The purpose of this study was to compare cardiovascular magnetic resonance (CMR) and echocardiography (echo) in patients treated with primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) with emphasis on the analysis of left ventricular function and left ventricular wall motion characteristics.CMR, %) and regional left ventricular function  were determined from cine-MR images. In echo the global left ventricular function  and regional wall motion abnormalities were determined. A segment in echo was scored as "infarcted" if it was visually > 50% hypokinetic.We performed CMR and echo in 52 patients with first AMI shortly after primary angioplasty and four months thereafter. CMR included cine-MR and T1-weighted first-pass and late-gadolinium enhancement (LGE) sequences. Global ejection fraction  but higher correlation at follow-up . The number of infarcted segments in echocardiography correlated best with the number of segments which showed systolic wall thickening < 30%  at baseline and  at follow-up. Improvement of EF was detected in both CMR and echocardiography increasing from 44.2 ± 11.6% to 49.2 ± 11% (p < 0.001) by CMR and from 51.2 ± 8.1% to 54.5 ± 8.3% (p < 0.001) by echocardiography.EFWall motion and EF by CMR and echocardiography correlate poorly in the acute stage of myocardial infarction. Correlation improves after four months. Systolic wall thickening by CMR < 30% indicates an infarcted segment with influence on the left ventricular function. Ischemic heart disease has become the leading cause of death from cardiovascular disease worldwide . TherefoFew studies have directly compared echo with CMR in patients with AMI ,17 – a cFifty-two patients (44 men and 8 women) admitted to the coronary care unit (CCU) at the Innsbruck University Hospital, presenting with first AMI defined by elevated cardiac enzymes and an ECG with ST-segment elevation ≥ 2 mm in 2 continuous electrocardiographic leads, were eligible for enrolment. Patients were included if they had a) no previous history of myocardial infarction b) a "Thrombolysis in Myocardial Infarction" (TIMI) flow of less than 3 prior to p-PCI) c) a TIMI flow of 3 after percutaneous revascularisation in the affected coronary artery and had no contraindications to CMR.The study protocol was approved by the hospital ethics committee, and informed consent was obtained from each patient.CMR and echocardiographic investigations were performed in all patients shortly after (3 ± 2 days) p-PCI and approximately four months after reperfusion (131 ± 45 days).Mean delay, defined as "onset of pain-to-balloon" time, was 4.6 ± 5 hours, ranging from 0.5 to 24 hours. All patients were treated with p-PCI and six received thrombolysis prior to mechanical revascularisation. Seven patients had to be excluded because of a delay lasting longer than 24 hours. Three patients had to be excluded because of claustrophobia during CMR, and in two CMR scans, no gadolinium was given. Those patients were excluded from the study prior to statistical analysis. Table Using a 1.5 Tesla MR scanner  providing total imaging matrix, cine-MR images in short- and long-axis were acquired during breath-hold, with retrospective ECG-triggered trueFISP (Fast Imaging with Steady-State Precession) bright-blood sequences with generalized autocalibrating partial parallel acquisition  reconstruction. The patients were positioned into the spine array coil and covered by an 8-channel array coil, resulting in a total of 16 array elements for signal collection. Since it is known that signal acquisition with the help of multiple receiver coil systems can be deranged by the non-uniformity of coil sensitivities , we emplThe short-axis sequence contained 11 slices and had a repetition time (TR) of 46.8 ms, an echo time (TE) of 1.1 ms, a slice thickness (SL) of 8 mm, a field of view (FoV) of 350 × 263 mm, a matrix of 320 × 260, and a flip angle (FA) of 71°. The long-axis sequence contained 3 slices with a TR of 54.5 ms, a TE of 1.28 ms, a SL of 6 mm, a FoV of 360 × 293 mm, a matrix of 320 × 260, and a FA of 71°.Each patient underwent dynamic bolus tracking with the help of an ECG-triggered single-shot trueFISP and a Gadolinium bolus of 0.1 mmol/kg body weight . The contrast bolus was injected into the cubital vein with a flow rate of 5 mL/s by using a commercially available MR injector .The dynamic trueFISP had a FoV of 380 × 265 mm, a SL of 8 mm, a matrix of 128 × 96, a TR of 172 ms, a TE of 0.96 ms and a GRAPPA iPat factor of 2.After a minimum of 10 min. and an additional contrast bolus (another 0.1 mmol/kg body weight) was applied. Late Gadolinium Enhancement (LGE) CMR was performed on the same scanner by using a phase-sensitive inversion recovery single-shot balanced steady-state free precession sequence with consecutive slices perpendicular to the short axis with a TR of 590 ms, a TE of 1.2 ms, a SL of 8 mm, an inter-slice gap of 2 mm, a FoV of 400 × 363 mm, a matrix of 256 × 232, a FA of 45°, and a GRAPPA iPat factor of 2.3] was calculated by multiplying the LGE area with slice thickness including the inter-slice gap.Planimetry of LGE images was performed off-line using a commercially available software tool . A threshold of +5 SD above the signal intensity of normal myocardium in the opposite non-infarcted myocardial segment was set to define the extent of LGE. Infarct volume [cm3).Volumetric evaluation was performed using standard software . Contouring of left ventricular endo- and epicardial borders was performed semi-automatically. Left ventricular myocardial mass was calculated by multiplying the wall volume and the specific density of cardiac muscle  analysis was performed for each slice on the basis of the same endo- and epicardial contours. For each segment, end-diastolic and end-systolic wall thickness  as well as end-diastolic to end-systolic wall thickening  were assessed and calculated. SWT was summed and then averaged for each segment from the short axis slices involved by this segment. All segments were divided into groups according to their SWT, resulting in 5 groups with SWT of 20, 30, 40, 50 and 60%. Subsequently, these groups were correlated to infarcted segments in echocardiography, segments showing late enhancement, infarct mass in grams and EFFor transthoracic echocardiography a Sequoia 256 ultrasound unit  was employed. Measurements of end-diastolic volume (EDV), end-systolic volume (ESV) and ejection fraction  were done using standard software. The apical 5-chamber and 3-chamber views were used to calculate end-diastolic and end-systolic volumes according to the apical biplane summation-of-disks algorithm according to the guidelines by the American Society of Echocardiography using an average of two or three beats .In the visual assessment of regional wall motion abnormalities, a segment was scored as infarcted if it was visually > 50% hypokinetic. The decision to use 50% as a cut-off value to define an infarcted segment in echocardiography was made by the authors out of practical reasons to achieve a higher accuracy of this visually based method. The visual assessment of wall motion abnormalities as well as the assessment of the EF were done by one highly experienced echocardiographer.All images (echocardiography and CMR) were analysed using the American Heart Association/American College of Cardiology (AHA/ACC) recommended 17-segment model  to proviAnalysis was performed with SPSS 16.0 for Windows . Normality was tested by Kolmogorov-Smirnov test. Pearson  and Spearman test (if not ND) were used for calculation of linear correlations for selected variables. With regard to the correlation of segments, paired Wilcoxon rank test was used to determine statistical significance of segmental improvement between baseline and follow-up. ANOVA with Bonferroni post-hoc testing  and Kruskal-Wallis test  were used to determine differences between groups. A probability value of p < 0.05 was considered significant. Data is presented as mean ± standard error (SE) if not stated otherwise. Sensitivity and specificity were assessed by cross tabulation.echo) correlated poorly with EF in magnetic resonance imaging (EFCMR) at baseline  but better at follow-up .  with EFCMR  revealed that echo measured statistically significantly higher global EF than cine-CMR at baseline and at follow-up (p < 0.001).EF in echocardiography  Table echo and EFCMR  and the infarct mass in grams (r: 0.591) at baseline and at follow-up  Table SWT < 30% in CMR showed a highly significant correlation (p < 0.001) with EFA cross tabulation of segments showing LGE with different SWT scores revealed the following sensitivities for baseline: SWT < 20% (sensitivity 20.9%), SWT < 30% (33.9%), SWT < 40% (45.2%), SWT < 50% (56.6%), SWT < 60% (63.8%) and at follow-up: SWT < 20% (sensitivity 17.4%), SWT < 30% (27.4%), SWT < 40% (37.5%), SWT < 50% (49.3%), SWT < 60% (58.3%). See Table Mean SWT for non affected segments at baseline was 63,6% ± 20.3%. 448 segments showed no transmurality (group 1), 59 had a transmurality less than 50% (group 2) and 325 showed a transmurality over 50% (group 3). In order to detect differences between the transmural extent of the infarct and change of SWT, we made three groups according to their transmurality. In the acute state of myocardial infarction we detected a highly significant difference in SWT between the first group and the third group. Within the groups there could not be detected any difference regarding SWT and transmurality and there was no detectable difference between group 1 and group 2. Table 4echo was 51.2 ± 8.1% and 54.5 ± 8.3% at follow-up (p < 0.001). The mean EFCMR increased from 44.2 ± 11.6% to 49.2 ± 11% , improvement of the following parameters was highly significant (p < 0.001) after a four-month period. The total number of infarcted segments in echo decreased from 111 to 57. At baseline the mean EFIn this study left ventricular function was measured both by echocardiography and CMR in the same patient population shortly after primary PCI in the setting of AMI and at four months follow-up.A comparison of the two imaging modalities regarding ejection fraction revealed a poor correlation both at baseline and follow-up, with the agreement being better at follow-up Figure . The difFurthermore, acute changes occurring in left ventricular loading conditions due to emergency medication or intravenous fluid administration are absent in the chronic scenario, which might also explain the differences in the EF readings obtained by both imaging modalities between acute and chronic conditions.echo (54.1% at baseline and 55% at follow-up) and EFCMR (45.3% at baseline and 49.3% at follow up) in patients with posterior wall infarction. This difference was not detected in anterior wall or lateral infarction (no significant difference). CMR, with its capability for volumetric evaluation, is able to view the whole left ventricle and detect wall motion abnormalities even in regions inaccessible to echo and it is less likely operator dependent than biplane echo.While interpreting the higher correlation in the chronic state of myocardial infarction it should be mentioned that 31 of the 52 patients presenting to the CCU with acute coronary syndrome had a posterior wall infarction. Since in biplane echocardiographic EF analyses contractility of the posterior wall may not fully account for EF, a slight overestimation in the calculation of the EF may result and might explain the higher echocardiographic EF values. This presumption is reinforced by a subanalysis showing a statistically highly significant difference (p < 0.001) between EFVentricular and contractile function improvement has been reported to occur as a result of successful reperfusion -27. Suchecho and EFCMR at 1 year follow-up of r: 0.70; p < 0.01. Thus, our findings on the higher grade of accuracy of echo under conditions of chronic myocardial infarction are in agreement with those reported in literature.Reichek et al.  presenteAnother point that has to be taken into account is that echo revealed statistically significant higher EF values at baseline and at follow-up. This would imply an underestimation of infarct size in both settings, acute and chronic. This is an important fact that may influence clinical acting, as the EF is the most common consulted value to define left ventricular function, and has been proven to be an important indicator of prognosis after acute myocardial infarction -31.Animal studies have found that, independent of wall motion or infarct age, the size and the shape of regions showing late enhancement coincide with regions of myocardial necrosis and irreversible injury; regions, however, with a lack of LGE are viable ,33. FurtIn Table CMR and EFecho. Through this correlation we were able to describe a cut-off value in CMR of less than 30% SWT to define an infarcted segment which has a bearing on the clinical outcome. Table No prior study has defined the exact degree of reduction in SWT in CMR needed to be interpreted as "infarcted". Therefore, we attempted to find this degree of SWT reduction by correlating different SWT scores with the number of affected segments in echo, the infarct mass in grams and the ejection fraction (measured both with echo and CMR). The best correlation of infarcted segments in echo and SWT in CMR was found at a SWT less then 30%. SWT less than 30% also correlated also highly significant with EFChoi et al.  reportedecho is 15%, with 12% of this ascribable to test-retest variability [Otterstad et al. reported that the coefficient of variation of EFiability . In ordeSecondly, because of relatively short delays – 19 patients had a delay of less than 3 hours, 24 were within a range of 3 to 6 hours, 7 patients were within a range of 6 to 12 hours and 2 patients had a delay longer than 12 hours – the infarcted mass could be kept relatively small, as previously reported by our research group . MyocardIn summary, the results of our study show that CMR might be the more accurate method for assessing left ventricular function in the acute phase of myocardial infarction, whereas in the chronic state, also echocardiography can be a valuable and accurate instrument. Furthermore, systolic wall motion thickening in CMR at less than 30% can be used as a cut-off value to define an infarcted segment with influence on the left ventricular function.The authors declare that they have no competing interests.MN analysed and interpreted the provided data and designed and wrote the article. MS participated in the design of the study and performed the statistical analysis. AM carried out the volumetric evaluation on cine-MR images using ARGUS software. KP carried out the post-processing of CMR and performed the planimetry of LGE images. GK has made contributions to conception of the data and participated in the statistical analysis. AK carried out the echocardiographic measurements. TB revised the manuscript critically for intellectual content. SM revised the manuscript and completed the method section on echocardiography. TT participated in the design of the study. OP has given final approval to carry out the study. BM conceived of the study, coordinated and helped to draft the manuscript. All authors read and approved the final manuscript


We report here, the case of a six-and-a-half-month-old boy investigated for persistent respiratory distress and homogeneous opacity in the left upper lobe. Echocardiography revealed a giant ductal aneurysm compressing the left pulmonary artery and upper lobe division of the left bronchus. Computerized tomography angiogram delineated the exact anatomy and prompt surgical resection provided a successful cure to this lesser known entity. S.G., a six-and-a-half-month-old boy, first in birth order, and product of a full-term normal delivery, was born with a weight of 2.5 kg, with bilateral congenital talipes equinovarus. Anomaly scanning including a neonatal chest X-ray failed to detect any other organ involvement. He was apparently well till one month of age and then developed persistent respiratory distress, failure to thrive, and had three episodes of 'pneumonia'. A chest X-ray revealed homogenous opacification of the whole left upper lobe , which wOn examination, the child weighed 5.6 kg (74% of expected) and was tachypneic . Cardiovascular examination revealed a normal cardiac size, normal heart sounds, grade 2/6 short ejection systolic murmur at the pulmonic area, and no evidence of congestive cardiac failure. All peripheral pulses and blood pressure were normal. Interestingly an expansile mass was seen in the suprasternal notch during crying.EchoDoppler examination performed using the Sonos 7500 machine with broadband transducers (S8 and S 12) in the subcostal, apical, parasternal, and suprasternal views showed no structural heart defect and normal ventricular dimensions and function. In the parasternal long axis view, the ascending aorta was dilated (Z score + 4.4). The aortic valve was tricuspid. Suprasternal long axis and short axis views showed a large ductal aneurysm rising from the descending aorta, distal to the left subclavian artery. The ampulla of this aneurysm was wide open (7 mm in size), but the pulmonary end was restricted and there was a tiny patent ductus arteriosus with a left-to-right shunt Figure ‐c. TherePreoperatively a ductal aneurysm of size 3 cm × 3 cm arising from descending aorta, just distal to the origin of the left subclavian artery, was seen. Under cardiopulmonary bypass, the pulmonary end of the ductus was ligated and then the aortic end was repaired with an autologous pericardium and the wall of the aneurysm was excised partially, while protecting the phrenic and recurrent laryngeal nerves. Postoperative follow-up at the end of two years showed complete regression of the aneurysm with laminar flow into the left pulmonary artery and descending aorta, on echocardiography.A ductus arteriosus aneurysm is a rare lesion characterized by localized saccular or tubular dilatation of the ductus arteriosus. A PubMed search revealed 144 cases; 106 spontaneous and 38 postoperative. SpontaneTwo different theories of pathogenesis have been proposed. Dr. Helen Taussig postulated that the primary event is failure of the duct to close at the aortic end after the pulmonary end has closed. This, along with concomitant exposure to systemic arterial pressure, causes aneurysmal dilatation. This observation is supported by the fact that 30% of the infantile ductal aneurysms are closed at the pulmonary end; the second theory suggests that congenital or acquired structural weakness of the ductal wall, such as reduced intimal cushion formation or abnormal deposition of elastin and glycoproteins, are responsible.[Our case supports this theory, as the pulmonary end was patent and the ascending aorta was also dilated. The presence of talipes and the unexplained dilated aortic root could be markers of connective tissue disorder. Our patient did not meet the required diagnostic criteria for any specific syndrome. Karyotyping was normal and so we cannot really comment on whether the concomitant presence of ductal aneurysm with talipes and dilated ascending aorta was a chance association or a hitherto unknown genetic syndrome.Because of the rarity and atypical presentations, often this diagnosis is missed. We feel that any infant with persistent lung collapse/consolidation should undergo echocardiography to exclude congenital heart disease. In young infants like our patient, conventional transthoracic echocardiography provides excellent images. Transesophageal echo, CT, magnetic resonance imaging (MRI) and Aortography may be required in the older age group. PreoperaSpontaneous rupture, erosion, thromboembolism, and compression of the adjacent structures are the feared complications occuring in as high as 31% of symptomatic infants less than two months. Surgery is recommended if a significantly large aneurysm does not regress spontaneously within a short follow up. In our pWe report this rare manifestation of ductal aneurysm and hope to increase the awareness among general pediatricians, radiologists, and echocardiographers to this possibility. Common investigations help in the complete diagnosis. Surgical intervention at an appropriate time can result in complete cure. However, these patients should also be screened for associated genetic and connective tissue disorder and detailed evaluation is mandatory.


Juvenile idiopathic arthritis (JIA) is the most common rheumatologic disorder of childhood. Cardiac involvement as pericarditis, myocarditis and valvular disease is common in JIA (JIA). There are, however, few descriptions concerning systolic and diastolic functions of the left ventricle (LV) in children with JIA. P wave dispersion (PWD) is a sign for the prediction of atrial fibrillation (AF). A recent study found that rheumatoid arthritis patients had an abnormally high P wave duration and PWD , markers for supraventricular arrhythmogenicity. The study was to assess PWD and its relation with systolic and diastolic function of the LV in a group of children with JIA.We performed electrocardiography and Doppler echocardiography on 50 patients with JIA and 70 healthy controls. Maximum and minimum P wave duration were obtained from electrocardiographic measurements. PWD defined as the difference between maximum and minimum P wave duration was also calculated.No statistically significant differences were found between the groups in minimal, maximal P wave duration and PWD Table . Among tP wave duration and PWD was not found to be higher in JIA patients than healthy control subjects. Larger observational studies and prolonged follow-up are therefore required before definitive conclusions can be made.


Cardiac biomarkers (CB) were first developed for assisting the diagnosis of cardiac events, especially acute myocardial infarction. The discoveries of other CB, the better understanding of cardiac disease process and the advancement in detection technology has pushed the applications of CB beyond the 'diagnosis' boundary. Not only the measurements of CB are more sensitive, the applications have now covered staging of cardiac disease, timing of cardiac events and prognostication. Further, CB have made their way to the intensive care setting where their uses are not just confined to cardiac related areas. With the better understanding of the CB properties, CB can now help detecting various acute processes such as pulmonary embolism, sepsis-related myocardial depression, acute heart failure, renal failure and acute lung injury. This article discusses the properties and the uses of common CB, with special reference to the intensive care setting. The potential utility of "multimarkers" approach and microRNA as the future CB are also briefly discussed. Blood cardiac biomarkers (CB) have become increasingly accurate for evaluating cardiac abnormalities during the past 40 years. Initially, with the focus on myocardial infarction (MI), the use of creatinine kinase-MB (CK-MB), first described in 1972, was a major step forward in the development of a highly cardiac-specific biomarker. The introduction of cardiac troponin (cTn) assays in 1989 was the next major advance, and subsequent refinement of the assays now has the definition of acute myocardial infarction (AMI) centered on it. This progression ironically has brought considerable difficulties to the critical care physician who deals with multiorgan failure rather than the patient presenting to the emergency department with chest pain or single-organ pathology. The recent penetration of high-sensitivity (hs) cTn, replacing the fourth-generation cTn assays further compounds these diagnostic challenges.Moving beyond a sole focus on MI, the search for alternative and supplementary serum markers to assist in unravelling the presence, severity, and type of cardiac injury has been intense Figure . Whilst In the critical care setting, the challenge of confounding factors brings about interpretation difficulties. Clarity in diagnosis and/or guidance for management frequently present when the heart is the only organ affected, such as in the emergency department or cardiology ward, does not always hold in the intensive care unit (ICU) setting. Even so, an understanding of the commonly used CB can be very helpful for cardiac evaluation of the critically ill patient.The search for clinically useful CB has resulted in a large number of circulating plasma substances being investigated. These can be broadly grouped temporally into three major categories: inflammatory, acute muscle injury, and cardiac stress Figure .Cardiac wound healing after MI can be divided into four phases: phase 1 begins with the actual death of myocytes commencing within 6 hours and continuing for up to 4 days; the phase 2 is that of an inflammatory response beginning 12-16 hours after onset of ischemia; phase 3 is when granulation tissue begins forming at the infarct border zone; and phase 4 consists of remodeling and repair and begins at 2-3 weeks, persisting for up to a year [Where an infective agent is responsible for myocardial damage, acute viral myocarditis being the prototype, once again clinically helpful inflammatory biomarkers are not available. Temporally, three phases exist when myocardial damage is due to infection: 1) myocyte destruction by the virus; 2) an innate immune response, which ultimately may cause more harm than good; and 3) possible myocardial damage, resulting in a dilated cardiomyopathy, and where once again, autoantibodies may play a role .What often is overlooked is the role of inflammation in the progression of coronary artery disease (CAD), even in the absence of myocardial necrosis, and here the role of inflammatory markers hold more promise . UnfortuThe evolving story of cTn to diagnose acute myocardial damage is as fascinating as it is beguiling. The troponin era began with the development of a double antibody, two-step enzyme immunoassay for TnT in 1989 . EvolutiThe cTn complex, consisting of three proteins  encoded by different genes, plays a pivotal role in the modulation of calcium-dependant sarcomere contraction ,11. cTnIth percentile of URL, or the concentration at which the assay achieves a coefficient of variation of 10% if that exceeds the 99th percentile [The central consideration in the interpretation of an elevated serum cTn is that it is a marker of myocardial damage, but on its own it does not determine the etiology of the damage. cTnT and cTnI demonstrate similar diagnostic ability in detection of myocardial damage despite analytical differences . The crircentile ,18. Clinth percentile, although close to the 99th percentile for two different hs-cTnI assays [The timing of cTn elevations becomes increasingly important with the development of more sensitive assays and an understanding of the manner in which cTn is released from the damaged myocyte is helpful. An acute process involves a rise and fall with an increase occurring 2-4 hours after symptoms and remaining elevated for 7-14 days. Therefore, serial measurements, usually 3-6 hours apart are recommended . The lesI assays .th generation cTnT, the admission hs-cTnT assay (at a cutoff of 99th percentile) detected more evolving non-STEMI cases (61.5% vs. 7.7%). The detection by hs-cTnT further improved to 100% within 6 hours. The overall diagnosis of MI increased by 34.6% [th percentile is associated with a PPV of 100% and NPV of 88% [The introduction of hs-cTn, with precision sensitivity improved from the μg/l to the ng/l range, has enhanced the sensitivity and reduced the time to diagnose AMI in the acute setting. The use of a single hs-cTnI measurement at 3 hours in patients presenting with chest pain, using a cutoff of 40 ng/l, gave a negative predictive value (NPV) of 84.1% and positive predictive value (PPV) of 86.7%; these findings predicted a 30% increase in cTn levels at 6 hours . The diaby 34.6% . A doublV of 88% . Such anThe sedated hemodynamically unstable patient on positive pressure ventilation does not usually provide the classical symptoms of myocardial ischemia. ECG changes, often on a background of an already abnormal ECG, are nonspecific, and confounding factors, such as renal failure or heart failure, are present. Many conditions commonly found in an ICU are associated with elevated cTn levels, even in the absence of definite coronary artery pathology leading to myocardial ischemia Table . Added tThe advent of hs-cTn brings a definite improvement in diagnostic accuracy but at the expense of lower specificity, a challenge already encountered on a daily basis in the ICU with standard assays. However, this development should be seen as a positive step with the higher diagnostic accuracy, but further studies in the critically ill population are required to better define its use in this population.Elevated cTn is associated with poor prognosis in patients with acute ischemia ,28. cTnIWhen first described in 1972, the electrophoresis methods required for separation of the cardiac isoenzymes had low analytical specificity . An immuFatty acid binding proteins (FABPs)--small proteins located in the cytoplasm--facilitate transport of fatty acids and other lipids within the cell. Heart-type FABP (H-FABP) is a sensitive marker of myocyte damage and, unlike troponin, is released by both ischemia and necrosis. It also is released more rapidly than troponin, although the advent of hs-cTn will overcome the advantage of FABP in this regard. H-FABP is released from the damaged cell within 1-3 hours, returning to normal by 12-24 hours. It is now available as a point of care test for the diagnosis of AMI in many countries and also has good data to support its use in prognostication from MI ,36. The Primarily for maintaining osmotic and cardiovascular homeostasis, the NP family includes multiple peptides and receptors. Present throughout all vertebrate classes, including fish, amphibians, mammals, and birds, this family of related peptides and specific receptors is an integral system in the control of hydromineral balance and blood pressure . In mammAlthough the earliest investigations into the application of NP in everyday medicine involved ANP, with more recent investigations on CNP, DNP, and urodilatin, BNP and NT-proBNP is where most effort has been directed. The pre-prohormone BNP is a 134 aminoacid peptide synthesized in ventricular myocytes, with subsequent cleaving into the 108 aminoacid prohormone BNP, which is released into the circulation during hemodynamic stress . Corin, The obvious clinical applications of BNP and NT BNP have led to the development of fully automated assays for both; some understanding by the clinician of the specific assay used is important, because some immunoassays cannot differentiate between active and inactive forms. For example, some assays actually measure a mixture of both BNP and NT-proBNP, whereas various breakdown products of BNP may be included in the assay .Breathing Not Properly, where a serum BNP level > 100 pg/ml was demonstrated to diagnose congestive heart failure (CHF) with a sensitivity of 90% and specificity 73% [The clearest clinical benefit of the application of BNP and NT-proBNP has been the diagnosis and prognosis of heart failure. Regular application in the emergency department is based on studies such as city 73% ,43. Simicity 73% ,45. BNP city 73% ,47.Only a weak correlation between pulmonary capillary wedge pressure and serum BNP level in the ICU patient has been found . In a reThe challenge is in translating the value of BNP in the diagnosis of HF in the emergency department, or prognostic value of CHF in the outpatient setting, to a role in the critically ill patient. Usually multiple comorbidities, particularly renal failure or sepsis, can cause elevation of serum levels in the absence of heart failure. Numerous factors may contribute to the measurement BNP level in the serum in a single patient Figure .Does a prognosis role exist for the natriuretic peptides? Numerous studies have sought to clarify a role for NPs as prognostic markers in the ICU setting, yet the results have been conflicting and insufficiently robust to modify a patient's management -58. AlthA peptide of 52 amino acids, ADM is synthesized and found in heart, adrenal medulla, lungs, and kidneys. In the heart, it is produced in response to volume and pressure overload and has similar actions to the NPs . It is aCB can have roles in both the diagnosis and prognosis of a patient with PE. Elevation of cTn results from increased metabolic demand and reduced myocardial perfusion, which causes right ventricular ischemia/microinfarction, whereas increased wall stress results in elevation of BNP. Kucher and Goldhaber in 2003 concluded that a cTn below the cutoff required for that required to diagnose AMI, or a BNP < 50 ng/ml, have a > 98% negative predictive value for in hospital death by PE . La VeccThe role of CB in risk stratification is firmly established, and CB are included as principal markers in the European Society of Cardiology guidelines on the diagnosis and management of acute pulmonary embolus . The preH-FABP seems to have better diagnostic accuracy and better prognostic value compared with cTn and BNP in cases of PE. Puls and associates in a study of 107 patients found that normal H-FABP on admission predicts an absence of significant complications or death. The PPV for H-FABP was 41% compared with 29% for cTn and 19% for proBNP . In a moIt has been recognized for more than a decade that elevated cTn in septic patients is associated with a higher mortality . cTn is The wide range of prevalence probably relates to the heterogeneity found in septic studies but clearly an elevated cTn is not uncommon. The real uncertainty comes from the cause of the troponin release, whether it is global myocardial ischemia , the myocytoxic effects of cytokines, reactive oxygen species or endotoxins, or exacerbation of chronic coronary artery small vessel disease . cTnI alIn a study of 207 patients with severe sepsis and septic shock, circulating cTnT was detected in 60% of the patients using the fourth-generation cTnT assays and 100% by the hs-cTnT assay . The levcTn is elevated in patients with HF even in the absence of CAD ,76. LackBecause baseline serum cTn levels are already elevated in chronic renal failure (CRF), the diagnosis of a MI is based on > 20% increase in levels at 6-9 hours after presentation . This reAlthough classically a "cardiac biomarker," BNP has perhaps best found a role in the ICU in the diagnosis of hypoxic respiratory failure and determining the optimal timing for extubation. Rana and colleagues found that a BNP level < 250 pg/ml supports the diagnosis of acute lung injury (AUC = 0.71), with improved accuracy when patients with renal failure were excluded (AUC = 0.82) . Other sA recent study of 100 patients, who underwent a 48-hour spontaneous breathing trial before extubation, underwent echocardiographic evaluation and NP sampling immediately before the trial commenced and at the end, before extubation. A baseline cutoff BNP level of 263 ng/l and 1,343 ng/l for NT-proBNP before the trial, or an increase of 48 and 21 ng/l respectively for BNP and NT-proBNP, accurately predicted those patients who failed extubation as a result of underlying cardiac failure. BNP performed better than NT-proBNP . A priorThe use of multiple biomarkers has the theoretical attraction of improving both sensitivity and specificity in the diagnosis of different cardiac disorders, with particular relevance in the ICU where multiple confounding factors exist. The combination of cTnT, ECG, and ischaemia-modified albumin identified ischemia in 95% of patients presenting with chest pain . HoweverIn predicting 6-month mortality from acute heart failure, Nunez and associates demonstrated the combination of CA-125 and BNP added prognostic value to that provided by BNP alone .MicroRNAs  are approximately 20-25 nucleotide long noncoding ribonucleic acids (RNAs) that negatively regulate or inhibit gene expression by binding to sites in the 3' untranslated region of targeted messenger RNAs -94. They1. miRNAs regulating endothelial function and angiogenesis: miR126, miR17-92 cluster , miR130a, miR221, miR212. Cardiac myocyte-specific mRNA: miR208a3. Cardiac myocyte (highly expressed) and skeletal muscle miRNAs: miR1, miR 133a, miR499.Smooth muscle miRNAs: miR143, miR145Since the half-life of circulating miRNA is counted in hours and their breakdown do not seem to be compromised by the presence of organ dysfunction, they hold promise as very specific, accurate markers of cardiac dysfunction in the critically ill patient.Measuring plasma CB is often a routine undertaking for most critical care physicians, and the increasingly accurate markers developed over the years have an important place in everyday practice. The obvious advantages experienced in the emergency department or cardiology ward are not always shared in the ICU where cofounders frequently make for a more cautious interpretation and careful consideration of subsequent management decisions. Yet, an understanding of the underlying strengths and weaknesses now available from a considerable research and clinical database should lead to an appreciation of their immense value.The authors declare that they have no competing interests.ASM and SJH both drafted manuscript. Both authors read and approved the final manuscript.


Hypertrophic cardiomyopathy (HCM) is associated with increased myocardial fibrosis and collagen deposition. Collagen reduces cardiovascular magnetic resonance (CMR) derived T2 times, however, the inflammatory milieu required for its deposition is often associated with localised oedema. Focal areas of high T2 signal intensity have been reported in association with areas of late gadolinium enhancement (LGE) in patients with HCM. However, this previous work has relied upon the subjective visual assessment of local changes in signal intensity. We hypothesised that quantitative CMR T2-mapping would reveal marked differences in myocardial T2 characteristics in patients with HCM relative to controls.Twenty-two consecutive patients with HCM  but no co-morbidity and 22 healthy controls  were studied. For each subject, a short axis mid-ventricular slice was acquired using a 1.5T Avanto . A breath-hold T2-prepared single-shot steady-state free precession (SSFP) sequence was used to produce three T2-weighted images with different T2 preparation times . Parallel imaging was used to reduce the imaging time and motion-correction was applied to improve the accuracy of T2 measurement. T2 maps were produced by fitting the signal intensity-time exponential decay curve using a linear 2-parameter model after logarithmic transformation . An inversion recovery prepared gradient echo sequence with the inversion time optimised to null normal myocardium was used 10 minutes after intravenous gadolinium contrast  to detect late enhancement. Imaging was repeated in an orthogonal phase encoding direction to exclude artifact.There were no significant differences in baseline demographic characteristics between HCM and control patients. LV-wall thickness, indexed LV mass and ejection fraction were significantly higher in HCM patients Table . In keepQuantitative myocardial T2 mapping did not reveal any evidence of inflammation and was unable to detect the presence of any oedema in our cohort. Whilst this technique has been shown to be of utility in other cardiomyopathies such as dilated cardiomyopathy and Duchenne muscular dystrophy-associated cardiomyopathy, it does not appear to guide the evaluation of HCM.This work is supported by the NIHR Cardiovascular Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust, and Imperial College. Dr Ismail is supported by the British Heart Foundation.


Hypertension is an important cardiovascular risk factor worldwide. It is associated with left ventricular hypertrophy (LVH). Both diastolic and systolic dysfunction may occur in hypertensive heart disease. The ventricles are structurally and functionally interdependent on each other. This was an echocardiographic study intended to describe the impact of left ventricular pressure overload and hypertrophy due to hypertension on right ventricular morphology and function.p < 0.05.One hundred subjects with systemic hypertension and 50 age- and gender-matched normotensive control subjects were used for this study. Two-dimensional (2-D), M-mode and Doppler echocardiographic studies were done to evaluate the structure and function of both ventricles. Data analysis was done using the SPSS 16.0 . Statistical significance was taken as p < 0.05). A similar pattern was found in the tricuspid E/A ratio . Hypertensive subjects also had reduced right ventricular internal dimensions  but similar peak pulmonary systolic velocity. The mitral e/a ratio correlated well with the tricuspid e/a ratio.Age and gender were comparable between the two groups. Hypertensive subjects had significantly increased left ventricular end-diastolic dimensions, posterior wall thickness, interventricular septal thickness, left atrial dimensions and left ventricular mass and index. The mitral valve E/A ratio was reduced among hypertensive subjects when compared to normal controls (1.15 ± 0.75 vs 1.44 ± 0.31, respectively; Systemic hypertension is associated with right ventricular morphological and functional abnormalities. Right ventricular diastolic dysfunction may be an early clue to hypertensive heart disease. Hypertension is an important non-communicable disease in Africa. It is the most important cardiovascular risk factor.The right ventricle is a thin-walled, low-pressure system. Studies that evaluated left ventricular function abound in the literature. However, studies about right ventricular structure and function among hypertensive subjects are rare. The aim of this study was to evaluate if any possible morphological and/or functional changes might occur in the right ventricle in subjects with systemic hypertension.Echocardiography is a very useful and non-invasive diagnostic tool, which can be used to diagnose ventricular hypertrophy and various flow and pressure parameters in all cardiac chambers. Echocardiography in the evaluation of right ventricular function is important, as right ventricular dysfunction has been shown to correlate significantly with disease progression in subjects with chronic obstructive pulmonary disease,This study was an echocardiographic evaluation of right ventricular systolic and diastolic function in subjects with systemic hypertension.The study group consisted of 100 adult Nigerian hypertensive subjects. Fifty age- and gender-matched normotensive subjects were recruited as controls. Hypertension was diagnosed using standardised criteriaAll subjects had echocardiography performed on them with the use of a SUIS APOGEE ultrasonograph with a 3.5-MHz transducer. Echocardiography was performed according to the recommendations of the American Society of Echocardiography (ASE).2 for both genders, as used in the Framingham study for the evaluation of LVH in subjects with hypertension.LV mass was calculated using the Devereux formulaThe pulse Doppler studies were reported from the apical four chambers or alternatively the parasternal short-axis view. The Doppler sample volume was placed at the level of the tricuspid annulus and recordings from three cycles were averaged. The following measurements were taken: peak early E wave, peak late atrial A diastolic velocities and velocities time intervals. At the right ventricular outflow tract, the maximum and mean pulmonary systolic pressures were obtained. Similar measurements were made at the mitral valve annulus and at the left ventricular outflow tract. All the recordings were obtained for three cycles and their averages were used for calculation. All measurements were taken with the subjects in quiet respiration.t-test and chi-square as appropriate. Correlation analysis was done for some diastolic and systolic parameters. Statistical significance was taken as p < 0.05.Data were analysed using the Statistical Package for Social Sciences SPSS 16.0, . Quantitative data were summarised using means ± standard deviation, while qualitative data were summarised using percentages and proportions. Comparisons between groups were made using independent Table 1p > 0.05). The mean age of the hypertensive subjects was 57.5 ± 13.3 years while the mean age of the control subjects was 55.9 ± 11.3 years (p > 0.05). The gender distribution was also similar between the two groups. As expected, the systolic blood pressure, diastolic blood pressure and pulse pressure were significantly higher among the hypertensive subjects than the controls . The hypertensive subjects also had a higher body mass index than the controls The hypertensive subjects were well matched in age and gender (p < 0.001).As shown in p > 0.05). However, the tricuspid early wave velocity was lower among the hypertensive subjects than among the controls  while the peak atrial velocity was higher among the hypertensive subjects, 0.44 ± 0.11 vs 0.38 ± 0.11 m/s, respectively; p < 0.05)  or some other indirect process.19This study also demonstrated significant differences in the pulse wave velocities between hypertensive and normotensive subjects, which suggest that right ventricular diastolic dysfunction occurs in association with left ventricular diastolic dysfunction among these subjects. Several studies have shown that left ventricular diastolic dysfunction occurs early in hypertension.26Doppler studies of cardiac flow and tissue movement remain the gold standard for estimating diastolic dysfunction with echocardiography.The abnormal relaxation that is frequently associated with ageing has been suggested to be due to the associated myocardial abnormalities and increased presence of cardiovascular risk factors and may therefore probably not constitute physiological aging.r = 0.405, p < 0.001, Fig. 1). Also, the peak aortic and peak pulmonary systolic velocities showed similar statistical correlations . This suggests furthermore that right ventricular function is affected by hypertension in a similar pattern to left ventricular function. These changes may be subtle in the early stages of the disease and may require the use of more specific diagnostic parameters such as tissue Doppler imaging and strain echocardiography.29This study demonstrated a similar pattern of tricuspid wave velocities in diastole and mitral wave velocities with good statistical correlations (However, this study failed to show a statistically significant difference in the mean pulmonary systolic and peak pulmonary systolic velocities between hypertensive subjects and controls. We suggest that the changes in the pressures of the right ventricle, although it is a low-pressure system, is influenced by the pressure and volume changes associated with hypertension. There is however no evidence that the right ventricular changes occur at the same time as those of the left ventricle. Prospective studies could document the timing of the right ventricular changes associated with hypertension.Hypertension affects the diastolic function of the left ventricle and these changes are accompanied by similar changes in the right ventricle. Whether these right heart changes occur early, at the same time as left heart changes due to the interdependence of the two structures, or whether it is a secondary phenomenon possibly related to pulmonary vascular changes remains to be proven by further studies. These changes occur in both the left and right ventricles. The changes are also prominent in the diastolic wave velocities, right ventricular wall dimensions and internal chamber dimensions.


Echocardiography is a non-invasive method for assessment of the ovine and caprine heart. Complete reference ranges for cardiac dimensions and time indices for both species are not currently available and reliability of these measurements has not been evaluated. The objectives for this study are to report reliability, normal cardiac dimensions and time indices in a large group of adult sheep and goats.Fifty-one adult sheep and forty adult goats were recruited. Full echocardiographic examinations were performed in the standing unsedated animal. All animals underwent echocardiography four times in a 72-hour period. Echocardiography was performed three times by one author and once by another. Images were stored and measured offline. Technique and measurement repeatability and reproducibility and any differences due to animal or day were evaluated. Reference ranges (mean ± 2 standard deviations) were calculated for both species.Majority of the images obtained were of good to excellent quality. Image acquisition was straightforward with 5.4% of animals demonstrating a small scanning window. Reliability was excellent for majority of dimensions and time indices. There was less variation in repeatability when compared with reproducibility and differences were greater for technique than for measurements. Dimensions that were less reliable included those for right ventricular diameter and left ventricular free wall. There were many differences in cardiac dimensions between sheep and goats.This study has demonstrated that specific reference ranges are required for these two species. Repeatability and reproducibility were excellent for the majority of cardiac dimensions and time indices suggesting that this technique is reliable and valuable for examination of clinical cases over time and for longitudinal research studies. Echocardiography is a non-invasive method for assessment of the ovine and caprine heart. However, it is a technique that has been utilised more frequently in the assessment of clinical disease in small animals and horses for evaluation of changes in wall thickness, chamber size and valvular appearance and function. For measurements to be accurate and reliable, images must be taken from correctly orientated imaging planes in relation to internal landmarks . For lonClostridial spp. and Mycobacterium spp.), viral (e.g. foot and mouth disease), parasitic (e.g. toxoplasmosis or sarcocystosis) or toxic causes  could be seen in small ruminants; reports are however lacking /LVDd) and left ventricular ejection fraction (LVEF). The latter was calculated with the integrated calculation program ([(A-B)*100/A] where A =  and Cohen’s Kappa). Concordance (ICC and Cohen’s Kappa) was considered excellent when greater than 0.8, good when 0.6-0.8, average when 0.4-0.6 and poor when less than 0.4 [T-test. Comparisons between this study and others were made using independent means T-test. All statistical analyses were undertaken using commercial statistical packagesd,e. Significance was assumed when p < 0.05.Data were presented as the mean ± standard deviation (SD) from both observers’ measurements. Reference ranges were also calculated (mean ± 2SD). Measurements between species were compared using a Student’s than 0.4 . ReliabiFifty-one sheep  and forty goats  were used in this study. The sheep were aged 2–4 years and weighed 74 ± 13Kg with a range of BCS from 2.0-3.5 out of 5. The goats were aged 18 months to 3 years and weighed 48 ± 10Kg with a range of BCS from 4–6 out of 9. No animals were tachycardic at the beginning or during any echocardiographic examination. No murmurs were auscultated in any of the animals. Two goats and one sheep had marked sinus dysrhythmia at rest, which was confirmed with electrocardiography. All other electrocardiograms demonstrated sinus rhythm.Heart rates of the sheep during the examination were 84.7 ± 7.5 beats per minute (bpm) and in goats was 90.1 ± 6.3 bpm. Two goats had mild tricuspid regurgitation and two sheep mild mitral regurgitation diagnosed using CFD; these were not associated with audible murmurs or any notable structural valvular abnormalities and thus the animals were not excluded from the study.The main minor limitation encountered with image acquisition involved the small scanning window in two of the goats and three of the sheep  due to obscurement of the heart by the pleural surface. This was overcome on re-examination, although image quality in these animals was deemed adequate, and thus they were not included in the final analysis. The animals were often unwilling to stand with the right forelimb protracted cranially, but were much more accepting of gentle persuasion to abduct this limb. This was most frequently required in order to obtain the right parasternal cranial long axis view of the right ventricular outflow tract and for the right parasternal short axis views.Nine 2-D image loops (short and long-axis) and three M-modes were obtained in all ninety-one animals. A summary of specific findings for each view is listed in Table Except for those 5.4% of animals that had a small scanning window, the images were relatively straightforward to obtain. Pleural surface interference was a minor problem in the majority of the animals; for the short axis views of the mitral and aortic valves, the probe had to be moved ventrally down the chest wall and angled dorsally. No problems were encountered regarding ICS width and image generation. Many of the animals were unwilling to stand with the limb moved cranially, but were much more tolerant of the limb being gently abducted.Overall 819 cineloops were obtained. Fifty-nine cineloops (7.2%) from 21 animals were deemed of average quality, 254 (31%) cineloops were deemed good quality and 506 (61.8%) were deemed of excellent quality. There was no correlation between image quality and bodyweight or BCS in these animals (p > 0.24).Reference ranges and mean ± SD for cardiac dimensions and time indices are displayed in Table Table Repeatability of technique was excellent for all measurements and time indices (ICC = 0.8-0.96), except for dimensions of the right ventricle (RV), which were good , except for FWs and FWd, which were good ICC = 0.73-0.76) and adequate for those of the RV  and RVDs (p < 0.01).There were differences in numerous echocardiographic dimensions between species. Pulmonary artery diameter , Ao (p < 0.04), IVSd (p < 0.01) and FWd (p < 0.02) were smaller in goats than sheep when considering absolute values and when corrected for bodyweight. Pulmonary artery diameter , IVSd (p = 0.02) and FWd (p = 0.03) were relatively smaller in goats when corrected for bodyweight using Ao. Left atrial diameter , IVSs (p = 0.01) and LVDd (p = 0.02) were different between sheep and goats when comparing absolute values, but not when corrected for bodyweight and Ao. Left ventricular diameter in systole  and FWs (p < 0.02) were different between sheep and goats when corrected for bodyweight and using Ao, but not when comparing absolute values. There were no differences for any of the measurements or time indices between the sheep (p = 0.37-0.85) and goats (p = 0.21-0.67) except for FS for both sheep and goats (p < 0.03).This study has demonstrated that good to excellent technique and measurement reliability can be obtained from echocardiographic dimensions and time indices obtained from sheep and goats, which has not previously been reported. Reliability of these measures becomes important when considering longitudinal studies and clinical evaluation of animals at different time points by different echocardiographers. Reference ranges for internal cardiac structures and time indices were further evaluated for both adult sheep and goats. These data, building on previous studies should improve identification, quantification and assessment of cardiac disease in sheep and goats.Echocardiography is a practical technique in sheep and goats, although a small acoustic window makes it challenging to achieve some of the images in certain animals, as has been reported previously , althougIt has been reported previously in both horses, cattle and goats that ICS width was a limiting factor in the quality of the images obtained ,23,24. TTo the authors’ knowledge, a full set of internal cardiac dimensions and time indices in adult sheep have not been previously published and time indices have not been published in goats. Internal cardiac dimensions that were statistically different from a previous study in goats  includedThere were numerous differences in cardiac dimensions between sheep and goats in this study. This difference may relate to differences in bodyweight between the sheep and goats used in this study or may be genuine species differences. Many of these differences remained when corrected for bodyweight and cardiac size using Ao. Previous studies performed in horses demonstrate controversy regarding the association between internal cardiac dimensions and bodyweight ,25,26. TThe variation in dimensions was greater in the current study in goats compared with a previous study  and lessThe time indices assessing cardiac function and one-dimensional distance index (EPSS) were not significantly different between the two groups, which is as would be expected, particularly as the two groups had similar heart rates and fractional shortening. Cardiac valve time indices  and one-dimensional distance index (EPSS) were similar to previously reported values in cattle  and horsAlthough none of the animals in this study had audible murmurs, a small number of sheep and goats had evidence of physiological pulmonary, aortic and tricuspid regurgitation. All of these valves appeared structurally normal. Although a previous study in goats described performing CFD , these dTechnique and measurement repeatability was found to be good or excellent for majority of measurements. Standardised views ,18 were There have been no studies assessing reproducibility of technique or measurement in sheep and goats and few in other species ,33. One Day-to-day differences mainly measure within animal variation , althougAn intrinsic problem of the study was that it was not possible to confirm that these animals had normal cardiac structure at post-mortem examination. At 24 month follow-up all sheep and goats used in this study were still alive and had been clinically well.This study has demonstrated that using this technique, reliable measurements can be obtained in these species. This means that measurements obtained over time in clinical cases and longitudinal research studies should be comparable. The amount of variation was smaller when evaluating repeatability than reproducibility and smaller for measurement assessment than technique as would be expected. Image acquisition was relatively straightforward and quality of images was good to excellent in the majority obtained. Due to differences between sheep and goats, even when corrected for bodyweight, each species requires its own reference range for cardiac dimensions.aAquasonic gel 100, Parker Labs Inc., Fairfield, NJ, USA; bMyLab30, Esoate, Genova, Italy; cGE Ultrasound, Bedford, UK dSPSS for Windows 15.0, SPSS Inc, Chicago, Illinois, USA; eGraphPad 4.0, Graphpad Software, La Jolla, California, USA.2-D: Two-dimensional; ANOVA: Analysis of variance; Ao: Aortic diameter measured in diastole; Ao-cs: Aortic cross-sectional diameter measured in diastole; AoS: Aortic sinus diameter measured in diastole; BCS: Body condition score; bpm: Beats per minute; CFD: Colour-flow Doppler; ECG: Electrocardiogram; EPSS: E-point to septal separation; ET: Ejection time; FS: Fractional shortening; FWd: Left ventricular free wall diameter in diastole; FWs: Left ventricular free wall diameter in systole; ICC: Intra-class correlation coefficient; ICS: Intercostal space; IVSd: Interventricular septal diameter in diastole; IVSs: Interventricular septal diameter in systole; LAD: Left atrial diameter measured in systole; LV: Left ventricular diameter; LVDd: Left ventricular diameter in diastole; LVDs: Left ventricular diameter in systole; LVEF: Left ventricular ejection fraction; PA: Pulmonary artery diameter in diastole; PEP: Pre-ejection period; RV: Right ventricular diameter; RVDd: Right ventricular diameter in diastole; RVDs: Right ventricular diameter in systole; SD: Standard deviation.GH’s research scholarship was generously funded by the Horserace Betting Levy Board and TP’s PhD project funded by Department of Environment, Food and Rural Affairs. The author’s have no other completing interests to declare.GH and MB conceived the study, all authors were involved in image acquisition and measurement, GH prepared the manuscript and performed all statistical analyses and all authors read and approved the final manuscript.GH is currently Associate Professor in Large Animal Internal Medicine and Critical Care at the University of Nottingham. She is a diplomate of both the American College of Veterinary Internal Medicine and of the American College of Emergency and Critical Care. Additionally she is an Associate Diplomate of the European College of Veterinary Diagnostic Imaging. She completed a large animal internal medicine and critical care residency and a PhD in Equine Cardiology and her research interests include medical imaging in all large animal species. MB is Associate Professor in Veterinary Internal Medicine at the University of Nottingham. He completed an equine medicine residency and a PhD focused on various aspects of equine cardiology and his research interests include many aspects of large animal cardiology. TP is currently in private food animal practice having completed a farm animal residency and PhD in Bovine Respiratory Disease.


Androgen deprivation therapy (ADT) is a cornerstone in the treatment of advanced prostate cancer. Adverse musculoskeletal and cardiovascular effects of ADT are widely reported and investigations into the potential of exercise to ameliorate the effects of treatment are warranted. The ‘Football Club (FC) Prostate’ study is a randomized trial comparing the effects of soccer training with standard treatment approaches on body composition, cardiovascular function, physical function parameters, glucose tolerance, bone health, and patient-reported outcomes in men undergoing ADT for prostate cancer.Using a single-center randomized controlled design, 80 men with histologically confirmed locally advanced or disseminated prostate cancer undergoing ADT for 6 months or more at The Copenhagen University Hospital will be enrolled on this trial. After baseline assessments eligible participants will be randomly assigned to a soccer training group or a control group receiving usual care. The soccer intervention will consist of 12 weeks of training 2–3 times/week for 45–60 min after which the assessment protocol will be repeated. Soccer training will then continue bi-weekly for an additional 20 weeks at the end of which all measures will be repeated to allow for additional analyses of long-term effects. The primary endpoint is changes in lean body mass from baseline to 12 weeks assessed by dual X-ray absorptiometry scan. Secondary endpoints include changes of cardiovascular, metabolic, and physical function parameters, as well as markers of bone metabolism and patient-reported outcomes.The FC Prostate trial will assess the safety and efficacy of a novel soccer-training approach to cancer rehabilitation on a number of clinically important health outcomes in men with advanced prostate cancer during ADT. The results may pave the way for innovative, community-based interventions in the approach to treating prostate cancer.NCT01711892ClinicalTrials.gov:  Prostate Cancer (PCa) is the most common non-cutaneous malignancy in men, with 650,000 estimated new cases per year in the developed world . AndrogeWhile ADT contributes to improved life expectancy, it is also associated with significant adverse effects, including loss of lean body mass (LBM), decreased bone mineral density (BMD), poor functional performance, increased fat percentage, insulin resistance, and increased risk of fractures -10. The . Indeed, such improvements have been reported after physical exercise in studies of PCa patients undergoing ADT. Galvão et al. found that 12 weeks of combined resistance and aerobic training improved muscle mass, muscular strength, physical function and balance  − (LVID)3] and indexed according to body surface area and LV volumes. LV ejection fraction will be evaluated with Simpson’s biplane method.Comprehensive transthoracic echocardiography will be performed on a GE Vivid 9 ultrasound machine with a 2.5 MHz transducer . The examination will be performed with the subjects resting in lateral supine position in a dark room by two experienced echocardiographers blinded for group allocation. All examinations will be analyzed off-line in random order, using the Echo Pac software version BT 11.0 by an independent and blinded echocardiographer. The full echocardiographic protocol has been described elsewhere . CardiacRight ventricular function will be evaluated as tricuspid annular plane systolic excursion. Diastolic function will be measured as peak transmitral inflow velocity in early (E) and late (A) diastole and the corresponding E/A-ratio and pulsed analyses of tissue Doppler Imaging (TDI) of diastolic velocities E´ and A´ will be obtained with a 5-mm pulsed (TDI) sample volume placed in the lateral, septal, anterior and inferior plane of the mitral annulus in the 2- and 4-chamber apical views. TDI peak systolic velocity  will also be measured. The values of E´ will be reported as an average of the septal and lateral early peak diastolic velocities and E/E´ will be calculated as a measure of left ventricular filling pressure. Two-D color tissue Doppler will be evaluated from six basal segments of septal, lateral, anterior, inferior, posterior, and anterior septal walls of the apical 2- and 4-chamber and long axis and values will be averaged. Measurements will include S´, E´ and A´. Diastolic dysfunction will be graded as previously described . LV longMeasurements of the reactive hyperemic index (RHI) and the augmentation index, respectively, will be measured with peripheral arterial tonometry (PAT) under standardized conditions in a quiet dark room. A pneumatic probe will be placed on the tip of each index finger and connected to a plethysmographic device . After this PAT measurements will be made before and during reactive hyperemia as previously described  in orderThe participants will be asked to drink 0.5 L of a 15% glucose solution within a 5-min period. Blood samples will be collected prior to the 75 g glucose intake as well as after 15, 30, 60, and 120 min to measure plasma glucose and insulin. Glucose tolerance will be measured by the 2 hour value and the area under the curve for glucose. To determine whole body insulin sensitivity the insulin sensitivity index (ISI) proposed by Matsuda and Defronzo will be calculated from fasting and mean plasma glucose and insulin concentrations obtained from the measuring time points during the OGTT .After a 1½ hr resting period during the OGTT, blood pressure will be measured with a digital sphygmomanometer (OMRON-M7) 5 times on the left arm at 2 min intervals. The average of the 5 measurements will be recorded for subsequent analysis.Blood samples will be obtained from a cubital vein and serve as a screening tool at baseline. Thus, hemoglobin and iron status will be measured to avoid inclusion of patients with anemia . Coagulation markers of International Normalized Ratio, activated partial thromboplastin time (APTT) and trombocytes will be measured to rule out coagulopathy . Serum concentrations of creatinine will be measured to rule out kidney disorders and levels of aminotransferases, alkaline phosphatase and bilirubine to rule out liver disorders . In addition all blood samples will be analyzed at baseline, 12 and 32 weeks for total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, and glycosylated hemoglobin, respectively, by automated analyzers  using enzymatic kits . All of the above mentioned blood markers will be analyzed in the Department of Clinical Biochemistry at Copenhagen University Hospital Rigshospitalet, Denmark.All samples will also be analyzed for bone markers, including procollagen type I C propeptide, osteocalcin, C-terminal telopeptide, tartrate-resistant acid phosphatase 5b and leptin, using ELISA and AlphaLISA apparatus  at the Scientific Laboratory at the University of Exeter, United Kingdom.Information on socio-demographic and lifestyle characteristics will be collected at baseline . Health-Detailed information about the time of PCa diagnosis, disease stage, PSA level at the time of diagnosis, duration of ADT at baseline, previous radiation treatment or surgery and pre-existing comorbidities will be obtained from the participants’ medical records.Participants will wear heart rate monitors  to determine heart rate zones and intensity.GPS monitors  will be worn by participants in week 2 and 11 to record standing, walking and running times, as well as running speeds and distance covered.In week 2 and 11 of the intervention participants’ perceived exertion and experience of flow will be determined with Visual Analogue Scales .Attendance and reasons for non-attendance of training sessions  will be recorded in a training log book.Serious adverse events occurring during the training will be reported immediately to the Unit for Patient Safety in the Capital Region of Denmark. Minor events related to physical contact or stumbling can occur during training, and only pain and soreness persisting for more than 24 h will be recorded.Since recreational soccer has not previously been applied as a rehabilitation strategy for men with PCa, the possible effect size on LBM is unknown. However, Krustrup et al.  have shoData entry will be undertaken using a secure web server and statistical analysis will be performed using Statistical Analysis Systems (SAS) version 9.2. The statistician will prepare results with no knowledge of the randomization coding. The primary endpoint will be reported as a two-sample t-test comparing change scores in the two randomization groups. Significance level will be set at 0.05.2max, HRmax, waist and hip circumferences, CMJ, and stair climbing parametres, and the patient reported outcomes, respectively, will be reported as either means with corresponding 95% confidence limits or as medians and interquartile range (IQR). For count data, i.e., the Flamingo balance test and the sit-to-stand test, Poisson regression will be used, and categorical data, i.e., single questionnaire items, will be reported as proportions and compared across randomization groups using chi-squared tests or logistic regression.Regarding secondary outcomes, the continuous variables, i.e., VOAdverse treatment side-effects of ADT for PCa patients include loss of LBM, increased fat percentage and increased risk of myocardial infarction , fracturThe current study will provide a comprehensive investigation into the effects of a relatively brief (12 weeks) and medium-term (32 weeks) exposure to physical exercise on numerous physiological outcomes including body composition, cardiovascular function, bone health, insulin sensitivity, mobility, muscle strength, balance and patient reported outcomes such as QoL in PCa patients undergoing ADT. Recreational soccer will be used as a unique and novel rehabilitation initiative and, to the best of our knowledge, this is the first time soccer has been proposed as a complementary intervention in the treatment of cancer. This is also the first study to examine cardiac function in PCa patients with comprehensive echocardiography, and to monitor the impact of exercise training in PCa patients on cardiac function and peripheral vascular function. Animal studies have provided evidence that exercise training may counteract left ventricular dysfunction associated with ADT in rodents . Our stuThe choice of soccer as an intervention is based on a number of considerations. Firstly, participation in sport is increasingly recognized as important for public health  and receOne particular aim of this study is to address whether an out-door intervention with little need for equipment can achieve effect sizes comparable to those of multimodal interventions requiring relatively expensive training facilities, i.e. resistance exercise machines and stationary bicycles. With a low cost to benefit ratio, potential positive results from the study may be disseminated to a broader population of men with PCa, in co-operation with existing community-based soccer clubs. This could potentially make an important contribution to the cancer care pathway for PCa patients and make a significant, positive impact on PCa survivorship both short- and long term.Finally, a goal of the current research project is to build a bridge between the clinical environment and the existing expertise within exercise- and sports psychology and physiology in order to meet the legitimate demands from male cancer survivors for patient-centered and action-orientated interventions aimed at improved health . CollaboADT: Androgen deprivation therapy; BMC: Bone mineral content; BMD: Bone mineral density; DXA: Dual-energy X-ray absorptiometry; IVST: Interventricular septal wall thickness; LBM: Lean body mass; LV: Left ventricular; LVEDD: Left ventricular end-diastolic diameter; LVID: Left ventricular internal dimension; OGTT: Oral glucose tolerance test; PAT: Peripheral arterial tonometry; PCa: Prostate Cancer; PWT: Posterior wall thickness; QoL: Quality of life; RER: Respiratory exchange ratio; RHI: Reactive hyperemic index; RM: Repetition maximum; TDI: Tissue doppler Imaging; VO2max: Maximal oxygen uptake.The authors declare that they have no competing interests.JM and JFC developed the study concept and initiated the project together with MR and PK. KB, JFS, LJA, PRH, TH, LLA, EWH, KBC and JU assisted in further development of the protocol. JU drafted the manuscript. KB will provide access to patients. All authors contributed to and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/13/595/prepub


Turbulent blood flow is a cause of energy loss in the cardiovascular system, and can thus be seen as a measure of flow inefficiency. Novel 4D flow CMR methods permit estimation of intracardiac turbulent kinetic energy (TKE). On the basis of the Reynolds number, one might expect that larger left ventricular (LV) size would promote higher TKE values, and thus lower flow efficiency. In this study, we hypothesized that the TKE of diastolic inflow would be larger in the dilated LVs of heart failure patients compared to normal LVs.http://medviso.com/products/segment/) at each diastolic time frame. Total TKE was calculated  within the segmented LV at each diastolic time frame   and 11 healthy subjects  . The LV was segmented . In the majority of subjects, peaks in total TKE could be observed at early and late diastolic filling. Peak total TKE at late filling was higher in DCM compared to Healthy ; there was no difference in peak total TKE at early filling between the groups (NS). At early filling, peak total TKE related moderately to mitral annular dimension and transmitral peak velocity (Table For both normal and DCM LVs, during early filling TKE relates to inflow characteristics of annular dimensions and mitral inflow velocity, but not to LV size. TKE values in normal LVs are highest during early diastole, and are lower when the LV is at its largest size. In contrast, in DCM LVs TKE increases as the LV size increases, and exceeds values in normal LVs. Energy loss due to late diastolic TKE may reflect inefficient flow in dilated and hypocontractile LVs of heart failure patients.This study was funded by the Swedish Research Council and the Swedish Heart-Lung foundation.


The purpose of this study was to assess the reliability of planar 123I-MIBG myocardial scintigraphy in patients with heart failure (HF).Despite its high prognostic value, widespread clinical implementation of Planar myocardial MIBG images of 70 HF patients were analysed by two experienced and one inexperienced observer. The reproducibility of early and delayed heart-to-mediastinum (H/M) ratios, as well as washout rate (WR) calculated by two different methods, was assessed using the intraclass correlation coefficient (ICC) and the Bland-Altman analysis. In addition, a subanalysis in patients with a very low H/M ratio (delayed H/M ratio <1.4) was performed. The delayed H/M ratio was also assessed using fixed-size oval and circular cardiac regions of interest (ROI).123I-MIBG images . In addition, the WR without background correction resulted in higher reliability than the WR with background correction . Furthermore, the delayed H/M ratio measurements remained reliable in a subgroup of patients with a very low delayed H/M ratio . Moreover, a fixed-size cardiac ROI could be used for the assessment of delayed H/M ratios, with good reliability of the measurement.Intra- and interobserver analyses and experienced versus inexperienced observer analysis showed excellent agreement for the measured early and delayed H/M ratios and WR on planar 123I-MIBG myocardial scintigraphy in HF patients, confirming that MIBG myocardial scintigraphy can be implemented easily for clinical risk stratification in HF.The present study showed a high reliability of planar  The ageing of the population and the improved medical treatment of cardiac patients has led to an increased prevalence of heart failure (HF) . Despite123I-labelled NE analogue meta-iodobenzylguanidine (MIBG) /(He − Me) × 100. In these two formulas H represents the mean counts per pixel in the cardiac ROI and M represents the mean counts per pixel in the mediastinal ROI in the early (e) and delayed (l) planar images. In this study, time decay was not corrected for in the calculation of WR.The WR was calculated from early and delayed planar images, using the two different methods as described in the proposal for standardization by Flotats et al. . In methTo assess the reproducibility of the measured H/M ratios and WR, the intra- and interobserver agreements were tested. Intraobserver variability was assessed by a single reviewer (C.E.V.) who reviewed all planar MIBG images twice, with at least 4 weeks between the first and the second review to avoid recall bias. For the interobserver analysis two reviewers (C.E.V. and M.J.B.) independently reviewed all planar MIBG images. Both observers were experienced in the analysis of MIBG myocardial scintigraphy. The reproducibility of the delayed H/M ratio measurements between an experienced (C.E.V.) and an inexperienced observer (J.E.M.) was also assessed. The inexperienced observer was given 2 h of training in the postprocessing of planar MIBG images. During this training, the postprocessing technique and the exact location of the mediastinal ROI and cardiac ROI were explained and five example cases were evaluated.Because the reproducibility of planar MIBG imaging might be different in patients with a very low delayed H/M ratio, a subanalysis was performed including only patients with a delayed H/M ratio of ≤1.4. The first measurements of one experienced observer (C.E.V.) were used to divide the study population into two groups: patients with a delayed H/M ratio of ≤1.4 were included and patients with a delayed H/M ratio of >1.4 were excluded. After selection of the patients with a very low delayed H/M ratio, the reproducibility of the delayed H/M ratio in this subpopulation was assessed by intra- and interobserver analyses.An additional analysis was performed to assess the reproducibility of the delayed H/M ratio using a fixed-size cardiac ROI or a manually drawn ROI. In this analysis the agreement between these two measurements was tested. Two types of fixed-size cardiac ROI were used. First, an oval cardiac ROI was placed over the myocardium including the left ventricular cavity. The size of the oval ROI was 60 × 70 pixels (approximately 85 × 100 mm) and the long axis of the oval was in line with the heart axis Fig. a. The seAll continuous variables are expressed as means ± SD. Intraclass correlation coefficients (ICC) were calculated to assess the reliability; a two-way mixed model was used with statistical significance set at 95 %. Single measures are reported for the intraobserver calculations and average measures for the interobserver calculations. For clinically relevant agreement the following criteria were used: ICC values <0.49, 0.49–0.59, 0.60–0.74 and >0.74 were considered poor, fair, good and excellent, respectively. Bland-Altman plots were used to evaluate the correlations between the measured values. The sample size was calculated using the method described by Shoukri et al. for the design of reliability studies . FurtherA total of 70 randomly selected patients  men) were included in the study. The baseline characteristics of the patient population are shown in Table The intra- and interobserver agreements, as well as the agreement between experienced and inexperienced observers for the early and delayed H/M ratio and the WR are summarized in Table In total, 37 patients (53 %) had a delayed H/M ratio of ≤1.4 and were selected for the subanalysis. The reproducibility of the measured delayed H/M ratio remained excellent with an ICC of 0.93 (95 % CI 0.85–0.96) and 0.93 (95 % CI 0.74–0.97), for the intra- and interobserver analyses, respectively  and 0.86 (95 % CI 0.72–0.93), respectively Table . The BlaHe − H1)/He × 100) provided more reliable values than the formula including background correction. Excellent agreement was also observed between the measurements of the H/M ratios and WR performed by an experienced and an inexperienced observer. A short period of training on the postprocessing technique was enough to accurately assess both the mediastinal ROI and the cardiac ROI, showing that a limited amount of experience in combination with basic anatomical knowledge is sufficient to successfully reproduce the results of an experienced observer. Subsequently, the results for the intra- and interobserver analyses could be reproduced in a subpopulation of patients with a very low H/M ratio, showing that the reproducibility remained excellent over the total range of delayed H/M ratios. These results imply that the measurements on planar MIBG myocardial scintigraphy are reliable even in patients with severe myocardial sympathetic denervation patterns.The present study showed excellent reproducibility of the assessment of the most reported clinical measurements on planar MIBG images in HF patients. In particularly, when using a manually drawn polygonal cardiac ROI the highest level of agreement was observed between the measured H/M ratios and WR. However, a fixed-size cardiac ROI can also be used for the assessment of delayed H/M ratios, since high agreement was seen between the measured delayed H/M ratios obtained using a traditional manually drawn cardiac ROI and those obtained using a fixed-size cardiac ROI. In addition, for the calculation of WR, the formula using only the cardiac ROI from the early and delayed planar MIBG images . However, slightly more variation was observed when the circular cardiac ROI was used. This variation could be explained by the fact that the circular ROI covers only a part of the heart. To prevent scatter from the lungs or liver, a circular ROI with a radius of 21 pixels was chosen, fitting into the apex of the myocardium without covering surrounding lung or liver tissue. However, because in most HF patients the left ventricle is enlarged, a circular cardiac ROI with a radius of 21 pixels (approximately 30 mm) often covers only a small part of the myocardium in these patients. This might influence the accuracy of the measured delayed H/M ratios in these patients. Okuda et al. used a cardiac ROI with a radius of 30 mm in the development of a semiautomated algorithm for the calculation of the H/M ratio, showing high reproducibility  . HoweverWhen routine clinical application of MIBG myocardial scintigraphy is encouraged by the effort to standardize the imaging procedure, knowledge about the acquired level of experience needed to evaluate the images would be valuable. This study showed that the early and delayed H/M ratios and WR measured by an inexperienced observer were in excellent agreement with the measurements of an experienced observer. A 2-h period of training examining five example cases was enough for accurate setting of the mediastinal and cardiac ROI. This indicates that the data analysis and the interpretation of planar MIBG images are feasible. Therefore, MIBG myocardial scintigraphy could be implemented easily in the clinical work-up of HF patients. Moreover, the subanalysis performed in patients with very low delayed H/M ratios showed that the reliability remains excellent over the total range of observed myocardial sympathetic activity patterns detected on MIBG myocardial scintigraphy in HF patients.The current study had several limitations. First, only the reproducibility was evaluated in this study, while the precision of planar MIBG myocardial scintigraphy also depends on the validity of the measurements performed. Second, the reproducibility of MIBG myocardial scintigraphy within subjects could not be evaluated, because MIBG myocardial scintigraphy was not repeated in time within the same patients. In the current study existing data were used of one-time MIBG myocardial scintigraphy evaluations. For the within-subject reproducibility of planar MIBG myocardial scintigraphy, a prospective study with repeated MIBG myocardial scintigraphy over time within the same patient is required. However, repeated MIBG myocardial scintigraphy within the same patient would involve an increased radiation dose. Third, we did not evaluate the influence of the size and location of the mediastinal ROI on the measured H/M ratio. However, the size of the mediastinal ROI was fixed (13 × 20 pixels) and the location was specified so that the variation in the mediastinal ROI was minimal in the current analysis (as shown in the Bland-Altman plot in Fig. The present study showed excellent reproducibility of planar MIBG myocardial scintigraphy in HF patients. Moreover, for the calculation of WR, the formula without background correction showed high reliability and might therefore be preferable in HF patients. Furthermore, we observed only a small influence of the level of experience on the assessment of H/M ratios and WR, indicating that the data analysis and interpretation of planar MIBG images is feasible. In addition, the use of a fixed-size oval cardiac ROI could make the image analysis procedure even more standardized. Consequently, these results could contribute to the standardization of the data analysis and interpretation of planar MIBG images and therefore might provide extra validation for the reliability of planar MIBG myocardial scintigraphy in HF patients.


Right ventricular (RV) dysfunction following implantation of a left ventricular assist device (LVAD) is a serious condition and is associated with increased mortality.t test was used to compare the data and estimate the p value.The aim of the study is to investigate the significance of pre-existing RV dysfunction, tricuspid valve (TV) insufficiency, and the severity of septal deviation following LVAD implantation on RV dysfunction, as well as the outcome and short-term complications in 51 patients from June 2006 to August 2010. Student p = 0.002). Preoperative RV dysfunction was a significant predictor of postoperative right heart dysfunction following implantation of an LVAD (p = 0.001).Mean age was 55.1 ± 13, with a male to female ratio of 3.25. The 30-day mortality was 13.7% (7/51 patients), and the overall mortality was 23.5% (12/51 patients). Meanwhile, 21 patients  have undergone orthotopic heart transplantation. The mean time of support was 314.5±235 days with a median of 240 days at the time of closing this study. Echocardiographic evaluation of RV function pre- and post-implantation of an LVAD demonstrated septal deviation towards the left ventricle in immediate postoperative phase, which correlated with acute RV dysfunction (Preoperative RV dysfunction is a predictor of RV failure in LVAD patients. The adjustment of septal deviation through gradual increase of the LVAD flow can prevent the acute RV dysfunction following LVAD placement. A preoperative RV dysfunction is associated with progressive RV dysfunction and failure following LVAD implantation in patients with congestive heart failure (CHF) . Acute RFurther, the significance of TV insufficiency has been debated lately as an important factor for RV dysfunction in LVAD patients.  A preopet test was used to analyze the data. A p value of < 0.05 was considered as significant. This study was approved by the Institutional Review Board at the Montefiore Medical Center, Albert-Einstein College of Medicine.This study is a retrospective review of our patients’ data (n = 51) who underwent implantation of non-pulsatile LVAD from June 2006 to August 2010. The aim of this study is to evaluate the impact of preoperative RV dysfunction, TV competency, and septal contribution to RV function following implantation of an LVAD, as well as outcome and adverse events requiring readmission of patients to the hospital. The available echocardiography data were used to evaluated the RV function, septal deviation, and TV regurgitation while on LVAD support. The student p = 0.001). Septal position was evaluated in 49 patients, while a deviation towards the left ventricle was seen in 17 patients (34%), which correlated with RV dysfunction (p = 0.002) indicating the significant role of the septum in RV function. The 30-day mortality was 13.7% (7/51 patients), and the overall mortality since 6/13/2006 until 1/11/2010 was 23.5% (12/51 patients). Twenty-one patients  have undergone orthotopic heart transplantation successfully. The initial post-implant length of stay (LOS) was 34.8±22.9 days, and LOS in CSICU was 14.7±16.2 days (median 9 days). Twenty-six patients (51%) were discharged home and 25 patients (49%) to a rehabilitation facility. The average days spent out off hospital until the next admission was 86.7±139 and 90.9±154 day for patients who were discharged home or rehab , ischemic cardiomyopathy (n = 27), postcardiac surgical shock , valvular (n = 1), and post partum cardiomyopathy (n = 2). The implanted devices included HeartMate II (n = 43), Ventriassist (n = 4), and HeartWare (n = 4). Additional procedures included tricuspid valve repair (n = 8), closure of PFO (n = 5), and aortic valve replacement (n = 5). The indication for assist device implantation included destination therapy , bridge to transplantation , and potential bridge to transplantation . The mean preoperative systolic pulmonary artery pressure (PAP) was 51.8±16.6 mmHg, and the pulmonary vascular resistance (PVR) was 3.58±1.83 woods. Preoperative cardiac index (CI) was 2.1±0.6, left ventricular ejection fraction (LVEF) was 21.97%±7.56%, with a median of 20%, and the preoperative RV work index was 564±372. Eighteen of 51 patients had intra-aortic balloon pump (IABP) in place. The intermacs level was 2.8±3.3, and the mean time of support was 314.5±235 with a median of 240 days at the time of closing this study. The preoperative RV dysfunction was diagnosed echocardiographically in 33 patients (65%), which correlated with postoperative worsening RV dysfunction in 32 patients (p = 0.002). Optimization of right heart function prior to implantation of an LVAD may reduce the risk of RV failure post-LVAD placement. In cases of severe right heart failure, simultaneous temporary mechanical support of the right heart may be indicated. Drakos et al. [Dynamic improvement in RV function is associated with favorable long-term outcome in patients with CHF . Our stu1s et al. . reportes et al. , howeverp = 0.02). The degree of septal shifting may predict the development of RV failure during LVAD support. This finding may help to adjust the flow following LVD placement and correct the septal deviation, which may then improve the RV dysfunction. A gradual increase of pump speed under echocardiography guidance can demonstrate the septal deviation and RV dysfunction immediately. An Adjustment of speed can be made under echocardiographic monitoring.During the LVAD support, the negative pressure in LV created by the LVAD causes deviation of interventricular septum towards the LV, which eliminates the septal contribution to right heart contractility. The severity of septal deviation may help in adjusting the LVD flow under echocardiography guidance and reduce the septal deviation towards the LV, which may then limit the RV dysfunction while on LVAD support. The RV function will eventually improve in days to weeks, postoperatively , howeverp = 0.29), which may be due to the small number of patients who had adequate echocardiographic evaluation of TV. Puwanant et al. [The importance of a competent TV on RV function has been underestimated. Potapov et al. 11 reported in a series of 54 patients that TV incompetence, RV dysfunction and shape, as well as right atrial dilation (short/long axis ratio >0.6), may help to predict the RV failure prior to LVAD placement [In this study we also evaluated the pattern of adverse events causing readmission of LVAD patients to the hospital Table . The advThis study has the common bias adherent to any retrospective study. Further, the study population was not uniform, and the etiology of heart failure was different. Some of the LVAD implantations were done up to 5 years ago and considering the improved techniques and advances in critical care, we should have fewer adverse events in coming years. The interobserver bias of clinicians who reviewed the echocardiograms is another limitation.An LVAD is an effective approach in bridging patients with end-stage heart failure to transplantation. Preoperative RV dysfunction is a predictor of post-implantation RV failure; however, the RV function may improve over time following LVAD implantation. In the presence of severe RV dysfunction, a temporary RVAD should be considered at the time of LVAD placement. An adequate medical adjustment of pulmonary hypertension and RV function In preoperative period may reduce the risk of RV failure during LVAD support. We recommend a TV ring repair at the time of LVAD implantation if there is echocardiographic evidence of significant TVR. An echocardiographic evaluation of RV function and septal deviation should be performed in patients following LVAD placement in the immediate postoperative period. An adjustment of LVAD flow based on echocardiographally monitored septal deviation can potentially prevent acute RV failure following LVAD implantation.The authors declare that they have no competing interests.S N-M, D D, R B, R M, D D’A were actively involved in operative procedures and contributed equally in preparing the manuscript. The statistical analysis was performed by S N-M and R B. All authors read and approved the final manuscript.


Left ventricular wall motion assessment following acute myocardial infarction (AMI) allows prediction of functional recovery. Current methods are based upon visual assessment, with inherent operator variability. CMR myocardial feature tracking (CMR-FT) is a recently introduced technique for tissue voxel motion tracking on standard steady-state free precession (SSFP) images to derive circumferential and radial myocardial mechanics. We sought to determine whether CMR-FT could be used as a quantitative measure of wall motion assessment and predict recovery in function following AMI.Patients presenting with non-ST elevation myocardial infarction (NSTEMI) were studied using a 3 Tesla Phillips Achieva system with Multi-transmit® technology and a 32-channel receiver coil, immediately prior to, and 3-months following, percutaneous coronary revascularization (PCI). Cine images were acquired using a SSFP cine technique, with analysis performed on the left-ventricular (LV) short-axis stack, covering the LV from apex to base. The acquisition pulse sequence provided a typical spatial resolution of 1.8 x 1.8 x 8 mm with a 2mm inter-slice gap and a temporal resolution of 50 frames per second. A 5-point wall motion scoring system was used to determine regional wall motion abnormalities (RWMA), with derivation of an indexed wall motion score (WMSI) specific to the region of infarction, according to the AHA 16-segment model. Myocardial strain parameters were derived following automated endo- and epi-cardial wall motion tracking of the SSFP cine short axis stack using dedicated software . Pre-PCI LV short axis circumferential (Ecc) and radial (Err) peak strains were related to WMSI using a Pearson correlation analysis. Visual and quantitative analyses were performed by two blinded reviewers.18 patients  with a mean Troponin T and LV ejection fraction (LVEF) of 1.6 ±1.1ug/L and 56±8% respectively completed the scanning protocol. Pre-PCI CMR-FT strain parameters were derived in all cases. Mean index WMSI was 2.57±0.03 reducing to 1.98±0.03 at follow-up (p=0.004). Mean index Ecc and Err were -23.1±15.5 and 21.0±15.5 respectively. Neither Ecc nor Err correlated with global LVEF . However, Ecc  and Err  showed a linear and inverse linear correlation, respectively, with the regional WMSI. In addition, index Ecc correlated with the 3-month WMSI .CMR-FT may be used to quantify severity of wall motion following an ACS. Circumferential strain parameters are more accurate in predicting infarct related wall motion abnormalities and recovery in function.Heart Research UK