Asthma is the most common cause of respiratory disorders among children. We aimed to investigate left (LV) and right (RV) ventricular function in asthmatic children as detected by conventional and tissue Doppler echocardiography.Fifty pediatric patients with asthma and forty healthy children were studied. Pulmonary function tests, electrocardiography and echocardiographic examinations were performed on all children.p = 0.044), the ratio between heights of early and late diastolic flow velocity peaks (E/A) (p = 0.019) and LV end-systolic wall stress (ESWSm) was lower (p = 0.003), RV stroke volume (SV) (p = 0.002), LV SV (p = 0.001), tricuspid annular plane systolic excursion (TAPSE) (p = 0.034), tricuspid annular peak velocity during systole (S’) (p = 0.022), tricuspid and mitral early diastolic velocities (E’)  were lower in asthmatic children than controls. The mitral valve ejection time (ET) was high in asthmatic group (p = 0.027).Rate-corrected velocity of circumferential fiber shortening (VCFc) (p = 0.018) (r = 0.382) and mitral ET (p = 0.018) (r = 0.381). PEF was negatively correlated with the RV work index (p = 0.032) (r = -0.348) and LV work index (p = 0.005) (r = -0.457).FEV1 was positively correlated with isovolumetric relaxation time (IVRT) (Although cardiac systolic function was found to be impaired in asthmatic patients, contrary to the literature, diastolic dysfunction was not observed in these patients, even by tissue Doppler imaging, and this finding may be attributed to using inhaled corticosteroid Asthma is a chronic inflammatory disease of the airways which is related to airway obstruction, hyper-responsiveness and characterized recurrent wheezing, coughing and breathlessness . BronchiOur study aimed to investigate ventricular diastolic and systolic functions, LV wall stresses and circumferential fiber shortening by using tissue Doppler imaging (TDI) and conventional echocardiography in asthmatic children, using regular inhaled corticosteroid, without any cardiovascular symptoms.We studied 50 pediatric patients , selected randomly from those with bronchial asthma, and 40 healthy subjects. Inclusion criteria include all patients meeting the criteria for bronchial asthma /(LVED+ hd/2 + sd/2)SFmid = Where the d : left ventricular end-diastolic posterior wall thicknesshd: end-diastolic septal thicknesssLVES stands for LV end systolic dimension and LVED stands for LV end diastolic dimension.LVEDP = 21.6 (Q-M1/A2-OS) + 1.1, OS: opening snap of the mitral valve, A2: aortic component of the second heart sound, Q: Q wave on the ECG, M1: mitral component of the first heart sound .RV and LV function were also evaluated using TDI: Peak systolic (S’) and early and late diastolic velocities (E’ and A’) were measured from the apical four-chamber view with the pulsed-wave Doppler sample volume placed at the tricuspid and mitral annulus.Cardiac time intervals comprising RV included IVCT from the end of the tricuspid flow to the beginning of the pulmonary flow, IVRT from the end of the pulmonary flow to the beginning of the tricuspid flow, and ET from the beginning to the end of the pulmonary flow were also measured.The statistical analyses were performed by the Statistical Package for Social Sciences (SPSS). Kolmogorov–Smirnov and Shapiro Wilk tests were used to assess normality of distribution.t test for normally distributed data and the Mann Whitney u test for not normally distributed data. Bivariate associations of the variables were assessed using Pearson’s correlation coefficients. Variables were expressed as mean ± SD and p value <0.05 was considered to indicate statistical significance.Parametric variables were compared using the Student’s The current study enrolled 50 patients (35 boys and 15 girls) with a mean age of 10.56 ± 3.03 years who had diagnosis of bronchial asthma. The characteristics of the children and healthy subjects are shown in Table p = 0.044), E/A ratio (p = 0.019), ESWSm was lower (p = 0.003), RSV (p = 0.002), LSV (p = 0.001), tricuspid annular peak velocity during systole (S’) (p = 0.022), TAPSE (p = 0.034) and tricuspid and mitral E’  were lower in asthmatic children than control subjects. Mitral valve ET was higher in the asthmatic group (p = 0.027). Distribution of ESWSm between groups is showed in Fig. LV and RV echocardiographic findings are listed in Tables o p = 0.09, ESWSm p = 0.018) (r = 0.382) and ET-MV (p = 0.018) (r = 0.381). PEF was negatively correlated with RVWI (p = 0.032), (r = -0.348) and LVWI (p = 0.005), (r = -0.457).We performed pulmonary function tests on patient and control groups and correlated FEV1, FVC, FEV1/FVC and PEF with cardiac parameters. There were no differences between the asthmatic and control group. In correlation analysis, FEV1 was positively correlated with IVRT  systolic and diastolic dysfunction were detected, even in mild cases, by echocardiography. On the other hand, left ventricular (LV) dysfunction usually presents itself in severe asthmatic cases which may be reversible in acute conditions , 18.Some studies showed that there were no differences in echocardiographic findings regarding the ventricular function with the exception of RV wall thickness , 19. We IVMA, MPI, EF, FS, TAPSE, MAPSE, SV, VCFc and ESWSm values of both ventricles were evaluated to assess ventricular systolic function. IVMA, MPI, EF, FS and MAPSE were similar in both groups. TAPSE was lower in asthmatic patients.. In this study we couldn’t show any differences between IVMA values in either group.IVMA is a measurement of ventricular contractile function that is unaffected by preload and afterload changes in a physiological range . In thisThe SV of both the RV and LV were lower in asthmatic children than in the controls in our study. Hedlin et al  reportedTo assess LV contractility, we also analyzed changes in LV VCFc and afterload (ESWSm) . The venTo evaluate ventricular diastolic function we used mitral and tricuspid E/A, E’, A’, DT, IVRT and IVCT by using conventional echocardiography and TDI. There are some studies which reported RV and LV diastolic dysfunction in patients with moderate to severe asthma , 23, 24.Mitral and tricuspid annulus early diastolic velocities were different by TDI. Mitral E’, tricuspid E’ and S’ were lower in the asthmatic group. There were no significant differences among the IVCT, IVRT and DT in either the mitral or tricuspid annulus. These findings showed that there was no diastolic dysfunction among our asthmatic children even by TDI. This result may due to use of inhaled corticosteroids. Shedeed  reportedr = 0.72). In one study it has been suggested that normal RPEP/RVET was not significantly influenced by age or heart rate, and therefore could be used as an index of RV performance throughout a wide range of pediatric age groups. On the other hand, the same study revealed that the RPEP/RVET ratio correlated with mean pulmonary artery pressure and was associated with pulmonary vascular resistance [Hirschfeld et al  measuredsistance . The curWe performed pulmonary function tests in both groups. FEV1 was positively correlated with IVRT and ET-MV. PEF was negatively correlated with RVWI and LVWI. Ozdemir et al  reportedInhaled corticosteroids exert a strong anti-inflammatory effect on airways; they represent the most effective agents for long-term asthma control . Some stIn our previous study on asthmatic children who use inhaled corticosteroid, arterial stiffness were decreased, distensibility and strain were increased . We suggAsthma affects ventricular contractility in children. Although cardiac systolic function was found to be impaired in asthmatic patients, contrary to the literature diastolic dysfunction didn’t observed in these patients even by tissue Doppler imaging, may be due to using inhaled corticosteroid. This was one of the most comprehensive studies among asthmatic patients. Further studies with larger sample sizes or without using corticosteroid treatment warranted to better elucidate the cardiac function in asthmatic children.A, Peak velocity during late diastole; A’, Annular peak velocity during late diastole; Aort VTI, Time velocity integral for aortic valve; AT/PAET, Acceleration time/Pulmonary artery Ejection Time; BP, Blood pressure; DT, Deceleration time; E, Peak velocity during early diastole; E’, Annular peak velocity during early diastole; EF, Ejection fraction; ESWSm, Meridional end-systolic wall stress; ET, Ejection time; FEV1, Forced expiratory volume in 1 s; FVC, Forced vital capacity; IVCT, Izovolumetric contraction time; IVMA-MV, Mitral valve myocardial acceleration during izovolumetric contraction; IVMA-PA, Pulmonery artery myocardial acceleration during izovolumetric contraction; IVMA-TV, Tricuspid valve myocardial acceleration during izovolumetric contraction; IVRT, Izovolumetric relaxation time; L-sist T, Left Systolic Time (Contraction time); LSV, Left ventricle stroke Volume; LVEDP, Left Ventricle end-diastolic Pressure; LV-FS, Left ventricle fractional shortening; LVM, Left ventricular mass; LVWI, Left ventricular work index; LVWT, Left ventricular wall thickness; MAPSE, Mitral annular plane systolic excursion; MFS, Myocardial fiber stress; MPI, Myocardial performance index; PA VTI, Time velocity integral for pulmonary artery; PEF, Peak expiratory flow; RPEP/AT, Right ventricle Pre-Ejection Period/Right ventricle Acceleration Time; R-sist T, Right ventricle systolic time (contraction time); RSV, Right ventricle stroke volume; RV-EF, Right ventricle ejection fraction; RV-FS, Right ventricle fractional shortening; RVPEP/RVET, Right ventricle Pre-Ejection Period/Right ventricle Ejection Time; RVWI, Right ventricular work index; RVWT, Right ventricular wall thickness; S’, Annular peak velocity during systole; TAPSE, Tricuspid annular plane systolic excursion; TDI, Tissue Doppler imaging; VCFc, Rate-corrected velocity of circumferential fiber shortening; WSM, Meridional LV wall stress.


Mitral valve repair is favored over replacement due to superior outcomes. However, extensive infective endocarditis (IE) often has been considered unreconstructable. We retrospectively analyzed the mid-term outcomes of an individualized repair approach using a lifting annuloplasty strip.Streptococcus 10, Staphylococcus 4, HACEK 3, Enterococcus 1, Gram negative bacilli 1). One case (4 %) had a previously repaired mitral valve—the repair was redone. Via right thoracotomy (74 %) or median sternotomy (26 %), repair was performed by removal of vegetation and resection of infected tissue, the defect typically then being repaired using a bovine pericardial patch (81 %). Artificial chordae were formed in 5 patients. Nine (33 %) of them had posterior leaflet augmentation (PLA) to get sufficient coaptation height. Clinical and echocardiographic follow-up were performed.Between December 2007 and March 2014, 27 consecutive patients with acute single mitral valve IE  underwent lifting mitral annuloplasty (LMA) with a strip . Blood culture was positive in 70 % (p < 0.01). The LV ejection fraction decreased immediately, but recovered . The latest follow-up echocardiograms (median 28 months) universally showed no or minimal regurgitation, with a preserved mitral valve opening area (2.27 ± 0.48 cm2). During the clinical follow-up , one (3.7 %) death was observed . There was no reoperation or major cardiovascular event. The 5 year survival rate was 96.3 %.Compared with preoperative ones, postoperative echocardiograms revealed decreases of left ventricular (LV) end-diastolic dimensions (57.2 ± 6.3 versus, 45.4 ± 6.2, or 44.8 ± 4.1 mm, all The repair technique of LMA and/or PLA in patients with IE achieved good structural and functional outcomes as well as an excellent 5 year survival rate. An individualized repair approach should be recommended in patients with acute phase IE. Despite advanced diagnostic modalities and therapeutic techniques, infective endocarditis (IE) remains a dangerous condition with an incidence ranging from 16 to 62 cases per million person-years .In the setting of degenerative mitral valve regurgitation, mitral valve repair is preferred over mitral valve replacement, but for treatment of mitral regurgitation due to IE, mitral valve replacement is preferred because of concerns about the durability of mitral valve repair, recurrence of IE, and mitral regurgitation –7. But rThe aim of the present single-center, consecutive patient study is to investigate the outcomes of mitral valve repair using lifting mitral annuloplasty (LMA) during acute phase IE having extensive destruction of the mitral valve.The Konkuk University Medical Center Institutional Review Board approved this retrospective study and waived the need for individual patient consent. The clinical records of patients who underwent mitral valve surgery for IE were reviewed from December 2007 to March 2014. A total 39 mitral valve open heart surgeries were performed during the study period for correction of acute phase IE in the mitral valve. Among them, there were 29 single mitral valve surgeries, the rest double valve, including the aortic valve. Of the 29 cases, two patients underwent mitral valve replacement—one underwent prior open heart surgery for mitral valve replacement and MAZE for rheumatic mitral valve stenosis and atrial fibrillation, the other underwent mitral valve repair for unknown etiology elsewhere. The study cohort of single mitral valve repairs due to acute phase IE therefore comprised 27 consecutive patients. The mean age was 43 ± 16 years , the baseline characteristics are summarized in Table Streptococcus in 11 patients (58 %)—Streptococcus mitis in 4, Streptococcus sanguinis in 2, Other Viridans streptococci in 2, Streptococcus pneumoniae in 1, Streptococcus gordonii in 1, and Enterococcus faecalis in 1. Next were Staphylococcus in 4 (21 %) , the Haemophilus parainfluenza in 3 (16 %), and other gram-negative bacilli in 1 (5 %). Culture-negative endocarditis was defined as endocarditis in which no microorganism could be identified either on serial blood culture or in cultures made from the explanted valvular tissue of patients presenting with the clinical picture of endocarditis. Its presentation was significant with systemic embolism in 12 patients (44 %): embolic stroke was the first presentation in 9 patients, and there were other combined systemic embolic infarctions in the spleen (2 patients), kidney (one patient), or other peripheral extremities (2 patients). The presentation with acute heart failure with acute pulmonary edema was 26 % and with septic shock, 11 %. The preoperative chest X-ray revealed pulmonary edema in 7 patients while electrocardiograms showed atrial fibrillation in 3 patients .Acute phase endocarditis was clinically diagnosed by the modified Duke criteria , and sur2 by the proximal isovelocity surface area method [The preoperative echocardiogram showed a mean left ventricular (LV) ejection fraction (EF) of 64.4 ± 9.6 % . One patient had prior mitral valve ring annuloplasty elsewhere, and the others showed native mitral valves with leaflet prolapse or chordae rupture, and suspicious underlying rheumatic pathologies (4 patients). The mitral vegetations were extensive in both anterior and posterior leaflets in 15 patients, mainly anterior in 9 patients, and posterior in 3 patients. The amount of mitral valve regurgitation was moderate or severe with an effective regurgitant orifice (ERO) of 0.59 ± 0.30 cma method .The timing for surgery varied. The median period from admission to operation was 4 days . As a referral center, the actual interval from diagnosis to operation was 20.9 ± 14.0 days, and according to the culture-driven antimicrobial therapy  preoperaRight anterolateral thoracotomy, as a standard approach of surgery for mitral valve regurgitation in our center, was performed in 74 % 20/27) of patients. Under general anesthesia with double-lumen intubation, patients were positioned in left decubitus. Cardiopulmonary bypass was initiated using peripheral cannulation through the right internal jugular vein, right femoral vein, and right femoral artery, under transesophageal echocardiography guidance. Median sternotomy was performed in 26 % (7/27) of patients who had obstructive or restrictive lung disease on the pulmonary function test (such as measuring forced expiratory volume in less than 1 s) or who underwent cardiac surgery via right thoracotomy previously. All operations were performed using a standard cardiopulmonary bypass with crystalloid cardioplegia and mild hypothermia. Operative data are summarized in Table 0/27 of pAll mitral valve repairs were performed through the left atrium via the groove of Sondergaard. All the visible vegetations and infected tissues were eliminated. In 22 patients (81 %), including the 3 patients with a previous perforation from destructive IE, the ruptured hole in mitral valve leaflets formed by the removal of vegetation or slicing of the leaflet was repaired with bovine pericardium . Chordal replacement with expanded polytetrafluoroethylene sutures was performed in 5 (19 %) patients, posterior leaflet augmentation (PLA) in 9 (33 %) . As the Enterococcus faecalis), full coverage of antimicrobial therapy was given, starting from the time of surgery; however, in most patients with a negative operative tissue culture, the duration of antimicrobial therapy was calculated from the preoperative antibiotics for 4 to 6 weeks, and minimum one week of post-operative period even if the duration extended the overall course. The duration of postoperative antibiotic therapy was 22.4 ± 11.1 days.In patients with a positive operative tissue culture . Baseline and follow-up data were expressed as mean (standard deviation) or median (interquartile range) for continuous variables and as a number (percentage) for categorical or binary variables. All continuous data were tested for a normal distribution using Kolmogorov-Smirnov nonparametric tests. Sphericity was tested using Mauchly’s test. Serial echocardiographic changes were assessed using a repeated measures analysis of variance. Post hoc analyses were performed using Bonferroni’s method. The cumulative event-free survival curve was determined according to the Kaplan-Meier method. Two-sided p values < 0.05 were considered statistically significant.Statistical analysis was performed with dBSTAT : a 72-year-old woman died from septic shock caused by cholangitis, pancreatitis, and pneumonia, and had a pre-existing diagnosis of stomach cancer—despite good immediate-postoperative cardiac function. None of the patients experienced valve-related complications such as thromboembolism bleeding events associated anticoagulation. During the follow-up, there was no recurrence of endocarditis and no reoperation. The 5 year survival rate was 96.3 %.p < 0.001) and from 35.7 ± 6.7 to 32.5 ± 6.3 mm (p = 0.046),respectively. But the LV EF decreased from 64.4 ± 9.6 % to 54.5 ± 9.8 % (p = 0.002). The LA dimension and estimated pulmonary artery systolic pressure (PASP) also significantly decreased from 46.5 ± 5.9 to 34.4 ± 8.9 mm (p < 0.001) and from 37.1 ± 14.9 to 24.5 ± 6.9 mm Hg (p < 0.001), respectively.Comprehensive transthoracic echocardiography was performed before patient discharge, the mean postoperative period being 7.4 ± 2.4 days. Immediately postoperatively, all patients showed mitral regurgitation less than grade 1. The LV end-diastolic dimension (EDD) and LV end-systolic dimension (ESD) decreased from 57.2 ± 6.3 to 45.4 ± 6.2 mm (p < 0.001) and 35.7 ± 6.7 mm to 28.3 ± 2.9 mm (p < 0.001). The decreased LV EF in the immediate postoperative period improved from 54.5 ± 9.8 % to 65.2 ± 6.1 %  and 37.1 ± 14.9 to 26.9 ± 5.1 mmHg (p = 0.012). The mean mitral valve area measured by two-dimensional area was 2.27 ± 0.48 cm2 at the last follow-up visit. The echocardiographic findings are summarized in Table The mean last-follow-up echocardiography interval was 30 ± 22 months. All of the survivors  in our series had trivial or mild mitral regurgitation at their last follow-up visit. Follow-up LV reversal remodeling measured by the change in LV EDD, ESD, and EF was observed after surgery. The LV EDD and ESD decreased significantly compared with preoperative findings, from 57.2 ± 6.3 to 44.8 ± 4.1 mm (Mitral valve repair is a standard treatment for noninfected valvular disease. One of the advantages of mitral valve repair over mitral valve replacement is the preservation of LV function. Kouris and associates reported that mitral valve repair in patients with mitral regurgitation achieved better preservation of LV systolic indices than mitral valve replacement, probably due to preservation of the subvalvular apparatus and LV geometry , and sevThe most recent reports suggest acceptable short- and long-term outcomes. Ruttmann et al. demonstrated that event-free survival at 1 year was 88.2 and 80.4 % at 5 years in the repair group . ShimokaIn active endocarditis, the feasibility of valve repair depends on the extent of the pathological lesion . In publAlthough an important surgical rule when dealing with valve surgery due to IE is to avoid the use of prosthetic material as often as possible, in our case, using the LMA strip with or without bovine pericardium to reconstruct the mitral valve defect, there was no recurrent endocarditis during the median follow-up of 54 months. The reported recurrence rates of endocarditis in patients undergoing mitral valve repair for active endocarditis were as low as 1 in 37 patients .In patients with rheumatic valve pathology such as shrunken or thickened leaflets, we sliced the leaflet to increase pliability and then augmented the posterior leaflet using bovine pericardium. This technique has been described by Chauvaud et al. . We usedThe normal mitral annulus is not a two-dimensional flat and fixed structure but rather takes the three-dimensional form of a saddle . The sadA decrease in atrial and ventricular size, called reverse remodeling, has been observed after mitral valve procedures. In our study, the immediate postoperative LV EF was decreased but recovered after follow-up. This phenomenon may be because the LV EDD is reduced more quickly than the LV ESD, resulting in a decreased LV EF; however, the negative remodeling of the LV ESD restored the LV EF Fig. . These fThis is a single-center experience with a relatively small number of patents. Our study excluded patients having mitral valve replacement in order to focus on the effects of our techniques on mitral valve repair with endocarditis per se, and comparison between mitral valve repair and replacement was limited due to only 2 patients undergoing replacement. Finally, we are aware that the lack of comparison with other repair techniques limits conclusions concerning the superiority of the LMA approach. However, repair techniques using bovine pericardium and LMA has enabled us to suggest that extensive IE is not a strong contraindication for mitral valve repair. Further studies incorporating a larger number of patients and comparable groups using other repair techniques are necessary to evaluate the relative advantages of our mitral valve repair techniques.This repair technique of LMA with or without PLA in patients with acute-phase IE achieved good structural and functional outcomes as well as an excellent 5 year survival rate. An individualized repair approach should be recommended in patients with acute-phase IE.


Dilated cardiomyopathy and ischaemic heart disease can both lead to right ventricular (RV) dysfunction. Direct comparisons of the two entities regarding RV size and function using state-of-the-art imaging techniques have not yet been performed. We aimed to determine RV function and volume in dilated cardiomyopathy and ischaemic heart disease in relation to left ventricular (LV) systolic and diastolic function and systolic pulmonary artery pressure.n = 23) with ischaemic heart disease. Volumes and EF were determined with magnetic resonance imaging, diastolic LV function and pulmonary artery pressure with echocardiography.A well-characterised group  of 46 patients with dilated cardiomyopathy was compared with LV ejection fraction (EF)-matched patients : LVEF , ratio of peak early and peak atrial transmitral Doppler flow velocity as measure of LV filling pressure  and tricuspid regurgitation flow velocity as measure of pulmonary artery pressure . RVEF was significantly worse in patients with dilated cardiomyopathy compared with ischaemic heart disease: median 48 % (interquartile range (IQR) 37–55 %) versus 56 % (IQR 48–63 %), p < 0.05.After multivariable linear regression, four factors independently influenced RVEF (RIn patients with dilated cardiomyopathy and ischaemic heart disease, RV function is determined by LV systolic and diastolic function, the underlying cause of LV dysfunction, and pulmonary artery pressure. It was demonstrated that RV function is more impaired in dilated cardiomyopathy. Right ventricular (RV) dysfunction and dilatation are correlated to limited exercise capacity and poor outcome –4, but oTwo groups of patients were included in the study: patients with DCM from Maastricht University Medical Center and patients with IHD from our infarct database matched for LVEF.Study subjects in the DCM group comprised 46 consecutive patients with DCM referred to our heart failure program. All underwent a standard diagnostic evaluation including electrocardiogram (ECG), coronary angiography, endomyocardial biopsy, echocardiography and cardiac magnetic resonance imaging (CMR). LV and RV volumes and systolic function were determined by CMR. LV diastolic function and RV systolic pressure were assessed with echocardiography as described later in the text. Patients with a history of myocardial infarction, history of cardiotoxic agents, significant coronary artery stenosis on coronary angiography, valvular heart disease on echocardiography as well as other known causes of impaired systolic function such as inflammation or infiltrative disorders on endomyocardial biopsy were excluded from the study. Patients with permanent pacemakers, rhythm other than sinus and significant chronic renal failure ( ≥ stage 3 kidney disease) were also excluded.Study subjects in the IHD group were included from our infarct database matched for LVEF as measured by CMR. Thus, 23 patients with impaired systolic LV function due to chronic non-inferior myocardial infarction (infarction in left anterior descending (LAD) or left circumflex (LCX) coronary artery territory to avoid inclusion of patients with RV infarction) and without significant valvular disease were included. The study was approved by the local ethics committee.Patients were examined with a 1.5-T scanner . ECG-gated cine images were acquired for functional analysis using a steady-state free precession sequence . A breath-hold multislice T1-weighted three-dimensional inversion-recovery gradient-echo sequence  to evaluate the presence of myocardial infarction of the left and right ventricle was used to acquire images 10 min after intravenous administration of 0.2 mmol/kg body weight gadolinium diethylenetriaminepentaacetic acid . Inversion times were adjusted to null normal myocardium (200–280 ms).CMR images were analysed by an investigator blinded to clinical and echocardiographic data. Endocardial and epicardial LV and endocardial RV contours were manually traced in end-diastolic and end-systolic phases on short-axis slices to determine LV and RV end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF) and LV end-diastolic mass. Areas of late enhancement were visually assessed to confirm the presence and extent of infarction in the LAD or LCX territory as the reason for impaired LVEF in the IHD group.Echocardiography was used to determine LV diastolic function, LA volume and peak tricuspid regurgitation (TI) Doppler velocity. Transthoracic echocardiograms were performed using dedicated systems . Echocardiographic investigations were performed in the standard views, according to the recommendations of the American Society of Echocardiography . LV dias2 test, Student’s t-test or Mann–Whitney U test, as appropriate. For correlations, Pearson’s r was used. Finally, independent variables influencing RVEF were sought by using the multivariable linear regression model with a backward procedure .Variables are expressed as percentage, mean ± standard deviation or median (interquartile range (IQR)) as appropriate. The Kolmogorov–Smirnov test was applied to test whether continuous variables were normally distributed. Group comparisons were performed by using the Pearson χThe clinical characteristics of the DCM and IHD patients are summarised in Table CMR image analysis was possible in all patients. In three patients, however, image quality on echocardiography was not sufficient to obtain reliable pulmonary vein flow Doppler signals. In two of them, image quality was also not sufficient to obtain tissue Doppler signals, but the E/A ratio could be determined in all patients.A total of 21 patients with IHD had infarcts in the LAD territory and 2 patients in the LAD and LCX territory . Other clinical parameters had no influence on RVEF (data not shown). Overall, there were no significant differences in these correlations between patients with DCM and IHD (data not shown).As depicted in Table Multivariable analysis revealed that the RV function (i.e. RVEF) was correlated with LVEF, DCM compared with IHD, E/A ratio as measure of LV filling pressure, and TI velocity as measure of PAP as depicted in Table In the current study, the non-invasive imaging techniques CMR and echocardiography were applied in patients with DCM and IHD without RV free wall infarction, to evaluate RV function and volumes. RV systolic function was influenced by different factors including the underlying disease process, i.e. the presence of DCM, systolic and diastolic function of the LV and elevation of the PAP.In ST-segment elevation myocardial infarction (STEMI) patients with cardiogenic shock, RV dysfunction had been identified as a prognostic parameter . BetweenRV infarction detected by late enhancement CMR and RV systolic function were outcome predictors in a general population of STEMI patients . In infeThe underlying process also determines RV function. Patients with DCM experienced larger RV volumes and more severe impairment of RV function. In contrast to previous suggestions , 20, assElevated LV filling pressure, which leads to passive elevation of PAP, was one of the factors related to RV dysfunction in the current study. Since the prognosis of patients with impaired RV function is worse in comparison with patients with impaired systolic LV function only , 26, assThe current study has some limitations. Patients in the IHD group were older and less often treated with diuretics. Older age had a negative influence on RV function. However, although the patients in the IHD group were older, they showed a less impaired RV function than the patients from the DCM group. Thus, not matching for age did not result in a relevant bias. Treatment with diuretics can lower LV filling pressure and PAP and might have had an influence on the lower TI peak velocity measured in patients with DCM . In contIn conclusion, RV systolic function was influenced by different factors including the underlying disease process, i.e. the presence of DCM, systolic and diastolic function of the LV and elevation of PAP. A better understanding of these mechanisms may help to define therapeutic targets for future studies in these patients with RV dysfunction known to have a poor outcome.


We previously demonstrated that older beagles have impaired whole body and myocardial insulin responsiveness (MIR), and that glucagon-like peptide-1 (GLP-1 [7–36] amide) improves MIR in young beagles with dilated cardiomyopathy (DCM). Here, we sought to determine if aging alone predisposes to an accelerated course of DCM, and if GLP-1 [7–36] amide would restore MIR and impact the course of DCM in older beagles.−1). Hemodynamic measurements were performed routinely as heart failure progressed.Eight young beagles (Young-Control) and sixteen old beagles underwent chronic left ventricle (LV) instrumentation. Seven old beagles were treated with GLP-1 (7–36) amide (2.5 pmol/kg/min) for 2 weeks prior to instrumentation and for 35 days thereafter (Old + GLP-1), while other 9 served as control (Old-Control). All dogs underwent baseline metabolic determinations and LV biopsy for mitochondria isolation prior to the development of DCM induced by rapid pacing , and impaired MIR. GLP-1 reduced plasma NEFA , improved MIR , and increased uncoupling protein-3 (UCP-3) expression in isolated mitochondria. Compared to the Young-Control, the Old-Controls experienced an accelerated course of DCM  and excess mortality, while the Old + GLP-1 experienced increased latency to the onset of DCM  and reduced mortality.Aging is associated with myocardial insulin resistance, which predispose to an accelerated course of DCM. GLP-1 treatment is associated with increased MIR and protection against an accelerated course of DCM in older beagles. The aging population in the western world continues to be burdened by a disproportionate share of cardiovascular (CV) disease and the morbidity and mortality of cardiovascular conditions such as heart failure is increased among the elderly ,2. CardiPrior studies from our laboratory have demonstrated that aging in beagles is associated with the development of both whole body and myocardial insulin resistance, independent of obesity or inactivity . Other sTherefore, new strategies designed to improve mitochondrial function and restore myocardial insulin resistance in older patients may prove cardio-protective. One such candidate is glucagon-like peptide −1  and 16 old (10–12 years) beagles, weighing 14–18 kg were used in the present study. Figure The animals were acclimated to the research laboratory for 6 weeks prior to surgical instrumentation. They were fed a standard chow once daily with a fixed carbohydrate and fat content, and underwent a supervised exercise regimen on a treadmill each day for 30 minutes four times per week for 6 weeks prior to surgical instrumentation as previously described .All dogs underwent sterile surgical instrumentation as previously described ,20,21. TAfter 4 weeks of training, the older dogs were randomized to receive either GLP-1 (7–36) amide though a continuous intravenous infusion at a dose of 2.5 pmol/kg/min  or saline (3 ml/day) control  using a MiniMed infusion system. The GLP-1 (7–36) amide treatment was initiated 2 weeks prior to surgery and was continued through surgery, recovery (1 week) and during the rapid pacing stimulus for 28 days  to determine the magnitude of whole body insulin resistance between young and old beagles prior to exposure to GLP-1. In addition, plasma norepinephrine, insulin, glucagon, adiponectin, non-esterified fatty acids (NEFA), and glucose were measured as previously described .−2 • min−1) was administered for 120 minutes to create a steady state concentration of plasma insulin (~1000 pmol/L). Arterial glucose concentrations were measured every 5 minutes and glucose was infused to maintain plasma glucose concentrations at 5 mmol/L ±5%. Myocardial glucose and NEFA balance and coronary blood flow were sampled every 15 minutes to determine myocardial glucose uptake. Trans-myocardial substrate balance was calculated as the difference between arterial and coronary sinus content. Basal myocardial substrate uptake was calculated as the product of myocardial substrate balance and coronary blood flow (CBF) [Additionally, whole body and myocardial insulin sensitivity was assessed using the hyperinsulinemic-euglycemic clamp after surgical instrumentation and prior to the pacing insult to assess the effects of 3 weeks of GLP-1 treatment ,19. Brie2)  were calculated. Coronary flow reserve  was determined before and after the development of DCM.After baseline metabolic and hemodynamic measurements, all animals underwent rapid right ventricular pacing using a customized pacemaker at 240 beats/ minute. The rapid pacing was confirmed daily. Animals underwent hemodynamic evaluation at baseline (prior to pacing), daily for the first 3 days after pacing and then every 3 days for the next 28 days or until pre-specified hemodynamic parameters indicative of advanced DCM were reached. Advanced DCM was defined by the presence of depressed LV contractility (LVdP/dt) <1500 mmHg/sec, increased LV end-diastolic pressure (LVEDP) > 30 mmHg, reduced cardiac output (CO) < 1.8 L/min, and increased LV end-diastolic dimensions (LVEDD) >45 mm. In addition, stroke volume (SV), and myocardial oxygen consumption  at a constant voltage (100 V) [LV myocardial biopsy for isolation of intrafibrillar mitochondria (IFM) was performed at baseline during surgical instrumentation. This timing allowed for comparison of mitochondrial proteins between Young and Old-Control and Old + GLP-1 treated beagles. Crude mitochondrial isolates were prepared from canine myocardium using a trypsin digestion procedure as described previously ,15. Brie (100 V) . Nonspecg for 5 min. The supernatants were collected, and absorbance at 586 nm was recorded. MDA concentration was calculated using a standard curve. All measurements were performed in duplicate.Mitochondrial lipid peroxidation was assessed by levels of malondialdehyde (MDA), a marker of lipid oxidation using lipid peroxidation assay kit  as previously described . To prev. Where differences were detected over time, a post hoc Student’s Newman Keuls’s test was performed to determine differences at respective time points. Differences in mitochondrial proteins and metabolic parameters were determined using Student T-test for unpaired data. A Bonferroni correction was used when multiple comparisons were evaluated. A level of p < 0.05 was considered statistically significant.Data are expressed as the mean value ± SEM. Differences in hemodynamic and metabolic responses between the groups were determined by two-way ANOVATable The intravenous glucose challenge in young and older beagles at baseline prior to GLP-1 infusion was associated with a higher peak plasma glucose response in the Old-Control and Old + GLP-1 groups Figure A and a m−5, p < 0.05) compared to Young-Control, but comparable heart rate, cardiac output, and LV ejection fraction. Old-Control dogs had higher resting MVO2 compared to Young-Control . GLP-1 treatment improved isovolumic relaxation in Old + GLP-1 compared to Old-Control (p < 0.05). GLP-1 had no significant effects on resting cardiac output or coronary blood flow. Mean arterial pressure, systemic vascular resistance and MVO2 tended to be lower in Old + GLP-1 dogs after 3 weeks of treatment compared to Old-Control, although the differences did not reach statistical significance.After 3 weeks of GLP-1 treatment and 7 days from surgical instrumentation Figure . There wFigure The beneficial effects of GLP-1 infusion on myocardial metabolism were assessed under conditions of the hyperinsulinemic-euglycemic clamp. Both basal and insulin stimulated myocardial glucose uptake were reduced in Old-Control dogs Figure A while bMoreover, GLP-1 infusion had a positive impact on reactive oxygen species and mitochondrial protein expression in Old + GLP-1. Aging was associated with increased cellular and mitochondrial reactive oxygen species (ROS) compared to Young-Control as demonstrated by higher levels of MDA, a marker of lipid peroxidation, in the Old-Control dogs Figure A. Aging There were no differences in basal coronary blood flow responses between groups either before Figure A or afte amide improved myocardial insulin sensitivity, reduced myocardial mitochondrial oxidative stress, preserved expression of key mitochondrial proteins associated with oxidative balance (UCP-3) and mitochondrial respiration (MCO), and preserved coronary flow reserve culminating in an improved clinical course and reduced mortality following rapid pacing. These findings underscore the role of mitochondrial dysfunction and associated impaired myocardial insulin responsiveness in the progression of heart failure in advanced age.Aging has been associated with altered mitochondrial protein expression and reduced energetic reserve in studies of skeletal muscle ,26. ThesIn the present study we observed myocardial insulin resistance and altered mitochondrial ROS generation in association with decreased MCO, and UCP-3 expression in intrafibrillar myocardial mitochondria in older beagles. We focused on IFM as the most relevant component given their role in myocardial contractility and because age-associated changes seem to affect IFM preferentially . DecreasWe have shown previously that GLP-1 infusion improves cardiovascular function when administered for 48 hours to young dogs with severe dilated cardiomyopathy . We haveWe have also previously shown that the development of advanced heart failure in conscious dogs is associated with impaired coronary flow and vasodilator reserve in response to coronary vasodilators . Here weThere is an extensive literature that has demonstrated the salutary effects of both DPP-4 inhibitors  and DPP-. Finally, GLP-1 treatment was associated with improved coronary flow responses, suggesting vascular protective effects of GLP-1. While we cannot ascertain the relative contribution of these favorable changes to the improved clinical outcome in Old + GLP-1 dogs, these data demonstrate that GLP-1 treatment has multiple salutary cardiovascular effects in heart failure beyond glycemic control.The findings of increased mitochondrial ROS, reduced mitochondrial protein expression, and impaired myocardial insulin resistance were associations that do not prove causality in terms of the accelerated course of DCM in Old-Control. Other cellular process may also be deranged which could contribute to the response. Nonetheless, GLP-1 treatment mitigated the mitochondrial and metabolic abnormalities and protected Old-GLP-1against an accelerated course. Secondly, we measured mitochondrial protein expression not function. Additional studies detailing mitochondria abundance and morphology may help to further understand the role of mitochondrial dysfunction in this model and the extent to which GLP-1 may influence mitochondrial biogenesis and autophagy. Thirdly, it took several years to complete this study as the availability of senescent beagles was rate limiting. We began using MDA as a method to assess lipid peroxidation and continued to do so for the purposes of consistency over time. We recognize that currently there may be better quantitative methods of lipid peroxidation quantificationAging and associated mitochondrial dysfunction and insulin resistance predispose to an accelerated course of dilated cardiomyopathy and early mortality. Infusion of GLP-1 (7–36) amide is associated with reduced myocardial mitochondrial ROS and improved myocardial insulin sensitivity and protection against an accelerated course of dilated cardiomyopathy and early mortality in older beagles, suggesting salutary cardiovascular effects in heart failure beyond glycemic control.


Sarcomeric gene mutations cause hypertrophic cardiomyopathy (HCM). In gene mutation carriers without left ventricular (LV) hypertrophy (G + LVH-), subclinical imaging biomarkers are recognized as predictors of overt HCM, consisting of anterior mitral valve leaflet elongation, myocardial crypts, hyperdynamic LV ejection fraction, and abnormal apical trabeculation. Reverse curvature of the interventricular septum (into the LV) is characteristic of overt HCM. We aimed to assess LV septal convexity in subclinical HCM.Cardiovascular magnetic resonance was performed on 36 G + LVH- individuals  with a pathogenic sarcomere mutation, and 36 sex and age-matched healthy controls . Septal convexity (SCx) was measured in the apical four chamber view perpendicular to a reference line connecting the mid-septal wall at tricuspid valve insertion level and the apical right ventricular insertion point.vs. 1.6 ± 2.4 mm, p ≤ 0.0001). Expected findings occurred in G + LVH- individuals: longer anterior mitral valve leaflet , higher relative wall thickness , higher LV ejection fraction , and smaller LV end-systolic volume index . Other morphologic measurements  were not different between G + LVH- and controls.Septal convexity was increased in G + LVH- compared to controls (maximal distance of endocardium to reference line: 5.0 ± 2.5 mm Septal convexity is an additional previously undescribed feature of subclinical HCM. Hypertrophic cardiomyopathy (HCM) is the most common inherited monogenetic cardiac disease . ApproxiThe collaboration between CMR specialists and echocardiologists permits the sharing of skills and ideas. For example, LV morphology has been extensively and classically characterized by echocardiography using specific parameters and indexes  , most ofPatients with overt HCM  display abnormal LV septal curvature: in the normal heart the interventricular septum is either in a neutral position or has a characteristic convexity into the right ventricle (RV); whilst overt HCM is associated with reverse septal curvature leading to a typical “banana-like” LV cavity –18. The http://www.project-redcap.org/).A collaborative group at the Heart Hospital  have previously created and published a case–control cohort  composedStandard 12-lead electrocardiography was performed in the supine position during quiet respiration. LVH was evaluated with the Romhilt-Estes  and elecGenomic analysis of this cohort has been previously described in detail , 24, 25.Standard clinical scans  were performed using a 1.5-T magnet . CMR short-axis volumetric studies  were acqThe morphology, systolic function and the structure of the LV were evaluated by cardiologists experienced in CMR . All CMR measurements were blinded to gene status. The presence of fibrosis and the structure of the LV were evaluated by other cardiologists experienced in CMR .LV volumes, LV ejection fraction (EF), LV outflow tract diameter, and LV mass were determined according to standardized CMR methods   insertion on the LV Fig. . Septal http://www.osirix-viewer.com) as previously described [LV mitral angle, mitral papillary muscles angle, and LV-aortic root angle were analyzed on the open source software OsiriX®  length was measured using the method previously described by Maron et al.  Addition2 tests. Non-categorical data were directly compared using paired t test. An optimal threshold value for SCx within this case–control population was calculated as the Youden Index derived from the area under the receiver operating characteristics curve. Mean variability within and between readers was evaluated using the mean of differences between two measurements. Paired measurements for repeatability of SCx were evaluated using the Bland–Altman method [Descriptive data were analyzed for normality using the Shapiro-Wilks test and were expressed as mean ± standard deviation except where otherwise stated. Categorical variables were compared using χn method . A 2-sidThe study population consisted of 36 G + LVH- individuals (aged 15–62 years) with complete DICOM short and long axis images from within the original Heart Hospital cohort. G + LVH- cases deriving from 30 unrelated families, were compared to 36 matched healthy volunteers (aged 14–59 years)  were greater in G + LVH- subjects than controls . G + LVH- patients with at least one crypt had mean SCx values of 6.0 ± 3.1 mm while patients without crypt (n = 25) had a mean value of 4.6 ± 2.2 mm (p = 0.12).vs. 4.2 ± 2.4, p = 0.16).G + LVH- individuals with isolated MYBPC3 mutation (n = 16) had a mean SCx of 5.3 ± 2.7 mm while individuals with other mutations a mean SCx of 4.7 ± 2.3 mm (p = 0.45). Individuals with thick filament mutations (MYBPC3 and MYH7) tended to have greater SCx than individuals with thin filament mutations   exhibit abnormal convexity of the interventricular septum into the LV. Four other features described here  have been previously identified using CMR , 7, as wPatients with HCM are at risk of developing complications such as heart failure, atrial fibrillation, stroke, and sudden cardiac death. Consequently, the detection of a subclinical HCM phenotype –32 in reThis paper advances the field by the identification of one new feature – abnormal septal convexity. This was found by increasing the collaboration between CMR experts and experienced echocardiographers with the sharing of skills and ideas – the CMR approach alone previously adopted by our group missed septal convexity. The development of academic silos between imaging modalities should be resisted: breaking them down increases insights for patient care. Reverse septal curvature is well known in overt HCM patients to be related to a higher incidence of pathological gene mutation detection (79 % of the HCM patients with MYBPC3 mutation and absent in those without the mutation in one paper) . More reSeptal convexity is a straightforward measure that can be taken from a standard four chamber cine image, and we provide a cut-point for analysis. Short axis views did not show the curvature – we think that part of the curvature is the centre point of the blood pool cavity not lying on a straight line – the familiar “banana shaped” cavity from overt HCM. Thus a “stack of discs” that are the short axis cines are not aligned, but any one SA view can be normal; only a view (4 chamber) showing the cavity from base to apex fully shows the distortion. Although ultimately this measure is likely to be assessed in combination with other known subclinical features of HCM  this technique could potentially also be applied to echocardiographic images More sophisticated methods could be used to assess septal curvature , and theThis is a single centre study. Preclinical HCM requires the presence of a known pathogenic mutation – early detection is really most needed where such mutations are not present. Follow-up is necessary to confirm that this abnormality precedes or predicts the subsequent development of significant LVH. Larger prospective cohorts of mutation carriers and individuals with a pretest probability of 50 % are needed, especially to determine subclinical phenotypic differences between specific gene mutations.We did not observe significant differences between the two groups when assessment of septal convexity was performed in short axis. This is probably due to a different approach with different benchmarks, different scale of distance, and a different direction of measurement. So, we recommend using apical 4 chamber view approach to differentiate subjects. Intra- and inter-observer variabilities were good in spite of the absolute values (only a few millimeters) of our measurements. Several factors such as ethnicity, age, gender, and hypertension might impact septal convexity. In this present case control study, our population was highly selected and predominantly comprised white females aged <60 years. No subject had hypertension. We acknowledge that in clinical practice, septal convexity into LV should be used and interpreted with caution, and used only for Caucasian relatives of HCM patients, <60 years old, and without hypertension. Echocardiographically, septal curvature has been assessed in overt HCM by a method using the radius of curves matching the endocardial border . FurtherSeptal convexity (into the LV) is an additional previously unrecognized feature of subclinical HCM. It should be assessed in combination with other known subclinical HCM features, occurring in the absence of LV hypertrophy. Further studies with follow-up are necessary to confirm that septal convexity really precedes LVH in HCM mutation careers.


Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders of women during the reproductive period. Cardiovascular risk factors are more frequent in patients with PCOS. We aimed to investigate the P-wave dispersion (Pd), inter- and intra-atrial conduction time and mechanical functions of the left atrium (LA) in patients with PCOS.Forty-eight patients with PCOS and 38 normal healthy women were enrolled in this study. A 12-lead surface electrocardiogram was used to evaluate Pd. Left ventricular (LV) functions were measured using conventional and tissue Doppler imaging (TDI) methods. Inter- and intra-atrial conduction times were measured by TDI. LA volumes were measured echocardiographically with the biplane area–length method from the apical four-chamber view.p = 0.014) and Pd were significantly increased in the PCOS patients . Transmitral E/A ratio was significantly lower in the PCOS patients than in the controls . Passive emptying volume  and passive emptying fraction  were significantly decreased in PCOS patients. Total emptying volume was significantly decreased  in PCOS patients. Interatrial  and intra-atrial  electromechanical delays were found to be significantly higher in PCOS patients.Heart rate (82.02 ± 13.15 vs 74.24 ± 11.02 bpm, This study showed that patients with PCOS had increased inter- and intra-atrial conduction delays, and decreased LA passive emptying volumes and fractions. Polycystic ovary syndrome (PCOS) is one of the most common endocrine/hormonal disorders that affect an estimated 5–10% of women of reproductive age. It is characterised by hyperandrogenism, chronic anovulation and polycystic ovaries.2Gonadal steroids have an effect on cardiac ion currents and autonomic function and therefore may cause cardiac arrhythmias.5It has recently been identified that left atrial (LA) volume and mechanical functional index are potential indicators of atrial arrhythmia and cardiac disease. LA function is an important factor for left ventricular (LV) filling, and atrial emptying pressure and volume may provide important information about LV resistance. As a result, the atrial emptying pattern is strongly affected by LV diastolic function. Intra- and interatrial conduction delay, which are evaluated by tissue Doppler imaging (TDI), as well as power Doppler (PD), are electrophysiological characteristics of the atria that are prone to atrial fibrillation (AF).7Although there are some studies investigating QT dispersion and ventricular diastolic function in women with PCOS, there is no literature, to our knowledge, on the PD and electromechanical properties of patients with this disease. Therefore we aimed to investigate PD, inter- and intra-atrial conduction times and mechanical function of the LA in patients with PCOS.A total of 86 women were consecutively enrolled in this study. Forty-eight patients with PCOS (mean age 24 ± 4 years) and 38 normal healthy women as controls (mean age 27 ± 5 years), who attended the gynaecology clinic of Canakkale Onsekiz Mart University between March and May 2012, participated in this study.PCOS patients were selected from subjects who were admitted due to oligo-amenorrhea, infertility or hirsutism. The control group was selected from healthy women who presented with infertility and the male factor was detected to be the cause of the infertility. PCOS was diagnosed by ultrasound if there were polycystic ovaries [enlarged ovaries (2–8 mm in diameter) with cysts ≥ 8], oligo-amenorrhea , hirsutism  and elevated serum testosterone levels .8Patients with hypertension, diabetes mellitus, electrolyte imbalance, a history of chronic renal failure or a glomerular filtration rate < 60 ml/min according to the MDRD formula, chronic inflammatory disease, chronic lung disease, heart failure or valve disease, thyroid function disorders, history of arrhythmia, sleep-apnoea syndrome, smoking and drug use in the last three months were excluded. The study protocol was approved by the local ethics committee and written informed consent was obtained from all patients.Laboratory, electrocardiographic and echocardiographic assessments were done on the second or third days of the menstrual cycle, which is the follicular phase. Fasting levels of blood glucose and insulin, lipid profiles and hormone levels were determined by standard laboratory methods. Insulin resistance as assessed using the homeostasis model assessment (HOMA–IR) calculation: fasting serum insulin (μIU/ml) × fasting plasma glucose (mg/dl)/405.9A 12-lead surface electrocardiogram was used to evaluate P-wave parameters. The paper speed was 50 mm/s and amplitude was 20 mm/mV. All electrocardiograms were recorded on the second or third day of the menstrual cycle. P waves were measured manually on all derivations and at least three cardiac cycles were recorded.max) and minimum (Pmin) P-wave duration. The onset of the P wave was defined as the point of first visible upward slope from baseline for positive waveforms, and as the point of first downward slope from baseline for negative waveforms. The return to baseline was considered as the end of the P wave.Pd was defined as the difference between the maximum . During echocardiography, a single-lead electrocardiogram was recorded simultaneously. Data were recorded from the average of three cardiac cycles.M-mode and Doppler measurements were performed adhering to the American Society of Echocardiography guidelines.Atrial electromechanical coupling, the time interval from the onset of the P wave to the beginning of the late diastolic wave, was calculated from the lateral mitral annulus (PAlat), septal mitral annulus (PAsep) and tricuspid annulus (PAtri). Interatrial electromechanical delay was defined as the difference between PAlat and PAtri, and intra-atrial electromechanical delay was defined as the difference between PAsep and PAtri.11max) was calculated at the onset of mitral valve opening, LA minimum volume (Vmin) at the onset of mitral valve closure, and LA presystolic volume (Vp) at the beginning of the P wave on a surface ECG. LA passive emptying volume [(PEV) = Vmax – Vp], LA passive emptying fraction [(PEF) = (Vmax – Vp)/Vmax], LA active emptying volume [(AEV) = Vp – Vmin], LA active emptying fraction [(AEF) = (Vp – Vmin)/Vp], and LA total emptying volume [(TEV) = Vmax – Vmin] were defined as LA emptying function parameters.13LA volumes were measured echocardiographically by the biplane area–length method from the apical four-chamber view. LA maximal volume  and testosterone levels were entered into the model. All statistical studies were carried out with the SPPS program ; p < 0.05 was accepted as statistically significant.All continuous variables were expressed as mean ± standard deviation and median (interquartile range). All measurements were evaluated with the Kolmogorov–Smirnov and Shapiro–Wilk tests, and comparisons of parametric and non-parametric values between two groups were performed by means of the Mann–Whitney p < 0.01; and 5.07 (2.92–10.1) vs 7.68 (2.02–19.10) mIU/ml, p < 0.001]. BMI  and serum estradiol levels  were significantly higher in PCOS patients than in the control subjects.Clinical and laboratory findings of the subjects are shown in p < 0.001]. Heart rate  and Pd were significantly increased in PCOS patients (27 ± 5 vs 24 ± 6 ms).Serum testosterone levels were higher in patients with PCOS than in the control group  were significantly decreased in PCOS patients. The total emptying volume was significantly decreased  in PCOS patients There were no differences in LA Vp < 0.01], PAsep  and PAtri  were significantly longer in patients with PCOS. Interatrial and intra-atrial electromechanical delays were found to be significantly higher in PCOS patients. Values of PAlat – PAtri were 19 ± 7.4 and 15 ± 6.4 ms in PCOS patients and control subjects, respectively (p = 0.035). Median values of PAsep – PAtri were 8.5 (1–19) and 5 (1–20) ms (p = 0.026), respectively.Tissue Doppler echocardiography measurements are shown in p = 0.071, β = 0.201 and p = 0.052, β = 0.242, respectively). In a multivariate stepwise regression analysis, age was demonstrated to be an independent predictor of interatrial electromechanical delay  Age and serum testosterone levels were associated with interatrial electromechanical delay in the linear regression analysis (In the present study, we showed that Pd, and inter- and intraatrial conduction times were increased, left atrial mechanical function was impaired, and transmitral E/A ratio was decreased in patients with PCOS. To our knowledge, this is the first study that has assessed the mechanical and electromechanical functions of the LA in patients with PCOS.et al. reported that PCOS patients had a lower peak E velocity and E/A ratio.16Previous investigations suggested that endothelial and diastolic dysfunction occurs in patients with PCOS due to insulin resistance and high androgen levels.A study showed a negative correlation between insulin levels and E/A ratio, which suggests that PCOS patients may be more prone to develop diastolic dysfunction.Atrial fibrillation is the most commonly observed arrhythmia in clinical practice and is associated with cardiovascular morbidity and mortality.25The autonomic nervous system plays an important role in heart rate and the conduction system. Imbalance between the sympathetic nervous system and vagal tone is an important predictor of AF.27et al. reported that heart rate is moderately reduced after surgical castration in both male and female canines. Heart rate is increased and PQ interval is lengthened with oestrogen replacement in male canines, and with testosterone replacement in female canines. Therefore, oestrogen and testosterone have identical effects on the heart rate and atrioventricular conduction time.3Gonadal sex hormones affect heart rate and atrioventricular conduction time. Fulop In our study, Pd, inter- and intra-atrial conduction times were increased in patients with PCOS. Therefore resting heart rate was higher in these patients. Elevated serum levels of oestrogen and testosterone may explain these findings.Ventricular filling pressure is an indicator of LV diastolic function, and LA function is an important determinant of LV diastolic filling.28 LA passive emptying volume is related to increased LV end-diastolic pressure.Insulin resistance, obesity and hyperlipidaemia, risk factors for cardiovascular disease, are more frequent in patients with PCOS.Impairment of LA mechanical and electromechanical function is known to be a risk factor for AF. LA mechanical function, conduction times and Pd have not been evaluated previously in patients with PCOS. Although there were no known cardiac risk factors, obesity or insulin resistance, we found not only impaired LV diastolic parameters but also increased LA conduction times and Pd in these patients. Hence, we suggest that decreased LA mechanical function, lengthening inter- and intra-atrial conduction times, and increased Pd may occur before the appearance of cardiovascular risk factors such as hypertension, diabetes mellitus and hyperlipidaemia.et al. reported a positive correlation between age and Pd, and LV diastolic parameters.Age is an important risk factor for the development of AF.Our study has some limitations that need to be addressed. It was based on a relatively small group of patients and the patients with PCOS were younger than the controls. There is a need for longitudinal studies to follow up on subjects and controls.This study showed that patients with PCOS had increased inter- and intra-atrial conduction delays, decreased LA passive emptying volume and fraction, and lower E/A ratios. Increased Pd is a risk factor for developing AF, therefore PCOS patients may have a high risk for developing atrial arrhythmias, unless they have other traditional cardiovascular risk factors.


To assess the relationship between the presence of myocardial interstitial fibrosis as reflected by the increase in native T1 values and alterations in left ventricular (LV) diastolic function evaluated by phase contrast cardiac magnetic resonance (PC-CMR), in subjects with severe aortic valve stenosis (AVS).We studied 20 subjects (71±10 years) with severe AVS including 19 with a preserved ejection fraction. All patients underwent transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) exams. CMR included conventional LV systolic function and delayed enhancement evaluations as well as a native T1 mapping acquisition using the modified Look-Locker inversion recovery sequence and velocity encoding data of the transmitral inflow for the evaluation of LV diastolic function. These latter CMR data were analyzed using custom software resulting in segmental T1 values and diastolic parameters such as transmitral peak velocities , peak flow rates , filling volume (FV), and myocardial peak velocities.For all patients, TTE revealed the presence of severe AVS according to ESC criteria . When compared to CMR data of 34 elderly controls (60±8 years) despite the preserved ejection fraction , diastolic parameters indicated an impaired LV relaxation in patients with severe AVS. Importantly, while dense fibrosis volume quantified from delayed enhancement images was not related to diastolic function parameters, a significant relation was found between native myocardial T1 values and parameters of LV filling such as: the ratio between the peak filling rate and the peak atrial rate EfMR/AfMR ; the ratio between the peak atrial rate and the filling volume Af/FVMR ; and the peak atrial rate Af .Interstitial myocardial fibrosis assessed non-invasively by native T1 is related to the severity of diastolic dysfunction in subjects with severe AVS.This study was funded by Assistance Publique des Hôpitaux de Paris.


Cardiotoxicity represents a rising problem influencing prognosis and quality of life of chemotherapy-treated patients. Anthracyclines and trastuzumab are the drugs most commonly associated with development of a cardiotoxic effect. Heart failure, myocardial ischemia, hypertension, myocarditis, and thrombosis are typical manifestation of cardiotoxicity by chemotherapeutic agents. Diagnosis and monitoring of cardiac side-effects of cancer treatment is of paramount importance. Echocardiography and nuclear medicine methods are widely used in clinical practice and left ventricular ejection fraction is the most important parameter to asses myocardial damage secondary to chemotherapy. However, left ventricular ejection decrease is a delayed phenomenon, occurring after a long stage of silent myocardial damage that classic imaging methods are not able to detect. New imaging techniques including three-dimensional echocardiography, speckle tracking echocardiography, and cardiac magnetic resonance have demonstrated high sensitivity in detecting the earliest alteration of left ventricular function associated with future development of chemotherapy-induced cardiomyopathy. Early diagnosis of cardiac involvement in cancer patients can allow for timely and adequate treatment management and the introduction of cardioprotective strategies. Chemotherapy is widely used in the treatment of several neoplastic diseases, leading to an improvement in survival and prognosis in a large number of patients. Side effects are the most common cause of restriction to its use. Cardiotoxicity represents a frequent complication secondary to the intake of some classes of chemotherapeutic agents, with significant consequences on patients' outcome . Heart fHF occurs with an incidence range included between 0.5 and 28%, depending on the medication used, and is the most common clinical manifestation of the cardiotoxicity induced by chemotherapy . The onsCoronary artery disease, presenting with asymptomatic T-wave changes, chest pain, acute coronary syndromes, and myocardial infarction, is mainly related to use of antimetabolites (particularly 5-fluorouracil). De Forni reported an incidence of acute coronary syndromes of about 7.6% in patients treated with 5-fluorouracil while cardiac mortality reached 2.2% [Hypertension is a relatively common side effect of several antiangiogenetic drugs like bevacizumab, sunitinib, and sorafenib. Underlying artery hypertension is the most important risk factor for the development of the secondary disease.Cancer patients have a high incidence of thromboembolic events depending on cancer-related factors   and addiThe majority of studies on cardiotoxicity focus on patients treated with anthracyclines and trastuzumab. Anthracyclines  use has been related to onset of HF within 1 year in about 2% of treated patients . RadiothMyocardial biopsy is still considered the most accurate and specific method in identifying the myocardial damage induced by chemotherapy, detecting the ultrastructural alteration of cardiomyocytes . NeverthCardiac Review and Evaluation Committee Criteria for Diagnosis of Cardiotoxicity. The diagnosis of cardiotoxicity is established if one or more criteria are present: cardiomyopathy characterized by a decrease in cardiac LVEF that was either global or more severe in the septum, symptoms of congestive heart failure, associated signs of congestive heart failure, including but not limited to third heart sound (S3) gallop, tachycardia, or both, decline in LVEF of at least 5% to less than 55% with accompanying signs or symptoms of congestive heart failure, decline in LVEF of at least 10% to below 55% without accompanying signs or symptoms.Although the evolution of most recent imaging techniques has allowed accurate and reproducible evaluation of volumes and of alteration of LVEF, recently it has appeared evident that the drop of LVEF represents a late phenomenon in the physiopathology of the chemotherapy-induced cardiotoxicity. This evidence has led the clinicians to look to other imaging methods that evaluate cardiac function independently of cardiac volumes changes, aiming to detect the earliest manifestation of cardiotoxicity and allowing for the appropriate management of the therapy. Some of these methods such as speckle tracking imaging have been already introduced in clinical practice whereas others are under investigation in experimental settings.http://dx.doi.org/10.1155/2015/263950). The Simpson biplane method is the most validated technique to obtain the left ventricle volumes, while monodimensional measurements are less accurate. However, LVEF derived by the Simpson formula relies on geometrical assumptions and the manual tracking of the endocardial border can differ when performed by different observers, particularly with poor quality images. Indeed, a recent investigation reported that 2DE is unable to estimate a decrease <10% within the 95% of confidence interval when performed by different investigators [LVEF evaluated by two-dimensional echocardiography (2DE) is the most used parameter in monitoring the cardiac function in chemotherapy-treated patients  [The accuracy in the measurement of volumes and LVEF is affected negatively by the poor quality of the acoustic window, which often limits the adequate visualization of the endocardial border. Use of contrast echocardiography demonstrated an incremental value, reducing the interobserver variability in evaluating the cardiac volumes and wall motion score index . Use of < 0.001) . Left ve< 0.001) , 19. The< 0.001) , while T< 0.001) .γ-camera with electrocardiogram-triggered acquisitions. The final result provides a highly reproducible and precise quantification of LV volumes and dyssynchrony independently of geometrical assumption [In the past, MUGA has been the most common alternative to echocardiography in the evaluation of chemotherapy-treated patients . MUGA masumption . LVEF vasumption . NeverthIn the last years, CMR has emerged as the criterion standard technique in the evaluation of LV mass  and voluE/A) ratio, the enlargement of the left atrium, and the increase of isovolumic relaxation time are common findings in chemotherapy-treated patients [ E1/A1 ratio [ E/E1 ratio >10 [ E, E1, E/A, and isovolumic relaxation time did not predict late LVEF <50% within three years after the start of treatment [ S1 within three months from the start of chemotherapy. The decrease was ≥0.6 cm/s in all 10 patients who later developed LVD [ S′ in chemotherapy-treated patients [Alteration of diastolic function precedes the systolic dysfunction often representing the first sign of early cardiac dysfunction caused by anticancer agents . 2DE is patients , 29 with1 ratio , 30, 31 atio >10 . Althougreatment . Analysioped LVD . Howeverpatients , 35. Myopatients , 37. NevP = 0.0001) in a sample of cancer treated patients [Two-dimensional speckle tracking echocardiography (2D-STE) analyzes the myocardial deformation on two-dimensional images by tracking natural acoustic reflections and interference patterns, called “speckle.” The software is able to provide the percentage of distance variation (deformation) between speckles within a predefined region of interest, obtaining a value defined as “strain.” The velocity of the deformation is defined “strain rate.” 2D-STE provides an accurate definition of longitudinal, circumferential, and radial component of the ventricular deformation. Twist, untwist, and torsion are additional parameters that evaluate the torsional deformation of the left ventricle. Strain evaluated by 2D-STE detected early myocardial dysfunction in chemotherapy-treated patients , 39  and greater systolic dyssynchrony index in comparison to healthy controls [Three-dimensional speckle tracking echocardiography (3D-STE) is one of the most advanced techniques in the evaluation of myocardial deformation. The possibility of evaluating the deformation on a full-volume model avoids the errors derived from the use of two-dimensional images. Xu compared 3D-STE to 2D-STE and revealed that GLS evaluation is slightly less feasible in comparison to 2D-STE (84.9% versus 97.2%); however, 3D-STE appeared less time-consuming (50.5 ± 6.4 sec versus 68.0 ± 9.2 sec) and the correlation was good between values obtained by the two methods appearing to be larger for structural measurements rather than for deformation analysis. Inter- and intraobserver variability ranged from 4.8% to 7.9% . Yu democontrols . Mornoş controls . AlthougStress-echocardiography revealed contrasting results in the evaluation of chemotherapy-treated patients: some studies report a reduction of LVEF during stress in patients treated with chemotherapy in comparison to controls , while oA good incremental value provided by CMR relies on the possibility of the method to perform a tissue characterization, identifying fibrosis and edema. The use of this technique can be used to investigate both early and late myocardial dysfunction in chemotherapy-treated patients.Preliminary human studies using T2 weighted sequences showed a significant increase of signal intensity after three days of therapy; this finding is indicative of interstitial edema and was predictive of LVEF reduction at 1 year . A studyThe improvement of cancer therapy has led to longer survival; accordingly, late cardiotoxic effects of chemotherapy have been observed in many patients. Reduction of LV mass has been evaluated as a marker of late cardiotoxicity. A sample of childhood cancer survivors presented LV mass <2 standard deviation (SD) of the mean value for normal population in 50% of cases . A studyNuclear imaging is rapidly evolving, providing new techniques with potential involvement into the evaluation of chemotherapy-treated patients. Functional imaging techniques are able to assess pathophysiologic and neurophysiologic processes at the tissue level. Metaiodobenzylguanidine (MIBG) shares the same metabolic pathway as norepinephrine; when marked with 123I, it is able to represent a scintigraphic image of the efferent sympathetic nervous innervations of the heart. A decrease in myocardial uptake is a strong predictor of mortality and cardiac death . PatientUse of chemotherapy and radiotherapy is essential for cancer patients and cardiotoxicity represents one of the most frequent causes of treatment interruption with significant implications on the prognosis. Early diagnosis and detection of high risk patients has become a central issue in the management of cancer patients involving both cardiologists and oncologists. Systematic and periodical monitoring of LVEF remains the most used technique to diagnose cardiotoxicity in clinical practice. 2DE is the most used method; however, 3DE has proved to be more accurate and reproducible and is preferable if available. CMR is the criterion standard but its low availability and the high cost limit its use to particular subsets of patients (poor acoustic window or patients in whom treatment interruption is highly hazardous). Nevertheless, the decrease of LVEF occurring only in end-stage has shown that it is not suitable as an early indicator of cardiotoxicity. Among the new techniques that evaluate the cardiac function independently of the analysis of volumes and only GLS derived by 2D-STE has validated supporting evidence in predicting late cardiotoxicity. Baseline and periodical evaluation of GLS is recommended by the recent guidelines by ASE/EACVI . PromisiVideos 1 and 2 show two-dimensional echocardiography. The videos show wall motion in the apical four-chamber view before (Video 1) and after (Video 2) one month of chemotherapy. The apical segments show a decreasing of the systolic function.Videos 3 and 4 show two-dimensional echocardiography; The videos show wall motion in the apical four-chamber view before (Video 3) and after (Video 4) chemotherapy. left ventricular ejection fraction is not significantly altered, however, global longitudinal strain revealed a subclinical impairment of the deformation in this patient .


Despite the routine prescription of rate control therapy for atrial fibrillation (AF), clinical evidence demonstrating a heart rate target is lacking. Aim of the present study was to run a mathematical model simulating AF episodes with a different heart rate (HR) to predict hemodynamic parameters for each situation.The lumped model, representing the pumping heart together with systemic and pulmonary circuits, was run to simulate AF with HR of 50, 70, 90, 110 and 130 bpm, respectively.Left ventricular pressure increased by 57%, from 33.92±37.56 mmHg to 53.15±47.56 mmHg, and mean systemic arterial pressure increased by 27%, from 82.66±14.04 mmHg to 105.3±7.6 mmHg, at the 50 and 130 bpm simulations, respectively. Stroke volume (from 77.45±8.50 to 39.09±8.08 mL), ejection fraction (from 61.10±4.40 to 39.32±5.42%) and stroke work  decreased by 50, 36 and 34%, at the 50 and 130 bpm simulations, respectively. In addition, oxygen consumption indexes  increased from the 50 to the 130 bpm simulation, respectively, by 186% (from 5598±1939 to 15995±3219 mmHg/min), 56% (from 2094±265 to 3257±301 mmHg s/min) and 102% (from 57.99±17.90 to 117.4±26.0 J/min). In fact, left ventricular efficiency (SW/PVA) decreased from 80.91±2.91% at 50 bpm to 66.43±3.72% at the 130 bpm HR simulation.Awaiting compulsory direct clinical evidences, the present mathematical model suggests that lower HRs during permanent AF relates to improved hemodynamic parameters, cardiac efficiency, and lower oxygen consumption. Atrial fibrillation (AF), the most common sustained tachyarrhythmia, affects 1% to 2% of the general population . DespiteAwaiting further clinical evidences, the use of a novel mathematical model , validatAim of the present study was to run the mathematical model during simulated AF episodes with heart rate ranging from 50 to 130 bpm and predict hemodynamic parameters for each situation.The present lumped model, consisting of a network of compliances, resistances, and inductances, simulates the pumping heart together with the systemic and pulmonary circuits . The resv = σ/μ , equal to 0.24, which is the typical value observed during AF beating [Both atria are maintained passive to mimic the loss of atrial kick, while RR values are extracted from an exponentially modified Gaussian distribution , which i beating . The resFor every HR, 5000 cardiac cycles are computed, which allows the statistical stationarity of the modeling results. Therefore, all the variables of the present work are intended as averaged over 5000 periods.la, Plaed, Plaes), left atrial volume , left ventricular pressure , left ventricular volume , systemic arterial pressure , pulmonary arterial  and venous (Ppvn) pressures. End-systolic values refer to the instant defined by the closure of the aortic valve, while end-diastolic values correspond to the closure of the mitral valve.In terms of pressure and volume, by evaluating also end-systolic (es) and end-diastolic (ed) values, as well as left ventricular pressure peak values (maximum and minimum), the following parameters are computed: left atrial pressure /2—Plved x /4 is the elastic potential energy , while SW is the stroke work. The left ventricular efficiency is defined by the ratio SW/PVA.Concerning left ventricle performance the following parameters are also computed: stroke volume, SV = Vcomputed : rate prr minute , TTI/minr minute , PVA/minlv), systemic pressure (Psas) and cardiac mechano-energetic indexes  varied more than 15% within the different HR simulations.The mathematical model was run to simulate AF with heart rate (HR) of 50, 70, 90, 110 and 130 bpm, respectively. All computed parameters, stratified by HR, are listed in lv increased by 57%, from 33.92±37.56 mmHg to 53.15±47.56 mmHg at the 50 and 130 bpm simulations, respectively.Mean value and representative examples of temporal series of left ventricular pressure are shown in sas increased by 27%, from 82.66±14.04 mmHg to 105.3±7.6 mmHg at the 50 and 130 bpm simulations, respectively. In details, systolic pressure  shifted from 103.8±5.1 mmHg (50 bpm) to 117.4±1.5 mmHg (130 bpm), and diastolic pressure  from 64.99±8.90 mmHg (50 bpm) to 94.92±3.93 mmHg (130 bpm).Systemic pressure variations are illustrated in Eventually, heart performance was assessed by several mechanic and energetic parameters . ConcernBased on the presented mathematical simulations a slower (50 bpm), compared to higher (130 bpm), HR during AF relates to improved ventricular pressure, systemic pressure and left ventricular efficiency (e.g. SW/PVA).Given several clinical trial  does not balance the dramatic absolute and relative increase of the mean Plv (nearly 20 mmHg). Moreover, Plves and both pressure peak values do not significantly vary (minimum pressure peaks remain even constant as HR increases).Left ventricular pressure greatly increased at faster ventricular rates , due toBased on the model’s predictions, lower HRs during AF relate to improved mechanic and energetic indexes. First, the reduction of SV and SW seen with the progressively higher HRs translates into a left ventricle’s EF decrease by far greater than the physiological reduction expected . FurtherEventually, although the present model currently does not present the ability to predict such setting, during exertion (a situation in which inotropism and chronotropism increase due to sympathetic stimulation) the reduction in left ventricle efficiency caused by faster HR may become even more limiting, perhaps, at least partially, accounting for the lower resistance to effort common in subjects with AF.la and Vla) or pulmonary pressures (Ppas and Ppvn) it cannot be concluded if either different HRs do not significantly affect their values, or the present model may not be able to detect variations.In addition to what previously discussed, the following limitations must be taken in account. First, the present mathematical model simulates a denervated heart; the effects of the autonomic nervous system on cardiac performance are therefore not included. Second, due to difficulties in the mathematical modelling of the coronary arteries dynamics, in the present model the coronary circle is not taken in account. Third, the present model-based approach predicts the global response of the cardiovascular system during episodes of AF at different HRs. For the purpose of the present study we considered “relevant” variations (maximum % variation), within the different HR simulations, above 15%. Concerning parameters not reaching this limit, such as left atrial parameters (PIn conclusion, awaiting compulsory direct clinical evidences, the present mathematical model suggests that lower HRs during permanent AF relates to improved hemodynamic parameters and cardiac efficiency, resulting in lower oxygen consumption for a given cardiac work.


Rheumatic fever (RF) remains endemic in many countries and frequently causes heart failure due to severe chronic rheumatic valvular heart disease, which requires surgical treatment. Here, we report on a patient who underwent an elective surgical correction for mitral and aortic valvular heart disease and had a post-operative diagnosis of acute rheumatic carditis. The incidental finding of Aschoff bodies in myocardial biopsies is frequently reported in the nineteenth-century literature, with prevalences as high as 35%, but no clinical or prognostic data on the patients is included. The high frequency of this finding after cardiac surgery in classical reports suggests that these patients were not using secondary prophylaxis for RF. We discuss the clinical diagnosis of acute rheumatic myocarditis in asymptomatic patients and the laboratorial and imaging methods for the diagnosis of acute rheumatic carditis. We also discuss the prognostic implications of this finding and review the related literature. Rheumatic fever (RF) remains endemic in many countries and frequently causes heart failure due to severe chronic rheumatic valvular heart disease, which requires surgical treatment. Another mechanism of heart failure in rheumatic patients is acute rheumatic myocarditis . Acute rCase report: a 45-year-old female patient with previous diagnoses of hypertension, diabetes, hypothyroidism, and chronic rheumatic valve disease was seen as an outpatient; she reported a 3-year history of progressive exertional dyspnea and chest pain. She also reported orthopnea and paroxysmal nocturnal dyspnea and was taking 25 mg/day of atenolol.parvus et tardus. Her cardiac auscultation presented a +++/6+ (according to the Levine classification) mid-systolic ejection murmur in the aortic area and a ++/6+ diastolic rumble in the mitral area. The pulmonary and abdominal examinations revealed no abnormalities.A physical examination revealed a blood pressure of 140 over 80 mmHg and a regular heart rate of 80 bpm, which was typically 2.A 12-lead electrocardiogram revealed left atrial and left ventricular (LV) hypertrophy. A chest X-ray showed left atrial enlargement, a normal LV size, and signs of pulmonary congestion evidenced by Kerley B lines. Transthoracic echocardiography showed that the LV diastolic diameter was 49 mm, the LV systolic diameter was 32 mm, the interventricular septum was 11 mm, the posterior wall was 12 mm, the LV ejection fraction was 72% and there were diagnoses of aortic stenosis with a peak systolic gradient of 82 mmHg, and mitral stenosis with a mitral valve area of 1.1 cmThe patient was referred to surgery for her chronic rheumatic heart disease with mitral and aortic stenosis and NYHA functional class III. Preoperative coronary angiotomography revealed a calcium score of 0 and no coronary disease.Surgery was performed, and the patient underwent mitral and aortic replacement with mechanical prostheses. Her recovery from the surgery was uneventful.The histopathological report of the surgical specimens revealed the presence of Aschoff bodies in the proliferative phase, which is suggestive of acute RF Figure . In addiThe histopathological findings led to the unexpected diagnosis of acute RF with myocarditis. Before histopathologic results were available, symptoms such as tachycardia and worsening of heart failure symptoms were thought to be due only to the underlying valvular heart disease. The diagnosis of rheumatic myocarditis allowed for a more complete treatment of the patient, with introduction of prednisone (60 mg daily) and resuming of secondary prophylaxis for RF with benzathine penicillin G 1.200.000 UI intramuscularly every 3 weeks. Even after cardiac surgery, she still presented tachycardia and exertional dyspnea, symptoms that may be suggestive of myocarditis because other causes were excluded.The combined treatment of the valvular heart disease and the myocarditis led to a complete resolution of symptoms, with resolution of the heart failure and tachycardia symptoms within 2 weeks after surgery and glucocorticoid treatment. Then, 60 mg of prednisone a day was maintained for 6 weeks, with a progressive dose reduction of 20%/week until discontinuation. This patient is still undergoing secondary prophylaxis for RF with benzathine penicillin G every 3 weeks for an indefinite time. She is presently asymptomatic.Rheumatic fever remains a leading cause of acquired cardiopathy in many regions, such as South America , Africa Still, ARF is a frequently underdiagnosed condition even in patients with valvular heart disease in RHD endemic countries.The histological finding of Aschoff bodies is the most characteristic finding of rheumatic inflammation in the heart  and effe+ cells in heart tissue biopsies of patients with rheumatic activity. In addition, CD4+ and CD8+ infiltrating T-cell clones recognized streptococcal M peptides and cardiac tissue proteins. These findings may open new possibilities of immunotherapy. In addition, it was demonstrated that the surgical procedure during the acute phase of the disease improved the quality of life of young RHD patients . Transesophageal echocardiography can sometimes show small multiple vegetations on the edge of native valves, representing the rheumatic  protein . The hig protein .The 12-lead electrocardiogram might be helpful because the first degree of an atrioventricular heart block is a sign of myocarditis, but this is not very sensitive in identifying rheumatic myocarditis.Imaging techniques that highlight inflammation in the heart are particularly useful for the diagnosis of acute rheumatic myocarditis. Gallium-67 myocardium scintigraphy can be used to demonstrate myocarditis and has been studied in the diagnosis of acute rheumatic patients . A good The real clinical and prognostic significance of Aschoff bodies in myocardial biopsies of patients undergoing elective surgery for valvular heart diseases is still unknown. However, if we consider that these patients have active rheumatic myocarditis, glucocorticoid treatment is indicated and can shorten the evolution of the disease and the clinical symptoms of heart failure . AdditioIn conclusion, acute rheumatic myocarditis is a difficult diagnosis that should be considered in any patient, including patients who have just undergone valve surgery, with rheumatic valvular heart disease who present with a sudden worsening of heart failure symptoms or rapid-onset ventricular dysfunction, particularly if the patient is not on secondary prophylaxis for RF.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.


Right ventricular function is of prognostic importance in a variety of clinical settings but its complex anatomic geometry can pose a challenge to 2-dimensional imaging modalities. Right ventricular dysfunction is thought to occur following cardiac surgery and independently predicts adverse outcomes. However a clear mechanism for this dysfunction remains undefined.We sought o accurately assess the effect of SAVR upon right ventricular function in patients treated for severe symptomatic aortic stenosis.All patients underwent an identical 1.5T CMR protocol . Multi-slice, multi-phase cine imaging was performed using a standard steady-state free procession pulse sequence in the short axis  340mm) to cover the entire left and right ventricle. Late gadolinium enhancement (LGE) imaging  was performed following a Look-Locker inversion time scout, 10min after the administration of 0.2mmol/kg of gadoteric acid  or gadolinium-DTPA . Identical contrast agent was used at both study time-points.53 SAVR patients  were studied before and 6 months after surgery. Six received a metallic prosthesis and the remaining 47 (89%) a tissue bioprosthesis. Fourteen (26%) received concomitant coronary bypass grafting, of which 6 involved use of the left internal mammary artery. For the group as a whole, the average bypass time was 105±48min and average cross clamp time 77±41min. The average length of stay in intensive care was 3.4±2.4 days. SAVR was associated with a significant decrease in RV ejection fraction and concomitant increase in indexed RVESV at 6 months, with no change in RV mass. However, in subgroup analysis of patients without LGE of the left ventricle at baseline, no significant change in RV function was seen following SAVR (p = 0.06).SAVR is associated with a significant reduction in right ventricular ejection fraction at 6 months mediated through an increase in end systolic volume. The presence of LGE may have the potential to identify patients at risk of post-operative RV dysfunction.This study was part-funded by the British Heart Foundation (BHF) (PG/11/126/29321).GP McCann and CD Steadman have received support from the NIHR Leicester Cardiovascular BRU.