Diabetic retinopathy (DR) is the most common complication of diabetes and is often characterized by damage to retinal vascular microcirculation, resulting in retinal exudation, hemorrhage, fibrosis, and neovascularization. With the aging of my country's population, the incidence of DR is increasing year by year, and it has become one of the main blinding eye diseases in ophthalmic diseases also tends to be younger. So far, although the pathogenesis of DR is not completely clear, scholars generally believe that DR is based on the disorder of glucose metabolism, causing changes in the microcirculation of ocular tissues, nerves, and blood vessels, resulting in chronic damage to the nutrition and visual function of the eye disease. In order to explore the demand for cardiovascular disease treatment, make up for the lack of chronic diseases affecting people's physical harm, and improve the success rate of cardiovascular disease treatment, a method to observe the efficacy and myocardial remodeling of trimetazidine combined with metoprolol in elderly patients with coronary heart disease and heart failure based on integrated traditional Chinese and Western medicine was proposed. 54 elderly people over 60 years old are afraid of cardiovascular disease and take active protection. A method based on observation of integrated traditional Chinese and Western medicine was proposed, and at the same time, an intelligent medical monitoring system was constructed to better study, observe, and improve the efficacy of trimetazidine combined with metoprolol in elderly patients with coronary heart disease, heart failure, and myocardial impact of refactoring. The results of the study show that trimetazidine has a good clinical effect on ischemic cardiomyopathy heart failure based on the observation of integrated traditional Chinese and Western medicine. Cardiovascular and other chronic diseases are relatively common, and they are also a special disease with very high mortality and high medical costs. The occurrence of these diseases is mainly a comprehensive symptom of myocardial systolic or diastolic dysfunction caused by various reasons. In other words, it can also be said to be a progressive syndrome caused by human ventricular dysfunction and pathological remodeling . DiabetiSeptianingrum and Susanto stated that currently, heart disease remains the leading cause of death and disability in industrialized countries . AlthougOphiopogon japonicus, and Schisandra chinensis which are responsible for replenishing qi, nourishing yin, solidifying yin and removing it, replenishing water, and stopping the sweating. It is most commonly used to treat myocardial infarction, cardiogenic shock, and septic shock [Reutersberg et al. say that Shengmai injection is based on the old Shengmai Powder formula. The main products are red ginseng, ic shock . Wang etic shock . Zhang eic shock . While aPart I: System Initialization. The initialization module of LoRa, LoRa sensor, and LoRa base station.Part II: Algorithms for Signal Reception and Symbol Parameters. The max31002 sensor detects the pulse wave of the fingertip, calculates the oxygen saturation of the blood by destroying the peak frequency and peak data of the pulse wave between the signal and the infrared light, and monitors the peak point of the pulse signal; the pulse wave conduction time is calculated by extracting the characteristic points of the pulse peak position irradiated by the same light source at the radial artery and fingertip, so as to calculate the blood pressure parameters [rameters . MLX9061rameters .Part III: OLED Display and LoRa Base Station. The main controller sends physical information to the OLED during operation. At the same time, the time data is sent to the LoRa central station through the LoRa sending module, and then sent from the LoRra central station to the medical center (PC clinic), which can be provided for medical staff. Treat patients with kindness [kindness .n data for all k significant data, where n − k is redundant [LoRa is a kind of LPWAN, which can realize wireless network transmission with longer distance and lower power consumption and solve the problem that low power consumption and long distance cannot be used at the same time. LoRa needs to adjust the transmission speed (SF), encoding speed (CR), and signal bandwidth (BW) during the wireless connection. The distribution spectrum is determined by the number of characters sent to the 6-12 bit data. The larger the spread spectrum factor, the slower the transmission rate and the larger the network range . The encedundant . The larThe system selects 0.96 inch OLED as the information display module. The module drives the chip SSD1306 and uses PC bus to transmit data through serial clock (SCL) and serial data line (SDA). PC protocol stipulates that there are three signal types during data transmission: start signal, stop signal, and reply signal . The timThe flow chart of OLED data display is shown in Pulse sensor is used on the blood pressure monitoring module to collect signals. Because the pulse wave signal belongs to physiological signal, its amplitude is small and easy to be disturbed by all kinds of noise. Therefore, low-pass filter and amplifier are added at the back end of the sensor, which can make the signal better collected by MCU ad.At present, the most common applications of signal preprocessing include moving medium filtering, adaptive filtering, and wavelet transform filtering. . Among tIn the Mallat algorithm, the selection of wavelet basis is very important. Because the signal characteristics presented by different wavelet basis functions are different, it is necessary to select the appropriate wavelet basis function. Usually, the selection is based on the wavelet base similar to the signal waveform to be processed. Another key factor in the Mallat algorithm is the selection of threshold. If the threshold is too small, the variance will be too large and the denoising is not complete; if the threshold is too large, it will lead to the loss of singularity of the signal and lead to deviation . In the j represents the decomposition process. Once the starting point is determined, the starting point needs to be measured (how the starting point is applied to the wavelet coefficients). The two most used startups are the hard work and soft work segments. The basic math problem is in formula  is the wavelet coefficient after signal wavelet decomposition. The processing method of hard threshold function is to directly set the wavelet coefficients whose absolute amplitude is less than or equal to the set threshold to zero, while retaining the wavelet coefficients whose absolute amplitude is greater than the threshold. The mathematical expression of soft threshold function is shown in formula λj=δ formula :(3)Whj, formula :(4)Wsj,It can be seen from the display that the operation of the eye is not as simple and rude as the hard start on the small-amplitude wavelet coefficients, but to suppress all the wavelet coefficients. Through the adaptive calculation of formulas , 3, and 4(1) Acquisition of Heart Rate. Heart rate is the amount of time a person's heart beats at rest, which is also the number of times the pulse beats. Heart rate is calculated as the average of patterns on adjacent peaks of infrared light over K cycles. The calculation formulas is shown in formulas  represents the abscissa of the peak point of K cycles, and peak_interval_num represents the average value of the coordinates between adjacent peaks in K cycles. The heart rate acquisition process is shown in formulas  and 6)[[(1) Acqu(2) Acquisition of Blood Oxygen Saturation. The maximum and minimum values of the collected pulse wave signal are used to represent the DC and AC components, as shown in formulas (formulas –9):(7):(7)(2) Iredmax is the pulse wave peak value collected by red LED irradiation, Iirmax is the pulse wave peak value collected by infrared LED irradiation, and Irirmin is the pulse wave valley value collected by infrared LED irradiation. According to the Lambert Beer's law, the calculation formula of bleeding oxygen can be calculated, as shown in formula (where  formula :(10)SpOA and B and the above formula can be obtained as shown in formula (The constant term of the above formula can be expressed by  formula :(11)SpOA and B. due to different manufacturers and detection locations, the two undetermined parameters are also different, so it is necessary to calibrate the blood oxygen parameters through experiments. At this stage, considering the cost and performance of the experiment, Yuyue YX301 finger-clip pulse oximeter is selected as the calibration device, and the R value is calculated by this system. The experiments were performed on 10 volunteers who exchanged human blood oxygen by holding their breaths. The experimental data are shown in It can be seen from the above formula that the estimation model includes two empirical constants R value as the abscissa and blood oxygen value as the ordinate, the calibration parameters can be obtained through data fitting. As shown in According to the above experimental data, taking X and Y, as shown in formulas (The system determined the use of two PPG markers to obtain the activity of the heartbeat to determine the continuous monitoring of blood pressure . Pulse sformulas  and 13)X and Y, X and Y parts represent the abscissa equation of the n feature point of the radial artery and the pulse wave signal of the fingertip, respectively. In this way, the difference of n similarity features can be expressed, as shown in formula (The  formula :(14)T=Xn and the sum of the sampling time (Ts) can be given. The sampling rate of the system is 100 Hz. As shown in formula   formula . (15)PTTThe first step in researching blood pressure algorithms is based on the relationship between pulse wave transmission and blood pressure. As shown in formula :(16)PTTBased on this principle, the polynomial absorption method is used to establish the structural relationship between pulse wave conduction and pressure, in order to find a wide range of blood pressure estimation model through data fitting. The following are the test steps: measure the blood pressure value of the model with a standard sphygmomanometer, calculate the running time of the pulse with a system sphygmomanometer, and record the data. Systolic and diastolic blood pressure measurements were selected as standard numerical criteria. Sixteen volunteers  were selected to measure blood pressure using a machine-type electric sphygmomanometer and a temporal pulse wave measuring machine. The tested object needs to sit still for 2~3 minutes and starts when the heart rate is stable. During the measurement, each blood pressure data group was measured 3 times, and the average value was taken. If the difference is greater than one measurement (greater than 8 mmHg), the measurement should be repeated. The average time for each measurement should be at least 2 minutes.The main factor of coronary heart disease causing myocardial hypoxia, ischemia, and myocardial infarction is heart failure. Epidemiological studies have pointed out that with the aging of the Chinese population, the incidence of coronary heart disease, hypertension, and other cardiovascular diseases is increasing year by year. The incidence of heart disease complicated by heart failure is also gradually increasing. Trimetazidine is a commonly used drug for the treatment of coronary heart disease and angina pectoris. It can selectively inhibit the oxidation process, increase the metabolic process, and regulate the energy metabolism of myocardial cells. Studies have shown that trimetazidine can reduce the release of oxygen free radicals and endothelial cells, reduce the decrease in myocardial function caused by injury or apoptosis, and achieve the purpose of improving myocardial function.In order to solve the problems existing in the process of measuring blood pressure with equation parameter equation, improve the measurement accuracy and intensity of measurement parameters, and facilitate everyone to use. After experimental comparison, the linear equation between pulse conduction time and blood pressure is used as the estimation model, and the proposed new individualized parameter calibration method is used to improve the calibration of fixed parameters.Smart clinical trials were designed and implemented. Its main function which is the front-end monitoring module combines LoRa wireless communication to monitor the patient's blood pressure, heart rate, blood oxygen, and body temperature in real time. Measurement systems and blood pressure monitors are responsible for collecting and transmitting data. Medical monitoring platforms identify the real-time presence of multiple malignancies and manage and maintain patient data . It can Oxidative stress injury is considered to be an important mechanism that leads to coronary heart disease and heart failure. Excessive reactive oxygen species act directly on unsaturated fatty acids in the body, leading to lipid peroxidation and resulting in oxidative stress injury and oxidative stress, and the body chronic inflammatory response is an important factor in the damage of vascular endothelial structure and function, and it is also the main reason for the increase in disease. The results of this study also showed that the patients in the observation group treated with trimetazidine combined with metoprolol had more significant improvement in LVEF, LVEDd, and LVESd.60 patients with ischemic cardiomyopathy and heart failure were hospitalized or outpatient in a hospital from February 2020 to October 2021. The inclusion criteria are (1) age > 50 years old. (2) According to the classification standard of cardiac function of the Heart Association, the cardiac function is grade, the left ventricular ejection fraction examined by echocardiography is, there is a clear history of myocardial infarction, or there are multiple lesions confirmed by coronary artery or coronary angiography. Inclusion criteria included acute pulmonary edema, severe hypertension, severe arrhythmia, severe liver and kidney failure, and acute cerebrovascular disease. They are divided into two groups: the management team and the medical team. There are 30 board members, 18 males and 12 females, aged 55-772, with an average age of 66.5 years and 30 outpatients included 16 males and 14 females, ages 56-774, with an average age of 67 years. Before treatment, there was no difference in age, sex, left ventricular injection portion, and cardiac function between the two groups .B-type natriuretic peptide (BNP) is a polypeptide synthesized in cardiomyocytes. It is produced when ventricular volume increases, cardiac pressure load increases, and ventricular wall muscle tension increases. It has the functions of natriuresis, diuresis, and vasodilation and a natural antagonist of the renin-angiotensin-aldosterone system (RAAS system) and the sympathetic nervous system.All patients received digitalis, angiotensin converting enzyme inhibitors, aldosterone antagonists, receptor blockers, and diuretics. The treatment group was given 20 mg 3 times/d as routine treatment. The duration of the exam is 2 months. All patients were screened every 2 months. Blood pressure and heart rate were measured on the first day and two months after the meal, and electrocardiogram, cardiac function, and color Doppler echocardiography were performed. Left ventricular and diastolic diameter, left ventricular fractional excretion, liver function, renal function, blood glucose, blood lipids, and hematuria were measured daily by biochemical parameters . Left veT test was used for each measurement before and after treatment. All statistical data were analyzed using SPSS 160 software (P < 0.05).All measurements are presented as a ± variance model, and analysis of variance was used for subgroup and control comparisons. A Left ventricular and diastolic LVEDD improved significantly compared with control group and postoperative group. The left ventricular ejection portion of the left ventricular septum was higher in the control and postoperative group than in the preoperative group. The improvement in the post-treatment group was significantly higher than that in the control group as shown in P < 0.005) as shown in In the treatment group, 16 cases were positive, 10 were positive, and 4 were negative. The overall success rate was 86%. On the board, 13 passes are good, 9 are good, and 8 are bad. The overall success rate was 73%. The outcomes and overall outcomes of the two treatment groups were significantly better than those of the control group (P < 0.005), as shown in In the treatment group, 15 cases were positive, 10 were positive, and 4 were negative. The overall success rate was 83%. On the board, 12 were excellent, 12 were positive, and 6 were negative. The overall success rate is 80%. The average outcome and summary of the two treatment groups were significantly better than those of the control group (P < 0.005). Trimetazidine does not affect hemodynamics as shown in There was no difference in blood pressure and heart rate in the treatment group before and after treatment (No abnormality was found in blood glucose, blood lipid, liver function, renal function, and hematuria in the two groups after treatment.Currently, heart disease is the leading cause of death and disability in industrialized countries. Although there is an increase in heart disease patients and their survival with treatment and surgery, many patients with ischemic cardiomyopathy are unable to perform revascularization . TherefoInflammatory factors play an important role in the onset of heart failure, and the degree of inflammatory response stress is closely related to myocardial function and disease severity. The results of this study showed that the inflammatory factors in the observation group treated with trimetazidine combined with metoprolol The degree of decline in the level is more obvious, indicating that the combination of the two drugs can effectively inhibit the release of inflammatory factors, reduce the body's inflammatory response stress level, improve the cell environment, and reduce myocardial cell damage. The specific reasons still need to be further explored.Chronic heart failure refers to the decline of myocardial contractility, so that the cardiac output cannot meet the needs of body metabolism, insufficient blood perfusion of organs and tissues, and the performance of monthly circulation and or systemic circulation blood addiction at the same time. The decisive mechanism of heart failure is ventricular remodeling. The decrease in the number of cardiomyocytes can reduce the contractility of myocardium, lead to the occurrence of myocardial infarction, and increase the load of viable cardiomyocytes, ventricular remodeling, and progressive deterioration. Studies have shown that there is an increase in apoptotic cardiomyocytes in the elderly, hypoxia, ischemia-reperfusion, myocardial infarction, and hypertrophic cardiorenal disease. The apoptosis of cardiac cells in patients with end-stage heart failure is times higher than that in normal people. In traditional Chinese medicine, heart failure is divided into five categories: “palpitations,” “asthma,” “edema,” “erectile,” and “phlegm-drinking”. These conditions recur and worsen over time. The main pathogenesis is deficiency, addiction, and drinking. Although it cannot communicate with the heart, moon, spleen, and kidney, its central qi deficiency is the most morbid variation. Since the heart does not contract, changes in RIC affect our lungs, spleen, and kidneys, and the liver is also affected.Ophiopogon japonicus, and Schisandra chinensis. It can improve the energy generation and protein generation of heart failure myocardium, eliminate oxygen free radicals, inhibit lipid peroxidation, and enhance the low cellular immunity. It can improve the whole body and heart circulation, increase myocardial blood supply, reduce the load before and after the heart, protect the structure and function of damaged cardiomyocytes, prevent and delay the role of cardiomyocyte remodeling, so as to strengthen the myocardial contractility of patients with heart failure, improve the ability of myocardial hypoxia resistance, expand coronary artery and antiarrhythmia, and improve and protect cardiac function. At present, it has been widely used in the treatment of heart failure, tike, and other diseases.The evaluation of myocardial changes and efficacy of trimetazidine combined with metoprolol in adults with congestive heart failure has been established. It can solve the problem of heart disease, meet the needs of shadow treatment of chronic diseases, make the difficulties of heart disease better, and improve the treatment effect of cardiovascular disease. Shengmai injection was replaced by a more form of Sanmai Changjing, an ancient Chinese herbal medicine. Maimendong plus Chuang Kong and ginseng are the two flavors of Shengmai injection. Shengmai injection is composed of red ginseng, β to produce acetylphthalein coenzyme A, and then recycled by tristate to produce ATP. The main sources of carbohydrates are glucose, lactic acid, and ketones. Myocardial glucose uptake generates pyruvate through glycolysis, and the absorbed lactic acid generates pyruvate through the action of lactate dehydrogenase. Pyruvate finally generates acetaldehyde coenzyme A under the action of pyruvate dehydrogenase, and then ATP is produced through trispinate cycle. Under the same oxygen supply conditions, fatty acids produce more energy than carbohydrates, but the oxygen utilization rate is low. To produce the same amount of ATP, fatty acids consume about 10% more oxygen than carbohydrates. This is particularly important when oxygen becomes a restrictive factor in oxidative metabolism. When the myocardial blood flow decreases by 20% -60%, the anaerobic glycolysis of glucose increases transiently, and the oxidation rate of free fatty acids decreases, but free fatty acids are still the main energy supply of myocardium. When the myocardial blood flow is reduced by more than 70% and the myocardial energy supply is still dominated by fatty acids, glycolysis will further increase, resulting in lactic acid accumulation and severe damage or complete loss of myocardial systolic function. When the blood flow is completely blocked, the intake of fatty acids stops completely, and glycolysis becomes the only energy source of cardiomyocytes. In the case of continuous hypoxia, the myocardium still takes fatty acids as the main source of energy, which will have an adverse effect. In the case of hypoxia, supplying energy in the way of high oxygen consumption will further aggravate the myocardial hypoxia. Fatty acids can inhibit the aerobic oxidation of glucose and reduce the production of ATP through PDH inhibition. A large amount of lactic acid accumulation, hydrogen ion accumulation, and pH value declination inhibits myocardial systolic function. The accumulation of intermediate metabolites of free fatty acids impairs the function of cell membrane. The etiology of ischemic myocardium the persistence of myocardial ischemia and hypoxia leads to the decrease of myocardial blood and oxygen supply, the increase of free fatty acid oxidation, the increase of energy consumption, the decrease of glucose metabolism, and the decrease of ATP production. Optimize myocardial energy metabolism, increase glucose metabolism, reduce free fatty acid oxidation, shift the oxidative metabolic substrate from free fatty acid to glucose, and use limited oxygen to produce more ATP. This study shows that trimetazidine combined with conventional heart failure drugs can increase muscle contractility and improve cardiac function in patients with ischemic cardiomyopathy without affecting hemodynamics. It was found that MCC950 can inhibit high glucose-induced damage of human retinal vascular endothelial cells, and the anti-inflammatory mechanism of MCC950 was verified to inhibit the activation of NLRP3 inflammasome by down-regulating NEK7-NLRP3 interaction.The form of energy used by the heart is ATP, but ATP is rarely stored in the myocardium and must be synthesized in time. In a normal and healthy heart, 60%-90% of the energy required for myocardial activity comes from mitochondrial fatty acid metabolism, and the remaining 10%-40% comes from carbohydrates. After being absorbed by cells, fatty acids are transported into mitochondria through carnitine lipophthalein transferase I and enzyme II, that is, they are oxidized by


Undernutrition is a frequently noticed medical problem in patients with heart failure. It is caused by poor nutrient intake, malabsorption, systemic inflammation, neurohumoral activation, oxidative stress, and hypermetabolic state. Undernutrition results in a decrease in the quality of life and the survival rate in patients with heart failure. There is a paucity of documentation on undernutrition among patients with heart failure in sub-Saharan African countries. The study aimed to determine the magnitude and associated factors of undernutrition among older adult patients with heart failure in the hospital setting in Northwest Ethiopia.P-value of <0.05 was used to declare a significant association.An institutional-based cross-sectional study was conducted at the University of Gondar Hospital, Northwest Ethiopia, between 1 June 2021 and 31 October 2021. A consecutive sampling method was used to recruit 262 study subjects. A Mini-nutritional assessment-full form (MNA-FL) Questionnaire was used to extract nutritional information among patients with heart failure. Patients with heart failure, who scored MNA-FL score <17, were declared to have undernutrition. The data were entered into EPI Info version 4.6.0.0 and then exported to SPSS version 26 for analysis. Explanatory variables associated with undernutrition in patients with heart failure were analyzed by applying a logistic regression model. A P-value < 0.001), with a duration of illness of 3–5 years , with a duration of illness of >5 years , presence of comorbidities , who underwent treatment with loop diuretics , and who reside in a rural area  were at risk of developing undernutrition.A total of 262 patients with heart failure were included in the study. The mean age (± SD) of the study subjects was 64.6 (± 9.2) years. Hypertensive heart disease  was the most common cause of heart failure. Hypertension was the frequently observed comorbid disease. Based on the MNA-FL score for nutritional status, 75 out of 262  were undernourished (MNA-FL < 17), while 124 out of 262  were at risk of undernutrition (MNA-FL = 17–23.5). The remaining 63 out of 262  study subjects were well nourished (MNA-FL > 24). On a multivariate analysis, patients with severe heart failure (New York Heart Association (NYHA) functional class III/IV) (AOR = 4.287, CI: 2.012–9.134, Undernutrition was a significant clinical problem in older patients with heart failure. Nutritional interventions should be prioritized for patients with chronic and severe heart failure. Heart failure (HF) is a clinical syndrome that results from structural or functional impairment of ventricular filling or ejection of the blood. It clinically presents with dyspnea and fatigue, which may limit exercise tolerance and fluid retention . Heart fAn institutional-based cross-sectional study was conducted at the Cardiac Clinic, Department of Internal Medicine, University of Gondar Hospital, between 1 June 2021 and 31 October 2021. The hospital is located in Northwest Ethiopia, which is 750 km away from the capital, Addis Ababa. The hospital served a catchment population of 7 million people. The hospital had all the major and minor clinical departments. Department of Internal Medicine was one of the major clinical departments. It had five general wards with 110 beds, one medical ICU with 12 beds, and five outpatient clinics. Other services in the department included multidrug resistant tuberculosis (MDR-TBC) service, dialysis service, endoscopy service, HIV/AIDS care, and chronic illness care. The Cardiac Clinic provided outpatient medical services for patients with cardiac diseases. The clinic was staffed with a cardiologist, internists, medical residents, medical practitioners, and unit nurses. The clinic was equipped with an Echo machine  and an ECG machine .Adult patients with heart failure were asked to return for follow-up at the Cardiac Clinic of the hospital.Patients with heart failure aged 50 years or older were asked to return for follow-up at the Cardiac Clinic of the hospital during the study period. Relatively older adult patients with heart failure were recruited to keep measuring the consistency of the MNA-FL score.Patients with heart failure who were unable to give consent were excluded from the study.Dependent variable: Undernutrition (MNA-FL score < 17).Independent variables are as follows: (1) sociodemographic characteristics—age, gender, residence, marital status, religion, and educational status; (2) clinical characteristics—cause of heart failure, duration of heart failure, severity of heart failure, comorbidities, and oral cardiac medication types.The sample size was calculated based on single population proportion formula at a prevalence of undernutrition among patients with heart failure in Southwest Ethiopia was 78%, with a confidence interval of 95% and an assumed margin of error of 5% . A conseData were collected through a structured questionnaire (MNA-FL). Patients were interviewed to obtain sociodemographic data and relevant medical and nutritional information. Weight (kg), height (m), mid-arm circumference (MAC) (cm), and calf circumference (cm) were measured and a focused clinical examination was carried out for each of the study subjects. Laboratory values were obtained from patients’ records. Echocardiography and ECG tests were carried out on all study subjects to determine the cause of heart failure and document the presence of arrhythmia, respectively.Nutritional status as undernutrition, at risk of undernutrition, and normal nutrition was declared by using the MNA-FL score. The MNA-FL score is a single and rapid nutrition assessment tool which was initially developed to assess the nutritional status of the elderly, but it was subsequently being used to assess the nutritional status of patients with chronic illnesses like patients with heart failure, malignancy, and chronic kidney disease. The MNA-FL score includes 18 items grouped into the following four categories: anthropometric assessment ; general assessment ; dietary assessment ; and subjective assessment . Each answer has a numerical value and contributes to the final score, which has a maximum of 30, with threshold values of ≥24 for subjects who were well nourished, 17–23.5 for subjects at risk of undernutrition, and <17 for subjects who were undernourished (2). The participant’s weight (kilogram) and height (meters) were measured according to the standard anthropometry procedures to determine the BMI. The adjusted dry weight was used in edematous patients (Body mass index (BMI) was calculated as weight in kilogram divided by height in squared meters  was performed for all patients by a physician with a standardization of 1 mV = 10 mm and a paper speed of 25 mm/sec. Abnormal findings on the ECG were interpreted by a cardiologist.Two-Dimensional Doppler Transthoracic Echocardio-graphy  was performed for all patients by a cardiologist to determine abnormalities in ventricular ejection fraction, valve morphology, ventricular wall size and motion, and atrial and ventricular chamber dimensions.Venous blood samples were collected from patients in plain tubes and centrifuged at 2500 rpm for 15 min at room temperature to obtain serum. Mindray BS-480  clinical chemistry analyzer was used to determine serum glucose and creatinine values by enzymatic glucose oxidase and kinetic alkaline picrate method, respectively. While radioimmunoassay (RIA) technique  was used to determine thyroid function tests, and kits were from Beijing Isotope Nuclear Electronic Co., Beijing, China.P-value of <0.25 in the bivariate analysis were exported to multivariate analysis. The results were presented as an odds ratio with 95% confidence interval. A P-value of <0.05 was used to declare a significant association.Data were entered into and cleaned in EPI Info version 4.6.0.0  and transported to and analyzed in SPSS version 26 . Categorical variables were reported as frequencies (percentages) and continuous variables as the mean with standard deviation. The results were summarized using frequency, tables, and graphs. Risk factors for undernutrition were analyzed by applying a logistic regression model. The adequacy of the model was checked by using the Hosmer and Lameshow goodness-of-fit test. Those variables with a The research protocol complied with the Declaration of Helsinki, and ethical clearance was obtained from the Institutional Review Board (IRB) of the College of Medicine and Health Sciences, University of Gondar . Study subjects were recruited only after written informed consent was obtained. All data obtained were treated confidentially. Patients with heart failure were taken care of as per the recommendation of 2013 ACCF/AHA Guideline for the management of heart failure  and body cell mass, leading to diminished physical and mental function and impaired clinical outcome from disease .Heart failure: Symptoms and/or signs of heart failure caused by a structural and/or functional cardiac abnormality and corroborated by at least one of the following: elevated natriuretic peptide level or objective evidence of cardiogenic pulmonary or systemic congestion .Hypertensive heart disease: Clinical symptoms and/or signs derived from left ventricular hypertrophy and dysfunction, myocardial ischemia, and rhythm abnormalities, all of them caused by the effects on the heart of chronically elevated blood pressure .Ischemic heart disease: Presence of typical angina with angiography-confirmed coronary artery stenosis, documented prior myocardial infarction, or documented prior coronary artery revascularization (either PCI or CABG) .Comorbidity: Any distinct additional entity that has existed or may occur during the clinical course of a patient who has the index disease under study .Urban population: People living in urban areas as defined by National Statistical Offices .Rural population: People living in rural areas as defined by National Statistical Offices .A total of 262 patients were included in this study. The mean age (± SD) of the study subjects was 64.6 (± 9.2) years. The majority  of the study participants were in the age range of 50–65 years, were women , and were rural residents  .Hypertensive heart disease  was the most common cause of heart failure, followed by ischemic heart disease  and valvular heart disease 43/262, 16%) . Three-f/262, 16%2), mid-arm circumference (MAC < 21 cm), and calf circumference (CC < 31 cm) were observed in 89/262 (34%), 86/262 (33%), and 135/262 (52%) of the study subjects, respectively  subjects were undernourished (MNA-FL < 17), while 124 out of 262  were at risk of undernutrition (MNA-FL = 17–23.5). The remaining 63 out of 262  study subjects were well nourished (MNA-FL ≥ 24) .P-value of <0.25 in bivariate analysis were regressed further in multivariate analysis, patients with severe heart failure , with a duration of illness of 3–5 years , with a duration of illness of >5 years , with the presence of comorbidities , who underwent treatment with loop diuretics , and who were rural residents  were at risk of developing undernutrition , longer duration of illness, presence of comorbidities, treatment with loop diuretics and aldosterone antagonists, and rural residents were at risk of developing undernutrition. However, those treated with ACEIs were protected from undernutrition. When variables with a utrition .P-value < 0.001). A review by Dunn et al. documented that there was an increased incidence of nutritional wasting with the severity of heart failure, ranging from 22% in heart failure NYHA class II to 63% in heart failure NYHA class III . The identified comorbidities among study subjects were known to cause hypercytokinemia from systemic inflammation and excessive REE from an increased catabolic state. The odds of developing undernutrition were three times higher in patients who were on diuretic therapy as compared to those who were not . It could be partly explained by diuretic-induced excessive renal loss of micronutrients and trace elements, or those patients on diuretic treatment might have advanced heart failure . This finding might be explained by differences in dietary habits and socioeconomic conditions among urban and rural dwellers in the catchment area. A study done in South Africa documented that urbanization was associated with an increased intake of fat, meat, sugar, and beverages. Rural residents often consumed traditional foodstuffs and had limited food choices (The magnitude of undernutrition among patients with heart failure was found to be 28.6% (95% CI: 22.9–34.4%). The estimated prevalence of undernutrition was 25–40% from an observational study by Rosa-Maria et al. . It was lass III . Similarlass III . A studylass III . Patientlass III . The odd failure . PatientThe cross-sectional study design might have a limitation on causal relationships and the absence of a control arm. The study subjects were relatively older adult patients, who might not be a true representative of the catchment population. In addition, the convenience sampling method was used, which might introduce selection bias.Undernutrition was a significant clinical problem in older adult patients with heart failure. Chronic and severe heart failure, presence of comorbidities, treatment with diuretics, and rural residence were significant predictors of undernutrition in patients with heart failure.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board (IRB) of the College of Medicine and Health Sciences, University of Gondar . The patients/participants provided their written informed consent to participate in this study.HuA contributed to the conception, design, data collection, analysis, writing, and review of the manuscript. AT contributed to the conception, design, analysis, writing, and review of the manuscript. HaA, AA, and MT contributed to the conception, design, analysis, and review of the manuscript. All authors read and approved the final manuscript and approved its submission for publication.


Significant functional tricuspid regurgitation (FTR) represents a poor prognostic factor independent of right ventricular (RV) function. It is usually the consequence of left-sided cardiac diseases that induce RV dilatation and dysfunction, but it can also resulted from right atrial (RA) enlargement and consequent tricuspid annular dilatation. FTR is very frequent among patients with heart failure, particularly in those with reduced LVEF and concomitant functional mitral regurgitation. The development of three-dimensional echocardiography enabled detailed assessment of tricuspid valve anatomy, subvavlular apparatus, and RA and RV changes, as well as accurate evaluation of FTR etiology. Due to high in-hospital mortality risk in patients who were operatively treated for isolated FTR, it has been treated only medically for a long time. Percutaneous approach considers mainly transcatheter tricuspid valve repair (edge-to-edge and annuloplasty) and represents a very attractive option for the high-risk patients. Studies that investigated the effects of different devices showed excellent feasibility and safety, followed by significant reduction in FTR grade, improvement in functional capacity and NYHA class, quality of life, and reduction in hospitalization due to heart failure. Some investigations also reported a decreased mortality in FTR patients. Nevertheless, the results of these investigations should be interpreted with cautious due to the small number of participants and relatively short follow-up. The aim of this review was to summarize the existing data about the clinical importance of FTR and FTR-induced right heart remodeling and currently existing therapeutic approaches for treatment of FTR. The importance of tricuspid valve (TV) disorders, at first place regurgitation, has not been considered as important for the outcome and overall survival for a long period of time. In the last decade, our knowledge about TV anatomy, morphology, and function significantly increased due to enormous development of imaging techniques and primarily three-dimensional echocardiography (3DE) . At the FTR is associated with significant remodeling of the right ventricle (RV), which includes the impairment of RV mechanical function, dilatation, and ultimately systolic dysfunction , 7. FTR The current review sought to summarize the existing data about the clinical importance of FTR including FTR-induced right heart remodeling, their impact on the outcome, and currently existing therapeutic approaches for treatment of FTR.Two-dimensional echocardiographic 2DE) TV assessment is challenging due to anatomical position of the tricuspid valve in the chest, specific saddle shape and nonplanar geometry, and 3 leaflets that could significantly vary in their size (surface area and length of the annular attachment). This is why 3DE with possibility to assess TV annulus, leaflets, and subvalvualr apparatus made a revolution in visualization of TV and enabled better understanding of FTR. 3DE datasets provide the overview of the TV from both sides - RV and RA. The later is known as the “surgical view,” and it has been predominantly used for the evaluation of TV changes, whereas ventricular view is used for assessment of tricuspid stenosis and severity of TR  . Recent The predictive importance of FTR is the crucial aspect that completely changed our clinical approach to these patients and enabled development of many modern interventional techniques. Study that included 8872 patients with some level of TR reported that 91% of patients had FTR . Almost Schneider et al. included almost 30,000 patients with some level of TR, without other valve disease or LV systolic dysfunction, and followed them at least 5 years . Severe n = 5083) reported that trivial FTR existed in 45%, mild in 37%, moderate in 15%, and severe in 3% patients [Some studies demonstrated that FTR severity was associated with worse outcome. During 47-month follow-up, Muraru et al. showed that event-free rate was 14%, 48%, and 93% in patients with severe, moderate, and mild FTR, respectively . Event wpatients . Survivapatients . Valvulapatients .Significant negative predictive impact of 30-day mortality of moderate and severe FTR was proven also in the patients after non-cardiac surgeries . InteresThe importance of FTR on outcome in patients with heart failure has been well established. Recently published study that included almost half-million US patients with heart failure showed that FTR was related with a significant elevation in mortality risk . AdjusteMeta-analysis of 32,601 patients with a mean follow-up of 3.2 years demonstrated that moderate and severe FTR was associated with a two-fold increased mortality risk compared to no or mild FTR , independently of pulmonary pressure and RV failure [FTR is associated with RV remodeling—RV dilatation is one of the lead causes of FTR, but once when FTR develops, it only further deteriorates RV structure and function. Viatez et al. included large number of patients TR, of whom even 92.6% had FTR, and reported that RV was dilated in 81.7% of patients with massive/torrential TR, in 55.9% with severe TR, and in 29.3% with moderate TR .Recently published study compared RV function and strain between patients with significant and non-significant FTR using 2DE and computed tomography (CT) and reported significantly higher CT-derived RV volumes and lower CT-derived RVEF, 2DE-derived LVEF, and free-wall RV longitudinal strain in patients with significant FTR (moderate and severe) in comparison to those with trace or mild FTR . UtsunomStudy that included HFrEF patients and followed them for 5 years showed that patients with moderate and severe FTR had significantly larger RV diameter, RV area, and RA volume than those with trace or mild FTR . TricuspThe research that followed for 5.4 years 78 patients who underwent TV surgery for FTR showed that CMR-derived RV end-systolic volume index and the systolic RV mass index were higher in patients with MACCEs than those without them . After aThe large study that involved 896 patients with significant FTR who were followed for a mean period of 2.8 years reported significantly higher RV diameters, RV volumes, and RA area in non-survivors than in survivors, whereas parameters of RV systolic function  were significantly lower in non-survivors than in survivors . MortaliKebed et al. recently proposed introduction of the term “massive” TR in patients with bi-plane vena contracta > 0.92 cm  Table 11. TricusCurrent European guidelines recommend surgical repair of TV in patients with severe FTR who undergo left-heart valve surgery (class I) or in patients with mild or moderate FTR with dilated tricuspid annulus who undergo left-heart valve surgery (class IIa) . Surgeryp = 0.004), but presentation was also more severe. Independent predictors of adverse outcome were NYHA Class III/IV, moderate/severe right ventricular dysfunction, and right-sided heart failure signs, whereas TR mechanism was not [n = 713) and showed that there was no difference between types of TV annuloplasty prostheses (rigid rings vs. flexible bands) in the management of FTR or change in the degree of TR over time [The investigation that included patients who underwent left-sided valve surgery with or without concomitant tricuspid annuloplasty due to FTR showed a significant reduction in RV diameters and improvement in RV systolic function (FAC) in patients with concomitant tricuspid annuloplasty, whereas RV diameters increased and FAC remained the same in the patients without tricuspid annuloplasty 3 years after operation . The lar was not . Alragniver time .Pawha et al. included 926 FTR patients who underwent TV replacement or annuloplasty over period of 25 years and found that congestive heart failure, renal failure, previous MV surgery, and TV replacement were independent risk factors for late mortality . Small sMeta-analysis that investigated the outcomes after surgery for FTR showed that pooled early mortality was 3.9%, and late mortality rate was 2.7%/year, of which cardiac-related mortality was 1.2%/year . NeverthTranscatheter TV interventions are fast-developing field in interventional cardiology, and they should serve as an alternative approach for symptomatic patients with high risk for conventional surgery. Currently available devices can be classified according to the therapeutic target in several groups: leaflet devices for edge-to-edge repair, annuloplasty devices, heterotopic caval valve implantation, and transcatheter TV replacement. Most commonly used solutions nowadays are devices for edge-to-edge repair (TriClip from Abbott and PASCAL from Edwards Lifesciences) and Cardioband (Edwards Lifesciences) for tricuspid annuloplasty.According to the current guidelines, TV surgery is recommended in patients with at least moderate TR who are undergoing left-sided valve surgery (level of evidence I) and in symptomatic patients with severe isolated TR—primary and secondary (level of evidence IIa and IIb) . The optp = 0.04) [The first device that has been long used for the edge-to-edge treatment of FTR was MitraClip. Study that included 249 TR patients (FTR was present in approximately 90%) reported clinical improvement measured by NYHA class reduction, but not reduction in mortality or rate in hospitalization due to heart failure after 1-year follow-up . Procedu = 0.04) . Similar = 0.04) . In addi = 0.04) . Further = 0.04) .The TRILUMINATE was the first study that investigated the device dedicated for treatment of TR  and showed the safety and effectiveness in reducing TR by at least 1 grade with small 6-month mortality rate (5%) . These rThe PASCAL system for MV has also been proven as safe and effective for the reduction of TR . The firThe FORMA repair system (Edwards Lifesciences) sought to improve the TV coaptation by reducing the regurgitant orifice with a spacer, which provided a surface for native leaflets coaptation to reduce the orifice area. The device contains a spacer that was advanced through a rail anchored at the septal portion of the RV apex. The first investigations showed good feasibility with a favorable 1-year safety profile . EchocarThere are several types of tricuspid annuloplasty: suture-based (TriAlign and TriCinch devices), minimally invasive tricuspid annuloplasty with pledget-assisted suture, and ring-based annuloplasty. The last one  is the most widely studied and used in the clinical practice so far. Davidson et al. recently reported Cardioband device success of 93% and no death outcome in the first 30 days, with significant reduction in septolateral tricuspid annular diameter, decrease in TR grade, improvement in NYHA functional class, and overall Kansas City Cardiomyopathy Questionnaire score . EuropeaComputed tomography (CT) has a very important role in the pre-procedural assessment of TV anatomy (annular dimension), as well as the relationship with other important structures, such as right coronary artery (RCA), aorta, and coronary sinus. One of the essential measurements during the procedure is the systematic measurement of the distance between TV hinge point and the RCA. This is determined by CT before procedure and used for the orientation during procedure, in combination with fluoroscopy. Furthermore, specific CT protocols can verify the presence of enough tissue on the tricuspid annulus for the anchors implantation in order to identify the best location for their implantation, which should prevent damage of RCA and other surrounding structures. Another orientation landmarks are aorta and coronary sinus that are easily detected by CT and correspond well with 3D TEE multiplanar reconstruction. New techniques enable fusion of CT, fluoroscopy, and echocardiography during interventional procedure, which provides a better alignment of the delivery system to place the anchors in the predicted position on the tricuspid annulus. However, encouraging results from studies that used interventional techniques to resolve the problem of severe TR showed that this approach should be strongly consideredTranscatheter TV implantation is still in experimental phase and although there are several devices, there are still not commercially available. The NaviGate valve (NaviGate Cardiac Structures) was one of the first implanted in a patient with a failed tricuspid annuloplasty ring and dilated tricuspial annulus . The EVOThe multicentre TriValve cohort included all existing interventional procedures for treatment of TR  showed that transcatheter treatment was associated with significant reduction of mortality compared to conservative therapy and might show its best treatment effects in patients with mid-range RV dysfunction TAPSE between 13 and 17 mm) . Meta-anThe importance and interest for FTR has extremely increase over last decade due to growing body of evidence that FTR has significant negative impact on survival in patients with different CVDs and new therapeutic approaches that primarily include interventional methods. According to the current guidelines, severe FTR should be surgically treated only at the time of surgery for left-sided valve disease. Isolated TV surgery is associated with high surgical risk, and therefore, less invasive approach would be very much appreciated. The results from the interventional trials demonstrated a significant improvement in survival, hospitalization rate, and quality of life in FTR patients treated with some of these methods. Several transcatheter techniques are currently available for clinical use and even more are under investigation. Nevertheless, existing studies included small number of patients with limited follow-up and many questions remained to be clarified in the future trials.


Among imaging parameters, peak VO2 positively correlated with global work efficiency , and global work index . The group of patients with high-risk CPET findings showed evidence of more advanced disease, such as higher NT-proBNP levels (p = 0.007), increased septal and posterior left ventricular wall thickness (p = 0.043 and p = 0.033 respectively) and decreased global work efficiency (p = 0.027) without substantial differences in cardiac MRI parameters. In this group of patients, peak VO2 and VE/VCO2 were not associated significantly with overall survival and cardiac response at one year. Conclusion: In patients with AL amyloidosis, evaluation of exercise capacity with CPET identified a group of patients with more advanced cardiac involvement. The potential of CPET as a risk stratification tool in AL amyloidosis with cardiac involvement warrants further research.Background: Cardiopulmonary exercise testing (CPET) has been widely used for the functional evaluation of patients with heart failure. Patients with amyloidosis and cardiac involvement typically present with heart failure with preserved or mildly reduced ejection fraction. We sought to evaluate the use of CPET parameters in patients with AL amyloidosis for the assessment of disease severity and prognosis and their association with cardiac imaging findings. Methods: A single-center prospective analysis was conducted, which included 23 consecutive ambulatory patients with AL amyloidosis with cardiac involvement, not requiring hospitalization or intravenous diuretics. Patient evaluation included CPET, laboratory testing, echocardiography and cardiac MRI. The cohort was divided according to the presence of high-risk CPET characteristics (below median peak VO2 and above median VE/VCO2). Results: Patients with AL amyloidosis and cardiac involvement  had median peak relative VO2 (VO2/kg) of 17.8 mL/kg/min, VE/VCO2 slope of 39.4 and circulatory power of 2362.5 mmHg⋅mL/kg/min. Peak relative VO2 gradually declined across Mayo stages ( Immunoglobulin light chain (AL) amyloidosis is the most common form of systemic amyloidosis, with an incidence of approximately 9 to 14 cases per million person-years . With thCardiopulmonary exercise testing (CPET) is a test used to assess a patient’s cardiorespiratory capacity. CPET has become an important tool for patients with heart failure (HF), since it aids in classifying disease and determining prognosis . FurtherThis is a single-center prospective analysis of twenty-three consecutive patients with AL amyloidosis who were ambulatory, not requiring hospitalization or intravenous diuretics in the previous month. All patients were diagnosed and underwent CPET between March 2021 and March 2022 with complete follow-up until July 2022 at the Department of Clinical Therapeutics of National Kapodistrian University of Athens . We excluded newly diagnosed patients with decompensated heart failure requiring hospitalization for intravenous diuretics, inotropes and vasopressors. Also, patients wheelchaired or bed-bound were not candidates for any exercise protocol and were excluded. The diagnosis of light-chain cardiac amyloidosis [AL CA] was based on a combination of typical features on echocardiography, cardiac magnetic resonance imaging and histologically proven systemic AL amyloidosis according to current international recommendation . PatientDemographic, clinical follow-up and laboratory data were obtained by review of the patients’ medical records and from the prospectively collected clinical database. All patients underwent laboratory testing for measurement of disease-specific biomarkers , echocardiographic and myocardial work tests and MRI assessment. The study was approved by the Institutional Review Board and was conducted in accordance with the Declaration of Helsinki. All participants provided their informed consent to participate.All participants underwent a CMR examination, using a 3.0T MRI Philips (Achieva TX) manufactured scanner. CMR analysis was performed by a radiologist experienced in CMR imaging and one MRI physicist blinded to participants’ clinical history using the commercially available software . Left ventricular endo- and epicardial borders were manually outlined in the short-axis slices at the end-diastolic and end-systolic phases. Left ventricular features and function, including LV wall thickness, wall mass, ejection fraction, end-systolic volume, end-diastolic volume and stroke volume were computed based on short-axis slices. Native and post contrast T1 myocardial relaxation images were firstly manually segmented, drawing endocardial and epicardial contours, and then were co-registered to eliminate motion-related artifacts, using CVI42 software. Subsequently, the automatically derived global T1, extracellular volume (ECV) and R2 maps were visually checked for the presence of artifacts. Regions of interest were drawn in artifact-free spleen area on the short-axis T1, T2 and ECV maps.At baseline, patients underwent a transthoracic echocardiography, including standard echocardiographic images and specific images appropriate for speckle tracking processing. Echocardiographic studies were performed by a single experienced operator using a standard commercial echocardiographic system . Standard echocardiographic images were acquired according to the recommendations of the European and the American Associations of Echocardiography . Left ve2), and carbon dioxide output (VCO2). Peak exchange values are the highest values achieved during the last minute of exercise. Anaerobic threshold was defined as the point of exercise when carbon dioxide output increased exponentially compared to oxygen consumption. Percent predicted peak VO2 was calculated using peak measured VO2 values divided by the reference peak VO2 values reported by Wasserman [2 slope. Circulatory power was determined by multiplying the relative peak VO2 (VO2/kg) by the peak systolic blood pressure. Also, end-tidal CO2 was measured, and breathing reserve (%) was estimated as the difference between maximal voluntary ventilation and maximal ventilation at peak exercise divided by maximal voluntary ventilation.CPET was performed using a stationary bicycle ergometer. Workload was determined using a ramp protocol (10 W/min), and patients exercised until exhaustion. Heart rate and blood pressure were measured during rest, throughout the exercise test, and during recovery, using a right hand cuff sphygmomanometer. Respiratory analysis was conducted using a breath-by-breath technique and an air-flow analyzer, which measured the minute ventilation (VE), respiratory rate, oxygen uptake  . The Shapiro-Wilk test was applied to determine if the estimated parameters are well-modeled by a normal distribution. Continuous variables were summarized using median and inter-quartile range, while categorical variables were listed as frequencies and percentages. Independent samples t-test and ANOVA tests were performed for comparisons between groups of continuous variables, while the chi-squared test was used to compare categorical variables. Skewed data were tested with the Kruskal-Wallis test. Pearson’s correlation coefficients and Spearman’s correlation coefficients were calculated for normally distributed and skewed data, respectively, to measure the strength and direction of association that exist between CPET parameters and certain laboratory and imaging features of patients. Survival and any response  were assessed with Cox regression analysis. Cardiac response at one year was assessed with logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was used to investigate the prognostic value of CPET results and the NT-proBNP biomarker, and the area under the curve (AUC) was calculated.2  and dFLC of 366.6 mg/L . According to the Mayo stage classification, 4 patients (17.4%) were at stage I, 11 (47.8%) were at stage 2 and 8 (34.8%) were at stage 3. Regarding NYHA classification at diagnosis, 8 patients (34.8%) were at class I, 12 (52.2%) were at class II and 3 (13%) at class IIIa. A total of 23 patients with AL amyloidosis were included in the analysis. Baseline patient characteristics, CPET and echocardiographic and cardiac MRI parameters are presented in 2 (VO2/kg) was 17.8 mL/kg/min , the median peak absolute VO2 was 1251 mL/min , and the median predicted VO2 was 71% . The VE/VCO2 slope was 39.4  and the circulatory power was 2362.5 mmHg·mL/kg/min . The median peak systolic blood pressure, diastolic blood pressure and heart rate observed during exercise testing were 140 mmHg, 80 mmHg and 120 bpm, respectively. Metabolic equivalents (METs) were also calculated, with a median value of 5.1, while the median respiratory quotient was 1.2. Lastly, the breathing reserve of patients undergoing CPET was 50.2%, the median VO2 measurement at the anaerobic threshold was 903 mL/min, and the median end-tidal CO2 pressure (PETCO2) was 29 mmHg.All 23 patients underwent CPET before the institution of any anticlonal therapy. The median peak relative VOAll patients underwent imaging modalities, including echocardiography and magnetic resonance imaging (MRI). Echocardiography measurements revealed a median intraventricular septum (IVS) thickness of 14 mm, a posterior wall (POW) thickness of 14 mm, a left ventricular ejection fraction (LVEF) of 55%, and a global longitudinal strain (GLS) of −15.3%. The median values of myocardial work quantification were: global work index (GWI) of 1257 mmHg% , global constructive work (GCW) of 1859 mmHg%, global wasted work (GWW) of 114 mmHg%, and global work efficiency (GWE) of 90%. Cardiac magnetic resonance imaging (CMR) analysis demonstrated a median native T1 value of 1437.5 ms, median ECV value of 40.5%, T2 value of 56.8 and GLS of −10.47%.2/kg and VE/VCO2, which were used as cutoff values, we dichotomized the patients into a group with more severely impaired exercise physiology according to peak relative VO2 and VE/VCO2. Their characteristics were compared with the remaining patients not exhibiting these derangements. Patients with both a VO2/kg ≤ 17.8 and a VE/VCO2 ≥ 39.4 were placed in group A (n = 8), while the rest of patients were placed in group B (n = 15). Medians of the patient characteristics, CPET results, echocardiography and myocardial work, as well as MRI features of the two groups were compared and are presented in According to the medians of VOp = 0.007) and significantly lower levels of eGFR  compared to patients in group B. Their high-sensitivity cardiac troponin T was also higher, although the result was not statistically significant . Several echocardiographic and myocardial work features presented also significant differences between the two groups, including IVS thickness , POW thickness  and GWE . No significant differences were observed on MRI parameters. Patients in group A had significantly higher baseline levels of NT-proBNP , as presented in 2/kg was significantly correlated with the baseline NT-proBNP levels , while the correlation between NT-proBNP and the VE/VCO2 slope was not significant  (p < 0.001) and GWI  both demonstrated significant positive correlation with the VO2/kg (p = 0.01) and PETCO2 .The correlation of the CPET results with Mayo stage, NT-proBNP and various imaging characteristics of the patients, including CMR results and myocardial work, was assessed. The peak relative VO2 gradually decreased in more advanced Mayo stages ( = 0.08) . A corree VO2/kg . Further2/kg values and overall survival or any organ response, as well as the risk of group A patients for mortality and any organ response, but the results were not significant, as seen on The prognostic value of CPET results was studied using the predefined endpoints of overall survival, any organ response and cardiac response. Cox regression was used to evaluate possible correlation between the VO2/kg, VE/VCO, and NT-proBNP were created and are presented in 2/kg was 60.5% , for the VE/VCO2 slope it was 61.2%  and for the NT-proBNP it was 65.8% .ROC curves for VOIn this prospectively collected cohort of patients with AL amyloidosis who underwent CPET and comprehensive cardiac imaging assessment, we identified a gradual decline in peak VO2 in more advanced stages of disease and correlation with echocardiographic parameters, such as global work efficiency and global work index. A group of patients with severe impairment in exercise capacity characterized by below median peak relative VO2 and above median ventilatory efficiency slope had biochemical and imaging evidence of more advanced disease. In this small cohort of AL patients with cardiac involvement, we did not identify significant association between CPET performance and disease outcomes; however, the small number of patients and the limited number of events does not allow for a meaningful survival analysis.AL amyloidosis is the most common type of amyloidosis, also having the worst prognosis. Despite that, advances have been made both in early diagnosis and treatment, resulting in an improved survival . This isPatients with cardiac AL classically present with HFpEF or mildly reduced ejection fraction, and CPET has been proven to be efficient at stratifying risk in patients with HFpEF . FurtherAs demonstrated by the study results, a significant correlation between CPET results and certain biomarkers, including the NT-proBNP and the eGFR of patients, was found. A significant correlation was also noted between VO2/kg and the Mayo stage of patients, which is one of the most important tools for assessing cardiac AL amyloidosis. Additionally, significant correlations were observed when comparing CPET results with echocardiographic features of patients and myocardial work results. Myocardial work is an emerging, non-invasive tool, which can be used to explore heart function and has been recently shown to yield a better predictive value than LVEF and myocardial contraction fraction in patients with cardiac amyloidosis . No signn = 4) in our study, as our CPET data correlate well with markers that have a well-established prognostic value, such as NT-proBNP and the Mayo Clinic Staging System. Moreover, median peak VO2 in previous studies was substantially lower compared with our measurements. This shows that our cohort included patients diagnosed in earlier stages of disease. Therefore, even in this cohort of less sick patients, peak relative VO2 correlates with disease severity.Regarding the prognostic value of CPET, no correlation was found in our study between CPET and mortality. We also evaluated the data for possible correlations between CPET results and any response or cardiac response without significant results. This is contrary to the results of previous studies by Bhutani et al. and Hein et al., who demonstrated that several values derived from CPET can aid in determining prognosis ,9. This Our study has some limitations, indicating that the results should be interpreted with caution. First, our study does not have a control group and, as such, has the fundamental limitations of its design. The number of patients was also relatively small, the follow-up was relatively short and our cohort’s low event rate could have limiting effects on survival analysis. The main strength of this analysis lies in the comprehensive evaluation of AL amyloidosis patients with cardiac imaging and CPET.In conclusion, CPET can become an important tool in assessing disease severity in patients with cardiac AL amyloidosis, giving a wide array of information, without having the drawbacks of biomarkers. It can possibly play a pivotal role in evaluating response and candidacy for advanced cardiac therapies. Although the prognostic value of CPET was not directly demonstrated in our cohort, the CPET results correlated well with well-established prognostic markers, indicating the need for larger cohorts that could produce significant results.


Unroofed coronary sinus syndrome (UCSS) is a rare cardiovascular malformation with nonspecific clinical manifestations that easily causes misdiagnosis and missed diagnosis. The aim of this study is to present the different features of UCSS by various CCT (cardiac CT) postprocessing techniques and evaluate the diagnostic advantages of CCT.9 UCSS patients who were diagnosed by imaging and undergone both CCT and transthoracic echocardiography (TTE) were included in this study, and their CCT images were reviewed. The UCSS images were classified by multiplanar reformations, maximum intensity projection, volume rendering and cinematic rendering. The size of CS roof defect was also measured.P < 0.05). UCSS was classified according to the Kirklin and Barratt Boyes’s method, including 1 case was classified as type I, 4 cases as type II, 1 case as type III, 2 cases as type IV, 1 case as type V (variant type), and TTE was undiagnosed in all type III-V patients. Additionally, CCT showed 12 extra malformations in these patients, only 5 of them were found by TTE , and TTE missed all extracardiac malformations. The mean size of CS roof defect was 3.04 ± 1.57 cm.Only 4 of 9 CCT confirmed UCSS patients were detected by TTE , the sensitivity of TTE was lower compared to CCT by Fisher’s exact test (CCT with various postprocessing technologies has excellent value in diagnosing and differentiating subtypes of UCSS, measuring size of coronary sinus defect, describing accompanying cardiovascular abnormalities. The coronary sinus (CS) has no traffic with the left atrium (LA), and it courses in the coronary sulcus between the left atrium and the left ventricle (LV), collecting the majority of the myocardiac blood. The main branches of the CS are the great cardiac vein (GCV), the middle cardiac vein (MCV), the small cardiac vein (SCV), oblique vein of left atrium (OVLA), the left marginal vein (LMV), and the left posterior vein (Lpv). UCSS, a rare type of atrial septal defect (ASD), is formed anatomically by complete or partial absence of the CS roof, which causes CS connect to LA. In some patients, UCSS is accompanied with the persistent left superior vena cava (PLSVC), and sometimes the left and right superior vena cava can be connected through innominate vein (Inn.V.) . If a riWith the approval of the hospital ethics committee, the database of our hospital from May 1st, 2016 to October 31st, 2021 was retrospectively screened. Among 5859 patients with congenital heart disease, a total of 14 UCSS patients diagnosed by imaging following the diagnostic criteria in previous publications . CS roofCardiac ECG-gated CT was engaged on a dual-source scanner  in this study. Scan range was from 10–15 mm below the tracheal bifurcation to the diaphragmatic surface of the heart. Tube voltage and tube current were regulated by Care Dose 4D and Care KV technology. The pitch was adjusted according to the heart rate, with rack speed of 0.25 s, layer thickness of 0.75 mm, and reconstruction interval 0.50 mm. The image series of optimal diastolic and systolic phase was reconstructed automatically or selectively. Nonionic contrast agent  in a dosage of 0.7 ml/kg body weight at 5 ml/s was injected by double-barrel high-pressure syringe following with 40 ml sanitary saline at the same rate. The duration of contrast agent injection was 6-13 s. Scanning was triggered 6 s after the CT value of ascending aorta reached 100 hounsfield (HU) by group note tracking procedures technology.Image postprocessing was carried out on Syngo.via workstation with postprocessing techniques: multiplanar reformations (MPR), maximum intensity projection (MIP), volume rendering (VR), cinematic rendering (CR). The short axis, long axis, oblique coronal and sagittal images of the coronary sinus and PLSVC were reconstructed. The size of CS roof defect was measured on coronal MPR images. UCSS was classified according to the Kirklin and Barratt Boyes’s method : Type I:P < 0.05 was considered statistically significant.The data was processed by GraphPad Prism 8 software. The sensitivity of CCT and TTE for the diagnosis of UCSS was compared by Fisher's exact test, There were 9 patients with UCSS, aged from 30 to 56 years, with an average of 48.1 ± 8.0 years, included 3 males and 6 females, the clinical characteristics were summarized in Table 9 patients were classified into 5 groups according to Kirklin and Barratt Boyes classification of UCSS , includiP < 0.05). TTE missed 1 type II , 1 type III , 2 type IV , and 1 type V . Additionally, CCT showed 12 extra malformations in these patients, only 5 of them were found by TTE , and TTE missed all extracardiac malformations including PLSVC, common pulmonary vein (CPV), total anomalous pulmonary vena cava (TAPVC), abnormalities in drainage of the great cardiac vein (ADG). The size of CS roof defect was from 0.74 to 6.02 cm, with an average value of 3.04 ± 1.57 cm  [With high temporal resolution and advantages of 3D visualization of cardiac anatomy, CCT technology has gradually become the preferred modality for cardiovascular disease in most medical centers , 13. CCT G (46%) . And it Kwak, J [UCSS is often associated with other malformations, such as atrial septal defect, ventricular septal defect, uniatrial heart, completely abnormal pulmonary venous drainage and tetralogy of Fallot . The excKwak, J .The surgical option for UCSS depends on the presence of PLSVC and the presence of a vascular bridge between RSVC and PLSVC . When noThis was a retrospective study aimed at providing mainly descriptive images to evaluate the CCT advantages in diagnosing UCSS and its malformations. However, small sample size limited the statistical power of analysis. In addition, UCSS patients should be followed up longer to understand the prognosis and treatment results.UCSS is a rare congenital heart disease, and its clinical presentation lacks diagnostic specificity. CCT has a advantage in the diagnosis of UCSS, differentiating subtypes of UCSS, depicting the size of the coronary sinus defect, describing other associated cardiovascular anomalies. The varied presentation of UCSS with the CCT postprocessing techniques allows clinicians to have a more direct and comprehensive view of the lesion, which can improve clinician choice of treatment mode or surgical plan and the assessment of prognosis.


Acute myocardial infarction patients are at high risk for heart failure, even after successful revascularization therapy. We performed a study that aimed to identify early predictors of heart failure after myocardial infarction. The study included 244 patients discharged with a normal heart function after their first myocardial infarction. At the 2- year follow-up, we found that 186 (76%) showed an improvement in left ventricular function and 61 (24%) had a deterioration of the latter. Comparing the two groups, we found patients in the latter group were older, more often hypertensive, smokers, and had more severe clinical presentations of the acute myocardial infarction and more extensive coronary disease. A total of 19 patients (8%) had experienced hospitalizations for heart failure, 6% being from group I and 12 % from group II, and this difference was notable. We observed that the presence of heart failure at the admission for acute myocardial infarction and abnormal deformation patterns of the infarct-related myocardial segments detected by echocardiography accurately predicted the occurrence of heart failure during the next two years. The presence of these parameters might enable a better risk-stratification and initiation of an effective preventive therapy in acute myocardial infarction patients.p < 0.0001). The Killip class at admission >2, infarct-related longitudinal strain ≤−12.5%, and the presence of LV remodeling were identified as independent predictors of HF hospitalizations. (4) Conclusions: About 26% of AMI patients with normal LV function after a successful PCI developed HF. More sensitive techniques are required that allow for a more efficient risk-stratification and preventive therapy to reduce LV remodeling and HF in AMI patients with LVEF ≥50% after a successful PCI. The detection of abnormal ventricular deformation patterns after PCI by speckle-tracking echocardiography might be a valuable method in this approach.(1) Acute myocardial infarction (AMI) patients are at risk of left ventricular (LV) remodeling and heart failure (HF), even after successful revascularization by percutaneous coronary intervention (PCI). We wanted to assess the independent predictors of these outcomes in AMI patients. (2) Methods: The study enrolled patients with a LVEF ≥50% after a successful PCI for their first AMI. After 24 months, patients were separated into two groups based on whether their LVEF remained ≥50% (group I), or decreased to <50% (group II). (3) Outcomes: 26% of the patients experienced a decrease in LVEF below 50%, 41% showed LV remodeling, and 8% had experienced HF hospitalizations. HF hospitalizations were significantly more frequent in group II patients ( Left ventricular (LV) remodeling after acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI) is a major determinant for both short-term and long-term clinical events . It implAlthough primary PCI has drastically improved the outcomes of AMI patients, detrimental left ventricular (LV) remodeling still occurs in 30% of them [It is well recognized that traditional echocardiography is the preferred imaging approach for the detection of heart failure (HF) in AMI patients, by evaluating the left ventricular (LV) ejection fraction (EF) and the score index of wall motion (WMSI) . Left veIt is essential to evaluate all AMI patients for risk in order to properly target them for treatments that may improve the outcome. The aim of this research was to identify independent predictors of LV remodeling and heart failure in adults with acute myocardial infarction and preserved LVEF following successful myocardial revascularization via PCI.This is a case-control observational study that enrolled all sequential patients hospitalized with a first acute myocardial infarction (STEMI/high-risk NSTEMI) between January 2019 and August 2021, who were in sinus rhythm and had a LVEF ≥50% after a successful PCI performed in the first 12 h after the onset of symptoms. Patients were high-risk NSTEMI and met ≥1 of the subsequent criteria: a Global Registry of Acute Coronary Events (GRACE) score >140, dynamic alterations in the ST-segment/T wave, or a relative increase or decline in cardiac enzymes . PatientThe research was carried out at the Cardiology Clinics of the Timisoara Institute of Cardiovascular Disease and of the Emergency Municipal Clinical Hospital of Timisoara. Patients with old myocardial infarctions and those with severe valvular disease were excluded. Conventional and 2D-spackle tracking echocardiography were performed at baseline (immediately following PCI) and after 24 months. Infarct-related segments were identified as those with longitudinal strains (LS) below −15% .According to the LVEF measured at 24 months after the AMI, the patients were divided into two groups based on whether the LVEF was ≥50% (group I), or <50% (group II).The follow-up period was 24 months, and the endpoints were cardiovascular deaths and hospitalizations for heart failure.The study was authorized by the Ethics Committee of the Victor Babes University of Medicine and Pharmacy in Timisoara. In compliance with the Helsinki Declaration, all patients signed an informed consent for involvement in the research.Age, gender, risk factors for cardiovascular disease , physical examination data, laboratory results, resting electrocardiogram in 12 leads, transthoracic echocardiography, and coronary angiography were acquired from the initial hospitalization for the AMI. During the follow-up period of 24 months deaths, hospitalizations for heart failure, repeated PCIs, and CABGs were recorded.STEMI was diagnosed when a minimum of two of the following criteria were present: (1) typical angina lasting more than 20 min; (2) ST-segment elevation of ≥1 mV lasting over 0.08 s starting from point J in at least two neighboring leads; and (3) transient rise in cardiac enzymes to more than twice the common laboratory level . NSTEMI According to their clinical presentation, the AMI patients were allocated to one of the Killip classes: Class 1—no heart failure; Class 2—mild heart failure ; Class 3—severe heart failure, acute pulmonary edema ; Class 4—cardiogenic shock  .Peripheral plasma samples were taken at the time of admission, within 24 h before echocardiography. NT-proBNP was measured immediately after blood sampling using a Modular Analytics E170 NT-proBNP immunoassay . During the hospital stay, a routine biochemical workup was performed, including creatinine, hemoglobin, LDL cholesterol, glycated hemoglobin (HbA1C), sodium, potassium, and peak troponin T. The four-variable Modification of Diet in Renal Disease (MDRD) procedure was used to calculate the estimated rate of the glomerular filtration (eGFR) .The PCI was performed, in agreement with the established procedures, as soon as possible after the confirmation of the AMI, without surpassing the 12 h interval for STEMI and high-risk NSTEMI patients. A stenosis of more than 75% in the right coronary, circumferential, or anterior descending artery, or and more than 50% in the left main coronary trunk, was considered notable. The presence of notable stenosis in more than one coronary vessel was characterized as multivessel coronary artery disease (CAD). A TIMI flow of grade 3 at the infarct-related artery deemed the PCI as successful.Initial echocardiography was performed in the hospital, at 1.3 ± 0.6 days following the PCI, using a GE Vivid E7 ultrasound system . The follow-up echocardiographic examination was conducted at 24 months after the initial exam.LV diameters, volumes, and LVEF were determined using Simpson’s biplane method, as recommended by the American Society of Echocardiography . A 17-seTo assess LV deformation patterns, 2D-STE was used ,15. OfflFigure 1Numbers and percentages were used to represent categorical variables. Continuous variables with normal distributions were reported as means ± 1 standard deviation, while those with non-normal distribution were reported as the median , as per Kolmogorov–Smirnov tests.p < 0.05 two-tailed values were considered statistically significant.The paired t-test was used to compare differences between the two patient groups for continuous and normally distributed parameters: the Mann–Whitney U-test was used for continuous non-normally distributed parameters, and the chi-squared test was used for categorical parameters. Univariate analysis was used to determine the odds ratio (OR) and confidence interval (CI) of several characteristics linked to LV remodeling. Univariately significant variables related to LV remodeling were included in the multivariate analysis using a forward stepwise logistic regression model. The receiver operating characteristic (ROC) curve was used to assess the sensitivity and specificity of the independent predictors found via multivariate logistic regression. The Kaplan–Meier method was used for survival analyses, and log-rank tests were used to examine differences among groups. For statistical analysis, we used the MedCalc Statistical Software, version 19.6. . A total of 9 of the 253 AMI who were initially included were removed and not analyzed because they underwent a second PCI during the 2-year follow-up period. Finally, the study group included 244 patients ranging in age from 32 to 74 years (mean age 66.4 ± 13.3 years), with 185 (73%) men.At the end of the 2-years follow-up period, we found that 58 (26%) of the patients had an LVEF <50% . The patp < 0.0001).Throughout the 2-year follow-up period, 19 (8%) of the patients were hospitalized for HF; no patient died. The hospitalization rate was 6% in group I, and 12% in group II (p < 0.0001).The echocardiographic findings are presented in p < 0.0001).During the 2-year follow-up, no patient died. A total of 19 (8%) were hospitalized due to heart failure, 12 (6%) from Group I and 7 (12%) from Group II , ILS <−12.8%  and ILSR ≤0.7/s , and the presence of 3-vessels CAD .The cutoff values that were identified by ROC curve analysis were: Killip class >2  and infarct-related longitudinal strain ≤−12.5% , the presence of LV remodeling , The ROC curve analysis established the following cutoff levels for the independent predictors of HF hospitalizations: Killip class >2  function, despite the presence of LV remodeling ,16. Becap < 0.0001).Our study showed that, even in AMI patients with LVEF ≥50% after a successful PCI performed within the first 12 h from the onset of symptom, adverse LV remodeling and HF still emerge. At the 24-month evaluation, we found that the majority (74%) of AMI patients experienced an improvement in LV systolic function, 26% suffered a decline in LVEF below 50%, and 8% suffered HF hospitalizations. The discharge medication was similar in both groups. No survival differences were observed among the two patient groups. Adverse LV remodeling was found in 41% of patients, and was seen significantly more frequently among those with a decrease in LVEF  and 3.8 times higher among those with echocardiographic signs of adverse LV remodeling .In patients who have had an AMI, either a STEMI or an NSTEMI, the LVEF is an important factor in determining the outcome . Since ip = 0.003) in a clinical trial that involved 153 AMI patients with LVEF over 55% at 2.5 days following a successful PCI. The authors hypothesized that by incorporating GLS into a screening model, it would be possible to improve the accuracy of predicting clinical heart failure following AMI [Previous research has shown that speckle-tracking imaging has the capability of evaluating the regional function of the LV . It has wing AMI . Our stuVan de Bijl et al.  also invHassell et al.  evaluateIn another study that investigated LV post-infarct remodeling with CMR after primary PCI, after a mean follow-up of 6 years, the primary endpoint  was achieved in 13% of patients .The higher rate of HF hospitalization in LV post-infarct remodelers suggests the need to intensify preventive strategies in this group, for example, by using speckle-tracking imaging (STI) to detect early subtle changes in LV function. Another preventive strategy could be the use of an angiotensin receptor neprilysin inhibitor (ARNI) , as it cEMPACT-MI and DAPA-MI are two large trials now evaluating sodium–glucose cotransporter 2 (SGLT2) inhibition in patients at risk for HF after MI. They are also investigating whether empagliflozin or dapagliflozin versus placebo improves the time to first HF hospitalization or CV death after an AMI ,32,33.In the acute MI phase, treatment with the anti-ischemic drug trimetazidine may restore energy supply, minimize mitochondrial damage, and limit ischemia/reperfusion harm. This medication is currently being studied to see if it can protect against persistent post-MI remodeling .This paper brings valuable data to the limited information regarding LV remodeling after successful myocardial revascularization by PCI, using a modern imagistic method to detect subclinical LV systolic dysfunction. We believe that our observational prospective study can build the groundwork for a randomized trial to evaluate latent LV dysfunction after AMI, as well as the efficacy of new drugs that could prevent and mitigate post-MI heart failure. According to the findings of this investigation, unfavorable LV remodeling following an acute myocardial infarction should be monitored for at least 2 years.Study limitations: the study has a number of limitations. This was a prospective, two-center research. We included only AMI patients at sinus rhythm and having a LVEF ≥50% following PCI, likely presenting small extent infarctions. Although it is known that myocardial contractility may improve within 2 days following revascularization, the earliest possible time after the PCI was 1.3 ± 0.6 days. These findings, on the other hand, lend support to the utilization of speckle-tracking imaging in the process of risk classification for AMI patients.Heart failure still occurs in AMI patients with normal LVEF after a successful PCI for AMI. We found that 26% of these patients experienced a decrease in LVEF below 50% during the 2-year follow-up, 41% with evidence of LV remodeling, and about 8% required hospitalization for HF. No differences in survival were noted.The study demonstrates the effectiveness of 2D-speckle tracking imaging, a more sensitive technique that allows for more efficient risk classification and preventative therapy in AMI patients to minimize pathological LV remodeling and HF.