There is a need to detect and prevent fluid overload and malnutrition inheart failure. Bioelectrical impedance analysis and bioelectrical impedancevector analysis are medical instruments that can advance heart failuremanagement by generating values of body composition and body water,assisting clinicians to detect fluid and nutritional status. However, thereis a lack of evidence to summarise how they have been used among heartfailure patients.A systematic search was conducted.Two hundred and four papers were screened. Forty-eight papers were reviewed,and 46 papers were included in this review. The literature shows thatbioelectrical impedance analysis and bioelectrical impedance vector analysiswere mostly used to assess fluid and nutritional status, together withdiagnostic and prognostic values. Contraindication of using BIA andimplications for practice are also demonstrated.The findings suggest that bioelectrical impedance vector analysis is superiorto bioelectrical impedance analysis when assessing hydration/nutritionalstatus in heart failure. Assessing a patient using bioelectrical impedanceanalysis /bioelectrical impedance vector analysis, together with natriureticpeptide -heart failure biomarkers, increases the diagnostic accuracy ofheart failure. Further studies are required to examine the costeffectiveness of using these instruments in clinical practice. Heart failure is commonly associated with fluid overload. An assessment of fluidcongestion is crucial in heart failure management as it determines diseaseprognosis, morbidity, and mortality . BioelecBIA uses bioelectrical impedance, described as resistance to flow of alternatingcurrent . BioimpeBased on frequency there are 2 types of BIA: the initial single 50 kHz frequencyBIA (SF-BIA), and the more recent multiple frequency BIA (MF-BIA), 1 kHz–500 kHz. Using sA derivative of BIA, BIVA has been used to assess nutritional and fluid status byplotting a bivariate vector analysis of reactance and resistance standardised byheight and overcome the limitations of BIA  Figure . Unlike A literature review was conducted to examine how BIA and BIVA are used in heartfailure patients and whether it is useful in heart failure treatment and management.A systematic search was conducted to identify relevant studies related to the topicarea via MEDLINE from 2002 to 19 April 2022 using search terms; ‘electricimpedance’, ‘bioelectrical impedance vector analysis’, ‘BIVA’, ‘heart failure’.Inclusion and exclusion criteria to select papers were applied. Inclusion criteriawere research paper in which the main aim of study is to examine whether using BIAand BIVA can benefit heart failure patients in the hospital setting. Exclusioncriteria were studies using other types of bioimpedance as the main aim of the paperand studies using BIA to investigate the effect of a specific drug, non-humanstudy.One-hundred and ninety-seven studies were identified through the database, a shown inSupplement 1).BIA and BIVA have been used in acute and chronic heart failure to assess fluidstatus to diagnose and manage heart failure  and N-terminal pro-BNP(NT-proBNP), are used to identify the degree of heart failure . Howeverr = 0.603, p < 0.001)  showed the highestsensitivity and specificity of 78% and 96%, respectively, compared to orthopnea(sensitivity and specificity: 28% and 90%), pretibial edema (72% and 92%),pulmonary congestion (68% and 86%), and rales (42% and 90%) in detecting fluidcongestion to help diagnose acute heart failure . Also, a< 0.001) .p <0.0001). This combination increased the net diagnosis of acute heart failureincreased from 19% (p = 0.016) to 77% (p <0.001)  and using BNP levels in conjunction with thehydration index, the diagnostic ability (AUC) in this regard was reported as0.77 with 65.3% sensitivity and 78.8% specificity (<0.001) . This suFluid overload in acute heart failure produces a bivariate vector that felloutside of 75% ellipse with 75%2  and exercise time    . This ma< 0.001) . Howeverr = −0.367, p≤ 0.0001) (p = 0.04) and diastolic heart failure(p = 0.01) (p < 0.05) (PA is inversely related to fluid overload . There i 0.0001) . PA was  = 0.01) . Thedec < 0.05)  and high < 0.05) . PA also < 0.05) .PA can  < 0.05) ; however < 0.05) .p < 0.0001; p < 0.001; mean ± SD; Furthermore, when hydration index is over 74.3% (50% BIVA ellipse)  Figure, this inSupplement 2). In chronic heart failure patients, those with ahigh lean body mass and body fat mass index had better 5-year clinical outcomesand better survival rates than those with low lean body mass  and body fat mass index   . This ph= 0.008) .p = 0.03; p = 0.01), and this combination of parameters could suggestadvanced heart failure regardless of gender    and (82.p < 0.0001 (p< 0.038 (p = 0.003), 180 days  and 18 months  and mortality atall time points  (p < 0.005). Additi< 0.038 . Therefo< 0.005). The benSupplement 3). BIA frequency is important when assessing bodycompositions and there are 2 types of BIAs: SF-BIA and MF-BIA. MF-BIA has beenused in heart failure patients due to the fact that multiple frequenciesprovides more accurate assessment of body water and therefore body cell mass,which improves accuracy of consequent anthropometric measurements (p < 0.01).This might relate to the occurrence of cachexia , fat mass (r = 0.96) and body mass (r =0.84) between MF-BIA and DEXA  with no differences in mean (mean (standard deviation) ofDEXA versus MF-BIA: body fat 28(6) versus 27(9); fat mass 20(6) versus 20(9);fat free mass 52(10) versus 53(11) . There wand DEXA . Howeverand DEXA . Thus, aand DEXA . Due to r = 0.3310 (p< 0.0001) and r = 0.3115 (p < 0.001),respectively . Following this, some versions of BIA were shownto be safe to use, under manufacturer guidance.Despite the potential advantages of BIA, there are some notablecontra-indications in heart failure patients associated with cardiac implantableelectronic devices . A potenBIVA is more advantageous in heart failure screening, treatments, and management,including determining fluid and nutritional status than BIAs. BIVA andhydrograph have potential benefits as they can be used to identify chronic oracute heart failure, facilitate heart failure treatment by avoidingcomplications when adjusting diuretic treatment in acute settings and monitoringfluid status. Currently, the American Heart Association recommends BIVA tooptimise fluid treatment to avoid cardiorenal syndrome . ThecomDespite the benefits of bioimpedance measurements, safety concerns must beacknowledged. In cased where BIA measurement cannot be performed due to concernsregarding contraindications, an alternative method to measure anthropometry orassessing fluid status should be considered. In addition to safety concerns, itis worth noting that although the statistical significances were reported in thefindings of this review, the effect size of some included studies might be smalland therefore should be interpreted with caution considering clinicalapplicability. Furthermore, due to lack of consistency in reports of BIA/BIVAparameters leading to difficulties in combining analyses, future studies shouldreport BIA/BIVA parameters, such as PA, edema index, hydration index,reactance/height and resistance/height, if applicable as these parameters tendto be accurate measurements that would further benefit heart failure managementand research, particularly, in a systematic review and meta-analysis to furtherinvestigate on which parameters would comprehensively reflect conditions ofheart failure patients.This review has demonstrated the uses of BIA and BIVA in acute and chronic heartfailure patients. It also emphasises the importance of using BIA and BIVA to screenand detect for malnutrition, assess, and monitor fluid status to provide treatment,predict prognosis, including the safety concern of using BIA. Indeed, BIVA and itsparameters, such as PA and hydration index, seem to be more superior than BIA inheart failure patients. The combinations of using BIVA and BNP/NT-proBNP increasesthe ability to detect heart failure and predict prognosis. However, further studiesare required to examine the replacement of current practice by using BIVA, includingcost effectiveness. Further work is needed on determining the effects of BIA onpatients with CIED.Click here for additional data file.Supplemental Material for A Current Review of the Uses of Bioelectrical ImpedanceAnalysis and Bioelectrical Impedance Vector Analysis in Acute and Chronic HeartFailure Patients: An Under-valued Resource? by Jenjiratchaya Thanapholsart,Ehsan Khan and Geraldine A. Lee in Biological Research For Nursing


Myocardial fibrosis has recently been proposed as one of the contributing factors to the diverse pathogenicity of cardiomyopathy in sickle cell disease.In this study, cardiac fibrosis and subclinical cardiac changes in children with sickle cell disease were evaluated using cardiac magnetic resonance imaging (MRI), tissue Doppler echocardiography and serum galectin-3.The study included 34 children with sickle cell disease who were compared with a similar number of healthy controls. Cardiac MRI was used to evaluate late gadolinium enhancement, native T1 mapping, extracellular volume, and T2* for estimation of iron load. Cardiac function and myocardial performance index  and serum galectin-3 were compared to controls.P = 0.017) and negatively correlated with hemoglobin levels (P = 0.005). Galectin-3 levels were significantly higher among cases than controls (P = 0.00), at a cutoff value on the receiver operating characteristic curve of 6.5 ng/ml, sensitivity of 82.5% and specificity of 72.8%. The extracellular volume was significantly higher in cases, with a MPI > 0.4.The mean age of the included patients was 13.3 ± 3.2 years. Myocardial iron load by T2* was normal. The mean level of extracellular volume (35.41 ± 5.02%) was significantly associated with the frequency of vaso-occlusive crises (Diffuse interstitial myocardial fibrosis can be detected early in children with sickle cell disease using T1 mapping and is associated with a high frequency of vaso-occlusive crisis. MPI of the left ventricle and serum galectin-3 are recommended screening tools for subclinical cardiac abnormalities.Supplementary material is available at 10.1007/s00247-023-05750-2. Sickle cell disease is the most common hereditary hemolytic anemia in the United States of America and one of the prevalent hereditary hemolytic anemias in sub-Saharan Africa, the Mediterranean region and central India . CardiovThe predominant manifestations of the disease are related to vaso-occlusive crises. Repeated episodes of tissue ischemic reperfusion injury, in addition to the effect of hemolysis, result in a chronic vasculopathy with an inflammatory state, which leads to chronic end-organ damage , 3. MultRecent studies have reported cardiac fibrosis in adult patients with sickle cell disease as a novel mechanism for cardiac dysfunction . CardiacThe noninvasive detection of myocardial fibrosis is challenging. Cardiac magnetic resonance imaging (MRI) studies using late gadolinium enhancement are currently the gold standard noninvasive method to detect focal myocardial fibrosis. However, focal myocardial fibrosis has only been reported in a few patients with sickle cell disease , 11–13. Other noninvasive imaging modalities have been employed to detect myocardial fibrosis including tissue Doppler echocardiography, nuclear imaging and cardiac computed tomography –18. In aThis study evaluated cardiac fibrosis in children with sickle cell disease using cardiac MRI and also aimed to detect the effectiveness of tissue Doppler echocardiography and serum galectin-3 in identifying subclinical cardiac abnormalities indicative of myocardial fibrosis.2) which is a contraindication to contrast administration were excluded from the study. Enrolment of children with recent vaso-occlusive  crises was delayed by two weeks aiming to perform cardiac MRI under more convenient circumstances on a cooperative child. This precaution was taken as most of these crises were moderate to severe painful crises that required hospitalization of critically ill, irritable children. This delay was also important because some authors [This prospective controlled study was approved by the ethical committee of Alexandria Faculty of Medicine according to the Declaration of Helsinki (IRB: 0201617). Informed consent was obtained from parents of all children enrolled in the study. A total of 68 children participated in this study between September 2021 and June 2022. The enrolled children included two groups, 34 children in each. The patient group included children between 8 and 18 years of age who were diagnosed with sickle cell disease by hemoglobin electrophoresis and recruited consecutively from the Hematology Clinic of the Pediatric Department of our institute. The second (control) group included healthy children  matched for age and sex with the patient group. Patients with overt heart failure and those with severe renal impairment (glomerular filtration rate <30 mL/min/1.73 mhttp://www.ncss.com).According to the study by Niss et al. , a minimThe demographic data and clinical profile of the patients including the frequency of vaso-occlusive crises, sites of pain, blood transfusion and hydroxyurea treatment were obtained. Cases and control subjects underwent routine laboratory and imaging investigations described in the following sections.oC until the time of assay. Galectin-3 was measured using enzyme-linked immunosorbent assay (ELISA) kits , according to the manufacturer’s recommendations [Blood samples from both patients and control subjects were collected for the measurement of galectin-3 levels. Samples were coagulated at room temperature for 15 min, then centrifuged at 3,000rpm for 10 min. Serum was collected and stored at − 80ndations .Echocardiographic assessment was performed using a Philips HD 11 ultrasound echocardiography machine  with a transducer of 2–4 MHz at the Pediatric Cardiology Clinic of our institute. All echocardiographic measurements were performed in three heart cycles and the mean value was used for analysis. Echocardiographic studies were performed by a single pediatric cardiologist (R.W.) with 15 years of experience. Echocardiographic measurements were performed using 2-dimensional, M-mode Doppler echocardiography and tissue Doppler imaging, because it is a reproducible tool for the detection of myocardial fibrosis –18, 24. Cardiac MRI was conducted on a 1.5 tesla MRI scanner . All images were electrocardiograph (ECG) gated using retrospective gating, with 25 images reconstructed per cardiac cycle. The estimated volume and function cardiac MRI measurements were independently performed by two radiologists (F. E. with 5 years of experience and G.S. with 3 years of experience) blinded to the case/control status of each scan and the results were compared to the values reported individually by van der Ven et al. and Robbers-Visser et al. for healthy children matched by age and sex , 29. TheThe motion-corrected (MOCO) modified Look-Locker Inversion recovery (MOLLI) sequence was acquired before and 10 min after bolus contrast administration with variable inversion preparation times. The myocardial extracellular volume was assessed using the equation reported previously . Our calThe patient group was further subdivided into subgroup I: < median age and subgroup II: > median age of the patient group and the galectin-3 levels, MPI and extracellular volumes of both subgroups were compared.t-test was used to compare two groups for normally distributed quantitative variables, The Pearson coefficient r, Pearson correlation, and Spearman correlation, rs were used to correlate two normally distributed quantitative variables and the Mann‒Whitney test was used. Our results were considered statistically significant at P-value ≤ 0.05. The significance of the receiver operating characteristic (ROC) curve was judged at the 5% level. The area under the ROC curve denotes the diagnostic performance of the test. An area of more than 50% gives acceptable performance and an area of approximately 100% is the best possible performance for the test.Data were analyzed using IBM SPSS software package version 20.0. . Student 2). The demographic and laboratory data of the included children are summarized in Table P < 0.001). Based on the ROC curve, the best cutoff value of galectin-3 for differentiating between patients and control subjects was 6.6 ng/ml, with a sensitivity of 82.5% and specificity of 72.8%  and a control group consisting of a similar number of age- and sex-matched healthy children. The consecutive selection of the patients from the hematology clinic was based on random chance. We excluded ten potential patients for the following reasons: five had experienced a recent vaso-occlusive crisis and (as per the study protocol), were advised to return in two weeks but did not; three had severe claustrophobia; and two patients had severe renal impairment (GFR < 30 mL/min/1.73 mP=0.001). However, tissue Doppler variables of the systolic and diastolic function at the lateral mitral annulus and the systolic variables of the medial mitral annulus were significantly different for cases when compared to controls  and systolic function (ejection fraction: 65.29 ± 5.8%) estimated by cardiac MRI were within the normal range for age and sex in all patients. The mean indexed left ventricular end-diastolic volume (LV-EDVI: 102.29 ± 19.8ml/m2) and the indexed left ventricular mass (74.62 ± 15.37gm/m2) were increased for age and sex in all patients. The left ventricular ejection fraction on cardiac MRI was positively correlated with the ejection fraction estimated by echocardiography and with the velocity of lateral and medial mitral leaflets . None of the patients was found to have myocardial iron overload. The mean myocardial iron T2* was 33.58 ± 6.83ms and the mean MIC was 0.68 ± 0.19mg/g. The mean hepatic iron T2* was 14.64 ± 9.66ms and the mean LIC of the patients was 4.97 ± 7.67mg/g. We found that 20 patients (59%) had normal hepatic iron concentrations, three patients (8.8%) had moderate hepatic iron overload, four (11.8%) had severe hepatic iron overload, while the remaining seven (20.6%) had mild hepatic iron overload. Of the control group, 15 had non-contrast cardiac MRI and the native T1 (precontrast) was estimated. The mean native T1 was significantly higher for patients when compared to control subjects . No significant difference was found between the septal and lateral wall extracellular volumes, . The average extracellular volume values  was used. We found that the average extracellular volume was significantly increased in 100% of patients when compared to the normal cutoff for age and sex (35.41 ± 5.02% versus 20.8 ± 2.4%). Figure r=− 0.5, P=0.005 and r=− 0.566, P< 0.00, respectively) as illustrated in Fig. r=0.62, P=0.006). A significant association between a high extracellular volume and the frequency of vaso-occlusive crises  was noted . Although the mean MPIm and extracellular volume were higher for the older group, they did not reach statistical significance (Table P = 0.03), as shown in Table The mean indexed left ventricular end-systolic volume , indicating diffuse myocardial fibrosis [P < 0.001) [r =  − 0.5, P = 0.005), which is in agreement with the findings of Niss et al. [t =  − 2.536, P = 0.017). Although blood ferritin levels were high in all patients, the T2* values were normal, which minimized the possibility that cardiac siderosis was the underlying cause of the myocardial alterations in children with sickle cell disease. This is in line with the findings of Junqueira et al. [In the current study, diffuse myocardial fibrosis was found to be a common subclinical feature in children with sickle cell disease. Using late gadolinium enhancement, increased extracellular volume was found in all patients, even in the absence of focal fibrosis. Our results highlight an important and underrecognized mechanism of heart pathology in sickle cell disease that appears to predate the development of cardiac dysfunction. A few studies have reported this abnormality in adult patients and this phenomenon has not been fully studied in children . Niss etfibrosis . Our resfibrosis , 38. Simfibrosis . Native < 0.001) . The rols et al. . Despites et al.  postulata et al.  who repoa et al. . In the P = 0.00). Other parameters of systolic and diastolic function of the left ventricle on tissue Doppler echocardiography were significantly decreased in patients compared to healthy control children. Eddine et al. [P = 0.038). This clarifies the impact of interstitial myocardial fibrosis on diastolic dysfunction and the restrictive pattern of sickle cell disease cardiomyopathy early in childhood. Similar findings were reported by Niss et al. [We were interested in evaluating left ventricular function among the patient group using echocardiography as myocardial fibrosis might affect cardiac function at a subclinical level. Combined systolic and diastolic function of the left ventricle was evaluated using the MPI, which was significantly higher in the children with sickle cell disease than in the control group. However, all patients showed normal systolic function on conventional echocardiography. Similarly, Caldas et al.  studied e et al.  conductee et al.  conductee et al. –47. Intes et al.  and Alsas et al.  in adultP = 0.03).The current study has demonstrated a correlation between the MPI and diffuse cardiac fibrosis, which has not previously been reported. Additionally, increased extracellular volume was correlated with a higher MPI. The mean extracellular volume was significantly higher for the subgroup with MPI > 0.4 (impaired) than the subgroup with MPI < 0.4  at a galectin-3 cutoff value of 3.5 ng/ml. In the current study, galectin-3 levels were significantly higher among children with sickle cell disease than among healthy control subjects (P < 0.001). At a cutoff value for galectin-3 of 6.5 ng/ml, the ROC curve showed a sensitivity of 82.5% and a specificity of 72.8%, and patients were discriminated from control subjects. These finding are in agreement with the results of Wagdy et al. [Galectin-3, a novel biomarker, has been predicted to play an important regulatory role in cardiac fibrosis and remodeling. In fact, galectin-3 expression appears to begin prior to the onset of heart failure , 50. They et al. .The tissOur study has some limitations. First, not all controls were subjected to cardiac MRI and we did not administer contrast to the controls who did have cardiac MRI as there is no ethical justification in our institute. This was a single-center study and studies with larger cohorts and longer follow-up are recommended. Children under the age of eight years were not included in our study as younger children usually require anesthesia for MRI scans. Finally, not investigating patients during their vaso-occlusive crises may be considered a limitation.Early detection of interstitial myocardial fibrosis and the determination of extracellular volume in pediatric patients with sickle cell disease is feasible with the use of T1 mapping. This observed fibrosis was generally diffuse rather than focal and was not explained by myocardial iron overload, which was normal in our patient population. An ischemia–reperfusion injury hypothesis would potentially be supported by our results. T1 values and extracellular volume abnormalities correlate well with galectin-3 and tissue Doppler echocardiographic-derived left ventricular MPIm, and these tools are recommended for the detection of early subclinical myocardial abnormalities in children with sickle cell disease.Supplementary file1 (DOCX 30 KB)Below is the link to the electronic supplementary material.


The analysis of right ventricular mechanics showed a significant improvement of fractional area change (FAC) immediately after BPV . On the other hand, right ventricular longitudinal systolic function parameters, TAPSE and global RVFWLS, did not improve significantly after intervention. The segmental analysis of the RVFWLS showed a significant regional increase in the myocardial deformation of the apical segments. Conclusions: Percutaneous BPV represents an efficient and safe procedure to relieve severe pulmonary valve stenosis. The analysis of the right ventricular function on echocardiography demonstrated an immediate global systolic function improvement, while longitudinal systolic function was persistently impaired 24 h after intervention, possibly due to the necessity of a longer recovery time.Introduction: Pulmonary valve stenosis determines multiple effects on the right ventricular dimension and function. Percutaneous balloon valvuloplasty is the treatment of choice in severe pulmonary valve stenosis in patients of all ages. However, little is known regarding right ventricular function immediate changes after percutaneous balloon dilation. Pediatric patients with isolated pulmonary valve stenosis represent a pure clinical model of chronic RV pressure overload not affected by other confounders or comorbidities. Aim of the study: This study seeks to explore right ventricle (RV) mechanics in pediatric patients early after percutaneous balloon pulmonary valvuloplasty (BPV) for valvar pulmonary stenosis (PS). Materials and Methods: Forty-three pediatric patients , mean age 3.2 ± 4.9 years old, with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited. All patients underwent standard transthoracic echocardiography (TTE), and speckle-tracking echocardiography (STE) with an analysis of right ventricle free-wall longitudinal strain (RVFWLS) one day before and one day after the procedure. For each patient, we collected invasive parameters during the interventional procedure before and after BPV. Results: After the procedure, there was an immediate significant reduction in both peak-to-peak transpulmonary gradient (peak-to-peak PG) and ratio between the right ventricle and aortic systolic pressure (RV/AoP) with a drop of ∆29.3 ± 14.67 mmHg and ∆0.43 ± 0.03, respectively. Post-procedural echocardiography showed peak and mean transvalvar pressure gradient drop . The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, affecting 29% of our patients post-BPV ( Pulmonary valve stenosis accounts for 6–9% of all congenital heart diseases. The main effect of this obstructive lesion is a rise in right ventricular pressure; this overload leads to multiple changes in the shape, dimensions, and volume of the ventricle ,2,3,4. TThis was a single-center study performed at the Department of Women’s and Children’s Health (W&CHD) of Padua University Hospital, Italy. The study was conducted from 2017 to 2021 and enrolled 43 consecutive pediatric patients with isolated congenital pulmonary valve stenosis and indication for percutaneous balloon pulmonary valvuloplasty (BPV) in the Cath Lab. The terms “pulmonary stenosis” and “PS” were used as keywords to search our electronic database and the collected data were subsequently validated against original medical records. The inclusion criteria were aged ≤18 years old at the time of the clinical evaluation and the presence of severe congenital pulmonary valve stenosis with indication for valvuloplasty. Patients with critical pulmonary valve stenosis , patients with associated complex cardiac lesions, and patients with a previous treatment for pulmonary valve stenosis, either percutaneous or surgical, were excluded. The data of each patient were collected through institutional software Galileo , which traced the clinical data and procedural reports. Echocardiographic scans were retrieved from the institutional archive and loaded into EchoPac Software Only v204  to analyze standard 2D images and for the calculation of the longitudinal strain and strain rates. Patients were then anonymized through codes, and the study data did not include personal data or identifiers. Therefore, the final dataset that was built was divided into demographic and clinical data, echocardiographic data, right ventricular strain analysis, and procedural related invasive parameters. The study was conducted in compliance with the Declaration of Helsinki principles. The local ethics committee of Padua hospital approved the study design and informed written consent was obtained from all parents or legal guardians.The collected data included the baseline demographic variables  and clinical variables .Standard two-dimensional (2D) transthoracic echocardiography was performed for all patients one day before and one day after the intervention. Scans were conducted following the present guidelines and the recommendations for cardiovascular imaging during the COVID-19 pandemic ,14,15. TBalloon valvuloplasty was performed, as previously reported . The folt-test was used to determine the significance of differences in the study variables pre- and post-intervention. Linear correlation was used to compare between hemodynamic variables and 2D TTE and 2D STE. A two-sided p-value < 0.05 was considered statistically significant.Data analyses were performed using STATA version 14 . Categorical variables were expressed as number (percentage) and continuous variables were presented as mean ± SD or median (interquartile range) for skewed variables. The absolute value of strain was used to facilitate the interpretation and analysis. The chi-squared or Fisher’s exact tests were implemented to compare the categorical variables between the defined groups, as appropriate. A paired student’s A total of 43 patients underwent BPV during the study period with a median age and body weight of 6 months (IQR 4 days–15 years) and 7.6 Kg (IQR 2–72), respectively, of whom 19 (44%) were males. Three patients (7%) of our cohort had Noonan syndrome, 7 (16%) patients had a PFO/small ASD not hemodynamically significant, 6 (14%) had a small and restrictive patent ductus arteriosus not hemodynamically significant, and 1 had tricuspid valve dysplasia causing mild regurgitation .The median pulmonary valve annulus diameter, as assessed by angiography, measured 9 mm (range: 6–23 mm). The median of the maximum balloon diameter used was 12 mm (range: 7–24) and the median of the maximum balloon diameter to pulmonary valve annulus ratio was 1.1 (range: 0.6–1.3). A single balloon was used in 31 (72%) patients, while 2 and 3 balloons were used in 9 (21%) and 3 (7%), respectively. Pre- and post-valvuloplasty hemodynamic data are listed and compared in p 0.007). Conversely, the incidence of moderate PV regurgitation did not worsen after the procedure . The incidence of tricuspid and pulmonary valve regurgitation before and after the procedure displayed an increase solely in the mild pulmonary regurgitation after PBV . Global RV systolic function measured by FAC improved after valvuloplasty . No significant changes in the longitudinal RV systolic function (TAPSE) or in the RVFW longitudinal strain values were observed . However, the segmental analysis of the RVFWLS showed a significant regional increase in the myocardial deformation of the apical segments  and children/adolescents  groups, except for TAPSE, which showed a slight improvement after BPV in the younger group .RV functions before and after the procedure were compared among the patients with a successful BPV procedure, as reported above . Conversely, a positive correlation was found between pulmonary transvalvular gradients (peak and mean) and the pre-operative RV/AoP ratio .The present study evaluated the functional changes in ultrasonic-derived RV systolic indexes 24 h after a successful BPV in pediatric patients affected by pulmonary valve stenosis. Our findings shed new light on the acute functional systolic changes in chronic pressure overloaded RV. The study of RV function has important prognostic implications ; thus, aOur sample size may seem small; however, to study the changes induced by BPV in a pure clinical model of RV chronic pressure overload, we only selected pediatric patients. We excluded patients with associated congenital abnormalities , and we only included patients for whom BPV was successful. In addition, all the echo measurements were conducted 24 h before and 24 h after the procedure in the whole studied sample. Sample age heterogeneity may constitute a limitation, as it ranged from 4 days to 15 years. The timing of the post-procedural ultrasound evaluation may represent a limitation, and further studies need to investigate our findings at the long-term follow-up.Our study, in a pure clinical model of chronic RV pressure overload exposed to successful acute pressure unloading, suggests that longitudinal function impairments persist longer than 24 h and the functional recovery starts from the RVFW apical segments.


This could be validated in an independent prospective cohort (n = 226) with symptomatic non-ischemic heart failure. DEV systematically overestimated LV mass in all tiers of LV remodeling as compared to TEICH. In conclusion, the TEICH method accounts for the changes in LV geometry with increasing LV mass and thus better reflects the different pattern of LV remodeling than the DEV method. This has important clinical implications, as TEICH may be more appropriate for use in clinical practice, rather than DEV, currently recommended.Left ventricular (LV) myocardial mass is important in the evaluation of cardiac remodeling and requires accurate assessment when performed on linear measurements in two-dimensional echocardiography (Echo). We aimed to compare the accuracy of the Devereux formula (DEV) and the Teichholz formula (TEICH) in calculating LV myocardial mass in Echo using cardiac magnetic resonance (CMR) as the reference method. Based on preceding mathematical calculations, we identified primarily LV size rather than wall thickness as the main source of bias between DEV and TEICH in a retrospective derivation cohort (n = 1276). Although LV mass from DEV and TEICH were correlated with CMR, TEICH did not show a proportional bias as did DEV (− 2 g/m Though cardiac magnetic resonance (CMR) imaging is regarded as the gold standard for non-invasive measurement of LV mass and morphology, transthoracic echocardiography (Echo) remains the daily armamentarium of cardiologists, due to availability and feasibility4. The current Echo guidelines recommend using the DEV method, based on Devereux’s formula, for LV myocardial mass assessment with one-dimensional linear measurements6. This method is recommended due to its simplicity and reproducibility for screening in large groups. Recently, doubts have arisen about the usefulness of the DEV method as it overestimates LV mass compared to CMR imaging in LVs with distorted morphology9. An alternative linear measurement method, the TEICH method, based on the Teichholz formula, has been validated by angiography and uses the same measurements as the DEV method10. As depicted in Fig. 12. Indeed, alternative measurement methods with higher agreement and precision have been proposed for Echo14, but require multiple measurements or depend on image quality, such as in three-dimensional Echo. However, the TEICH method has not been systematically evaluated on a large cohort of patients for its feasibility and accuracy. Thus, our study aims to address this gap in knowledge by testing the accuracy of the linear TEICH method. Specifically, we plan to evaluate the DEV and TEICH equations mathematically to understand the impact of measurement parameters on LV mass calculation. Using CMR as the reference, we will identify confounders that cause differences between the two methods and validate our findings in an independent cohort of heart failure patients with different types of LV geometry. Our approach offers a novel and systematic way to assess the differences between these methods. Furthermore, it will provide insights into their practicality in terms of accuracy as compared to the current Echo method.Assessing left ventricular (LV) myocardial mass is important in evaluating a patient’s cardiovascular risk and prognosisThe study was approved by the ethics committee of the Technische Universität Dresden, Dresden, Germany, (Reference number: 157052018), and all patients included prospectively in the validation cohort (see below) provided written informed consent. For patients included retrospectively for the derivation cohort (see below), written informed consent was waived by the ethics committee of the Technische Universität Dresden, Dresden, Germany, (Reference number: 284092012). The study was performed in accordance with the Declaration of Helsinki of 1964 and later revisions.Two timely independent cohorts were analyzed in this study:5 and (3) CMR image acquisition followed the standard in-house protocol as described below. Among them (n = 1710), we excluded patients with unsatisfactory image quality in Echo (n = 298) and unsatisfactory CMR protocol adherence or quality (n = 136). Finally, a total of 1276 patients were included. A flow chart of the screening procedure is provided in the Supplemental data  CMR and Echo examinations were performed within 48 h, (2) Echo imaging conformed to current Echo guidelinesata Fig. .5 and were performed by two experienced cardiologist. CMR acquisition followed our in-house standard protocol. All patients provided written informed consent.The validation cohort (n = 226) was obtained from an ongoing prospective observational study, the Myocardial Heart Failure Study, conducted at our institution since December 2019. Patients with symptomatic heart failure other than ischemic or valvular heart disease underwent standardized Echo and CMR imaging within 24 h before a myocardial biopsy. The primary aim for the study and for myocardial biopsy is to characterize molecular and cellular changes in the myocardium of patients with heart failure, other than ischemic or valvular heart disease. The Echo examinations conformed to current guidelines5.All Echo images were obtained using a commercial ultrasound imaging system . B-Mode directed measurements of LV end-diastolic diameter (EDD) and intraventricular septum (IVS) and posterior wall (PW) at end-diastole from the LV parasternal long-axis view were manually reassessed as depicted in Fig. LV myocardial mass was calculated offline from the Echo measurements using following equations:6 :(i) DEV method applied the Devereux formula10 :(ii) TEICH method used the Teichholz formula15, CMR images were obtained using a 1.5-Tesla scanner  (18-channel body array and 32-channel spine array coil). Balanced steady-state free precession electrocardiogram-triggered cine images were acquired using retrospective gating and parallel imaging techniques during 10- to 15-s breath-holds with a temporal resolution of 20–30 frames per cardiac cycle. 4-chamber, 2-chamber, 3-chamber, and short-axis views with a slice thickness of 6 mm with 1.6-mm gaps were acquired in all patients. In addition, late gadolinium enhancement (LGE) imaging was performed 7–10 min after the administration of 0.15 mmol/kg of intravenous gadolinium chelate contrast agent  applying delayed enhancement images of segmented inversion-recovery spoiled echo gradient sequences (2D LGE: 1.3 mm × 1.3 mm × 8 mm). CMR images were analyzed using a dedicated post-processing software  as shown in Fig. According to standardized protocols16, categories of LV hypertrophy and LV end-diastolic dilation were defined a priori relative to sex-matched subjects with > 2 standard deviation (SD) above their respective mean reference values : For females: LV mass index > 59 g/m2 and LV end-diastolic volume index > 93 ml/m2; For males: LV mass index > 75 g/m2 and LV end-diastolic volume index > 107 ml/m2  was kept constant for the following levels: 0.8, 1.0, 1.2 and 1,5 cm. The mean wall thickness was incrementally increased, ranging from very thin 0.5 cm to very thickened 1.8 cm, while EDD was kept constant for the following levels: 2.5, 4.5, 5.0 and 6.5 cm. The expanded ranges and levels of the variables used in this calculations are based on previous reports for a wide range of etiologies of cardiac diseases18. Second, based on these univariable calculations, we performed bivariable calculations with concomitant continuous changes in EDD and mean wall thickness. The differences of LV mass results between DEV and TEICH were plotted as contour plots with the corresponding EDD and mean wall thickness. The modeling was used to show the specific output characteristics in LV mass calculation for the DEV or TEICH equations, and to reveal discrepancies based on the different LV geometric assumptions and calculation methods.The mathematical calculation of LV myocardial mass was performed using the (i) DEV and (ii) TEICH equation for Echo as describedIntra- and inter-observer variability for LV CMR analysis of mass and end-diastolic volume, as well as for Echo measurements of EDD, IVS, and PW used in mass calculations with the TEICH and DEV formulae, were evaluated in 30 randomly chosen patients.P value < 0.05. Sample size calculations  using data from previous studies20 on repeated measurements for agreement between methods21  and for the tier analysis  resulted in n = 100 of repeated measurements/observations. Continuous variables are expressed as mean ± standard deviation (SD) or median with interquartile range  as appropriate, and compared using a paired/unpaired Student’s t-test or Wilcoxon test if not normally distributed . In multiple pairwise comparisons the Bonferroni correction was applied. Categorical variables were reported as counts (%), and compared using a Chi-square or Fisher’s exact test as appropriate. Inter-technique comparisons of parameters of LV mass with intraclass correlation coefficient (ICC), simple linear regression equation and Bland–Altman analysis were applied to assess the bias and limits of agreement (± 1.96*SD). In addition, we assessed intra- and inter-observer agreement using ICC with one- and two-way random effects models for absolute agreement, and determined inter-observer variability using the coefficient of variation (CV)22. For comparison purposes, LV mass was related to body surface area. To evaluate the measurement bias between TEICH and DEV as well between Echo and CMR in the derivation cohort, multivariable least square regression analyses were carried out separately, respectively, with following parameters: LV EDD, mean wall thickness (average of PW and IVS due to assumed collinearity), any presence of LGE, sex, and age. Continuous variables were fitted using restricted cubic splines (4 knots) so as to not assume linear relationships between them and the response variable23. Hereby, regression results of bias were presented as inter-quartile range effects and depicted as adjusted marginal effects. The multivariable regression assumptions and diagnostics of the models were visually inspected. The coefficient of determination of the multivariable regression model is given as adjusted R2 and as predictive R2. The predictive R2 is based on repeated tenfold cross-validation measuring the goodness of fit and therefore represents an internal validation of the presented model24.All statistical analyses were performed with R, the open-source software . Statistical significance was defined as a two-tailed Mathematical calculations showed that the DEV method disproportionately increased calculated mass, especially as a function of LV EDD, compared to the TEICH method Fig. . These dThe anthropomorphic and clinical characteristics of the derivation n = 1276) and validation (n = 226) cohort are summarized in Table 276 and vp < 0.001 for all). However, the DEV method exhibited a proportional bias with increasing mass for the derivation and validation cohort. TEICH exhibited virtually no bias vs. CMR in both cohorts (mean bias: − 2 and + 3 g/m2). Results of the correlation and the Bland–Altman analyses of the derivation cohort are shown in Fig. The main Echo and CMR characteristics of LV measurements are summarized in Table 2  in patients with LGE and 87 g/m2  without, while TEICH-calculated mass showed medians of 81 g/m2  with LGE and 70 g/m2  without. The bias to CMR mass with DEV was 24 g/m2  with LGE and 16 g/m2  without LGE, whereas TEICH demonstrated minimal bias with LGE  and a slight negative bias without LGE . Similar results were found for patients with known or suspected coronary artery disease .The tier criteria of LV hypertrophy and dilation based on reference values of CMR imaging are shown in Table The intra- and inter-observer ICC values for measurements obtained from both Echo and CMR are presented in Table The main findings of the study are: 1) Mathematical computation of the DEV equation postulated a systematic overestimation of LV mass in dilated left ventricles, which increases with further incremental wall thickening. 2) Using these findings, we were able to elucidate that the LV diameter is the main source of disproportionate error in the DEV method and 3) the TEICH equation incorporates a flexible correction factor that enables closer agreement with the gold standard CMR than the DEV method in 4) almost all LV morphology, except in cases with the most severe LV geometrical aberrations. 5) We assessed the reproducibility of the TEICH method for different clinical entities on a timely independent cohort.13. Both methods . In a mathematical sense, the only modification of the TEICH equation is the correction parameter, which aims to minimize the error in the fundamental CUBE formulation if the geometry of the LV cavity is distorted. Indeed, the inherent assumptions of the DEV technique assume a fixed (i.e. symmetric) geometry of the ventricle, resulting in an overestimation of LV mass, especially with the progressive ventricular dilation typical for ischemic heart disease8. In line with these findings, the TEICH method yielded lower measurement variation across the 4-tier classification of LV morphology, and TEICH did not exhibit the same proportional measurement bias as the DEV method , but the differences between TEICH and CMR imaging were less pronounced than those between DEV and CMR (Fig. 25 conducted a curvature analysis in non-ischemic and ischemic cardiomyopathies, revealing a range of LV shapes that underscore diverse LV symmetries. These configurations are suggestive of the nature and extent of myocardial injury, and reciprocally, they exert an influence on prognosis26. In the absence of additional LV geometric and myocardial injury data, we can only speculate about the potential influence of diverse remodeling on the performance of the DEV and TEICH methods, as showcased in tier 4 of our study. This highlights the imperative for further research, encompassing comprehensive LV shape analysis, detailed LGE extent and localization data, and advanced CMR parameters like extracellular volume, to gain deeper insights. However, in patients with isolated LV dilation, LV hypertrophy or normal LV geometry the TEICH calculations show good agreement with CMR imaging. Certainly, the calculation of LV mass with one-dimensional measurements is based on geometric assumptions of the fundamental CUBE method and is prone to technical errors and varies highly dependent on the level of measurement especially in distorted left ventricles27. Indeed, our study revealed a notable disparity in measurement inconsistency, notably evident in posterior LV wall thickness, followed by the septum (Table 28. Although this new method provides more precise results than the DEV method, it requires a more elaborate measurement technique than the TEICH method.Recent studies questioned the accuracy of the DEV method in patients with concentric LV hypertrophyrt Figs. . This isod Figs. . With thCMR Fig. . Salgo aGiven that several outcome studies have demonstrated that LV mass measured by DEV provides prognostic information, one may question the rationale for assessing the accuracy of an already known method like TEICH. However, as our comprehensive analysis underscores Figs.  and 5, tWe acknowledge several limitations of this single-center study. Men were over-represented in both the derivation and the validation cohort. However, our study included a large number of patients with a wide range of LV morphology and various entities of cardiac disease that are commonly encountered in clinical practice. LV mass calculations using DEV and TEICH methods were based on B-mode measurements, which may limit comparability with previous studies using M-mode measurements. However, we used B-mode measurements for both methods and clearly demonstrated the higher accuracy of the TEICH equation. While the presence of LV myocardial LGE could potentially affect the DEV method more adversely than the TEICH method, it is important to note that our study did not evaluate a more nuanced spectrum of LGE characteristics. Finally, it is important to note that our validation cohort consisted of a restricted number of patients. Therefore, further research is necessary to fully assess the utility of the TEICH method in clinical context.Our analyses show that the DEV method based on Echo B-mode measurements systematically overestimates LV mass. In contrast, the TEICH method provides measurement results comparable to those obtained from CMR imaging. The advantage of the TEICH method is that it takes into account the change in LV geometry with increasing LV, and thus reflects the different pattern of LV remodeling.Supplementary Information.


Editorial on the Research TopicManagement of right ventricular failure: pathophysiology, medical treatment and use of ventricular assist devicesHao et al., Zhang et al., Bravo et al.) (The right ventricle (RV) has a crucial role in the evolution and prognosis of multiple cardiovascular conditions. The RV is anatomically and functionally different from the left ventricle (LV). RV adaptation to hemodynamic changes is determined by hemodynamic overload as well as by its intrinsic contractile function. The close relationship between both the RV and LV (ventricular interdependence) and the pulmonary circulation further modulates RV behavior . This re et al.) .Hao et al. present a case report of postoperative RV dysfunction in a woman with adult congenital heart disease  who presented with a type-A aortic dissection and an ascending aortic aneurysm (diameter: 71 mm) at 20 weeks of gestation. The patient underwent Bentall's surgery, but unfortunately the fetus died in the postoperative period. After C-section, the woman developed cardiogenic shock (CS). The differential diagnosis included: amniotic liquid embolism, pulmonary embolism, and myocardial infarction (MI). The final diagnosis was MI with right coronary artery occlusion. Echocardiography showed mild depression of LV function and severe RV dysfunction that was successfully treated with vasoactive drugs. This case shows the importance of diagnosis of RV dysfunction in different aetiologies of CS. On the other hand, it is worth highlighting that the woman was in WHO grade IV classification, in which case surgical is indicated before pregnancy.Zhang et al. explore the value of RV strain as a tool for estimating RV function  or late (>30 days), and late RV is defined as the presence of signs and symptoms of RV failure in combination with an increase of diuretics and/or a need for inotropes for at least 72 h . The article by Rodenas-Alesina et al. is an excellently structured guidance focused on the evaluation of RV failure post-LVAD implantation. Predictive preoperative assessment based on clinical features and a combination of echocardiographic and hemodynamic RV metrics is essential to detect patients with high risk of RV failure. Other intraoperative measures to avoid RV failure post-LVAD implantation are reduction of bleeding events, prevention of coagulopathy, avoidance of pericardiotomy and cardiopulmonary bypass, repair of valvular insufficiencies, and treatment of coronary artery disease if present.Two manuscripts focus on extensive reviews of the failure of RV post-LVAD  trying to maintain high HR to improve RV CO, through epicardial pacemaker or endocardial stimulation if the patient has a device. The last resort when other therapies fail is mechanical support (MS) of the RV. The specific device should be selected, based on the level of support needed and the center's experience.Late RV failure is relatively common, with moderate-severe episodes occurring in 20% of patients at one month and 3%–5% at three months . The manWe would like to finish this Research Topic with a call for action to perform more studies on different aspects of RV failure post-LVAD implantation. Significant gaps remain in our understanding and optimal treatment of this pathology.


The review focuses on the mechanism of ventricular interdependence, a frequently encountered phenomena, especially in critically ill patients. It is explained by the anatomy of the heart, with two ventricles sharing a common wall, the septum, and nested in an acutely inextensible envelope, the pericardium. In pathological situation, it results in abnormal movements of the interventricular septum driven by respiration, leading to abnormal filling of one or the other ventricle. Ventricular interdependence has several clinical applications and explains some situations of hemodynamic impairment, especially in situations of cardiac tamponade, severe acute asthma, right ventricular (RV) overload, or more simply, in case of positive pressure ventilation with underlying acute pulmonary hypertension. Ventricular interdependence can be monitored with pulmonary arterial catheter or echocardiography. Knowledge of this phenomena has very concrete clinical applications in the management of filling or in the prevention or treatment of RV overload. Besides that both ventricles interact in series and so that the right ventricle is responsible for the filling of the left ventricle by its ejection of blood into the pulmonary circulation, a phenomenon called heart-lung interaction , the perVentricular interdependence occurs in most cases in critically ill patients when the pericardial pressure is abnormally elevated, either because of some abnormal liquid inside or because right ventricular (RV) overloading occurs. Due to the sharing of myocardial fibers, a systolic alteration of one can also alter the performance of the other. In this review, our objectives are to physiologically describe abnormal ventricular interdependence and to illustrate clinical applications of such a description.Ventricular interdependence has probably been described for the first time in 1910, when Bernheim  suggestepost mortem and ex vivo hearts of dog where progressive RV filling led to progressive abnormal LV diastolic function , and increases at expiration (less negative). During cardiac tamponade, ventricular interdependence causes pulsus paradoxus . Indeed,ce versa .Pulsus paradoxus and ventricular interdependence are also described in severe asthma . HoweverInterestingly, while cardiac tamponade and acute asthma both generate pulsus paradoxus, different hemodynamic effects occurs in part explain by ventricular interdependence.Ventricular interdependence has been also reported when the right ventricle is overloaded in pressure or in volume. RV volume overload can result from atrial septal defect, tricuspid insufficiency, or pulmonary insufficiency. It causes an increase in RV end-systolic and end-diastolic volumes with normal RV ejection fraction  but abnoex-vivo heats of cats with each ventricles connected to an independent pump able to gradually generate an augmentation of pulmonary arterial resistance mimicking an obstruction to RV ejection  hypertension , or acutejection . It has pressure .Invasive mechanical ventilation can generate what is called “reverse pulsus paradoxus”, namely, a rise of the arterial systolic and diastolic pressures, presumably related to an inspiratory increase (during insufflation) in left ventricular output . VentricWhile pulsus paradoxus or reverse pulsus paradoxus are mainly mediated by ventricular interaction (both ventricles in series), ventricular interdependence may either magnify  or attenuate  such a phenomenon according to the different clinical situations described above.Consequences of ventricular interdependence in critically ill patients are numerous, notably in the field of hemodynamic monitoring. Historically, it has been recommended to monitor hemodynamically unstable patients during septic shock or ARDS with pulmonary arterial catheter (PAC). PAC gives several useful information to manage such patients, like cardiac output, pulmonary capillary wedge pressure (PCWP), pulmonary arterial pressure, central venous pressure. However, its insertion is not without any risk, and more interestingly, PAC does not well appreciate ventricular interdependence. As an illustration, increasing PEEP was suspected to induce LV systolic dysfunction on five patients monitored with both the PAC and left atrial catheter, as cardiac output decreased at high level of PEEP and PCWP and left atrial pressure increased, mimicking LV failure , while wEventually, biomarkers like atrial natriuretic peptide can suggest RV overload .Limiting pericardial pressure is the general principle to correct or limit pathological ventricular interdependence. Beyond compressive pericardial effusion, which must be drained urgently, RV overload, especially in pressure in critically ill patients submitted to mechanical ventilation, is also a factor of increased pericardial pressure and of pathological interdependence as described above. Then, RV overload must be tracked and treated.In ARDS, a situation where lung compliance is decreased, positive pressure ventilation abnormally increases transpulmonary pressure during tidal ventilation and sometimes during expiration when a too high PEEP is applied . As a coVentricular interdependence also explains the possible deleterious effects of fluid infusion in RV overload. A useless fluid expansion will magnify ventricular interdependence with their deleterious consequences on the left ventricle and hemodynamics. Moreover, an inadequate and massive volume expansion can lead to RV failure by itself . This deFinally, in acute cor pulmonale with severe circulatory failure, ones can discuss the use of temporary RV extra corporeal support. Peripheral veno-arterial ECMO, by unloading the RV and then, inverting the trans-septal gradient, has been described efficient in situation of high risk pulmonary embolism , while sMany clinical situations are responsible for pathological ventricular interdependence with adverse effects on hemodynamics. This involves an abnormal increase in pericardial pressure, whatever the cause, and therefore abnormal movements of the interventricular septum towards one ventricle or the other according to changes in the trans-septal pressure gradient. Knowledge of these phenomena has very concrete clinical applications in the management of filling or in the prevention or treatment of RV overload.


There are no current recommendations for oxygen titration in patients with stable coronary artery disease. This study investigates the effect of iatrogenic hyperoxia on cardiac function in patients with coronary artery disease undergoing general anaesthesia.Patients scheduled for elective coronary artery bypass graft surgery were prospectively recruited into this randomised crossover clinical trial. All patients were exposed to inspired oxygen fractions of 0.3 (normoxaemia) and 0.8 (hyperoxia) in randomised order. A transoesophageal echocardiographic imaging protocol was performed during each exposure. Primary analysis investigated changes in 3D peak strain, whereas secondary analyses investigated other systolic and diastolic responses.P<0.01), whereas in patients with normoxaemic LV-GLS <–15.4%, LV-GLS worsened with transition to hyperoxia (P<0.01). The same was seen for right ventricular GLS with a cut-off at –24.1%. Diastolic function worsened during hyperoxia indicated by a significant increase of averaged E/e′  and E/A ratio (1.4 (0.4) vs 1.3 (0.4), P=0.01).There was no statistical difference in systolic function between normoxaemia and hyperoxia. However, the response in systolic function to hyperoxia was dependent on ventricular function at normoxaemia. Patients with a normoxaemic left ventricular (LV) global longitudinal strain (GLS) poorer than the derived cut-off (>–15.4%) improved with hyperoxia (Although the response of biventricular systolic variables is dependent on systolic function at normoxaemia, diastolic function consistently worsens under hyperoxia. In coronary artery disease, intraoperative strain analysis may offer guidance for oxygen titration.NCT04424433. Fio2) for preoxygenation during critical periods of general anaesthesia, for example induction und airway management, in order to prevent deoxygenation.Fio2 ranging from normoxaemic to hyperoxic levels.Approximately 30% of patients who undergo major surgery have cardiovascular disease and consequently have a higher perioperative risk for cardiac complications.Spo2) is more than 90% or arterial partial pressure of oxygen (Pao2) is greater than 60 mm Hg (8 kPa).Hyperoxia is known to be associated with coronary vasoconstriction. Hyperoxia-induced reduction of coronary blood flow may lead to ischaemic events in susceptible myocardium.Assessment of systolic and diastolic function using transoesophageal echocardiography (TOE) has become routine during cardiac surgery. Recently, myocardial deformation (strain) analysis has been shown to be a sensitive perioperative marker of systolic function.17Fio2 levels. Secondary analyses investigated changes in traditional echocardiographic variables including diastolic function and ejection fraction, and if echocardiographic findings at normoxaemia contributed to individual responses to hyperoxia.The objective of this study was to investigate the effects of hyperoxia in comparison with normoxaemia on biventricular function assessed by TOE in anaesthetised patients before coronary artery bypass graft (CABG) surgery. The primary goal was to investigate changes in 3D myocardial peak strain as a marker of systolic function between targeted 2) trial is an investigator-initiated, single-centre, randomised cross-over trial with partially blinded echocardiographic image data analysis. The study was conducted at Inselspital, Bern University Hospital, Switzerland, and was approved by the Cantonal Research Ethics Board of Bern , registered on clinicaltrials.gov (NCT04424433) and on the Swiss National Clinical Trials Portal (SNCTP000003911). Patients were enrolled after written informed consent was obtained. The trial was performed in accordance with the Declaration of Helsinki. The detailed trial design has been published.The Myocardial Strain Analysis in Anaesthetized Coronary Artery Disease Patients During Hyperoxia and Normoxaemia -certified echocardiographers. As previously described, after establishing a stable respiratory and haemodynamic equilibrium, standard two-dimensional (2D), 3D, M-mode, and Doppler images were acquired to assess systolic and diastolic function, both at normoxaemia and hyperoxia.E (early) and A  transmitral inflow velocities derived by pulse waved Doppler (PW), and left ventricular outflow tract velocity time integral. The 3D images were then coded, and the remaining analyses were performed by blinded readers offline, using TOMTEC-Arena . This included quantification of 3D left and right ventricular volumes, ejection fraction (LVEF and RVEF), RV fractional area change (FAC) and 3D strain. The key variables acquired from the strain analysis were global peak longitudinal strain of the left ventricle (LV-GLS) and of the right ventricular free-wall (RV-GLS), whereas other measures of strain including, end-systolic strain, time to peak strain, and mechanical dispersion were also derived. The workflow is described in further detail in Supplementary methods.All TOE images and cine loops were acquired using Philips EPIQ 7c (X7-2t probe) or EPIQ CVx . During the study period under general anaesthesia, TOE examinations were performed by the anaesthetists who had targeted the The primary outcome was the difference in 3D longitudinal global peak strain measured in 3D TOE datasets, obtained in the same individual at normoxaemia and hyperoxia. Secondary outcomes were other volumetric and functional variables derived from 3D LV and RV assessment, and standard echocardiographic descriptors of systolic and diastolic function. Anaesthesia and haemodynamic variables were recorded and patient characteristics.Fio2 levels, a mixed-effects general linear model was used that included the randomised group category as a cofactor to account for possible order effect. The difference (Δ) in each variable between the oxygenation levels was then calculated (Fio2 0.8–Fio2 0.3) to determine if individuals worsened or improved with hyperoxia. We considered the normoxaemic state as our arbitrary baseline of myocardial function, as it is closest to the patients' status at room air, though with the clear limitation of disregarding other effects of general anaesthesia.For the comparison of the two Fio2=0.3) imaging results to discriminate the individual echocardiographic variable response to hyperoxia was assessed using receiver operating characteristic (ROC) curves and the associated area under the curve (AUC). The binary outcome for this ROC analysis was defined as either worsening or improving in the functional marker with the transition from normoxaemia to hyperoxia. For peak strain and diastolic variables, a worsening was defined as an increase (Δ>0) of the respective variable. For volumetric markers and TAPSE, a worsening was defined as a decrease (Δ<0). Ultimately to derive the ROC curve, the true positive and false positive rates were examined for varying thresholds of the normoxaemia measurements (detailed in Supplementary methods). From the generated ROC curves, an optimal cut-off point was derived using the Youden index, a value which represents the best compromise between sensitivity and specificity. Additional thresholds to designate individuals with a high probability of improving or worsening of the respective measurements with hyperoxia were defined based on the 95% sensitivity and specificity of the ROC curves. For interobserver reliability, a second blinded reader analysed 20 random datasets for the primary endpoint (LV-GLS) and the diastolic variables, then an intra-class correlation (ICC) was calculated for absolute agreement. Statistical significance was defined with a two-sided P-value of <0.05. GraphPad Prism version 9 , and IBM SPSS Statistics 26  were used for analysis.The ability of normoxaemic (n=3), new-onset atrial fibrillation (n=2), or failure to reach the targeted degree of hyperoxia (n=1). The patient characteristics were similar in both groups (Fio2 levels (n=206 datasets). For 3D LV analysis, 176 of 206 (85%) of the 3D LV images and 180 of 206 (87%) 3D RV images could be successfully analysed with 82 of 103 (80%) patients having usable 3D datasets for both exposures  diagram . Of the h groups . Standarxposures .Table 1P−1) and lateral (<10 cm s−1) tissue velocities below accepted cut-offs . Consequently, E/A and E/e′ ratios were significantly increased during the hyperoxic state  was found between readers for the primary outcome measurement of LV-GLS. Furthermore, an excellent reliability  was shown for the diastolic function variables  and LVEF . In the subgroup with a baseline LV-GLS better than the cut-off of –15.4%, a significant worsening in LV-GLS was observed with transition to hyperoxia from –19.2 (2.4) to –16.6 (3.0), P<0.01 . Optimal cut-offs were 1.0 for E/A and 7.6 for E/e′. When applying these cut-offs to E/A and E/e′, patients with diastolic markers under this cut-off (better diastolic function) worsened with hyperoxia. Although, unlike systolic markers, patients on the other side of the optimal cut-off (worse diastolic function) did not significantly benefit from hyperoxia . ROC curve analysis implied that free-wall RV-GLS can discriminate patients with reduced myocardial function under hyperoxia. The optimal cut-off value for RV-GLS was –24.1%. ROC curves are also provided for TAPSE and RV FAC in vs –21.0% [4.2%], P<0.05) in those with worse function than the cut-off. Whereas those with a normoxaemic RV-GLS better (more negative) than the cut-off had a significant decrease from –27.6 (2.8) to –23.8 (4.0)%, P<0.01  analysis are in accordance with a recent prospective study, which also did not find any general benefit of normoxaemia vs hyperoxia during general anaesthesia. However, stratifying patients at risk according to their staged response to Fio2 changes, as suggested in our post hoc analysis, may result in tailored management of oxygenation during general anaesthesia and thus benefit cardiac performance in patients with established coronary artery disease.,Fio2 was associated with increased odds of myocardial injury until 30 days after noncardiac surgery.Fio2 setting in individuals with vulnerable coronary anatomy and function may also affect clinical cardiac outcomes. This study, however, only investigates short-term changes in function as the outcome: future analysis will need to investigate independent outcomes such as cardiac biomarkers and data on morbidity and mortality. Preoperative evaluation of myocardial function with strain analysis and testing for changes in GLS in response to defined hyperoxic and hypocapnic challenges may help to adapt and improve intraoperative management of oxygenation and ventilation.,To preserve diastolic function, a normoxaemic post hoc blinded analysis of mitral inflow variables and tissue Doppler in 20 random samples showed excellent reliability with the non-blinded ad hoc primary analysis (ICC)  . The TOMThis randomised cross-over clinical trial in anaesthetised patients with well-defined stable coronary artery disease before incision for elective CABG surgery found a significant worsening of diastolic function at hyperoxia but no significant changes in systolic function parameters. Individually, hyperoxia yielded very heterogeneous effects on systolic myocardial function. coronary artery disease patients with impaired contractile function at normoxaemia improved, whereas myocardial contractility of patients with better systolic function at normoxaemia deteriorated with hyperoxia in both ventricles. Perspectives of this research are to preoperatively assess predictors for the perioperative hyperoxic myocardial response to personalise intraoperative oxygen management for high-risk coronary artery disease patients, and to relate such findings to clinical cardiac outcomes.Acquisition of data: JOF, JM, RB, RR, KF, AL, SB, TH, DG, GE, BE, DPG.Analysis of data: JOF, JM, RB, RR, KF, AL, SB, TH, DG, GE, RM, BE, DPG.Interpretation of data: all authors.Drafting of the article: JOF, KF.Study administration: KF, DPG.Conception and design of the study: KF, DPG, BE.Critical revision for important intellectual content: KF, DG, GE, FSS, TPC, RM, BE, DPG.Final approval of the version to be submitted: DPG.All authors agree to the final version of this manuscript and are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


Dear Editor,th century was the conception and use of cardiopulmonary bypass (CPB)to facilitate open heart surgery. This innovation paved the way for additionaldevelopments like extracorporeal circulatory support, ventricular assist devices,mechanical circulatory support, and total artificial hearts. With the ability to bypassboth the heart and lungs, surgeons can now fix cardiac abnormalities, replace defunctvalves, and bypass occluded coronary arteries. Subsequently, there was a demand for people who could operatethe new life-supporting devices when open heart procedures with extracorporealcirculation became a reality.One of the most significant clinical medical breakthroughs during the latter half of the20. By removing the heartand lungs from circulation, CPB primarily aims to facilitate cardiothoracic procedureswhile providing adequate gas exchange, systemic organ perfusion, and a way to regulatebody temperature. Extracorporeal membrane oxygenation (ECMO) is a therapy that enablesthe technology associated with CPB to be utilised in intensive care units.Conventional approach has been that a ‘still and bloodless field’ is the ideal settingfor cardiothoracic surgery. CPB does this by integrating a pump to take place of theheart and a gas exchange device ‘oxygenator’, which functions as artificiallungs. It is a life-saving intervention for individuals withrefractory, severe respiratory, and circulatory failure. In the current coronavirusdisease 2019 (or COVID-19) situation, a vast majority of patients experience acuterespiratory distress syndrome, and ECMO is advised in such situations.ECMO can substitute the function of the heart and lungs, hence it is seen as a medicalapproach for both cardiac and respiratory dysfunction. Exhaustion due to manpower issues — as the workloadand the number of patients grow daily with limited number of perfusionists — is also anunnoticed workplace challenge that perfusionists encounter. From the time of initiationof ECMO, a perfusionist must be on duty around-the-clock to monitor the patientparameters and to prevent any unusual events. Establishing ECMO for patients infected with contagiousdiseases puts the perfusionist on risk of contracting the disease. Also, wearing thepersonal protective equipment kit for eight to 12 hours is quite aggravating anddraining. Hence, factors related to job demands like stress, conflict, callresponsibilities, working hours, and case load, all have an absolute correlation withburnout. As the necessity for the use of life support devices grows daily, so does theneed for perfusionists to run these complex machines. The grim reality is that among allhealthcare employees, perfusionists have the least recognition for what they do as theyare given the least credit for it and are usually overlooked. People frequently don’tunderstand what our work entails or how we contribute to healthcare. To address theseissues, it can be beneficial to enhance the working environment, acknowledge the valuethat our industry brings to society, increase the hiring rate, and offer enough economicbenefits. By publishing this brief letter, we hope that this profession will emerge fromthe shadows and demonstrate the actual potential of perfusionists and their dedicationto the community.Since ECMO is only available in specialised facilities, patients may need to travel fortreatment. Critically ill individuals, who are frequently mechanically ventilated,receiving continuous drug infusions and/or receiving extracorporeal circulationtreatment, may need to be transported from one facility to another, which is done withthe help of an air ambulance. Due to the intricacy, ongoing lack of time, andenvironmental pressures, transporting patients while they are receiving ECMO support isextremely difficult. Air missions also expose both the patient and the medical team torisks like hypoxia, reduced air humidity, changes in barometric pressures, temperaturevariations, and the potential to easily become fatigued


Patients with hypertrophic cardiomyopathy may develop symptoms of shortness of breathing due to diastolic dysfunction which is not related to the severity of left ventricular outflow tract obstruction. As these patients usually develop a non-ischemic pattern of myocardial fibrosis, this may represent a mechanism for increased myocardial stiffness leading to impaired diastolic filling. The study aimed to determine the prevalence of myocardial fibrosis assessed by magnetic resonance imaging in children with hypertrophic cardiomyopathy and to evaluate its relationship with echocardiographic parameters including left ventricle diastolic dysfunction and to find echocardiographic indices which correlates with myocardial fibrosis as detected by cardiac magnetic resonance. A cross-sectional study was done for data of 50 children with hypertrophic cardiomyopathy from July 2018 to July 2021, patients were divided into (group 1) having myocardial fibrosis and (group 2) with no myocardial fibrosis, and results of echocardiographic parameters were compared between the two groups.E′), E/E′ ratio, presence of left ventricular out flow tract obstruction and the grade of diastolic dysfunction.Results showed strong relationship between presence of myocardial fibrosis and each of the following: Interventricular septum thickness, lower lateral and septal early diastolic tissue velocities  allows early detection of left ventricular diastolic dysfunction in children with hypertrophic cardiomyopathy. The prevalence of diastolic dysfunction is higher in obstructive hypertrophic cardiomyopathy. The diastolic dysfunction severity is higher in patients with myocardial fibrosis.The trans-mitral lateral and septal  Hypertrophic cardiomyopathy (HCM) is a relatively common genetic cardiac disease, accounting for 42% of childhood cardiomyopathy . The sevMagnetic resonance imaging has been widely accepted for detection of myocardial fibrosis, which has been implicated as a factor in cardiovascular events and left ventricular (LV) function . EchocarThe aim of this study is to determine the diastolic dysfunction in children having hypertrophic cardiomyopathy (HCM) by echocardiography modalities and to evaluate its relationship with prevalence of myocardial fibrosis as detected by cardiac magnetic resonance imaging and if possible to find echocardiographic indices which correlates with myocardial fibrosis as detected by cardiac magnetic resonance (CMR).The current study is a cross-sectional study which was done for data of 50 patients with hypertrophic cardiomyopathy (HCM) in pediatric age group (below age of 18 years). All cases were evaluated at Aswan Heart Centre, Aswan, Egypt.Inclusion criteria: Age group: below age of 18 years, both sexes, echocardiographic evidence of myocardial hypertrophy defined as a diastolic septal thickness or left ventricular diastolic wall thickness z-score > 2. The MRI and echocardiography were done during the same visit.Exclusion criteria: Presence of hemodynamic conditions that could account for the observed hypertrophy (as systemic hypertension), presence of congenital anomalies resulting in pressure overload against left ventricle . Atrial fibrillation also was one of the exclusion criteria.Full history taking focusing on patient demographics: age, sex, weight, height & body surface area, clinical symptoms of heart failure or low cardiac output , family history of hypertrophic cardiomyopathy (HCM), family history of sudden cardiac death (SCD) defined as one or more cardiac death in first-degree relatives of < 40 years of age with or without a diagnosis of hypertrophic cardiomyopathy (HCM) or sudden cardiac death (SCD) in first-degree relatives with confirmed hypertrophy at any age [ any age .Echocardiography all echocardiograms were done by echo machine Philips IE33, Two-dimensional ECHO focusing on: Presence of hypertrophic cardiomyopathy was diagnosed when the diastolic septal thickness or left ventricular diastolic wall thickness z-score > 2 in the absence of hemodynamic conditions that could account for the observed LV hypertrophy [E′) and late diastolic (A′) tissue Doppler velocities (cm/s) were measured at the lateral as well as the septal mitral annular points and subsequently averaged over 3 cardiac cycles. Trans-mitral E/E′ ratios  were calculated for each patient. M-mode echocardiography focusing on septal wall thickness (SWT) and left ventricular posterior wall thickness (LVPWT) .ertrophy , Left atertrophy . AssessmE/E′ ratio > 14, left atrial (LA) volume indexed > 34 ml/m2, Atrial flow reversal (AR-A wave) duration > 30 ms, Peak velocity of tricuspid regurgitation (TR) jet by CW Doppler > 2.8 m/sec. In case of severe mitral regurge only 2 variables are applied which are AR-A duration and peak velocity of tricuspid regurgitation (TR) jet. Presence of more than half of the variables means that left atrial pressure (LAP) is elevated and grade II diastolic dysfunction is diagnosed; if less than half of the variables is present, then left atrial pressure (LAP) is normal and grade I diastolic dysfunction is diagnosed. Grade III diastolic dysfunction is diagnosed in the presence of restrictive filling pattern and abnormally reduced annular E′ velocity . Absence of any of the variables means that no diastolic dysfunction [http://parameterz.blogspot.com/2008/09/z-scores-of-cardiac-tructures.html.Diastolic dysfunction is assessed in patients with hypertrophic cardiomyopathy (HCM) as follows: 4 cut-off values for assessment of diastolic dysfunction are: Average function . Z scoreCardiac magnetic resonance imaging (CMR) Magnetic resonance imaging was performed on a 1.5 T scanner . Cine images were acquired with steady-state free-precession technique  in three long-axis planes and contiguous short-axis slices  from the atrioventricular ring to the apex. An intravenous bolus of 0.1 mmol/kg of gadodiamide is given and late gadolinium images were acquired in the same planes after 10 min, with a breath-hold (whenever possible) segmented inversion-recovery sequence (inversion time: 280–400 ms). The presence of left ventricular late gadolinium enhancement (LGE) was determined using visual assessment by two independent observers.All patients were subjected to:2) was used as a test of significance. For interpretation of results of significance, significance was adopted at P < 0.05.The collected data were organized, tabulated, and statistically analyzed using SPSS software statistical computer package version 18 SPSS Inc, USA. For quantitative data, the mean and standard deviation (SD) were calculated. Independent t-test as used in comparing between two groups as regards mean values of different variables. Qualitative data were presented as number and percentages; Chi-square (XThe current study aimed to determine the diastolic dysfunction in children having hypertrophic cardiomyopathy (HCM) by echocardiography modalities and to evaluate its relationship with prevalence of myocardial fibrosis as detected by cardiac magnetic resonance imaging. Based on the MRI findings, children were divided into two groups as follows: Group A: children diagnosed as having hypertrophic cardiomyopathy (HCM) with myocardial fibrosis. Group B: children having hypertrophic cardiomyopathy (HCM) without myocardial fibrosis. The results of echocardiographic parameters regarding presence or absence of diastolic dysfunction and its degree were analyzed and compared between the two groups.The current study was conducted on 50 patients in pediatric age group with hypertrophic cardiomyopathy (HCM) from July 2018 to July 2021 , which was caused mainly by systolic anterior motion (SAM) of mitral valve leaflets, 36% of the studied group had severe mitral regurgitation which affected cut-off points used in evaluation of diastolic dysfunction  , mean medial E` velocity was 6.2 cm/s  and mean septal E/E′ was 18.57  as seen in Table E′ and (E/E′) ratio (Table Tissue Doppler imaging (TDI) parameters results showed mean values which meet cut-off values for diagnosis of diastolic dysfunction, mean velocity of lateral E` was 8.76 cm/s , mean lateral Studying relationship between myocardial fibrosis and diastolic dysfunction Table  showed vP value ≤ 0.001) (Table Data showed significant relationship between presence of hypertrophic obstructive cardiomyopathy (HOCM) and diastolic dysfunction (1) Table . Studyin1) Table  showed tP-value = 0.001) which can explain the cause of the large discrepancy between both studies in the prevalence of diastolic dysfunction.To our knowledge, this is the youngest population in which diastolic dysfunction was studied in hypertrophic cardiomyopathy (HCM). We found that the percentage of diastolic dysfunction in our study was 84% Table , the perIn current study, 44% of the studied group had myocardial fibrosis (22 patients) in comparison with Ziolkowska et al.  who founn = 22; 44%) or without fibrosis . In adult patients with hypertrophic cardiomyopathy (HCM), the presence of fibrosis according to MRI correlated with left ventricular (LV) wall thickness and left atrial (LA) size [P ≤ 0.0001), compared to patients without fibrosis  size , 14. SimLA) size , we foun n = 28; 6%. In adE′ and (E/E′) ratio (Table E′) as well as a significantly higher lateral and septal E/E′ ratio compared to patients without fibrosis, Ziolkowska et al. [Our results showed that MRI-based presence of myocardial fibrosis was strongly correlated with tissue Doppler velocity indices especially septal io Table , And thea et al.  reporteda et al.  reporteda et al. , who fouOur results showed significant relationship between presence of hypertrophic obstructive cardiomyopathy (HOCM) and diastolic dysfunction, Table . Our datIn our study we faced some limitations as studying diastolic dysfunction in young (sedated) or older non co-operative children was difficult as its optimally done with breath holding during 3 consecutive cardiac cycles which is practically difficult. Similarly young (sedated) and older non co-operative patients with latent left ventricular outflow tract obstruction (LVOTO) which isn’t diagnosed by resting Echocardiography were missed as they couldn’t do exercise or Valsalva maneuver. Also there was high risk of anesthesia in patients with both severe left ventricular outflow tract obstruction (LVOTO) and severe right ventricular outflow tract obstruction (RVOTO), and in patients with impaired LV systolic and these patients couldn’t be studied by MRI, and hence were excluded, and being expensive, MRI couldn’t be repeated in minority of cases when its relatively old.E/E′  together with measurement of inter-ventricular septal thickness allow early detection of myocardial fibrosis in children with hypertrophic cardiomyopathy. Echocardiography with tissue Doppler imaging is a feasible and sensitive method for evaluating left ventricular diastolic dysfunction in children with hypertrophic cardiomyopathy and myocardial fibrosis. Pediatric patients with obstructive form of hypertrophic cardiomyopathy have higher incidence (and high grade when present) of diastolic dysfunction that non-obstructive form. Higher degrees of diastolic dysfunction are higher in patients with myocardial fibrosis who always have at least 2nd degree of diastolic dysfunction, while patients without myocardial fibrosis never had grade 3 diastolic dysfunction.Myocardial fibrosis in children with hypertrophic cardiomyopathy was associated with markers for disease severity such as greater septum thickness and impairment of left ventricular diastolic function. So, the trans-mitral lateral and septal