Assessment of cardiac function is key in the management of intensive care unit (ICU) patients and frequently relies on the use of standard transthoracic echocardiography (TTE). A commercially available new generation ultrasound system with two-dimensional imaging capability, which has roughly the size of a mobile phone, is adequately suited to extend the physical examination. The primary endpoint of this study was to evaluate the additional value of this new miniaturized device used as an ultrasonic stethoscope (US) for the determination of left ventricular (LV) systolic function, when compared to conventional clinical assessment by experienced intensivists. The secondary endpoint was to validate the US against TTE for the semi-quantitative assessment of left ventricular ejection fraction (LVEF) in ICU patients.In this single-center prospective descriptive study, LVEF was independently assessed clinically by the attending physician and echocardiographically by two experienced intensivists trained in critical care echocardiography who used the US  and TTE. LVEF was visually estimated semi-quantitatively and classified in one of the following categories: increased (LVEF > 75%), normal (LVEF: 50 to 75%), moderately reduced (LVEF: 30 to 49%), or severely reduced (LVEF < 30%). Biplane LVEF measured using the Simpson's rule on TTE loops by an independent investigator was used as reference.A total of 94 consecutive patients were studied , 63 being mechanically ventilated and 36 receiving vasopressors and/or inotropes. Diagnostic concordance between the clinically estimated LVEF and biplane LVEF was poor  and only slightly improved by the knowledge of a previously determined LVEF value . In contrast, the diagnostic agreement was good between visually assessed LVEF using the US and TTE  and between LVEF assessed on-line and biplane LVEF, regardless of the system used .In ICU patients, the extension of physical examination using an US improves the ability of trained intensivists to determine LVEF at bedside. With trained operators, the semi-quantitative assessment of LVEF using the US is accurate when compared to standard TTE. In intensive care unit (ICU) settings, several studies have long shown that physical examination was inaccurate in predicting the hemodynamic status of patients with circulatory or respiratory failure, even when performed by experienced intensivists ,2. SpeciStandard transthoracic echocardiography (TTE) is currently the first-line imaging modality recommended for the measurement of LVEF . Miniatu2 associated with a sustained hypotension, or not [This single-center prospective descriptive study was approved by our institutional Ethical Committee, which waived the need for informed consent. During a six-week period, all patients hospitalized in our medical-surgical ICU underwent, systematically, a clinical and echocardiographic assessment of LVEF using standard TTE and a new generation US within the first 12 hours of admission. The presence or absence of congestive heart failure was clinically evaluated by the attending physician  based on medical history, physical examination and admission chest X-ray as previously described , or on aThe tested US was a new generation  miniaturized , battery-operated  device with a broad-band width (1.7 to 3.8 MHz) phased array probe (120 × 33 × 26 mm). This system can store digital still-frames or image loops, uses a color-coded overlay for real-time blood flow imaging, and allows distance measurements using integrated electronic calipers, but has neither spectral nor tissue Doppler capability  as follows: clinical evaluation vs. measured LVEF, visual assessment using the US and TTE vs. measured LVEF, and visual assessment using the US vs. visual assessment using TTE. A P-value < 0.05 was considered statistically significant.Results are expressed as means ± standard deviations or frequencies and percentages. Paired comparisons were performed using the paired Student n = 26), or an age < 18 years (n = 2). Finally, 94 patients were studied : 41 ± 15). Reasons for admission to the ICU were predominantly a circulatory failure (n = 56) or an acute respiratory failure (n = 26). Sixty-three patients (67%) were mechanically ventilated and 36 patients (38%) received vasopressors and/or inotropes (Table P = 0.0014) but its overall mean image quality was inferior to that of TTE (5.9 ± 3.7 vs 6.9 ± 3.7: P = 0.0009). Noticeably, the proportion of good-to-excellent image quality grade in the apical four-chamber view used to visually assess LVEF was not significantly different with the US and TTE , and LVEF was not visually evaluable in a similar proportion of patients (12/94 vs 10/94: P = 0.50).Among the 122 patients admitted to our ICU during the study period, 33 were excluded due to the unavailability of one investigator . The sensitivity and specificity of the clinical judgement to identify a decreased LVEF  was 60% (95% CI: 39 to 79) and 83% (95% CI: 71 to 92), respectively.LVEF was measured off-line in 84 patients (89%) in the apical four-chamber view and in 44 patients (47%) in the apical two-chamber view. Interobserver variability for LVEF measurement was 9 ± 7%. Mean LVEF was 54 ± 19%. According to TTE-derived LVEF values, 8 patients had an increased LVEF, 51 patients had a normal LVEF, 14 patients had a moderately reduced LVEF and the remaining 11 patients had a severely reduced LVEF. Diagnostic concordance between the clinically estimated LVEF by the attending physicians and the measured LVEF was poor , and only slightly improved by the knowledge of a previously determined LVEF value . Similarly, the visually assessed LVEF using the US and TTE was in agreement with the measured reference values . When compared with the reference LVEF, the visual assessment using the US overestimated LVEF in nine patients and underestimated LV systolic function in a single patient  when using right heart catheterization as a reference. In these series, the cardiac index was adequately graded as low, normal or high in only approximately half of the cases when compared to measurements obtained by the thermodilution technique ,2. Similet al.  reportedet al. ,17 and tAs previously reported using the same US , a fairlVisual assessment of LV systolic function using TTE has been shown to be reliable when performed by trained operators . In the Taken together, these results suggest that the tested US is reliable to semi-quantitatively assess LVEF during a short, focused examination in ICU patients. Importantly, the European Association of Echocardiography recently stated that current pocket-size imaging devices should only be considered as screening tools or used to complement the physical examination in various clinical settings, including in ICUs . The ranThe present study has several limitations. Although technically possible, LVEF has not been measured off-line on images obtained with the US. Nevertheless, the concept of US is based on a target-oriented , rapid evaluation to obtain information which is not accessible to physical examination. Accordingly, off-line measurement of LV volumes using the specific software provided with US is not clinically relevant. Both the order of echocardiographic examinations and allocation of ultrasound systems were not randomized, but rather depended on the availability of devices and investigators. Nevertheless, this potential methodological bias should have a minor impact on the observed results since surface echocardiography has long been used in our ICU by highly trained operators . AccordiIn ICU patients, the extension of physical examination using an US improves the ability of trained intensivists to determine LVEF at the bedside. With trained operators, the semi-quantitative assessment of LVEF using the US is accurate when compared to standard TTE.• In the present study, the pocket-size device used as an ultrasonic stethoscope (US) by intensivists trained in critical care echocardiography improved the clinical evaluation of left ventricular ejection fraction (LVEF) in intensive care unit (ICU) patients• In this setting, the tested US was accurate for the semi-quantitative evaluation of LVEF when using standard transthoracic echocardiography (TTE) as a reference• The concordance of visually estimated LVEF using the US and TTE on the one hand, and the biplane LVEF value on the other hand, were similar in our ICU patients• These results should not be extrapolated to other indications of echocardiography and to less experienced examiners. The design of the present study does not allow us to validate the use of this US to perform basic critical echocardiography.CI: confidence interval; EF: ejection fraction; ICU: intensive care unit; LV: left ventricle; LVEDV: left ventricular end-diastolic volume; LVESV: left ventricular end-systolic volume; TTE: transthoracic echocardiography; SAPS: simplified acute physiologic score; US: ultrasonic stethoscopeThe authors declare that they have no competing interests.JBA, GL, AD, MC, BF, NP and PV participated in the acquisition of data. BM, AG and PV participated in the analysis and interpretation of data. JBA and PV contributed to the conception and design of the study and were involved in the drafting and revision of the manuscript. All authors read and approved the version of the manuscript to be submitted.


There are physiological reasons for the effects of positioning on hemodynamic variables and cardiac dimensions related to altered intra-abdominal and intra-thoracic pressures. This problem is especially evident in pregnant women due to the additional aorto-caval compression by the enlarged uterus. The purpose of this study was to investigate the effect of postural changes on cardiac dimensions and function during mid and late pregnancy using cardiovascular magnetic resonance (CMR).th week of gestation and at 32nd week of gestation without history of cardiac disease were recruited to the study and underwent CMR in supine and left lateral positions. Cardiac hemodynamic parameters and dimensions were measured and compared between both positions.Healthy non-pregnant women, pregnant women at 20Five non-pregnant women, 6 healthy pregnant women at mid pregnancy and 8 healthy pregnant women at late pregnancy were enrolled in the study. In the group of non-pregnant women left ventricular (LV) cardiac output (CO) significantly decreased by 9% (p = 0.043) and right ventricular (RV) end-diastolic volume (EDV) significantly increased by 5% (p = 0.043) from the supine to the left lateral position. During mid pregnancy LV ejection fraction (EF), stroke volume (SV), left atrium lateral diameter and left atrial supero-inferior diameter increased significantly from the supine position to the left lateral position: 8%, 27%, 5% and 11%, respectively (p < 0.05). RV EDV, SV and right atrium supero-inferior diameter significantly increased from the supine to the left lateral position: 25%, 31% and 13% (p < 0.05), respectively. During late pregnancy a significant increment of LV EF, EDV, SV and CO was observed in the left lateral position: 11%, 21%, 35% and 24% (p < 0.05), respectively. Left atrial diameters were significantly larger in the left lateral position compared to the supine position (p < 0.05). RV CO was significantly increased in the left lateral position compared to the supine position (p < 0.05).During pregnancy positional changes affect significantly cardiac hemodynamic parameters and dimensions. Pregnant women who need serial studies by CMR should be imaged in a consistent position. From as early as 20 weeks the left lateral position should be preferred on the supine position because it positively affects venous return, SV and CO. Pregnanth week of gestation and at 32nd week of gestation with no history of cardiac disease were recruited to the study between June 2009 and January 2010. Study participants underwent CMR in supine and left lateral positions. Exclusion criteria were the common contraindications for CMR studies . The study was approved by the institutional review board and each subject gave informed consent.Healthy non-pregnant women, pregnant women at 20I, GE Medical System, Milwaukee, WI). Firstly the patient was placed in the supine position and entered feet first into the magnet. A dedicated cardiac 8 channels coil was placed on the thorax of the subject and used for the acquisition of the images. CMR cines were obtained using a breath-holding ECG triggered balanced steady state free precession sequence. Imaging parameters were as follows: FOV 36-40 × 28-32 cm; matrix 224 × 196; TR: 3.4 milliseconds; TE: 1.5 milliseconds; flip angle 45 degrees; 12 views per segment. Slice thickness was 8 mm with a gap of 2 mm. These parameters resulted in a temporal resolution per image of 41 milliseconds. At first, three rapid surveys were obtained for the determination of the cardiac position and orientation; two- and four-chamber cine MR images were then obtained. The series of short axis (SA) images were obtained from the reference images provided by the two- and four- chamber end-diastolic images at the end of expiration. Approximately 10 to 12 slices were acquired to cover the entire length of the heart. Directly after the first CMR study, the subject was repositioned on the left lateral side position for the second examination. The acquisition of images was performed by the same operator.CMR was performed using a 1.5T scanner . Left end-diastolic volume (EDV) and end-systolic volume (ESV) were calculated using a combination of classic SA and long-axis images. The long-axis view was used to limit the extend of volumes at the base and at the apex of the heart. The Simpson rule was used to calculate volumes based on the SA images where the first basal and the last apical were only partially included relating to the area outlined on two- and four- chamber images. More details about this approach have been previously reported . The papRight EF, EDV, ESV, SV and CO were calculated using cine images acquired in SA view, parallel to the tricuspid valve annulus and applying the same methods of the left ventricular hemodynamic measurements without long-axis corrections. In addition, lateral (RAlat) and supero-inferior (RAsi) right atrium diameters were taken during the phase of the cardiac cycle with the largest right atrium, on a four-chamber view Figure . The RAlDue to the low inter-observer variability reported in a previous study  image anth gestational week and the third group of women in the 32nd gestational week.The patients were categorized into 3 groups according to gestational age. The first group consists of non-pregnant controls, the second group of women in the 20All analyses were done using SPSS 15 (SPSS Inc.) software. Parametric data were reported as mean ± standard deviation. For each gestational group mean values of HR, EDV, ESV, EF, SV, CO, left and right atrium diameters of supine and left lateral positions were tested for significance, using Wilcoxon's two sample test. A p-value < 0.05 was considered significant. The percentage of change in the measure of left ventricle (LV) and right ventricle (RV) parameters (X) and left atrium (LA) and right atrium (RA) parameters (X) between supine and left lateral position was calculated using the following formula:A total of 14 healthy women with singleton pregnancies 30.3 ± 5.2 years) were included in the study. Five non-pregnant women (29.4 ± 5.7 years) were recruited as controls. The time interval between the examinations in supine and left lateral position ranged between 8 and 12 minutes. Table  years weHR did show a slight although not significantly decrease between supine and left lateral position: 78 ± 12 versus 73 ± 12. Left CO significantly decreased by 9% (p = 0.043) and right EDV significantly increased by 5% (p = 0.043). There were no other significant changes of hemodynamic parameters and cardiac dimensions between the two recumbent positions.th gestational week. HR was 80 ± 11 bpm in the supine position and 72 ± 5 in the left lateral position (p = 0.15). A significant increment of EF and SV of the left ventricle was observed between the supine and the left lateral position: 8% (p = 0.046) and 27% (p = 0.028), respectively. Left atrial dimensions increased significantly between the supine and the left lateral position by 5% for LAlat (p = 0.028) and by 11% for LAsi (p = 0.027). Regarding the right side of the heart, EDV increased by 25% (0.028) and SV increased by 31% (0.028) between the supine and the left lateral position. RAsi significantly increased by 13% (p = 0.042) between the supine and the left lateral position.Six pregnant women were in the 20nd gestational week. HR did not significantly change between the supine and the left lateral position: 81 ± 16 versus 75 ± 8 bpm (p = 0.237). A significant increment of EF, EDV, SV and CO was observed between the supine and the left lateral position: 11% (p = 0.012), 21% (p = 0.012), 35% (p = 0.012) and 24% (p = 0.012), respectively. Left atrial dimensions increased significantly between the supine and the left lateral position by 15% for LAlat (p = 0.012) and by 13% for LAsi (p = 0.025). No significant changes of right hemodynamic parameters and dimensions were observed between the two recumbent positions with the only exception of CO (p = 0.025).Eight pregnant women were in the 32th gestational week with an increase of left ventricle EDV and LA dimensions but with no clear impact on CO. For the right side of the heart we observed a similar trend of increment of ventricular and atrial dimensions at 20 weeks but no further increase during late pregnancy.A progressive increase of percentage changes of hemodynamic parameters and cardiac dimensions of the left side of the heart was found throughout gestation. The only exception was the percentage change of ESV which substantially did not change between 20 and 32 weeks of gestation. During late pregnancy left ventricle CO significantly increased between supine and left lateral position; the percentage of increment at 32 weeks was 24%. This was associated to an increase of 21% of left ventricle EDV. A significant increase in LA dimensions was also found. The difference between the two recumbent positions was less clear at 20This study investigated how the supine and the left lateral positions during CMR affects heart rate, cardiac volumes and dimensions at different gestational ages. To our knowledge this is the first study investigating the effect of two recumbent positions on cardiovascular hemodynamic measurements and changes in cardiac dimensions during pregnancy using CMR. The data show a clear difference between the two positions, which become more marked as pregnancy advances but are significant from as early as 20 weeks. There were minimal changes in the non-pregnant subjects. The existing data from non-pregnant humans with regards to the effect of different positions on hemodynamic parameters are limited and sometimes conflicting. Some report that cardiac output is higher in the supine position compared to the right or left lateral position ,13, whilPregnancy itself is a circulatory burden with a significant impact on the cardiovascular system. Cardiac output increases 30-50% above pre-pregnancy levels. In addition, when a pregnant woman lies flat on her back, the gravid uterus partially compresses the inferior vena cava with the consequent reduction of venous filling load and cardiac output ,17. FromSome concerns may develop regarding the use of CMR in pregnant patients. Most studies evaluating MR safety during pregnancy do not show ill effects on the fetus -23. It iSeveral limitations of this study should be highlighted. First, our results should be tested in a larger sample of women including women with cardiac disease. Indeed the normal physiological respond to pregnancy could be different in patients with congenital or acquired cardiovascular diseases. In addition, the small sample size may justify the large standard deviation in our series. Second, because the interval between each MR acquisition was between 8 and 12 minutes it is possible that cardiac parameters had not returned to baseline. Additional studies using more time points and also investigating the reverse change from lateral to supine could clarify this interesting subject. Third, this study is a cross-sectional study. The effects of the position on cardiac hemodynamic should preferably be studied in a prospective-longitudinal study investigating the same population at different gestational times.In the non-pregnant state, turning from supine to left lateral position has minimal effect on cardiac parameters. During pregnancy, from as early as 20 weeks, turning to the left lateral position has positive effects on cardiac hemodynamics inducing a significant increase of venous return, SV and CO. Pregnant women requiring CMR should be studied in a consistent position for serial studies and the left lateral position is preferred from early pregnancy onwards, also to limit uteroplacental hypoperfusion.CMR: cardiovascular magnetic resonance; SA: short-axis; EDV: end-diastolic volume; ESV: end-systolic volume; EF: ejection fraction; SV: stroke volume; CO: cardiac output; LV: left ventricle; RV: right ventricle; LA: left atrium; RA: right atrium; LAlat: lateral left atrium diameter; LAsi: supero-inferior left atrium diameter; RAlat: lateral right atrium diameter; RAsi: supero-inferior right atrium diameterThe authors declare that they have no competing interests.The contributions of each author to this manuscript are as follows; AR was involved in the acquisition, analysis and interpretation of the data and drafting of the manuscript. YK, TS and PO were involved in the conception and acquisition of the data. JC, MRJ, AM, GPK, ES were involved in revising the manuscript critically for important intellectual content. JRH was involved in the design of the study and revising the manuscript. RJG was responsible for the conception and design of the study, interpretation of the data and drafting the manuscript. All authors have read and approved the final manuscript.


Myocardial crypts are discrete clefts or fissures in otherwise compacted myocardium of the left ventricle (LV) commonly located in basal inferior or inferoseptal segments. Few small studies reported higher prevalence of crypts in patients with hypertrophic cardiomyopathy (HCM) or their unexpressed relatives, and linked crypts to a marker of genotype positive phenotype negative carrier status. The exact clinical significance of crypts is unclear. We assessed the prevalence of myocardial crypts seen in consecutive subjects referred for cardiac magnetic resonance (CMR).We analyzed a cohort of consecutive subjects referred for clinical CMR during a period of 9 months . Based on pre-test probability and CMR findings , 3 groups were formed and examined for the presence of myocardial crypts. The non-ischemic cardiomyopathy group was further stratified into subgroups of identified etiology. Myocardial crypts were described according to their shape , depth  and the segment location.Overall, myocardial crypts were identified in 136 subjects (19%) with no gender difference . Crypts were similarly proportioned in normal group  and those with ischemic  or non-ischemic cardiomyopathy  (p=0.40). In the latter group, crypts were most common in subjects with HCM  again p - value against the other groups. In relatives to the patients with confirmed genetic cardiomyopathy only 11% crypts were found. Crypts most commonly presented by the u-shape (45%), followed by the v - (40%) and i - shape (15%). Sixty-percent of crypts were 30-50% deep, followed by 50-70% (35%) and 5 % > 70% myocardial diameter. Most of the myocardial crypts could be identified in the basal inferior segment (49%). In twenty percent, crypts were multiple, with no difference in representation in health or disease (p=0.22-0.89).In a large study cohort we demonstrate that myocardial crypts are similarly prevalent in subjects with and without cardiomyopathy. A subanalysis of non-ischaemic group reveals disproportionate representation with bias towards HCM. Contrasting previous reports, crypts were less common in relatives. Prospective studies are needed to confirm the clinical significance of myocardial crypts, if any.NIHR


This study aimed to evaluate the correlation between coronary stenosis and left ventricular function using dual-source computed tomography (DSCT). DSCT coronary angiography (CAG) was performed on 66 patients with coronary disease and 36 healthy volunteers. The degree of coronary stenosis, end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF) and myocardial mass (MM) were measured for the left ventricle. These values were compared with the results obtained by echocardiography (ECHO) and selective CAG, which were both adopted as controls. The diagnoses of coronary stenosis based on DSCT CAG and those based on selective CAG were not significantly different (P>0.05). Similarly, the values of EDV, ESV, SV or EV measured by DSCT CAG were not significantly different from thoses obtained by ECHO (P>0.05). However, significant differences were observed in the ESV, EF and SV of the severe stenosis group compared with the moderate and mild stenosis groups (both P<0.05). The values of EDV and MM significantly varied between the mild, moderate and severe stenosis groups (P<0.05). DSCT CAG is a highly accurate and highly reproducible method for evaluating the preliminary changes in cardiac function based on the variations of coronary stenosis. Significant changes were detected in the EDV and MM of the moderate stenosis group and in all parameters of the severe stenosis group. Clinical imaging uses a variety of methods for the evaluation of coronary arteries and ventricular function; these techniques are categorized as either invasive or non-invasive and include X-ray cardioangiography, transesophageal echocardiography (ECHO), transthoracic ECHO, cardiac magnetic resonance imaging, cardiovascular radionuclide imaging and cardiovascular computed tomography (CT) imaging. Compared with the traditional single-source multi-slice spiral CT, dual-source CT (DSCT) has a faster scanning rate and a higher time resolution of 83 msec. Therefore, coronary imaging using DSCT is less susceptible to interference from the heart rate and expands the clinical applications of CT in coronary imaging. DSCT is relatively consistent in terms of accurately diagnosing coronary lesions when used with coronary arteriography . The imaging quality is susceptible to multiple factors, including heart rate irregularities such as tachycardia and arrhythmia, artifacts due to respiration and body movement, parameters in scanning and reconstruction, selected trigger points in the monitored layer, chosen reconstruction phases, adopted injection velocity, dosage of the contrast and options of pitch –4. StudiData were collected from 66 patients with coronary heart disease, which included 40 males and 26 females aged 41 to 88 years old , with heart rates between 65 and 120 bpm as well as normal rhythm. The patients enrolled in the study underwent DSCT CAG between January 2012 and January 2013. A diagnosis was established for every patient based on their history, physical examination, electrocardiography (ECG), serum biochemistry and myocardial enzyme levels. Patients with diseases such as rheumatic heart disease were excluded. The patients underwent CAG and ECHO within one week. This study was conducted in accordance with the Declaration of Helsinki. This study was conducted with approval from the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University, Nanjing, China. Written informed consent was obtained from all participants.The control group included 36 healthy volunteers who underwent DSCT CAG. This group included 21 males and 15 females aged 16 to 74 years-old , with heart rates of 60 to 110 bpm and normal rhythm. The volunteers were healthy; those with a predisposition to any organic diseases were excluded. No abnormalities were observed during the detailed inquiry of patient history, physical examination, ECG, ECHO, serum biochemistry or results of the examination of hepatic or renal function.Retrospective ECG-gated scanning was performed using a DSCT machine . Prior to the scanning, the participants were prohibited from taking heart rate-reducing agents, such as Betaloc. A scout view was obtained for a patient holding his breath in a supine position, while scanning from 1 cm inferior to the tracheal carina to 1.5 cm inferior to the inferior border of the heart. A plain scan was initially generated prior to the injection of the nonionic contrast agent iohexol (350 mg I/ml) via the ulnar vein at a dosage of 80–100 ml at a rate of 4.5–5.5 ml/s. A contrast-triggered enhanced scanning was then performed with the tracing level at the root of the ascending aorta and the trigger threshold at 90–100 HU. The scan was launched with a 6 sec delay and performed for 5 to 12 sec. Following injection of the contrast agent, 30 ml 0.9% normal saline was injected at the same rate. The following scanning parameters were used: detector dimensions, 2×32×0.6 mm; layer thickness, 2×64×0.6 mm; rack rotation time, 330 msec; heart rate-dependent pitch, 0.2–0.5; tube current time, 400 mAsec/cycle; and tube voltage, 120 kV.Off-line reconstruction was performed for the raw material after the scanning was finished, with a 1 mm-thick reconstruction layer, a 1 mm interval, a 10% R-R interval, and a convolution function value of B26f. All-phase reconstruction at 0 to 95% was adopted to obtain images of the 20 cardiac cycles, which were transferred to the workstation for analysis by Syngo Circulation (Siemens). The short-axis, four-chamber, and two-chamber views in each cycle were observed in cineloop to define the ends of the diastole and systole. The LVA software (Siemens) was used to analyze the cardiac function and delineate the endocardium and epicardium, by covering the entire area from the outflow tract to the left ventricle; the papillary muscles were irregular and small, and therefore ignored. The end-diastolic volume (EDV), endsystolic volume (ESV), stroke volume (SV), ejection fraction (EF) and myocardial mass (MM) of the left ventricle were automatically calculated based on the Simpson’s rule for numerical integration. The mean of triplicate measurements was recorded. The data included in this study were obtained by one physician proficient in the use of the software.The degree of stenosis was qualitatively evaluated using the area method. The stenoses were categorized into three groups based on the routine standards commonly used in clinical practice, namely, the mild group with <50% stenosis, the moderate group stenosis with between 50 and 75% stenosis, and the severe group with ≥75% stenosis . The steTwo-dimensional ECHO was performed using a Color Doppler intelligent diagnostic system . The examinations were performed by one senior physician.2 test was performed to compare the coronary stenosis evaluated by CAG and DSCT CAG. The two-sample Student’s t-test and the Pearson correlation analysis were used to correlate the cardiac function based on DSCT against the ECHO findings. The two-sample Student’s t-test and q-test were used to analyze the effect of different degrees of coronary stenosis on cardiac function. P<0.05 was considered to indicate a statistically significant result.The data were expressed as mean ± standard deviation. A paired χ2 test (McNemar test) with P=0.701 (P>0.05) and κ coefficient test (kappa test) with κ=0.824  suggested a high level of consistency between the DSCT CAG and selective CAG results. No significant differences in the capacity to diagnose coronary stenosis were observed between the two approaches , left anterior descending artery (LAD), diagonal branch (Diag), left circumflex coronary artery (LCX), left obtuse marginal branch (LOM)] of 66 patients, out of which 196 were confirmed by selective CAG. Only 12 instances of selective CAG-identified stenoses were not detected by DSCT CAG . The paiproaches .The results showed that the EDV, SV and EF of the left ventricle in the disease and control groups were slightly higher, while ESV was slightly lower when measured by DSCT, as compared with those measured by ECHO. However, no significant differences were observed between the parameters of cardiac function measured by the two methods P>0.05;  and III.There were 36 individuals in the control group, and 8, 22 and 36 patients in the mild, moderate and severe stenosis groups, respectively. The q-test of paired comparisons revealed significant differences in the ESV, EF and SV in the severe group, as compared with those of the mild or the moderate groups (both P<0.05). However, these parameters were not significantly different between the mild and the moderate groups (P>0.05). Significant differences were observed in EDV and MM among the three stenosis groups (P<0.05). No significant differences were demonstrated among the parameters of the control group, as compared with those of the mild stenosis group P>0.05; .The use of CAG with spiral CT has become an important invasive approach for coronary imaging. In addition, the parameters of ventricular function may be obtained while angiography is conducted and thus provide more informative data for clinical practice. The dosage of heart rate-reducing agents prior to the examination may interfere with the results  ThereforPrevious studies ,11 have By distinguishing the defined borders of the endocardium and epicardium, DSCT may reveal the anatomical structure of the heart more clearly than ultrasound scan. Due to its large capacity for raw data and a powerful post-processing software, DSCT is capable of semi-automatically delineating the ventricular contours and enabling the repeated playback of three-dimensional movies that simultaneously show multiple positions of the heart , therebyCoronary stenosis leads to myocardial ischemia. The blood flow reserve for coronary vessels gradually decreases with the increasing severity of coronary stenosis, and resting ventricular ataxia occurs at this stage. This proceeds to altered cardiac functions, including weakened myocardial contractility, enlarged heart and decreased compliance, as well as congestion in the left ventricle and the left atria. The increased EDV and decreased EF reflect the gradual loss of compensation on the left side of the heart, as well as predict the onset of left-sided heart failure and poor prognosis. Myocardial ischemia and anoxia may cause myocardial hypertrophy and thickened ventricular walls, thereby increasing MM but decreasing myocardial contractility. In clinical practice, the evaluation of varying cardiac functions according to the degree of coronary stenosis is of great importance. Along with the increasing number of coronary branches with lesions and the aggravating stenosis, cardiac function gradually worsens. In this study, patients were categorized into three groups by evaluating the coronary stenosis, which is frequently used in clinical practice. No significant variation was observed in the parameters in the mild group compared with those of the controls. Similarly, no significant changes were observed in the ESV, SV or EF in the moderate stenosis group. However, significant changes were noted in the severe stenosis group. Myocardial compensation continued to be achieved in certain cases of mild or moderate stenosis of the coronary arteries. The enhanced myocardial contractibility may aid maintenance of systemic circulation and avoid a significant reduction of the EF, which may occasionally undergo a compensatory increase. A significant reduction in the EF occurred with the decompensation of cardiac function in the severe stenosis group. The decreasing EF was closely correlated with the incidence and mortality of acute myocardial infarction. EDV and MM were significantly increased in the moderate stenosis group, and increased further in the severe group relative to the moderate group. Therefore, EDV and MM are likely more sensitive than EF in terms of reflecting the variation of cardiac function. Along with the increasing EDV that occurs with ventricular wall tension, myocardial oxygen consumption was further increased with aggravated myocardial ischemia. Simultaneously, the MM may gradually increase and further aggravate cardiac contractibility, thereby suggesting that severe myocardial ischemia damages LV systolic functions.This study is primarily limited by the use of only the mild, moderate and severe categories in the interest of simplification and pragmatism. Our results would have been more meaningful if stenosis sites at the trunk or branch, as well as the lesions in single or multiple branches were considered. Our study is further limited by the size of the samples used. Therefore, further studies are required to investigate patients with different types of arrhythmias. Despite its high temporal and spatial resolution, DSCT has a limited capacity to accurately identify stenosis due to motion and halo artifacts induced by arrhythmias and calcification, respectively. DSCT is similarly challenged by controversies concerning ionizing radiation ,20. ThusNone of the previously available data indicate that heart CT scans have been used to evaluate cardiac function alone. However, data with regard to cardiac function may be utilized during CAG to obtain additional information . Our res


The value of the 12-lead electrocardiogram (ECG) to provide prognostic information in the deadly and disabling syndrome peripartum cardiomyopathy (PPCM) is unknown.To determine the prevalence of major and minor ECG abnormalities in PPCM patients at the time of diagnosis, and to establish whether there are ECG correlates of persistent left ventricular dysfunction and/or clinical stability at six months of follow up, where available.Twelve-lead ECGs were performed at the point of diagnosis on 78 consecutive women presenting with PPCM to two tertiary centres in South Africa and 44 cases (56%) at the six-month follow up. Blinded Minnesota coding identified major ECG abnormalities and minor ECG changes.2]. The majority of cases  presented in sinus rhythm (mean heart rate 100 ± 21 beats/min). At baseline, at least one ECG abnormality/variant was detected in 96% of cases. Major ECG abnormalities and minor changes were detected in 49% (95% CI: 37–60%) and 62% (95% CI: 51–74%) of cases, respectively; the most common being T-wave changes (59%), p-wave abnormality (29%) and QRS-axis deviation (25%).The cohort mainly comprised young women of black African ancestry (90%) [mean age 29 ± 7 years and median body mass index 24.3 (IQR: 22.7–27.5) kg/mp < 0.001) and abnormal QRS axis . On an adjusted basis, major T-wave abnormalities on the baseline 12-lead ECG were associated with lower left ventricular ejection fraction (LVEF) at baseline  and at six months . Similarly, baseline ST-segment elevation was also associated with lower LVEF at six months .Of the 44 cases (56%) reviewed at six months, normalisation of the 12-lead ECG occurred in 25%; the most labile ECG features being heart rate (mean reduction of 27 beats/min; In this unique study, we found that almost all women suffering from PPCM had an ‘abnormal’ 12-lead ECG. Pending more definitive studies, the ECG appears to be a useful adjunctive tool in both screening and prognostication in resource-poor settings. Peripartum cardiomyopathy (PPCM) is a form of heart failure (HF) with poorly understood aetiology, occurring between the last trimester of pregnancy and up to the first five to six months postpartum.8Some studies suggest the incidence of PPCM is one in 3 000 live births. However, one African study found it to be one in 1 000 live births.Definitive diagnosis and subsequent management of PPCM requires a high index of suspicion. It also usually requires referral to a tertiary centre for echocardiographic studies and specialist cardiological management. Anecdotal evidence suggests that many women who initially present with signs and symptoms indicative of PPCM are diagnosed with ‘non-specific symptoms of the puerperal period’. The misdiagnosis of PPCM  represents a clear target for early intervention and prevention. Until specific aetiologies are identified, PPCM remains a diagnosis of exclusion.Women in their peripartum period suspected with PPCM require rigorous investigation; a costly and laborious process for the patient and healthcare provider. This is particularly difficult in a resource-poor environment. Although screening with (point-of-care derived) brain natriuretic peptide (BNP) levels may offer a means of detecting elevated atrial pressures secondary to systolic dysfunction  is common in individuals with HF syndrome, with common anomalies including supraventricular arrhythmias, bundle branch block, and sinus bradycardia.de novo PPCM to two tertiary centres in South Africa  between January 2003 and August 2008 were studied. Patients were referred from primary and secondary health facilities, as well as internally from other departments. Only patients aged ≥ 17 years who fulfilled the diagnostic criteria for PPCM4 were considered eligible for the study. For recruitment, previously describedConsecutive patients presenting with Ethical approval was obtained from each of the local ethical committees of the universities of Cape Town and the Witwatersrand, respectively, prior to the commencement of the study. This study complied with all the requirements of the Declaration of Helsinki. All patients were offered treatment and follow up as per the local standard of tertiary care.n = 34), three patients died (3.9%). Importantly, patients with repeat six-month ECG data did not differ significantly with respect to baseline heart rate, NYHA functional class, and left ventricular ejection fraction (LVEF) from the remaining cohort.A total of 78 women presenting with PPCM were studied. Of these, 56% had follow-up ECG data and were included in the comparative study analyses. Of those patients who had not had six-month ECGs , using the Minnesota code classification system.Standard methods for two-dimensional Doppler transthoracic echocardiography were applied as per the American Society of Echocardiography guidelines.t-tests for normally distributed numerical variables, Mann-Whitney/Wilcoxon signed rank tests for non-parametric paired numerical variables, and chi-squared tests for categorical variables and proportions. Multivariate analysis was conducted using linear and logistic regression for numerical and categorical outcome variables, respectively.All data analyses were performed with STATA-8.Interestingly, no patients under the age of 17 years presented to either study unit and 90% of patients included were young women of African ancestry. Of the 10% that were of non-black African ethnicity, almost all were of mixed ancestry, with only one Caucasian patient. The majority of respondents were normotensive and experienced onset of symptoms in the postpartum period . However, 8% of respondents reported the onset of symptoms prepartum, of which only two were hypertensive .24n = 78). The majority of cases (90%) were in sinus rhythm, although mean heart rate was markedly elevated, with 45% of cases in sinus tachycardia . Only three patients (4%) had completely normal ECGs; excluding those with an elevated heart rate, this increased to nine patients (12%). Overall, 49% (95% CI: 37–60) of cases had a major Minnesota ECG abnormality detected, while 62% (95% CI: 51–74) had a minor ECG variant. A combined total of 63  cases had one or both forms of abnormality detected on their 12-lead ECG. Of the major abnormalities, major T-wave anomalies (38%), followed by abnormal QRS axis (26%) were the most common p = 0.03%) reduction in LVEF compared to those without T-wave changes.Univariate analysis showed no association between LV systolic function and baseline ECG readings. However, on adjustment for age, functional class, echocardiographic LV dimensions, and all the other ECG parameters listed in Table 3, major T-wave abnormalities correlated negatively with left ventricular systolic dysfunction. The presence of major T-wave changes was associated with a clinically relevant 9%  p < 0.001), although 10% still reported functional impairment (NYHA class II or more). Overall, 25% of this sub-set of cases had a normal 12-lead ECG at six months.At six months, a number of clinical parameters had improved in surviving cases subjected to study follow up (p = 0.006) compared to those without T-wave changes at baseline. In addition, ST-segment elevation at baseline was associated with an even greater reduction in LVEF at six months  compared to those without this ECG pattern at baseline.According to univariate analyses, no difference between ‘clinically stable/responded to treatment’ (i.e. recovered LV function) versus non-responders (persistent LV dysfunction) were found in respect of any ECG parameter. However, on an adjusted basis, major T-wave changes and major ST-segment depression found on the baseline 12-lead ECG subsequently correlated with persistently impaired systolic function at six months. Specifically, the presence of major T-wave changes at baseline was associated with a markedly lower LVEF at six months  in detecting underlying LV dysfunction in confirmed cases of de novo PPCM in African women. This would require a high underlying level of ECG abnormalities in such a cohort in order to discriminate against (presumably) more normal 12-lead ECGs in African women experiencing healthier pregnancies.To the best of our knowledge, this is the first study to systematically describe the 12-lead ECG in Of the 78 cases studied, 49% demonstrated major ECG abnormalities, usually associated with significant underlying cardiac pathology, while 62% demonstrated one or more forms of minor variation/abnormality, potentially indicative of the same. We also attempted to examine whether the 12-lead ECG is a useful tool for discriminating between those cases who respond to treatment  and those who had persistent LV dysfunction. In this respect, we found that the presence of two major abnormalities (T-wave inversion and ST-segment depression) and a third Minnesota code criterion not listed as one of the major or minor criteria (ST-segment elevation) found on the baseline 12-lead ECG correlated with persistently poor LV systolic function at six months. T-wave inversion also correlated with LV systolic function at baseline.Typically, LV systolic functional recovery in PPCM is a slow and drawn-out process that enters the second year of treatment.Our findings and the overall utility of the 12-lead ECG in this clinical setting require careful interpretation when fundamental investigations such as echocardiography remain inaccessible to most hospitals and patients in sub-Saharan Africa. Serum levels of NT-proBNP are known to strongly predict the degree of heart failure,26The scarcity of the serum NT-proBNP test in our setting almost mandates using something as inexpensive and easy as the 12-lead ECG to screen for PPCM, even if its sensitivity and specificity prove to be imperfect. These data will be particularly useful if . In Western countries, major ST-segment depression and T-wave abnormalities are often regarded as indications of myocardial ischaemia, bearing consistent prognostic significance for cardiovascular disease mortality across prospective studies, especially for men.28We remain wary of the fact that gender differences in ECG findings often show women to have a higher prevalence of ST-segment depression or T-wave changes, such as to question the true significance of any association between ST-segment depression and T-wave abnormalities with coronary heart disease (CHD) mortality in women.19Studies reporting on the ECG in prognostication of PPCM remain scarce, with two from Nigeria suggesting it to be a weak predictor of recovery and long-term prognosis in PPCM.Systematic reports of ECG abnormalities associated with idiopathic dilated cardiomyopathy (IDCM), which bears some resemblance to PPCM, are few. One such study of IDCM reported that the ECG was found to be normal in up to 25% of affected relatives of IDCM patients , although these were not all newly diagnosed IDCM cases.It remains fair to say that the shortage of studies systematically reporting on the prevalence of ECG anomalies in PPCM may account for most for our inability to corroborate our findings with other available evidence, yet no reports contradict our findings. Overall, therefore, our data can only suggest that the 12-lead ECG in PPCM may be sensitive to underlying LV dysfunction and/or that it can serve as a marker of more extensive cardiac insult early in the disease process.Lastly, we note that the 1% prevalence of first-degree heart block, usually not considered to bear any significant risk to adverse CVD outcome, except for its association with lamin A/C mutation in familial DCM, may in our PPCM cohort merely reflect the 1–2% prevalence in normal young adults.Furthermore, evaluation of this conduction disorder may be of particular importance in PPCM, in view of several reports of first-degree AV block being among one of the earliest signs of lamin A/C mutation, which in turn commonly leads to a phenotype of apparently unexplained DCM.This pilot study has a number of limitations that require comment. Firstly, the Minnesota code may not be sufficiently validated for the detection of heart disease in pregnant women. Moreover, the ‘normal’ 12-lead ECG in African women is yet to be definitively described. Whether the combined presence (81% of cases) of major abnormalities and minor variations is sufficient to support further investigation of the 12-lead ECG as a screening tool , is open to debate.In determining the sensitivity of ECG changes over time, relative to underlying LV dysfunction, we had valid data for only 56% of the cohort. Although our PPCM patients who did not have follow-up ECGs did not differ in clinical and echocardiographic outcome from those with follow-up data, the possibility that the former group may have been clinically worse off than those with six-month data cannot be excluded, given that greater proportions of the former manifested minor T-wave anomalies, and that their left ventricular diameters and BMI at baseline appeared greater than those who had six-month ECGs. However, in light of the lower prevalence of QRS-axis deviation and bundle branch block among the former group, interpretation of the similarity of patients with and without follow up with regard to ECG characteristics becomes speculative.Further data are required to better characterise the 12-lead ECG as a marker of LV dysfunction in this specific clinical (and ethnic) context, before any firm recommendations can be made in respect of obtaining a 12-lead ECG at the conclusion of each pregnancy in sub-Saharan Africa.Despite a number of limitations, this still represents a unique study that will prove to be invaluable in determining the future role of the 12-lead ECG as an inexpensive and simple ‘rule-out’ screening tool for PPCM, and perhaps an important tool for increasing the intensity of subsequent treatment and management. Overall, we found the majority (96%) of PPCM patients presented with ‘abnormal’ 12-lead ECGs, which improved significantly to 75% after the first six months of treatment. Over 80% of patients displayed either major abnormalities or minor variations using the Minnesota code. Of these, sinus tachycardia and QRS-axis deviation were most likely to be attenuated after six months. Even though these ECG abnormalities were mostly non-specific and similar to those of other dilated cardiomyopathies, our study further suggests the ECG to be useful in simple monitoring of clinical progress during treatment and prognostication.Specifically, the baseline presence of major T-wave and ST-segment abnormalities in the context of PPCM patients may place these patients at similar risk of adverse outcomes to those with myocardial ischaemia. More definitive studies are required to determine if this simple and relatively inexpensive tool will prove to be of particular clinical use in the setting of PPCM. Any progress in this regard will be welcome, given the persistently poor health outcomes associated with PPCM in resource-poor settings.


Introduction: The aim of the study was to investigate the occurrence, the aetiology and the management of congestive heart failure in the cardiac centre of the St. Elizabeth catholic general hospital Shisong in Cameroon. Methods: Between November 2002 and November 2008, a population of 8121 patients was consulted in the referral cardiac centre of St. Elizabeth Catholic General Hospital. Of these patients, 462 were diagnosed with congestive heart failure according to the modified Framingham criteria for the diagnosis of heart failure. Complementary investigations used to confirm and establish the aetiology of the disease were the chest X-ray, electrocardiography, bi-dimensional Doppler echocardiography. Results: The results showed that the occurrence of congestive heart failure in our centre was 5.7%. Congestive heart failure was diagnosed in 198 females and 264 males, aged between 8 and 86 years old (42.5±18 years old). Post rheumatic valvulopathies (14.6%) and congenital heart diseases (1.9%) were the first aetiologic factor of congestive heart failure in the young, meanwhile cardiomyopathies (8.3%) in elderly followed by hypertensive cardiomyopathy (4.4%). Congestive heart failure was also seen in adults with congenital heart diseases in 0.01%. In this zone of Cameroon, we discovered that HIV cardiomyopathy (1.6%) and Cor pulmonale (8%) were represented, aetiological factors not mentioned in previous studies conducted in urban areas of Cameroon. The mean duration of hospital stay for the compensation treatment was thirteen days, ranging between 7 and 21 days), the mortality being 9.2%. All the medications recommended for the treatment of congestive heart failure are available in our centre but many patients are not compliant to the therapy or cannot afford them. Financial limitation is causing the exacerbation of the disease and premature death. Conclusion: Our data show a high incidence of congestive heart failure mainly due to post rheumatic valvulopathies in young patients in our centre. National program to fight against rheumatic fever and complications are of great urgency in our country. The compensation treatment of congestive heart failure is challenging in our milieu, characterized by poor compliance and financial limitations. Heart failure is a major and growing public health problem around the world. Although published literature on heart failure in sub-saharan Africa is rare , there iThe cardiac centre is situated in a rural area of the North-West Cameroon where the population still rely on unprocessed biomass fuels in the form of wood, dung and crop residues. Furthermore, there is a very high incidence of HIV AIDS. The aim of this study was to investigate the occurrence and aetiology of CHF in the Cardiac Centre of St. Elizabeth catholic general hospital in Shisong, north-west Cameroon.Patients and screeningThe study was approved by the Ethics Committee of St. Elizabeth Catholic General Hospital. Between November 2002 and November 2008, a population of 8121 patients was consulted in the referral cardiac center of St. Elizabeth Catholic General Hospital. Of these patients, 462 aged between 8 and 80 years  were diagnosed with CHF according to the modified Framingham criteria for the diagnosis of heart failure [Major criteria: Paroxysmal nocturnal dyspnoea raised jugular venous pressure, clinical cardiomegaly, basal crepitations, S3 gallop, clinical acute pulmonary oedema, pulmonary upper lobe blood diversion on chest X-ray (or pulmonary oedema on chest X-ray).Minor criteria: tachycardia, orthopnoea, exertional dyspnoea, nocturnal cough, hepatomegaly, pleural effusion, diuretic use. CHF was diagnosed if the patient had two major and one minor or one major and two minor criteria. Severity of heart failure on admission was assessed using the NYHA functional classification. Detailed history including patients' socio-demographic characteristics, past medical history, and drug history were obtained from each patient through a standard questionnaire.Instrumental investigationsComplementary investigations used to confirm and establish the aetiology of the disease were: chest X ray, electrocardiography, Trans-thoracic bi-dimensional Doppler echocardiography (TEE). TTE was performed according to the recommendations of the American Society of Cardiology using commercially available echocardiography equipment  with a 4-7 Megahertz transducer. The TTE indices analysed included the left ventricle telesystolic diameter (LVIDS), left ventricle telediastolic diameter (LVIDD) using the parasternal long axis position in M-mode, and the M-mode ejection fraction (EF). Post rheumatic valvulopathy was defined by the presence of any definite evidence of mitral or aortic valve regurgitation seen in two planes by the TTE, accompanied by at least two of the following three morphologic abnormalities of the regurgitating valve: restricted leaflet mobility, focal or generalised valvular thickening, and abnormal subvalvular thickening .Data analysisValues are expressed as mean ± the standard deviation (SD) and statistical analysis were performed using the Student’s t-test. The SPSS 11 statistical analysis software was used for all analysis. The chi squared test was used to test for association between categorical variables. The student t-test was used to compare means of two variables, whilst the ANOVA was used to compare more than two variables. The level of significance was set at p < 0.05, and a 95 % confidence interval was applied to the numerical variables which are normally distributed.Aetiology of heart failureThe results showed that the occurrence of CHF in our centre was 5.7% while mortality from CHF was 9.2%. CHF was diagnosed in 198 females and 264 males, aged between 8 and 86 years (42.5±18 years old). CHF due to left ventricular systolic dysfunction was more prevalent (87.2%) than congestive heart failure due to diastolic dysfunction (12.8%), (p<0.05). Forty-four percent of patients were in class III of the NYHA and 7% in class IV. Dyspnoea was a constant symptom (95.2%) frequently associated to paroxystic nocturnal dyspnoea (68.1%). Lower limbs oedema and hepatomegaly were the most frequent physical findings (41.9%). In St. Elizabeth catholic general hospital Shisong, cardiac centre, congestive heart failure  is mainlSubgroupsa) Post rheumatic mitral valve regurgitation was the pathology more encountered ; b)The mInstrumental assessment Electrocardiography: Left ventricular hypertrophy was the abnormality more frequently encountered (80%), followed by left auricular hypertrophy (31%) and right ventricular hypertrophies (15%). Left bundle branch block was seen in 27.7% of patients while right bundle branch block in 29.1%. Sinus rhythm was present in 62%, sinus tachycardia in 28% and atrial fibrillation in 10% of cases. Atrioventricular block I degree was also represented in few cases (7.2%). Myocardial infarction scar could be observed in 2.3% cases.Trans-thoracic Doppler echocardiography: Patients with dilated cardiomyopathy showed diffuse dilatation of the four heart chambers and in particular of the left ventricle, the mean was 68.2 ± 2.5mm. Left ventricular function was significantly reduced (EF 32 ± 6%). Functional mitral valve regurgitation related to mitral valve annulus dilatation was frequently seenIn subjects with chronic obstructive disease of the lungs, the right atrium and ventricle were significantly dilated with associated moderate to severe tricuspid regurgitation and systolic pulmonary artery hypertension .Patients with post rheumatic valvulopathies showed fibrotic destruction of the mitral valve and aortic valves, calcified leaflets, abnormal subvalvular thickening rigid opening with coaptation default in patients with regurgitation and poor opening in patients with stenosis. In In patients with hypertensive cardiomyopathy, we observed a concentric hypertrophy of the left ventricle with conserved systolic function but poor diastolic function.Hospital stay and treatmentForty-five percent of patients were coming from traditional healers. These subjects came frequently with skin infections after scarification, refractory lower limbs oedemas, prolonging their stay in the hospital. The main medications for the compensation treatment of congestive heart failure consisting of loop diuretics, angiotensin-converting enzyme inhibitor, digoxin, aldosterone inhibitors and beta blockers were prescribed in our centre as reported in literature. Being a caritative hospital, some of these medications are provided by non-government non-profit organisation from Europe and United States of America. The mean hospital stay for the compensation treatment was 13 ± 7 days (the range was7 to 21days). While admitted, all patients are receiving all medications recommended for the pathology. Pericardial tap in patients with tamponade was done with success in 78% cases. After the compensation treatment, patients with 25 patients with valvulopathies were operated upon in IRCCS Policlinico San Donato with the help of non-profit non-governmental organisations: Cuore Fratello and Associazione bambini cardiopatici nel mondo. Surgical total correction of congenital heart diseases was done in IRCCS Policlinico San Donato in 95 cases. In the newly open cardiac centre of Shisong, correction of congenital heart diseases was performed in mitral valve replacement was done in 22 cases surgical valvuloplasty was done in 8 cases, aortic valve replacement was performed in 6 cases.Follow-upIn six years, there was loss of follow up 32.1%, late at follow up 40.1%. Loss at follow-up was related to financial limitations. Furthermore, the hospital is located far from main big Cameroonian cities and this situation discourages patients. Sometimes, because of the patient’s poverty, the cardiologist is obliged to choose among medications: instead of prescribing all the medication needed doctors have to prescribe just few drugs and more frequently loop diuretics, angiotensinconverting enzyme inhibitor, digoxine, potassium supplement. We call this way of prescribing “managing prescription”. Finally lack of finances causes the exacerbation of the disease and premature death.Our results showed that the occurrence of congestive heart failure in St. Elizabeth catholic general hospital, cardiac centre is 5.7%, the mortality being 9.2%. In Spain, incidence of HF increased from 296 per 100,000 person-years in 2000 to 390 per 100,000 person-years in 2007  . HospitaAccording to age, post rheumatic valvulopathies and congenital heart diseases are the first aetiological factor of CHF in young. Meanwhile dilated cardiomyopathies and hypertension were more frequently diagnosed in adults and elderly. In our experience, the causes of heart failure in subsaharan African remain largely nonischemic. However, coronarography was not available in our hospital during the time of the study. We believe that more cases of ischemic dilated cardiomyopathy could have been diagnosed by using an invasive approach.In literature, it is reported that rheumatic heart disease, hypertension, chronic lung disease and pericardial disease are the main contributors to the aetiology of cardiac failure in sub-Saharan Africa, accounting for over 90% of cases . DominanIn this study, HIV cardiomyopathy and cor pulmonale are represented as aetiologic factors in heart failure, not mentioned in previous studies conducted in urban areas of Cameroon and some countries of sub-saharan Africa ,15,16, aLessons from the changing epidemiology of heart failure in developed countries suggest that the burden of this disease will dramatically increase over the first half of this century . Heart fOur data show a high incidence of congestive heart failure mainly due to post rheumatic valvulopathies in young patients in our centre. National program for fight against rheumatic fever and complications are of great urgency in our country. The compensation treatment of congestive heart failure is challenging in our milieu, characterized by poor compliance and financial limitation.The authors declared no one declared.ICMJE criteria for authorship met. All the authors have approved the final version of the manuscript.The authors want to thank the congregation of the Tertiary Sisters of St Francis for their effort in the care of the patients, also the partners of the cardiac centre, Cuore Fratello, Associazione bambini cardiopatici nel mondo for their support and contribution in the realisation of the manuscript.


Left ventricular dysfunction and the development of heart failure is a frequent and serious complication of myocardial infarction. Recent animal experimental studies suggested that metformin treatment reduces myocardial injury and preserves cardiac function in non-diabetic rats after experimental myocardial infarction. We will study the efficacy of metformin with the aim to preserve left ventricular ejection fraction in non-diabetic patients presenting with ST elevation myocardial infarction (STEMI).The Glycometabolic Intervention as adjunct to Primary percutaneous intervention in ST elevation myocardial infarction (GIPS)-III trial is a prospective, single center, double blind, randomized, placebo-controlled trial. Three-hundred-and-fifty patients, without diabetes, requiring primary percutaneous coronary intervention (PCI) for STEMI will be randomized to metformin 500 mg twice daily or placebo treatment and will undergo magnetic resonance imaging (MRI) after 4 months. Major exclusion criteria were prior myocardial infarction and severe renal dysfunction. The primary efficacy parameter is left ventricular ejection fraction 4 months after randomization. Secondary and tertiary efficacy parameters include major adverse cardiac events, new onset diabetes and glycometabolic parameters, and echocardiographic diastolic function. Safety parameters include renal function deterioration and lactic acidosis.The GIPS-III trial will evaluate the efficacy of metformin treatment to preserve left ventricular ejection fraction in STEMI patients without diabetes. Primary percutaneous coronary intervention (PCI) reduces early mortality and improves late clinical outcome in patients with acute myocardial infarction (MI). Large MI size and adverse left ventricular remodeling may cause post infarct deterioration of left ventricular function and development of overt heart failure.Metformin, a biguanide oral antihyperglycemic agent used widely for the treatment of patients with type 2 diabetes mellitus, enhances glucose control through increased glucose utilization and decreased endogenous glucose release , 2. SeveSeveral preclinical studies in non-diabetic animals reported that metformin may confer cardioprotection by limiting MI size and preventing adverse remodeling. Recently, our group demonstrated that metformin reduces infarct size by 22 % in an experimental non-diabetic rat model of MI, resulting in a relative improvement in left ventricular ejection fraction (LVEF) of 52 % compared to placebo Fig.  12]. Th. Th12]. Current medical strategies are predominantly aimed at establishing reperfusion and secondary prevention including prevention of thrombo-embolism and inhibition of the renin-angiotensin system. Reducing infarct size and positive cardiac remodeling by metformin therapy provides a potential novel strategy to preserve functional myocardium and thereby improve prognosis.Effects of metformin include decreased hyperglycemia, hypoinsulinemia, higher peripheral muscle glucose uptake, decreased hepatic glyconeogenesis, reduced hypercoagulability, improvement of the lipid profile, nitric oxide mediated vasodilatation, and additional cardioprotective effects . ReporteCollectively, the metformin induced changes in myocardial gene and energy program, especially the activation of AMPK, are associated with decreased infarct size, prevention of adverse remodeling, and result ultimately in improved cardiac function.The GIPS-III trial is a single center, prospective, double-blind, randomized, placebo-controlled trial, designed to evaluate the efficacy of a 4 month metformin treatment on preservation of LVEF in non-diabetic STEMI patients requiring primary PCI treatment. A total of 350 non-diabetic STEMI patients will be included in the GIPS-III trial.In- and exclusion criteria are listed in Table All patients will receive standard medical treatment for a STEMI according to European practice guidelines .The flow chart of the GIPS-III trial is shown in Fig. Subjects are scheduled for return visits at 2 weeks, 2 months, 4 months, and 12 months after hospital discharge. During every visit examination, assessment of clinical events and 12-lead electrocardiography are performed. During the 4 month visit the amount of study drug received, dispensed, and consumed will be recorded.2), or 4) when subjects develop a condition which, in the investigator’s judgment, precludes further therapy. Discontinuation will have no consequence for the regular patient care. Since metformin therapy used as a single antihyperglycemic drug is not associated with hypoglycemia and due to the blinded nature of this trial, there will be no dose modifications of the study medication.Study drug treatment will be discontinued in the following situations: 1) when subject withdraw consent, 2) in case of pregnancy, 3) when subjects develop severe renal dysfunction , stroke, non-elective hospitalizations for chest pain or heart failure, all recurrent coronary interventions, and internal cardiac defibrillator implantations. Mortality will be divided into cardiac and non-cardiac. Cardiac death will be divided into three categories: heart failure, sudden death and other. A cardiologist will confirm deaths from cardiovascular causes by examining medical records obtained from hospitals and attending physicians or from the attending general practitioner if the patient died at home. Further, echocardiographic parameters of diastolic function, incidence of new onset diabetes, additional parameters measured by MRI, skin autofluorescence, electrocardiographic parameters, and blood sample analyses, will be used as tertiary efficacy endpoints.Cardiovascular MRI is considered the most accurate measure to date for evaluation of LVEF, the extent of myocardial infarct size, and several other functional parameters . The diaThe MRI data are analyzed using a dedicated software package. On the stack of short-axis cines, the endocardial and epicardial borders are outlined in end systolic and end diastolic images. Left ventricular end diastolic volume (LVEDV) and left ventricular end systolic volume (LVESV) are calculated using the summation of slice method multiplied by slice distance. LVEF is calculated as LVEF = 100 % × (LVEDV-LVESV)/LVEDV. Summation of the volumes per slice of areas of hyperenhancement is outlined, allowing to calculate total infarct size.E/E’), the ratio of the early (E) to late (A) mitral valve flow velocity, the deceleration time, the left atrial volume index (LAVI), and the difference between the duration of reverse pulmonary vein atrial systole flow (Ard) and mitral valve atrial wave flow (Ad) will be used to determine and classify diastolic function.Two-dimensional echocardiography with a phased array electronic ultrasound will be performed 0–2 days after randomization and 4 months after randomization. Tissue Doppler (TD) imaging of the early mitral valve flow velocity/early TD lengthening velocity  reader  . In shorA standard 12-lead electrocardiogram is acquired at the time of presentation, after the PCI procedure, before hospital discharge, and at each outpatient clinic visit. Mean time interval between pre and post intervention will be registered. Pre-intervention ECG will be analyzed on the presence of ST-deviation. The post-intervention ECGs will be used to score persistent ST-deviation and ST-segment resolution, and the incidence and location of new Q-waves.During hospitalization, blood will be sampled at baseline and at 3, 6, 9, 12, and 24 h after PCI to monitor values of cardiac enzymes and high sensitive troponin . Less frFurthermore, during PCI, 24 h after PCI, and at every visit to the outpatient clinic, blood samples for additional analyses will be collected . These aFor assessment of diabetes and prediabetes, an oral glucose tolerance test (OGTT) will be performed during initial hospitalization and after study medication is stopped according to protocol and after primary endpoint analysis, next to the level of glycated hemoglobin (HbA1c) . DiabeteThe sample size is calculated for the difference in the primary efficacy parameter (LVEF measured by MRI at 4 months) between the intervention group and the placebo group. With 80 % power to detect a 3 % difference in LVEF between active treatment and control (assuming a 2-sided α of 0.05 and an SD of 9 % for the change in LVEF) 141 patients are needed in each study group. A 3 % difference in LVEF is considered to be a clinically relevant outcome . Based ot test or a Mann–Whitney U test will be used, as appropriate. For clinical outcomes such as the incidence of major adverse cardiac events, Cox regression will be used to evaluate the association between the intervention and the endpoints. Kaplan-Meier curves displaying the pattern of events over the 4-month and long-term follow-up period will be drawn.The primary efficacy parameter of the study is measured 4 months after randomization. For the analysis of binary endpoints, treatment comparisons will be performed using Fisher exact probability test or Chi-square analysis. For continuous outcomes, independent samples www.clinicaltrials.gov).The GIPS-III trial is performed by the GIPS-III investigators , superviThe GIPS-III trial will be the first randomized, double-blind, placebo-controlled trial to study the efficacy of metformin on preservation of LVEF in non-diabetic STEMI patients. This trial will provide valuable information on whether metformin can preserve LVEF and reduce myocardial infarct size after STEMI and might extend its clinical efficacy beyond patients with diabetes. LVEF was chosen as the primary efficacy parameter as this provides an important reflection of the functional consequences of post infarction cardiac remodeling and is probably more important than anatomical area at risk.A unique aspect of the GIPS-III trial is that we evaluate non-glycemic effects of metformin in a non-diabetic population. In the current trial we excluded patients with a history of diabetes. Diabetes diagnosed after randomization will be regarded as “new onset diabetes” and will be treated by an endocrinologist which could include metformin treatment in addition to study drug treatment. According to the intention-to-treat principle, these patients will be included in the primary efficacy parameter analysis. For the secondary per protocol analysis these patients will be excluded.We excluded patients with documented myocardial infarction from the GIPS-III trial to avoid inclusion of subjects with reduced LVEF at baseline, which might complicate the interpretation of our data. We also included only subjects with a STEMI based on a vessel requiring a stent diameter of at least 3 mm as an indicator of a relatively large area at risk which might potentially result in a clearly reduced LVEF. Although the exact mechanism of metformin remains to be elucidated, we start study treatment immediate (within 3 h) after PCI to have the largest possible window of opportunity. Our primary efficacy parameter will be evaluated 4 months after primary PCI. After 4 months would healing should be completed and partial or complete remodeling should have occurred .Several prospective trials in patients with diabetes have reported a favorable outcome associated with metformin. Several retrospective analyses have demonstrated additional effects on cardiovascular endpoints. No prospective trial has yet shown the effects of metformin on myocardial infarct size and cardiac function. The effects and pathways allegedly responsible for the metformin-induced cardioprotective effects have not yet been studied in the human setting. Moreover, the exact contribution and efficacy of the supposed metformin mediated mechanisms to improved systolic and diastolic myocardial function is unclear. However, retrospective data consistently showed that metformin therapy was associated with improved outcome in diabetic patients Table . In non-The GIPS-III trial has been approved by the local institutional review board, national regulatory agencies, and is being carried out according the Declaration of Helsinki (Seoul 2008). GIPS-III has enrolled its first patient in January 2011. As of August 1st, 2012, 266 patients have been randomized. Completion of the inclusion is anticipated in January 2013. Primary endpoint analysis of the final randomized patient is expected in April 2013.The GIPS-III trial is a single center, prospective, double-blind, randomized, placebo-controlled trial to determine whether a 4 month metformin treatment can improve LVEF in 350 non-diabetic patients presenting with STEMI requiring primary PCI treatment.


Although the assessment of diastolic dysfunction (DD) is an integral part of routine cardiologic examinations, little is known about associated electrocardiographic (ECG) changes. Our aim was to investigate a potential role of ECG indices for the recognition of patients with DD.ECG parameters correlating with echocardiographic findings of DD were retrospectively assessed in a derivation group of 172 individuals  and their diagnostic performance was tested in a validation group of 50 controls and 50 patients. The patient group with a DD Grade 1 and 2 showed longer QTc  and shorter Tend–P and Tend–Q intervals, reflecting the electrical and mechanical diastole . The PQ–interval was significantly longer in the patient group . After adjusting for possible confounders, a novel index (Tend–P/[PQxAge]) showed a high performance for the recognition of DD, stayed robust in the validation group  and proved a substantial added value when combined with the indexed left atrial volume .A novel electrocardiographic index Tend–P/(PQxAge) demonstrates a high diagnostic accuracy for the diagnosis of DD and yields a substantial added value when combined with the LAESVI. Diastolic dysfunction (DD) has gained much attention over the last decades and its assessment is nowadays not only an integral part of echocardiographic routine examinations but also of great importance in the evaluation of patients with dyspnea and/or heart failure symptoms . As halfIn contrast, electrocardiographic (ECG) parameters are generally less prone to acute hemodynamic changes, show a great reproducibility and are operator-independent –6. Howev For the retrospective part of the study all individuals were included from the in-hospital echocardiographic database of the University Hospital of Zurich, Switzerland. Primary inclusion criterion of patients was a DD of any class according to the latest recommendations of echocardiographic assessment of DD as well as age > 18 years ) provides a substantial diagnostic performance, even after adjustment for possible confounders and when validated in an independent patient group. the novel index shows a considerable added diagnostic value when combined with the indexed left atrial volume. Different approaches are conceivable for the explanation of these observations. Generally, DD is associated with parameters mirroring functional and morphologic alterations including age and left atrial enlargement as well as left ventricular hypertrophy irrespective of the cause. Left atrial dimensions are frequently viewed as a “barometer” of the chronicity of DD, which can reliably be deducted from ECG - based P wave and PQ - interval measures ,14–16. FProlongation of the PQ - interval can also occur in association with overt cardiovascular disease; however, this confounder is unlikely to explain our findings, since many of the individuals included in our study were generally healthy. Extensive discussions have focused on the question whether prolongation of the PQ - interval as such might also be indicative for general degenerative, i.e. age-related processes in the whole cardiovascular system contributing to a worse prognosis and/or emergence of cardiovascular comorbidities such as DD –22. AccoBesides, we found P wave dispersion to be more pronounced in patients with DD, another parameter, which has been described to have a certain association with remodeling processes of the left atrium and a higher risk for development of atrial fibrillation . HoweverChanges in left atrial dimensions most frequently come along with an elevated septal or posterior left ventricular wall thickness, eventually presenting as overt concentric left ventricular hypertrophy or remodeling. As these findings are very common and with rising prevalence in patients with hypertensive heart disease, they are one of the most frequently encountered abnormalities in patients with DD . Left veOn the other hand, QTc intervals were longer in the patient group. This is in line with previous studies indicating a correlation between Doppler-derived parameters of DD and QTc duration ,39. The  Numerous noninvasive estimates of diastolic function and left ventricular filling pressures have been extensively investigated in the past decades including particularly Doppler-echocardiographic indices. However, many of them failed to yield a robust criterion for DD as a single parameter, why a comprehensive assessment of various indices and different algorithms have been proposed ,2,48,49.Owing to the low number of patients with a DD grade 2 and 3, the patient group with a DD grade 1 is certainly overrepresented in the performed statistical analyses. However, this proportion mirrors the usual prevalences in the clinical setting. Nevertheless, we purposely showed demographic, echocardiographic and electrocardiographic parameters of the patient group with DD Grade 2 in order to depict congruent trends of the calculated mean values. Furthermore, matching groups in heart rate and age would have substantially lowered our population size and turned out not be entirely necessary as proven in the validation group. The novel electrocardiographic index Tend–P/(PQxAge) shows a high diagnostic accuracy for the diagnosis of DD and yields a substantial added value when combined with the indexed left atrial volume. Our findings add substantially to the growing evidence of a probable interplay of structural remodeling processes and electromechanical coupling in the pathogenesis of DD.


Right ventricular apical pacing-related heart failure is reported in some patients after long-term pacing. The exact mechanism is not yet clear but may be related to left ventricular dyssynchrony induced by right ventricular apical pacing. Right ventricular septal pacing is thought to deteriorate left ventricular function less frequently because of a more normal left ventricular activation pattern.We report the case of a 55-year-old Tunisian woman with preserved ventricular function, implanted with a dual-chamber pacemaker for complete atrioventricular block. Right ventricular septal pacing induced a major ventricular dyssynchrony, severe left ventricular ejection fraction deterioration and symptoms of congestive heart failure. Upgrading to a biventricular device was associated with a decrease in the symptoms and the ventricular dyssynchrony, and an increase of left ventricular ejection fraction.Right ventricular septal pacing can induce reversible left ventricular dysfunction and heart failure secondary to left ventricular dyssynchrony. This complication remains an unpredictable complication of right ventricular septal pacing. Right ventricular apical (RVA) pacing results in abnormal left ventricular (LV) electrical and mechanical activation and is associated with an increased risk of developing heart failure -3. RightWe report the case of a 55-year-old Tunisian woman with preserved ventricular function, implanted with a dual-chamber pacemaker for complete atrioventricular block. RVS pacing induced a major ventricular dyssynchrony, severe left ventricular ejection fraction deterioration and symptoms of congestive heart failure. Upgrading to a biventricular device was associated with a decrease in the symptoms and ventricular dyssynchrony, and increased left ventricular ejection fraction (LVEF).A 55-year-old Tunisian woman presented with syncope. An electrocardiogram (ECG) upon admission showed complete heart block with a narrow QRS complex <120 ms) and an escape ventricular rate of 45 bpm. Our patient's medical history included arterial hypertension. She did not have diabetes mellitus, and had no family history of coronary artery disease. A two-dimensional echocardiography showed normal LV function with a 60% EF, the absence of significant valvulopathy and no regional wall motion abnormalities or pulmonary artery hypertension. A conventional dual chamber pacemaker  was implanted with the right ventricular (RV) lead positioned to her RV septum. The septal position was confirmed by fluoroscopic images; defined as a leftward orientation of the lead confirmed by 40° left anterior oblique projection . The pac20 ms andDespite instauration of optimal medical therapy, our patient remained at NYHA functional class III. She was upgraded to a cardiac resynchronization therapy (CRT)-device with implantation of a lateral left ventricular lead Figure . After oAfter one month, an echocardiography showed a decrease in the aortic PEP (130 ms), LV reverse remodeling, with a reduction of the LVEDV from 153 mL to 135 mL, and significant improvement in LVEF to 40%. She had no symptoms of heart failure or syncope afterwards and device interrogation showed that her cumulative biventricular pacing was 100%.Pacing from RVS sites has been suggested as an alternative to RVA pacing in an attempt to avoid long-term adverse consequences on LV function . This caThere is an increasing body of literature in which the authors investigate the acute and chronic effects of RVS pacing on electrical and mechanical synchrony, systolic and diastolic ventricular function and cardiovascular morbidity and mortality. Alternative RV pacing sites appear advantageous when compared to RVA pacing but their superiority has not been uniformly proven.et al. [et al. [Ten Cate et al.  have dem [et al.  demonstrIn patients with standard indications for pacing, the prediction of heart failure is difficult and the exact mechanism of RV pacing-related heart failure is not clear but may be related to LV dyssynchrony induced by RV pacing . The besThe Pacing to Avoid Cardiac Enlargement study  showed tRVS pacing can induce reversible LV dysfunction and heart failure secondary to LV dyssynchrony. This remains an unpredictable complication of RV pacing. It should be highlighted that not all patients develop LV dyssynchrony and new onset heart failure after RV pacing. Therefore, early predictive factors -15, suchWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SO was the major contributor in writing the manuscript. All authors read and approved the final manuscript.


Sudden death in the young is rare. About 25% of cases occur during sports. Most young people with sudden cardiac death (SCD) have underlying heart disease, with hypertrophic cardiomyopathy and coronary artery anomalies being commonest in most series. Arrhythmogenic right ventricular dysplasia and long QT syndrome are the most common primary arrhythmic causes of SCD. It is estimated that early cardiopulmonary resuscitation and widespread availability of automatic external defibrillators could prevent about a quarter of pediatric sudden deaths. Excluding the Sudden Infant Death Syndrome (SIDS), which has an incidence around 1–1.5/1000 infants, sudden death in a young person is a rare event. Yet, it has a devastating impact when it occurs precisely because it is so unexpected. Sudden cardiac death (SCD) is defined as death that is abrupt, unexpected, and due to a cardiovascular cause. It is generally recognized as death that occurs within 1 hour from the onset of cardiovascular symptoms. However, in young people, it typically occurs within a few minutes of symptom onset. When resuscitation restores spontaneous circulation, it is referred to as “aborted sudden death.” The estimated incidence of pediatric SCD ranges from 0.6 to 6.2 per 100,000 children in the United States. In compaThere are several known causes of sudden death in young people . These eHypertrophic cardiomyopathy (HCM) is the most common cause of SCD in the United States in people 30 years old or younger.9 The dis10121315LMNA) mutations are a relatively common cause of DCM  and are associated with a high risk for SCD. In fact, a study in the New England Journal of Medicine in 2006 found 8 of 19 (42%) patients who underwent permanent pacing and internal cardioverter and defibrillator (ICD) implantation solely on the basis of LMNA gene mutations associated with cardiac conduction defects and normal ventricular function received an appropriate ICD intervention.[Although less common than HCM, dilated cardiomyopathy (DCM) is also a known cardiac risk factor for SCD. DCM is characterized by cardiac dilation and decreased systolic function. It can be acquired from ischemic injury, myocarditis or toxins, or it can be inherited, usually as an autosomal dominant trait, with variable penetrance. There are currently more than 20 different gene mutations identified that cause DCM. The genes responsible encode diverse myocyte proteins including those of the sarcomere, cytoskeleton, nucleus, sarcoplasmic reticulum, and the cell membrane. It is estimated that 20–50% of “idiopathic” DCM has a genetic basis. Although the disease is progressive and often clinically silent in childhood, SCD can occur prior to the development of heart failure and symptoms. Genetic testing may help to identify those at risk for sudden death prior to heart failure. Lamin A/C  is a familial genetic disorder that occurs in about 1 in 2500–3500 individuals. It manif34RYR2) which encodes a sarcoplasmic calcium ion channel.[Catecholaminergic polymorphic ventricular tachycardia (CPVT) is characterized by ventricular ectopy induced by exercise or emotional stress. It is a  channel. The onseSCN5A is the most commonly occurring defect. Treatment is limited to ICD implantation.Brugada’s syndrome is an inherited arrhythmogenic syndrome characterized by specific ECG abnormalities and life-threatening ventricular arrhythmias. It commoArrhythmogenic right ventricular dysplasia or cardiomyopathy (ARVD/ARVC) is a rare cause of SCD in the United States, but has been reported as the most common cause of SCD in the young athletes in Italy. Clinical42Commotio cordis, defined as SCD due to a relatively innocent chest wall impact in individuals with a normal heart, is a very rare cause of SCD in young people, although it may be underestimated in its frequency.46 Victim48The incidence of sudden death in patients with congenital heart disease is about 100/100,000 patient years. It is hiAs reviewed above, sports participation has been associated with an increased risk of SCD in young people. Therefore, cardiovascular screening for conditions that could lead to an increased risk of sudden death has focused mainly on the pre-participation screening of athletes. In the United States, current recommendations are for a focused personal and family history of the athlete with special emphasis on history of exertional chest pain, syncope or a family history of early sudden death, as well as examination for blood pressure, murmurs, and stigmata of Marfan’s syndrome. If any a29Although each of the conditions discussed above have specific therapies, the most effective immediate treatment to change SCD into resuscitated SCD is to increase the prevalence of CPR training in the general population, and the availability of automatic external defibrillators (AEDs). AEDs are best located in places where large groups of people gather, including where young athletes may be competing. Such devices have continued to decrease in cost and have improved ease of use, but financial and other barriers still remain to their widespread deployment.For survivors of near SCD events, systematic evaluation should be performed to determine the cause of the event and treatment should be focused around the underlying etiology. For many of the underlying cardiac pathologies, an ICD is indicated.Sudden death in the young is rare. About 25% of cases occur during sports. Most young people with SCD have underlying heart disease, with HCM and coronary artery anomalies being most common in most series. ARVD and LQTS are the most common primary arrhythmic causes of SCD. It is estimated that early CPR and widespread availability of AEDs could prevent about 25% of pediatric sudden deaths.