We assessed the effect of anemia on cardiovascular findings in obese adolescents.We studied 29 anemic and 33 nonanemic obese adolescents, and 33 nonobese healthy adolescents. These three groups were investigated for clinical and laboratory features of anemia and obesity. Echocardiography was used to examine cardiac functions.The anemia was mild (mean hemoglobin: 11.67±0.79 g/dL), ferritin level was significantly low, and C-reactive protein and fibrinogen levels were significantly high in anemic obese patients. Increased cardiac pulse and echocardiographic findings, which may be indicative of early left ventricular diastolic dysfunction, were present in these patients.Anemia may develop due to iron deficiency and chronic inflammation in obese adolescents. Even mild anemia may cause increased heart rate and affect left ventricular diastolic functions. Diet programs for obese children should be carefully planned to avoid iron deficiency anemia, which may worsen the cardiac events in long-term follow-up. The prevalence of childhood obesity has progressively increased in the world in the last decades due to sedentary life style and poor dietary habits ,2. Childrd and 85th percentiles were included as the control group. Adolescent patients admitted to our hospital with exogenous obesity between the ages of 12 to 18 years were included. The study group was divided into two groups as anemic obese (n=29) and nonanemic obese (n=33) patients. Those who had endogenous obesity, infection, chronic use of medications, or other accompanying diseases were excluded. Healthy adolescents (n=33) whose body mass indexes (BMIs) were between the 3th percentile for children and teenagers of the same age and sex. BMI is calculated by dividing a person’s weight in kilograms by the square of height in meters [th percentile for children and teenagers of the same age and sex [Obesity was defined as a BMI at or above the 95n meters . Anemia n meters . Hyperte and sex . Clinical data and results of laboratory measurements of patients were obtained from the hospital records, including complete blood cell count; renal, liver, and thyroid function tests; serum glucose, insulin, insulin resistance, lipid, fibrinogen, and C-reactive protein (CRP) levels; and iron parameters. Echocardiography was performed after 15 min of resting by a pediatric cardiologist. Standardized M-mode echocardiography, PWD, and TDI echocardiography were performed to evaluate the status and functions of the heart . By usinAll statistical analyses were performed using SPSS 15 . Differences between groups for categorical variables were compared by chi-square test. The Student t-test and Mann-Whitney U test were used for the comparison of continuous variables. One-way analysis of variance (ANOVA) and Kruskal-Wallis tests were used for the comparison of more than two groups.Demographic data and clinical features of the groups are given in M-mode and TDI echocardiographic parameters are given in In our study, a significant proportion of anemic obese children were found to be on a diet to lose weight. Their ferritin levels were significantly lower even though there were signs of chronic inflammation, such as high levels of fibrinogen and CRP. Anemia may be seen in the obese population due to poor dietary habits and as a result of chronic inflammatory condition ,16,17,18Anemia may cause hemodynamic changes, cardiomegaly, and left ventricular hypertrophy in the long-term period ,20. EF iTachycardia, a well-known complication of anemia, develops as a compensatory response of the heart to inadequate tissue oxygenation caused by decreased erythroid mass . In our Regarding the cardiac geometry, an increased LVMI has been shown in obese children . Sharpe In this study, the number of patients was relatively low and the anemia was mild, so we recommend further studies with larger samples of obese adolescents with different stages of anemia for more accurate investigation of effects of anemia in obese adolescents. Follow-up of these adolescents is also important to provide a prompt therapeutic approach and better outcome.   Anemia may develop due to iron deficiency and chronic inflammation in obese adolescents. Our study suggests that blood pressure, heart rate monitoring, and echocardiographic measurements should be carefully checked in anemic obese adolescents at frequent intervals for early detection of hypertension, tachycardia, and left ventricular diastolic dysfunction. Even mild anemia may cause increased heart rate and change the left ventricular diastolic functions in obese adolescents. Diet programs of obese children should therefore be carefully planned to avoid iron deficiency anemia, which may worsen the cardiac outcome in long term follow-up.


The aim of this study was to compare the prevalence of diastolic dysfunction between the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging and 2009 ASE/European Association of Echocardiography recommendations in patients undergoing living-donor liver transplantation (LDLT).A total of 312 adult patients who underwent LDLT at our hospital from January 2010 to December 2017 were retrospectively analyzed. Exclusion criteria were systolic dysfunction, arrhythmia, myocardial ischemia, and mitral or aortic valvular insufficiency.The study population was largely male (68.3%), and the median age was 54 (49–59) years. The median model for end-stage liver disease score was 12 (6–22) points. A predominant difference in the prevalence rates of diastolic dysfunction was observed between the two recommendations. The prevalence rates of diastolic dysfunction and indeterminate diastolic function were lower according to the 2016 recommendations than the 2009 recommendations. The level of concordance between the two recommendations was poor. The proportion of patients with a high brain natriuretic peptide level (> 100 pg/mL) decreased significantly during surgery in the normal and indeterminate groups according to the 2009 recommendations; however, only the normal group showed an intraoperative decrease in the proportion according to the 2016 recommendations. Patients with diastolic dysfunction showed a poorer overall-survival rate than those with normal function according to both recommendations. However, there was a difference in the survival rate in the indeterminate group between the two recommendations. A significant difference in patient survival rate was observed between the dysfunction and indeterminate groups according to the 2009 recommendations; however, the difference was not significant in the 2016 recommendations.The 2016 classification may be better able to identify patients with a risk for diastolic dysfunction. Particularly, patients in the 2016 indeterminate group seemed to require a cardiac diastolic functional evaluation more frequently during and after surgery than those in the 2009 indeterminate group. Diastolic dysfunction is a major component of cirrhotic cardiomyopathy and more frequently occurs than systolic dysfunction in patients with cirrhotic cardiomyopathy . DiastolCardiac imaging has played an integral role in the assessment of LT candidates, and echocardiography, such as transthoracic (TTE) and/or transesophageal (TEE) echocardiography, has primarily been used in all liver transplant candidates to assess chamber size, hypertrophy, systolic and diastolic function, valvular function, and a left ventricular outflow tract obstruction ,10. HoweAmong cardiac biomarkers, brain natriuretic peptide (BNP) is mainly produced by elevated atrial or ventricular wall stretch and has been a promising factor to measure cardiac dysfunction. Accuracy in the risk stratification for heart failure is excellent with a cut-off value > 100 pg/mL . Serum lCurrently, the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) recommendations have been proposed to more accurately diagnose cardiac diastolic dysfunction in the daily clinical setting than the previous 2009 ASE/European Association of Echocardiography (EAE) recommendations . HoweverThis study was approved by the Institutional Review Board of Seoul St. Mary’s Hospital Ethics Committee (KC18RESI0205) according to the Declaration of Helsinki, and the requirement for informed consent was waived due to the retrospective study design.A total of 366 adult patients (≥ 19 years) underwent LDLT at the Seoul St. Mary’s Hospital from January 2010 to December 2017. The data were retrospectively reviewed using the medical records system in our hospital. Exclusion criteria for this study were: systolic dysfunction  (n = 3), arrhythmia  (n = 23), history of myocardial ischemia  (n = 5), mitral or aortic valvular insufficiency  (n = 10), and missing or inappropriate data (n = 54), including transthoracic echocardiography (TTE) findings (n = 13). In total, 312 adult patients were analyzed.According to our hospital LDLT protocol that was described previously in detail ,25, the Cardiac function was carefully measured preoperatively to prevent foreshortening the atrium and ventricle and averaged over three serial cardiac cycles using two transthoracic echocardiographic devices ,  by experienced cardiologists. Left ventricular (LV) EF was calculated using the biplane method  on apical four- and two-chambered views. Lateral or septal mitral annulus velocity  was evaluated using tissue Doppler imaging for LV diastolic function measured on apical views. Mitral inflow velocities  and deceleration time were measured using pulse-wave Doppler imaging. Peak tricuspid regurgitation (TR) velocity was measured using continuous-wave Doppler imaging. Left atrial (LA) volume was measured using the biplane method (modified Simpson’s rule) on apical views and indexed to body surface area (BSA) . LV hypertrophy type was classified by the LV mass index and relative wall thickness ,28.2) in the 2016 recommendations, the patients were classified into three groups, including the normal diastolic function group , indeterminate function group , and the diastolic dysfunction group . Normal diastolic function was determined as the available diastolic parameters < 50%; diastolic dysfunction was determined as the available diastolic parameters > 50%; and indeterminate function was determined as the available diastolic parameters of 50%. In the 2009 recommendations, septal e’ velocity < 8 cm/s or lateral e’ velocity < 10 cm/s and LAVI ≥ 34 mL/m2 were used to evaluate diastolic function. The normal group was defined as no available diastolic parameters, and the diastolic group was defined as all available diastolic parameters. When it was not possible to determine diastolic function because of a discrepancy in diastolic parameters, the subjects were placed in the indeterminate group.The prevalence of diastolic function was evaluated according to the 2016 and 2009 recommendations . Accordivs. low based on a cut-off value of 100 pg/mL [Intraoperative BNP levels were evaluated three times, such as in the preanhepatic phase ; in the anhepatic phase ; and in the neohepatic phase  ,29. BNP 00 pg/mL .Preoperative factors included age, sex, body mass index (BMI), diabetes mellitus, hypertension, model for end-stage liver disease (MELD) score, etiology, hepatic decompression signs, QTc prolongation (> 440 ms) , and labU-test as a post-hoc test. The categorical data were evaluated using χ2 or Fisher’s exact tests, as appropriate. The test for trends was conducted using a linear-by-linear association method. Concordance in the prevalence of diastolic dysfunction according to the 2016 ASE/EACVI and 2009 ASE/EAE recommendations was evaluated using a Cohen’s kappa coefficient with 95% confidence intervals (CIs). The strength of concordance was classified into poor (kappa < 0.2); fair (kappa range 0.21–0.4); moderate (kappa range 0.41–0.6); good (kappa range 0.61–0.8); and very good (0.81–1.0). Intraoperative changes in the proportions of patients with high BNP levels (≥ 100 pg/mL) were analyzed using Cochran’s Q test with the McNemar post-hoc test. Overall patient survival during the follow-up period was analyzed using the Kaplan–Meier test, and compared between the normal, indeterminate, and dysfunction groups using the log-rank test. Multiple comparisons were adjusted with Bonferroni’s method. A p-value<0.05 was considered significant. Statistical analyses were performed using SPSS for Windows  and MedCalc for Windows .The distribution of continuous data was assessed using the Shapiro–Wilk test. The values are expressed as medians (interquartile range) and numbers (proportion). The perioperative data were compared between the normal, indeterminate, and dysfunction groups using the Kruskal–Wallis test with the Mann–Whitney 2. The incidence rates of diabetes mellitus and high blood pressure were 25.0% (n = 78) and 19.6% (n = 61), respectively. The etiologies for LDLT were hepatitis B (54.5%), alcohol (20.8%), hepatitis C (9.3%), autoimmune (4.5%), hepatitis A (2.2%), drug or toxin (1.6%), and cryptogenic hepatitis (7.1%). 146 patients (46.8%) underwent LDLT because of hepatocellular carcinoma (HCC). The median MELD score was 12 (6–22) points, and hepatic decompensation signs were encephalopathy (West Haven grade III or IV) (5.3%) [9/L and 3.0 (2.6–3.6) g/dL, respectively. The median surgical duration was 490 (445–540) min. A total of 239 patients (76.6%) developed PRS, and 215 patients (69.4%) were required to receive a strong vasopressor  to stabilize their hemodynamics. The median PRBC and FFP requirements were 7 (4–12) and 6 (4–10) units, respectively. The median graft volume was 891.9  mL, and the median total graft ischemic time was 92 (69–129) min.) (5.3%) , esophag2) were evaluated in our study cohort (2 in 41.7% (n = 130). The prevalence of these diastolic parameters increased from the normal group to the indeterminate and dysfunction groups. The mitral E/A ratio was lower in the indeterminate group and higher in the dysfunction group than in the normal group. Deceleration time was shorter in the dysfunction group than in the normal group. LVEF was comparable between the three groups. The proportion of abnormal chamber geometry  was higher in the indeterminate and dysfunction groups than in the normal group.Four diastolic dysfunction parameters in the 2016 recommendations  with normal diastolic function according to the 2009 recommendations were in the normal diastolic function group according to the 2016 recommendations . HoweverHigher MELD score was moderately correlated with the degree of diastolic function in the 2016 recommendations, but the correlation between MELD score and diastolic function in the 2009 recommendation was weak . In bothPatients with diastolic dysfunction (2016 recommendations) remained in the ICU longer and had a higher incidence of overt HFrEF than those with normal diastolic function . The proAccording to the 2016 recommendations, the survival rate was better in the normal group than in the dysfunction group; however, no differences in survival rates were observed in the indeterminate group compared with the normal and dysfunction groups . AccordiThe main findings of this study were that there was a predominant difference in the prevalence rate of diastolic dysfunction between the 2016 and 2009 recommendations in patients undergoing LDLT. The prevalence rates of diastolic dysfunction and indeterminate diastolic function were lower according to the 2016 recommendations than the 2009 recommendations. The level of concordance between the 2016 and 2009 recommendations was poor. The proportion of patients with a high BNP level (> 100 pg/mL) during surgery decreased significantly in the normal and indeterminate groups according to the 2009 recommendations; however, only the normal group showed an intraoperative decrease in the proportion according to the 2016 recommendations. Patients with diastolic dysfunction had a worse overall-survival rate than those with normal function according to both recommendations. However, there was a difference in the survival rate in the indeterminate group between the 2016 and 2009 recommendations. In the 2009 recommendations, there was a significant difference in patient survival rate between the dysfunction and indeterminate groups; however, the difference was not significant according to the 2016 recommendations.et al. and 1.4% by Almeida et al.) in the 2016 recommendations than the prevalence determined by the 2009 recommendations [The 2016 ASE/EACVI recommendations were proposed to simply identify the patients at risk of diastolic dysfunction using TTE findings in a daily clinical setting [ndations ,23. Thisndations . TR velondations ,23, our ndations . In line2), may require meticulously and continuously monitored cardiac status using ECG or laboratory factors during LDLT.BNP is derived from the ventricular wall due to hemodynamic volume or pressure stress and is significantly related to the severity of left ventricular function. Furthermore, a close correlation between serum levels of BNP and diastolic parameters on echocardiography, such as tissue Doppler imaging, is present so that high serum levels of BNP (> 100 pg/mL) are reflected by increased left ventricular filling pressure ,39. In pet al.[et al.[et al.[Cardiovascular complications are a major cause of mortality in patients undergoing LT, including graft rejection and infection that relates to approximately 20% of post-transplant deaths . More thet al. suggestel.[et al. showed tl.[et al. suggestel.[et al..Some limitations of our study should be discussed. First, our study included only patients with a preserved EF (> 50%); therefore, our findings do not apply to patients with a reduced EF. Particularly, because of peripheral vasodilatation, cardiac systolic dysfunction in patients with ESLD is latent at rest . FurtherClinical application of diastology according to the 2016 ASE/EACVI recommendations in patients who underwent LDLT resulted in a lower prevalence of indeterminate function and overt diastolic dysfunction, and a higher prevalence of normal diastolic function. Therefore, the concordance between previous and current recommendations was poor, which was caused by reclassification of the diastolic functional evaluation. The current 2016 classification may be able to more clearly identify patients at risk for diastolic dysfunction that may result from inclusion of TR velocity > 2.8 m/s. This finding was supported by the intraoperative BNP level, as a diastolic marker. Particularly, patients in the 2016 indeterminate group seem to require an evaluation of cardiac diastolic function more frequently than those in the 2009 indeterminate group, during and after surgery, because the 2016 indeterminate group included ill patients who most likely should be evaluated and treated like the diastolic dysfunction group. Additionally, this finding is not limited to patients undergoing LDLT, but also can be addressed in patients undergoing deceased donor LT ,54. The S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Heart failure (HF) is a major chronic illness and results in high morbidity and mortality. The most frequent cause of HF with reduced ejection fraction (HFREF) is coronary artery disease (CAD). Although revascularisation of ischemic myocardium lead to improvements in myocardial contractility and systolic function, it cannnot restore the viability of the already necrotic myocardium.Harvest SmartPReP2 . The study population will be a total of 40 patients with established CAD, systolic dysfunction with LV EF of ≤40% and HF in the NYHA class 3. Patients have been on standard HF therapy for 3 months and in a stabilised state for at least 1 month, before enrolling in the clinical study. Patients will be randomised 1:1 to either retrograde BMAC administration via coronary sinus or standard HF therapy. The primary end-points (left ventricular end-systolic and end-diastolic diameters [LVESd/EDd] and volumes [LVESV/EDV] and left ventricular ejection fraction [LV EF]) will be assessed by magnetic resonance imaging. The follow-up period will be 12 month.The aim of our prospective randomised study is to assess the efficacy of the retrograde application of non-selected bone marrow autologous cells concentrate (BMAC) in patients with HFREF of ischemic aetiology. The evaluated preparation is concentrated BMAC, obtained using The application of bone marrow stem cells into affected areas of the myocardium seems to be a promising treatment of ischemic cardiomyopathy.The Harvest BMAC contains the entire population of nuclear cells from bone marrow aspirates together with platelets. The presence of both platelets and additional granulocytes can have a positive effect on the neovascularisation potential of the resulting concentrate. Our assumption is that retrograde administration on non-selected BMAC via coronary sinus, due to the content of platelets and growth factors, might improve left ventricular function and parameters compared to standard HF therapy. Furthermore, it will be associated with improved exercise tolerance in the six-minute corridor walk test and an improvement in the life quality of patients without increasing the incidence of severe ventricular arrythmias.https://clinicaltrials.gov; NCT03372954).(ClinicalTrials.gov;  Heart failure (HF) is a major chronic illness and results in high morbidity and mortality; for instance, the mean mortality rate of severe heart failure in the NYHA IV class is 40–50% per year . The mosSubstitution of impaired myocytes in affected areas of the myocardium could stimulate cardiomyocytes regeneration, support the neovascularisation and thus prevent remodelling of the left ventricle. Primary pluripotent progenitor cells in bone marrow are able to disperse into functional vascular tissue, which has led to great interest in their use in the treatment of acute myocardial infarction (MI), left ventricular systolic dysfunction and HF .As preclinical data prove, bone marrow autologous cells concentrate (BMAC) are able to separate in vascular structures and with the aid of paracrine mechanisms can improve the function of existing cardiomyocytes or angiogenesis , 3. StudHarvest SmartPReP2 .The aim of this prospective randomised study is to assess the efficacy of the retrograde application of non-selected BMAC in patients with HFREF of ischemic aetiology. The evaluated preparation is concentrated BMAC, obtained using Our assumption is that non-selected BMAC administrations will lead to improvements in the left ventricular ejection fraction (LV EF), the left ventricular end-systolic and end-diastolic diameters and volumes (LVESd/EDd and LVESV/EDV) compared to standard HF therapy. Furthermore, it will be associated with improved exercise tolerance in the six-minute corridor walk test, a decrease in NYHA and CCS classes and an improvement in the life quality (QoL) of patients. At the same time, this therapy will not increase the incidence of severe ventricular arrythmias detected by 24-h ECG Holter monitoring.The study population will be a total of 40 patients with established CAD and left ventricular systolic dysfunction with an EF of ≤40% and HF in the NYHA class 3. CAD will be demonstrated based on previous coronary angiography  or Tc SPECT (perfusion defects). The patient follow-up duration will be 12 months.Patients have been on standard HF therapy for 3 months and in a stabilised state for at least 1 month, before enrolling in the clinical study. A list of inclusion and exclusion criteria is provided in Table Patients will be randomised 1:1 to one of the following treatment methods: either retrograde BMAC administration via coronary sinus or the control group with standard HF therapy. Patients randomised to the control group will not undergo bone marrow collection, due to ethical reasons. Only standard right heart catheterisation will be performed as sham procedure.The primary objectives of the clinical study are to improve the LV EF and reduce the LVESd/EDd and LVESV/EDV assessed by magnetic resonance imaging (MRI), and to improve exercise tolerance in the six-minute corridor walk test.The secondary objectives include identifying the occurrence of severe ventricular arrhythmias according to 24-h ECG Holter monitoring, improving on the NYHA and CCS classes, reducing hospitalisations due to decompenzation of HF, assessing the impact on QoL of patients using the Kanas City Cardiomyopathy Questionare (KCCQ-12) and ensuring the safety of BMAC retrograde administration via coronary sinus by evaluating all adverse events (AE).All patients will continue on the standard HF treatment during the clinical follow-up  and medication necessary for secondary CAD prevention . The monitored parameters will be measured echocardiographically in ICD-implanted patients not able to undergo MRI. Patient with cardiac resynchronization therapy (CRT) device (or CRT-ICD) with LV lead placed in CS will not be included. We also not include patients with known contrast allergy.ClinicalTrials.gov .Written informed consent was obtained from each patient before enrollment in the study. The study protocol complied with the Declaration of Helsinki and was approved by the Ethics Committee of University Hospital Ostrava, Czech Republic. The study was registered at The course of the clinical study is illustrated in Fig. Bone marrow aspiration will be performed in local anesthesia with lidocaine and analgosedation with propofol or midazolam using a Yamshidi aspiration needle, and 240 ml of bone marrow will be aspirated and collected in an ACD-A transfer bag. A sample of 5 ml will be taken to assess the baseline count of nuclear cells.Harvest SmartPReP2 instrument. Next, 2 ml of 8.4% bicarbonate will be added to the obtained concentrate, to adjust pH, and 18 ml of the patient’s plasma – the original 240 ml of aspirate will thus produce a total of 60 ml of BMAC. Quantitative and qualitative analyses of 5 ml of bone marrow aspirate (BMA) and 5 ml of BMAC will be perormed to assess the cellular composition and content of CD43+ cell. The remaining part of the concentrate will be transferred to opaque 10 ml syringes for application.The aspirate will be transferred to centrifuge bottles to produce BMAC, using the Advance CS  balloon catheter of appropriate size will then be inserted onto a 0.035″ guide wire and inflated (at a maximum pressure of 2 atm), and a small amount of contrast medium will be administered to confirm sufficient coronary sinus occlusion. The total volume of 60 ml of BMAC preparation, divided into 10 ml injection vials, will be infused into the coronary sinus during over a five-minute period. Subsequently, the balloon catheter will remain inflated for 10 min, to allow cells to migrate to cardiac tissue. After this procedure, patients will be hospitalised for a minimum of 24 h, with ECG and vital signs monitoring.Coronary sinus cannulation will be performed via the femoral vein under standard conditions. The diameter of the coronary sinus will be measured using contrast medium injection. An [Table 2], and a physical examination as well as 12 lead ECG and laboratory tests  will be performed during each visit and any AEs  recorded. An echocardiographic examination will be performed during screening, and MRI examinations will take place on enrolment (Visit 1) and on the final Visit 6 in month 12. LV parameters and a percentage of total myocardial scar (TMS%) and peri-infarct border zone  will be measured using delated myocardial enhancement assessment  and angiostatin) –9.The main methods involved in applying stem cells to ischemic myocardium are direct intramyocardial injection and intracoronary or retrograde administration via the coronary sinus .Direct intramyocardial stem cell administration leads to high myocardial capture without affecting coronary flow. Percutaneous endoventricular intramyocardial administration using dedicated catheters is relatively safe, although it may be associated with a risk of perforation and tamponade or the induction of ventricular arrhythmias within the first 2 weeks after acute MI. Intramyocardial cell retention may be up to 20–30%, with the remaining cells being retained in pulmonary circulation and the liver. Another advantage of endoventricular administration is the real-time assessment of myocardial viability and contractility, using electromechanical mapping (e.g. NOGA system), and the possibility of targeted stem cell administration to hibernated myocardial areas .Perioperative epimyocardial stem cell injection during CABG allows for targeted administration with visual control, though one disadvantage is the need for surgical access. As an alternative, endoscopic procedures are being developed to ensure transepicardial administration .Intracoronary infusion is the most common route of administration in acute MI patients. The main advantage of this approach is the safety and simplicity of administering stem cells selectively into the infarction artery supplying the ischemised myocardium. However, intracoronary application results in only 1–3% of the cells being captured in the myocardium, with most of the cells being flushed and trapped in the lungs and the liver. Furthermore, infusion of these relatively large cells may lead to the obstruction of coronary microcirculation , 12. GyöRetrograde infusion through the coronary sinus after previous balloon catheter obstruction is an alternative to antegrade intracoronary administration. Retrograde cannulation of the coronary venous system seems to be safe and is commonly used by arrhythmologists, e.g. for implanting the left ventricular pacing leads in resynchronisation therapy , 14 or fIn the metaanalysis by Gathier et al., only a transient increase in troponin-I levels was seen after retrograde stem cells infusion with resolution within 24 h. No arrhythmias were detected in this patients and there was no evidence of damage to the CS or increase of mortality rate releated to retrograde CS infusion .However, there is a lack of information about retrograde application of BMSC through coronary sinus in patients with cardiac resynchronisation therapy (CRT) and LV lead in CS. Due to safety reason, these patients will not be included in the study.Suzuki et al. on a mouse model demonstrated that retrograde infusion through the coronary sinus allows the penetration of cells into single layers of myocardium, with minimal risk of damage. The retention of cells administered in this way is somewhat higher, and in some studies it reaches 3.2% compared to 2.6% in anterograde intracoronary administration .p = 0.05, respectively), while the difference between the last two was not significant . No differences were detected in the numbers of senescence-associated β-galactosidase-positive  cells or the mean telomere length in early passage cells obtained from young and old donors. However, MSCs from old donors exhibited accelerated senescence, evidenced by the increased numbers of SA β–gal+ cells per PD compared with the young participants  [Senderup et al. compared the proliferative capacity of bone marrow stromal cell (MSC) cultures from young (aged 18–29 years) and old (aged 68–81 years) donors. MSCs from old donors exhibited a decreased maximal life span compared with cells from young donors  .A direct comparison of young and old BMSCs from human donors (age 17–90 years) showed age-related multifold increase in SA β–gal+ cells in the old BMSCs, which had nearly twofold longer doubling time in culture .It seems that age of the donors cells remains an important factor to consider in the clinical studies. Therefore, our study will include patients aged 40–80 years.Harvest BMAC concentrate differs from the concentrate prepared using the Ficoll method, which is considered standard. Ficoll concentrate primarily contains mononuclear cells (60+/− 20%) and only 5% of granulocytes and 0.5% of platelets. In addition, the Ficoll method requires manual steps to stretch the plasma, platelet layers and mononuclear layers before washing out any additional material from the separated cells. These steps depend on the operator and must be performed in a sterile laboratory environment .The Harvest BMAC system concentrates the entire population of nuclear cells from bone marrow aspirates together with platelets. This technique is much faster and does not depend on the operator, so it is less prone to any human factor failure. BMAC concentrate contains mononuclear cells, thrombocytes, circulating endothelial progenitors of CD34+/CD31- and CFU-fibroblasts. The presence of both platelets and additional granulocytes can have a positive effect on the neovascularisation potential of the resulting concentrate – an effect attributed to the increased presence of “angiogenic factors”  and cytokines . The celIn order to assess the clinical effect of the therapy, patients enrolled in a study should be in a stable condition. Heart failure may be assessed as chronic at least 6 month after a myocardial infarction (MI), and before enrolling in the study, patients must have been on standard HF therapy for at least for 3 months  and in a stabilised state for at least 1 month  .Several limitations relating to blinding should be mentioned. Due to ethical reasons, patients randomised to the control group will not undergo bone marrow collection. However, the intervention will be blinded, and a right heart catheterisation as a sham procedure will be performed in this group. Interventional cardiologists will not be blinded to the assigned therapy, but clinical evaluation, measurement of MRI parameters and data processing will be performed by blinded, independent persons.Retrograde administration on non-selected BMAC via coronary sinus, due to the content of platelets and growth factors, might improve observed left ventricular function parameters and improve exercise tolerance in patients with heart failure caused by the systolic dysfunction of ischemic aetiology.


TTN) and lamin A/C (LMNA) genes are the two most significant contributors in familial DCM. Previously mutations in the desmoplakin (DSP) gene have been associated with arrhythmogenic right ventricular cardiomyopathy (ARVC) and more recently with DCM.Dilated cardiomyopathy (DCM) is a condition characterized by dilatation and systolic dysfunction of the left ventricle in the absence of severe coronary artery disease or abnormal loading conditions. Mutations in the titin  variant in 17 individuals of which 11 (65%) fulfilled the DCM diagnostic criteria. This pathogenic variant presented with left ventricular dilatation, dysfunction and major ventricular arrhythmias. Two patients showed late gadolinium enhancement (LGE) and myocardial edema on cardiac magnetic resonance imaging (MRI) that may suggest inflammatory process at myocardium.We identified DSP variant in the probands’ family members by the age of 40. Further studies are needed to elucidate the possible relations between myocardial inflammation and pathogenic DSP variants.The patients diagnosed with DCM showed an arrhythmogenic phenotype as well as SCD at young age supporting the recently proposed concept of arrhythmogenic cardiomyopathy. This study also demonstrates relatively low penetrance of truncating  Dilated cardiomyopathy (DCM) is characterized by left ventricular systolic dysfunction and dilatation of left ventricle in the absence of severe coronary artery disease or abnormal loading conditions such as hypertension or valvular disease . Diagnos(TTN) [LMNA) are the second most common cause of DCM, causing 5–8% of familial DCM [TTN, LMNA, DSP, MYH7 (beta-myosin heavy chain), RBM20 (RNA binding motif protein 20), TNNT2 (Troponin 2), TPM1 (tropomyosin 1), FLNC (filamin C) and DES (desmin) [. Mutations in sarcomeric proteins have some overlap to HCM [DSC2 (desmocollin-2) and DSG2 (desmoglein 2) have also been associated with DCM and arrhythmogenic right ventricular cardiomyopathy (ARVC) [Familial DCM is typically considered to be a monogenic disorder and most commonly autosomal dominant inheritance has been reported , 2, 6, 7(TTN) –11. Mutalial DCM . The mos(desmin) , 14. MutDSP codes for the protein desmoplakin, which binds intermediate filament proteins to desmosomal plaques and is thus an essential part of a functional desmosome [esmosome , 16. Desesmosome .DSP gene have mostly been associated with ARVC, which is an inherited cardiac disorder affecting usually the right ventricle [Earlier mutations in the entricle –19. The entricle , 20. Venentricle .Previously the classification of cardiomyopathies has been based mainly on cardiac imaging or complex criteria, as for ARVC. More recently it has been observed that some phenotypes do not fit these earlier classifications. The concept of arrhythmogenic cardiomyopathy (ACM) has also been proposed, however, there are no diagnostic criteria for it so far. ACM comprises a group of cardiomyopathies with ventricular arrhythmias and right and/or left ventricular affection.DSP c.6310delA, p.(Thr2104Glnfs*12) variant interesting because it was found in a previous study in six patients who were diagnosed with DCM [DSP variant in ten Finnish index patients and their family members.We found this with DCM . In thisDSP variant c.6310delA, p.(Thr2104Glnfs*12), of which six participated earlier Finn-DCM study [DSP variant in the families, all the available family members were examined. All the participants gave written informed consent, and the study was approved by the Ethical Review Committee of The Department of Medicine, University of Helsinki . We have the permission from Statistics Finland and Ministry of Social Affairs and Health to obtain clinical data from deceased patients for research purposes.The study included ten index patients with the CM study  and were2 and left ventricular systolic dysfunction (Left ventricular ejection fraction < 45%) in the absence of significant coronary artery disease or abnormal loading conditions such as hypertension or valvular disease. The relatives were also considered to be possibly affected if they had one or more of the following clinical abnormalities: conduction defects, atrial fibrillation (at age of < 50 years), sinus node dysfunction and dilatation or impaired systolic function of the left ventricle.The probands with DCM were diagnosed with the following criteria: left ventricular end-diastolic diameter (LVEDD) > 27 mm/mFamily history was obtained, and pedigrees were drawn. All the available hospital records of the participants were acquired, and clinical data were collected from these records. Some of the patients were evaluated as part of this study by physical examination, 12-lead ECG, echocardiography and appropriate laboratory tests at the Heart and Lung Center in Helsinki. Cardiac magnetic resonance imaging (MRI), Holter, angiography and myocardial biopsy were performed in some cases. All participants of this study are of Finnish ethnicity.DSP variant in the probands’ family members was studied by using bi-directional Sanger sequencing.The genetic testing was carried out at the Blueprint Genetics laboratory at Helsinki, Finland. Eight index patients were tested using the Blueprint Genetics Pan Cardiomyopathy Panel covering 101 genes associated with cardiomyopathies and other large NGS panels including 72 and 133 genes were each used for one patient. The presence of the DSP) with nucleotide one being the first nucleotide of the translation initiation codon ATG. The pathogenicity of this DSP variant was evaluated based on the American College of Medical Genetics and Genomics (ACMG) classification scheme [Mutation nomenclature is based on GenBank accession NM_004415.2  variant was observed in ten Finnish probands with cardiomyopathy. This variant causes a frameshift leading to a premature stop codon at residue 12 in a new reading frame. Thus, it is predicted to cause loss of normal protein function either through protein truncation (2114 out of 2871 aa) or nonsense-mediated mRNA decay from the other allele. It affects both RefSeq transcripts of DSP. There are 13 individuals heterozygous for this variant in the Genome Aggregation Database . Of the heterozygotes, 11 are from the Finnish European cohort. Database curators have made every effort to exclude individuals with severe pediatric diseases from these cohorts. Altogether the variant was detected in 17 individuals of which 11 (65%) fulfilled DCM diagnostic criteria and 1/17 (6%) had a slightly dilated ventricle (118.8% of the estimated LVEDD using the Henry’s formula [A heterozygous  formula ). In twoDSP mutation had a heart transplantation and the other one also carried a heterozygous pathogenic TTN variant.The main clinical features of the index patients and their relatives are presented in Table DSP variant. Of these seven, three fulfilled DCM diagnostic criteria, two had LGE as well as cardiac edema, one had only LGE. Fibrofatty replacement was not identified in any of the patients.Nine patients underwent cardiac MRI and seven of them were carriers of the Two out of seven genotype positive family members had DCM at ages 57 and 60, one had dilated LV with normal EF at age 56, one had second degree AV block at age 43 and three others were considered as genotype positive yet phenotype negative at ages 40, 49 and 53. All genotype negative family members were unaffected.DSP c.6310delA, p.(Thr2104Glnfs*12) variant can be considered as pathogenic.Based on the variant classification scheme that follows the ACMG guidelines, this DSP variant, the proband also had a pathogenic variant, TTN c.100230_100234delinsGACA, p.; NM_001267550.1. The same TTN deletion, but not the DSP variant, was also found in two other members of the family, the proband’s brother (II.4) and nephew (III.7) who both were affected.Proband (II.5) of this family was diagnosed with DCM at the age of 51. His BNP (b-type natriuretic peptide) concentration was 2135 ng/l at its highest. He had no history of arrhythmias, but ECG showed left anterior hemiblock. On echocardiography his LVEDD was 80 mm and LVEF 10–15%. The proband later received a heart transplant. Myocardial biopsy was taken, and no amyloidosis was observed. In addition to the Proband (II.2) of this family was a 67-year-old female diagnosed with DCM at the age of 46. The patient had suffered from atrial fibrillation and ECG showed right bundle branch block as well as left anterior hemiblock. Her pro-BNP (pro b-type natriuretic peptide) concentration was 650 ng/l and on echocardiography her LVEDD was 68 mm and LVEF 35%. The proband died at the age of 69 suddenly. In autopsy both cardiac ventricles were enlarged, there was no significant coronary artery disease, neither signs of myocardial infarct nor pulmonary embolism. The cause of death was considered to be cardiac. Proband’s genotype positive sister (II.4) was diagnosed with DCM at the age of 60. She has no arrhythmias, but ECG showed 1-degree AV block and left anterior hemiblock. On echocardiography her LVEDD was 55 mm and LVEF 45%. Her pro-BNP concentration was 1742 ng/l at its highest. Proband’s 49-year-old genotype positive daughter (III.2) had normal findings in cardiac evaluations. At first cardiac evaluation proband’s genotype positive 40-year-old nephew (III.6) had normal findings. One year later a cardiac MRI was performed and his LVEDV (Left Ventricular End-Diastolic Volume) was 182 ml, LVEF 54%, RVEDV (Right Ventricular End-Diastolic Volume) 173 ml and RVEF (right ventricular ejection fraction) 56%. There was considerable acute edema in the basal and mid-third anterolateral left ventricle as well as subepicardial intensive late gadolinium enhancement (LGE) within the same area.DSP variant. Proband’s eldest son (III.1) is a 56-year-old male with coronary artery disease. He has no conduction defects nor arrhythmias. On echocardiography his LVEDD was 60 mm (118.8% of the estimated LVEDD using the Henry’s formula) and LVEF 52%. Cardiac MRI demonstrated a slightly dilated left ventricle with impaired function and the wall-thickness in inferolateral area was 3–4 mm locally. Proband’s other son (III.2) is a 53-year-old male who had normal findings in cardiac evaluations.Proband (II.1) is an 81-year-old male diagnosed with DCM at the age of 72. He has had ventricular tachycardia as well as atrial fibrillation. ECG showed a first-degree AV block and left bundle branch block. The proband had very high levels of pro-BNP  and on echocardiography his LVEDD was 83 mm and LVEF 18–24%. Proband’s both sons  were found to be heterozygous for the Proband (II.3) was diagnosed with DCM at the age of 43. She suffered from ventricular tachycardia and ventricular extrasystoles. On echocardiography her LVEDD was 60 mm and LVEF 30–35%, ECG showed a 1-degree AV block and left anterior hemiblock. Cardiac MRI demonstrated a dilated left ventricle with end-diastolic volume of 219 ml and LVEF of 41%. Her pro-BNP concentration was 1400 ng/l at its highest.Proband (II.1) was diagnosed with DCM at the age of 48. He had high levels on pro-BNP (9836 ng/l) and on echocardiography his LVEDD was 83 mm and LVEF 19%. He had mild mitral regurgitation and later developed a 3-degree AV block. He had ventricular tachycardia as well as atrial fibrillation and he later received a pacemaker. At the age of 59 he received a heart transplant. The proband was the only member of this family to participate in the study.Proband (II.2) is a 70-year-old female who developed DCM by the age of 50 years. ECG showed 2-degree AV block and left anterior hemiblock. She suffers from ventricular extrasystoles and atrial fibrillation. She has later received a CRT-D pacemaker. On echocardiography her LVEDD was 60 mm and LVEF 15–20%. Her pro-BNP concentration was 2428 ng/l at its highest. Proband’s genotype positive brother (II.5) is a 57-year-old male. ECG showed no conduction defects, but he has had ventricular extrasystoles. On echocardiography his LVEDD was 67 mm and LVEF 32%. His pro-BNP concentration was 455 ng/l. Proband’s son (III.2) died in car accident.Proband is a 48-year-old female, diagnosed with DCM at the age of 42. She has suffered from ventricular tachycardia and ECG showed a 1-degree AV block. She has later received a pacemaker. Echocardiography showed mild mitral regurgitation and her LVEF was 22% and LVEDD 70 mm. Cardiac MRI demonstrated a dilated left ventricle, LVEF of 20%, reduced wall-thickness and no fibrosis. Her pro-BNP was 3117 ng/l at its highest. The proband was the only member of the family to participate in the study.Proband is a 27-year-old female who was diagnosed with DCM at the age of 22. ECG showed no conduction defects, but she has suffered from ventricular extrasystoles. On echocardiography her LVEDD was 60 mm and LVEF 40%. At its highest her pro-BNP concentration was 400 ng/l. Cardiac MRI demonstrated an increase in signal intensity on the lateral wall of the left ventricle and there was also patchy LGE on the lateral left ventricular wall subepicardially and on the right ventricle side of the septum. Also, slightly elevated Troponin T (TnT) concentrations were observed . Endomyocardial biopsy was taken 6 months later and it showed variation in nucleolar shape and size and myodegeneration but no sign of myocarditis. The proband was the only member of this family to participate in the study.Proband (III.1) was an apparently healthy 14-year-old male, who had ventricular fibrillation while watching TV at home. He was resuscitated but succumbed 2 days later at the hospital. At the hospital ECG showed no conduction defects, and on echocardiography his LVEF was 17% and LVEDD 55 mm. No known Long QT Syndrome (LQTS) causing variants were found on genetic evaluation. On autopsy, histology did not demonstrate findings compatible with acute myocarditis. There were no signs of amyloidosis or hemochromatosis. Plakoglobin staining was normal. Interstitial fibrosis of varying grades could be observed. Proband’s genotype positive father (II.1) has had ventricular extrasystoles whereas ECG showed no conduction defects. His pro-BNP concentration was 21 ng/l and on echocardiography his LVEDD was 54 mm (111% of the estimated LVEDD using the Henry’s formula) and LVEF 52%. Cardiac MRI demonstrated no clear LGE.Proband is a 43-year-old male with a 2-degree AV-block. Cardiac MRI demonstrated slightly dilated ventricles and atriums, LVEF was 58% and RVEF 60%. There was no edema. Linear and midmyocardial LGE compatible with fibrosis was observed. Proband was the only member of the family that could be recruited to this study and we have no knowledge of proband’s parents’ genotypes, but we do know the following considering their cause of death. Proband’s mother died suddenly at the age of 24 while pulling a sled on the street. During the 4 years that preceded her death, she had suffered from palpitations of unknown cause and she had visited the hospital several times because of chest pains. On the last of these visits, a 1-degree AV-block was observed. Proband’s father had alcoholic liver cirrhosis and he died suddenly at later age due to intoxication.DSP c.6310delA, p.(Thr2104Glnfs*12) in ten Finnish index patients with DCM. This study also demonstrates relatively low penetrance of truncating DSP variant in the probands’ family members before age of 40 but phenotype became evident in about half of the family members by age 60. In addition to the previous FinnDCM study [DSP gene mutation. In both cases the phenotype was cardio-cutaneous and in the other case, the patient suffered sudden cardiac death [We have identified the CM study , this vaac death , 25.DSP pathogenic variants and myocardial inflammation.Nine of the index patients and two relatives fulfilled the diagnostic criteria for DCM but at least one of the subjects, a young previously healthy individual, had ventricular fibrillation and SCD as the first manifestation of the disease. The age of diagnosis varied greatly as the youngest was 14 years old while the oldest participant was 72 years old when the diagnosis was made. Two of the participants presented edema on cardiac MRI. From one of these patients TnT was measured and initially elevated, then normalized in follow-up. The findings were suggestive of some kind of inflammatory process. The inflammatory process in the myocardium could explain some of the sudden arrhythmias as the disease might process periodically rather than continuously. However further studies are needed to elucidate the possible relations between DSP gene as a cause of arrhythmogenic cardiomyopathy.The major findings in our subjects are ventricular arrhythmias and dilatation of the left ventricle. Three of the patients died suddenly and two of them at young age. Our findings confirm the significance of Even though some of the patients do meet the DCM diagnostic criteria, it seems that the arrhythmogenic side of this phenotype is more important in practice, because the deaths were caused by arrhythmogenic events rather than ventricular dysfunction.DSP gene on chromosome 6p24.3, and there are two isoforms produced by alternative splicing. Desmoplakin is a crucial part of forming functional desmosomes as it interacts with intermediate filaments and binds them to desmosomal plaques [Desmoplakin is coded by the  plaques , 16. Des plaques . To adap plaques . The mec plaques . The mai plaques . Desmopl plaques .DSP manifest in the skin, hair and heart in humans. The participants in this study were not studied systematically for skin or hair abnormalities, but there were no mentions of these kinds of defects in the patient records. Autosomal recessively inherited mutations have previously been associated with severe disorders such as Carvajal syndrome [DSP have been associated with ARVC [DSP variants reported in ClinVar (May 2019) of which 156  were classified as pathogenic or likely pathogenic. Most of the variants classified as non-pathogenic are located in the C-terminus.Mutations in syndrome –30, skinsyndrome . Autosomith ARVC , DCM andith ARVC . There aDSP c.6310delA, p.(Thr2104Glnfs*12) frequency in Finnish population is 0.0005081. Total allele frequency is 0.00005170. The variant is enriched in Finnish population but the presence of this variant in the reference population could possibly be explained by the variant’s low penetrance before the age of 40. Because of the late expression of the phenotype, this could lead to the inclusion of variant carriers in the reference population, who have not yet developed the disease.According to gnomAD the According to the 2008 position statement of the European Society of Cardiology, cardiomyopathies have been divided into groups based on the phenotypes and each phenotype is divided into familial and non-familial forms . DCM is PKP2 (plakophilin 2), DSP, DSG2 and DSC2, have been associated with ARVC [Arrhythmogenic right ventricular cardiomyopathy is a myocardial disorder defined by the dysfunction of the right ventricle and the left ventricle may also be affected. Histologically ARVC is characterized by fibrofatty replacement of the myocardium, abnormal contraction and dilatation of the right ventricle. The diagnosis is based on the latest revised Task Force diagnostic criteria, that was published in 2010 . Mutatioith ARVC . The 200ith ARVC .Not all of our participants had their right ventricles systematically evaluated, but no abnormalities in the size or function of the right ventricle on echocardiography were reported in hospital records. Those who had cardiac MRI performed, did not show any defects in the function nor structure of the right ventricles.DSP mutations seem to be associated with left dominant or biventricular form of ARVC rather than the classical right dominant form, and DSP mutation carriers have a higher risk of SCD when compared to other mutation carriers [DSP were associated with higher risk of developing LV dysfunction in ARVC [This is in line with some previous studies, in which it has been noted that carriers , 34–36.  in ARVC .Increasing amount of reports of clinical variants characterized by left ventricular involvement which may be parallel or greater than the RV involvement, has led to the use of a broader term of “arrhythmogenic cardiomyopathy” (ACM) . ArrhythDSP variant causes an arrhythmogenic phenotype in addition to the suboptimal function of the left ventricle although fibrofatty infiltration was not observed. Our findings concur with the proposed concept of arrhythmogenic cardiomyopathy but more research in the subject is still needed. The variant is more common in the Finnish population as compared to many other populations. It might also modify the risk of ventricular arrhythmias for example in the context of coincidental coronary artery disease. Understanding the genetic background may have some significance in the diagnosis and treatment of these diseases in the future.This s.6310delA


Up to nine (18%) children presented with LVMD (LVTX > 0.5), with a higher incidence of PICU admission . The diagnostic performance of NT-proBNP in predicting LVMD was high (area under the receiver operator characteristic curve (AUC) 0.95, CI 95% 0.90–1). The diagnostic yield of the predictive model for PICU admission that included NT-proBNP was excellent , and significantly higher than the model without NT-proBNP (p = 0.026). Conclusions: LVMD could be present in healthy infants with RSVB who develop severe disease. NT-proBNP seems to improve traditional clinical markers for outcomes.Aim: To investigate whether the presence of left ventricular myocardial dysfunction (LVMD) assessed by Tei index (LVTX) impacts the outcomes of healthy infants with Respiratory Syncytial Virus Bronchiolitis (RSVB). To explore whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) increases the accuracy of traditional clinical markers in predicting the outcomes. Methods: A single-centre, prospective, cohort study including healthy infants aged 1–12 months old admitted for RSVB between 1 October 2016 and 1 April 2017. All patients underwent clinical, laboratory and echocardiographic evaluation within 24 h of admission. Paediatric intensive care unit (PICU) admission was defined as severe disease. Results: We enrolled 50 cases of RSVB (median age of 2 (1–6.5) months; 40% female) and 50 age-matched controls. We observed higher values of LVTX in infants with RSVB than in controls (0.42 vs. 0.36;  Respiratory Syncytial Virus Bronchiolitis (RSVB) is the leading cause of lower respiratory infection and hospital admission among children up to 2 years of age worldwide . ApproxiCardiovascular involvement seems to be a relevant prognostic factor in RSVB. Cardiovascular complications are present in up to 9% of cases of RSVB and constitute the second most common extrapulmonary manifestation after infectious complications . These eAdverse RV–LV interactions and left ventricle (LV) myocardial dysfunction (LVMD) are emerging as important determinants of PH outcomes. PH can induce complex changes in LV geometry and causes an abnormal relaxation and non-uniform contraction pattern in the LV wall, leading to LVMD ,15,16. HN-terminal pro-B-type natriuretic peptide (NT-proBNP) is a hormone synthesized and released into the circulation by ventricular myocytes in response to pressure/volume overload and an increase in myocardial wall stress . ElevateIn this study, we aimed to investigate the presence of adverse RV–LV interactions and LVMD (assessed by TDI-echocardiography) in previously healthy infants with RSVB. We hypothesized that acute PH with RV pressure overload may indeed have a direct impact on LV performance. We also hypothesized that those infants with LVMD are prone to developing a more severe form of disease. Finally, we sought to test NT-proBNP as a biomarker for LVMD and explore whether NT-proBNP increases the accuracy of traditional clinical markers in predicting the severity of the disease. This was a single-centre, prospective, cohort study including infants aged 1–12 months old admitted to the paediatric department in our institution  due to RSVB  antigen test) between 1 October 2016 and 1 April 2017. All patients underwent clinical, laboratory and echocardiographic evaluation within 24 h of admission. We excluded patients with co-existing CHD or CLD, prematurity, those that received MV or intravenous fluid before assessment, and those with poor-quality echocardiographic images or incomplete medical records. Severe cases were screened for coinfection and, if present, were also excluded. The control group consisted of age-matched healthy infants who underwent evaluation for heart murmur at our paediatric cardiology outpatient clinic during the study period. These controls followed the same echocardiographic protocol as study patients. Our Institutional Review Board approved the study. Informed consent was obtained for all patients.The bronchiolitis score of Sant Joan de Déu (BROSJOD)  was usedStandard techniques to obtain M-mode, two-dimensional and Doppler  echocardiograms were performed by the same experienced paediatric cardiologist (RGM) as recommended in the guidelines for the paediatric echocardiogram . Images The RV end-diastolic diameter (RVEDD) and the RV/LV ratio (RVLVr) were used as indicators of RV dilation. RV systolic function was assessed by the tricuspid annular plane systolic excursion (TAPSE) , and by The LV end-diastolic diameter (LVEDD) was used as an indicator of LV dilation. The LV shortening fraction (LVSF) and the tissue Doppler imaging (TDI)-derived peak systolic annular velocity at the mitral level of the LV free wall (Sm) were used to assess LV systolic function. To assess the diastolic LV function, we obtained the mitral peak early (E) and late (A) diastolic velocity using the pulsed wave Doppler of the mitral valve inflow. Also, the TDI-derived early diastolic mitral annulus velocity (Em) was measured at the lateral part of the mitral annulus. The E/Em ratio and E/A ratio were calculated as indicators of LV filling pressures. LV Tei index (LVTX) was used as a measurement of global (systolic and diastolic) LV function. It was calculated using the TDI-derived isovolumic contraction (IVC), isovolumic relaxation (IVR) and ejection time (ET) intervals  as previously described . Cui andTo explore intra-observer and inter-observer agreement, 30 echocardiographic studies were randomly selected and analysed offline. To estimate the intra-observer agreement, the first observer (RGM) remeasured the LVTX, RVTX and LVEI with a 30-day interval blinded to previous measurements and patient information. To assess the inter-observer agreement, the means of both observers for each measurement were compared.t test or Wilcoxon Mann–Whitney test as appropriate. Proportions were compared using the Chi-square test or exact methods as necessary. Pearson and Spearman coefficients were used to assess correlations between continuous data. A receiver operator curve (ROC) analysis was used to determine the diagnostic accuracy of NT-proBNP for LVMD. The best cut-off value of NT-proBNP to detect LVMD was empirically estimated based on the Liu method, and values of sensitivity (Se), specificity (Sp), negative predictive value (NPV) and positive predictive value (PPV) were calculated for the obtained cut point. We selected 2 predefined predictive models for PICU admission. The selection of the included variables was based on the theoretical background and the exploratory analysis. Model 1 (proposed model) included age, BROSJOD score and NT-proBNP levels and model 2  included age and BROSJOD score. Prediction models were evaluated through multivariate logistic regression analysis. The discriminating ability of each model was assessed by the area under the receiver operator characteristic (AUC) curve. The AUCs from the obtained models were then compared by using the DeLong method [p value < 0.05 was considered statistically significant.Continuous data are presented as the median (range) or mean (standard deviation) after testing for normality with the Shapiro–Wilk test; categorical data are presented as frequencies and percentage. Mean comparison was performed using the Student’s g method  to deterg method . Based oWe enrolled a total of 50 cases of RSVB with a median age of 2 (1–6.5) months . The control group consisted of 50 healthy infants with no differences regarding age, sex or body surface area (BSA) distribution . RSVB pap < 0.001). All cases of pericardial effusion were mild and did not require any treatment. We observed higher values of LVTX  in infants with RSVB than in controls (p = 0.003), and higher TRJG , RVTX  and LVEI  than the control group. There were no differences between RSVB and control groups regarding echocardiographic parameters of ventricular dimensions, systolic or diastolic function , higher RV pressures , and decreased RV global function (Rho RVTX= 0.74). We did not find associations of echocardiographic measurements of RV systolic function (TAPSE and St) with LVTX . These patients presented with a higher BROSJOD score , lower SpO2 , more cases of RA , and higher NT-proBNP levels  than those with a normal LV myocardial function. The LVTX was also strongly correlated with NT-proBNP levels (Rho = 0.73)  patients with RSVB . LVMD wa = 0.73) .The diagnostic performance of NT-proBNP to predict LVMD in infants with RSVB resulted in an area under the ROC curve of 0.91 (CI95% 0.79–0.98) . The besp = 0.026). In model 1, the presence of NT-proBNP levels > 1500 pg/mL was the only independent predictive factor for PICU admission in RSVB, with an OR 27.03 (CI95% (1.50–487), p = 0.025) , and NT-proBNP as biomarker for LVMD. Model 1 (the proposed model) included age < 3 months, BROSJOD score > 10, and NT-proBNP > 1500 pg/mL. Model 2  included age < 3 months and BROSJOD score > 10. The diagnostic yield of model 1 for PICU admission was excellent , and significantly higher than the yield for model 2 (= 0.025) .The intra-observer and inter-observer agreement for LVTX, RVTX and LVEI were good or excellent, with all ICC coefficients > 0.75 .The main finding of our study is that LVMD was observed at the early stages of the disease in up to 18% of previously healthy infants with RSVB when assessed by DTI-derived LVTX. The LVMD was associated with a more severe respiratory state, PICU admission, and echocardiographic signs of RV pressure overload and RVMD, indicating the presence of adverse RV–LV interactions in cases of severe RSVB. Also, we observed that NT-proBNP accurately identified LVMD. Moreover, we found an added benefit to the addition of NT-proBNP to the clinical evaluation in predicting the development of severe disease in this population.CHD is an important cause of morbidity and mortality in RSVB . This maTo the best of our knowledge, this is the first study to evaluate LVMD using TDI-derived LVTX, and to assess RV–LV interactions in infants with RSVB. LVTX, which includes both systolic and diastolic time intervals to assess the global cardiac dysfunction, is an easily performable, recordable and reproducible parameter with normal reference values that can be applied to the entire spectrum of the paediatric population, regardless of age, heart rate, and BSA . Using LIn RSVB, the major goals are the prevention and early identification of infants at risk for severe disease in order to provide the best management options and decrease morbidity. Current guidelines recommend only clinical observation for this purpose in infants without known comorbidities . HoweverAnother interesting finding of our study was that NT-proBNP could be a useful biomarker for LVMD and subsequent outcomes in RSVB. Previous studies have also documented the correlation between LVTX and NT-proBNP plasma levels ,43,44. WThis work included some limitations. Our study was performed at a single centre and with a relatively small size. We excluded irritable or unstable patients, where the technical difficulties due to respiratory comorbidity and the patient’s inability to tolerate the evaluation could impact the results. The PICU admission criteria and, subsequently, the definition of severe diseases in the study are based on the protocol of our hospital, which can vary between institutions. Therefore, a larger multicentre cohort study including irritable or unstable cases and with uniform PICU admission criteria may be needed for the verification and generalization of our results. Finally, the assessment of myocardial function and PH on echocardiography was not confirmed by an independent gold-standard method, such as cardiac magnetic resonance imaging or right heart catheterization, and therefore some patients could have been misclassified.Adverse RV–LV interactions and LVMD could be present in healthy infants with RSVB during the early stages of the disease, negatively impacting the outcome. NT-proBNP seems to be an adequate biomarker for LVMD. Adding NT-proBNP to traditional clinical markers to assess outcomes in RSVB could improve the early detection of those cases that will develop a severe illness. Future research is need in order to confirm these results and to design new therapeutic approaches based on them.


Aims: Despite continuous efforts in improving the selection process, the rate of non-responders to cardiac resynchronization therapy (CRT) remains high. Recent studies on intraventricular blood flow suggested that the alignment of hemodynamic forces (HDFs) may be a reproducible biomarker of mechanical dyssynchrony. We aimed to explore the relationship between pacing-induced realignment of HDFs and positive response to CRT.Methods and results: We retrospectively analyzed 38 patients from the CRT database of our institution fulfilling the inclusion criteria for HDFs-related echocardiographic assessment early pre and post CRT implantation, with available mid-term follow-up (≥ 6 months) evaluation. Standard echocardiographic and deformation parameters early pre and post CRT implantation were integrated with the measurement of HFDs through novel methods based on speckle-tracking analysis. At midterm follow-up 71% of patients were classified as responders (reduction of Left Ventricular Systolic Volume Indexed ≥ 15%). Patients did not display significant changes between close evaluations pre and post-implant in terms of ejection fraction and strain metrics. A significant reduction of the ratio between the amplitudes of transversal and longitudinal force components was found. The variation of this ratio strongly correlates (R2 =0.60) with Left Ventricular (LV) end-systolic volume variation at mid-term follow up.Conclusion: Pacing-induced realignment of HDFs is associated with CRT efficacy at follow up. These preliminary results claim for dedicated prospective clinical studies testing the potential impact of HDFs study for patient selection and pacing optimization in CRT. Cardiac resynchronization therapy (CRT) is an established strategy for patients with symptomatic heart failure (HF), reduced systolic function and prolonged QRS duration, improving symptoms and long-term survival –4. NeverElectrocardiographic criteria are considered the most reliable for eligibility to CRT. However, a heterogeneity of CRT response is found even in carefully selected patients with LBBB morphology and QRS duration >120 ms. Therefore, imaging markers of mechanical dyssynchrony were considered as adjunctive criteria for patient selection; however, results were still heterogeneous in wide QRS patients, and even negative in narrow QRS ones .Hemodynamic Forces (HDFs), or equivalently intraventricular pressure gradients (IVPGs), are a relatively novel imaging marker of LV function. HDFs drive blood motion during both ventricular ejection and ventricular filling, and are deeply interconnected with physiological vortex formation inside the LV . Under nTherefore, in the present study we sought (A) to describe the pattern of HDFs in reduced ejection fraction HF (HFrEF) patients with wide QRS, (B) to assess early CRT-induced changes in HDFs and (C) to assess the potential relationship between CRT-induced changes in HDFs orientation and mid-term clinical response.We retrospectively analyzed all patients with successful CRT device implantation consecutively included in the CRT-Registry of our Institution  from January 2008 to December 2016. Follow-up ended on 31 June 2017. Indication for CRT was symptomatic HF with LV ejection fraction (LVEF) ≤35% and QRS duration ≥120 ms, despite optimal medical therapy. The study received institutional review board approval, and informed consent was obtained under the institutional review board policies of the hospital administration. Ischemic etiology of HF was considered in the presence of significant CAD (stenosis >50% of a major coronary artery on coronary angiography) and/or history of prior myocardial infarction or revascularization.According to institutional protocol the majority of patients implanted underwent complete echocardiographic examination prior and after CRT implantation. Inclusion criteria for the present study were: (1) available complete transthoracic echocardiographic examinations within a close time range of 2 months before and after CRT implantation; (2) available complete transthoracic echocardiographic examination at mid-term follow-up (~6 months). Patients with poor quality imaging, in particular not allowing the complete tracking of endocardial profile in 4-, 2-, and 3-chamber apical view along with optimal LVOT and aortic valve visualization, or with insufficient frame rate (<50 Hz) for speckle tracking analysis, were excluded.TTPLS)] and in HDFs, where compared between PRE and POST, and subsequently correlated with LV volumetric remodeling at follow up. LV remodeling at follow up was defined, as previously described (*100)] and categorized as follows: super-responders (SR) patients had a LVESV reduction ≥30%; responders (R) had a LVESV reduction ranging between 29 and 15%, non-responders (NR) had a LVESV reduction ranging between 14 and 0% and finally negative-responders (NegR) had an increase in LVESV.All the metrics of interest, in particular HDFs, were analyzed retrospectively in the last echo within 2 months before CRT implantation (PRE) and in the first echo within 2 months after implant (POST). CRT-induced changes in main parameters [LVEF, LV End Systolic and End Diastolic Volume Indexed (LVESVI and LVEDVI), end-systolic Global Longitudinal Strain (GLS), Standard Deviation of Time To Peak of Longitudinal Strain .The HDFs-related metric which resulted significantly correlated with LV remodeling at midterm follow up, was finally selected for prediction test of patient's responder status   were used. Unipolar or bipolar leads were implanted in posterolateral or lateral veins when feasible. Ablation of the atrioventricular node after the procedure was considered for patients with an unsatisfactory proportion of ventricular pacing (<95%).Echocardiograms were recorded on digital media storage devices at the echocardiographic core laboratory of our Institution and analyzed offline according to current international guidelines .TTPLS).The three apical echocardiographic recordings  were re-analyzed offline by a prototype version, that includes the evaluation of HDFs, of a commercially available speckle tracking solution . The software requires drawing the end-systolic (ES) endocardial borders and tracks the endocardial border over the entire heartbeat; it then allows correcting the end-diastolic (ED) border and propagates the correction over the entire cycle to match the original ES border. The ES and ED volumes are computed by the Simpson method, the GLS is computed as by guidelines ; then a F(t), exchanged between blood and tissues at every instant during the cardiac cycle is evaluated by the balance of momentum inside the LV volume V(t)From the three endocardial borders estimated by speckle tracking during the cardiac cycle the software also computes the HDFs. The calculation procedure is described in detail in Pedrizzetti et al. , which rS(t) is the surface bounding the volume, v is the velocity vector and the subscript n indicates the outward normal component. The first term in the right-hand side of the previous formula represents the flux of momentum across the instantaneous LV volume boundary. This is computed from the velocity at the LV endocardium, given by speckle tracking, and by the mean velocity across the mitral and aortic valves that is evaluated by the LV volume rate divided by the valve area. The second term, due to blood inertia, is obtained by the rate of change of the average velocity inside the LV, which can be reliably estimated through simple assumptions on the global intraventricular fluid dynamic (Fz(t), apex-to-base) and of the main transversal component (Fx(t), inferolateral-anteroseptal) are thus obtained, and they are normalized with the instantaneous LV volume, and the blood specific weight, to have a dimensionless number not directly affected by the chamber size.where  dynamic . The timTThe global amplitude of the individual HDF components is described in terms of the root mean square (RMS) value of the corresponding time profile during the heartbeat period The entity of the deviation of the HDF from the longitudinal direction is estimated by the ratio of the amplitudes: RMSx/RMSz.Summary statistics of clinical and instrumental variables were expressed as the mean and standard deviation (SD), median and interquartile range (IQR), or counts and percentage, as appropriate.t-test or Wilcoxon test according to Gaussian or Non Gaussian distribution, with significance level taken as p < 0.05.The longitudinal evolution of the parameters under study from PRE- to POST- CRT examination was assessed by the two-tailed paired Student Mechanical echocardiographic variables, and their changes from PRE- to POST-CRT were correlated (Pearson test) with the relative changes in LVESV (ΔLVESV), where Δ indicated the difference from PRE to mid-term follow-up, divided by PRE LVESV.2, with significance threshold, R2 > 0.4. A receiver operating characteristic (ROC) curve analysis was performed to determine the best cutoff value (according to Youden criterion) of RMSx/RMSz PRE, RMSx/RMSz POST, and δ(RMSx/RMSz), where δ indicated the change from PRE to POST, for differentiating “all grade” responders  and “all grade” non-responders .Correlations were graded by the coefficient of determination RThe Prism Software (GraphPad) version 5 was used for descriptive analyses, and the Statistical processing was performed with MatLab .t-test with significance level assumed p = 0.05. Bland—Altman analysis was also performed to verify the absence of systematic bias.Inter-operator variability of HDFs quantification was evaluated by repeating evaluation on the same images by a second operator, blind to the previous results, on all 38 patients both on echo PRE and POST CRT (76 triplane samples). This allowed to obtain a power of 80% to identify an intraclass correlation coefficient (ICC) of 0.70, under the null hypothesis of ICC equal to 0.50, using an F test at a level of significance equal to 5% and intra-operator ICC of 0.80 under the null hypothesis of 0.60. The differences were described in terms of average with 95 confidence interval; statistical comparison was also verified by a paired two-tailed Student Of the about 300 patients included in CRT registry in the selected period, only 38 fulfilled inclusion criteria. p < 0.001 for both) reduction from PRE to POST. The other variables, LVEF, GLS, SDTTPLS and the amplitude (RMS) of HDF force components did not present significant changes; however, a small increase in GLS and in the value of RMSz was noticed POST implant. Most importantly, the ratio between transversal and longitudinal HDFs (RMSx/RMSz) shows a significant reduction POST CRT (p = 0.011). This ratio was selected for further evaluation: with respect to the evaluation of single RMSz or RMSx taken separately, their combined evaluation expressed by this ratio seems to offer a more accurate representation of the degree of alignment of LV IVPGs distribution in disease state. In TTPLS . R2 = 0.60) with the variation of LVESV at mid-term follow-up (ΔLVESV). The early change in LVEF and in SDTTPLS did not display any correlation with follow up; a small non-significant correlation (R2 = 0.30) was found between the early (δ) and the midterm follow up (Δ) variation in LVESV  and the variation of LVESV at midterm follow up (ΔLVEVS) was performed. This evaluation was compared with respect to the early changes (δ) in LVEF (as a main indicator of LV systolic function), LVESV (to differentiate midterm follow up with respect to early changes), and in SDThe early decrease in the RMSx/RMSz ratio corresponds to an improved alignment of HDFs after CRT, which represents a measure of the extent of restored physiological LV IVPGs: this correlates with the reduction of LVESV found at a later time. In this perspective, the significance of early change in this ratio was tested with ROC analysis to evaluate if it is predictive of the response status at midterm follow up.p < 0.001). The optimal cut-off of δRMSx/RMSz identified at ROC analysis was −15.1% with a sensitivity and a specificity of 73% and 92%, respectively, for R/SR prediction. Neither the absolute value of this ratio evaluated separately at PRE  nor POST (As shown in p = 0.51 in the paired Student t-test. Intraclass correlation coefficient (ICC) resulted equal to 0.91 (95% CI: 0.86–0.94). The Bland-Altman analysis, reported in The mean of inter-operator difference for the ratio RMSx/RMSz was −0.006 , with In this pilot, hypotheses-generating retrospective study we demonstrated the feasibility and the potential utility of the sequential echocardiographic assessment of HDFs in CRT recipients as an early marker of resynchronization efficacy at follow-up. To the best of our knowledge, this is the first paper assessing this technique in this setting, and we found it capable to provide us valuable new information about LV function at baseline and early after therapy. In our scenario, this information contributes to a better categorization of patients in terms both of therapy's response and efficacy at follow up.The main objective of LV function is that of creating flow that, by the law of physics, can develop only in consequence of an intraventricular pressure gradient (IVPG). Normal IVPGs are aligned along the base-apex direction in compliance with the ejection-filling blood motion that occurs from base to apex during systole and vice versa during diastole , 9. ThisRecent 4DFlow studies demonstrated that the increase of the transversal component of HDF with respect to the longitudinal one represents a sensible quantitative marker for the presence of mechanical dyssynchrony , 12. TheThis paper applies for the first time a novel method for the estimation of HDFs by regular B-mode images in patients undergoing CRT. This pilot observational study shows, in line with above mentioned preliminary observations , 12, thaper se at baseline (PRE) the potential to predict a higher probability of favorable response to CRT: in respect to the current claim for more accurate selection criteria in CRT recipients (The main net outcome of CRT is ascribed to the responder status at follow up. In the complex world of CRT, many measures of mechanical synchrony have been suggested in order to identify the criteria with highest predictive value –24. Howecipients , this asThe present study was performed retrospectively on a small sample of patients. Thus, our preliminary results should be considered as proof of concept and hypotheses generating, future larger prospectives investigations are required to explore more extensively the applicability and the advantages of this methodology in candidates to CRT. The time intervals between PRE and POST echocardiographic evaluations were slightly different among patients. However, in our opinion the limit of 2 months avoided that the progression of the underlying disease, rather than the net effect of biventricular pacing, might have influenced HDFs. With respect to the optimization of the recording protocol, the echocardiographic exams PRE and POST implant were performed without considering the need of a comparative assessment, thus a variability may also be partly imputable to small changes in the acquisition practice including different operators.This study was aimed to provide an initial evaluation of an approach based on HDFs for the prediction of response to CRT. This preliminary work was required for verifying whether this approach could deserve the design of a prospective clinical study in the same subject.This pilot observational study demonstrated that the realignment of LV HDFs induced by biventricular pacing, assessed through a new echocardiographic technique early after implantation, correlates with LV reverse remodeling at follow-up in HFrEF patients treated with CRT. These results should encourage the design of a larger prospective clinical study to verify the potential of systematic HDFs assessment in selecting the optimal candidates to CRT and in guiding pacing optimization.The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.This study was carried out in accordance with the recommendations of our clinical institution, the Azienda Ospedaliera Universitaria Integrata of Trieste. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Institutional Review Board of the Azienda Ospedaliera Universitaria Integrata of Trieste.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.GP is a shareholder of AMID SRL, which is a partner of TomTec Gmbh. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.