Postoperative cardiac outcomes after intracardiac repair (ICR) are determined by numerous factors whereas right ventricle (RV) dysfunction is considered essential for them, as only few studies attempted to evaluate it postsurgically. RV's function is supposed to be the strong prognostic factor for patients diagnosed with congenital heart defects; therefore, assessing it is the main objective of the study.This is a prospective single‐centered cohort study performed on 50 pediatric patients with congenital heart disease (CHD) who underwent ICR between January 2019 and January 2022. All patients underwent echocardiographic assessment of RV function via tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC) at 1, 24, and 48 h. After surgery, where pre‐ and postoperative RV pressure, cardiopulmonary bypass (CPB), and aortic cross‐clamp (ACC) time were assessed. Similarly ventilation intensive care unit (ICU) and hospital stay times and mediastinal drainage were also monitored.p value of <0.002 and <0.001, respectively. The mean ± standard deviation of CPB and ACC times was 120.92 ± 74.17 and 78.44 ± 50.5 min accordingly, while those for mean ± standard deviation of ventilation time, mediastinum chest drainage, ICU and hospital stays were 30.36 ± 54.04, 43.78 ± 46.7 min, 5.9 ± 4.01 h, were 30.36 ± 54.0, 43.78 ± 46.7 min, 5.9 ± 4.01 and 10.3 ± 4.83 h, respectively.The mean ± standard deviation for pre‐ and postoperative RV pressure was 49.1 ± 16.12 and 42.7 ± 2.9 mmHg, respectively, whereas that for pre‐ and postoperative pulmonary artery pressure was 30.4 ± 2.6 and 24.2 ± 12.9 mmHg, with RV dysfunction plays the important role in longer recovery and intraoperative time, while its effect is mostly transient. The use of TAPSE and FAC methods is valuable in the evaluation of postoperative outcomes, and the former proved to be more effective. One of the most serious complications associated with it is right ventricle (RV) dysfunction that can lead to profound ischemia and myocardial infarction.CPB guarantees a motionless and bloodless surgical field by involving an extracorporeal circuit to provide physiological support. Typically, blood is drained by gravity out of the heart and lungs to a reservoir by venous cannulation and tubing. Later, a pump and artificial lung (oxygenator or gas exchanger) facilitate the return of the oxygenated blood to the arterial system.CPB is a surgical intervention that significantly affects systemic metabolism and endocrine function. Many trials have attempted and tried to assess the predictive value of fatty acid‐binding protein compared with other biomedical markers to predict perioperative myocardial injury and early ventricular dysfunction.Conversely, on the other hand, most interventions with CPB with cardioplegic arrest lead to ischemic–reperfusion injury resulting in myocardial dysfunction. This dysfunction may be temporary (up to 24 h), stunning, and even persistent in profound ischemia and myocardial infarction cases. However, there are many contributing factors such as preoperative myocardial dysfunction, degree of myocardial protection, systemic inflammatory responses, and alterations in signaling transduction systems.RV dysfunction pathology includes high RV preload or afterload, impaired right coronary artery perfusion, and decreased contractility. In contrast to the left coronary artery, perfusion of the right coronary artery occurs during the whole heart cycle. Moreover, high RV pressure due to pathological causes such as pulmonary hypertension leads to lower coronary artery perfusion, highlighting the importance of preserving the normal pressure inside the two ventricles. Additionally, the RV normally provides low‐pressure perfusion for the pulmonary vasculature, making it highly sensitive to even moderate increases in pulmonary arterial pressure. However, RV dysfunction is usually a result of different mechanisms, and that is why RV failure is associated with many underlining conditions. Contractility impairment as one of the major causes of RV dysfunction is mainly caused by perioperative RV ischemia and infarction. Volume overload, on the other hand, is commonly developed as a result of tricuspid or pulmonic regurgitation leads. However, the causes of pressure overload include left‐sided valvular disease, cardiomyopathy, pulmonary hypertension, embolism, acute respiratory distress syndrome (ARDS), and high positive‐pressure ventilation. Pulmonary hypertension or contractile impairment may lead to RV failure associated with rapid progression to RV dilation, resulting in higher end‐diastolic pressure. That can push the ventricular septum toward the already underfilled left ventricle (LV) chamber, which, in its turn, reduces LV preload and decreases CO.The physiopathological process of RV failure after cardiac surgery is more complex than what we have described above in the traditional model. More than one mechanism is involved in the process, including pulmonary hypertension primarily associated with CPB, pre‐existing pulmonary hypertension, and ventricular interdependency. Inflammatory mediators after CPB may mediate the increase in pulmonary resistance and vasoconstriction after CPB. These mediators may result from endothelial damage or ischemic and reperfusion mechanisms due to inadequate blood flow through the bronchial arteries. As a result, nitric oxide and prostacyclin go down, while thromboxane A2 and endothelin level up. This represents the imbalance between vasoconstriction and vasodilation factors. Additional factors disturb the hemodynamic status of RV and increase pulmonary hypertension, such as administration of heparin and/or protamine, pulmonary microembolism phenomena, ischemia of the RV, metabolic acidosis, hypercapnia, hypothermia, hydric overload, poor myocardial protection, extended extracorporeal circulation time, obstruction of vascular grafts, and loss of auricular–ventricular synchrony.The relevant diagnostic methods are used to prevent these complications, and one of them is echocardiography.The echocardiographic machine uses ultrasound waves, and it must have some features to perform standard pediatric echocardiograms. These features must include two‐dimensional (2D) imaging, M‐mode, pulsed‐wave and continuous‐wave Doppler, color flow Doppler mapping, electrocardiogram 2D gating, Doppler velocities, and a color monitor. Additionally, it must have the ability to measure cardiac structures and store moving images. A hard‐copy paper printout is desirable but not required.Although evaluating ventricular function is an essential part of every echocardiographic study on children with congenital or acquired heart disease, it is still challenging to evaluate the systolic function. That is because of the confounding effect of different factors, such as ventricular structure and the difference in loading conditions.Evaluating contractility, on the other hand, is also difficult because of the complex structure physiology of RV. Many indices have been described as surrogate parameters of RV global systolic function. According to the latest guidelines for cardiac chamber quantification, sonographers recommended observing the right heart from various perspectives using multiple acoustic windows. Additionally, including multiple parameters is strongly needed to give the best result.During cardiac anesthesia and in the intensive care unit (ICU), clinicians use echocardiography to make the right decisions regarding surgical procedures and perioperative management.Thus, considering the prevalence of heart diseases in children, the use of echocardiography to assess RV performance during the heart cycle is crucial to determine the long‐term outcomes of surgery and to take the appropriate intervention in case of poor RV performance, especially if there are congenital diseases present. Therefore, RV evaluation using the appropriate measurements should be performed routinely using various parameters according to the main diagnosis.In modern clinical practice, the evaluation of RV systolic function is routinely implemented via Doppler tissue imaging, tricuspid annular plane systolic excursion (TAPSE), derived tricuspid lateral annular systolic velocity (S wave), and fractional area change (FAC).2The FAC is a 2D measure of RV global systolic function where the normal value is >35% in adults.3TAPSE is another 2D measuring procedure that evaluates systolic RV function in the M‐mode apical four‐chamber view by placing the cursor on the lateral section of the tricuspid valve annulus. It assesses the tricuspid valve's excursion by calculating the difference in distance between the annulus and the apex at the end‐diastole and end‐systole phases. This distance can also be easily quantified with 2D imaging techniques,Electrocardiogram (ECG) tracing can be used to determine the optimal frame to measure the longitudinal shortening of the RV. The normal value in adults is greater than 1.6 cm, which is different from that of children. TAPSE, conversely on the other hand, can assess RV function effectively in patients with pulmonary hypertension or those with nonoperated hearts. Despite the reproducibility of the measure, it correlates poorly with EF compared with MRI measures. Therefore, it should be cautiously used in congenital heart defects that involve RV, such as single and systemic RVs, and Tetralogy of Fallot.As RV function plays a crucial role in the outcomes of patients who undergo cardiac surgery, our study aims to compare the efficacy of TAPSE and FAC in the postoperative measurement of RV function. This also includes an investigation of the influence of the surgical approach and its correlation with CPB.4This is a prospective observational study on pediatric patients with CHD who underwent cardiac surgery at Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India, between January 2019 and January 2020.A total of 50 patients were enrolled, and the following inclusion criteria were applied: age between 1 month and 18 years and the presence of CHD. Exclusion criteria comprised consisted of preoperative moderate‐to‐severe RV dysfunction, single ventricle physiology, an abnormal left coronary artery from the PA (ALCAPA), and LV dysfunction besides moderate‐to‐severe RV dysfunction Table .4.1The study was approved by the institutional ethics committee, and all the participants provided written informed consent. All the operations, including the aorta‐bicaval cannulation, were performed under traditional CPB through median sternotomy. All the surgical procedures were provided access through the right atrium where we cross‐clamped the aorta, all patients were cooled to 28°C, and cold‐blood cardioplegia (CP) was supplied through the aortic root to stop the heart.4.2Anesthesia was induced and maintained by the weight‐related doses of thiopental, fentanyl, midazolam, and pancuronium.After shifting patients to the operation theater, standard monitoring viz. ECG, pulse oximetry, and invasive blood pressure monitoring, temperature monitoring with the nasopharyngeal probe was done for all the patients enrolled in the study.Anesthesia induction was done by injecting ketamine 1 mg/kg, fentanyl 2 mcg/kg, and midazolam 0.02–0.05 mg/kg, and orotracheal intubation was facilitated by injecting vecuronium 0.08–0.1 mg/kg.Routine airway and ventilator management was done. Anesthesia was maintained with oxygen, sevoflurane, and top‐up doses of injected fentanyl, vecuronium, and midazolam.4.3In the postoperative period, analgesia and sedation were achieved via dexmedetomidine infusion at a rate of 0.2–0.7 mcg/kg/h. It is titrated as per the pain score. In patients with relative bradycardia, fentanyl/midazolam infusion was used. The dose of fentanyl infusion is at a rate of 0.5–2 mcg/kg/h and the dose of midazolam infusion is at a rate of 1–5 mcg/kg/h.In all cases, CPB was performed in the standard manner using a nonpulsatile roller pump, membrane oxygenators, and standard (uncoated) extracorporeal circuits under mild hypothermia (28°C). The circuit was primed with appropriate amounts of Plasmalyte‑A solution, mannitol, and sodium bicarbonate. Blood was added as required.Through the right atrium, the surgeon performed aorto‐bicaval cannulation, cold‐blood root CP (with del Nido solution), and ventricular septal defect repair with a glutaraldehyde‐treated pericardial patch. The right atrium was used to close the ventricular septal defect. Then, a restricted ventriculotomy was done in the RV outflow tract, beginning 0.5 cm below the annulus and extending for 1–2 cm, through which infundibular resection and pulmonary valvotomy were performed. Commisssurotomy  or release of tethering was used to treat pulmonary valve stenosis, as well as dilating the pulmonary valve with an appropriately sized Hegar dilator. The ventriculotomy was subsequently closed by a primary RV outflow tract patch using autologous glutaraldehyde‑fixed pericardium along with a bovine pericardial patch. From either route, the pulmonary annulus was assessed by passing a Hegar dilator expected for that weight if the pulmonary annulus was stenotic and of small size, followed by an incision of the RV outflow tract that extended across the annulus with resection of parietal and septal bands in the RV outflow tract.4.4Perioperative data were collected for CPB and aortic cross‑clamp (ACC) times, mean arterial pressure, and RV pressure. After the repair was completed, the pressure in the right ventricle/pressure in the left ventricle was measured in all patients. If there was no gradient between the RV and the PA and the hemodynamics was as steady, the value of 0.8 was accepted. All patients had intraoperative transesophageal echocardiography to assess the repair's adequacy and biventricular function. Hemodynamic status, particularly central venous pressure, cardiac rhythm stability, time to peripheral warming, and attainment of negative fluid balance were all measured postoperatively. We assessed the need for inotropes by calculating the inotropic score using the following formula:Inotropicscore = dopaminedose(μg/kg/min) +dobutaminedose(μg/kg/min)+100×epinephrinedose(μg/kg/min)+10 × milrinone dose(μg/kg/min)+10,000×vasopressin.4.5A single echocardiographer assessed the patients (using an ACUSON X300™ ultrasound machine with a frequency range of 1.2–13 MHz). As a reference for RV performance, TAPSE was estimated in the apical four‐chamber view using M‐mode echocardiography. The longitudinal excursion of the TAPSE's lateral annulus was found to have a high association with RVEF calculated from isotopic data. FAC was defined as (end‐diastolic area − end‐systolic area)/end‐diastolic area × 10. The values were obtained postoperatively by tracing the RV endocardium both in end‐diastole and end‐systole from the annulus, along the free wall to the apex, and then back to the annulus, along the interventricular septum. We recorded the values preoperatively and in the postoperative period after 1, 24, and 48 h.4.6t‐test. A p value of <0.05 was considered statistically significant.All the patients' data were entered into Microsoft Excel, and the analysis while it was carried out by STATA 14.2. Descriptive statistics (mean (SD), frequency [%]), where the characteristics of the study participants were described and analyzed with the paired 5The demographic data and male:female ratios are represented in Table According, to the postoperative echocardiographic data, the mean ± SD of TAPSE and FAC was 35.62 ± 3.59 and 14.4 ± 1.5 at baseline as compared with 8.80 ± 2.2 and 26.5 ± 2.40 at 1 h postoperatively respectively. However, the difference was statistically significant. The mean ± SD of TAPSE and FAC was 8.82 ± 2.21 and 26.5 ± 2.40 at 1 h postoperatively and 9.8 ± 1.9 and 28.5 ± 2.19 at 24 h postoperatively, respectively; the difference was statistically significant. The mean ± SD of TAPSE and FAC was 9.8 ± 1.9 and 28.5 ± 2.19 at 24 h postoperatively as compared with 11.7 ± 2.02 and 25.1 ± 12.6 at 48 h postoperatively, respectively. This comparison was statistically significant. The mean ± SD of TAPSE and FAC was 35.62 ± 3.59 and 14.4 ± 1.5 at baseline as compared with 25.1 ± 12.6 and 11.7 ± 2.1 at 48 h postoperatively, respectively, which was a statistically significant difference. From the echocardiographic data, the difference in CPB time between 1, 24, and 48 h postoperatively was statistically significant. The difference in ACC time at these same time was also significant.At 1 h after the operation, all 50 patients had RV dysfunction, and after 48 h, RV function was poor and additionally increased. In addition, TAPSE was a more accurate echocardiographic parameter than FAC.6The primary goal of this study was to use recognized deformational RV techniques to characterize and predict the acute intraoperative change in RV function. Improvements in surgical procedures and advances in sedation and critical care have increased postoperative cardiac endurance. Many factors have been attributed to the poor postoperative cardiac outcome, including underlying defect with a small primary PA annulus, extreme hypoplasia or insufficient right or left PA, ventriculotomy and RV outflow patch, myocardial hypoxia during CPB, or ARDS.6.1In the early postoperative period, RV dysfunction is described by elements of prohibitive physiology on Doppler echocardiography .Multiple processes such as increased RV afterload due to pulmonary hypertension affect RV contractility in cases of idiopathic dilated cardiomyopathy (DCM). RV is also affected by cardiomyopathic activity such as ventricular interdependence caused by septal dysfunction and myocardial ischemia due to lessened coronary perfusion. However, RV systolic dysfunction is believed to be a conventional final pathway in heart failure, which may lead to a poor prognosis.Tricuspid regurgitation forth and indications of foundational venous blockage, like raised jugular venous tensions, foresee higher mortality in patients with cardiovascular breakdown.CMRI is recommended as the gold standard approach for RV evaluation in guidelines; however, it is not readily available, which is seen as a serious limitation to its use.n = 13/24) of patients demonstrated RV dysfunction. After 12 weeks, only 15.3% (n = 2/13) still present the dysfunction. The presence of cyanotic spell (p = 0.006), recurrent chest infection (p = 0.002), increased hematocrit (p = 0.02), and increase in serum iron level (p = 0.002) were considerably correlated with postoperative RV dysfunction, resulting in extended ICU stay and slower recovery. Preoperative RV dysfunction was related to difficult weaning from bypass and poor postoperative outcomes (p < 0.001). Singh et al. concluded that RV dysfunction is frequently present even after adequate ICR. However, in this setting, its etiology remains to be established. In this study, the preoperative clinical profile and fluctuations in serum iron levels were important contributing factors to postoperative outcomes.Singh et al.p = 0.41). Though, only RV dysfunction patients had an iron overload. The myocardium of the tetralogy of Fallot lacks antioxidants, making it susceptible to free radical‐mediated injury and leading to impaired RV functions. The CK‐MB levels were significantly higher in patients who acquired postoperative RV dysfunction. That indicates that myocardial impairment in patients after ICR is significantly greater in patients with RV dysfunction than in those patients with a normal postoperative course.Chaturvedi et al.B = 0.56, p < 0.0001, and B = 0.35, p = 0.0002 per mm, respectively) and nonischemic etiology of heart failure  were independent predictors of TAPSE . TAPSE's predictive value was not related to the cause of heart failure or any of the other clinical parameters studied. The authors thought that TAPSE might have diminished in heart failure individuals with heart failure with LV dysfunction, especially those who have reduced longitudinal septal motion. TAPSE levels were also lower in patients with ischemic heart failure. However, the absolute decrease in TAPSE was minimal. It appears to have no major impact on TAPSE's clinical use, whether as a marker of RV systolic function or as a predictive factor.In heart failure, Kjaegaard et al.6.26.2.1Repair at a young age has been shown to minimize postoperative RV dysfunction caused by persistent hypoxia and stress loading, which causes the substrate in the myocardium that is liable for arrhythmias and diastolic brokenness in patients going through late repair. Significant RV remodeling has been predicted if repairs are carried out before the age of 6 months. It has been suggested that irreversible changes are set in by 4 years of age, based on microscopic analysis; consequently, repair before the age of 3 years is optimal. According to the research above, repairs performed before 3 years of age may cause myocardial changes to recur. Still, the best functional outcome is attained before 1 year of age when changes are just starting to emerge. Therefore, at 3 years of age, the foundation of irreversible changes, “age” may have decreased the effect on postoperative outcomes.6.3According to the literature, more than 18 g% hemoglobin level has been linked to serious disease. RV physiology can be unreliable preoperatively or postoperatively. It is unclear whether this is part of the same pattern or if the same functional substrate is involved. Diastolic dysfunction may indicate greater ischemia myocardium, hence a higher risk of reperfusion injury or ischemic offense.p values of <0.002 and <0.001, respectively.In this prospective observational study, we examined the demographic attributes and other factors of 50 patients. The difference between preoperative and postoperative RV and PA pressure was statistically significant with The management of the CPB machine and the CP emulsion directly influence postoperative states. Davidson et al.7After ICR, RV dysfunction causes a long recovery time and a delayed postoperative course. Preoperative RV diastolic dysfunction could be another marker for distinguishing populations with a higher risk of postoperative mortality or requiring vasoactive support and those with difficulty weaning from bypass.CPB time is directly proportional to RV dysfunction that commonly occurs after ICR and is transient and resolves in the maximum number of patients after 48 h. The application of TAPSE and FAC pre‐ and postoperatively enables the evaluation of to evaluate postoperative outcomes  effectively, whereas TAPSE proved to provide a more accurate estimate of RV function when compared than FAC.8This study has limitations, such as the small sample size from a single center and the lack of follow‐up data to evaluate the effect of RV systolic dysfunction on survival. The patients enrolled in the study were assessed by a pediatric cardiologist and designated echocardiographer who were coauthors in the study. Further studies involving a greater sample size, and long‐term follow‐up data will be required to better understand the effect of RV systolic dysfunction on survival rate.Vishal V. Bhende: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing–original draft; writing–review and editing. Tanishq S. Sharma: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing–original draft; writing–review and editing. Bhadra Y. Trivedi: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Amit Kumar: Data curation; formal analysis; investigation; methodology; project administration; software; supervision; validation; visualization. Dushyant M. Parmar: Data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Paresh Nerurkar: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Prachi M. Shah: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Naresh J. Fumakiya: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Hardil P. Majmudar: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Sohilkhan R. Pathan: Data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization.The authors declare no conflict of interest.The lead author Vishal V. Bhende affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.


In fetuses with left-sided congenital diaphragmatic hernia (CDH), left heart structures may appear small, but usually normalize after birth in the absence of structural cardiac anomalies. To decrease the possibility of an erroneous diagnosis of structural heart disease, we identify normal values for left heart structures in the presence of left CDH and secondarily investigate the relationship of left heart size and survival to neonatal hospital discharge.Left heart structures  were measured by fetal echocardiogram in fetuses with left CDH and no congenital heart disease. We generated linear regression models to establish the relationship of gestational age for each left heart structure using data from fetuses who survived after birth. We calculated z-scores , and assessed the relationship of survival to the size of each structure.p < 0.0001 for all comparisons). Non-survivors had worse z-scores than survivors for all measurements, but this did not reach statistical significance.One hundred forty-two fetuses underwent fetal echocardiogram . Left heart structures were deemed small when using published normative data from unaffected fetuses . CDH-specific models derived from log-transformed values yielded left-shifted distributions, reflecting the small structures (mean z-score lower by: MV 0.99 ± 0.30, AoV 2.04 ± 0.38, LV length 1.30 ± 0.36, and LV width 4.69 ± 0.28; Log-transformed linear models generated new normative data for fetal left heart structures in left CDH, which may be used to allay antenatal concerns regarding structural left heart anomalies. There were no significant differences in z-scores between survivors and non-survivors, suggesting that in the absence of true structural disease, cardiac evaluation is not predictive in isolation and that causes of mortality are likely multifactorial in this population. Congenital diaphragmatic hernia (CDH) is characterized by bilateral lung parenchymal and vascular hypoplasia –9. Assocvia the foramen ovale  and left ventricle (LV), measured flows in the pulmonary circulation and the ductus arteriosus (DA), and the path of umbilical venous flow into the heart –25. LV oen ovale , 25.Thus as the left heart is expected to be small in the fetus with CDH, it is difficult to interpret fetal heart measurements obtained using published normative values derived from fetuses without CDH. Standardized values for left heart structures in fetuses with CDH but without congenital heart disease have not been defined. We first aimed to define the normal size of left-sided heart structures in fetuses with left CDH without significant structural cardiac disease who survived postnatally and were confirmed to have no heart disease. We hypothesized that normal CDH-specific curves would be left-shifted compared to curves generated from normal fetuses. Secondarily, we investigated whether the size of left-sided heart structures [mitral valve (MV) and aortic valve (AoV) annulus diameters and LV length and width] normalized for gestational age using CDH-specific data, was associated with neonatal survival in fetuses without congenital heart disease.•The mitral valve and tricuspid valve (TV) annulus diameters in the 4-chamber view during the peak filling in early diastole at maximum excursion of the leaflets from inner edge to inner edge at hinge points of the leaflet attachments,•The aortic valve and pulmonary valve (PV) annulus diameters in long axis views at the inner edge of the annular hinge points at maximal opening in systole,•Left ventricle major axis length (LV length) measured at end-diastole, defined as the frame at which the MV and TV closes, taking care not to foreshorten the ventricles, from the middle of the annulus level to the apical endocardium, and•Left ventricle short axis (LV width) dimension at end-diastole  at the level of the papillary musclesGA-specific z-scores were generated for each measurement based on prior studies of fetuses unaffected with CDH or congenital heart disease, with GA specified as completed weeks by best obstetrical dating. We used published equations for predicted left heart parameters from McElhinney and colleagues and we assessed the robustness of our findings and any influence on right heart structures with application of widely-used equations derived by Schneider et al.  Fetal Treatment Center with diagnosis of CDH (2000–2010). All fetuses underwent ultrasound evaluation at UCSF, with anatomic description of the CDH [including lung-to-head ratio (LHR) ], and dor et al. , 29. TheMeasurements from a single evaluation of consecutive fetuses were included if newborn was liveborn and cared for at UCSF Children's Hospital after birth, and fetal cardiac structural measurements were possible from the available stored echocardiogram images. Fetuses with abnormal karyotype, suspected or confirmed genetic syndromes, and those undergoing fetal tracheal occlusion were excluded . Neonatat-test, using both published GA-specific norms for unaffected fetuses and the left CDH-specific norms generated from the current study. Finally, logistic regression was used to derive area under the receiver-operator characteristic (AUROC) curve with CDH-specific z-scores, to further assess the utility of fetal left heart structures for survival.Statistical analyses were undertaken for each cardiac parameter . Cardiac parameters were plotted vs. GA to assess for linearity with and without log transformation with a goal of identifying the best approach for all parameters; prior published work presents models with both non-transformed and transformed data , 29. Linn = 22) and without one or more missing parameters . The distribution of right-sided cardiac measurements was similar to that of unaffected fetuses. Left-sided cardiac measurements, however, were generally small, with LV width the most affected measurement. Differences in predicted parameters by the two sets of prediction equations were not substantial, with Schneider predictions slightly higher than McElhinney predictions for MV annulus diameter, and slightly lower for AoV annulus diameter . However, these differences translated into a more substantial, inverted, difference in z-scores, with the standardized Schneider scores lower than McElhinney scores for MV annulus diameter and higher than McElhinney scores for AoV annulus diameter .Of referrals to the UCSF Fetal Treatment Center during the study period, 197 with documented left CDH without abnormal karyotype or genetic syndrome underwent imaging evaluation by ultrasound and echocardiogram (including measures of cardiac structure). Nine underwent fetal tracheal occlusion, 15 had a diagnosis of congenital heart disease, and 31 had incomplete follow up or inadequate images available for review, leaving 142 fetuses eligible for the study, with evaluation at 18–37 weeks' GA. At the time of the evaluation, 136 fetuses had LHR measured. Cardiac parameters obtained at fetal echocardiogram performed at median of 25 weeks' GA (range 18–37 weeks) are shown, with no missing data for MV and TV diameters, and limited missing data for other parameters . There w(1)β * gestational age) + constant]Mean predicted value = exp [((2)z-score = [ − ln]/root MSEThe best linear representation for the relationship of GA to the four left heart parameters was by log transformation, as applied in prior studies . Equation = 92) better explained the relationship between gestational age and each measurement than models including all fetuses  and left ventricular width (p = 0.02) in models generated with data from both survivors and non-survivors, supporting the generation of normative values from models developed with data from only survivors  we secondarily evaluated the relationship of the size of fetal cardiac structures to survival to hospital discharge in our larger cohort. We used both z-scores from unaffected fetuses and the z-scores derived from our left CDH cohort for these analyses. Overall survival after birth was 65% (92/142). Although fetal z-scores from infants who died were lower than z-scores for those who survived for all parameters, the differences were not statistically significant, regardless of the equation used to derive z-scores . ConsistFetal evaluation of CDH provides important information for families and clinicians as they consider fetal and neonatal interventions and outcomes. Fetuses with anomalies in addition to the CDH, and in particular cardiac anomalies, have a significantly worse prognosis. Many fetuses with CDH may appear to have small left heart structures, but though relative hypoplasia of the mitral and aortic valves and left ventricle raise the possibility of true structural heart disease in these fetuses, the size of most structures will in fact normalize after birth . We presThe lack of association between left heart size and survival in this contemporary cohort is consistent with prior reports , 23. Z-svia nitric oxide)  , 33, 34.c oxide) , 36. Thuc oxide) . The neoc oxide) , 36, 37.c oxide) , 23, 38.Interestingly, we demonstrated poorer left heart development with advancing gestation by survival status, consistent with prior fetal cardiac studies , that shConsistent with the physiology of fetal intervention for CDH , tracheal occlusion can impact fetal markers of severity , 41. LefOur findings are based on single-center data, which may limit generalizability. However, experienced ultrasonographers may be required for the consistent ascertainment of important fetal markers of CDH severity, with strong agreement between expert evaluators , 44–47. Normative data on left heart structures from fetuses with left CDH without congenital heart disease result in z-scores that are significantly left-shifted compared to normal curves from unaffected fetuses. We suggest the use of these CDH-specific equations during fetal evaluation, as this may mitigate antenatal concern regarding structural left heart disease, since measurements of these structures in CDH have been shown to normalize after birth . However


Severe aortic stenosis (AS) is the most common valve disease in the elderly and is associated with poor prognosis if treated only medically. AS causes chronic pressure overload, concentric left ventricular (LV) hypertrophy, myocardial stiffness, and diastolic dysfunction. This adverse remodeling also affects the left atrium (LA), which dilates and develops myocardial fibrosis, with a reduction in intrinsic function and a consequent high risk of the development of atrial fibrillation. Speckle-tracking echocardiography is able to detect myocardial dysfunction before other conventional parameters, such as LV ejection fraction, and also predict clinical outcomes. This review aims at describing LV and LA remodeling in AS and before and after aortic valve replacement and the usefulness of myocardial strain analysis in this clinical setting. Aortic stenosis (AS) is the most common heart valve disease both in Europe and North America . Its inc2. In AS, the valve opening gradually decreases and the degree of stenosis becomes severe with a valvular area lower than 1 cm2 [The normal aortic valve area is >2 cman 1 cm2 . The resan 1 cm2 , with rean 1 cm2 .The prognosis of patients with untreated symptomatic severe AS is poor, affecting approximately 80% of patients within 4 years of the onset of clinical manifestations . The typLA and LV remodeling can be noninvasively assessed with echocardiography. In the last years, speckle-tracking echocardiography (STE) has emerged as an easy, quick, and advanced tool to provide early detection of myocardial functional and structural properties. Much research showed cardiac chamber remodeling anticipating the changes in basic echocardiographic parameters, with important diagnostic and prognostic implications.The aim of this review is to provide information on the pathophysiology of left atrial remodeling after SAVR and TAVR in patients with AS and to provide an overview of the increasing evidence on the use of speckle-tracking echocardiography to detect these changes. A literature review was conducted to identify English language studies in Pubmed from 2009 to 2022, using combinations of the following search terms: ‘left atrial,’ ‘remodelling’ or ‘remodeling’, ‘aortic valve replacement’, ‘aortic valve repair’, ‘aortic valve implantation’, ‘speckle-tracking echocardiography’, ‘myocardial strain’. Examination of reference lists of these studies yielded additional studies. Studies were reviewed by two independent authors and then used for the first paper draft, which was implemented and reviewed by all the authors.LV and LA function are closely related; in fact, the latter modulates LV filling and plays an important role in the diastolic phase of the cardiac cycle, while LV function influences LA contraction and relaxation. This interdependence means that changes in the intracavitary pressures of one chamber also affect the other .In AS, systolic pressure overload leads to compensatory concentric LV hypertrophy to preserve normal wall stress and EF . Wall thCardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) is currently the gold standard imaging technique for the detection and quantification of both focal and diffuse myocardial fibrosis . GadolinMore recently, STE has been used to evaluate myocardial function, showing high accuracy in detecting myocardial fibrosis and early LA function disturbances, particularly in patients with preserved LV EF and normal LA volume quantified by two-dimensional measurements . This teBoth surgical and transcatheter aortic valve replacement reduce trans-valvular pressure drop (gradient) and increase the aortic valve orifice area. This leads to a reduction in pressure overload and wall stress and, consequently, improvement of structural, systolic, and diastolic LV parameters. Garg V. et al., in their systematic review of changes in myocardial deformation after aortic valve replacement , have shStudies have shown that myocardial recovery demonstrated by strain parameters continues to develop for up to one year after TAVR ,35 and 1Myocardial reverse remodeling after aortic valve replacement also involves the LA. SAVR and TAVR both result in an improvement of LA atrial function with a reduction in LA volume and an increase in PALS 40 days after intervention, which become stable at the 3-month follow-up ,39. The LA speckle-tracking analysis proved to be associated with clinical outcomes. Galli et al. studied 128 patients with severe AS, a quarter of whom underwent TAVR, and found that an overall PALS lower than 21% was a significant predictor of major adverse cardiovascular events (MACE), unlike LA volume . Other rLA function evaluated by STE proved also to be the strongest predictor of post-operative atrial arrhythmias , which aFurthermore, studies have shown that LA strain is one of the major determinants of right heart pressures in patients with severe AS and preserved LV EF ,47. ThisThe STE technique has been developed on two-dimensional strain echocardiographic imaging and is based on the analysis of standard two-dimensional grey-scale echocardiographic images for myocardial function analysis. The speckle patterns (acoustic backscatter generated by the reflected ultrasound beam) are followed frame by frame by the software, using a statistical approach based on the detection of the best matching area. The displacement of these speckles is expected to follow myocardial movement, tracing a movement curve , which is assumed to represent myocardial deformation . DifferLA intrinsic myocardial function is obtained using STE from the apical four- and two-chamber views, applying the method described above for LV longitudinal myocardial intrinsic function. Care should always be taken in obtaining true apical images using standard anatomical landmarks to avoid foreshortening the LA, therefore allowing a clear delineation of the LA endocardial border. As previously described ,49. LA ePALS was shown to be correlated with prognosis in patients with several degrees of AS ,51, and AS is one of the most frequent valvular heart diseases requiring surgical treatment. Pressure overload due to aortic valve stenosis results in adverse LV and LA remodeling with the development of myocardial fibrosis and diastolic dysfunction with an increased risk of HF and AF. This adaptation is only partially reversible, and recovery is not complete even after aortic valve replacement. The reduction of longitudinal strain evaluated by STE proved to be closely related to myocardial fibrosis and, indeed, is a good predictor of cardiac outcome and the development of atrial arrhythmias. The latest ESC guidelines on the management of valvular heart diseases consider invasive treatment of AS based on patient symptoms or LV impairment evaluated by EF but do not consider strain evaluation when deciding on the optimal timing of valve replacement. This strategy often results in late management with irreversible cardiac structural changes. As illustrated in this review, alterations in LV GLS and PALS are able to detect myocardial dysfunction before the reduction of EF and LA enlargement take place. In the near future, their routine use in clinical practice could help identify patients requiring earlier invasive treatment in order to improve post-operative outcomes and recovery.


LV strain was not associated with arch architecture. Differences in LV morphology were observed between CoA and BAV patients. Increasing LV sphericity was associated with reduced strain, independent of aortic arch architecture and functional aortic valve disease.Functional implications of left ventricular (LV) morphological characterization in congenital heart disease are not widely explored. This study qualitatively and quantitatively assessed LV shape associations with a) LV function and b) thoracic aortic morphology in patients with aortic coarctation (CoA) with/without bicuspid aortic valve (BAV), and healthy controls. A statistical shape modelling framework was employed to analyse three-dimensional (3D) LV shapes from cardiac magnetic resonance (CMR) data in isolated CoA (n = 25), CoA + BAV (n = 30), isolated BAV (n = 30), and healthy controls (n = 25). Average 3D templates and deformations were computed. Correlations between shape data and CMR-derived morphometric parameters  or global and apical strain values were assessed to elucidate possible functional implications. The relationship between LV shape features and arch architecture was also explored. The LV template was shorter and more spherical in CoA patients. Sphericity was overall associated with global and apical radial ( Left ventricular (LV) morphology has been proposed as an important marker of remodelling and related to clinical outcomes, with adverse remodelling being a strong predictor of cardiovascular disease4. The LV geometry plays a critical role in the mechanics of the heart, and as early as 1892, Woods used a spherical model to quantitatively assess this relationship6. Three-dimensional (3D) patient-specific anatomical information can be derived by non-invasive imaging techniques, such as cardiovascular magnetic resonance (CMR) imaging. This allows further exploration of LV morphology using tools such as statistical shape modelling (SSM), which our group has previously applied to capture apical ballooning in Takotsubo cardiomyopathy7 and other studies used to assess aortic and LV remodelling in scenarios such as myocardial infarction, AAo thoracic aneurysm and aortic stenosis11. Here, we apply this methodology to congenital heart disease (CHD), particularly to aortic coarctation (CoA) and bicuspid aortic valve (BAV) disease, which have a prevalence of 3/10,000 and 1–2% respectively12. Patients with CoA can have BAV in up to 85% of cases, while both diseases can result in aortic vasculopathy, which is associated with morbidity and mortality in young patients with CHD13.The ability of the heart to change its shape and function in order to maintain normal cardiac output has been characterized as “remodelling”, which can either be adaptive or maladaptive, acute or chronic14. Clinical observations suggest that CoA patients tend to have rounder LVs, but this has not been assessed quantitatively, nor have possible functional implications of this characteristic been explored. Thus, this study aims to assess LV morphology in patients with CoA and/or BAV, using CMR-derived sphericity and conicity indices, and by means of SSM15 thus providing novel observations including 3D assessment. Morphological quantification through SSM allows exploring possible previously unreported associations between morphological features and functional implications, such as differences in CMR-derived global and apical strain indices across different LV morphologies. In addition, previous work from our group suggested potentially unfavourable aortic arch configurations in patients with BAV and repaired CoA11 and so this study also aimed to explore possible associations between LV morphological features and aortic arch architecture.To our knowledge, only one study has described LV morphology in adults with CoA or BAV, assessing LV sphericity pre- and post-stent implantation in CoA patientsThis was a retrospective single-centre study, screening patients who underwent clinical cardiovascular magnetic resonance (CMR) examination at a large tertiary centre between 2007 and 2020. Data were acquired at 1.5 T . Patients for the morphological 3D analysis were selected from databases of n = 521 BAV patients, n = 633 CoA patients and n = 435 patients without structural heart disease . Primary exclusion criteria were: connective tissue disorders , any concomitant either complex or moderate CHDs , unrepaired CoA, pseudo-CoA, Kawasaki disease, previous operation of aorta (apart from CoA repair) and/or valve replacement, valvotomy or aortic arch reconstruction, reduced ejection fraction (EF) < 40%, and pregnancy. Further exclusion criteria included sub-optimal image quality or absence of cine CMR images of the left ventricle required for 3D shape reconstruction. We selected patients between 19 and 75 years of age and created four groups: i.e., isolated CoA, CoA + BAV, isolated BAV and healthy controls. Sample of n = 25–30 was arbitrarily deemed as sufficiently large, based on SSM literature, to explore differences between groups. Ethical approval was waived by the University Hospitals Bristol & Weston. Research & Innovation (R & I) Department for this study. Informed consent was given by all patients for research use of images at the time and as part of the CMR scan consent. The study was carried out in accordance to local protocols and regulations.16], presence and severity of CoA as classified in the literature17, history of hypertension, and CMR-derived EF, end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and LV mass in end-diastole, collected from clinical CMR reports. The ECG gating—CMR acquisition parameters for the LV analysis were as follows: echo time (TE) = 1.14 ms, effective temporal resolution = 40.05 ms, 25 phase reconstructions giving a reconstructed temporal resolution of 40 ms at a heart rate of 60 bpm, slice thickness = 8 mm, field of view (adapted to patient size) typically 350 × 284 mm, acquisition matrix 192 × 156 mm, giving a typical pixel size 1.8 mm × 1.8 mm. The whole of the LV was examined in the short axis with the basal slice planned on the mitral valve annulus from the long axis images. If a further slice was needed to show the whole of the LV outflow tract this was added. Post gadolinium aortic angiography (gadovist) 0.1–0.2 ml/kg as per radiographic/physician preference slice thickness 1 mm. Acquisition matrix 448 × 294 with field of view adapted to give an ~ 1 × 1 × 1 mm voxel.Demographic variables gathered from clinical records included sex, age and body mass index. Anatomical variables included aortic valve morphology, classified according to the pattern of coronary leaflet non-separation. Functional variables included presence of functional aortic valve disease , and sphericity correlated with both global and apical radial  and circumferential  strain, overall showing that the more spherical LVs are associated with reduced strain indices. Also, conicity was correlated with GRS  and GCS  , GCS (p = 0.01) and apical radial strain (p < 0.0001). When assessing the association between sphericity and strain indices in a multiple regression model accounting for aortic arch gothicity and tortuosity, only sphericity was associated with strain . On the same line, controlling for age and hypertension status, the association between M3 (sphericity) and global strain indices remained significant . The same was observed for CMR sphericity measurements and global strain indices . Also, controlling for age and hypertension, a significant association was confirmed between sphericity and apical strain indices . Similarly, when assessing the association between sphericity and strain indices in a multiple regression model accounting for BMI and sex, only sphericity was significantly associated with GRS (p = 0.002), GCS (p = 0.003) and apical radial strain (p < 0.0001). Finally, when considering arch architecture, tortuosity and gothicity measurements as derived from 3D aortic shapes showed no group differences .When assessing the association between sphericity and strain indices in a multiple regression model accounting for the presence of AR and AS, only sphericity was significantly associated with GRS .This study focused on CMR LV shape characterization for the first time in four different groups, i.e., isolated CoA, CoA + BAV, isolated BAV and healthy controls. A computational analysis was performed to compute LV average and shape deformations within the population using a methodological framework previously described by our team and colleagues25. In a follow-up study of chronic AR patients to assess LV remodelling and progression, LV volumes and sphericity index were increased whereas GLS, GRS, apical rotation and twist were decreased, independent of drug therapy24. Of note, in our study, we observed that the relationship between sphericity and reduced strain continued to remain significant when accounting for the presence of moderate or severe AR and/or AS in a multivariable regression model. Also, in a follow-up study of clinical correlations and prognostic significance of change in LV geometric patterns, higher blood pressure, greater BMI, advancing age and male sex have been found to be key factors for developing abnormal LV geometry, whereas in our study LV geometry was independent of the above factors26.The sphericity index has been previously found to be associated with LV diastolic dimensions and able to predict systolic dysfunction better than echocardiographic measurements alone in an experimental AR model27. However, in this population comprising patients with CoA and/or BAV, tortuosity and gothicity measurements as derived from 3D aortic shapes showed no group differences. Furthermore, multiple regression revealed that sphericity measures remained significantly associated with LV strain whilst tortuosity and gothicity did not. It should be noted that in this study all patients had a normal EF (~ 65%), whilst in previous studies exploring the functional implications of arch morphology, patients with lower EFs were also included. The functional implications of aortic arch shape remain an interesting point to explore in patients with CHD , and previous work has suggested that, from a functional standpoint, it is not associated with a hypertensive response to exercise in patients with repaired CHD28. In relation to LV shape changes, it is also interesting to consider that the association between sphericity and radial/circumferential strain components remained significant also when accounting for age and hypertension status. This may be reflecting of our study population. Previous work observed that LV volumes and mass rise in adolescence and decline with age29 and LV shape is the same among the age groups, except for young subjects (< 20 years) in which the highest sphericity and lowest conicity were observed30.Another factor that could potentially be associated with the morphology and remodelling of the LV is the concurrent variant architecture of the aortic arch. Intuitively a more gothic and tortuous arch would represent higher impedance for the underlying LV, and previous observations in patients with repaired CoA suggested an association between aortic arch gothicity and tortuosity and parameters of LV function 31. Our analysis revealed a functional implication for the observed morphological differences and therefore it may be possible to use these techniques to identify patients at higher risk of adverse remodelling, which could allow for earlier medical intervention and improved outcomes. Thus, by using this methodological framework on bigger cohort and applying clustering (i.e. patient grouping/categorization) we could then unpack the relationship between morphological and functional element and risk-stratify the groups. Also, future studies can take advantage of such a powerful tool as the atlas-based disease assessment to reveal haemodynamic insights32. Changes in myocardial thickness were beyond the scope of this study but could be included in future investigations.Strain difference correlated to shape changes might be partially explained by myocardial fiber re-orientation and shortening, although this study lacks this information and future research with diffusion tensor imaging could be very interesting in further investigating the architecture of the LV in these patients. There is a growing body of evidence showing that LV strain is not only a more sophisticated and thus more useful measure of LV systolic function, but that it is also more reproducible and relates to prognosis in a variety of clinical scenariosLimitations This study has the disadvantages of being a retrospective design with a relatively small number of patients per subgroup. Nevertheless, the overall population (n = 110) is one of the largest described using SSM, with previous studies modelling smaller populations33. Blood pressure data (cuff pressure at the time of CMR) were not available, thus a history of hypertension, as found in clinical notes, was reported instead. Finally, gothicity and tortuosity measurements were not available in a substantial portion of cases, limiting the assessment of the relationship between LV morphology and arch architecture. The observed positive correlation between arch tortuosity and ventricle sphericity is intriguing but it should be noted that this was observed in a subset of cases that mostly had CoA (53/67). These observations could be expanded in the future but a 3D sequence is a necessary requirement for this analysis and this is not necessarily part of the routine clinical imaging protocol.This study illustrates computationally-derived LV templates, characterizing LV shape in both CoA and BAV patients for the first time. The analysis revealed an association between increasing LV sphericity and reduced LV strain indices, suggesting a functional implication for the observed morphological differences as well as a possible role for computational techniques to identify patients at higher risk of adverse remodelling.Supplementary Information 1.Supplementary Information 2.


Background: Osteoprotegerin (OPG) is a molecule which belongs to the tumor necrosis factor receptor superfamily. OPG concentration is elevated in patients with left ventricle hypertrophy, heart failure and acute myocardial infarction. OPG concentrations rise in chronic kidney disease (CKD). The aim of this study was to investigate the association between OPG concentrations and cardiovascular complications, such as left ventricle hypertrophy, systolic and diastolic dysfunction of left ventricle and dysfunction of right ventricle in chronic kidney disease patients not treated with dialysis. The relation between OPG and the amount of pericardial fluid was also examined. Methods: One hundred and one men with CKD stage 3–5 not treated with dialysis were included in the study. Overhydration, body fat mass and lean body mass were measured using bioimpedance spectroscopy (BIS). Echocardiography was performed to evaluate the amount of pericardial fluid and to measure the thickness of the interventricular septum (IVS), systolic and diastolic function of left ventricle, as well as systolic function of right ventricle. Results: We observed a significant positive association between OPG and the thickness of the interventricular septum, the size of the left atrium (LA) and the presence of pericardial fluid. A negative relationship was observed between OPG and ejection fraction (EF). Conclusions: Our results suggest that OPG can be an independent marker of left ventricular hypertrophy, systolic and diastolic dysfunction of left ventricle and the presence of pericardial fluid in chronic kidney disease patients. Osteoprotegerin (OPG) is a glycoprotein which belongs to the tumor necrosis factor (TNF) receptor superfamily. The OPG gene is located on chromosome 8q and consists of five exons. OPG is an inhibitor of the receptor activator of the nuclear factor kappa-β ligand (RANKL). OPG prevents the binding of RANKL to its membrane-bound receptor-RANK which results in an inhibition of bone resorption by downregulation of osteoclastogenesis . OPG is CKD is associated with cardiovascular complications such as atherosclerosis, hypertension, heart failure (HF) and coronary artery disease . Left veThe purpose of our study was to investigate the association between OPG concentrations and cardiovascular complications such as left ventricle hypertrophy, systolic and diastolic function of the left ventricle and dysfunction of the right ventricle in chronic kidney disease patients not treated with dialysis. We also examined the relation between OPG and the amount of pericardial fluid.2.An observational study in male patients with chronic kidney disease not treated with dialysis was performed. The inclusion criterion was eGFR lower than 60 mL/min/1.73 m2 were included in the study. The local ethics committee accepted the study protocol .Participants were recruited for the study between November 2018 and February 2020. Patients visited the Nephrological Outpatient Clinic of Military Institute of Medicine, in Warsaw, Poland for a routine checkup. If they fulfilled the inclusion criteria and agreed to participate in the study, a new visit was arranged for further assessment. The inclusion and exclusion criteria are summarized in Blood samples were drawn from the fasted patients and were immediately transported to the local Department of Laboratory Diagnostics. Serum creatinine concentrations were measured using the Jaffe method . Samples for measuring osteoprotegerin (OPG) and TNF-alpha were kept frozen at −80 °C. OPG concentrations and TNF-alpha were assessed using the Luminex MAGPIX platform.2 = 175 × SerumCr − 1.154 × age − 0.203 × 1.212 (if patient is black) × 0.742 .GFR was evaluated using the short modification of diet in renal disease (MDRD) formula. GFR in mL/min per 1.73 mBioimpedance spectroscopy (BIS) was performed using a body composition monitor  in supine position after a five-minute rest. Electrodes were placed on one hand and one foot in a tetrapolar configuration.Echocardiography was performed using a GE Logiq P6 manual ultrasound. Transthoracic echocardiography included two-dimensional and doppler studies according to American Society for Echocardiography guidelines for obtaining images, chamber dimensions and assessment of transvalvular flow .Heart failure is classified into 3 phenotypes depending on the left ventricle ejection fraction (EF). Heart failure with EF ≤ 40% is defined as heart failure with reduced ejection fraction—HFrEF. Heart failure with ejection fraction from 41–49% is defined as heart failure with mildly reduced ejection fraction—HFmrEF. When EF is ≥ 50% but there are symptoms of heart failure, it is defined as heart failure with preserved ejection fraction (HFpEF) .The value of tricuspid annular plane systolic excursion (TAPSE) is most frequently used to assess the right heart dysfunction. The currently recommended lower limit cut-off for TAPSE is < 17 mm .Impaired relaxation is responsible for the development of left ventricle diastolic dysfunction. The mitral valve inflow assessment is the most frequently used technique to evaluate the diastolic function of the left ventricle. The E wave reflects the flow through mitral valve in the early diastolic and the A wave—in the later atrial contraction. An E/A ratio ≥ 1 is the correct value. Impaired relaxation is defined as reversal of the normal E/A ratio (<1) . The impUsing tissue doppler, the value of E/E’ is measured. E/E’ ratio > 9 is helpful to diagnose the diastolic dysfunction of the left ventricle .2. The correct width of the LA is ≤40 mm. More accurate than the area-length method is the estimation of the left atrium volume index (LAVi) [2 is related to higher cardiovascular mortality [2 [The increased size of the left atrium (LA) is another indicator of impaired relaxation. When two-dimensional (2D) echocardiography is used, the systolic surface area of the left atrium is recommended to be less than 20 cmx (LAVi) . LAVi > ortality . The uppality [2 .4.LVH develops with the increase in myocardial thickness. The correct value of end-diastolic interventricular septum thickness (IVS) does not exceed 12 mm .t-test for normally distributed data and the non-parametric Mann–Whitney test for non-normally distributed parameters. For gradual change estimation across categories, one-way ANOVA with linear trend analysis, Jonckheere–Terpstra test for trend or chi-square test for trend were applied, where appropriate. To control for confounders, logistic regression was used. A p value < 0.05 was considered to be statistically significant. Statistical analyses were performed using IBM SPSS v. 25.0 software.The results are presented as means ± standard deviations (SD) for normally distributed data or medians and ranges or interquartile ranges (IQR) for non-normally distributed variables. The Kolmogorov–Smirnov test was used for evaluating distributions for normality. For correlation analysis, Spearman ρ was applied. Differences between groups were assessed using Student’s 2 not treated with dialysis. The median age of the study participants was 66 years (range: 59–72). There were 37 patients in the G3A group (GFR 45–59 mL/min/1.73 m2), 32 in the G3B group (GFR 30–44 mL/min/1.73 m2) and 32 in the G4–G5 group (GFR <30 mL/min/1.73 m2). Median OPG concentration was 425.61 (range 152.89–1239.35 pg/mL). We observed significant negative correlations between OPG concentrations and GFR  and between OPG concentrations and age . OPG concentrations were higher in patients with lower GFR and in elderly individuals. Clinical data and prognostic factors for unfavorable CKD and cardiovascular outcomes are presented in The study sample consisted of 101 male patients with chronic kidney disease and eGFR lower than 60 mL/min/1.73 mThe differences in OPG concentrations were analyzed and compared with the measurements from echocardiography examinations such as systolic and diastolic function of the left ventricle, the thickness of the interventricular septum, the size of the left atrium, the presence of pericardial fluid and the right ventricle function . When app = 0.044). However, there were only 2 patients with reduced EF in our study. OPG concentrations were significantly higher in patients with reduced EF (p = 0.006).OPG concentrations were significantly higher in patients with higher myocardial thickness ; This association was independent of the presence of hypertension and BMI in the logistic regression model, where ORp = 0.003). The association with the size of the left atrium was independent of hydration status, hypertension and BMI in the logistic regression model, where ORadj = 1.004 ; p = 0.081).OPG concentrations were significantly higher in patients with elevated size of the left atrium .OPG concentrations were significantly higher in patients with pericardial fluid in the echocardiography examination ; This association was independent (on the border of significance) from the hydration effect in the logistic regression model, where ORp = 0.016).OPG concentrations were significantly higher in patients with past myocardial infarction (p < 0.001) was observed in our study. We also found a significant positive correlation between OPG and age (p < 0.001), which was also demonstrated in other studies [The role of OPG in the development of cardiovascular disease is not well understood. Many studies report that OPG concentrations rise along with a decrease in glomerular filtration rate ,25. Card studies .p = 0.010), which leads to the conclusion that OPG is an independent marker of LVH in the studied population. The role of OPG in CKD is not well understood. The aim of our study was to assess whether OPG is associated with the development of cardiovascular complications in CKD. Some studies have investigated the role of OPG in the progression of cardiovascular complications in CKD ,27,28. Tp = 0.045), independent of overhydration, hypertension and obesity. Although we did not find statistically significant relationships between OPG and impaired relaxation or E/E’, we may conclude that OPG can be a significant marker of the development of left ventricle diastolic dysfunction. This results from the fact that OPG was significantly and independently associated with LVH in our study (p = 0.010), and LVH is the condition which leads to diastolic dysfunction of the left ventricle. The increased size of the LA, which was also significantly and independently associated with OPG in our study (p = 0.045), is in turn the result of increased LVEDP, the condition which is also related to left ventricle diastolic dysfunction. Hypertension, LVH, diabetes and obesity are the conditions which lead to diastolic dysfunction of the left ventricle. The augmented mass of the left ventricle results in the rise of left ventricular end-diastolic pressure (LVEDP). Diastolic dysfunction is very often associated with increased LA size, which is the result of high LVEDP. The increased size of the LA may also be caused by hypertension, obesity, atrial fibrillation, coronary artery disease and annular calcification. Large LA diameter may be a strong predictor for an increased risk of cardiovascular death . Diastolp = 0.044; p = 0.016). However, in our study there were only two patients with impaired EF < 50%. Therefore, OPG may be an independent marker of systolic heart failure in the studied population.There are studies which also evaluated the association of high OPG concentrations with the development of HF. Elevated OPG levels were associated with increased all-cause mortality in hospitalized patients with HF and with increased HF risk among males in the general population ,34. In tRymarz et al., OPG was an independent marker which may identify patients with poor prognostic factors, e.g., overhydration in CKD [Kleiman et al. described echocardiography as a way to examine the presence of pericardial fluid in CKD patients [p = 0.050).As it was shown in the study of n in CKD . Pericarpatients . NowadayTamulènaitè et al. showed that end-stage renal disease patients treated with hemodialysis had more frequently impaired right ventricle function compared with healthy controls [The aim of our study was also to evaluate the association between OPG and the dysfunction of the right ventricle in CKD patients. Transthoracic echocardiography is very useful for evaluating the dysfunction of the right ventricle, and the simplest method to do so is to visualize the TAPSE. Dysfunction of the right ventricle is one of the leading predictors of mortality and heart failure in end-stage renal disease patients . The stucontrols . There aThe limitation of our study is a relatively small population. An increased number of participants could have enabled us to divide the studied population into subgroups with different GFRs. Another limitation is the fact that we evaluated the size of the LA by measuring the surface area of the LA using two-dimensional transthoracic echocardiography rather than estimating LAVi, which is the most recommended way to measure the size of the LA. It would be more challenging to estimate left ventricle hypertrophy by measuring the thickness of the left ventricle posterior wall.Cardiovascular complications, such as atherosclerosis, hypertension, heart failure, coronary artery disease and left ventricular hypertrophy, are the main causes of mortality and morbidity in CKD. Patients with impaired renal function are at high risk of developing of cardiovascular disease. Early detection of cardiovascular complications in this group of patients may be helpful to predict the future risk of cardiovascular events. It may also allow the implementation of a therapeutic method before the development of symptomatic heart failure. Serum concentrations of OPG are elevated in CKD. OPG levels are also increased in patients with metabolic syndrome, diabetes, hypertension and heart failure in the general population. OPG levels in CKD patients not treated with dialysis are significantly associated with the thickness of the interventricular septum, the size of the left atrium and the presence of pericardial fluid. OPG concentrations are higher in patients with systolic dysfunction of the left ventricle and in individuals with incidence of myocardial infarction in the past. Therefore, OPG seems to be worth further investigation as a possible marker of cardiovascular complications, such as systolic and diastolic dysfunction of the left ventricle, left ventricular hypertrophy and the presence of pericardial fluid, in CKD patients.


The present article reviews the role of multimodality imaging to improve risk stratification and timing of intervention in patients with valvular heart disease (VHD), and summarizes the latest developments in transcatheter valve interventions.Growing evidence suggests that intervention at an earlier stage may improve outcomes of patients with significant VHD. Multimodality imaging, including strain imaging and tissue characterization with cardiac magnetic resonance imaging, has the ability to identify early markers of myocardial damage and can help to optimize the timing of intervention. Transcatheter interventions play an increasing role in the treatment of patients who remain at high surgical risk or present at a late stage of their disease.Multimodality imaging identifies markers of cardiac damage at an early stage in the development of VHD. Together with technological innovations in the field of percutaneous valvular devices, these developments have the potential to improve current management and outcomes of patients with significant VHD. Valvular heart disease (VHD) is a major health problem, affecting more than 2% of the general population. It is associated with a decreased quality of life and an increased risk of cardiovascular events, including heart failure hospitalizations and mortality . BecauseTimely diagnosis and adequate risk stratification remain essential in the decision-making process of patients with significant VHD. According to the European and American guidelines, left ventricular (LV) ejection fraction (EF) and the onset of symptoms remain the most important parameters when deciding to refer a patient with left-sided VHD for intervention , 3. SimiIn this review, we discuss how multimodality imaging can help to improve the management of VHD and highlight the latest developments of transcatheter interventions in AS, as well as in secondary MR and TR.AS is the most common VHD worldwide, and its prevalence is rising rapidly due to the aging population , 4. CurrTo optimize risk stratification and management of asymptomatic patients with severe AS, a more thorough understanding of the underlying pathophysiology is imperative. Severe AS causes pressure overload of the LV, whereafter LV hypertrophy develops to reduce wall stress and maintain cardiac output. With the development of LV hypertrophy, myocardial oxygen demand increases while coronary flow reserve decreases due to concomitant microvascular dysfunction, low coronary perfusion pressure, and reduced diastolic perfusion time . This oxReduced LV GLS is a more sensitive marker of impaired LV contractile function than LVEF and shows a strong association with the presence of myocardial fibrosis on CMR , 12  TR is frequently observed in heart failure patients, with a prevalence of up to 23% . DespiteAlthough the optimal timing for TV surgery remains a conundrum, patients should probably be referred for TV surgery at an earlier stage, prior to the onset of symptoms, severe RV systolic dysfunction, and end-organ damage. Evaluation of the right heart plays a central role in optimizing the risk stratification of patients undergoing TV surgery. Dietz et al.  showed tSimilar to patients with AS and secondary MR, the evaluation of myocardial fibrosis by late LGE-CMR has prognostic importance and could help to define the optimal timing for TR intervention . HoweverRecently, several transcatheter techniques have been developed, aiming to reduce TR severity. Although edge-to-edge repair is most often used, it does not directly address tricuspid annular dilation and may therefore not be applicable to all anatomies. In these situations, other devices such as annular reduction devices, spacer devices, bicaval valve implant devices, or transcatheter TV replacements could be of additional help to effectively reduce TR severity . These dVHD is a major health problem and is associated with increased morbidity and mortality. Treatment options are often underutilized due to increased surgical risk and late patient referral. Multimodality imaging has the potential to change the management paradigm of VHD by identifying markers of cardiac damage at an earlier stage. In addition, transcatheter valvular interventions could play a pivotal role in the treatment of patients who remain at high surgical risk or present at a later stage of their disease.


DYS). RV global longitudinal strain (GLS) is an emerging index of RV function; however, the magnitude of agreement between RV GLS by echocardiography (echo) and cardiac magnetic resonance (CMR) and the relative utility of each modality for both the diagnosis of RVDYS and prognostication of all-cause mortality and heart failure hospitalization remain unknown.Functional mitral regurgitation (FMR) is a known risk factor for right ventricular dysfunction (RVDYS (EF < 50%) on CMR, among whom there was more advanced NYHA class and lower LV and RV ejection fraction . RV GLS was impaired in patients with RVDYS whether quantified via STE or FT-CMR, with strong correlation between modalities (r = 0.81). Both STE and FT-CMR derived GLS yielded excellent detection of RVDYS (AUC 0.94 for both), paralleling similar performance for free wall strain by both modalities  with lower accuracy demonstrated by STE derived septal strain (STE AUC 0.78 and FT-CMR AUC 0.92). RV S’ and TAPSE showed lower diagnostic accuracy (RV S’ AUC 0.77 and TAPSE AUC 0.81). During median follow up of 51 months , all-cause mortality or HF hospitalization occurred in 25% (n = 25). Both STE and FT-CMR derived RV GLS stratified risk for adverse prognosis  whereas conventional RV indices, TAPSE and RV S’, did not .32% of patients had RVDYS irrespective of modality which provides incremental diagnostic value and improves risk stratification for event free survival beyond conventional RV indices.RV GLS is a robust marker of RV DYS) due to multiple mechanisms. Mitral regurgitation can result in RV impairment due to increase in atrial volume, resulting in progressive increase in atrial pressure and increased RV afterload and end-diastolic pressure [Functional mitral regurgitation is an established risk factor for Right Ventricular dysfunction  is a technique which relies on stable acoustic markers that result from positive interference of the myocardial tissue with the ultrasound beam. The position of these speckles in relation to each other can be used as a surrogate for myocardial contraction. Feature tracking cardiac magnetic resonance (FT-CMR) imaging requires high spatial resolution cardiac MRI cine images to track myocardial motion during the cardiac cycle. While RV GLS has been shown to be feasible with each modality and to provide prognostic utility , 10, theDYS in functional mitral regurgitation, this study sought to assess the relative prognostic and diagnostic value of FT-CMR and STE for RV strain in a prospective cohort of patients with functional mitral regurgitation undergoing same day CMR and transthoracic echo using a standardized protocol tailored for assessment of the RV. Study aims were three-fold: 1. To test the relative diagnostic performance of STE and FT-CMR for both global and regional RV function by the reference standard of volumetric quantification on CMR; 2. Compare RV strain based analyses by both CMR and echo to conventional RV linear performance indices; 3. Evaluate the relative prognostic utility of conventional, strain and volumetric methods for prediction of all-cause mortality or heart failure [Given the importance of early detection of RV failure  hospital2, intrinsic mitral valve disease  or mitral valve replacement, or unrelated clinical condition (e.g. stage IV neoplasm) with life expectancy < 12 months prohibiting follow-up. Comprehensive demographic data were collected using standardized questionnaires, including cardiac risk factors and medications and mortality was recorded via follow up phone call and chart review in accordance with study protocol. All patients provided informed written consent at the time of imaging and the study was conducted with approval of the Weill Cornell Medical College (WCMC) institutional review board.The study population comprised a prospectively enrolled cohort of patients in a multimodality imaging protocol examining the right heart in functional mitral regurgitation. In all patients, comprehensive demographic data were prospectively obtained via a standardized questionnaire and review of medical history. Eligible patients had functional mitral regurgitation (≥ mild) on echo and were being considered for invasive angiography based on suspected/known obstructive CAD or prior abnormal stress test. Patients were excluded enrollment if there were contraindication to CMR or gadolinium . Images were acquired in accordance with consensus guidelines, inclusive of functional and flow-based Doppler imaging. Examinations were interpreted by investigators within a high-volume laboratory for whom reproducibility has previously been documented  , 12. RV CMR was performed using 3.0 Tesla scanners . Cardiac chamber volumes were assessed via cine-CMR (steady state free precession), which included long axis  as well as contiguous short axis slices acquired from the atrio-ventricular  annuli through the LV and RV apices that were quantified at end-diastole and end-systole for calculation of LV and RV ejection fraction (EF). RV strain was measured using cine-CMR 4-chamber view datasets for which automated border detection was performed using a commercially available program . Borders were then manually edited to optimize myocardial tracking to then acquire RV global (RV GLS), septal and free wall strains. Standardized clinical protocols  were implemented to minimize field inhomogeneity and reduce artifacts, including banding and pulsation artifacts.t-test (for continuous parametric data) and Pearson’s chi-square analysis  were conducted to determine the significant difference in clinical and imaging characteristics between patients with RVDYS (RVEF < 50%) [Independent samples F < 50%) , 15 and F < 50%) . Bland AF < 50%)  curves. DYS defined as RVEF < 50%. Table DYS… As shown, patients with RVDYS were more likely to report symptoms of dyspnea, have advanced NYHA class and require loop diuretics . Regarding imaging parameters, as shown in Table DYS was associated with greater LV and RV chamber remodeling as evidenced by increased chamber size whether assessed via echo or CMR .The population comprised 100 prospectively enrolled patients with functional mitral regurgitation who underwent same day echo and CMR. 32% (n = 32) had RVDYS whether quantified via STE or FT-CMR  which were paralleled by RV regional  function with lower septal strain  and free wall strain .STE and cine enabled FT-CMR were performed in all patients Fig. . As showAs shown in Fig. DYS as adjudicated by CMR defined as RVEF < 50%. As shown, ROC curves in Fig. STE and FT-CMR quantified RV strain were tested with regard to diagnostic test performance for RVDuring median follow up duration after imaging of 51 months , 25% of the study population experienced a composite event inclusive of all-cause mortality (n = 21) and/or HF hospitalization (n = 9). Table DYS, diagnostic performance of septal STE for discriminating global RVDYS was poor. Finally, impaired RV GLS stratified adverse prognosis with similar incremental predictive value yielded by CMR and echo over conventional RV indices (RV S’ and TAPSE). Taken together, our findings support the concept that RV GLS via STE and FT-CMR are robust markers of RVDYS with each providing incremental prognostic value, though importantly, absolute GLS parameters acquired from each modality are not interchangeable.This is the first study to date to our knowledge to directly compare RV GLS via STE and FT-CMR with respect to its relative diagnostic performance as well as prognostication for all-cause mortality and heart failure hospitalization among patients with functional mitral regurgitation. The main findings of our study are as follows: First, RV strain via STE and FT-CMR generally agreed closely with one another with strongest correlations demonstrated for RV GLS and modest correlations for septal and free wall strain. Additionally, while strain values correlated closely, there was a small underestimation of RV GLS by STE compared to FT CMR. Second, whereas STE and FT-CMR RV global strain assessment yielded nearly equivalent diagnostic performance in relation to the reference standard of CMR defined RVOur findings are supported by and extend on prior research with respect to RV strain quantification across modalities. Recent work by Taha et al. showed moderate correlations between RV strain values obtained by STE and FT-CMR in 110 patients with arrhythmogenic right ventricular cardiomyopathy . In thisRegarding differences in absolute value of GLS by STE and FT-CMR, there are several factors at play which contribute to non-uniformity in strain assessment across modalities. First, there are modality dependent differences in how the RV is imaged leading to differences in scanning angle on echo and CMR. The complicated contour and position of the RV is particularly susceptible to small changes in scanning angles which have the potential to lead to differences in reproducibility and accuracy. Secondly, there are differences in resolution between the two modalities with feature tracking strain having higher signal to noise ratio and spatial resolution whereas STE generally has higher temporal resolution. It should also be noted that STE tracking may be difficult in patients with suboptimal endocardial definition and thus GLS calculations may be superior via FT-CMR in these cases. Additionally, regarding differential diagnostic and prognostic performance of free wall and global RV strain, we note that the interventricular septum is an integral component of LV function and therefore, it is possible that better prognostic performance of RV global strain vs. free wall strain observed in this study may reflect composite LV and RV assessment for RV global strain.DYS which provides incremental diagnostic and prognostic value as compared to standard assessment in patients across a wide spectrum of conditions including HF and CAD [DYS in mitral regurgitation is particularly important as prompt diagnosis has the potential to impact timing and nature of intervention. RVDYS as assessed via conventional parameters has been shown to be an adverse prognostic marker among patients with advanced mitral regurgitation [DYS via GLS may provide additional risk stratification for mitral regurgitation to identify patients who may benefit from more prompt intervention.RV GLS is an emerging marker of RV and CAD , 19. Reg and CAD . Early dgitation , 22 and gitation . EarlierDYS is known to confer serious clinical consequences. Mortality risk is increased up to threefold in patients with RVDYS, among whom prognosis varies in proportion to magnitude of RV contractile impairment [DYS also impacts morbidity: for example, RV dysfunction increases the risk of clinical heart failure and hospital admissions [DYS to independently impair exercise tolerance [DYS remain limited. One reason for uncertainty regarding RVDYS in patients with CAD stems from limitations in imaging methods that have been used for RV assessment. RV GLS has the potential to overcome limitations of conventional assessment and provide incremental value to detection of RV dysfunction among patients with CAD.” Despite advances in therapeutic approaches for CAD, management approaches for RV dysfunction remains limited. One reason for uncertainty regarding RV dysfunction in patients with CAD stems from limitations in imaging methods that have been used for RV assessment. RV GLS has the potential to overcome limitations of conventional assessment and provide incremental value to detection of RV dysfunction among patients with CAD. Our study examining RV strain across modalities with respect to both its diagnostic and prognostic performance provides additional evidence of the robustness of this technique.Additionally, even among patients with CAD alone, RVpairment , 24. RVDmissions . Effort olerance . DespiteSeveral limitations should be noted in this study. First, this study examined RV performance in patients with functional mitral regurgitation and thus further validation studies are needed to extrapolate these findings to broader cohorts. Second, our CMR and echo exams were performed for research purposes and thus may have yielded higher diagnostic and prognostic performance as compared to that derived from routine clinical exams. On the other hand, this study was designed to test characteristics of multiparametric RV functional indices acquired under optimal conditions and identify whether systematic offsets exist between strain and RV indices, so as to inform larger scale applications in both clinical and epidemiologic research applications. Lastly, it is important to keep in mind that given uncertainty regarding optimal cutoff and wide variation in reported RV GLS threshold for prediction of outcomes , 27–30, DYS and incremental prognostic utility among patients with functional mitral regurgitation. Further studies are warranted to test whether strain-based assessments of RVDYS provide utility for informing therapeutic decision making in patients with mitral regurgitation and whether longitudinal changes in strain parallel differential clinical prognosis.This study demonstrates RV GLS as quantified by both CMR and echo to yield close agreement and near equivalent diagnostic performance for volumetric RV


Symptomatic sick sinus syndrome is one of the indications for pacemaker implantation, and we have to consider to program the pacemaker to an asynchronous pacing mode during an operation.We reported two cases with a pacemaker implanted for sick sinus syndrome undergoing cardiac operation. We changed programming of the pacemaker to an asynchronous pacing mode (DOO) and modulated the programmed atrioventricular delay to avoid ventricular pacing, resulting in better hemodynamic condition. Although we observed premature ventricular contraction, no lethal arrhythmias induced by the R-on-T phenomenon were noted.Programming of the pacemaker to an asynchronous pacing mode and modulation of the programmed atrioventricular delay to avoid ventricular pacing may be an option for pacemaker management during an operation. Symptomatic sick sinus syndrome (SSS) is one of the indications for pacemaker (PM) implantation. Dual-chamber rate-modulated (DDD) pacing may be a desirable pacing mode in SSS patients with impaired atrioventricular (AV) conduction or concern over future . One of Hemodynamic stability is one of the important issues during anesthetic management of patients undergoing a cardiac operation. Now, we reported two cases with a PM implanted for SSS undergoing a cardiac operation. We changed to program the PM to an asynchronous pacing mode (DOO) and modulated the programmed AV delay to avoid ventricular pacing, leading to better hemodynamic status.Written patient consent was obtained, and our institutional ethical committee approved the publication of this report.A 77-year-old female  was scheduled to undergo mitral valve replacement (MVR) and tricuspid annuloplasty (TAP) for severe mitral regurgitation (MR) and moderate tricuspid regurgitation (TR). Her past history included aortic valve replacement for severe aortic stenosis and pacemaker implantation for SSS. Her preoperative cardiac function was as follows: left ventricular ejection fraction (LVEF) 58%, ischemia in the apex, left ventricular end-diastolic and end-systolic diameter (LVDd/Ds) 50/35 mm, left atrial diameter 40 mm, no aortic regurgitation, severe MR with mitral annular enlargement and valve degeneration, and moderate TR with tricuspid annular enlargement and TR pressure gradient 18 mmHg. The preoperative pacemaker programming mode was DDD with a programmed rate of 60 bpm, and the electrocardiogram (ECG) showed all atrial-pacing with QT prolongation (QTc = 0.526 s). However, there was no evidence of atrioventricular block, premature atrial contractions (PACs), or premature ventricular contractions (PVCs)..kg−1.min−1 and noradrenaline 0.01 μg.kg−1.min−1  was scheduled to undergo MVR and TAP for severe MR and moderate TR. Her past history included mitral valvuloplasty for severe MR and pacemaker implantation for SSS. The preoperative cardiac function was as follows LVEF 71%, LVDd/Ds 63/37 mm, left atrial diameter 60 mm, severe MR with postmedial mitral annular ring dissociation and moderate TR with tricuspid annular enlargement, and TR pressure gradient 36 mmHg. The preoperative pacemaker programming mode was DDD with a programmed rate of 50 bpm. The preoperative ECG showed sinus rhythm with a heart rate of 64 bpm and sporadic PVCs. The pacemaker records showed 25% atrial-pacing and no ventricular-pacing. There was no AV block, PAC, or QT prolongation..kg−1.min−1 and noradrenaline 0.01 μg.kg−1.min−1  and modulated the programmed AV delay to avoid ventricular pacing and to obtain a better hemodynamic status in patients with a PM implanted for SSS undergoing cardiac operation.The previous study by Nitardy et al.  documentIn the first case, the patient’s PR interval was slightly prolonged to 154 ms, and the original programmed AV delay was shorter, so all atrial-ventricular-pacing was programmed in the DOO mode  and modulated the programmed AV delay to avoid ventricular pacing, resulting in better hemodynamic status.