Introduction: P wave axis is one of the most practical clinical tool for evaluation of cardiovascular disease. The aim of our study was to evaluate the P wave axis in electrocardiogram (ECG), left atrial function and association between the disease activity score in patients with systemic lupus erythematosus (SLE).Methods: Standard 12-lead surface ECGs were recorded by at a paper speed of 25 m/s and an amplifier gain of 10 mm/mV. The heart rate (HR), the duration of PR, QRS, QTd (dispersion), the axis of P wave were measured by ECG machine automatically.Results: The P wave axis was significantly increased in patients with SLE  and the disease activity score was found positively correlated with P wave axis . The LA volume and the peak systolic strain of the left atrium (LA) were statistically different between the groups (P = 0.024 and P = 0.000). The parameters of the diastolic function; E/A and E/e’ were better in the control group than the patients with SLE .Conclusion: P wave axis was found significantly increased in patients with SLE and positively correlated with SELENA-SLEDAI score. As the risk score increases in patients with SLE, P wave axis changes which may predict the risk of all-cause and cardiovascular mortality. Sinus tachycardia, atrial fibrillation and atrial ectopic beats are most frequent and transient supraventricular arrhythmias which may be related to myocarditis and exacerbations of SLE.2The arrhythmias have higher incidence in patients with systemic lupus erythematosus (SLE) than in the general population due to the rhythm and conduction disturbances.3P wave axis is one of the routinely reported variables on the printout of most electrocardiograms (ECGs) that may be the most practical clinical tool for evaluation of cardiovascular disease and may provide better predictive value than the currently used P wave indexes. The P wave is the first positive deflection on the ECG and represents atrial depolarisation. Normal P wave axis is between 0° and +75°. However, the relationship between P wave abnormalities and the cardiovascular death has been determined before.4 The previous studies demonstrate that the advanced diastolic dysfunction is strongly associated with increased mortality.7The left atrium (LA) size was found that it largely influences diastolic LV filling which reflects the duration and severity of the diastolic dysfunction.The aim of our study is to evaluate the P wave axis in ECG, left atrial function and association between the disease activity score in patients with SLE.We planned a study with 43 experimental subjects and 32 control subjects by using the PS Power and Sample Size Program. In a previous study the response within each group was normally distributed and the population means of the experimental and control groups were equal with probability (power) 0.803. The Type I error probability associated with this test of null hypothesis was 0.05.8 The screening for coronary artery diseases was undertaken in all cases. Among patients with SLE included in the study, 38 patients had normal cardiac stress test, 3 patients had normal myocardial perfusion SPECT and 2 patients had normal coronary angiogram. Patients with known coronary artery disease, left bundle branch block in ECG, arrhythmia, pericarditis, pulmonary hypertension, congestive heart failure, stroke and peripheral arterial disease were excluded. Also, none of the patients had a history of dissection, any previous cardiac surgery or any clinical disorders known to compromise myocardial function such as diabetes mellitus, renal impairment, anemia, thyroid or liver disorder. In addition, smoking and excessive alcohol consumption were considered as exclusion criteria. We also excluded the patients with other forms of autoimmune diseases. SLE disease activity was assessed using the SELENA-SLEDAI score.10 It was evaluated by the past history, physical examination, laboratory findings and consultation with their rheumatologists.The experimental subjects fulfilled at least four of the American College of Rheumatology criteria for SLE.The control group consisted of 32 individuals without significant differences in age, sex, weight or height from the patients with SLE. The control group was evaluated carefully and the individuals with the similar demographic characteristics were enrolled the study.Standard 12-lead surface ECGs were recorded by ‘The Cardiac Science Burdick Atria 6100 EKG Machine’ at a paper speed of 25 m/s and an amplifier gain of 10 mm/mV. The heart rate (HR), the duration of PR, QRS, QTd (dispersion), the axis of P wave were measured by ECG machine automatically.11 Pulsed-wave Doppler at the tip of mitral valve leaflets allowed us to measure the early (E) and late (A) diastolic filling velocities and we calculated the E/A ratio. Also, the peak early diastolic myocardial tissue velocity was measured by tissue Doppler imaging of the lateral mitral annulus (e’) and E/e' was calculated. The diameters of the LA were measured; the maximum anterio-posterior diameter (D1), superior-inferior diameter (D2) and medial-lateral diameter (D3). LA volume was calculated by the formula; D1×D2×D3×0.523. To measure the peak systolic longitidunal left atrial strain by 2-dimensional speckle tracking echocardiography, the gray scale image of apical 4-chamber and 2-chamber views were obtained with the frame rates of 50-80 Hz. The process was recorded with software , allowing off-line analyses.Two-dimensional grayscale harmonic images at a frame rate of 60 to 80 frames/s were obtained in the left lateral decubitus position using a commercially available system . The LV ejection fraction was calculated by Simpson's biplane method of discs according to the American Society of Echocardiography.P < 0.05 was considered significant. Simple correlations were evaluated by Pearson’s r correlation coefficients. Independent samples t test was used to test differences between groups.Statistical analyses were performed using SPSS software version 15.0 . Data are presented as mean ± standard deviation for continuous variables and as proportions for categorical variables. For all statistical analyses, a two-tailed Of the 43 patients with SLE enrolled in this study, 8 were male (18%). Demographic properties and echocardiographic parameters of both the SLE patients and the control group are shown in P = 0.037) and the disease activity score was found positively correlated with P wave axis . The left ventricular end diastolic volume (LVED volume) and ejection fraction (EF) of the patients with SLE and the control group were similar . The Sm lateral and Sm septal with tissue Doppler echocardiography were significantly lower in SLE . Also, the parameters of the diastolic function; E/A and E/e’ were better in the control group than the patients with SLE   .12P wave axis was found significantly changed and positively correlated with SELENA-SLEDAI score in patients with SLE, in this study. The determination of P wave axis is important because in the analysis from the NHANES III survey, abnormal P wave axis was found associated with an increased risk of all-cause and cardiovascular mortality in a representative sample from the US population.13 Li et al recently demonstrated that according to the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI), patients with a SDI ≥ 1, left atrial mechanical function and volume were found impaired in SLE patients with an increased disease activity. They reported the impairment in left atrial performance by using real-time 3-D echocardiography (RT3DE) technology.14 We found significantly decreased values of the left atrial peak systolic strain by using 2–dimensional speckle tracking echocardiography and larger volumes of the LA than the control group. Kurt et al were demonstrated that diastolic heart failure is associated with larger LA volumes and decreased LA peak systolic strain.15 The major problem caused an increase in LA volume and decrease in LA peak systolic strain in patients with SLE may be the reduced diastolic reserve due to the abnormal myocardial relaxation.The principal role of the LA is to modulate and augment the left ventricular filling trough the late diastole like a booster pump. An emerged parameter in assessing LA function is longitudinal strain which is a robust, well validated and reproducible technique for the measurement of LA longitudinal deformation. The impairment of left atrial function has many serious consequences. Sasaki et al has reported that decreased LA peak systolic strain was also independently associated with LA appendage dysfunction in patients with acute ischemic stroke.16 Likewise, we could not find any association between the P wave axis and the LA volume and LA peak systolic strain.According to a study by Win et al, there was an association between p wave duration and increase in LA volume and decrease in LA emptying fraction and reservoir function but they did not find any association with P wave axis.20 In our study, QTd which predicts the increased risk of ventricular tachyarrhythmias was found significantly increased in patients with SLE alike the literature.Also, increased QTd can be seen because of myocardial involvement even in the absence of clinical cardiac manifestations in patients either with SLE and other rheumatologic disorders such as rheumatoid arthritis and ankylosing spondylitis.SLE disease activity score was found positively correlated with the P wave axis degrees which means that; as the SLE activity getting impaired, P wave axis degree increases that may also increase the risk of all-cause and cardiovascular mortality in patients with SLE.First of all, the number of our patients is few. Second, the long term monitoring to detect the possible arrhythmia or the risk of mortality is lacking. Altough SLE patients did not have abnormal P wave axis, we should emphasize that they were in the remission period. The P wave axis degrees are greater than the control group even in the lack of disease activity. The most important limitation of our study is, we did not compare them with the SLE patients in the active period.P wave axis was found significantly changed in patients with SLE and positively correlated with SELENA-SLEDAI score. The LA volume was increased and the LA peak systolic strain was decreased in patients with SLE, but there was not any association with the P wave axis. Consequently, as the risk score increases in SLE, P wave axis changes which may predict the risk of all-cause and cardiovascular mortality.Written informed consent was obtained from each subject, and the institutional ethics committee approved the study protocol.Authors declare no conflict of interest in this study.


Imaging changes in left ventricular (LV) volumes during the cardiac cycle and LV ejection fraction do not provide information on regional contractility. Displacement ENcoding with Stimulated Echoes (DENSE) is a strain-encoded cardiac magnetic resonance (CMR) technique that measures strain directly. We investigated the relationships between strain revealed by DENSE and the presence and extent of infarction in patients with recent myocardial infarction (MI). 50 male subjects were invited to undergo serial CMR within 7 days of MI (baseline) and after 6 months . DENSE and late gadolinium enhancement (LGE) images were acquired to enable localised regional quantification of peak circumferential strain (Ecc) and the extent of infarction, respectively. We assessed: (1) receiver operating characteristic (ROC) analysis for the classification of LGE, (2) strain differences according to LGE status  and (3) changes in strain revealed between baseline and follow-up. 300 and 258 myocardial segments were available for analysis at baseline and follow-up respectively. LGE was present in 130/300 (43 %) and 97/258 (38 %) segments, respectively. ROC analysis revealed moderately high values for peak Ecc at baseline  and at follow-up . Differences were observed between remote, adjacent and infarcted segments. Between baseline and follow-up, increases in peak Ecc were observed in infarcted segments (median difference of 5.6 %) and in adjacent segments (1.5 %). Peak Ecc at baseline was indicative of the change in LGE status between baseline and follow-up. Strain-encoded CMR with DENSE has the potential to provide clinically useful information on contractility and its recovery over time in patients with MI. Regional left ventricular (LV) systolic function has prognostic importance in survivors of myocardial infarction (MI) , 2. ImagDuring the cardiac cycle, the heart moves through and rotates within a given imaging plane. The relationship between the apparent motion of the endocardial and epicardial borders and the contraction and relaxation of the myocardium is complex, and a true assessment of contractile function requires tracking of discrete points within the myocardium . Three tThe main drawbacks of myocardial tagging and SENC techniques are that the need to apply a saturation grid limits the resolution, and quantitative analysis can be complicated and time consuming. Velocity-encoded phase contrast methods are sensitive to accumulated errors that can result in inaccuracies in position measurements, and displacements can only be measured over short periods of time.Displacement ENcoding with Stimulated Echoes (DENSE) is an alternative method for the quantification of myocardial strain , 15. StiMuch of the research performed with DENSE so far has been methods development, and its diagnostic value in a clinical setting is uncertain. Recently, Miyagi et al.  reportedFifty male patients (age 56 ± 10 years) underwent CMR within 7 days of ST-elevation myocardial infarction (STEMI), and were invited to return for a follow-up scan after 6 months. All patients underwent revascularization with primary percutaneous coronary intervention (PCI) in the Golden Jubilee National Hospital, according to contemporary standards of care.The research protocol was approved by the regional Research Ethics Committee and written informed consent was obtained from each subject.All images were obtained using a 1.5 T Siemens Avanto MRI scanner  with a 6-channel phased-array body coil (anterior) and an 8-channel phased-array spine coil (posterior). The CMR protocol included DENSE imaging for the assessment of strain and LGE imaging in a co-registered mid-ventricular short axis slice, positioned at mid-papillary level. Cine imaging was also acquired to enable quantification of LV dimensions and function.DENSE imaging parameters were as follows: echo time 8 ms; repetition time 16.3 ms; flip angle 20°; slice thickness 8 mm; field of view 360 mm × 270 mm; matrix size 112 × 84; displacement encoding of 0.2 π/mm; EPI factor of 8.2+-DOTA, Dotarem, Guebert S.A., Villepinte, France) using segmented phase-sensitive inversion recovery (PSIR) turbo fast low-angle shot sequence in all cases  were compared using Kruskal–Wallis with individual Mann–Whitney tests. A similar comparison was then performed to assess if differences in strain values obtained at baseline could be detected between sub-categories.p value of 0.05 was adopted to reject the null hypothesis of no difference.A Bonferroni correction for multiple testing was used with non-parametric tests including the Kruskal–Wallis and Mann–Whitney tests. A Table From the 50 STEMI patients who underwent baseline scans, 47 attended for follow-up scans, and DENSE images from 4 of these patients were considered non-diagnostic due to breathing artefacts. This gave totals of 300 and 258 segments which were available for analysis at baseline and follow-up respectively. LGE was present in 130/300 (43 %) and 97/258 (38 %) segments, respectively.The ROC curves for strain-encoded CMR with DENSE and the classification of LGE (present/absent) on a per-segment basis at baseline and at follow-up are shown in Fig. The peak Ecc strain threshold, area-under-the-curve (AUC), sensitivity and specificity for the classification of contractile abnormalities associated with the presence of LGE at baseline and follow-up are shown in Table Differences were observed for peak Ecc measured in infarcted segments versus peak Ecc in both remote and adjacent segments, and between peak Ecc in remote and adjacent segments, at both baseline and follow-up. The results are illustrated in Fig. From the 43 patients who attended for both baseline and follow-up scans, 122 segments had LGE at baseline and/or at follow-up.A comparison of the peak Ecc strain values obtained at baseline and follow-up found differences in segments classified as adjacent and infarcted, but not in remote segments. An increase in peak Ecc was observed in both adjacent and infarcted segments, with median differences (follow-up—baseline) of 1.5 and 5.6 % respectively.The results of the Kruskal–Wallis test with individual Mann–Whitney tests comparing the three categories of tissue pathology  are illustrated in Fig. Within each designated pathological tissue category , comparison of tissue categories showed no statistically significant differences when considering the change in strain between baseline and follow-up. However, differences were observed when comparing baseline strain between sub-categories, as illustrated in Fig. On a per-segment basis at the mid-ventricular level, peak Ecc Fig. a and chaThe results of this investigation have shown that, firstly, in line with previous studies , the numThe standard CMR assessment of LV function in patients with a history of MI involves using cine images to measure global parameters such as LV end-systolic volume, LV end-diastolic volume and LV ejection fraction. However, most pathologies do not affect the heart uniformly, and regional dysfunction may be masked by seemingly “normal” values of global function . AssessmIn a study which used strain measurements obtained with SENC to compare myocardial segments with non-transmural and transmural infarction, with transmural infarction defined as >75 % hyperenhancement in LGE imaging, an optimal threshold for peak Ecc of 10 % was identified, with a corresponding sensitivity of 97 %, specificity of 94 % and AUC of 0.96 . A similThe higher threshold value identified at follow-up compared to baseline indicates that the presence of LGE at follow-up may be associated with a lower degree of contractile dysfunction, however the relationship between peak Ecc and LGE may be complicated by the complex remodelling process. In a patient with recent MI, the injured territory revealed by LGE may also contain oedema and viable myocardium amenable to salvage . The potDifferences in peak circumferential strain between remote and infarcted segments can be detected using tagging . The resWe observed that when segments were sub-categorised according to the change in LGE status between baseline and follow-up, there were differences in baseline strain between sub-categories for adjacent and infarcted segments. Higher strain values were obtained in adjacent segments which would subsequently be re-classified as remote, and lower strain values were obtained in segments which would be re-classified as infarcted. Infarcted segments which would subsequently be re-classified as adjacent had higher strain than those which remained infarcted. Strain measurements in adjacent and infarcted segments at baseline may have prognostic value relating to the progression or recovery of contractile abnormalities in the chronic setting.The results of this study show that DENSE has the potential to provide clinically useful information in patients with recent and chronic MI. However, the limitations in the design should be noted. Only one mid-ventricular slice was obtained for each participant, and the analysis method does not take adjacent segments and/or slices into account. The implementation of DENSE available at our institution does not account for through-plane motion of the myocardium during image acquisition; however 3D versions of the DENSE pulse sequence have been developed –28 and cDENSE has the potential to provide clinically useful information relating to contractile abnormalities associated with the presence of LGE, and the recovery of contractile function over time. Continuing developments in the technique, including 3D versions which account for through-plane motion, will increase the applicability in the clinical setting.


Number of left ventricular assist device (LVAD) implantations increases every year, particularly LVADs for destination therapy (DT). Right ventricular failure (RVF) has been recognized as a serious complication of LVAD implantation. Reported incidence of RVF after LVAD ranges from 6% to 44%, varying mostly due to differences in RVF definition, different types of LVADs, and differences in patient populations included in studies. RVF complicating LVAD implantation is associated with worse postoperative mortality and morbidity including worse end-organ function, longer hospital length of stay, and lower success of bridge to transplant (BTT) therapy. Importance of RVF and its predictors in a setting of LVAD implantation has been recognized early, as evidenced by abundant number of attempts to identify independent risk factors and develop RVF predictor scores with a common purpose to improve patient selection and outcomes by recognizing potential need for biventricular assist device (BiVAD) at the time of LVAD implantation. The aim of this article is to review and summarize current body of knowledge on risk factors and prediction scores of RVF after LVAD implantation. Despite abundance of studies and proposed risk scores for RVF following LVAD, certain common limitations make their implementation and clinical usefulness questionable. Regardless, value of these studies lies in providing information on potential key predictors for RVF that can be taken into account in clinical decision making. Further investigation of current predictors and existing scores as well as new studies involving larger patient populations and more sophisticated statistical prediction models are necessary. Additionally, a short description of our empirical institutional approach to management of RVF following LVAD implantation is provided. Heart failure is one of the most common causes of death in western world. Number of patients diagnosed with heart failure is growing and it remains a target for many preventive and treatment efforts ,2. MechaIndications for LVAD implantation include: 1. bridge to transplantation (BTT); 2. bridge to candidacy for transplantation; 3. destination therapy (DT), ie, patients who are not suitable for transplantation; and 4. temporary support for patients whose cardiac function is expected to recover.Scientific and technological improvements of LVAD implantation, as well as perioperative medical management have led to significant reduction in complication rates, and improved survival and quality of life, all leading to outcomes approaching those achieved with heart transplant -8. ThereRVF has been recognized as a serious complication of LVAD implantation, and as such has been a subject of considerable research. The purpose of this article is to review existing literature on predictors and risk scores for RVF following LVAD implantation. To identify studies of interest we used MEDLINE search with Boolean term “AND,” limited to Title/Abstract and English language using terms “RV failure,” “LVAD,” and “predictors,” which yielded 15 articles. Citation indexing on the included studies was done to screen for other relevant publications not identified by our search strategy, which yielded additional 40 articles that were reviewed in detail. After careful review of these 55 articles, we identified a total of 11 studies that developed original prediction models for right ventricular failure after LVAD. Of these 11 studies, 7 used available preoperative and intraoperative demographic, laboratory, and comorbidity variables in their models (Supplementary Table 1)Many definitions of RVF after LVAD have been used. Most common definition describes RVF after LVAD as need for intravenous inotrope or pulmonary vasodilator therapy for 14 days postoperatively and/or need for RVAD implantation -14. A feReported incidence of RVF after LVAD varies from 6% to 44% ,16,18-33Patients who develop RVF have higher incidence of end organ dysfunction, and overall worse morbidity and mortality. In addition, RVAD implantation as a treatment option for RVF leads to increased morbidity secondary to increased infection risk, need for transfusion, and risk of device failure. Therefore, one of the most important issues since introduction of LVAD as treatment for heart failure has been to determine the need and optimal timing of RVAD support.There have been many studies that developed prediction models and scores for RVF risk after LVAD, with common purpose to improve patient selection, and successfully predict the need for BiVAD at initial surgery, possibly leading to improved outcomes.Although it seems intuitive that implanting BiVAD early during initial surgery would improve outcomes in patients who are at risk for RVF, and thereby prevent end organ dysfunction and associated complications, supporting data are lacking. To the best of our knowledge, there have been only two studies showing outcome benefit for planed vs delayed RVAD implantation, while others showed either no benefit or mixed results ,16,28,34Factors determining right ventricular (RV) output and function include RV preload, afterload, and contractility. Changes in physiology following LVAD affect all these RV output determinants and may lead to acute RV failure.RV preload increases as a result of increased left ventricular (LV) output which might increase up to 100% following LVAD implantation . In addiIt is well known that the most common cause of RVF is LV failure . Left veContractility of RV is influenced by LV function through the concept of ventricular interdependence. Effect of ventricular interdependence is most prominent in a setting of loading changes such as after LVAD implantation, and has an important role in pathophysiology of RV dysfunction following LVAD . It has RVF complicating LVAD implantation is associated with worse postoperative mortality and morbidity including worse end-organ function, longer hospital length of stay, and lower success of BTT therapy ,11,15,27As already indicated, available prediction models differ with respect to inclusion of different types of LVADs. The next few sections provide a summary of most important pertinent studies in a chronological order, starting with those involving patients receiving pulsatile flow LVADs and moving toward combination cohorts and newer generation continuous LVADs cohorts only.3/mcgL, serum albumin ≤3.3 g/dL, international normalization ratio (INR)>1.1, vasodilator therapy at time of implantation, mean pulmonary artery pressure ≤25.3 mm Hg, aspartate aminotransferase >45 U/dL, hematocrit <34%, blood urea nitrogen >51 U/dL, and lack of intravenous inotropic support as statistically significant predictors. A weighted risk score was assigned to each of the above nine variables to develop DTRS. Discrimination C-statistic for DTRS was good . Patients were divided into 4 operative risk categories for 90-day in-hospital mortality. The observed survival to hospital discharge in low-, medium-, high-, and very high-risk operative candidates was 87.5%, 70.5%, 26%, and 13.7%, and 1-year survival was 81.2%, 62.4%, 27.8%, and 10.7%, respectively. Although this was one of the most commonly used scores clinically, its utility is questionable in today’s era of newer generation continuous flow LVADs predominance. A study evaluating DTRS for continuous LVADs found that the score was able to discriminate statistically significant differences in survival only for DT, and not BTT patients, but with poor discrimination in both groups  (Destination therapy risk score (DTRS) was based on analysis of a cohort that included 222 patients receiving pulsatile flow LVADs for DT . Variabl2 (odds ratio [OR] 5.1), severe pre-operative RV dysfunction (OR 5.0), pre-operative creatinine ≥1.9 mg/dL (OR 4.8), previous cardiac surgery (OR 4.5), and systolic blood pressure ≤96 mm Hg (OR 2.9) as important predictors for RVF. Authors emphasized severe preoperative RV failure as likely the most significant factor determining which patients would require BiVAD, which was substantiated by low RVSWI and severe echocardiographic RV dysfunction identified as two strongest predictors of need for biventricular support , and early systolic equalization of RV and right atrial pressure demonstrated as decreased time interval between onset and cessation of tricuspid regurgitation flow corrected for heart rate (TRDc) ,24,30.In summary, there has been a lot of effort to identify risk factors for RVF following LVAD and develop clinically useful predictor scores to help improve overall survival. However, most models and respective scores faced limitations making their implementation and clinical usefulness questionable. Regardless, value of these studies lies in providing information on potential key predictors for RVF that can be taken into account in clinical decision making. Further investigation of current predictors and existing scores, as well as new studies involving larger patient populations and more sophisticated statistical prediction models, are necessary.It has been suggested that central venous pressure (CVP) is not a reliable surrogate of intravascular volume status. Nonetheless, elevated CVP has been identified as one of the significant predictors of RVF after LVAD, and it is still used in clinical decision making. Empirical value that we use as a target in our practice with LVAD patients is CVP<15 mm Hg. Aggressive intravenous fluid administration in a setting of already distended RV with decreased contractile capability will not increase RV output. On the contrary, it will lead to further increase in CVP, hepatic and systemic congestion, and reduced transmyocardial perfusion pressure gradient. Therefore, our approach is to be judicious with intravenous (iv) fluid administration, and rely on increasing inotropic support  to help RV contractility. Also, decrease in pulmonary afterload is achieved with adequate ventilation (to avoid hypoxic pulmonary vasoconstriction) and/or use of inhaled Flolan (epoprostenol sodium) and/or NO (nitric oxide). Maintaining continuous perfusion pressure >70 mm Hg to preserve RV function and transmyocardial gradient is imperative, and often requires use of one or more vasopressors . IABP is sometimes required to optimize RV function in coronary artery disease patients by increasing perfusion of coronary arteries.o2>110, Paco2<40), RV mechanical support is commonly the next step in patient management.Importance of interdisciplinary approach and excellent communication between all team members involved in perioperative management  cannot be overemphasized. Transesophageal echocardiogram (TEE) surveillance for adequate ventricular filling and optimal midline septal position is important to anticipate, treat and prevent a suction event. In case of the suction event, commonly employed interventions include maintaining perfusion pressure >70 mm Hg, and careful challenging with iv fluids and temporarily allowed increase in CVP>15 mm Hg. In the event of persistently inadequate LVAD filling despite higher CVP (15-20 mm Hg), maximal inotropic and vasopressor support, and adequate respiratory function (absence of acidosis, Pa


Angiotensin-converting enzyme (ACE) inhibitors improve left ventricular (LV) remodelling and outcome in heart failure and hypertensive heart disease. They may be similarly beneficial in patients with aortic stenosis (AS), but historical safety concerns have limited their use, and no prospective clinical trials exist.n = 50) or placebo (n = 50) for 1 year, and underwent cardiac magnetic resonance, echocardiography, and exercise testing at 0, 6, and 12 months, with follow-up data available in 77 patients. There was a modest but progressive reduction in LVM (the primary end point) in the ramipril group vs. the placebo group . There were also trends towards improvements in myocardial physiology: the ramipril group showed preserved tissue Doppler systolic velocity compared with placebo , and a slower rate of progression of the AS . There were no significant differences in major adverse cardiac events.We conducted a prospective, randomized, double-blind, placebo-controlled trial in 100 patients with moderate or severe asymptomatic AS to examine the physiological effects of ramipril, particularly LV mass (LVM) regression. Subjects were randomized to ramipril 10 mg daily (ACE inhibition leads to a modest, but progressive reduction in LVM in asymptomatic patients with moderate–severe AS compared with placebo, with trends towards improvements in myocardial physiology and slower progression of valvular stenosis. A larger clinical outcome trial to confirm these findings and explore their clinical relevance is required. Early retrospective studies of statins suggested that the progression of AS could be delayed,6 but subsequent larger randomized trials were negative,9 underlining the importance of prospective trials.Aortic stenosis (AS) is the most common form of valvular heart disease in the Western world affecting 5% of those aged over 75 years.10 and both the aortic valve area11 and measures of the myocardial response  have been shown to determine prognosis in these patients.The response of the myocardium is likely to be as important as the degree of valve stenosis,15 the extent of fibrosis in the myocardium,16 and may even play a role in aortic valve thickening.17 RAS inhibitors reduce LVM independent of blood pressure (BP) ,18 can reduce the extent of myocardial fibrosis,19 and have been shown to improve clinical outcome through LV remodelling in other disease areas—e.g. post-myocardial infarction,20 heart failure,21 and hypertension-induced LVH.18 Inhibition of the RAS with angiotensin-converting enzyme inhibitors (ACEi) would therefore seem an attractive option to improve LV remodelling and myocardial physiology in AS, resulting in better tolerance to the valve obstruction, potentially delaying the onset of symptoms and reducing need for aortic valve surgery. ACEi have, however, been traditionally regarded as contraindicated in moderate or severe AS due to the theoretical danger of syncope caused by afterload reduction, and current guidelines still advise caution. There are however no clinical studies indicating harm, and in fact, the limited animal and human data that exist do not suggest harm, and even suggest benefit.24 Recent retrospective studies suggest a potential benefit in AS patients taking ACEi or ARBs25 as well as reductions in the progression of AS,26 but these studies are subject to significant selection and other biases, in a similar way to the early retrospective statin studies in AS, and a prospective clinical trial is required.The renin–angiotensin system (RAS) has a major influence on myocardial physiology, and there is some evidence for this in AS: it regulates the degree of LVH,To examine changes in myocardial physiology, in particular the regression of left ventricular mass (LVM), as well as other LV physiological parameters  using multi-parametric cardiac magnetic resonance (CMR) in patients with moderate to severe AS.To assess the safety and tolerability of ramipril in these patients.To examine potential improvements in effort tolerance.With the Ramipril In Aortic Stenosis (RIAS) trial, we therefore sought to carry out the first prospective, randomized, placebo-controlled study of ramipril in AS. Given the perceived historical problems of ACEi in this population and the large scale required for a clinical outcome trial, we planned an intermediate  study to determine whether there were any positive physiological changes, and an absence of harm, before embarking on a large-scale clinical outcome study. The aims of this study were as follows:27 and a concise summary is provided here. The protocol was approved by the Oxfordshire research ethics committee C (reference 07/H606/139) and the Medicines and Healthcare products Regulatory Agency . The trial was also registered with the European Community clinical trials database (EudraCT no 2007-005224-32) and the ISRCTN register (24 616 095). All patients gave their written informed consent.The study protocol and detailed methods have been previously published,2, or peak velocity >3.0 m/s ],2 who were asymptomatic as judged by patient-reported symptoms, and who did not have indications for valve replacement surgery were invited to participate. All had normal LV function (ejection fraction >50% by echocardiography) and no other significant (>mild) valvular heart disease, excess hypo- or hypertension (BP < 100/40 or >200/110 mmHg). Intolerance of ACEi or angiotensin receptor blockers (ARBs) or their prescription over the previous 3 months were also exclusion criteria.Subjects were recruited from clinics at the John Radcliffe Hospital and surrounding institutions. All patients aged >18 years with moderate or severe AS by standard echocardiographic criteria [valve area <1.5 cmFigure 1 summarizes the study design. After baseline visits, subjects were randomized to ramipril or placebo for 1 year. An initial pack of study medication (ramipril 2.5 mg daily or placebo) was provided for 2 weeks to ensure no adverse symptoms. The ramipril was then increased to 5 mg daily and again to 10 mg daily at 12 weeks. The occurrence of adverse events and any changes in laboratory parameters were noted throughout the study. Full assessments occurred at baseline, 6 months and 1 year, and researchers were blinded to the randomization until after data analysis by the statisticians. The primary outcome was the change in LVM from baseline to 12 months measured by CMR. Secondary end points included changes in left ventricular ejection fraction (LVEF), change in other myocardial functional parameters assessed by CMR , and echocardiography (including diastolic parameters); change in B-type natriuretic peptide (BNP); and change in distance walked on ETT.This was a randomized, double-blind, placebo-controlled trial to assess physiological changes in the myocardium with ramipril; it was not powered for clinical end points. 28 The aortic valve was imaged using short-axis steady-state free precession (SSFP) cine sequences at the valve tips in mid-systole, and transvalvular velocity was measured using breath-hold through-plane phase-contrast velocity mapping just distal to the aortic valve (at the vena contracta).Patients were scanned using a 1.5-T Avanto CMR system . Comprehensive CMR assessment was carried out at baseline and 1 year, while at 6 months only LV volumetric analysis was performed to determine the time course of any changes in the primary end point. LVM, LV volumes, and LV function were assessed using a stack of steady-state free precession short-axis cine images, in accordance with the Society for Cardiovascular Magnetic Resonance guidelines.29 in the horizontal long-axis (four chamber) and three short-axis views , each during a single breath hold. Diffuse myocardial interstitial fibrosis was assessed using non-contrast myocardial T1 mapping, as a surrogate marker for this in AS.30 A Short Modified Look Locker Inversion recovery (ShMOLLI) technique was used,31 in a single mid-ventricular slice, with the assumption that the degree of diffuse fibrosis was similar throughout the myocardium, and the average T1 value over this whole slice was calculated as previously described.30 Late gadolinium enhancement (LGE) imaging was also performed to assess more patchy, confluent areas of fibrosis 10 min after the injection of gadolinium for perfusion (see below) using a standard inversion recovery technique.32 This was repeated with the phase-encoding direction swapped to exclude artefact.Myocardial strain was assessed using a grid-based ‘tagging’ sequence33 following administration of adenosine at a rate of 140 µg/kg/min for 3 min. Gadolinium-based contrast  was administered intravenously, to maintain a linear relationship between signal intensity and perfusion. Perfusion imaging was performed in three short-axis sections during the first pass of the contrast bolus34 and repeated at rest at least 20 min later. Myocardial perfusion reserve index was calculated for all 16 segments, and the average value was used .Myocardial perfusion reserve was assessed according to guidelines,35 LV diastolic function was assessed using tissue Doppler measurements of medial and lateral mitral annular velocities in early diastole and mitral valve inflow.36Transthoracic echocardiography was carried out, particularly to assess diastolic function, using a Philips iE33 advanced echo system . A full echo study was performed according to guidelines for assessment and classification of AS and chamber quantification, including Tissue Doppler measurements of systolic tissue deformation.37 as it contains multiple small increments in speed and incline, to provide a smooth increase in workload more applicable to a continuous variable than fewer large increases in workload, which occur in other protocols. The test was carried out under medical supervision with continuous 12-lead electrocardiogram recording and regular BP monitoring.Exercise testing was carried out to assess the maximum walking distance as a continuous variable in the study population . The Naughton protocol was chosenThese were not a primary aim of this study, which was too small to examine this robustly, but any major adverse cardiac events  were recorded. Any decision to refer patients for AVR was taken by the patient's treating cardiologist, who was also blinded to the study medication.27 and a brief summary is included here. Analyses were carried out by an independent statistician (SG) at the Centre for Statistics in Medicine, University of Oxford in accordance with the trial statistical analysis plan. The sample size was based on changes in LVM, using a baseline from a prior study of AS with CMR (142 ± 35 g/m2),38 and a 15% (21.3 g/m2) reduction in LVM—the mean change from a large meta-analysis of antihypertensive treatments.18 We used a one-sided test (only including reduction in LVM) with 85% power (β error) and 95% confidence (α error). The number needed in each study group with these calculations was 43, and a total of 50 patients per group was planned, allowing for a 15% drop-out rate. Primary and secondary analyses were conducted on the modified intention to treat (mITT) population, including all participants who received study medication and at least one follow-up measurement.A full description of these is published with the trial protocol,n = 80) or severe (n = 20) AS were recruited between October 2008 and April 2011, and baseline patient characteristics are summarized in Table 1. Four patients withdrew after randomization, leaving 96 patients who received the trial medication . Nineteen patients withdrew during the trial (mostly within the first 6 months), leaving 77 patients who completed the 1-year assessment—only 2 patients (one from each group) withdrew between 6 and 12 months; see Figure 2 for CONSORT diagram. Treatment groups were balanced at baseline with respect to demographics, symptoms, CMR, echocardiography, and exercise testing data (Table 1). Any differences were slight and the numbers too small to draw any inferences.One hundred patients with moderate . The change in LVM was also progressive, with a similar reduction in LVM with ramipril and increase with placebo at 6 months, though with half the degree of change that occurred at 1 year: mean difference between groups 4.0 g (P = 0.089).There was a modest but significant difference between treatment groups at 1 year: the ramipril group showed a reduction in mean LVM of −3.9 g compared with an increase of +4.5 g in the placebo group, leading to an overall mean difference of 8.4 g (Table 2). This included LVEF, myocardial T1 values , perfusion indices, strain, and diastolic function. Systolic myocardial velocity (measured using tissue Doppler S-wave) worsened slightly in the placebo group compared with ramipril . However, these group differences are small and baseline S-wave measurements were lower than normally expected, so this may reflect measurement variability.Most assessments of myocardial physiology using CMR and echocardiography did not show significant differences between treatment groups (2) compared with a reduction in the placebo group (−0.2 cm2), P = 0.067. This did not, however, impact on the peak velocity across the aortic valve which did not differ significantly between the ramipril and placebo groups: change at 1 year +0.03 and +0.12 m/s, respectively, P = 0.28.At 1 year, there was a trend towards a slower rate of progression of AS in the ramipril group, with a static aortic valve area (0.0 cmP = 0.086), and these changes were very small, which, coupled with the low mean baseline values (15–21 pmol/L), limits any interpretation.There was a trend towards stabilization in BNP in the ramipril group (−0.50 pmol/L) and increase in the placebo group (+8.2 pmol/L), but the difference between groups was not statistically significant (P = 0.18).There was no significant difference in the mean change in distance walked on the treadmill at 12 months compared with baseline .BP reduced slightly in both groups at 12 months, with systolic pressure falling by −5.5 vs. −2.9 mmHg for ramipril and placebo, respectively, though differences between groups were not statistically significant . The trial was not powered for clinical events, and there were the same number of major adverse cardiac events (5) in each group, and a similar number of AVRs: ramipril 4 vs. placebo 2; In the first prospective, randomized, placebo-controlled trial of ACEi in patients with moderate and severe asymptomatic AS, we have shown that ramipril reduces the hypertrophic response of the myocardium, may have additional benefits, and is well tolerated.Figure 3), which may have continued if ramipril had been given for longer, and these changes occurred despite the fixed outflow tract obstruction from the AS. There were small differences in BP between the groups at 12 months, but the differences were not statistically significant, suggesting that this reduction in mass was driven by direct effects of ramipril on the myocardium, similar to the benefits described in the hypertensive population,39 though a contribution from the BP is difficult to rule out given the moderate group sizes. Baseline LVM index was also significantly smaller than reference group used for power calculations , but the previous study38 examined patients just prior to AVR, and it is likely that these were at the more severe end of the spectrum, which may explain the difference (our study included many patients with moderate AS). Patients with severe LVH from non-valvular causes have an adverse prognosis,12 and reductions in LVM have been associated with improvements in prognosis.40 Reduced LVH in response to pressure overload in AS might therefore lead to improvements in prognosis, and some studies suggest a stronger prognostic association with LVM than the severity of AS per se.12 It would thus be reasonable to hypothesize that ramipril may lead to improved prognosis in AS by reducing LVH, and this is supported by findings from a retrospective study that showed reduced mortality in patients taking ACEi in AS.25 The current study was not powered for clinical outcomes however, and any prognostic benefit from RAS inhibition in AS requires a larger clinical outcome trial to address this question.We found a modest reduction in LVM with ramipril, and although the observed differences are small, these represent group mean differences, suggesting an overall shift in LVM within the cohort. There was also a progressive change over the year (30)—or presence of LGE did not differ between groups for the most part. There were small improvements in the echocardiographic tissue Doppler S-wave  with ramipril, though baseline values were lower than normal—this may reflect reduced long-axis contraction in established AS and would be in keeping with the reduced longitudinal strain values in both groups, but it could also be partly due to mitral annular calcification restricting systolic mitral annular velocities (this is relatively common in AS and was not assessed in our study). There were also no differences in exercise capacity between groups, either at baseline or any changes during the trial, in keeping with small, if any, differences in myocardial physiological parameters. All patients had normal ejection fractions at baseline, however, which may partly explain the lack of a consistent beneficial effect on myocardial physiology with ramipril , though the study may also be under-powered to show changes in these parameters.Other CMR measures of LV physiology—perfusion, strain, T1 values  may have been due to the imaging technique being insufficiently sensitive to pick up small changes in interstitial fibrosis. Alternatively, the reduction in LVM may be due to a reduction in myocyte size, as recently shown in patients post-AVR,42 and there may have been little, if any, regression of fibrosis. Further, in other studies, the regression in cardiac fibrosis in hypertensive patients (associated with improvements in diastolic parameters) was only seen in those with severe interstitial fibrosis—no changes in either fibrosis or diastolic function were seen in those with mild or moderate fibrosis.19 As the majority of patients in our cohort had moderate AS , the fibrosis burden may have been too light for significant changes with medical treatment to be demonstrated.We hypothesized at the outset that ramipril might improve interstitial cardiac fibrosis by lowering circulating angiotensin II, a promoter of interstitial cardiac fibrosis,43 The number of patients who completed perfusion imaging at both time points in our study was small however (n = 30), and the reduction in LVM may have been too small and the relationship between LVM and perfusion too weak to show any changes. This relationship between perfusion and increased LVM may also differ in moderate AS (which represented the majority of our cohort).Our study did not show any significant improvement in perfusion indices, despite myocardial perfusion previously being associated with LVM in patients with severe AS.2 in the ramipril and placebo groups respectively, though the statistical strength of the difference was weak (P = 0.067). There is nonetheless some evidence to support the involvement of the RAS in aortic valve calcification. Activation of the local RAS in aortic valves has been seen in AS;45 angiotensin II is implicated in aortic valve thickening;17 and aortic valve weights (extracted at the time of AVR) are significantly lower in AS patients taking ARBs.46 Retrospective clinical studies show conflicting results however: O'Brien et al.47 reported significant reductions in aortic valve calcification in AS treated with ACEi, while Rosenhek et al.5 found no change in the progression of aortic valve disease or calcification. The ongoing ROCK-AS trial (NCT00699452) aims to analyse the degree of valvular inflammation, calcification, lipid accumulation, and fibrosis from histology of aortic valves removed at surgery from AS patients taking candesartan compared with placebo and may help to answer these questions.The ramipril group showed a trend towards reduced progression of the AS . S.B. was supported by a British Heart Foundation Clinical Research Training FellowshipFS/10/015/28104. Funding to pay the Open Access publication charges for this article was provided by the University of Oxford.The work was supported by a


The transition from healthy myocardium to hypertensive heart disease is characterized by a series of poorly understood changes in myocardial tissue microstructure. Incremental alterations in the orientation and integrity of myocardial fibers can be assessed using advanced ultrasonic image analysis. We used a modified algorithm to investigate left ventricular myocardial microstructure based on analysis of the reflection intensity at the myocardial-pericardial interface on B-mode echocardiographic images. We evaluated the extent to which the novel algorithm can differentiate between normal myocardium and hypertensive heart disease in humans as well as in a mouse model of afterload resistance. The algorithm significantly differentiated between individuals with uncomplicated essential hypertension (N = 30) and healthy controls (N = 28), even after adjusting for age and sex (P = 0.025). There was a trend in higher relative wall thickness in hypertensive individuals compared to controls (P = 0.08), but no difference between groups in left ventricular mass (P = 0.98) or total wall thickness (P = 0.37). In mice, algorithm measurements (P = 0.026) compared with left ventricular mass (P = 0.053) more clearly differentiated between animal groups that underwent fixed aortic banding, temporary aortic banding, or sham procedure, on echocardiography at 7 weeks after surgery. Based on sonographic signal intensity analysis, a novel imaging algorithm provides an accessible, non-invasive measure that appears to differentiate normal left ventricular microstructure from myocardium exposed to chronic afterload stress. The algorithm may represent a particularly sensitive measure of the myocardial changes that occur early in the course of disease progression. Hypertensive heart disease is characterized by remodeling of the myocardium in response to chronically elevated blood pressure and wall stress.Ultrasonic indices may be able to distinguish pathological tissue properties including myocardial disarray, size heterogeneity, increased myocyte density, and interstitial fibrosis.Supporting Information File S1). The algorithm functions to hierarchically order pixels within the region of interest, and then provide characteristics of the signal intensity distribution. The general region of interest was defined as the inferolateral mid-to-basal myocardial segment of the LV in the parasternal long-axis view ; the specific region of interest was defined as the pericardium adjacent and parallel to the mid-to-basal section of the inferolateral segment of the myocardium. The Signal Intensity Coefficient (SIC) was calculated as (1-p/256), where p is the 25th percentile of pericardial signal intensity distribution; the SIC demonstrates limited variation with change in image acquisition gain . Intra-class correlation coefficients for inter-reader and intra-reader reproducibility are 0.89 and 0.90, respectively.We developed a computational method of analysis using the ImageJ software platform v1.46  to perform measurements of signal intensity distributions within 2D ultrasound images. We created an ImageJ macro to analyze a user-selected region-of-interest within an 8-bit DICOM echocardiographic image or an 8-bit .jpg image, with individual pixels ranging from 0 to 255 intensity.In addition to the advanced image analyses described above, we also assessed conventional echocardiographic measures of structure and function including: LV wall thickness (LVWT) calculated as interventricular septum width plus posterior wall width, LV end-diastolic diameter (LVDD), LV end-systolic diameter (LVSD), LV mass, LV fractional shortening (FS), LV ejection fraction ,To capture information regarding both the microstructural and gross (i.e. ‘macroscopic’) morphological changes that can occur early in the progression of hypertensive heart disease, we also calculated an aggregate measure referred to as the myocardial structural index (MSI) and defined the MSI as equal to SIC/0.13+RWT/0.05 .From a database of routine echocardiographic studies performed on patients referred to our institution's clinical laboratory, we selected echocardiograms from normotensive healthy controls (N = 28) and individuals with hypertension (N = 30) without diabetes or prevalent cardiovascular disease . All images underwent review, while blinded to clinical data, for image quality and appropriateness for image analysis . In addition to conventional echocardiographic measures,ad libitum. All animals were studied over a period of 7 weeks, after being randomized into one of the following 3 groups: vehicle control with sham operation at baseline (N = 3), ascending aortic constriction applied surgically at baseline (N = 4), and ascending aortic constriction applied surgically at baseline with subsequent removal of the aortic band at 3 weeks (N = 3). Details regarding the experimental protocol, including the surgical aortic banding procedures, have been described previously.We studied a cohort of 12 adult mice  that were housed in a climate controlled facility with 12-hour alternating light cycles and access to food and water For analyses in humans, we compared clinical and echocardiographic characteristics of normotensive versus hypertensive individuals using the two-sided Student's T-test for continuous variables and the chi-square test for categorical variables. We then used regression analyses to examine the association of both conventional and advanced echocardiographic parameters (including both SIC and MSI) with hypertension status (present versus absent). In addition to unadjusted models, we performed regression analyses adjusting for age and sex. We also examined the association of conventional and advanced echocardiographic measures with increasing tertiles of each BP measure . Additionally, in the total sample of individuals studied, we used regression analyses to examine the association of variation in SBP, DBP, and MAP with both conventional and advanced echocardiographic measures of LV structure (including both the SIC and MSI).For the experimental study, we assessed differences in LV mass, RWT, SIC, and MSI at 7 weeks across all animal groups using the Kruskal-Wallis test, and between pairs of groups using the two-sided Student's t-test.All analyses were performed using Stata SE , and a 2-sided P value<0.05 was considered statistically significant.Clinical and echocardiographic characteristics for individuals in the healthy control group (N = 28) compared with individuals in the hypertensive group (N = 30) are shown in In analyses of variation in BP across all the individuals studied, there was no significant association of SBP, DBP, or MAP with LV mass Figure 1In regression analyses examining the relation of BP indices with echocardiographic traits, there were no significant associations of BP with the following conventional measures of structure: LV size, total wall thickness, or mass Table 3.After 7 weeks of the experimental protocol, echocardiographic images were acquired and analyzed for all 3 animal groups: mice that underwent the sham surgery (control), mice that underwent ascending aortic constriction at baseline and then debanding at 3 weeks (debanded), and mice that underwent ascending aortic constriction at baseline without further intervention (banded). With respect to conventional echocardiographic parameters Figure 2We evaluated an ultrasound-based image analysis algorithm designed to differentiate microstructural characteristics of LV myocardium exposed to varying degrees of afterload stress. We also compared this algorithm with conventional echocardiographic parameters of adverse LV remodeling. The main findings of our study were three-fold. First, we observed that the SIC, an indirect measure of LV microstructure, was significantly higher in hypertensive compared to non-hypertensive myocardium in both our clinical study and experimental model. Second, the SIC was positively related to increasing levels of blood pressure exposure in humans as well as to increasing levels of afterload stress in mice. Third, we also observed in humans that the SIC demonstrated stronger associations with hypertension status and degree of blood pressure elevation than established echocardiographic measures of adverse LV remodeling (i.e. ‘macrostructure’). Overall, these results demonstrate the potential of an imaging algorithm to identify the presence and extent of microstructural changes that can arise early in the development of hypertensive heart disease.In our clinical study, the individuals with hypertension were otherwise healthy and were similar to normotensive controls with respect to age and sex. Thus, the clinical cohort included younger to middle-aged individuals, in whom elevations in DBP are known to be more common than elevations in SBP.th percentile of the signal distribution in the region of interest. Many published techniques for assessing myocardial microstructure have relied on mean gray-scale values, obtained through integrated backscatter or comparable signal analysis methods. However, other studies have suggested that using the complete distribution of signal intensity values allows for a more sensitive and specific assessment of signal alterations compared with use of only the mean signal intensity value. Ciulla et al. demonstrated that kurtosis and other measures of signal distribution were positively correlated with collagen content in hypertensive patients.The image analysis algorithm used to produce the SIC measure differs in several ways from similar algorithms employed in prior studies. First, the SIC is based on the 25The exact mechanism by which the SIC measure is able to differentiate between states of afterload resistance is not entirely clear. Studies of microstructural image analysis have long sought to understand how pathologic changes of the myocardium manifest as sonographic signal intensity variation. Prior investigators using echocardiographic analyses of hypertensive disease have suggested that pathologic compared with non-pathologic changes within the LV wall can effectively change tissue impedances, thereby altering sonographic signals. Several studies have noted that cyclic variation in mean gray levels of integrated backscatter signals, which normally increase at end-diastole and decrease at end-systole, show less variation in the setting of hypertension and coronary disease.In the present study, the positive correlation observed between SIC and BP indicates that a pre-specified percentile value of pericardial signal intensity decreases as BP increases. Signal that is more diffusely scattered due to increased tissue heterogeneity and fiber disarray may demonstrate lower signal intensity upon reaching the interface of the myocardium and pericardium. Alternatively, signal that is reflected in the myocardium more proximally, due to collagen or calcium deposits, may also result in reduced pericardial intensities. This kind of “acoustic speckle” effect has been described previouslyThe present study extends prior work by comparing and integrating established measures of structural heart disease with ultrasonic measures of LV myocardial microstructure. Although conventional echocardiographic measures, such as LV mass and wall thickness, are known to reflect worsening hypertensive heart disease, the relations of these gross morphologic parameters with BP exposure are non-linear and complex.The SIC and the MSI measures offer the potential to serve as markers of myocardial disease severity in the assessment of hypertensive heart disease in humans, including changes in myocardial structure over time and responses to treatment. Advantages of the SIC and MSI include their wide accessibility and ease of use through open access software that can be applied to routinely acquired echocardiographic images. Although further evaluation in more diverse clinical cohorts is warranted, our initial results in a human sample and in an animal model suggest that the SIC may be particularly robust to variation in image acquisition settings and physiology. As a measure of cardiac microstructure, the SIC may also be used to differentiate the severity of myocardial pathology in non-hypertensive disease states. Further studies are needed to assess the extent to which the SIC correlates with histologic changes in myocardial microstructure during the course of disease progression. Further studies are also needed to assess the potential utility of the SIC as well as MSI in broader clinical contexts. In addition to potential clinical applications, validated microstructural image analysis techniques may be used as adjunctive tools for investigating the pathophysiology of hypertensive heart disease. Hypertensive heart disease is recognized as a complex entity with multiple subclinical and clinical disease manifestations.Several limitations of the study merit consideration. Our study design was retrospective, although all analyses were performed while blinded to clinical characteristics. Additionally, our human study sample size was small, although findings in this small-sized cohort demonstrated significant associations between the novel ultrasonic measures of LV microstructure and hypertension status as well as BP variation; nonetheless, further studies in larger samples are warranted. Because BP is known to be difficult to measure in mice,We evaluated a novel image analysis algorithm designed to assess alterations in cardiac microstructure due to hypertension. We observed that the SIC significantly differentiates between hypertensive and non-hypertensive myocardium, both in humans and in mice. Furthermore, the SIC measure correlated with even mildly increased levels of BP exposure in humans, as well as with increasing levels of chronic afterload stress in mice. Overall, the SIC demonstrated stronger associations with the presence and degree of hypertension exposure when compared to established echocardiographic measures. Thus, the SIC may represent a particularly sensitive measure of cardiac remodeling that adds complementary information to conventional methods for assessing myocardial changes occurring during the progression of hypertensive heart disease.File S1File S1 contains additional information relevant to the manuscript, including the Protocol for Image Analysis, Figure S1 , and Figure S2 .(DOC)Click here for additional data file.


Rest, Pacing (at 130 b/min), and Recovery. Myocardial lactate exchange and oleate oxidation were also measured. At Rest, DCM patients showed a reduced nonesterified fatty acids (NEFA) myocardial uptake, while glucose utilization increased only in DCM-AGT. In response to Pacing, glucose uptake promptly rose in N-AGT , did not change in DCM-AGT, and slowly increased in DCM-NGT. DCM-AGT sustained the extra workload by increasing NEFA oxidation , while DCM-NGT showed a delayed increase in glucose uptake. Substrate oxidation rates paralleled the metabolites data. The presence of AGT in patients with DCM exacerbates both the shift from fat to carbohydrates in resting myocardial metabolism and the reduced myocardial metabolic flexibility in response to an increased workload. This trial is registered with ClinicalTrial.gov NCT02440217.Dilated cardiomyopathy (DCM) is characterized by a metabolic shift from fat to carbohydrates and failure to increase myocardial glucose uptake in response to workload increments. We verified whether this pattern is influenced by an abnormal glucose tolerance (AGT). In 10 patients with DCM, 5 with normal glucose tolerance (DCM-NGT) and 5 with AGT (DCM-AGT), and 5 non-DCM subjects with AGT (N-AGT), we measured coronary blood flow and arteriovenous differences of oxygen and metabolites during  The relationships between diabetes and impaired glucose tolerance  and dilated cardiomyopathy (DCM) are complex both at the clinical and the biochemical levels. Patients with AGT are more prone to develop both ischemic and nonischemic DCM –3 and deOur hypothesis is that the diabetic milieu attenuates the myocardial metabolic abnormalities of DCM, but it further reduces the already poor metabolic flexibility of the organ. To reduce the confounding effects of the systemic hormonal and substrate changes induced by either diseases and/or by their treatments, and also the variability induced by the different aetiology of DCM, we accurately selected only patients with NYHA class II/III idiopathic DCM and impaired glucose tolerance (IGT) or diet-controlled type 2 diabetes, with normal or impaired fasting glucose (<7.0 mmol/L).The study was approved by the Ethics Committee of Institute of Clinical Physiology which is an autonomous institution of the National Research Council, and a written informed consent was obtained from each candidate on the day before cardiac catheterization after an exhaustive explanation of the protocol and its potential risks.++-antagonists, β-blockers, and ACE-inhibitors, were suspended at least 24 hours before catheterization.We enrolled 5 patients with DCM and normal glucose tolerance (DCM-NGT) at the standard 75 g oral glucose tolerance test (OGTT), 5 patients with DCM and with either IGT or diabetes at the OGTT (DCM-AGT), and 5 patients with normal left ventricular function but with either IGT or diabetes at the OGTT (N-AGT). The subjects were preselected on the bases of clinical history, OGTT results, and left ventricular function, and they were admitted to the Cardiology Department of the NRC Institute of Clinical Physiology to undergo a diagnostic coronary angiography. If the subject had angiographically normal coronary arteries, then he/she was enrolled in the study. DCM was defined as left ventricular ejection fraction (LVEF) <40% and left ventricular end diastolic diameter (LVEDD) >56 mm. Exclusion criteria were NYHA class IV, atrial fibrillation, age ≥70 or ≤20 yrs, previous myocardial infarction, valvular heart disease, myocarditis or pericarditis, severe to moderate systemic arterial hypertension, fasting hyperglycaemia (>7.0 mmol/L) or treated diabetes, autoimmune diseases, neoplasia, and kidney, liver, or respiratory failure. N-AGT patients underwent coronary angiography because of either history of angina-like chest pain and/or previous stress tests suspicious for myocardial ischemia. Normal left ventricular function was defined as LVEF >50% and LVEDD <56 mm. All coronary-active drugs, including nitrates, CaA 6F guide catheter was placed in the left main coronary ostium through a 7F femoral artery introducer. An intracoronary heparin bolus (100 U/Kg) was given and a 0.014 Doppler flow wire  was advanced into the LAD. A 2.9 F, 10 MHz intravascular ultrasound (IVUS) catheter  was passed over the flow wire and positioned in the LAD immediately distal to the first septal perforating branch. The position of the IVUS catheter and flow wire was documented by angiography and was verified throughout the study by fluoroscopic control. After calibration, phasic and mean coronary perfusion pressure (from the guiding catheter) and coronary flow velocity signals were continuously recorded together with ECG (leads DI-DII-DIII). IVUS images were obtained for ≥30 seconds at each step of the protocol, with temporal synchronization with flow velocity signal, and recorded for offline analysis. After LAD instrumentation, a 5F catheter was advanced into the coronary sinus, up to the great cardiac vein, to withdraw venous blood from the LAD territory. Then, a unipolar pacing catheter was positioned into the right atrium. Arterial sampling was done from the 7F femoral artery introducer catheter. Rest, Pacing, and Recovery. After the instrumentation was completed (about 30 min), Rest arteriovenous sampling was performed at times −15 min and 0 min. After 0 min, heart rate was increased by atrial pacing to 110 bpm for 3 minutes and to 130 bpm for 3 additional minutes and arteriovenous sampling was repeated at the end of each step (at times 3 and 6 min). Pacing was then stopped and at times 1, 5, 15, and 30 min into the Recovery period other pairs of arterial and venous samples were withdrawn. The first 5 mL of blood from each line was discarded to avoid contamination and then blood samples were transferred in ad hoc prepared tubes and kept in ice. In 4 N-AGT and in 5 DCM-AGT subjects, paired A-V blood samples were also collected in heparinised syringes and gas analysis immediately executed . In 5 N-AGT, in 4 DCM-AGT, and in 4 DCM-NGT, after the completion of diagnostic angiography, a bolus of 110 mg of [3-13C]-L-lactate and 50 μCi of -oleate was followed by i.v. continuous infusion of -oleate (84 μCi/h) and [3-13C]-L-lactate (130 mg/h) allowing a 30-minute equilibration period. The lactate stable isotope was used to measure net lactate uptake and net lactate release from the myocardium by the difference with the unlabelled lactate exchange. Labelled oleate was used to measure fractional oleate extraction and the fraction of oleate undergoing oxidation from the measurement of the myocardial 3H2O production -L-lactate was measured by gas chromatography-mass spectrometry in plasma samples deproteinized with perchloric acid and derivatized using N-methyl-N-(t-butyldimethylsilyl)-trifluoroacetamide . Plasma -oleate concentration was measured by extracting fatty acids from 0.5 mL of plasma in 3 mL of HCl-heptane-isopropanol (1 : 10 : 40) and counting the radioactivity of the organic phase with a liquid scintillation counter  while 3H2O concentration, derived from  oleate oxidation, was measured by counting the water phase. Myocardial substrate uptake, release, and oxidation were calculated as the arteriovenous concentration difference times CBF as previously described -palmitate extraction rates have also recently been reported in DCM patients and type 2 diabetic patients with normal left ventricular function [β-OH-uptake in DCM-AGT are probably only the consequence of the lower arterial levels of the substrate.We also found that the reduction in NEFA uptake is essentially caused by a reduced substrate supply  and not by an impaired substrate extraction. This finding was confirmed by the tracer exchange data that revealed similar extraction rates in N and DCM despite the different net balances. The discrepancy between the tracer and the natural substrate estimated tissue extraction, which has already been observed and extensively discussed , was simfunction ; however Rest and Pacing oxygen uptake (and energy expenditure) per g of tissue are approximately 40–50% lower in DCM patients suggesting a reduced myocardial energetics density (per g of tissue); however, the small sample size and the lack of accurate measurements of cardiac work prevent from quantitatively comparing the energetic efficiency in the two groups. The normal aerobic metabolism  is also independently and directly confirmed by lactate tracer-derived release data during either Pacing or Recovery in each and all study groups  and potentially to a dangerous reliance on plasma NEFA availability, whose plasma concentration, for example, is dramatically reduced in the postabsorptive state. In the long term, it would be important to understand whether the different responses to pacing observed in AGT and NGT are adaptative or maladaptative and/or whether they modify the natural course of the myocardial disease. This might influence the clinical response to drugs that directly shift myocardial substrate utilization from NEFA to glucose  and also to drugs like beta blockers that are able to interfere with the changes in systemic and myocardial metabolism induced by catecholamines and eventually by the presence or absence of ischemia .The small number of subjects per group, due to the complexity of the experimental procedure, is a potential limitation of this study. However, our main hypothesis that an impaired glucose metabolism might prevent the metabolic changes described in the myocardium of patients with DCM can be rejected with a high level of confidence having observed in AGT patients, if any, a more severe metabolic derangement. The use of pacing as a tool to stimulate myocardial metabolism is a limitation since in physiology the extra cardiac work is normally associated with hormonal  and substrate changes (NEFA mobilization); however, our choice was dictated by the need of constant plasma substrates concentration (required for the use of metabolic tracers) and by the constraints of the Catheterization Laboratory setting. The lack of a control group with normal glucose metabolism and normal heart function is also a limitation of our study. However, this choice was related to the fact that these subjects are very rare among those who undergo a coronary angiography and, most importantly, our major concern was to avoid attributing the differences observed in myocardial metabolism between AGT and NGT patients with DCM to the presence of AGT, whose impact on myocardial metabolism has not been carefully characterised.The presence of mild derangements in glucose metabolism (IGT and early diabetes) exacerbates the metabolic shift from fat to carbohydrates that occurs at rest in the myocardium of patients with dilated cardiomyopathy and also the already poor metabolic flexibility of the tissue in facing an acute myocardial workload increase. This might render the myocardium less efficient and/or more vulnerable and might modify its response to therapies that interfere with glucose metabolism.


Perioperative myocardial ischemia is common in high-risk patients. The use of interventional revascularisation or even thrombolysis is limited in this patient subset due to exceedingly high bleeding risks. Blockade of voltage-gated sodium channels (VGSC) with lidocaine had been suggested to reduce infarct size and cardiomyocyte cell death in ischemia/reperfusion models. However, the impact of lidocaine on cardiac function during sustained ischemia still remains unclear.in vivo phenotyping. Infarct size and cardiomyocyte cell death were assessed post mortem histologically and indirectly using troponin measurements.Sustained myocardial ischemia was induced by ligation of the left anterior descending artery in 12–16 weeks old male BALB/c mice. Subcutaneous lidocaine (30 mg/kg) was used to block VGSC. Cardiac function was quantified at baseline and at 72h by conventional and speckle-tracking based echocardiography to allow high-sensitivity Ischemia strongly impaired both, global systolic and diastolic function, which were partially rescued in lidocaine treated in mice. No differences regarding infarct size and cardiomyocyte cell death were observed. Mechanistically, and as shown with speckle-tracking analysis, lidocaine specifically improves residual contractility in the ischemic but not in the remote, non-ischemic myocardium.VGSC blockade with lidocaine rescues function of ischemic myocardium as a potential bridging to revascularisation in the setting of perioperative myocardial ischemia. Outcome of acute myocardial ischemia remarkably improved with the availability of interventional and pharmacological revascularisation techniques. Unanticipated myocardial ischemia in the perioperative phase however is frequent in high-risk patients and substantially affects morbidity and mortality . Unfortu+i) and, through mechanisms including the sacrolemmal Na+/Ca++ exchanger and other pathways, an increase in intracellular calcium (Ca++i). This accumulation of Ca++i during ischemia is deleterious as it results in increased diastolic wall tension, myocardial contractile work and oxygen consumption /L0).Echocardiography was performed using a digital small animal ultrasound system  with a 18 to 38 Mhz linear-array probe. AnimalsPulsed-wave Doppler was used in the apical 4-chamber view to measure early (E) and late (A) mitral inflow velocities. Early (Ea) and late (Aa) mitral valve velocities were quantified by tissue Doppler imaging. Due to the in our experience insufficient image quality in the apical 4-chamber views in mice following thoracotomy, tissue Doppler was performed in the parasternal short-axis view on the level of the chordae tendineae as described before.Analysis of all images was performed offline by two  independent, blinded investigators for the conventional measurements and by one (BME) blinded investigator for the semi-automated strain measurements using the Vevo2100 Software Version 1.6. The inter-observer-variability was low with an intra-class-correlation coefficient for EF and FAC of 0.93 and 0.92, respectively.www.randomizer.org). Animals of the treatment group received a total of six doses of 30mg/kg bodyweight of lidocaine . We chose the subcutaneous route to allow for a sustained drug effect and decreased toxicity. The reported LD50 of subcutaneous lidocaine in mice is 200–400 mg/kg . Animals were injected in 12h intervals, starting 30 minutes following LAD ligation. Animals of the control group received an equal volume of phosphate-buffered saline in the before mentioned interval.Animals were randomized to the control or treatment group prior to the baseline echocardiography using a free online randomizer . The detection limit of this assay is 3 pg/ml.Hearts were fixed in 4% formaldehyde, cut into three transverse slices of equal size  parallel to the atrioventricular groove as described before  and embeTotal LV endocardial circumference and the endocardial circumference occupied by scar tissue staining positive for Masson-Trichrome at the basal, mid ventricular and apical level was analysed in a semi-automatic fashion by a blinded investigator using imageJ . Infarct size was then calculated as the mean percentage of endocardial circumference occupied by the scar tissue of the LV.Mortality between mice of the control and treatment group was compared using the Log-rank test. Data was checked for normality using Kolmogorov-Smirnow-test. Normally distributed data were analysed using t-test (two groups) or One-way-ANOVA with Holm-Sidak posthoc test (> two groups).Non-normally distributed data was compared using the Kruskal-Wallis-test with Dunn posthoc test (> 2 groups) or Mann-Whitney-test (2 groups).Intraclass-correlation to compare the interobserver agreement of the two independent echo analysts was calculated for absolute agreement in two-way mixed mode. Hotelling T-Test was used in the analysis of mitral flow velocities.A p < 0.05 was considered significant. Statistical calculations were carried out using either SPSS Statistics Version 22  or Graphpad Prism Version 6 .Preoperative descriptive and baseline echocardiographic values did not differ between animals that were randomized to the treatment or control group .Ligation of the LAD resulted in an average histological infarct size 72h following ligation of 45.3% of the left ventricular circumference, which is in line with reported results for this model,15. MortGlobal systolic LV function in terms of EF, FAC as well as speckle-tracking based measurements of LS was drastically impaired with LS demonstrating the strongest percentage change 15]. Reg. Reg15].LAD ligation led to a deterioration of global LV systolic function. Functional impairment, however, was reduced in lidocaine-treated mice . In contrast, no effect of lidocaine was demonstrated in non-ischemic, viable regions . In lineex vivo- or short-term in vivo-models focusing on histological parameters of cardiac injury[in vivo data, which demonstrate that blockade of voltage-gated sodium channels with lidocaine attenuates deterioration of global heart function by improving the residual contractility in ischemic regions of the heart.Perioperative myocardial ischemia remains a clinical challenge as an exceedingly high bleeding risk limits the use of pharmacological lysis therapy or interventional revascularisation in these patients. Targeting the intracellular sodium homeostasis during ischemia was reported to be beneficial in ac injury,8,18. Weex vivo studies using isolated and perfused hearts[Previous work on the effect of sodium channel blockade during myocardial ischemia was limited to ed hearts,18, or ted hearts.in vivo model of myocardial infarction. We took advantage of the most recent small-animal echocardiography techniques that allow detailed phenotyping of global and regional heart function, while limiting physiological alterations due to prolonged sedation, as needed for cardiac magnetic resonance imaging, to a minimum[In our study, we addressed for the first time the functional impact of lidocaine treatment on cardiac function in an a minimum. We founa minimum.Subcutaneous application of lidocaine twice daily rescued global systolic function in our model. The beneficial effect was evident in conventional echocardiographic measurements as well as in speckle tracking analysis of LS.Significant systolic dysfunction is often associated with an impaired left ventricular filling during diastole. We found that LAD ligation leads to a strong decrease in late mitral inflow (A) and late mitral valve velocity (Aa) and consecutively increase in the E/A- and Ea/Aa ratios as signs of impaired diastolic function,21. TreaLidocaine had been suggested to reduce both infarct size and the release of troponins as serum markers of cardiomyocyte cell death in animal models of myocardial ischemia and reperfusion. KaczmarKaczmarek et al. further reported that reductions in infarct size and troponin release were due to a decrease in cardiomyocyte apoptosis in the lidocaine group. Previous findings demonstrated that cardiomyocyte cell death differs between ischemia and reperfusion: while cell death during ischemia is thought to be mainly due to necrosis, restoraThe mode of delivery of lidocaine might also contribute to the observed differences, as Kaczmarek et al used a continuous infusion during their short-term model as compared to subcutaneous injection in 12h-intervalls in the current study. While osmotic micropumps for use in mice that would allow a continuous release over several days are now available, simultaneous LAD ligation and implantation of such pump would significantly increase the burden on the animals and presumably mortality.Volatile anesthetics such as isoflurane that was used in the current study are well known for their cardioprotective properties in tissue ischemia when applied before the ischemic event (preconditioning). We usedex vivo [We observed differences in global systolic and diastolic function although infarct sizes were comparable in both, control and treatment groups. Analysis of regional wall motion of non-ischemic segments of the left ventricle by speckle tracking showed unaltered function with lidocaine treatment. However, segments of the ischemic region demonstrated improved residual contractility with lidocaine treatment, accounting for improved overall cardiac function. Blockade of VGSC was demonstrated before to decrease diastolic LV pressure ex vivo –24. In lVoltage-gated sodium channels are involved in the rapid depolarisation during the phase 0 of the action potential and VGSC-blocking drugs can therefore affect impulse propagation. While class Ib antiarrhythmics such as lidocaine have in general only little proarrhythmic effects, we cannot exclude fatal arrhythmias in mice of our treatment group as continuous ECG-monitoring was not available in our animal facility.in vivo by sustaining residual contractility of the ischemic myocardium. Lidocaine treatment might therefore be beneficial as a bridging therapy to revascularisation in perioperative myocardial ischemia until revascularisation can be performed with a tolerable risk for bleeding.In summary, we extend previous studies by demonstrating that blockade of VGSC with lidocaine improves global LV systolic and diastolic function in myocardial ischemia S1 File(PDF)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 FigKaplan-Meier curves are shown for postoperative survival in control (solid line) and lidocaine-treated mice (dashed line) during the observation period of 72h. The survival curves are compared using the log rank test (p = 0.77).(TIF)Click here for additional data file.S3 FigA LAD ligation lead to a strong decrease in conventional echocardiographic parameters of EF (**p<0.0001) and FAC (**p<0.0001), as well as speckle-tracking measurement of LS (**p<0.0001). B Percentage change following LAD ligation was higher for speckle-tracking derived LS than for conventional measurement of of EF (= 0.0432), but not FAC (p>0.05). C + D Regional quantification of LS revealed the most pronounced change in segments of the infarcted region  as compared to remote, non-ischemic segments  *p<0.05, **p<0.001 in C; **p = 0.0002 in D. EF ejection fraction, FAC fractional area change, LS longitudinal strain, BA basal-anterior, MA mid-anterior, AA apical-anterior, AI apical-inferior, MI mid-inferior, BI basal-inferior.12 to 16 weeks old BALB/c mice were subject to LAD ligation via left-sided thoracotomy. Echocardiography was performed before ligation (white bars) and 72h postoperative (black bars). (TIF)Click here for additional data file.S4 FigA Early (E) and late (A) mitral inflow velocites and E/A ratio are given. LAD ligation leads to a drop in late mitral inflow velocity (p<0.0001) and consecutive rise in E/A (**p = 0.0037). B Early (Ea) and late (Aa) mitral valve anulus velocities and Ea/Aa ratio are given. As shown for mitral inflow velocities, mitral valve anulus late velocity (Aa) drops following LAD ligation (p = 0.008) with a consecutive rise in Ea/Aa ratio (**p = 0.0023). White bars show preoperative values, black bars show values 3 days postoperative.(TIF)Click here for additional data file.S5 FigEF ejection fraction; FAC fractional area changePercentage changes to preoperative values 3 days following sham operation in animals without and with lidocaine treatment are shown. (TIF)Click here for additional data file.


Serial surveillance endomyocardial biopsies are performed in patients who have recently undergone heart transplantation in order to detect acute cardiac allograft rejection (ACAR) before symptoms occur, however the biopsy process is associated with a number of limitations. This study aimed to prospectively and longitudinally evaluate the performance of multiparametric cardiovascular magnetic resonance (CMR) for detecting and monitoring ACAR in the early phase post-transplant, and characterize graft recovery following transplantation.All patients receiving a heart transplant at a single UK centre over a period of 25 months were approached within one month of transplantation. Multiparametric CMR was prospectively performed on the same day as biopsy on four separate occasions . CMR included assessment of global and regional ventricular function, myocardial tissue characterization  and pixel-wise absolute myocardial blood flow quantification. CMR parameters were compared with biopsy findings. As is standard, grade 2R or higher ACAR was considered significant.88 CMR-matched biopsies were performed in 22 patients. Eight (9%) biopsies in 5 patients demonstrated significant ACAR. Significant ACAR was associated with a reduction in circumferential strain  but there was considerable overlap between groups. Whilst trends were observed between ACAR and proposed CMR markers of oedema, particularly after adjusting for primary graft dysfunction, differences were not significant. Significant improvements were seen in markers of graft structure and contractility, oedema and microvascular function over the period studied, although few parameters normalised.This study provides novel insight into the myocardial injury associated with transplantation, and its recovery, however multiparametric CMR was not able to accurately detect ACAR during the early phase post-transplantation. Acute cardiac allograft rejection (ACAR) affects approximately 20% of patients in the first year post-transplantation, and represents a leading cause of death during this period . MoreoveClinical features of ACAR are unreliable, with patients usually remaining asymptomatic until hemodynamic complications ensure. Routine screening is therefore performed in order to detect ACAR, and hence augment immunosuppressive therapy, at an earlier stage, with the aim of preventing progression to more severe disease, and potentially reducing the risk of long-term complications. ACAR surveillance is performed via histological analysis of right ventricular myocardial tissue obtained at endomyocardial biopsy, and patients undergo frequent biopsies (10–15) during the first post-operative year. However, the procedure is invasive (complication rate 0.5-1.5%), expensive and disliked by patients, factors which prevent more frequent monitoring, limiting optimal titration of immunosuppressive therapy . FurtherCardiovascular magnetic resonance (CMR) is a potentially attractive screening modality for ACAR due to its lack of ionizing radiation and its multiparametric nature, i.e. its ability to assess multiple aspects of myocardial injury in a single examination, including global and regional ventricular function, myocardial oedema (quantitative T1 and T2 mapping), myocardial blood flow and focal  and diffuse  myocardial interstitial expansion.Systematic evaluation of multiparametric CMR for diagnosing ACAR has not been reported to date. The aims of this prospective study were to assess the performance of multiparametric CMR for detecting and monitoring ACAR, to characterize the graft injury following transplantation and to longitudinally evaluate graft recovery in the early phase post-transplantation.All patients receiving a heart transplant at a single center over a 25 month period were prospectively approached within one month of undergoing transplantation Figure . The onl2 or less did not undergo the parts of the protocol requiring contrast agent. In addition, 10 age- and sex-matched healthy volunteers  were recruited to undergo CMR scanning.Each patient was prospectively scanned on the same day as biopsy on four separate occasions. As pre-specified, scans were performed to coincide with biopsies scheduled for 6 weeks, 10 weeks, 15 weeks and 20 weeks post-transplant. Investigators were blinded to biopsy results i.e. scans were not performed on the basis of confirmed or suspected ACAR. CMR was performed immediately before or after biopsy, the order of which was determined randomly. Due to concerns over cumulative gadolinium contrast agent dose, the parts of the protocol requiring contrast agent were performed in two out of the four scans in each patient. Patients with an estimated glomerular filtration rate of 35 ml/min/1.73 m2 -prepared SSFP sequence was acquired in short-axis at mid-ventricular level in late diastole at preparation times, T2prep, of 0, 24, 45, 65 ms. . Ho. Ho1 and2, which is in keeping with the findings of an early CMR study by Marie et al. . Th. Th23]. 1 and T2 to be elevated in all patients during the very early period post-transplant however values returned to normal 25 days post-transplant. In the current study myocardial T1 and T2 remained elevated for considerably longer, which is in keeping with contemporary CMR findings in other pathologies such as myocardial infarction or myocarditis [There has been little previous investigation into temporal changes in allograft structure and function in the early phase post-transplant. Using echocardiography, Antunes et al.  found LVcarditis . Finallycarditis  demonstrTaking the findings of the current study and of Usman et al.  togetherDespite over 2 years of recruitment and a recruitment rate of over 75% in those eligible, the number of patients included is relatively small. This is in part reflective of the robust study design, although the size of the cohort and number of scans performed here are in keeping with many studies assessing non-invasive approaches to ACAR surveillance. As acknowledged earlier, the number of episodes of significant ACAR captured is also relatively small. It is also recognized that biopsy is limited as a reference standard, with ‘biopsy-negative’ ACAR widely reported , howeverIn this study, multiparametric CMR demonstrated that multiple factors affect cardiac allograft structure and function in the early phase post-transplantation. Whilst CMR provided novel insight into the myocardial injury associated with transplantation, it was not able to accurately detect ACAR as diagnosed by biopsy during this period.ACAR: Acute cardiac allograft rejectionCMR: Cardiovascular magnetic resonanceECV: Myocardial extracellular volumeEF: Ejection fractionLGE: Late gadolinium enhancementLV: Left ventricleMBF: Myocardial blood flowMPR: Myocardial perfusion reservePGD: Primary graft dysfunctionROC: Receiver operating characteristicThe authors declare that they have no competing interest.All authors have contributed significantly to the work. CAM and MS conceived and directed the project. JHN and CAM developed the CMR analysis tools with input from GC. CAM, SMS, NY and SGW recruited the patients. DC, CAM, MPA and MS performed the CMR scanning and analysis. PB performed the histological analysis. All authors provided critical review of the manuscript. All authors read and approved the final manuscript.


T1 and T2 mapping has shown great promise for the identification of acute myocardial infarction. However, most of this work has been performed in patients with ST-elevation myocardial infarction (STEMI). We prospectively studied the diagnostic accuracy of two novel  and one established (T2 STIR) MRI methods for imaging the ischaemic area-at-risk (AAR) in patients with a recent NSTEMI.NSTEMI patients underwent contrast-enhanced cardiac MRI at 3.0 Tesla after percutaneous coronary intervention (PCI). The presence/extent of infarction was assessed with late gadolinium enhancement imaging . The infarct-related territory (IRA) was identified independently using a combination of angiographic, ECG and clinical findings. AAR was assessed with T1, T2 and T2 STIR methods by 2 observers who were blind to all of the clinical data. Comparisons were made between MRI and clinical findings.Seventy-three NSTEMI patients  underwent 3TMRI. The mean infarct size was 5.5 ± 7.2% of left ventricular (LV) volume. The AAR T1 and T2 times (ms) were 1323 ± 68 ms and T2 57 ± 5 ms, respectively. The extent of AAR (% of LV volume) estimated with T1 (15.8 ± 10.6%) and T2 maps  was similar (p = 0.838), and moderately well correlated . The 95% limits of agreement for mean area-at-risk estimated with T1 versus T2 maps were -13% and 13%. Mean AAR estimated with T2 STIR (7.8 ± 11.6%) was significantly lower than that estimated with T1 (P < 0.001) or T2 maps (P < 0.001). There were moderate correlations between AAR estimated with T1 maps vs. T2 STIR , and AAR estimated with T2 maps vs. T2 STIR . The 95% limits of agreement for mean myocardial AAR estimated with T1 vs. T2 STIR maps were -28% and 12% and for T2 vs. T2 STIR maps -32% and 16%. The IRA was correctly identified in 52 patients (71%) when using T1 maps, 56 (77%) for T2 maps, and 32 (44%) for T2 STIR maps. There was no difference in diagnostic accuracy with T1 and T2 maps (P = 0.125). A difference in diagnostic accuracy was observed between T1 maps and T2 STIR (P < 0.001), and T2 maps and T2 STIR (P < 0.001) for detecting IRA. Inter-observer agreement of infarct-related artery assignment was moderately high when analysed with T1  and T2  maps, but low with T2 STIR .T1 and T2 maps have much higher diagnostic accuracy than T2 STIR maps, implying superior clinical utility.This study was funded through the British Heart Foundation and Health Science Scotland.