Exercise causes alterations of the heart in hemodynamic response to the increased systemic and pulmonary demand during exercise. The understanding of these adaptations is of high importance, since they may overlap with those caused by pathological conditions. Cardiac imaging assessment of the athlete’s heart should begin with a complete echocardiographic examination. In recent years classical echocardiographic surveys have been joined by new developments: tissue Doppler imaging, strain rate echocardiography, and real-time 3-dimensional echocardiography. This review paper focuses on the importance of these new echocardiographic techniques in delineating the morphological characteristics and functional properties of the athlete’s heart. Long term physical training causes structural, functional and electrical changes in the heart that are physiological responses to the hemodynamic demands of increased cardiac output during effort. This adaptive remodelling can be defined as “athlete’s heart”.2.The understanding of these changes is of high importance, since they have to be distinguished from those caused by pathological conditions. Moreover, there is some evolving evidence suggesting that some of the exercise-induced changes may be associated with acute and chronic cardiac damage and that in a small number of athletes this may predispose to atrial and ventricular arrhythmias. Thus, the need for a standardization of cardiovascular pre-participation screening of competitive athletes for sports eligibility has emerged, since athletes with underlying, masked cardiomyopathy may be at risk of lethal consequences during physical exertion2. Endurance training characterizes aerobic sports with dynamic-isotonic muscular involvement – such as long-distance swimming and running. These activities cause a gradual decrease in systemic arterial resistance and an increase in venous return, with a predominant volume overload, with higher left ventricular (LV) end diastolic volume (EDV) and stroke volume (eccentric hypertrophy).According to the Morganroth’s original hypothesis, two main models of training can be identified, which cause two distinct patterns of cardiac remodelling On the other hand, strength training is typical of anaerobic sports characterized by predominant static-isometric muscular exercise, such as body-building, short-distance running and swimming. These sports categories cause mainly an increase in myocardial wall thickness rather than cavity diameters (concentric remodelling and hypertrophy), in response to the predominant pressure overload.Morganroth’s original hypothesis has been criticized, because cardiac remodelling is also influenced by other factors like ethnicity, age, sex, genetics and body size. Moreover it has to be noted that most sports are actually characterized by a variable combination of both endurance and strength exercise, rather than only one of them.3. Previous authors4 in a large series of top level athletes reported that 55% had increased LV end-diastolic diameter and only 15% of them had values > 60 mm, even if ejection fraction (EF) was normal. Competitive athletes have LVH, involving all myocardial segments, with a maximal septal thickness < 12 mm. Conversely, patients with hypertrophic cardiomyopathy (HCM) show increased wall thickness (>15 mm), mainly in the basal septum, and in 20% of cases there is systolic anterior motion (SAM) of the mitral valve, or aortic valve mid-systolic closure5. After a deconditioning period of at least three months a reduction in wall thickness can be observed in athletes, but not in HCM.Standard echocardiography has an essential role in assessing the characteristics of the athlete’s heart and in differentiating physiological and pathological LV hypertrophy (LVH)7. In the last few years, development of new echocardiographic techniques have improved the knowledge of the athlete’s heart and differential diagnosis of physiological and pathological LVH.Identification of HCM is challenging, when wall thickness is between 13 and 15 mm 8.In the athlete’s heart, LV diastolic function is often supranormal, in particular in endurance-trained athletes, when compared with untrained individuals. LV remodelling in athletes is associated with normal or increased myocardial relaxation, as an expression of increased elastic recoil, different from HCM patients, in whom diastolic dysfunction may be the first expression of the disease and may precede the development of LVH9.In athletes transmitral E/A ratio is often > 2, with typical low A velocity (late diastole), and this parameter is useful to distinguish this condition from pathological LVH, where E/A ratio is < 1 and E velocity deceleration time is prolonged10. Lewiset al. suggested that an e’ peak velocity threshold of < 11.5 cm/sec on TDI can be useful to raise suspicion for pathological LVH11 (Pulsed tissue Doppler (TDI)-derived early diastolic myocardial velocity (e’) of basal septal and basal lateral wall is increased in athletes. Conversely, HCM is characterised by an e’ reduction in both the hypertrophic septum and the normal thickness of lateral wall LVH11 .12.Athletes have no regional diastolic dysfunction (e’/a’ < 1), while this is evident in 25% of myocardial segments of HCM patients and in hypertensive patients13.Finally E/e’ ratio is low in athletes, but increased in HCM patients, it being related with NYHA class and exercise capacity. Reduction of e’ velocity of both septal and lateral annulus is common after ultra-long duration exercises14. In athletes, LVH is combined with normal EF, normal or supranormal stroke volume and systolic peak velocity (s’) > 9 cm/sec, while in pathological LVH  s’ is < 9 cm/sec, with EF normal or high in early stages and reduced in advanced stages15.Moreover, pulsed TDI gives additional information regarding myocardial systolic performance at rest, showing normal or supranormal values in athlete’s heartThe athlete’s heart can be considered an interesting model of strain variation at different loading conditions, because there is a LV adaptation of at rest and a load dependency of strain measurement. .17. Athletes had higher values for transverse, radial, and circumferential strains when compared with HCM18.In particular, in athletes mild impairment of global longitudinal strain (GLS), lower apical radial strain and lower twisting at rest than in sedentary controls have been observed, together with an increase of basal and middle radial and circumferential strain19.While conventional echocardiographic parameters often failed to distinguish between endurance (runners) and strength (bodybuilders) athlete’s heart, a speckle tracking echocardiography (STE) analysis showed a different pattern of myocardial deformation in these two groups: while global radial strain (GRS) was similar, GLS was lower in runners and global circumferential strain (GCS) was lower in bodybuilders: correlations were found in runners between GLS and end-diastolic volume  and body surface area , while in bodybuilders, GCS was closely related to LV mass  and systolic blood pressure 20. Moreover, hearts of hypertensive are characterized by reduced GLS, whereas GCS, GRS, and torsion are similar to those of athletes' hearts: the extent of GLS is strongly associated with LV diastolic function, independently of afterload changes and the degree of LVH21.Another study used strain rate imaging to distinguish between individuals with hypertensive LVH and those with strength-training athletic LVH, reporting a significant reduction of systolic and diastolic strain and strain rate in hypertensive individuals, but not in athletes: an e′/a′ ratio >1 was found in 100% of a large population of competitive athletes, 90% of subjects had e′ ≥16 cm/s, s′ ≥10 cm/s, and GLS ≤21%et al. stated that LV apical circumferential strain in endurance athletes group was lower than the strength group and control groups . The endurance group had lower LV twisting (LVT) and untwisting (UTW) than strength group  and control group 22.Santoro23.Finally, STE showed reduction of longitudinal, circumferential and radial strains and also reduction and delay of peak twisting in triathletes soon after ultralong-duration exercises24.Three-dimensional (3D) echocardiography offers the ability to improve the diagnostic capability of cardiac ultrasound for evaluating cardiac anatomy, ventricular function, valvular disease and blood flow velocity. This technique is able to quantify LV volume and mass in a fashion which is similar to cardiac magnetic resonance. However, 3D echocardiography is more reproducible, has lower costs and is applicable to a large population of athletes. 3D echocardiography gives more detailed information than two dimensional (2D) echo techniques, providing data on LV remodelling and function; 3D is better in describing morphological features, showing differences in the length and shape of the LV chamber, which are not adequately assessed using 2D techniqueet al. showed LV end-diastolic volumes and mass increased in athletes compared to untrained controls; gender and type of sport had the highest impact on LV remodelling. In particular, male gender and endurance disciplines had the highest impacts on LV end-diastolic volume and mass. Body surface area (BSA) was also an important factor on LV remodelling, while age and blood pressure had only minimal effects. Preserved LV systolic function was observed in athletes, with average values similar in athletes and untrained controls25.Using 3D echocardiography, Caselliet al. measured LV remodeling index (LVRI) to describe the pattern of LV remodelling in athletes: athletes' LVRI was similar to that of controls, suggesting that the LV remodeling associated with intensive athletic conditioning does not alter LV geometry. Athlete’s heart has a “symmetric” remodeling pattern, because an increased cavity dimension and volume are accompanied by an increased thickness and mass of the ventricles, in the absence LV systolic dysfunction26.De Castro27. The athlete’s heart is therefore characterized by harmonic LV remodelling, differently from patients with hypertrophic or dilated cardiomyopathy28  is present in patients with either physiological or pathological LVH using two-dimensional strain rate imaging: LA maximum volume was increased but similar between the two groups of patients with LVH. Peak systolic myocardial atrial strain was significantly impaired in patients with pathological LVH compared with controls and athletes. As assessed by multivariate analysis, LV end-diastolic volume/BSA and LV mass in athletes were the only independent factors influencing LA lateral wall peak systolic strain. In contrast, in hypertensive patients, an independent negative association of LA lateral wall peak systolic strain with both LV mass and circumferential end-systolic stress was observed. Moreover, in the overall population of patients with LVH, LA lateral wall systolic strain was an independent predictor of maximum workload during exercise testing29.D’Andrea33. Moreover, the reversibility of the changes induced by sport after detraining was considered a typical feature of the athlete’s heart, but several studies have showed that structural and functional recovery might be incomplete, in particular for RV changes and this is particularly true in more practiced athletes33.In the recent years, the substantial structural and functional adaptations of the right heart (RH) have been documented, highlighting the complex interplay with the left heart. There is also evolving evidence of acute and chronic cardiac damage, mainly involving the right heart and which may predispose to atrial and ventricular arrhythmias, configuring an exercise-induced cardiomyopathy. Endurance exercise seems to be associated with the greatest extent of cardiac remodelling, involving both LV and right ventricle (RV), while strength training seems to impact minimally on the RVet al. documented that RH measures were all significantly greater in highly-trained endurance athletes, compared to age and sex matched strength-trained athletes35.Standard echocardiography is the first line imaging exam to differentiate athlete’s heart RV remodeling from pathological conditions. The RH clearly participates in the process of enlargement of the athlete’s heart, with an increase in internal diameters and thickness of its free walls. RV shows greater inflow and outflow dimensions in athletes compared with sedentary controls, with no significant difference in the systolic function. D’Andrea36. In addition, the inferior vena cava appeared to be dilated in a study involving 58 endurance athletes37.Typical RV characteristics of the athlete’s heart can resemble those found in arrhythmogenic right ventricle cardiomyopathy (ARVC): in ARVC the enlargement of the RV cavity involves both RV inflow and outflow, and may be associated with RV wall segmental morphological and functional abnormalities; in athletes RV enlargement involves only the inflow tract and systolic function is typically normalLV stroke volume and pulmonary artery systolic pressure (PASP) were found to be powerful independent predictors of both RV and right atrial (RA) dimensions.40.Interesting changes in the pulmonary vascular haemodynamics of highly trained athletes can be detected at rest. Concerning the PASP values, whose upper limit of normal was 40 mmHg, endurance-trained athletes showed the highest values, compared with strength trained athletes, and LV stroke volume was an independent predictor of PASPResting RV global systolic function as measured by fractional area change (FAC) and Tricuspid Annular Plane Systolic Excursion TAPSE seems to be lower in endurance athletes comparing with non-athletic controls. The reduction was more pronounced in the presence of higher RV dilation.34.Concerning the advanced ultrasound technologies, TDI velocity measurements showed that the early-diastolic phase of LV filling was increased, along with a prolonged isometric relaxation time. LV stroke volume was an independent predictor of the early diastolic velocity (Em) and the time of regional isovolumic release (RTm) of RV free walls42.As for RV systolic function, both TDI and 2D-strain-derived deformation indexes are reduced at rest in endurance athletes at the RV inlet and mid-free wall level. These changes in RV function at rest are not caused by myocardial damage, in fact there are no increases in NT-proBNP levels among athleteset al. showed that by combining 3D echo and STE, RV preload exerts its maximal influence on lateral longitudinal fibres 41.Galderisiet al. found comparable 2D and 3D RV systolic indexes between endurance athletes and controls. In this setting, a mild reduction in global RV function could be considered a physiological consequence of RV dilation, since an efficient stroke volume will be reached with higher end-diastolic volumes and then at lower ejection fraction. On the other hand, a severe reduction in RV global systolic function should be considered an abnormal finding even among athletes43 51 51 .In the last few years, clinical exercise practice, both for recreational and competitive purposes has been spreading worldwide and an increase in the number of subjects with features of exercise-induced cardiac remodeling can be expected. It is important to distinguish healthy, physiological modifications of the athlete’s heart from pathological conditions such as cardiomyopathies.Cardiac imaging is essential in identifying cardiovascular disease in athletes, but it must be integrated with medical history, symptoms, age, gender, ECG and genetic analyses.Standard echocardiography has a pivotal role in assessing the athlete’s heart characteristics while the latest developments in ultrasound techniques, such as TDI, 2D strain imaging and 3D echocardiography are important to improve knowledge about physiological and pathological heart remodeling related to sport exercise. This is a very well structured contemporary review paper on role of echocardiography in subjects with athletic heart. Overall, this will add value to this journal. et al. (2015).LeischikIn the paragraph of LA function, the introduction line needs a reference. I suggest the following:et al.(2014)Hoffman,et al. (2012)O'Keefe.Please clearly define that strain will add incremental value to current routine assessment with TDI in finding out individuals who may develop adverse myocardial fibrosis. Add the following references:Minor suggestions: I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The paper is a current, high quality review of the novel echocardiographic approaches to quantification of myocardial function in the context of training-induced remodeling.The authors provide a fair overview of methods used for discriminating right and left ventricular pathology which is important for sudden death risk stratification in this subset.The review is of interest for the readership and I suggest to accept it on "as is" basis.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Severe Pulmonary Hypertension (PAH/PH) has high morbidity and mortality. CMR is the 'gold standard' for evaluation of RV structure and function. However, currently CMR has no means to directly measure right heart pressures analogous to the invasive RHC. Hypothesis: RV/LV geometric indices are predicative of right ventricular pressure measured during the RHC.Subjects were eligible for entry if they had documented PAH as defined by WHO Criteria and were referred for a clinically indicated CMR exam where routine 3D metrics and LGE were performed. All images were retrospectively reviewed. The data collected as follows: right and left ventricular RV/LV EDVI and ESVI; RVEF and LVEF; RV anterior and inferior hinge point angle measurements (systole and diastole); LV diameters to determine eccentricity index in diastole and systole; RV hinge point LGE and right heart catheterization: RV and pulmonary arterial (PA) pressures. The hinge point angles were measured at the level of the head of the papillary muscles in the short axis. LGE was determined on the SA LGE images as not present, mild, moderate or severe . All were related to right heart derived pressures. All patients were analyzed using IBM Statistical Package, PASW, version 18 .Fifty (50) subjects were analyzed including 37 patients with documented PAH . A group of 13 non-PAH subjects who underwent routine CMR served as the control group . Regarding the 37 PAH patients, 6 did not have a RHC within the pre-specified time (2 months). The remainder had RHC within 2 weeks ± 5 days of the CMR exam. Measurements were included to determine the degree of correlation with RHC data. In univariate analysis, no single parameter predicted PAP with statistical significance and clinical value. However, for RV pressure multivariate analysis showed that combining Right Ventricular Anterior Angle in systole RVAAs) (r = 0.404), Left Ventricular Eccentricity in systole (LVECCs) (r = 0.43) in a linear regression model, better predicts RV pressure than the variables used separately: RV pressure index = [12.34+0.509*RVAAs+9.031*LVECCs] . For the controls the RV pressure index was lower than in patients . Further, LGE grading correlated with the RV pressure, but to a lesser degree (r = 0.49).Non-invasive testing has been shown to determine the patient's prognostic future. Herein we show RV angles and systolic eccentricity, when combined in a linear regression model better predicts RV pressure than does LGE extent in the RV hinge point region. This model may provide earlier indicator of risk.Internal.


Diffuse myocardial fibrosis may be quantified with cardiovascular magnetic resonance (CMR) by calculating extra-cellular volume (ECV) from native and post-contrast T1 values. Accurate ECV calculation is dependent upon the contrast agent having reached equilibrium within tissue compartments. Previous studies have used infusion or single bolus injections of contrast to calculate ECV. In clinical practice however, split dose contrast injection is commonly used as part of stress/rest perfusion studies. In this study we sought to assess the effects of split dose versus single bolus contrast administration on ECV calculation.Ten healthy volunteers and five patients  were studied on a 3.0 Tesla (Philips Achieva TX) MR system and underwent two (patients) or three (volunteers) separate CMR studies over a mean of 12 and 30 days respectively. Volunteers underwent one single bolus contrast study (Gadovist 0.15mmol/kg). In two further studies, contrast was given in two boluses (0.075mmol/kg per bolus) as part of a clinical adenosine stress/rest perfusion protocol, boluses were separated by 12 minutes. Patients underwent one bolus and one stress perfusion study only. T1 maps were acquired pre contrast and 15 minutes following the single bolus or second contrast injection.2 = 0.973, p = 0.001)). Inter-study agreement with split dose administration was good .ECV agreed between bolus and split dose contrast administration (coefficient of variability 5.04%, bias 0.009, 95% CI −3.754 to 3.772, rECV quantification using split dose contrast administration is reproducible and agrees well with previously validated methods in healthy volunteers, as well as abnormal and remote myocardium in patients. This suggests that clinical perfusion CMR studies may incorporate assessment of tissue composition by ECV based on T1 mapping. Expansion and composition change of the myocardial extra-cellular matrix (ECM) is seen in a range of myocardial diseases and correlates with measures of systolic and diastolic function -5. CardiLongitudinal relaxation time (T1) mapping allows quantitative characterisation of the myocardium, thereby enabling detection of diffuse myocardial disease processes that has previously required cardiac biopsy ,9. FurthT1 measurement before and after the administration of an extra-cellular contrast agent allows the relative volumes of the intra-cellular and extra-cellular components of myocardial tissue to be quantified as long as equilibrium between the extra-cellular compartments (interstitium and blood) has been reached. Equivalence of primed slow intra-venous infusion and bolus only administration of contrast agent has been demonstrated previously ,12. HoweThe research protocol was approved by the local ethics committee and all subjects gave written informed consent. All studies were performed at a single centre equipped with a 3 T MRI scanner  using RF shimming and a 32-channel cardiac phased array receiver coil.A total of ten healthy volunteers were recruited to undergo CMR. Subjects were excluded if they had a history of cardiac disease, hypertension, renal impairment, diabetes or contra-indication to CMR.All subjects underwent a total of three CMR studies on separate days.Study 1. Single bolus: In one CMR study, the contrast agent  was administered as a single bolus (0.15 mmol/kg) with post-contrast T1 mapping acquired 15 minutes later.Study 2. Split dose: Contrast was administered as a split doses (0.075 mmol/kg twice) as part of an adenosine stress perfusion protocol. For stress perfusion, intra-venous adenosine was administered at 140 mcg/kg/min, via an intra-venous cannula sited in the ante-cubital fossa, for a minimum of three minutes and until an appropriate haemodynamic response had occurred. Contrast agent was delivered at a dose of 0.075 mmol/kg at peak haemodynamic stress. For rest perfusion, the same contrast injection regime was repeated twelve minutes later. A total Gadovist dose of 0.15 mmol/kg was administered. Post-contrast T1 mapping was performed 15 minutes after the second contrast administration.Study 3. Split dose: Split dose stress perfusion CMR study as 2.A total of five patients that had undergone a clinically indicated, non-urgent, adenosine stress perfusion CMR were recruited if they exhibited an area of enhancement on LGE imaging on the clinical study, which included native T1 map and 15 minute post contrast T1 map as per our local protocol. Patients were then recalled for one single bolus CMR study on a separate day in keeping with the above protocols.In each study, the cardiac long-axis was located as per standard practice using balanced steady-state free precession pulse (bSSFP) cine images. Cine imaging was performed using a contiguous stack of parallel short-axis slices covering the whole left ventricle (LV), with a bSSFP pulse sequence (echo time (TE) 1.3 ms; repetition time (TR) 2.6 ms; flip angle 40°, spatial resolution 1.6 × 2.0 × 10 mm, 40 phases per cardiac cycle).For all studies, contrast was delivered via a peripheral cannula, followed by a 20 ml saline flush delivered by automated injector  at 5 ml/second.3 (reconstructed to 1.25×1.25 mm), single-shot, sensitivity encoding (SENSE) factor 2, trigger delay set for end-diastole, flip angle 35°, acquisition duration per image 170-185 ms (dependent upon FOV) a range of inversion times are calculated by the system in order to provide good sampling of T1 recovery.Native and 15 minute post-contrast data for T1 value estimation were obtained using breath-held Modified Look-Locker Inversion recovery (MOLLI) acquisition ,15,16. IPerfusion imaging acquisition used a spoiled turbo GRE sequence (echo time (TE) 2.8 ms; repetition time (TR) 1.28 ms; flip angle 15°, acquired spatial resolution 2.42×2.42 × 10 mm) in three 10 mm short axis slices with a 148×148 matrix, FOV 300–420, sensitivity encoding factor 2.4, half scan factor of 0.65 and a saturation pre-pulse delay of 80 ms.LGE imaging was performed at 7–10 minutes following final contrast dose .the area displaying visual enhancement on the LGE acquisition; matched using standard image planning techniques and left and right ventricular anatomical features.remote myocardium .Study images were saved as Digital Imaging and Communications in Medicine (DICOM) format. T1 values were calculated from source images using manual motion correction on CMR42 . Mis-registration was avoided by visually comparing left and right ventricular anatomical features  any mis-registered images were discarded. In volunteers a narrow region of interest (ROI) in the infero-septum of the mid-ventricular slice was drawn as per Puntmann  in an efThe blood pool contour was drawn in the centre of the LV cavity on the same slice away from any papillary muscle. Signal intensity was measured from each MOLLI source image and T1 estimated based on the mean signal from myocardial and blood pool ROIs. ECV was calculated using the formula:Statistical analysis was performed using IBM SPSS® Statistics 21.0 . Unless otherwise stated the results are presented as mean ± standard deviation (SD). Reproducibility and agreement was assessed by coefficient of variation and Bland Altman plot. Normality of distribution was determined with Kolmogarov-Smirnov testing, normality was assumed with a value of >0.2. Correlation was assessed with Pearson’s correlation coefficient.2), LV mass (52 ± 7 g/m2) and ejection fraction (57% ± 2) were normal. All volunteers had normal right ventricular function and demonstrated no hyper-enhancement on late gadolinium enhancement images. All volunteers had an appropriate response to adenosine, with mean resting heart rate of 61.4 ± 5.2 beats per minute that increased on stress perfusion by 22.6 ± 7.6 beats per minute. Stress perfusion images were assessed qualitatively and no perfusion defects were identified. Split dose administration contrast agent doses were separated by 12.0 ± 3.7 minutes.Demographic characteristics of the study volunteers are as presented in Table 2), LV mass (64 ± 20/m2) and ejection fraction (42% ± 13). Patient pathologies were: 4 chronic ischaemic heart disease with established myocardial infarction; 1 hypertrophic cardiomyopathy. All patients had extensive LGE, and no inducible perfusion defects on stress perfusion imaging outwith the area of LGE.Patient characteristics are as displayed in Table 29 of 30 sets of volunteer mid-ventricular short axis MOLLI acquisitions were available for final analysis; in one MOLLI an acquisition error prohibited analysis. 10 of 10 patient MOLLI acquisitions were suitable for analysis.2 = 0.973, p = 0.001)). Bland-Altman plot of the data set can be seen in Figure There was a strong positive correlation between ECV calculated following single or split bolus contrast administration in healthy volunteers, as well as abnormal and remote myocardium in patients . Bland-Altman plot can be seen in Figure Inter-study agreement for ECV calculation with split dose administration visits was good in the 10 volunteers studied (coefficient of variability 5.67%, rThe insights that T1 mapping offers into tissue composition are increasingly applied as a research tool. T1 mapping is also being integrated into clinical protocols, particularly in the investigation of unexplained left ventricular hypertrophy. Consequently, comprehensive CMR protocols that interrogate not only cardiac structure, function and perfusion but also tissue composition in one protocol have great potential clinical value.Previous studies have shown that ECV calculated using either an infusion or bolus of contrast agent  is reproGiven that reliable ECV calculation requires steady state of contrast agent concentration, split dose administration may have given rise to different estimates against single bolus administration or a continuous contrast infusion. Any such differences would have prevented the application of established normal ranges that have been published over recent years to subjects undergoing stress perfusion protocols ,9,19-21.This study has now shown that ECV estimation with split dose contrast administration as part of a stress/rest perfusion CMR protocol agrees well with bolus administration in healthy volunteers. Reproducibility and inter-study agreement was good for split dose ECV calculations and in line with that previously published for ECV calculation following bolus contrast administration .Previously published data suggested that bolus contrast administration may underestimate ECV at values of >40% . HoweverThis study was performed in a limited number of healthy volunteers and patients. It has previously been shown that at fifteen minutes contrast equilibrium may not have been reached for post contrast T1 mapping, especially in individuals with higher ECVs.  This stuThis study investigated one particular MOLLI acquisition scheme which is consistent with international recommendations. However, other methods have been published and as yet there is no firm MOLLI scheme recommendation. It is difficult to select the ideal T1 mapping sequence as different sequences may perform differently depending upon the T1 of the tissue studied. Consequently the demonstration of the inter-study reproducibility of locally adopted sequences, in line with SCMR guidance, is important.Split dose contrast T1 mapping, in keeping with a stress perfusion protocol, is reproducible and agrees with bolus contrast administration. This suggests ECV measurement maybe incorporated into stress perfusion protocols in both clinical and research CMR.


Good quality of life correlates with a good exercise capacity in daily life in patients with Tetralogy of Fallot (TOF). Patients after correction of TOF usually develop residual defects as pulmonary regurgitation or pulmonary stenosis of different severity. We investigated the impact of several hemodynamic parameters measured by cardiovascular magnetic resonance (CMR) and echocardiography and analysed these data together with results of cardiopulmonary exercise testing (CPET) of these patients.136 consecutive patients with TOF were tested during routine follow-up with CMR, echocardiography und CPET. Right and left ventricular volume data, ventricular ejection fraction, pulmonary regurgitation were evaluated by CMR. Echocardiographic pressure gradients in the right ventricular outflow tract (RVOT) and through the tricuspid valve area were measured.All data were classified and correlated with the results of CPET evaluations of these patients. The analysis was performed using the Random Forest model (classification and regression model with measurement of variable importance through permutation). In this way we calculated the importance of the different hemodynamic variables related to the maximal oxygen uptake in CPET figure .Right ventricular pressure showed the most important influence on maximal oxygen uptake, whereas pulmonary regurgitation and right ventricular end-diastolic volume were not important haemodynamic variables to predict maximal oxygen uptake in CPET.Patients with TOF and elevated right ventricular pressure showed a reduced exercise capacity. Maximal exercise capacity was only weakly influenced by right ventricular enddiastolic volume and not at all by pulmonary regurgitation.N/A.


Viability testing prior to revascularization in ischaemic cardiomyopathy has courted controversy in the literature over recent years. Viability assessment prior to revascularization at our institution is largely requested for patients with severely impaired left ventricles (LV). This study however aims to review the outcomes of the patients with preserved or mildly impaired LV function who underwent cardiac magnetic resonance imaging (CMR) for viability assessment during consideration for revascularization and to evaluate its use in this group.Patients undergoing CMR scans to assess viability prior to coronary artery revascularization were identified from January 2011 until June 2013. Demographics, viability and outcome data were collected for all.Viability assessments were undertaken in 256 patients who were referred for revascularization of coronary artery disease by either percutaneous or surgical methods. Of these patients 71 (27.7%) were found to have preserved or mildly impaired LV function, defined by an ejection fraction greater than 45% . Adenosine stress perfusion was performed in 25.4%. Ultimately 76% were revascularized (38% underwent coronary artery bypass grafting (CABG) while 38% had percutaneous coronary intervention (PCI)). The remaining 24% were turned down for revascularization. The reason not to revascularize in 11.7% of cases was LAD territory nonviability. Other reasons were independent of the viability findings and included poor target vessels, co-morbidities and patient decision. Mean LV measurements within each group were as follows: ejection fraction CABG 56.67±7.58%, PCI 57.41±8.58%, medical management 59.4±19.65% (p=0.58) LVEDV CABG 87.74±19.37mls, PCI 85.22±20.62mls, medical management 80.41±16.14mls (p=0.47). The number of non-viable segments within each group was: CABG 2.15±1.99, PCI 2.15±2.13 and medically managed 2.41±2.06 (p= 0.90). The nonviable segments were in LAD territory in: CABG 22.2%, PCI 33.3% and medical management 29.4% (p=0.66). Median follow up was 2.4 years. Outcome data was as follows; MACE: CABG 14.8%, PCI 7.4% and medical management 11.8% (p=0.69); death: CABG 11.1%, PCI 7.4%, with no reported deaths in the medical management group (p=0.37); revascularization: CABG 3.7%, PCI 11.1% and medical management 11.8% (p=0.53) and cardiac rehospitalisation: CABG 14.8%, PCI 3.7% and medical management 11.8% (p=0.37).LV function and volume measurements and the number and territory of nonviable segments in preserved or mildly impaired left ventricular function was not significantly different between revascularized and medically managed patients. The rates of events or death did not differ significantly. Therefore CMR for viability assessment has not been shown to be a useful tool in guiding revascularization for patients with preserved or mildly impaired ventricles. We propose that stress perfusion without viability would improve the utility of CMR in this group of patients.N/A.


Recent perioperative trials have highlighted the urgent need for a better understanding of why sympatholytic drugs intended to reduce myocardial injury are paradoxically associated with harm . We hypothesised that following a standardised autonomic challenge, a subset of patients may demonstrate excessive sympathetic activation which is associated with exercise-induced ischaemia and impaired cardiac output.2peak), anaerobic threshold (AT)) and perioperative heart rate.Heart rate rise during unloaded pedalling (zero workload) prior to the onset of cardiopulmonary exercise testing (CPET) was measured in 2 observation cohorts of elective surgical patients. The primary outcome was exercise-evoked, ECG-defined ischaemia  associated with an exaggerated increase in heart rate . Secondary outcomes included cardiopulmonary performance (oxygen pulse (surrogate for left ventricular stroke volume), peak oxygen consumption . Patients with EHRR had higher heart rates perioperatively (p<0.05). Significant ST segment depression during CPET was more common in EHRR patients (relative risk 1.7 (95% CI 1.3 to 2.1); p<0.001). EHRR was associated with 11% (95%CI 7% to 15%) lower predicted oxygen pulse (p<0.0001), consistent with impaired left ventricular function.EHRR is common and associated with ECG-defined ischaemia and impaired cardiac performance. Perioperative sympatholysis may further detrimentally affect cardiac output in patients with this phenotype. POISE-1 and POISE-2 trials reported that sympatholytic drugs  aimed at reducing perioperative myocardial infarction paradoxically increase the risk of hypotension and, for metoprolol (POISE-1), death. Patients with propensity for tachycardia are more likely to receive such drugs, both in trials and routine perioperative practice.Using cardiopulmonary exercise testing, we identify patients with a propensity for tachycardia in whom cardiac performance is already significantly impaired. Administering sympatholytic drugs to these patients would be expected to further compromise cardiac output, resulting in hypotension and consequently further deleterious outcomes.Identifying patients with this exaggerated tachycardia phenotype will enable more personalised perioperative monitoring and treatment in an effort to gain the benefit of sympatholysis  while mitigating risks (hypotension).Perioperative pharmacological interventions aimed at attenuating sympathetic activation to reduce myocardial ischaemia7As a potent trigger of increased heart rate and acute endothelial dysfunction,15We therefore hypothesised that exaggerated heart rate increases prior to the onset of routinely performed preoperative cardiopulmonary exercise testing (CPET) would be associated with ECG evidence for ischaemia, impaired cardiopulmonary performance and inferior postoperative outcome.Patients were enrolled at University College London Hospitals and Derriford Hospital, Plymouth, UK, having obtained IRB approval (MREC: 11/H0805/58). Informed written consent was obtained from patients undergoing preoperative CPET as routinely requested by their clinical teams prior to major elective surgery. Adherence to STROBE guidelines is documented in online supplementary table S1. Inclusion criteria were any surgical patient referred for CPET by their primary surgical and/or anaesthesia team. Exclusion criteria were according to American Thoracic Society (ATS) guidelines.16Patients completed symptom-limited maximal CPET as part of their routine preoperative assessment on a stationary cycle ergometer . Heart rate readings were obtained via ECG with the patient sitting on the cycle ergometer. Continuous 12-lead ECG recordings were made throughout the CPET period to enable the detection of ischaemia and/or development of dysrhythmias. ST-segment depression was quantified in lead II, which is superior for detection of atrial dysrhythmias and more easily obtained with conventional monitors.Anaerobic threshold (AT), which is associated with increased postoperative morbidity and mortality,We interrogated serial heart rates in patients (n=54) who had heart rate rise measured during CPET as part of their enrolment into the Post-Operative Morbidity-Oxygen delivery trial (POM-O) randomised controlled trial.Baseline characteristics of participants were compared according to quartile using analysis of variance . For continuous data, tests for skewness were performed to assess normality and, where appropriate, the data were analysed with ANOVA. Non-parametric data were analysed with the Kruskal-Wallis test. The Gehan-Breslow-Wilcoxon method was used to analyse hospital stay since this gives more weight to accelerated hospital discharge at earlier time points, which is most relevant to the hypothesis that sympathetic autonomic dysfunction increases the risk of early postoperative morbidity and hence delayed discharge. All reported p values are two-sided, with significance set at p≤0.05. Statistical analyses were performed using NCSS V.8 .The primary outcome was ST depression ≥1 mm detected during CPET. Using the VISION study definition of myocardial injury after non-cardiac surgery as a guide,Eight hundred and eighteen patients were recruited across both centres. Changes in heart rate while patients acclimatised to the exercise bike conditions at zero workload (unloaded cycling) were similar between centres .Upper tertile values were similar to previous data showing that an abnormal EHRR ≥12 bpm was associated with an increased risk of sudden cardiac and all-cause cardiovascular death.We found that baseline and peak heart rates during exercise were not associated with EHRR . ConsistIn both centres, similar proportions of patients (27.3–40.4%) demonstrated ST-segment depression ≥1 mm during CPET. Continuous ECG recordings revealed an association between EHRR and ST-segment depression ≥1 mm in both cohorts . Across Given we found an association between EHRR and ECG changes compatible with coronary artery dysfunction, we predicted that this occult sympathetic autonomic dysfunction phenotype should also be associated with impaired cardiopulmonary reserve. In addition to lower ith EHRR . Left vePatients with preoperative EHRR (n=22/54) had higher heart rates throughout the perioperative period p=0.017; A. OutcomThese data demonstrate from two separate cohorts of surgical patients that the sympathetic autonomic response elicited during unloaded pedaling prior to ramped exercise (EHRR) is associated with increased risk of ECG-defined ischaemia, inferior cardiac performance and prolonged hospital stay. There is compelling physiological evidence to show that EHRR is chiefly due to mental stress. Similar rises in heart rate occur in patients sitting on a bike before exercise, but not pedalling, which are not accounted for by changes in posture.Previous studies have demonstrated that ST-segment depression to levels ≥1 mm independently predict future cardiac events in asymptomatic populations.42Strengths of these data are that all analyses were performed blinded to primary and secondary outcomes, in two separate centres. Describing this dysautonomic parameter in the context of a highly phenotyped cardiovascular test enables correlation with comprehensive cardiopulmonary physiological data. Established biological plausibility for this phenomenon and preceding similar findings, albeit with different testing methodology in non-operative patients, lends important support. Interindividual genetic variation in adrenergic receptor and signalling may influence these responses.There are several clinical implications raised by these data. A clearer understanding is required of which patients may benefit from perioperative sympatholysis. Identifying highly phenotyped patients at the highest perioperative risk of excess sympathetic activation could provide a new rationale for targeted sympatholysis, rather than a ‘one-size-fits-all’ approach which does not appear to have an acceptable therapeutic risk-benefit ratio.In summary, we have identified a significant number of patients who exhibit cardiovascular changes associated with excess sympathoadrenal activity in the preoperative setting. These patients develop exercise-induced, ECG-defined ischaemia and sustain prolonged hospital stay. This subset of patients may benefit from interventions designed to counteract the multiorgan, deleterious impact of excessive sympathetic activity and/or inappropriately targeted sympatholysis on cellular function.


NOS3). Reduced NO bioavailability and thus the Glu298Asp polymorphism of NOS3 may enhance right ventricular (RV) afterload and hypertrophic remodeling and influence athletic performance. To test this hypothesis world class level athletes  with a VO2 maximum greater than 50ml/kg/min were compared with non-athletic volunteers (n = 155). Cardiopulmonary exercise tests and cardiac magnetic resonance imaging (cMRI) were performed to determine structural or functional changes. Genotype distribution of the NOS3 Glu298Asp polymorphism was not affected by gender or physical performance. Cardiac MRI showed increased stroke volume with eccentric hypertrophy in all athletes regardless of their genotype. However, the Asp allelic variant carriers had increased RV mass index  and larger RV stroke volume index  than athletes with a Glu/Glu genotype. Genotype was not significantly associated with athletic performance. In the non-athletic group no genotype related differences were detected. The association between the NOS3 Glu298Asp polymorphism and RV structure and dimension in elite athletes emphasizes the importance of NOS3 gene function and NO bioavailability in sport related cardiac adaptation.Nitric oxide (NO), an important endogenous pulmonary vasodilator is synthetized by the endothelial NO synthase ( Intensive physical conditioning results in cardiac adaptive responses known as the “athlete’s heart.” These changes include development of left- and right ventricular  hypertrophy and increased stroke volumes, which correlate with maximal work capacity and are known to be load and sports discipline dependent –4.Recent recognition of the endurance training-induced disproportionate right ventricular load highlighted a more pronounced fatigue and a potentially larger damage of the right—compared to the left—heart chamber ,6. DiminNitric oxide (NO) is an important cardiovascular regulator, modulating flow patterns in the pulmonary circulation and influencing exercise performance through effects on skeletal muscles and cardiac function –11. EndoNOS3 gene in different clinical conditions displayed significant ethnicity- and genotype distribution-related differences. The three most widely studied NOS3 polymorphisms include the G894CT (Glu298Asp) in exon 7, the 4a/5b 27-basepair variable number of tandem repeats in intron 4, and the T-786C variant in the promoter region [Examination of several genetic variants of the r region .NOS3 gene predicts a Glu to Asp amino acid substitution at codon 298 in the mature protein, which increases NOS3 susceptibility to enzymatic cleavage in vitro and may result in decreased NO production [The 894 G/T variant of the oduction . Aspartaoduction –19. Thesoduction .NOS3 Glu298Asp polymorphism has already been associated with exercise induced cardiac phenotypes. Carriers of the Asp allelic variant developed higher stroke volumes and lower heart rates during sub-maximal exercise in endurance trained women [NOS3 298 Glu/Glu genotype [The ed women . In triagenotype . Despitegenotype .NOS3 298 polymorphism and cardiac function—with special emphasis on athletic adaptation—may suggest changes in physiologic or even pathologic cardiac remodeling and to our knowledge these associations were not yet studied.These associations of the NOS3 function and endogenous NO production may influence myocardial hypertrophy in athletes. Therefore, NOS3 298 genotype  was determined and athletic cardiac adaptation using cardiac magnetic resonance imaging (cMRI) was investigated in a selected population of world class athletes. Within the framework of a national screening program for the Hungarian national sport teams the most elite representatives of athletic disciplines with substantial endurance training incorporating power components were selected and compared with non-athlete individuals.We hypothesized that altered 2 maximum greater than 50ml/kg/min during cardiopulmonary stress test using a bicycle ergometer were referred to cardiac magnetic resonance (cMRI). Eight players were excluded due to low VO2 maximum (<50ml/kg/min) and eleven athletes did not complete the cardiac magnetic resonance examination (cMRI) due to intolerance (2 maximum consumption level (<50ml/kg/min) was part of the inclusion criteria in this group, control individuals with higher than 50ml/kg/min VO2 maximum (n = 3) were excluded from the study and four volunteers who could not tolerate cMRI (n = 4) were not able to complete the study protocol.Hungarian athletes were screened and selected on the basis of event/sport participation, high level qualification and recent international representation. Inclusion criteria consisted of at least 10 years of national and 3 years of international qualifications (world championships and / or Olympic Games). . Athleteolerance . Sport dIn this study, all athletes belong to the same ethnic group, are subjected to similar environmental factors including dietary habits, smoking status (only 6/126 athletes were active smokers during the study), duration of elite athletic status and timing (during season) of the examinations.2 maximum greater than 50ml/kg/min and controls with VO2 maximum lower than 50ml/kg/min were referred for cardiac magnetic resonance imaging. Blood samples for DNA isolation were collected at the first visit. Athletes were all tested and measured during their competitive season period in two consecutive years. Participation, including cardiac magnetic resonance imaging and blood sampling for DNA extraction was voluntary and part of a prospective athletic screening program. Written informed consent was collected from all participants and approval of the Hungarian Scientific Council National Ethics Committee for Scientific Research (ETT-TUKEB 13687-1/2011) was provided before data and samples were used in this study. The Hungarian Scientific Council National Ethics Committee for Scientific Research (ETT-TUKEB) is a supreme authority of the Semmelweis University Ethics Committee, which received and approved the national level decision.Stress test was performed in both athletes and non-athletes using a bicycle ergometer with an “all-out” protocol. Athletes with a VOA continuous ramp test to exhaustion was performed on an electromagnetically braked bicycle ergometer . The initial exercise load was 50 W and increased in a linear ramp pattern with 25 W every 60 seconds. Athletes and non-athlete individuals were asked to continuously pedal until exhaustion, maintaining constant revolutions-per-minute at 40–50 rpm. Gas exchange parameters and ventilatory variables were recorded breath-by-breath . Vital parameters and blood lactate levels were measured before and after the stress test. Rating of perceived exertion  was collected and exhaustion was defined by completing the BORG scale.Cardiac MRI scans were performed on a Philips Achieva 1.5T magnet. . The imaging instrument had Dual Nova HP gradients  and running software version R2.5.3 and recently R2.6.3.  Five element cardiac coil was used for signal reception. The MR protocol included retrospectively gated balanced steady-state free precession cine movies in three long axis orientations  and short axis slices covering both ventricles. Slice thickness was 8mm, while inter-slice gap was set to zero. Each cardiac cycle was divided into 25 to 30 phases. Triggered blood suppressed T2-weighted spectral inversion recovery (T2w-SPIR) sequence was used for edema detection. Delayed enhancement images were recorded in the same views as the cine movies to assess abnormal contrast uptake. While administering the Gadovist contrast (0.125mmol/kg IV) k-t BLAST (Broad-use Linear Acquisition Speed-up Technique) balanced turbo field echo (b-TFE) sequence was used to capture rest perfusion datasets of the three long axis slices. Respiratory motions were corrected using breath-holds in end-expiration. In selected cases coronary origins were depicted using a fat-suppressed 3-dimensional b-TFE sequence utilizing respiratory navigator with prospective motion correction. Medis QMASS MR 7.1 and 7.2  were used for evaluation. Endocardial and epicardial contours were traced manually for both the left and the right ventricles and volumetric measures (including papillary muscles), ejection fractions, maximal end-diastolic wall thickness and maximal end-diastolic wall thickness, left ventricular end diastolic volume index ratios were determined[Genomic DNA was isolated from whole peripheral blood with a protease based technique . Samples (1 ml) were added to a lysis buffer and were thoroughly mixed and centrifuged. After discarding the supernatant, samples were denaturized, DNA was ethanol precipitated and reconstituted in the provided buffer. Samples were stored at -80°C. Estimation of the DNA yield and quality control was done by spectrophotometry and determination of the 260/280 absorption ratio . Genotyping of The Glu298Asp single nucleotide polymorphism  was done with RT-qPCR . Pre-designed primers were provided by Applied Biosystems (kit number: C___3219460_20) and the reaction was performed according to the manufacturer’s protocol. For each run parallel samples with positive controls were used. Genetic analysis was performed blinded to patient data, with the provided software. Results are presented according to the National Heart, Lung, and Blood Institute recommendations on reporting genetic results in research studies .Data are presented as mean ± SD for continuous variables, or n (%) for categorical variables. Comparisons between two groups were performed using Student’s t-test for continuous variables (MR parameters), chi-square test for categorical data . Analysis of variance (ANOVA) indicated that genotype and athletic status may influence right ventricular indices (post-hoc test: Tukey HSD). Linear regression was used to explore whether gender and genotype are independent predictors for changes in right ventricular stroke volume index (RVSVi) and right ventricular mass index (RVMi). Mulivariate analysis was performed on groups based on genotype and athletic status . P values less than 0.05 were considered significant. Calculations were performed using the SPSS 22.0 program package (IBM Corporation).Elite athletes, including men (n = 94) and women (n = 32) and Hungarian non-athletic controls (n = 109 men and n = 46 women) were screened . Age dis2, p<0.0001). There were significant gender-related differences with higher end-diastolic and end-systolic LV volumes and larger LV mass in men versus women, irrespective of athletic activity . Both, RVSVi and RVMi were higher in men than in women. At exhaustion both VO2 maximum,  and minute ventilation  were significantly higher in athletes than in non-athletic controls and within each group, also significantly higher in men than in women.Left ventricular end diastolic and end systolic volumes and left ventricular myocardial mass, indexed to body surface area  were significantly higher in athletes than in the non-athletic group, suggestive of eccentric hypertrophy . Restingactivity . Similaractivity . Restingp = 0.73, p = 0.59, with OR (CI 95) of 0.8 (0.5–1.4). The proportion of the G/G genotype varied between 49 and 57% in both genders in both groups. Overall, genotype distributions were in Hardy-Weinberg equilibrium for the SNP in the population.Allelic distributions in athletes and controls were similar with aminor allelic frequency of 0.27 in athletes vs. 0.26 in controls. In 64 athletes the Glu homozygous genotype, in 56 the heterozygous while in 6 out of 126 athletes the Asp homozygous genotype was found. The genotype distribution was similar in the non-athletic control group  and for RVMi 26±6 versus 27±6 g/m2 .Resting RV stroke volume index (RVSVi) and RV mass index (RVMi) were both higher in Aspartate carriers  compared to Glutamate homozygous participants , for RVSVi 60±9 versus 62±12 ml/m2, p<0.01, Tables 2, p<0.001, Tables 2 maximum) was not different between the Asp allelic variant carriers and the Glu homozygous individuals, irrespective of the athletic status . There was, however, a trend towards higher maximal minute ventilation in Asp allelic variant carrier versus Glu homozygous athletes . The genotype was not associated with ventilation in non-athletes.Athletes carrying the Asp allelic variant had higher right ventricular mass index, than those homozygous for the Glu allelic variant  could affect athletic performance via several mechanisms, including improved coupling of cardiac oxygen consumption to physical performance, enhanced LV relaxation and decreased LV end-diastolic pressure, increased NO-dependent myocardial Cale force ,32–34. TNOS3 genotype and left ventricular parameters neither in athletes, nor in untrained-individuals. Interestingly, without a significant effect on maximal oxygen uptake, there was a trend towards higher minute ventilation at peak exercise in Asp allelic carrier compared to Glu homozygous athletes. This phenomenon was not observed in non-athletes.In our study, however, no connection was found between the NOS3 protein [Bench-side and clinical data support the theory that the hypoxia-induced pulmonary vasoconstriction may be further enhanced by the increased cleavage of the Aspartate containing  protein ,13. Unde protein ,35,36. A protein ,37.NOS3 Glu298Asp polymorphism on enzymatic cleavage and thus NO availability has been shown to reduce treatment efficacy in heart failure patients. In a genetic sub-study of the African-American Heart Failure Trial (A-Heft) Glu298Glu genotype predominance was associated with the positive impact of NO donors  on heart failure survival [The influence of the survival ,13.NOS3 Glu298Asp polymorphism has also been associated with cardiac adaptation to long-term athletic performance. This association included the cardiovascular adaptation of untrained individuals to long term endurance training with a blunted responsiveness of submaximal exercise, diastolic blood pressure and rate pressure product in previously sedentary Asp homozygous subjects. Higher stroke volume and lower heart rate during sub-maximal exercise was reported in postmenopausal women carrying the Asp allelic variant [NOS3 Glu298Asp variant was also associated with the actual contest performance in elite ultra-endurance athletes [The  variant ,25. The athletes .In elite athletes we found larger right ventricular myocardial mass and increased RV stroke volume (both indexed to body surface area) in Asp allele carriers versus Glu homozygous individuals. The higher stroke volume observed in the Asp carrier athletes was associated with a non-significant trend of larger end diastolic volumes compared to the Glu homozygous athletes.These associations could be the consequences of the increased afterload and adverse pulmonary remodeling brought forth by reduced NO bioavailability. Knockout murine experiments highlighted the fact that albeit all three isoforms are present in the lung, NOS3-derived NO is the major regulator of pulmonary vascular tone. Loss of NOS3 function results in a markedly enhanced hypoxic pulmonary vasoconstriction, significantly elevates right ventricular pressure and induces airway hyper-responsiveness ,39. In aNOS3 Glu298Asp polymorphism with athletic remodeling. As this study was focused on a highly selected group of athletes, individuals from several sports disciplines—although with very similar training regimes—had to be screened to reach an acceptable number of participants. Given our single gene candidate approach, other polymorphisms in linkage disequilibrium with the Glu298Asp polymorphism may be the true cause of this association.Cross sectional study design limits insight on the interaction of the NOS3 Glu298Asp polymorphism. Our study supplements evidence in the literature showing another aspect of NOS3 genotype influence on cardiac adaptation. Whether this has a positive or negative effect on the individuals’ long term cardiovascular health and athletic performance has yet to be determined. Combined use of non-invasive cutting edge imaging modalities and genotyping tools may help to track the extent of influence both during training and late life deconditioning.In this study cardiac function and structure of elite athletes was determined and a previously unknown correlation was found between load-dependent right ventricular adaptation and a candidate genetic variant, the Given the high frequency of the nitric oxide synthase 3 gene 298 Glu/Asp polymorphism this could have substantial impact if there was more evidence related to its functional and long-term implications.


Heart failure is accompanied by abnormalities in ventricular-vascularinteraction due to increased myocardial and arterial stiffness.Galectin-3 is a recently discovered biomarker that plays an importantrole in myocardial and vascular fibrosis and heart failureprogression.The aim of this study was to determine whether galectin-3 is correlatedwith arterial stiffening markers and impaired ventricular-arterialcoupling in decompensated heart failure patients.A total of 79 inpatients with acute decompensated heart failure wereevaluated. Serum galectin-3 was determined at baseline, and duringadmission, transthoracic echocardiography and measurements of vascularindices by Doppler ultrasonography were performed.Elevated pulse wave velocity and low arterial carotid distensibility areassociated with heart failure in patients with preserved ejectionfraction . Pulse wave velocity, carotiddistensibility and Young’s modulus did not correlate with serumgalectin-3 levels. Conversely, raised galectin-3 levels correlatedwith an increased ventricular-arterial coupling ratio (Ea/Elv) p =0.047, OR = 1.9, 95% CI (1.0‑3.6). Increased galectin-3 levels wereassociated with lower rates of left ventricular pressure rise in earlysystole (dp/dt) (p=0.018) and raised pulmonary artery pressure (p =0.046). High galectin-3 levels  and arterialpulmonary pressure  were found to be independentrisk factors for all-cause mortality and readmissions.This study showed no significant correlation between serum galectin-3levels and arterial stiffening markers. Instead, high galectin-3levels predicted impaired ventricular-arterial coupling. Galectin-3may be predictive of raised pulmonary artery pressures. Elevatedgalectin-3 levels correlate with severe systolic dysfunction andtogether with pulmonary hypertension are independent markers ofoutcome. Part of these changes are due to exaggeratedneurohormonal activation which has been found to have a direct relationship witharterial stiffness.5Studies have pointed out a close relationship between macrophage activation andfibrosis in heart failure pathogenesis.6 Galectin-3 has been proved to be involved in fibrosis,hypertrophy and heart failure progression.7 Given the aforementioned pathogenic mechanisms and thepro-inflammatory state that is found in heart failure, we considered galectin-3a possible mediator of vascular fibrosis and a link between myocardial andarterial stiffening. Therefore we aim to evaluate whether galectin-3 correlateswith arterial stiffening markers and impaired ventricular-arterial coupling indecompensated heart failure patients.Recent attention has been focused on one emerging biomarker, galectin-3, which isdistributed in various cells including macrophages and is up-regulated duringinflammation.This study was conducted in 2014. Seventy-nine inpatients were evaluated at theclinical county hospital with a primary diagnosis of acute decompensated heartfailure. Serum galectin-3 of patients was determined at baseline. Of thiscohort, 60 patients had heart failure with reduced ejection fraction (EF) (meanof 25%) and 19 patients had heart failure with preserved EF (mean of 45%). Thestudy was approved by the hospital Medical Ethics Committee and complied withthe Helsinki Declaration. Written informed consent was obtained from allpatients.Transthoracic ECG was performed on each patient during hospitalization. Thefollowing structural indices were assessed: left ventricular (LV)end-diastolic and systolic volumes and diameters, LV wall thickness, LVmass (Devereux equation), relative wall thickness (RWT), left atrialindexed volume, pulmonary artery systolic pressure (PASP). Markers ofsystolic function included determination of LV EF by the biplane modifiedSimpson's method, fractional shortening and the rate of LV pressure rise inearly systole (dp/dt). Markers of diastolic dysfunction were alsodetermined: transmitral diastolic velocities , transmitral flowpropagation velocity (Vp), early deceleration time (DTE), septal mitralannulus velocities  by tissue Doppler, diastolic ratios E/A, E/e',and E/Vp. Each patient was evaluated using the same echo-machine, and twoinvestigators analyzed the echocardiographic data.2-Dmin2)/Dmax*MAP; Young Modulus =MAP*Dmax/ (Dmax-Dmin)*h; Pulse wave velocity = Dist/T2-T1, Distensibility coefficient =. After acquisition of Doppler tracing, we made threeconsecutive recordings from both arteries, and measured the time from the Rwave of the QRS to the foot of the Doppler waveform using digital calipers(the time taken by the blood ejected from the heart to reach the studiedarteries). We calculated the average time of the three recordings, andmeasured the distance between the sites where we traced the Dopplerwaveforms. For the carotid distensibility coefficient and Young's modulus,we used the M-mode echo to measure the diameter of the vessel duringsystole and diastole, and the vessel's wall thickness. Finally, we measuredthe intima medial thickness by echo-2D. These parameters were calculated byexisting mathematical formulas:8 Stroke volume was determinedechocardiographically by Simpson's modified biplane method. Next weevaluated the LV elastance (Elv) index which is a parameter used toestimate the LV contractility based on the following equation Elv =end-systolic pressure/ end-systolic volume - V0, whereV0 is the theoretical volume at zero pressure, andconsidered to be negligible compared to end-systolic volume.8 Finally weevaluated arterial-ventricular coupling by determining the Ea/Elvratio, which estimates cardiovascular hemodynamics through theinteraction between the arterial system and the left ventricle.Brachial blood pressure was determined with patient at rest, using asphygmomanometer and a standard stethoscope. Arterial elastance (Ea)is a parameter used to estimate the arterial load which represents thechange in volume for any change in pressure. The Ea index includescharacteristics such as arterial compliance and peripheral vascularresistance, and is calculated as Ea = end-systolic pressure/strokevolume. A non-invasive estimation of the end-systolic pressure wasmade by using the approximation formula: 0.9 x brachial systolicpressure, which accurately predicts pressure-volume loop measurementsof end-systolic pressure.Blood samples were collected during admission. The samples were centrifuged,and serum galectin-3 concentration was determined using an optimizedenzyme-linked immunosorbent assay kit , and measured using a TecanSunrise microplate reader. This is an immunoassay in which abiotin-conjugated anti-human galectin-3 antibody binds to human galectin-3captured by the coating antibody. Calibration and standardization of theassay were performed according to the manufacturer's protocol.Continuous variables with normal distribution are presented as means andstandard deviation, and significance of differences was tested by Student'st-test. Continuous variables with non-normal distribution are expressed asmedians , and significance of differences wastested by Kruskal-Wallis test or the Mann-Whitney U test. Categoricalvariables are expressed as percentages. Normality of distribution wasevaluated by Shapiro-Wilk test. Correlations of vascular indices withclinical and echocardiographic variables were assessed using the Spearmancorrelation analysis. We also used Pearson's chi-square test for comparisonof categorical values, multivariate logistic regression to assess therelationship between dependent categorical variables and independentvariables, and Cox regression survival analysis to identifying predictorsof composite endpoint . All theanalyses were performed using the IBM SPSS 20 package. Statisticalsignificance was assessed by two-tailed test and a p < 0.05 wasconsidered significant.Mean age of the cohort was 64 ± 11 years of which 73% were males and 26%were females. During a 12-month follow-up, 35 readmissions for worsening ofheart failure and 1 death (cardiogenic shock) were recorded. First, we dividedthe patients in two groups on the basis EF, reduced or preserved  .Median Association between covariates  and vascularindices was assessed using the Spearman bivariate correlation. High pulsewave velocity levels were significantly associated with higher EF , increased Ea/Elv ratio , smallerventricular diameters , and elevated systolic bloodpressure . Lower carotid distensibility coefficientwas associated with higher EF , increased Ea/Elvratio , higher age , andelevated systolic blood pressure  and low septal (e')tissue Doppler velocity . Carotid intima-mediathickness was significantly correlated with higher age  and hyperglycemia . Neither of the vascularindices  correlated with serum galectin-3 levels . Regression analysis showed a significant association between elevatedgalectin-3 levels (> 9.9 ng/ml) and an increased arterial ventricularcoupling ratio (Ea/Elv)  .Assessment of the association between echocardiographic variables and serumgalectin-3 levels revealed a strong correlation of the protein withsystolic function. More specifically, higher galectin-3 levels were relatedwith lower rates of LV pressure rise in early systole (dp/dt) 524 [262-982]mmHg/s (median and IQR) (p = 0.01 for trend) (versus 682 [340-1882]mmHg/s). When grouped by type of diastolic dysfunction, high levels ofgalectin-3 were associated with type I diastolic relaxation abnormalitydefined as E/A < 1 ratio (p = 0.017). A regression model analysis ofechocardiographic indices and galectin-3 concentrations revealed that PASP(p = 0.04), E/A ratio (p = 0.001), RWT (p < 0.001), EF (p = 0.02),end-systolic volume (p = 0.01) and end-systolic diameters (p = 0.04) wereassociated with higher galectin-3 concentrations . IncreasA multivariate Cox regression was carried out to identify independent riskfactors for outcomes. High galectin-3 levels  and increased PASP  were foundto be independent risk factors for all-cause mortality and readmissions inthis model .9 Pathophysiological aspects of this condition includeLV stiffness with reduced compliance ,chronotropic incompetence, pulmonary hypertension and vascularstiffening.10 In ourstudy, heart failure with preserved EF patients were older and presented higherblood pressure compared with those with reduced EF, similarly to the datareported in the Acute Decompensated Heart Failure National Registry (ADHERE)database.11One major finding of this study was that arterial stiffening is strongly presentin the heart failure with preserved EF group. Clinical trials have useddifferent cut-off points for EF  to define heartfailure with preserved EF syndrome. In this study we used an EF cut-off point> 40% as in Candesartan in heart failure - assessment of reduction inmortality and morbidity (CHARM) trial.12 showed thatpatients with heart failure with preserved EF have increased arterial stiffeningby measuring the arterial elastance. Pulse wave velocity is known to be a markerof arterial stiffening and is widely used in clinical trials. It is ofprognostic value and is increased in congestive in heart failurepatients.13 We haveshown that pulse wave velocity is consistently higher in the group withpreserved EF than in the group with reduced EF, which is consistent with thatreported by Balmain et al.13(10.7 m/s vs.8.9m/s. p < 0.05)14. Patients from the group with reduced EF had lower pulsewave velocities probably due to reduced cardiac output and blood pressure. Thesefindings indicate that patients with heart failure with preserved EF havedecreased carotid arterial distensibility and advanced age. Kitzman etal.15 also reportedthat carotid arterial distensibility is decreased in older heart failurepatients with preserved EF and is correlated with impaired exercise tolerance.An additional finding of this study is that increased carotid intima-mediathickness, which is a marker of atherosclerosis, highly correlates withconcentric LV remodeling and hypertrophy. Another study, carried out by Xu etal.16 on the generalChinese population pointed out that increased carotid intima-media thickness isassociated with an increase of the LV mass index and posterior wallthickness.Kawaguchi et al.17 Becauseof its role in fibrogenesis, galectin-3 has been proposed as a potentialbiomarker involved in both cardiac and vascular remodeling. Increased expressionof galectin-3 has been documented in decompensated heart failure patients andwas associated with LV remodeling.19 A recentstudy carried out by Calvier et al.20 has shown that galectin-3 is a mediator of vascularfibrosis. The authors demonstrated that galectin-3 levels are overexpressed byvascular smooth muscle cells in aldosterone treated mice, which in turnincreases the deposit of collagen type I in these cells.20 Based on these findings andthe fact that neurohormonal activation is enhanced in heart failure patients, wetried to establish whether there is a link between serum galectin-3 levels andvascular stiffening indices. Our data showed no correlation between thesemarkers, even though there was a slight increase, but not significant, inarterial rigidity with higher levels of galectin-3. Contrary to theseobservations, Libhaber et al.21 in a community sample study involving 966 participants,showed that galectin-3 was independently associated with carotid-femoral pulsewave velocity.21 Our findingsare the first to suggest that increased galectin-3 levels are associated withabnormal ventricular-arterial coupling, meaning that it could be involved in thestiffening process of both myocardial and arterial components. Arterialstiffness and reduced cardiac compliance are responsible for increased couplingratio (Ea/Elv).22 The Ea/Elvratio is a complex parameter that includes arterial compliance, peripheralvascular resistance, impedance, systolic and diastolic time intervals, LVcontractility and LV function.23 It can be used to assess the interaction between themyocardium and the arterial system. In heart failure with reduced EF patients,there is an elevation in Ea/Elv ratio due to an increase in the arterial loadand a decrease of LV contractility. On the other hand, this ratio is balanced inpatients with heart failure with preserved EF compared with normal subjects dueto a simultaneous rise in both arterial and LV elastance, which is in line withour findings.23Galectin-3 has been demonstrated to promote fibrosis via increased activation ofthe transforming growth factor beta / Smad-3 (TGF-beta/Smad-3) signalingpathway.24 we found that serum levels of galectin-3 did notdiffer between patients with heart failure with preserved EF and those withreduced EF.24 So far, the roleof galectin-3 in cardiac stiffness has been shown by its association withechocardiography markers of diastolic dysfunction: high LV filling pressures(expressed by the E/e ratio) and abnormal LV relaxation (e-wavevelocity).25 As forthe systolic function, in a study realized by Van der Velde et al.,26 galectin-3 was proven to bean independent predictor for EF in patients after myocardialinfarction.26 In ourstudy, we observed that high galectin-3 levels were associated with impaired LVsystolic function reflected by lower rates of LV pressure rise. To ourknowledge, this is the first study to report a correlation of this kind. Therate of LV pressure rise in early systole (dp/dt) assesses global LVcontractility by Doppler examination of mitral regurgitation jet. As thecontractility force exerted by the LV decreases in advanced heart failure, therates of LV pressure rise become lower. In addition, since heart failurepatients with reduced EF and increased LV diameters have significantly lowerdp/dt rates, galectin-3 could be involved in eccentric remodeling, representinga possible marker of severe systolic dysfunction. The negative effects ofgalectin-3 on systolic function were also seen in increased end-systolic volumeand end-systolic diameter. Lok et al.19 were the first to demonstrate a positive correlationbetween high baseline levels of galectin-3 and the increase of end-diastolic andend-systolic diameters over time in heart failure patients. Another interestingfinding was that increased arterial pulmonary pressure was predictive of highergalectin-3 serum levels. The association between pulmonary hypertension andgalectin-3 has been demonstrated in patients with diastolic heartfailure-induced pulmonary hypertension, and galectin-3 levels has been shown tobe positively correlated with right ventricular systolic pressure(p<0.01).28 Pathophysiology of pulmonaryhypertension in heart failure is characterized by pulmonary arterial remodeling,in which medial hypertrophy and intimal fibrosis are the maincomponents.29 Havingthis in mind and the fact that diastolic dysfunction is associated withdifferent grades of myocardial hypertrophy and fibrosis, galectin-3 is likely tobe involved in myocardial and pulmonary artery remodeling processes. This is ofparticular importance since it may explain both the active precapillarypulmonary hypertension that plays an important role in the prognosis andworsening of heart failure and the passive postcapillary component as a resultof increased end-diastolic pressures.As previously observed by De Boer et al.,18 in which the authors noted recurrence ofcardiac decompensation and mortality in patients with galectin-3 levels above9.42 ng/mL. However, the evaluation period was shorter than ours, comprising 60days. In another study on 592 heart failure patients, baseline galectin-3 levelspowerfully predicted outcome over a period of 18 months.24 With respect to pulmonaryartery systolic pressure, less is known about its prognostic value in left heartfailure. De Bursi et al.30were the first to evaluate the impact of PASP on a large community sample ofheart failure patients. They indicated that PASP measured by echo-Dopplerstrongly predicted mortality in these patients, which makes it a relevantindicator of outcome in this population.30Here, we report that serum galectin-3 levels above the mean of 10 ng/mL andincreased PASP are independent prognostic factors for all-cause mortality andreadmissions of heart failure patients over a period of 12 months. Our findingsare somewhat similar to those reported in "The N-terminal Pro-BNP investigationof dyspnea in the emergency department (PRIDE)" studyThis study was designed to fill the gap in knowledge about vascular remodeling andits progression in heart failure patients, which is considered to be responsiblefor adverse outcomes. This study showed no significant correlation between serumgalectin-3 levels and arterial stiffening markers in this population. Even so,our data suggest that galectin-3 contributes to abnormal ventricular-vascularcoupling. Galectin-3 might be involved in vascular and myocardial stiffening ofheart failure patients, but larger samples would be useful to confirm thepreliminary findings of our study. Also, galectin-3 may be predictive of raisedpulmonary pressures and could be responsible for the pathological changes in thedistal pulmonary arteries with consequent pulmonary vascular resistance andhypertension described in heart failure. Both galectin-3 and PASP wereindependent prognostic factors. The present study extends previous findings thatarterial stiffening is increased in heart failure with preserved EF and isassociated with LV concentric remodeling. Our findings highlight the involvementof galectin-3 in diastolic and systolic impairment, but most importantly, thathigh galectin-3 concentrations are associated with severe systolicdysfunction.One potential limitation of our study is that the measurement of aorticlength to estimate the pulse wave velocity required some approximations dueto anatomical changes of the aorta especially in the elderly. As well asthat, the estimation of vascular dimensions from the body surface remains aquestionable technique. Another limitation is in determining the time takenby the blood ejected from the heart to reach the arteries, given the factthat this parameter is dependent on factors such as conductionabnormalities or rhythm. Since some of our patients presented conductionabnormalities (bundle branch blocks) or atrial fibrillation, severalmeasurements were needed to determine this parameter and to record goodpulse waves.During admission, there might have been some delays from the obtaining ofvascular indices and collection of blood samples for galectin-3determination. This may have affected the assessment of the relationshipbetween these parameters, particularly because the biological half-time ofgalectin-3 has not been established. However, unlike NT-proBNP whichdecreases in LV loading, due to its role in fibrosis, galectin-3 does notrespond to a hemodynamically compensated condition. For this reason, itwould have been more accurate to evaluate whether changes in theconcentration of galectin-3 would affect arterial stiffening. In addition,the relatively small size of our cohort limited the evaluation ofcorrelations of galectin-3 with echocardiographic indices. Due to theselimitations, we hope that our study serve as a hypothesis-generating basisfor further large prospective studies to confirm our findings.


To meet these challenging demands, we and others developed physiologically relevant mouse models and characterized their hearts with planar AP mapping. Here, we summarize the progress toward panoramic fluorescence imaging and its prospects for the mouse heart. In general, several high-resolution cameras are synchronized and geometrically arranged for panoramic voltage mapping and the surface and blood vessel anatomy documented through image segmentation and heart surface reconstruction. We expect that panoramic voltage imaging will lead to novel insights about molecular arrhythmia mechanisms through quantitative strategies and organ-representative analysis of intact mouse hearts.To investigate the dynamics and propensity for arrhythmias in intact transgenic hearts comprehensively, optical strategies for panoramic fluorescence imaging of action potential (AP) propagation are essential. In particular, mechanism-oriented molecular studies usually depend on transgenic mouse hearts of only a few millimeters in size. Furthermore, the temporal scales of the mouse heart remain a challenge for panoramic fluorescence imaging with heart rates ranging from 200 min In addition, AP duration (APD) and the stability of cardiac repolarization are regulated by distinct K+ channel types, e.g., during ischemia activation of ATP-sensitive K+ channels (KATP) leads to APD shortening thereby preventing potentially detrimental intracellular Ca2+ overload. While each principle contributes to impulse generation, propagation and/or modulation in heart tissue, the molecular mechanisms of AP modulation and disease changes are exceedingly complex and depend on thorough analysis in intact heart tissue based on non-invasive imaging methods.Molecular physiology and genetic engineering studies have established complex genetic and cellular determinants of impulse propagation in mouse models. Four distinct molecular principles were identified: connexin channels at gap junctions control solute flux between myocytes and electrical current flow throughout the myocardial syncytium Figure ; cardiac2+ dye) have become a central strategy to study impulse propagation in transgenic mouse hearts in which EC coupling cycles occur an order of magnitude faster than human heart. High VSDI based resolution has allowed the functional characterization of anisotropic impulse propagation in mouse hearts. This has revealed the physiological relevance of select Nav1.5 channel membrane targeting mechanisms and led to the concept of distinct, locally confined pools of Nav1.5 channels at the intercalated disc (ICD) vs. the lateral cell membrane  or multiparametric imaging  and a planar resolution of 50–100 μm are achieved. Each sensor pixel records the fluorescent signal average of multiple cells. The tissue-specific propagation of epicardial AP wave fronts can be analyzed during sinus rhythm Figure  or durinFurthermore, both physiological and pathological changes of cardiac repolarization can be analyzed. Abnormal AP formation  as mechanism of triggered arrhythmias, abnormal AP propagation , and reentry contribute to arrhythmia initiation and/or propagation. Optical signals recorded by individual pixels can be analyzed to determine local APD, e.g., repolarization at 80% of the signal amplitude Figure . Similar2+ transients) cannot be analyzed continuously throughout the whole surface of the mouse heart, especially the spatially complex 3D impulse spread during fast arrhythmias. In addition, the high curvature-to-volume ratio of mouse hearts distorts fluorescent signals originating from shallow angles of peripheral boundaries, limiting the effective ROI of single camera approaches , while ex vivo imaging additionally facilitates detailed analysis about the time and location of residual chaotic activity in the heart. Finally, detailed experimental knowledge about the electrical activity on the cardiac surface together with internal tissue structures can be combined through 3D computational methods to reconstruct the hidden spatiotemporal dynamics of arrhythmias and therapeutic interventions inside the heart tissue in a non-invasive manner.External and internal cardioverter defibrillators (ICDs) are routinely used in clinical medicine, but electrical shocks can cause significant side effects including tissue damage and traumatic pain. Recently, a new strategy for arrhythmia control using low-energy antifibrillation pacing (LEAP) was developed. LEAP uses a series of five low-energy pulses to terminate atrial fibrillation 2+ transients. Recent data from transgenic mouse hearts identified novel molecular determinants of ion channel expression and targeting in cardiac myocytes with marked effects on the conduction properties of the ventricles. This led to the realization that complex molecular mechanisms underlie the anisotropic activation pattern of the intact hearts, namely ion channel complexes at gap junctions, lateral membranes, and T-tubules, and all with specific effects on conduction properties. In general, acquired or genetic changes result in decreased spatiotemporal AP propagation and conduction delay, which may contribute to arrhythmogenesis. Panoramic imaging of mouse and larger hearts will contribute to better understanding of arrhythmia propensity and onset, as well as support clinical translation of important new therapeutic concepts, in particular 3D-MIMS and LEAP.In summary, panoramic imaging of rabbit and larger mammalian hearts has been successfully developed whereas panoramic imaging of smaller, particularly transgenic mouse hearts will most likely be realized in the near future based on the success of VSDI and multiparametric readouts such as combined CaThe 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.