Echocardiography is increasingly used for haemodynamic evaluation and titration of therapy in intensive care, warranting reliable and reproducible measurements. The aim of this study was to evaluate the observer dependence of echocardiographic findings of left ventricular (LV) diastolic and systolic dysfunction in patients with septic shock.r was used to test the correlation and Bland-Altman plots to assess the agreement between observers. Kappa statistics were used to test the consistency between readers and intraclass correlation coefficients (ICC) for inter- and intraobserver variability.Echocardiograms performed in 47 adult patients admitted with septic shock to a general intensive care unit (ICU) were independently evaluated by one cardiologist and one intensivist for the following signs: decreased diastolic tissue velocity of the base of the LV septum (é), increased early mitral inflow (E) to é ratio (E/é), decreased LV ejection fraction (EF) and decreased LV global longitudinal peak strain (GLPS). Diastolic dysfunction was defined as é <8.0 cm/s and/or E/é ≥15 and systolic dysfunction as EF <50% and/or GLPS > −15%. Ten randomly selected examinations were re-analysed two months later. Pearson’s In 44 patients (94%), image quality was sufficient for echocardiographic measurements. The agreement between observers was moderate  to good (k = 0.71 for GLPS). Pearson’s r was 0.76 for é, 0.85 for E/é, 0.78 for EF and 0.84 for GLPS . The ICC between observers for é was very good  0.73-0.92), good for E/é , very good for EF , excellent for GLPS , and very good for all measures repeated by one of the observers. On Bland-Altman analysis, the mean differences and 95% limits of agreement for é, E/é, EF and GLPS were −0.01 (0.04 – 0.07), 2.0 (−14.2 – 18.1), 0.86 (−16 – 14.3) and 0.04 (−5.04 – 5.12), respectively.Moderate observer-related differences in assessing LV dysfunction were seen. GLPS is the least user dependent and most reproducible echocardiographic measurement of LV function in septic shock.The online version of this article (doi:10.1186/s12947-015-0015-6) contains supplementary material, which is available to authorized users. Cardiac dysfunction is a well-known complication of septic shock. It was first described using radionuclide cineangiography , and hasThe frequency of cardiac dysfunction in septic shock as well as its impact on mortality has differed vastly between studies ,3,5. DifIn this study, we assess the reliability of echocardiographic parameters used to indicate left ventricular dysfunction in patients with septic shock. Our aim is to identify the least observer-dependent echocardiographic parameter describing diastolic and systolic left ventricular function.This study was approved by the Regional Ethical Review Board in Linköping, Sweden (Dnr 2012/233-31). When possible, informed consent was sought from patients at inclusion. Due to the observational nature of the study we were permitted to assume consent in patients who because of acute illness were unable to give their permission. In these cases, informed consent was obtained as soon as possible after recovery.The dataset used for this study was originally collected for a study assessing speckle tracking echocardiography in septic shock patients . PatientSeptic shock was defined according to the Surviving Sepsis Campaign (SSC) criteria, and all patients were managed in compliance with the SSC guidelines for the treatment of septic shock . PatientTransthoracic echocardiography was performed on the day of admission, all by an expert echocardiographer not involved in patient care (JE). A Vivid E9 ultrasound scanner was used, acquiring two-dimensional (2D) apical two-chamber, four-chamber and long axis views  of the left ventricle at a frame rate of >40 frames/sec. Images were analysed offline using dedicated software , independently by two observers (LDG and JE). E-velocity was measured using pulsed wave (PW) Doppler in the mitral inflow at the tip of the valve. Diastolic tissue velocity of the base of the LV septum (é) was measured in the apical 4C view using PW tissue Doppler, and E/é ratios were calculated. Left ventricular (LV) volumes and ejection fraction (EF) were calculated using the modified biplanar Simpson’s method. Global longitudinal peak strain (GLPS) was calculated as the average speckle tracking strain from the 18 LV segments from the 2C, 4C and ALAX views (six segments per view in three different views). All echocardiographic studies were recorded over three consecutive cardiac cycles, independently of breathing cycles, and averaged. In patients with non-sinus rhythm measurements were collected and averaged over 5 – 10 heartbeats. Diastolic dysfunction was defined as E/é >15 and/or é <8 cm/s , and GLPClinical data on co-morbidities and on ICU length of stay and outcome were all collected prospectively. To assess severity of illness, Simplified Acute Physiology Score 3 (SAPS 3) and Sequential Organ Failure Assessment (SOFA) score were calculated on admission.Data are presented as medians (lower quartile – upper quartile), numbers (percentages), and means with standard deviations (range), as appropriate. Inter-observer variability of echocardiographic parameters was determined by the intra-class correlation coefficient, Pearson’s correlation coefficient and Bland-Altman plots . ReliabiFifty patients in septic shock were included. Two patients died before echocardiography could be undertaken and in one patient, images were lost in the storage process. These three patients were excluded from the statistical analysis. In the remaining 47 patients, echocardiograms from the day of ICU admission were available. Twenty-three of the patients (49%) had previously known cardiac comorbidities, but there were no patients with severe valvular regurgitation, and none with endocarditis. A three-lead electrocardiogram (ECG) recorded for monitoring purposes was analysed regarding cardiac rhythm, but 12-lead ECG was not performed. Table In three patients (6%), image quality was too poor to allow echocardiographic analysis. In the remaining 44 patients (94%), E, é, LVEF and GLPS could be assessed. Table The é measured by the two observers was 8.1 ± 3.0 and 9.0 ± 4.1, respectively Table . On PearThe E/é ratio derived from measurements by the two observers was 14.4 ± 11.7 and 11.4 ± 8.9 Table . The BlaEF measured by the two observers was 49 ± 11 and 50 ± 12, r = 0.78  was 0.84 . ICC (95% CI) improved slightly to 0.83 (0.64 – 0.92), 0.88 (0.75 – 0.95), 0.88 (0.76 – 0.94) and 0.90 (0.79 – 0.95) for é, E/é, EF and GLPS. On Bland-Altman analyses, the mean differences and 95% limits of agreement (1.96 SD) for é, E/é, EF and GLPS were −1.8 (−7.8 – 4.2), 3.82 (−6.8 –14.5), −0.26 (−15.2 – 14.7) and 0.09 (−5.5 – 5.7), respectively.In this study, we aimed at analysing the observer dependence of echocardiographic signs of cardiac dysfunction in patients with septic shock to establish the most robust, user independent parameter. Our findings suggest that there are moderate inter-individual differences regarding the measurement of diastolic and systolic parameters used to identify cardiac dysfunction in septic shock. GLPS is the least user-dependent and most reproducible parameter.LV dysfunction in septic shock has been described with varying incidence. Impaired diastolic function with decreased é or increased E/é, as well as systolic dysfunction with decreased EF, has been reported in 20 – 60% of patients. A direct comparison between studies is complicated by differences in study size and in the prevalence of pre-existing cardiac disease, but also by the lack of true consensus on the definition of LV dysfunction in septic shock. In cardiology settings, the impact of observer dependence on echocardiographic measurements regarding diastolic as well as systolic parameters has been studied -10, but The echocardiographic measures to assess diastolic myocardial function, in this study é and E/é, reflect different aspects of LV filling, each with potential limitations. Furthermore, the measurements are manually obtained and therefore inherently subjective. Also, the accuracy and reproducibility of é and E/é is debated in patients with atrial fibrillation (AF), ischaemic heart disease or hypertrophic cardiomyopathy -22. The The accuracy of é as well as E/é has been shown to be dependent on changes in volume loading and ventilator settings -26, possFor evaluating systolic LV function, we used the biplane Simpson method which is widely recommended and has been shown to reliably detect even small changes in EF in ischaemic heart disease ,27. One In stress echocardiography a high degree of variability has been demonstrated even among expert observers . A recenOur findings have clinical implications since echocardiography is used for the diagnosis of cardiac dysfunction in septic shock. Furthermore, echocardiography is increasingly recommended for circulatory monitoring in septic shock patients ,30. SincThe selection of patients has a heavy influence on the results of echocardiographic assessment. In this study, patients expected to survive less than 24 hours were excluded, and this may have contributed to the high percentage of successful acquisitions. LV function parameters used in this study are all well established in patients with cardiac disease, but there is no clear definition on cardiac dysfunction in septic shock. Neither is there any consensus on what degree of variability in measurements is acceptable in this group of patients, since this aspect of echocardiographic assessment has not been addressed before. Furthermore, the number of patients studied is limited and the dataset used was not originally collected for these analyses.A strength of the study is the fact that images were collected by an expert-level echocardiographer. Thus, the focus of the study is on the repeatability of measurements, irrespective of image acquisition. Moreover, all echocardiographic analyses were performed independently and while blinded to patient identity and clinical background, and the samples used for comparison are therefor of equal size. Further strength lies in the systematic approach to assessing inter- as well as intraobserver reliability and reproducibility.We conclude that echocardiographic measurement of LV function is feasible and reproducible in the majority of septic shock patients. Because of the observer-related differences in the measurements used, results should be interpreted in relation to other clinical findings when used for guiding therapy. GLPS is the least user dependent and most reproducible echocardiographic finding of LV function in septic shock. GLPS may thus represent a useful tool in the evaluation of LV function in this group of patients.


Patients with Ebstein's anomaly are at risk of tachyarrhythmia, congestive heart failure and sudden cardiac death. There are few data regarding the value of modern non-invasive diagnostic testing in prediction of outcomes. Therefore, we aimed to evaluate cardiovascular magnetic resonance (CMR) and compare it to known predictors in Ebstein's anomaly.Seventy-nine consecutive adult patients (aged 37±15 years) with unrepaired Ebstein's anomaly underwent CMR and were followed prospectively for a mean of 3.5±2.6years.The major adverse cardiovascular events were defined as sustained ventricular tachycardia(VT)/heart failure hospital admission/transplantation or death. Sub-group analysis of first-onset atrial tachyarrhythmia (AT) was performed.Univariate predictors of the major adverse cardiovascular events  were New York Heart Association class >2 , left ventricular (LV) ejection fraction (HR) 0.43[95%CI 0.245-0.742],p=0.003/5%), LV stroke volume  and right ventricular (RV) ejection fraction ; all remained significant even when tested solely for mortality. In all but one patient VT/death was preceded by AT and AT was predictive of major adverse cardiovascular events , emphasizing its role as an early marker of long-term adverse events. Freedom from first-onset AT  declined during the follow-up. Univariate predictors for first-onset AT included RV ejection fraction ], RV/LV end diastolic volume ratio  and apical tricuspid septal leaflet displacement indexed to LV length ; when used together as a score, risk prediction was further enhanced .Ventricular functional impairment by CMR was highly predictive of mortality and VT in a large contemporary cohort of unrepaired adult patients with Ebstein's anomaly supporting the potential of CMR in risk stratification and clinical follow up. Furthermore, VT and death were preceded in almost all patients by presentation of AT suggesting that AT predicts long term adverse events early on in the disease progression. Onset of AT was best predicted by routinely measured CMR parameters feasible for clinical approach.Riikka Rydman was supported by the Swedish Society of Medicine, Swedish Heart-Lung Foundation and Swedish Society for Medical Research and by the Section of Clinical Physiology, Department of Molecular Medicine and Surgery, at Karolinska Institutet, Stockholm, Sweden. Sonya V. Babu-Narayan is supported by an Intermediate Clinical Research Fellowship from the British Heart Foundation (FS/11/38/28864). This project was supported by the National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Unit of Royal Brompton and Harefield National Health Service (NHS) Foundation Trust and Imperial College London. This report is independent research by the NIHR Biomedical Research Unit Funding Scheme. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.


Stage III patients had decreased LV global longitudinal systolic strain (LVε) compared with controls . Stage III patients also had decreased peak atrial longitudinal strain rate during ventricular systole (ALSRsyst), peak atrial longitudinal strain rate during ventricular early diastole (ALSRearly), and peak atrial longitudinal strain rate during ventricular late diastole (ALSRlate) compared with controls . Multiple regression analysis revealed severity of gout had an independent negative impact on LA pump function (ALSRlate). In conclusion, gout caused LV diastolic dysfunction, LV subclinical systolic dysfunction and LA reservoir, conduit, and booster pump dysfunction.The purpose of our study was to evaluate the left ventricular (LV) and left atrial (LA) function in patients with gout. A total of 173 patients underwent a comprehensive Doppler-echocardiography examination. Participants were divided into four groups–Stage 0: control (n = 35), Stage I: asymptomatic hyperuricemia (n = 30), Stage II: gouty arthritis without tophi (n = 58), and Stage III: tophaceous gout (n = 50). Serum uric acid levels were not significantly different between stage I, II and III. Stage III patients demonstrated a higher ratio of the transmitral and myocardial peak early diastolic velocities (E/Em) , and larger maximal LA volume index (LAVi) (29.60±9.89 vs. 20.07±4.76 ml/m Gout is a common metabolic disorder characterized by hyperuricemia and chronic inflammation Clinically, severity of gout, rather than hyperuricemia, is more representative of the chronic inflammation in patients with gout. Epidemiological studies have found gout is associated with increased incidence of coronary heart disease and stroke. However, the exact pathological mechanism underlying this association is unclear LA remodeling has been previously proposed to be a predictor of cardiovascular disease, including atrial fibrillation, congestive heart failure, and cardiovascular death Between October 2010 and February 2013 patients diagnosed with gout including asymptomatic hyperuricemia, gouty arthritis without tophi, and tophaceous gout were enrolled in this prospective study. Age-matched individuals without hyperuricemia or gout served as controls. Exclusion criteria included the presence of moderate or severe valvular heart disease, dilated or hypertrophic cardiomyopathy, LV systolic dysfunction (defined as an LV ejection fraction <50%), cardiac arrhythmia, pacemaker implantation, congenital heart disease, coronary artery disease and a history of cardiac surgery. Patients were also excluded if they had poor echocardiographic images for analysis.All study protocols were approved by the Chang Gung Medical Foundation Institutional Review Board (IRB100-3022B) in our hospital and signed informed consent was obtained from all patients. Background and demographic data was collected from enrolled patients and included age, sex, height, body weight, systolic blood pressure, serum creatinine level, UA level, and absence or presence of hypertension, diabetes mellitus (DM), hypercholesterolemia, and medications for gouty arthritis. Asymptomatic hyperuricemia was defined as serum UA ≥7 mg/dl without a history of clinically painful joints histories. The diagnosis of gouty arthritis was made according to the American College of Rheumatology (ACR)/Wallace criteria According to the guidelines of the American Society of Echocardiograhy Thickness of the interventricular septum (IVS) and posterior wall (PW) in end-diastolic phase, and LV end-diastolic and end-systolic dimensions were determined using the M-mode in the parasternal long-axis view. The LV mass was estimated using the Devereux formula. The LV mass index was obtained based on LV mass/body surface area (BSA). Mitral inflow velocities were evaluated using a 1- to 2-mm sample volume placed at the mitral valve tip by pulse-wave Doppler in the apical four-chamber view. Diastolic peak early (E) and late (A) transmitral flow velocity, and E to A ratio (E/A) were measured. In the apical-four chamber view, the peak early diastolic mitral annular velocity (Em), and peak late diastolic annular velocity (Am) were obtained by pulse-wave tissue Doppler imaging at the septal site of the mitral annulus. The E/Em ratio was calculated for assessment of the LV diastolic dysfunction and was used as an index of LV filling pressure LA volume (LAV) was measured in the apical four-chamber and two-chamber views using the biplane modified Simpson's method. Maximal, precontraction, and minimal LAV were measured just before mitral valve opening, at the beginning of the P wave, and at mitral valve closure, respectively. The following indexes of LA function were calculated: maximal LAV index (LAVi) was calculated as maximal LAV/BSA, precontraction LAVi was calculated as precontraction LAV/BSA, and minimal LAVi was calculated as minimal LAV/BSA. During each cardiac cycle, total LA ejection fraction (LAEF) was defined as /maximal LAV×100%, passive LAEF was defined as /maximal LAV×100%, and active LAEF was defined as /precontraction LAV×100%.syst, ALSRearly, and ALSRlate were assessed as the average of six segmental values in apical four-chamber view demonstrated in syst, ALSRearly, and ALSRlate indicate LA reservoir, conduit and booster pump function.For speckle tracking analysis, apical four-, two-, and three-chamber views were gained using echocardiography . For each view, adequate gray scale images were obtained to outline the endocardial and epicardial border of the LV and the LA. At least three consecutive cardiac cycles were acquired during the patients held breath following complete exhalation with a stable eletrocardiographic recording. Speckle-tracking analysis was performed using EchoPAC software . For each analysis the endocardial border was traced manually, a second line was generated by the software near the epicardium using an automatic default width. We were able to adjust the width to ensure the entire LV or LA myocardial wall was included manually. The region of interest was then divided into six segments and labeled as acceptable or unacceptable based on adequate tracking quality. In poor tracking segments, the endocardial trace line was able to be adjusted until improved tracking quality was achieved. The LV global longitudinal systolic strain (LVε) was the average values of peak longitudinal systolic strain obtained from 17 segments of LV by analysis of the apical four-, two-, and three-chamber views. LA speckle-tracking analysis was performed from the apical four-chamber view to obtain longitudinal LA strain and strain rate. Peak atrial longitudinal strain (PALS) and LA strain rate parameters including ALSR2 test. Univariate correlations were determined using Pearson's coefficient for continuous variables. Multiple regression analyses were performed to determine the associations between gout stage with PALS, ALSRsyst, ALSRearly, and ALSRlate. The first multivariate model adjusted for age, UA, creatinine, and LV mass index. The second multivariate model adjusted for E/Em and LVε. Statistical significance was set at P<0.05.Statistical analysis was performed using SPSS 18.0 statistical software . Continuous data are presented as mean ± standard deviation, and dichotomous data as number and percentage. Comparisons of continuous variables between groups were performed using an analysis of variance (ANOVA). Categorical variables were compared using the χA total of 200 patients were screened for study inclusion. 27 patients were not enrolled because of LV systolic dysfunction (n = 2), hypertrophic cardiomyopathy (n = 2), pacemaker implantation (n = 2), atrial fibrillation (n = 2), and poor echocardiographic images (n = 19). Thus, the final study population consisted of 173 patients. Patients were divided into four groups– stage 0: age-matched controls (n = 35); stage I: asymptomatic hyperuricemia (n = 30), stage II: gouty arthritis without tophi (n = 58); and stage III: tophaceous gout (n = 50). 2; P<0.001). There were no significant differences between the four groups with respect to LV end-diastolic dimensions, end-systolic dimensions, LVEDV, and LVESV. Additionally, there were no significant differences in LV systolic function measured by biplane modified Simpson's method between the four groups. The E, A, E/A ratio, and Am were not significantly different between the four groups. The stage III patients had a significantly lower Em compared with controls . Lastly, the Em/Am ratio was lower in stage III patients compared with controls  and the E/Em ratio was higher in the stage III patients compared with controls . The absolute value of the LVε in stage II and III is lower than in stage 0 and I (P = 0.002).The LV echocardiographic parameters are summarized in syst, ALSRearly, and ALSRlate decreased progressively from the control group to those patients in stage III. And the value of PALS, ALSRsyst, ALSRearly, and ALSRlate in stage III patients was significantly lower compared with patients in the control group .The echocardiographic parameters in terms of LA volume and function are listed in syst, and ALSRearly were significantly correlated with E/Em  in gout patients including asymptomatic hyperuricemia, gouty arthritis without tophi and tophaceous gout. Conversely, ALSRlate was not correlated with E/Em   . The mul= 0.865)  also sholate measurements were assessed by the coefficient of variation, where differences between measurements were expressed as the ratio of the standard deviation to the mean. Inter-observer variability was assessed using two independent observers and intra-observer variability using one observer twice within a two-week period. The inter-observer variability of E/Em was 3.3%, maximal LAV was 2.2% and ALSRlate was 6%. The intra-observer variability of E/Em was 1.8%, maximal LAV was 1.5% and ALSRlate was 5%.In 20 randomly selected subjects, the interobserver and intraobserver variability in E/Em, maximal LAVi and ALSRThe major findings of this study was that severity of gout caused LV diastolic dysfunction, subclinical systolic dysfunction and LA reservoir, conduit, booster pump dysfunction and LA volume enlargement.Gout is a metabolic disorder characterized by hyperuricemia and is a type of chronic inflammatory arthritis induced not only by xanthine oxidase-mediated oxidative stress, but also by the deposition of monosodium urate (MSU) crystals in synovial fluid and other tissue As the LV undergo remodeling, the LV filling pressure increases. The E/Em reflects the LV filling pressure and is a parameter of LV diastolic function. The higher E/Em, the poor LV diastolic function The LA acts as a reservoir during LV systole, as a conduit in LV early diastole, and as a booster pump in the LV during late diastole. Reduced LA reservoir and booster pump functions can reflect the progressive deterioration of LV diastolic dysfunction syst, and ALSRearly were significantly correlated with E/Em, except ALSRlate . These results suggest LA booster pump is not only modulated by impaired LV diastolic function but also modulated by ongoing inflammation mediated by MSU crystals in patients with gout. As the progressive severity and inflammation of gout, the LA booster pump function decreased. Reduced LA booster pump function has been demonstrated to predict new-onset atrial fibrillation In this study, maximal LAVi, PALS, ALSRALSRlate . This suThere are several limitations in the present study. First, it was a cross-sectional study, further follow-up cohort studies are necessary to demonstrate a reduced LA booster pump is a predictive factor of adverse cardiac events in patients with gout. Secondly, the biological link between gout and organic heart remodeling remains unclear, our current hypotheses and results require further clarification through additional studies.Severity of gout was significantly associated with the deterioration of LV diastolic dysfunction, LV subclinical systolic dysfunction, enlarged LA volume, and impaired LA function including reservoir, conduit, and booster pump functions.


Takotsubo cardiomyopathy (TCM) is a life-threatening systemic consequence early after subarachnoid hemorrhage (SAH), but precise hemodynamics and related outcomes have not been studied. The purpose of this study was to investigate TCM-induced cardiac function by transpulmonary thermodilution and its impact on clinical outcome of SAH.We retrospectively analyzed 46 consecutive postoperative SAH patients who developed TCM. Patients were divided into two groups of echocardiographic left ventricular ejection fraction (LVEF) <40% (TCM with left ventricular (LV) dysfunction) and LVEF ≥40% (TCM without LV dysfunction). Cardiac function index (CFI) and extravascular lung water index (ELWI) were monitored by transpulmonary thermodilution in parallel with serial measurements of echocardiographic parameters and blood biochemical markers.r = 0.82, P < 0.0001). The CFI between days 0 and 7 was significantly lower in patients with LV dysfunction (LVEF <40%) than in patients with LVEF ≥40% (P < 0.05). CFI had a better ability than cardiac output to detect cardiac dysfunction (LVEF <40%) . A CFI value <4.2 min−1 had a sensitivity of 82% and specificity of 84% for detecting LVEF <40%. CFI <4.2 min−1 was associated with delayed cerebral ischemia (DCI) (odds ratio (OR) = 2.14, 95% confidence interval (CI) = 1.33 to 2.86; P = 0.004) and poor 3-month functional outcome on a modified Rankin Scale of 4 to 6 . An extravascular lung water index (ELWI) >14 ml/kg after day 4 increased the risk of poor functional outcome at 3-month follow-up .Transpulmonary thermodilution-derived CFI was significantly correlated with LVEF  contains supplementary material, which is available to authorized users. Autonomic storm after aneurysmal subarachnoid hemorrhage (SAH) can adversely affect cardiovascular parameters and may result in stress-related cardiomyopathy . One disCardiovascular monitoring is essential for the diagnostic and therapeutic management of critically ill patients and for assessing LV systolic function. Echocardiography is currently the most frequently used imaging modality for bedside assessment of LVEF ,8, but iThe aims of this study were (1) to investigate the changes in cardiac function in postoperative SAH patients with TCM by transpulmonary thermodilution, and then (2) to test whether CFI and EVLW could predict outcome of TCM ,15 in teIn this retrospective analysis of a prospectively collected data set, we considered all patients enrolled in our cohort trials  between April 2005 and March 2013. This study was approved by the institutional review boards of the two participating stroke centers . According to the informed consent guidelines in Japan , it is uTransthoracic echocardiography was performed for all patients immediately after admission to the emergency department and was repeated simultaneously with CFI measurements using the PiCCO™ device at least more than once daily until day 14. LV ejection fraction (LVEF) was measured using the Simpson method . The echocardiographic criteria for a diagnosis of TCM included the presence of severe regional wall motion abnormalities, mostly affecting the apical and midventricular segments .plus monitor  for determination of CO, GEDV, CFI and EVLW in the ICU immediately after surgery. CO, GEDV and EVLW were indexed for body surface area to obtain CI, GEDI and ELWI, respectively. Full details of the PiCCO™ measurements are described elsewhere  was corrected by increasing daily intravenous fluids . Low CI associated with TCM was treated with milrinone  or dobutamine (3 to 9 μg/kg/min) to maintain CI ≥3.0 L/min/m2 [Hemodynamic stability was defined as CI ≥3.0 L/min/mry edema ,23. HypoL/min/m2 . Elevate2) until the resolution of symptoms [Clinical deterioration due to DCI or evidence of cerebral vasospasm on transcranial Doppler ultrasonogram  was treated initially with volume expansion with 500 ml of 6% hydroxyethyl starch ;if this treatment was ineffective, it was followed by hyperdynamic therapy with incremental doses of dobutamine  or milrinone  to raise the CI above the normal limit (>5.0 L/min/msymptoms .2); GEDI (680 to 800 ml/m2); ELWI (3 to 7 ml/kg); CFI (4.5 to 6.5 min−1); and plasma levels of cardiac troponin I (0 to 0.5 ng/ml), adrenaline (0 to 0.1 ng/ml), noradrenaline (0.1 to 0.5 ng/ml) and brain natriuretic peptide (0 to 18.4 mg/dl). Heart rate (HR), mean arterial blood pressure (MAP), central venous pressure (CVP) and systemic vascular resistance index (SVRI)  were simultaneously recorded. Measurements of transthoracic echocardiographic parameters and plasma biochemical markers were performed simultaneously with the PiCCO™ measurements at least once daily.The following parameters were measured at least twice daily during the study period (days 0 to 14 after the onset of SAH): CI  ,27 betweDCI was defined as a new focal neurological deficit or global neurological deterioration  lasting longer than 2 hours, after exclusion of intracranial hemorrhage, hydrocephalus, seizures, metabolic derangements and infection, with or without radiological signs of cerebral vasospasm . In uncoFunctional outcome was assessed with the mRS at 3 months, divided into either poor outcome (score of 4 to 6) or favorable outcome (score of 0 to 3) ,27. We aWe also considered those variables available at the time of admission: age, sex, comorbid conditions, World Federation of Neurosurgical Surgeons (WFNS) grade, modified Fisher grade and cardiopulmonary complications .post hoc Bonferroni–Dunn correction, as appropriate. Univariate analyses of the relationships of categorical variables with outcomes of interest were assessed using a χ2 test or Fisher’s exact test. Univariate analyses of the relationships of normally distributed variables with outcomes of interest were assessed using Student’s t-test, and of nonnormally distributed variables were assessed using the Mann–Whitney U test. The variables showing significant associations with DCI and poor functional outcome on univariate analyses were entered into a multivariate logistic regression analysis. To determine the correlation between CFI and echocardiographic LVEF over time (day after SAH onset), a mixed-effects regression model was used. The ability of CFI to predict LVEF <40% was determined by receiver operating characteristic (ROC) curve analysis. The area under the curve (AUC) was calculated based on the ROC curves and expressed as a 95% confidence interval. AUC ranges from 0.5 to 1.0. An AUC closer to 1 indicates a higher predictive power. All analyses were performed using JMP Pro 11.0.0 software . P-values <0.05 were considered statistically significant.Data are expressed as the mean (standard deviation) or median (interquartile range), unless otherwise indicated. Continuous data were compared using mixed-effects analysis of variance  with the P = 0.014) and a higher frequency of pulmonary edema  at presentation than those with LVEF ≥40%. There were no significant differences between the two groups for other baseline parameters, including age, sex, modified Fisher grade based on computed tomographic scan, aneurysm location, treatment modality and hypotension.Forty-six (8%) of the five hundred seventy-five screened patients were diagnosed with TCM. Their baseline characteristics are shown in Table 2 versus 698 ± 70 ml/m2; P = 0.03)   had low CFI Figure  may alsoP < 0.0001). A statistically significant difference between the groups was detected only by CFI . The CFI between days 0 and 7 was significantly lower in patients with LV dysfunction (LVEF <40%) than in patients with LVEF ≥40% (P < 0.05). No statistically significant group differences were observed for HR, MAP, CVP or SVRI throughout the study period . The transpulmonary thermodilution-derived CFI correlated significantly with echocardiographic LVEF  . A CFI value <4.2 min−1 had a sensitivity of 82% and specificity of 84% for detecting LVEF <40%.LV dysfunction was defined by echocardiograms performed simultaneously with the PiCCO™ measurements (P < 0.01) or a slight increase in CI  induced by 500 ml of 6% hydroxyethyl starch (10 ml/kg/hr). In contrast, hyperdynamic therapy with an incremental dose (3 μg/kg/min) of dobutamine (maximum dose = 9 ± 3 μg/kg/min) resulted in a change in CFI of 17 ± 9% after each dose increment (P < 0.05), with an overall clinical response rate of 52%.We further analyzed whether CFI was useful for estimating cardiac function during hypervolemia or hyperdynamic therapy for treating DCI in 25 patients Figure . CFI was−1   and greater incidence of pulmonary edema after day 4  than patients with LVEF ≥40%, resulting in a longer ICU stay  and poorer functional outcome at 3 months   was independently associated with DCI (odds ratio (OR) = 2.14, 95% confidence interval = 1.33 to 2.84; P = 0.004) and poor 3-month functional outcome on mRS score of 4 to 6  (Table P = 0.04).Multivariate logistic regression analysis including significant factors associated with DCI  and functional outcomes  on univariate analysis  lasting 4 days or more should alert the physician that LV contraction is probably impaired and that there is an increased risk of DCI and poor functional outcome. Persistent LV dysfunction has also been reported to be associated with pulmonary edema [Several comorbid risk factors predictive of SAH-induced TCM and neurogenic pulmonary edema may operate via increased catecholamines ,31. Unfory edema , indicatry edema ,34,35.−1 to predict LVEF <40% with sensitivity of 82% and specificity of 84%) and concurrent pulmonary edema during DCI risk period (days 4 to 14 after SAH) are associated with prognosis in patients with post-SAH TCM. Transient LV dysfunction is a well-recognized complication of SAH and is often referred to as neurogenic stunned myocardium [Our data demonstrate that duration of LV dysfunction  % to 15% . This stThe results of this study suggest that prolonged cardiac dysfunction and concurrent pulmonary edema contribute to poor functional outcome in SAH patients with TCM. Serial measurements of transpulmonary thermodilution-derived CFI and ELWI may provide an easy bedside method of estimating changes in LV systolic function and EVLW and predicting clinical outcome.The incidence of TCM in treatable SAH patients was 8%, and half of them had concurrent pulmonary edema.Prolonged cardiac dysfunction and pulmonary edema associated with TCM increased the risk of DCI, contributing to poor functional outcome in SAH patients.Serial measurement of CFI and ELWI by transpulmonary thermodilution may provide an easy bedside method of detecting early changes in TCM-induced cardiopulmonary function to direct proper post-SAH treatment.


The adipokine omentin, also known as intelectin, is a secretory protein, expressed in visceral adipose tissue and is highly abundant in plasma. It is involved in the development of chronic inflammatory diseases, but nothing is known about its impact on the cardiovascular event risk. Here, plasma omentin was measured in 295 patients undergoing coronary angiography for the evaluation of established or suspected stable coronary artery disease (CAD). Patients were separated according to the median plasma omentin concentrations into a high and low omentin group and cardiovascular events occurring during a period of 3.5 years have been recorded. We observed that patients within the high omentin group had significantly more cardiovascular events than patients in the low omentin group. This was true even if using different study endpoints. This article describes data related to a research article titled “High Plasma Omentin Predicts Cardiovascular Events Independently From the Presence and Extent of Angiographically Determined Atherosclerosis”   Specifications Table1–Up to date, no prospective data on the power of the adipokine omentin to predict cardiovascular events are available.–The data from our prospective cohort study for the first time shows that elevated plasma omentin significantly predicts cardiovascular events.–This data are important, because the limited existing literature on omentin had rather suggested benefits on cardiometabolic parameters in other populations.–The adipokine omentin may serve as a potential new biomarker in coronary patients.–The data may stimulate future research addressing omentin in different patient cohorts.2n=147) and low  omentin. The event-free survival (pLog-Rank=0.037), if including all cardiovascular events but excluding revascularization in arterial beds (EP B pLog-Rank=0.012), or if including only major cardiovascular events .The data presented here show the incidence of cardiovascular events and study endpoints (EP) respectively in 295 coronary patients according to their plasma omentin concentration. Patients were separated into a group with high  and a low omentin group (n=148). The present study has been approved by the Ethics Committee of the University of Innsbruck; written informed consent was given by all participants.From a large cohort of 1751 Caucasian patients, who were referred to coronary angiography for the evaluation of established or suspected stable coronary artery disease (CAD), 295 were randomly drawn, except for CAD status (161 had significant CAD and 134 did not have significant CAD) and sex (140 women and 155 men). Patients with acute coronary syndromes were not included. In these 295 patients, we measured plasma omentin. Subsequently, these 295 patients were separated according to the median of measured omentin concentrations into a high omentin group  kit  from the same batch of kits (lot no. 20110234), specific for omentin-1 with an inter-assay variation less than 10%. We assessed a mean (+SD) omentin concentration of 17.4 (+14.3) ng/ml and a median of 13.4 (interquartile range 7.9–21.5) ng/ml. Thus the data range is comparable to omentin levels reported for healthy control subjects ranging from 14 to 34 ng/ml 5Mortality data were collected annually from a national survey ; follow-up visits to our institution were planned after 3–4 years in order to assess endpoints among survivors. The mean follow up time was 3.5 ±1.1 years after the baseline investigation. To assess non-fatal endpoints we conducted standardized interviews; additionally, hospital records were reviewed.The data refer to cardiovascular events comprising coronary death , fatal ischemic stroke, non-fatal myocardial infarction non-fatal ischemic stroke, and need for coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or revascularization in the carotid or peripheral arterial beds. The combination of all these events has been referred to as our primary study endpoint (EP A). Additional endpoints include the composite of coronary death , fatal ischemic stroke, non-fatal myocardial infarction, non-fatal ischemic stroke, and need for coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) – i.e. the primary endpoint without revascularization in the carotid or peripheral arterial beds (=EP B); and the composite of coronary death , fatal ischemic stroke, non-fatal myocardial infarction and non-fatal ischemic stroke – i.e. major cardiovascular events (=EP C).Coronary angioplasty and bypass surgery were considered as cardiovascular events unless they were planned as a consequence of the baseline angiography and therefore were not “future” events. A follow-up rate of 95% was achieved.6n=15) were not included in the prospective analyses. Statistical analyses were performed with the software package SPSS 22.0 for Macintosh, IBM SPSS; Chicago, IL.Survival analysis was performed using Kaplan–Meier and Log-Rank tests respectively. Patients who were lost during the follow-up (


The common pathophysiological consequences of chronic mitral regurgitation (MR) are left atrial (LA) remodeling/dilatation and pulmonary hypertension (PH). We aimed to study the association between LA volume (LAV) and PH in patients with chronic organic MR.We prospectively studied 154 patients  with isolated moderate to severe chronic organic MR. Severity of MR was assessed using proximal isovelocity surface area method. LAV was assessed using the area-length biplane method. PH was defined as pulmonary artery systolic pressure > 50 mmHg.2) was described in 123 (79.9 %) patients. Dyspnea, history of heart failure and atrial fibrillation was reported in 37.7 %, 20.1 % and 29.4 % of patients, respectively. Left ventricular (LV) ejection fraction was 68.1 ± 5.9 %. LAV index and EROA were 67.1 (24.7–391.3) ml/m2and 60.3 (10.5–250.9) mm2, respectively. Age, presence of atrial fibrillation, EROA, LV end-systolic and end-diastolic volume, LV mass index, LAV index and tricuspid annular plane systolic excursion were all factors univariately associated with PH. In multiple logistic regression analysis, age , EROA  and LAV index  were independently associated with PH.Ruptured chordae and flail leaflets were the most common etiology of MR (53.2 %). Severe MR (effective regurgitant orifice area (EROA) > 40 mmIn patients with chronic organic MR, a significant association exists between LAV index and PH. Age, the severity of MR as assessed by EROA, and LAV index are the independent determinants of PH. Mitral valve diseases, mitral stenosis and mitral regurgitation (MR), remain a common health problem worldwide. The typical pathophysiological consequences of mitral valve diseases, regardless of the etiologies, are left atrial (LA) dilatation and pulmonary hypertension (PH). Organic MR is a common problem and its prevalence increases with age . Dilatat2. Patients excluded from the study were those with insignificant MR (EROA < 20 mm2), combined mitral valve disease of significant degree, functional/ischemic MR, previous percutaneous balloon mitral valvotomy, associated significant aortic valve disease (moderate to severe degree), prosthetic valve at any position, previous cardiac or valve surgery, left ventricular (LV) systolic dysfunction (LV ejection fraction < 50 %), congenital or pericardial disease, renal dysfunction (serum creatinine > 2 mg/dL), pulmonary or hepatic disease and those with limited or poor-quality echocardiographic study. The patients were included in the study, regardless of symptoms. Symptomatic patients were defined as those in New York Heart Association function classes II – IV. The institutional review board of Siriraj Hospital, Mahidol University , approved the study protocol. Informed consent was obtained from all patients.The study cohort consisted of consecutive patients who were referred to the echocardiographic laboratory for clinical evaluation of cardiac disease. An electrocardiogram was obtained in all patients on the day of echocardiography. After the results of echocardiography were available, those with the diagnosis of isolated organic MR were prospectively enrolled in the study. Eligible patients were adults over 18 years of age with the diagnosis of chronic organic MR who had effective regurgitant orifice area (EROA) of MR ≥ 20 mm2 and regurgitant volume ≥ 60 ml. Tricuspid regurgitation velocity (continuous-wave Doppler) was measured to allow the calculation of pulmonary artery systolic pressure, using the simplified Bernoulli equation [m’) myocardial velocity, indicating LV systolic function, was measured in apical 4-chamber view using TDI with the sample volume at the medial mitral annulus. The LV diastolic function was evaluated by Doppler echocardiography of transmitral flow and TDI of the mitral annulus. Peak early (E) and late (A) diastolic velocities of mitral inflow and deceleration time of E were measured using pulsed-wave Doppler with the sample volume at the tip of mitral valve. The TDI determination of diastolic function was performed in apical 4-chamber view with the sample volume at the septal aspect of mitral annulus. Longitudinal early (E’) and late (A’) diastolic myocardial velocities were measured. Right ventricular systolic function was evaluated by assessing both the tricuspid annular plane systolic excursion (TAPSE), determined using M-mode echocardiography at lateral tricuspid annulus, and the peak systolic velocity of lateral tricuspid annulus (St’), measured by TDI.A comprehensive transthoracic echocardiographic examination consisted of two-dimensional, M-mode, Doppler echocardiography and tissue Doppler imaging (TDI). The average of echocardiographic measurements of 3–5 consecutive cardiac cycles was used for the analysis. The severity of MR was quantitatively assessed using proximal isovelocity surface area method and grading according to the recommendation by American Society of Echocardiography . Patientequation . Continuequation –16. PH wequation , 12. Regequation . LA diamequation . LAV wasequation . LAV andequation . Longitup-values are reported as 2-tailed, except where otherwise indicated. A p-value of ≤ 0.05 was considered statistically significant. Statistical analyses were performed using SPSS statistical package version 18.0.Clinical and echocardiographic data were analyzed using descriptive statistics, including means, standard deviation, number and percentage. The Student’s t-test or Mann Whitney U test were used to compare continuous variables between 2 groups of patients. Comparison of categorical variables was performed using the Chi-square test. Spearman rank correlation was used to relate the LAV index and the magnitude of MR, pulmonary artery systolic pressure in all patients and the subgroups. The Mann Whitney U test was used to compare LAV index in patients with and without AF. The receiver operating characteristic curve (ROC) analysis was performed to determine the cutoff values of LAV index for predicting PH. Univariate binary logistic regression analysis was used to assess the relationship between PH and other variables. Multiple binary logistic regression analysis was performed using PH as the dependent variable. Risk factors or independent variables  were selected on the basis of clinical and statistical significances. The model was fitted by backward stepwise method for variable selection in and out of the model. All p = 0.005). More patients with PH had the abnormalities on the electrocardiogram (such as LA enlargement and LV hypertrophy by voltage criteria) than those without .A total of 154 patients  were enrolled in the study. The majority of patients (62.4 %) were asymptomatic at the time of echocardiography. Among symptomatic patients, 31.2 %, 5.2 % and 1.3 % were in New York Heart Association functional class II, III and IV, respectively. Severe MR and PH were reported in 123 (79.9 %) and 41 (26.6 %) of patients, respectively. Baseline clinical characteristics in all patients and patients grouped according to the presence of PH are shown in Table p = 0.001). Table m’ and St’ were not significantly different between patients with and without PH. Table Regarding the etiology of MR, ruptured chordae and flail leaflets were the most common 53.2 %). Mitral valve prolapse without ruptured chordae or flail leaflet, and isolated rheumatic MR were reported in 54 (35.1 %) and 7 (4.5 %) patients, respectively. Pulmonary artery systolic pressure was higher in patients with severe MR than those with non-severe MR , LAV index (p = 0.037), and EROA (p = 0.006) remained independent predictors of PH . The correlation between LAV index and pulmonary artery systolic pressure remained moderate to good in the subgroup of asymptomatic patients , while the correlation was fair in symptomatic patients . Regarding the severity of MR, the correlations between LAV index and pulmonary artery systolic pressure was fair in the subgroup of patients with severe MR , and moderate to good in patients without severe MR . Table r = 0.47, p < 0.001), and regurgitant volume . Furthermore, patients with AF had a higher LAV index than those in sinus rhythm (median 98.1 (33.9–391.3) vs. 59.7 (24.7–202.4) ml/m2, p = 0.001).There was a moderate to good positive correlation between LAV index and pulmonary artery systolic pressure  and pulmonary artery systolic pressure. However, recent study in asymptomatic patients with moderate or severe MR by Arias A et al. showed that there was no statistically significant difference in pulmonary artery systolic pressure between patient with LAV index <55 and ≥55 ml/m2 [In patients with chronic organic MR, LA enlargement and PH commonly co-exist. The regurgitant volume of MR adds an excess volume load to LA, leading to LA dilatation, an increased LA pressure and PH. The more severe the MR becomes, the more likely the LAV increases. Atrial fibrillation and PH eventually occur and lead to clinical symptoms and adverse clinical outcomes. The prognostic importance of LA enlargement and PH in patients with chronic organic MR has been well established –10. Theo55 ml/m2 . The preThe present study is unique in demonstrating not only the association between LAV index and PH, but also the significance of LAV index as an independent determinant of PH in patients with chronic organic MR. Although there are several studies regarding the prognostic implication of LA enlargement and PH in patients with chronic organic MR, the issue verifying the importance of LA enlargement as an independent determinant of PH is under-recognized. Barbieri et al. demonstrated that age and LA size were independent predictors of PH in patients with MR . HoweverIn the present study, apart from LAV index, age and the severity of MR as assessed by EROA were found to be the independent determinants of PH in patients with chronic organic MR. Previous studies in general population showed that age was associated with an increase in pulmonary artery systolic pressure as the result of diastolic dysfunction, an increased medial thickness and impaired elastic properties of pulmonary vessels , 22. In The present study employed the proximal isovelocity surface area method as the only method to determine the severity of MR. Pulmonary artery pressure used in this study was determined solely by Doppler echocardiography, not by right heart catheterization. However, the estimations of MR severity and pulmonary artery pressure by Doppler echocardiography are reliably obtained and the current literature supports their values in routine clinical practice –16. NeveIn patients with chronic organic MR, a significant association exists between LAV index and PH. Age, the severity of MR as assessed by EROA and LAV index provide useful information as the independent determinants of PH. This finding supports the common pathophysiological and hemodynamic consequences of chronic organic MR.m’, longitudinal systolic myocardial velocity of medial mitral annulus; St’, longitudinal systolic myocardial velocity of lateral tricuspid annulus; TAPSE, tricuspid annular plane systolic excursion; TDI, tissue doppler imagingA, peak late diastolic velocity of mitral inflow; A’, longitudinal late diastolic myocardial velocity; AF, atrial fibrillation; E, peak early diastolic velocity of mitral inflow; E’, longitudinal early diastolic myocardial velocity; EROA, effective regurgitant orifice area; LA, left atrial; LAV, left atrial volume; LV, left ventricular; MR, mitral regurgitation; PH, pulmonary hypertension; ROC, receiver operating characteristic; S


T2* is sufficiently repeatable and sensitive to detect clinically relevant oxygenation levels in head and neck squamous cell carcinoma (HNSCC) at 3T.To determine whether quantitation of T2* maps. A quadratic function was used to model the blood transverse relaxation rate as a function of blood oxygenation. A set of published coefficients measured at 3T were incorporated to account for tissue hematocrit levels and used to plot the dependence of fractional blood oxygenation (Y) on T2* values, together with the corresponding repeatability range. Repeatability of T2* using Bland–Altman analysis, and calculation of limits of agreement (LoA), was used to assess the sensitivity, defined as the minimum difference in fractional blood oxygenation that can be confidently detected.Ten patients with newly diagnosed locally advanced HNSCC underwent two magnetic resonance imaging (MRI) scans between 24 and 168 hours apart prior to chemoradiotherapy treatment. A multiple gradient echo sequence was used to calculate T2* LoA for 22 outlined tumor volumes were 13%. The T2* dependence of fractional blood oxygenation increases monotonically, resulting in increasing sensitivity of the method with increasing blood oxygenation. For fractional blood oxygenation values above 0.11, changes in T2* were sufficient to detect differences in blood oxygenation greater than 10% (ΔT2* > LoA for ΔY > 0.1).T2* at 3T can detect clinically relevant changes in tumor oxygenation within a wide range of blood volumes and oxygen tensions, including levels reported in HNSCC. J. Magn. Reson. Imaging 2016;44:72–80.Quantitation of  Tissue oxygenation is an important parameter of the tumor microenvironment that influences both proliferation and angiogenesis.T2*) have been proposed as imaging biomarkers of tissue oxygenation status in both preclinical and clinical settings.R2* (=1/T2*) of water in blood and surrounding tissues, which provides the opportunity to image tissue oxygenation at high spatial resolution. The T2* of the vascular space is dependent on fractional blood oxygenation (Y), and can be described by a quadratic function of hematocrit levels (Hct) and magnetic field strength (B0).R2* are used to study brain activity associated with modulated regional brain perfusion (the blood oxygen level dependent or BOLD effect).R2* and tissue oxygen partial pressure (pO2), measured using oxygen electrodes, and immunohistochemical detection of the hypoxia marker pimonidazole, has been reported to be only weak to moderate.Magnetic resonance imaging (MRI) measurements of the transverse relaxation time , vessel caliber,T2* to tumor hypoxia varies according to the nature of the tumor vasculature and its host hematological status. It therefore should not be surprising that tumor T2* and its response to various tumor challenges  varies according to tumor type.In contrast, studies in breast cancer have shown differing results, as tumors were found to exhibit T2* is also dependent on physiochemical and methodological parameters.T2* measurements. The measured T2* value within a voxel is a composite of spin relaxation rates within the intra‐ and extravascular tissue spaces, a consequence of the scanning spatial resolution. Spin relaxation in the extravascular space has a much weaker and variable dependency on blood oxygenation than that for the intravascular space within a tumor.In addition to the tumor vascular microenvironment, quantitation of T2* measurements are sufficiently sensitive to detect clinically relevant oxygenation levels in HNSCC at 3T, acknowledging the influence of measurement repeatability, blood volume, and hematocrit.Hypoxia is a common and well‐recognized cause of radioresistance in HNSCC, and therefore MRI‐based measurements of oxygenation in this region are of significant interest.MR images were acquired in two scanning sessions, between 24 and 168 hours apart, in 10 patients  with newly diagnosed locally advanced HNSCC, prior to their treatment. A summary of the patient characteristics is presented in Table T2‐weighted images  were obtained first in order to assess the extent of the disease and aid axial sequence planning. Subsequently, T2‐weighted  and T2* images were acquired over the volume of interest (VOI) identified by a clinician (L.W. or K.W.). T2* was measured using a 2D gradient echo sequence with six echo times . Echoes were acquired with the same gradient polarity with in‐phase fat and water signal. No signal normalization or filtering was used. All the imaging data were anonymized, coded, and exported to a dedicated research PACS database system (XNAT).MRI was performed at 3T  using a dedicated 20‐channel head and neck coil. Patients were aligned in a supine position with slight neck extension using a standard headrest and lateral cushions for improved stabilization. Anatomical coronal T2* relaxivity maps. Data processing was performed using in‐house MatLab software . Signal intensity decay, measured for increasing echo times, was fitted on a voxel‐by‐voxel basis to a monoexponential model using a least‐squares fit method. No data truncation or filtering was used. Calculated T2* maps were exported in the DICOM format allowing further analysis with a radiotherapy treatment planning system (TPS).Paired image datasets were retrieved for image coregistration, VOI definition, and image processing. Signal changes on the multiple gradient echo images were used to calculate 3D T2* maps from both MRI sessions were coregistered using operator‐assisted rigid body algorithms. T2* images with significantly varying neck flexion or translation of tumor volume were identified and the coregistration manually corrected. For such cases primary tumor and involved lymph nodes were coregistered independently to compensate for interscan anatomical and positional variation. T2* values for respective VOIs were exported from the TPS and used for statistical evaluation.VOIs, including primary and nodal tumor sites, were manually delineated by radiologists  using the Pinnacle3 TPS . Axial images and T2* values were analyzed using boxplots and T2* difference maps were generated for each VOI to investigate the data distribution and spatial repeatability. Median T2* values were calculated for each VOI and used to assess the quantitative repeatability, to account for a skewed parameter distribution previously described in the literature.T2* distribution. Second, the Wilcoxon signed rank test was used to compare T2* distributions from each session to check whether the observed interscan variability could be attributed to measurement error. The Bland–Altman method was used to plot the T2* differences between two scan sessions against the mean value of median VOI T2* for both sessions.T2* changes between sessions and VOI volumes, and also between T2* changes and the interval between scans.Tissue R2* as a function of fractional blood oxygenation (Y)0 and Hct.A quadratic model was used to describe the blood transverse relaxation rate R2* values in the full range of blood oxygenation fractions.Coefficients A*, B*, C* previously measured empirically for Hct in the range 0.21–0.57 at 3Ttiss) was used, incorporating the BV fraction and a vascular factor (fvas = 0.85) to account for differences between erythrocyte concentration in large vessels and the tissue capillary networkIn our simulations, a “tissue hematocrit” (HR2*(Y) values for Hct in the range 0.21–0.57 were linearly extrapolated to calculate a new set of R2* values at the tissue hematocrit levels. Five blood volume fractions in the range 1–30 ml/100g were considered, including values typical for muscle  and to recognize the effect of tissue‐specific extravascular spin relaxation. Finally, the Hill equation  was used to identify the clinically relevant region of hypoxia .A simulated y‐intercept value for BV = 5 mL/100g was subtracted to derive and plot the relative P = 0.57) in the group mean Hct across the two MRI sessions, with a respective mean value of 0.4 (range: 0.283–0.459). Anatomical image coregistration revealed varying degrees of differences in patient neck flexion between the MRI sessions, despite having attempted to replicate patient positioning at each visit. However, it was possible to compensate for these differences in patient positioning by independent regional coregistration for primary and nodal VOIs.The median time interval between two scans was 84 hours (range: 24–168 hours). For all patients there was no significant difference  differed between nodes (23.6 msec) and primary tumor sites (18.7 msec). The distribution of intra‐VOI T2* values was positively skewed. An example of the spatial distribution of differences between the relaxation times in two MR examinations (ΔT2*) is presented in Fig. T2* can be observed within analyzed VOIs.In total, 22 VOIs were identified and outlined. An example of a VOI overlaid on a y P < 0.0 differedT2* for all patient VOIs did not differ from normality  and the population mean values did not differ between the two scan sessions . A Bland–Altman plot showing T2* difference between the two scans (MR2‐MR1) against the mean value of VOI median T2* for both sessions is shown in Fig. T2* differences and the VOI volumes , and also between median T2* differences and interval between scans .The distribution of tiss, were calculated using a mean of patient Hct values, and for BV = 1, 5 10, 20, and 30 ml/100g were 0.003, 0.017, 0.034, 0.068, and 0.1, respectively. Simulated relative transverse relaxation time constants T2* plotted as functions of fractional blood oxygen saturation in HNSCC are shown in Fig. T2*Y=0 y‐intercept value was 19.4 msec. The relative T2* dependence plot for BV = 5 ml/100g with LoA is illustrated in Fig. T2* dependence of fractional oxygen saturation increases monotonically, resulting in increasing sensitivity of the method with increasing blood oxygenation. In normoxic conditions, small changes of ΔY result in T2* changes greater than the repeatability LoA (ΔT2* > LoA). For example, an increase of fractional blood oxygenation from 0.4 to 0.5 would lead to an increase of T2* of 4.8 msec, with the corresponding repeatability threshold of 1.9 msec (LoA = 13%). T2* value differences were lower than the measurement repeatability for fractional blood oxygen saturation below 0.11, or pO2 of 12.4 mmHg. For Y values above that threshold, changes in T2* were sufficient to detect differences in blood oxygenation greater than 10% (ΔT2* > LoA for ΔY > 0.1).The average tissue hematocrit levels, HT2* dependence on additional biological and physicochemical factors, together with significant intra‐ and intertumor variations. These concomitant independent parameters are likely to explain the moderate correlation between T2*, direct measurement of tumor tissue oxygen tension, and immunohistochemical detection of pimonidazole. It is therefore desirable to directly measure these nonoxygen‐related contributions and to stratify tumors into more homogenous subgroups depending on disease site, level of edema, necrosis, and perfusion. Several methods for BV calculation using MRI have been proposed, including measurements of changes in T2* induced by injection of paramagnetic contrast agents such as ultrasmall superparamagnetic iron oxide (USPIO) particlesT2* to study changes in tissue oxygenation as a result of an acute intervention such as blood transfusion, vascular disruptive therapy, or hyperoxic gas challenge, where the significance of relative T2* changes rather than absolute oxygenation levels is of interest.MRI measurements of transverse relaxation times have the potential to characterize tissue oxygenation and therefore are of interest in the context of tumor hypoxia imaging. Nevertheless, quantitative tissue oxygenation measurements using BOLD MRI remain a challenge due to T2* is strongly dependent on measurement repeatability, which in turn is influenced by the iterative shimming process employed. Our data show that a minimum change in median tissue T2* of 13% is required to be regarded as statistically significant within an individual primary tumor or metastatic lymph node. In general, primary HNSCC tumors are expected to be affected by motion and shimming imperfections associated with tissue/air interfaces, and which can explain the increased differences seen in the lower T2* regions. Our model simulation of tissue T2* shows that the sensitivity of the measured change in T2* increases as a function of fractional blood oxygenation. For HNSCC tumors, measured oxygen partial pressure vary widely across a range of 0–70 mmHg, but with a median of between 10 and 20 mmHg.T2* is thus sufficient to permit detection of clinically significant changes in tumor tissue oxygenation for most HNSCC tumors. However, an exception exists for anoxic, and severely hypoxic, tumor regions (Y < 0.11), where the T2* value differences are lower than the measurement repeatability (LoA = 13%).It is important to recognize that the sensitivity of the quantitative determination of tissue vas) used in the quadratic model of T2* dependence on fractional blood oxygenation.T2* repeatability disregards the presence of true physiological fluctuations in blood flow within the tumor capillary network that lead to transient or cyclical hypoxia, which has been reported in a number of studies.T2* for all patient VOIs, however, was distributed normally, allowing for a reliable repeatability analysis. The accuracy of measured T2* values can also depend on the choice of echo times and type of data processing. In general, the signal‐to‐noise ratio (SNR) in the VOI should be adequate for images acquired using all echo times.T2*. These effects are not likely to significantly affect the relatively long mean T2* values measured at 3T in HNSCC nodal and primary tumor sites . The noise bias should not be neglected when calculating relaxation times of tissues with short T2*, or in the case of subregional voxel‐based analysis, in which case Bayesian or data truncation methods might be required.T2* studies have employed between 4 and 16 echo times.Several limitations of our study must be considered. First, BOLD measurements are mainly sensitive to the vascular space and therefore are not suitable for assessment of tissue oxygenation in the absence of functional erythrocyte perfused blood vessels, such as within necrotic tumor cores, which may often be present within metastatic H&N lymph nodes. In addition, there is uncertainty with regard to the appropriate value for the vascular factor (fT2* data and quantitative measurements of tissue oxygenation using BOLD imaging, such as blood volume fraction and macroscopic field homogeneity affecting measurement repeatability. Future investigations of T2* as an imaging hypoxia biomarker should include these confounding factors and would benefit from a direct histological verification, which was not available in this study.Simulations highlight the necessity of additional measurements to enable interpretation of T2* values measured in the primary tumors were significantly lower than in metastatic lymph nodes, which is likely a consequence of a higher blood volume rather than more severe hypoxia. Similarly, interpretation of lower T2* tumor subregions is possible if the spatial distribution of blood volume is known. The information on tissue oxygenation could be used to assist treatment management, enabling the identification of radioresistant tumors, for which radiotherapy dose escalation, radical surgery, or targeted chemotherapy could be used as an alternative or a supplement of a conventional treatment.The median T2* at 3T to detect clinically relevant tumor tissue oxygenation across a wide range of BV and oxygen tensions, including those reported for HNSCC. This establishes tumor tissue T2* measurement as a sensitive and reproducible quantitative imaging technique that may be used in future studies of tumor hypoxia.In conclusion, our results confirm the utility of quantitative measurements of


The diagnosis of acute myocarditis is described to be challenging. Novel techniques like native and contrast enhanced T1 mapping have proven to be superior to standard sequences for differentiation between healthy individuals and acute myocarditis, but a comparison in the clinical setting is not yet done.We sought to assess the diagnostic performance of native and contrast enhanced T1 mapping compared to T2w-imaging, Relative Enhancement (RE) in T1w as well as Late-Gadolinium-Enhancement (LGE).We investigated 284 patients undergoing CMR examination with suspected myocarditis by performing additional pre and post contrast T1 mapping sequences. Furthermore T2 w dark blood turbospin echo (TSE) sequences, pre and early post Gd T1 w dark blood TSE sequences and inversion recovery spoiled gradient echo sequences for LGE were utilized for myocardial tissue evaluation. Assessment of T1 relaxation time and ECV values was based on 3 short axis views and 1 long axis view. For T2w-imaging evaluation the T2-signal intensity (SI) ratio of myocardium compared to skeletal muscle was used. Additionally T2-SI of potential lesions was compared to remote myocardium and the standard deviation. Relative Enhancement (RE) was calculated from pre and post Gd administration T1w-imaging.T2-SI ratio and myocarditis associated LGE pattern, were assessed. Reference standard was an elevated troponin level, and a more than 10-fold elevation was considered relevant (0.14ng/ml).Native T1 and ECV showed good association with relevant troponin elevations. AUC was 75% (p = 0.0004) for native T1 with an optimal threshold of 993ms  and 83% (p < 0.0001) for ECV with and optimal cutoff of 32.4% .AUC for T2w imaging (T2-SI ratio) was 72% (p = 0.0029) with an optimal cutoff of 2.26 .AUC for T2w imaging (T2-SI compared to remote) was 66 % (p = 0.014) with an optimal cutoff of 1.5 standard deviations above remote .Additionally we found good correlation for native T1 and ECV with the Lake-Louise-Criteria.ECV performed significantly better compared to T2-SI in comparison to remote myocardium (p = 0.037) and showed a trend to be superior to T2-imaging in comparison with skeletal muscle (p=0.85).Although ECV and native T1 mapping detect other myocardial alterations besides acute damage, these techniques perform at least equally well in comparison to established CMR-techniques in detecting acute myocardial damage. ECV is superior to comparing T2-SI in the myocardium of remote and lesion and at least comparable with the other established methods for evaluation of acute myocarditis. Considering the potential of T1 mapping supposed to be relatively robust in acquisition, routine T1 mapping might augment the diagnostic value of CMR.N/A.


Background. Noncompaction/hypertrabeculation left ventricle (NCM/HVM) is most commonly reported in one or more segments of left ventricle and sometimes both ventricles. In this case, we present noncompaction of all segments of right and left ventricle, in a young man with mental retardation. Case Presentation. A 19-year-old male was referred to us with sudden dyspnea at rest and chest discomfort. He was a known case of mental retardation. He was born full term with birth weight = 1250 grams. On physical examination. A systolic murmur (II/VI) at left sternal border was heard. ECG showed increased voltage in precordial lead and deep ST segment depression. Chest X-ray (CXR) was within normal limits. Transthoracic echocardiography showed situs solitus, D loop, normal connection of great vessels, noncompaction LV at all segments (noncompaction/compaction = 2.5/0.5) with moderate systolic dysfunction (LVEF = 40%), diastolic dysfunction grade II, normal RV size with mild systolic dysfunction and hypertrabeculation, mild tricuspid regurgitation (TR), and normal pulmonary artery systolic pressure. After injection of agitated saline some bubbles were passed from right to left through patent foramen oval (PFO). Conclusions. Extensive sinusoid formation and trabeculation of RV and nearby all LV segments and its association with mental retardation suggest presence of strong genetic background. Noncompaction/hypertrabeculation left ventricle (NCM/HVM) occurs consequent to disorder of endomyocardial morphogenesis due to the failure of trabecular compaction during development of myocardial tissue . This coA 19-year-old male was referred to ED of Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran, due to sudden dyspnea at rest and chest discomfort. He was a known case of mental retardation. He was born full term with birth weight = 1250 grams. On physical examination, silent pericardium and percussion dullness from second to fifth left intercostal space were detected. A systolic murmur (II/VI) at left sternal border was heard. ECG showed giant voltages in precordial lead and deep ST segment depression . Chest XNCM/HVM is a rare congenital cardiomyopathy in which apical-lateral and basal-septal segments are most and least commonly affected walls, respectively . InterruOur case showed typical echocardiographic patterns of NCM as two-layered myocardial tissue with a thin compacted outer layer, a thinner noncompacted inner band, and deep myocardial trabeculation. By color Doppler imaging, at least three deep intratrabecular recesses which communicate with ventricular cavity should be identified. A noncompaction/compaction ratio >2.0 measured in systole is considered a diagnostic measure . TrabecuExtensive sinusoid formation and trabeculation of RV and nearby all LV segments and its association with mental retardation suggest presence of strong genetic background.Non compaction/hyper trabeculation left ventricle (NCM/HVM) is most commonly reported in one or more segments of left ventricle and sometimes both ventricles. In this case, we present non compaction of all segments of right and left ventricle, in a young man with mental retardation.


Schistosomiasis associated pulmonary arterial hypertension (Sch-PAH) might represent the most prevalent form of PAH worldwide. In Sch-PAH, the presence of aneurismal dilation of the pulmonary artery has been described, although it is still a matter of debate whether on average the pulmonary artery is more enlarged in Sc-PAH than IPAH.n = 25) and Sch-PAH (n = 22) who underwent computed tomography pulmonary angiogram and right heart catheterization.We retrospectively evaluated patients with IPAH (p = 0.018). For the same level of mean pulmonary artery pressure, the MPAD in Sch-PAH was 0.89 cm larger than in IPAH (Covariance model p = 0.02).Sch-PAH patients were older and presented less severe hemodynamic profiles. Main pulmonary artery diameter (MPAD) was greater in Sch-PAH than IPAH (4.5 ± 1.8 vs 3.7 ± 1.1 cm, This study demonstrated that pulmonary artery enlargement is more pronounced in Sch-PAH than IPAH, independently of mean pulmonary artery pressure level, suggesting that this is more likely a feature of Sch-PAH. Schistosomiasis associated pulmonary arterial hypertension (Sch-PAH) has gained attention in recent years because it might represent the most prevalent form of PAH worldwide , 2. In BIn patients with pulmonary hypertension, the main pulmonary artery diameter (MPAD) is significantly increased when compared to controls. Badagliacca et al.  demonstrSchistossoma mansoni eggs in stool examination or rectal biopsy [We retrospectively evaluated charts from IPAH and Sch-PAH patients who underwent CTPA and right heart catheterization (RHC) in our institution, as part of their baseline evaluation, without the use of any targeted therapy. The diagnosis of IPAH was established when other causes and associated diseases were excluded as described in previous studies . Patientl biopsy .CTPAs were reanalyzed by a chest radiologist blinded to the final diagnosis and hemodynamic profiles. Diameter measurements were obtained from the pulmonary trunk, left and right PAs. MPAD was defined as the largest diameter of the pulmonary trunk obtained from its origin to 3 cm above its bifurcation. The right pulmonary artery diameter (RPAD) was measured in its horizontal portion, in a midline plane, posterior to the ascending aorta and superior vena cava. The left pulmonary artery diameter (LPAD) was measured in its inflexion, where it crosses over the left upper lobe bronchus. The protocol was approved by the Institutional Review Board of the University of Sao Paulo Medical School Hospital (HCFMUSP - protocol number 10303) without requiring informed consent due to the retrospective nature of the study.p-value of 0.05 was considered to be significant.Continuous variables were expressed as mean ± SD and compared using unpaired t-tests. Categorical variables were expressed as proportions and compared using Fisher’s exact test. Normality of the distribution in both samples was tested using Kolmogorov-Smirnov test. Pearson correlation test was used to evaluate the association of hemodynamic variables and main pulmonary artery diameter. Covariance analysis was used for the comparison of the MPAD, correcting for the level of mean pulmonary artery pressure (mPAP). A p = 0.02), as previously described [The study sample consisted of 47 patients: 25 with IPAH and 22 with Sch-PAH. Sch-PAH patients were older  . LPAD was larger in the Sch-PAH group although not significantly . There was no significant correlation between MPAD and mPAP .To avoid bias that might occur due to a different hemodynamic profile, we performed an analysis of covariance, correcting the comparison of the MPAD for the level of mPAP. For the same level of mPAP, the MPAD in Sch-PAH is 0.89 cm larger than in IPAH   and the Concomitant finding of PA enlargement and better long-term outcome is commonly seen in patients with PAH associated to congenital heart disease , 15. IntInflammation and endothelial dysfunction have been demonstrated to be involved in the pathogenesis of PAH. Mononuclear inflammatory infiltrates, lymphocytes and machophages are present surrounding the vascular site of plexiform growth. Increased levels of proinflammatory cytokines interleukin  and exaggerated production of chemokines have been reported in patients with IPAH , 17. In This study has limitations that need to be acknowledged. This was a single center study in which baseline and hemodynamic data were collected retrospectively limiting the availability of some important variables like duration of the disease; the demonstration of different duration of the disease development would further strength the hypothesis that this could be the main reason for the differences found in our study. In fact, the finding of a significant number of patients with important enlargements in PA might already suggest chronicity of these changes. Hemodynamic study was not performed on the same day as CTPA; nevertheless, no therapeutic interventions or clinical deterioration existed in the interval between the two exams. In addition, patients with Sch-PAH were significantly older than patients with IPAH; however, observed differences remained significant even after correcting for age. It is important to highlight that, as in other forms of pulmonary hypertension, the definition of Sch-PAH is based on empirical criteria; nevertheless, these criteria were used in order to raise the chance of association between PAH and schistosomiasis.In conclusion, significant PA dilatations are more likely a feature of Sch-PAH that should raise the diagnostic suspicion in PAH patients coming from endemic regions for schistosomiasis.


Guidelines from the SCMR board try to standardize the acquisition and post processing protocols for uniform and reproducible analysis of cardiac data. However, for short axis cine acquisition, the definition of the image orientation for data acquisition is not well defined, possibly leading to variation in the evaluation of the Left Ventricular cardiac function. Having a standard definition is particularly important for multi-center and longitudinal studies. Very little work has been done to evaluate the impact of the various proposed protocols on measurement results of Left Ventricular function, which is the aim of this study.2 in-plane resolution) following 4 different acquisition planes commonly used in clinical practice (see figure): (A) Septum: short axis slices are perpendicular to the septum with one cutting through the septum junction. (B) LongAxis: short axis slices are perpendicular to the long axis with one cutting through the septum junction. (C) Left AtrioVentricular Junctions: one plane cuts through the left atrioventricular junction. (D) AtrioVentricularJunctions: one plane cuts through the right and the left atrioventricular junctions. Global LV function was quantified by a trained analyst using Segment v1.9 R3556 (http://segment.heiberg.se). Protocols were compared pair-wise using Bland Altman analysis , Pearson's correlation and t-tests based on measurements of ejection fraction (EF), mass, and stroke volume (SV). Results are given as mean across pairs in the Table.20 volunteers were recruited  without CMR contraindications or known cardiovascular diseases. The study was performed on a Siemens Prisma 3T MRI. Breath-hold CINE steady state free precession (SSFP) short axis sequences were acquired , the 4 protocols are highly correlated (Pearson consistently >0.9) with no protocol showing significantly different values compared with the others . Mean left ventricular EF, mass and SV are similar with every protocol.When rigorously following the SCMR guidelines for post processing, the differences in the acquisition planes do not appear to lead to significant variations in the assessment of LV function for volunteers. Consistency is preferred for clinical studies, but these results seem to indicate that a slight discrepancy in protocols would probably not affect significantly the measurement results of LV function. A similar study will be performed on a patient cohort to confirm this.N/A.


In preterm infants, postnatal myocardial adaptation may be complicated by bronchopulmonary dysplasia (BPD). We aimed to describe the development of left ventricular function by serial 2D, Doppler, and speckle tracking echocardiography (2D-STE) in infants with and without BPD during the neonatal period and compare these to anthropometric and conventional hemodynamic parameters.Prospective echocardiography on day of life (DOL) 1, 7, 14, and 28 in 119 preterm infants <1500 g birth weight of whom 36 developed BPD . Non-BPD and BPD infants differed significantly in median (IQR) gestational age (25.5(24–26.5) weeks vs. 29(27–30) weeks, p<0.001) and birth weight (661(552–871) g vs. 1100(890–1290) g, p<0.001).The intra- and inter-observer variability of the 2D-STE parameters measured did not depend on time of measurement, although there were significant differences in the reproducibility of the parameters. Low intra- and inter-observer variability was seen for longitudinal systolic strain and strain rate mid septum with a median CV (coefficient of variation) of <4.6%. Much higher CVs (>10%) were seen for the apical segment. While anthropometric parameters show rapid development during the first 4 weeks of life, the speckle tracking parameters did not differ statistically significantly during the neonatal period. Infants with and without BPD differed significantly (p<0.001) in the development of anthropometric parameters, conventional hemodynamic parameters except for heart rate, and 2D-STE parameters: global longitudinal systolic strain rate (GLSSR) and longitudinal systolic strain for the mid left wall (LSSR). The largest differences were seen at DOL 1 and 7 in GLSSR (p<0.001) and in LSSR (p<0.01).Reproducible 2D-STE measurements are possible in preterm infants <1500 g. Cardiac deformation reveals early (DOL 1 and 7) ventricular changes (GLSSR and LSSR) in very low birth weight infants who develop BPD. After birth, newborn life is dominated by a process of adaption. In order to survive deprived of the maternal supply of oxygen and metabolites, the infant’s organism has to develop significantly in the first hours and days of life In order to better monitor the cardiopulmonary development of these patients, new diagnostic tools are always needed and emerging 2D-STE based deformation imaging has shown promising results in various clinical studies and its reliability and repeatability has been demonstrated in adult and pediatric populations These results are encouraging and indicate that 2D-STE might also deliver new insights into the cardiac function of very low birth weight infants. In contrast to anthropometric and conventional hemodynamic parameters, very little is known about the development of 2D-STE parameters during the neonatal period, especially in patients who develop BPD. We hypothesized that there are significant differences in the development of the speckle tracking parameters between infants who subsequently did and did not develop BPD. Therefore, the goal of this study was to assess the applicability and reproducibility of the speckle tracking parameters in VLBW infants and the development of 2D-STE based strain and strain rate in the first 28 days of life compared to hemodynamic and anthropometric parameters.The study was conducted prospectively at our perinatal center from September 2008 to January 2011. During the study period, we enrolled 119 of the 167 VLBW infants who were admitted to our neonatal intensive care unit. 48 infants were excluded from our study. Of these, 5 had congenital heart malformations, and for 7 no parental consent was given. 18 infants died within 48 h after birth and 18 in the first month of life, so they did not have the full set of four sequential echocardiograms and were therefore later excluded from the study. All infants received standard intensive care, no infant required inotropes or vasopressors, and they were examined without sedation. The study protocol was approved by the local institutional review board (Ethikkommission der Charité. # EA2/072/08), and written informed parental consent was obtained.Weight and length at birth and at 1, 7, 14 and 28 days of life were documented. Bronchopulmonary dysplasia, defined as a requirement for supplemental oxygen at 36 weeks gestational age, was recorded as morbidity. We also recorded when hemodynamically significant PDA (hsPDA) treatment  was required using the following previously established criteria: PDA with left-to-right-shunt, narrowest diameter >2 mm in addition to the need for invasive ventilatory support Noninvasive systolic, diastolic and mean arterial blood pressure were assessed using an IntelliVue MMSX2 (Philips) monitor and recorded at the same time as echocardiographic measurement. Philips infant BP cuffs were used (sizes 1 to 3). The smallest cuff size that covered at least two-thirds of the right upper arm or encompassed the entire arm was selected.All patients were examined using the same 7S transducer interfaced with a Vingmed System Vivid 7 Dimension’06 . Transthoracic imaging was performed on the neonates at the ages of 1, 7, 14 and 28 days in a supine position without sedation. All scans were performed by the same experienced operator.M-mode tracings of the left ventricular cavity were recorded from the parasternal long-axis view with a single beam directed at the level of the tips of the mitral leaflets. We used LV fractional shortening (FS) as a measure of systolic left ventricular function. FS was defined as the difference in left ventricular end-diastolic diameter (LVEDD) and left ventricular end-systolic diameter (LVESD) divided by LVEDD and then multiplied by 100.Left ventricular output (LVO) was calculated as the total time velocity integral of mitral inflow multiplied by mitral valve (MV) area and heart rate, then divided by body weight. The diameter of the MV annulus was measured using the end-diastolic hinge points extracted from the apical four-chamber view frames. The MV area was calculated from the MV diameter in diastole assuming circularity of the left ventricle. The total time velocity integral of mitral inflow was measured using pulsed wave Doppler from the same apical four-chamber view. The measurement procedure is standard throughout our department and a detailed description has already been published We acquired LV four-chamber views using a median frame rate of 115 frames per second. Five consecutive cardiac cycles were acquired for each plane and digitally stored on a hard drive for offline analysis. Image analysis was performed offline on a PC workstation using custom analysis software. Strain quantification was performed using commercially available software .In all patients, the left ventricle endocardial border in the end-systolic frame was manually traced during the automatically selected next to last cycle. Based on this line, the software automatically created a region of interest that included the mid layer of the ventricular wall. Linear drift compensation was applied. In the present study, peak systolic longitudinal strain and strain rate were assessed in the six LV regions in the apical four-chamber view, and their average values were displayed by the device expressed as global longitudinal strain and strain rate . Strain sR). The Bonferroni method was used as an alpha adjustment for multiple comparisons. Statistical analysis was performed using Statgraphics Centurion  and MedCalc  software. A p-value below 0.05 was considered the limit for statistical significance.Patient characteristics were described as rates (%) or median and interquartile ranges (IQR). To describe the intra-observer variability of the speckle tracking parameters, 20 randomly selected patients were reevaluated by the same investigator (SR) on two separate occasions and the coefficient of variation (CV) calculated for the four measurement points. To describe inter-observer variability, the same procedure was repeated by a second observer (CC). The CVs of the repeated measurements were presented as medians and quartiles and the Friedman test was used to investigate the changes in intra- and inter-observer variability at the four time points. The Kruskal-Wallis test was used to compare the intra- and inter-observer variability between the different speckle tracking parameters. The Intraclass correlation coefficient (absolute agreement) (ICC) of the pooled data was calculated to describe the reliability of the speckle tracking measurements. The anthropometric and cardiological parameters measured and calculated were depicted as median and IQR in the text and in the figures: differences at the 4 measurement time points were investigated using the Friedman test. To investigate differences in the parameter development between infants with and without BPD development or hsPDA, a two-factor ANOVA for repeated measurements with BPD or hsPDA as a between-subject factor was used. If statistically significant differences in the parameter development emerged, median and IQR of these parameters were calculated for both patient groups at the four time points and the Mann-Whitney rank test was used post hoc to investigate the differences. The relationships LVO, FS, GLSSR and LSSR with the heart rate were assessed by Spearman rank order correlation coefficients  for the septum apical segment showed statistically significant parameter development after Bonferroni correction of the p-value. However, LSS was only significantly reduced at day 1; on day 7, 14 and 28 LSS did not show statistically significant changes (p = 0.114).The differences in the development of anthropometric, conventional hemodynamic, and speckle tracking parameters between infants with and without BPD or with and without hsPDA are shown in The development of bodyweight and body length in infants with and without BPD at day 28 is shown in Of the speckle tracking parameters, only the development of GLSSR and LSSR for the left wall mid segment were different between infants with and without BPD (both p<0.001). The effect of hsPDA on both parameters was lower with p = 0.006 for GLSSR and p = 0.004 for LSSR  and afteRs = −0.2653, p = 0.015) which would disappear after Bonferroni correction.The development of GLSSR and LSSR in infants with and without BPD at day 28 is shown in This study has shown that speckle tracking measurements of the left ventricle can be performed in VLBW infants with good reproducibility for the longitudinal systolic strain and strain rate, especially of the mid septum. While anthropometric parameters show rapid development during these infants’ first 4 weeks of life In contrast to the development of the anthropometric parameters, our results demonstrate that initial age-related changes in LSS of the septum apical segment diminished after the second week of life. This agrees with the findings Seghal et al 2011 achieved using conventional hemodynamic measurements Additionally, the myocardium in VLBW infants is exposed to additional significant changes in loading conditions during the early neonatal period. A PDA is a very common finding in preterm infants that results in chronic left ventricular volume loading. This left ventricular volume loading may be reflected in our results on the development of conventional hemodynamic and echocardiographic parameters, because most infants in the BPD group who have increased FS and LVO at day 7 and 14  and 4 neThe changes in hemodynamic parameters associated with PDA have been well studied in surfactant-treated preterm lambs Myocardial strain rates are strong indices of LV contractility Although recent studies have described not only alterations in right ventricular function in patients with BPD and pulmonary hypertension but also alterations in LV The etiology of LV changes in children and adults with chronic lung disease is still poorly understood. The altered LV function in patients with obstructive pulmonary disease has been explained by either a shift of the interventricular septum toward the LV cavity or circumferential myocardial fiber changes that impact contractile function Many studies have also shown that infants with severe BPD develop systemic hypertension, and that the abnormal LV myocardial performance index may be caused by changes in systemic vascular resistance In our population, the magnitude of longitudinal deformation was different than in other studies that investigated speckle tracking parameters in mature newborns, infants or adolescents. Lorch et al. and Marcus et al. describe normal values and maturational changes in LV longitudinal deformation from birth to adolescence in large pediatric cohorts This study has a number of strengths and limitations. The main strengths include the longitudinal measurements over 4 weeks using a large sample size with the same investigator. We used the same equipment and protocol for all patients. The study was limited by offline speckle tracking analysis. We were unable to investigate the effect of mechanical ventilation on parameter development in BPD infants because nearly all (94%) BPD infants required mechanical ventilation during the first days of life. Mechanical ventilation could alter the pre- and after-load conditions, though we found no such effect in a previous study The Bonferroni correction used to counteract the problem of multiple comparisons is a common method. However, it is a conservative method and may increase type 2 errors. There are also technical limitations. The dependence of 2D-STE imaging on the frame-by-frame tracking of the myocardial pattern means it is influenced by image factors, including reverberation artefacts and attenuation. Finally, we measured only longitudinal strain and strain rate, and not radial or circumferential strain.In conclusion, our study demonstrates that measuring LV longitudinal systolic strain and strain rate derived by speckle tracking is feasible in VLBW infants. The development of the derived parameters differs from the development of anthropometric and hemodynamic parameters during the first weeks of life and is also influenced by morbidity such as BPD. Further studies should focus on real-time speckle tracking and volume monitoring because this new technique allows LV volumes to be measured without manual tracing.


In this work, we investigate the performance of T2W-weighted spectral attenuated inversion recovery (T2WW-SPAIR), modified look-locker inversion recovery (MOLLI) T1 mapping and late gadolinium enhancement (LGE) sequences were applied as short axis stacks in 10 healthy volunteers and 62 STEMI patients. Receiver operator characteristic (ROC) analysis was applied to calculate a cut-off T1 to to discriminate AAR from normal myocardium. The presence of LGE was used as the positive ROC test state, while healthy myocardium, as measured in volunteers, was used as the negative ROC test state. For comparison with T1 mapping, the AAR was also measured on T2WW images using a threshold signal intensity > 2SD greater than remote. The derived myocardial edema volumes and salvage indices were compared between MVO+ and MVO- groups.CMR imaging was conducted on a Philips 3T Achieva MRI scanner. T1 mapping, ROC analysis gave a significantly larger area-under-the-curve (AUC) as compared to T2WW-SPAIR for delineating myocardial edema  as well as better sensitivity/specificity (83/83% vs 73/73%). Neither method was significantly affected by the presence of MVO. The calculated ROC cut-off for T1 mapping was 1243 ms, and this gave a significantly larger AAR than that measured with a T2W-SPAIR 2SD threshold (p = 0.006). Using the T1 mapping cut-off, patients with MVO had a significantly larger AAR and a poorer salvage index than patients without MVO (p < 0.05 for both). The AAR measured using each of the two methods is illustrated in Figure For T1 mapping at 3T can be used to automatically delineate AAR one week post-STEMI. It delimits larger volumes of edema and demonstrates less variability than T2WW-SPAIR. MVO did not significantly affect the discriminatory power of either of these techniques at seven days post-STEMI.TThis study was supported by a Medical Research Council (UK) grant, as a sub-study of Nitrites in Acute Myocardial Infarction, NCT01388504.