Commercially available digital stethoscopes can be used as a phonocardiograph to record heart sounds. However, procuring a costly digital stethoscope may not be possible under resource-limited conditions. A low-cost, wire connected, and mobile phone-assisted phonocardiograph has been reported previously. The aim of this study was to develop a low-cost and wireless phonocardiograph for resource-limited settings. A Bluetooth headset was dismantled to find its microphone. A stethoscope ear knob was cut to make a small bell and it was attached to the microphone. This modified Bluetooth headset was capable of recording sounds while connected to a mobile device with audio recording application. The modified Bluetooth headset, mobile phone, and audio recording software can serve as a wireless phonocardiograph (WiPCGh). Heart sounds were successfully recorded with the help of the newly developed WiPCGh. The audio files were shared with a personal computer (PC) via Bluetooth. The wave form was analyzed in a PC-based audio editing application. First and second heart sounds with systolic and diastolic murmur were identified. WiPCGh can be utilized in recording heart sounds for academic and telemedicine purposes. However, the capability of WiPCGh in the diagnosis of cardiac diseases is yet to be explored in future studies. A 20-year-old patient, suffering from ventricular septal defect recorded heart sounds by simply holding his mobile phone on the chest wall. When the physician heard the sound and analyzed it using audio editing software, the result was impressive . Later, Costly digital stethoscopes have been on the market for a long time. However, the devices shown in With this background, the aim of this study was to build a low-cost, wireless phonocardiograph which can be used by keeping the mobile phone away from subjects.This study was divided into two parts—(i) development of the wireless phonocardiograph, and (ii) recording of heart sounds in normal subjects.The device was made by the first author with his personal household devices and instruments. In the second part of the study, heart sounds were recorded by a noninvasive method with negligible risk to the study subjects. The aim and procedure of the study were fully explained to the subjects in vernacular language before recruitment. After that, their written consent for participation was obtained. The recording of the female subjects was done in front of a female attendant with maintenance of full privacy and comfort. Recruitment of subjects and further study weredone according to full compliance with the Declaration of Helsinki 2013 after obtaining permission from the institute (No: 015/PHY/FMMCHB) .This study was conducted in the Department of Physiology of a medical college in eastern India. The device was made during the month of September 2018 to October 2018. Heart sounds were recorded from 1–15 November 2018.Following are the details of the instruments used for development of the modified Bluetooth headset: (i) hacksaw blade  to cut the Bluetooth headset cover , (ii) poly vinyl carbonate (PVC) electrical insulation tape  to fix and fill the gaps on the device, (iii) instant adhesive  to fix the microphone with the circuit board of the device and to fix the bell with the microphone, (iv) stainless steel blade  Limited, Shanghai, China) to cut the stethoscope ear knobs, (v) Bluetooth headset H904  to record the heart sound, and (vi) soft rubber ear knob of a stethoscope  to make the bell. The materials are shown in For recording heart sounds, the following materials were used: (i) newly modified Bluetooth headset, (ii) a mobile phone  to run the software which can record sound from Bluetooth headset, and (iii) Android application—Parrot version 2.4.12.184  to record the sound on the mobile phone from the headset. The combination of the modified Bluetooth headset, mobile phone, and audio recording application can act as a wireless phonocardiograph (WiPCGh).®  were used [For visualization of sound wave patterns, a personal computer (PC)  and a PC-based software application—Audacityere used .(a)The cover on the opposite side of the speaker was opened.(b)The direction of the microphone was reversed. Normally the microphone is kept facing towards the face of the user when it is worn on the ear. We needed it to face the opposite direction.(c)The microphone was fixed to the spare part of the circuit board with the help of instant adhesive. This was done to make the microphone stable.(d)The ear knob of a stethoscope was cut circumferentially with the help of a blade on the side which normally faces the ear canal. This was done to make the opening wider.(e)The other end of the knob was put on the microphone. With a little push, the groove was fitted on the microphone. Then, the knob was also fixed to the circuit board with the help of instant adhesive.(f)The cover was measured according to the position of the knob on the circuit board.(g)The cover was cut with the help of the hacksaw blade.(h)The middle portion of the cover was discarded.(i)The rest of the cover was placed and fitted as it previously was. (j)Paper-based packaging materials were cut into pieces and used to fill the gaps between the ear knob and the cover.(k)PVC tape was cut into appropriate pieces and wrapped to fill the gaps.(l)The final modified Bluetooth headset device is shown with its intact earphone and the fitted bell.The Bluetooth headset was modified by the following steps :(a)The cConveniently selected normal subjects  were taken as a sample for the study. The Bluetooth device was switched on and connected to the mobile device. Then, the Parrot application was opened on the mobile. The mobile was kept in airplane mode to avoid any unwanted calls during the recording. After that, the rubber bell was wiped with surgical spirit and it was placed firmly on the precordium. To reduce noise, the position immediately adjacent to the apex beat was avoided. After securing a firm contact on the precordium, the recording was started on the Parrot app . After recording sounds for 1 min, the audio file was saved.® software application to observe and analyze the wave form. Screenshots were captured by the Greenshot software application  to use in this manuscript.The sound files were shared from the mobile phone to a PC through Bluetooth connectivity. The sound files were opened in the AudacityThe wave pattern of the audio files obtained from the first two subjects  is shown in According to the aim of the study, a miniature, simple, and wirelessly controlled phonocardiograph was built. The cost for developing this device was minimal. This device can be built in resource-limited settings to record heart sounds for further use of the audio files. Simultaneously listening and visualizing the wave pattern would help medical students understand the first and second heart sounds. Hence, this WiPCGh may serve as an adjunct educational tool in teaching cardiovascular physiology.The audio files  are recorded in the mobile device. They can be easily shared with anyone via a wide array of media . A study by Springer et al. found that mobile phone recorded heart sound is of sufficient quality for further analysis . Hence, This miniature modified Bluetooth headset can be carried in pockets. As the bell is made up of an ear knob of a stethoscope, it can be wiped with an alcohol-based solution for cleaning purposes. When the bell is placed firmly on the chest wall, the skin acts as the diaphragm and the sound is conducted through the air column to the microphone. Thus, the sound is recorded. In previously developed devices , the samThe notable difference between the previously developed devices  and thisComparative features of previously developed devices and this device are presented in In There are certain limitations of using this WiPCGh. This device does not have any noise cancelling properties as the commercially available stethoscopes have . Hence, A low-cost, wireless, and miniature phonocardiograph was made with easily available instruments and a Bluetooth headset. This device can be used to record heart sounds with minimal expertise. Medical teachers, science teachers, and doctors may record academically interesting heart sounds with this device on their mobile phone. Recorded audio files  can be easily shared via the web for the purpose of telemedicine. Further studies are required for testing the diagnostic utility of the WiPCGh.


Patients with left ventricular (LV) hypertrophy may suffer ischemia-reperfusion injuries at the time of cardiac surgery with impairment in left ventricular function. Using transesophageal echocardiography (TEE), we evaluated the impact of glucose-insulin potassium (GIK) on LV performances in patients undergoing valve replacement for aortic stenosis.In this secondary analysis of a double-blind randomized trial, moderate-to-high risk patients were assigned to receive GIK (20 IU insulin with 10 mEq KCL in 50 ml glucose 40%) or saline over 60 min upon anesthetic induction. The primary outcomes were the early changes in 2-and 3-dimensional left ventricular ejection fraction (2D and 3D-LVEF), peak global longitudinal strain (PGLS) and transmitral flow propagation velocity (Vp).P <  0.001) increased compared with baseline values. After Placebo infusion, there was a decrease in LV-FAC , 2D-LVEF  and Vp .At the end of GIK infusion, LV-FAC and 2D- and 3D-LVEF were unchanged whereas Vp , and PGLS  as well as higher Vp , compared with baseline. In contrast, in the Placebo group, 2D-LVEF , 3D-LVEF , and Vp , all decreased after bypass.Administration of GIK before aortic cross-clamping resulted in better preservation of systolic and diastolic ventricular function in patients with LV hypertrophy undergoing aortic valve replacement.NCT00788242, registered on November 10, 2008.ClinicalTrials.gov:  Currently, aortic valve replacement (AVR) remains the standard of care to treat patients with severe aortic valvular stenosis, although elderly and high-risk patients may now benefit from a lesser invasive transarterial vascular approach . Low carThe term “postcardiotomy ventricular dysfunction” (PCVD) has been coined to define new onset or worsening heart failure that develops following weaning from cardiopulmonary bypass (CPB) and that requires support with inotropes . TransesIn animal models of ischemia-reperfusion, there is strong evidence that the infusion of glucose-insulin-potassium (GIK) minimizes myocardial injuries , 8. In pThe aim of this study was to investigate the changes in left ventricular function using TEE, in moderate-to-high risk patients undergoing AVR.ClinicalTrials.gov (NCT00788242). Written consent was obtained from each eligible participant. The trial was conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement  -5.7%, P < 0.001; MD + 5.1 cm/s, P < 0.001, respectively) and compared with the Placebo group. As indicators of cardiac preload, the E/e’ ratio was increased at the end of surgery, compared with baseline, in the Placebo group  whereas this cardiac filling parameter remained unchanged in the GIK group.In the GIK group, the E/A ratio and Vp were higher at the end of surgery compared with baseline , dobutamine (5 [13.2%] vs 29 [53.7%] in the Placebo group), epinephrine , or a combination of at least two inotropes (4 [10.5%] vs 32 [59.3%] in the Placebo group).In this randomized controlled trial including patients undergoing isolated AVR for aortic stenosis, we demonstrated that the infusion of GIK, − in addition to usual cardioprotective techniques -, prevented the early impairment in LV systolic and diastolic function following separation from CPB and resulted in lesser requirement of cardiovascular drug support. The extent of the benefit was similar to that seen in patients undergoing CABGS .Patients included in this trial are likely to correspond to recent evolution of real-world cardiac surgery. Using the Parsonnet score, the increased operative risk profile was mainly related to hypertension (91% of patients), advanced age (61% ≥70 years) hyperlipidemia (72%) and diabetes mellitus 33%), all factors known to be implicated in promoting LV hypertrophy and impaired LV function. The development of valvular aortic stenosis was another trigger for structural remodeling of the LV as characterized by cardiomyocytes hypertrophy and apoptosis, decreased coronary flow reserve, reduced capillary density, as well as intercellular matrix fibrosis 3%, all f. In the ATP channels [In both groups, standardized cardioprotective strategies were applied including antegrade administration of cold blood cardioplegia and pre-ischemic exposure to volatile anesthetics. Although no clear benefit has so far been demonstrated by varying the composition of cardioplegia or its delivery (retrograde vs antegrade), many cardiac teams have adopted the infusion of cold oxygenated blood as it provides effective buffering and uniform capillary flow through the myocardium –18. Aneschannels , 20.Besides standard 2D TEE examination, additional imaging techniques including 3D echocardiography and speckle tracking have been used to improve the reliability of the TEE assessment. Three dimensional echocardiography has shown an excellent agreement with magnetic resonance imaging in assessing LV function  whereas In patients with aortic stenosis undergoing AVR, two previous randomized controlled trials have evaluated the potential cardioprotective effects of perioperative infusion of GIK and reported opposing results. Using speckle tracking echocardiography, Duncan et al. failed to demonstrate any clinically relevant improvement in longitudinal myocardial strain in patients treated by hyperinsulinemic normoglycemic clamp . In contThis study has several limitations that have already been highlighted previously . Indeed,The addition of GIK therapy to standard cardioprotective techniques in moderate-to-high risk patients with severe aortic valve stenosis, resulted in better preservation of LV systolic and diastolic function and lesser requirement of cardiovascular drug support in the early period following AVR. Further evidence is required to ascertain myocardial recovery along with improved long term survival and clinical outcome.


Myocardial deformation imaging using speckle-tracking echocardiography to assess global longitudinal strain (GLS) is today considered a more sensitive measure of left ventricular (LV) systolic function than ejection fraction. General anesthesia and positive pressure ventilation (PPV) are known to change the right ventricular (RV) and LV loading conditions. However, little is known about the effects of anesthesia and PPV on RV free wall and LV GLS. We studied the influence of general anesthesia and PPV on RV and LV longitudinal strain in patients without myocardial disease.Twenty-one patients scheduled for non-cardiac surgery were included. The baseline examination was performed on the un-premedicated patients within 60 min of anesthesia. The second examination was performed 10–15 min after induction of anesthesia , intubation and start of PPV. The examinations included apical four-, two- and three-chamber projections, mitral and aortic Doppler flow velocities and tissue Doppler velocities of tricuspid and mitral annulus. LV end-systolic elastance (Ees) and aortic elastance were determined (Ea).p <  0.0019), stroke volume index  and cardiac index . RV end-diastolic area index and LV end-diastolic volume index decreased significantly, while systemic vascular resistance was not significantly affected. Ees decreased significantly with the induction of anaesthesia , while there was a trend for a decrease in Ea (p = 0.053). The ventriculo-arterial coupling, Ea/Ees, was not significantly affected by the anesthetics and PPV. The LV GLS decreased from − 19.1 ± 2.3% to − 17.3 ± 2.9% (p <  0.001) and RV free wall strain decreased from − 26.5 ± 3.9% to − 24.1 ± 4.2% (p = 0.001). One patient (5%) had at baseline a LV GLS > − 16% compared with 6 patients (28%) during general anesthesia and PPV. Three patients (14%) had a RV free wall strain > − 24% compared to 8 patients (38%) during general anesthesia and PPV.General anesthesia and PPV reduced the mean arterial blood pressure (− 29%, General anesthesia and PPV reduces systolic LV and RV function to levels considered indicating dysfunction in a substantial proportion of patients without myocardial disease. Conventional two-dimensional echocardiography is the method of choice for the evaluation of left (LV) and right (RV) ventricular global and regional myocardial function in patients undergoing surgery and in the critically ill patient. Two-dimensional speckle tracking echocardiography is a relatively new method, which is increasingly used to detect LV and RV dysfunction . SpeckleExperimental studies have shown that myocardial strain is a load-dependent index –9. Data,Mechanical ventilation with the application of positive end-expiratory pressure (PEEP) increases intrathoracic pressure, which will affect venous return and cardiac output  and thusIn the ICU, myocardial dysfunction occurs frequently and speckle tracking echocardiography has the ability to detect impaired LV systolic function not appreciated by conventional echocardiography , 16 . Pawww.epn.se) . Written informed consent was obtained from all patients.The study was approved by the Regional Ethical Review Board in Gothenburg (− 2.Patients scheduled for non-cardiac surgery were included in this study. The inclusion criteria were: a) Low-risk (ASA I-II) elective surgery, b) surgery planned to be performed under total intravenous anaesthesia and positive pressure ventilation and c) informed consent was obtained. Exclusion criteria were: a) history or clinical or laboratory signs of cardiac, pulmonary or systemic disease, b) any cardiac or antihypertensive medication, c) abnormal ECG d) age < 18 year and e) a body mass index ≥30 kg m2 x TVI-LVOT). Stroke volume index (SVI) was calculated as SV/ BSA. Mitral and aortic Doppler flow profiles were recorded for measurements of LV isovolumetric relaxation time, maximum flow velocity during LV early (E-max) and late (A-max) diastolic filling. RV systolic function was assessed by using tricuspid annular plane systolic excursion (TAPSE) by M-mode and tricuspid lateral annulus tissue Doppler systolic velocity. RV end-diastolic and end-systolic area were measured (indexed to BSA) and RV fractional area change (%) were calculated.Two transthoracic 2D echocardiographic examinations were performed with a 5-MH transducer  left ventricular ejection fraction (LVEF) by the modified Simpson’s rule, time velocity integral in the LV outflow tract (TVI-LVOT) and stroke volume (SV) (= π x LVOT radiusSystolic (SAP) and diastolic (DAP) arterial blood pressure were measured non-invasively and intermittently at 5 min interval, using an occluding upper-arm cuff of suitable size in the supine position and mean arterial pressure (MAP) were calculated. Heart rate and arterial blood pressure were recorded just before and during the echocardiographic examination. Systemic vascular resistance index was calculated according to standard formula (MAP/cardiac output)× 80 /BSA.Effective arterial elastance (Ea) was measured as 0.9 x SAP / SV. Ea incorporates all elements of total LV afterload, including vascular resistance, arterial compliance and characteristic impedance.The LV end-systolic elastance Ees, a load-independent measure of myocardial contractility, was calculated according to single-beat method described by Chen et al.  using thEes(sb) = [DBP - (ENd(est) × SBP × 0.9)] / [SV × ENd(est)], where.Ees(sb) is the single-beat LV end-systolic elastance. ENd(est) is the noninvasively estimated normalized elastance at the onset of ejection and is calculated as:ENd(est) = 0.0275–0.165 × EF × (DAP/SAP × 0.9) + 0.515 × ENd (avg), where.EF is the LV ejection fraction and ENd (avg) is calculated as:i x tNdi, where ai are  = ∑ a− 856.92, 571.95, − 159.1) for i = 0 to 7, respectively and tNd is the ratio of pre-ejection period to total systolic period.0) and end-systole (L) and calculated as: (L – L0)/L0 × 100. Negative values of strain indicate myocardial shortening. Impaired LV GLS and RV free wall strain was defined as > − 16% [Strain measurements were performed off-line in the four-chamber, long axis- and two-chamber views. All off-line analyses were performed by an investigator experienced in speckle tracking analysis using the EchoPAC workstation version 201. From the strain analysis, we calculated the longitudinal strain of the free RV wall and the global longitudinal strain (GLS) for the LV. Myocardial strain (S) is presented as fractional change (%) in length between two time points, end-diastole  was commenced with ventilator settings at the discretion of the attending anaesthesiologist. Hypotension, defined as a MAP < 60 mmHg was treated with i.v. bolus doses of 50 mg phenylephrine or 5 mg ephedrine.The first (baseline) transthoracic echocardiography (TTE) was performed after the arrival in the preoperative area within 60 min before induction of anesthesia, with the patient awake, un-premedicated and in a partial left lateral position. Ten to fifteen minutes after induction of anaesthesia, intubation and start of intermittent positive pressure ventilation (IPPV), the second echocardiographic examination was performed also in a partial left lateral position by the same investigator. General anaesthesia was induced and maintained by infusion of propofol and remifentanil. Rocuronium 0.6 mg kgp-value) of less than 0.05 was considered to indicate statistical significance. Statistical analysis was performed using SPSS for Mac version 21.The intra-observer agreement of RV free wall strain and LV global longitudinal strain were assessed by the coefficients of variation for paired observations of RV and LV strain from the measurements of the first (baseline) examination. Our data were normally distributed and expressed as mean ± SD. To detect a difference in LV GLS of 1.5% units, 17 patients were needed to be included at a standard deviation of the mean differences of paired measurements of 2. Paired t-test was used to compare the means before and after induction of anaesthesia. A probability level  (Table p = 0.038), while systemic vascular resistance index was not affected. Ees decreased significantly with the induction of anaesthesia , while there was a trend for a decrease in Ea (p = 0.053). The ventriculao-arterial coupling, Ea/Ees, were not significantly affected by the anesthetics and PPV (p = 0.102).The induction of total intravenous anaesthesia combined with positive pressure ventilation was associated with a significant reduction of mean, systolic and diastolic arterial blood pressure (1) Table . Two patp <  0.001), LV end-diastolic volume index  and TVI-LVOT , while LVEF or LV end-systolic volume index was not affected. A decrease was observed in E-max  and A-max , while LV isovolumic relaxation time was not affected after induction anaesthesia combined with positive pressure ventilation.After induction of anaesthesia combined with positive pressure ventilation a decrease was observed in LV GLS , tricuspid annular peak systolic velocity , tricuspid annular plane systolic excursion , RV fractional area change  and RV end-diastolic area index . RV end-systolic area index was not affected by anaesthesia with PPV.After induction of anaesthesia combined with positive pressure ventilation a decrease was observed in RV free wall strain  had an impaired GLS at baseline GLS < − 16%) compared with six patients 20%) during general anesthesia and positive pressure ventilation  on myocardial systolic function evaluated by LV global longitudinal strain (GLS) and RV free wall strain. The main findings of the study were that general anaesthesia plus PPV induced a significant reduction of LV GLS and RV free wall strain and that in some patients the reduction of GLS and RV free wall strain reached values considered to indicate LV or RV dysfunction. This could be explained by changes in myocardial loading conditions and myocardial contractility caused by the intravenous anaesthetics combined with PPV. Thus, in the evaluation of myocardial function in anaesthetised/sedated mechanically ventilated patients during surgery, or in the critical care unit, systolic function may be underestimated by strain echocardiography.In the present study, anaesthesia and PPV caused a decrease in preload, as assessed by the fall in RV end-diastolic area index (RVEDAI) and LV end-diastolic volume index (LVEDVI). The reduction in preload is also supported by a decrease in maximum flow velocity during LV early (E-max) and late (A-max) diastolic filling. The fall in LVEDVI may to some extent also explain the decrease in stroke volume and cardiac output. The decrease in cardiac output explained the fall in MAP, as systemic vascular resistance was not affected by anaesthesia and PPV. Previous experimental studies have shown that strain is a preload-dependent index –9. HowevIn a recent clinical strain-echocardiograhic study, Fredholm et al. evaluated the load-dependence of myocardial deformation variables in mechanically ventilated propofol-sedated postcardiac surgery patients. Propofol is known to induce a considerable attenuation of the baroreflex sensitivity  and therWhat are then the mechanisms behind the fall in cardiac preload as a response to anaesthesia combined with PPV? A propofol-induced hypotension has been ascribed to reductions in preload and afterload by direct dilation of venous capacitance vessels , 24 and 2O PEEP, which will decrease not only preload but also LV GLS and RV free wall strain. Franchi et al. investigated the effects of mechanical ventilation with PEEP on speckle tracking-derived myocardial strain in ICU patients under a multimodal ICU treatment and shown that increasing levels of PEEP causes a decrease in RV strain [In addition to the effects of propofol on LV GLS and RV free wall strain, one should also consider the effects of PPV on cardiac filling and thereby strain. During anaesthesia and in critically ill patients, PPV increases intrathoracic pressure, which will severely affect venous return and cardiac output . It has V strain .The fall in RV free wall strain and LV GLS induced by anaesthesia and PPV could to some extent be explained by a propofol-induced negative inotropic effect. Experimental data have provided evidence that propofol impairs myocardial contractility –41,whileOne limitation of the present study is that we cannot distinguish the effects of the anaesthetics themselves to those of PPV on RV free wall strain and LV GLS, in the present study, as the patients need to be intubated and mechanically ventilated within minutes after induction of anaesthesia. Furthermore, the use of single bolus doses of ephedrine and phenylephrine in three patients could have attenuated the fall in blood pressure, cardiac filling and myocardial contractility. The strength is that we provide, for the first time, data on the effects of the transition from spontaneous breathing to anaesthesia combined with positive pressure breathing on LV and RV systolic function, as assessed by speckle tracking-derived myocardial strain of the LV and RV.General anesthesia combined with PPV reduces LV global longitudinal and RV free wall strain in patients with no heart disease. The fall in myocardial strain was most likely caused by a decrease in ventricular preload, caused by a propofol-induced dilation of venous capacitance vessels and PPV, together with a negative inotropic effect of propofol. These effects should be taken into account when evaluating heart function in surgical or critically ill patients subjected to anaesthesia /sedation and PPV.www.epn.se).Protocol no. 477–17, approved by the Regional Ethical Review Board in Gothenburg: July 27th 2017 (


Experimental studies suggest that morphine may protect the myocardium against ischemia-reperfusion injury by activating salvage kinase pathways. The objective of this two-center, randomized, double-blind, controlled trial was to assess potential cardioprotective effects of intra-coronary morphine in patients with ST-segment elevation myocardial infarction (STEMI) referred for primary percutaneous intervention.Ninety-one patients with STEMI were randomly assigned to intracoronary morphine (1 mg) or placebo at reperfusion of the culprit coronary artery. The primary endpoint was infarct size/left ventricular mass ratio assessed by magnetic resonance imaging on day 3–5. Secondary endpoints included the areas under the curve (AUC) for troponin T and creatine kinase over three days, left ventricular ejection fraction assessed by echocardiography on days 1 and 6, and clinical outcomes.p = 0.28). Troponin T and creatine kinase AUCs were similar in the two groups. Morphine did not improve left ventricular ejection fraction on day 1  or day 6 . The number of major adverse cardiac events, including stent thrombosis, during the one-year follow-up was similar in the two groups.Infarct size/left ventricular mass ratio was not significantly reduced by intracoronary morphine compared to placebo .ClinicalTrials.gov,  Ischemic heart disease is the leading cause of morbidity and mortality worldwide. Although the prognosis of ST-segment elevation myocardial infarction (STEMI) has improved significantly in recent years , heart fATP channels [Morphine holds promise for preventing ischemia-reperfusion injury. Several experimental studies in rodents showed a reduction in infarct size after morphine injection at the time of reperfusion , 6. The channels , 8. Simichannels .The aim of this randomized, double-blind, placebo-controlled, two-center study in patients with STEMI was to evaluate whether intracoronary morphine administration at the time of reperfusion diminished myocardial injury assessed by magnetic resonance imaging (MRI).This randomized double-blind placebo-controlled trial compared intracoronary morphine to placebo in patients with STEMI.Eligible patients were men and women with STEMI referred for primary percutaneous coronary intervention (PCI) within 6 h after chest symptom onset. STEMI was defined as chest pain lasting more than 15 min with at least one of the following criteria: ST elevation ≥1 mm in at least two contiguous leads or presumed or certain appearance of a Q wave in three contiguous leads. Only patients with a TIMI coronary flow score of 0 on the first angiogram were included. Exclusion criteria were fibrinolysis, known allergy to morphine hydrochloride, uncontrolled epilepsy, brain injury or intracranial hypertension, previous STEMI or coronary artery bypass grafting (CABG), resuscitated cardiac arrest, cardiogenic shock or mechanical ventilation at admission, mechanical complication, sustained ventricular arrhythmia, high-grade atrioventricular block, decompensated respiratory insufficiency, serious hepatocellular insufficiency, and contraindication to cardiac MRI or gadolinium injection.The study was performed in accordance with the ethical principles stated in the Declaration of Helsinki. The protocol was approved by the institutional review board of Pitie-Salpetriere hospital and all patients gave written informed consent. All data were measured off-line by a physician blinded to group allocation.Patients in both the morphine and placebo groups routinely received intravenous aspirin and a loading dose of P2Y12 inhibitors before PCI. Intravenous heparin was administered to maintain an activated clotting time > 250 s.All coronary angiography and stent implantation procedures were performed using standard interventional techniques. Thromboaspiration, balloon predilation, stent type selection, and use of glycoprotein IIb/IIIa inhibitors were at the operators’ discretion.Randomization (1:1) sequences were generated by the biostatistician using random number tables and stratified by center using random blocks of 4. Pharmacists prepared sequentially numbered identical syringes of morphine  or placebo  according to the randomization sequence. Interventional cardiologists were blinded to allocation group. The study treatment was administered immediately after the artery was reopened (TIMI flow 2 or 3).MRI was performed between day 3 and day 5 on a clinical 1.5 T system  using a 6-channel phased-array cardiac coil to assess myocardial injury. Unenhanced cine Steady State Free Precession (SSFP) sequences were acquired in the short axis plane. Eight to 10 sections encompassing the left ventricle were acquired for each patient. T2W–short tau inversion recovery (T2W-STIR) sequences were acquired in the short axis section covering the whole left ventricle using the following parameters . Fifteen minutes after injection of 0.2 mmol/Kg of gadolinium , late gadolinium enhanced (LGE) images were acquired using a segmented three-dimensional IR Gradient Echo T1-weighted technique. Left ventricular (LV) end-diastolic and end-systolic volume indexes and ejection fraction were measured from SSFP images using dedicated software . The extent of myocardial edema was quantified on the T2W images using semiautomatic detection with the full width at half-maximum approach on a dedicated software . Same approach  was used to calculate infarct size. LV mass was calculated by countering inner and outer boundaries of the LV wall on LGE images. Infarct size and LV mass were expressed in grams . The relative proportion of myocardial infarction was calculated by dividing infarct size by total LV mass.Transthoracic echocardiography was performed on days 1 and 6. Left ventricular ejection fraction (LVEF) was calculated from parasternal long axis and apical four-chamber views using the biplane Simpson’s method.The primary endpoint was infarct size/LV mass ratio measured by MRI between days 3 and 5. Secondary endpoints included the ratio of infarct size over area at risk measured by MRI, the areas under the curves (AUCs) of serum creatine kinase and troponin T levels (measured every 4 h during the first 24 h then every 6 h during the next 48 h), LVEF measured by echocardiography on days 1 and 6, infarct size/LV mass ratio by MRI after 1 year, and clinical outcome after 3 months and 1 year.A previous study reported a mean infarct size measured by MRI of 14% ± 6% of LV mass . The estp values were two-sided, and p values lower than 0.05 were considered statistically significant. All analyses were performed using Stata V14.1 .Continuous variables are described as mean ± standard deviation and categorical variables as numbers (%). For the primary outcome, patients were assessed according to randomized treatment group under the intent-to-treat (ITT) principle. Continuous variables were compared using the Student or Mann-Whitney test, depending on the normality of distributions as assessed by the Shapiro-Wilk test, and categorical variables using the chi-square test or Fisher’s exact test, as appropriate. Pearson or Spearman correlation coefficients were computed to assess relationships between selected continuous parameters (i.e. troponin T and creatine kinase AUCs against infarct size/left ventricular mass ratio), as appropriate. All We included 91 patients with STEMI, who were randomly assigned to intracoronary injection of either morphine or placebo at the time of reperfusion. One patient withdrew consent after study inclusion, leaving 90 patients in the intention-to-treat population  received glycoprotein (GP) IIb/IIIa receptor inhibitors or bilavirudin Table .Table 1Pp = 0.96)  or III (47.4% vs. 40.0%) were similar in the two groups (p = 0.28). Infarct size remained similar in the two groups when adjusted on the area at risk  and creatine kinase . Neither were peak troponin T or creatine kinase values significantly different .These results are supported by cardiac enzyme release. Morphine did not significantly reduce AUCp = 0.84) and day 6 . The percentage of patients with LV systolic dysfunction defined as LVEF below 45% was not significantly lower with morphine . Diastolic function assessed based on the E/E’ ratio was similar in the two groups . Similarly, MRI showed no significant differences in LV structural or functional parameters on day 3–5  and LVEF  values in the two groups. The frequency of major adverse cardiac events (MACEs) after 12 months was not lower in the morphine group: MACEs occurred in 7 (15.6%) patients in the morphine group and 8 (18.6%) patients in the placebo group. The most common MACE was unplanned admission for decompensated heart failure. Stent thrombosis occurred in one patient in each group. All MACEs were ascribed by the investigators to the underlying cardiovascular disease . In contrast, no effect was evidenced in the subgroup of diabetic patients .Post-hoc analyses were performed to examine the consistency of results across subgroups and to generate hypotheses to explain the study results. All tests for interaction were non-significant for age, sex, symptom-to-balloon time, and hypercholesterolemia, with The main finding from this randomized controlled trial was that intracoronary morphine, when added to an optimal reperfusion strategy, did not significantly alleviate reperfusion injury or improve secondary endpoints in patients with STEMI. Intracoronary morphine was safe, and serious adverse events occurred with similar frequencies in the two groups.In recent years, many experimental studies suggested that opioid receptor agonists used in everyday practice might protect the heart against ischemia-reperfusion injury , 6. A feThe potential cardioprotective effect of opioid agonists has also been investigated during cardiac surgery. Murphy et al. reported that morphine administration improved LV function recovery after CABG compared to fentanyl . A possiThe MIAMI study was designed to assess the potential cardioprotective effects of morphine in STEMI patients. The dose was selected based on previous experimental studies . IntracoRecently, concern has been raised about the use of intravenous morphine as an analgesic in patients with STEMI . SeveralBoth the route of administration and the dose of morphine differed markedly between these previous studies and the present study. However, our trial adds new evidence to the morphine debate. Intracoronary morphine had no adverse effect on infarct size in randomized patients. Clinical outcomes were similar with morphine and the placebo. The overall rate of serious adverse events was comparable to that seen in a recent similar trial.One limitation of this study should be noted. Our study was powered to detect a difference in the primary endpoint, and the subgroup analyses remain exploratory.The MIAMI trial reported here assessed whether adding intracoronary morphine to optimal PCI diminished reperfusion injury in patients with STEMI. Intracoronary morphine was safe but did not significantly diminish LV infarct size or improve LV systolic function.


Aortic valve regurgitation (AR) results in left ventricle (LV) volume overload (VO) leading to its dilation and hypertrophy (H). We study a rat model of severe AR induced by puncturing one or two leaflets using a catheter. Most of our studies were conducted in male animals. Recently, we started investigating if sex dimorphism existed in the AR rat model. We observed that AR females developed as much LVH as males but morphological remodeling differences were present. A head-to-head comparison of LV morphological and functional changes had never been performed in AR males (M) and females (F) using the latest modalities in cardiac imaging by echocardiography.We performed a longitudinal study to evaluate the development of LV hypertrophy caused by chronic AR in male and female rats over 6 months. Sham-operated (sham) animals were used as controls.p < 0.01). AR resulted in significant LV dilation for both sexes (54% vs. 51% increase in EDV) vs. baseline values. Since normal cardiac growth was less in females, dilation from AR was relatively more important for them (88% (M) vs. 157% (F) increase in EDV over sham). AR caused LV wall thickening in both males and females. It happened sooner for AR females and was more important than in males (25% (M) vs. 56% (F) increase in septum thickness at 2 months and 10% (M) vs. 30% (F) at 6 months). We then evaluated if AR was associated with changes in LV strain using speckle-tracking 2D echocardiography. Global longitudinal strain remained similar between AR and sham animals. Circumferential strain was negatively modulated by AR but only in females and early after VO induction (13% (M) vs. 26% (F)).LV diastolic volumes (EDV) increased more over 6 months in sham males than in females (38% vs. 23% for EDV, both AR resulted in more LV dilation and quicker wall thickening in female AR rats compared to males. Global circumferential strain was negatively modulated in AR females but not in males. AR also seemed to lead to a more spherical LV shape in females whereas; it kept mostly an ellipsoid shape in males. This can influence validity of mass estimation of the dilated LV in females by echocardiography. Study of volume overload (VO) has sometimes lagged behind the research dedicated to pressure overload (PO). Often secondary to other causes, heart valve regurgitation has received less interest in part because their main historical cause, rheumatic fever, has been mostly eradicated in modern industrialized countries. Rheumatic valve diseases are still occurring at a significant rate in low/middle-income countries and in poor and remote indigenous communities in richer countries. The estimated burden worldwide of rheumatic valve diseases is estimated to more than 15 million existing cases with 280 k new cases each year and 230 k deaths  where: EDD is the internal dimension of the LV at the end of diastole, PW is the thickness of the posterior wall at the end of diastole and IVSW is the thickness of the inter-ventricular septum at the end of diastole [2 - ESD2)/EDD2 where: ESD is the internal dimension of the LV at the end of systole. Pulsed wave Doppler was used to measure the mitral flow from an apical four-chamber view. Peak early diastolic filling velocity (E wave), peak filling velocity at atrial contraction (A wave), E wave deceleration slope (slope) and the E/A ratio were calculated.2D echo: M-mode images were recorded to measure diastolic and systolic LV wall thickness from the parasternal long-axis (PSLAX) view and the short-axis (SAX) view at the papillary muscle level. From these measurements, LV Mass was obtained using the following equation: 1.053 x [(EDD + PW + IVSW)diastole , 15. A c3 for every slice and every time point. Diastolic volume, systolic volume, stoke volume  and ejection fraction /(Diastolic volume))) were obtained from these LV volume measurements.4D echo: 4D-Mode images were acquired from the PSLAX and short-axis  views to measure LV diastolic and systolic volumes. 4D-Mode is a 3-dimensional EKV mode  image acquisition at every 3D motor position during a complete heart cycle. Thus, we obtained a 2D loop at every motor position, creating a 4D clip of the heart cycle. The Multi-slice method was used to measure LV volumes. LV contour was drawn for 3 slices minimum (middle and both LV end) in the PSLAX and SAX views. Vevo LAB software automatically determined contour on every slice between the drawn contours. These contours were manually adjusted, if needed. These steps were completed for the first, the middle and the quarter time point. The volume is displayed in mmSpeckle-tracking echo (STE): 2D echo B-mode loops were acquired from the PSLAX and SAX views and analysed using Vevo Strain software . Images were acquired at the highest frame rate possible and strain analysis was performed in the longitudinal, radial and circumferential axes. PSLAX view was used for longitudinal and radial strains, whereas SAX view was used for circumferential strain analysis. Three cardiac cycles of the highest quality cine loop were selected to avoid animal respiration, echo gel artefact, and significant obstruction from the ribs. Endocardial and epicardial borders were traced at mid-diastole. For the PSLAX view, tracing was started from the anterior wall close from the aorta root to the posterior wall close from the mitral valve. For the SAX view, borders were traced in the counter-clockwise direction, starting from the top anterior wall. Vevo Strain software then build the dynamic LV tracing for all selected frames. Cine loops were replayed to confirm good border tracking over cardiac cycles and manual adjustments were made if needed. LV myocardium was divided into 6 equal anatomical segments and peak systolic strain were calculated for every segment. Peak systolic strain = (Ls - Ld)/(Ld) where: Ls = Length at end-systole and Ld = Length at end-diastole. Global peak systolic strain in the 3 directions were calculated by averaging the peak systolic values of the 6 segments.At the end of the protocol, euthanasia was performed under isoflurane anesthesia. Saturated potassium chloride (2–3 ml) was injected directly in the heart. The thorax was then opened and the heart and lungs were harvested and weighed.p value lower than 0.05 was considered significant. Raw data from this study are presented as an Additional file Results are presented as the mean and the standard error of the mean (SEM). Statistical analyses were performed on the log of the data. . A Student’s t-test was used when two groups were compared. ANOVA and Holm-Sidak post-test was used when more than two groups were compared. A Eleven out of twelve AR rats were alive at the end of the protocol for each sex. All sham-operated rats survived the duration of the protocol. In Table AR Table  significWe used two views to estimate 2D echo parameters namely PSLAX and SAX views. As illustrated in Fig. Four dimensional (4D)-mode images were acquired from the PSLAX and SAX views to measure LV diastolic and systolic volumes. In Fig. The estimation of ejection fraction using M-mode 2D views Table e-f. LV mIn Fig. The availability of improved pre-clinical imaging systems designed for small rodents now allow thorough analysis of the geometric and functional changes taking place during the development of cardiac remodeling and can help identify differences associated with the biological sex. In this study, we observed several differences in the evolution of LV remodeling in male and female rats where a severe and similar aortic valve regurgitation had been induced. AR females displayed relative to sham control more dilation and wall thickening, quicker decrease in ejection fraction as well as deterioration of global circumferential strain compared to AR males. Diastolic function remained similar between sham and AR animals notwithstanding the biological sex.In both males and females, LV end-diastolic volume gained 50% over their baseline values after only two weeks of severe VO. This raise in LV volume stabilized after 2 months in males (85% over sham), and after 4 months in females (150% over sham). In sham females, LV EDV and stroke volume (SV) remained mostly stable  over time. In males, EDV and SV increased over time in sham males . This suggests that normal cardiac growth taking place in females did not resulted in the LV pumping more blood in sham females although end-diastolic diameter was larger  reduced normal cardiac growth of both sham and AR rats and pathological LVH in AR animals . For femWe want to point out several limitations in this study. Heart adaptations to VO in women (with the exception of pregnancy) have received very little attention in the literature. Observations made in animals cannot necessarily be transposed to humans, and caution must be used. This study did not take into account ageing (only young rats were used) and menopause (Ovx), factors that are highly relevant to heart disease in women. Simpson’s method was not used for the evaluation of EF as routinely performed in humans. We limited ourselves to the simple 2D M-mode method which is the most frequently used in rodents and the one using volumes estimated from 4D echo. Longitudinal strain could not be integrated from three-angle views: apical four chamber, two chamber and long-axis views, because rat anatomy limits good quality image acquisition in apical views.In conclusion, we showed that sex differences exist between male and female rats in which a severe LV VO was induced. Both the extent of the hypertrophic response to AR and its development showed interesting sexual dimorphisms.Additional file 1. Raw data of the study.


Background: Fabry disease (FD) is characterized by early development of vasculopathy and endothelial dysfunction. However, it is unclear whether these findings also play a pivotal role in cardiac manifestation. As Fabry cardiomyopathy (FC) is the leading cause of death in FD, we aimed to gather a better insight in pathological mechanisms of the disease.Methods: Serum samples were obtained from 17 healthy controls, 15 FD patients with and 7 without FC. FC was defined by LV wall thickening of >12 mm in cardiac magnetic resonance imaging and serum level of proBNP, high sensitive Troponin T (hsT), and globotriaosylsphingosine (lyso-GB3) were obtained. A multiplex ELISA-Assay for 23 different angiogenesis markers was performed in pooled samples. Markers showing significant differences among groups were further analyzed in single samples using specific Elisa antibody assays. L-homoarginine (hArg), L-arginine, asymmetric (ADMA), and symmetric Dimethylarginine (SDMA) were quantified by liquid chromatography—mass spectrometry.Results: Angiostatin and matrix metalloproteinase 9 (MMP-9) were elevated in FD patients compared to controls independently of the presence of FC . SDMA concentrations were highest in patients with FC (0.90 ± 0.64 μmol/l) compared to patients without  and vs. controls  and was positively correlated with indexed LV-mass , hsT , and lyso-Gb3 . Accordingly, the ratio of L-homoarginine to SDMA (hArg/SDMA) was lowest in patients with FC (2.63 ± 1.78) compared to controls . For L-arginine, hArg and ADMA no significant differences among groups could be detected, although a trend toward higher ADMA and lower hArg levels could be observed in the FC group. Furthermore, a significant relationship between kidney and cardiac function could be revealed (p = 0.045).Conclusion: Elevated MMP-9 and angiostatin levels suggest an increased extracellular matrix turnover in FD patients. Furthermore, endothelial dysfunction may also be involved in FC, as SDMA and hArg/SDMA are altered in these patients. Fabry disease (FD) is an X-linked recessive multi-systemic storage disorder caused by a decreased activity of the lysosomal enzyme alpha-Galactosidase A (GLA) , 2. Due Clinical studies provide evidence of increased intima-media thickness (IMT) and impaired artery flow-mediated dilatation in FD , 15 indiSerum samples from 15 FD patients with FC, 7 without FC, and 17 healthy controls were collected between September 2014 and December 2016. FD was confirmed by molecular genetic analysis revealing the following mutations: 4x p.N215S, 2x p.E341K, 2x c.1277_1278delAA, 2x c.718_719delAA, p.N320l, p.A143T, p.A230_I232del, p.Q327L, p.A389V, c.717delAA, p.I384N, p.P205T, p.S247P, p.Q327L, p.R227Q. FC was defined by LV wall thickening of >12 mm assessed in cMRI. Furthermore, 11 FD patients with FC and one patient without FC received ERT at the time of blood sampling. The study was in line with the principles outlined in the Declaration of Helsinki and approved by the local ethics committee. All participants gave their written informed consent for participation in the study.n = 15), FD without FC (n = 7), and controls (n = 17). The assay allowed a simultaneous and semi-quantitative analysis of 23 targets  and was performed in duplicates. Visualization of membrane signals was performed by ChemiDoc™ MP Imaging System and the densitometry software Image Lab™.Blood samples were centrifuged at 4000 × G for 10 min at room temperature and obtained serum was aliquoted and stored at −80°C until use. For the multiplex Enzyme-Linked Immunosorbent Assay (ELISA) a Human Angiogenesis Antibody Array Membrane  was used. Aliquots of serum samples were pooled into three groups: FD with FC , and vascular endothelial growth factor (VEGF) quantification according to the manufacturers' instructions.2H7-arginine, 134-hArg, and 2H7-ADMA solved in methanol. Proteins were precipitated and residues were derivatised to their butylester derivatives. Twenty microliter of reconstituted samples were injected into the 1200 L Triple Quadrupole MS/MS system  chromatography. Analytes were separated on a Polaris C18-Ether column  using an elution gradient of the two mobile phases (A): 1 mL/L formic acid in water and (B) acetonitrile-methanol  containing 1 mL/L formic acid in water (0:00 min 95/5 (A/B) – 0:30 95/5 – 2:00 50/50 – 2:01 95/5 – 4:00 95/5). The flow rate was 0.3 mL/min. Peak area ratios were calculated with internal standards and external calibration curves prepared in dialysed EDTA plasma. Intra- and interassay coefficients of variation were below 15 % for all analyses.L-Arginine, L-homoarginine (hArg), asymmetric (ADMA), and symmetric Dimethylarginine (SDMA) were quantified as described previously , 25. In Cardiac MRI was performed with a 1.5 Tesla MRI scanner . The examination contained a retrospectively gated cine-MRI in cardiac short and long axis orientations using a steady-state free precession (SSFP) sequence to quantify regional and global left ventricular (LV) function and the LV-myocardial mass. Ten minutes after bolus injection of 0.075 mmol/kg Gd-BOPTA (MultiHance®), end-diastolic late gadolinium enhanced (LGE) images were acquired by phase-sensitive inversion recovery (PSIR) sequences to quantify areas of myocardial fibrosis. LGE images were obtained in the LV short-axis as well as in two-, three-, and four-chamber views and quantified using cvi42® software . All quantified parameters included LV function, end-diastolic and end-systolic volumes, stroke volume, ejection fraction, left ventricular mass, regional wall thickness, and LGE. Left ventricular mass was indexed to the body surface area calculated by DuBois & DuBois formula.Post-hoc group comparisons were analyzed if the global differences were significant. Correlations were investigated by Pearson's correlation tests. Logistic regression was performed to investigate the relationship between renal and cardiac function. Concentrations are presented as mean ± standard deviation and a p-value of < 0.05 was set as statistically significant.Obtained data were analyzed using SPSS, version 23. Not normally distributed variables were log transformed if necessary. Assessment of group differences was performed by analysis of variance (ANOVA) or analysis of covariance (ANCOVA) when additionally adjusted for age, sex and eGFR. Cardiac MRI measurements revealed significantly higher indexed left-ventricular masses of FD patients with FC compared to controls and FD patients without FC as shown in Table The multiplex ELISA indicated differences among the pooled groups for angiostatin, MMP-9 and suPAR. In Figure LC-MS/MS measurements revealed 1.4 times higher SDMA concentrations in FD patients with vs. FD patients without FC and equally 1.4 times higher concentrations compared to controls, whereas no statistically significant difference could be shown between FD patients without FC and controls Table . AccordiNo statistically relevant age or sex dependencies for MMP-9, angiostatin, SDMA, or hArg/SDMA could be observed. As shown in Figure p = 0.045). This finding is supported by the correlation of renal parameters with the LV-mass  and cardiac function (existence of a FC) in FD patients. This test showed a significant relationship  turnover in FD.In patients with FC higher concentrations of SDMA and a decreased ratio of hArg/SDMA could be revealed compared to healthy controls as well as to FD patients without overt cardiomyopathy. These parameters correlate with the ventricular mass as well as with cardiac and renal markers suggesting a potential causal relationship of kidney function and cardiac disease progress.MMP-9 is part of a family of endogenous zinc-dependent endopeptidases. In the myocardium MMPs play an important role for structural integrity of the ECM . In patiMMP-9 cleaves matrix-bound plasminogen into angiostatin  which isInterestingly, a study from Matsunaga et al. could demonstrate that reduced NO production leads to an increase of MMP-2 and MMP-9 activity and higher angiostatin concentrations concluding that NO production influences coronary angiogenesis . Furtherp < 0.001, r = 0.74) could be revealed.Soluble uPAR is an important regulator of ECM proteolysis and is also involved in MMP activation by plasmin generation . For suPy+ transporter, which mediates the intracellular uptake of L-arginine . DDAH-1 for example is highly expressed in the kidney and liver  and as FThis study provides evidence for an altered ECM turnover with higher levels of MMP-9 and angiostatin in FD patients independent of an existing FC. Moreover, patients with FC showed higher SDMA and hArg/SDMA level, which correlated with LV mass, hsT, and lyso-Gb3 concentration but also with impaired renal function. Renal and cardiac function showed a relationship leading to the hypothesis that accumulation of SDMA due to renal insufficiency in FD might contribute to the development of endothelial dysfunction and subsequently lead to FC.A major limitation of this study is the small sample size of 22 investigated FD patients with only 7 patients without FC compared to more than twice as much patients with FC. Another limitation is the unequal distribution of male and female patients in the FD groups and the fact that this study is a single center study. Moreover, whether the relationship between kidney and cardiac function is causal cannot be proven by this study design.To validate these findings multicenter studies including more patients to investigate the effects of MMP-9 and angiostatin on endothelial dysfunction in FD and to clarify the pathological impact of SDMA accumulation in Fabry associated cardiomyopathy are required.This study was carried out in accordance with the principles outlined in the Declaration of Helsinki. The protocol was approved by the local ethics committee of the Ärztekammer Hamburg, Germany .JL: writing of the manuscript, experimental work. NL: experimental work, writing assistance. MA: MRI data acquisition, critical review of the data. NM: acquisition of clinical data, critical manuscript review. SL: statistical analysis. KC and ES: supervision and design of experiments, critical review of data analysis and manuscript. MP: experimental design, supervision of data analysis. writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling Editor declared a shared affiliation, though no other collaboration, with authors JL, NL, MP.


Dilated cardiomyopathy (DCM) is a life-threatening heart muscle disease characterized by progressive heart failure, which often requires left ventricular assist device (LVAD) implantation or heart transplantation (HTx). A tissue engineering strategy using cell sheets for end-stage heart failure has emerged in recent years.Here, we describe a 50-year-old DCM patient with severe symptoms of heart failure with severe mitral regurgitation (MR) who was not a candidate for LVAD or HTx. The patient underwent mitral valve replacement followed by the transplantation of autologous myoblast sheets.The patient’s clinical symptoms improved with a preservation of cardiac performance, and he has survived for over 6 years since the combined surgery. This combined method was feasible and appeared to be effective, and thus represents a promising strategy for treating severe heart failure in end-stage DCM and as an alternative treatment for selected patients who are not candidates for LVAD or HTx. Although left ventricular assist device (LVAD) implantation and heart transplantation which made great contributions to treatment for heart failure have been introduced to clinical situation with excellent clinical results, these surgical strategies have some limitations to treat end-stage heart failure such as durability of LVAD  and the Conventional surgical strategy such as mitral valve surgery in dilated cardiomyopathy (DCM) patients with mitral regurgitation (MR) may have positive impacts on severe heart failure in selected patients . But surHere, we report a 50-year-old DCM patient with severe symptoms of heart failure with severe MR and treat by the combination of mitral valve replacement (MVR) and autologous myoblast sheet transplantation and have achieved long-term survival with functional preservation.Here, we report that a DCM patient with severe mitral regurgitation received MVR followed by the transplantation of autologous myoblast sheets, which had been manufactured in temperature-responsive culture dishes, and since then has survived for over 6 years with preserved cardiac performance and improved symptoms. The combined method was feasible for treating heart failure, and thus represents a potential strategy for heart failure patients with end-stage DCM who are not suitable for LVAD or HTx.A 50-year-old man who suffered from idiopathic DCM had dyspnea on effort in 2000 and was emergently referred to a hospital. Ultrasonography revealed that the ejection fraction (EF) was 27%, MR grade was moderate, and tricuspid valve regurgitation grade (TR) was mild. Drug therapy including beta-blocker and ACE inhibitor was administered, but the symptoms did not improve. Instead, the patient was referred to the hospital several times due to recurrent heart failure. In 2011, he had a low-grade fever, poor appetite, and high T-bilirubin in the serum, and was admitted to Osaka University Hospital because of severe heart failure. Catecholamine infusion was started, his symptoms improved, and he was discharged from the hospital for several weeks. However, 3 months later, he was referred to the hospital again due to a recurrence in the heart failure.Ultrasonography and right-heart catheter examination demonstrated severe heart failure . Considering the patient’s severely distressed cardiac hemodynamics, he appeared to be a candidate for LVAD or HTx. However, he lacked familial support to maintain an implanted LVAD and therefore was not approved for LVAD or HTx. Ultrasonography and right-heart catheter examination indicated that the patient’s symptoms might have resulted from secondary pulmonary hypertension induced by severe MR. Because pulmonary hypertension can be lowered by mitral valve surgery, this procedure was planned to attempt to alleviate the patient’s symptoms.In 2011, mitral valve  replacement (MVR) was performed without cardiac arrest, and the extracorporeal pump was successfully removed with an intra-aortic balloon pump (IABP) and adequate catecholamine infusion, and post-operative heart failure was well controlled with catecholamine infusion. The patient was weaned from the high dose of catecholamine without recurrent heart failure. He was then discharged from the hospital with a status of NYHA class II and free of catecholamine infusion. Six months after the operation, the patient’s exercise tolerance was well improved, with decreased pulmonary pressure and pulmonary wedge pressure, although the ejection fraction was severely reduced compared to its pre-operation value, because of damaged myocardium due to the DCM and the increased afterload after MVR. We therefore considered that an additional therapy to heal the damaged myocardium and preserve the cardiac structure or physiology might be effective for maintaining the patient’s cardiac performance.https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&recptno=R000003959&type=summary&language=J). An approximately 10-g piece of skeletal muscle was excised from the patient’s medial vastus muscle under general anesthesia. The autologous myoblasts derived from the skeletal muscle were then cultured according to published procedures, until 4 × 108 cells were obtained . These cells were then seeded onto temperature-responsive culture dishes and formed cell sheets after 48 h, as previously reported , and follow-up examinations revealed that the LV systolic function was improved after myoblast sheet implantation and preserved for 6 years after the operation , suggesting that mitral valve surgery should be recommended for selected heart failure patients. In the patient reported here, the LV stroke work index was 11.3 g/m/beat/m2, which did not support an indication for mitral valve surgery according to our previous data. Nevertheless, we performed the surgical intervention to improve the patient’s symptoms by reducing the PAP, because he had a contraindication for LVAD. Further study may be needed to elucidate the appropriate criteria for mitral valve surgery in DCM patients with severe MR in addition to poor functional data.According to the recent guidelines for surgical options for heart failure , mitral In Japan and other countries, the number of heart transplants performed is quite small , and thuOne remaining question is whether MVR or mitral ring plasty (MAP) is better for severe heart failure patients. Although one report showed that the operative results were almost the same for MVR versus MAP for heart failure patients , we perfSevere heart failure is occasionally accompanied by MR, which is responsible for symptoms and an extremely damaged myocardium, worsening the progression of the disease. Some reports show that mitral valve surgery alone for MR does not reverse LV remodeling or preserve the LV geometry in heart failure patients who have a severely dilated LV chamber . These fThe end point of this combined surgery in heart failure patients is not yet established. Although this treatment is unlikely to be superior to LVAD or HTx for obtaining higher perfusion in the organs, this combined therapy may be able to prolong the lifespan, improve symptoms, and reduce hospital readmissions, possibly by preserving both the systolic and diastolic LV performance. This combined therapy might have prolonged the lifespan of the patient in this case, as evidenced by his longer survival compared with the estimated survival rate calculated by the Seattle Heart Failure Model . Thus, tIn conclusion, anti-heart failure surgery combined with MVR and myoblast sheet implantation may be feasible for treating DCM with severe MR and may represent an alternative surgical strategy for treating severe heart failure that prolongs survival and improves symptoms. Promising results regarding the safety and functional recovery with this combined procedure warrant further clinical follow-up and larger studies to confirm its efficacy for DCM with severe MR.


Circulatory shock is a life-threatening disease that accounts for around one-third of all admissions to intensive care units (ICU). It requires immediate treatment, which is why the development of tools for planning therapeutic interventions is required to deal with shock in the critical care environment. In this study, the ShockOmics European project original database is used to extract attributes capable of predicting mortality due to shock in the ICU. Missing data imputation techniques and machine learning models were used, followed by feature selection from different data subsets. Selected features were later used to build Bayesian Networks, revealing causal relationships between features and ICU outcome. The main result is a subset of predictive features that includes well-known indicators such as the SOFA and APACHE II scores, but also less commonly considered ones related to cardiovascular function assessed through echocardiograpy or shock treatment with pressors. Importantly, certain selected features are shown to be most predictive at certain time-steps. This means that, as shock progresses, different attributes could be prioritized. Clinical traits obtained at 24h. from ICU admission are shown to accurately predict cardiogenic and septic shock mortality, suggesting that relevant life-saving decisions could be made shortly after ICU admission. Shock (or circulatory shock) is a life-threatening medical condition that requires immediate treatment. It is prevalent in the Intensive Care Unit (ICU) and a major concern in Critical Care in general. This condition occurs when the organs and tissues of the body do not receive enough blood and, as a result, cells see their oxygen and nutrients supply restricted so that organs become damaged. Hypotension, tissue hypoperfusion and hyperlactatemia are amongst the most common symptoms . The outFour types of shock are commonly defined: hypovolaemic shock (e.g. hemorrhagic shock), cardiogenic shock, distributive shock (e.g. septic shock) and obstructive shock. The mortality rate of the condition remains very high and depends on its type. It is quantified at 30% for septic shock (according to the new definition of such condition ) and betMachine Learning (ML) techniques can help find a list of attributes to predict the outcome of shock patients from clinical data (i.e. data routinely monitored in the ICU). However, there is a large amount of attributes that characterize each patient, ranging from base pathology information, to lab procedures or hemodynamic data and treatment, to name a few. As a result, data are likely to be very high dimensional and, therefore, feature selection (FS) methods are often required to reduce data dimensionality and its associated variability. The combination of statistics and ML may provide an appropriate framework to retrieve new knowledge from data, as well as causal relationships between different features from high-dimensional datasets –6.ShockOmics research project. The main objective of this project was to find ‘omics’ signatures of shock and it included two types of shock: septic and cardiogenic. Septic shock is the most common, and it is caused by infection. The second most frequent form of shock is the cardiogenic shock and it is a result of a heart failure. The multiscale nature of the ShockOmics database allows to search for attributes that are related to mortality induced by these two types of shock.This study analyzes the clinical database gathered within the When it comes to the detection of circulatory shock, physicians and therapists largely depend on a combination of clinical, hemodynamic and biochemical signs. For a treatment to be chosen, prompt identification of shock is necessary. Appropriate treatment is based on a good understanding of the physiological mechanisms behind the condition. The management of shock is challenging and patient survival is highly dependent on the timely administration of the appropriate treatment. Normally, it requires the administration of vasoactive drugs and fluid resuscitation. This treatment is usually given to counteract the other conditions that go along with shock ). The fact that they have similar symptoms makes addressing the causes of shock very difficult. As a result, decision making at the onset of the condition is not a trivial task and, therefore, it is important to design fast, reliable and interpretable tools to plan therapeutic interventions to prevent mortality, or any irreversible consequences caused by shock.et al. : APACHE II T1, SOFA T1, Respiratory rate T1, Urine Output (mL/day) T1, E wave (cm/s) T1, Fluid Balance (ml) T1, K Ur T1, Lactate levels (mmol/L) T1, Tidal volume (VT) T1, Pulmonary artery systolic pressure (TR jet by CW + CVP) (mmHg) T1, * Norepinephrine (mg/kg/min) T1, PCT Value (mg/mL) T1, Heart rate (bpm) T1, E/e’ T1, PEEP T1, Pplat T1, Platelet count T1, Na Ur T1, pH T1, PaO2/FiO2 T1;: APACHE II T1, SOFA T1, Respiratory rate T1, Glasgow Coma Scale T1, K Ur T1, Platelet count T1, Tidal volume (VT) T1, Tricuspid regurgitation maximal velocity (by CW) (cm/s) T1, HCO3 (mmol/L) T1, LA dilatation by eyeballing T1, Pulmonary artery systolic pressure (TR jet by CW + CVP) (mmHg) T1, Base Excess (mmol/L) T1, E wave (cm/s) T1, PCT Value (mg/mL) T1, Respiratory rate (rpm) T1, Pplat T1, Tricuspid annular tissular doppler S wave (DTI) (cm/s) T1, * Norepinephrine (mg/kg/min) T1, * Dobutamine (mg/kg/min) T1, Lactate levels (mmol/L) T1;: Lactate levels (mmol/L) T2, SOFA T2, Tidal volume (VT) T2, APACHE II T1, Urine Output (mL/day) T1, Urine Output (mL/day) T2, APACHE II T2, Respiratory rate T1, K Ur T2, SOFA T1, * Norepinephrine (mg/kg/min) T2, Neutro abs count T2, E wave (cm/s) T1, Na Ur T2, pH T2, K Ur T1, Glasgow Coma Scale T2, Tricuspid regurgitation maximal velocity (by CW) (cm/s) T1, PT T2, Pulmonary artery systolic pressure (TR jet by CW + CVP) (mmHg) T1;: APACHE II T1, SOFA T2, Tricuspid regurgitation maximal velocity (by CW) (cm/s) T1, Glasgow Coma Scale T1, Neutro abs count T2, Glasgow Coma Scale T2, Platelet count T1, K Ur T1, APACHE II T2, SOFA T1, Respiratory rate T1, HCO3 (mmol/L) T1, Lactate levels (mmol/L) T2, E wave (cm/s) T1, Tidal volume (VT) T1, Respiratory rate (rpm) T1, K Ur T2, Na Ur T2, PT T2, LA dilatation by eyeballing T1;: Neutro abs count T1, Platelets (10 3/mm 3) T3, E/e’ T2, Lateral e’ (cm/s) T2, Creat Ur T2, Urine Output (mL/day) T2, Lateral e’ (cm/s) T1, Respiratory rate (rpm) T1, Lympho abs count T1, Mean arterial pressure (mmHg) T1, Diastolic Blood Pressure (mmHg) T2, E wave deceleration time (ms) T2, Tricuspid annular tissular doppler S wave (DTI) (cm/s) T1, Sat O2/FiO2 T2, Platelets (10 3/mm 3) T1, FiO2 T3, Tidal volume (VT) T1, RBC count T3, Fluid Balance (ml) T2, Platelet count T2;: A wave (cm/s) T2, Systolic blood pressure (mmHg) T2, Heart rate (bpm) T1, Respiratory rate (rpm) T1, Weight (kg), Height (cm), A wave (cm/s) T1, PT T1, E wave deceleration time (ms) T3, Hematocrit (%) T2, Platelet count T3, Creat Ur T1, E wave deceleration time (ms) T1, PaCO2 (mmHg) T1, K Ur T1, E wave (cm/s) T2, aPTT T1, Mean arterial pressure (mmHg) T1, Base Excess (mmol/L) T1, PaO2 (mmHg) T2.Within square brackets: the subset of data that was used to obtain the feature set and the applied FS technique.Result in ICU), the second one (the CBN ‘b’) included all features and the target. This section contains the CBNs and their descriptions for the  and  feature sets. For the rest of CBNs, please refer to the For each of the feature sets there are two corresponding CBNs. The first one  feature set. As it can be seen, two nodes, namely E wave and E/e at T1 are detached from the rest of the network in both CBNs. In CBN ‘a’, all edges are undirected, but the addition of the target feature, Result in ICU, changes most of them to directed. Moreover, adding this feature replaces the edge between Lactate levels and Norepinephrine at T1 to the edge between K Ur and Na Ur at T1, connecting these two nodes to the CBN. According to the CBN ‘b’, Result in ICU can be potentially influenced by Norepinephrine, Respiratory rate, Platelet count and SOFA at T1. feature set. In both CBNs, no edges are connected to K Ur at T1. This time, the addtion of the outcome attaches E wave at T1 and Neutro abs count at T2 to the rest of the network. There are multiple changes across the CBN that involve other features as well. For example, edges between Glasgow Coma Scale at T1 and Lactate levels at T2, and between Lactate levels at T2 and PT at T2 disappear. Moreover, for all edges the causal directions become clear, and new edges emerge. The CBN ‘b’ shows that Result in ICU is potentially influenced by E wave at T1, Norepinephrine at T2, Neutro abs count at T2 and SOFA at T2.Full models were undirected and the parts of the network were detached from each other. Adding Result in ICU does not connect these separate parts. This contrasts with the T1 and T1+T2 models, that have more or less connected CBNs. As for the T1 and T1+T2 CBNs, they have common patterns that are noticeable throughout the experiments. More importantly, the two best models described in this section have some common features that are close to the outcome in both CBNs. These similarities are discussed in the next section.In most of CBNs pairs, the presence of the target value did not imply much change. The majority of edges of the Aggr. tables in page 19. For T1 the most common features are APACHE II, SOFA, respiratory rate, Glasgow coma scale and K Ur. All these features except Glasgow coma scale scored high with the model that showed the best results for this dataset. Moreover, some of them were also present in the results for T1+T2. Interestingly, there are many similar features that scored high in both T1 and T1+T2, which is a clear indication of their importance for the mortality prediction task.Analyzing the results of the FS experiments, one may notice that there are a lot of reoccurring features with high stability scores for each of the datasets. These features can be clearly seen from the T1+T2 dataset, the most stable features are APACHE II at T1, SOFA at T2, tricuspid regurgitation maximal velocity at T1, Glasgow Coma Scale at T1 and neutrophils absolute count at T2. It is especially interesting that some attributes at T1 occurred more frequently than their T2 counterparts. This can be explained by the fact that features at later time-steps present more noise and missing features. However, the  showed the best predictive power in our experiments, which means that at least some T2 features improved the results obtained.Regarding the Full dataset. Its most stable features include A wave at T2, systolic blood pressure at T2, heart rate at T1, respiratory rate at T1 and weight. These features scored the highest, but their stability scores are very low. Moreover, the difference between all scores of the Full dataset is very small. This means that during the FS procedures across 100 random experiments, very different features were selected making them unreliable for their low stability. This supports the hypothesis that adding more time-steps  increases noise, and that the current amount of data is not sufficient enough to bypass this problem.In contrast, the worst performance was that obtained for the  model. More specifically, the performance measures of  were tested against the measures of other models, using the Welch’s t-test. The null hypothesis was that each pair of performance measures has identical values. Setting the threshold for the p-value to 0.05 shows that there is a significant chance that the  and  models perform similarly according to all five performance measures. For this reason, these models were singled out in the causal discovery experiments.The performance of features from different datasets and models were further compared to the model that showed the best results, which was the The CBN structures revealed connections between the features and the outcome. The assumption behind the evaluation of the most important clinical attributes for outcome prediction was that such features are the closest to the outcome in a graph. The direction of the edge from feature to the outcome is also a good indicator that a certain feature is important.RF and Aggr. CBNs for the T1 dataset, Result in ICU is influenced by norepinephrine and SOFA at T1. Both models presented direct connections between these two features and the outcome. The additional possible candidates, supported by the , are respiratory rate and platelet count at T1. E wave, dobutamine and tricuspod regurgitation maximal velocity at T1 were considered important by the  pair. As for the T1+T2 dataset, its RF and Aggr. models show the significance of neutrophils absolute count at T2. Additional features that are directly connected to Result in ICU in the RF CBN include norepinephrine at T2, E wave at T1 and SOFA at T2. The Aggr. model adds APACHE II at T2 to the list. The Full CBNs show that the selected features do not create any coherent structure and, hence, cannot be used to draw any conclusions. This can be explained by the low stability scores and the lack of variability among them in the previous experiments.According to the Aggr. stability scores and those that were considered important in the causal discovery experiments. These features were ranked very high by the FS techniques and had the direct connection to the outcome. These features include SOFA at T1, respiratory rate at T1, tricuspid regurgitation maximal velocity at T1, neutrophils absolute count at T2 and SOFA at T2. Additional features that were in the top 20 of the Aggr. stability scores tables but were ranked lower are norepinephrine at T1, platelet count at T1, E wave at T1 and dobutamine at T1. The full list of features that were considered valuable for the mortality prediction task can be found in Full features had very low stability scores, only the first few T1 and T1+T2 features from Aggr. tables were considered important.Some parallels can be seen between the features that achieved high High stability scores features: APACHE II T1, SOFA T1, Respiratory rate T1, Glasgow Coma Scale T1, K Ur T1, SOFA T2, Tricuspid regurgitation maximal velocity T1, Neutro abs count T2, Glasgow Coma Scale T2.Causal discovery features: Norepinephrine T1, SOFA T1, Respiratory rate T1, Platelet count T1, E wave at T1, Dobutamine T1, Tricuspod regurgitation maximal velocity T1, Neutro abs count T2, Norepinephrine T2, SOFA T2, APACHE II T2.List of attributes that were considered promising for the outcome prediction in patients with shock.et al. . Th. Th34]. et al. , targetiet al. , mean aret al. , or low et al.  did not neutrophils absolute count at T2, tricuspid regurgitation maximal velocity at T1 and dobutamine at T2 were selected far more often than their counterparts. This might be due to the specifics of imputation or due to the lack of data. In any case, this hypothesis requires a more thorough investigation, that is beyond the scope of this work.Finally, it should be noted that some features seem more important at certain time-steps. For example, the difference in stability scores shows that In this paper, we have analyzed and experimentally compared several models for the prediction of mortality in patients with cardiogenic or septic shock, identifying those clinical traits that are more relevant for such prediction in the ICU at different time-points. These models are the result of the application of different FS techniques over the available clinical data. In particular, we were interested in obtaining an actionable classifier for the acute phase of shock, which is the most critical to implement an appropriate therapeutic response and, therefore, has the greater impact on the prognosis of patients. For the acute phase (i.e. the first 24 hours of evolution of shock), we have obtained a classifier that leverages upon well established attributes for septic shock such as the SOFA or APACHE II scores and treatment with vasopressors , which are part of the cardiovascular SOFA score. This classifier for the acute phase of shock also resorts to other valuable attributes such as those obtained through echocardiography during cardiogenic shock ). Other important attributes are related to respiratory function , fluid balance, pulmonary artery pressure, renal function (such as urine output and urea levels), lactate levels, acidosis and C-reactive protein levels. These significant attributes are very closely related to the new official definition of shock and its corresponding management guidelines, in particular those related to organ dysfunction and respiratory function. However, our causal discovery experiments showed that treatment with pressors, respiratory rate, platelet count and the SOFA score presented the highest dependence with ICU outcome. The best classifier for the acute phase yielded an accuracy of 0.870, a sensitivity of 0.755 and a specificity of 0.922. The accuracy results were not statistically different from those obtained with the best classifier at T1 and T2.The main conclusion of this study is that it is possible to predict the risk of death in the acute phase of septic and cardiogenic shock with quite acceptable results by taking into consideration the attributes routinely measured through echocardiography in the ICU. Use of this data for assessing the prognosis of patients is considered valuable for the clinical management of patients with shock in the ICU at ICU admission or during the first day of evolution.The results presented here open up a new line of research for the study of the pathophysiology of shock when combined with other data related to organ dysfunction beyond the commonly used scales such as the SOFA score. In the next step of this research, we plan to add other types of data that are related to the patient’s response to shock and assess to what extend the expanded models may yield improved results. This new layer of data will include transcriptomics, proteomics and metabolomics features as detailed in the scope of the ShockOmics European project.S1 AppendixThe resulting features from applying multiple FS techniques to the three available datasets, their stability scores, additional CBNs and a full list of ShockOmics attributes.(PDF)Click here for additional data file.


Various cardiac arrhythmias and conduction defects have been described in patients with mitral valve prolapse. We describe a case of a young woman affected by a mitral valve prolapse, involving the posterior mitral leaflet, with mild mitral regurgitation and an episode of syncope due to asystolia. It is hoped that this short communication will once again focus attention on the as yet unexplained association between mitral valve prolapse and various cardiac conduction disorders. Various cardiac arrhythmias and conduction defects have been described in patients with mitral valve prolapse (MVP). 10This is a case report of a 23–year–old woman who presented to our Department of Cardiology with an episode of syncope. Clinical examination revealed a grade II systolic murmur and the electrocardiogram showed a first–degree atrio–ventricular block . EchocarFurther diagnostic tests, including a chest X–ray, thyroid function tests and coronary angiography were all within normal limits. Telemetric electrocardiography revealed multiple episodes of asystole, the longest of which lasted for four seconds . FollowiTachyarrhythmias have been shown to represent the most frequent and potentially dangerous clinical manifestation of MVP and there is an association between mitral valve prolapse and sudden cardiac death.13Atrio–ventricular conduction disturbances occur in mitral valve prolapse but the true mechanism(s) of arrhythmia is still unclear. In some patients with mitral valve prolapse, electro– physiological studies have demonstrated prolonged atrio–hisian intervals and/or abnormal responses to atrial pacing. In addition, a significant proportion of these patients had abnormalities of both sinus and atrio–ventricular node function, as well as distal His–Purkinje conduction abnormalities.Atrio–ventricular block of all three degrees are well documented in mitral valve prolapse,16The prevalence of AV conduction disturbances among patients with mitral valve prolapse is probably higher than expected. It is hoped that this short communication will focus attention on the as yet unexplained association between mitral valve prolapse and various cardiac conduction disorders.