.Conventional quantitative assessment of myocardial perfusion analyzes the temporal relation between the arterial input function and the myocardial signal intensity curves, thereby neglecting many of the spatial and temporal relations within the myocardial signal intensity curves. These relations can be described by calculating the perfusion gradient between the left ventricular (LV) epicardial endocardial layers and expressing indexes such as the persistence (seconds), and strength  of the gradient. As myocardial ischaemia predominantly affects the endocardial myocardial layer due to its higher oxygen demand, transmural gradient indexes may be sensitive markers of ischaemia.11 patients listed for coronary angiography underwent first-pass perfusion imaging at 3T . Perfusion data were acquired in three LV short axis slices with a saturation recovery gradient echo method  during adenosine-induced hyperaemia (140µg/kg/min) using 0.05mmol/kg Gd-DTPA  at 4ml/minute followed by a 20 ml saline flush.Transmural perfusion gradients were measured for 60 angular positions per slice. Based on results from pilot studies in volunteers, these values were thresholded for values of 5% peak gradient, i.e. a peak endocardial to epicardial gradient at maximal hyperaemia of >5% was considered abnormal. Sensitivity and specificity were calculated comparing the results of segmental gradients and coronary angiography. Correlation between myocardial segments and angiography used the standard 16-segment AHA model.At a threshold of 5%, the transmural perfusion gradient analysis yielded a sensitivity of 94% and a specificity of 42% for the detection of significant coronary stenosis on a per-vessel basis. Additional analysis combining the persistence or the strength of the gradient with a 5% threshold resulted in significant differences between positive and negative segments Table  and a seTransmural perfusion gradient analysis allows for a sensitive identification of ischaemic coronary artery territories. The additional analysis of derived transmural perfusion indexes improves the specificity of the analysis by allowing the identification of small and non-significant perfusion gradients.


CALM2) gene polymorphism might be responsible for the variation in the left ventricular mass amongst healthy individuals. The aim was to evaluate the correlation between left ventricular mass (LVM) and g.474955027G>A (rs7565161) polymorphism adjacent to the CALM2 gene. Healthy Polish newborns (n = 206) were recruited. Two-dimensional M-mode echocardiography was used to assess LVM. Polymorphisms were determined by polymerase chain reaction-restriction fragment length polymorphism and sequencing analyses. The carriers of the G allele of the CALM2 polymorphism had significantly higher left ventricular mass/weight (LVM/BW) values, when compared with newborns homozygous for the A allele . The AG genotype of CALM2 was associated with the highest values of LVM/BW, exhibiting a pattern of overdominance . The results of this study suggest that G>A CALM2 polymorphism may account for subtle variation in LVM at birth. Calmodulin II ( Left ventricular hypertrophy (LVH) and increased left ventricular mass (LVM) are strong risk factors for cardiovascular disease and morbidity . Cardiac2+) is arguably the most important messenger in cardiac muscle and plays a central role in regulating contractility, gene expression, hypertrophy, and apoptosis. It has been well described that Ca2+ transient movements regulate the transcription and gene expression that characterize the hypertrophic response of cardiomyocytes [2+ are precisely controlled.Calcium Ca+ is argumyocytes . The lev2+ transient movements is calmodulin (CaM). The Ca2+CaM complex binds and activates enzymes, including protein kinases, protein phosphatases, phospholipases, nitric oxide synthases, and endonucleases. Three Ca2+ calmodulin dependent enzymes have significant roles in cardiac function: Ca2+ calmodulin-dependent protein kinase (CaMK), protein phosphatase 2B , and myosin light-chain kinase (MLCK). CaMK and CaN have been shown to play key and often synergistic roles in transcriptional regulation in cardiomyocytes [A major sensor and mediator of intracellular Camyocytes . It has myocytes , 6.2+-CaM-dependent kinase II (CaMKII), a major CaM target protein, is a uniquely regulated multifunctional regulatory enzyme. The CaMKIIδ isoform is the predominant cardiac isoform [δ have increased incidence of cardiac hypertrophy [CALM1, CALM2, and CALM3. There are very few studies indicating the functional role of CALM2 gene polymorphism. Mototani et al. [CALM2 is a candidate gene for primary open-angle glaucoma. To date, only Vasan et al. [CALM2 polymorphism rs7565161 and echocardiographic diameter LVM in adults. The guanine to adenine transition at nucleotide position 474955027  of human chromosome 2p21 is intergenic, adjacent to the CALM2 gene. However, there are no reports which have focused on the association of intergenic adjacent CALM2 polymorphisms with left ventricular mass in newborns. The factors influencing heart development during fetal life or first days of life, when external environmental factors such as diet, lifestyle, smoking or diseases have not yet had a marked impact, are still being sought. We hypothesize that adjacent intergenic CALM2 polymorphism could potentially modify LVM during fetal life and in the first period of life in newborns. In the present study, the relationships between g.474955027 G>A (rs7565161) being adjacent intergenic CALM2 gene polymorphism and LVM in a population of Polish newborns have been investigated.Ca isoform , 8. Ther isoform . In hype isoform , 11. Expertrophy . Inhibitertrophy . Thus, ai et al.  discoveri et al.  indicaten et al.  have demThe study was approved by the Pomeranian Medical University ethics committee. Study subjects were informed about the project and written consents were obtained.μL) of neonates was obtained for isolation of genomic DNA. The gender of the newborn, BL, BW, and HC were taken from standard hospital records. Body surface area (BSA) was calculated using the following equation [The population included 206 consecutive healthy Polish newborns , born after the end of the 37th week of gestation (from 37 to 40 weeks). Mothers in this study were healthy without any complications such as preeclampsia or eclampsia, and there was no fetal growth restriction. The scientists identifying the calmodulin genotypes were blinded to the clinical characteristics of subjects. Newborns in this study were appropriately grown for their gestational age (defined as birth mass above the 10th centile). Exclusion criteria were twins, intrauterine growth restriction, chromosomal aberrations and/or congenital malformations, or “small for gestational age,” that is, below the 10th centile body length (BL), birth weight (BW), or head circumference (HC). At birth, cord blood (500 equation :(1)BSA=[A diascope oscillometer (Artema) was used to determine systolic and diastolic blood pressure , and only one of the investigators performed all of the blood pressure (BP) measurements using a standardized protocol. The smallest cuff size that covered at least two thirds of the right upper arm and encompassed the entire arm was selected. BP was measured in a supine position on the 3rd day after delivery. Newborn measurements were taken at least one and a half hours following their last feeding or medical intervention. An appropriately sized cuff was applied to the right upper arm, and the newborn was then left undisturbed for at least 15 minutes or until the infant was sleeping or in a quiet awake state. Three successive BP recordings were taken at three-minute intervals.2)), respectively.Echocardiographic measurements in newborn on the 3rd day after delivery were made by one pediatric cardiologist. Two-dimensional M-mode echocardiography was performed using an Acuson Sequoia 512 unit (USA), equipped with a 2–4 MHz imaging transducer. Measurement techniques were consistent with the American Society of Echocardiography conventions. In a parasternal long-axis view, LVIDd-left ventricular internal diameter-diastolic, LVIDs-left ventricular internal diameter-systolic, LVPW-left ventricular posterior wall thickness at end diastole, IVS-thickness of interventricular septum at end diastole, LAD-left atrial diameter, AoD-aortic diameter, PAD-pulmonary artery diameter, LVV-left ventricular volume, and LVEF-left ventricular ejection fraction were measured (using M-mode formulas). The left ventricular masses (LVM) were calculated from the echocardiographic left ventricular dimension measurements, using the Penn convention with the equation modified by Huwez et al.  (1994) aCALM2 (rs7565161) polymorphism, a polymerase chain reaction-restriction fragment length polymorphism (PCR/RFLP) method was designed with the following primer pair: forward 5′-AgggCCTgCAATCTAAT-3′ and reverse 5′-ATATAATCCCCACCTTCAg-3′ . The CALM amplicons were subsequently digested with the AciI restriction enzyme . The PCR product of 417 base pairs (bp) was cut into fragments of 258 bp, 137 bp, and 22 bp in the presence of the G allele and into fragments of 395 bp and 22 bp in the presence of the A allele. Restriction fragments in each case were electrophoretically separated and visualized in midori green-stained (Nippon Genetics) 3% agarose gels. To verify the results, sequencing analyses were performed. All tested individuals had genotypes confirmed by sequencing. Each CALM2 amplicon was cleaned with GenElute PCR Clean-Up Kit (Sigma). Sequencing was performed according to the dideoxy Sanger method in a GeneAmp PCR System 9700 thermal cycler (Applied Biosystems), using BigDye Terminator v3.1 Cycle Sequencing Kit (Applied Biosystems). Afterwards, samples were purified , and 20 μL deionized formamide (Applied Biosystems) was added. Sequencing analysis using an ABI PRISM 3100-Avant machine (Applied Biosystems) was performed. The sequencing results were read using Sequencing Analysis Software v5.1 (Applied Biosystems). In each case, the result obtained with PCR-RFLP method was identical with that appropriate one from sequencing.Genomic DNA from cord blood was isolated using the QIAamp Blood DNA Mini Kit , according to the manufacturer's protocol. For the analysis of the intergenic G>A CALM2 genotypes frequencies from Hardy-Weinberg equilibrium was assessed using χ2 tests, and the distribution of each quantitative variable was tested for skewness. Quantitative data were presented as means ± SD and analyzed either by Student's t-test or by one-way ANOVA. Left ventricular mass indexes (LVMIs) were tested for association with genotype using multivariate analysis (ANCOVA) in order to adjust for possible confounding factors: neonatal  and maternal . Dominant, recessive, and additive modes of inheritance were tested. Statistical significance was defined as P < 0.05. All data were analyzed with STATISTICA .The divergence of n = 206) are shown in CALM2 homozygotes (33.5%), 95 GA heterozygotes (46.1%), and 42 AA homozygotes (20.4%) were identified. There were no significant differences in CALM2 genotype or allele distributions between boys and girls . The CALM genotype distributions conformed to the expected Hardy-Weinberg equilibrium (P = 0.396).Characteristics of the newborn cohort ( CALM2 polymorphism). The carriers of the G allele of the CALM2 polymorphism had significantly higher LVM/BW values, when compared with newborns homozygous for the A allele . The AG genotype of CALM2 was associated with the highest values of LVM/BW, exhibiting a pattern of heterozygote advantage   in order to adjust for possible confounding factors, after adjusting for newborn  and maternal  parameters. We revealed a significant association between LVMIs . Carriers of the allele A of the CALM2 gene had an increased incidence (%) SBP ≥ 90 percentile . Lastly, the CALM2 polymorphism was significantly correlated with maternal history of gestational age (P = 0.019). An overview over the data can be found in An association was observed between genotype and DBP ≥ 90 percentile  are involved in increasing proliferation [The connection between calmodulin and modulating cardiac contractile function and growth is well documented , 31. Othferation , 36.CALM2 may be partly involved in regulating myocardial cell proliferation and growth, during embryogenesis and in the first days of life. It is possible that genetic variation in CaM may have been involved in regulating the activity or/and levels in serum kinases and phosphorylases  during fetal life. In the current study, we investigated healthy newborns born at full term. Our previous studies reported that RAS (renin-angiotensin system) or BMP4 (bone morphogenetic protein 4) and BMPR1A  genetic variation may partially account for subtle variation in LVM or parameters or heart parameters in newborns [Although such knowledge indicates the important role of calmodulin-dependent protein kinases and phosphatases in regulating cardiac hypertrophy , the rolnewborns , 38. To CALM2 polymorphism, and DBP and MAP was found, but the mechanism by which this might act is not clear. Blood pressure is regulated by multiple neuronal, hormonal, renal, and vascular control mechanisms, as well as genetic and environmental factors. It is also dependent, inter alia, on the force of contraction of the heart muscle which is connected indirectly to the left ventricular mass. There are many known candidate genes that have huge influence on the blood pressure or development of hypertension [Additionally, an association between rtension –41. Howertension . A recenrtension . HoweverCALM2 polymorphism is associated with left ventricular mass in newborns. This might be the consequences of variation in cell proliferation and growth, and this finding may indicate an important role for genetic variation of CALM2 in expansion-induced heart growth in fetal life.In conclusion, we have shown that the intergenic adjacent


Right ventricular strain assessment by feature tracking from cine images shows acceptable levels of agreement with echocardiographyRV ejection fraction is the recognised marker of RV function although the assessment of deformation by strain analysis provides potential means for assessing early ventricular dysfunction before other recognised markers fall.RV strain analysis by tagging is time consuming and requires significant operator expertise due to the nature of the RV anatomy . The potential to analyse RV strain from cine images using semi automated software to track the endocardial border now exists, feature tracking ‘FT’ . Our aims are to:1. Assess the agreement between FT RV HLA view and 2D echocardiography (2DE) for global peak RV free wall longitudinal strain2. To assess the correlation between FT derived basal peak systolic velocity and basal displacement with common markers of echocardiographic RV longitudinal performance .19 individuals underwent 3T CMR  to obtain RV HLA cine images. Apical 4 chamber views to assess the RV free wall by 2D echocardiography was performed using Toshiba Artida (2.5MHz PST-25SX probe).Post processing assessment was carried out using TomTec Diogenes (for FT) and TomTec Cardiac Performance Analysis (for 2DE)Data is presented as mean ± SD and agreement assessed using Bland Altman analysis and Pearsons Correlation.Heart rates during CMR (64.8 ± 8.8) and 2DE (63.4 ± 12.2) were similar (P = 0.64). The temporal resolution of 2DE (16.5 ± 1.2ms) was shorter than that for CMR (37.8 ± 4.2ms), P<0.05. The analysis time needed for FT HLA was 220 ± 40s.Results are presented in Table No significant correlations were seen between FT and 2DE for peak basal velocity or peak basal displacement.FT allows the assessment of RV strain from cine images and shows acceptable levels of agreement with 2DE. The lack of correlation between FT velocities and displacement values when compared with 2DE is likely due to a combination of the improved temporal resolution of 2DE together with the precise locations for the FT tracking measurements not being known.The ease of analysis of RV free wall FT is promising although further insights into the algorithms used are needed to make more accurate judgements as to the agreement with echocardiography, to define normal values and to assess its use in disease populations with RV dysfunction.The research is funded by the Engineering and Physical Sciences Research Council (EPSRC) grant EP/G030693/1.