Although the benefits of sodium–glucose cotransporter 2 inhibitors (SGLT2i) on cardiovascular events have been reported in patients with type 2 diabetes mellitus (T2DM) with or without heart failure (HF), the impact of SGLT2i on cardiac remodelling remains to be established.We searched the PubMed, Embase, Cochrane Library and Web of Science databases up to November 16th, 2020, for randomized controlled trials reporting the effects of SGLT2i on parameters of cardiac structure, cardiac function, plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) level or the Kansas City Cardiomyopathy Questionnaire (KCCQ) score in T2DM patients with or without chronic HF. The effect size was expressed as the mean difference (MD) or standardized mean difference (SMD) and its 95% confidence interval (CI). Subgroup analyses were performed based on the stage A–B or stage C HF population and HF types.2 = 0%), and did not affect the global longitudinal strain in the overall analysis including stage A–B HF patients. SGLT2i showed benefits in the E/e’ ratio , plasma NT-proBNP level , and the KCCQ score  in the overall population.Compared to placebo or other antidiabetic drugs, SGLT2i showed no significant effects on left ventricular mass index, left ventricular end diastolic volume index, left ventricular end systolic volume index, or left atrial volume index. SGLT2i improved left ventricular ejection fraction only in the subgroup of HF patients with reduced ejection fraction (MD 3.16%, 95% CI 0.11 to 6.22, p = 0.04; IThe use of SGLT2i was associated with significant improvements in cardiac diastolic function, plasma NT-proBNP level, and the KCCQ score in T2DM patients with or without chronic HF, but did not significantly affect cardiac structural parameters indexed by body surface area. The LVEF level was improved only in HF patients with reduced ejection fraction. Heart failure (HF) is one of the leading causes of morbidity and mortality worldwide. Type 2 diabetes mellitus (T2DM) can cause diabetic cardiomyopathy, which typically manifests first as left ventricular hypertrophy, diastolic dysfunction, and impaired systolic reserve before gradually showing clinical indications of heart failure with preserved ejection fraction (HFpEF), followed by systolic dysfunction and heart failure with reduced ejection fraction (HFrEF) . T2DM alThe effects of sodium–glucose cotransporter 2 inhibitors (SGLT2i) on the prognosis  of T2DM –9 patienCardiac anatomical and functional parameters partially predict the prognosis and quality of life of patients with T2DM and patients with HF and serve as important surrogate endpoints. Experiments in rodent T2DM models revealed the benefits of SGLT2i on left ventricular hypertrophy  and dilaRecent clinical studies have also reported conflicting results. In T2DM patients, the DAPA-LVH trial showed that SGLT2i reversed left ventricular hypertrophy compared to placebo , but theTo make better use of up-to-date clinical evidence, we conducted this meta-analysis to further clarify the effect of SGLT2i on cardiac structure, cardiac function, plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) level and the Kansas City Cardiomyopathy Questionnaire (KCCQ) score in T2DM patients with or without chronic HF. Subgroup analyses were performed based on the stage A–B or stage C HF population and HF types.This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines .We systematically searched PubMed, Embase, Cochrane Library and Web of Science databases up to November 16th, 2020, using specific MeSH terms and random words with no restriction of language or publication status. The inclusion criteria were as follows: (1) reported the effect of SGLT2i in adult T2DM patients (≥ 18 years) with or without chronic HF; (2) placebo or other antidiabetic agents were accepted as comparison; (3) reported the outcomes of interest; (4) was an RCT; and (5) had complete data for extraction. Observational studies, single-arm studies, studies in acute heart failure patients and studies with a sample size of < 10 were excluded. The reference lists of eligible studies and related articles were reviewed manually to identify additional studies. The main search was conducted on April 21st, 2020, and the supplementary search was performed before data analysis with the same strategy in case of omission. We also sent data request letters by email to the authors of articles with insufficient data for analysis. In the case of two independent reports of the same study, only the one with more complete data was included. Searching details and the flow diagram (including the exclusion criteria) are available in Additional file The extracted data included (1) general information: title, author, publication year, trial name, eligibility and the reasons; (2) clinical information: age, sex, country or area of the participants; specific agent of the SGLT2 inhibitor given to the experiment group; therapy for the control group; whether the participant was diagnosed as HF at baseline; HF types by reduced or preserved ejection fraction; (3) data for overall effect size calculation: the sample size of each group, as well as the mean value and standard deviation (SD) of the change of outcomes before and after treatment in each group; and (4) methodological information. Data were extracted from the main article reporting the included studies, related articles reporting the same study, and the study registry websites. T2DM patients with an established diagnosis of HF was classified as stage C HF, and those without were classified as stage A–B HF.We used the revised Cochrane risk-of-bias tool to assess the quality of the RCTs  to formulate the evidence profile table.We assessed the certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation (GRADE) approach. We used the Guideline Development Tool  independently, and disagreements were resolved by consensus.The outcomes of this meta-analysis were (1) cardiac anatomic changes including left ventricular mass indexed by body surface area (LVMI), left ventricular end-diastolic volume indexed by body surface area (LVEDVI), left ventricular end-systolic volume indexed by body surface area (LVESVI), and left atrial volume indexed by body surface area (LAVI); (2) cardiac functional changes including LVEF, GLS, and the mitral inflow to mitral relaxation velocity ratio (E/eʹ); (3) changes in plasma NT-proBNP level; and (4) the KCCQ score, or the score of any scale in the questionnaire including the symptom section.2 statistics. Sensitivity analyses included heterogeneity analysis using the leave-one-out method, analysis of only high-quality studies, and analysis of only studies using placebo as the control group. Subgroup analyses were performed if each subgroup contains two or more studies, basing on the stage A–B or stage C HF population and the LVEF level in stage C HF patients. All analyses were performed using Review Manager software version 5.4 (The Cochrane Collaboration), R version 3.6.1 , and STATA software version 15.0 .All the variables of interest were continuous and expressed as the mean ± SD. Data reported as the median and interquartile range were transformed to the mean and SD according to the methods suggested by McGrath  and Wan A total of 21 RCTs , 39–52 w2, 95% CI − 2.69 to 0.77, p = 0.27; I2 = 23%)        , but was insignificant in HFpEF patients   but not in stage C HF population   and HFpEF  groups  but not in stage A–B HF population   but not in the HFpEF subgroup   SGLT2i showed no significant effects on LVMI, LVEDVI, LVESVI, and LAVI; (2) SGLT2i improved LVEF in HFrEF patients but not in HFpEF patients or stage A–B HF patients with T2DM, and showed no significant effects on GLS in stage A–B HF patients with T2DM; (3) SGLT2i reduced the E/e’ ratio in the overall population and stage A–B HF patients but not in stage C HF patients; (4) SGLT2i improved the plasma NT-proBNP level in the overall population and stage C HF patients, and showed no significant results in stage A–B HF patients; and (5) SGLT2i improved the KCCQ score in stage C HF patients with T2DM.2 = 0%). The inconsistency in the results of SGLT2i regarding LVM and LVMI may be attributed to the concomitant effect of weight loss, which was also observed in studies included in our analysis and a previous meta-analysis [. [Our searching and analysis results on the LVM, LVEDV, and LVESV were the same as those reported in a recently published meta-analysis , thus weanalysis , 39, 54.lysis [. , showinglysis [.  as well lysis [.  in stageTaken together, the results of the overall and subgroup analyses suggested that SGLT2i significantly reduced LVEF in HFrEF patients but not in HFpEF patients, showing benefits in patients with obvious systolic dysfunction. However, the results in HFrEF subgroup suffered from a low certainty in the GRADE evidence profile, calling for more future studies in the population. The effect of SGLT2i on GLS, a more sensitive parameter reflecting even mild systolic dysfunction –59, was The use of SGLT2i significantly reduced the plasma NT-proBNP level in the stage C HF population. However, the effect on NT-proBNP level between the SGLT2i and control group was − 333 pg/ml in the T2DM subgroup in the DAPA-HF trial   , EMPA-HEWe found in this meta-analysis that SGLT2i improves the parameters of cardiac diastolic function, plasma NT-proBNP level, and the KCCQ score in T2DM patients with or without chronic HF, but did not significantly affect cardiac structural parameters indexed by body surface area. The LVEF level was improved only in HF patients with reduced ejection fraction. Future studies are anticipated to further elucidate the mechanisms and intermediate links in the effect of SGLT2i.Additional file 1: Data S1. Strategy for the main search conducted on April 21st, 2020.Additional file 2: Figure S1. Quality assessment of RCTs using the revised Cochrane risk-of-bias tool. (a) Risk of bias graph; (b) Risk of bias summary.Additional file 3: Figure S2. Funnel plots for publication bias assessment. (a) LVMI; (b) LVEDVI; (c) LVESVI; (d) LAVI; (e) LVEF; (f) GLS; (g) E/e’; (h) NT-proBNP; (i) KCCQ.Additional file 4: Figure S3. Subgroup analyses of the effects of SGLT2i on (a) LVEF in HFrEF vs. HFpEF patients; (b) E/e’ in HFrEF vs. HFpEF patients; (c) NT-proBNP in HFrEF vs. HFpEF patients. Abbreviations: SGLT2i: sodium-glucose cotransporter 2 inhibitors; HFrEF: heart failure with reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction; LVEF: left ventricular ejection fraction; E/e': mitral inflow to mitral relaxation velocity ratio; NT-proBNP: N-terminal pro-brain natriuretic peptide.


P < 0.0001). There is also a linear correlation (either positive or negative) with EF and transferrin; no established relationship related to the sex of the patients was found. Patients with elevated serum TLR4 at baseline also exhibited an increase in serum transferrin levels and Dox-induced left ventricular dysfunction with a decreased EF (< 50%); this phenomenon was observed in 7 of 25 patients (28%) at the 6-week follow-up. There were no significant differences or correlations based on sex. We concluded that there is a direct relationship between Dox-induced CTX (indicated by elevated serum TLR4) and the times (ms) for T2* (decreases in which correspond to immediate and rapid iron overload).Although doxorubicin (Dox) is an effective antitumor antibiotic in the anthracycline class, it often induces the undesirable side effect of cardiomyopathy leading to congestive heart failure, which limits its clinical use. The primary goal of this study is to evaluate a reliable translational method for Dox-induced cardiotoxicity (CTX) screening, aiming to identify a high-risk population and to discover new strategies to predict and investigate this phenomenon. Early identification of the presence of iron deposits and genetic and environmental triggers that predispose individuals to increased risk of Dox-induced CTX ) will enable the early implementation of countermeasure therapy, which will improve the patient’s chance of survival. Our cohort consisted of 25 consecutive patients with pathologically confirmed cancer undergoing Dox chemotherapy and 12 control patients. The following parameters were measured: serum TLR4 (baseline), serum transferrin (baseline and 6-week follow-up) and iron deposition (baseline and 6-week follow-up). The average number of gene expression units was 0.121 for TLR4 (range 0.051–0.801). We subsequently correlated serum TLR4 levels in our cohort with myocardial iron overload using the cardiac magnetic resonance (CMR) T2* technique, the ventricular function  and serum transferrin levels. There is a strong negative linear relationship between serum TLR4 and CMR T2* values (r =  − 0.9106, **** However, Dox also induces cardiomyopathy leading to congestive heart failure, thus often limiting its clinical useCardiotoxicity (CTX), including subclinical, acute and late-onset CTX, is a well-known adverse effect of many antitumor agents. Early identification of patients with risk factors associated with CTX is important to ensure prompt clinical intervention and to minimize toxic effects from the antitumor drug.2.To maximize the benefits of anthracyclines, a high-risk population needs to be identified, and new strategies to predict and investigate this phenomenon need to be developed for monitoring patients and minimizing toxic side effects4.The etiology of chemotherapy-induced cardiotoxicity (CIC) is multifactorial. Actual traditional methods used in our daily clinical practice to assess for CIC typically include serial measurements of cardiac function and parameters via multimodality imaging techniques, of which the most commonly used is 2D echocardiography to assess the left ventricle ejection fraction (LVEF)5.Several Toll-like receptors (TLRs) are expressed in cardiomyocytes, including TLR2 and 4. Through these TLRs, cardiomyocytes can respond to endogenous or exogenous signals that influence pathophysiological responses to dilated cardiomyopathy. Human TLR4 was among the first mammalian Toll-related proteins to be described and is secreted from the endoplasmic reticulum. The expression or activation of TLR4 is upregulated in experimental models of cardiomyopathy and in patients with hypertension and/or clinical heart failure6.TLRs are members of the interleukin-1 receptor family (IL1) and are involved in the ability to react to molecular triggers associated with pathogenic microorganisms. Recent studies have shown that TLRs are activated by endogenous signals, such as heat shock proteins and oxidative stress, which can contribute to congestive heart failureDuring the inflammatory response, TLRs recognize pathogens associated with molecular patterns such as lipopolysaccharides, peptidoglycan, bacterial lipoproteins and oligonucleotides.7. Moreover, TLRs are expressed in different organs, such as the lung, brain, kidney, and heart8.Intracellular signaling pathways of TLRs are similar to IL1-like pathways and lead to the nuclear localization of the nuclear factor (NF) kb/Rel-type6. These studies also indicate that free radicals play an important role in Dox-induced CTX.Oxidative stress is one of the major effects in Dox-induced cardiac dysfunction. In a previous study, we hypothesized and showed that TLRs contribute to the pathogenesis of Dox-induced cardiac dysfunction via an inflammation-induced mechanism9, which might drive future research in this field.We must also keep in mind that the TLR family was recently demonstrated to play an important role in ventricular remodeling after myocardial infarction as well as in cardiac specificity11.Adult men and women have approximately 3.5 g and 2.3 g of total body iron, respectively. This iron is dispersed in various organ systems: approximately 65% and 75% are bound to circulating hemoglobin, 22% and 12% are deposited in liver (ferritin and hemosiderin), and 2.9% and 4.6% are bound to various enzymes. For both sexes, approximately 10% of iron is coupled with myoglobin, which is an oxygen-binding protein located in muscle tissue, and only a small percentage of red blood cells bound to transferrin was observed in men (0.1%) and in women (1.3%)12.During the processes of infection and inflammation, serum ferritin levels are frequently within the normal range (> 12 μg/L and < 100 μg/L), and iron deficiency can only be excluded by an equivalent measurement of soluble transferrin receptor and at least two acute phase proteins—C-reactive protein and α-1-acid glycoproteinWe define iron overload as increased serum ferritin levels (> 200 μg/L in men and > 150 μg/L in women) and transferrin saturation > 50%.The main reason for strict iron regulation is that elemental iron is a highly effective pro-oxidant; as such, its free form stimulates the formation of free radicals, which are very distressing  to cell membranes, intracellular components and macromolecules.13. Additionally, in support of this connection, suppressing the iron metabolism master regulator IREB2 (iron-responsive element-binding protein 2) decreases sensitivity to ferroptosis14. To better understand these interrelationships, we specify that the IREB2 gene is involved in encoding the iron-responsive element-binding protein (IRP), which controls the expression of proteins involved in iron metabolism  and the heavy and light ferritin chains . IREB2, similar to IREB1 (100880), has differing functions in iron-deficient and iron-replete states16. In a study involving a mouse model, controlled targeted disruption of the Ireb2 gene was followed by dysregulation of iron metabolism in the intestinal mucosa and onset of a de novo neurodegenerative disease 17.Iron itself is a key element required for the intracellular accumulation of lipid peroxide molecules and for the initiation of the ferroptosis cascade. Thus, the import, export, storage, and turnover of iron has an important impact on ferroptosis sensitivity. Transferrin and transferrin receptors, which function in iron import from the extracellular environment, are mandatory for the ferroptosis processNonapoptotic forms of cell death can trigger a systemic inflammation cascade process through the release of danger-associated molecular patterns (DAMPs), which are recognized by innate immune receptors (IIRs).19.Dox-based chemotherapy drugs have an effect on cancer cells by essentially intercalating the target DNA and by disrupting and/or inhibiting topoisomerase II function20. Ferroptosis is dependent upon intracellular iron but not upon other metals and is considered morphologically, biochemically and genetically distinct from apoptosis, necrosis and autophagy14.Ferroptosis is a recently discovered form of programmed cell death that occurs via lipid peroxidation caused by iron accumulation22. The precise cell death pathways and signaling events that orchestrate early inflammation after heart transplantation are unknown, as is anthracycline-induced CTX (Dox in particular). Both processes share a similar, if not identical, cardiovascular response 22.Recent animal studies have provided new data and conclusions that ferroptotic cell death triggers initial inflammatory responses after heart transplantation. It is further postulated that nonapoptotic forms of programmed cell death, such as necroptosis or ferroptosis, result in the release of DAMPs that ultimately result in the initiation of the inflammatory, which is referred to as necroinflammationDox thus plays an important role in this scenario, both directly by activating TLR4-dependent events  and indirectly via the inflammatory cascade generated by DAMPs. The common element in all these scenarios is intracellular iron loading.23. LVEF can be calculated based on multigated acquisition (MUGA) radionuclide angiocardiography, echocardiography, or cardiovascular MRI.The common clinical parameter indicative of subclinical CTX is usually outlined on cardiac imaging as clinically asymptomatic left ventricular systolic dysfunction (LVSD) with a decrease in the LVEF by > 10% and an overall EF < 50%24.However, there is no clear consensus for the definition for early cardiac injury or any other imaging biomarkers beyond those associated with functional assessment. Cardiovascular MRI may identify additional biomarkers that could facilitate a more sensitive and specific identification of CTXRecent developments in techniques to assess cardiac function include not only qualitative techniques for tissue level differentiation  but also quantitative approaches .26.Several studies have determined that screening for CTX by assessing the EF may be inadequate to detect subclinical disease. Thus, more sensitive methods for the assessment of cardiac structure and function, such as MRI, biomarkers and genetic screening, have a stronger ability to detect the subclinical forms of CTXThis study was an analytical, multicenter prospective study that took place between 2018 and 2019.Our cohort included 25 consecutive patients aged 18–65 years old who received Dox treatment for hematological malignancies  with a survival probability > 6 months and an LVEF > 50% and who provided written informed consent. Exclusion criteria consisted of previous anthracycline therapy, previous radiotherapy, history of heart failure or chronic renal failure, atrial fibrillation or other significant arrhythmias, pregnancy and any past medical history involving iron deficiency or accumulation (including an extended period of iron supplementation).A peripheral blood sample was drawn from all patients who were in the fasting state to assess serum TLR4 gene expression and serum transferrin levels. Gene expression was assessed by qRT-PCR using the following steps: blood collection (3 ml), RNA isolation, cDNA reverse transcription, qRT-PCR and quantification of the relative expression. Patient blood was drawn directly into a Tempus Blood RNA Tube (4342792 Applied Biosystems). Serum transferrin levels were also quantified at follow-up (3 and 6 weeks). A schematic of the whole process is illustrated in Fig. .Figure 1At enrollment, all patients were clinically evaluated, and a CMR examination was performed. The CMR parameters determined were those of LV systolic function (EF%) and T2* determination of iron overload in a specific septal region of interest (ROI) .P value < 0.05 was considered statistically significant.Statistical analysis of potential risk factors and correlations (direct or indirect) with the development of early cardiomyopathy as a function of Dox-induced CTX was conducted. Statistical analyses were performed using GraphPad Prism version 8.0.0 for Mac OS X . Continuous (numeric) variables were expressed as the means ± standard deviation (SD) or medians [quartiles] if not normally distributed; by contrast, categorical variables were reported as counts and percentages. Descriptive and inferential statistical analysis methods were used. Correlations between variables were calculated using the simple Pearson correlation coefficient. All tests were two-tailed, and a Following the application of these tests, the main parameters of interest for our study were discussed, and the conclusions were established based on the values of the parameters in question.6.Tempus Blood RNA tubes were used to collect peripheral human blood samples . Each tube contained 6 ml of stabilizing reagent that ensured RNA stabilization for 4 to 5 days at room temperature or for a minimum of 7 days at 4 °C. RNA was isolated within three days of collection. In each tube, 3 ml of peripheral venous blood was collected from patients−127.After isolation, the RNA quantity and quality were measured using a NanoDrop 1000 Spectrophotometer (Thermo Scientific). Before using RNA samples in subsequent experiments, the integrity of the RNA was assessed by running aliquots of the RNA sample on a denaturing agarose gel spiked with ethidium bromide. Only samples that showed clear 28S and 18S rRNA bands were used in cDNA reactions. For cDNA synthesis, we used High Capacity cDNA Reverse Transcription Kits  according to the manufacturer’s instructions, and the concentration of the RNA template was 25 ng μlFor qRT-PCR, we used a LightCycler 480 SYBR Green I Master kit and a Thermocycler-µl Light Cycler 480. The primers used were as follows: TLR4, forward TTGAGCAGGTCTAGGGTGATTGAAC and reverse ATGCGGACACACACACTTTCAAATA and GAPDH, forward GCACCGTCAAGGCTGAGAAC and reverse TGGTGAAGACGCCAGTGGA .https://www.ncbi.nlm.nih.gov). The primer concentration for qRT-PCR was 10 ng/µl, and 5 µl from cDNA solution was used for each reaction. All samples were assessed in triplicate. Following qRT-PCR, the samples were verified by agarose gel electrophoresis. The data were analyzed using Light Cycler 480 Software, Basic/Advanced Relative Quantitation program 6.The primer sequences were verified using Primer-BLAST at the National Center for Biotechnology Information  were calculated using the 2-∆∆Ct method, which were considered significant when the mRNA levels varied by a factor of more than 1.8.The T2* values from the ROIs at the mid-left ventricle by the 1.5 T CMR unit for chemotherapy patients and healthy controls were assessed at baseline and at 6 weeks after treatment initiation. The LVEF was also quantified.28.T2* quantification was performed in myocardium assessed by a breath-hold and ECG-triggered, spoiled gradient echo sequence with multiple echoes; T2* mapping was performed with a breath-hold multislice gradient echo sequence. A full-thickness ROI was measured in the LV myocardium in both epicardial and endocardial regions. This ROI was located in the septum distant from the cardiac veins, which reduced the sensitivity for obtaining artifacts29.We used this approach as a predetermined standard that hinged on the hypothesis that changes in CTX are represented by the decrease in the EF < 50% or a decrease by more than 10% of the determined initial valueSerum transferrin concentration was determined using an Axsymanalyzer . The assays were performed according to the manufacturer’s instructions.All methods were performed in accordance with the relevant guidelines and regulations enforced from the time of study enrollment to the publication of the data obtained. Subjects provided written informed consent, which was obtained before enrollment in the study.2, and the Dox clearance was 1442 ± 111 ml/min/m2.A total of 25 consecutive oncological patients were included in this study. Subjects in the study and control groups were well matched for age and sex distribution. Out of the 25 patients, 13 (52%) were males and 12 (48%) were females. The mean age was 57.3 years, the mean dose of Dox administered ranged between 100 and 250 mg/mThe main demographic and clinical characteristics are presented in Table The average number of gene expression units for TLR4 was 0.121 (range 0.051–0.801). The mRNA levels of target genes were normalized to that of GAPDH; the result is presented as relative gene expression. The mean quantity of mRNA extracted was 113.571 ng/µl , where r = maximum simple correlation coefficient (Pearson). There is also a linear correlation (either positive or negative) with EF and transferrin; however, there is no established relationship related to the genetic sex of the patients. The main TLR4 correlations are presented in Table There is a strong negative linear relationship between TLR4 expression and CMR T2* values  with the 6-week levels(108 ± 40.13 ηg/ ml). There was no sex-based significant difference or correlation for this evaluated parameter  were significantly correlated .Regarding baseline myocardial iron levels and CMR assessment, in accordance with the normal range of myocardial T2* , parameters of ventricular function  fell within the normal confidence values (23 ± 1.97 ms)Dox-induced LV dysfunction with a decreased EF (< 50%) was found in 7 of 25 patients (28%) at the 6-week evaluation compared to that at the baseline evaluation, where only 2 patients presented a borderline EF% (55% and 54%)  for TLR4 expression and a large increase in transferrin levels .22. The pathophysiological mechanisms that trigger cardiomyocyte dysfunction secondary to an iron overload process; however, are partially unknown . Endotoxin represents, in this case, a reasonable scenario comprising a key component for Gram-negative bacteria and a ligand of TLR435. It is possible that this molecule will directly elevate the level of TLR4 in macrophages, resulting in stronger inflammatory responses to endotoxin and more severe damage to various organs.Furthermore, Dox was found to upregulate the expression of TLR2 and TLR4 in cardiomyocytes36. However, until now, these biomarkers have not proven to be practical as anthracycline-induced CTX screening and management tools.Typically, significant LV dysfunction (more than 10% decrease for LVEF) has already occurred when CTX is detected by imaging techniques . Biomarkers, most importantly cardiac natriuretic peptides and troponins, are promising markers for identifying patients potentially at risk for symptoms relating to clinical heart failure37.Specifically, troponin was mainly demonstrated as a marker after administration of antineoplastic and β-sympathomimetic drugs, although routine use of these markers in monitoring patients receiving anthracycline therapy is far from being solvedPre-existing comorbidities  or unhealthy lifestyles  have long been known to increase the risk of CTX in patients scheduled to receive anthracyclines and were thus determined and analyzed within our batch study.In our daily medical practice, identifying patients at increased risk of CTX is extremely important.It should be noted that there is also a large individual variability of anthracycline sensitivity for each patient.38.The term ferroptosis was first introduced in 2012 and was used to describe the form of cell death induced by a small molecule named erastin, which inhibits the import of cystine, leading to glutathione depletion and inactivation of the phospholipid peroxidase glutathione peroxidase 4 (GPX4)Our observations imply that endogenous substances released during ferroptotic cell death plays a key role in triggering TLR4 signaling in endothelial and cardiomyocyte cells. It is also more likely that ferroptosis results in the release of multiple DAMPs and other alarmin molecules that are recognized by a variety of cells within the heart, including immune cells, endothelial cells, and fibroblasts, thus triggering a cascade of interconnected and mutually amplified inflammatory phenomena Fig. . It has 39.Normally, iron overload occurs due to either increased supplementary gastrointestinal absorption or secondary to repetitive blood transfusions. Humans do not have a specifically adapted mechanism for excreting excess iron, which is usually deposited as crystalline iron oxide within ferritin and hemosiderin. The etiology of iron overload has consequences for iron tissue distribution. As an example, in hereditary hemochromatosis, iron is transported from the intestine to the liver via the portal vein (as transferrin) to be deposited in periportal hepatocytes. In other severe diseases with iron overload, iron is deposited in the pancreas and endocrine organs, especially in the heartP < 0.0001) as a general reflection of an inflammatory process ).The data obtained from our study align with these facts, demonstrating a colinear interrelationship between TLR4 receptor expression and transferrin  for increased genetic expressiveness of TLR4. Upon further exploring this relationship and causality, we deepened the correlation and analysis of the data and also found a decrease in T2* values (which reflects the iron load and cardiac sequestration and the onset of immediate cardiac dysfunction following treatment with Dox). By performing an in-depth evaluation of these cases, we determined that these changes corresponded to patients who initially expressed an increased TLR4 value (well above average) and a large increase in Transferrin ..If we draw an even wider parallel at the level of TLR4 gene expression, and T2*, we see that there is a direct relationship reflected by an above average expressive level of the increased base of TLR4 and an above average decrease in times (ms) for T2*, which corresponds to immediate and rapid iron loading as a consequence of Dox treatment)Our study showed a strong significant curvilinear correlation between genetic TLR4 expression and myocardial T2* (as obtained with the CMR technique) corresponding to iron overload in the heart as an immediate side effect of Dox treatment (most likely) through various mechanisms of action but with common effects.EF, as an accepted marker of CTX, is also correlated in the whole table of the studied parameters, showing direct relationships with both TLR4 and T2*.Risk stratification of Dox treatment with parameters already available to us can prove its usefulness in predicting the risk (immediate or acute) for the development of CTX as soon as possible; furthermore, more careful clinical follow-up and the initiation of possible treatments to counteract CTX can be implemented if screenings are conducted early in the disease course.


Traumatic brain injury is a common cause of disability worldwide. In fact, trauma is the second most common cause of death and disability, still today. Traumatic brain injury affects nearly 475 000 children in the United States alone. Globally it is estimated that nearly 2 million people are affected by traumatic brain injuries every year. The mechanism of injury differs between countries in the developing world, where low velocity injuries and interpersonal violence dominates, and high-income countries where high velocity injuries are more common. Traumatic brain injury is not only associated with acute problems, but patients can suffer from longstanding consequences such as seizures, spasticity, cognitive and social issues, often long after the acute injury has resolved. Spasticity is common after traumatic brain injury in children and up to 38% of patients may develop spasticity in the first 12 months after cerebral injury from stroke or trauma. Management of spasticity in children after traumatic brain injury is often overlooked as there are more pressing issues to attend to in the early phase after injury. By the time the spasticity becomes a priority, often it is too late to make meaningful improvements without reverting to major corrective surgical techniques. There is also very little written on the topic of spasticity management after traumatic brain injury, especially in children. Most of the information we have is derived from stroke research. The focus of management strategies are largely medication use, physical therapy, and other physical rehabilitative strategies, with surgical management techniques used for long-term refractory cases only. With this manuscript, the authors aim to review our current understanding of the pathophysiology and management options, as well as prevention, of spasticity after traumatic brain injury in children. Traumatic brain injury (TBI) is a common cause of disability in children worldwide . In the The TBI-associated cognitive, behavioral, and memory impairments can make evaluating and managing spasticity more difficult compared to other causes of spasticity . The degIt is challenging to predict which TBI patients will develop spasticity. From older literature, such as the noble prize winning work of Sherrington, it was assumed that spasticity is caused by injury to the corticospinal tract that leads to a loss of “higher center control” of the monosynaptic reflex arc . We knowPositive signs  and Negative signs   definition refers to a disorder of “sensory-motor control” that is caused by disruption to the upper motor neuron system . Lance degments) . This arSpasticity is also not always all bad. In some cases the spasticity may even aid in movement and add the much needed increased tone that a child requires to stand up, even if it is with the help of an abnormal supportive reflex . IndiscrHowever, in its severe form spasticity is detrimental to the child and should be treated. If spasticity impairs function, hinders personal and hygienic care, causes deformities, pressure sores or pain, it should always be treated. Spasticity can even impact growth in children as it may lead to imbalanced muscles, abnormal deposition of bone and injury to growth plates .Sherrington's studies on cats were the ground breaking work that started our understanding of the physiological principles of muscle tone and spasticity . Before We know today that the original argument that spasticity is caused by hyper excitability of the gamma-loop, due to interruption of the pyramidal tract, is not the complete story , 18. SheOther than these central processes, there are also some more peripheral explanations for spasticity. Abnormal intraspinal processing whereby the alpha-motor neuron becomes hyperactive after cerebral injury, such as stroke or TBI, can also lead to spasticity . FurtherAt the level of the spinal cord there are also some changes in patients with spasticity that adds to the pathophysiology. Histochemical changes occur in the spinal cord due to this loss of inhibition from the descending parapyramidal tracts. Researchers have also shown that the muscle sarcomere and tendon itself undergo physiological changes in patients with spasticity . These cTBI includes a heterogeneous group of injury mechanisms and patterns. The distribution of contusions, tissue tears, hemorrhagic damage and ischemic injury varies greatly, making each patient's injury unique. Therefore, predicting the spread, or even presence, of spasticity after TBI is very difficult, if not impossible. We do know, however, that there are some useful broad generalizations.Most of what we know about spasticity comes from research in children with cerebral palsy and adults after stroke. From stroke research it is known that few patients who initially develop increased tone, often within the first week after ictus, will have long-lasting spasticity . The iniAround 42% of patients with initial central paresis after stroke, will develop spasticity that is still present at 3 months after ictus . althougPatients with a more severe initial paresis post stroke developed more disabling persistent spasticity . AssociaUnderstanding the pathophysiology of spasticity helps predict which cerebral injuries may lead to spasticity. Spasticity in humans is less likely from an isolated injury to the primary motor area or the corticospinal tract, but more likely from an associated injury to the supplementary motor area and area's of associated motor planning and function . Some reWidespread cortical injury involving the premotor area and the supplementary motor area causes weakness as well as spasticity in monkeys, while injury to the motor area alone, causes weakness only . WoolseyLesions in the frontal cortex and internal capsule may also lead to spasticity due to loss of cortical input to the inhibition center in the brainstem. However, brainstem lesions in humans rarely cause spasticity. Lesions in the inhibitory center in the brainstem will often involve the respiratory and vasomotor center, so these are mostly fatal  Deep-seaInjury to the anterior funiculus of the spinal cord can lead to spasticity due to damage to the vestibulospinal and reticulospinal tracts. It therefore seems, that to cause spasticity, the lesion must involve the dorsal half of the lateral funiculus. This is where the reticulospinal tract runs , 35. InjRecovery after TBI, similar to cerebral stroke, follows a reasonably predictable sequential pattern. Brunnstrom outlined the stages of motor recovery after stroke as follows: flaccidity; synergies, some spasticity; marked spasticity; out of synergy, less spasticity; selective control of movement; isolated/coordinated movement . AlthougDue to the concern of potential negative interactions between drug therapies for spasticity and the process of neural recovery, therapeutic interventions to treat spasticity early after TBI are delayed, often for the first year after injury , but thiPatients may benefit from physical therapy and mobilization in the acute phase, even while patients are still in the Intensive Care Unit. A delicate balance, however, needs to be maintained between stimulatory activities and allowing adequate rest for the brain so as not to compromise neural recovery . StretchConsidering the patients and their experience of spasticity when deciding on a treatment strategy is important. Patients experience spasticity differently from what the clinician observes and their definition of spasticity is often also different . SpasticIt is important to differentiate spasticity from other conditions of increased muscle tone such as dystonia and rigidity, which can be precipitated by trauma to the basal ganglia and thalamus. The management of these conditions, that affect the basal ganglia and thalamus, is different.Psychological and social supportive strategies such as play therapy, formal psychology management and support are all valuable, as the loss of function, together with the brain injury itself, often lead to psychosocial challenges in these patients . ReintegSystemic medication aid in the management of spasticity after TBI, especially in the acute phase, where surgical techniques should be avoided. However, some of the associated side effects may be detrimental such as the use of oral Baclofen and benzodiazepines to reduce muscle tone and aid in mobilization and positioning. These agents may reduce the level of consciousness at higher doses and impact all striated muscle, including the oropharyngeal and laryngeal musculature. However, oral Baclofen does not negatively impact breathing and apnoea frequency during sleep , 44. AniInfection, metabolic crises, undiagnosed fractures and pain (noticeable or not) are all factors that will lead to increased muscle tone in the severely injured child.Baclofen forms the mainstay of all oral regimens to treat spasticity in children and in adults, including post TBI. Baclofen is a GABA-B receptor agonist and has similar pharmacodynamics to the benzodiazepines  and the drug is delivered directly where it is needed. Most centers will only trial Intrathecal Baclofen if spasticity is still present after 6 months  as well as the pharmacological strategies used (Baclofen and Tizanidine) in treating or preventing spasticity in patients after TBI . The revThere are also on-going studies looking at new drugs, these include Cannabinoid receptor agonists, Serotonin receptor agonists, Glycine agonists and Kynurenic acid, which is a derivative of Tryptophane .It is important to note that there are concerns about all the above-mentioned drugs and their potential to impair neural recovery after cerebral injury such as stroke and TBI. It is therefore wise to limit their use and duration to where absolutely necessary , 46. TheDue to the lack of definite evidence showing improved spasticity outcomes after TBI from any one modality in isolation , combinaBotulinum toxin A  also shows promise aiding the process of locomotor retraining . The effA large basic science fraternity is investigating the role of inflammation in the injury causation as well as the recovery of patients after TBI. There may be a place for down regulating the inflammatory response to prevent or treat spasticity after TBI as well . This isWhen choosing lesioning techniques to manage spasticity after pediatric TBI, it is important to evaluate therapies for spasticity against the loss of function that may follow the treatment. Patients with severe spasticity are sometimes able to “walk” in their own way. The deformities and abnormal wear that is placed on their limbs and joints cause severe pain and further long term complications such as spinal deformities and hip dislocations . EffectiThe evaluation of each child for spasticity surgery is a meticulous process wherein the patient should be evaluated over time, in various scenarios, and in their daily milieu to which they must return after rehabilitation. The physiotherapists and occupational therapists play a very important role herein and video recording is a valuable aid. It is paramount that the child and caregivers are involved in the decision making process . FunctioInvolving the family in the daily rehabilitation process post-surgery is invaluable. Children do better if their day is filled with regular activities that are guided by caring parents and families, interspersed with formal physiotherapy and occupational therapy sessions . ContinuIn deciding which surgical technique is best suited for each child, the spasticity should be classified according to its spread: focal spasticity vs. global spasticity. Certain techniques are best suited to treat focal spasticity, while others are better suited to global spasticity—see Botulinum toxin can be used safely in patients with TBI related spasticity . The autSelective peripheral neurotomy (SPN) offers an effective long-term therapeutic strategy for focal spasticity in patients after TBI. Its use in pediatrics has been demonstrated in children with spasticity due to cerebral palsy . The proChildren recover well from SPN and aggressive mobilization can start immediately postoperative. No casting or immobilization is needed. Active strengthening of the antagonist muscles must be prioritized, as weakness is only appreciable once the spasticity is reduced. Parents should be prepared for this to avoid unnecessary panic. The technique aids rehabilitation and is a good adjunct to the more traditional therapies such as physiotherapy and occupational therapy as it does not require immobilization post operatively and effectively in reduces troubling spasticity.Performance of a peripheral nerve block, or the preoperative Botulinum test, can indicate if any concomitant orthopedic surgery to lengthen tendons, etc. will be required. These procedures are often done in the same sitting in our unit if range of motion will be significantly impaired due to short muscles and tendons. Mild muscle shortening will mostly improve with reduced spasticity and aggressive stretching, therefore routine orthopedic surgery may not be required.Some units also discuss selective dorsal rhizotomy (SDR) to treat spasticity related to TBI, but working in the unit that has been performing modern SDR for the longest period (Warwick Peacock started performing his variation of an old technique here in 1979) , we feelEarly mobilization and active positioning is important from the outset. In the acute phase the goal is to maintain full range of movement in all limbs . This maThere is no clear evidence-based guideline or stepwise approach to treating spasticity in children, or adults, after TBI. It is, however, possible to recommend an approach based on the author's experience and the scientific knowledge available in the literature. Immediately after the injury: cerebral protection and treating the brain injury is the main priority. Sedation and hemodynamic stabilization are key. Perform passive range of motion bed exercises only, and this only if it does not cause an increase in ICP or hemodynamic instability. Limited stimulation is important, as cerebral autoregulation is often impaired. Usually the child will have weakness or hypotonia in this phase. If spasticity is detected it is important to differentiate this from brainstem reflex patterns that require sedation treatment, or that may be indicative of serious brain injury and poor prognosis, such as decerebrate posturing. If localized limb spasticity is present, slow and maintained stretching and positioning exercises can start in the bed and splints can be employed to keep the limbs in a neutral position in between the stretching sessions. Pressure care and pain management is important. Manage associate injuries and fractures.When the child is stable regular, even 2–3 times a day, physical therapy should begin. Passive full range of motion exercises should be done. In the child who is awake, even if still confused, activities that allow the shoulder girdle, pelvic girdle, and trunk to rotate and stretch through their full range are advised. Weight bearing through a spastic limb and joint forms a major part of the neuro-rehabilitation process and the earlier it can start the better. If limbs show early spasticity, splinting to keep the joint and muscle in a neutral position can be used in bed.As soon as the comorbid injuries  and the brain injury allows, even if still on a ventilator for airway or with impaired consciousness, mobilization in and out of the bed should start. Placing a child in a well-supported buggy is excellent for lung function, renal function, cognitive rehabilitation and family morale. The benefit of enrolling the postural- and vestibular- control systems early in the neural rehabilitation process is immense.If muscle tone is significantly increased, and impairs the movement therapy, oral Baclofen can be initiated. Start with low doses and slowly increase as needed in 5 mg increments and as regularly as four times a day if needed. Slow increases are important, as children become drowsy easily. If this is still not enough then a low dose of long acting benzodiazepine can be added daily. Keep in mind that all these drugs may reduce wakefulness and impair cognitive function as well as neural recovery, so only use if really needed to make mobility therapy possible.Once the child is out of ICU and mobility is easier, standing and walking activities should start. Weight bearing is again very important, and together with daily activity simulation and retraining, this forms the cornerstone of all neuro- rehabilitation strategies. Standing frame or tilt-table is useful.Use splints and casting as needed to keep limbs in a neutral position, or to maintain stretch on spastic muscles, as needed. Pressure care is important throughout.If after 1 month the spasticity is chronic, we recommend starting Botulinum injections under ultrasound guidance in a selective way from the onset. This will aid in surgical decision making later, if needed. Clear documentation of the muscles targeted, and the functional effect of their injection must be maintained. Use the reduced tone in the rehabilitation process. Reintegration into school and society/home life is the goal.® effect 3–6 months), once the Botulinum Toxin has worn off, and the treating multidisciplinary team notices that function-impairing spasticity returns, a selective peripheral neurotomy can be done to allow continuous mobility and activities as was possible during the Botox period. In our unit I prefer to allow up to 2 years before lesioning techniques are used, as neural recovery can still take place 2–3 years post-injury (from my own experience) and I do not want to limit the natural neural recovery process by any unnecessary surgical intervention. There are some exceptions, however, where we notice after 1 year that the spasticity is progressing, and no rehabilitation is possible outside of the Botox®-effect period.After 6 months , newer developments in the field of neuromodulation, where spasticity is targeted (such as DBS) may hold promise in future to treat this very difficult condition. Newer targets are constantly found in the brain and as the movement control network is further explored, new therapies are, hopefully, on the horizon.JE: writing of the article and research for the article. UR: editing and flow check of the manuscript. AF: supervisor, editing, and scientific writing help.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


CHOP  represents standard chemotherapy in non-Hodgkin's lymphoma (NHL) with risk of cardiotoxicity. To define new parameters, such as 3D myocardial deformation, arterial stiffness, and biomarkers for early diagnosis and prediction of cardiotoxicity. 110 NHL patients with LVEF > 50%, scheduled for CHOP, were evaluated at baseline, after third cycle and chemotherapy completion. 3DE assessed LVEF and myocardial deformation: longitudinal (LS), radial, circumferential, area strain. Echo-tracking analysed arterial stiffness: PWV, β index, wave intensity. Troponin I and NT-pro-BNP were measured. After chemotherapy completion, 18 patients (16%) (group I) developed cardiotoxicity ; 92 patients (group II) did not. Significant reduction of 3D LV deformation and increase of arterial stiffness developed starting with third cycle, with greater changes in group I. LS reduction and PWV increase after third cycle were the best independent predictors for LVEF decrease; the association of LS decrease by > 19% and PWV increase by > 27% after third cycle predicted cardiotoxicity after chemotherapy completion (90% sensitivity and 81% specificity). 3D LS and PWV can detect early chemotherapy-induced cardiotoxicity and predict LVEF decline. These parameters should be incorporated in clinical protocols to monitor cardiovascular function during chemotherapy and early intervention. CHOP regimen  is the standard chemotherapy for NHL, providing high rate of cure and reduced recurrence of disease, with good tolerability1. The most severe side effect of these agents, which might determine early withdrawal of therapy, is represented by cardiotoxicity2. Cardiac dysfunction, mainly due to anthracyclines, may be present from asymptomatic forms, with reduction of left ventricular ejection fraction (LVEF), in 57% of patients, to overt heart failure in 16% of patients4. Cardiac dysfunction induced by chemotherapy is defined by the current guidelines as a LVEF decrease below 50%, with more than 10 percentage points, 2 to 3 weeks after initiation of therapy2. Three-dimensional echocardiography (3DE) is the method recommended for assessing LVEF2. However, 3D LVEF assessment allows only late diagnosis of cardiotoxicity, often irreversible. Thus, description of new and simple parameters of myocardial deformation and arterial stiffness, affected before decrease of LVEF, might diagnose subclinical, early changes of cardiac function induced by CHOP therapy, and might be able to predict cardiotoxicity6. Moreover, a role in the early diagnosis of cardiotoxicity can be added by the cardiac biomarkers. Thus, troponin I (TnI), marker of myocardial injury, may increase before occurring of symptomatic cardiotoxicity, while NT-pro-BNP, marker of increased preload, can predict onset of LV dysfunction7.Non-Hodgkin’s lymphoma (NHL), the most common hematological neoplasia, represents an important public health problem, due to increased risk of morbidity and mortalityOur aim was to define new parameters, such as 3D myocardial deformation, arterial stiffness, and biomarkers, in early detection and prediction of cardiovascular toxicity, in NHL patients receiving CHOP chemotherapy.110 patients were included in the study: 18 patients (16%) developed cardiotoxicity at the end of CHOP chemotherapy (group I), whereas 92 subjects (84%) did not. Baseline characteristics of two groups are presented in Table 3D echocardiographic parameters at baseline, after third cycle, and at the end of CHOP chemotherapy are shown in Table Arterial stiffness parameters had no significant differences between the two groups at baseline. After third cycle, arterial stiffness increased, being persistently increased at the end of therapy, with higher values in the group with cardiotoxicity Table .TnI levels were increased after third cycle and persistent after CHOP completion treatment, with higher values in group I than in group II Table . Althoug2 = 0.516, p = 0.0001).By univariate analysis, reduction of LVEF at the end of therapy correlated with reduction of myocardial deformation, increase of arterial stiffness, TnI, and doxorubicin dose Table . By stepROC analysis showed that a decrease of 3D LS by more than 19% from baseline, after the third cycle, predicted the occurrence of cardiotoxicity at the end of CHOP chemotherapy with a sensitivity of 89% and a specificity of 85%; an increase of PWV by more than 27% after the third cycle comparing with baseline, predicted also the occurrence of cardiotoxicity at the end of chemotherapy with a sensitivity of 88% and a specificity of 83% Table . More thIntraobserver, interobserver, and test–retest variabilities for 3D LV EF, volumes, and myocardial deformation parameters, are shown in Table In a study on 110 patients with NHL, we showed that the assessment of 3D myocardial deformation, arterial stiffness, and cardiac biomarkers can detect and predict subclinical cardiotoxicity. From our best knowledge, this is the first study assessing, in a comprehensive way, systolic LV function by EF and myocardial deformation using 3D echocardiography, vascular function by arterial stiffness, and cardiac biomarkers, in a large population diagnosed with NHL, who received a single CHOP-type chemotherapeutic regimen.2. Cardiotoxicity remains the most feared side effect of chemotherapy, with growing incidence of 20–30%8. Myocardial direct toxic effect of chemotherapy can lead to irreversible cardiomyopathy, with diastolic and/or dysfunction, which progresses to heart failure4. Using myocardial deformation and cardiac biomarkers, in patients with NHL receiving CHOP therapy, we demonstrated that an early decrease of longitudinal strain with more than 19%, after third cycle of therapy, predicts occurrence of cardiotoxicity after CHOP completion treatment. These results are essential for monitoring patients during chemotherapy and for early detection of patients at risk for heart failure.CHOP regimen, very effective in achieving complete remission of NHL, has numerous side effects that cause increased morbidity and mortality4. LVEF is the standard parameter used to diagnose cardiotoxicity2. Cardiotoxicity is defined as LVEF decrease with more than 10 percentage points, to a value below 50%, evaluated 2–3 weeks after initiation therapy2. To avoid LV geometric assumptions, foreshortening, and inappropriate visualization of apex, we measured LVEF by 3DE, as recommended by current guidelines2. Compared to 2D echocardiography, 3DE has better intra- and inter- observer variability, and test–retest variability, and allows a more accurate assessment of LV volumes and ejection fraction, with better agreement with cardiac magnetic resonance (CMR), considered the “gold standard”9. In cancer patients, 3D LVEF is more sensitive and robust in detecting anthracyclines-induced cardiotoxicity in patients with different forms of solid or hematological tumors11.Echocardiography is the best method for monitoring patients before, during, and after chemotherapy, being widely available, noninvasive, and cost effective2. Risk for cardiotoxicity is greater when cumulative dose of doxorubicin is high, in association with other anticancer drugs or radiotherapy, or in single injection administration (versus long infusion)3. A dose of doxorubicin that exceeds 500 mg/m2 is an important factor in occurrence of cardiotoxicity, while doses below 300 mg/m2 are associated with low risk2. Our study showed a significant reduction of LVEF after a moderate dose of doxorubicin (429 ± 61 mg); however, asymptomatic cardiac dysfunction occurred since third cycle of CHOP, after a low dose of anthracycline (183 ± 42 mg), with reduction of all 3D myocardial deformation parameters. Our findings are consistent to those of Olivieri et al.12, Boyd et al.13, and Yu et al.14, who demonstrated occurrence of cardiotoxicity in 11–35% of patients, with frequent subclinical forms, at low and moderate doses of doxorubicin, between 150 and 450 mg/m2. Cyclophosphamide can induce cardiotoxicity in less than 2% of cases, manifested by arrhythmias and arterial or venous thromboembolism, but the dose used in CHOP regimen is too low to induce cardiac dysfunction by itself15; in fact, none of our patients experienced arrhythmia or thromboembolic events. Vincristine can lead to different non-cardiac side effects, but no cardiac side effects have been reported16. Corticosteroids may induce hypertension or atrial fibrillation2, but none of our patients developed atrial fibrillation, while blood pressure remained within the normal limits.Of the four chemotherapeutic agents used in CHOP therapy , doxorubicin is by far the most important for occurrence of heart injury2. Our research group8, similarly with others17, identified an early decrease of 2D LS or CS, before reduction of LVEF, in patients with cancers treated with anthracyclines. Although still not used routinely, 3D myocardial deformation had demonstrated its usefulness, feasibility, and superiority versus 2D, with good agreement with CMR strain, through independence from geometry-related deformation, direction, and angle18. We showed a significant decrease of all 3D deformation parameters after third cycle of CHOP, before 3D LVEF reduction by criteria used for diagnosis of cardiotoxicity. Similarly, Mornos et al.19 and Armstrong et al.20 showed reduction of 3D LS, RS, or CS after anthracyclines treatment, associated with increased troponin levels, occurring before decrease of LVEF. Current guidelines define occurrence of cardiac dysfunction during chemotherapy by a reduction of global longitudinal strain with more than 15%2. We also identified longitudinal strain as a powerful independent predictor for LVEF decrease. Reduction of this parameter by more than 19% after third cycle of CHOP therapy was able to identify patients with chemotherapy-induced cardiotoxicity at the end of treatment with a c-statistics (AUC) of 92%.Decrease of myocardial deformation parameters, assessed by speckle-tracking echocardiography, precedes LVEF reduction, and may persist during and after chemotherapy21. In patients with solid or hematological tumors, anthracyclines and adjuvant agents, including CHOP therapy, favor occurrence of arterial stiffness, assessed by increased PWV or WI, persistent after treatment completion23. Narayan et al. demonstrated that early decrease of myocardial deformation and increased ventriculo-arterial coupling are best independent predictors for LVEF reduction23. These results are similar to our data, by which we demonstrated an early, progressive, and significant increase of arterial stiffness and altered ventriculo-arterial coupling during chemotherapy, with a significant correlation between vascular function and occurrence of cardiotoxicity, suggesting a possible additional mechanism of chemotherapy-induced cardiac dysfunction. We identified PWV and LS as the best independent predictors for 3D LVEF decrease at the end of chemotherapy. An increase of PWV by more than 27% after the third cycle of CHOP therapy may identify patients with cardiovascular toxicity after chemotherapy with c-statistics (AUC) of 90%. Furthermore, the combination of LS decrease by more than 19% and PWV increase by more than 27% after third cycle of CHOP had a greater prediction value, with a c-statistics (AUC) of 96%.Besides cardiac effects, chemotherapy determines negative arterial remodeling with increased arterial stiffness, favoring LV hypertrophy and altered ventricular-arterial coupling, worsening preexisting cardiac dysfunction2. Several studies demonstrated the role of troponin I and NT-pro-BNP in assessing cardiac dysfunction in hematological neoplasia treated with anthracyclines7, however, other studies failed to show contribution of these biomarkers for early detection of cardiotoxicity24. In our study, troponin I increased early, while 3D LVEF maintained within normal ranges, persistent after CHOP completion treatment, and significantly higher in group who developed cardiotoxicity. Even if NT-pro-BNP level increased numerically during treatment, no significant difference was found between groups.Cardiac troponin I is the most sensitive and specific biomarker, used for diagnosis of myocardial injury after chemotherapy. On the contrary, NT-pro-BNP, marker of high filling pressures, has a controversial role in early detection of cardiac dysfunctionCardiac assessment of cancer patients should be done at baseline, before starting treatment, during chemotherapy and periodically after its completion. In our study, an early cardiac comprehensive evaluation, after only 3 cycles of CHOP (full treatment had 8 ± 2 CHOP cycles) identified predictive parameters for further cardiotoxicity after chemotherapy ended. Follow-up visits are mandatory, in order to diagnose late chemotherapy-induced cardiovascular toxicity.25. Second limitation is that we used only proper echo images, without stitching artifacts or poor quality, taking into consideration that quality of ultrasound images can decrease the accuracy of assessment of 3D LV EF and myocardial deformation parameters. However, feasibility of our data was more than 90% for all myocardial segments. Moreover, we used only troponin I, which is currently provided by our laboratory. High-sensitivity troponin I might have a better accuracy, but is not used routinely for the diagnosis of cardiotoxicity. Finally, follow-up of patients after chemotherapy ended is mandatory, knowing the risk of anthracyclines-induced late cardiotoxicity.First limitation of our study is related to the low number of patients which developed cardiotoxicity (18 out of 110). Comparing with other studies, enrolling between 50 and 70 patients, we enrolled a higher number of oncological patients. However, percentage of those who developed cardiotoxicity was similar in all studies, less than 20%Assessment of 3D longitudinal strain and pulse wave velocity is able to detect early chemotherapy-induced cardiotoxicity, and to predict with good accuracy further decline of 3D LVEF in patients with non-Hodgkin’s lymphoma. Thus, these parameters should be incorporated in clinical protocols, for better monitoring of cardiac function during chemotherapy, and for early intervention.147 consecutive patients diagnosed with NHL, were prospectively enrolled from a single hematology department between January 2014 and October 2018. Inclusion criteria were: age > 18 years; signed informed consent; 3D LVEF > 50%; sinus rhythm; NHL scheduled to receive CHOP chemotherapy according to hematological guidelines. Exclusion criteria were: history of cardiovascular disease; history of radiotherapy. Study protocol was approved by the local ethics committee and conforms with the principles outlined in the Declaration of Helsinki. All patients gave written inform consent to participate in the study. Of the 147 patients, 8 died during chemotherapy due to aggressive forms of NHL, 11 were lost to follow-up and 18 were excluded because of poor image quality on 3DE. Thus, 110 patients  remained in the study.2, vincristine 1.4 mg/m2, and doxorubicin 50 mg/m2 on day 1, and orally administration of prednisone 100 mg on days 1–5. Full treatment included 8 ± 2 CHOP cycles, repeated at every 21 ± 3 days. Blood collection, 3DE, and echo-tracking were performed at baseline, one day after completion of third cycle, and at end of CHOP chemotherapy. Cardiotoxicity was defined as 3D LVEF reduction below 50%, with more than 10 percentage points, at any time after initiation of CHOP therapy. According to 3D LVEF value at the end of therapy, two groups were defined: patients who developed cardiotoxicity (group I) and patients who did not fulfill these criteria (group II).CHOP chemotherapy consisted of intravenously administration of cyclophosphamide 750 mg/m26. Three cardiac cycles were achieved at each recording. Digital achieved data were analyzed offline using a dedicated software package  with 4D auto-LVQ system. 3DE full-volume LV data sets were achieved in six consecutive electrocardiographically gated subvolumes, with good visualization of all segments, excluding any stitching artifacts. Endocardial border tracing was initiated manually, by identifying two points in 4-chamber view  at end-diastole and end-systole. Then, the software generated semiautomated complete endocardial contour that included papillary muscles and LV outflow tract for end-diastolic and end-systolic volumes27; manual edits were performed if needed. 3D strain analysis was the last step of the 4D auto LVQ software. Strain region of interest was automatically generated at end-systole, and had two borders: endocardial, the same used for 3D volumes assessment, and epicardial, generated in previous stage; both contours were adjusted, if necessary. Deformation parameters  were automatically calculated for each of 17 LV segments after tracking was confirmed visually8.All ultrasound examinations were performed with a commercially available system equipped with a 4 V probe for 3DE . Before every recording, blood pressure and heart rate were measured; one-lead electrocardiogram was used during examination. Images were obtained in left lateral decubitus position, during breath holding, performed by the same investigator and taken in accordance with our previously reported protocol and current guidelines28. Following parameters of arterial stiffness were assessed: pulse wave velocity (PWV), augmentation index (AIX), beta index, Young modulus of stiffness (Ep), arterial compliance (AC), and wave intensity (WI)  was used to determine arterial stiffness at right common carotid artery, using our protocol published previouslyWI) Fig.  (detaileWI) Fig. . WI reco29.Blood was collected in EDTA tubes and TnI and NT-pro-BNP concentrations were measured by CLEIA method with Pathfast Synttergy 2005 analyzer . The reported value for the 99th percentile for TnI was < 0.02 ng/ml, and less than 112 pg/ml for NT-pro-BNP28.For 3D LV EF and deformation parameters, intraobserver, interobserver, and test–retest variability (repeatability) were assessed in our laboratory for 20 consecutive patients, by two observers with same experience. For arterial stiffness and ventriculo-arterial coupling, reproducibility in our laboratory has been reported previouslyt-test (for means) and χ2 test (for proportions). Comparisons of parameters within each group at baseline, after third cycle, and after CHOP completion, were assessed with one-way analysis of variance (ANOVA); Scheffé test was used for subgroup analysis. Association between two variables and influence of a parameter on LVEF reduction below 50% at the end of chemotherapy were evaluated by univariate Pearson correlation and multiple linear stepwise regression analysis. Receiver operating characteristic (ROC) curves were obtained for parameters that were predictive for occurrence of cardiotoxicity after the last cycle of CHOP treatment. Intraobserver, interobserver, and repeatability were calculated as 2SD/√2 and reported as percentages from mean value and coefficient of variation30.SPSS version 19.0  was used for data analysis. Results are presented as mean ± standard deviation (SD) or as percentages (%). P < 0.05 was considered significant. Differences between variables of two groups were quantified with independent Our research was approved by Ethics Committee of the University and Emergency Hospital of BucharestSupplementary Information.


Myocardial salvage can be assessed retrospectively by T2-weighted and delayed enhancement images as shown in animal studies . CurrentAim of this trial was to establish myocardial salvage imaging by MR as a surrogate endpoint in a randomized single-blinded trial and to show that high-dose N-ACC reduces reperfusion injury by its antioxidative properties. Furthermore, N-ACC might reduce the incidence of contrast-induced nephropathy (CIN).Two hundred-fifty-one patients undergoing primary PCI were randomized to either high-dose N-ACC (2 × 1200 mg/d for 48 hours) or placebo plus optimal hydratation. The two primary endpoints were: 1) occurrence of CIN defined as an increase in the serum creatinine concentration of >25% from the baseline value within 72 h; 2) Myocardial salvage measured by T2-weighted STIR-images (covering the left ventricle from base to apex) and delayed enhancement MRI at day 2–4 after primary PCI. Myocardial salvage index was calculated as area at risk-infarct size/area at risk.Secondary endpoints were infarct size and microvascular obstruction, ST-resolution at 90 minutes and occurrence of MACE at 30 day follow-up.Due to contraindications MRI could not be performed in 31 patients. All images were assessable for the calculation of the myocardial salvage index. The area at risk was 47.3% of the left ventricular mass  in the N-ACC group versus 42.7%  in the placebo group. The primary endpoint reperfusion injury measured by myocardial salvage index was not different between both treatment groups . In addition, no differences in infarct size  and microvascular obstruction  as well as in ST-segment resolution were observed. The median volume of an iso-osmolar contrast agent during PCI was 190 ml  in the N-ACC and 180  in the placebo group (p = 0.67). The primary endpoint CIN occurred in 14% in the N-ACC group and in 22% in the placebo group (p = 0.12).MRI can reliably measure the area at risk and infarct size retrospectively and served as a surrogate endpoint in this randomized clinical trial which showed that high-dose N-ACC does not provide an additional clinical benefit to placebo with respect to prevention of myocardial reperfusion injury and CIN and in patients undergoing primary PCI.


While anabolic hormone deficit is a common finding in heart failure with reduced ejection fraction (HFrEF), few data are available in heart failure with preserved ejection fraction (HFpEF).  Blood samples were collected for metabolic  and hormonal  determination, comparing 30 patients with HFpEF and 20 patients with HFrEF. Total antioxidant capacity was evaluated by using the spectrophotometric method using the latency time in the appearance of the radical species of a chromogen  as a parameter proportional to antioxidant content of the sample. Echocardiographic parameters were also assessed in the two groups. p < 0.05) and DHEA-S deficiencies was observed in HFpEF patients. Echocardiographic parameters did not correlate with hormone values. A significant direct correlation between T  and DHEA-S  with LAG was observed only in HFpEF.  A high prevalence of testosterone (32% in HFrEF and 72% in HFpEF,  Anabolic hormone deficiency is clearly shown in HFpEF, as already known in HFrEF. Although longitudinal studies are required to confirm the prognostic value of this observation, our data suggest different mechanisms in modulating antioxidants in the two conditions, with possible therapeutic implications. Chronic heart failure (CHF) is defined as a clinical syndrome based on an unbalance between cardiac output and metabolic requirements of organism . Any strThe main classification of CHF relies on left ventricular ejection fraction (LVEF), evaluated by echocardiography, or, less frequently, myocardial scintigraphy and magnetic resonance of the heart; its measurement identifies three classes of CHF: from the well known and classic heart failure with reduced ejection fraction (HFrEF), which includes patients with left ventricular ejection fraction (LVEF) <40%, to heart failure with preserved ejection fraction (HFpEF), which comprises patients with LVEF <50%, to the grey area of LVEF in the range of 40–49%, which describes the new entity of heart failure with midrange ejection fraction . HFrEF aBoth the conditions present with a high prevalence of multihormonal deficiencies , 14. TheTotal antioxidant capacity (TAC) expresses the whole effects of nonproteic nonenzymatic antioxidants, as widely discussed in previous studies , 22. PreThus, the aim of the present study was to explore the correlation between anabolic hormones, echocardiographic parameters, and TAC in HFpEF and HFrEF and correlate them with metabolic parameters .50 subjects involved in this study were admitted to the University Hospital “Policlinico Gemelli” Dept. of Internal Medicine and were enrolled after being given an explanation of purposes and nature of the study, conducted in accordance with the Declaration of Helsinki, as revised in 2013. The study protocol was approved by the Institutional review board of “Medical Pathology” of our University Hospital.Twenty patients with HFrEF, aged 42–88 years (mean 69.5), and thirty patients with HFpEF, aged 59–90 years (mean 77.7), were recruited. The diagnosis of HFpEF was established according to the current guidelines of the European Society of Cardiology . PatientBetween 08.30 and 09.00 a.m., after an overnight fast, a polyethylene catheter was inserted into the antecubital vein of one forearm and the blood was collected using a 6 mL vacutainer blood collection tube containing lithium heparin and immediately centrifuged (4°C at 3000 ×g for 15 min) with aliquots stored at −80°C until assayed.We evaluated metabolic  and hormonal pattern .Fasting glucose and insulin levels were quantified with commercial kits using ADVIA automatic analyser .Plasmatic concentrations of NT-proBNP, TSH, fT3, fT4, DHEA-S, T, and IGF-1 were measured by using immunochemiluminometric assays on a Roche Modular E170 analyser . The intra- and interassay CV for all hormones were, respectively, <5.0% and <7.0%.μUI/ml), fT3 (2.4–4.2 pg/ml), fT4 (8.5–16.5 pg/ml), DHEA-S (800–3500 ng/ml), and T (2.5–8.4 ng/ml). Values equal or below the lower limit of normal ranges were used to define as deficiency. For IGF-1, due to the age-related variations, we applied, to define IGF-1 deficiency, criteria of the TOSCA registry referring to the 33th percentile of a population of men with chronic heart failure  [Normal ranges in our laboratory were NT-proBNP (>126 pg/ml), TSH (0.4–3.2 5 years) , 17.A complete echocardiographic evaluation was performed , measuring the following parameters: left ventricular ejection fraction (EF), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LV-ESD), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LV-ESV), septal thickness (IVS), posterior wall thickness (LV-PW), peak E-wave velocity (E), peak A-wave velocity (A), E/A ratio, pulsed-wave TDI E′ velocity (E′), E/E′ ratio, deceleration time (DT), left atrial volume (LAV), indexed left atrial volume (LAVI), systolic pulmonary artery pressure (SPAP), tricuspid annular plane systolic excursion (TAPSE), and tricuspid peak velocity (TPV).2O2-metmyoglobin with the chromogen ABTS, whose radical form is spectroscopically detectable. The latency time (LAG in sec.) before the appearance of radical species is proportional to the antioxidant concentration in the sample.Total antioxidant capacity (TAC) was evaluated with the method of Rice-Evans and Miller , modifieHOMA-IR was used as an index of insulin resistance and was obtained from the fasting blood insulin (immunoreactive insulin (IRI)) concentration and the fasting blood sugar (FBS) level early in the morning, based on the following equation: HOMA-IR = (IRI × FBS)/405.To estimate the sample sizes, the estimated decrease prevalence of T deficiency between the two groups was set at 20%, based on the only reported work that, at the best of our knowledge, evaluated these data in HFrEF vs HFpEF patients , with a U test was employed to evaluate differences between the two groups of subjects. A p value of 0.05 was considered statistically significant. Linear regression analysis was employed to correlate TAC with hormonal parameters. The X square test was used to compare percent differences between the two groups, when considering the prevalence of hormone deficiencies and comorbidities.The Mann–Whitney p < 0.05). On the contrary, the A wave was significantly higher in HFpEF (p < 0.05).X square analysis showed a significant difference only in hypertension and peripheral atherosclerotic disease (p < 0.05).Comorbidities, as expected, were more prevalent in HFpEF patients  than in HFrEF patients . X square test (p < 0.05).No significant correlation was present when correlating T or DHEA-S with echocardiographic parameters. On the contrary, both T and DHEA-S significantly correlated with LAG values, but only in patients with HFpEF .Our data confirm a high prevalence of anabolic hormones deficit in the two HF subgroups, thus expanding the concept that anabolic deficiencies are a common finding not only in HFrEF but also in HFpEF, a poorly explored condition in this concern. We found a significant difference in the prevalence of low T in HFpEF; this datum is not fully in agreement with the only report of hormone evaluation in HFpEF ; howeverFocusing on T levels, there are several evidences that, in HFrEF, low levels can represent a bad prognostic sign , 25. At We have neither found correlations between T or DHEA-S levels and echocardiographic parameters nor differences comparing patients with low or normal T and low or normal DHEA-S.On the contrary, interesting data emerge when correlating hormonal levels with TAC. Previously, we have shown that antioxidant systems can counteract OS in patients with HFrEF when one single hormonal deficit is detected, while such compensation is less effective when more deficits ensue .This is the first report on TAC in HFpEF. We have found a significant correlation between T and DHEA-S with LAG in such model, while this is not evident in HFrEF.Two consequences can be argued from these data: first, an important role of anabolic hormones in modulating antioxidant systems in HFpEF; second, different pathophysiological mechanisms underlying the two models of HF.in vivo and in vitro studies have shown that DHEA-S limits lipid peroxidation [For both hormones, conflicting data are reported in literature showing pro-oxidant or antioxidant effects, depending on concentration or different models studied. For instance, DHEA-S administration can induce oxidative stress in hearts of male wistar rats, defining various histologic cardiac lesions in rats, such as misshapen cell nuclei, leukocytic infiltrates, disorganized myocardial fibers, and echocardiographic alterations (increased LV-PW and LV-ESD) , 27, whixidation , 32. Morxidation .The same double-faced effects are attributed to T. In fact, ROS production in vascular smooth muscle cells in culture is stimulated by T, especially in hypertensive animal models ; T also The literature concerning the T evaluation in CHF has been extensively reviewed, also for the therapeutic implication. T deficiency has a key role in some pathophysiological aspects of CHF, such as reduced muscle mass, abnormal energy handling, dyspnoea, and fatigue . The so-Our study clearly shows the correlation of the two hormones with antioxidant systems and is therefore in favour of a positive role on OS, which is one of the main players in the pathophysiology of HF.According to literature, our patients with HFpEF, with a higher prevalence of obesity and other metabolic comorbidities, exhibited a trend toward increased LAG values. It can be speculated that a further increase in oxidative stress condition could induce a compensatory increase in antioxidant systems, possibly influencing T levels with a reciprocal vicious circle due to the modulatory role of T itself on antioxidants. Such correlation is not evident in the HFrEF group in which a worse cardiac performance or systemic catabolic status is present in CHF. Therefore, two different pathophysiological models seem to be involved in the two kinds of CHF. As recently proposed, in HFrEF, the process starts with primary ischaemic or oxidative damage of cardiomyocytes, whereas in HFpEF, a cascade of events is increased by the systemic proinflammatory state related to multiple comorbidities. The resultant endothelial damage leads to microvascular coronary inflammation and, ultimately, to myocardial dysfunction .Nevertheless, there are some potential limitations of the present study. Firstly, the number of subjects is relatively small, and our findings need to be validated in a larger cohort. It is not possible to express a cause-effect relation between anabolic hormones and antioxidant status. Moreover, only one parameter of antioxidant status has been evaluated although, in our previous study, the positive effect of T replacement therapy on TAC in hypogonadal patients was described .In conclusion, deficit of anabolic hormones is clearly revealed in HFpEF, as already known in HFrEF. Although longitudinal studies are needed to confirm a prognostic value of this observation, our data suggest a different mechanism in modulating antioxidant systems in these two conditions. Moreover, a possible therapeutic role of antioxidants needs to be investigated, particularly when T therapy is contraindicated.


Secondary hyperparathyroidism is a common complication of end-stage renal disease (ESRD), which may be associated with cardiovascular diseases. Thus, this study aimed to explore myocardial damage using non-contrast cardiovascular magnetic resonance (CMR) in ESRD patients undergoing hemodialysis and further investigate its relationship with parathyroid hormone (PTH) toxicity.Seventy-two adult ESRD patients receiving regular hemodialysis and 30 healthy subjects underwent CMR examination. Continuous CMR cine sections from the mitral valve level to the left ventricular (LV) apex in the short-axis plane, cine series of vertical two-chamber long-axis plane, and horizontal four-chamber plane were acquired. Native T1 mapping was obtained using modified Look-Locker inversion recovery (MOLLI) sequences. Native T1 values and myocardial strain were analyzed.  Immunoreactive parathyroid hormone (iPTH) was obtained from all enrolled patients.Forty (55.6%) hemodialysis ESRD patients were found to have increased iPTH levels. LV ejection fraction (LVEF) of both ESRD patients with targeted and increased iPTH levels was decreased compared with healthy subjects . The mean peak radial strain (PRS), peak circumferential strain (PCS), and peak longitudinal strain (PLS) were lowest in ESRD patients with increased iPTH; however, no significant difference was observed among these three groups. Segmentally, from base to apex, the native T1 of ESRD patients with increased iPTH levels tended to be higher than those with targeted iPTH and healthy subjects . In ESRD patients with targeted iPTH, both native T1 of basal and middle segments were significantly higher than normal subjects . Comparing global native T1 values in the three groups, ESRD patients with targeted and increased iPTH level showed increased native T1 . Native T1 values of the basal segment and global native T1 were moderately associated with iPTH . Multiple linear regression analysis showed that global native T1 values  were independently associated with iPTH.Elevated iPTH level was associated with and was an independent risk factor for myocardial damage in ESRD patients undergoing maintenance hemodialysis.Trial registration: Chinese Clinical Trial Registry (http://www.chictr.org.cn/index.aspx) ChiCTR-DND-17012976, 13/12/2017, retrospectively registered. Secondary hyperparathyroidism is a common complication of end-stage renal disease (ESRD) with maintenance hemodialysis, which begins in the earlier stages of chronic renal insufficiency and is shown to be deteriorated with declining renal function. Hyperphosphatemia, hypocalcemia, decreased calcium, and vitamin D receptor expression, 1,25-dihydroxyvitamin D3 deficiency, and parathyroid hormone (PTH) resistance may partly play a role in the secondary hyperparathyroidism pathogenesis , 7. Seve2 [A total of 100 adult ESRD hemodialysis patients were prospectively recruited from September 2017 to July 2019. The inclusion criteria of ESRD patients were deteriorating renal function or kidney damage for more than 3 months and stage 5 chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) of < 15 mL/min/1.73 mFasting venous blood from patients with ESRD was drawn for routine blood examination, biochemical indicators, and uremic toxins. The eGFR of each ESRD patient was calculated with serum creatinine using the CKD-Epidemiology Collaboration equation . All patAll patients were imaged supine on a 3 T CMR scanner  with an 18-element body phased array coil. Electrocardiogram (ECG) and breath-hold triggers were required for each patient to acquire high-quality images. Stacks of retrospectively gated cine balanced steady state free precession (bSSFP) sequences  from the base to apex were obtained in the short-axis (SAx) plane as well as the cine series of vertical two-chamber long-axis plane and horizontal four-chamber plane. Native T1 mapping was performed by using a modified Look-Locker inversion recovery (MOLLI) sequences, the scanning model of native T1 MOLLI sequence was 5(3)3 , and B0 shimming (targeted cardiac mode) was used to minimize the off-resonance artifacts. The basal, middle, and apical SAx slices of native T1 mapping were acquired. Eight echoes of native T1 source imaging and color-coded native T1 maps were generated for analysis.Post-processing of all images was conducted using offline commercial software . For cardiac function assessment, LV function parameters  were measured and automatically computed by manually tracing the endo- and epicardial borders on the stacks of SAx cine images at the end-diastolic and systolic phases. Blood volume and papillary muscles were excluded. For myocardial strain measurement, sets of SAx slices and horizontal four-chamber and long-axis two-chamber cine images were loaded into the tissue tracking module. Afterwards, endo- and epicardial boundaries were manually drawn on the LV end-diastolic phase of all series, and the LV extending from the mitral valve to the apex was defined in both the four-chamber and two-chamber series. Subsequently, the anterior and posterior SAx reference points were placed on the insertion point of the septum and LV free wall on the SAx plane. Blood volume and papillary muscles were also excluded. Myocardial strain parameters including peak radial strain (PRS), peak circumferential strain (PCS), and peak longitudinal strain (PLS) directions were calculated. For segmental native T1 value measurements, native T1 source images were loaded into the T1 calculation module, endo- and epicardial boundaries were manually traced, and T1 recovery curve, native T1 color maps, R2 maps, and native R2 values were generated  or GraphPad Prism . The Shapiro–Wilk test was used to examine the normality of data. Data was presented as the mean ± SD or median (quartile), which refers to the normality result. The Mann–Whitney U test and independent t-test were used to compare the characteristics between the healthy and ESRD groups according to the data’s characteristics. Comparisons among multiple groups were performed by one-way analysis of variance with post hoc Bonferroni correction. Bivariate correlations were calculated using the Pearson or Spearman method as appropriate. Multiple linear regression was performed to detect the CMR correlates of iPTH in myocardial damage. The reproducibility of myocardial strain and native T1 was assessed using the intraclass correlation coefficient (ICC). Two-tailed P < 0.05 were considered statistically significant.The demographic and biochemical indicators of the 72 ESRD patients and 30 healthy controls are shown in Table 2+, and Mg2+, were found between ESRD patients with targeted and increased iPTH. Otherwise, all ESRD patients were orally administered calcium acetate management.Biochemical results are listed in Table For LV function Table , the LVEThe correlation coefficients of iPTH for secondary hyperparathyroidism evaluation are presented in Table LV basal, middle, and apical myocardial native T1 showed excellent interobserver ICC  and intraobserver agreement . For the global myocardial native T1, the interobserver ICC was 0.999 (95% CI 0.996–1.000), and the intraobserver ICC was 0.998 (95% CI 0.993–0.999). Myocardial strain parameters also showed excellent interobserver ICC  and intraobserver ICC .2 [2 [+ overload, Ca2+ and serum phosphorus abnormalities, and chronic inflammation, cardiovascular disease in CKD may also be driven by specific risk factors including anemia and malnutrition, hormonal imbalances, soft tissue calcification, erythropoietin resistance, renal replacement therapy (RRT)-related electrolyte imbalance, and high PTH level. In all the risk factors, secondary hyperparathyroidism has been linked with mineral bone disorders as well as increased cardiovascular mortality, which may be critical factors for uremic cardiomyopathy. PTH influences LV function in chronic hemodialysis patients, and plasma PTH reduction is beneficial to the uremic heart [As a worldwide public health problem due to its association with multiple comorbidities, CKD is highly associated with cardiovascular events, mortality, and high medical cost burden . CKD mor2 –24. Card2 [2 . Cardiovic heart . PTH lowic heart . Most ofic heart . PTH may2+ and serum phosphorus abnormalities were also found in the ESRD cohort. The iPTH of 32 patients was within the normal range by routine calcitriol and hemodynamic dialysis therapy. We found that LVEF was decreased, but still preserved in ESRD patients with either targeted iPTH or increased iPTH levels. Although no myocardial strain deterioration was detected in both ESRD cohorts, on normal iPTH, native T1 of the basal and middle segments in the LV were significantly increased. The global native T1 in subjects with both targeted and increased iPTH was higher than that in normal subjects, which may lead to the assumption that myocardial tissue deterioration happens prior to myocardial deformation. Previous studies have reported LV mechanical dyssynchrony and microvascular dysfunction detected by single-photon emission computed tomography (SPECT), and regadenoson SPECT myocardial perfusion imaging also provided a significant prognostic value in ESRD patients [In our study, iPTH levels in ESRD patients were much higher than the normal range. Capatients –31. Howepatients , 34. Thupatients . Converspatients . Many stpatients . Thus, cCKD contributing to decreased cardiac function, cardiac hypertrophy, and increased risk of adverse cardiovascular events is referred to as chronic renocardiac syndrome. Diffuse interstitial edema, inflammation, and fibrosis always occur in CKD patients, which can manifest as increased native myocardial T1 times . We founAlthough this research has demonstrated that increased iPTH levels were associated with myocardial damage in ESRD patients evaluated by CMR native T1, some limitations still exist. First, all enrolled patients in this study had ESRD and lacked the effect of iPTH on the myocardium in early-stage CKD. Second, we could not acquire an endocardial biopsy. Thus, direct association of native T1 with histologic abnormalities is lacking. Since several studies have demonstrated that native T1 plays a critical role in measuring myocardial edema and fibrosis , T2 mappMyocardial damage was found to be increased in ESRD patients with both normal and increased iPTH levels following conventional therapy. In addition, consistently high iPTH levels may be independently associated with myocardial damage in ESRD patients.