Diastolic dysfunction refers to an impaired relaxation and an abnormality in a heart’s filling during diastole while left ventricular systolic function is preserved. Diastolic dysfunction is commonly observed in patients with primary hypertension, diabetes and cardiomyopathies such as hypertrophic cardiomyopathy or restrictive cardiomyopathy. We have generated a restrictive cardiomyopathy (RCM) mouse model with troponin mutations in the heart to mimic the human RCM patients carrying the same mutations.2+.In the present study, we have investigated the ventricular muscle internal dynamics and pressure developed during systole and diastole by inserting a micro-catheter into the left ventricle of the RCM mice with or without treatment of desensitizer green tea extracts catechins. Our results demonstrate that green tea catechin is able to correct diastolic dysfunction in RCM mainly by improving ventricular compliance and reducing the internal muscle rigidity caused by myofibril hypersensitivity to CaGreen tea extract catechin is effective in correcting diastolic dysfunction and improving ventricular muscle intrinsic compliance in RCM caused by troponin mutations. Diastolic dysfunction refers to an impaired relaxation and an abnormality in a heart’s filling during diastole while left ventricular systolic function is preserved. Diastolic dysfunction is a common sign in elderly population and in patients suffering from primary hypertension and various cardiomyopathies , 2. For 2+ is a key factor associated with impaired relaxation in the heart [2+ hypersensitivity in RCM can correct phenotypes and rescue the RCM mice [2+ desensitizer green tea catechins can reverse diastolic dysfunction in RCM mice with troponin mutations [2+ dynamics in RCM myocardial cells. Our results demonstrate that green tea catechin is able to correct diastolic dysfunction in RCM mainly by improving ventricular compliance and reducing the internal muscle rigidity caused by myofibril hypersensitivity to Ca2+.In our previous studies, we have demonstrated that hypersensitivity of myofibrils to Cahe heart , 10. FurRCM mice , 12. In utations . However193His transgenic mice (TG) used in this study were generated in our laboratory by transgenic expression of cTnI193His mutant protein in the heart under the α-myosin heavy chain promoter [th edition, 2011) and approved by the Institutional Animal Care and Use Committees at Florida Atlantic University.RCM cTnIGreen tea extract (-)-epigallocatechin-3-gallate (EGCg) was obtained from Sigma-Aldrich . The compound was dissolved freshly in 15 % DMSO (200 mg/ml) as described previously . Both WTCardiac function in experimental mice was examined and analyzed using a Vevo 770 High-Resolution In Vivo Imaging System  in our laboratory as described previously , 14. To P/dtmax as a measure of systolic function. For diastolic function, LV end-diastolic pressure (LVEDP), −dP/dtmin, and Tau were determined. Tau was determined from fitting to the pressure decay curve from the time when −dP/dtmin occurs using a zero asymptote. At least eight mice were measured for each group. In β-adrenergic stimulation assay, bolus injection of the β-receptor agonist isopretelenol (1.5 mg/kg body wt). Assays were performed on five TG and five WT mice.Mice were anesthetized with 3 % isoflurane and were supported by a ventilator with a maintenance dose of 1 % isoflurane after tracheostomy. A research pressure-volume micro-catheter  was inserted into the left ventricle through the right carotid artery of the experimental mice. Intra-cardiac pressure (P) and volume (V) were simultaneously measured and real time data were displayed and recorded using a P–V conductance system  coupled to a digital converter . Heart rate was continuously monitored using either ECG electrodes or direct pressure pulses corresponding to each heartbeat. Hemodynamic parameters were measured under different preloads, which were elicited by transiently compressing the abdominal inferior vena cava. The catheter was advanced into the LV to obtain +dCardiac samples were resolved in NuPAGE 4–12 % gradient BT gels using an Xcell II sure lock Mini Cell gel system from Invitrogen. The proteins were transferred to a nitrocellulose membrane using the Xcell IITM blot module as described previously , 10. Thet test were used to determine the statistical significance. Statistical significance was set as P <0.05.The results are presented as means ± SE. ANOVA followed by post hoc Newman–Keuls (SNK) tests and Student’s The data from cardiac function measurements using high resolution echocardiography in experimental mice indicate that enlarged left and right atria are significantly reduced in RCM mice after the treatment of EGCg Fig. . Left vet max  in tested mice. The data indicate that ISO treatment cannot increase the heart filling and has no effect on LVDP in RCM mice Fig. . However2+ handling proteins do not show any significant changes both in WT and RCM mice after the treatment of green tea extract EGCg  is the leading cause of mortality in the United States . In two t are common physiologic measurement of cardiac tissues. EDPVR is an index that reveals the internal ventricular muscle dynamics and developed pressure in diastole. Our data indicate that the EDPVR increased significantly in RCM heart compared to the WT hearts, suggesting an increased ventricular muscle internal pressure (force) that is Ca2+ independent in RCM hearts with troponin mutations. The increased ventricular muscle internal pressure (force) causes a rigid ventricle and enlarged left atrium or both atria, which are consistent with what we reported previously of cellular and morphological examination on the same RCM mice [2+ dynamics in myocardial cells by altering Ca2+ handling proteins or their phosphorylation status.In the present study, we have further confirmed that diastolic dysfunction occurs in RCM mice with troponin mutations in the heart and desensitizing green tea extract EGCg can reverse the diastolic dysfunction in RCM hearts. Using micro-catheter based P-V loop measurements in both WT and RCM TG mice, we have successfully analyzed P-V loops and end diastolic pressure and volume relationship (EDPVR) in the experimental mice. The P/V index reflects the elastance of the left ventricles. The P/V plus dP/dRCM mice , 11. GreThis is the first study investigating the ventricular muscle internal dynamics and pressure developed during diastole in RCM hearts with troponin mutations. It is also novel to demonstrate that green tea desensitizing EGCg reverse diastolic dysfunction by correcting the internal EDPVR in the RCM hearts. It is interesting to note that a beta-adrenergic agonist has barely any effect on diastolic function and heart filling although it can increase heart rate and ejection fraction in RCM mice.The results from this study and our previous studies indicate that myofibril hypersensitivity is a key factor that causes impaired relaxation in HCM or RCM hearts associated with myofibril protein troponin mutations in myocardial cells. Green tea extract EGCg can reverse the impaired relaxation by correcting the hypersensitivity-induced abnormal ventricular muscle internal pressure in RCM hearts. Recently, the desensitization effect of green tea extracts has been further confirmed in cells from a patient with HCM . The effGreen tea extract catechin is effective in correcting diastolic dysfunction and improving ventricular muscle intrinsic compliance in RCM caused by troponin mutations.A, mitral Doppler A peak velocity; E, mitral Doppler E peak velocity; EDD, end diastolic dimension; EF, ejection fraction of LV; ESD, end systolic dimension; FS, fractional shortening of LV; HCM, hypertrophic cardiomyopathy; IVCT, isovolumetric contraction time; IVRT, isovolumetric relaxation time; IVS, intra-ventricular septum; LA, left atrium; LV, left ventricle; LVID:d, left ventricular internal diameter end diastole; LVID:s, left ventricular internal diameter end systole; PW, posterior wall thickness of LV; RA, right atrium; RCM, restrictive cardiomyopathy


The level of right ventricular (RV) systolic function has prognostic importance in right ventricular ST-segment elevation myocardial infarction (RV-STEMI). This study aimed to evaluate the changes in RV systolic function in patients with RV-STEMI according to the revascularisation method used for their management.The first group consisted of 132 patients who received primary percutaneous coronary intervention (PPCI). The 78 patients who had received thrombolytic therapy (TT) in external centres before referral to our centre for PCI within three to 12 hours of RV-STEMI were included in the second group. All patients were evaluated by conventional and two-dimensional speckle-tracking echocardiography.There were 172 male patients and their mean age was 63.7 ± 11.8 years. There were no significant differences between the two groups with regard to right ventricular systolic parameters at admission and at the one-month follow-up visit. The echocardiographic changes between admission and the one-month follow up were investigated for the patients included in the study groups. Mean values of each parameter observed at the one-month follow up were significantly increased compared to those at admission within each group.Our study demonstrated that PCI within three to 12 hours following TT provided similar benefits on right ventricular systolic function compared to PPCI in patients with RV-STEMI. ST-elevation myocardial infarction (STEMI) is characterised by a loss of contractile tissue and a change in ventricle geometry that causes substantial impairment of the ventricular systolic and diastolic functions.RV-STEMI has been reported in 10 to 60% of patients with inferior STEMI.8The time lapse between the onset of symptoms and admission to hospital is known as the symptom-to-door time. Myocardial damage and cardiac complications are more likely to progress with prolonged periods without intervention after STEMI.Successful reperfusion within the first three hours is reported to provide improved prognosis. For this purpose, the selection of appropriate reperfusion strategy is an important discussion topic. Reperfusion strategies include fibrinolysis and primary percutaneous coronary intervention (PPCI) techniques. PPCI is preferable in a 24-hours-a-day, seven-days-a-week centre with an established coronary intervention facility.When the transfer time from centres without coronary intervention laboratories does not exceed 120 minutes and the door-to-balloon time does not exceed 90 minutes, PPCI is again the preferred method for revascularisation. If these requirements are not met, fibrinolytic therapy may be performed for the patients.RV-STEMI requires immediate revascularisation in affected patients. Revascularisation can be achieved with methods such as percutaneous coronary intervention or thrombolytic therapy. Current guidelines recommend the appropriate treatment of coronary arteries after performing coronary angiography within three to 24 hours following TT. 12This study aimed to evaluate the effects of coronary intervention on right ventricular systolic function by comparing PPCI with PCI performed within three to 12 hours of TT, as assessed by transthoracic echocardiography, in patients with RV-STEMI.This prospective, observational cohort study was carried out between January 2012 and February 2013. We interviewed 210 patients who met the criteria for admission and had had inferior myocardial infarction with right ventricular involvement (RV-STEMI) for the first time. RV-STEMI was defined as new ST-segment elevation ≥ 0.1 mV at the J-point in two contiguous inferior leads accompanied by new ST-segment elevation ≥ 0.1 mV in the right ventricular leads (V3R–V4R).Patients who had infection, heart muscle disease or chronic inflammatory disease were not included in the study. At hospital admission, the patients who had cardiogenic shock, chronic pulmonary disease or systolic pulmonary artery pressure > 35 mmHg, renal failure (creatinine > 2.5 mg/dl) or a history of cerebrovascular events were also excluded from the study. Since RV systolic function was evaluated in our study, those who had diseases such as pulmonary hypertension that could impair the RV systolic function were excluded from the study. As right heart catheterisation could not be applied during primary PCI, the patients with echocardiographically measured systolic pulmonary arterial pressure > 35 mmHg were not included in the study. Patients with unknown time of symptom onset or a StD time longer than 12 hours were also not included in the study.The patients were divided into two groups according to admission to hospital; 132 patients who underwent PPCI were identified as the first group. Seventy-eight patients who underwent PCI in our centre within three to 12 hours after receiving TT in other centres were included in the second group.Our centre is a tertiary hospital and coronary intervention facilities are available 24 hours a day, seven days a week. Patient records are kept on a regular basis, starting at admission to the emergency department. In addition to these data, the onset of symptoms was sought from the patients themselves or their relatives.The exact time of patient admission in the emergency department was identified as door-time. Symptom-to-door (StD) time was determined by calculating the difference between the two periods. The exact time the patient’s coronary balloon had been inflated was recorded in the angiography laboratory. The time lapse from the patient’s admission to the emergency department to inflating the balloon was calculated as doorto- balloon time (DtB). Symptom-to-balloon (StB) time was calculated in addition to StD and DtB. Symptom-to-needle (StN) time was calculated as the time from the initial onset of symptoms to the start of thrombolytic drug administration. The time lapse from the patient’s admission to the emergency department to the start of thrombolytic drug administration was calculated as door-to-needle time (DtN).During the study, intervention was performed only for the culprit arteries responsible for the infarction. Elective interventions were performed for the other lesions. The invasive treatment methods applied during PCI, and balloon and stent diameters and lengths were recorded. The diameters of the vessels with lesions were calculated from the coronary angiography examinations.Traditional variables that have been used to assess response to TT were decrease in chest pain, ST-segment resolution and reperfusion arrhythmias. Patients who had < 50% ST-segment resulution were excluded from the study. Patients who required rescue PCI, patients scheduled for coronary artery bypass grafting (CABG) or those who underwent percutaneous intervention for all critical lesions due to haemodynamic instability were also excluded from the study. Patients with a DtB time longer than 30 minutes in the PPCI group, and those with a door-to-needle (DtN) time longer than 30 minutes in the TT group were not included in the study.All patients received dual antiplatelet therapy with acetylsalicylic acid and clopidogrel (300–600 mg) loading dose before coronary intervention. Peri-procedural anticoagulation consisted of intravenous unfractioned heparin (70 IU/kg) in all cases. Clopidogrel (75 mg per day) and acetylsalicylic acid (100 mg per day) were prescribed for at least one year. Blood samples were collected from each subject immediately after presenting at the emergency department. Cardiac enzymes, liver function tests, kidney function tests, complete blood count and thyroid function tests were performed on these samples.A Vivid-S5 echocardiography device is readily available in the emergency department of our centre . Echocardiographic evaluation is performed rapidly in all patients presenting at the emergency room (ER) with acute coronary syndrome (ACS). Imaging is performed by the echocardiography operator simultaneously while patients with STEMI are prepared for coronary intervention. In our study, prolonged StD durations were avoided in order to assess echocardiographic parameters.Echocardiographic evaluation of the RV is more difficult than that of the LV. An appropriate imaging window may not be achieved due to restrictions caused by the sternum and other anatomical structures. Therefore, patients with inadequate echocardiographic imaging quality were excluded from the present study.American Society of Echocardiography (ASE) recommendations were followed for the evaluation of RV systolic function. RV end-systolic and end-diastolic diameters were measured from the left parasternal long-axis view. RV basal, mid and longitudinal diameters were measured from the apical four-chamber view. Endocardium margins were drawn from the tricuspid annulus to the RV apex and from there to the opposite side of the tricuspid annulus in the apical four-chamber view in order to calculate RV fractional area change (RV-FAC). End-systole and end-diastole areas were individually calculated with this approach. RV-FAC was determined by means of the formula:RV-FAC = end-diastole area – end-systole area/end-diastole areaTricuspid annular plane systolic excursion (TAPSE) was calculated by measuring the movement magnitude of the RV annular segment in the longitudinal plane using the M-mode method. This measurement was performed on the apical fourimaging window of the tricuspid lateral annulus.Right ventricle isovolumic acceleration (RV-IVA) was calculated by dividing the peak isovolumic myocardial velocity calculated at the time of isovolumic contraction by the time to peak velocity using tissue Doppler on the lateral tricuspid annulus. RV-S′ was calculated by measuring systolic velocity using tissue Doppler on the right ventricular lateral tricuspid annulus.Right ventricle myocardial performance index (RV-MPI) is one of the methods recommended for the evaluation of global RV function. It was calculated by dividing the sum of isovolumic contraction time (IVCT) and isovolumic relaxation time (IVRT) by the tricuspid ejection time: 17RV-MPI = IVRT + IVCT/ETLeft ventricular ejection fraction (LVEF) was calculated from the four- and two-chamber views using the modified Simpson biplane method. LV wall-motion score index (LV-WMSI) was calculated according to the 16-segment model of the American Society of Echocardiography. In accordance with this model, normokinesis, mild-moderate hypokinesis, severe hypokinesis, akinesia and dyskinesia were evaluated with the scores 1, 2, 3, 4 and 5, respectively. The total value was divided into the evaluated segment number and WMSI was obtained.18Echocardiographic examinations were performed by the same investigators, who were blinded to the patients’ data, at baseline and after the first month. All measurements were calculated from three consecutive cycles, and the average of the three measurements was recorded.Two-dimensional speckle-tracking echocardiography (2D STE) is a novel technique used for the measurement of cardiac mechanics. It assesses myocardial deformation and the myocardial deformation rate by tracking speckles in the myocardium on grayscale (B-mode) images, and can be used to evaluate both global and regional myocardial strain and strain rate.20The investigations were performed with the patients in the left lateral decubitus position, in the parasternal and apical four-chamber views. Digital routine grayscale 2D ciné loops and tissue Doppler ciné loops were obtained from three consecutive beats with end-expiratory apnoea from standard apical fourand two-chamber views. Frame rates of 70–90 Hz were used for routine grayscale imaging in the speckle-tracking analysis. Sector width was optimised to allow for complete myocardial visualisation while maximising the frame rate. Gain settings were adjusted for routine clinical grayscale 2D imaging to optimise endocardial definition.Longitudinal deformation in the RV free wall was assessed by 2D speckle-tracking longitudinal strain using a routine grayscale RV focused-view image, which was performed offline with dedicated software  by one experienced cardiologist blinded to data about the patients’ status.Briefly, a region of interest (ROI) was traced with a point-and-click approach on the endocardium at end-diastole in the RV from the RV focused view. A second, larger ROI was then generated and manually adjusted near the epicardium. The RV was divided into six standard segments , and six corresponding time–strain curves were generated. RV free-wall longitudinal speckle-tracking strain (RV-free-S) was calculated by averaging each of the three regional peak systolic strains along the entire RV free wall and RV free systolic strain rate (RV-free-SR), were calculated in the same manner.The patients were prospectively followed during the in-hospital period and first month after RV-STEMI. Informed consent was obtained from each subject, and the study was conducted in accordance with the Helsinki Declaration. The study protocol was approved by the ethics committee.Intra- and inter-observer variability were assessed in the echocardiographic data obtained from a subgroup of 30 subjects. One month later, the first operator repeated the analysis to assess intra-observer variability. To assess inter-observer variability, the second operator who was unaware of the previous measurements, analysed the rotational parameters two days later.Agreement analysis for inter- and intra-observer variability of RV measurements revealed a high level of agreement, with a mean difference of 0.18 . For intra-observer variabilities, intraclass correlation coefficient of RV-free-ST and RV-free-STR-S were 0.907 (95% CI 0.840–0.943) and 0.954 (95% CI 0.823–0.967), respectively. SPSS 17  was used for statistical analysis. The Kolmogorov–Smirnov test was used to evaluate whether the numerical variables were normally distributed. For data showing an abnormal distribution, median and interquartile ranges were displayed. Continuous variables were presented as mean ± standard deviation, and categorical ones were presented as percentage (%).t-test or Mann–Whitney U- and chi-squared or Fisher’s exact tests, as appropriate. In each group, follow-up comparisons (early period and one month) were performed using the paired t-test and Wilcoxon rank test, as appropriate. Intraclass correlation coefficients and Bland–Altman analysis were used for echocardiographic measurements to assess intra- and interobserver reproducibility, respectively. A p-value < 0.05 was considered statistically significant.The two study groups were compared using the Student’s There were 172 male patients in the study and the mean age was 63.7 ± 11.8 years. One-month clinical follow up was available in all 172 patients (100.0%). There was no difference between the groups in terms of age, diabetes, hypertension and smoking status, and length of hospital stay. Average values were similar for heart rate, and systolic and diastolic blood pressure. Creatinine and troponin I values were higher in the TT group. No difference was found between the groups with regard to blood glucose and haemoglobin levels, and platelet count.The StD time from the onset of symptoms to admission to hospital was similar across the patients who had received similar medical treatment. Average DtB duration was 20.2 minutes for the PPCI group. DtN time was 23.2 minutes and StN time was 291.7 minutes in the TT group.Although the mortality rate in the first month was higher in the TT group, the difference was not statistically significant (p = 0.077). Re-MI and re-hospitalisation rates were similar between the groups during the first month. There were more ventricular tachycardia (p = 0.039) and ventricular fibrillation (p = 0.005) cases in the TT group. Rate of atrioventricular block of at least second degree, observed during the hospital stay, was similar. Rates of TIMI 0 and TIMI I–II flow following PCI were similar across the groups. The groups were similar in terms of SYNTAX score, one of the indicators of extent and complexity of coronary lesion There was no difference between the two groups regarding RV dimensions, volumes and function on admission to our hospital. There was no difference between the two groups with regard to the conventional RV systolic parameters, RV dimensions and volumes at the one-month follow up. There was no difference between the groups regarding the LVEF and LV-WMSI on admission to hospital and at the one-month follow up Echocardiographic changes between admission and one-month follow up were investigated for the patients included in the study groups. Mean values of each parameter were significantly increased at the one-month follow up compared to the early period within each individual group 2D-STE analysis of the RV revealed that the study groups had similar RV-free-S and RV-free-SR levels in the early period and at the one-month follow up Tables . Accordip = 0.015) and lengths (0.005) were observed in the PPCI group Evaluation of the angiographic parameters in the PPCI and TT groups revealed a higher number of patients with singlevessel disease in the TT group. Triple-vessel disease was more common in the PPCI group. The groups were similar in terms of bifurcation lesion, left dominance, drug-eluting stent use, direct stenting, coronary ectasia, thrombus aspiration and tirofiban infusion. Similar balloons were used with regard to diameters and lengths. Increased stent diameters  is considered a useful method to evaluate RV systolic function.In our study, there was no difference between the groups in terms of pre-PCI RV-IVA. Although pre-PCI, RV-IVA levels were low in the two groups, mean levels were improved to normal at the one-month follow up in both groups. The difference between the early period and the one-month follow up was significant in each group.MPI may be used for the assessment of global heart function.22et al., patients who were managed with PPCI following non-anterior STEMI were compared to those who received TT alone, and similar mean RV-MPIs were observed in both groups at 72 hours after the infarction.In a study by Karakurt et al. have shown, TAPSE < 14 during the 24 hours following RV-STEMI is associated with a poor prognosis.TAPSE is easily obtainable and is a measure of RV longitudinal function.RV-S′ is a very reliable and easily measured parameter in young adults. However, it may fail to fully reflect systolic function in the elderly. It can be measured from the tricuspid lateral annulus by means of tissue Doppler. RV-S′ < 10 cm is associated with RV systolic dysfunction.Assessment of RV function using conventional echocardiography is challenging due to the complex geometry of the RV and the predominantly longitudinal orientation of its myofibrils.13Peak RV longitudinal strain, which quantifies the maximal shortening in the RV free wall from apex to base, is likely to be a good estimator of RV function because 80% of the stroke volume is generated by longitudinal shortening of the RV free wall.According to conventional methods, sensitive changes in RV circulation can be detected earlier with 2D-STE.RV dysfunction is an independent predictor of adverse prognosis after acute MI. The involvement of the RV during inferior acute MI has been defined as a strong predictor of morbidity and in-hospital mortality.et al., post-PCI, TIMI 0–2 flow rate was reported as 14.7%.et al., however, no reflow was 11%.In the study by Mehta In a recent study, ventricular tachycardia (VT) and fibrillation rates were higher in the TT group. Patients were monitored by event recorder monitors in the intensive care unit and service follow ups. Therefore, reperfusion arrhythmias such as accelerated idioventricular rhythm were excluded in the VT evaluation. The rates given in the tables were documented from the time of admission to hospital until discharge. However re-MI, re-hospitalisation and mortality rates were similar in both groups in hospital and at the one-month follow up.Patients should be revascularised as early as possible in order to minimise potential complications following RV-STEMI. RV function may recover within days or weeks, especially after successful reperfusion.The main limitation of this study is its relatively small sample size. Our study included the in-hospital and one month after RV-STEMI periods only, and may therefore have failed to capture differences in relevant parameters. For this study, a group had been planned to include patients undergoing PCI within 12 to 24 hours of TT; however, the number of patients revascularised at our centre during this time period was insufficient for statistical analysis.Because the patients in the TT group had been referred from external centres, echocardiographic evaluation prior to thrombolytics was not possible. Therefore the RV systolic function determined in the TT group may have been overestimated.RV strain was assessed by 2D speckle-tracking echocardiography software, which has been developed mainly for LV strain. However, investigators demonstrated that the reproducibility of RV strain was acceptable using a speckletracking programme for LV strain.Moreover, RV septal and RV free wall were not separately evaluated during the RV strain analysis. However, previous studies suggested that RV septal strain showed no association with RV functional parameters. A possible explanation is that current speckle-tracking software cannot accurately separate LV septal from RV septal components, because the latter includes both RV and LV functional components.In our study, we could not evaluate 2D-derived estimation of RVEF because of the heterogeneity of methods and the numerous anatomical assumptions. We did not have 3D software during the study period.Our study included inferior STEMI with RV involvement alone. RV function, which evaluated conventional and RV strain/strain rates, was similar between the two groups at admission and at the one-month follow up. In light of these results, we believe that revascularisation within three to 12 hours from TT may be as beneficial as PPCI for restoring RV systolic function. RV-STEMI diagnosis should be prompt and TT should be initiated in centres where PPCI cannot be performed. Patients should then immediately be referred to centres with coronary laboratories.


Microvascular dysfunction in HCM has been associated with adverse clinical outcomes. Advances in quantitative cardiovascular magnetic resonance (CMR) perfusion imaging now allow myocardial blood flow to be quantified at the pixel level. We applied these techniques to investigate the spectrum of microvascular dysfunction in hypertrophic cardiomyopathy (HCM) and to explore its relationship with fibrosis and wall thickness.CMR perfusion imaging was undertaken during adenosine-induced hyperemia and again at rest in 35 patients together with late gadolinium enhancement (LGE) imaging. Myocardial blood flow (MBF) was quantified on a pixel-by-pixel basis from CMR perfusion images using a Fermi-constrained deconvolution algorithm. Regions-of-interest (ROI) in hypoperfused and hyperemic myocardium were identified from the MBF pixel maps. The myocardium was also divided into 16 AHA segments.Resting MBF was significantly higher in the endocardium than in the epicardium , a pattern that reversed with stress . ROI analysis revealed 11 (31%) patients with stress MBF lower than resting values . There was a significant negative association between hyperemic MBF and wall thickness  and a significantly lower probability of fibrosis in a segment with increasing hyperemic MBF .Pixel-wise quantitative CMR perfusion imaging identifies a subgroup of patients with HCM that have localised severe microvascular dysfunction which may give rise to myocardial ischemia. Cor. Cor3]. istology . The preCardiovascular magnetic resonance (CMR) allows the non-invasive assessment of myocardial blood flow and replacement fibrosis without the use of ionising radiation . Only onWe have previously shown that first-pass gadolinium-enhanced CMR stress perfusion imaging allows the pixel-wise quantification of absolute MBF with high fidelity and spatial resolution . We applThirty-six patients with HCM referred for CMR at the Royal Brompton Hospital were studied. HCM was diagnosed in accordance with standard clinical guidelines . PatientAll patients were asked to abstain from caffeine-containing beverages or drugs for 24 hours prior to imaging and from β-blockers and rate-limiting calcium channel antagonists for 48 hours prior to imaging. Images were acquired using a dedicated 1.5 T scanner with a twelve-channel phased-array receiver coil . A retrospectively-gated balanced steady-state free-precession sequence was used to obtain breath-hold cine images in three long-axis planes, followed by a contiguous stack of short axis slices from the atrioventricular ring to the apex . The endThree short axis images and an image at the basal slice of the arterial input function were acquired every cardiac cycle for a minimum of 50 cycles. Two initial proton density-weighted images were acquired prior to the arrival of contrast as part of perfusion imaging and were used for subsequent surface coil intensity correction. After ~10 min, late gadolinium enhancement (LGE) images were acquired with an inversion recovery-prepared segmented turbo FLASH sequence . InversiVentricular volumes, function, mass, and ejection fraction were measured using a semi-automated threshold-based technique . All volume and mass measurements were indexed to body surface area . End-diaAbsolute MBF was quantified pixel-wise at rest and at peak stress as outlined in Figure To avoid potential underestimation of the severity of perfusion defects in a sector-wise analysis, ROI analysis was performed using the MBF pixel maps to compare hypoperfused areas and remote hyperemic areas at stress to corresponding areas at rest. Hypoperfused areas were defined as areas which visually appeared to have the worst perfusion on stress perfusion pixel maps. Based on the minimum myocardial perfusion reserve index (MPRI = stress MBF/rest MBF) as measured from these ROI, the cohort was divided into two groups for further comparison: severe microvascular dysfunction (defined as minimum MPRI < 1.0) and non-severe groups (minimum MPRI ≥ 1.0).To assess the relationship between perfusion, wall thickness, and the presence of late enhancement, the myocardium was also divided into 16 segments according to the 17-segment AHA model, omitting the apex. Segments were further divided into endocardial and epicardial layers to assess for transmural perfusion gradients . Perfusi2 and Fisher’s exact tests as appropriate.Continuous variables are expressed as mean ± standard deviation (SD) for normally distributed variables and as medians with interquartile ranges for non-parametric data. The Kolmogorov-Smirnov test was used together with histograms to assess the normality of continuous data. Differences between parametric continuous variables were assessed using Student’s t-test, and for non-parametric data, the Mann–Whitney U-test. Categorical data are presented as frequencies and percentages. Differences between categorical variables were assessed using the χTo take into account correlation of repeated measurements and clustering of data from ROI and sectors within slices and patients, the perfusion data was analysed using a multilevel linear mixed effects model with patients treated as a random intercept. The relationship between the presence of LGE and perfusion was assessed using binary logistic regression together with a mixed effects multilevel generalised linear model. Two-tailed values of P < 0.05 were considered significant. Statistical analysis was performed using Stata SE Version 12 .The final study cohort was comprised of 35 patients Table . One patExamples of perfusion pixel maps for the severe microvascular dysfunction and the non-severe patients are presented in Figure ROI analysis of hypoperfused areas in the severe microvascular dysfunction patients Figure A revealeAdenosine achieved hyperemia, with MBF rising significantly between rest and stress. When considering the most normal sectors in each of the patients, the mean MPRI was significantly lower in the severe versus non-severe patients for sectors as a whole and in endocardial sub-sectors, with a trend towards significance in the epicardium Figure . When coThere was no significant relationship between resting MBF and sector end-diastolic wall thickness. However, at stress, there was a negative correlation between the two  with similar falls in the endocardium and the epicardium .Segments with LGE were significantly associated with lower perfusion at rest . This relationship remained consistent at stress  and when examined in relation to MPRI . Both rest and stress MBF appeared to be significantly lower in segments with LGE relative to those without  who have been deemed high risk will have been excluded due to the contraindication of CMR in this group potentially counterbalancing this. In addition, 97% of patients had 0 or only 1 risk factor for SCD.Myocardial fibrosis was assessed using the LGE technique. Whilst this detects replacement fibrosis, it does not allow the quantification of interstitial fibrosis . The assFinally, we were unable to determine the prognostic significance of our findings given our limited sample size and the relatively low event rate seen in HCM . NeverthIn summary, coronary microvascular dysfunction is a common finding in HCM and is associated with increasing wall thickness and with the presence of LGE. Fully quantitative pixel-wise first-pass CMR perfusion imaging identifies a significant number of patients with localised severe microvascular dysfunction that is likely to result in ischemia. Further work is required to determine if this phenomenon heralds an increased risk of future adverse cardiovascular events.Professor Dudley J Pennell is a consultant to Siemens and a director of Cardiovascular Imaging Solutions. The Royal Brompton Hospital has research collaboration agreements with Siemens.TFI, LYH, DF, DJP, SKP, and AEA were involved in the conception and design of the study as well as data collection, analysis, interpretation, and drafting of the manuscript. TFI, LYH, AMG, CG, BH, NM, RW, PF, and PG were involved in data gathering, analysis, interpretation, protocol development, drafting and revision of the manuscript. AJ, AG and ROH were involved in data analysis, drafting of the manuscript and in its revision for important content. MR performed all statistical analysis. All authors critically revised the manuscript for important intellectual content, read and approved the final manuscript.


Cardiac involvement drives outcome in systemic AL amyloidosis. Late gadolinium enhancement (LGE) CMR is useful for the detection of cardiac amyloid, but characteristic LGE patterns do not always occur or may appear late in the disease. Using CMR T1 mapping, we measured the pre contrast myocardial T1 and myocardial Extracellular Volume (ECV), reflecting myocardial amyloidosis burden and determined their prognostic significance.102 patients underwent CMR and T1 mapping pre- and post contrast. Myocardial ECV was calculated at contrast equilibrium. 54 healthy volunteers served as controls. Patients were followed up for a median duration of 23 months and survival analyses were performed. A secondary analysis compared predictive power of the following techniques: pre contrast T1, post contrast T1, ECV at equilibrium (ECVi) and ECV at 15 minutes i.e. bolus only ECV (ECVb).ECVi and ECVb were both raised compared to normals , as was native T1 . All 3 tracked pre-test probability of cardiac involvement, cardiac biomarkers and systolic and diastolic dysfunction. During follow-up, 25 deaths occurred. An ECVi of > 0.44 carried a hazard ratio for death of 3.76 (95% CI: 1.50 - 9.43), P = 0.005 and pre contrast T1 of > 1080 ms = HR 3.38 (95% CI: 1.21 - 9.45), p = 0.020. ECVi and ECVb performed similarly. Both ECVi and ECVb were stronger predictors of survival than pre contrast T1 as assessed by the (Harrell's C statistic). Isolated post contrast T1 was non predictive.Myocardial ECV (bolus or infusion technique) and pre contrast T1 in AL amyloidosis are strong predictors of mortality with ECV (however measured) being the better predictor.GSK.


Reduced left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI), which implies the occurrence of cardiac dysfunction, impacts cardiac prognosis, even after primary percutaneous coronary intervention (PCI). This study was designed to clarify the difference of clinical and angiographic predictors for reduced LVEF in ST-elevation myocardial infarction (STEMI) patients with left anterior descending artery (LAD) or non-LAD vessel as culprit artery.This was a retrospective study to review a total of 553 patients of STEMI underwent primary PCI in our hospital. All patients underwent echocardiography. Univariate analysis, multivariate analysis and classification and regression tree (CART) were performed between LAD related AMI and non-LAD related STEMI. The primary outcome was the occurrence of reduced LVEF 4–6 days after PCI.P < 0.01). Multivariate analysis indicated that elder (>65 years), time to hospital and proximal occlusion were associated with reduced LVEF (<55 %) in LAD related STEMI patients. However, in non-LAD patients, time to hospital, multivessel stenosis and post-PCI blood pressure predicted the occurrence of reduced LVEF. Furthermore, CART analysis also obtained similar findings.In this study, culprit arteries of STEMI were 315 in LAD system  and 238 in non-LAD system (63 in left circumflex and 175 in right coronary artery). Compared with non-LAD group, post-MI LVEF was significantly reduced in LAD related STEMI group (52.4 ± 9.3 % vs. 57.1 ± 7.8 %, Patients with LAD or non-LAD related STEMI could suffer reduced LVEF, while the clinical and angiographic predictors for the occurrence were different. Reduced left ventricular ejection fraction (LVEF), which is significantly associated with cardiac dysfunction, occurs approximately in 30–40 % of patients who suffer ST-elevation myocardial infarction (STEMI). Although the incidence of reduced LVEF after STEMI declined significantly  because Given to the impact of new-onset cardiac dysfunction after STEMI on the cardiac prognosis, it is important to investigate the difference of clinical and angiographic predictors for reduced LVEF in STEMI patients with different culprit vessels. These findings will provide rapid prediction and beneficial effects on the early prevention of cardiac dysfunction after STEMI.n = 664) in our hospital from Jul 2011 to Oct 2013. Baseline 12-lead electrocardiograms were performed at admission. A total of 553 patients were included in this study, while 111 patients were excluded according to follow exclusion criteria. The inclusion criteria were: (1) patients with 18 to 85 years of age; (2) diagnosed as acute STEMI; (3) underwent primary coronary intervention within 12 h after chest pain on-set. The exclusion criteria were as follows: (1) incomplete clinical history record (n = 23); (2) excluded the diagnosis of myocardial infarction by angiography, such as viral myocarditis, pericarditis or cardiomyopathy (n = 26); (3) not finish the detection of echocardiography in-hospitalization because of any reason (n = 17); (4) confirmed clinical heart failure before this admission, complicated with cardiomyopathy, congenital heart diseases and rheumatic heart disease (n = 19); (5) active chronic inflammation (n = 14); (6) dysfunction of hematological and immunological system (n = 4); (7) carcinoma or a condition treated with immunosuppressive agents (n = 8). This study and consent procedure were approved by our local ethics committee , and were carried out in accordance with the principles of the Declaration of Helsinki. Consent for publication of these data was obtained from each patient when they were admitted in our hospital.This was a retrospective clinical study to review the patients of acute STEMI underwent primary PCI  and D-to-B time .Prior to primary PCI, all patients received adequate loading doses of aspirin (300 mg) and clopidogrel (300 mg) or ticagrelor (180 mg) immediately after diagnosed as STEMI. Procedure of PCI was performed immediately via the femoral or radial access route. The characteristics of coronary angiography were record, such as culprit artery, acute occlusive segment and multi-vessel disease . A lesion was considered proximal if it was located proximal to the first diagonal branch in the LAD, the first obtuse marginal branch in LCX, or the first acute marginal branch in RCA .The usages of interventional techniques, thrombus aspiration and platelet glycoprotein IIb/IIIa receptor inhibitor were chosen at the operators’ discretion. The phenomenon of no reflow or slow flow post-stenting was record. Post-PCI blood pressure, including systolic blood pressure (SBP) and diastolic blood pressure (DBP), was detected by invasive blood pressure monitor from radial or femoral vascular sheaths.n = 315) and non-LAD related STEMI .Echocardiography was performed before discharge (4–6 days post-PCI) in all patients using a Philips IE33 instrument  with a 2–3.5 MHz transducer (X3-1), while left ventricular ejection fraction (LVEF) were detected by Simpson method. It was defined as reduced LVEF while LVEF less than 55 %. All exams were performed by one of three echocardiography operators. These three operators underwent standardized training before this study. Observers who detected LVEF were blinded to the results of coronary angiography and clinical record. The incidence of reduced LVEF after STEMI was compared between two different culprit artery systems, including LAD related STEMI . Stratification according to different risk subsets was also made by classification and regression tree (CART) analysis. All P-values were two-sided, and P < 0.05 was considered to indicate statistical significance.All statistical analyses were performed with SPSS software 19.0. Data were presented as the percentage or mean ± standard deviation (SD). P < 0.01) and higher incidence of reduced LVEF .A total of 553 STEMI patients enrolled with average age 64.0 ± 12.0 years. There were 447 men (80.8 %) and 106 women (19.2 %). The prevalence of hypertension and diabetes were 60.4 % (334 patients) and 48.8 % (270 patients), respectively. Culprit arteries of STEMI were 6 in LM, 309 in LAD, 63 in LCX and 175 in RCA, respectively. Baseline clinical and angiographic characteristics of patients with different culprit arteries were shown in Table In order to clarify the predictor difference for reduced LVEF in LAD system and non-LAD system groups, several clinical and angiographic predictors were analyzed by univariate analysis, shown in Table P < 0.01), proximal occlusion  and time to hospital  were major independent predictors for reduced LVEF in LAD system, while time to hospital , multi-vessel stenosis  and post-PCI SBP < 100 mmHg  in non-LAD system.Multivariate logistic analysis was performed to demonstrate the independent effect of these predictors  on the occurrence of reduced LVEF after STEMI, In this analysis, reduced LVEF (LVEF < 55 %) was employed as a dependent variable in both LAD and non-LAD system subgroups, while age > 65 years, multi-vessel stenosis, acute occlusion in proximal segment, time to hospital, post-PCI SBP <100 mmHg and post DBP <65 mmHg were set as independent variables, shown in Table In order to confirm the impact of predictors on reduced LVEF and simply the prediction process, CART analysis was also applied to assess the incidence of reduced LVEF after STEMI in multivariate subgroups. Reduced LVEF was employed as a dependent variable, while age > 65 years, male gender, stable angina history, diabetes, hypertension, culprit vessel (LAD system or non-LAD system), time to hospital >5 h, multi-vessel stenosis, occlusion in proximal segment, slow or no reflow, post-PCI SBP <100 mmHg and post DBP < 65 mmHg were set as independent variables. CART analysis results were shown in Fig. Acute myocardial infarction (AMI), which is mostly caused by coronary plaque rupture or erosion, could result in several clinical complications and impact cardiac prognosis , 13. RedP < 0.01). In order to clarify the difference of predictors between these two different culprit vessels, sub-group analyses and multivariate logistic analysis were also performed. We found that elder age, Time to hospital and proximal occlusion were critical for reduced LVEF in LAD related STEMI, while multi-vessel stenosis, Time to hospital and post-PCI blood pressure contributed most to reduce LVEF in non-LAD related STEMI.In this study, we confirmed the occurrence of reduced LVEF (LVEF < 55 %) in non-LAD related MI patients, although this prevalence was lower than that in LAD related MI group (26.9 vs. 53.7 %, De Luca G reported  that eldHypertension has also been one of well-established factors for increasing risk of cardiovascular diseases, such as acute myocardial infarction and heart failure . MeanwhiAs we know, reperfusion time to STEMI is one of the most important factors for short- and long-term cardiac prognosis . In our We should note some of our study’s limitations. First, the number of included patients was small size. Second, its retrospective nature limited its potency to clarify the cause relation between predictions and reduced LVEF. Third, the inclusion of LVEF in this study was only short-term data, therefore, long-term data will be needed to document the association between predictors and post-PCI LVEF. These limitations will be taken into account in our further clinical researches and prospective studies.Patients with LAD or non-LAD related STEMI could suffer reduced LVEF, while the clinical and angiographic predictors for the occurrence were quite different.


Accurate quantification of iron load is of importance in tailoring the therapy for patients with iron load disease. Magnetic resonance (MR) imaging is commonly used to assess iron load in different organs by calculating the T2* value. Estimation of precision and uncertainty of the obtained T2* value may be useful for determining changes in iron load between follow-up scans and for titration of treatment. Therefore, the purpose of this study was to develop and validate a new T2* analysis method, providing certainty estimates for quantification of iron load in heart and liver.The proposed method is a region of interest (ROI)-based algorithm which changes curve-fitting procedure based on the results from an initial T2* estimate using a 3-parameter, noise-corrected model. The certainty estimate, presented as the T2* value confidence interval, is derived from multiple sub-regions within the selected ROI. Except for ROI delineation, the proposed method does not require any user interaction.Phantom imaging was performed on a 1.5T system, with two clinically available multi-echo gradient-recalled echo sequences for cardiac and liver imaging. Phantoms were constructed to cover the clinically important range of T2*. A T2* single-echo gradient-echo sequence with TR set to 6 × T1 and a 50° flip angle was used as reference standard. Computer simulations were performed to assess accuracy and precision from 2 000 repetitions at SNR=15. Inter- and intra-observer variability was obtained in patients (n=22) by one experienced and one inexperienced observer.The phantom study showed bias and variability of 0.21 ± 2.19 ms (bias ± SD) and -0.16 ± 0.90 ms, for cardiac and liver sequences respectively (Figure The proposed method accurately quantifies T2*, also providing T2* certainty estimates. The algorithm is freely available for research purposes.The Swedish Heart-Lung Foundation; the Medical Faculty of Lund University, Sweden; Skane University Hospital Lund, Sweden; the Swedish Societies of Medicine, Radiology and Cardiology, Sweden; Region Scania, Sweden; the Swedish Research Council; Wellcome Trust, UK; British Heart Foundation, UK.


Mitral valve stenosis is a common manifestation of chronic rheumatic heart disease. The presence of spontaneous echo contrast in the left atrium and left atrial appendage has been reported to be an independent predictor of thrombo-embolic risk in patients with mitral stenosis. The objective of this study was to retrospectively investigate various clinical and echocardiographic variables to predict the spontaneous echo contrast in these patients.This is a bicentric retrospective study which includes 159 cases of symptomatic mitral stenosis from January 2011 to June 2012. All of the patients had transthoracic and transesophageal echocardiography. Patients who had significant mitral regurgitation (> Grade I), significant aortic valve disease, previous mitral valvulotomy and anticoagulation or antiplatelet therapy were excluded from the study. Our study population was divided into two groups based on the presence (Group I) or absence (Group II) of spontaneous echo contrast.Left atrial spontaneous contrast was present in 34.6% of cases. Patients in this group have more frequent atrial fibrillation (P = 0.001), larger left atrial area (P = 0.027) and diameter (P=0.023), smaller mitral valve area (P = 0.025), and higher mean transmitral diastolic gradient (p = 0.003) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean age (p = 0.38), duration of symptoms (p = 0.4) and left ventricular ejection fraction (p = 0.7) between patients with and without spontaneous echo contrast. On multivariate analysis, only mitral valve area and transmitral diastolic gradient  were found to be independently associated to the presence of spontaneous echo contrast.Patients with severe rheumatic mitral stenosis in atrial fibrillation or sinus rhythm have a higher risk of developing spontaneous echo contrast. These patients might benefit from prophylactic anticoagulation. The long-term outcomes can be ascertained in a study over a longer period and with periodic follow-up. Rheumatic fever primarily affects children in developing countries, especially where poverty is widespread. Globally, almost 2% of deaths from cardiovascular diseases are related to rheumatic heart disease, while 42% of deaths from cardiovascular diseases is related to ischaemic heart disease, and 34% to cerebrovascular disease ,2. RheumSpontaneous echo contrast (SEC) is an echogenic swirling pattern of blood flow caused by an increased ultrasonic back-scatter from aggregation of the cellular components of blood in conditions of blood stasis or low-velocity blood flow ,4. The iVarious factors determine individual risk for the development of spontaneous echo contrast in patients with rheumatic mitral stenosis, including mitral valve area (MVA) ,11,14,15Our study analyzes clinical and echocardiographic factors which have previously been implicated in the development of left atrial spontaneous echo contrast in a large population of patients with symptomatic rheumatic mitral stenosis. All of the patients were retrospectively examined by transthoracic and transesophageal echocardiograph.This bicentric retrospective study included 159 patients who had been admitted for symptomatic mitral stenosis in Avicenne University Hospital and Mohamed V Military Teaching Hospital in Rabat, Morocco, from January 2011 to June 2012. All of the patients had a clinical examination, EKG, transthoracic echocardiography, and transesophageal echocardiography. Patients who had significant mitral regurgitation (> Grade I), significant aortic valve disease, previous closed mitral valvulotomy and anticoagulation or antiplatelet therapy were excluded from the study.Transthoracic echocardiography measurements were LA dimension, LA area and mitral valve (MV) areas . All measurements were taken according to the recommendations of the American Society of Echocardiography . Transest-test was used for continuous variables and χ2-test for categorical variables, and values were considered significant when the P value was <0.05. Univariate, multiple logistic regression analysis was done for all variables to determine the factors that independently predict the presence of spontaneous contrast.Statistical Package for Social Sciences 10 was used to perform the statistical analysis. Quantitative variables were expressed as mean ± standard deviation. For comparison of measurements between Groups I and II, Student’s 159 subjects  were assessed over a 17-month period. All of them had severe rheumatic mitral stenosis with no significant mitral regurgitation. The mean age was 40.87 ± 12.19 years (range 11–75 years). A history of rheumatic fever was reported in 35.2% of patients. The disease was revealed by dyspnea and ischemic stroke in 87% and 4.4% of patients, respectively.Fifty-five patients had demonstrable spontaneous echo contrast (Group I) in the left atrium and left atrial appendage in 31 and 24 cases, respectively. Six cases of thrombus were detected in Group I. Table Compared to patients without SEC, patients with SEC have more frequent atrial fibrillation (P = 0.001), smaller mitral valve area (p = 0.025), high transmitral diastolic gradient , larger left atrium area (p = 0.023), and diameter (p = 0.027). The difference in left ventricular ejection fraction between two groups was not statistically significant (p = 0.7).Univariate analysis regression is presented in Table = 0.013) and transmitral diastolic gradient (p = 0.004) were found to be independently associated with the presence of spontaneous echo contrast in the left atrial and left atrial.However, as shown in Table In this retrospective study of patients with rheumatic severe mitral stenosis, we evaluated several clinical and echocardiographic variables which correlated with the presence of left atrial and left atrial appendage spontaneous echo contrast.The presence of spontaneous echo contrast has been reported to be an independent predictor of thrombo-embolic risk in patients with rheumatic mitral valve disease ,23,24. IOur patient population was younger with a female predominance, but there were no significant differences in age and gender between two groups. This could be explained by the method of recruitment, which was done at Mohammed V Military Teaching Hospital and whose patient population is primarily composed of young male soldiers and military wives. Studies by Deveral  and FatkP < 0.01), although their patient population was also younger. This was due to a referral bias compounded by the aggressive nature of disease in the Indian subcontinent and echocardiography performed later.Kewal et al.  demonstrThe duration of symptoms did not correlate with the presence of left atrial and left atrial appendage spontaneous echo contrast on multivariate analysis in our study. This may mean that stasis of blood in the left atrium occurs relatively early in patients with mitral stenosis. Stasis of blood has been widely thought to be responsible for the appearance of left atrial spontaneous echo contrast. A review of literature supports our results ,16-23.P < 0.0001). On multiple regression and discriminant function analysis, atrial fibrillation alone was found to be an independent clinical predictor of left atrial spontaneous echo contrast.Earlier studies -8 have oWe found that atrial fibrillation was positively correlated with the presence of spontaneous echo contrast. However, when all meaningful variables were included in multivariate analysis, this parameter was not significant, suggesting that other echographic variables, such as mitral valve area and diastolic gradient, had a more influential affect.In the present study, all patients underwent a routine transesophageal echocardiography following transthoracic echocardiography. We measured MV area using two methods, computed planimetry and pressure half time method.We found that left atrial size, mitral valve area and mean diastolic gradient were significantly correlated with the presence of left atrial spontaneous echo contrast. Yet, after multiple regression analysis, only mitral valve area and diastolic gradient  respectively, were found to be independently related to the presence of spontaneous echo contrast.2 in patients with SEC and 1.32 ± 0.45 cm2 in those without it. Black et al. [2 was predictive of SEC. Beppu et al. [2 with heavy SEC, 1.1 cm2 with mild SEC, and 1.5 cm2 with no SEC.Several studies have shown that spontaneous echo contrast (SEC) is increasingly prevalent with decreased mitral valve (MV) area. Kasliwal et al.  reportedk et al.  found thu et al.  classifi2 exposes the patient to a higher risk of developing spontaneous echo contrast. In contrast to previous studies conducted by Beppu et al. [In our study, it’s possible that a mean mitral valve area of 0.91 ± 0.23 cmu et al. , we have2.The mitral diastolic gradient was the second independent variable found to be an independent predictor of SEC in our patients, with a mean of 13.91 ± 5.43 cmThis data could be attributed to the fact that all of our patients had severe mitral stenosis, without associated regurgitation, and were already with high risk for formation of spontaneous echo contrast.2; p < 0.02). They conclude that, in the left atrium in patients with mitral stenosis and normal sinus rhythm, spontaneous echo contrast is common and is associated with a significantly smaller mitral valve area and higher mitral gradient. Conversely, Kewal et al. [An earlier study conducted by Bernstein et al.  supportsl et al.  reportedFinally, it must be said that left atrial and left atrial appendage spontaneous echo contrast was an important predictor of systemic embolization ,23,24 in2 and a high transmitral diastolic gradient of 13 mmHg were independent predictive of spontaneous echo contrast in the left atrium and left atrial appendage. It’s possible that these patient although normal sinus rhythms have a higher risk to develop spontaneous echo contrast, and might benefit from prophylactic anticoagulation. The application of this data to clinical practice will require a larger sample size, longer study duration, and follow up.We concluded that in patients with rheumatic mitral stenosis, a small mitral area of 0.9 cmThe study was retrospective, with short duration. The discriminate function analysis was not used. Measures of thromboembolic risk like left atrial appendage size, and filling and emptying velocities were not studied. Since the relation of spontaneous echo contrast with systemic embolic event was not the objective of our study. A larger prospective study with longer duration and follow up could probably address.A written informed consent was obtained from all patients for the publication of this paper.The authors declare that they have no competing interest.HS participated in the sequence alignment and drafted the manuscript. AO participated in the sequence alignment and drafted the manuscript. NM participated in the sequence alignment and drafted the manuscript. MS participated in the sequence alignment and drafted the manuscript. AB participated in the sequence alignment and drafted the manuscript. EZ participated in the sequence alignment and drafted the manuscript. LK participated in the sequence alignment and drafted the manuscript. participated in the sequence alignment and drafted the manuscript. NE participated in the sequence alignment and drafted the manuscript. All authors read and approved the final manuscript.


Right ventricular (RV) myocardial infarction and subsequent dysfunction complicating STEMI is independently associated with a higher mortality. Emerging research suggests that mechanisms for RV dysfunction may be different than those governing left ventricular dysfunction. The relationship between DM and RV dysfunction is currently unknown. The primary purpose of this study was to determine whether DM is an independent predictor for the development of right ventricular dysfunction.The World Health Organization estimates that diabetes mellitus (DM) affects 347 million people worldwide and will be the 7106 patients post primary percutaneous coronary intervention for STEMI were enrolled in this study between the years 2009-2013. Each patient had a cardiac MRI done on a on a 1.5T scanner within 48-72 hours of admission. Cardiac function was determined using contiguous short axis slices covering the left and right ventricle acquired with a standard SSFP sequence. RV dysfunction was defined as an MRI derived RVEF <50%. Univariate analyses were performed using the chi square, fisher's exact test, t-test, or Wilcoxon rank sum test as appropriate. Subsequently, multivariable logistic regression analysis was done in order to determine if the presence of DM was independently predictive of RV dysfunction. Predictor variables with a p value <0.25 in the univariate analysis were included in the multivariable model.Median age of our entire patient population was 58 years . 30% of the patients had diabetes, 44% had hypertension, 42% were active smokers and 32% had dyslipidemia. Out of 99 patients for which RV data was available, 40 had RVMIs and 59 did not (see Table The presence of DM is an independent predictor for the development of RV dysfunction post STEMI. In fact, its presence was associated with an approximately 3 fold greater odds of developing RV dysfunction. No other major cardiovascular risk factors were independently associated with the development of RV dysfunction in our cohort.Research support for this project was provided by GE healthcare and the Ontario Research Fund.


However, if images with incremental T2Prep duration are acquired in a sequential fashion, irregular breathing patterns and heart rates may adversely affect the quality of the T2 maps due to misalignment of the source images. A logical alternative is then to acquire all images in an alternating manner , with the possibility to apply the T2Prep durations of 60/30/0 ms in both an alternating and sequential manner. Bloch equation simulations were performed in order to estimate the fitting residual due to T1 relaxation  as well as the accuracy over a range of heart rates. The sequences were validated at 3T  in agar-NiCl2 phantoms by comparing the resulting T2 maps to gold-standard spin-echo (SE) T2 measurements. A mid-ventricular short-axis T2 map was then acquired with both pulse sequences in 7 healthy adult volunteers. The myocardial surface area was measured in the T2 maps, while a Student's t-test was applied to detect differences in T2 values and surface area.A navigator-gated ECG-triggered radial gradient-recalled-echo pulse sequence  was implemented to obtain source images for the T2 = 45.4 ± 0.7 ms for the alternating method, vs 45.3 ± 0.7 ms for the sequential method and 45.1 ± 0.7 ms for the gold-standard). The myocardial surface area was increased in the alternated T2 maps of the volunteers  .The alternating sequence was as robust to heart rate variation as its sequential counterpart Figure , while i2 mapping methodology in which magnetization preparation is alternated. The in vivo T2 maps demonstrate that the alternated acquisition intrinsically aligns its sources images, resulting in a larger available myocardial surface, which in turn may allow for more accurate T2 value quantification.We successfully implemented and tested a TN/A.


The purpose of this study was to evaluate the discriminant power of these non-invasive parameters in identifying elevated LV end-diastolic pressure (LVEDP) (i.e. LVEDP≥15ml) and provide a non-invasive index to predict elevated LVEDP.Echocardiographic tissue Doppler or magnetic resonance imaging (MRI) measurements of early diastolic mitral annular velocity with other appropriate parameters are frequently used as a non-invasive diagnostic tool of diastolic dysfunction. Previously published global approach utilizing normalized left ventricular (LV) torsion shear angle volume loop  curve and expressed as its sensitivity, specificity, accuracy and area under the curve (AUC).A group of 23 patients with LV ejection fraction≥50% without acute infarct undergoing cardiac catheterization that did not undergo percutaneous coronary intervention were studied using high-fidelity pressure measurement. Echocardiogram with flow and tissue Doppler quantification was performed on the same date of cardiac catheterization for all participants. Cine and tagged cardiac MRI were performed on all subjects, followed by comprehensive volumetric and strain analysis. The database consisted of five parameters collected from all subjects: torsion hysteresis area (THA), peak -dφ_hat/dV_hat at early diastole, has the highest chi-square score of 2.45 (p=0.12), indicating it as the best discriminator compared with others. All other variables had chi-square score<1 and p value>0.4. Stepwise selection chose peak peak -dφ_hat/dV_hat at early diastole, at early diastole, THA and echo measured E/A to construct the logistic regression model (Table Among all parameters, peak -d2.45 p=0.2, indica2.45 p=0.2, indica2.45 p=0.2, indicaφ_hat/dV_hat at early diastole was the best discriminator compared with other non-invasive measures in identifying elevated LVEDP. Moreover, by combining THA, peak -dφ_hat/dV_hat at early diastole and echo measured E/A through stepwise selection, the logistic regression model can identify LVEDP≥15ml with great accuracy, indicating that these parameters are determined by different factors and together, they are able to predict diastolic dysfunction non-invasively.MRI derived global parameter peak -dNIH NHLBI R01-HL104018.