Recognition of congestion and hypoperfusion in patients with chronic left ventricular dysfunction (LVD) has therapeutic and prognostic implications. In the present study we hypothesized that a multiparameter echocardiographic grading of right ventricular dysfunction (RVD) can facilitate the characterization of hemodynamic profiles.n = 105, age 53 ± 14 years, males 77%, LV ejection fraction 28 ± 11%) referred for heart transplant or heart failure work-up, with catheterization and echocardiography within 48 h, were reviewed retrospectively. Three hemodynamic profiles were defined: compensated LVD  and normal mixed venous saturation (SvO2 ≥ 60%)); decompensated LVD  and LV failure . We established a 5-point RVD score including pulmonary hypertension, reduced tricuspid annular plane systolic excursion, RV dilatation, ≥ moderate tricuspid regurgitation and increased right atrial pressure.Consecutive patients ] showed significant in-between the three groups differences with 1 , 1  and 3.0  in patients with cLVD, dLVD and LVF, respectively. The finding of RVD score ≥ 2 or ≥ 4 increased the likelihood of decompensation or LVF 5.2-fold and 6.7-fold, respectively. On the contrary, RVD score < 1 and < 2 reduced the likelihood 11.1-fold and 25-fold, respectively. The RVD score was more helpful than standard echocardiography regarding identification of hemodynamic profiles.In this proof of concept study an echocardiographic RVD score identified different hemodynamic severity profiles in patients with chronic LVD and reduced ejection fraction. Further studies are needed to validate its general applicability. It is evident that grading the severity of LVD is important to guide therapy and risk-assessment. Still, the potential of echocardiography in this respect has gained little attention.Echocardiography is a first line tool in the assessment of patients with suspicion of heart failure and important in the follow-up of patients with chronic left ventricular dysfunction (LVD) . ElevateIncreased right ventricle (RV) afterload due to increased LV filling pressures and secondary pulmonary hypertension is the most common cause of RV dysfunction (RVD) in patients with LVD . The effWe retrospectively identified 105 patients ≥ 18 years who were consecutively referred for heart transplant or heart failure work-up between July 2015 and July 2019, with right heart catheterization and echocardiography within 48 h. Exclusion criteria comprised 1) acute myocarditis; 2) myocardial infiltrative disease (e.g. amyloidosis and sarcoidosis); and 3) adult congenital heart disease. Among the total study population 72% performed a symptom-limited cardiopulmonary exercise test. Fasting blood samples were drawn in connection with the right heart catheterization. The study was approved by the Regional Ethics Review Board in Gothenburg (Dnr. 286–18) and conducted according to the Declaration of Helsinki.The RVD score is empirical and the echocardiographic parameters included in the RVD score were selected because they are known to be common findings in patients with RVD or overt RV failure. The RVD score includes the following parameters and findings: 1) increased systolic pulmonary artery pressure (representing the common cause of RVD), 2) reduced tricuspid annular plane systolic excursion , 3) increased RV diastolic area (a sign of RV-pulmonary artery uncoupling), 4) moderate or severe tricuspid regurgitation (a sign of RV-pulmonary artery uncoupling) and 5) reduced collapsibility of the inferior vena cava  problems with the visual assessment of tracking, mainly because the apical segment was only partly included in the sector.Speckle tracking was performed on the RV free wall by manual tracing. Only the middle and basal segments were used, and their mean defined as the RV free wall longitudinal strain. We omitted the apical segment due to often occurring  was introduced using the Seldinger technique. The following variables were measured or derived: heart rate, right atrial pressure, RV end diastolic pressure, systolic pulmonary artery pressure, diastolic pulmonary artery pressure, mean pulmonary artery pressure, PCWP, cardiac output, pulmonary vascular resistance and SvOlic area .P value < 0.05 considered statistically significant), we continued with a post-hoc analysis of inter-group comparisons using the independent-sample t-test or Mann–Whitney test when appropriate. Using the Bonferroni correction for multiple testing, the null hypothesis was rejected if the P value was < 0.016. Receiver operator characteristic curve analysis were applied to assess the diagnostic ability to identify patients with 1) decompensation (PCWP ≥ 15 mmHg) and 2) overt LVF (PCWP ≥ 15 mmHg and SvO2 < 60%). The cut-off values for natriuretic peptide (NT-proBNP) and left ventricular ejection fraction were identified using the optimal Youlden index. The diagnostic performance was described using sensitivity, specificity, positive likelihood ratio and negative likelihood ratio. To evaluate the inter-observer variability of the RVD score the measurements and assessments were performed by two investigators  on the same investigation (n = 20). The variability for continuous variables  was described by the coefficient of variation and expressed as the SD of differences divided by the mean value of two measurements. For categorical parameters  we used kappa statistics. The statistical analysis was performed using SPSS for Macintosh, version 27 .Continuous variables are expressed as the means ± standard deviation (SD), medians with interquartile ranges or as numbers with percentages when appropriate. The degree of the linear relationship was assessed by the Spearman correlation coefficient (R). To compare multiple groups, we used one-way ANOVA test when the distribution was normal and Kruskal–Wallis test when the distribution was skewed. In cases where the null-hypothesis was rejected , 25 patients had dLVD with increased PCWP (wet-warm), 5 patients had normal PCWP and reduced SvO2 (dry-cold) and 33 patients had LVF with both increased PCWP and reduced SvO2 (wet-cold). Patients in the dry-cold group were due to the small number omitted from further comparison with the other three hemodynamic profiles.Forty-two patients had cLVD with normal PCWP and SvOTable n = 1, 1%), only one positive of two available parameters  and less than two parameters . The proportion of patients with correct echocardiographic assessment of hemodynamic profile was in cLVD 54%, in dLVD 44% and in LVF 73% . The agreement between the assessment of normal or increased left atrial pressure and invasive PCWP was moderate  with correct assessment in 78% and overestimation in 17%  with correct assessment in 66% and incorrect hypoperfusion in 24% of the patients . The classification was indeterminate due to missing Doppler cardiac index , increased to a modest degree with positive likelihood ratio 2.8 Table . The likThe ability of the RVD score, NT-proBNP, LV ejection fraction, global LV longitudinal strain and E/E’ to identify different hemodynamic profiles were tested using ROC analysis Fig. A-B. As cThe inter-observer variability for RV diastolic area, Doppler systolic pulmonary artery pressure and TAPSE was 8.8%, 8.6% and 22%, respectively. The agreement in echocardiographic assessment of right atrial pressure, tricuspid regurgitation and RVD score by kappa (95% CI) was 0.90 (0.71 to 1.0), 1.0 and 0.69 (0.47 to 0.92), respectively.The main findings in the present study were as follows: firstly, the function of the RV-pulmonary artery unit is closely related to the LV hemodynamic profile; secondly, a standard echocardiographic assessment is less useful when it comes to identifying hemodynamic profiles; and thirdly, assessment of degree of RVD using a novel RVD score, can improve the assessment and differentiation of LVD beyond conventional echocardiography indices.In patients with chronic heart failure and reduced LV ejection fraction, congestion and hypoperfusion at clinical examination are important findings with independent prognostic value beyond symptoms, biomarkers or chronic heart failure risk score , 16. BedIn the present study, we sought for other indices that could identify different hemodynamic profiles. We hypothesized that a score system consisting of multiple parameters related to RVD could improve the detection and differentiation of hemodynamic profiles . Our resDuring the last two decades, the RV function in patients with LVD has gained increased attention since RVD has been shown to carry prognostic information beyond traditional markers of LVD –25. ThesThe most important limitations to discuss are related to the general applicability of our findings. Firstly, the study was retrospective and dominated by patients with advanced heart failure. To what extent our results can be extrapolated to patients with chronic but less symptomatic LVD is of crucial importance. Secondly, the study patients had predominantly heart failure with reduced LV ejection fraction. RVD in patients with heart failure and preserved ejection fraction is known to be a major predictor of the clinical outcome . TherefoIn the present study we hypothesized that degree of RVD is coupled to the degree of LVD. This coupling will be less tight if the underlying disease process engage the RV myocardium. We excluded patients with myocarditis and infiltration disease, still, there is a possibility that the RVD observed in our patients to a degree that we cannot estimate, is caused by the underlying disease process involving both ventricles.Today RV free-wall strain is of many considered a better descriptor of RV function than TAPSE. Still, in the present study we chose TAPSE for mainly two reasons. Firstly, due to often occurring problems related to inclusion of the apical segment and the assessment of the quality of the tracking, the proportion of patients with 3-segment free-wall strain will be less than with TAPSE, that can be achieved in almost 100%. Secondly, free-wall strain is known to be vendor-dependent and, strictly, any proposed cut-off indicating RV dysfunction can only be used if the same vendor is used.In the present study assessment of RV size was based on 2D area and linear dimensions. It is well known that due to the complex RV anatomy, dilatation can pass unnoticed by echocardiography. Therefore, it is conceivable that future use of 3D based echocardiography can improve the detection of RV dilatation and allow assessment of RV ejection fraction .In the present study we found that a 5-point echocardiographic multiparameter RVD score identified patients with different LV hemodynamic severity profiles. This method outperformed the assessment offered by standard echocardiographic measurements. The RVD score, which is based on the pathophysiology of RV decompensation, is easily obtained from a standard echocardiographic examination. The standard echocardiographic assessment of LV filling pressure and cardiac out-put are hampered by a substantial number of false positives. In that context, in clinical practice, assessing the RV function using an easily obtainable multiparameter RVD score can give additional support for a patient being compensated (RVD score 0) and with increasing score increasing likelihood of decompensation or overt LVF.


Abnormalities of the mitral valve (MV) apparatus are typical features of hypertrophic cardiomyopathy (HCM). These abnormalities include leaflet elongation, thick leaflets, displacement of papillary muscle, and systolic anterior motion (SAM) of the MV anterior leaflet. Mitral valve chordal rupture associated with HCM is a rare but serious issue capable of change the clinical apparence and the prognosis of the patient.A 57-year-old lady with a history of diabetes, dyslipidemia, and a previous single episode of atrial fibrillation , presented to the Emergency Department for worsening dyspnea (New York Heart Association Classification class IV). A trans-thoracic echocardiogram (TTE) showed a significant, septal, and asymmetric left ventricular hypertrophy  with normal left ventricle systolic function. A SAM of AML was evident together with a left ventricular outflow tract gradient of 56 mmHg at rest, rising to 136 mmHg during the Valsalva maneuver. In addition, there was evidence of moderate to severe mitral regurgitation (MR) with an anteriorly directed jet, not very typical of MR related to SAM. A 2D-3D trans-esophageal echocardiogram (2D-3D TEE) revealed a combined MR mechanism based on PML degenerative prolapse with P2-flail from ruptured chordae with related eccentric anteriorly directed regurgitant jet, together with a second regurgitant posteriorly directed jet, related to SAM of AML. The patient underwent MV repair together with septal myectomy, with a good final outcome.Pre-operative echocardiography (both TTE and 2D-3D TEE) is an essential tool in order to detect different MV abnormalities in patients with HCM. These types of patients should never be treated by septal reduction alone. Surgical MV repair or replacement, together with septal myectomy, may be the preferred approach. Hypertrophic cardiomyopathy (HCM) is the most frequent monogenic cardiac disease, with a prevalence of almost 1 in 500 individuals . In abouIn almost 3% of cases, MR is the consequence of degenerative MV prolapse of the posterior mitral leaflet (PML). Of these, 19% of cases present an associated PML flail due to chordae tendineae rupture . The corA 57-year-old lady with a history of diabetes, thyroid disease, dyslipidemia, and an episode of atrial fibrillation, resolved with pharmacological cardioversion several years before, presented to the Emergency Department for worsening dyspnea (New York Heart Association Classification—NYHA: IV). Her medical therapy included levothyroxine once daily, dapagliflozin 10 mg once daily, metformin 1,000 mg twice daily, rosuvastatin 5 mg, and ezetimibe 10 mg every night. She had no prior heart failure admissions. Other symptoms included orthopnea and paroxysmal nocturnal dyspnea but no chest pain or syncopal episodes. Physical examination showed a pulse rate of 95 bpm, blood pressure of 140/70 mmHg, and 97% of peripheral oxygen saturation. Cardiac auscultation revealed a pansystolic murmur of 3/6 Levine grade over the apex as well as an ejection systolic murmur over the second intercostal space at the left sternal border. There were moderate bibasal lung crepitations and mild ankles edema. Intravenous furosemide was given with resolution of the lungs and ankles edema. Her electrocardiogram showed ectopic atrial rhythm, left anterior hemiblock as well as LV hypertrophy . LaboratA trans-thoracic echocardiogram showed a significant septal, asymmetric LV hypertrophy . Left and right ventricular systolic functions were normal. There was a clear SAM of the AML and an LVOT gradient of 56 mmHg at rest rising to 136 mmHg during the Valsalva maneuver . In addiSystolic anterior motion-dependent MR is a typical picture of the obstructive form of HCM. It is due to the narrowed LVOT producing a rapid acceleration of blood flow, inducing drag forces to attract the AML during mid and late systole. The result is a SAM of AML worsening LVOT gradient and an eccentric regurgitation jet, directed to the posterolateral wall of the left atrium , 6.Systolic anterior motion is distinguished in three grades of severity:•Mild: no contact between mitral leaflet and ventricular septum, with a minimum distance of 10 mm.•Moderate: mitral leaflet-septal contact <30% of systolic time.•Severe: mitral leaflet-septal contact >30% of the systole duration .The SAM can involve not only the mitral leaflet but also the chordae tendineae but usually, this condition alone is not able to produce a significant LVOT obstruction .Intrinsic abnormalities of MV apparatus, with or without the coexisting presence of LVOT obstruction, can lead to different kinds of MR.About half of patients with HCM present an abnormal elongation of MV leaflets . The firSub-valvular abnormalities usually involve papillary muscles which can be abnormal in position, number, and form in about 50% of patients with HCM.We may have several possibilities:a.Hypertrophy of papillary muscle heads.b.Higher number of papillary muscles (3–4 papillary muscles are present in more than 50% of HCM patients).c.Anterior and apically displaced papillary muscles. This alteration can shift the MV leaflets anteriorly, leading to chordal and leaflet laxity.d.Anomalous insertion of one or both heads of the anterolateral papillary muscle directly to the ventricular surface of the AML .Changes in size, shape, motion, and angulation of the MV annulus are less common but still possible in presence of LVOT obstruction and deviation of mitral-septal angle .Prevalence and pathophysiological mechanisms of MV chordal rupture in HCM are unknown. While a higher prevalence of chordal rupture (5.4%) has been reported in a small surgical series , a largeprimary phenotypic expression of HCM  can demonstrate MV abnormalities in patients with HCM. These patients should never be treated by septal reduction alone. Surgical MV repair or replacement, in association with septal myectomy, is the preferred approach .MM and AS: manuscript writing. GG and SD’A: literature searching and references setting. UI: table, figures, and video setting. VP: supervisor. All authors contributed to the article and approved the submitted version.


Moreover, 71 participants were recruited as the control group. These participants were examined by two-dimensional speckle tracking and three-dimensional echocardiography to obtain the right ventricular strain parameters, three-dimensional volume, and function parameters.P < 0.05), and the strain parameters in the concentric remodeling, eccentric hypertrophy, and concentric hypertrophy groups were lower than those in the control and normal geometric groups (P < 0.05). The right ventricular three-dimensional echocardiographic parameters only changed in the eccentric hypertrophy group (P < 0.05) and the concentric hypertrophy group (P < 0.05) in the form of an increase in volume and a decrease in function. Multivariate linear regression analysis showed that the right ventricular free wall longitudinal strain was independently associated with the systolic blood pressure (SBP), LVMI, and RWT (P < 0.05) and was primarily affected by the LVMI .The right ventricular strain parameters decreased gradually from the normal geometric group to the concentric hypertrophy group (The systolic function of the right ventricular myocardium declined in the elderly with essential hypertension due to impaired myocardial mechanics. The right ventricular strain parameters could indicate mechanical damage in the concentric remodeling group earlier than the right ventricular three-dimensional volume and function parameters. The right ventricular free wall longitudinal strain was primarily subject to the LVMI. Hypertension is a common chronic disease leading to end organ damage and is a factor in multiple cardiovascular complications, including stroke, coronary heart disease, and heart failure. The number of elderly patients with hypertension is increasing annually, with relatively high morbidity, disability, and mortality rates . Long-teThe left and right ventricles are anatomically enclosed within the same pericardial cavity (sharing the interventricular septum). They are wound by the same helical ventricular myocardial band; thus, they affect each other's structure and function . StudiesA total of 285 elderly patients diagnosed with essential hypertension in Shanxi Bethune Hospital from January to June 2017 were recruited for this study; 37 cases were excluded due to low-quality images, and the remaining 248 cases were included, comprising 122 males and 126 females aged 65–79 (68.46 ± 2.73) years. Another 71 elderly people with a corresponding age and gender distribution and without cardiovascular disease were recruited as the control group, comprising 32 males and 39 females aged 65–72 (68.34 ± 2.53) years. This study was approved by the medical ethics committee of the hospital (YXLL-2020-045). All subjects signed the informed consent form.The inclusion criteria were as follows: patients aged 65–79 years; patients whose blood pressure (measured three times across different days) showed a systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg without the use of antihypertensive drugs, and patients who received medical treatment to control blood pressure and were diagnosed as elderly with hypertension despite their blood pressure being less than 140/90 mmHg.The exclusion criteria were as follows: elderly patients suffering from secondary hypertension, pulmonary hypertension, history of stroke, dilated or hypertrophic cardiomyopathy, rheumatic heart disease, congenital heart disease, severe valvular heart disease, acute myocardial infarction or unstable angina pectoris, diabetes, and severe hepatic or renal diseases.The GE Vivid E9 color Doppler ultrasound , M5S transducer (1.5–4.5 MHz), 4V real-time three-dimensional cardiac volume transducer (1.5–4.5 MHz), and EchoPAC analysis software (version 203) were used.2, and BSA = 0.0061 × height + 0.0128 × weight – 0.1529. For the blood pressure measurement, each subject was allowed to sit down and wait for 15 min in the resting state; then, sphygmomanometry was performed to take three blood pressure readings at an interval of 3 min from the right upper arm, which was lifted to the level of the heart. Finally, the average of the three measures was calculated, and the SBP and DBP were recorded.The age, gender, heart rate, height, weight, and hypertension duration of the subjects were measured and recorded to calculate the body mass index (BMI) and body surface area (BSA) as follows: BMI = height(kg)/weight(m)3 – LVEDD3] + 0.6 g. The LVMI was corrected by the BSA as follows: LVMI = LVM/BSA. Finally, the RWT was calculated as follows: (2 × LVPWTd)/LVEDD. The left ventricular geometric patterns were divided into four categories by the LVMI and RWT: normal geometric , concentric remodeling , eccentric hypertrophy , and concentric hypertrophy .Echocardiography was performed on every subject. Each subject was instructed to take a left lateral position and breathe normally, and the echocardiogram machine was connected synchronously. Then, M-mode echocardiography was performed on the long-axis section of the left ventricle to obtain the interventricular septum end-diastolic thickness (IVSTd), left ventricular posterior wall end-diastolic thickness (LVPWTd), left ventricular end-diastolic diameter (LVEDD), and left ventricular end-systolic diameter (LVESD). The left ventricular ejection fraction (LVEF) was calculated using the biplane Simpson method from the apical four-chamber section. The above measurements were averaged across three cardiac cycles. The LVM was calculated with the formula specified in the American Society of Echocardiography (ASE) guidelines as follows: LVM = 0.8 × 1.04 × [(IVSTd + LVPWTd + LVEDD)2  and 115 g/m2 , and that for RWT is 0.42 (irrespective of gender).According to the ASE guidelines (2015) , the cutIn addition, each subject was instructed to hold their breath after exhaling, and two-dimensional gray-scale dynamic images (frame frequency: 60–120/s) were continuously collected from the apical four-chamber section throughout at least three cardiac cycles. These images were stored and analyzed offline to obtain the right ventricular strain parameters. Next, the 4V transducer was enabled, and the four-dimensional full volume function key was activated. The subject was instructed to hold their breath after exhaling, and full-volume images (frame frequency adjusted to 40% of the subject's heart rate) were continuously collected from the apical four-chamber section throughout 4–6 cardiac cycles. These images were stored and analyzed offline to obtain the right ventricular three-dimensional volume and function parameters.The image analysis was conducted in the EchoPAC workstation by importing each subject's two-dimensional gray-scale dynamic images, entering the Q-Analysis strain analysis program, and clicking “2D Strain” to trace when the right ventricular endocardial surface was clear. The software automatically generated the region of interest; the width and position were manually adjusted to adapt to the thickness of the myocardial wall and exclude the pericardium. Then, “Approve” was clicked to obtain the right ventricular free wall longitudinal strain peak and right interventricular septum longitudinal strain. Afterward, the right ventricular full-volume image of the subject was imported, and “4D Auto RVQ” was clicked to manually trace the right ventricular endocardium. The software automatically obtained the right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), RVEF, TAPSE, and right ventricular fractional area change.Twenty subjects were randomly selected for imaging. Two experienced doctors were assigned to analyze the images obtained in the abovementioned manner and measure and record the right ventricular free wall longitudinal strain and right interventricular septum longitudinal strain, thus carrying out the interobserver reproducibility study. Then, either of the doctors analyzed these data again after a week to carry out the intra-observer reproducibility study.t-test was used for multiple comparisons. Cases expressed the data, and the χ2 test was used for comparisons among groups. Univariate and multivariate linear regression analyses were applied to the correlation between right ventricular free wall longitudinal strain (RVFWLS) and clinical and echocardiographic parameters. A P-value < 0.05 indicated that the difference was statistically significant.Statistical software, SPSS 24.0, was used to analyze these data. The Kolmogorov–Smirnov test was used with these measurement data for the normality test. The normally distributed data were expressed as the mean ± standard deviation. The data among multiple groups were compared with a one-way analysis of variance (ANOVA), and the least significant difference (LSD)-P < 0.05). Compared with the normal geometric group, the SBP, DBP, and hypertension duration were increased in the eccentric hypertrophy and concentric hypertrophy groups, and the differences were statistically significant (P < 0.05). There was no significant difference in gender, age, BMI, or heart rate between the control and hypertension groups , and the differences were statistically significant .Compared with the other four groups, the LVEDD and LVESD were increased in the eccentric hypertrophy group; compared with the control, normal geometric, and concentric remodeling groups, the LVMI was increased in the eccentric hypertrophy group; the differences were statistically significant . The TAPSE of the concentric hypertrophy group was lower than that of the control and normal geometric groups, and the difference was statistically significant . The right ventricular free wall longitudinal strain and right interventricular septum longitudinal strain were not significantly different between the normal geometric group and control group (P > 0.05) but significantly decreased in the order of the normal geometric group, concentric remodeling group, eccentric hypertrophy group, and concentric hypertrophy group . There was no statistically significant linear relationship between the other variables and the right ventricular free wall longitudinal strain . That is, those three factors were independently correlated with the right ventricular free wall longitudinal strain, and the LVMI had the dominant influence on the longitudinal strain , followed by the SBP  and RWT , consistent with previous studies . This waCompared with the control and normal geometric groups, the RVEF and FAC were decreased in the eccentric hypertrophy and concentric hypertrophy groups, and TAPSE was decreased in the concentric hypertrophy group. This indicated that impaired right ventricular systolic function could be detected based on right ventricular function parameters in patients with hypertension with left ventricular hypertrophy. Hypertension may cause right ventricular dysfunction in the following way: First, overstimulation of the renin-angiotensin-aldosterone system and sympathetic nervous system produces vasoactive substances, oxidative stress, and endothelial dysfunction, which can induce accumulation of myocardial collagen and myocardial fibrosis, followed by remodeling of the left and right ventricles . At the In patients with hypertension, as the LVMI increases, the continuous right ventricular myocardial proliferation and hypertrophy result in right ventricular myocardial fibrosis, wall thickening, decreased deformability, and progressive mechanical damage of the right ventricular myocardium . Tadic eThe current study provides novel findings on the relationship between the right ventricular strain and the left ventricular geometric pattern. Compared with the concentric remodeling group, the right interventricular septum longitudinal strain and right ventricular free wall longitudinal strain increased in the control and normal geometric groups. That is, for the concentric remodeling group, the right ventricular longitudinal strain decreased when the volume and function parameters were still normal, indicating that the right ventricular myocardial mechanics of the patients with hypertension was impaired despite their normal TAPSE, FAC, and RVEF values. The right ventricular myocardium comprises subendocardial longitudinal muscle fibers and epicardial circumferential muscle fibers. Right ventricular ejection is primarily caused by contraction of the longitudinal muscle fibers, and the endocardium is more sensitive to pressure load and ischemia/hypoxia . Therefovia the helical muscle bundle, interventricular septum, and pericardium shared by the two ventricles, which increases with the LVMI . Therefore, clinicians should focus on the right ventricular function of patients with hypertension with abnormal left ventricular geometric patterns to identify subclinical right ventricular systolic dysfunction in the early stage, thus providing a basis for clinical treatment and prognosis.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committee of Shanxi Bethune Hospital. The patients/participants provided their written informed consent to participate in this study.CK, JX, and XK: conception and design of the research. JM, JX, and XK: acquisition of data. JM and QQ: analysis and interpretation of the data. XK and SL: statistical analysis. JX and QQ: writing of the manuscript. CK: critical revision of the manuscript for intellectual content. All authors read and approved the final draft.The 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Sports medicine is often involved in the evaluation of a wide population composed by active or less active individuals. The context of sports medicine assessment is recently moved from the high-level athletes toward general population. In many cases some specific aspects of the cardiac function need to be investigated in deep to exclude any eventual structural myocardial damage. Despite the first approach is usually the ECG exam, that is mandatory to obtain the eligibility, some additional evaluations are important. Among them, the echocardiographic exam represents the first non-invasive investigation after ECG evaluation. Trained athletes can show some “grey zone” of interpretation, due to cardiac morphological modifications induced by exercise . The decIn addition to the normal population of athletes, the emerging classes of athletes, such as subjects with previous cancer or transplants story, need to be studied using specific cardiac echographic parameters, either in the exercise prescription process, a a structured phyical activity program, or in the eligibility.Especially master athlete’s category can show various clinical condition, suggestive for coronary artery disease (CAD) or mild left ventricular hypertrophy (LVH), as well ST-T abnormalities particularly if associated with LBBB. Particularly this last ECG pattern, is important for sport medicine, as possible consequence of a structural cardiomyopathy, potentially related to an ischemic event. For this reason, master athletes, affected by LBBB are often investigated using echocardiography stress test. No data are now available about the effective impact of a regular sports activity in them, and an absolute contraindication does not exist among the principal recommendations.Another dubious condition is represented by QRS ECG fragmentation, which could be expression of a pathological substrate . It is nRegarding 2D echocardiography evaluation, some studies approached the population of patients with previous cancer using this non-invasive method. In order to evaluate pathological conditions, traditional 2D echocardiography, supported by strain analysis of cardiac chambers, has been applied in a specific trial . In partStrain is a dimensionless quantity that describes the deformation produced by stress and, in addition to ejection fraction, is a non-invasive method for assessment of myocardial function. It represents the percentage change in size compared to original length. The strain rate (SR) is also equivalent to the rate of deformation during time. Left ventricular twist movement is defined as the difference of rotation between the basal segment and the apical one calculated by spatial velocity gradient. All these parameters contribute to identify a normal LV functioning . More recently a new system has been created to complete the investigation of the myocardial performance by the vorticity blood flow study. It consists in the hyperdoppler echocardiographic method. This is a sort of eveolution of the echocardiographic investigation. The hyperdoppler method combines the strain analysis with colour image. It has highlighted the role and the importance of the intracardiac vortex and the intracardiac forces. Until now, the evaluation of intracardiac flows was a prerogative of the MRI . The echWe know that fiber orientation and function have been described as a major determinant of blood flow orientation in heart chambers playing an essential role in cardiac performance.This distribution generates important changes in blood flow direction and magnitude as it passes through the atria and ventricles. Multilayer cardiac magnetic resonance imaging (CMRI) can illustrate asymmetries and changes in the direction of flow through heart chambers redirecting the amount of blood flow to the next cavity. One such change in flow movement is the appearance of eddies, regions of major vorticity.Eddies are formed as follows: when blood flows through a tubular structure, central fluid layers move faster than those adjacent  creating eddies.When the boundaries disappear or expand abruptly (as in the case of systole and diastole), the stress created by the friction generates a swirling tendency of fluid’s peripheral layers that rotate away from the central jet.Some peculiar geometric and kinetic data of the myocardial chamber are obtained from the Hyperdoppler analysis application. Among them the shape and the movement of the principal vortex in the LV chamber, characterized by deep, length and intensity, are fundamental to distinguish a normal myocardial work from a condition in which heart is involved in a major energy dissipation. Other parameters are kinetic parameters such as vorticity (W), wall shear stress (WSS), relative strength (RS), energy dissipation index (DI), kinetic energy fluctuation (KEF), and vortex fluctuation. These could be considered, especially in sports medicine, important indicators for detecting and monitoring abnormalities in patient’s LV dysfunction. The acquistion is possible following the standard 2D echo imaging, following the American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations .Measures are acquired from 3 cardiac cycles in sinus rhythm or 5 in atrial fibrillation, using Doppler and 2D-mode modalities. Study by hyperdoppler starts with early diastolic filling  which leads to formation of a vortex. The presence of vorticities is recognized through flow-based visualization techniques using colordoppler mapping . In firsIn a healthy heart the left ventricle works producing an intraventricular flow pattern to minimize the energy dissipation. Instead in case of abnormal vorticities the transfer in blood flow can increase energy consumption during ejection. The eventual differences can clarify the eventual incorrect situations where the heart woks in a not adequate situation and therefore with high level of energy lost. Strain analisys is recently largely included in the evaluation of athletes especially in case of previous pathological conditions, where the exclusion of cardiotoxicity or reduced contractile function is determinant to plan a physical activity program. The hyperdoppler is a novel ultrasonic biomechanics method based on the integration of both, LV vortex and wall motion, to fully assess and understand the LV structure and function.The hypothesis is to propose a large use of the hyperdoppler in combination with myocardial deformation study, especially in those subjects where there is a doubt of a cardiomyopathy, despite not evident. The method has a high reproducibility despite not completely compared among the software available. Some research proposed the hyperdoppler in the investigation of the dissincronicity of the myocardial function. As recently shown a large clinical application of this method is possible both in healthy people, athletes and pathological clinical situations ,13. Cons


Combined cases of hypertrophic obstructive cardiomyopathy (HOCM) and pulmonary arterial hypertension (PAH) are rare and have a management dilemma. Although preload is crucial in the management of HOCM, anti-PAH agents dramatically change the preload, leading to improving or worsening heart failure in patients with HOCM. We had a 74-year-old woman with Sjogren-syndrome-associated PAH. Her heart failure worsened following the initiation of anti-PAH agents due to an incremental preload on the left ventricle, whereas HOCM clinically developed following the termination of anti-PAH agents and progressing anorexia due to the progression of the left ventricular outflow obstruction. Careful monitoring of the left ventricular outflow obstruction during initiation/termination of anti-PAH agents and medical intervention to the HOCM are highly recommended. Combined cases of hypertrophic obstructive cardiomyopathy (HOCM) and pulmonary arterial hypertension (PAH) are rare and have a management dilemma . An apprWe had a patient with Sjogren-syndrome-associated PAH. The initiation of anti-PAH agents worsened her heart failure. Clinical symptoms and signs of HOCM developed following the termination of anti-PAH agents. We struggled to diagnose the cause of the heart failure during anti-PAH-agent treatment and how to manage these comorbidities that required opposite treatments.2). Computed tomography of the chest, ventilation-perfusion scintigraphy, and pulmonary arteriography found no abnormalities. She was diagnosed with Sjogren syndrome due to her symptoms of dry eye and dry mouth, the existence of anti Ro/SSa antibody and impaired salivary gland function. However, she had a previous history of steroid-associated necrosis of the talus. Thus, she initiated sildenafil 60 mg/day to treat her PAH, instead of steroids.We present here a 74-year-old woman. Eleven years ago, the patient was diagnosed with PAH according to the results of the right heart catheterization: elevated mean pulmonary arterial pressure (34 mmHg) and pulmonary vascular resistance (4.1 Wood units), normal pulmonary arterial wedge pressure (15 mmHg), and preserved cardiac output/cardiac index , and her body weight was 42.4 kg. The mid-systolic murmur was heard at the left sternal border, not radiating to the neck. She had no peripheral edema. The plasma B-type natriuretic peptide level was 1641 pg/mL and serum creatinine level was 2.35 mg/dL.A chest X-ray showed slight cardiomegaly without the bilateral pleural effusions and congestion. Electrocardiography showed sinus rhythm and a negative T wave in I, II, aVF, and V3–6. Transthoracic echocardiography displayed 50 mm of the left atrial diameter, 15 mm of the interventricular septal, 14 mm of the posterior wall of left ventricle, 40 mm of the left ventricular end-diastolic diameter, and 79% of the left ventricular ejection fraction. The trans-mitral flow pattern had an impaired relaxation, with an E/A ratio of <1.0 and the existence of an L-wave. The inferior vena cava was collapsed and the estimated right atrial pressure was <3 mmHg. Of note is that the left ventricular outflow tract obstruction and moderate mitral regurgitation due to systolic anterior motion of the mitral valve were observed.Given all together, we suspected the physiology of hypertrophic obstructive cardiomyopathy (HOCM), which was manifested by a decline in preload on the left ventricle by the termination of anti-PAH agents, and continued diuretics despite the progression of anorexia. We terminated diuretics and initiated intravenous fluid supplementation.2 of cardiac index. The left ventricular end-diastolic pressure was 23 mmHg. The left ventricular pressure gradient was 56 mmHg at rest (Right heart catheterization showed 42/14/26 mmHg of pulmonary artery pressure, 7 mmHg of mean right atrial pressure, 10 mmHg of pulmonary artery wedge pressure, and 2.9 L/min/m at rest A. The Br at rest B. An endFollowing the initiation of cibenzoline succinate 50 mg/day, she was discharged on day 15. At one month following the index discharge, the left ventricular outflow tract obstruction and mitral regurgitation due to systolic anterior motion of the mitral valve disappeared B. AlthouSjogren-syndrome-associated PAH has rarely been reported thus far, whereas several studies reported PAH induced by other collagen diseases ,5. DetaiA therapeutic strategy has not yet been established for this syndrome, but immunosuppressive agents are empirically utilized . Given tThe degree of preload is crucial for the management of HOCM. In general, aggressive dehydration is contraindicated in this cohort. Such an intervention facilitates the outflow obstruction and reduces the cardiac output. On the contrary, excessive volume loading increases intra-cardiac pressure and further impairs the cardiac diastolic function . Anti-PAIn our patient with potential diastolic dysfunction, the initiation of anti-PAH agents increased the forward flow toward the left ventricle and induced congestive heart failure. On the contrary, termination of multiple anti-PAH agents and progressive anorexia, as well as ongoing diuretics, dramatically reduced preload on the left ventricle and manifested the left ventricular outflow obstruction, resulting in the clinical diagnosis of HOCM.In patients with potential diastolic dysfunction, irrespective of the definite diagnosis of HOCM, it may be recommended to monitor the degree of the left ventricular outflow obstruction during titration/termination of anti-PAH agents. Drastic changes in the preload might manifest occult HOCM. Instead, an appropriate adjustment of preload, using the right heart catheterization and aggressive therapeutic intervention to HOCM, should be prioritized using beta-blockers and cibenzoline, which are effective for reducing the pressure gradient at both rest and during exercise, not through the change of preload and afterload, but through the decreased contraction force, as we did.For symptomatic drug-resistant HOCM patients, septal reduction therapy should be aggressively considered. Generally, in younger patients, surgical intervention would be preferable. Alcohol septal ablation is alternative in older patients or those with severe PAH. Stabilization of heart failure might improve pulmonary congestion and decrease pulmonary artery pressure . Anti-PAWe reported combined case of HOCM and Sjogren-syndrome-associated PAH. The aggressive therapeutic intervention to HOCM should be prioritized in those patients.


We found a positive correlation  between total scar burden (TSB) on CMR and LV GLS. After 6 months of follow-up, GLS showed marked improvements in myocarditis patients on optimal medical therapy (p < 0.01). Furthermore, we showed a strong association between baseline GLS, left ventricular ejection fraction (LVEF) and TSB with LVEF at 6 months of follow-up. After a multivariable linear regression analysis, baseline GLS, LVEF and TSB were independent predictors of a functional outcome at follow-up (p < 0.0001). Cardiac function and myocardial longitudinal deformation, assessed by echocardiography, are associated with TSB at CMR and have a predictive value of functional recovery in the follow-up.SARS-CoV2 infection, responsible for the COVID-19 disease, can determine cardiac as well as respiratory injury. In COVID patients, viral myocarditis can represent an important cause of myocardial damage. Clinical presentation of myocarditis is heterogeneous. Furthermore, the full diagnostic algorithm can be hindered by logistical difficulties related to the transportation of COVID-19 patients in a critical condition to the radiology department. Our aim was to study longitudinal systolic cardiac function in patients with COVID-19-related myocarditis with echocardiography and to compare these findings with cardiac magnetic resonance (CMR) results. Patients with confirmed acute myocarditis and age- and gender-matched healthy controls were enrolled. Both patients with COVID-19-related myocarditis and healthy controls underwent standard transthoracic echocardiography and speckle-tracking analysis at the moment of admission and after 6 months of follow-up. The data of 55 patients with myocarditis  and 55 healthy subjects were analyzed. The myocarditis group showed a significantly reduced global longitudinal strain (GLS) and sub-epicardial strain, compared to the control ( Coronavirus disease 2019 (COVID-19) was first noticed at the end of 2019 as several isolated cases of pneumonia in China . Blood samples were picked up to evaluate inflammatory indices and enzymatic markers of myocardial necrosis.The study protocol involved a complete 2D echocardiography and STE analysis, performed with a Vivid E80 Ultrasound Machine and an M5Sc transducer  at admission and after 6 months of optimal medical therapy (OMT). Echocardiographic images were analyzed offline, blinded to patient data, using a specific software .Left ventricular (LV) cardiac diameters (end-diastolic and end-systolic) and thicknesses, LV systolic and diastolic function were assessed, according to American and European recommendations ,8. LV ejFor the STE analysis, the cine-loop clips were acquired from four-chamber, three-chamber and two-chamber apical views and analyzed offline. The peak systolic longitudinal strain was examined in all 17 LV segments and then the global longitudinal strain (GLS) was extrapolated from segmental values. The 2D strain of subendocardial, median wall and sub-epicardial regions of the myocardium were also calculated.Cardiac magnetic resonance (CMR) was performed within 14 days of hospital admission with a 1.5 Tesla MRI Scanner . The protocol of imaging was based on T2-weighted sequences to identify myocardial edema , on early gadolinium enhancement (EGE) in T1-weighted images to identify myocardial hyperemia , and on late gadolinium enhancement (LGE) in T1-weighted images to identify necrosis or fibrosis . The localization of LGE was represented through the 17-segment standard LV model . The degThe diagnosis of acute myocarditis was based on the latest Lake Louise consensus criteria .Descriptive statistics were performed: frequency and percentage were reported for the categorical variables; mean and standard deviation (SD) were used to summarize continuous variables.t-tests to study differences intra-group and between groups. To evaluate univariable relations, linear regression analyses and Pearson’s correlation test were used. Multivariable linear regression analysis was performed to investigate parameters independently associated with functional recovery at FU.Continuous variables were compared using paired and unpaired p value < 0.01. To select optimal cut-off values of strain measurements, a receiver operating characteristic (ROC) curve analysis was evaluated. Intra-observer and inter-observer variability were evaluated with the coefficient of variation (COV), defined as the ratio of the standard deviation (σ) to the mean (μ) (%), and by Bland–Altman analysis. CV, 95% confidence intervals (CIs) and percent errors were reported. Statistical analyses were performed by SPSS for Windows release 21.0 .Parameters included in the multivariable analysis, with a stepwise backward elimination method, were: age, sex, BMI, mean blood pressure, LV diameters, LVEF, Doppler mitral inflow measurements, LA volume, strain measurements (LVGLS) and cardiac CMR indexes. The statistical significance was defined as two-sided Data from 55 patients with COVID-related acute myocarditis (mean age 46.4 ± 15.3 years) and 55 age- and gender-matched healthy controls (mean age 45.5 ± 16.7 years) were analyzed. Baseline clinical features and echocardiographic data of the overall population are reported in p < 0.001). Furthermore, left atrial volume index, average E/e’ ratio, pulmonary artery systolic pressure and LV dimensions were significantly increased in the myocarditis group.The myocarditis group showed LVEF, SV and CO were significantly reduced compared with control group   . Layer-sAll patients with myocarditis had myocardial edema at CMR, and myocardial hyperemia was found in 88.3% of patients . LGE wasp < 0.01) and a stronger positive correlation between TSB and baseline LVGLS  were discovered at bivariate correlation analysis. Scatter plots of these correlations are respectively shown in A negative correlation between TSB and baseline LVEF , GLS  and TBS  were correlated to LVEF at 6 months of FU .Segmental peak systolic strain was significantly impaired in segments with LGE on CMR  ,12. OverThe exact pathogenetic mechanism of myocarditis in COVID-19 patients is not widely known, but direct viral damage or cell-mediated cytotoxicity are possible mechanisms hypothesized to be involved . A propoThe clinical presentation ranges from paucisymptomatic forms, to forms with acute coronary syndrome-like manifestations, to forms with a prevalent arrhythmic component and to cases of acute heart failure or cardiogenic shock. The highly variable clinical presentation and sometimes the difficulty related to the transport of patients in a critical condition to the radiology department make diagnosis challenging.Although EMB is the diagnostic gold standard, it is indicated only in life-threatening conditions in which histological and immunohistochemical characterization (IHC) can influence therapeutic approach.Conversely, in the setting of stable patients, CMR is the primary diagnostic exam for the diagnosis of acute myocarditis on the base of Lake Louise criteria . The scar, identified with LGE, shows a distribution within the myocardial wall with a tendency to exclude the sub-endocardial region, giving us the possibility to distinguish this pattern from ischemia-related damage . It has been widely demonstrated that CMR scar has a strong prognostic value, according to several studies that showed a correlation with the risk of major adverse cardiovascular events (MACE) and cardiovascular death ,16.Recently, several studies have underlined the role of STE in the diagnosis of myocarditis, demonstrating how the reduction of longitudinal strain correlates with areas of LGE at CMR assessment ,18,19,20The results of this study confirmed the role of speckle-tracking echocardiography in predicting scar burden, detected by CMR, even in the setting of COVID-19-related myocarditis.GLS in patients with COVID-19-related myocarditis appears to be impaired if compared to the control group or to the reference values described in the literature ,22.The reduction of longitudinal strain shows a layer-specific distribution. In particular, the tendency to preserve the sub-endocardial layer gives us the possibility to exclude ischemic injury. As a result, STE may also represent an important tool for differential diagnosis, especially in the case of myocarditis starting with an acute coronary syndrome-like presentation .Of note, longitudinal strain correlates with scar in CMR more accurately than LVEF evaluated with the Simpson’s biplane method, confirming that STE has a greater sensitivity and is capable of detecting subclinical systolic dysfunction . GLS impCompared to CMR, echocardiography allows us to carry out a bedside diagnostic and prognostic assessment in order to overcome difficulties related to transport of COVID-19 patients who are in critical conditions.Our study has some limitations. First of all, the small sample size hinders the possibility to carry out precise assessments of the role of STE in COVID-19-related myocarditis.Furthermore, there are intrinsic limitations of STE method. In particular STE depends on the frame rate. If the frame rate is too low, speckle tracking varies greatly from frame to frame, hampering precise characterization of myocardial deformation and systolic LV function. On the other hand, as the frame rate increases, there is a loss of spatial resolution.Furthermore, the reduction of longitudinal strain may also be due to the increased wall stress in the acute setting since the strain is greatly influenced by hemodynamic conditions: preload and afterload. Finally, in the cases of mechanical ventilation, the acoustic window may not have been optimal to acquire images suitable for STE assessment. In fact, patients with high acoustic impedance of chest wall were excluded from the present study.Previous studies identified STE as an important diagnostic tool in acute myocarditis. Our study confirmed that in the setting of COVID-19-related myocarditis, STE parameters are also surrogate markers of fibrosis replacement, evaluated by LGE at CMR. As a result, STE could play an important role in the prognostic assessment allowing a bedside risk stratification of COVID-19-related myocarditis.


In conclusion, hyperprolactinemia in humans may be associated with a slight impairment of diastolic function, with an overt diastolic dysfunction in a subgroup of females which correlated with poorer exercise performance, in the absence of significant abnormalities of LV structure and systolic function.Despite the myocardial prolactin (PRL) binding activity and the known effect of enhancing contractility in the isolated rat heart, little information is available concerning the cardiovascular consequences of hyperprolactinemia in humans. To elucidate the effects of chronic hyperprolactinemia on cardiac structure and function, twenty-four patients with isolated PRL-secreting adenoma and twenty-four controls underwent a complete mono- and two-dimensional Doppler-echocardiography. Blood pressure and heart rate were similar in the two groups, and no significant differences were observed as to left ventricular (LV) geometry between patients and controls. Resting LV systolic function was normal in patients with hyperprolactinemia, as shown by similar values of fractional shortening and cardiac output. Conversely, hyperprolactinemic patients exhibited a slight impairment of LV diastolic filling, as demonstrated by the prolongation of the isovolumetric relaxation time and the increase of the atrial filling wave of mitral Doppler velocimetry (58 ± 13 vs. 47 ± 8 cm/s,  Stimulation of lactation is classically described as the most relevant biological action of prolactin (PRL) . HoweverThe demonstration of PRL binding sites by means of various techniques in both ventricular and atrial tissues provides a solid background to the hypothesis of a direct cardiovascular effect of PRL ,6. In myTwenty-four patients , with isolated PRL-secreting adenoma, were enrolled at Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II” from June 2021 to September 2022, after their informed consent was obtained. The diagnosis was based on the presence of plasma prolactin levels of at least 100 ng per ml and CT scan showing a pituitary adenoma. Eight out of 24 patients showed a macroadenoma. The average PRL concentration was calculated on the basis of 6-h time course with hourly sampling. Mean serum PRL concentration was 678 ± 996 ng/mL. Routine clinical and hormonal evaluations showed no evidence of any other pituitary hypersecretion and/or deficiency. None of the patients were treated with sexual steroids or bromocriptine before entering the study. Cardiac disease including systemic hypertension or coronary artery disease was excluded in all patients and all known cardiovascular risk factors were equally distributed in the two study groups.Patients and control subjects underwent a standard 12-lead electrocardiogram and a complete mono- and two-dimensional Doppler-echocardiographic study. Complete M-mode and two-dimensional analyses were performed using an ultrasound mechanical system equipped with 3.5 mHz transducer . M-mode and two-dimensional recordings were made with the subjects in a lateral recumbent position according to the standardizations of the American Society of Echocardiography . LV mass2, and peak TR velocity > 2.8 m/s. Diastolic function was established as follows: normal diastolic function with no or one abnormal parameters; undetermined diastolic function with two abnormal parameters; diastolic dysfunction with three or four parameters. A six-minute walking distance (6-MWD) test was obtained for all participants.Doppler tracings were obtained during quiet respiration with the transducer positioned at the cardiac apical impulse and oriented to obtain an apical four-chamber view. The Doppler beam was aligned parallel to the presumed mitral inflow. The sample volume was placed at the inflow area of the left ventricle just below the mitral valve annulus, and its position was optimized to obtain maximal diastolic flow velocities and a better-defined Doppler waveform. The time interval from aortic valve closure to the onset of mitral early diastolic flow or isovolumic relaxation time (IRT) was determined as index of LV filling by simultaneous recording of the aortic and mitral flow by continuous-wave Doppler. Tissue Doppler was used to determine e′ at lateral and septal basal segments of LV. Left ventricular diastolic function was evaluated as recently recommended . In our Serum PRL levels were assessed by RIA using commercial kits . The intra- and inter-assay coefficients of variation for PRL were 5% and 7%, respectively. The normal range was below 20 ng/mL. Serum estradiol levels were assessed by RIA using commercial kits . The intra- and inter-assay coefficients of variation for estrogen were 3.5% and 4.8%, respectively. In females, the normal range was 25–100 pg/mL during the follicular phase; in males, the normal range was 15–60 pg/mL. Serum progesterone levels were assessed by RIA using commercial kits . The intra- and inter-assay coefficients of variation for progesterone were 7% and 9%, respectively. In females, the normal range was 0.2–1.0 ng/mL during the follicular phase; in males, the normal range was 0.2–0.8 ng/mL. Serum FSH levels were assessed by IRMA using commercial kits . The intra- and inter-assay coefficients of variation for FSH were 4.7% and 7.4%, respectively. The normal range was 3–11 U/mL in females during the follicular phase and 1.5–7 U/mL in males. Serum LH levels were assessed by IRMA using commercial kits . The intra- and inter-assay coefficients of variation for LH were 1.8% and 4.8%, respectively. The normal range was 0.5–12 U/mL in females during the follicular phase and 1.1–11.7 U/mL in males. Serum androstenedione levels were assessed by RIA using commercial kits . The intra- and inter-assay coefficients of variation for androstenedione were 5% and 8%, respectively. The normal range was 1.2–2.5 ng/mL.n. 245/21).The study protocol was approved by the Ethics Committee of the Federico II University of Naples ; the end-diastolic dimension (mm) was 48 ± 3 vs. 48 ± 2 (p = NS); the end-systolic dimension (mm) was 29 ± 3 vs. 29 ± 3 (p = NS); there was a slight, but not significant, increase of left atrial anteroposterior diameter and indexes volume in the PRL group. LV systolic function was not altered in chronic PRL excess, as shown by similar values of ejection phase indexes between the two study groups (LV ejection fraction (%): 61 ± 3 vs. 62 ± 2, p = NS; FS: 39 ± 5 vs. 39 ± 5, p = NS; CO (L/min): 5.5 ± 10 vs. 5.3 ± 1, p = NS). On the contrary, the two groups displayed a significant difference in the LV diastolic filling pattern with mitral Doppler velocimetry in PRL groups showing an increased A wave (cm/sec) , which represents the atrial contribution to LV filling. Consequently, the early-to-late filling velocity (E/A) ratio was lower in the PRL group  suggesting an early impairment of LV relaxation pattern (p < 0.05). A more pronounced reduction of 6-MWD was observed in PRL individuals with diastolic dysfunction compared with those showing normal or undetermined function , which was about 26% lower than mean 6-MWD in controls.In particular, LV mass (g) was 163 ± 52 vs. 169 ± 39  underlying the impaired diastolic filling in hyperprolactinemia. It is possible that PRL excess per se impairs relaxation by interfering with the rates of Ca++ sequestration by the sarcoplasmic reticulum, possibly reducing ATP disposal. Alternatively, indirect mechanisms might be at play, such as the hypoestrogenism induced by hyperprolactinemia. It is well accepted that estrogens target the cardiovascular system also independently of the known effects on lipid metabolism and have significant impacts on diastolic function. Long-term estrogen deprivation alters LV filling and function and decreases cardiac myosin ATPase activity in adult rats . ConversThe clinical relevance of an impaired diastolic function in hyperprolactinemic humans is unclear. For example, it is of interest to see whether more overt signs of cardiac involvement appear later during the disease course. Further longitudinal evaluation is needed to clarify this issue and to assess the efficacy of therapeutic interventions on the reversal of cardiac abnormalities in hyperprolactinemia.


Takotsubo syndrome (TTS) describes an acute and transient left ventricular (LV) dysfunction that, although not obligatory, is many times associated with an underlying emotional, physical, or combined trigger. We describe a rare case of an 80-year-old female who developed TTS after pacemaker implantation in the context of a complete atrioventricular block (CAVB). During the patient's workup, right ventricular (RV) lead dislodgment was found. She developed acute heart failure symptoms 12 hours after device implantation with transthoracic echocardiogram showing de novo severe systolic biventricular dysfunction with dyskinesia of the apical segments and hyperdynamic contractility of the basal segments of both ventricles. Coronarography was normal, and left ventriculography demonstrated apical ballooning. TTS was then considered the most probable diagnosis. The patient received supportive care with diuretics, beta-blocker, and angiotensin-converting enzyme inhibitor (ACEI); an RV lead repositioning was also done. After four weeks, left ventricular function had fully recovered, confirming the diagnosis. This is a rare case of a post-pacemaker implantation TTS with concomitant lead dislodgment that can be assumed as a likely contributing factor. This report emphasizes that, although rare, TTS should be considered in the differential diagnosis of patients with acute heart failure development after pacemaker implantation. Takotsubo syndrome (TTS) describes an acute and transient left ventricular (LV) dysfunction that, although not obligatory, is many times associated with an underlying emotional, physical, or combined trigger. While the exact mechanism of TTS remains unknown, it is hypothesized that it can result from an excess of circulatory catecholamines secondary to an exaggerated sympathetic response to a stressor . PatientComplications related to pacemaker implantation are relatively common, occurring in a total of 5.3% of the patients in the first six months post-procedure . On the An 80-year-old female, with known hypertension and dyslipidemia treated with amlodipine 5 mg once daily (od) and rosuvastatin 10 mg od, presented to the emergency department complaining of extreme fatigue that started a week before. There was no history of syncope, and she wasn't on any anti-arrhythmic drugs. On examination, the patient was hemodynamically stable, bradycardic, and eupneic; physical examination was unremarkable. Electrocardiogram (ECG) revealed complete atrioventricular block (CAVB) with ventricular escape rhythm at 33 beats per minute (bpm)  1188 pg/mL), including no hydroelectrolytic abnormalities. Chest X-ray had no significant alterations. Transthoracic echocardiography (TTE) revealed no dilation of cardiac chambers, good biventricular systolic function, and no changes in segmental contractility of the LV  of 416 ms. A TTE was performed showing diffuse hypokinesia of the mid and distal segments of the LV and the RV free wall, as well as evident hyperkinesia of the basal segments of both ventricles. LV systolic function was severely reduced with an LV ejection fraction of 20% , BNP of 3550 pg/mL, and D-dimers of 2800 ng/mL. Given the elevation of the latter and the new RV dysfunction, a CT scan was performed, which showed no signs of pulmonary embolism but, instead, revealed dislodgment of the ventricular electrocatheter that was inserted at the RV free wall with no extravasation of contrast to the pericardial space (Figure A pacemaker check was performed, revealing elevation of both threshold and sensing ventricular values; there were no records of capture failure from the ventricular lead, with the patient having 100% of RV pacing since device implantation. Lead repositioning was then executed. Coronary angiography was performed on the next day showing no coronary stenosis Figure , and lefTTS was assumed as the most probable diagnosis. Accordingly, the patient was treated with beta-blocker, angiotensin-converting enzyme inhibitor, and diuretics. She was discharged on bisoprolol 2.5 mg once daily and ramipril 10 mg once daily. A follow-up TTE at one month after discharge revealed an LV ejection fraction of 54% and resolution of regional wall motion abnormalities (Video Available reports in the literature regarding post-pacemaker TTS between 2006 and 2022 Table  show thaIn our case, given the hemodynamic stability of our patient, there was no need for the use of catecholamines before device implantation; additionally, there were no echocardiographic significant alterations at admission, and the patient evolved with heart failure symptoms only several hours after device implantation. Although it's not possible to exclude its contribution, this makes CAVB per se a less likely cause to the development of TTS. Consequently, the ventricular lead dislodgment seems to prevail as a relevant underlying stressor to take into consideration, which makes it a unique case. Different underlying pathophysiological mechanisms can be hypothesized such as myocardial inflammation due to partial perforation of the RV free wall or the marked LV dyssynchrony induced by improper positioning of the RV lead.In conclusion, our case report emphasizes that TTS, although rare, should be considered a potential complication of pacemaker implantation in patients evolving with symptoms of acute heart failure. A correct diagnosis is important to promptly identify potential associated complications such as LV outflow obstruction and severe arrythmias and proceed with adequate treatment. The rarity of this entity in this context and the possibility of its typical ECG changes being masked by ventricular pacing rhythm may preclude an early recognition making the diagnosis difficult and dependent on a high clinical suspicion. In these cases, lead dislodgment can be an underlying trigger and should be considered.


P > 0.05). The consistency analysis revealed that the aVTIs in the SAV, PAV, and VV intervals presented a good consistency (P < 0.01), which were obtained by the echocardiography and QuickOpt functional optimization; the concordance correlation coefficient (CCC) in them was 96.16%, 98.03%, and 95.48%, respectively. The left ventricular ejection fraction (LVEF) showed an increasing trend over time in both groups, while the left ventricular end systolic volume (LVESV), left ventricular end diastolic volume (LVEDV), and morphological right ventricle (MRV) showed the downward trends over time, and the differences between two groups were not significant (P > 0.05). For the premature ventricular contraction (PVC) of ventricular arrhythmia episodes, there was no significant difference between the two groups in log (PVCs) and log (PVC runs) (P > 0.05). It was also found that both echocardiography and QuickOpt algorithm could improve the cardiac function of patients with heart failure significantly and reduce ventricular arrhythmia episodes and ventricular remodeling via optimized CRT; there was no difference in the improvement effect of the two optimization methods. However, echocardiography was inferior to QuickOpt algorithm in terms of time-consuming optimization in the intervals. This provided a reference for the clinical diagnosis and treatment of elderly patients with heart failure.This research was aimed at analyzing the application value of echocardiography and QuickOpt algorithm in optimizing parameters of cardiac resynchronization therapy (CRT) in elderly patients with heart failure. 50 elderly patients who were diagnosed with chronic heart failure and underwent CRT were chosen as the research objects. According to the different optimization methods, the patients were divided into the echocardiography group and QuickOpt algorithm group, 25 cases in each group. The general data, optimized intervals, corresponding maximum aortic velocity time integrals (aVTIs), cardiac ultrasound indicators, and ventricular arrhythmia episodes of the patients in the two groups were analyzed. The results showed that there was no significant difference in the optimized sensed atrioventricular (SAV), paced atrioventricular (PAV), and ventricle to ventricle (VV) intervals and the corresponding aVTIs obtained by echocardiography and QuickOpt ( Heart failure refers to the syndrome dominated by circulatory dysfunction, which caused by that the myocardial diastolic and/or systolic dysfunction and insufficient cardiac output cannot maintain tissue metabolism with moderate venous return –3. In clClinically, physical examinations are generally used to find signs of heart failure in patients. In addition, there are troponin, electrocardiogram, echocardiography, X-ray examination, cardiac magnetic resonance, cardiopulmonary exercise test, etc., –14 can bFifty elderly patients who were diagnosed with chronic heart failure and underwent CRT in hospital from October 2019 to February 2021 were chosen as the research objects. With different optimization methods, they were divided into the echocardiography group and QuickOpt algorithm group of 25 patients in each. This study had been approved by ethics committee of hospital, and the patients and their families signed the informed consents.−1, complete atrioventricular block, mental illness, or allergic constitution were excluded.The included patients must suffer from the refractory congestive heart failure, and the left ventricular end-diastolic inner diameter was greater than or equal to 55 mm. The surface electrocardiogram result was greater than 120 ms under QRS wave complex, and the left ventricular ejection fraction (LVEF) was less than 35%. What is more, they got a successful CRT. Patients with persistent atrial fibrillation, an autonomous heart rate of less than 40 f/minDigital color Doppler ultrasound diagnostic apparatus with 3.5 mHz probe was applied in this study. The left ventricular end systolic volume (LVESV), left ventricular end diastolic volume (LVEDV), and morphological right ventricle (MRV) were measured through Simpson method, and the LVEF was also calculated.−1, which was greater than the autonomous heart rate. As the PAV interval was 210, 190, 170, 150, 130, and 110 ms, respectively, the optimized PAV intervals and the corresponding aVTIs were worked out. For the VV interval optimization, the pacing heart rate was set less than the autonomous heart rate, and the VV interval was set as 70, 50, 30, and 10 ms, respectively, in the left ventricle and 10, 30, 50, and 70 ms, respectively, in the right ventricle. With the optimized SAV intervals obtained, the optimized VV intervals and its corresponding aVTIs were worked out.Data collection was done by the same physician, and the optimizations of sensed atrioventricular (SAV), paced atrioventricular (PAV), and ventricle to ventricle (VV) intervals were carried out. For the SAV interval optimization, the pacing heart rate was set to be less than the autonomous heart rate; then, when the SAV interval was 160, 140, 120, 100, 80, and 60 ms, respectively, the optimized SAV intervals and the maximum aortic blood flow velocity integrals (aVTIs) were obtained. For the PAV interval optimization, the pacing heart rate was set as about 5-10 f/minIn the programmed state, the QuickOpt  was usedThe general preoperative information of patients was collected, including the age, gender, underlying diseases of heart failure, hypertension and other concomitant diseases, blood creatinine, and drug treatment plan. The cardiac function classification of New York Heart Association, QRS duration, and echocardiogram indicators were recorded before and after surgery. In the follow-ups, the patients were readmitted to hospital for heart failure or all-cause deaths and medication regimens were also recorded.During the postoperative outpatient follow-ups, the ventricular arrhythmia data saved by the pulse generator was recorded at each follow-up, including the number of premature ventricular contractions (PVCs) and premature ventricular contraction runs (PVC runs). PVC is defined as any ventricular sensing episodes in the refractory and nonrefractory period, which were not accompanied by atrial episodes of pacing, refractory sensing, and nonrefractory sensing before ventricular episodes of pacing, refractory sensing, and nonrefractory sensing. PVC runs are defined as two or more consecutive PVCs that are not accompanied by atrial episodes. The total numbers of PVCs and PVC runs were accumulated, respectively, and divided by the number of follow-up days to obtain the average numbers per day, which was regarded as the number of middle ventricular arrhythmia episodes within six months after the surgery.P < 0.05.The data processing was performed by SPSS19.0 in this study. The measurement data was expressed by the mean ± standard deviation (As shown in P > 0.05). The compared general data included the age, male proportion, and history of diabetes; the postoperative medications included diuretics, digoxin, angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARB), and β-receptor blockers; the ultrasound indicators were LVEF, LVESV, LVEDV, and QRS duration (QRSd).As shown in −1. From the echocardiograms, the LVEF was 50%, the left ventricular end-diastolic inner diameter was 6.6 cm, and there was no obvious valve abnormality.P > 0.05).In P > 0.05). The consistency analysis showed that the aVTIs of the SAV, PAV, and VV intervals obtained by the echocardiographic optimization and the QuickOpt functional optimization had good consistency (P < 0.01), and the CCC was 96.16%, 98.03%, and 95.48%, respectively.In P < 0.05).As shown in P > 0.05). The LVESV, LVEDV, and MRV of patients in the echocardiography group and the QuickOpt algorithm group 1, 3, and 6 months after surgery showed a downward trend over time, but still, there was not a statistically significant difference between two groups (P > 0.05).It is shown in P > 0.05).In log (PVCs) and log (PVC runs) of patients' ventricular arrhythmia episodes between the two groups were not statistically significant (P > 0.05).P > 0.05). Such consistencies of general information provided the feasibility for follow-up research. Besides, the echocardiographic data of some cases were shown in this study, and it could be observed that echocardiography showed the changes in ventricular functions of patients with heart failure clearly, pointing out the patients' condition of heart failure and providing help for the evaluation of clinical treatment [Heart failure is the most important cause of death from cardiovascular diseases. It is not an independent disease, but a common end for multiple cardiac diseases. In clinical practice, CRT is used to treat heart failures generally, as it can improve the life quality and rehabilitation of patients to a certain extent; however, there are still 30% of patients are treated ineffectively. It is generally believed that the main reasons for the poor treatment effect include the evaluation of left ventricular contraction asynchrony, the poor position of the left ventricular electrodes, and the failure of pacing parameter optimization after surgery , 19. Botreatment .P > 0.05), which suggested the optimized intervals obtained by the echocardiography differed little from those by the QuickOpt algorithm (P > 0.05), and both the two methods achieved great optimization effects. There was also no statistically significant difference in aVTIs of the SAV, PAV, and VV intervals between the two groups (P > 0.05). It was found via the consistency analysis that the aVTIs of SAV, PAV, and VV intervals obtained by the echocardiography and QuickOpt algorithm had a good consistency (P < 0.01), and the CCC was counted as 96.16%, 98.03%, and 95.48%, respectively. Such results were similar to those turned out of Tavazzi et al. [P < 0.05). This was similar to the study results of Mozzini et al. [The optimized indicators by echocardiography and QuickOpt algorithm were compared. It was found that the differences of the pairwise optimized SAV, PAV, and VV intervals of two groups were not statistically significant . It was indicated that both echocardiography and QuickOpt algorithm optimization on CRT improved the cardiac function of patients with heart failure greatly, and there was no significant difference in the improvement effect between the two groups [log (PVCs) and log (PVC runs) of ventricular arrhythmia episodes were not statistically significant (P > 0.05) between the echocardiography group and the QuickOpt algorithm group. Previous studies showed that the cardiac mechanical remodeling was related to ventricular arrhythmia episodes, as carvedilol was proved to reduce the onset of ventricular arrhythmia episodes while affecting ventricular remodeling in drug trials [For patients in the echocardiogram group and the QuickOpt algorithm group, the LVEFs 1, 3, and 6 months after surgery showed an upward trend over time, while the LVESV, LVEDV, and MRV showed a decreasing trend, without statistically significant difference between the groups (o groups . The veng trials . This alAs 50 elderly patients with chronic heart failure and CRT were examined by echocardiography, the optimal interval and corresponding aVTI, echocardiographic indicators, and adverse events were determined. It was suggested from the results that both echocardiography and QuickOpt algorithm had good effects in improving cardiac function and reducing ventricular remodeling in patients with heart failure. But QuickOpt algorithm was superior to echocardiography in time-consuming of the interval optimization. Although the changes of postoperative hemodynamic parameters in patients were explored in this research, there was no long-term follow-up result after the optimization. In the future, a larger amount of patient data would be collected again for a double-blind, multicenter, randomized, and controlled test, and frequent interval optimization would be performed after CRT surgery in patients, so as to analyze whether the two optimization methods have a different effect on the long-term prognosis of patients. All in all, the results of this study gave a reference for the effect evaluation of CRT postoperative parameter optimization in patients with heart failure clinically.


To the Editor,Methodology to monitor impending heart failure decompensation is receiving great concern to improve clinical outcomes in patients with chronic heart failure. Guerra et al.One of the major concerns of this technology is its sensitivity and specificity to identify worsening heart failure. Of 242 alerts, 105 (44%) were not associated with heart failure‐related events.Other modalities have also been introduced to monitor the degree of pulmonary congestion and adjust the dose of diuretics, including CardioMEMS and Remote Dielectric Sensing.In their manuscript, high doses of diuretics are recommended to manage the alerts, whereas they might rather activate renin‐angiotensin system and worsen future cardiovascular outcomes.


Survivors of preterm birth are at risk of long-term cardiovascular consequences. The objective of this prospective observational study was to assess left heart function at preschool age in preterm children with very low birth weight (VLBW).We recruited children aged 5–6 years from preterm infants and full-term children. All subjects underwent conventional echocardiography and speckle-tracking echocardiography. The results were compared between the preterm and term groups.p = 0.048; and 20.0 vs. 21.6 mm, respectively; p = 0.024), lower LV end-diastolic and end-systolic volumes . Left atrial (LA) maximal and minimal volume were also significantly smaller in the preterm group . LV global longitudinal strain  and systolic strain rate  were significantly lower in the preterm group than in the term control group. LA longitudinal strain was decreased  and left atrial stiffness index  was increased in preterm infants. However, all the measurements in both groups were within normal range.Eighty-seven VLBW preterm children and 29 term controls were included in the study. After adjusting for body surface area, the preterm group compared to the full-term group had significantly smaller left ventricular (LV) end-diastolic and end-systolic internal dimensions (31.2 vs. 33.5 mm, Subclinical changes of left heart structure and function were found in VLBW infants at preschool age. Additional long-term follow-ups of the cardiovascular outcomes are needed in this vulnerable population. Improvements in perinatal and neonatal care have led to increased survival of very low birth weight  preterm infants. Several cohort studies have linked preterm birth to an increased risk of hypertension, cardiovascular disease, and stroke in adulthood . HoweverAssessing myocardial function in preterm infants is challenging. Although conventional echocardiography has been used to evaluate ventricular function, conventional methods do not provide detailed information on ventricular remodeling and myocardial performance. Myocardial deformation imaging using two-dimensional speckle-tracking echocardiography (2DSTE) has the advantage of measuring regional and global myocardial function. Strain and strain rate (SR) measurements have been demonstrated to be sensitive markers of early-stage LV dysfunction in pediatric populations –12. ManyTo better understand the importance of early cardiac performance, we conducted this prospective, observational study to evaluate left heart dimensions, volumes, and functions in a cohort of VLBW preterm survivors at preschool age (5–6 years old) using conventional echocardiography and 2DSTE. We hypothesized that, compared to term controls, former VLBWs would be associated with reduced myocardial function in early childhood at preschool age.This prospective study was performed at MacKay Children's Hospital, Taipei, Taiwan. Preschool children aged 5 to 6 years, who were born at a gestational age (GA) of <37 weeks and with a birth weight (BW) <1,500 g, who were followed up at our institution's premature outpatient clinic, were invited to participate in this study. Term healthy controls  of the same age were recruited from the well-child clinic. Children with chromosomal abnormalities, major congenital heart or pulmonary diseases, and neuromuscular diseases were excluded from the study. The study protocol was approved by the institutional review board of our institution (IRB number: 17MMHIS037e). Written informed consent was obtained from the parents or guardians of each participating child. Data regarding the perinatal and neonatal periods for preterm birth were obtained from chart reviews. The same subjects also enrolled in another lung function study .All subjects underwent a standardized clinical examination by pediatricians. Heights, weights, and body mass indices (BMI) were measured and expressed as z-scores and adjusted for sex and age according to Taiwanese child references; body surface area (BSA) was also calculated.At the time of cardiac function measurement, all participants were in stable clinical condition. Blood pressure (BP) and heart rate were measured using a Dinamap  with an appropriate cuff size; the average of three measurements was used for analysis. Hypertension was defined according to the recent guidelines .All echocardiographic examinations included two-dimensional imaging, M-mode imaging, and 2DSTE for detailed evaluation of cardiac anatomy and myocardial function, with a specific focus on left heart function. Echocardiography was performed using a Vividi system  equipped with a 2-to 4-MHz transducer. Echocardiography was performed by a single experienced cardiologist to minimize bias and inter-observer variation. Data were digitally stored and analyzed offline by the same experienced operator who was blinded to the clinical details of the participants.*(LAV max – LAV min)/LAV max. LV volumes at end diastole (LVEDV) and at end systole (LVESV) were also estimated. LV systolic function was evaluated based on stroke volume (SV) and fractional shortening (FS). SV and FS were derived from the LV end-systolic and end-diastolic diameters and volumes, respectively. The mitral inflow of the peak velocity of early (E) and late (A) diastolic filling was assessed using a pulsed-wave Doppler and measured according to the reported guidelines . Statistical analyses were performed using IBM SPSS version 25.0 for Windows . For all analyses, a P-value < 0.05 was considered statistically significant.Categorical data were expressed as proportions and analyzed using the chi-square test or Fisher's exact test, as appropriate. The numerical data are presented as the means ± SDs and analyzed using the Student's At preschool age, 153 former VLBW children who attended our follow-up program were invited to participate in this study. Of these, 87 (56.9%) consented to participate in the current study (preterm group). The preterm group was born between April 2015 and March 2017 at a mean GA of 28.6 ± 2.7 weeks and with a mean BW of 1,042 ± 247 g. Demographic, perinatal, and neonatal characteristics for the VLBW survivors are presented in p < 0.001), there were no significant differences in the sexes, Apgar scores, and delivery methods of the preterm and control groups.The comparison group comprised 29 term-born controls (term control group) with a mean GA of 38.5 ± 1.0 weeks and a mean BW of 3,030 ± 322 g. Except for GA and BW . LV systolic functions, including SV and FS, did not differ significantly between the groups. LV diastolic function  also did not reveal any significant group differences.The cardiac measurements of the left heart dimensions, wall thickness, volumes, and the systolic and diastolic are presented in post-hoc power analysis, the study was powered at more than 90% to detect a 2.2% difference in mean LV GLS between groups given the size of our study population. LV longitudinal peak systolic SR was significantly reduced in preterm children compared to term controls, whereas early and late diastolic SR did not differ significantly between the groups.The results of endocardial deformations as determined by 2DSTE are presented in r = 0.016, p = 0.864) or LV  strain.LA peak longitudinal strain was significantly lower in the preterm group than in the term control group. The mean LA stiffness index was significantly higher in preterm children than in term controls. Pearson correlation test did not find an association between LVM index and LA , and BW . We also stratified our analyses by the existence of small for gestational, bronchopulmonary dysplasia , and patent ductus arteriosus need treatment in the preterm group. There were no differences between these subgroups in the indices of conventional echocardiography and 2DSTE .The results of the present study showed that left heart function was altered at preschool age in former VLBW preterm infants when compared with term controls. Conventional echocardiographic measurements revealed that the left atrium and ventricle had a reduced cardiac volume in preterm children. When using 2DSTE to assess myocardial deformation, significantly lower LV longitudinal strain and lower LV strain rates were found in preterm children compared to term controls. This study also demonstrated for the first time that a reduction in LA strain and an increased LA stiffness had developed in preschool-aged preterm children. The underlying mechanisms of these significant changes observed in formerly preterm children remain incompletely understood.Preterm infants, particularly those with VLBW, are also prone to different insults such as oxidant injury, sepsis, hypotension, or inflammation, which can also affect myocardial cells and tissues . Animal The link between preterm birth and increased BP has been well-documented from childhood to adulthood , 40. Nonp = 0.045) in the current study. Lower longitudinal deformation values in VLBW infants are most likely explained by the immaturity of the myocardium, which generates less active tension than the more mature myocardium, which could result in reduced myocardial contractile elements and inefficient myofibril shortening.Preterm births not only alter cardiac structures, but may also affect systolic and diastolic functional performance. Cardiac mechanics utilizing 2DSTE renders early detection of myocardial dysfunction, even at a pre-clinical stage, where overt structural remodeling not yet happens. Previous studies reported that strain, SR, and myocardial velocity were reduced in preterm infants and adults , 36, 42,p = 0.048). However, LA strain as a single parameter may have limited clinical utility . Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.H-YC, C-LH, and M-RC prepared the project of this study. H-YC, J-HC, C-HH, and C-CP performed participant recruitment. H-YC, C-LH, and MK performed data collection and statistics. H-YC, MK, C-LH, and M-RC prepared the draft of manuscript. All authors revised and approved the final manuscript.This study was financially supported by a grant (MMH-106-67) from MacKay Memorial Hospital and research projects  from Ministry of Science and Technology, Taiwan.The 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.