Diastolic dysfunction is an important determinant for prognosis and survival in several paediatric heart diseases. We aimed to explore its possible impact on outcome in children with dilated cardiomyopathy. From 2006 to 2016, children less than 18 years old with dilated cardiomyopathy were retrospectively enrolled. Echocardiographic diastolic function parameters and child outcomes were analysed. Of 43 children aged 0.2 to 16.1 years old referred with dilated cardiomyopathy, 8 patients required cardiac transplant or mechanical assist devices (18%), 24 had persistently abnormal left ventricular function and/or dilatation (56%) and 11 patients recovered (26%). There was no significant difference in mitral velocities on Tissue Doppler Imaging, mitral valve inflow velocities, isovolumic relaxation time, left atrial area z-score and mitral lateral E/e’ ratios between patients with recovery and patients with disease progression or persistently abnormal ventricular function and/or dilation. This is the first study on childhood dilated cardiomyopathy to address individual echocardiographic diastolic function parameters and their association to recovery. In this study, echocardiographic parameters for diastolic function did not predict recovery. Paediatric dilated cardiomyopathy has a poor prognosis and it remains the main indication for paediatric heart transplantation . A multiPaediatric studies have often focused on systolic function and on left ventricular dilatation as outcome predictors in dilated cardiomyopathy ,6,7. NovThe aim of this study was to explore the possible prognostic value of echocardiographic diastolic function parameters in paediatric dilated cardiomyopathy.We retrospectively reviewed the first echocardiogram in which diastolic function had been assessed in all children aged ≤ 18 years with dilated cardiomyopathy due to myocarditis, familial or idiopathic dilated cardiomyopathy who were referred to our unit between January 2006 and August 2016 and who last had an assessment for outcome between June 2015 and December 2016.Patients with dilated cardiomyopathy due to other causes, such as ischemic, toxic, neuromuscular, endocrine and metabolic diseases, were excluded. Other forms of cardiomyopathy, for example, mixed-type cardiomyopathy, restrictive and non-compaction cardiomyopathy, were excluded.Diagnosis of dilated cardiomyopathy was based on two-dimensional echocardiographic criteria with a left ventricular end-diastolic dimension (LVEDD) > 5.5 cm (or z-score > +2 for age) and a left ventricular fractional shortening (LV FS) < 28%.Outcome was defined as the three following possibilities: recovery, stabilization and progression of heart failure, leading to the need for mechanical circulatory support as bridge-to-transplant, cardiac transplant or death. Recovery was characterized by normalization of left ventricular size and systolic function. Stabilization was defined as persistent impairment of cardiac systolic function and/or persistent LV dilatation. Outcome was assessed at last recorded visit.For all patients, we recorded age at assessment and timeframe to the last visit. Echocardiographic data, including parameters for LV dimensions , LV systolic function from M-mode in parasternal long axis view and from tissue Doppler Imaging (TDI) in 4-chamber view , were recorded. Echocardiographic parameters for diastolic function included measurements from mitral valve inflow Doppler , measurements from left lateral and septal TDI  in 4-chamber view, z-scores for left atrial area (LA area z-score) and isovolumic relaxation time (IVRT). Extracted values of the aforementioned measurements, including mitral E/e’ ratios, were calculated.The association between individual diastolic and systolic function parameters on initial echocardiogram and outcome at last visit was analysed.Baseline characteristics between groups were compared by means of a Kruskal–Wallis test, with the Dunn post-hoc procedure. For further data analysis, patients with persistent impairment of LV dimensions and/or LV systolic function (stabilization) and patients with disease progression  were merged and compared to those who recovered.2-test. Statistical significance was assigned at p < 0.05.The Mann–Whitney test was applied to compare continuous data between groups. Categorical data were compared by means of the χIn total, forty-three baseline echocardiograms of children with dilated cardiomyopathy were reviewed. The cause of dilated cardiomyopathy was familial for 8 patients (18%), idiopathic for 24 (56%) and probable myocarditis for 11 (26%). Of the forty-three children, at the last follow-up, 8 patients had required cardiac transplant or mechanical assist devices for bridge-to-transplant (18%), 24 had persistently abnormal left ventricular function and/or dilatation (56%) and 11 patients had recovered (26%). Probable myocarditis was the most common cause leading to recovery (55%) .Clinical characteristics are depicted in While looking at LV dimensions and systolic function, results showed that higher left ventricular end diastolic diameter z-scores (LVEDDz) and lower indices for left ventricular systolic function  were predictors for worse outcome .Echocardiographic diastolic function parameters for patients with recovery, compared to patients needing cardiac transplant or mechanical assist devices and patients with persistent abnormal LV systolic function and/or LV dimensions are shown in To the best of our knowledge, this study is the first to address the issue of diastolic dysfunction in paediatric dilated cardiomyopathy.Clinical characteristics of the patients are in line with the literature with most patients having idiopathic dilated cardiomyopathy  and probHowever, in the current study, values for selected echocardiographic diastolic function parameters did not show significant association with outcome categories.This may be explained by the fact that these parameters are highly influenced by age, heart rate, especially in young children, and load, which is a problem in children with dilated cardiomyopathy. In fact, the population studied had a wide age range. For obvious reasons, most patients with a progressive deterioration needed mechanical assist device implantation or heart transplant, which explains their shorter length follow-up.Outcomes of paediatric patients diagnosed with dilated cardiomyopathy are bleak, as only about one third of these patients will ultimately have a complete recovery. Tools permitting a better risk stratification would be helpful in order to better target management of these patients. Indeed, it might be particularly helpful to be able to identify patients likely to recover, as opposed to patients needing closer follow-up, and who may have persistent left ventricular impairment or even progressive deterioration.Several studies have focused on echocardiographic parameters as they are thought to provide a more objective assessment of disease severity, compared to clinical symptomatology.A retrospective, single centre study by Mondal et al.  identifiThe current, pilot study exploited available data to try solving the question whether echocardiographic diastolic dysfunction parameters can predict dilated cardiomyopathy recovery. It presents at least two major strengths. The first is the serial echocardiography with standardized procedures and measures. The second is the respectable follow-up of >3.5 years.On the other side, this study is subject to the usual limitations of a retrospective and single-centre study. Furthermore, this being an explorative, retrospective study, the small sample size available limits the power and interpretability of the results. Third, echocardiographic diastolic function parameters in Paediatrics have many limitations, and assessment of diastolic function needs the integration of different parameters. However, most parameters are simple measurements and easily feasible in clinical setting. Finally, this study focused on the initial echocardiographic findings, while the prognostic value of diastolic function may be greater in stable outpatients, presenting in regular follow-up clinics and having serial measurements.This is the first study to explore the prognostic value of diastolic function in children presenting with dilated cardiomyopathy. Although the small sample does not allow a firm conclusion, selected echocardiographic measurements for diastolic function did not show a significant association with outcomes. Studies with bigger sample size, including stable outpatients presenting in heart failure clinics and involving several centres may be helpful and should be considered. Finally, it might be worth integrating novel diastolic parameters in a comprehensive diastolic assessment .


Background: Centenarians represent an under-studied population within cardiovascular medicine. This study aimed to describe the echocardiographic characteristics of a cohort of centenarians at a tertiary referral center.Materials and methods: The institutional Echocardiography database was retrospectively reviewed and identified 100 consecutive centenarians referred for transthoracic echocardiography between January 2009 and December 2020. Cardiac chamber quantification, diastology, and valvular heart disease were assessed according to the American Society of Echocardiography guidelines. Independent t-tests and Mann-Whitney U-tests compared data between males and females.Results: The mean age was 101.5 ± 1.7 years, 78% were female, and the most common co-morbidities were hypertension (77%), coronary artery disease (46%), and congestive heart failure (42%). The mean left ventricular (LV) ejection fraction measured 56.9 ± 11.3% . Males had larger LV end-diastolic  and end-systolic diameter  indices; a smaller relative wall thickness ; and a lower E/e’ ratio , when compared with females. The prevalence of severe valvular lesions was 13.5%, and similar between genders. However, in patients with aortic stenosis, the transaortic pressure gradients were significantly higher in females .Conclusions: The present study on centenarians affords a cross-sectional evaluation of cardiac structure and function in a growing population, and highlights important differences between male and female patients. In our progressively aging population, it is common to encounter a centenarian in clinical practice. As modern medicine advances and therapies aimed at risk factor modification become widespread, the elderly population is expected to continue to grow at a rapid pace. Indeed, the number of centenarians has doubled every decade since the 1950s and is estimated to increase five-fold by the year 2050 . Among tTransthoracic echocardiography is universally utilized as a first-line imaging assessment in patients suspected of cardiovascular pathology, carries minimal inherent risk, and provides an unmatched wealth of information regarding cardiac remodeling, hemodynamics, and valvular heart disease. This imparts a significant benefit in the diagnosis and treatment of cardiovascular disorders across age groups. Nevertheless, cardiac structural and physiologic changes have not been studied in centenarians to the extent that they have in younger populations, and published data have generally been limited by small sample sizes and differing methodologies -10. ThisPatient selectionThe study protocol was drafted in accordance with institutional regulations and the ethical guidelines of the 1975 declaration of Helsinki and was approved by the Mount Sinai Medical Center Institutional Review Board in Miami Beach, Florida. We retrospectively analyzed the Echocardiography digital database and identified 100 consecutive patients referred for echocardiography between January 2009 and December 2020 who were aged 100 years or older. The database includes both inpatient and outpatient echocardiograms, of which each represented approximately 50% of the present cohort. The indications for echocardiography were dyspnea on exertion, cerebrovascular accident, arrhythmias, and/or heart failure surveillance. There were no exclusion criteria with the exception of age less than 100 years. A review of the institutional electronic health records was performed to assess patient demographics, clinical risk factors and co-morbidities, and laboratory values.EchocardiographyAll transthoracic echocardiograms were performed using a GE cardiovascular ultrasound system . The assessment of left ventricular (LV) systolic function, estimation of the ejection fraction, and assessment of geometry were performed in accordance with the American Society of Echocardiography chamber quantification guidelines . In the The assessment of LV diastology was performed according to the American Society of Echocardiography guideline recommendations . The tra2. The right ventricular systolic pressure was estimated from the addition of the peak tricuspid regurgitant pressure gradient (using the modified Bernoulli equation) and the right atrial pressure. Finally, the left atrial size was expressed as the anteroposterior diameter measured in the parasternal long-axis view at end-systole, and the volume index was estimated by the biplane method of discs.Valvular heart disease was assessed in a multi-parametric manner according to the American Society of Echocardiography native valve regurgitation and stenosis guidelines ,14. The Statistical methodsThe variables are expressed as the mean ± 1 standard deviation, median and interquartile range, or as absolute number and percentage. An independent t-test was used to compare continuous data stratified between males and females, while a Mann-Whitney U-test was utilized for non-parametric variables. A two-tailed p-value was calculated to test for statistical significance. The statistical analyses were conducted using Statistical Package for Social Sciences, version 21 .Demographics and clinical characteristics2, 126 ± 24 mmHg, and 69 ± 13 mmHg, respectively. The most common co-morbidities were hypertension (77%), coronary artery disease (46%), and congestive heart failure (42%), with a small minority of patients having undergone surgical or percutaneous coronary revascularization (6%). When compared with female patients, males had a larger body surface area  and a greater serum creatinine level   were female. The mean body mass index, systolic blood pressure, and diastolic blood pressure measured 23.5 ± 4.8 kg/mLeft ventricular geometry, function, and diastologyThe mean LV ejection fraction measured 56.9 ± 11.3%, and notably was greater in females when compared with males . Male patients also had a higher prevalence of severe LV systolic dysfunction, defined as an ejection fraction <30% ; larger end-diastolic  and end-systolic diameter  indices; and a smaller relative wall thickness . The most common LV geometry patterns were concentric hypertrophy (46%) and remodeling (39%), with few patients exhibiting normal geometry (9%) or eccentric hypertrophy (6%); this was similar in both males and females. Finally, females had a higher E/e’ ratio consistent with a greater LV diastolic filling pressure, when compared with males  . The least common pathology was mitral stenosis (3%). The three patients who had undergone prior valve surgery had a bioprosthetic aortic valve replacement, and all prosthetic valves were functioning normally  the majority of patients were female, with the overall cohort exhibiting a healthy body mass index and blood pressure; 2) as a group, 85% of centenarians had a preserved LV size and systolic function, and the vast majority either concentrically remodeled or hypertrophied ventricles; 3) as a group, there was a mild elevation in the mean LV filling pressure and mild pulmonary hypertension, as assessed by the E/e’ ratio and right ventricular systolic pressure; 4) mild valvular heart disease was common, with mitral and tricuspid regurgitation being the most prevalent lesions observed; and 5) females had a greater LV ejection fraction, a smaller chamber size, a higher filling pressure, and greater transaortic stenotic pressure gradients when compared with males.Given their longer documented life expectancy it is not surprising that females represented the majority of centenarians in the present study; indeed, the female prevalence in prior small centenarian cohorts has ranged from 60% to 85% -9. SigniThe most prevalent cardiovascular co-morbidity in the present cohort was hypertension, which was observed in 77% of patients, and is similar to prior registry data . Aging i2, and a median NT-proB-type natriuretic peptide of 5832 pg/mL. Collectively these findings are indicative of mildly elevated LV filling pressures, mild pulmonary hypertension, and LV myocardial wall stress. Of note, females were found to have a more elevated LV filling pressure when compared with males, which has been noted to differentiate the HFpEF phenotype between genders [Congestive heart failure is one of the leading causes of death in the centenarian population, with the majority of patients having a preserved LV ejection fraction (HFpEF) ,8,10. As genders .The prevalence of valvular heart disease in older adults has risen exponentially over the last several decades owing to an aging population in an era of improved medical and interventional therapies. Approximately 10% to 15% of patients aged 75 years or greater have at least one moderate to severe valvular lesion, and it is well established that morbidity and mortality are commensurate to regurgitant or stenotic severity . SimilarThere are limitations to the present study that should be considered when interpreting the findings. First, the cross-sectional nature of the study provides an analysis of variables only at a single point in time. This does not allow for a temporal outcomes analysis, and findings cannot be used to imply causality. Secondly, given the population studied, the sample size was relatively small. This limits the power to identify differences between genders in the statistical analyses, which is also exacerbated by the imbalance between the number of male versus female patients. Thirdly, data regarding the medical management of co-morbidities were not available, which may impact measured hemodynamic, clinical, and echocardiographic variables. Fourthly, not all patients had data available for analysis with regard to diastology and serum levels of NT-proB-type natriuretic peptide. This is a form of selection or attrition bias and represents an uncontrollable confounder. Fifthly, while valvular lesions were assessed and graded in a multi-parametric manner, detailed quantitative parameters were not independently captured in the current study with the exception of the transaortic pressure gradients among patients with aortic stenosis. While a multi-parametric approach allows for the integration of all available qualitative and hemodynamic measures of valvular function, it should be noted that interobserver variability cannot be excluded.In conclusion, the present study on centenarians affords a cross-sectional clinical and echocardiographic evaluation of a growing and under-studied population within cardiovascular medicine and highlights important differences between male and female cardiac structure and function. Future prospective and registry studies of centenarians will be important in identifying the natural history of their co-morbidities, as well as the management of their heart failure, diastolic dysfunction, and valvular heart disease.


This Research Topic presents the highlights in Cardiovascular Imaging and includes a range of studies and reviews across multiple imaging modalities and subspecialities, that describe recent advances in established modalities, including echocardiography, cardiac computed tomography (CT), and cardiac magnetic resonance imaging (CMR). It also presents novel applications of micro-CT and X-ray phase-contrast imaging, as well as innovative techniques e.g., 3D holograms, and discusses the use of artificial intelligence (AI) in cardiovascular imaging. We selected the studies from the most read and downloaded articles in 2021 in this journal. The selection of articles by the authors aimed to highlight novel techniques and applications across the broad range of cardiovascular imaging.Bard et al. as well as Kameshina et al.Artificial intelligence (AI) algorithms have revolutionized image analysis and improved the predictive value of imaging parameters as shown by Bard et al. successfully compared an AI approach to both segment and quantify pericardial adipose tissue (PAT) by CMR in a dataset from the UK Biobank. The results were compared to the gold standard of PAT quantification by cardiac CT. This study showed that the CMR-derived PAT volumes were comparable to the PAT estimated by CT and that PAT volume was associated with the presence of diabetes independently from other clinical characteristics.Kameshima et al. machine learning (ML) methods were used to phenotype heart failure (HF) patients with diastolic dysfunction. These patients from a Japanese HF registry were grouped using two approaches: the first relied on a ML based approach and the second on the grading system recommended by the echocardiographic guidelines for assessing diastolic dysfunction. The ML approach showed to be superior to the echocardiography guideline categories in predicting HF hospitalization in these patients highlighting its value for more accurate risk stratification.In the study of Karagiannidis et al. to visualize and analyse extracted thrombus material in 113 patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in a single center. Micro-CT provided non-destructive visualization of aspirated thrombus, allowing reproducible quantification of thrombus volume, surface, and density. The authors found that patients with high angiographic thrombus burden and higher residual thrombus had larger thrombus aspirated; more importantly they showed that, higher thrombus volume and surface area were associated with adverse angiographic outcomes .Novel micro-CT technology was used by This analysis highlighted the value of micro-CT in assessing the extracted thrombus burden and its clinical implications. This is especially significant as a meta-analysis of 3 randomized trials demonstrated that there is no prognostic benefit of the routine use of thrombus aspiration in patients with STEMI but in patients with high thrombus burden thrombus aspiration can be beneficial as it is associated with a reduction in cardiovascular mortality and all cause mortality, at the expense of an increased risk of stroke or TIA at 30 days .Liu et al. summarized the methods introduced for coronary plaque segmentation in cardiac CT. Thirty one approaches were presented and categorized into either 2D or 3D plaque extraction methods, with each relevant study within each category subsequently characterized with respect to data quality, methodological innovation and performance.The review of This detailed review not only highlighted recent advances in CT image but also underscored the need for further research in the field. There is apparently an unmet need to validate the developed methods in large databases and improve plaque extraction accuracy using advanced methods that will allow not only fast and accurate quantification of the atheroma burden but also assessment of plaque vulnerability.Leng et al. examined 360 healthy subjects from West China prospectively, and included patients aged 21–79 years with no known cardiovascular disease or uncontrolled cardiovascular risk factors. CMR was used to measure right heart function parameters, including tricuspid annular dynamics as well as longitudinal strain values of the right ventricle and the right atrium. This data allowed for the first time the definition of established age and sex specific reference ranges for tricuspid annular dynamics derived by CMR in healthy individuals which are expected to allow more accurate evaluation of right ventricular function.Reference ranges are key elements for diagnosis of cardiovascular disease, risk stratification and treatment planning and can be assessed by the distribution of the relevant variable or its predictive value. The study of Zhao et al. compared LV geometry by three-dimensional (3D) echocardiography and CMR. The authors analyzed 70 subjects  who had both an 3D-echocardiography and CMR, within 1 h. The authors found there was a systematic bias between the volumes assessed by 3D-echocardiography and those by CMR. They concluded that the systematic signal dropout and the differences in appearances of trabeculae have led to discrepancies in the delineation of LV geometry at anterior and lateral regions resulting in an underestimation of the LV volumes by echocardiography.Li et al. prospectively assessed in 73 patients with a clinically suspected myocarditis which CMR parameters from the 2009 and 2018 LLC can diagnose myocarditis most accurately at a 3.0 Tesla scanner. The gold standard in that study was the presence of inflammation on endomyocardial biopsy (EMB). T1 and T2 mapping techniques showed the highest positive predictive value and were superior compared to the LLC 2018 and LLC 2009 criteria: the area under the curve for T1 mapping + T2 mapping was 0.95 while it was 0.91 for LLC 2018 alone, 0.76 for LLC 2009.Suspected acute myocarditis is a leading indication for CMR. State-of-the-art diagnostic criteria for myocarditis are based on the consensus Lake Louise Criteria (LLC) published in 2018 which are an update of the LLC presented in 2009 . Li et aMeng et al., examined the value of right ventricular 3D speckle-tracking strain and ejection fraction in predicting heart failure (HF) related hospitalizations or death in patients with HF with preserved ejection fraction (HFpEF). During a median of 17 months 48% of the included patients (n = 93) reached the primary endpoint; in that study impaired 3D-speckle-tracking echocardiography values showed to be strongly associated with the occurrence of the primary endpoint of the study suggesting that these variables may be a useful tool for risk stratification in this population.Tadic et al. noted that right ventricular LS is not routinely assessed, and summarized the existing methodologies for evaluating right ventricular longitudinal strain (LS) using transthoracic echocardiography and presented the evidence supporting its prognostic value in patients with pulmonary hypertension, heart failure and valvular heart disease. For example, a meta-analysis of 1,169 patients with pulmonary hypertension found that those with an RV free-wall strain >- 22% had a significantly higher risk of all-cause mortality. The authors suggest that routine measurement of right ventricular LS may therefore aid risk stratification, with patients possibly being reclassified into higher risk groups when it is taken into account.Furthermore, Tokodi et al. have recently provided details of the updated ReVISION method and algorithm, particularly for volumetric partitioning of the RV cavity and calculation of longitudinal, circumferential, and area strains using 3DE datasets, and also compared the reproducibility of RV function obtained from 3DE and CMR. This method can be used to further evaluate RV function in different disease states, providing further valuable information when compared with routine echocardiographic evaluation.With the growing evidence supporting the value of assessing RV function, the ReVISION method was described in 2017 . This usLoncaric et al. provided novel insight into visualizing myocardial remodeling in left ventricular hypertrophy (LVH). Synchrotron radiation-based X-ray phase-contrast imaging (X-PCI) is a research methodology that enables direct measurement of myocardial structure based on changes in X-ray intensity and phase, and enables visualization of individual myocytes and analysis of cardiac microstructure. The authors used 3D X-PCI on myocardial tissue samples obtained during surgical myectomy for three patients with obstructive LVH to assess myocyte organization, 3D connective tissue distribution, and vasculature and compared these findings with the non-invasive cardiac imaging findings (transthoracic echocardiography and CMRI) performed prior to myectomy. The authors found that the myocyte and connective tissue microstructural organization was different in different myocardial pathologies. This is a small pilot study which highlights the potential utility of 3D X-PCI and is expected to provide the substrate for the conduction of larger scale studies that will provide compelling evidence which will justify its routine use in clinical setting (e.g. more compact synchrotrons), with the aim of establishing the etiology of LVH when non-invasive imaging is non-diagnostic.A pilot study of 3 patients undertaken by Rank et al. examined the long term implications of aortic valve replacement on reverse ventricular remodeling. The authors analyzed CMR data acquired 1, 5, and 10 years after aortic valve replacement (AVR) for both aortic stenosis (AS) and aortic regurgitation (AR). The authors found that patients with AR had more long term alteration of myocardial function compared with patients with AS, for example patients with AR had no improvement in myocardial longitudinal strain following AVR, whereas patients with AS show an improvement 1 year after AVR and this remains constant after. The authors conclude that CMR is a useful tool to monitor patients with aortic valve disease, helping to plan AVR at an appropriate stage prior to irreversible structural heart damage.Sahiti et al. use myocardial work analysis derived from echocardiographic and blood pressure measurements, to show that increased LV volume and mass reduce global work efficiency as the cardiac cycle demands more energy. They also found altered myocardial work patterns in hypertensive patients even with normal LV volume and mass. These findings indicate that increased wasted energy combined with LV hypertrophy might be an early sign of hypertensive heart disease; however, further longitudinal studies and more compelling evidence are required to prove this hypothesis.Moreover, Gehrsitz et al. described how preoperative planning in pediatric patients with congenital heart disease can be optimized by using cinematic rendering to create three-dimensional (3D) images from two-dimensional (2D) CT or CMR. These 3D images were shown to the surgeon preoperatively on a 2D screen, as a hologram with special glasses (HoloLens®) and as a 3D print. This value of this information was assessed using questionnaires. It was shown that the combination of an extremely photo-realistic presentation via cinematic rendering and the spatial presentation in 3D space via mixed-reality technology enabled detailed assessment of the anatomy and pathology prior to the surgery which was helpful for treatment planning.Li et al. demonstrated that routine non-contrast chest CT imaging in patients with COVID-19, performed to evaluate lung disease, also provided useful prognostic implications and prediction of cardiovascular complications. In that study 241 consecutive hospitalized patients with confirmed COVID-19 were enrolled; three cardiac measurements were taken on CT imaging: left atrial diameter (LAD), left ventricular (LV) length and the cardiothoracic ratio (CTR). The authors found that a combination of LAD+LV (cutoff of 11.8 cm) and the CTR (cutoff of 0.8) was a predictor of major adverse cardiovascular events with a sensitivity of 82.6% and specificity of 80.2%.The implications of COVID-19 infection on cardiovascular pathology is of great interest. Tanacli et al. evaluated the value of endomyocardial biopsies (EMB) in COVID-19 compared to CMR to assess myocardial injury. They included 32 patients with persistent symptoms after COVID-19, 22 patients with acute myocarditis not related to COVID-19 and 16 healthy volunteers. These subjects had a baseline CMR as well as a follow-up scan; 10 of the post-COVID-19 and 15 of the non-COVID-19 patients had an EMB. All COVID-19 patients showed impaired myocardial deformation as well as altered functional and anatomical characteristics , nevertheless the LLC criteria for myocarditis were only fulfilled in 9% of patients. In these patients traces of previous myocardial inflammation were identifiable without evidence of ongoing inflammation in EMB.These papers were the most frequently downloaded and distinguishing manuscripts of 2021. It is clear from the breadth of research and data presented in this topic, that cardiovascular imaging research is a fast moving field, with advances that have potential clinical applications across a wide range of cardiac pathologies, contributing in improved diagnosis, risk stratification and better treatment planning.DH and KC drafted and revised the manuscript. SK and CB initiated the manuscript and guided with editorial comments after review. All authors contributed to the article and approved the submitted version.DH received a CMR specific research grant from the German Centre for Cardiovascular Research .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The objective of our study was to evaluate the effects of exercise-based cardiac rehabilitation (ECR) program on the preoperative exercise capacity of a HTx candidate. A male patient, aged 50–55 years, with chronic heart failure was placed on the HTx list and performed 12 weeks of intensive ECR (5 sessions-a-week). Our results showed that the cardiac index continuously increased between the onset and the end of ECR (1.40 vs. 2.53 L.min–1.m2). The first 20 sessions of ECR induced a eak2p increase . The peak 2 plateaued between the 20th and the 40th ECR session (19.3 vs. 19.4 ml.min–1.kg–1) then progressively increased until the 60th ECR session to reach 25.7 ml.min–1.kg–1, i.e., 71.0% of the maximal predicted values. The slope of E/2 showed a biphasic response during the ECR program, with an increase between the onset and the 20th ECR session (58.02 vs. 70.48) and a decrease between the 20th and the 40th ECR session (70.48 vs. 40.94) to reach its minimal value at the 60th ECR session (31.97). After the first 40 sessions of the ECR program, the Seattle Heart Failure Model score predicted median survival time was estimated at 7.2 years. In conclusion, the improvement in exercise capacity and cardiorespiratory function following the ECR helped delay the heart transplant surgery in our patient awaiting heart transplantation.Preoperative peak oxygen uptake ( The Vreferral , 7. Patiantation . Similar therapy , 9.eak2p in heart transplant candidates   . Hence,  outcome , 22. Thu–1), an aldosterone inhibitor (50 mg.day–1), a beta-blocker (3.75 mg.day–1), a hyper polarization-activated cyclic nucleotide-gated (HCN) inhibitor , and Entresto® . Before participation, the subject was informed of the risks and discomforts associated with the protocol and gave his written informed consent in accordance with the local ethics committee approval and the Ethical Standards in Sport and Exercise Science Research published in the International Journal of Sports Medicine , had, at the beginning of the exercise-based cardiac rehabilitation program, severe ischemic heart disease with a dilated and hypertrophic left ventricle (LV), a bi-ventricular dysfunction  with impaired right ventricular systolic function, moderate grade 2 mitral insufficiency, a significant grade 3 diastolic dysfunction, and a chronic tendency to hypotension (systolic blood pressure ≃ 80–90 mmHg). These complications followed a myocardial infarction that occurred 5 years previously resulting in the insertion of a triple-chamber defibrillator, three stents, and a resynchronization. At presentation, he was a sedentary former smoker and former drinker. The Seattle Heart Failure Model (SHFM) score predicted a median survival time of 1.5 years. His height, weight, and body mass index (BMI) were 180 cm, 61.0 kg, and 18.8, respectively. His medication consisted of a diuretic (125 mg.dayMedicine . Written0), as well as after 20 (T1), 40 (T2), and 60 (T3) sessions of exercise-based cardiac rehabilitation. LV volume and left ventricular ejection fraction (LVEF) were calculated using classical methods previously described by Shah et al. , carbon dioxide production (2), and minute ventilation (E) were measured using a breath-to-breath gas analyzer . The 2peak was defined as the highest oxygen up takeover in any 15-s period, and the ventilatory efficiency was obtained from the E/2 slope (2curve against 2 plot (V-slope method) and expressed in absolute and in percentage of measured peak values  and an incremental exercise test with gas exchange measurements were performed before  with an altered ejection fraction—visually assessed at 15 and 20%, at the onset and at the end of ECR program, respectively. TAPSE also increased from 6.0 to 17.8 mm, which approached the normal values in adults  at the end of the ECR program. NT-proBNP , GFR by MDRD (T0: 100.59 vs. T3: 92.04 ml.min–1), and natremia (T0: 136 vs. T3: 140 mmol.L–1) changes induced by the ECR program showed that the renal function was preserved throughout the whole ECR program. 2peak and maximal heart rate (HR) were 15.0 ml.min–1.kg–1 and 95 beats.min–1, which corresponded to 42.0 and 57.0% of the maximum predicted values, respectively. These peak values were reached at a maximal tolerated power (MTP) equal to 70 w . The first 20 sessions of ECR (between T0 and T1) induced an increase in MTP (70 vs. 90w), eak2p (15.0 vs. 19.3 ml.min–1.kg–1), and peak HR (95 vs. 106 beats.min–1) reaching 54.0% of MTP and eak2p predicted values and 63.0% of maximal theoretical HR at T1. Then, the cardiorespiratory measurements remained stable between the 20th and the 40th ECR session . Thereafter, the eak2p progressively increased until the end of ECR to reach 25.7 ml.min–1.kg–1 at T3, corresponding to 71.0% of the predicted value. The MTP was 120 W, which was also consistent, reaching 71.0% of the maximal predicted power value. Additionally, the ECR program induced a decrease in resting HR and an improvement in cardiorespiratory parameters with a decrease in AnTh. Consequently, baseline eak2p and MTP were slightly lower than the 2, and the mechanical power associated with AnTh was determined at the end of the ECR program. The slope of E/2 showed a biphasic response following the ECR program, with an increase between the baseline and the 20th ECR session  then the slope of E/2 decreased between T1 and the 40th ECR session  to show its lowest value after 60 ECR sessions (T3: 31.97). Finally, the SHFM predicted median survival time increased from 1.5 to 7.2 years at the end of the 40 sessions of ECR .Medical treatment did not change during the intervention period. 2peak remained 70% lower in transplanted patients compared to age-matched controls. The reduced 2peak may be related to heart and locomotion skeletal muscle dysfunction  as a result of heart failure  and the increased 2 at the anaerobic threshold in our patient. Gimeno-Santos et al. recently showed the beneficial effects of 16 exercise sessions  on 2 peak (+ 27.0 ± 45.0%) in 11 patients placed on a heart transplantation list , was classically used to evaluate chronotropic responses . It was Despite some methodological limitations, our results, taken together, may explain the improvement in the Seattle Heart Failure Model score. Therefore, we can conclude that the improvement in exercise capacity and cardiorespiratory function following ECR helped delay the heart transplant surgery in our patient on the transplant waiting list.Our patient continued to perform regular physical exercise until the first COVID19 lockdown when he completely stopped any form of physical activity. In January 2022, he was hospitalized for septic and cardiogenic shocks and died several days later.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the relevant individual for the publication of any potentially identifiable images or data included in this article.P-ML, AP, YG, and FK contributed to conception and design of the study. FK and YG organized the database. AP and P-ML wrote the first draft of the manuscript. PL reviewed and edited all sections of the manuscript. All authors contributed to manuscript revision, read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The pericardium is a thin connective tissue membrane that surrounds the heart and is an integral regulatory component of cardiopulmonary performance. Pathological growth and remodeling of the right ventricle (RV) stemming from structural heart diseases are thought to include a significant role of the pericardium, but its exact role remains unclear. The objective of this study was to investigate potential biomechanical adaptations of the pericardium in response to pulmonary hypertension and their effects on heart behavior. Integrated computational-experimental modeling of the heart offers a robust platform to achieve this objective. We built upon our recently developed high-fidelity finite-element models of healthy and hypertensive rodent hearts via addition of the pericardial sac. In-silico experiments were performed to investigate changes in pericardium reserve elasticity and their effects on cardiac function in hypertensive hearts. Our results suggest that contractile forces would need to increase in the RV and decrease in the left ventricle (LV) in the hypertensive heart to compensate for reductions in pericardium reserve elasticity. The discrepancies between chamber responses to pericardium addition result, in part, from differences in the impact of pericardium on the RV and LV preload. We further demonstrated the capability of our platform to predict the effect of pericardiectomy on heart function. Consistent with previous results, the effect of pericardiectomy on the chamber pressure-volume loop was the largest in the hypertensive RV. These insights are expected to motivate further computational investigations of the effect of pericardiectomy on cardiac function which remains an important factor in surgical planning of constrictive pericarditis and coronary artery bypass grafting. Efficient operation of the cardiopulmonary system requires precisely coordinated performance of the left (LV) and right ventricles (RV) . The peracute pressure overload  rat heart model of cardiac contraction throughout the cardiac cycle of both normal and post-PH states. . In thisin-vivo passive and active properties of RV and LV myocardium at normal and hypertensive states. The estimated material parameters produced model behavior that closely matched the experimental data. Additional details regarding the animal model, measurements, and inverse model can be found in our previous work  and post-PH (4 weeks) rat hearts were developed . Brieflyous work . In thisE is the Green-Lagrange strain tensor, and c, α, B1, B2, and B3 are material constants. The strain components refer to the local preferred material directions with the axis “1” denoting the fiber direction. The active behavior was characterized by the following stress-like function of the fiber strain (Ef = e1 ⋅Ee1)β is a factor representing Frank-Starling effect of changing preload. The myocardial passive and active parameters in normal and post-PH heart models, without pericardium, were determined previously through an inverse modeling approach to match the organ-level pressure-volume (P-V) measurements  and structural (DT-MRI) imaging data. An animal-specific pericardium was incorporated by the addition of a FE shell adjacent to the epicardium  made up hickness . Nodes ohickness  as a frihickness  was usedαP and cP, in the normal heart were estimated by matching the end-diastolic pressure volume relationship (EDPVR) of hearts with pericardium. As the experimental P-V data used to estimate material properties for the previously developed heart models  remains nearly unaffected following pericardiectomy in hearts with non-infected pericardium . Having icardium .• Although the pericardium can experience fibrosis due to infection, such as constrictive pericarditis , there itoe region of the tissue  leading to an increase in apparent stiffness of pericardium.• However, the pericardium must stretch to accommodate significant ventricular dilation in hypertensive hearts (as seen in the PH heart in our study.) As a connective tissue, this stretch alters the • We estimated this increase by calculating the amount of stretch in pericardium induced by RV dilation in the PH heart and the relative stiffening due to the shortening of toe region. We used existing biaxial mechanical data available for bovine and canine pericardium  and esti• The material parameters of the pericardium were prescribed to the PH heart model such that the stress-strain response was scaled appropriately.To the best of our knowledge, there have been no measurements of pre- and post-pericardiectomy diastolic P-V measurements in the hypertensive heart. As such, we made an approximation as to estimating the material properties of the pericardium in the PH heart, summarized by the following remarks.Similar to the case of the normal heart, a P-V loop for the PH heart with intact pericardium was estimated using the changes in the diastolic behavior and maintaining the SV, and inverse modeling was performed to estimate A 35% increase in the area of pericardium from the control to the PH heart decreased the toe region by 25% in extensional strain and stiffened the pericardium by 48% . RemovalAddition of the pericardium, while maintaining the stroke volume, caused a ∼ 50% increase in the peak value of n the LV . SimilarRemoval of the pericardium resulted in a notable increase in end-diastolic volume (EDV) in the RV in both control and post-PH cases . Predictfraction .Removal of the pericardium reduced longitudinal movement in both control and PH hearts. While little change was observed in the strain distributions between hearts with and without pericardium, a notable increase in RV stress was predicted in the heart models with pericardium in both control and post-PH hearts . No signIn this work, we have presented the first computational investigation of pericardial adaptation in the hypertensive heart. The pericardium has an innate influence on cardiac function, which could be upset by G&R events stemming from structural heart diseases. The objective of this study was to determine how the adaptation of the pericardium in the hypertensive heart impacts passive and active cardiac behaviors.reserve” elasticity is minimized leading to substantial increase in the compressive pressure exerted by pericardium to the ventricles , and in turn limits the extent to which the Frank-Starling mechanism can be used by the heart, one could predict that the removal of the pericardium would induce a decrease in myocardial contractility necessary to maintain the SV for both ventricles. However, a rather counter-intuitive finding from our inverse model predictions was that while the RV contractility notably decreased, the LV contractility was slightly increased following the removal of the pericardium. This finding highlights the role of the pericardium in enhancing the “cooperative” RV-LV coupling as well as disparity in the changes of the RV and LV preload following the removal of pericardium. In the PH heart, removal of the pericardium induced, qualitatively similar, but quantitatively more notable, changes in the systolic behavior of the RV and LV when compared to those in the control heart. In essence, the pronounced changes in systolic function suggest that the Frank-Starling relationship is significantly altered due to excessive dilation of the RV in the PH heart such that the removal of the pericardium could significantly undermine the RV systolic function. These changes in predicted active stress are consistent with the results of chronically stressed pericardium , although the predicted changes are expected to be qualitatively accurate.Stretch-induced stiffening of the pericardium imposed by geometric remodeling of the ventricles was assumed to be the only remodeling mechanism of the pericardium in the hypertensive heart. Additional intrinsic remodeling of the pericardium due to chronic ventricular pressure overload remains understudied and was not considered here. The fiber orientation distribution of the pericardium was taken to be the same as that of respective epicardial region in each heart. The pericardial-myocardial fiber orientation relationship and its effect on cardiac function remains to be studied, although pilot simulations suggest this effect is considered to be secondary to the effect of pericardial passive properties on cardiac function. Lastly, the changes in As existing evidences indicate that the pericardium contributes substantially to the intracavity pressures of both ventricles , underst


The left ventricular ejection fraction (LVEF) is commonly used as a marker of aortic stenosis (AS) disease severity and to indicate surgical intervention. However, an LVEF <50% identifies mainly advanced disease. Hence, earlier detection of subclinical LV systolic dysfunction may improve clinical decision-making. The global longitudinal strain (GLS) can identify subclinical systolic dysfunction at earlier stages of AS progression even in the presence of preserved LVEF. To this end, we evaluated the preoperative prognostic significance of the LVGLS to identify patients who will undergo a more extensive postoperative LV reverse remodeling as a surrogate marker for clinical recovery.We performed a prospective observational study based on detailed pre- and postoperative 2D transthoracic echocardiographic examinations, including strain analysis with speckle tracking. We screened 60 consecutive patients with severe AS and a preoperative LVEF ≥50% indicated for surgery; 39 patients met the study entry criteria and consented to their participation.P=0.001 and the intraventricular septal thickness in diastole (IVSd) r=0.462, P=0.003. Furthermore, patients with a normal GLS (≤-18.9%) at baseline experienced a better recovery of their LV morphology and systolic function during the postoperative course compared to those with an abnormal GLS (>-18.9%). The effect size, hedges g, was at least >0.75 for the LVMI, IVSd, intraventricular septal thickness in systole (IVSs), left ventricular posterior wall thickness in diastole (LVPWd) and LVEF, suggesting a clinically significant difference between subgroups at follow-up.The median age was 67 (range 30-79) years; 56.4% were female. At baseline, the GLS was 61.64±7.22%. Surgery led to an improvement in the GLS; the mean difference was 3.23% [95% CI=1.96 to 4.49%] during a median follow up time of 5 (interquartile range 4-6) months. The preoperative GLS correlated with the postoperative LV mass index (LVMI) r=0.526, A normal preoperative left ventricular global longitudinal strain is associated with an improved left ventricular reverse remodeling and systolic function following surgery to resolve aortic stenosis. Current guidelines recognise a ejection fraction (EF) <50% as a class I indication for aortic valve replacement (AVR). Nevertheless, clinical decision-making, according to the left ventricular ejection fraction (LVEF), has been questioned in recent years. LVEF may remain normal for years, due to compensatory mechanisms, despite the occurrence of deep sub-clinical structural and functional myocardial changes that dictate disease progression, which can affect the clinical outcome.The assessment of left ventricular (LV) systolic function is crucial in the risk stratification of aortic stenosis (AS) patientsIt is well established that patients with severe AS and significant LV systolic dysfunction can benefit from surgical aortic valve replacement (SAVR). Nevertheless, severe AS patients with LV systolic dysfunction are at higher risk to experience postoperative complications with an increased risk of intrahospital and long-term mortality in comparison to patients with preserved LV function.. We speculate that the normalisation of GLS values might signify a reversal of pathological myocardial changes and correlate with left ventricular reverse remodeling (LVRR). GLS can be routinely evaluated using 2D-speckle tracking echocardiography.The global longitudinal strain (GLS) is a more accurate marker of myocardial fibrosis compared to LVEF. In comparison to other indexes of LV systolic function, the parameters of LV longitudinal deformation are superior in detecting myocardial dysfunction and damage. Current evidence suggests that patients with severe AS have sub-clinical LV systolic dysfunction, resulting in distorted GLS values despite preserved LVEFConsequently, GLS has the potential to be incorporated into clinical decision-making in patients with severe AS and to predict SAVR procedural success according to the postoperative LVRR.This study evaluated the correlation between preoperative GLS and postoperative echocardiography parameters associated with LVRR. Furthermore, we analysed whether GLS can stratify patients who will experience more pronounced resolution of LV hypertrophy and improvement in systolic function following SAVR.We prospectively screened 82 consecutive patients indicated for SAVR at our clinic between November 2016 and June 2017. The STROBE study flow diagram describing the inclusion and exclusion criteria is shown in Inclusion criteria were:Fulfilled echocardiographic criteria for severe aortic stenosis.LVEF >50%.Written consent for study participation.Clinically stable patients.Exclusion criteria were:Previous cardiac surgery.Concomitant moderate or severe valve morbidity.Atrial fibrillation or flutter.Unstable coronary artery disease.Severe renal or liver failure.Technically unsuitable echo window.Patients who refused a control check-up.Postoperative mortality.vs. GE).Postoperative evaluation on a different echocardiography device  and a coronary angiogram for the possibility of existing CAD.Echocardiographic examinations were performed on a Philips Epiq 7 Cardiology Ultrasound Machine; saved recordings were examined using the Philips IntelliSpace Cardiovascular Portal platform..We performed the measurements according to the guidelines and recommendations.EF was calculated by Simpson’s method, mean and peak trans-aortic gradients were determined using the continuous wave Doppler method, and aortic valve area was calculated with the continuity equation. Relative wall thickness (RWT) was calculated according to the following formula 2 × PWd/LVEDd: “double the thickness of the posterior wall divided by left ventricular end-diastolic dimension”.Tissue Doppler imaging was used to obtain peak systolic (S’) and peak early diastolic (E’) mitral annular velocities measured on the septal and lateral sides of the mitral annulus and after the calculation of E/E’,The LV mass was calculated according to the linear method using the American Society of Echocardiography formula: Where:LVIDd = Left ventricular internal diameter at end-diastolePWTd = Posterior wall thickness in diastole2/kg).SWTd = Septal wall thickness in diastole and indexed to the body surface area  was measured in millimetres with M-mode echocardiography at four different points  in apical 4- and 2-chamber views; a value ≥10 mm was considered within the reference range.High-quality ECG-gated images were obtained and recorded with frame rate >50 frames/s in long apical axis 4- and 2- chamber views; recordings were subsequently analysed using 2-D speckle tracking, where segmental strains were presented as a bull’s-eye map. A GLS value of -18.9% was set as the cut-off for normal longitudinal strain as recommended by the vendorThe Zan Mitrev Clinic’s ethics committee approved the clinical practice and treatment procedures described in this case series.The Zan Mitrev Clinic’s ethics committee approved the publication of clinical data under the condition of full anonymity.All data generated or analysed during this study are included in this published article and its supplementary information files.Surgical aortic valve repair proceeds according to the standard protocol for cardiopulmonary bypass (CPB) placing patients under mild hypothermic conditions (32°C). Myocardial protection is achieved through continuous retrograde and antegrade cardiac perfusion with warm blood cardioplegia.Categorical parameters were summarised as absolute numbers and percentages. Continuous data are shown as mean±SD or median+interquartile range (IQR).t-test, and non-parametric continuous variables were assessed using the Mann-Whitney test for independent comparisons. Comparisons of preoperative versus postoperative data were performed using a paired T-test or Wilcoxon signed-rank test for non-parametric data.Continuous variables were evaluated using the D’Agostino-Pearson normality test - independent parametric data were analysed using the Student’s g as a measure for the effect sizes due to unequal and small samples sizes.Fisher’s exact test was applied to evaluate the association between categorical variables with the outcome. Regression analysis between preoperative GLS and echocardiographic markers were performed using Pearson’s or Spearman’s correlation testing. We adopted the hedges’ Data were analysed with the statistical softwares Graphpad Prism, version 7.03 and Statsdirect, version 3.1.20.Baseline patient characteristics are presented in MG), transvalvular peak aortic jet velocity (pTAS) and LVEF were 0.42±0.09 cm2/m2, 37.7±15.1 mmHg and 4.08±0.81 m/s and 61.64±7.22%, respectively.The echocardiographic parameters before and after SAVR are summarised in The mean (± SD) GLS was -16.58±4.25%, and the LV fractional shortening was 36.95±9.92% before surgical intervention.2, of which 15 out of 17 had concentric hypertrophy. In female patients, the mean (± SD) LVMI was 150.3±47.39 g/m2 with 19 out of 22 having concentric hypertrophy at baseline.We observed LV hypertrophy in all patients. The mean (± SD) left ventricular mass index (LVMI) in males was 216.3±48.45 g/mAfter a median follow-up time of 5 IQR 4-6) months, several parameters associated with AS severity were improved  to 4. SA-6 monthsP=0.0001  and LVMI   and the “abnormal”= GLS >-18.9% group, n=26. The sub-groups were equally matched for age, BMI and BSA .p=0.477; P=0.0023) with the extent of preoperative LV hypertrophy; patients with NYHA class 3 had a more pronounced LV hypertrophy compared to those with NYHA class 2, mean difference in LVMI was 59.71 g/m2 (95% CI 17.21 to 102.4 g/m2), P=0.0072 . We observed a trend suggesting higher NYHA status in the abnormal GLS sub-group. However, this difference did not reach statistical significance. On the other hand, NYHA class was associated  had a more favourable LVMI compared to the “abnormal” subgroup (>-18.9%) . FurtherFinally, we evaluated the postoperative values of candidate echocardiography outcome measures associated with LVRR . The mosIn conclusion, patients with a normal GLS experience a faster normalisation of LV dimensions after SAVR.. However, reduced LVEF (<50%) manifests in the late stages of the disease and has been associated with irreversible myocardial dysfunction and is an independent risk factor for sudden death in patients with severe AS.Aortic stenosis (AS) is the most common degenerative valvular heart disease; a result of immune-mediated calcification of the valve leaflets. Failure of compensatory mechanisms over time leads to clinical symptoms as a consequence of progressive fibrosis, impairment of myocardial contractility and reduced LVEF. Early detection of subclinical systolic dysfunction may optimise the timing of aortic valve intervention. GLS is a promising and sensitive marker of the subclinical systolic dysfunction,14.To this end, more sensitive markers for the early stages of AS that overcome the limitations of LVEF-guided clinical decision-making are warrantedIn the present study, we assessed the prognostic significance of LVGLS in a cohort of severe AS patients with preserved LVEF. We demonstrate that 1) the baseline GLS value strongly correlates with several echocardiography parameters linked to LV hypertrophy and LV systolic functions. Moreover, 2) patients with a normal GLS (<-18.9%) experienced a more pronounced LVRR during the early postoperative period. In contrast, LVRR extent was significantly impaired in patients with an abnormal GLS (≥-18.9%) at baseline.Notably, sub-groups were matched for age, gender and BMI; both groups were similar concerning the degree of AS severity, LV hypertrophy, LVEF and NYHA class at baseline. The main difference between sub-groups before SAVR was their sub-clinical LV systolic function as determined by speckle-tracking echocardiography strain analysis ..SAVR forms the cornerstone of AS management. It has been shown that the degree of LV hypertrophy and extent of LVRR after SAVR determines long-term clinical prognosis,14, strain analysis by speckle tracking echocardiography is currently not implemented in major clinical practice guidelines. Nonetheless, our data suggest that the preoperative GLS has the potential to classify patients who will experience accelerated LVRR after SAVR. Thus, a normal GLS is associated with better postoperative recovery of normal LV geometry.Even though the evaluation of GLS can detect subclinical systolic dysfunction with high sensitivity. Of importance, the LVGLS is independently associated with all-cause mortality in AS patients.Our data align with recent reports that advocate the inclusion of LVGLS analysis to improve risk stratification of patients with severe AS, facilitate clinical decision-making and timing of aortic valve replacement. Reported reference values of GLS vary from -15.9% to -22.1%. Nevertheless, our comparative study was built on a cut-off value of -18.9% as recommended when using the Philips Epiq 7.Heterogeneity in GLS measurements among published clinical studies hampers the inclusion of the LVGLS analysis in clinical practice guidelines; the recorded measurements vary among different vendors because of proprietary differences in the software used to calculate deformationAccordingly, patients with a normal GLS (<-18.9%) experienced a faster recovery of normal LV geometry and substantial improvement in their LV functionality . In cont and attenuate signalling effectors underlying pathologic remodelling.Based on our data, one could hypothesise that normal GLS values pertain to LV cardiomyocytes with the intrinsic capacity to overcome interstitial fibrosis; on the other hand, recent reports suggest that a rapid improvement of the LVMI is paradoxically linked to a high(er) 30-day mortality,20. There were no early mortality cases in our study; currently, our long-term follow-up is still ongoing, and long-term mortality can not be assessed yet. Given the complexities of LV mass regression post-AVR, the limitations of 2D imaging-derived calculations, SV adaptions it will be of high interest to determine potential differences in mid-to-long-term mortality rates between the “normal” and “abnormal” GLS subgroups.Resolution of pathological LV hypertrophy is generally considered a marker of favourable prognosis and prolonged survivale.g. stratification based on NYHA class, classification of AS stages and strict comparison based on comorbidities such as coronary artery disease, might strengthen the data. Also, a subgroup analysis comparing patients with or without concomitant CABG revealed no differences in the extent of LVRR based on postoperative values of GLS, LVMI and IVSd  mortality.Despite these limitations, our conclusions are based on highly significant mean/median differences  and largIn conclusion, a normal preoperative LVGLS is associated with improved postoperative recovery of normal LV geometry and function. GLS correlates with several echocardiography markers of LVRR.The results advocate the use of the LVGLS as an early and more sensitive marker to establish AS stenosis severity, facilitate indication for AVR and classify patients with a better postoperative prognosis following surgery.


To evaluate right ventricular diastolic function in patients with coronary slow flow phenomenon (CSFP) by using Doppler tissue imaging (DTI).CSFP patients diagnosed using coronary angiography from June 2019 to December 2020 at the third Hospital of Quzhou were retrospectively investigated, with a similar number of patients with normal coronary blood flow during the same period taken as the control group. Right ventricular systolic and diastolic function index was measured via DTI.No differences were found between CSFP and control groups in terms of baseline data, RV end systolic diameter, RV end diastolic diameter, or RV ejection fraction. The peak velocity E in the early diastolic phase of the right ventricle was decreased in CSFP patients, while the peak velocity a in the late diastolic phase of the right ventricle was increased, resulting in a lower E / a ratio.Right ventricular diastolic function in patients with CSFP is decreased, and this can be identified using DTI. DTI has important applicative value for evaluating right ventricular diastolic function in patients with CSFP. Coronary slow-flow phenomenon (CSFP) is an angiographic phenomenon where dye passage is slow in coronary angiography in the absence of significant arterial lesions or other causes.The records of patients who underwent coronary angiography echocardiography in Quzhou Third Hospital from June 2019 to December 2020 due to chest tightness and chest pain, suspected of coronary heart disease, were retrospectively selected. Inclusion criteria was : echocardiography showing normal cardiac function (left ventricular ejection fraction > 50%). Exclusion criteria included presence of acute myocardial infarction, prior myocardial infarction, coronary aneurysm, coronary artery dilation, coronary spasm, cardiomyopathy, heart valve disease, myocardial bridge, or congenital heart disease; infectious diseases; liver and kidney diseases; presence of tumors; mild anemia (blood protein lower than 90g/L), severe cerebrovascular disease, or systemic immune system diseases. Based on these criteria, 45 patients were included in the CSFP group, while 42 patients with normal coronary artery blood flow comprised the control group. This research plan was approved by the medical ethics committee of our hospital .Patient information, including gender, age, BMI index, heart rate, and past medical history  were compiled and summarized. Laboratory examination results  were reviewed. Doppler tissue ultrasound examination and measurement indices  were collected. Right ventricular histologic ultrasound results  were examined.CSFP was diagnosed via coronary angiography mainly using the corrected thrombolysis in myocardial infarction (TIMI) blood flow measurement frame method. The criteria for this method are as follows:Doppler tissue echocardiography and measurement methods were as follows: Live Five echocardiography  was used, with a probe frequency ranging between 2.5-4.0 mhz. The patient assumed left supine position for routine echocardiography. Doppler tissue imaging (DTI) was then used to measure right ventricular end systolic diameter (RVESD), right ventricular end diastolic diameter (RVEDD), and ejection fraction (EF). DTI sampling was taken under the tricuspid valve to obtain the forward bimodal laminar flow spectrum in the diastolic phase. The peak velocity (E) in early diastolic phase and peak velocity (a) in late diastolic phase were measured, and the E/A ratio was calculated.2 inspection. P < 0.05 indicated statistical significance.Excel software (Microsoft) was used for data collection, and SPSS 22.0 software was used for data processing. Measurement data with normal distributions were summarized as Mean±SD and independent sample t tests were used to compare between groups. Counting data were expressed as n (%), with comparisons between groups performed using χThere were no significant differences in gender, age, BMI, heart rate, fasting blood glucose, serum creatinine levels and history of smoking, drinking, coronary heart disease, furosemide use and hyperlipidemia between CSFP and control groups P>0.05, . No signRight ventricular diastolic function, tricuspid annular velocity, and E peak on the blood flow spectrum were significantly decreased in the CSFP group (P< 0.05) while a peak was significantly increased (P<0.05). This resulted in a decreased E/A peak ratio (P<0.05). Tei index increased significantly in the CSFP group .CSFP is defined by the presence of a delayed perfusion in the distal vessel despite a lack of an obvious lesion in the coronary artery during coronary angiography.The Tei index, first proposed in 1995, evaluates the systolic and diastolic function of the heart.18The main limitation of the study is the relatively small sample size and retrospective single-center nature. Larger multi-center studies that include different types of patients are merited.Although the sample size of this study is small, we demonstrated that right ventricular diastolic dysfunction in patients with CSFP may be an early manifestation of coronary slow flow. Therefore, accurate evaluation of right ventricular diastolic dysfunction may provide a reference point for early diagnosis of CSFP.XZ: Conceived and designed the study.XX & ZW: Collected the data and performed the analysis.XZ: Was involved in the writing of the manuscript, is responsible for integrity of the studyZZ: Edited the manuscript and data analysis.All authors have read and approved the final manuscript.


Limited data are available on athlete’s heart for rugby athletes. This study aimed to investigate cardiac structure and its relationship with cardiorespiratory fitness in young Japanese rugby athletes. A prospective cross-sectional study using echocardiography and cardiopulmonary exercise testing (CPET) was conducted on 114 male collegiate rugby players. There was a higher prevalence of increased left ventricular (LV), atrial, and aortic dimensions in the young athletes than that in previously published reports, whereas the wall thickness was within the normal range. Anthropometry and CPET analyses indicated that the forwards and backs presented muscular and endurance phenotypes, respectively. Indexed LV and aortic dimensions were significantly larger in the backs than in the forwards, and the dimensions significantly correlated with oxygen uptake measured by CPET. On the four-tiered classification for LV hypertrophy, abnormal LV geometry was found in 16% of the athletes. Notably, the resting systolic blood pressure was significantly higher in athletes with concentric abnormal geometry than in the other geometry groups, regardless of their field positions. Japanese young athletes may exhibit unique phenotypes of cardiac remodeling in association with their fitness characteristics. The four-tiered LV geometry classification potentially offers information regarding the subclinical cardiovascular risks of young athletes. Long-term exercise training is associated with a spectrum of morphological and functional adaptations of the heart known as athlete’s heart . HoweverRugby comprises mixed activities involving moderate-to-high isometric and isotonic components within the sports discipline . These cCardiovascular evaluation and care of college student-athletes is gaining increasing attention . Therefon = 120; age, mean 18.4 years) on a rugby team at Nippon Sport Science University from 2015 to 2019 at our institution. The team belonged to the Japanese collegiate rugby union group A. Almost all athletes started their rugby career between 10 and 13 years of age and continued training for competitive rugby teams of their schools and/or communities. More than half of the freshman athletes entered the university on a sports scholarship. The athletes participated in structured exercise training with the college team for >10 h/week including both position-specific and common programs.Cardiac evaluation was performed for all male freshman athletes , and the backs, including the positions of the half, center, and full backs, and wings (n = 62). At the time of cardiac screening, bioelectrical impedance analysis was performed using InBody S10  to determine body composition, including body fat mass and appendicular skeletal muscle mass [The athletes were divided into two groups according to their field position: the forwards, including the scrum positions of the prop, hooker, lock, flanker, and number 8 . Standard measurements were performed in accordance with the guidelines of the American Society of Echocardiography and the European Association of Cardiovascular Imaging . Two-dimWe measured LV global longitudinal strain (GLS), as previously described . In brie2 for both 2TC and 4TC systems. For 2TC, the threshold for concentric remodeling/concentric hypertrophy was set at RWT > 0.42. For 4TC, LV geometry was specified by LV concentricity (LVM/LVEDV2/3) and indexed LVEDV. Echocardiographic thresholds for increased concentricity were ≥9.1 g/mL2/3 and those for increased LVEDV/BSA were ≥76 mL/m2. In 4TC, LV geometry was classified according to the thresholds described above: normal geometry; concentric remodeling; concentric LVH, including dilated and non-dilated forms; and eccentric LVH, including dilated and non-dilated forms.Phenotypic characterization of LV geometry was based on the 2- and 4-tiered classifications (2TC and 4TC) for LV hypertrophy (LVH) . LVH was2) of 5 mL/min through increases in speed and grade. The protocol was designed using the following equation: VO2 (mL/min/kg) = 0.15S2 + 0.14SG + 0.45S + 0.40G + 4.23, where S is speed (km/h), and G is grade (%) [2 was defined as the highest VO2 value achieved during peak exercise. The oxygen uptake efficiency slope (OUES) was calculated using a logarithmic regression curve between VO2 and ventilation during exercise. OUES/kg was able to assess cardiopulmonary functional capacity in children and adolescents with and without congenital heart disease, even at the submaximal level of exercise [2 to the heart rate at peak exercise time.CPET was performed using cycle or treadmill ergometers in 110 athletes, as previously described ,14. The exercise . The oxyt-test, respectively. Pearson’s simple linear regression analysis was used to determine correlation coefficients between the two parameters. p-values of <0.05 were considered statistically significant.Data were analyzed using commercial software . All data are expressed as mean ± standard deviation unless otherwise indicated. Categorical and continuous variables were compared between the groups using the chi-square test and unpaired 2 and OUES/kg were significantly higher in the backs than in the forwards  and 18.4% of athletes (LAV/BSA ≥ 35), respectively b. The foIncreased AOD was detected in 8.8% of athletes (AOD ≥ 35 mm) c. There 2 and OUES/kg, respectively. OUES/kg appeared to show a better association than the peak VO2. LVEDV/BSA was correlated with OUES/kg and oxygen pulse. The oxygen pulse was significantly correlated with LVM/BSA. The AOD/BSA ratio was significantly associated with peak VO2 and OUES/kg. In contrast, LAV/BSA did not exhibit any association with the CPET parameters.We investigated the association between the CPET parameters and indexed values of cardiac structure using Pearson’s linear regression analysis . LVEDD/BLV geometry was assessed using the 2TC and 4TC to further elucidate the phenotype of cardiac remodeling in young athletes.n = 79) in 69.3% of athletes, concentric remodeling (n = 21) in 18.4%, and eccentric LVH (n = 14) in 12.3% , concentric remodeling , concentric LVH , and eccentric LVH  , and eccentric LVH geometry groups, whereas resting systolic blood pressure during CPET was significantly higher in the athletes with concentric abnormal geometry (141.3 ± 17.9 mmHg) than in the athletes with normal  and eccentric LVH geometry .The 4TC was developed to provide a more refined assessment of the geometric patterns of increased LVM.  The 4TC 5, 5.3%) b. The prThere was a strong relationship between indexed LVM and LV concentricity on the 4TC in these young athletes, whereas no correlation was found between indexed LVM and RWT on the 2TC.In this study, we investigated specific cardiac structure and cardiorespiratory fitness in young rugby athletes. The data presented here are unique because (i) the variables were derived from two distinct types of athletes, the forwards and backs; (ii) CPET data were involved not only to evaluate cardiorespiratory fitness but also to demonstrate its correlation with cardiac morphology; and (iii) to the best of our knowledge, this is the first study to show LV geometry in young athletes during late adolescence with the use of the 4TC.Cardiac structure in the young rugby athletes. The present results demonstrated a higher prevalence of increased LV and LA size, and AOD in young rugby athletes compared with the reference ranges of the guidelines [idelines .A previous study found that all absolute and indexed structural indices of echocardiography were significantly larger in the professional rugby athletes than in the age-matched sedentary controls . The JapIn a recent study  on the C2 and 97.1 ± 19.3 g/m2, respectively) were smaller.In sports, a mixed discipline is characterized as an activity with alternate phases of intense exercise work and recovery . TypicalCardiorespiratory fitness and athlete’s heart in rugby athletes. Two studies with small numbers of participants were available for evaluating cardiorespiratory fitness using CPET in rugby athletes. Professional rugby players in Italy showed 46.8 ± 4.3 mL/min/kg of a peak VO2 (n = 15 including both the forwards and bocks) [n = 28) from an English Premiership rugby union club demonstrated a significantly higher peak VO2 in backs than in forwards (48.3 ± 2.1 vs. 41.2 ± 2.7 mL/kg/min), similar to our results. The peak VO2 difference was likely attributable to the different typical body habitus of forwards and backs as well as position-specific training programs. The forwards are generally taller and heavier players, with greater muscle and fat mass; this could explain their lower peak VO2.d bocks) . A studyd bocks)  on profeHowever, forwards have shown higher overall exercise intensity than backs during a game . In a stThe endurance capacity of our study population appeared to be relatively lower than that of participants in previous studies ,22. We s2 and LVEDD or LVM in trained males, other studies [2 and LVEDD in highly trained male cyclists and accomplished female athletes.Although several studies have evaluated the relationship between cardiac structure and cardiorespiratory fitness in athletes ,27,28,292 and OUES/kg on CPET analysis. Athletes with higher endurance performance likely exhibited not only larger cardiac, but also larger aortic dimensions even after corrections for BSA. Intriguingly, OUES/kg showed a slightly stronger association with the dimensions than peak VO2.To the best of our knowledge, this is the first study to show the significant correlation in rugby athletes. The present study of young athletes demonstrated that indexed LV dimensions and AOD were significantly larger in the backs than in the forwards, and they were also significantly correlated with the peak VOLV geometry evaluated by the 2TC and 4TC in young athletes. The 4TC has been developed for a more distinct classification of LV geometry than conventional 2TC, taking three-dimensional information of the LV into account [ account . Compare account .A study  by TrachResting systolic blood pressure was significantly higher in the young athletes with concentric abnormal geometry than in those with normal geometry and eccentric LVH. Thus, the 4TC may be better for identifying athletes at risk of hypertension and/or subclinical cardiovascular disorders than the 2TC, although further investigation will be necessary.Study limitations. There are some limitations to the present study, although it provides detailed information about athlete’s heart in young rugby players. First, the cross-sectional nature of this study limits the understanding of the mechanisms underlying remodeling processes. Second, since our population included a relatively small number of athletes, further studies with larger sample sizes are needed to confirm our results. Third, this study was conducted with a selected cohort of Japanese male athletes. Therefore, our study cannot characterize female athletes. Ethnicity has also emerged as a determinant of athlete’s heart. In a study of rugby athletes, Pacific Islander ethnicity showed greater LV and RV wall thickness and mass than their Caucasian counterparts [terparts . FurtherIn young rugby athletes, major echocardiographic abnormalities are quite rare, but measurements of LV and LA size and AOD were frequently larger than the guideline reference ranges. Measurements of anthropometry, exercise capacity, and cardiac structure differed between forwards and backs. Changes in left heart dimensions relative to body size occurred more in backs than in forwards. The utility of CPET should also be emphasized. OUES could be useful as a unique parameter to assess fitness and to interpret athlete’s heart in rugby athletes. Finally, compared with the 2TC, the 4TC of LV geometry appeared to contribute to better risk stratification of athletes with LVH.