Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months.ClinicalTrials.gov (NCT02342522) and is completed.We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated  to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group . No important unexpected adverse events or side effects of remote ischaemic conditioning were observed.Remote ischaemic conditioning does not improve clinical outcomes  at 12 months in patients with STEMI undergoing PPCI.British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden. Despite timely reperfusion with primary percutaneous coronary intervention (PPCI), morbidity and mortality following acute ST-elevation myocardial infarction (STEMI) remain substantial, and improvements in mortality and survival free of heart failure have plateaued.3In the clinical setting, the cardioprotective remote ischaemic conditioning stimulus can be applied using serial inflations and deflations of a pneumatic cuff placed on the upper arm or thigh to induce brief cycles of ischaemia and reperfusion.Evidence before this studyTo improve clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PPCI), new treatments are needed to protect the heart against acute ischaemia–reperfusion injury and thus reduce myocardial infarct size and prevent heart failure. Remote ischaemic conditioning with transient ischaemia and reperfusion of the arm or leg as an adjunct to PPCI has been shown in several small randomised controlled trials to reduce myocardial infarct size and increase myocardial salvage in patients with STEMI when compared with use of PPCI alone. However, whether remote ischaemic conditioning can improve clinical outcomes such as mortality and heart failure has not been confirmed. A PubMed search undertaken up to the start date of the trial  using the terms “remote ischemic conditioning; acute myocardial infarction; mortality; and heart failure” revealed no randomised controlled trials investigating the effect of remote ischaemic conditioning on clinical outcomes in patients with STEMI treated by PPCI.Added value of this studyIn this large, sufficiently powered, multicentre, randomised controlled trial of 5401 patients with STEMI, we investigated whether remote ischaemic conditioning applied as an adjunct to PPCI could reduce the incidence of cardiac death or hospitalisation for heart failure within 12 months post-PPCI, when compared with PPCI alone. Our findings showed that remote ischaemic conditioning did not improve clinical outcomes in terms of cardiac death or hospitalisation for heart failure at this timepoint. Furthermore, no improvements in any of the secondary endpoints were found, including major adverse cardiovascular and cerebral events and myocardial infarct size evaluated by troponin T release. Furthermore, no effects of the intervention versus the control were seen among prespecified subgroup analyses by age, presence of diabetes, pre-PPCI coronary flow, ischaemia time, or infarct location.Implications of all the available evidenceThe CONDI-2/ERIC-PPCI trial has provided definitive evidence that remote ischaemic conditioning offers no benefits on either myocardial infarct size or clinical outcomes at 12 months in patients with STEMI treated with PPCI. Two follow-up randomised controlled trials and a prospective single-centre randomised controlled trial, published since the commencement of our trial, had suggested that remote ischaemic conditioning might improve clinical outcomes in patients with STEMI undergoing PPCI. The two follow-up trials were not prospectively designed or powered to detect a difference in clinical outcomes with remote ischaemic conditioning. The prospective single-centre trial might not have been sufficiently powered, and it had an extended follow-up period. Until now, remote ischaemic conditioning had been the most promising potential cardioprotective strategy for improving clinical outcomes following STEMI. Therefore, identification of novel cardioprotective targets and discovery of innovative approaches to cardioprotection are needed to improve clinical outcomes in patients with STEMI treated by PPCI. Such approaches might include combination multitarget therapy. Remote ischaemic conditioning might still be beneficial in other clinical settings of acute ischaemia–reperfusion injury, including renal transplantation, acute kidney injury, and stroke.We did an international, multicentre, single-blind, randomised controlled trial at 26 centres in the UK (the ERIC-PPCI component study), and at four hospitals in Denmark, two hospitals in Spain, and one hospital in Serbia (the CONDI-2 component study). The CONDI-2/ERIC-PPCI study received ethical approval from regional and national health service research ethics committees and was conducted in accordance with the principles of good clinical practice. In the CONDI-2 component study, all participants provided written informed consent before randomisation. In the ERIC-PPCI component study, all patients provided initial verbal assent before randomisation, which was followed by written informed consent. The London School of Hygiene & Tropical Medicine Clinical Trials Unit  coordinated the trial in collaboration with the Cardiology Trial Unit and Department of Clinical Epidemiology of Aarhus University Hospital . Details of the trial design have been reported previously,Patients with chest pain and suspected ST-segment elevation on electrocardiogram (ECG) were screened for possible inclusion. Patients were included if they were older than 18 years of age, had ST-segment elevation on ECG, and were eligible for PPCI. Exclusion criteria were previous coronary artery bypass graft surgery, myocardial infarct within the previous 30 days, left bundle branch block on ECG, treatment with therapeutic hypothermia, conditions precluding use of remote ischaemic conditioning , and life expectancy of less than 1 year due to a non-cardiac pathology.Sealed Envelope , and was stratified by centre with use of random permuted blocks (block sizes of 4 or 6). For CONDI-2, randomisation was done through a web-based clinical trial support system accessible 24 h a day  and stratified by centre using random permuted blocks . In both trials, access to the randomisation website and list were strictly controlled at each site and limited to unmasked study team members. Study team members collecting the data and assessing outcomes were masked to the treatment allocation.In both trials, patients were randomly allocated (1:1) to a remote ischaemic conditioning group or a control group by a designated study team member who was unmasked to treatment allocation. For ERIC-PPCI, randomisation was done via a secure website, An automated AutoRIC cuff device  was used to deliver the remote ischaemic conditioning protocol, which comprised four alternating cycles of cuff inflation for 5 min to 200 mm Hg and deflation for 5 min. At the UK sites, the control group received a sham simulated remote ischaemic conditioning intervention. At the sites in Denmark, Spain, and Serbia, the control group received standard therapy. The remote ischaemic conditioning and control protocols were implemented before PPCI and did not delay the onset of PPCI. Where ambulance transit times allowed, remote ischaemic conditioning was administered in the ambulance (in Denmark and Spain). Where ambulance transit times were shorter, remote ischaemic conditioning was delivered immediately upon arrival at the PPCI centre (in Serbia and the UK).Before PPCI, patients were treated with 300 mg aspirin orally or intravenously, 600 mg clopidogrel or 180 mg ticagrelor orally, and standard weight-adjusted heparin intravenously. The PPCI procedure followed guideline recommendations;The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months post-randomisation in the intention-to-treat population. Hospitalisation for heart failure included heart failure both during the index hospitalisation and during rehospitalisation for heart failure. Hospitalisation was defined as treatment occurring during a hospital admission. Heart failure was judged to be present on the basis of at least one of the following symptoms and signs: new or worsening dyspnoea, orthopnoea, or paroxysmal nocturnal dyspnoea; increasing fatigue or worsening exercise tolerance; ejection fraction less than 45% on echocardiography; new pulmonary oedema seen on chest x-ray in the absence of a non-cardiac cause; crepitations believed to be due to pulmonary oedema; and use of loop diuretics to treat presumed pulmonary congestion.Prespecified secondary endpoints, analysed in the intention-to-treat population, included combined cardiac death or hospitalisation for heart failure at 30 days; cardiac death and hospitalisation for heart failure  at 30 days and 12 months; major cardiovascular and cerebral adverse events  with 80% power and 5% significance would have required 4300 patients (2000 patients in ERIC-PPCI and 2300 in CONDI-2), allowing for 15% attrition. A blinded review of accruing data revealed that the estimated event rate was lower than anticipated and the sample size was, therefore, increased to 5400 patients (2800 patients in ERIC-PPCI and 2600 in CONDI-2).The primary and secondary time-to-event outcomes were compared between the remote ischaemic conditioning and control groups with use of a Cox regression model stratified by the two component studies on an intention-to-treat basis, and presented with Kaplan-Meier curves. To account for recurrent hospitalisation for heart failure and competing mortality risk, a negative binomial model was used to compare the total number of outcomes experienced by the two groups up to 12 months after randomisation. The proportion of patients with an implantable cardioverter-defibrillator, biventricular pacemaker, or single-chamber or dual-chamber pacemaker at 12 months was compared using a generalised linear model for a binary outcome with a log link.Prespecified analyses by subgroup  were done on the primary outcome. The subgroups were analysed by including an interaction term between treatment group and subgroup in the Cox regression model.Troponin T values were converted into a 48-h AUC summary measure for analysis, using multiple imputation by chained equations to account for missing data. As the distribution of the outcome variable was highly skewed, a log transformation was done. Differences were analysed by use of a linear regression model with the treatment effect presented as a ratio of the geometric means.We also did a per-protocol analysis of all primary and secondary outcomes limited to patients who had a confirmed STEMI, received the full intervention as specified in the protocol, and had a completed PPCI.Results were considered statistically significant if the two-sided p value was less than 0·05. Full details of the statistical methods are provided in the protocol and statistical analysis plan, which are available in ClinicalTrials.gov (number NCT02342522) and is a planned prespecified collaboration between the CONDI-2 and ERIC-PPCI studies  were included in the intention-to-treat analysis . The treThere was no evidence of difference between the control group (8·6% [n=220]) and the remote ischaemic conditioning group (9·4% [n=239]) with respect to the combined primary end point of cardiac death or hospitalisation for heart failure at 12 months  within 30 days, major cardiovascular and cerebral adverse events  after 30 days, or incidence of implantable cardioverter-defibrillator implantation within 12 months . NumbersThe AUC for high-sensitivity troponin T did not differ between the control group  and the remote ischaemic conditioning group  patients and transient pain or paraesthesia was reported for 147 (5·8%) patients. There were no withdrawals due to adverse events.In this large, appropriately powered, prospective, international, multicentre trial, we found no clinically meaningful beneficial effects of remote ischaemic conditioning administered as an adjunct to PPCI on clinical outcomes  at 12 months in patients with STEMI when compared with PPCI alone. Furthermore, remote ischaemic conditioning had no effect on major secondary endpoints, including myocardial infarct size assessed by cardiac biomarkers.These findings are in direct contrast to previously published clinical studies of remote ischaemic conditioning in patients with STEMI that reported increased myocardial salvage  and reductions in myocardial infarct size (assessed by cardiac biomarkers and cardiac imaging),12vs 11 [5%] in the control group) and hospitalisation for heart failure events (eight [3%] in the remote ischaemic conditioning group vs 17 [8%] in the control group) were small. An alternative explanation could be that the primary effect of remote ischaemic conditioning was on post-STEMI left ventricular remodelling rather than acute myocardial infarct size—although this mechanism would contradict experimental animal studies, which have clearly shown a beneficial effect of remote ischaemic conditioning on reducing acute myocardial infarct size. Notably, a clinical study investigating the cardioprotective effects of ischaemic postconditioning in patients with STEMI treated by PPCI showed no effect on myocardial infarct size, but still found reduced severity of adverse left ventricular remodelling at 1 year of follow-up, especially in patients with microvascular obstruction.Although myocardial infarct size is a known independent determinant of clinical outcomes post-PPCI in patients with STEMI, it is unclear whether a reduction in myocardial infarct size by a cardioprotective intervention applied as an adjunct to PPCI can be translated into improved clinical outcomes. The RIC-STEMI trial by Gaspar and colleaguesFollow-up (median 3·8 years) of participants in the initial CONDI-1 trialThe reasons for the failure of remote ischaemic conditioning to reduce myocardial infarct size and improve clinical outcomes in our study are not clear. One potential reason could relate to the remote ischaemic conditioning protocol itself. Although four 5-min cycles of upper arm cuff inflations and deflations applied before PPCI has been shown to increase the myocardial salvage indexThe timing of the remote ischaemic conditioning protocol in relation to reperfusion by PPCI might also be important. Previous clinical studies have shown that remote ischaemic conditioning is effective at reducing myocardial infarct size when administered before PPCI  due to infarcts in the left anterior descending artery.Remote ischaemic conditioning has shown mixed effects on outcomes in other clinical settings including cardiac surgery. Three large, prospective, multicentre, randomised controlled trials failed to find any beneficial effects of remote ischaemic conditioning on post-surgical clinical outcomes,A potential limitation of our study is the short follow-up time of 12 months post-STEMI for the primary outcome of cardiac death and hospitalisation for heart failure, which might have been too short to observe any effect of remote ischaemic conditioning on clinical outcomes.In summary, the findings from our trial provide conclusive evidence that remote ischaemic conditioning offers no benefits on either myocardial infarct size or clinical outcomes at 12 months in patients with STEMI treated by PPCI. Unfortunately, remote ischaemic conditioning had been the most promising cardioprotective strategy for improving clinical outcomes following STEMI, and few other prospective options exist. As such, further studies are needed to identify novel cardioprotective targets and innovative approaches to cardioprotection such as combination multitarget therapy.Requests for data collected for the study can be made to the co-corresponding authors and will be considered on an individual basis. Additional, related documents are immediately available  and can be requested from the co-corresponding authors.


Microbubbles (MB) can be compressed to nanometer-sized droplets and reactivated with diagnostic ultrasound; these reactivated MB possess unique imaging characteristics.We hypothesized that droplets formed from compressing Definity MB may be used for infarct-enhancement imaging.Fourteen rats underwent ligation of their left anterior descending (LAD) artery, and five pigs underwent 90 minute balloon occlusions of their mid LAD. At 48 hours in rats, transthoracic ultrasound was performed at two and four minutes following 200 μL intravenous injections (IVI) of Definity droplets (DD), at which point the MI was increased from 0.5 to 1.5 to assess for a transient contrast enhancement zone (TEZ) within akinetic segments. In pigs, 1.0 mL injections of DD were administered and low frame rate (triggered end systolic or 10 Hz) imaging 2–4 minutes post iVI to selectively activate and image the infarct zone (IZ). Infarct size was defined by delayed enhancement magnetic resonance imaging (DE-MRI) and post-mortem staining (TTC).Increasing MI to 1.5 (at two or four minutes after IVI) resulted in a TEZ in rats, which correlated with infarct size . A TEZ was not seen at 2–4 minutes in any rat (n = 8) following Definity MB injections. Fluorescent staining confirmed DD presence within the infarct zone 10 minutes after intravenous injection. In pigs, selective enhancement within the IZ was achieved by using a low frame rate single pulse harmonic mode; IZ size matched the location seen with DE-MRI and correlated with TTC defect size .DD formulated from commercially available MB can be acoustically activated for selective infarct enhancement imaging. The frobubble  has a unrobubble , and remrobubble , 8. One robubble . Alternarobubble . Thereforobubble , 4. Therrobubble –13. ThesWe have demonstrated with <2 MHz frequencies, that diagnostic transthoracic ultrasound pressures at or above 1.0 mechanical index (MI) can reactivate these droplets , 8. SincDefinity  was used in all the studies. Definity microbubbles (DMB) were activated via mechanical agitation  for 45 seconds , 8. BrieThe solution was then allowed to warm to room temperature before administration. DMB and DD were both sized (n = 3 for each solution) using a Nano Zetasizer , which is capable of sizing particles from 50 nm up to 10 μm diameter. The Zetasizer utilizes dynamic light scattering to determine particle size. Microbubble and droplet concentrations were determined with Nanosight laser scattering analysis .The Institutional Animal Care and Use Committee at the University of Nebraska Medical Center approved all rodent and porcine studies. All animals were group housed. Fourteen rats  underwent left anterior descending (LAD) artery ligation using an established protocol  under isSubsequent to this, a 200 μL intravenous injection of a 1:1 dilution of DD was given. Any contrast produced by the 0.5 MI setting was noted, which was consistently no or faint left ventricular cavity contrast. At two to six minutes post IVI, the MI was transiently increased to 1.5 (while triggering at end systole once every three to four cardiac cycles) which resulted in significant left ventricular and myocardial enhancement from DD activation, including transient enhancement 3–4 frames) within the hypokinetic infarct zone (termed TEZ). The TEZ was defined then as the planimetered area of transient myocardial contrast enhancement observed within the hypokinetic zone as the MI was increased to 1.5, and which partially or completely disappeared on subsequent triggered frames at the high MI setting  was administered without imaging, and the animals were euthanized 10 minutes later. The location of the transducer probe on the chest wall was marked to ensure the same location was sliced for subsequent post mortem staining and fluorescent microscopy. Triphenyltetrazolium chloride (TTC) staining for infarct size was performed at 37°C using standardized techniques .In five otherwise normal swine, balloon occlusion of the mid left anterior descending was performed for 90 minutes followed by reperfusion and recovery from anesthesia. Procedures were performed under isoflurane anesthesia (1.5–4%) utilizing aseptic technique. Analgesia was provided by carprofen . At 48 hours post reperfusion, the pigs underwent cardiac magnetic resonance imaging (CMRI) using a 1.5 Tesla field strength magnet (Philips Achieva) again utilizing isoflurane inhalation anesthesia. Imaging sequences included standard steady state free precession imaging  followed by T2 weighted spin echo images in the same short axis views. Delayed enhancement imaging (DE-MRI) was then performed in the same short axis offsets at 10 minutes following a 0.2 mmol/kg injection of gadopentetate dimeglumine .and subsequent imaging of only the slow moving or stationary droplets that were retained within the infarct zone. Therefore, for these studies we used a Philips iE 33  phased array transducer to activate and image at two to four minutes post IVI. Harmonic imaging was performed using either a 1.3/3.4 MHz ultraharmonic or 1.7/3.4 MHz harmonic setting at low frame rates (10 Hz or end systolic triggered) with MI’s of either 0.7, 1.0 or 1.3. All images were digitally stored. Pigs were then sacrificed and post-mortem TTC staining utilized again to define the extent of the infarct zone in the same short axis plan used to detect for acoustic activation and imaging.Following this, the pigs were removed from the magnet and proceeded to echocardiographic imaging. Prior to DD injection, short axis ultrasound images were obtained to correspond to a region with a resting wall motion abnormality and a scar zone by DE-MRI. Immediately following this, 1.0 ml injections of 1:1 dilutions of DD were administered. Based on the rat studies that used multipulse schemes (amplitude and phase modulating) that resulted in simultaneous activation and imaging of droplets within the cavity and normal microcirculation, we hypothesized that single pulse harmonic or ultraharmonic imaging at slower frame rates (or triggered frame rates) would permit activation In order to confirm presence of DD within the infarct zone in the rat studies, Definity microbubbles were fluorescently labeled with a commercially available lipophilic fluorophore, dioctadecyltetramethylindocarbocyanine (DiI), prior to droplet formulation. DiI  was added to preformed DMB as previously described . This sohttps://imagej.nih.gov/ij/) software by analyzing size by side the TEZ during and following its enhancement period, as shown in In rats, quantitative measurements of the TEZ following DD injections, and contrast defects produced by DMB, were determined by a consensus of two experienced reviewers (FX and TRP) blinded to the TTC and fluorescent images. The triggered images were digitally reviewed during the transition from 0.5 to 1.5 MI, which resulted in immediate left ventricular cavity and normal myocardial zone enhancement and a transient (3–4 triggered frames) enhancement within the akinetic zone detected on short axis two-dimensional echocardiographic images. The normal myocardium was distinguished from the TEZ by the persistence of myocardial contrast beyond the transient enhancement. The TEZ was planimetered with Image J  was performed on post mortem sections to identify any locations exhibiting emission spectra near 590 nm (emission spectra for DiI). The Image J software was used to also quantify the fluorescent zone and unstained TTC area.Statistical analysis was performed using SigmaPlot V13.0 . Since we were comparing continuous variables, the size of the TEZ was compared to three other modes of infarct size detection using a Pearson correlation coefficient. The first was the planimetered size of the contrast defect obtained following DMB injections, which was chosen from triggered frames within the two minutes following the DMB injections. The second comparison was with the size of the infarct zone on post mortem TTC staining. The final comparison was with the size of fluorescently DiI stained area on the same short axis slice used for TTC staining. Linear regression was used to compare TTC unstained defect size and fluorescent area with both the contrast defect observed following DMB injections and the TEZ observed with droplet activation at >2 minutes following DD injection. In six rats, a repeat 200 uL injection of DD was administered to determine reproducibility of the planimetered TEZ size using Bland-Altman analysis. In pigs, correlation coefficients were used to compare the selectively enhanced area at high MI low frame rate imaging and the infarct zone by TTC.The formulated DD had a polydisperse size distribution, with two main peak sizes of 82 nm and 427 nm .12, while the concentration of DMB in the 200 μL solution was 4.9x1011. Note these are larger numbers than recorded in the package insert [12 droplets in the one-milliliter bolus injections.The DMB were monodisperse with a mean size of 767 nm. The number of droplets in the 200 μL doses used for rat studies was 1.7x10e insert  because 2 of the mid to distal papillary muscle short axis plane imaged. Of the 14 animals, 11 had transmural infarctions and 3 had either no or a non-transmural infarction , respiratory rate, or oxygen saturation were seen following DD or DMB injections in any rat. By TTC staining, infarct size ranged from 0–11.6 mmfarction .DMB injections consistently produced a contrast defect within the infarct zone at 0.5 MI immediately following bolus injection in all but two rats, who subsequently were found to have no or smaller-sized infarctions . In all In comparison, DD injections did not produce myocardial enhancement following bolus injection at the 0.5 MI in any animal and just trace amounts of LV cavity contrast . When thFluorescent staining was feasible in 11 of 14 rats. In 3 animals . The correlation between the measurements of TEZ following repeated injections was good .There was slight injection to injection variability in TEZ measurements with repeated measurements  at slow frame rates, with attempts to activate and image at two and four minutes following IVI. Transmural infarcts were observed in four of the six pig studies by DE-MRI and TTC staining  following bolus injections of DD in the rodent models, there was no activation or contrast enhancement within the LV cavity or myocardium, while a similar concentration of intravenous DMB at this same MI produced myocardial contrast enhancement following bolus passage that was no longer evident at two minutes following IVI. This indicates rapid clearance of DMB from the systemic circulation. Furthermore, brief high MI impulses at two minutes post IVI did not produce any evidence of retained microbubbles within the risk area. DD, on the other hand, appear to persist for at least four minutes following IVI within both ischemia/reperfused zones and normal zones. Since the droplet shell composition was not different than the microbubble, the most likely explanation is the gas escapes from the microbubbles because of high surface tension, while the liquid fluorocarbon within droplets is at a lower surface tension and remained within the shell until either activation or shell metabolism. Their persistence within the infarct zone may indicate either increased adherence to leukocytes adherent to venular endothelium (which was not seen with DMB) or accumulation within the interstitial border zones known to exist in the infarction zones .The timing of droplet activation and imaging within the infarct zone was a critical factor for determining the infarct zone location and size in the rat models of infarction. As the MI was increased to 1.5 with a multi-pulse sequence scheme at 2–4 minutes post IVI, there was cavity and normal myocardial enhancement, as well as transient enhancement within the infarct zone. The transient enhancement in the infarct zone can be explained by droplets that had accumulated within the infarct zone, but could not replenish in between high MI frames. Because the multi-pulse scheme (Contrast Pulse Sequencing) has a longer pulse sequence than standard imaging sequences , the lonThis is why we modified the pulse sequence scheme for the pig studies, utilizing a shorter pulse sequence (harmonic single pulse), slightly lower MI (1.0), and a slow frame rate (end systolic triggered) for imaging and activation. A higher MI has consistently been required for activation and imaging of DD in normal myocardium with transthoracic imaging , 8, and Although microbubble contrast agents have always been considered pure intravascular tracers, the re-formulation of them into droplets changes their characteristics and clinical utility. First, they could potentially be imaged at a high MI immediately after injection, allowing them to be reconverted back to microbubbles when they reach the left ventricular cavity and assess myocardial perfusion as has previously been demonstrated . SecondlThe timing of the droplet activation chosen for this study was set to two or four minutes post IVI, mainly because at this time microbubble bolus injections were no longer producing myocardial contrast and were clearing the blood pool. It is unclear how long after IVI one may still be able to produce sufficient droplet activation that would permit enhancement exclusively within an infarct zone. The longer the time interval, the more likely there would be less interference from cavity droplet activation, and “interfering” myocardial contrast from activated droplets in normal zones. Shorter harmonic pulses significantly improve this selective enhancement, but activation and imaging sequences need to be optimized further and tested in inferior infarctions, where attenuation of harmonic impulses may occur. As can be seen in High background signal intensities in regions outside of the myocardium  can be seen prior to droplet injection due to non-linear signal generation as a function of distance from the transducer Figs  and 8. HDD produced from compressed commercially available perfluoropropane microbubbles accumulate within acute myocardial infarct zones, and serve as a method of infarct enhancement imaging with conventional echocardiographic pulse sequence schemes at prolonged time periods following intravenous injection. Selective activation of the infarct zone is possible with IV DD and a harmonic imaging sequence, similar to what is observed with DE-MRI. Although this would be considered an off-label use for the Definity ultrasound enhancing agent, the potential for translation into clinical practice is high, as the pulse sequence schemes which activate the droplets within the infarct zone are commercially available, and the droplet formulation process appears to be safe, bedside technique.S1 File(XLSX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.S3 File(PDF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Mechanically ventilated patients with left ventricular (LV) dysfunction are at risk of weaning failure. We hypothesized that optimization of cardiovascular function might facilitate the weaning process. Therefore, we investigated the efficacy of levosimendan in difficult-to-wean patients with impaired LV performance.  Nineteen mechanically ventilated patients, with LV ejection fraction (LVEF) 34 ± 8%, difficult-to-wean from the ventilator, were assessed by transthoracic echocardiography before the start and at the end of a spontaneous breathing trial (SBT) (first SBT). Eight patients successfully weaned. The remaining 11 failed-to-wean patients received a 24-hour infusion of levosimendan, and they were reassessed during a second SBT. p=0.01). End-SBT peak e′ velocity increased from 7 to 9 cm/s (p=0.02). E/e′ increased from 10.5 to 12.9 during the first SBT, whereas it remained constant at 10 throughout the second SBT (p=0.01). During the second SBT, partial pressure of arterial oxygen and central venous oxygen saturation improved, compared to the first one . Nine of the 11 patients were successfully weaned from the ventilator.  After levosimendan administration, LVEF increased from 30 ± 10 to 36 ± 3% ( In difficult-to-wean from mechanical ventilation patients with LV dysfunction, levosimendan might contribute to successful weaning by improving both systolic and diastolic LV function. Among the multiple causes of weaning failure from mechanical ventilation , cardiovThe concept of optimizing the cardiac function before a spontaneous breathing trial (SBT) in anticipation of a difficult weaning process in patients with LV systolic dysfunction is appealing. Still, the administration of inotropes such as dobutamine does not seem to be a reasonable therapeutic option because of the potential adverse effects such as increased heart rate with concomitant-increased myocardial oxygen demand. Furthermore, the sympathetic nervous system activation during failed SBTs , 16 doesWe hypothesized that levosimendan would facilitate the weaning process in patients with LV systolic dysfunction and repeatedly failed weaning attempts from mechanical ventilation. To this aim, we studied the efficacy of levosimendan administration in these patients during weaning trials, assessed by transthoracic echocardiography (TTE).This prospective study was conducted in the multidisciplinary intensive care unit and in the coronary care unit of Evangelismos Hospital, a tertiary referral center. The study was approved by the Hospital Ethics Committee (protocol number 67/6.3.12), and informed consent was obtained from each patient or the patient's next of kin.Critically ill patients, mechanically ventilated because of acute respiratory failure of various etiologies, who had difficult or prolonged weaning from mechanical ventilation and LV systolic dysfunction, defined as LV ejection fraction (LVEF) of less than 50% , were coVE) was measured at 2 minutes after disconnection from the ventilator with a calibrated Wright spirometer  through the endotracheal tube. The average tidal volume (VT) was obtained by dividing VE by the respiratory frequency (f). The ratio of f to VT (f/VT index) was calculated [Minute ventilation (lculated . Maximumlculated .2) were continuously monitored. For gas exchange measurements, partial pressures of oxygen (PaO2), carbon dioxide (PaCO2), pH, and hemoglobin oxygen saturation (SaO2) were determined from blood samples drawn from the arterial line and also simultaneously from the internal jugular or the subclavian vein for central venous hemoglobin oxygen saturation (ScvO2) measurement, used as a surrogate for the mixed venous oxygen hemoglobin saturation. Samples were immediately analyzed .Invasive systemic blood pressure, heart rate, and oxygen saturation by using a pulse oximeter  and late filling  velocities and the mitral E/A ratio . The deceleration time of the E-wave was also measured (DT). Tissue Doppler recordings were measured with sample volume at the lateral mitral annulus. From tissue Doppler imaging, the mitral annulus velocity (e′) was obtained with the sample volume placed at the lateral side of the mitral annulus. The ratio of early diastolic LV inflow velocity to lateral mitral annular velocity (E/e′) was calculated as an estimate of LV filling pressure. The ratio of peak E to peak e′ was calculated from the average of at least 3 cardiac cycles.A comprehensive 2-dimensional (2D) and Doppler echocardiography examination was performed in all patients. LV size and function were measured according to the American Society of Echocardiography and European Association of Cardiovascular Imaging recommendations , 32. TheLV diastolic dysfunction was graded according to the standard recommendations . PatientBefore the start of the SBT, all patients were under mechanical ventilation , in the assist control mode with the ventilator settings prescribed by the attending physicians. Demographic and clinical characteristics, laboratory values, and fluid balance in the 48 hours prior to SBT were also recorded.f greater than 35 breaths per minute), SpO2 less than 90%, tachycardia (heart rate greater than 120 beats per minute) or a sustained change in the heart rate of more than 20%, systolic arterial blood pressure of greater than 180 to 200 mmHg or less than 90 mmHg, arrhythmias, increased accessory muscle use, diaphoresis, and onset or worsening of discomfort [All patients then underwent a SBT via a T-piece (“first SBT”). The SBT lasted for 2 hours, unless patients met any of the criteria for SBT failure: tachypnea  within 24 hours after levosimendan infusion.Subsequently, patients who failed the first SBT were treated with levosimendan , administered by continuous intravenous infusion over 24 hours, at a dose titrated to 0.1-0.2 t-test, the Mann–Whitney U test, or Fisher's exact test, as appropriate. We compared the measurements of the group that received levosimendan at the end of the first SBT to those at the end of the second SBT using the paired t-test. Analyses were performed with IBM SPSS version 20.Continuous variables are presented as mean ± standard deviation or range (median) for heavily skewed distributions, and categorical variables as percentages. We compared the baseline values of patients who failed the first SBT with the values of the patients who successfully completed it using the independent samples Nineteen consecutive patients  were enrolled. Admission diagnosis was surgical in 6 and medical in the remaining 13 patients. Patients had been on mechanical ventilation 11 days  and had difficult weaning with repeatedly failed weaning trials. During the first SBT, 8 patients tolerated the trial and were extubated. The remaining 11 patients met the a priori criteria for weaning failure, and mechanical ventilation was reinstituted. Characteristics of the patients according to the first SBT outcome are shown in 2O, respectively, p=0.02). There were no significant differences in gas exchange parameters between the two groups. In both groups, baseline ScvO2 values were barely normal . Also, proBNP displayed greater variability in the failed trial group.Compared to those successfully weaned, patients who failed had significantly worse values of MIP (−32 ± (−10) vs. −46 ± (−13) cm HComorbidities were evenly distributed with the significant exception of the preadmission diagnosis of systolic heart failure, which every one of the 11 patients in the failed group had. In contrast, among the 8 patients who were successfully weaned, only 4 (50%) had an established diagnosis of systolic heart failure prior to their current admission . The remSystolic function did not differ significantly between the 2 groups although there was a trend for a lower LVEF for the group of patients who failed to wean from the ventilator. In addition, all patients exhibited some degree of diastolic dysfunction .Among the 11 patients that failed to wean with the first SBT attempt and received levosimendan, 9 patients were successfully extubated after the second SBT. The remaining two patients, one with baseline LVEF = 32% and one with baseline LVEF = 36%, both with grade II diastolic dysfunction, failed the second SBT.f was 33 ± 8 and 25 ± 6 breaths/minute at the first and the second SBT, respectively (p=0.04). Correspondingly, the f/VT index dropped from 94 ± 24 at the 2-minute landmark of the first SBT to 69 ± 26 at the same time point of the second SBT (p=0.05). PaO2 improved from 67 ± 28 mmHg at the end of the first SBT to 93 ± 34 mmHg at the end of the second SBT (p=0.03). ScvO2 dropped by 6 percentage points during the first SBT and, while it was also reduced during the second SBT, the mean reduction was of 1.8 percentage points. As a result, ScvO2 at the end of the second SBT was 66 ± 11% from 57 ± 9% at the end of the first SBT (p=0.02).In this subset of 11 patients, p=0.01) between the first and second SBT . The behavior of E/e′ during the second SBT was similar to that observed in the successful group during the first SBT .The echocardiographic indices at the end of the two SBTs were modified after the treatment, as shown in cond SBT . End-tri p=0.02, . The E/eirst SBT . The E/AE/e′ throughout the second SBT to significantly lower levels than during the first SBT, associated with a significant increase in e′ during the SBT; and (iii) a successful weaning outcome in 9 out of the 11 patients who received the drug.The present study assessed the effects of levosimendan on LV performance and weaning outcome from mechanical ventilation in patients with LV systolic dysfunction and failed weaning attempts. The main findings are the following: levosimendan administration resulted in (i) a significant increase in LVEF; (ii) maintenance of a constant LV systolic dysfunction is a known risk factor for weaning failure –11. At tE/e′ is considered a reliable surrogate of LV filling pressures [E/e′ increase during the second SBT in contrast to that observed during the first SBT could possibly indicate that levosimendan reversed the consequences of SBT on LV filling pressures and, accordingly, prevented a potential pulmonary congestion. Moreover, the increase in the early diastolic mitral annulus velocity (e′) during the second SBT, in contrast to the first SBT, indicates the left ventricle relaxation rate enhancement [As tissue Doppler imaging-derived parameter ressures , 33–36, ancement . Therefo2 and ScvO2 decrease during the second SBT, as compared to the first one, further supporting a possible reduction of weaning-induced increase of LV filling pressures.These echocardiographic changes following levosimendan administration were associated with a lesser extent of both PaOThe beneficial effects of levosimendan on our patients are consistent with the pharmacological properties of this widely used calcium sensitizer. Specifically, levosimendan increases myocardial contractility by increasing myofilament sensitivity to calcium and is also a potent vasodilator due to activation of ATP-dependent potassium channels in vascular smooth muscle cells, leading to a decrease in RV afterload through pulmonary vasodilatation as well as decreases in both LV preload and afterload. Furthermore, levosimendan has favorable effects on LV diastolic function , 38. Of So far, only two studies have evaluated the impact of levosimendan on ventilator-dependent patients with cardiovascular dysfunction , 25. TheTo our knowledge, the present study is the first to provide precise echocardiographic assessment of the impact of levosimendan upon cardiac function during weaning trials in ventilator-dependent patients with low LVEF, showing beneficial effects in both systolic and diastolic cardiac function and giving, thus, a pathophysiological interpretation for its favorable effects on weaning outcome.Additionally, use of levosimendan effectively contributed to successful weaning in a patient with dilated cardiomyopathy after repeated weaning failures , as wellThis study comprised a heterogeneous group of high risk patients for weaning failure, with LV systolic dysfunction and major comorbidities, such as diabetes mellitus, renal impairment, and COPD. The small size of the study and the lack of randomization or a control group are the main limitations that prevent firm conclusions from being drawn regarding the effectiveness of levosimendan on this specific setting. However, each patient was studied four times , serving, thus, as their own control. A further limitation could be considered that the s' wave was not assessed in order to estimate the systolic function. However, to this end, we used Simpson's method, which is considered the gold standard method of the systolic function estimation.In conclusion, among mechanically ventilated patients with LV systolic dysfunction and difficult-to-wean from mechanical ventilation, levosimendan administration induced beneficial effects on both systolic and diastolic function and, possibly, contributed to the observed successful weaning from mechanical ventilation. Although pilot, this study might help to a future design of a randomized trial. Probably, further studies are warranted to confirm these results.


Median N–Type natriuretic peptide (Nt-proBNP) decreased from 1865 ± 2318 to 1514 ± 2205 pg/mL, (p = 0.01). Furosemide dose reduced from 131.3 ± 154.5 to 120 ± 142.5 (p = 0.047). Ejection fraction (from 27± 5.9% to 30 ± 7.7% (p < 0.001) and E/A ratio (from 1.67 ± 1.21 to 1.42 ± 1.12 (p = 0.002)) improved. Moderate to severe mitral regurgitation  and tricuspid velocity decreased from 2.8 ± 0.55 m/s to 2.64 ± 0.59 m/s (p < 0.014). Conclusions: Sacubitril/valsartan induce “hemodynamic recovery” and, consistently with reduction in Nt-proBNP concentrations, improve NYHA class despite diuretic dose reduction. Background: Sacubitril/valsartan has been shown to be superior to enalapril in reducing the risks of death and hospitalization for heart failure (HF). However, knowledge of the impact on cardiac performance remains limited. We sought to evaluate the effects of sacubitril/valsartan on clinical, biochemical and echocardiographic parameters in patients with heart failure and reduced ejection fraction (HFrEF). Methods: Sacubitril/valsartan was administered to 205 HFrEF patients. Results: Among 230 patients  205 (89%) completed the study. After a follow-up of 10.49 (2.93 ± 18.44) months, the percentage of patients in New York Heart Association (NYHA) class III changed from 40% to 17% ( Liking renin-angiotensin-aldosterone system (RAAS) blockade with natriuretic peptide system enhancement may bear specific therapeutic benefits to patients with heart failure and reduced ejection fraction (HFrEF). The first-in-class angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan combines the angiotensin II type-1 receptor blocker (ARB) valsartan with the neprilysin inhibitor sacubitril. Sacubitril/valsartan was superior to enalapril in decreasing risks of death and new admission for HF in patients with HFrEF in the Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) study ,3. Therest September, 2017 and 15th January, 2019, and was approved by the Institutional Research Review Board of the Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT) center in Palermo, Italy. In this prospective observational single center study, sacubitril/valsartan was administered to patients with HFrEF, in addition to recommended therapy  after switching to sacubitril/valsartan. Echocardiography is a standard imaging method for the evaluation of MR, but it is not as accurate as cardiac MRI for measurement of LV volumes. However, this study enrolled 80% of patients with ICD and 25% with CRT hampering optimal imaging acquisition for magnetic resonance imaging. Our choice of echocardiography as the primary imaging tool could be the limitation for assessment of LV remodeling. In addition, some echocardiographic parameters useful in the assessment of reverse remodeling  were not performed. MR was visually assessed because quantitative assessment of functional MR could be unreliable: the PISA method is limited by its radius which is frequently not constant, and the geometry of the PISA varies  underestimating the degree of functional MR. Vena contracta was not measured as well because intermediate values are not accurate at distinguishing moderate from mild or severe MR (large overlap); they usually require the use of another method for confirmation.Furthermore, the magnitude of reverse remodeling associated with the reduction in MR entity might have been substantially underestimated with shorter follow-up.In summary, our findings are strongly suggestive of “hemodynamic recovery” in which a modulation of neurohormonal activation determined by sacubitril/valsartan may lead to a hemodynamic effect that may impact cardiac hemodynamic and in association with Nt-proBNP concentration abatement could lead to a ameliorate NYHA class and reduce diuretics administration and consequently to preserve renal function.


SV) and its determinants is confounded by variations in volume status that occur along different thyroid states. This study applied the pressure‐volume (PV) framework to obtain relatively load‐independent estimates of cardiac function in hypothyroidism as compared to euthyroidism. Ten athyroid patients were assessed echocardiographically after 4 weeks in deep hypothyroid state, and again after supplementation with oral Levothyroxine (LT4) for 3 months. Thyroid hormone levels were assessed and noninvasive pressure‐volume (PV) analysis based on dedicated repeated echocardiograms was performed. Changes were assessed using paired tests. Results are presented as medians and interquartile ranges. Hypothyroidism was associated with reduced stroke volume , preload , and contractility . Afterload was constant  and the total energy spent was lower . Hemodynamic manifestations of frank hypothyroidism in humans are characterized by reduced preload and contractility, and unchanged total afterload. LT4 therapy increased work efficiency and heart rate, but not the net energy expenditure. Noninvasive PV analysis may be useful to follow‐up different thyroid states.Thyroid hormone importantly affects the cardiovascular system. However, evaluation of stroke volume ( Thyroid hormone (TH) has important cardiovascular effects. Thyroid dysfunction is a well‐recognized risk factor for many cardiovascular diseases. Hyperthyroidism is associated with increased risk of atrial fibrillation (AF) as well as sudden cardiac death  hypertrophy and left atrium (LA) enlargement are part of the initial manifestations of hyperthyroidism, later progressing to rate‐related systolic dysfunction if left untreated  in subclinical hypothyroidism following subtotal thyroidectomy, but used vasodilators on the process and hence could not draw conclusions on the afterload  became widely popular as load‐independent indices of the cardiac function. When used invasively, the PV framework is today the gold standard for evaluating the cardiac function as it minimizes the effects of variations in loading conditions over the estimations. Further ahead, single‐beat algorithms developed to estimate systolic and diastolic relations extended the framework reach to the noninvasive spectra  framework is a time‐varying elastance model inspired on Otto Frank`s first descriptions of the cardiac PV relations in conjunction with Starling`s Law of the Heart, Sarnoff`s ventricular function curve, and Sonnenblick`s force–velocity curve. Inferences on contractility were firstly validated in canine excised hearts by H. Suga in 1969 and later extended to ventricular energetics. Based on these developments, the This is an interesting perspective in the context of the cardiac effects of THs. Most studies on this regard lacked load‐independent estimates of cardiac function or applied it partially. The present study provides the first noninvasive load‐independent evaluation of cardiac function using state‐of‐the‐art PV analysis in patients exposed to a standardized period of deep hypothyroidism followed by thyroxine (LT4) supplementation.Patients of 18–70 years old with differentiated thyroid cancer (DTC) were recruited from the outpatient clinic of the Erasmus Medical Center Rotterdam, between June 2015 and March 2016. Initial therapy consisted of total thyroidectomy. Patients were eligible for inclusion if they were scheduled for ablation with radioactive iodine (RAI) and did not have heart failure or drugs interfering with TH metabolism. The first measurement was scheduled after 4 weeks off LT4  and the second measurement after 3 months on LT4 replacement therapy once TSH (thyroid‐stimulating hormone) suppression was reached. The Medical Ethics Committee of the Erasmus Medical Center approved the study protocol (MEC‐2014‐489) and written informed consent was obtained from all study participants.Serum‐free T4 (FT4), total T4, and total T3 concentrations were measured by chemoluminescence assays . Serum TSH was measured by immunometric assay .Ea) using available algorithms for noninvasive PV analysis , the elastance at mid‐isovolumic contraction (Ed) is derived using systolic time intervals and the diastolic blood pressure. Subsequently, the estimated value of Ed normalized to the end‐systolic elastance was calculated and used to derive the Ees. β was calculated using a specific algorithm obtained from pressure and volume‐normalized EDPVRs obtained from 80 ex vivo human hearts with different pathologies  and stroke work (SW), reflecting respectively the total energy available for each cardiac cycle and the work done by the ventricle to eject the stroke volume, were obtained. Their ratio, reflecting the rate of PVA to SW conversion , was derived. The ratio of cardiac output (CO) to PVA∙HR (to account for 1 min of PVA) was compared prior and after treatment to evaluate the effect of the chronotropic changes.Transthoracic echocardiography using an iE33 Ultrasound System  was performed by experienced technicians who were not aware of the thyroid state of the subjects. Preload was assessed before and after LT4 replacement through measurements of left atrial volume (LAV) and left ventricular end‐diastolic volume (EDV), obtained with biplane Simpson's method . The end‐diastolic pressure (EDP) was estimated using the Nagueh formula. Total afterload was evaluated before and after LT4 replacement as the effective arterial elastance (ρ was used to assess correlations between changes in Ees and changes in TH levels. The R v3.3.3 package was applied with type I error set to 5%. Multiplicity corrections were not applied because this study was exploratory and most of its variables are correlated (Bender and Lange Data are expressed as median (IQR) or mean (SD) as appropriate. Parametric data were compared with Student t‐tests and nonparametric data with Wilcoxon signed rank tests between patients off and on LT4 treatment. Spearman P = 0.024).Baseline characteristics are described in Table E/A and E/e′ ratios were unchanged, suggesting that the reduced preload in hypothyroidism decreased the magnitude of the mitral inflow.During hypothyroidism, markers of preload  were significantly reduced. Also, NT‐pro‐BNP levels were significantly reduced. The E‐wave was significantly lower but the Ees was significantly lower and the end‐systolic pressure‐volume relationship (ESPVR) was shifted to the right and downwards  and with T3 levels , as exhibited in Figure Contractility was decreased in hypothyroidism, as the rds Fig. . Ees shEa) was not different from euthyroidism. Nevertheless, as contractility was lower, the balance of forces favoring and opposing blood ejection into the ascending aorta (VAC) was significantly worse  in the hypothyroid state.SVR was increased in hypothyroidism, but SBP was significantly lower. As a consequence, the total afterload . This indicates less mobilization of the myocardial energy. Conversely, the SV/PVA ratio was unchanged suggesting that after correction, the fraction of SV displaced by 1J of PVA remained the same.This is the first study measuring full‐scale changes in the cardiac function of patients with deep hypothyroidism versus high‐normal thyroid states, applying noninvasive, relatively load independent, PV analysis Table . Previouμm diameter, can be better evaluated by the SVR, which represents the steady component of the arterial load  and SV, has been proposed to represent the net arterial load against which blood is ejected, thus reflecting the resultant of the abovementioned variables. It has the advantage of being readily comparable with the Ees, a measure of contractility  + 0.42/C–0.04, where C represents TAC  with ET under different thyroid states  was constant, WEF was higher in euthyroidism. This indicates better mobilization of the metabolic and viscoelastic energetic reserves at myocardial level at the same total energetic cost. Contractility changes after LT4 replacement are demonstrated by up‐shifting of the ESPVR and by a significant increment on the slope Higher values of WEF and increased SV occurred at similar SV/PVA ratio indicating an improvement in both work efficiency and flow production. Nevertheless, when accounting for the increased HR, the net amount of energy available during 1 min, estimated in joules of PVA (PVA∙HR), was higher posttreatment. Hence, as a result of the chronotropic response to TH, the efficiency gain verified at beat level was not translated into a less energetically costly cardiovascular state.Limitations of this study consist on small sample size, shortness of exposure periods, and absence of tonometric measurements that would warrant a more precise quantification of the pulsatile component of the afterload. Also strain analysis was not possible. The study is exploratory and its findings require further confirmation prior to implementation in clinical practice. Strengths consist in a fully integrated cardiac and global hemodynamic assessment with well‐established and state‐of‐the‐art tools, minimizing the bias derived from the variation in fluid status. In addition, the use of paired analysis to reduce confounding should be mentioned, as well as the entirely noninvasive way of data collection using dedicated echocardiography.In conclusion, in patients with deep hypothyroidism, LT4 therapy increases contractility and preload, while the total afterload remained constant. The new state was more energetically efficient at beat level and theoretically explains the increase in systolic pressures. Positive chronotropism, however, elevates CO and the net energetic cost in 1 min. The results indicate for the first time that integrated pressure‐volume analysis can be noninvasively applied in the follow‐up of patients using levothyroxine. A large‐scale study screening patients with noninvasive PV analysis on different phases of thyroid disease would be desirable to characterize this technique as a predictive tool for systolic dysfunction and other cardiovascular outcomes. Also, a clearer demonstration of how the different components of afterload would respond to TH would be adequate. The obtained information should be useful for tailoring therapeutics.The abovementioned authors have no conflicts to disclose.


Vorticity is a novel index that reflects diastolic function of left ventricle. The size of the ventricle can influence the ventricular diastolic blood flow. We evaluated effect of ventricular size on diastolic function and diastolic intracardiac blood flow using a particular species of dogs, which has a wide range of body size. Vector flow mapping was used for evaluation of intracardiac blood flow, and intraventricular pressure gradient (IVPG) was used for evaluation of diastolic function. 58 dogs weighing 1.3–42.3 kg were included in this study. Vorticity was found to be inversely proportional to the length of the ventricular chamber. Intraventricular pressure difference was positively correlated with the length of the left ventricle, whereas IVPG was not. This study showed that the vorticity is influenced by the size of the left ventricle independently of other factors. To evaluate the hemodynamic state of each individual appropriately by using vorticity and IVPD, ventricular size should be taken into account especially in the field of veterinary medicine and human pediatric and adolescent cardiology. Pulsed-wave Doppler derived transmitral flow velocity patterns are commonly used for assessment of diastolic function. However, left ventricular diastolic dysfunction can display elevation of left atrial pressure, which can easily affect left ventricular inflow patterns2. Noninvasive method that is less load-dependent to assess diastolic function is strictly needed.Diastolic heart failure is recognized as one of the major causes of congestive heart failure4. Left ventricular vorticity during early diastolic phase reflect tau, which is the gold standard for measuring left ventricular relaxation property, independent from preload5. Another report showed that the vorticity related to clinical signs of diastolic dysfunction5. These reports suggested vorticity have a potential of to be a novel marker of diastolic function. “Also, VFM is promising method that it enables evaluation” of cardiac function from a new viewpoint particularly in evaluating the energy efficiency7. Intraventricular pressure gradient (IVPG) can be measured by analyzing color M mode Doppler images is used to evaluate suction force of left ventricle8, which closely correlated to vorticity5. As is said in IVPG in a previous report, intracardiac blood flow can be affected by chamber size of the ventricle9. In order to verify the utility of index derived from intracardiac flow analysis such as vorticity, it is necessary to elucidate the influence of the heart size on the intracardiac blood flow and clarify the causal relation between the heart size and the diastolic function. Understanding the relation between the heart size and intracardiac blood flow enables us to utilize vorticity especially in the field of veterinary medicine and human pediatric and adolescent cardiology.Vorticity can be obtained by intracardiac flow analysis using Vector Flow Mapping (VFM) or 4D-flow MRI10. Therefore, the study design using growing human is not suitable for the evaluating the contribution of chamber size to the cardiac function. Also, because cardiac anatomy and the conduction system can vary considerably between species11 and its effect on cardiac flow dynamics is unclear, comparative research using different species that have different heart sizes always make a question of how much the myocardial structure and conduction system differ from species to species. To remove specific differences, it is desirable to study a single species.It is difficult to elucidate the relationship between the heart size and the cardiac function by evaluating the cardiac function during the growth period over time in humans. Because the echocardiographic indices change as human grows. The changes in cardiac function during the growth period can be explained by the functional change due to the developing myocardial function rather than the change in the ventricular sizeIn the present study, we used dogs to examine the difference in diastolic blood flow depending on the heart size. Dogs are characterized by wide range of body size among the same species. For this reason, it is possible to compare the changes in intraventricular blood flow between a variety of heart sizes by comparing adult dogs of various body size. This study will show the effect of the heart size on the intraventricular blood flow and the diastolic function.Client owned adult dogs referred to Tokyo University of Agriculture and Technology Animal Medical Center that had undergone echocardiographic examination and showed no obvious signs of cardiac disease were included. Dogs with hypertension and abnormal hydration status were excluded. The medical records of the dogs were reviewed, and clinical data including body weight, age, breed and conventional echocardiographic data were collected. Ethics Committee attached to Tokyo University of Agriculture and Technology Animal Medical Center approved this study. Owner’s consent was gained before each examination. The dogs were handled with the guidelines for the Institutional Animal Care and Use Committee of the Tokyo University of Agriculture and Technology.Echocardiographic examination was performed using a ProSound Alpha 10 ultrasonography system equipped with a 5 MHz sector probe . All examinations were performed on non-sedated awake dogs. Cardiac cycles were recorded for each plane at the end of the expiratory phase. Left ventricular inner diameter at diastole (LVIDd), left ventricular inner diameter at systole (LVIDs), ejection fraction (EF) and fractional shortening (FS) were obtained from left ventricular short axis M-mode images. Peak E wave velocity (E-vel), peak A wave velocity (A-vel) and E/A ratio were measured from the pulse-wave Doppler images of the mitral inflow. The peak myocardial velocity during early diastole (e′) and late diastole (a′) at lateral annulus and septal annulus were measured, respectively, using tissue Doppler imaging. The length of the left ventricle (LVL) was measured as the distance between the mitral annulus to LV apex. Sphericity index (SI) was calculated with LVIDd divided LVL. For acquisition of the data for VFM analysis, all dogs were connected to an ECG and placed in a recumbent position on the left side. Two-dimensional movies of the left parasternal long axis five chamber view were recorded. The color area was adjusted so as to include the inflow tract, the entire lumen and the outflow tract of the left ventricle. The Nyquist limit was maximized to minimize aliasing phenomenon. At least three images were recorded for each dog.et al.4. The aliasing was corrected by color baseline shift when the aliasing phenomenon was recognized. Based on VFM images, the vorticity and intracardiac energy loss (EL) of the region of interest were automatically calculated as previous study by Goya et al.12.Obtained data were processed using software  to acquire the velocity vector fields in the left ventricle. Briefly, manual tracing in the first frame of the endocardial border of LV followed by speckle tracking was applied to determine the cardiac wall motion of all the frames. The software computed the velocity vector fields from the color Doppler and LV wall motion information using a system established by Itatani 13. Briefly, for the analysis of IVPG, color M-mode apical four chamber views were stored. The cursor of M-mode was set parallel to mitral inflow.IVPD was calculated using in-house code written in MATLAB  as previously described8. IVPG is used rather than IVPD when there is a great difference in the heart size of each individual. IVPG was calculated by dividing the IVPD by the LVL. To evaluate the segmental pressure difference of each part of the heart, the left ventricle was trisected as previously described13. The apical side of the heart was named “apical”, the middle part was named “mid”, and the basal part was named “basal”. IVPG data was obtained after conventional echocardiography in the same situation. The average of the calculated values of three heartbeats was taken as the measurement data.In Eq. , P is thThe statistical analyses were performed using R software version 3.3.2. The significance level was set at p < 0.05. The Vorticity and EL values were logarithmically transformed for the statistical analysis. Grubbs test was used for the outlier test. If outliers were present, they were removed. Pearson’s correlation coefficients were used to evaluate correlations between vorticity, EL, IVPD, IVPG and echocardiographic parameters. Multivariate linear regression analysis was performed to determine the independent variables that correlate with vorticity and EL. A stepwise method was used for selection of the variables, choosing the variables which minimized Akaike’s information criterion.The number of cases was 58. The mean weight was 8.65  kg. The length of the left ventricle was 34.0  mm on average. The mean heart rate was 117.6  bpm. In this study, 10 Mongrel dogs, 10 Miniature Dachshunds, 9 Toy Poodles, 7 Beagles, 3 Chihuahuas, 3 Labrador Retrievers, 2 Pomeranians, 2 American Cocker Spaniels and one from each of the following breeds: Border Collie, Boston Terrier, Chinese Crested dog, Cavalier King Charles Spaniel, English Cocker Spaniel, French Bulldog, Miniature Schnauzer, Maltase, Papillon, Shiba Inu and Yorkshire terrier were included.The echocardiogram data were shown in the Table The mean value of the short axis inner diameter of the left ventricle (LVIDd) was 25.90  mm. The sphericity index (SI) of the left ventricle was 0.75 . The relationship between short and long axis diameter was shown in Fig. Conventional indexes of diastolic property  were not statistically correlated with LVL.Significant negative correlation between LVL and vorticity  was observed, but correlation with LVIDd and SI were not Fig. . A typicLVL showed a significant positive correlation with total IVPD  and IVPD of each part , whereas no correlation was found between LVL and IVPG  = 12.75, p < 0.001), with an adjusted R2 of 0.41. Participants’ predicted log2 of 0.2784. Participants’ predicted MIVPG was equal to 0.5414 × log10Vorticity.VFM derived vorticity was identified as independent predictor of MIVPG. A significant regression equation was found  = 19.91, p < 0.01), with an adjusted R2 of 0.5165. Participants’ predicted log10peak EL was equal to 0.4801 × E-vel + 0.3934 × MIVPG.Transmitral peak E wave velocity and MIVPG were identified as independent predictors of peak EL. A significant regression equation was found  = 26.11, p < 0.01), with an adjusted RWe evaluated the effect of ventricular size on diastolic function and diastolic intracardiac blood flow using dogs, which had a diversity of body size. Sparse relation between SI and LVL implies that size of the heart did not dramatically affect shape (fatness or thinness) of the heart in dogs.As with cardiac function, conventional diastolic indexes were not correlated with the chamber size of the heart. These characteristics of the canine heart allowed us to simply consider the impact of the size of the ventricular chamber on intracardiac flow.15, strength of the vortex in the right ventricle was attenuated as dilatation of the ventricle progressed. He explained the reason by using the concept of convective deceleration load (CDL). When blood flows into the larger ventricle, CDL is greater than in the small heart and mitral inflow is attenuated by CDL. In this study, IVPG equivalent to CDL was relatively insensitive to changes in heart size. This indicates that in a healthy heart, CDL cannot explain the relationship between ventricular size and blood flow. The reason why the longitudinal size of the heart affects the vortex remains unclear. Hydrodynamic computational simulation may be useful to further verify this phenomenon.Vortex is reported to be smaller in a pathologically dilated heart5, and it is not surprising that the strength of the vortex correlates with the peak E wave velocity in the present study as also reported in study in humans16. On the other hand, the relationship between vorticity and peak E can change depending on the pathological conditions. When a relaxation abnormality is observed, the vortex is strongly correlated with the E wave16. However, in the volume overloading model dogs, despite the inflow velocity was higher, the obtained vortex strength was weaker than in the normal dog14. They explained that the cardiac dilatation due to the volume overload made stronger impact to the strength of the vortex than the ventricular inflow velocity. To further verify the relationship between vorticity and mitral inflow velocity, an additional clinical study including pathological state is warranted.In the present study, the independent predictors of vorticity other than LV length was peak E wave velocity. Both the vortex and transmitral flow are considered to be influenced by ventricular relaxation17. As we showed, within a single species of animal, IVPD was positively correlated with LV length and IVPG was not. Because IVPD is susceptible to the heart size even within the single species, IVPG should be used when comparing the groups of various heart sizes in the field of veterinary medicine and human pediatric/adolescent cardiology. Popovic considered that small animals such as rats and mice might require a larger IVPG to keep the filling pressure within short RR intervals9. In our study, the change of IVPG by the size of the heart was not seen using a single species. Additionally, HR was not selected as a predictor of IVPG in the multivariate analysis. It was presumed that the IVPG is larger in smaller animals because it reflects the difference in baseline cardiac function due to the difference in species in the previous study.IVPG is an important factor of left ventricular relaxation ability and is reported to be associated with diastolic heart failure18. On the other hand, in this study, EL was correlated with IVPG, which is an index of relaxation. However, because the target group in this study did not include individuals with pathological relaxation ability, further research is needed to clarify its clinical significance.From a new viewpoint of the energy efficiency, EL was not correlated with the size of the left ventricle, unlike vorticity. The larger the E wave and the IVPG, the greater the energy loss in the left ventricle. This is consistent with a previous study that suggested EL is affected by the E wave, which is an indicator of preloadWe showed that the strength of the vortex is influenced by the size of the left ventricle independently of other factors. We should take this consideration into account to evaluate the hemodynamic state of each individual appropriately by using vorticity and IVPD especially in the field of veterinary medicine and human pediatric and adolescence cardiology.


Anderson-Fabry disease is an X-linked lysosomal storage disorder caused by mutations in the GLA gene that result in deficiency of the enzyme alpha-galactosidase A. The worldwide incidence of Fabry’s disease is reported to be in the range of 1 in 40,000–117,000, although this value may be a significant underestimate given under recognition of symptoms and delayed or missed diagnosis. Deficiency in alpha-galactosidase A causes an accumulation of neutral glycosphingolipids such as globotriaosylceramide (Gb3) in lysosomes within various tissues including the vascular endothelium, kidneys, heart, eyes, skin and nervous system. Gb3 accumulation induces pathology via the release of pro-inflammatory cytokines, growth-promoting factors and by oxidative stress, resulting in myocardial extracellular matrix remodelling, left ventricular hypertrophy (LVH), vascular dysfunction and interstitial fibrosis. Cardiac involvement manifesting as ventricular hypertrophy, systolic and diastolic dysfunction, valvular abnormalities and conduction tissue disease is common in AFD and is associated with considerable cardiovascular morbidity and mortality from heart failure, sudden cardiac death and stroke-related death. GLA gene that result in deficiency of the enzyme α-galactosidase A. The worldwide incidence of Fabry’s disease is reported to be in the range of 1 in 40,000–117,000, although this value may be a significant underestimate given under recognition of symptoms and delayed or missed diagnosis (Zarate and Hopkin Anderson-Fabry disease (AFD) is an X-linked lysosomal storage disorder caused by mutations in the Deficiency in α-galactosidase A causes an accumulation of neutral glycosphingolipids such as globotriaosylceramide (Gb3) in lysosomes within various tissues including the vascular endothelium, kidneys, heart, eyes, skin and nervous system Clarke . Gb3 accCardiac involvement manifesting as ventricular hypertrophy, systolic and diastolic dysfunction, valvular abnormalities and conduction tissue disease is common in AFD and is associated with considerable cardiovascular morbidity and mortality from heart failure, sudden cardiac death and stroke-related death  means that α-galactosidase levels in plasma and white cells can fall within the normal range but disease expression still occurs, albeit later and generally less severe than in male hemizygotes  is the commonest structural cardiac abnormality observed . Concentric LV remodelling precedes overt left ventricular hypertrophy, but when hypertrophy is established, it can be clinically indistinguishable from other causes of left ventricular hypertrophy including hypertrophic cardiomyopathy (HCM)  and 8.2  in females  and a positive correlation between LV mass and the common carotid intima-medial thickness  are within the normal range in most patients, but left ventricular and papillary muscle hypertrophy can cause a reduction in LV cavity size as well as contribute to the development of left ventricular outflow tract obstruction (LVOTO) or mid-cavity obstruction (MCO) which exacerbate symptoms of chest pain, dyspnoea and syncope  has been shown to positively correlate with late gadolinium enhancement, and elevated hs-TnT levels are associated with a reduction in LVEF over follow-up suggesting that it may be a useful biomarker for progression in Fabry’s cardiomyopathy  helps to identify early subclinical cardiac involvement before the onset of left ventricular hypertrophy or systolic and diastolic impairment   due to left atrial enlargement and diastolic dysfunction, non-sustained ventricular tachycardia (NSVT) or sustained malignant ventricular arrhythmia such as ventricular tachycardia (VT) or ventricular fibrillation (VF). The frequency of AF or NSVT in studies vary and reflect differences in cohort characteristics and the method of arrhythmia monitoring. In a study of 60 Fabry patients undergoing 24-h Holter analysis, 3.9% had persistent AF and 13.3% had paroxysmal AF. Age was an independent predictor for AF  are attributed to malignant bradyarrhythmias or tachyarrhythmia but are rarely recorded  of the coronary arteries identifies evidence of diffuse coronary plaques which are hypo-echogenic and more likely to have lipid cores compared to control patients  for multi-vessel coronary arterial disease, the internal mammary artery was found to be occluded at 1 year post-cardiothoracic surgery with recurrence of chest pain. This occlusion of a LIMA graft is unusual as they typically have a 98% patency rate at 1 year. Histological analysis of the LIMA artery showed diffuse glycosphingolipid storage in smooth muscle cells and the presence of fibrous tissue contributing to an abnormal arterial structure  imaging. ERT does not improve this parameter  and agalsidase-β . Agalsidase-α is derived from human fibroblasts whereas agalsidase-β is derived from Chinese hamster ovarian cells. Side effects of ERT include mild infusion reactions although serious side effects can include anaphylaxis. Patients may also develop IgG antibodies which might reduce treatment efficacy, and both formulations have similar antibody cross-reactivity  and 7.8 in males  on outcome  than in those without cardiovascular events (20.3%)   or loop diuretics (e.g. furosemide) to reduce LV filling pressures and pulmonary pressures. Higher doses of diuretics may also be needed in patients with fluid overload in the context of pulmonary or peripheral oedema especially in the setting of significant left ventricular systolic dysfunction. Coronary disease is treated identically to the general population.In those with atrial fibrillation (AF), no established disease-specific guidelines are present, but in general, the threshold for anticoagulation is lower even with short paroxysms of AF given the increased risk of thromboembolism in the setting of structural or valvular heart disease  may also be implanted as a prophylaxis to protect against the risk of sudden cardiac death in those thought to be at higher risk of such an event. Secondary prevention ICDs are implanted in those who have survived an aborted sudden cardiac death episode with successful resuscitation from ventricular dysrhythmia or in those with haemodynamically significant ventricular tachycardia.In individuals that develop left ventricular systolic dysfunction, conventional heart failure medication and guidelines are followed with use of ACE inhibitors (or angiotensin receptor blockers), β-blockers and spironolactone (Ponikowski et al. GLA is currently underway (ClinicalTrials.gov Gene therapy represents a potential curative treatment modality in AFD. As with various genetic disorders, research has been undertaken to assess the potential utilisation of gene therapy by recombinant adeno-associated virus-mediated gene transfer to correct the genetic defect in animal models of disease. Preliminary work has limited results but has suggested elevated α-galactosidase levels and reduced Gb3 deposition in various organs in transfected animals (Choi et al. Anderson-Fabry disease is a genetically transmitted condition that affects patients from a young age and substantially impairs their quality and quantity of life. Cardiovascular disease accounts for considerable morbidity in patients with AFD and in affected relatives, and a collaborative multi-disciplinary model of care for affected patients is essential to minimise morbidity and to optimise survival. Timely institution of ERT or chaperone therapy prior to the development of advanced cardiac disease or end-stage irreversible complications is essential to alter the natural course of disease. Conventional cardiovascular risk factor modification, including hypertension, is also important to minimise the risk of LVH progression and to avoid adverse cardiovascular events. In individuals with an established cardiac phenotype, management involves conventional medical therapy and regular monitoring enables pre-emptive intervention with pacemakers and primary prevention ICDs.


Thyroid hormones have an important role in the regulation of the cardiovascular system. The aim of this study was to investigate the presence of subclinical myocardial dysfunction in children with euthyroid Hashimoto’s thyroiditis (eHT) without evident heart disease using tissue doppler imaging (TDI) and speckle tracking echocardiography (STE) methods.m), peak early diastolic velocity (Em), peak late diastolic velocity (Am), isovolumetric contraction time (IVCT), isovolumetric relaxation time (IVRT) and ejection time (ET), TDI was performed at the base of the interventricular septum (IVS) and in the left and right ventricles . Analysis of myocardial deformation by STE including strain (S) and strain rate (SR) was performed globally in two planes, longitudinal (L) and mid-circumferential (C) in LV  and RV .TDI and STE were peformed in 50 children with eHT and in 35 healthy children. To assess myocardial velocities and time intervals, including peak systolic velocity . There was a negative correlation between thyroid antibody levels and LV global longitudinal and circumferential strain and strain rate values .Among TDI parameters, ET at LV and IVS were significantly lower, IVRT and myocardial performance index at LV and IVS were significantly higher in the eHT group compared to controls (p=0.001). There were no significant differences in SThe results show that myocardial function in children with eHT is impaired in the absence of any clinical symptoms and that conventional echocardiography is inadequate to determine these changes. The cardiovascular system is affected by abnormal thyroid hormone levels, which are detected in overt hyperthyroidism, hypothyroidism and states of subclinical thyroid dysfunction. However, the effect on cardiovascular function in thyroid patients who are euthyroid on treatement is unclear.Impairment of global left ventricle myocardial function is present in children with Hashimoto’s thyroiditis who are euthyroid on treatment and conventional echocardiography is inadequate to determine these changes. In this study, we demonstrated that speckle tracking echocardiography is a useful method in the early detection of myocardial dysfunction in children with euthyroid hashimoto’s thyroiditis.Abnormal thyroid hormone levels in states of overt hyperthyroidism, hypothyroidism and subclinical thyroid dysfunction affect many biological functions including the cardiovascular system. However it is unclear if, changes in cardiac performance associated with overt thyroid dysfunction are the result of alterations in myocardial contractility or loading conditions or both remains unclear ,2,3,4. HThe aim of this study was to evaluate myocardial function using tissue doppler imaging (TDI) and speckle tracking echocardiography (STE) methods in children with eHT with no obvious heart disease. STE is a method that has been recently developed that evaluates parameters of myocardial deformation, even in the absence of clinical signs of abnormal cardiac function ,6,8. To Assessment of myocardial parameters in eHT with normal LV ejection fraction (EF) may be informative because these echocardiographic indices assess the multidirectional function of the entire myocardium of the LV and RV.In this study, TDI and STE for both LV and RV were performed in children with eHT and in healthy children. The relationship between changes in left ventricular myocardial mechanics and laboratory markers was also investigated.This cross-sectional and case-controlled study was conducted from January to December 2016. A total of 50 patients with eHT, aged 5-18 years were recruited from the Pediatric Endocrinology Outpatient Clinics of Ankara Children’s Hematology and Oncology Research and Training Hospital. Detection of goiter was the reason for referral to the endocrinology department. The diagnosis of Hashimoto’s thyroiditis was based on estimation of thyroid stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), antithyroglobulin antibody (Tg-Ab) levels and antithyroid peroxidase antibody (TPO-Ab) levels, supported by ultrasonographic findings of thyroid parenchymal heterogeneity. The study included patients who presented to the pediatric endocrinology outpatient clinic with goiter and were diagnosed as eHT and remained euthyroid by clinical and laboratory findings for at least six months of follow-up. Inclusion criteria were positive antibodies against thyroid TPO-Ab and/or Tg-Ab, euthyroid function , Hashimoto’s thyroiditis duration ≥6 months, normal LV EF (≥60%), good metabolic control. Patients with a normal TSH levels and positive thyroid autoantibodies were evaluated once more after six months, and were included in the study if their TSH levels were still within normal levels and two thyroid autoantibodies were positive. None of the patients had any other systemic or autoimmune disease and were not on any medication. Patients who had congenital and organic heart disease, arrhythmia and anemia were excluded from the study. There were no children receiving thyroid hormone replacement therapy because hormone levels were within normal ranges in all patients.The control group consisted of 35 age and gender matched, healthy children who had presented to the pediatric cardiology clinic for evaluation of innocent heart murmurs. The same physical examinations and laboratory investigations were performed in the control group. Children with abnormal findings on laboratory testing, electrocardiograms and echocardiography were excluded.Anthropometry and blood pressure measurements were carried out in both eHT patients and controls. Goiter staging was performed according to the definition proposed by Perez et al . After 1Thyroid ultrasonography was performed by using a 10 MHz linear transducer  by experienced radiologists. In all patients, findings of thyroid ultrasonography  were recorded. Thyroid volume was calculated for each lobe by using the following formula: height x width x depth x 0.529 . ThyroidA commercially available ultrasound system , equipped with a broadband (1-5 MHz) S5 transducer was used to obtain 2D grayscale harmonic images at a frame rate of 60-80 frames per second (frames/s). Two-dimensional and M-mode echocardiography was used to measure left ventricular end-diastolic and end-systolic diameter, end-diastolic septal and posterior wall thickness, EF and shortening fraction (FS), according to the guidelines of the American Society of Echocardiography .m), and early and late diastolic myocardial velocity (Em and Am) were measured. The isovolumetric contraction time (IVCT) was calculated from the beginning of QRS in the echocardiogram until the beginning of the Sm wave. Isovolumetric relaxation time (IVRT) was calculated from the end of the Sm wave until the beginning of the Em wave. Ejection time (ET) was measured from the beginning to the end of the Sm wave. Mean values were recorded by averaging the results of three consecutive measurements. The myocardial performance index , which is a doppler-derived index including both systolic and diastolic time intervals to generate a combined index of global ventricular function, was calculated according to the formula; (IVCT+IVRT)/ET /ET .All two-dimensional STE analyses were performed by the same investigator to avoid inter-observer variability. Myocardial deformation parameters (S and SR) were measured using commercially available software  on standard 2D grayscale LV images from the standard apical 4-chamber view (AP4) for longitudinal strain and standard parasternal short axis at the papillary muscle level (PML) for circumferential strain. Two consecutive beats synchronized to a continous electrocardiography (ECG) were recorded with frame rate set to >60 frames/s. The data were transferred to the QLAB software system for off-line analysis. The endocardial borders were identified manually to include the entire myocardium in all view areas. The following peak systolic LV and RV STE parameters were measured:- LVGLS: Left ventricular global longitudinal strain at AP4,- LVGLSR: Left ventricular global longitudinal strain rate at AP4,- LVGCS: Left ventricular global circumferential strain at PML,- LVGCSR: Left ventricular global circumferential strain rate at PML,- RVGLS: Right ventricular global longitudinal strain at AP4,- RVGLSR: Right ventricular global longitudinal strain rate at AP4.SPSS for Windows  was used for the statistical analysis. Kolmogorov-Smirnov test was used to analyze the distribution of continuous variables. Numeric variables are expressed as the mean±standard deviation. Chi-square analysis were used to compare continuous and categorical variables between groups. Comparisons of demographic data and echocardiographic parameters between patients and controls were performed using Mann-Whitney U test for non-normally distributed variables. A difference was considered statistically significant at a p value of <0.05. Spearman’s correlation coefficient was used to disclose possible correlations between thyroid volumes, Tg-Ab, TPO-Ab and all echocardiographic data.The number of patients that should be included in the study was calculated by Russ Lenth’s power analysis software (www.stat.uiowa.edu/~rlenth/Power/). The control group of the study was smaller than the study group. For this reason the Power analysis was based on the “mean LVGLS levels” as main outcome, when the mean levels for the study and control groups was given as -23 and -25, respectively, and a common standard deviation of 3. The difference between the two groups can be compared with 34 cases in each group  using the Independent Samples t-test with an effect size of 0.7 (medium), a two-sided p value of 0.05, and a power of 81%.2) between the eHT group and the controls. Heart rate, systolic and diastolic blood pressure values were similar in both groups. No significant differences in fT3, fT4 and TSH levels were found between the groups. Compared to the control group, patients with eHT had significantly higher Tg and TPO antibody levels (p<0.001). A stage 1a goiter in 16 (32%) and stage 1b goiter in 34 patients (68%) were detected. The mean thyroid volume in the patient cohort (n=50) was 10.1±3.5 mL (range: 4.9-16.0 mL). The patient and control groups had normal ECG findings. Baseline characteristics and laboratory results of study groups are given in A total of 50 patients with eHT and 35 healthy controls were evaluated. The mean age of the patients was 12.5±3.2 years. Of the patients, 37 were girls (74%) and 13 boys (26%). There was no significant difference in age, gender and body mass index , each of which undergoes alternate splicing to generate receptor subtypes with differing tissue distributions. The TRα has been shown to play an important role in regulation of cardiac genes. T3 is the biologically active form of thyroid hormone and effects the heart by increasing some of these genes ,18,19,20The cardiovascular effect of eHT in adults have been extensively studied ,10. HoweDeleterious effects of eHT on the LV and RV systolic and diastolic functions have been reported, indicating that Hashimoto’s thyroiditis affects myocardial function regardless of thyroid hormone levels ,10. ConvRecently new imaging techniques have been introduced to evaluate myocardial mechanics. STE is a novel echocardiographic method and strain and strain rate obtained by STE provides an opportunity for quantitative assessment of cardiac function. STE can be used as a diagnostic method in the early stages of many cardiomyopathic diseases. Myocardial global longitudinal strain values were shown to have reduced without any changes in conventional echocardiographic parameters . SubclinThe underlying pathophysiologic mechanism leading to the cardiovascular effects of eHT have not yet been fully understood. Some mechanisms leading to cardiovascular system involvement have been reported previously in patients with Hashimoto thyroiditis.Firstly, the majority of eHT patients are in a state of slow, progressive thyroid dysfunction. It is widely acknowledged that most of these patients will progress to a state of hypothyroidism. Thus, it may be hypothesized that the insidious progression to thyroid dysfunction in Hashimoto’s thyroiditis may be responsible for the cardiovascular adverse effects, even in subjects with normal serum thyroid hormone levels ,28,29.Secondly, the spectrum of clinical signs may change during the course of HT. Thus, eHT patients may have been hypothyroid or hyperthyroid previously even though they are euthyroid at the time of assessment and LV and RV functional changes might be due to a previous hypothyroid or a hyperthyroid phase . In the Thirdly, the autoimmune state associated with Hashimoto’s thyroiditis could be the responsible for cardiovascular changes, rather than the effects of secreted hormones. Autoimmunity induced endothelial dysfunction and inflammation may have an important role in the pathogenesis of cardiovascular conditions seen in these patients, such as hypertension, atherosclerosis and myocardial dysfunction ,10,28,29Our study has several limitations. Firstly, the relatively small number of patients could be considered as a limitation. Secondly, we did not investigate the effect of thyroid replacement therapy on LV and RV functions in eHT patients.Further clinical research is needed with larger patient groups to investigate the mechanisms on myocardial dysfunction with normal LV EF in eHT patients.In this study, it was demonstrated that STE is useful in the early detection of myocardial dysfunction in patients with eHT. Impairment of global LV myocardial function is present in children with Hashimoto’s thyroiditis who are euthyroid and replacement therapy naive. In addition, conventional echocardiography was inadequate to detect these changes. It is important to increase the data available in this field, particularly prospective data. There is also a need for additional prospective data related to cardiac function in eHT patients. Subclinical myocardial dysfunction in the early disease may be considered as an indication for initiation of thyroid replacement treatment even in euthyroid patients.