The use of veno-arterial extracorporeal membrane oxygenation (ECMO) in patients with sepsis-induced cardiogenic shock has been reported, but the clinical implication of the Impella percutaneous axial-flow left ventricular assist device for such patients remains unknown. We had a 37-year-old man with septic shock and severely reduced cardiac function. Veno-arterial ECMO and concomitant Impella CP support ameliorated his end-organ dysfunction and achieved cardiac recovery, whereas severe mitral valve regurgitation due to chordal rupture developed later. Mitral valve replacement concomitant with ECMO removal as well as an Impella upgrade successfully treated the patient. ECMO and Impella support might be an effective therapeutic strategy for the bridge to recovery in patients with sepsis-induced cardiogenic shock; however, paying attention to mitral chordal rupture is highly encouraged. Approximately 15% of patients with sepsis develop septic shock, which is defined as persistent hypotension and elevated lactate levels refractory to adequate fluid resuscitation and requiring vasopressors. Its in-hospital mortality exceeds 40% . The patA retrospective cohort study confirmed the survival improvement by using extracorporeal membrane oxygenation (ECMO) in the cohort with sepsis-induced cardiogenic shock , whereasThe clinical implication of percutaneous axial-flow left ventricular assist device Impella in patients with sepsis-induced cardiogenic shock has not yet been investigated. ECMO alone would be insufficient, particularly for those with severe hepatorenal dysfunction and congestive heart failure with severely impaired left ventricular function. Given the accumulating evidence of Impella with/without ECMO in patients with cardiogenic shock, Impella-incorporated mechanical circulatory support therapy might also have a promising outcome for those with sepsis-induced cardiogenic shock.A 37-year-old man without any medical history visited the former out-patient clinic complaining of high fever, swelling of the neck on the right side, and appetite loss. He had no symptoms of cough and sore throat, as well as pharyngeal exudate and sputum. He was diagnosed with cervical lymphadenitis, and oral antibiotics and non-steroidal anti-inflammatory drugs were prescribed. However, his symptoms worsened, and he was readmitted to the same hospital three days following the clinic visit. Despite intravenous antibiotics and corticosteroid administration, his systolic blood pressure decreased to 60 mmHg, which was refractory to the administration of massive fluid and norepinephrine. The next morning, laboratory data showed an elevation of serum creatinine (3.7 mg/dL) and total bilirubin (5.4 mg/dL). A transthoracic echocardiogram showed a reduced left ventricular ejection fraction of 20% with diffuse severe hypokinesis. Intravenous dobutamine infusion was initiated. He was transferred to our hospital for further treatment.3), C-reactive protein (22.64 mg/dL), and procalcitonin (6.72 U/mL) (>0.05) were markedly elevated. The levels of plasma B-type natriuretic peptide (494.8 pg/mL) and serum N-terminal-pro-B-type natriuretic peptide  were also elevated. The lactate was 2.5 mmol/L. A polymerase chain reaction test for SARS-CoV-2 was negative.On arrival, his blood pressure was 83/63 mmHg with a heart rate of 128 bpm under intravenous dobutamine and norepinephrine infusion. His body temperature was 38.9 degrees, and oxygen saturation was 96%. Cardiac Troponin I was 494.8 pg/mL (>26.2) with normal serum creatine kinase of 102 ng/mL. Serum creatinine (4.26 mg/dL), total bilirubin (4.8 mg/dL), white blood cell  in our patient. Macrophage-predominant monocyte infiltration was observed in his myocardium. Although the definite diagnostic criteria remain unestablished, we defined him as having sepsis-induced cardiogenic shock.A retrospective cohort study for patients with sepsis-induced cardiogenic shock showed a greater improvement in survival for patients treated with veno-arterial ECMO . A case Our patient was young, without prior cardiopulmonary resuscitation, and had advanced biventricular dysfunction with severe hepatorenal dysfunction on admission. ECMO alone would increase the afterload on his left ventricle and delay the recovery of the left ventricular ejection fraction as well as worsen his pulmonary congestion, whereas ECMO unloads the right ventricle and increases systemic perfusion. ECMO, concomitant with Impella support, provided a sufficiently high cardiac output of 7.5 L/min in total, ameliorated end-organ dysfunction, unloaded the right and left ventricle, and facilitated the weaning off of ECMO .Iatrogenic acute mitral regurgitation, as a complication of Impella CP and 5.0, following acute myocardial infarction has been reported ,9. MitraThe Mitral chordal rupture that our patient encountered would have also been triggered by a similar mechanism. We selected a mechanical valve, which has no protrusions under the mitral valve and less possibility to interface with Impella 5.0. Specific caution should be paid to avoid interfacing between the intra-cardiac devices, including the Impella, and the cardiac structure, including the mitral valve, to avoid such a complication.Support with Impella and veno-arterial ECMO might be a viable rescue strategy in sepsis-induced cardiogenic shock, as long as we pay caution to the complication of mitral chordal rupture.


Background/Objective: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a cardiac natriuretic hormone that cardiomyocytes release in response to ventricular stretch. It helps with the diagnosis of heart failure in adults, but this application in preterm infants has rarely been reported. This study aimed to evaluate whether NT-proBNP could be used for the early detection of reduced cardiac ejection fraction in preterm infants and the optimal timing for NT-proBNP assessment. Design/Methods: This prospective, single-center, observational study enrolled all preterm infants with NT-proBNP measurements from October 2014 to February 2022. They underwent echocardiographic examinations within 48 h of the NT-proBNP measurements. Reduced left ventricular ejection fraction was defined as below 60%. Receiver operator characteristic (ROC) curves were generated to assess the optimal NT-proBNP cutoff point for the early prediction of reduced cardiac ejection fraction. Results: A total of 68 preterm infants were enrolled, with a total of 134 NT-proBNP measurements being available for analysis. Reduced left ventricular ejection fraction was present in seven infants (10.3%) due to various underlying diseases. The NT-proBNP cutoff level for detecting reduced left ventricular ejection fraction was 9248 pg/mL, with 71.4% sensitivity and 60.8% specificity; the area under the curve was 0.623 (95% CI: 0.487~0.760). The threshold for the optimal postnatal age for applying NT-proBNP to detect reduced left ventricular ejection fraction was >2 days of life , with 70% sensitivity and 67.1% specificity. Conclusions: Although the NT-proBNP levels declined dramatically after birth, a NT-proBNP serum level of 9248 pg/mL might be helpful for the early detection of reduced ejection fraction in preterm infants, and the optimal age for detection was after 2 days of life. NT pro-B-type natriuretic peptide (NT-proBNP) is a natriuretic peptide produced by cardiomyocytes. Its precursor is pro B-type natriuretic peptide (pro BNP), a 108-amino acid (aa) protein. ProBNP is enzymatically cleaved to form NT-proBNP, a 76-aa N-terminal peptide, and B-type natriuretic peptide (BNP), a 32-aa peptide [NT-proBNP has a longer plasma half-life of 1–2 h, compared to BNP’s half-life of 15–20 min; consequently, it has a higher plasma concentration [NT-proBNP can be an independent predictor of heart failure in adults . It has This was a prospective observational study that recruited preterm infants born at less than 37 weeks gestation and admitted to the Neonatal Intensive Care Unit of Cathay General Hospital from October 2014 to February 2022. The inclusion criteria were all preterm infants with available NT-proBNP results who underwent echocardiographic examinations within 48 h after admission for blood sampling including NT-proBNP measurements. The study excluded patients with major congenital malformations or those without available NT-proBNP measurements. Ethical approval for the data collection was granted by the Ethics Committee of the Cathay General Hospital Taipei, Taiwan (No. CGH-P110091/24 December 2022).patent ductus arteriosus, heart failure, pulmonary hypertension, or perinatal asphyxia. Repeated measurements were performed when the clinical condition had changed or at follow-up after the treatment of heart failure. Blood samples were collected using ethylenediaminetetraacetic acid tubes and processed immediately. The NT-proBNP levels were measured using an electroluminescence immunoassay kit with the Elecsys proBNP II test . The test has detection limits of 5–35,000 pg/mL. All the patients in the study underwent Doppler echocardiography performed by an independent cardiologist blinded to the NT-proBNP study, by whom the left ventricular ejection fraction (LVEF) was assessed. The modified Quinones method was used to estimate the left ventricular cavity size from the M-mode study. The LVEF was the stroke volume/end-diastolic volume × 100. A Philips Ultrasound System iE33 × MATRIX with a neonatal probe was used for each study. A reduced ejection function was defined as an LVEF < 60% [patent ductus arteriosus (hsPDA) was diagnosed as left-to-right shunting across the PDA associated with a left atrial-to-aortic root ratio > 1.4, and/or left pulmonary artery end-diastolic flow velocity > 0.2 m/s, and/or retrograde diastolic blood flow in the descending aorta [NT-proBNP measurements were obtained for premature infants with clinical suspicion of altered cardiac function, such as congenital heart disease, ng aorta .Statistical analysis. Qualitative data were presented as frequencies and percentages and were compared using Fisher’s exact tests or chi-square tests. Quantitative variables were presented as means and standard deviations or medians and ranges according to their distributions. Mann–Whitney U Wilcoxon tests or Student’s t-tests were applied after normality tests were processed in the bivariate analysis of the quantitative variables. Correlation analyses were performed to determine the relationship between NT-proBNP levels and the patient’s age.p value of less than 0.05 was considered statistically significant.To determine an appropriate cut-off value of plasma NT-proBNP for diagnosing reduced ejection fraction in preterm infants, the area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were analyzed. An age threshold for using NT-proBNP for early detection was also explored. Statistical analyses were performed with SPSS version 17.0 . A The study enrolled 68 preterm infants with 134 NT-proBNP measurements. The mean gestational age was 30.8 ± 3.3 weeks (range: 23–36 weeks). The mean number of times that blood samples were taken per patient was 1.97 times . The timepoint for collecting the samples ranged from 0 to 146 postnatal days (median: 7 days). There was no difference in gestational age between infants with and without reduced ejection function, and there was also no difference in birth body weight between these two groups .Among the 68 enrolled preterm infants, thirty-six (52.9%) had a patent ductus arteriosus (PDA), thirteen patients (19.1%) had congenital heart disease, five patients (7.4%) had severe respiratory disease, four patients (5.9%) had proven sepsis, and the others were included due to necrotizing enterocolitis, hypovolemic shock, neuromuscular disease, infection events, or perinatal asphyxia, etc. There were seven patients (11.1%) with reduced ejection fraction, the causes of which were cardiomyopathy, Pompe disease, ventricular septal defect, perinatal asphyxia, infective endocarditis, the recipient of twin-to-twin transfusion syndrome, and sepsis. The median LVEF of all the patients was 71.00% (44~89%) .p= 0.003, Mann–Whitney U test). Among the patients who received PDA treatment, five had serial NT-proBNP measurements before and after receiving treatment .Among the thirteen patients with congenital heart disease, eight had ventricular septal defects, two had hypertrophic cardiomyopathy, one had coarctation of the aorta, one had an atrial septal defect, and one had dilated cardiomyopathy. Among them, four patients had reduced left ventricular ejection fraction including congenital hypertrophic cardiomyopathy (two patients), dilated cardiomyopathy (one patient), and a ventricular septal defect (one patient). The median NT-proBNP level was higher in the patients with congenital heart disease than in the patients without congenital heart disease, but this was not statistically significant ; however, there was no negative correlation in the patients with reduced left ventricular ejection function  (The NT-proBNP levels had a negative correlation with the age of the patients without reduced left ventricular ejection function (rum test) .The optimal NT-proBNP cutoff value for detecting reduced ejection fraction was 9248 pg/mL : 0.623; 95% CI: 0.487~0.760; positive likelihood ratio: 1.82; negative likelihood ratio: 0.47). Because the NT-proBNP level was negatively correlated with postnatal age among the patients without reduced left ventricular ejection fraction, a different ROC curve was used for different postnatal days. A NT-proBNP level > 9421 pg/mL after 2 days of age had the most discriminatory power for detecting reduced left ventricular ejection fraction  . A previous study had noted that the levels of NT-proBNP were the highest in the first days of life in full-term infants and showed a marked decline during the first week of life. They noted that the reference values of NT-proBNP in infants and children varied across wide ranges, 260–13,224 pg/mL and 28–7250 pg/mL, during days 0–2 and 3–11 of life, respectively, and found that the level dropped dramatically after 3 days of life . In thisThe pulmonary pressure is usually higher among preterm infants than term infants, which might be due to the delayed occurrence of the diuretic phase. Some studies had noted that the NT-proBNP levels were higher in preterm infants than in full-term infants . In our In our study, the LVEF, measured via echocardiography, was used to define reduced ejection fraction, so the method of determining the LVEF could have influenced the diagnosis of reduced ejection fraction. The modified Quinones method was used, which is less precise for tracing the left ventricular cavity than the modified Simpson method . HoweverSome studies had used measures of the infant’s clinical condition, such as the modified Ross score or the NYHA classification, to define heart failure . Lin et One of the primary causes of heart failure in premature infants is congenital heart disease. In this study, patients with congenital heart disease had significantly higher NT-proBNP levels than patients without congenital heart disease. This was also noted in a previous study using BNP levels to diagnose congenital heart disease in the first month of life, where the test’s diagnostic accuracy was the lowest in the first 3 days of life . One proNT-proBNP levels can also be influenced by several extracardiac conditions such as pulmonary disease, endocrine or metabolic disorders, liver cirrhosis with ascites, renal failure, inflammatory diseases, cardiotoxic drugs, anemia, obesity, severe infection, and cardiac trauma . TherefoIn conclusion, our study demonstrated that an NT-proBNP serum level of 9248 pg/mL might be helpful for the early detection of reduced left ventricular ejection fraction in preterm infants, but the discrimination power was only fair. From our observation, it was difficult to use NT-proBNP to predict heart failure in preterm infants because it could remain high during the first two days of life. In addition, multiple other factors could also influence the NT-proBNP levels in preterm infants including cardiovascular conditions, fetal distress, pulmonary hypertension, respiratory status, PDA, and renal function. Furthermore, our total number of cases is limited and as there are small numbers of reduced left ventricular ejection fraction in our study, more large-scale studies in the future are needed to make the cut-off values much more precise.


Chinese residents generally had insufficient intake of dairy products. The correct mastery of dairy related knowledge helps to develop a good habit of dairy intake. Dairy intake and purchasing behavior were related to multiple factors. As an attempt to lay a scientific basis for guiding the rational intake of dairy by Chinese residents, we launched a survey to discover Chinese residents’ knowledge about dairy product, intake and purchasing behavior of dairy and its influencing factors.An online survey was conducted from May to June 2021, and 2500 Chinese residents aged 16–65 were selected using the convenient sampling method. A self-designed questionnaire was adopted. Analysis of the demographic and sociological factors influencing Chinese residents' knowledge about dairy products, behavior towards dairy intake and purchasing were measured.P < 0.05). On average, Chinese residents consumed 255.61 ± 88.40 ml dairy product per day. The elderly residents, residents with low education level, residents who lived with family members without milk-drinking habits and residents with poor knowledge of dairy product had worse dairy intake behavior (P < 0.05). When purchasing dairy products, young and middle-aged people  were most concerned about whether probiotics were added to dairy products. The elderly (47.25%) were most concerned about whether dairy products were low sugar / sugar free. Chinese residents (52.24%) tended to purchase small-packaged dairy products that could be consumed easily anytime and anywhere.The average score of knowledge about dairy product of Chinese residents was 4.13 ± 1.50 points. 99.7% of the respondents considered that drinking milk was beneficial, whereas only 12.8% gained a correct insight into the specific benefits of drinking milk. 4.6% of the respondents correctly knew what nutrients they could get from milk. 4.0% of the respondents could correctly identify the type of dairy product. 50.5% of the respondents knew that adult should drink at least 300 ml milk per day. Female, young and high-income residents had better dairy knowledge, while residents with lactose intolerance and whose family members do not have a milk-drinking habit had worse dairy knowledge (Chinese residents had a lack of knowledge regarding dairy products, and their dairy intake was insufficient. We should further strengthen the popularization of dairy product related knowledge, guide residents to choose dairy products correctly, and increase the intake of dairy products by Chinese residents.The online version contains supplementary material available at 10.1186/s12889-023-15254-1. Dairy is a type of food with high nutritional value. The common dairy products on the market consist of milk, yogurt, cheese, milk powder, etc. As a good source of high-quality protein, dairy provides the whole set of exogenous amino acids required by the synthesis of body protein. Dairy also contains fat, lactose, and multiple vitamins and minerals . BesidesAs revealed by existing studies, the dairy intake of residents aged 18–44 in nine provinces in China in 2006 was 11.45 ml per day . In 2011It has been demonstrated that the correct grasp of nutrition knowledge is conductive to the development of healthy dietary behavior . The purThe cross-sectional survey was conducted from February to March 2021. 2,500 Chinese residents aged 16–65 were selected as participants by the convenient sampling method. The samples were sourced from 20 cities in China . The respondents filled in an online questionnaire via a link established on Dataway Horizon's platform. A total of 2500 questionnaires were collected, and 21 invalid questionnaires (data missing) were excluded, with the effective recovery rate of 99.16%.A self-designed questionnaire was used. The questionnaire included the following information: (1) Demographic information: gender, age, education level, region, annual income; (2) Whether the respondent was lactose intolerant; (3) Milk drinking habits of family members; (4) 10 choice questions of dairy knowledge, with question 9,11,13,14,16,17 as single choice questions, question 8,10,12,15 as multiple choice questions. For each single choice question, 1 point for correct choice. For each multiple-choice question, if all the correct answers are selected, 1 point will be counted. The total score is 0–10. Respondents with scores higher than 60% of all respondents were defined as having good mastery of dairy [This protocol was approved by the Ethics Committee of Wusong Central Hospital, Baoshan District, Shanghai (2021-Y-09) and all the participants gave informed consent to participate in the study before taking part.P < 0.05 was considered statistically significant.SPSS 20.0 was used for data processing and analysis. Percentage and median were used to describe the basic characteristics of demography and the correct answer rate. Measurement data were expressed as mean(X) ± standard deviation(S). T test was used for comparison of measurement data between two groups, and F test was used for comparison between multiple groups. Multiple response analysis was used to describe the multiple-choice response distribution. Chi-square test was used as a univariate analysis to compare the differences in knowledge mastery of dairy products among different groups. Multivariate logistic regression analysis was conducted to analyze the influencing factors of dairy knowledge mastery. All statistical analysis was conducted by two-sided test, and A total of 2,479 people were analyzed. There were 1,203 women and 1,276 men. The respondents ranged from 16 to 65 years in age, with a mean age of 37.30 ± 11.97 years . 99.7% of the respondents considered that drinking milk was beneficial, 84.8% considered that people should drink milk every day. 43.9% correctly knew who should drink milk every day, and only 12.8% knew the specific benefits of drinking milk. 4.6% of the respondents correctly knew what nutrients they could get from milk. 50.5% of the respondents knew that adult should intake at least 300 ml of dairy products per day. 3.1% of the respondents knew that adults should intake at least 800 mg of calcium a day. (Table SP < 0.05)  Table .Table 2SMulti-factor logistic regression analysis showed that women, young residents and residents with high income had a good mastery of dairy knowledge, while residents with lactose intolerance and who lived with family members without milk-drinking habits had a poor mastery of dairy knowledge Table .Table 3MP < 0.05) and persisted in consuming dairy products for longer years (P < 0.05). Some people were old, or poorly educated, or did not always check dairy products’ ingredient labels, or their family members didn’t habitually drink milk, or had little knowledge about dairy products. They showed worse performance in the number of days they consume dairy products each week, number of years they keep consuming dairy products, and the daily intake amount of dairy products (P < 0.05). , “low fat/defat” (50.02%), and “low sugar/no sugar”(47.27%). The information that Chinese residents wanted the most to know about dairy products was “nutrition composition and function of dairy products”(69.46%). When asked “Which of the following possible additional consumption pattern of dairy products would you like to try in the near future?”, 52.24% of Chinese residents selected “dairy products in small packages that can be eaten anytime and anywhere” as the top choice. The elderly were less likely to check the labels when purchasing dairy products. The proportion of the elderly who "occasionally" checked the labels (26.37%) and "never" checked the labels (5.49%) were higher than that of young and middle-aged residents. When purchasing dairy products, young and middle-aged people  were most concerned about whether probiotics were added to dairy products. The elderly (47.25%) were most concerned about whether dairy products were low sugar / sugar free.  has found the coexistence of high calcium intake and high incidence of osteoporosis in some countries, which is called calcium paradox . ResidenVitamin D is closely related to the absorption and metabolism of calcium and phosphorus in intestine . Long-teSodium is one of the body's essential electrolytes. Dairy products contain sodium, and cheese is high in sodium. It is acknowledged that high sodium diet results in increased risk of cardiovascular disease . A studyDairy products also contain magnesium. Magnesium is an essential element involved in the normal life activities and metabolism of the human body. Studies have shown that appropriate supplementation of magnesium can improve vascular endothelial function  and reduThis survey showed that the vast majority of respondents (99.7%) considered that drinking milk was beneficial, and 84.8% considered that they should drink milk every day, revealing that Chinese residents had realized the importance of drinking milk and had a good sense of drinking milk. Unfortunately, only 43.9% of the respondents correctly identified who should drink milk every day, and 12.8% correctly identified the specific benefits of drinking milk. Milk can provide a variety of nutrients for human body. Fermented dairy products play an important role in protecting oral cavity . Only byWe found that compared with the elderly, young group had a better mastery of dairy knowledge. This survey was an online survey, and the respondents were mainly young and middle-aged people who often used the internet. Since young people have more access to more information channels and receive more information regarding dairy, they master more dairy-related knowledge. This may probably be the reason for the knowledge differences between different age groups.It was reported that women had better knowledge about nutrition than men . In our In our survey, high-income groups had a better grasp of dairy knowledge. Income was often positively correlated with education level , 34. TheWe found that lactose intolerant group had a poor mastery of dairy knowledge. When people with lactose intolerant drink milk containing a certain amount of lactose, they will undergo abdominal discomfort, and these discomfort symptoms often lead them to avoid eating dairy products. However, this group of people can choose yogurt or low-lactose dairy products such as low-lactose milk, yogurt and cheese to increase nutrition intake. Furthermore, they can also check ingredient statement on the label for lactose levels, avoid drinking milk on an empty stomach, drinking milk in small amounts and multiple times or drinking milk with other grain foods . For peoOur survey indicated that residents whose family members had no habit of drinking milk had a worse mastery of dairy knowledge. The study of Drywień M et al. showed that nutrition intake behavior was affected by family environment . A correThis study showed that the average daily intake of dairy product of the respondents was 255.61 ± 88.40 ml, and there’s still a gap between it and the recommended daily consumption of at least 300 ml of milk in the Chinese Dietary Guideline. However, compared with the per capita dairy purchase quantity of 93.33 ml/d in 2019 , it had Our research suggested that the elderly residents had poor dairy intake behavior. For the elderly, dairy intake can increase the intake of protein and calcium and prevent them from sarcopenia and osteoporosis, which is of high significance to their health . ImproviAccording to our survey, the information about dairy products the respondents wanted to know most was “nutrition composition and function of dairy products” (69.5%). Through effective popularization of science and health education, people are bound to improve their knowledge about dairy products.54.3% of the respondents were most concerned about whether probiotics were added in dairy products, which contributes to human gastrointestinal health. In 2017, the World Gastroenterology Organisation (WGO) pointed out that probiotics could effectively prevent and treat gastrointestinal diseases . In 2018Whether the dairy products were low fat/defat 48.4%) was also of concern to respondents. Saturated fatty acids were the main type of fatty acids found in dairy fats . Studies.4% was aThe top concern among the elderly was whether dairy products were "low sugar/no sugar". Dairy products contains lactose. Lactose in natural dairy products is not high, such as pure cow milk contains about 4.5–5% of lactose. However, in the manufacturing process of some dairy products, sugar is added in order to elevate the palatability. Excessive intake of sugar can be a risk factor for obesity and metabolic syndrome . In receWhen answering “Which of the following possible additional consumption pattern of dairy products would you like to try in the near future?”, the answer “small packages of dairy products that can be eaten anytime and anywhere” was the most selected (52.2%) by respondents. With the accelerated life rhythm, instant food has gradually become a fast nutritional source favored by people, which indicating that increasing the convenience of the consumption of dairy products should be one of the factors to be considered in the development of dairy products. In recent years, the single life has gradually become popular, and small packaged food is welcomed by single consumer groups benefitting from the light size, convenient storage and the availability to determine the amount based on individual needs to avoid waste. Developing small packaged dairy products for this consumer group will be a good choice.There are some limitations in this study. For instance, due to the limited sampling method, the online survey could merely represent a limited group. The questionnaire would be dependent on retrospective self-report of dietary behavior, which may cause deviations from the actual situation. To effectively improve the dairy-eating behavior of Chinese residents, more research should be carried out in depth to provide strong evidence.To sum up, Chinese residents still lack knowledge about dairy nutrition and have insufficient dairy intake. Strengthening the popularization of dairy knowledge and guiding residents to choose dairy products correctly are the entry points to improve the dairy consumption behavior of Chinese residents.Additional file 1:Table S1. Dairy knowledge of the respondents.Additional file 2:Table S2. Analysis of dairy intake behavior of Respondents.Additional file 3:Table S3. Diary purchasing behavior of Chinese residents.Additional file 4. Questionnaire on public milk drinking.


In patients with AHF, NT-proBNP correlated with cQTi (p = 0.027), pathological Q wave (p = 0.029), complex premature ventricular contractions (PVCs) (p = 0.034) and ventricular tachycardia (p = 0.048). Hs-cTnI and CK-MB were correlated with ST-segment modification  and hs-cTnI alone with complex PVCs (p = 0.031). Conclusions: The statistical relationships found between cardiac biomarkers and ECG patterns support the added value of ECG in the diagnosis of AHF. We emphasize the importance of proper ECG analysis of more subtle parameters that can easily be missed. As a non-invasive technique, ECG can be used in the outpatient setting as a warning signal, announcing the acute decompensation of HF. In addition, the information provided by the ECG complements the biomarker results, supporting the diagnosis of AHF in cases of dyspnea of uncertain etiology. Further studies are needed to confirm long-term prognosis in a multi-marker approach.Background: Biomarkers, electrocardiogram (ECG) and Holter ECG are basic, accessible and feasible cardiac investigations. The combination of their results may lead to a more complex predictive model that may improve the clinical approach in acute heart failure (AHF). The main objective was to investigate which ECG parameters are correlated with the usual cardiac biomarkers  in patients with acute heart failure, in a population from Romania. The relationship between certain ECG parameters and cardiac biomarkers may support future research on their combined prognostic value. Methods: In this prospective case-control study were included 49 patients with acute heart failure and 31 participants in the control group. For all patients we measured levels of prohormone N-terminal proBNP (NT-proBNP), high-sensitive cardiac troponin I (hs-cTnI) and MB isoenzyme of creatine phosphokinase (CK-MB) and evaluated the 12-lead ECG and 24 h Holter monitoring. Complete clinical and paraclinical evaluation was performed. Results: NT-proBNP level was significantly higher in patients with AHF ( Heart failure (HF) continues to be one of the leading causes of morbidity and mortality worldwide, as it represents the end stage of most heart diseases. Cases of acute decompensated HF (AHF) are particularly important, since they require a considerable amount of resources for hospitalization and treatment. Since the symptoms are not specific and can interfere with other diseases, diagnosis is often uncertain, delaying appropriate therapeutic intervention . The staHF is defined as a complex clinical syndrome caused by decreased cardiac output (CO), lack of efficient venous return and inadequate fulfillment of metabolic and tissue demands. HF develops as a secondary cardiac complication of several cardiovascular conditions. Different etiologies alter cardiac function through several mechanisms: pressure overload , volume overload , decreased contractile efficiency  and decreased cardiac filling . All of these conditions can lead to left ventricular systolic or diastolic dysfunction. The type of left ventricular dysfunction is determined by the ejection fraction (EF), which quantifies the amount of blood pumped by the ventricle in one heartbeat. Systolic dysfunction is defined by an EF < 40%, while an EF > 40% is characteristic of diastolic dysfunction ,4. The cDecreased CO and insufficient tissue perfusion in HF, trigger several compensatory mechanisms. In the early stages of HF, the Frank–Starling mechanism acts by improving CO through the increasing of LV end-diastolic volume. On the other hand, decreased CO is associated with low blood pressure, which in turn activates the sympathetic nervous system (SNS) and renin–angiotensin–aldosterone system (RAAS). Stimulation of the SNS and release of catecholamines (norepinephrine and epinephrine) have direct effects on the heart (increased heart rate and contractility) and peripheral vasculature (vasoconstriction). Excess catecholamines may play a role in arrhythmias and heart rate variability. RAAS is activated by decreased renal perfusion, leading to sodium–water retention and vasoconstriction. Natriuretic peptides (NPs) are released in response to atrial and ventricular overload and have a role in sodium and water homeostasis, intervening in the regulation of vascular hemodynamics ,4.The response of the myocardium to the chronic increase in parietal stress is remodeling, an adaptive process, through which mechanical, neurohumoral and possibly genetic factors affect the size, shape and function of the left ventricle. These dynamic phenomena, starting with myocyte hypertrophy, followed by fibrosis and deposition of extracellular matrix, ending with myocyte apoptosis and necrosis, lead to changes in the geometry of the cavity, with the aim of maintaining the stroke volume, subsequently perpetuating a vicious circle, the process becoming maladaptive ,4. GiuliThe resting electrocardiogram (ECG) is part of the initial evaluation of patients with heart failure according to the guidelines . Its sigSpecific ECG parameters were identified as markers of acute decompensation or prognosis in previous studies. QT prolongation proved to be an independent predictor of total mortality in patients with HF, reduced EF and myocardial infarction ,10,11. QThe inherent complexity of ECGs and the subtle differences in the ECG waveform have led to abundant research in recent years into new advanced ECG technologies and digital ECG markers. The role of ECG in the diagnosis of various pathologies is strengthened by the results of new automatic analytical systems. Iñigo Monedero showed in its paper that, with the aid of an automatic system, the standard 12-lead ECG may provide the diagnosis for 13 different diseases . Long shA wide variety of portable ECG devices are becoming available to the general population, bringing the ECG to the center of patient care. A review of their use in the clinical setting concluded that the information provided by these ECG devices often resulted in reduced time to diagnosis and lower rates of ED visits .NPs are a family of neurohormones with similar primary amino acid structure but different physiological effects. Currently, three NPs have been identified: atrial natriuretic peptide, also known as ANP; brain natriuretic peptide, also known as BNP (B-type natriuretic peptide); and C-type natriuretic peptide, also known as CNP . ANP is BNP and NT-proBNP are the current established biomarkers for confirming the diagnosis of AHF, assessing the prognosis and monitoring disease progression . The diaTroponins (cTn) are cardiac proteins, found in the cytoplasm of cardiac myocytes, involved in the cardiac muscle contraction by facilitating the interaction between actin and myosin filaments. Cardiac troponins are divided in 3 subunits: cTnC, cTnI and cTnT. cTnI and cTnT have greater sensitivity and specificity for cardiac muscle compared to cTnC, which established them as biomarkers of cardiac muscle injury. However, since small amounts of cTnT have been found in skeletal muscle, cTnI is considered to be the most specific subunit for cardiac muscle ,39. As aElevated troponin levels were also observed in the absence of acute myocardial infarction, suggesting the involvement of multiple mechanisms, including necrosis, apoptosis, necroptosis, cellular injury and decreased clearance . RecentlThe MB isoenzyme of creatine phosphokinase (CK-MB) is an enzyme present in the cardiac muscle, and it participates in the conversion of ATP to ADP. As an indicator of cardiac muscle damage, with a rapid increase in circulating levels, CK-MB is mainly used in the diagnosis of myocardial infarction . In patiThe role of ECG in the diagnosis and prognosis in acute heart failure is well established by previous data. Cardiac biomarkers are essential for establishing the diagnosis, bringing valuable information about the short and long-term prognosis. The relationship between cardiac biomarkers and specific ECG parameters in patients with acute HF has not been previously investigated. Furthermore, it is well known that differences in ethnic and cultural origins among enrolled populations can significantly influence the risk evaluation in patients with heart failure . TherefoWe conducted a prospective case-control study on consecutive adult patients with acute onset dyspnea due to acute heart failure, admitted to our emergency hospital  from February 2022 to September 2022. The patients were followed up on during hospitalization in the Cardiology Department. For the control group, we included ambulatory patients, without HF or with stable compensated HF. The exclusion criteria were: all patients aged < 18 years, presence of pregnancy, value of NT-proBNP < 300 pg/mL, patients with end-stage malignancies.® methodology, and the manufacturer reference interval is <15–128 pg/mL for the NT-proBNP and 0–29 ng/L for hs-cTnI, with the 99th percentile of URL of 29.7 ng/L for males and 20.3 ng/L for females.A fasting venous blood sample was collected from all patients within 72 h after hospitalization, in order to determine the levels of cardiac biomarkers: NT-proBNP, hs-cTnI and CK-MB. Among natriuretic peptides, we measured plasma NT-proBNP levels, as it proved to have higher blood concentrations compared to BNP and ANP in heart failure . Among cThe laboratory parameters were completed with standard blood tests: D-dimers, blood count, renal function, liver function, C reactive protein, spot urinary sodium concentration (UNa), urine albumin to creatinine ratio (ACR), microalbuminuria, spot urinary creatinine concentration, uric acid, total protein, thyroid function, serum iron, ferritin, serum lactate.A standard 12-lead ECG, two-dimensional echocardiography and 24-h Holter ECG monitorization were performed in all included subjects. The parameters analyzed on the 12-lead ECG were: PR/corrected QT (QTc)/QRS intervals, rhythm type , heart rate, the presence of Q wave/U wave/negative T wave/changes of the ST segment/fragmented QRS (fQRS)/poor r-wave progression (PRWP)/low QRS voltage (LQRSV)/extrasystoles/intraventricular or atrioventricular conduction disturbance/left ventricular hypertrophy.We recorded 24 h Holter ECG for 62 patients (77.5%) using a Cardiospy Holter machine. The parameters analyzed on the Holter ECG tracings were: standard deviation of the NN (R-R) intervals (SDNN), standard deviation of the average normal-to-normal (NN) intervals (SDANN), root mean square of the successive differences (RMSSD), HRVTi (heart rate variability triangular index), the presence of extrasystoles, atrial fibrillation, atrial flutter, ventricular tachycardia. The ECG readings were manually inspected, and all of the intervals containing artifacts and ectopic beats were excluded, replaced by the preceding normal RR intervals. Patients with no sinus rhythm were excluded from the analysis of HRV.Echocardiography was performed for all patients, using a GE Vivid S70 echocardiography device.Acute heart failure was considered for patients that met the Framingham criteria. The major criteria are: acute pulmonary edema on X-ray, cardiomegaly (cardiothoracic index > 0.5 on X-ray), paroxysmal nocturnal dyspnea, orthopnea, jugular vein distension, hepatojugular reflux, pulmonary rales, the presence of the third heart sound , weight loss > 4.5 kg in 5 days in response to treatment. The minor criteria are: ankle edema, dyspnea on exertion, hepatomegaly, nocturnal cough, pleural effusion, tachycardia (heart rate > 120/min). For the diagnosis, at least 2 major criteria or 1 major criterion plus 2 minor criteria are required.left ventricular hypertrophy (LVH) was considered in patients that met the Estes criteria and Morris index (point score ≥ 5);correction of the QT interval (QTc) was done using the Fridericia formula;a fragmented QRS complex (fQRS) was defined by: the presence of notched R or S or the existence of an additional wave-like RSR’ pattern in the original QRS complex, a duration of <120 ms, not accompanied by a typical bundle branch block;poor R-wave progression (PRWP) was considered after exclusion of LVH features: RV3 or RV4 < 2 mm plus a decrease in RV2 to RV3 or RV3 to RV4, RV3 < 1 mm plus < 0.25 mm increase from RV2 to RV3;low QRS voltage (LQRSV) was defined as a peak-to-peak QRS amplitude of <5 mm in the limb leads and/or <10 mm in the precordial leads;left bundle branch block (LBBB) was defined by: QRS duration > 120 ms, dominant S wave in V1, broad monophasic R wave in lateral leads , absence of Q wave in lateral leads, prolonged R wave peak time > 60 ms in V5–V6;pathological Q wave was considered if: >40 ms wide (>1 mm), >2 mm deep, >25% of depth of QRS complex, seen in leads V1–V3;complex premature ventricular contractions (PVC) were considered in the presence of: doublets, triplets or non-sustained ventricular tachycardia (NSVT).For cardiac biomarkers the normal range was defined according to the following cut-off values: NT-proBNP < 300 pg/mL, high-sensitive cardiac troponin < 14 ng/L, CK-MB ≤ 16 U/L, D-dimers < 500 µg/L.The ECG parameters were defined as follows:p value < 0.05 with a Shapiro–Wilk test. Normally distributed variables were expressed as means ± standard deviation (STD), while non-normally distributed data were presented as medians with interquartile ranges (IQRs: 25–75%). For biomarker values that were not normally distributed, we performed log-transformation.For statistical analysis, we used IBM SPSS statistical software, version 19.0 . The categorical variables were expressed as frequencies (numbers) and percentages (%). For the quantitative variables we performed the Shapiro–Wilk test for the assessment of the variables’ normal distribution within the study population. The deviations from normality was considered for p-value was <0.05.For the comparison of parametric values between the two groups we used means of two independent sample Student’s t or Mann–Whitney U tests. The comparison of categorical variables was performed using the chi-square or Fisher’s exact test. Assessment of the correlations between different parameters was performed using Pearson’s (for continuous variables) or Spearman’s  coefficients (r). Statistical significance was considered when a two-sided The study included a total of 80 participants. The subjects were divided into two groups: 49 patients with acute decompensated heart failure (AHF) and 31 participants in the control group, representing patients without heart failure or with chronic heart failure. A total of 51 participants were males (63.8%), while 29 were females (36.6%), and the mean age was 65.18 ± 12.98 years (variations between 35 and 88 years). The area of residence was equally represented at 50% for both urban and rural areas .We assessed common cardiovascular risk factors in comparison for the two groups, concluding that they had a similar cardiovascular risk profile, as no statistical difference was observed in acute HF patients versus control group .p = 0.046), atrial fibrillation  and chronic obstructive pulmonary disease (COPD) .Comorbidities are frequently associated with heart failure, contributing to the prognosis of the disease. In the group of acute HF patients, we identified a higher prevalence of chronic kidney disease (CKD) .The mortality rate was 6.5%, all the fatality cases being recorded in patients with acute HF. The absence of statistical significance for mortality was due to the small number of cases. Regarding self-care capacity, there was a significant number of impaired patients in the AHF group compared to the control group , amiodarone , nitroglycerine  and CPAP (continuous positive airway pressure) non-invasive ventilation  in the AHF group.As there are specific treatment indications for acute heart failure, we looked at the differences in therapy in the two groups, detailed in Meanwhile, beta-blockers, mineralocorticoid receptor antagonists (MRA), inhibitors of the renin–angiotensin–aldosterone system, calcium-channel blockers and sodium-glucose cotransporter-2 (SGLT2) inhibitors were equally prescribed in AHF group and control group, given the fact that they are also indicated in chronic heart failure.We expected to find a significant difference for dobutamine, vasopressor drugs and invasive ventilation given the greater severity of AHF, but, due to the small number of cases, the hypothesis was not confirmed.Routine laboratory tests were included in the analysis, with significant higher values detected in acute HF for: leukocytes, electrolytes , renal function , urinary albumin-to-creatinine ratio (ACR), microalbuminuria (MAU), spot urine creatinine), uric acid, serum iron, markers of cholestasis , lactate dehydrogenase (LDH) and total protein. The detailed values are presented in The detailed characteristics of patients with acute HF are presented in p = 0.01); the left ventricle was more dilated , and the systolic pulmonary artery pressure was higher . Besides, as atrial fibrillation is more frequently present in cases with AHF, we expected left atrial dilation to be associated with this group, a theory confirmed by our study .Comparing the echocardiographic profiles between the groups, we observed that the severity of parameter changes was significantly associated with acute HF . Ejectiop value < 0.05). The descriptive analysis of log-transformed biomarkers values showed asymmetry of the distribution and significant deviations from normality  (p < 0.001).The descriptive statistics for cardiac biomarkers values (NT-proBNP and hs-TnI) are presented in  < 0.05) . As the p = 0.050) than control group.The detailed ECG and Holter monitoring data are presented in groups determined by the presence or absence of acute HF in p = 0.021), who had a very high percentage (81.6%) of ECG changes. Looking at specific ECG abnormalities, patients with acute HF more frequently had a non-sinus rhythm (p = 0.026), prominent U wave (p = 0.043), poor R wave progression (PRWP) (p = 0.012) and atrial fibrillation (p = 0.029). No difference was noted between the groups for pathological Q wave, negative T wave, LQRSV, fQRS, ST-segment modification and complex premature ventricular contractions (PVCs).In Holter ECG monitoring allows analysis of the heart-rate variability through parameters such as SDNN, SDANN, RMDDS and HRVTi, which can be seen in p = 0.039, r = 0.296) and cQTi , as shown in In patients with acute HF, we investigated the correlations between different cardiac biomarkers and ECG or Holter parameters. Detailed results are presented in p = 0.029, F = 5.057), complex PVCs , ventricular tachycardia  and NT-proBNP .Regarding the association of biomarkers with different pathological patterns on ECG and Holter, we found statistical significance for pathological Q wave  showed that NT-proBNP and comorbidities  are the main determinants of the quality of life in patients with AHF . AccordiLaboratory test results were also comparable to previous studies, as serum iron deficiency, elevated serum creatinine and low urinary sodium levels were more common in patients with AHF. In addition, our analysis showed elevated values for functional liver tests  in AHF group compared to controls. Secondary to congestive hepatopathy (CH) or acute cardiogenic liver injury (ACLI), laboratory signs of liver damage have been previously described and have been associated with a higher risk of cardiovascular events and mortality ,50,51.Apart from urea and creatinine, we looked for additional, more sensitive markers of kidney damage. Among them, urinary ACR, microalbuminuria (MAU) and spot urine creatinine were found to have abnormal values in patients with AHF, with statistical significance compared to control group. As other studies show, albuminuria is more common in adults with chronic HF (CHF) than in those without CHF; it has clinical value in improving the accuracy of diagnosis of HFpEF (heart failure with preserved ejection fraction) and is a predictor of mortality in patients with HF ,53,54,55Spot urinary sodium (UNa) provides useful information concerning the volume status, lower concentrations typically reflecting enhanced renal sodium retention in the context of extracellular fluid volume deficit . As MartFor our study, the profile of patients with acute heart failure included most frequently an ischemic etiology, a NYHA class III dyspnea and reduced ejection fraction. Concerning the echocardiographic results, patients in AHF group had a more reduced ejection fraction compared to controls, a more dilated left ventricle and left atrium and pulmonary hypertension.NT-proBNP has become the cornerstone biomarker for diagnosis and prognosis of AHF, being part of the guideline recommendations ,62,63,64hs-cTnI had significantly higher values in the AHF group compared to controls in our study. In acute heart failure, the primary role of troponin measurement is to detect acute coronary syndrome as a precipitant of acute HF ,70. HoweFurthermore, the complexity of mechanisms involved in the development of HF can be better explored by a multi-marker strategy. While elevated NP levels reflect myocardial stretch, elevated circulating troponin level is a marker of myocardial injury, bringing added value in prognostic assessment. Studies have confirmed this relationship, concluding that the combined measurement of high-sensitivity cardiac troponins and natriuretic peptides shows additional prognostic value and superior risk stratification in acute HF ,78,79.ECG is one of the first investigations indicated in patients with acute HF, being able to detect possible causes of decompensation, complications or even structural changes. As other studies have shown, the information provided by the ECG increases the diagnostic sensitivity for acute HF, since most cases of decompensated HF associate some ECG abnormalities ,80. Our Besides its value in establishing the diagnosis, ECG proved to have an important role in prognosis assessment, being able to predict in-hospital and long-term mortality or readmission risk ,82. In pHolter ECG monitoring is not currently considered a basic diagnostic method for AHF but should not be excluded as an important tool in risk stratification. Early activation of neurohormonal system and influence of autonomic nervous system on cardiovascular system can lead to dynamic changes in electrocardiographic parameters, which can only be detected through continuous monitoring . MoreoveArrhythmias and HF have a close and bidirectional relationship. In HF, fibrosis, increased intracardiac pressure and ischemia predispose the vulnerable myocardial tissue to arrhythmias. At the same time, the presence of arrhythmias can precipitate acute decompensation of HF and favor the progressive deterioration of cardiac function, through arrhythmia-induced cardiomyopathy ,87. One In this context, we expected to find an association between AHF and rhythm disturbances. On ECG, and also on Holter monitoring, atrial fibrillation was significantly associated with cases of AHF. However, when we looked for correlations with NT-proBNP, hs-cTnI or CK-MB, we did not find a relationship between biomarker levels and the presence of atrial fibrillation in our study, which means that they fail to predict supraventricular arrhythmias in patients with AHF. The only association we found was with spot urinary sodium, with lower values in the presence of atrial fibrillation on Holter monitoring. The inability to efficiently excrete sodium in patients with AHF is due to sustained activation of the renin–angiotensin–aldosterone system and sympathetic nervous system, which can precipitate paroxysmal arrhythmic events. Our results support the value of spot urinary sodium determination in patients with AHF as a predictor of atrial fibrillation.Regarding ventricular arrhythmias detected by Holter monitoring, we found correlations between NT-proBNP and complex PVCs or ventricular tachycardia in patients with AHF, which shows that NT-proBNP levels may be an indicator of malignant ventricular arrhythmias. Complex PVCs were also correlated with troponin values in patients with AHF, which highlights its prognostic role. Ventricular arrhythmias are associated with an increased risk of sudden cardiac death in HF patients, as Chen et al. demonstrated in an analysis . From thAlthough we did not identified correlations of spot UNa with PVCs or ventricular tachycardia events, the presence of fragmented QRS (fQRS) was significantly associated with spot UNa. fQRS is an ECG abnormality associated with myocardial scarring and fibrosis. Consequently, its presence has been correlated in previous studies with a higher risk of ventricular arrhythmias, sudden cardiac death and all-cause mortality ,92,93,94cQTi prolongation is an ECG parameter used frequently in clinical practice to assess the risk for malignant ventricular arrhythmias. As several studies have shown, the QT interval is associated with torsade de pointes and mortality ,95,96,97A pathological Q wave is typically associated with prior myocardial infarction ,99,100. European Heart Journal, who concluded that PRWP independently predicted all-cause and cardiovascular mortality [Another ECG finding present in AHF group was a poor R-wave progression (PRWP), identified significantly more frequently than in controls. PRWP is associated, as Schröder et al. demonstrated, with adverse prognosis in general population and with sudden cardiac death in patients with coronary artery disease . The proortality . RegardiST-segment modifications were not significantly more frequent in patients with AHF in our study, but they presented correlations with troponin and CK-MB. Since both troponin and CK-MB are biomarkers associated with coronary syndrome, the correlation with ST-segment modifications was expected, as previously confirmed by several studies ,108,109.The present study has some limitations. The main limitation is the bias due to the single-center design and the small number of patients and controls enrolled in the study. In addition, only in-hospital adverse cardiovascular events were analyzed, which limited the possibility of evaluating the long-term prognosis. Data on long-term cardiovascular events and follow-up are planned to be included in a future study. We plan to expand our study to a larger number of cases that would allow the multivariable regression analysis of the data and the design of a multiparameter risk stratification score.The objective of the present study was to assess the relationship between the usual cardiac biomarkers  and patterns of ECG or Holter ECG monitoring in patients with acute heart failure, in an adult population from Romania.Patients with AHF had significantly more frequent abnormal ECG patterns, i.e., non-sinus rhythm, prominent U wave, prolonged cQT interval, PRWP and atrial fibrillation. Holter ECG parameters of heart rate variability were similar for the two groups. NT-proBNP correlated with QTi and cQTi, pathological Q wave, complex PVCs and ventricular tachycardia. hs-cTnI and CK-MB were associated with ST-segment modifications, and hs-cTnI alone with complex PVCs. We identified statistical significance for spot UNa and urinary ACR levels in AHF patients compared to the control group. They were also associated with fQRS, atrial fibrillation, QTi, cQTi and SDNN.The statistical relationships found between cardiac biomarkers and ECG patterns support the added value of ECG in the diagnosis of AHF. We emphasize the importance of the proper ECG analysis of more subtle parameters that can be easily missed. As a non-invasive technique, ECG can be used in the outpatient setting as a warning signal announcing the acute decompensation of HF. In addition, the information provided by the ECG complements the biomarker results, supporting the diagnosis of AHF in cases of dyspnea of uncertain etiology. Further studies are needed to confirm long-term prognosis in a multi-marker approach.


Data regarding cardiovascular magnetic resonance (CMR) reference values in athletes have not been well determined yet. Using CMR normal reference values derived from the general population may be misleading in athletes and may have clinical implications.To determine reference ventricular dimensions and function parameters and ratios by CMR in high performance athletes.Elite athletes and age‐ and gender‐matched sedentary healthy controls were included. Anatomical and functional variables, including biventricular volumes, mass, systolic function, wall thickness, sphericity index and longitudinal function were determined by CMR.2 in the control group and increased from 65 ± 14 g/m2 in the low intensity sport category to 83 ± 16 g/m2 in the high cardiovascular demand sport category; P < 0.001. Regarding right ventricular (RV) mass, the data were 20 ± 5, 31 ± 6, and 38 ± 8 g/m2, respectively; P < 0.001. LV and RV volumes, and wall thickness were higher in athletes than in the control group, and also increased with sport category. However, LV and RV ejection fractions were similar in both groups. LV and RV dimensions, wall thickness and LV/RV ratios reference parameters for athletes are provided.A total of 148 athletes  and 124 controls  were included. Left ventricular (LV) mass excluding papillary muscles was 67 ± 13 g/mLV and RV masses, volumes, and wall thicknesses are higher in athletes than in sedentary subjects. Specific CMR reference ranges for athletes are provided and can be used as reference levels, rather than the standard upper limits used for the general population to exclude cardiomyopathy.The online version contains supplementary material available at 10.1186/s12968-023-00910-7. Long-term physical training leads to a number of structural and functional cardiac adaptations usually known as ‘athlete’s heart’, a physiological process that includes biventricular dilatation and left ventricular (LV) hypertrophy to facilitate increased stroke volume in response to exercise . This prCardiomyopathy is recognized as one of the leading causes of sudden death in athletes . ConsequCardiovascular magnetic resonance (CMR) has excellent accuracy for the measurement of biventricular volumes, mass and function, stress induced perfusion defects, and for analysis of coronary origin. It also has a unique capability of detecting myocardial fibrosis. CMR provides a comprehensive evaluation of the heart and is an appropriate technique for the preparticipation assessment of athletes in whom symptoms or signs suggest heart disease, and of asymptomatic athletes with either abnormal examination, abnormal electrocardiogram (ECG), or definite (or high suspicion for) family history of inheritable heart disease .The use of CMR normal reference values derived from the general population may be misleading in highly trained athletes. Reliable CMR reference values obtained in these athletes are thus mandatory to reduce inconclusive reports caused by the grey area between physiological adaptation and cardiopathy, to prevent athletes being barred from sports because of false positive findings and to prevent reassurance of athletes in whom cardiac pathology goes undetected.The aims of this study were, firstly, to assess differences between high-performance athletes and age and gender-matched controls with respect to variables including LV and right ventricular (RV) morphological and functional parameters, secondly, to detect significant predictors of ventricular dimensions and function in athletes and, finally, to establish reference values for biventricular parameters normalized for independent influences such as age, gender, height, body surface area and type of sport in athletes.This was an observational and prospective study carried out with CMR at 1.5 T in which elite athletes in regular competition with ≥ 10 h training per week, and age‐ and gender‐matched sedentary healthy controls were included. Sport disciplines were classified according to their characteristics . All subData collected included age, gender, sport discipline, years of training, average training hours per week, height, weight, and body surface area that was calculated according to the Mosteller formula . All CMRCMR was performed according to standardized CMR imaging protocols . CMR wasImages were analyzed with a specific software  by two experienced observers (more than 10 yr experience). End-diastole and end-systole were selected from the time-volume curve. LV and RV endocardial and epicardial borders were manually delineated in all planes in end-diastole, while in end-systole only the respective LV and RV endocardial borders were delineated. LV papillary muscles were also delineated in end-diastole in all the planes in which they appeared.2.7 for comparative analysis. LV ejection fraction (LVEF) and RV ejection fraction (RVEF) were calculated as (end-diastolic volume – end-systolic volume)/end-diastolic volume. LV and RV atrioventricular plane displacement were measured in the lateral wall of both the LV and RV and in the septum and expressed as a percentage of the end-diastolic length. End-diastolic and end-systolic LV and RV sphericity indexes were also calculated. Other definitions included: relative wall mass (RWM): mass relative to end-diastolic volume (g/mL); wall thickness dispersion index: the standard deviation of the wall thickness of all 16 segments; atrioventricular plane descent (AVPD): the length  in diastole minus this length in systole divided by the length in diastole * 100; sphericity index: LV basal radial length/longitudinal length, measured in the apical 4-chamber views during end-diastole and end-systole; anterior apical to basal ratio: the wall thickness of the anterior wall in the apical segment divided by the wall thickness in the anterior wall at the basal segment [LV mass (LVM) was calculated from the end-diastolic frames. Papillary muscle mass was also calculated, and LVM values were obtained both including and excluding papillary muscle mass. LV segmental wall thickness was quantified in diastole for all 16 segments . Papilla segment . First pCategorical variables were described by their absolute (n) and relative frequencies (%) and continuous variables by the mean and standard deviation or median and interquartile range according to normality distribution. Univariate normality assumptions were verified with the Shapiro–Wilk test. Differences between athletes and controls with respect to variables regarding baseline characteristics and ventricular dimensions and function were assessed using analysis of variance (ANOVA) or Kruskal–Wallis test for continuous variables, as appropriate, and Chi-square for categorical variables. Two-way ANOVA or Kruskal–Wallis test, as appropriate, were used to analyze differences in LV and RV dimensions and function parameters according to age, gender and intensity of sport. Simple linear regression was used to analyze variations in ventricular dimensions and function according to age, gender and sport, to model the data and to construct reference ranges as mean and 95% confidence intervals. A level of statistical significance of 0.05 was applied in all the statistical tests. The data were analyzed using the statistical package SPSS .A total of 148 athletes  and 124 controls  were included in the study. The reasons for athletes to perform a CMR included post-acute pericarditis to rule out myocardial involvement (n = 11); for minor symptoms, defined as subjective decrease in sport performance, atypical chest pain, palpitations (n = 56); for suspicion of coronary anomaly (n = 2); to rule out intracavitary mass (n = 9); for suspicion of RV anomalies in echocardiogram, such as RV dilation, wall motion abnormalities, or systolic dysfunction (n = 34); and for suspicion of LV anomalies in echocardiogram, such as LV hypertrophy, LV dilatation, LV systolic dysfunction, or hypertrabeculation (n = 36).Athletes and controls were well balanced with regard baseline clinical characteristics. Table 2 in control group and increased from 65 ± 14 g/m2 in the low intensity sport category to 83 ± 16 g/m2 in the high intensity sport category; P < 0.001. Similarly, LV end-diastolic volume was 77 ± 14 mL/m2 in the control group and increased from 79 ± 10 to 106 ± 19 mL/m2 according to sport category, respectively; P < 0.001 and for LV end-systolic volume, these numbers were 27 ± 9 mL/m2, 28 ± 7 mL/m2 and 40 ± 10 mL/m2, respectively; P < 0.001. LVEF was 66 ± 7% in the control group, without significant differences between groups. Regardless segment, wall thickness was significantly greater in athletes than in the control group, even in the low intensity group, and increased with the intensity of sport. Interestingly, apical-to-basal wall thickness ratios did not differ between controls and athletes. LV relative wall mass excluding papillary muscles was 0.83 ± 0.14 g/mL in the control group and decreased from 0.81 ± 0.15 to 0.78 ± 0.18 g/mL, respectively, according to the intensity of sport; P < 0.05.LV morphology parameters, as well as LV wall thickness ratios, LV/RV ratios and RWM for ventricular parameters in controls and athletes according to sport category are reported in Table 2 in the control group and increased from 31 ± 6 g/m2 in the low intensity sport to 38 ± 8 g/m2 in the high sport category; P < 0.001. Similarly, RV end-diastolic volume was 78 ± 15 mL/m2 in the control group and increased from 81 ± 12 to 105 ± 17 mL/m2 according to sport category, respectively; P < 0.001 and for RV end-systolic volume, these numbers were 30 ± 9 mL/m2, 31 ± 9 mL/m2 and 41 ± 11 mL/m2, respectively; P < 0.001. RVEF was 62 ± 7% in the control group, without significant differences between groups. RV wall thickness was higher in athletes than in the control group, regardless intensity of sport; P < 0.001.With regard to RV  are reported in Table 2, RV end-diastolic volume 102 ± 17 mL/m2, RV end-systolic volume 40 ± 10 mL/m2, and RVEF 61 ± 6%. In the multivariate analysis, in general, RV parameters were greater in men than in women, without relevant differences according to sport or age, except for a limited number of variables , large error in the estimates could occur, causing wider confidence intervals. In addition, not all types of training were equally represented, and should be specifically analyzed in further researches. As previously commented, cardiac remodeling is influenced by age. Unfortunately, only in some specific variables reference values could be provided according to age. Therefore, when considering reference values, training regimen, intensity, years of training, gender and age should be considered. On the other hand, late gadolinium enhancement was not performed, but this was not the scope of the study. Finally, as this study was performed in European Caucasian subjects, the current results cannot be necessarily applied to athletes of other races or origin and further CMR studies are needed in these populations.CMR is a relevant tool in the evaluation of athlete’s heart and may be considered for a most comprehensive approach in the management of athletes to assess for pathology. LV and RV masses, volumes, and wall thickness were higher in athletes than in the control group, but also these numbers gradually increased with the intensity of sport. LVEF and RVEF were independent of the intensity of activity. Specific CMR reference ranges for athletes are provided and can be used as reference levels in this population, rather than the standard upper limits used for the general population to establish normality and exclude cardiomyopathy.Additional file 1: Table S1. Additional LV morphology parameters, LV segmental wall thickness and LV ratios for ventricular parameters in controls and athletes classified with respect to sport category. Table S2. Additional RV morphology parameters in controls and athletes classified with respect to sport category. Table S3. Additional LV morphology parameters, LV segmental wall thickness and LV ratios summary data  for athletes of medium and high intensity sports, with gender cut-offs when applicable. Table S4. Effect size of sport type (medium and high intensity), gender and age on LV parameters, LV wall thickness, LV and LV/RV ratios on multivariate analysis. Table S5. Additional RV dimensions reference parameters summary data  for athletes of medium and high intensity sports, with gender cut-offs when applicable. Table S6. Effect size of sport type (medium and high intensity), gender and age on RV parameters on multivariate analysis.


Cardiomyopathies (CMPs) are a heterogeneous group of diseases that involve the myocardium and result in systolic or diastolic impairment of the cardiac muscle, potentially leading to heart failure, malignant arrhythmias, or sudden cardiac death. Occurrence in pediatric age is rare but has been associated with worse outcomes. Non-invasive cardiac imaging techniques, integrated with clinical, genetic, and electrocardiographic data, have shown a pivotal role in the clinical work-up of such diseases by defining structural alterations and assessing potential complications. Above all modalities, cardiovascular magnetic resonance (CMR) has emerged as a powerful tool complementary to echocardiography to confirm diagnosis, provide prognostic information and guide therapeutic strategies secondary to its high spatial and temporal resolution, lack of ionizing radiation, and good reproducibility. Moreover, CMR can provide in vivo tissue characterization of the myocardial tissue aiding the identification of structural pathologic changes such as replacement or diffuse fibrosis, which are predictors of worse outcomes. Large prospective randomized studies are needed for further validation of CMR in the context of childhood CMPs. This review aims to highlight the role of advanced imaging with CMR in CMPs with particular reference to the dilated, hypertrophic and non-compacted phenotypes, which are more commonly seen in children. Cardiomyopathies (CMPs) are defined as a heterogeneous group of diseases of the myocardium characterized by structural, mechanical, and electrical abnormalities which result in systolic or diastolic dysfunction. These conditions refer to a wide group of etiologies and associated genetic, infectious, metabolic, or neuromuscular conditions . In pediatric age, CMPs are rare disorders, with an annual incidence between 0.65 and 1.24 per 100,000 children, which becomes significantly higher in the first 2 years of life [In the last few years, several classification systems have evolved due to advances in genetic examinations and evolution of imaging techniques. The most frequent type of CMPs in pediatric age is dilated CMP (DCM), which accounts for about half of the cases, followed by hypertrophic CMP (HCM), which is the second most common group. Rarer CMPs are left ventricular non-compaction (LVNC) and restrictive phenotypes. Of note, arrhythmogenic CMP (ARVC) is rarely diagnosed in pediatric age . Interestingly, children may present a mixed phenotype or even modify from a predominant phenotype to another during the course of disease and growth . ChildreA multiparametric approach with integration of imaging and clinical data, electrocardiogram (ECG), familiar history and genetic analysis is crucial for complete assessment of CMPs. Non-invasive cardiac imaging techniques are fundamental tools to define the phenotypic and pathognomonic aspects of the various forms of CMPs.Transthoracic echocardiography (TTE) is the standard imaging modality for diagnosis and follow-up of CMPs in children. TTE is a worldwide used, easily accessible, safe and low-cost technique that provides both morphological and functional data information. Technological advances, such as strain analysis and three-dimensional (3D) echocardiography, have recently improved its diagnostic and prognostic abilities. However, TTE is limited in its interobserver variability, acoustic window dependence and the absence of myocardial tissue characterization .Performance of cardiovascular magnetic resonance (CMR) is of greatest value in the context of childhood CMPs secondary to its high diagnostic accuracy with excellent spatial and temporal resolution, lack of ionizing radiation, low-operator dependency and good reproducibility, which make it an ideal and unique technique for the assessment of congenital and acquired cardiac diseases in the pediatric age. CMR is considered the gold-standard for measurement of myocardial wall thickness, calculation of myocardial mass, heart chambers volumes and function, as well as detailed assessment of regional wall motion abnormalities. CMR also allows acquisition of 3D datasets of images and representation of cardiovascular anatomy, which is of fundamental value in children . MoreoveIn the last few years, cardiac computed tomography (CCT), which is a validated tool for the non-invasive assessment of coronary arteries, has also emerged as a valid alternative to CMR in the evaluation of CMPs, although its role in children is mainly limited by its radiation exposure. Novel applications of CCT for detection of myocardial fibrosis and volume quantification with latest generation scanners have shown good agreement with CMR data but are not currently used in clinical practice .The aim of this review is to highlight the role of CMR in the management of the CMPs most frequently found in pediatric age, such as DCM, HCM and LVNC. This work focuses on the diagnostic and prognostic features of pediatric CMPs which can be assessed with CMR. Considerations about clinical issues, genetics and the spectrum of medical and surgical therapies are fundamental in the evaluation of pediatric CMPs but are beyond the scope of this paper. Integration of CMR in the preparation and follow-up phase of cardiac transplantation in children is also an issue, but evidence is still limited and it would be a very interesting topic to deal with in the next future.Recommendations for adequate performance of CMR studies in the pediatric population have been provided by recent consensus documents . In the For volumetric assessment and evaluation of kinetics, multiphase, possibly breath-holding, steady-state-free-precession (SSFP) cine sequences with retrospective ECG-gating should be acquired in short-axis and long-axis planes with a recommended slice thickness from 4 to 8 mm according to body weight. Reference values for children have been proposed .For tissue characterization, sequences that are usually acquired include T1- and T2-weighted imaging, with and without fat saturation, T1-weighted sequences with and without GBCA and late gadolinium enhancement (LGE). Of note, the assessment of fibrosis with CMR is a cornerstone in the management of patients with CMPs and LGE represents the gold standard for the in vivo assessment of myocardial fibrotic tissue and showed an excellent correlation with histology . Novel pComplementary pure anatomical sequences, such as 3D balanced SSFP, may be added to exclude concomitant congenital vascular and thoracic anomalies. Of note, ECG and respiratory navigator-gated, free-breathing, 3D balanced SSFP sequences can achieve a 3D anatomic dataset with high spatial resolution (isotropic voxel size of 0.9–2 mm) and without the need for a contrast agent. In patients affected by HCM, stress protocols may be performed to assess patients for inducible myocardial ischemia, but few evidence exists on vasodilator perfusion imaging in children .Sedation is generally required in CMR studies in children less than 5 years old. An optimal scanning setting, entertainment of children with audible books and films, and the presence of parents during the CMR examination can potentially avoid sedation at very young ages and improve image quality. In neonates, the “feed, swaddle, and sleep” technique can be applied with achievement of good scanning times . AlternaFor tissue characterization and perfusion imaging, GBCA are commonly administered intravenously in pediatric patients of all ages. Many of them are often used “off-label” in this subset of patients, but the documented overall rate of adverse events in both adults and children is very low .Several promising CMR techniques, including strain analysis, artificial intelligence and machine learning applications, have opened new frontiers for diagnosis and patient welfare in the last few years, although further validation is required to fully integrate them into routine clinical use .DCM is currently defined by the presence of left ventricular (LV) or biventricular dilation and systolic dysfunction in the absence of other cardiac alterations such as coronary artery diseases, valvular, or congenital heart diseases . AdditioClinically, signs of congestive heart failure are described in 70–90% of children, with the most severe forms during the first year of life . DespiteAmong all imaging modalities, TTE represents the standard diagnostic approach in children with DCM, but in recent years CMR has shown great applicability, diagnostic and prognostic power in pediatric patients with DCM . Use of In neonates with development of severe LV dilatation and dysfunction, a complete diagnostic approach should be addressed in order to exclude presence of ongoing myocarditis, or, most probably, of congenital coronary artery anomalies. In this case, TTE may reveal anomalous origin or proximal course of epicardial coronary arteries in 90% of cases and detect regional LV wall motion abnormalities. However, in the most challenging cases invasive coronary angiography may be performed to confirm the diagnosis. Among second-level non-invasive imaging techniques, in neonates with a very high heart rate CCT should be preferred, while in older children CMR angiography can be performed with high diagnostic accuracy and no radiation exposure . LGE mayIn young patients affected by Duchenne muscular dystrophy (DMD) cardiac involvement with CMP represents the major cause of death . TypicalAdvanced forms of DCM may show presence of characteristic linear mid-wall LGE in a non-coronary distribution, usually in the interventricular septum , which is reported in approximately 30% of DCM cases of all ages , and corDCM is also associated with an increased risk of ventricular arrhythmias and SCD. Risk stratification and indication for ICD implantation in primary prevention in children affected by DCM is extremely challenging due to the lack of randomized, multicenter studies in the pediatric population. LVEF has historically been considered the most relevant factor for risk stratification, but presence of LGE was revealed as a powerful predictor of fatal arrhythmias and SCD in many studies . In younDCM presents an extremely bad prognosis in neonatal age, and CMR data concerning follow-up of the cardiomyopathy are poor, as many of these children die or undergo cardiac transplantation in the first months of life. Moreover, prognostic data provided by CMR are still limited to small, single-center studies and larger, prospective, randomized trials are needed for further validation.HCM is characterized by excessive and inappropriate thickening of the ventricular myocardium in the absence of loading conditions responsible for it. Other typical morphological features of HCM are myocardial crypts, hypertrophic and apically displaced papillary muscles, and elongated leaflets with systolic anterior motion (SAM) of the mitral valve (MV) in obstructive forms of HCM ,47. In cIn childhood, HCM presentation could be more heterogeneous and in some cases related to specific malformation syndromes, metabolic defects or neuromuscular conditions, such as Pompe disease, Noonan syndrome and Friedreich ataxia . ClinicaDiagnosis of HCM requires exclusion of other causes of LV hypertrophy, similar to HCM but with a different etiology, which are known as HCM phenocopies. In children and young adults, most common HCM phenocopies are physiologic remodeling secondary to long-standing training (athlete’s heart), metabolic and storage diseases, and cardiac tumors . ConsequTTE is currently the mainstay for standard diagnostic approach and follow-up, as well as for familial screening. In adults, diagnosis of HCM can be made when the maximal end-diastolic wall thickness is ≥15 mm in one or more myocardial segments, in the absence of other causes of LV hypertrophy. In children, LV hypertrophy is considered when LV wall thickness is ≥2 standard deviations above the mean (z score ≥ 2) for age, sex and body size .The classical phenotype of HCM is characterized by asymmetric hypertrophy, prevalent at the basal anterior septum , while less common types are non-septal asymmetric hypertrophy, symmetric and concentric hypertrophy, right ventricular (RV) and apical HCM . Basal sSecond-level imaging, principally with CMR, is often needed for diagnostic confirmation. CMR has emerged as a powerful diagnostic tool able to refine these challenging diagnoses, given its ability to define the extension and localization of hypertrophy and its ability in soft tissue characterization . A recenPositive LGE is described in approximately 60% of adult patients with HCM, although its real prevalence in children and adolescents is not well defined. A recent study by Raja et al. described a 46% prevalence of LGE in children with overt HCM . MoreoveIn pediatric patients, diffusely increased T1 values and decreased global longitudinal strain values were found in HCM patients compared to controls , as a siHCM is the most common cause of SCD in young patients, and a complete identification of specific pediatric risk factors for SCD is fundamental to guiding implantable cardioverter defibrillator (ICD) implantation. If an indication for implantation of ICD in secondary prevention is well established, in the context of primary prevention from SCD, the selection of candidates for ICD implantation is often challenging and multiple SCD risk factors have been developed in the last few years. In a recent systematic review, a history of previous adverse cardiac events, non-sustained ventricular tachycardia, unexplained syncope, and very severe LV hypertrophy have been identified as major risk factors for SCD in children with HCM . NorrishThe presence and extent of LGE have shown important prognostic implications in both adults and children with HCM, as extensive fibrosis is associated with a higher risk for later LV dilatation and systolic dysfunction ,71. In cComprehensively, the diagnosis of HCM is provided by 2D cine SSFP sequences supported by positive LGE in most hypertrophied segments. The presence of LGE is less frequent than in adults but typically presents with an intramyocardial, patchy pattern of distribution. In contrast, risk stratification of children with HCM is still challenging, and no uniformity exists on clinical risk scores and prognostic data, which require more detailed investigation and standardization.LVNC is a heterogenous type of CMP characterized by excessively elongated ventricular trabeculations separated by wide and deep intertrabecular recesses communicating with the ventricular cavity, usually associated with a thinner compacted layer . Other tCurrently, there is still much debate about whether to consider LVNC as a distinct entity or a morphological variant phenotype of LV hypertrabeculation. On one side, the ESC and the World Health Organization include LVNC in the group of unclassified CMPs, while the American College of Cardiology/American Heart Association (ACC/AHA) classifies LVNC as a distinct primary genetic cardiomyopathy ,79.Comprehensively, such disease may be isolated or associated with other CMPs, congenital heart diseases, or specific syndromes. For example, LVNC has been reported in patients affected by Ebstein anomaly , Barth syndrome, metabolic myopathies, mitochondrial disorders, neuromuscular diseases, and genetic syndromes. The most common genetic defects involve sarcomeric proteins . Many geImaging techniques allow diagnosis of LVNC, but there is no formal consensus for diagnostic criteria which are still debated. This causes great uncertainty not only related to the presence or absence of the disease, but also in defining its real prevalence, etiology, therapy and prognosis and results in a cardiac imaging challenge . LV hypeCMR offers unlimited views to all cardiac structures with high spatial resolution, which is particularly useful in cases of suspected LVNC due to excellent visualization of all apical segments, which are typically involved in non-compaction. As for TTE, different sets of diagnostic criteria by CMR have been proposed. First in 2005, Petersen et al. proposed a ratio of non-compacted layer to compacted layer (NCL/CL) ≥2.3 measured in a long-axis view at end-diastole as diagnostic for LVNC. This showed a sensitivity of 86% and specificity of 99% in patients with a known LVNC diagnosis . In 2012However, all these methods were derived from small population samples and no formal agreement exists about their use for diagnosis of LVNC. In the Screen to Prevent (S2P) Study, a cross-sectional study involving 5169 children in Texas, CMR was used as a screening modality to identify congenital cardiac anomalies associated with SCD. LVNC was incidentally detected by CMR in 959 cases (18.6%), according to the Petersen criteria . The samAn alternative technique for diagnosis as well as for follow-up of LVNC is CCT, although it is not routinely used for children due to its radiation exposure. A cut-off value of NCL/CL greater than 2.2 or even 1.8 has been proposed in recent studies , but no The long-term outcome of LVNC is highly variable and related to the age of presentation and the phenotype manifestation. Early presentation in the pediatric age, especially in the first year of life, is recognized as an independent risk factor and associated with ventricular arrythmias and SCD . In addiGiven the lack of definitive diagnostic criteria, in the presence of extensive trabeculation, follow-up with echocardiography and eventually CMR should be regularly performed even in asymptomatic children to assess for potential remodeling, intraventricular thrombi and systolic dysfunction. Ivanov et al. assessed LVNC prevalence by 4 sets of criteria and adverse events at 7-year-follow-up in a large adult population of non-selected patients referred for CMR. Overall prevalence of LVNC was high  and no significant correlation was found between presence of LVNC and adverse clinical outcome, independent of the applied criteria. Moreover, an NCL/CL ratio > 3 as assessed with Petersen criteria did not show any correlation with future cardiovascular events .Standard and additional CMR sequences for a complete assessment of LVNC cardiomyopathy in children is described in Given the high prevalence of disease, a simplified diagnostic path should be provided for the diagnosis of LVNC. Current evidence is based on a paucity of data and many parameters result often discordant and not always feasible in the same patients . Concerning prognosis, CMR data are still limited and a comprehensive assessment of concomitant systolic dysfunction, arrhythmias and positive family history is of paramount importance for risk stratification and follow-up.Although echocardiography remains the standard frontline diagnostic approach and is an ideal tool for periodic re-evaluation of childhood CMPs, growing evidence supports the integration of CMR into routine clinical practice. CMR can be safely performed in the pediatric population and, in addition to echocardiography, can provide information on tissue characterization. The presence and distribution of fibrosis aids the recognition of CMPs from differential diagnoses. However, differently from the adult population, findings in children are more variable and less specific. Concerning risk stratification and follow-up, data in children are lacking as prognosis is poor and the main studies are restricted to single research groups. Given the potential value of CMR in terms of diagnosis and risk assessment in childhood CMPs, a further standardized prospective investigation in larger pediatric populations is warranted.