While cardiac involvement including heart failure represents the first cause of mortality in idiopathic inflammatory myopathies (IM), subclinical alterations may be largely underdiagnosed by conventional tests. CMR T1 mapping may provide more sensitive diagnostic markers of cardiac involvement in both acute and chronic phases in IM irrespective of cardiac function or late gadolinium enhancement (LGE). Our aim was to determine the ability of CMR T1 relaxometry derived parameters to detect subclinical cardiac involvement in IM.Fifty-five patients  with proven IM were compared to 18 healthy controls comparable in age and body size. CMR was performed to evaluate biventricular function, LGE, T1 mapping using a 3(3)5 MOLLI sequence. Myocardial and blood T1 values were determined in a basal short axis view at baseline and 15 minutes after gadolinium injection and used to calculate T1 decay=100·[1-T1 post contrast/T1 baseline] and extra cellular volume (ECV). Biology included creatine kinase, troponin T and NT-proBNP.Left and right end-diastolic ventricular volumes were smaller in patients compared to controls but ejection fractions were similar. Fourteen (25%) of the patients and none of the controls had LGE. T1 relaxometry parameters were significantly increased in patients compared to controls . ROC area under curve for the diagnosis of IM were respectively for T1 baseline: 0.66; T1 decay: 0.81 and ECV: 0.73. T1 baseline values were positively related to increased BNP but not to troponin or CK levels. Eleven (20%) patients had LVEF<50%. Decreased LVEF was associated with increased LGE prevalence and T1 baseline values.Baseline myocardial T1, T1 decay and ECV were significantly increased in IM patients and demonstrated their ability to detect cardiac involvement irrespective of enzyme levels, even in patients with normal cardiac function and absence of LGE.


P/dtmax (614±299 mmHg/s) than without stent release . Our results indicate that this novel drainage catheter with retractable stent can effectively prevent aortic insufficiency by maintaining the catheter in the center of the aortic valve leaflets, thereby lowering left ventricular end diastolic pressure and improving systolic function.Left ventricle (LV) assist, which refers to the use of a mini-pump or catheter implanted across the aortic valve connected to the pump, can promote myocardial recovery after left ventricle failure. However, conventional LV assist catheters compress the aortic valve, which can induce aortic insufficiency. Here we describe a novel LV assist catheter containing a retractable stent at its distal end that may prevent such insufficiency. The device was tested in six goats in which the coronary artery was ligated to induce acute LV failure, and then an LV assist was installed with a novel catheter in the left ventricle via the left subclavian artery. Inserting the catheter into the left ventricle caused mild to moderate aortic insufficiency. Releasing the stent maintained the catheter in the center of the three valve leaflets, which resolved the aortic insufficiency and, within a few minutes, led to significantly lower left ventricle end diastolic pressure (9.0±3.0 mmHg) than without stent release  as well as significantly higher left ventricle d Temporary mechanical circulatory support is a well-established procedure to restore sufficient myocardial function in patients with cardiac failure, or to provide a bridge to cardiac transplantation. For patients with severe left heart failure, left ventricle (LV) assist is commonly used to increase myocardial perfusion and reduce oxygen consumption in the left side. LV assist pumps blood from the left side of the heart into the arterial system. This reduces preload of the LV. One approach to LV assist is transeptal placement of a cannula into the left atrium, but this fails to drain the LV sufficiently and leaves a residual atrial defect –2. AnothWe hypothesized that it may be possible to reduce AI by maintaining the catheter in the middle of the three aortic leaflets to prevent the catheter from compressing the aortic valve. To test this hypothesis, we developed a retractable stent located on the distal end of an LV drainage catheter, such that deployment of the stent would help keep the tube centrally positioned in the valve leaflets. We validated this novel LV component in a goat model of LV failure.2 at 35–45 mmHg and O2 above 100 mmHg during the experiment. Anesthesia was maintained using 1–3% isoflurane inhalation as well as continuous infusions of propofol (60–120 mcg/kg/min), vecuronim bromide (0.2 mg/kg/h) and sufentanyl (0.03 mcg/kg/min). Body temperature was maintained at 36–37 °C throughout the experiment. After femoral vein cannulation, Ringer’s lactate solution was administered at 10–30 ml per kg per hour. At the end of the experiment, animals were euthanized with an overdose of sodium pentobarbital.This study was performed on six adult goats weighting 30–40 kg. Anesthesia was induced with 4 mg/kg propofol  and 0.3 mcg/kg sulfentanil . Goats were ventilated  at a fraction of inspired oxygen of 0.4 and respiratory frequency of 18 per minute. Tidal volume was adjusted to maintain arterial partial pressures of COThe animals used in this study were provided by West China Center of Medical Sciences, Sichuan University. Its location is No. 1, Gao Peng Avenue, Wuhou District, Chengdu, Sichuan. These animals were bred for research purpose. This study was approved by the Institutional Animal Care and Use Committee of Sichuan University(No.2015061A). The procedures were in compliance with the US National Institutes of Health Guide for the Care and Use of Laboratory Animals .The LV drainage catheter  was designed to contain an outer tube, inner tube, introducer and stainless steel guide wire. The novel component of this catheter is a retractable stent located on the distal part of the inner tube, which allows the inner tube to remain centered within the three valve leaflets when the stent is released .Left cardiac dysfunction was established in goats by inducing myocardial ischemia as described . BrieflySystemic heparinization was carried out by administering a bolus of heparin (300 U per kg) intravenously in order to achieve an activated clotting time longer than 420 sec. The left subclavian artery was exposed, and a guide wire was inserted into the LV through the aortic valve. The novel catheter was inserted into the LV under wire guidance, then both the introducer and guide wire were removed, leaving the outer and inner tubes inside the blood vessel. Pulling back the outer tube allowed release of the retractable stent, which propped up the wall of the ascending aorta and thereby maintained the inner tube in the center of the ascending aorta . All ope®, B. Braun, Shenyang, China) and connected to the inner tube of the LV catheter and the femoral artery catheter. This LV assist withdrew blood from the LV and delivered it to the femoral artery. LV assist was initiated after induction of left heart failure and adjusted to maintain mean arterial pressure at 60–70 mmHg. At this point, rotational speed was fixed and it remained constant throughout the entire experiment, with and without stent release.To set up the LV assist, another femoral artery catheter  was inserted into the right femoral artery. A centrifugal pump  was primed through injection with succinylated gelatin  were extracted off-line from the LV pressure trace, which was recorded every minute for 5 min before induction of heart failure (baseline), after induction of heart failure, and after LV assist initiation with and without stent release.Arterial catheters  were placed into the right femoral artery to record systemic blood pressure. A catheter tipped with a 5F micromanometer  was inserted into the LV through the apex to measure its pressure. Pressures in the femoral artery and LV were continuously recorded using a multi-channel system . Heart rate was measured by standard electrocardiography. Peak rates of change of LV pressure , immediately after heart failure, LV assist without stent, and LV assist with stent. The threshold of significance was defined as p < 0.05.All data were presented as the mean ± standard deviation of the values from all six animals. One-way ANOVA and paired Student’s After acute LV failure was established, the novel catheter was smoothly inserted into the LV via the aortic valve in all six goats. No aortic valves in any of the animals showed visible damage at the end of experiments. The rotational speed of the pump was 2200–3300 rpm, which allowed continuous blood flow at 2–3 L/min throughout the experiment. The rate of Ringer’s lactate administration was adjusted according to blood loss during sternotomy in order to provide stable hemodynamics.AI was not detected in any animal at baseline or after induction of LV dysfunction. Insertion of the catheter into the LV compressed the non-coronary valve of the catheter, which induced mild to moderate AI in all six animals. Initiating the pump aggravated AI until it became a moderate to severe eccentric aortic regurgitation jet toward the anterior mitral leaflet, resulting in aortic cusp distortion . ReleaseLVEDP increased from 6.8± 4.6 mmHg at baseline to 16.8 ± 4.4 mmHg after induction of acute heart failure (p = 0.011). LVEDP after initiation of LV assist (17.6 ± 5.0 mmHg) was similar to the pressure immediately after heart failure (p = 0.706). After stent release, LVEDP decreased slowly to 9.0±3.0 mmHg within a few minutes, and this value was significantly lower than the corresponding value without stent release  decreased significantly from 109.5±14.5mmHg at baseline to 95.6±23.5 mmHg after induction of LV failure (p = 0.008). Without stent release, LVESP after initiation of LV assist (85.3±12.1 mmHg) was similar to the value immediately after LV failure (p = 0.327). With stent release, LVESP after LV assist initiation (102.6±30.6 mmHg) was slightly but not significantly higher than the corresponding value without stent release Click here for additional data file.S2 VideoLong-axis view of the left ventricle illustrating aggravation of AI into a moderate to severe eccentric aortic regurgitation jet toward the anterior mitral leaflet. This leads to aortic cusp distortion after initiation of the pump.(AVI)Click here for additional data file.S3 VideoLong-axis view of the left ventricle showing that stent release from the drainage catheter eliminates eccentric AI or reduces it to trivial central AI, as well as allows the aortic valve leaflets to recover normal shape and movement.(AVI)Click here for additional data file.S4 VideoLong-axis view of the left ventricle demonstrating the flapping of the drainage catheter caused by the opening and closing of the aortic valve during cardiac cycle.(AVI)Click here for additional data file.


In patients with transposition of the great arteries corrected by interatrial baffle (TGA) and those with congenitally corrected transposition of the great arteries (ccTGA) the right ventricle (RV) is subjected to systemic pressures and fails prematurely. We sought to further characterize the geometric, global and regional functional differences between these two groups.Using cardiac magnetic resonance imaging (MRI) the RV was reconstructed from manually traced borders of the ventricles, valves, and other anatomic landmarks of 25 patients with TGA, 17 patients with ccTGA, and 9 normal subjects. Global function was assessed by calculating RV ejection fraction (RVEF) as well as tricuspid annular plane systolic excursion (TAPSE). Regional wall motion was assessed in ten anatomic territories of the RV using the centersurface method.2 in ccTGA, p= 0.09).The RV in TGA and ccTGA was more dilated, rounder, and had reduced global and regional function when compared to the normal RV. RVEF correlated better with transverse than longitudinal contraction. When the subgroups were compared, TGA patients had lower RVEF than ccTGA , lower normalized TAPSE , and weaker basal segment contraction (image 1 and 2). However RV shape was similar in the two groups, and there was only a tendency towards a more dilated TGA RV (end diastolic volume index 145 ± 35 vs. 132 ± 41 mL/mAs a result of the hemodynamic overload, the RVs in both TGA and ccTGA are dilated and rounder than normal. The weak correlation of RVEF with TAPSE may be attributable to increased reliance on transverse shortening. Furthermore, TGA and ccTGA RVs have distinct wall motion and remodeling patterns with the added insult of reduced basilar function in the TGA RV. The possibility of basilar scarring, either attributable to congenital differences between the two patient populations, the interatrial baffle, or the surgery itself, may account for the morphological and functional differences seen between the two groups with systemic RVs.


No differences between patients and healthy subjects in terms of GLS, GCS and GRS were observed. We found a significant correlation between mean blood pressure and GAS . No significant influence of age at repair, CoA correction method or LV mass on three-dimensional deformation was observed. Summarizing, global area strain derived from 3D-STE may be a sensitive indicator of subclinical LV dysfunction in patients after optimal repair of CoA. Mean blood pressure, but not age at correction seems to determine LV deformation.Aortic coarctation (CoA) in adults is associated with reduced survival. Despite successful repair, some unfavorable changes in the left ventricular (LV) myocardial function are reported. Three-dimensional speckle-tracking imaging (3D-STE) is a novel method that allows to assess regional myocardial function in all directions simultaneously and to calculate global area strain which integrates longitudinal and circumferential deformation. The aim of our study was to assess whether 3-D STE provides any new characteristics of LV deformation in patients with optimal CoA repair. Adults after CoA correction underwent transthoracic echocardiographic examinations. Patients with significant concomitant lesions were ruled out. Global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) were assessed using 3D-STE . The data were compared with those obtained from healthy subjects. 26 adults  with repaired CoA were studied. Despite preserved LVEFs, patients with repaired CoA had decreased GAS compared with controls (−28.8 vs. −31.7 %;  Coarctation of the aorta (CoA) is not a localized lesion of the vessel, but a diffused cardiovascular disease. Despite successful surgical or catheter interventional treatment, CoA is known to be associated with high long-term morbidity and shortened life expectancy , 2. In pWe studied 26 consecutive adult patients after surgical or percutaneous CoA correction who were referred to our outpatient clinic for a routine check-up. All patients had preserved LV ejection fraction (EF). The exclusion criteria for the study were: (1) age >50 years, (2) CoA repair <6 months before the study, (3) recurring or residual CoA that require intervention, (4) significant concomitant congenital cardiac defects , (5) poorly controlled systemic arterial hypertension in follow-up at our center (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg), (6) any evidence of coronary heart disease, (7) arrhythmia at the echocardiographic study, (8) asymptomatic left ventricular dysfunction (LV EF < 55 %) or congestive heart failure. Echocardiographic data obtained in CoA patients were compared with those of a control group of 18 healthy volunteers who did not have any structural or functional cardiovascular abnormalities, nor did they take any medications. The study was approved by the local ethics committee and each patient signed informed written consent.R wave of electrocardiogram. The aortic arch and descending aorta diameters were measured in the suprasternal view. Maximal and mean pressure gradients across the coarctation site were assessed using continuous wave Doppler recordings in the same view. Blood pressure (BP) measurements at the right arm were obtained using a cuff sphygmomanometer . The average of three successive readings was taken into account. Central aortic pulse pressure (PP) was defined as a difference between systolic (SBP) and diastolic blood pressure. Subsequently, we calculated three indices of aortic elastic properties  to be measured. The area strain is defined as the percentage change in the endocardial area at LV end-systole from its original area at end-diastole [Intra-observer and inter-observer reproducibility was assessed in 15 randomly chosen subjects. It was expressed as percentage of error, derived as the absolute difference between 2 sets of measurements divided by the mean of the observations and using intraclass correlation coefficients. Intra-observer measures were performed at least 1 month apart. To calculate inter-observer variability the second experienced observer (M.K.), who was blinded to the first observer’s findings, analyzed 3D-STE data sets.p < 0.05 was considered statistically significant.Results, unless stated otherwise, are presented as the mean value ± SD. Normal distribution of variables was checked using the Kolmogorow–Smirnov test. The comparisons of mean differences between the groups were made using unpaired Student’s t test and the linear Pearson correlation was used to indicate the strength of a relationship between GAS and other parameters taken into account. In the multivariate regression analysis, the backward elimination method with t tests was used to select variables. A confidence level of n = 21) or percutaneous (n = 5) CoA correction were studied. CoA repair had been performed at a mean age of 8.6 ± 12.1 years (range 0–40 years). In half of the study group bicuspid aortic valve  was diagnosed and 58 % of patients were on antihypertensive treatment. No significant differences were observed between patients and controls with respect to age, gender and heart rate. Patients had significantly higher systolic and mean blood pressure. Clinical characteristics of the study group are given in Table Twenty-six patients (9 women and 17 men), mean age 24.4 ± 6.7 years (range 18–41 years) after surgical . An average volume rate for 3D acquisition was 25.5 ± 9.2 vol/s.p < 0.05).3D echocardiographic examination showed that LV volumes and EF were similar in both groups Table . Both suR = 0.39; p < 0.05), Fig. R2 = 0.62; p = 0.002). Among clinical and echocardiographic parameters characterizing patients with CoA only mean blood pressure correlated significantly with global area strain  and 9 % (ICCs 0.641). The values are comparable to those reported for GAS in normal adults  and patip value not given) as the LV deformation values proved to be age-related [It was the first study that examined 3D LV deformation from echocardiography in adults after optimal CoA repair. The important new finding is the subtle LV myocardial dysfunction as assessed by global area strain. Area strain reflects the change in the endocardial surface from its original dimensions at end-diastole and it integrates both longitudinal and circumferential deformations of the LV. We speculate that reduced GAS values can reflect subclinical microvascular abnormalities in the population analyzed. In the present study the remaining deformation parameters  did not differ significantly, which corresponds with optimal clinical outcome of CoA repair. Our results are in agreement with those by Cook et al. who studied a similar group of adults with repaired CoA. Using non-invasive angiography in combination with CMR the authors demonstrated subendocardial perfusion abnormalities despite a lack of LV hypertrophy, epicardial coronary artery disease or recoarctation . Thus, i-related , 22.The subendocardial layer of the myocardial fibers is more vulnerable to functional impairment due to direct impact of intraventricular blood pressure and the unfavorable coronary flow in this area. Our analysis showed that the reduction of GAS was associated with an increased pressure overload. The results are consistent in this field with our previous observation that a higher degree of narrowing across the coarctation site leads to greater reductions in local 2D deformation indices for the midsegment of the LV anterior wall . SimilarIn contrast to previous data on patients with aortic valvular disease  or hyperThe age at correction did not have an impact on the values of 3D deformation indices in patients with optimal CoA repair, neither was such a relationship found in our previous study in adults where 2D deformation indices were used . On the Our findings regarding aortic elastic properties are consistent with those reported in previous studies, which showed that aortic strain, distensibility and stiffness index of the ascending aorta remained abnormal despite successful CoA repair , 25. HowSummarizing, our study provides new insights into the LV regional function in patients after optimal CoA repair and the potential explanation of higher rate of cardiac events and reduced life expectancy in this population. The decreased GAS might be an early indicator of late cardiovascular complications and 3D-STE seems to be useful in risk stratification. Thus, further studies will help to define the clinical benefit of 3D deformation analysis.The major limitation of our study relates to the small sample size mainly due to restrictive inclusion criteria as we decided to assess patients after optimal CoA repair with no significant comorbidities. Different techniques of CoA correction should also be pointed out. Another issue corresponds to the influence of LV imaging quality on deformation analysis. The feasibility of 3D-STE was high in the present study, however, our patients were relatively young and they presented no substantial myocardial hypertrophy. In the study we analyzed only global deformation parameters. The analysis of regional function of 17 LV segments might provide more information, however, such an approach is much more time consuming and hard to apply in every day practice. Finally, the limitations of the 3D-STE analyses are different vendor’s algorithms with poor inter-vendor reproducibility  that makGlobal area strain derived from three-dimensional speckle-tracking echocardiography detects LV myocardial damage in a subclinical stage in patients after optimal repair of CoA. Mean blood pressure, but not the age at correction or techniques of CoA repair impacts LV deformation.


The purpose of the work was to evaluate the incremental diagnostic value of free-breathing, contrast-enhanced, whole-heart, 3 T cardiovascular magnetic resonance coronary angiography (CE-MRCA) to stress/rest myocardial perfusion imaging (MPI) and late gadolinium enhancement (LGE) imaging for detecting coronary artery disease (CAD).Fifty-one patients with suspected CAD underwent a comprehensive cardiovascular magnetic resonance (CMR) examination . The additive diagnostic value of MRCA to MPI and LGE was evaluated using invasive x-ray coronary angiography (XA) as the standard for defining functionally significant CAD (≥ 50% stenosis in vessels > 2 mm in diameter).p < 0.01), no change in specificity , and higher accuracy  for CAD detection . Compared to LGE alone, the addition of CE-MRCA resulted in higher sensitivity , inferior specificity , and higher diagnostic accuracy .90.2% (46/51) patients  completed CE-MRCA successfully. On per-patient basis, compared to MPI/LGE alone or MPI alone, the addition of MRCA resulted in higher sensitivity (100% vs. 76.5%, The inclusion of successful free-breathing, whole-heart, 3 T CE-MRCA significantly improved the sensitivity and diagnostic accuracy as compared to MPI and LGE alone for CAD detection. Coronary artery disease (CAD) is a leading cause of mortality and morbidity around the world , 2. AccuFrom October 2015 to February 2017, consecutive patients with suspected CAD were prospectively recruited. Inclusion criteria were: (1) age 30 years or older, (2) presence of at least one major cardiovascular risk factor , (3) documented stable angina. Figure The study protocol was approved by the Ethics Committee of Beijing Anzhen Hospital. Written informed consent was obtained from the participants for publication of their individual details and images in this manuscript. The consent forms are held at the authors’ institution and are available for review by the Editor-in-Chief.All examinations were performed on a 3 T whole-body scanner  with a 32-element matrix coil. Detailed protocols with CE-MRCA and CMR are given in Fig. 3 and interpolated to 0.65 × 0.65 × 0.65 mm3. Data acquisition was accelerated by employing generalized autocalibrating partially parallel acquisitions (GRAPPA) in the phase-encoding direction with a factor of 2. A non-selective inversion pulse was applied prior to the navigator gating and data acquisition to suppress background tissues. The inversion recovery time (TI) was 200 msec.For CE-MRCA, a navigator-gated, electrocardiogram (ECG)-triggered, fat-saturated, inversion-recovery prepared segmented 3D gradient-echo sequence was employed . Before 2, slice thickness = 8 mm. Three left ventricular (LV) short-axis slices  were acquired under maximal hyperemia achieved with 140 μg/kg/min IV adenosine infusion for 5 min, during the first pass of a bolus of 0.05 mmol/kg of contrast media  injected at 5 ml/s. During the examination, blood pressure and ECG were continuously recorded. Ten minutes after the stress perfusion, the same scan was repeated at rest.For CMR MPI, a T1-weighted saturation-recovery fast gradient echo sequence was used with TR/TE = 165.0/1.1 ms, flip angle =12°, TI = 100 ms, FOV = 350 × 450 mm2, slice thickness = 8 mm). LGE images were acquired in two LV long-axis (two-chamber and four-chamber) views and in multiple short-axis views with a slice distance of 8 mm, covering the whole LV from base to apex.For LGE imaging, a 2D phase-sensitive inversion recovery breath-hold sequence was used at least 10 min after the last administration of gadolinium  classification system was used for CAD diagnosis. Examples of various CE-MRCA image qualities (ImQ) are shown in Fig. CMR perfusion images were assessed by visual comparison of stress and rest scans (17 segment American Heart Association (AHA) model, excluding the apex ). A perfPatients underwent x-ray coronary angiography (XA) within 1 week after CMR. The 15-segment AHA classification system was used for CAD diagnosis. Stenoses were quantitatively evaluated for segments with a diameter of > 2 mm . Functionally significant CAD was defined as the presence of luminal stenosis ≥50%. Correspondence between LV myocardial segments and coronary arteries was determined based on the AHA model .P < 0.05 was considered a significant difference.Continuous data are reported as mean ± standard deviation. Data analysis was performed on both patient- and vessel-bases. Sensitivity and specificity were calculated using true positive (TP), true negative (TN), false positive (FP), and false negative (FN) rates using XA as reference. The McNemar test was used to calculate differences between proportions  obtained from paired observations. Receiver operating characteristic (ROC) curves were calculated to assess the diagnostic efficacy and the area under the ROC curves (AUC) were compared between different imaging methods. Cohen’s kappa statistic was used to assess inter-observer agreements. SPSS statistics  was used for data analysis. n = 5). Patient characteristics are shown in Table One hundred and fifty one patients met the inclusion criteria of which 51 underwent CMR scanning. Detailed exclusion reasons were summarized in Fig. p = 0.28).A total of 90.2% (46/51) of CE-MRCA studies were included in data analysis. Five patients were excluded: CE-MRCA was aborted in three patients due to extremely low respiratory gating efficiency ; severe motion artifacts were present in two patients as evaluated by an experienced radiologist. The mean scan time was 10.4 ± 3.2 min, ranging from 3.9 to 19.5 min. Patients did not receive medicine to reduce their heart rate (HR), thus 22 patients had a HR > 65 bpm and 24 patients had HR ≤ 65 bpm, with a mean HR of 67.3 ± 9.6 bpm. The average navigator respiratory gating efficiency was 35.0 ± 9.1%. CE-MRCA was acquired during diastole in 21 patients (77% with HR ≤ 65 bpm) and during systole in 25 (67% with HR > 65 bpm). The average scan time of patients with diastolic acquisition was similar to that of systolic acquisition  based on MRCA. The kappa value for inter-observer agreement on per-patient basis for the identification of significant stenosis was 0.78 . Of the 34 patients, 16 (47.1%) had 1-vessel CAD, 11 (32.4%) had 2-vessel CAD, and 7 (20.6%) had 3-vessel CAD. On per-vessel basis, 42.8% (59/138) vessels had significant stenosis detected by MRCA, including 30.5% right coronary artery (RCA) (18/59), 40.7% left anterior descending artery (LAD) (24/59), and 28.8% left circumflex artery (LCX) (17/59).Of the total 690 segments, 529 segments had diameter > 2 mm and 96.4% (510/529) were judged to have adequate image quality  with an average ImQ of 3.7 ± 0.5. For stenosis grade, of 510 segments, 410 (80.4%) had grade 0 or 1, 89 (17.5%) had grade 2. Eleven segments had grades 3 (uninterpretable) or 4 (invisible).On per-patient basis, CE-MRCA had a sensitivity of 97.1%, specificity of 91.7%, accuracy of 95.7%, and AUC of 0.94 . On per-vessel basis, CE-MRCA had a sensitivity of 89.3%, specificity of 89.0%, accuracy of 89.1%, and AUC of 0.89 .The mean heart rates were 91 ± 11.4 bpm (ranging from 70 to 120 bpm) during stress perfusion and 67 ± 9.5 bpm (ranging from 50 to 86 bpm) during rest perfusion. The average increased HR was 23 ± 8.5 bpm (ranging from 9 to 42 bpm). On per-patient basis, the kappa value for inter-observer agreement for the identification of perfusion defect was 0.73 .Of the total 736 segments in the 46 patients, 23.2% (171/736) was positive on MPI alone, corresponding to 52 main branches . After adding CE-MRCA, the positive results increased to 75 main branches .p < 0.01), similar specificity , and higher accuracy  on per-patient basis . AUC was improved in vessel-based analysis  , the number of FNs was dramatically decreased from 20 to 1, compared to LGE alone Fig. .p < 0.01) translating into better diagnostic performance  , diagnostic accuracy was significantly increased from 54.3% to 93.5%, compared to LGE alone  and similar specificity . Overall accuracy was improved from 73.9% to 89.1% on per-patient basis . AUC was improved on per-vessel basis   was positive on MPI/LGE. The diagnostic performance for the combination of CE-MRCA and MPI/LGE compared to MPI/LGE are given in Table It should be pointed out that these results were the same as that of MPI/LGE compared to MPI alone. A positive diagnosis is obtained when either of MPI or LGE is positive. Positive LGE in comparison to negative MPI may result from small subendocardial infarcts. Apparently it was not the case in this patient population.To our knowledge, this is the first study to evaluate the additive value of 3D whole-heart CE MRCA to conventional CMR MPI and LGE for detecting CAD on a 3 T CMR system. We demonstrated that the integration of CE-MRCA into a comprehensive stress-rest MPI and LGE protocol significantly improved sensitivity and diagnostic accuracy. These results conflict with the previous study at 1.5 T , in whicAnother difference between this study and the previous studies at 1.5 T is the definition of significant stenosis. In this study, significant stenosis was defined as luminal narrowing of ≥50% as determined on XA, while in previous studies, significant stenosis was defined as luminal narrowing of ≥90% stenosis or fractional flow reserve (FFR) ≤ 0.80 by Bettencourt N et al. ; or lumin = 4), 70–80% stenosis (n = 2), chronic total occlusion with good collateral circulation (n = 2). CE-MRCA accurately identified these stenoses without myocardial ischemia or infarction, thereby reducing false negatives and improving the sensitivity of diagnosis. By adding CE-MRCA to LGE, 19 of the 20 false negatives were correctly depicted by CE-MRCA.In this study, adding CE-MRCA to MPI and LGE reduced the incidents of false negative (from 8 to 0). These 8 false negative patients were confirmed by coronary angiography as having 50–70% stenosis  and severe image artifacts and poor signal and contrast (19/690). This is a single center study with very small patient numbers. A prospective, multicenter study with a larger sample size is needed to further confirm the findings of the study.On 3 T, integration of successful 3D whole-heart CE-MRCA into a comprehensive stress-rest myocardial perfusion or LGE protocol significantly improved sensitivity and diagnostic accuracy for detection of CAD.


Left ventricular remodeling after acute myocardial infarction increases cardiovascular events and mortality. But few study was done in patients with preserved ejection fraction (EF > 40%). We investigate whether the strain and strain rate by 2D speckle tracking echocardiography could predict left ventricular remodeling after acute myocardial infarction in this cohort.The 83 patients  with new-onset acute myocardial infarction receiving echocardiography immediately, and 6 months after admission were grouped by the presence or absence of left ventricular remodeling. Strain and strain rate including longitudinal, circumferential, and radial direction were calculated. The average of strain and strain rate of which segmental longitudinal strains > – 15% were defined as the injury longitudinal strain (InjLS).Left ventricular remodeling occurred in 24 of 83 patients (28.9%). In univariate logistic regression analyses, gender, peak CK-MB, log BNP, use of statin before discharge, wall motion score index, and InjLS were significantly associated with left ventricular remodeling (p < 0.05). In multivariate analysis using the forward stepwise method, gender, CK-MB, and InjLS were independent predictors. The hazard ratio for InjLS was 1.48 (p = 0.04). Receiver operating characteristic curve (ROC) analyses showed the area under the curve (AUC) of InjLS was largest . In ST-segment elevation myocardial infarction subgroup, InjLS was the only predictor according to ROC analysis  and multivariate logistic regression analysis .InjLS was an excellent predictor for left ventricular remodeling after acute myocardial infarction in patient with preserved ejection fraction. Adverse left ventricular (LV) remodeling begins in some patients with acute myocardial infarction (AMI) even after percutaneous coronary intervention (PCI), and according to previous studies, the incidence is around 30%–35% –4. LV reFrom March 2010 to July 2013, we enrolled 94 patients who were admitted with new-onset AMI. Exclusion criteria included patients with severe valvular disease, atrial fibrillation or flutter, or history of myocardial infarction. Echocardiography was performed at baseline 3.2 ± 1.6 days after admission (2.7 ± 1.6 days after PCI), 3 months, and 6 months after AMI was diagnosed. This study was approved by the Ethics Committee of the Chiayi Chang Gung Memorial Hospital, and all patients provided written informed consent.Following the diagnosis of AMI, PCI was completed as soon as possible. The average of door-to-balloon time for STEMI patients was 122 ± 289 min (median = 71 min) and for NSTEMI patients was 1937 ± 1864 min (median = 1417 min). PCI was considered successful if the residual stenosis was < 30% and the flow in the culprit vessel was ≥ Grade 2 according to the Thrombolysis in Myocardial Infarction (TIMI) score. The diseased vessel was defined as ≥ 50% stenosis. Findings of coronary angiography including culprit vessel, diseased vessels, left main involvement, single or multi-vessels (≥ 2 vessels) were recorded.Comprehensive 2D transthoracic grayscale echocardiography was performed using a GE Vivid 7 echocardiographic system . Images of 3 consecutive cardiac cycles in 3 apical views and short-axis views were stored digitally for off-line analysis with EchoPAC, version 11.0 (GE Vingmed). Frame rate of these images were 66–79 frames/s. LV and atrial volume, wall motion, and EF were assessed. LV end-diastolic diameter and end-systolic diameter were calculated according to the American Society of Echocardiography recommendations ,19. StroPeak early (E) and late diastolic wave velocity (A) were measured by pulse-wave velocity, and tissue Doppler imaging measured peak early (e′) and late (a′) diastolic velocity at the mitral septal annulus .LV remodeling was defined as a > 15% increase in biplane LV end-systolic volume from the initial presentation to the 6-month follow-up. The population was divided into 2 groups: the remodeling group and nonremodeling group. Preserved EF was defined as EF > 40%.The stored grayscale images were analyzed off-line to measure LV deformation performance via the 2D speckle-tracking technique (EchoPAC version 11.0). Global and segmental strain and strain rate in 3 directions  were calculated. The LV radial and circumferential strains and strain rates were determined from the short-axis views at the basal, middle, and apical levels, and longitudinal strains and strain rates were determined from the apical 2-, 3-, and 4-chamber views of the LV. We traced the endocardial border manually at end-systole and adjusted width of the region of interest to cover the entire myocardium. The software then automatically tracked the myocardium. Poor tracking quality was revised manually until the quality was acceptable. Each apical view or short-axis view was divided into 6 segments and there were 18 segments in total. The global peak longitudinal strain (GLS), global peak circumferential strain (GCS), and radial strain (GRS) were averaged from the total 18 segments. Systolic strain rates were analyzed for longitudinal systolic strain rates (LSRs), circumferential systolic strain rates (CSRs), and radial systolic strain rates (RSRs). According to previous studies, segmental longitudinal strains > – 15% were defined as injured segments ,21. The Biochemical tests during hospitalization included serum creatinine level, high-sensitivity C-reactive protein (hs-CRP) and brain natriuretic peptide (BNP). Serial creatine kinase MB isoenzymes (CK-MB) were collected immediately and after 8 hours and 16 hours. Estimated glomerular rate (eGFR) was measured from 4-variable Modification of Diet in Renal Disease (MDRD) formulath, 75th percentile) for variables that were not normally distributed by Kolmogorov–Smirnov tests. Categorical variables are presented as the numbers of subjects and percentages. We used SPSS 21  for statistical analyses. For comparisons between the 2 study groups, two-tailed Student’s t-test was used for continuous normal-distributed variables and Mann-Whitney U test was used for non-normal-distributed variables, and chi-squared tests were used for categorical variables. Binary logistic regression analysis was used to assess the predictors for LV remodeling. Significant variables with a p value < 0.1 by univariate analyses underwent further multivariate analyses using a forward stepwise logistic regression model. A p value < 0.05 was considered significant. A receiver operating characteristic curve (ROC) analysis was performed to assess the abilities of GLS, InjLS, InjLSRs, EF, and WMSI to predict LV remodeling and to identify the optimal cut-off value with optimal sensitivity and specificity. A p value < 0.05 was regarded as significant.Continuous variables are expressed as means ± standard deviations for variables with normal distribution and as median . LV remodeling occurred in 24 of 83 patients (28.9%). th month follow-up became larger. There was no difference in EF, stroke volume index, left atrial volume index, E/A ratio, and E/e′ ratio. WMSI was higher in LV remodeling group (p = 0.03).th month. At baseline, only InjLS and InjLSRs were significantly worse in the remodeling group. Number of injured segments was not different. ROC analyses  . Table 8Intra-observer variability for GLS, GCS and GRS was 3.4 ± 2.1%, 3.5±2.8 and 9.4±8.6, respectively. For LSRs, CSRs and RSRs, it was 6.8±7.3%, 6.4±8.3% and 11.8±5.5%.Inter-observer variability for GLS, GCS and GRS was 7.1±5.1%, 8.5±8.9% and 11.8±6.9%. For LSRs, CSRs and RSRs, it was 10.7±5.0%, 7.7±5.8% and 12.6±10.5%.LV remodeling after AMI is an importantly prognostic issue. Global longitudinal strain (GLS) by 2D speckle tracking echocardiography has proven to be predictive for LV remodeling but no reports have investigated its role in patient with preserved EF. We reported a new index, the injury longitudinal strain (InjLS), defined as the average strain of which segmental longitudinal strains >– 15%. Our study assessed the clinical value of LV deformation performance indices based on 2D speckle tracking echocardiography in predicting LV remodeling in patients with acute myocardial infarction with EF > 40%.The well-known implications of LV remodeling include higher mortality and higher rates of heart failure, and the incidence is around 30%–35% –4. In ouIn 2008, Park et al  first reOur study is the only one that has assessed the clinical use of 2D speckle tracking echocardiography in patients with relatively preserved LVEF after AMI. In multivariate logistic regression, InjLS was an independent predictor for LV remodeling and indeed was more predictive than WMSI. GLS, GCS or GRS was not different between patients with or without LV remodeling. The association between GLS and infarct size has been studied recently –27. SjolIn our study, peak CK-MB was an independent predictor of adverse LV remodeling, as previous studies reported ,16,30. TThe present study has several limitations. Our study cohort was relatively small and was limited to patients with few complications. Patients who required mechanical ventilation or intra-aortic balloon pumping were excluded because images with vivid endocardial edges through the whole cardiac cycle are required for 2D speckle tracking analysis. Our group was not limited to STEMI, and some patients with Killip class IV were also enrolled. However, we demonstrated the feasibility of the 2D speckle tracking technique in the real-world setting of acute coronary syndrome with patients who were not highly selected. We performed echocardiography after PCI (mean 2.7 ± 1.6 days after PCI), which is not like protocols of major published studies in which echocardiography was performed on the first day of admission or immediately after PCI. Recovery of myocardial contractility following ischemia or infarction after PCI can occur early . Our stuWe used CK-MB instead of troponin-I, because troponin-I is checked once only for diagnosis in our hospital and is not follow-up routinely. So we don’t have the peak value of troponin I. Serial CK-MB are collected once acute coronary syndrome is diagnosed.The criteria of our government insurance for statin is LDL>100 mg/dL or total cholesterol >200 mg/dL. Only 30.5% patients meet the criteria . Then use of statin depended on physicians and patients’ decision when the government insurance did not cover the cost of statin. This could explain the low percentage of patients taking statins although about 80% patients have LDL>70 mg/dL in both groups (53[89.8%] vs 20 [87%]).LV remodeling occurred in 28.9% of AMI patients with preserved EF even after PCI. The 2D speckle tracking echocardiography was a promising, feasible, and noninvasive modality to evaluate myocardial deformation in this cohort. In the present study, InjLS was an independent predictor for LV remodeling in patients with preserved EF.S1 Dataset(XLSX)Click here for additional data file.


Global single ventricle longitudinal strain and SR was similar in patients after TCPC with single left and single right ventricular morphology . STE myocardial deformation parameters do not correlate with single ventricle ejection fraction assessed by cMRI.Survival of children with single ventricle heart defects after the total cavopulmonary connection (TCPC) has improved, but impaired cardiac function remains a major cause of morbidity and mortality. Cardiac magnetic resonance imaging (cMRI) is the gold standard in assessing single ventricle volume and function, but high costs and limited availability hamper its routine use. A cheaper and more available alternative is echocardiography. Myocardial function can be studied in more detail using speckle tracking echocardiography (STE). The purpose of the study was to describe the association between myocardial deformation assessed by speckle tracking echocardiography (STE) and single ventricle function assessed by cMRI and to evaluate differences in myocardial deformation in children with single left and single right ventricular morphology. Cross-sectional, multicenter study in 77 children after TCPC was conducted. STE segmental and global longitudinal peak strain and systolic strain rate (SR) of the dominant ventricle were measured. Impaired SV function by cMRI was defined as ejection fraction (EF) < 45%. Mean age was 11.8 (range 9.7–14.3) years. Pearson R for cMRI EF versus global longitudinal strain and SR was − 0.25 ( The Fontan circulation is a palliative surgical strategy for children with congenital heart disease who cannot be offered a biventricular repair . The FonWhile the short- and median-term survival in children palliated with a TCPC has improved considerably during the last decades , it is wCardiac magnetic resonance imaging (cMRI) is considered to be the gold standard for the non-invasive assessment of single ventricle volume and function, although its routine use is hampered by high costs, long analysis time, lack of availability, need for sedation in small children, and inability to use in most patients with pacemaker devices . EchocarThe purpose of this study is to describe the association between longitudinal STE-derived myocardial deformation parameters and single ventricle function assessed by cMRI in a relatively large cohort of contemporary pediatric TCPC patients and to evaluate differences in myocardial deformation in patients with single right versus single left ventricular morphology.We performed a cross-sectional multicenter study in single ventricle patients with a TCPC. Details of the recruitment procedures and in- and exclusion criteria are described elsewhere . In shorAll patients underwent a detailed transthoracic echocardiographic examination performed by an experienced technician following the recommendations of the American Society of Echocardiography . All imaAnalyses were performed offline using EchoPAC version 11.0 . All measurements were performed using 3 different cardiac cycles and the values were averaged. Pulsed wave Doppler flow measurements were obtained at the right upper pulmonary vein. Continuous wave Doppler flow velocities of the ascending (neo) aorta and descending aorta were obtained. Pulsed wave Tissue Doppler measurements were obtained at the basal segment of the lateral wall of the dominant ventricle. Annular plane systolic excursion (APSE) was assessed using M-mode interrogation of the lateral side of the dominant AV valve.Apical grayscale images were acquired at frame rates of 55–90 frames/s. The images were analyzed by a single investigator (LMG) using EchoPAC  according to the vendor’s instructions and as previously described by our group . In shorThe participants underwent a cMRI study on the same day as the echocardiographic study. Patients with pacemaker devices were excluded for undergoing cMRI. The ventricular volumes were imaged using a multi-slice, multiphase, steady-state, free precession sequence as previously reported . In shorInter-observer and intra-observer variability of global longitudinal strain measurements were assessed in 10 randomly selected studies. To assess intra-observer variability, the same observer who performed all the measurements re-measured the same segments at least 2 weeks later to avoid recall bias (LMG). To assess inter-observer variability, deformation parameters were measured by one independent and blinded observer (LK). Reproducibility was expressed as bias (limits of agreement) and the coefficient of variation, COV (the standard deviation of the difference of paired samples divided by the average of the paired samples times 100).T test . Categorical data are presented as counts and percentages. Pearson’s correlations and their statistical significance were calculated as measures of raw associations between measurements. Two-sided p values ≤ 0.05 were considered to be statistically significant.Statistical analysis was performed using SPSS 21.0. . Normal distribution of the data was tested using Shapiro-Wilk test. Data are expressed as frequencies, mean (standard deviation) in case of normal distribution, or median (interquartile range) in case of non-normal distribution. Comparisons between groups were made using the independent Table Feasibility of STE was highest for mid and apical septal segments and lowest for the basal septal segment , Fig. p = 0.01). No association was found between cMRI EF and SV S’ .In Fig. Figure This multicenter study in a relatively large cohort of children and young adults with a TCPC shows that myocardial deformation parameters assessed by STE are not related to single ventricle function assessed by cMRI and conventional echocardiography (APSE). This study also shows that single ventricular morphology in TCPC patients is unrelated to longitudinal myocardial deformation parameters.We found no correlation between longitudinal strain of the single ventricle assessed by echocardiography and single ventricle ejection fraction, single ventricle volume and cardiac index assessed by MRI. Khoo et al. performed a study in single RV patients before performing the bidirectional cavo-pulmonary connection (mean age 0.42 year) combining cMRI data with myocardial deformation data assessed by speckle tracking echocardiography . In thisp = 0.01). Studies performed in TCPC patients with only one type of single ventricle morphology report global longitudinal strain values in RV morphology ranging from − 12.0 to − 18.9% [p = 0.001) [Conceptually, a single RV may be more likely to fail over time compared to a single LV, since a RV is not intrinsically designed to sustain systemic blood pressures. Studies in patients with a systemic RV due to transposition of the great arteries  show that short- and mid-term ventricular function is generally well preserved, but that the majority of patients develop clinical RV failure after the age of 25 years , 16. Man − 18.9% , 18–21 a − 18.9% , 23. How= 0.001) , suggestLongitudinal deformation measurements by STE in patients with a TCPC were feasible in 65–81%  and > 80%  of the participants. We have previously reported feasibility figures for normal children in the range of 91–96% for segmental longitudinal deformation and 97–100% for global longitudinal deformation . PreviouReproducibility data are not reported in many studies using STE in children and adults with a TCPC , 17, 27.The major strengths of this study are the relatively large number of TCPC patients included and the ability to compare a number of potentially relevant functional parameters, including extensive echocardiographic data  as well as cMRI data. Other studies using myocardial deformation in single ventricle patients with a TCPC often included rather small numbers of patients –23, 28 wA recent study by Ghelani et al. investigated the comparability of myocardial deformation assessed by echocardiography and myocardial deformation assessed by cMRI using vendor independent software . They foWe decided to only include longitudinal deformation in our study. In contrast to the experience of Ghelani et al., who used circumferential strain and SR in a rather large study in young adults with a TCPC , we founFinally, although sample size of our study is considerably larger compared to previously published studies, data were missing in some participants for echocardiographic or cMRI parameters due to poor echocardiographic acoustic window, the presence of a pacemaker device or claustrophobia.The present study emphasizes that echocardiography and cMRI are complementary diagnostic tests to evaluate the cardiac function of TCPC patient. Our results provide little support that myocardial deformation by STE might have a role in the assessment of this patient group, at least at this relatively young age. Since our study was of cross-sectional design, we cannot exclude that STE might have a role in predicting single ventricle failure in follow-up studies and further investigations on this topic are warranted.Myocardial function in contemporary TCPC patients with univentricular hearts is on average well preserved in children and young adults. Longitudinal myocardial deformation by STE, a novel non-invasive technique yielding relatively low costs, does not predict the presence of low EF by cMRI. Clinical utility is also hampered by moderate feasibility and variability of the current available techniques. Based on STE-derived parameters, the myocardial function in morphological RVs is similar compared to morphological LVs.


Oxidative stress and autophagy both play key roles in continuous cardiomyocyte death and cardiac dysfunction after reperfusion therapy for acute myocardial ischemia-reperfusion injury. Coenzyme Q10 (CQ10), which is a fat-soluble quinone antioxidant, is involved in the pathophysiological processes of neurodegenerative diseases, cancer, diabetes, heart failure, and other diseases. Our objective was to determine if, and by what mechanism, CQ10 can ameliorate acute myocardial ischemia-reperfusion injury and improve heart function.  Fat-soluble CQ10 in soybean oil solvent was preconditioned in rats with acute myocardial ischemia-reperfusion injury by intraperitoneal injection. Oxidant and antioxidant levels were compared between the preconditioned and control groups. Autophagy was measured by Western blotting analysis of autophagy proteins. Proapoptotic proteins and immunofluorescence were used to assess cell apoptosis. Infarct size was determined by triphenyl tetrazolium chloride (TTC) staining and Evans blue staining and visualized myocardial pathology by tissue staining. Finally, we assessed cardiac function by electrocardiography (ECG) and hemodynamics.  This study reveals that CQ10 preconditioning regulates antioxidant levels and the oxidant balance, enhances autophagy, reduces myocardial apoptosis and death, and improves cardiac function in rats with acute ischemia-reperfusion injury. These results imply that CQ10 protects against acute myocardial ischemia-reperfusion injury via the antioxidative stress and autophagy pathways. Percutaneous coronary intervention is a principal therapeutic approach for the treatment of acute myocardial infarction, which has threatened the life and health of millions of people in recent years . HoweverOxidative stress is particularly important in ischemia-reperfusion injury through cellular homeostasis, mitosis, cell differentiation, and intracellular signal transduction, which result in cell membrane rupture, swelling, or death . DisruptCoenzyme Q10 (CQ10) is a fat-soluble quinone antioxidant with a structure that is similar to those of vitamin K and vitamin E. Recent research has identified CQ10 as an effective antioxidant for the prevention of oxidative damage, and it breaks down macromolecules to prevent inflammatory responses , 21. EmeTherefore, in this study, we aimed to determine if, and by what mechanism, CQ10 can ameliorate acute myocardial ischemia-reperfusion injury and improve heart function.Adult male Sprague Dawley (SD) rats (body weight: 250 ± 10 g) were provided by the animal center of the Medical College of Xi'an Jiaotong University. Throughout the experiment, the animals were given ad libitum access to tap water.The rats were divided into two groups: an acute myocardial ischemia-reperfusion group (AMI/R) and an acute myocardial ischemia-reperfusion with CQ10 group (CQ10 + AMI/R). The two groups were further divided into groups according to the following time points: sham, 2 h (2 h after reperfusion), 24 h, and 72 h.−1·mL−1)  in soybean oil solvent was intraperitoneally injected [In the AMI/R group, soybean oil solvent was intraperitoneally injected; in the CQ10 + AMI/R group, 5 mL fat-soluble CQ10 (6 mg·kginjected . CQ10 wa−1) and connected to animal electrocardiography (ECG) equipment . Before exposing the heart, the rats were ventilated by positive pressure using a small animal respirator  after tracheal intubation. The left anterior descending (LAD) coronary artery was consecutively ligated for 45 min before reperfusion injury, whereas in the sham group, the LAD coronary artery was not ligated but was merely wound with string. A benzylpenicillin sodium (400000 U/kg) injection was administered through intraperitoneal once a day for 3 days to prevent infection. Successful AMI/R operations were confirmed by ST segment-characterized ECG.The AMI/R rat model was established as described previously . SD ratsDuring the whole operation, the tension of the limbs, the heart rate, and autonomous respiration were monitored to assess the level of anesthesia. A mixture of pentobarbital and feed was supplied to minimize the pain caused by the procedure. As described in a previous study , a singl−1) was injected into the abdomen of each rat to induce euthanasia before analysis of the AMI/R model. Eight rats in which the induction of remodeling had been successful were identified in each group. There were totally 134 rats  in this research for avoiding unsuccessful construction and that the same one could not be used in various detecting methods, such as echocardiography, hemodynamics, myocardial staining, histopathology, and immunohistochemistry.At the end of the experiment, 2% pentobarbital , respectively. Three consecutive cardiac cycles were captured from at least six subjects from each group by digital image analysis software. Subsequently, a sidearm of the aortic cannula was inserted into the left ventricle from the right carotid artery and was connected to a pressure transducer . The organism function experimental system  was used to amplify the signal and analyze the data. Myocardial tissue was preserved for the subsequent step.β-Actin proteins were used as loading and internal controls. The data are shown as the grayscale ratio of the target protein to β-actin.Equal amounts of proteins from each sample were separated with Any-kD sodium dodecyl sulfate (SDS) precast gel. After blocking with 5% nonfat milk, polyvinylidene fluoride membranes were hybridized with the following antibodies: monoclonal beclin-1 antibody at 1 : 1000 dilution, monoclonal Atg5 antibody at 1 : 1000 dilution, monoclonal LC-3A/B antibody at 1 : 1000 dilution, monoclonal p53 antibody at 1 : 1000 dilution, and monoclonal caspase-3 antibody at 1 : 1000 dilution. The membranes were subsequently hybridized with the corresponding secondary antibodies. Each myocardial tissue sample was cut transversely. Myocardial pathology was observed by hematoxylin and eosin (HE) staining and Masson trichrome staining. Myocardial ischemic risk areas were determined as described previously . To deliFor immunofluorescence staining, 4′,6-diamidino-2-phenylindole (DAPI), Bax antibody, Bak antibody, and the corresponding fluorescent secondary antibodies were used. Immunofluorescence staining was quantified by Image-Pro Plus software. In the AMI/R rats, the DAPI, Bax, or Bak fluorescence density values of the sham group were set to 100 standard density; other groups were represented by fluorescence density values relative to the standard density.Heart tissue was weighed and homogenized in ice-cold normal saline. Heart homogenate was mixed with an equal volume of cold Tris-ethylenediaminetetraacetic acid (EDTA). The separated cytosolic fraction was used for the subsequent measurement.Oxidant levels were measured using a thiobarbituric acid reactive substances (TBARS) assay kit .The levels of the antioxidants glutathione peroxidase (GPx), glutathione reductase (GR), glutathione (GSH), and superoxide dismutase (SOD) were measured in each group according to the instructions provided by the manufacturers of the GPx assay kit , the GR assay kit , the GSH assay kit , and the SOD assay kit , respectively.The ATPlite Luminescence Assay System  was used to evaluate cellular energy supply according to manufacturer's instructions. Data are shown as ATP concentrations relative to the ATPlite Assay System standard sample.p < 0.05 was considered statistically significant. Analysis of variance (ANOVA) was used to examine differences between the two groups, followed by either the least significant difference (LSD) test or the Games–Howell test according to the homogeneity of variance.The random variables follow a normal distribution in this analysis. All data are presented as mean ± standard, and The animal protocol was approved by the Xi'an Jiaotong University laboratory animal ethics review board (number A-2012-975SL), and the animal procedures conformed with the guidelines provided by Directive 2010/63/EU of the European Parliament on the protection of animals used for scientific purposes.p < 0.05, n = 6) and decreased oxidant TBARS levels  in rats with acute myocardial ischemia-reperfusion injury . Furthermore, the ratio of LC-3II to LC-3I as a standard of autophagy activity was clearly increased by CQ10 at the same time points as acute myocardial ischemia-reperfusion injury . However, the total LC-3 and negatively associated autophagy protein p62 levels were significantly reduced in the CQ10 group compared with the AMI/R group at the same time points in .We used Western blotting detection to demonstrate that CQ10 noticeably increased the levels of the positively associated autophagy proteins beclin-1 and Atg5 at the same time points of acute myocardial ischemia-reperfusion injury .We also proved that CQ10 reduced proapoptotic protein p53, and the ratio of active caspase-3 to procaspase-3 was significantly higher at 2 h, 24 h, and 72 h in rats with acute myocardial ischemia-reperfusion injury than in the control rats (p < 0.05).DAPI fluorescence revealed the number of intact nuclei, but did not show myocardial necrosis due to DNA and RNA condensation, fission, or burst. Compared with the AMI/R group, there were more myocardial nuclei in the CQ10 group at the same time points. Bak/Bax fluorescence expression was stronger in the CQ10 group than in the AMI/R group at the same time points .Infarct size was estimated as a percentage of the ischemic area-at-risk. At 2 h, 24 h, and 72 h following acute myocardial ischemia-reperfusion injury, CQ10 significantly reduced infarct size . From 2 h after reperfusion, CQ10 preconditioning improved cardiac systolic and diastolic functions (left ventricular ejection fraction (EF), left ventricular systolic pressure (LVSP), and left ventricular systolic pressure (LVEDP), the maximum change rate of left ventricular pressure rise (+dp/dtmax), and the maximum change rate of left ventricular pressure fall (−dp/dtmax) compared with the AMI/R group ).We used echocardiography and hemodynamic analysis to investigate cardiac function during acute myocardial ischemia-reperfusion injury. There was no difference between the two groups with regard to the following parameters: diastolic interventricular septal wall thickness (IVSd), systole interventricular septal wall thickness (IVS), diastolic left ventricular internal dimension (LVIDd), systole left ventricular internal dimension (LVID), and systole volume (SV), which represented cardiac structure and size at the same average heart rate (Finally, the relative ATP concentration, which is representative of direct energy supply, was increased by CQ10 during acute myocardial ischemia-reperfusion injury .It has become increasingly clear that the level of oxidants is greatly increased in the postischemic heart, and oxidants play a critical role in postischemic injury. Lipid peroxidation, induced by oxygen radicals, results in cell membrane breakdown, which leads to inhibition of the sodium-potassium ATPase, cell swelling, and mitochondrial dysfunction . As prevAutophagy is a widespread self-ingesting phenomenon that normally takes place in the biosphere at a low level. It is considered to be a protection mechanism that acts by degrading impaired proteins and/or organelles. It ensures that the cells survive with adequate supplies of materials and energy through recycling under most conditions of stress, such as acute ischemia and reperfusion, chemical toxicity, and oxidation –33. HoweEmerging evidence suggests interactions among the crucial proteins of autophagy and apoptosis as follows: beclin-1 binding to Bcl-2 family, caspase-3 cleaving beclin-1, , p53 proIn all, antioxidative function, energy survival, and autophagy activation are the major causes of infarct size reduction and cardiac function improvement after acute ischemia-reperfusion injury with CQ10 preconditioning. But timely reperfusion of the acute ischemic myocardium is essential for myocardial salvage. A number of mechanisms have been proposed to explain the mediation of reperfusion injury. These include cellular calcium loading, endothelium cell swelling, impaired vascular relaxation, and the action of oxygen radicals –6. The iFor some limitation, this study just focuses on short period of outcome after ischemia-reperfusion injury. In order to sufficiently evaluate whether CQ10 preconditioning reduces or only delays the detrimental effect of ischemia-reperfusion injury, a research designed for different doses of CQ10 and a long of outcome after ischemia-reperfusion injury is needed.In summary, we have established that CQ10 preconditioning regulates the balance of antioxidants and oxidants, enhances autophagy levels and activity, reduces myocardial apoptosis, and improves cardiac function in rats with acute ischemia-reperfusion injury. This study provides a new therapeutic target for acute ischemia-reperfusion injury and enriches our understanding of the clinical application of CQ10.


Improvements in palliative surgery for infants born with single ventricle heart defects have increased their survival rate into adulthood, but the risk of developing heart failure remains high. The ventricles remodel to geometric extremes, making statistical comparison with the normal population difficult beyond the assessment of mass and volumes. We present a new method for evaluating cardiac geometry and systolic contraction variations in patients with single ventricle physiology with respect to the normal range of end-diastolic (ED) and end-systolic (ES) left ventricle (LV) shapes seen in the asymptomatic population.Cardiac MRI of four single-ventricle patients with tricuspid atresia and > 10 years post-Fontan surgery were analyzed using custom software . EDV (ml) = {183.5, 122.9, 123.6, 77.7}, ESV (ml) = {97.7, 60.9, 72.7, 35.3}, EF (%) = {46.8, 50.5, 41.2, 54.6}, and LVM (g) = {143.4, 116.8, 134.9, 63.3}. Each patient's LV shape was projected onto Principal Component Analysis (PCA) models previously derived from 1,991 asymptomatic volunteers [Geometric LV shape extremes were identified at ED for P2 and P3 Figure , even thAtlas-based statistical shape analysis allows for identification of abnormal shape characteristics beyond mass and volume, as well as regional systolic contraction patterns. This may provide valuable new measures of disease progression and remodeling into heart failure relative to population norms.


To compare cine MR b-TFE sequences acquired before and after gadolinium injection, on a 3T scanner with a parallel RF transmission technique in order to potentially improve scanning time efficiency when evaluating LV function.25 consecutive patients scheduled for a cardiac MRI were prospectively included and had their b-TFE cine sequences acquired before and right after gadobutrol injection. Images were assessed qualitatively  and quantitatively with measurement of LVEF, LV mass, and telediastolic volume and contrast-to-noise ratio (CNR) between the myocardium and the cardiac chamber. Statistical analysis was conducted using a Bayesian paradigm.No difference was found before or after injection for the LVEF, LV mass and telediastolic volume evaluations. Overall image quality and CNR were significantly lower after injection  = 0% and -0.23 CI = , prob(coef>0) = 4%) respectively), but this decrease did not affect the visual assessment of LV wall motion  = 15%).In 3T cardiac MRI acquired with parallel RF transmission technique, qualitative and quantitative assessment of LV function can reliably be performed with cine sequences acquired after gadolinium injection, despite a significant decrease in the CNR and the overall image quality. MRI is currently the standard technique for the assessment of cardiac chambers volumes and function ,2, with In addition to these cine sequences dedicated to the evaluation of the cardiac chamber volumes and ventricular systolic function, CMR protocols frequently include late-gadolinium enhancement (LGE) sequences that are acquired 5 to 10 minutes after the contrast agent injection ,14. To gThe aim of this study is therefore to compare the diagnostic performances and the image quality of CMR cine sequences acquired before and after gadolinium injection on a 3T MR scanner equipped with dual-source RF transmission technology.This study was approved by our institutional review board (Comité de Protection des Personnes Est—IV) and written informed consent was obtained from all participants.i.e. severe renal impairment with an eGFR<30 mL/min, proven allergy to gadolinium), a subject younger than 18 years old, a pregnancy, inability to give informed consent, or a severe agitation or any other condition that could interfere with the patient’s ability to comply with the examination.For 2 consecutive months (July and August 2012), all patients referred to our department for a gadolinium-enhanced CMR were prospectively enrolled. Exclusion criteria were, in addition to the classical contraindications to MRI or to gadolinium injection  equipped with a fully flexible dual-source RF transmission technology (i.e. Tx MultiTransmit®) and a dedicated 6-channel SENSE torso coil.All patients underwent a 3T cardiac MRI  sequences were acquired in the three cardiac planes  in two steps: before contrast agent injection and immediately following the injection of a gadolinium-based contrast agent  at a dose of 0.1 mmol/kg (flow rate 3mL/s), followed by a saline flush of 30mL (flow rate 3mL/s). Acquisition parameters of the b-TFE cine sequences in the LV short axis plane are summarized in 3D-IR), acquired at 9 minutes after a Look-Locker sequence to visually determine the inversion time and 3D-PSIR acquired 13 minutes after the injection. The T1 and T2 black blood sequences and the LGE sequences were only used for clinical purpose, and their quantification was out of the scope of this study.The same acquisition protocol was applied to all patients. Morphological « Black-Blood » T1 and T2-weighted Spin Echo Single Shot sequences were first acquired. Then the ECG-gated cine B-TFE . Qualitative assessment of the cine images in the three cardiac planes was performed on a dedicated workstation  using a 4-level Likert scale successively evaluating the overall image quality, the edge sharpness of the cardiac chambers , the artifacts and the visual assessment of left ventricular wall motion . One scoMR Viewforum in version 2.6.3.4, Philips Medical Systems, Best, The Netherlands) with manual delineation of the LV epicardium and endocardium on the telesystolic and telediastolic phases, after optimal adaptation of the window settings so as to get an optimal and reproducible visualization of the LV myocardium.The quantitative assessment was blindly performed by a single observer (AS) on the cine b-TFE sequences in the LV short axis after randomization of patients as well as pre- and post-contrast images. LV ejection fraction, LV end-diastolic volume and LV myocardial mass were measured using dedicated software (2 (Contrast to noise ratio (CNR) was obtained by the signal intensity measurement of the LV cavity and of the adjacent healthy myocardium in the LV short axis, with a circular region of interest (ROI) averaging at least 0.5 cm2  using thThis ROI was positioned in the same region  in each patient, with careful exclusion of off-resonance artifacts. CNR was measured on a single (end-diastolic) temporal phase of all the LV short axis slices.Descriptive analyses were calculated by using generic statistics, such as mean, standard deviation, min, and max for quantitative variables. Effectives and percentages were used for qualitative variables. Cohen’s Kappa with quadratic ponderation was used to measure concordance between readers.Inferential analyses were calculated utilizing a Bayesian paradigm –19, by uAnalysis was performed on both software WinBUGS version 1.4.3. (Windows Bayesian Inference Using Gibbs Sampling) and R version 3.0.1 .25 consecutive patients  were ultimately enrolled in this study. 5 (20%) patients had signs of ischemic cardiomyopathy, 1 patient had an acute myocarditis and 6 (24%) were diagnosed with idiopathic (hypertrophic or dilated) cardiomyopathy. The remaining 8 examinations were normal. LVEF was altered (<55%) in 9 (36%) patients and normal in 16 (64%). LV end-diastolic volume was increased in 8 patients (32%), and LV mass was increased in 3 (12%) patients. Regarding LV wall motion, 14 patients (56%) had normal wall motion, whereas segmental hypokinesia was present in 11 patients (44%), segmental akinesia in 2 patients (8%) and segmental dyskinesia in 2 patients (8%).Descriptive analysis revealed quantitative superiority of the cine sequences acquired before contrast agent injection for all criteria , Table 3Bayesian analysis  confirmeThere was no significant difference in terms of LVEF, LV end-diastolic volume and LV myocardial mass measured before and after gadolinium injection. This was the case whether the LVEF was normal (16 patients) or altered (9 patients). Mean intra-patient variability for LVEF was only 5.1% ± 4.2 (minimum 0% and maximum 13%). CNR was significantly inferior after gadolinium injection (mean drop of 23%).The results of the descriptive and bayesian analyses are reported in Tables Measurement of Cohen’s Kappa  found miThis work answered our initial question: despite significantly worsened overall image quality, the b-TFE cine sequences acquired at 3T after gadolinium injection are as effective as those acquired before in terms of quantitative  and qualitative  assessment of the left ventricle.The acquisition of these cine sequences right after the gadolinium injection, during the impregnation time, shortens the examination by about 3 to 4 minutes. This can be added with other optimizations in the choice of LGE sequences  to signiDespite wide utilization in the routine clinical setting, very few studies investigating the diagnostic performances of post-contrast cine sequences exist in the literature. Their conclusions are in agreement with ours, even though they were conducted using other contrast agents and/or other sequences than the ones used in the present work. At 1.5T, two studies showed no difference in the overall image quality  or in thThe presence of gadolinium both in the blood pool and in the myocardial interstitium is responsible for the CNR decrease and thus the decrease of the LV edge sharpness definition and the overall image quality, in comparison to the cine sequence acquired before injection.Indeed, myocardial signal increases more than the intracavity signal , thus leading to both signal values being closer and to a 23% drop of the CNR. This has been studied more formally on a small cohort by Sharma et al , with anin fine as good as in the sequences before gadolinium injection, meaning that the reader could compensate the loss in the overall image quality and perfectly identify the LV margins. That is certainly why the quantitative manual LV evaluation is identical between both sequences; we can speculate that such consistent results would not have been obtained with fully automatic LV quantification software, for which the image quality and CNR loss could lead to incorrect segmentation.In our study, the mean intra-patient differences for the LVEF, the LV volume and the LV myocardial mass were statistically non-significant based on the bayesian analysis. They are in agreement with the intra-observer variability described in the literature for CMR and superior to the intra- and inter-observer reproducibility obtained by other cardiac imaging modalities . Indeed,The use of a dual-source RF transmission technology could have helped in compensating some of the usual pitfalls of 3T CMR. This technology improves the performance of MR high-field imaging by reducing dielectric shading, B1 inhomogeneity and local energy deposition, and therefore enhances the image quality and reduces the acquisition time . Advantade facto leading to a loss of information. Nevertheless, this loss is limited as the difference between sufficient diagnostic quality  and insufficient examinations (grade ≤2) remains. One can also point out the relatively small number of patients as a limitation. However, the use of a Bayesian inference analysis, with simulation of large population derived from this sample, gives us sufficient statistical power to demonstrate the equivalence in LV assessment. Another limitation is the only moderate agreement between the two radiologists. This result needs to be put into perspective with (i) the number of categories -four- of our evaluation: the greater number of categories, the lower the concordance, (ii) the fact that the disagreement was, in the vast majority of cases, between class 3 and 4  which does not impact on the diagnosis or work-up of patients. One last limitation is that this study is vendor-specific, and limited to 3T scanner with dual-source RF transmission technology. It is, however, more than likely that our results could be applied to any 3T scanner.This study has several limitations. One of the study limitations is inherent in the Bayesian inference analysis: although it enables superior statistic power with simulation of large population derived from our study sample, a binary clustering of all qualitative data was needed , We demonstrated that in 3T cardiac magnetic resonance imaging with dual-source RF transmission technology, the acquisition of b-TFE cine sequences after gadolinium injection does not lead to any significant differences in the qualitative and quantitative assessment of left ventricular ejection fraction, mass and volume, despite a significantly deteriorated overall image quality.S1 Dataset(PDF)Click here for additional data file.


Pulmonary regurgitation (PR) is the most common complication after tetralogy of Fallot (TOF) surgical repair, and long-term PR might result in cardiovascular events. The aim of this study was to assess the influence of pre-operative right ventricle (RV) and pulmonary artery (PA) parameters assessed by dual-source computed tomography on post-operative PR. A total of 41 TOF patients who underwent trans-valve surgical repair were retrospectively recruited. The RV and PA parameters evaluated by pre-operative DSCT were compared between the PR and non-PR groups. Our result revealed that the PA parameters  and RV parameters (RV length diameter and RV short diameter) all showed significant differences between the two groups . There was a significant correlation between PR and LPA diameter (r = 0.361), McGoon ratio (r = 0.413), and Nakata index (r = 0.482). Receiver operating characteristic analysis also revealed a moderate sensitivity and specificity of LPA , McGoon ratio , and Nakata index  for predicting the occurrence of PR. This study indicated that these pre-operative indices calculated by DSCT are associated with post-operative PR and that these pre-operative PA and RV parameters may serve as novel predictors of the risk of PR. Severe PR after TOF surgical repair requires reoperation. Thus, the ability to accurately predict the occurrence of PR may help early monitor and help improve patient prognosis.Tetralogy of Fallot (TOF) is one of the most common cyanotic congenital heart diseases (CHDs), and pulmonary regurgitation (PR) is the most common complication after TOF surgical repair. Long-standing PR may result in chronic right ventricle (RV) volume overload, ventricular dysfunction, arrhythmia, and adverse cardiovascular events5.Trans-thoracic echocardiography (TTE) as the traditional and routine clinical investigation for TOF, is good at hemodynamic detection; however, the results of TTE are largely dependent on the operators. Dual-source computed tomography (DSCT) post-processing techniques for the heart and vessels, which enables better anatomical delineation of cardiac structures at a higher spatial resolution and lower radiation dose compared to older generation CT scanners, are more widely used in CHD10. Although study has pointed out that trans-valve surgical repair has been linked with post-operative PR, the preoperative anatomic characteristics, which play a major role in deciding the surgical approach and the response of the perivalvular structures to the hemodynamic load have not been thoroughly discussed13.In recent years, numerous TOF-related studies have focused on the clinical managements after the TOF surgical repair, such as the close monitoring of ventricle function changes in the long-term postoperative follow-up, discussion about indications, methods, and optimal timing of pulmonary valve replacement (PVR) have persistedIn this study, we collected fifty-five patients to assess the influence of pre-operative RV and PA imaging characteristics by DSCT on post-operative PR.A total of 55 patients who did not pre-operative PR were enrolled in the study, these included 20 patients in whom post-operative PR was confirmed by TTE and 35 patients who did not have postoperative PR. Of the 55 patients, there were 41 patients had received trans-valve surgery. In the post-operative PR group, 18 patients had received trans-valve surgery (90.0%), and in the non-PR group, 23 patients had received trans-valve surgery.The demographic and clinical data for patients with or without PR are as given below: age , systolic pressure , and diastolic pressure  , and left pulmonary artery (LPA) diameter  in the PR group were significantly higher compared with those in the non-PR group. No significant statistical difference was observed with respect to MPA (21.88 ± 6.96 mm/m2 vs. 21.63 ± 7.79 mm/m2) and RPA diameter (17.88 ± 5.44 mm/m2 vs. 16.56 ± 4.60 mm/m2) , Nakata index  and the right ventricular short diameter  were significantly higher in the PR group compared with those in non-PR group. No significant difference was observed with respect to RV wall thickness (18.61 ± 3.35 mm/m2 vs. 18.88 ± 3.88 mm/m2), RVOT diameter (9.51 ± 3.63 mm/m2 vs. 10.06 ± 4.52 mm/m2), and RVOT length (26.50 ± 10.11 mm/m2 vs. 23.42 ± 9.06 mm/m2)  and the occurrence of post-operative PR .The diameters of the right ventricle (RVLD and RVSD) exhibited a negative correlation with PR  Table .ROC analysis showed that a McGoon ratio >1.63, Nakata index >270.05, and LPA diameter >18.29 based on DSCT were optimal cutoff values that predicted the risk of post-operative PR . The Youden index of the three parameters  was 0.40, 0.44 and 0.49, respectively ; RVSD: sensitivity 77.8%, specificity 60.9% (AUC:0.70)]. The Youden index of RVLD and RVSD were 0.49 and 0.39 Fig. .Two experienced radiologists finished the intra- and inter-observer variability and all the indexes and size values using DSCT were calculated. The ICCs of intra-observer variability for the measurements were 0.878–0.997; the ICCs of inter-observer variability for the measurements were 0.824–0.996 Table .Table 3IAs infant patients are susceptible to ionizing radiation, the radiation dose in our study was as low as could be reasonably achieved. The mean DLP for patients between 4 months and 1 year of old was 46.63 ± 24.81 mGy·cm; the mean ED based on DLP was 1.26 ± 0.62 mSv. The mean DLP for patients between 1 and 6 years of old was 37.29 ± 15.12 mGy·cm and the mean ED was 0.67 ± 0.27 mSv.In this study, we demonstrated that PR is more likely to occur in patients who have undergone trans-valve surgery (90.0%). Pre-surgical PA measurements including the McGoon ratio, Nakata index and LPA diameter had a positive correlation with PR. Meanwhile, the right ventricle diameters (RVLD and RVSD) had a negative correlation with PR. We postulated that these PA indexes and RV diameters might serve as novel predictors of PR and facilitate clinical intervention and management for TOF patients.14. Infant patients with TOF usually require early surgical repair to reduce the risk of death16. The surgery includes the infundibulotomy with or without trans-valve repair. PR is the most serious complication after the surgical repair, persistent PR might lead to RV dilatation, ventricular arrhythmias, and even cardiac event decades21. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease point out that pulmonary valve replacement (PVR) is reasonable in adults with previous tetralogy of Fallot, severe pulmonary regurgitation, and any of the following: a. moderate to severe RV dysfunction or RV enlargement; b. development of symptomatic or sustained arrhythmias; c. moderate to severe tricuspid regurgitation22. The early interventions for patients who are at higher risk of post-operation PR may help to prevent or delay the occurrence of these cardiovascular events. Therefore, it is important to identify appropriate predictive parameters to improve the post-operative follow-up and clinical management of TOF patients. This study was designed to assess the influence of pre-operative RV and PA parameters on post-operative PR in infant TOF patients by DSCT.TOF is the most common cyanotic CHD and accounts for 7–10% of all CHD23. Our results are consistent with this theory and we assumed that the injury to the pulmonary valve and the surrounding tissue during the trans-valve incision might be the culprit.None of the patients had PR before surgery, however, immediate post-operative TTE showed the presence and different degrees of regurgitation. Patients with trans-valve surgery presented a higher probability of PR (90.0% vs. 65.7%). Although the mechanism of development of PR is not completely understood. One of proposed cause is the ventriculotomy incision crossing the pulmonic valve annulus, a surgical process considered in patients in whom the pulmonary valve annulus is too small2/m2 are considered as essential indicators for one-stage surgery. A previous study mentioned that larger and expansile PA exhibited a tendency for higher PR fractions; the author proposed that PR was exacerbated by PA compliance but was limited by more proximal resistance23. Similarly, in our study, the McGoon ratio value and Nakata index value were significantly higher in the patients who developed PR. The expanded PA might attenuate the vascular elasticity and lead to reduced PA compliance. What’s more, the blood flowing through the PA is venous blood; however, the PA lacks an intravenous valve. We assumed that the well-developed and even expanded PA streams back more blood to the surgical incision at the PV level, which results in instant PR post-operatively; further, the relatively narrow valve compared with the large diameter of the pulmonary bifurcation adds to this possibility. The development parameters of PA not only described the severity of the patient’s condition, but also considered as a new predictive factor for possible PR occurring after repair surgery. However, whether the late PR is also attributable to this phenomenon is worthy of further investigation.For patients who received trans-valve surgery, the McGoon ratio, Nakata index, and the LPA diameter shown a positive correlation with PR. The above artery development parameters reflect the degree of distal stenosis of pulmonary bifurcation and a McGoon ratio higher than 1.2 and a Nakata index higher than 150 mm24, and the contribution of LPA to total regurgitation flow is far greater compared with that of RPA25. In the event of compensatory PR after the trans-valve surgery, more blood should stream from the wider LPA back to the relatively narrow pulmonary annulus as compared with that from RPA.In our results, the LPA diameter was a better predictor of PR than RPA. The LPA diameter value was significantly different between these two groups and showed a moderate positive correlation with the presence of PR. The ROC analysis demonstrated a moderate predictive value of LPA diameter (AUC:0.71). However, the RPA diameters was not significantly different between these two group, and it did not show a significant correlation with the PR. The phenomenon might be explained as follows: a great amount of blood that streams back toward the heart is largely from the LPAAnother finding of this study was that RV linear dimensions were also related to PR. The RVLD and RVSD both showed a negative correlation with the PR. Different form the size of PA, the size of RV reflects the pre-load of the pulmonary valve, namely a relatively smaller size of RV represents a lower diastolic and systolic volume before the surgery. We presume that the smaller volume may make it harder to compensate the abrupt increase in blood flow after repair and the relatively higher pressure would at least result in transient PR. However, our measurements pertained only to the early stage of post-operative period. The hemodynamic characteristics reflected in the pre-operative RV parameters and how changes in these measures on the long follow-up may provide more clues on this issue.26. Therefore, we may help predict the risk of PR after the one-stage operation using DSCT. The surgeon should recommend regular follow-up examination of these patients in the post-operative period.In our study, there was a good reproducibility of the inter- and intra-observer variabilities. With the fast scanning speed and high temporal resolution, the DSCT can provide more accurate information for PA and RV parameters. The accurate measurements can not only reflect the patients’ individual details, but also help to predict the occurrence of post-operative PR in TOF patients. PR is the most common complication after the first TOF surgical repair and is especially associated with the trans-valve surgery, however, most of patients can tolerate for several years or even decades. In the event of severe PR, the surgeon should suggest the patients to undergo the PVRThere were several limitations in this study. First, there was a likely assembly bias. Patients selected for DSCT were all from our institution. Second, only pre-operative and immediate post-operatively changes were assessed; continued follow-up of these patients is required to determine the long-term predictive value. Third, although the radiation dose was prominently reduced through DSCT, and much lower than cardiac catheterization, infant patients are still vulnerable to ionizing radiation.In conclusion, this study demonstrated that PA developmental parameters and RV size might be associated with post-operative PR. An increase in the LPA diameter, McGoon ratio, and Nakata index or smaller size of RV may indicate an increased risk of PR. These easily acquired pre-operative DSCT measurements can not only be used as surgical indications, but also have a certain correlation with PR incidence; these may be considered as anatomic predictive factors for the occurrence of PR.This retrospective study collected 98 patients with DSCT confirmed by TOF at our hospital from January 2011 to September 2016. The exclusion criteria included (a) no-surgical patients or surgery after the age of six, (b)surgical results confirmed as not TOF, (c)incomplete clinical data, (d). Patients with poor clinical conditions. Finally, 55 patients  with an average age of 1.67 ± 1.32 years (range: 5 months–6 years) were included in the study. Of the 55 patients, there are 41 patients received infundibulotomy with an incision across the pulmonary valve annulus, and the other 14 patients without pulmonary valve incision. This study was approved by the institutional review board of West China hospital (No. 14–163), and we pledged to abide by the declaration of Helsinki (2000 EDITION) in accordance with the relevant medical research rules of China in the study. Ensure that all patients and patients’ parents signed the relevant informed consent, and having been informed of potential adverse reactions to the iodinated contrast agent and radiation.All examinations were performed using a DSCT scanner . Short-term sedation  was achieved by intravenous injection of chloral hydrate prior to the cardiac DSCT examinations. Scanning was performed using a retrospective ECG-gated protocol with the following acquisition parameters: tube voltage of 80 kV, tube current of 100 mAs, gantry rotation time of 0.28 s, and pitch of 0.2–0.5 (according the heart rate with a higher pitch used for higher heart rates). The ECG-pulsing window was set on Auto. Scanning was performed in the craniocaudal direction from the inlet of the thorax to 2 cm below the diaphragm level with a scan cycle including systolic and diastolic phases. The nonionic contrast agent  was injected into an antecubital vein at a rate of 1.2–2.5 ml/s, followed by 20 ml of saline solution at the same flow rate. The injected volume was adjusted according body weight (1.5 ml/kg). Bolus tracking was used in the region of interest (ROI) in the descending aorta with a predefined threshold of 100 HU. Image acquisition was triggered following a delay of 5 s when the ROI attenuation threshold reached 100 HU. The workstation  processed all acquired data. A slice thickness of 0.75 mm and an increment of 0.75 mm were chosen for image reconstruction.All patients underwent TTE using a Philips SONOS 7500 ultrasound system  pre-operatively and immediately after surgical repaired to detect the occurrence of PR. The examination included M-mode, two-dimensional, continuous wave, and Color Doppler Flow Imaging as recommended by the American Commission on echocardiography. Post-operative PR was detected by color Doppler flow mapping and continuous wave Doppler, and the results presented as a binary carriable (present and not present). All the TTE images and detection of PR were acquired by an experienced echocardiographer.27.Two experienced radiologists analyzed each subject, recorded the measurements, and calculated the index. All diameters were measured using the computer caliper during systole. The multiple planar reconstruction (MPR) was used for DSCT image analysis. Recordings and assessments of RV and PA followed the American Society of Echocardiography guidelinesThe main pulmonary artery (MPA) was measured at the site of pulmonary bifurcation in the axial slices, while the right pulmonary artery (RPA) and left pulmonary artery (LPA) were measured proximal to the first branching point of each artery Fig. . RV wallRadiation dose parameters, including volume CT dose index (CTDIvol) and dose-length product (DLP), were automatically displayed on the CT console after the examination. Infant-specific DLP conversion coefficients, based on the 2007 recommendations of the International Commission on Radiological Protection, were used to calculate the effective dose (ED) using conversion coefficients of 0.039 for patients <4 months of age, 0.026 for patients between 4 months and 1 year of age, and 0.018 for patients between 1 and 6 years of age.The data were analyzed using the SPSS software for Windows  and MedCalc software . The McGoon ratio and Nakata index were calculated using PA diameters and cross-section areas. Continuous variables were expressed as mean ± standard deviations (SD). Categorical variables were expressed as numbers. The significant differences of these measurements between the PR and non-PR group in trans-valve surgical group were analyzed using an non-parametric test. Spearman’s rank correlation test was used to evaluate the association between these pre-operative parameters and the occurrence of PR. Receiver operating characteristic (ROC) analyses calculated the sensitivity and specificity of the effective parameters to predict post-operative PR. The intraclass correlation coefficient (ICC) was used to assess the inter-observer and intra-observer variability. A two-tailed p-value of <0.05 was considered statistically significance.