Pernicious anemia (PA) is an autoimmune disease (AID) which is caused by lack of vitamin B12  due to its impaired uptake. PA is a multifactorial disease which is associated with a number of other AID comorbidities and which is manifested as part of autoimmune polyglandular syndrome. Due to the shortage of family studies on PA, we planned to address the problem by assessing familial risks for concordant PA between family members and for discordant PA in families of other AID patients.  We collected data on patients diagnosed with AIDs from the Swedish hospitals and family data from a population register. We calculated standardized incidence ratios (SIRs) in families for concordant and discordant risks.  The number of PA patients in the offspring generation  was 7701; 278 (3.6%) patients had a family history of PA. The population prevalence of PA was 0.9/1000. The familial risk for PA was 3.88 when any first-degree relative was the proband, equal for men and women. The familial risk was two times higher between siblings than between offspring and parents which may be due to complex genetic background. Associations of PA with 14 discordant AIDs were significant; these included some AIDs that have previously been described as comorbidities in PA patients and several yet unreported associations, including rheumatoid arthritis and other AIDs.  The familial risks for PA were high suggesting multifactorial genetic etiology. The results call for further population-level studies to unravel mechanisms of familial PA which may help to understand the etiology of this disease. Pernicious anemia (PA) is an autoimmune disease (AID) which is diagnosed because of anemia caused by lack of vitamin B12  in the blood . The preAutoantibodies in PA attack both IF and the gastric parietal cells producing IF. They may block either the vitamin B12 binding site or the ileal mucosal receptor . PA is sAlthough many comorbidities are well characterized in PA patients, disease risks between family members are less known . Due to N = 896,270) were identified from the Swedish Hospital Discharge Register  and the Outpatient Register (2001 through 2015). Only the first recorded AID was considered in the analyses. Various revisions of the International Classification of Diseases (ICD) codes were used for AIDs as described elsewhere [AID patients N = 89,270 wereStandardized incidence ratios (SIRs) were calculated for the offspring generation . All guidelines of the Helsinki Declaration were followed. The study was conducted in accordance with the approved guidelines with explicit statement that no informed consent was required. The study is national register-based study on anonymous personal data.The number of PA patients in the offspring generation  was 7701 with a mean diagnostic age  of 47.7 years; considering also the parents, the total number was 35,906 of whom 42.3% were men . OffspriThe age-specific incidence for PA is shown in Supplementary N = 100, 95% CI 0.99–1.47).Familial risks for PA are shown in We analyzed familial risks between PA and all 42 other AIDs, and the significant discordant associations are shown in The present study covered 35,906 patients diagnosed with PA in Swedish hospitals, which accounted for 4.0% of all diagnosed AIDs in the country. Epidemiological data on PA are scanty, but our prevalence estimate of 0.9/1000 is close to the rate reported for USA and some other countries . Our ageTo our knowledge, this is the first family study on concordant PA and on all main types of other AIDs. The results showed that the concordant familial clustering was observed for 3.6% of PA patients. The familial risk for first-degree relatives was 3.88, and the SIR was only marginally higher for men than women. There was a significant difference in familial risk when siblings (6.43) compared to parents (3.08) were probands, which is usually considered to suggest either recessive inheritance or influence by shared childhood environment. The genetic basis of PA is not fully characterized, but several genes have been identified which influence vitamin B12 serum levels, including FUT2, FUT6, CUBN, TCN1, MUT, and CLYBL . Human lIn the present study, we showed association of PA with 14 other AIDs, and as 10 of these could be confirmed in the bidirectional analyses, the results are likely to represent true associations. Limited data are available on discordant familial associations of PA. Our old family studies on Graves disease, type 1 diabetes, and rheumatoid arthritis detected associations with PA , 9, 10. A common limitation of studies on rare diseases is the limited sample size. Although we were able to detect 14 discordant associations, 10 of which were confirmed bidirectionally, many more may have remained undetected due to the rarity of many AIDs. Another possible weakness is that we only included hospitalized patients, but those with mild symptoms may be taken care of in general practice (primary care). A further point is that diagnostic underreporting may be at least a theoretical option; as PA is the end stage of chronic atrophic gastritis, gastritis diagnosis may be rendered first, and PA may remain unreported. However, for the sake of the present analysis, the correctness of the PA diagnosis is most important, and some underreporting should not cause severe bias. A related diagnostic problem is that for the sake of epidemiological design, we only considered the first AID diagnosis. As PA patients experience multiple AID comorbidities, those diagnosed after the first one were not considered in this study. Finally, as the global epidemiology of PA is underdeveloped, we cannot generalize the Swedish results to other population.We showed novel evidence for familial risks in concordant PA and for discordant associations of PA with 14 other AIDs. Among 3.6% of the patients, a family member was also diagnosed with PA. The familial risk was two times higher between siblings than between offspring and parents, which may be due to complex genetic background. The discordant associations included some AIDs that have been previously described as comorbidities in PA patients and several yet unreported associations, including rheumatoid AIDs and other AIDs. The result calls for further population-level studies to unravel the mechanisms of familial PA which may lead to further insight into the etiology of PA.


Myocardial impairment is a major complication and an important prognostic predictor of sepsis. Therefore, early and accurate diagnosis as well as timely management of septic cardiomyopathy is critical to achieve favorable outcomes.To investigate the risk factors of septic cardiomyopathy.Cross-sectional study.This study performed between May 2016 and June 2018 recruited 93 septic patients from the intensive care unit. All patients received standardized treatments. Septic patients were divided into two groups: non cardiomyopathy (n=45) and septic cardiomyopathy group (n=48). Blood samples were collected and transthoracic echocardiography was performed within 24 hours of intensive care unit admission. Septic patients with one ultrasound abnormality but no history of heart disease were diagnosed as having septic cardiomyopathy. Plasma histones, cardiac troponin I, and N-terminal pro-brain natriuretic peptide were measured using ELISA. Sequential Organ Failure Assessment scores, vasopressor use, and the outcomes of intensive care unit stay were analyzed. Spearman rank analysis was used to determine the correlation between plasma histone H4 and other parameters. Binary logistic regression and receiver operating characteristic curve analysis were used to determine the risk factors for septic cardiomyopathy.Compared with the non-cardiomyopathy group, the septic cardiomyopathy group had significantly higher plasma H4 and cardiac troponin I levels, a higher Sequential Organ Failure Assessment score, more frequent vasopressor use, and a higher mortality rate (p<0.05). Plasma histone H4 levels positively correlated with cardiac troponin I , N-terminal pro-brain natriuretic peptide , and Sequential Organ Failure Assessment scores . Binary logistic regression and receiver operating characteristic curve analyses revealed that elevated plasma histone H4 levels and vasopressor use were important risk factors for septic cardiomyopathy (p<0.05).Elevated plasma histone H4 levels could be used to predict septic cardiomyopathy in patients with sepsis. Sepsis is a life-threatening condition caused by uncontrolled systemic inflammation resulting from infection. Septic shock is a hypotensive condition characterized by elevated blood lactate levels Lac>2 mmol/L) and cannot be corrected solely by fluid resuscitation . Myocard mmol/L aSeptic cardiomyopathy is primarily assessed using hemodynamic devices such as a pulmonary artery floating catheter (PAC) and pulsed continuous cardiac output (PiCCO) monitoring. However, PAC and PiCCO suffer several drawbacks including an inability to monitor cardiac diastolic function and right heart function, invasiveness, potential catheter-related infection, and difficulty with data measurement and interpretation. Therefore, solely relying on PAC and PiCCO may lead to significant underestimation of the actual incidence of septic cardiomyopathy . EchocarHistones are a class of proteins that bind to DNA in eukaryotic cells to form chromatin . The corThe present study investigated the epidemiological data of patients with septic cardiomyopathy using echocardiography, elucidated the correlation between plasma histone H4 levels and commonly used markers of myocardial injury, and identified the significance of histone H4 in predicting the development of septic cardiomyopathy.All procedures in this study complied with medical ethical standards and were approved by the Medical Ethics Committee of the hospital (protocol no. 20160223). A total of 158 patients with sepsis who were admitted to the intensive care unit (ICU) of a grade-A first-class general hospital between May 2016 and June 2018 were initially registered. Patients who were diagnosed with sepsis  score ≥2)  previousst, 3rd, and 7th day after ICU admission) using a GE Vividi color ultrasound system (USA) with an s3 Rs probe with a f of 1.7 to 3.4 MHz. TTE was operated by an ultrasound physician who was blinded to the patient groups. The following parameters were obtained from TTE: LVEF, peak early diastolic transmitral flow velocity (E), peak late diastolic transmitral flow velocity (A), peak early diastolic mitral annular velocity (e’), left ventricular systolic mitral (LV-Sm) annulus velocity, and right ventricular systolic tricuspid (RV-Sm) annulus velocity. An apical four-chamber view was acquired during the measurement. When the tissue Doppler mode was initiated, the pulsed tissue Doppler sample volume was placed on the side wall of the mitral annulus to obtain the LV-Sm annulus velocity, i.e., the systolic S wave peak velocity. To measure LVEF, we used M-mode ultrasound in patients with normal ventricular wall motion and the Simpson’s method in patients with regional wall motion abnormality. Left ventricular systolic dysfunction was defined as LV-Sm <8 cm/s or LVEF <50%. The pulsed tissue Doppler sample volume was placed on the side wall of the tricuspid annulus to obtain the systolic S peak wave velocity. The right ventricular systolic dysfunction was defined as RV-Sm <12 cm/s. The pulsed tissue Doppler sample volume was placed on the side wall of the mitral annulus to obtain E and e’. The left ventricular diastolic dysfunction was defined as E/e ‘>15 or e’< 8 cm/s.Routine transthoracic echocardiography (TTE) was performed three times (on the 1Septic cardiomyopathy was diagnosed based on the following three criteria: 1) the patient was diagnosed with sepsis, 2) the patient had one of the following three ultrasound abnormalities: A) LV-Sm <8 cm/s or LVEF <50%; B) RV-Sm <12 cm/s; or C) E/e’>15 or e’ <8 cm/s, and 3) the patient had no history of heart disease, including chronic heart failure regional ventricular wall motion abnormality, dilated cardiomyopathy, hypertrophic obstructive cardiomyopathy, or heart valve disease.Demographic and baseline clinical characteristics were obtained from all participants. These included age, gender, body mass index (BMI), past disease, site of infection, and disease diagnosis. All enrolled patients were administered antibiotics and fluid resuscitation in compliance with treatment guidelines. Vasoactive drugs and ventilators were also used if necessary. Circulating levels of troponin, N-terminal pro-brain natriuretic peptide (NT-proBNP), and histone H4 were measured using ELISA . In brief, blood samples from patients were collected into ethylenediaminetetraacetic acid tubes  within 24 hours of admission to the ICU. Supernatants were obtained after centrifugation at 3,000 rpm for 10 minutes and were frozen at -80° within half an hour for subsequent analysis. The following data were recorded from each participant: blood procalcitonin (PCT), lactate level, SOFA scores, vasopressor use, length of ICU stay (d), and outcomes of ICU stay.For the histone H4 assays, wells for both standards and tests were prepared. To generate a standard curve, 50 μL of the standard solution was added, while 10 μL of the test sample plus 40 μL of sample diluent were added to the test wells. A blank well was also prepared. Next, 100 μL of an HRP-conjugated reagent was added and incubated for 60 minutes at 37°, followed by four washes with wash solution (400 μL). Thereafter, 3,3′-diaminobenzidine substrate chromogen solution (50 μL) and 3% aquae hydrogenii dioxide substrate chromogen solution B (50 μL) were added to each well and incubated for 15 minutes at 37° in the dark. Using a microtiter plate reader, optical density was measured at a wavelength of 450 nm within 15 minutes of addition of the stop solution (50 μL).All statistical analyses were performed using the SPSS 22.0 statistical software package. Normally distributed data are presented as mean ± standard deviation (x ± SD) and non-normally distributed data are presented as median  [M ]. The independent sample t-test was used to compare normally distributed data, while the Wilcoxon rank sum test was used for comparing non-normal data. Count data are expressed as frequency (f), composition ratio, or percentage, and statistically analyzed using the chi-square test. Spearman rank correlation analysis was used to determine the correlation between plasma histone H4 and cTnI and NT-proBNP levels. Binary logistic regression and a receiver operating characteristic (ROC) curve were used to determine the risk factors for prognosis of septic cardiomyopathy. Triplicates were used in each case. The evaluation index is represented as the odds ratios (ORs), and p<0.05 was considered statistically significant.A total of 93 patients, including 71 patients with septic shock and 22 patients without shock, were enrolled in this study. Among these patients, 64 survived whereas 29 died during ICU treatment. There was no significant difference in the number of primary infection sites between the patient group that died versus those that survived (p>0.05) . No signAmong the 93 patients with sepsis, 40 had left ventricular diastolic dysfunction, 24 had left ventricular systolic cardiomyopathy, and 11 had right ventricular systolic dysfunction. Of those with cardiomyopathy, 19 suffered concomitantly from left ventricular systolic and diastolic dysfunctional cardiomyopathy, and 4 concomitantly suffered from left ventricular systolic, diastolic, and right ventricular dysfunction. A total of 48 patients (51.6%) had septic cardiomyopathy .We used the Spearman correlation analysis to determine the correlation between plasma histone H4 levels and cTnI, NT-proBNP, and SOFA score. As shown in As shown in Binary logistic regression analysis was used to determine the risk factors for septic cardiomyopathy. SOFA score, vasopressor use, plasma histone H4 levels, and cTnI levels were included in the binary logistic regression analysis. As shown in In the present study, we investigated the risk factors of septic cardiomyopathy and found that: 1) sepsis patients who died in the ICU had significantly higher SOFA scores and more frequent vasopressor use, 2) patients in the septic cardiomyopathy group had significantly higher plasma histone H4 levels, cTnI levels, and more frequent vasopressor use, and 3) elevated plasma histone H4 levels and frequent vasopressor use were important risk factors for septic cardiomyopathy.Previously, septic cardiomyopathy substantially increased the mortality rate (up to 70%) in septic patients ,16,17. IHistones are structural proteins in eukaryotic nuclei that bind to DNA and form nucleosomes, the basic structural unit of chromatin . Under pcTnI and NT-proBNP are the two most commonly used clinical markers of myocardial injury. cTnI can only be released into the blood when the myocardial cell membranes are injured and is highly sensitive and specific for myocardial injury . Favory NT-proBNP is a neuroendocrine hormone that is mainly synthesized in and secreted from ventricular myocytes and is released in large amounts as ventricular wall tension increases. A previous study  showed tHistorically, there was insufficient evidence to support the standard use of troponin or pro-BNP as a biomarker for septic cardiomyopathy. We provide evidence of an additional biomarker, histone H4, in predicting septic cardiomyopathy. Nonetheless, identification of other novel biomarkers is encouraged.Few studies have examined the independent risk factors for septic cardiomyopathy. In this study, we found that plasma histone H4 levels and vasopressor use were both important risk factors for the development of septic cardiomyopathy. An OR of 21.5 for histone H4 meant that the probability of septic cardiomyopathy increased 20.5 times, while the value of histone H4 increased one unit, suggesting the key role of histone H4 in predicting the development of septic cardiomyopathy. ROC analysis showed moderate accuracy of H4 as a predictor of septic cardiomyopathy as its NPV was higher than its PPV. Previously, Kalbitz et al.  found thIn septic shock, microcirculatory disorders, abnormal blood flow distribution, and an imbalance between oxygen supply and demand affect cardiac perfusion. This results in myocardial hypoxia, which may be another important cause of septic cardiomyopathy. Therefore, our findings indicate that severe sepsis and/or septic shock are indicators of vasopressor use. We noted that septic shock was accompanied by extremely low blood pressure requiring medication . Thus, bSome limitations of this study need to be acknowledged. Firstly, although this was a prospective study, we did not perform a cause-effect investigation. Secondly, as the study endpoint was patient outcomes during ICU stay, it did not include long-term follow-up analysis. Thirdly, this was a single-center study with a small sample size. Multi-centered large cohort studies are needed to further corroborate our findings. Lastly, we acknowledge that the accuracy and reproducibility of ELISA in measuring plasma histone levels is less than satisfactory and a more efficient and sensitive tool is needed for histone identification and quantification.In conclusion, the current study demonstrates that elevated plasma histone H4 levels could potentially be used as a predictive biomarker for cardiomyopathy in patients with sepsis.


The impact of volume overload due to aortic regurgitation (AR) on systolic and diastolic left ventricular (LV) indices and left atrial remodeling is unclear. We assessed the structural and functional effects of severe AR on LV and left atrium before and after aortic valve replacement.n = 65) underwent two- and three-dimensional echocardiography, including left atrial strain imaging, before and 1 year after surgery. A control group was selected, and comprised patients undergoing surgery for thoracic aortic aneurysm without aortic valve replacement (n = 20). Logistic regression analysis was used to assess predictors of impaired left ventricular functional and structural recovery, defined as a composite variable of diastolic dysfunction grade ≥ 2, EF < 50%, or left ventricular end-diastolic volume index above the gender-specific normal range.Patients with severe AR scheduled for aortic valve replacement .Diastolic dysfunction was present in 32% of patients with AR at baseline. Diastolic LV function indices and left atrial strain improved, and both left atrial and LV volumes decreased in the AR group following aortic valve replacement. Preoperative left atrial strain during the conduit phase added to left ventricular end-systolic volume index for the prediction of impaired LV functional and structural recovery after aortic valve replacement (model One-third of patients with severe AR had signs of diastolic dysfunction. Aortic valve surgery reduced LV and left atrial volumes and improved diastolic indices. Left atrial strain during the conduit phase added to the well-established left ventricular end-diastolic dimension for the prediction of impaired left ventricular functional and structural recovery at follow-up. However, long-term follow-up studies with hard endpoints are needed to assess the value of left atrial strain as predictor of myocardial recovery in aortic regurgitation. Severe chronic aortic regurgitation (AR) is characterized by volume overload of the left ventricle. This induces structural and functional left ventricular (LV) alterations, which have a negative prognostic impact even in patients who are asymptomatic –3.Despite the emerging potentials of transcatheter valve replacement, the treatment of choice for severe AR is still aortic valve replacement (AVR), with intervention timing based on the presence of symptoms or evidence of increased LV dimensions or systolic dysfunction –6. RecenLA function, in terms of the reservoir, conduit, and contraction phases, can be assessed quantitatively by measuring left atrial strain (LAS) using speckle-tracking echocardiography . LAS hasWe hypothesized that the reduction in LV overload following aortic valve surgery would improve markers of diastolic LV function and LA phasic function. To address this, we performed a prospective, longitudinal study of patients with chronic, severe AR without coronary artery disease using three-dimensional (3D) and two-dimensional (2D) echocardiography, including speckle-tracking echocardiography. We aimed to assess the effects of AR-related LV volume overload on LV and LA structure and function before, and 1 year after, aortic valve surgery. As a secondary aim, we sought to evaluate whether preoperative LA remodeling and functional changes could predict postoperative LV dysfunction.n = 26) or atrial fibrillation (n = 5). Five additional cases were excluded for technical reasons (data stored in incompatible format); the final study group consisted of 65 patients.The study group was recruited from a prospective, observational study at Karolinska University Hospital in Stockholm, Sweden, conducted from 2007 to 2013. The study included consecutive adult patients free from coronary artery disease  who were undergoing elective open-heart surgery for aortic valve disease or thoracic aortic aneurysm (TAA) . From thA control group was included comprising 20 consecutive patients with TAA and no significant aortic valve disease, defined as no or mild AR and transvalvular mean pressure gradient < 20 mmHg, who underwent surgery for TAA during the same period.Comprehensive transthoracic 2D and 3D echocardiographic examinations were performed 1 week or less before surgery and at a follow-up visit 1 year after surgery, using commercially available equipment . 3D data were acquired over four or seven cardiac cycles, generating full volume datasets. The echocardiograms were performed following current recommendations by two experienced sonographers . Data wes × SV × 0.014, where BPs is systolic blood pressure and SV is 3D echocardiographic stroke volume [2D echocardiographic data were analyzed using dedicated software . LV dimensions and wall thickness were measured in the parasternal long-axis view. LA volume was calculated using the biplane method of disks and indexed to body surface area (BSA). LV stroke work (in gram-meters) was calculated as SW = BPe volume .Diastolic function variables were acquired and analyzed according to the current guidelines, and DD was defined by incorporating the ratio between early and late diastolic filling velocities (E/A ratio), the ratio between mitral early filling velocity and average annular tissue velocity (E/e′ ratio), tricuspid regurgitation velocity, and LA volume index (LAVi). Patients were classified into three categories: (i) no or grade 1 DD, (ii) grade 2 DD, and (iii) grade 3 DD . Cases tLV global longitudinal strain (GLS) was measured using dedicated software . The LV wall was traced automatically throughout the cardiac cycle using a speckle-tracking algorithm. The region of interest was manually adjusted if needed. GLS was calculated by averaging the peak systolic longitudinal strain of 17 segments and is expressed as an absolute percentage (|%|).LAS was calculated using dedicated software . Two points were placed at the mitral annulus and a third at the LA roof. The LA wall was then automatically tracked through the cardiac cycle, generating an atrial GLS curve. If needed, delineation was corrected manually at end-systole and end-diastole. The zero-strain reference point was set to the end-diastolic frame following mitral valve closure Fig. . The LASICC). ICC values for intraobserver agreement of the LASr, LAScd, and LASct estimates were 0.83 (95% CI 0.62–0.93), 0.87 (95% CI 0.69–0.95), and 0.69 (95% C.I. 0.35–0.87), respectively. ICC values for interobserver agreement were 0.76 (95% CI 0.43–0.90), 0.85 (95% CI 0.66–0.94), and 0.76 (95% CI 0.19–0.92), respectively.Intraobserver variabilities in LASr, LASct, and LAScd measurements were assessed by repeated measurements in the same images acquired from 20 randomly selected cases by one blinded observer (A.I.). To determine the interobserver variability, the measurements were repeated in the same images by a second observer (J.J.) who was blinded to the results obtained by the first observer. Agreement was assessed by calculating the intraclass correlation coefficient . The endocardial surface was outlined using a semi-automated contour detection algorithm, yielding the end-diastolic volume (EDV) and end-systolic volume (ESV). Papillary muscles and trabeculations were included in the cavity. Stroke volume (SV) was calculated from EDV–ESV, and the ejection fraction (EF) was calculated as EDV–ESV/EDV × 100%.LV mass was calculated using the biplane method of disks in four- and two-chamber views obtained from 3D datasets. The endocardium and epicardium were traced manually in each view, with the papillary muscles included in the LV cavity. The myocardial mass was then calculated by the software. Measurements were made at end-diastole and end-systole, and the LV mass was estimated as the mean of the two measurements and indexed to BSA.n = 16), mechanical valve prostheses (n = 15), aortic root bioprostheses (n = 5), or aortic root replacement with a mechanical composite graft (n = 5). Isolated aortic valve repair was performed in 21 patients, while 3 underwent aortic root replacement with reimplantation of the native valve. The group with isolated TAA received synthetic tubular aortic grafts but no valve surgery.All patients were operated on via a midline sternotomy using cardiopulmonary bypass. In the AR group, AVR was performed using biological valve prostheses . NTproBNP concentration is reported as normalized protein expression (NPX) units. NPX is a logp value < 0.05 was considered statistically significant. Correlations between continuous variables were assessed by calculating Pearson’s correlation coefficient r. Between-groups comparisons of the means of continuous variables were performed using Student’s t-test and analysis of variance (ANOVA). Bonferroni correction was used to adjust for multiple comparisons. Differences between unrelated samples of ordinal data were assessed using the Mann–Whitney U test. Relationships between categorical variables were assessed using the chi-squared or Fisher’s exact test.Continuous variables are expressed as the mean ± SD or the median and interquartile range (IQR) depending on the data distribution. A p values < 0.10 in simple logistic regressions were assessed for collinearity and entered pairwise in multiple logistic regression models. The reason for restricting the models to two variables at a time was the risk of overfitting. All combinations were tested, and classification tables and Nagelkerke R2 (RN2) values were assessed to rank the models with respect to their predictive performances. The likelihood ratio test (LRT) was used to determine whether a variable contributed significantly to the model. Discriminatory ability was assessed by receiver operating characteristic (ROC) analysis and shown as area under the ROC curve (AUC). Statistical analyses were performed using IBM SPSS Statistics .Simple and multiple logistic regression analyses were performed to assess predictors of impaired LV functional and structural recovery, which was defined as a composite variable comprising one or more of the following echocardiographic characteristics at the follow-up examination: EF < 50%, DD grade ≥ 2, and EDV index (EDVi) greater than the gender-specific normal range . Baselinp < 0.001). At the follow-up examination, no patient undergoing valve replacement, and 3 patients with valve repair, had moderate residual AR; none of which warranted reoperation. Of these 3 patients, one had EF < 50%. There were no cases of atrial fibrillation at the follow-up examinations.The baseline characteristics of the AR and control groups are listed in Table r = − 0.43, p = 0.001), but not with EF (p = 0.076).At baseline, the patients with AR had increased LV dimensions and volumes, larger SV, increased LV mass index (LVMi), and lower EF compared with the controls, whereas no difference in GLS was found Table . In patir = 0.35, p = 0.007) and LAScd , LAScd , and LAVi .At baseline, patients with AR had larger LAVi, a higher prevalence of DD grade 2 or 3, and lower LASct measures compared with the control group  [p = 0.001). Variables with p values < 0.10 in simple regressions were tested for collinearity and subsequently added to ESVi in multiple regression analyses. The model that best predicted impaired LV functional and structural recovery was LAScd combined with ESVi ; the model with LAScd and ESVi had greater discriminatory ability compared with ESVi alone .At follow-up, 27 patients fulfilled one or more of the composite outcome criteria: EF < 50%, DD grade ≥ 2, EDVi above the normal range according to current guidelines (> 79 mL/mr women) . BaselinTo the best of our knowledge, this is the first follow-up study to assess changes in LA phasic function following AVR in patients with severe AR. Our results demonstrate that patients with AR have larger LAVi and reduced LASct compared with controls. One year after surgery, LAVi and LAScd had decreased, LA strain during LASr and LASct had increased, and an improvement was seen in diastolic function indices and consequently DD grade. These findings suggest that the volume overload imposed by AR affects not only LV volume and mass and systolic function but also LV diastolic properties and LA structure and function. We also found that preoperative LA function, in terms of LAScd, added to the established measure of end-systolic LV dimension for the prediction of impaired LV functional and structural recovery following AVR for severe AR.Severe AR leads to increased preload of the LV, inducing progressive dilation, which in turn increases wall stress and, over time, can cause structural myocardial changes and depressed ventricular systolic function . Thus, LWe further analyzed the relationship between changes in LAS and GLS, finding that the latter had a moderate linear correlation with changes in LASr and LAScd. This finding confirms that GLS and LAS partly interact during systole, probably because systolic atrioventricular plane movement affects LA strain in segments close to the mitral annulus.LV–LA interaction is complex in patients with AR. If the LV is compliant, increased preload results in increased EDV without any increase in diastolic LV filling pressure. In the latter disease stages, there is an increase in the fibrous content of the LV myocardium, leading to increased stiffness, which contributes to increased LV filling pressure and a subsequent increase in mean LA pressure and LA volume; at some point, this will become associated with symptom development , 31. PreIn a previous study of patients with DD and preserved EF, mild DD was associated with reductions in LAScd and LASr and an increase in LASct, whereas all components of LA phasic function were reduced in patients with higher degrees of DD . We alsoThe reduced preoperative LASct in our patients with AR with DD grade >1 indicates a diminished active atrial contraction, consistent with a previous report showing that LA contraction force is lower in patients with AR than in those with aortic stenosis . In a miThe echocardiographic assessment of LV diastolic function and filling pressure in patients with AR remains challenging. There are limited data regarding the accuracy of current criteria for the assessment of increased LV filling pressures in these patients . Neverth.Our control group consisted of patients free from significant aortic valve disease, who underwent open thoracic surgery for TAA. Our goal was to assess whether cardiac surgery per se would induce changes in LV function or LAS. Although we cannot exclude small changes in loading conditions due to the surgical correction, we could not demonstrate any significant changes in LV or LA volumes or function in the control group. Therefore, we believe that the volumetric and functional changes observed in our patients with AR were not significantly affected by the trauma of surgery per seOur relatively short follow-up time precluded use of hard outcomes such as mortality or admissions for recurrent heart failure. Furthermore, we used a composite variable to define impaired LV function and structure, which may limit the generalizability of the results. Thus, our study should be considered a hypothesis-generating one. The prognostic implications of LAS in patients with AR warrants validation with larger cohorts with additional clinical outcome variables.One-third of patients with chronic severe AR had signs of impaired LV diastolic function. Aortic valve surgery improved diastolic LV function, decreased LV and LA volumes, and increased LA reservoir and contractile function. We found that LA strain components have an incremental prognostic value to the well-established LV end-systolic dimension for the prediction of impaired LV functional and structural recovery following aortic valve surgery. However, further research in this area with larger, longer-term follow-up studies with hard endpoints will be needed to establish the role of LAS in the preoperative evaluation of patients with AR.


Sulcus-specific morphometry analysis may help disentangle the contribution of coexisting neurodegenerative and neurodevelopmental processes, but such an approach has never been used in HD. Here, we investigated cortical sulcal depth, related to degenerative process, as well as cortical sulcal length, related to developmental process, in early-stage HD and age-matched healthy controls. This morphometric analysis revealed significant differences in the HD participants compared with the healthy controls bilaterally in the central and intra-parietal sulcus, but also in the left intermediate frontal sulcus and calcarine fissure. As the primary visual cortex is not connected to the striatum, the latter result adds to the increasing in vivo evidence for primary cortical degeneration in HD. Those sulcal measures that differed between HD and healthy populations were mainly atrophy-related, showing shallower sulci in HD. Conversely, the sulcal morphometry also revealed a crucial difference in the imprint of the Sylvian fissure that could not be related to loss of grey matter volume: an absence of asymmetry in the length of this fissure in HD. Strong asymmetry in that cortical region is typically observed in healthy development. As the formation of the Sylvian fissure appears early in utero, and marked asymmetry is specifically found in this area of the neocortex in newborns, this novel finding likely indicates the foetal timing of a disease-specific, genetic interplay with neurodevelopment.Huntington's disease (HD) is an inherited, autosomal dominant disorder that is characteristically thought of as a degenerative disorder. Despite cellular and molecular grounds suggesting HD could also impact normal development, there has been scarce systems-level data obtained from  While the striatum is the most atrophied structure in HD, there is evidence that the cortical atrophy is more widespread than previously thought based on symptoms . Importact in HD . These act in HD .Here, we carried out for the first time in HD a sulcal morphometry analysis using a tool that automatically reconstructs and labels sulci from T1-weighted images . This apWe thus expected that sulcal morphometry analysis might reveal evidence for coexisting abnormal degenerative and developmental processes, in line with the duality, observed for the mutant protein, of both gain-of-function and loss-of-function  . As this2This study was part of the MIG-HD project  and was approved by the ethics committee of Henri Mondor Hospital in Créteil. All subjects gave written informed consent.2.1Twenty-three HD patients  were included from four different hospitals . All were scanned using the same scanner, in the same imaging centre in Orsay. To meet inclusion criteria, all had genetically proven HD, with an abnormal number of CAG repeats ranging from 40 to 57 (46 ± 4). None had juvenile HD. They all had clinical symptoms for at least 1 year and 15 were at stage I of the disease according to their total functional capacity score (TFC ≥ 11) , i.e., t2.22 in-plane resolution, slice thickness 1.2 mm, TI/TE/TR (inversion/echo/repetition time) 600/2/10.2 ms, flip angle (α) 10°, read bandwidth (RBW) 12.5 kHz.Whole-brain anatomical MRI was acquired in all 41 participants with a 1.5 T Signa imager  with a standard 3D T1-weighted inversion recovery fast spoiled gradient recalled (IR-FSPGR) sequence with the following parameters: axial orientation, matrix 256 × 256, 124 slice locations, 0.9375 × 0.9375 mm2.3http://brainvisa.info  was created for each image, based on the analysis of the histogram and a morphological opening, before being segmented into left and right hemispheres, as well as cerebellum. Next, the complement of the white matter, defined as the space between the brain envelope  and the GM/WM boundary (identified from the intensities of the two tissues), was skeletonised to create a 3D print of each sulcus. We thus obtained the 3D reconstruction of sulci for each of the 23 HD patients and 18 healthy controls.Various sulcal features can then be analysed, but here we focused on two that are easily interpretable: depth and length of the sulcus. Decrease of depth of sulci has been consistently reported in case of neurodegeneration , as the sulci become more shallow as adjacent gyri degenerate . In contAs there is a substantial inter-subject variability in the shape and location of the sulci, making a non-linear warping to standard space approach not appropriate, the strategy here was to use the automatic recognition of the sulci based on supervised learning from a database created by neurosurgeons and using neural networks . This prTo create an additional variable, we manually delineated the striatal regions on each axial plane of each individual T1-weighted scan, after all the images were rigidly reoriented so that the anterior and posterior commissures were located in the same axial plane . The acc2.4P < 0.05 (two-tailed), corrected for false discovery rate (FDR) across all sulci (n = 57).We carried out an ANCOVA to compare sulci between the two populations, with diagnosis, age, and age by diagnosis interaction as covariates to make the results easily comparable with a previous voxel-based study in this population (18 out of 23 HD patients in common) . ResultsWe additionally checked that our sulcal results held when: 1. adding sex and handedness as additional covariates, 2. normalising for intracranial volume by calculating the residuals for depth and length after the linear contribution of the intracranial volume to the power 1/3 was removed .We further ensured that our results showing differences in the length of the sulci – presumably of developmental nature – were in fact not associated with disease burden ((nCAG-35.5) × age) or disease stage (TFC). To this effect, we calculated the correlation coefficient within the HD group between these two clinical measures and our imaging measures of length showing significant group differences.a posteriori with their behavioural and clinical scores  .3Several sulci were significantly abnormal in the HD patients (3.1In line with the literature and our previous voxel-based results based on the same HD population (18 out of 23 HD participants in common) , we foun3.2This individual measure approach further revealed significantly shallower left intermediate frontal sulcus, decreased by 12.9% in the patients, in line with the consistent cortical post mortem observation of dorso-lateral prefrontal cortex atrophy  and 3. T3.3Beyond these consistent findings of reduced sulcal depth pointing at cortical degeneration, the sulcal analysis also revealed a strong difference in the length of the posterior Sylvian fissure, with a length increased by 18.9% for the HD participants compared with healthy controls  and 4. Tlonger sulcus in the patients, it can thus be interpreted more appropriately as an almost complete absence of asymmetry for this sulcus in HD, asymmetry that is normally found in healthy participants (R + L), is significantly decreased (towards 0) in the HD group .Investigating further the measure of length in the Sylvian fissure, it is clear that, in healthy controls, this fissure is in fact considerably shorter in the left hemisphere than the right . Rather icipants . The lef23=0.49, 24% of variance explained, P = 0.017, Supplementary Figure 1).As the length of the left posterior Sylvian fissure seemed to be a hallmark of abnormal asymmetry in HD, we further investigated within this group if it was associated with their striatal volumetric asymmetry, as measured using careful manual segmentation of the subcortical structures . We foun21 = 0.08, P = 0.38) or TFC .Finally, we established that the abnormal length of the Sylvian fissure in HD was not correlated with either disease burden (r3.4r > 0.70). This allowed us to assess correlations between the significant sulcal findings of depth and length with the Motor UHDRS, Behavioural UHDRS, Stroop Interference , Functional Assessment , TFC and Sum Fluency . Associations are summarised in Supplementary Table 1, but briefly: these showed an association between Stroop Interference and depth of the right intra-parietal sulcus , Functional Assessment and depth of the left intermediate frontal sulcus , and Behavioural UHDRS and depth of the left calcarine fissure . After regressing age out, we also found an association between the sum of the fluency scores and the depth of the left intermediate frontal sulcus (Supplementary Table 1).We first reduced the set of scores to those that did not share more than 50% of explained variance : , or evenurements . Remarka20==0.40, Supplementary Table 1), a measure of selective attention whose functional network is centred on the intra-parietal sulcus (Supplementary Table 2). While mainly redundant (and less sensitive) than the measure of sulcal depth, the surface of sulci solely revealed a significant difference in the left olfactory sulcus, which might be linked to the smell deficits consistently observed in HD , and at a trend level with TFC (r20 = 0.31)(Supplementary Table 1).Findings of a left-lateralised degeneration around the intermediate frontal sulcus concur with the wealth of post-mortem evidence on the injury to the dorso-lateral prefrontal cortex e.g., . As it win vivo surface-based studies of HD, where degeneration was found in the occipital lobe and in particular around the left calcarine fissure . This association might perhaps be related to the association observed between behavioural symptoms – visual hallucinations and depression – and this specific region of the brain also seen in Parkinson's disease   and Independence Scale . It could thus be that the subcortical volume asymmetry seen in the striatum of HD patients is both a combination of developmental and degenerative processes.Interestingly, this sulcal analysis also revealed an increase of nearly 20% in the length of the left posterior Sylvian fissure in HD compared with the healthy participants. The consistent decrease of depth found in various sulci are consistent with a neurodegenerative process, and thus mainly consistent with volume-based and surface-based findings. A significant difference in the length of one sulcus, on the contrary, is more difficult to be interpreted, especially in light of the absence of colocalised atrophy, and the lack of association with disease stage or burden, and age. As such, it is more likely related to an altered development. This left peri‑Sylvian region is for instance well known to be associated with functional language lateralisation and specialisation, although it did not correlate with verbal fluency , the onlrocesses . This alnewborns , this liigure 1) . Such stSupplementary Table 3). This relatively small sample size also meant large effect sizes for our significant results, such as a difference of 19% in length of the Sylvian fissure, or of 21% in the depth of the calcarine fissure. Finally, another clear limitation is that our participants were already symptomatic. Especially for the findings in the Sylvian fissure, a study on  gene carriers far from the onset of symptoms - such as done in Compared with a technique such as VBM, this specific sulcal approach cannot show precisely where some of the abnormalities might be localised along a sulcus . Newest developments might be able to resolve these limitations . In any in vivo indication of an interplay between disease and neocortical development.In summary, we used for the first time a detailed analysis of sulcal morphology in HD. This approach, which precisely targets cortical features, offers complementary sources of information, not only to conventional voxel- and vertex-wise approaches, but also in how they relate to different underlying physiopathological processes, and could help detect subtle neurodevelopmental abnormalities that would otherwise go unnoticed in other degenerative disorders with a genetic susceptibility. It revealed in HD abnormalities consistent with a neurodegenerative process, but also importantly with an altered neurodevelopment. While the atrophy found in the left visual cortex adds to the increasing wealth of data indicative of a primary cortical degeneration in HD, this study provides, to the best of our knowledge, the first Jean-Francois Mangin: Conceptualization, Formal analysis, Software, Writing - original draft. Denis Rivière: Formal analysis, Software, Writing - original draft. Edouard Duchesnay: Formal analysis, Software. Yann Cointepas: Software. Véronique Gaura: Resources. Christophe Verny: Resources. Philippe Damier: Resources. Pierre Krystkowiak: Resources. Anne-Catherine Bachoud-Lévi: Resources, Funding acquisition. Philippe Hantraye: Supervision, Funding acquisition. Philippe Remy: Supervision, Resources, Funding acquisition. Gwenaëlle Douaud: Conceptualization, Resources, Investigation, Formal analysis, Funding acquisition, Writing - original draft, Writing - review & editing.The authors declare no competing financial interests.


Right ventricle (RV) dysfunction is the strongest predictor of mortality in pulmonary arterial hypertension (PAH), but, at present, there are no therapies directly targeting the failing RV. Although there are shared molecular mechanisms in both RV and left ventricle (LV) dysfunction, there are important differences between the 2 ventricles that may allow for the development of RV-enhancing or RV-directed therapies. In this review, we discuss the current understandings of the dysregulated pathways that promote RV dysfunction, highlight RV-enriched or RV-specific pathways that may be of particular therapeutic value, and summarize recent and ongoing clinical trials that are investigating RV function in PAH. It is hoped that development of RV-targeted therapies will improve quality of life and enhance survival for this deadly disease.  Pulmonary arterial hypertension (PAH) is caused by pathological remodeling of the pulmonary vasculature, which subsequently increases right ventricular (RV) afterload and ultimately manifests as RV dysfunction. RV dysfunction is the strongest predictor of mortality in PAH , 2, 3, aIn addition to PAH, RV dysfunction is prognostic in the 2 leading causes of pulmonary hypertension (PH): PH caused by left heart disease  and lung disease (WHO Group 3) , 10, 11.Mechanistic dissections of RV dysfunction have lagged behind our understanding of left ventricular (LV) dysfunction. This is exemplified by the fact that there are multiple therapies with proven survival benefits for LV failure ,19 but nThere are developmental, anatomic, and functional differences between the RV and LV  that mayThere are divergent molecular responses between RV and LV failure documented in animal and human studies ,38,39. ISeveral commonly used preclinical models of PAH are discussed in the following sections. A previous review highlighted the evidence of sympathetic nervous system (SNS) dysregulation in RV dysfunction in PAH, and completed clinical trials of beta blockers in PAH are largely neutral . ConversNumerous studies show that the RAAS is involved in pulmonary vascular remodeling , which, In human studies, ACE protein concentration is increased, but there is downregulation of the angiotensin II type 1 (AT1) receptor in the failing PAH RV, likely caused by higher stimulation of AT1 receptors by angiotensin II . HoweverClearly, the roles of the SNS and RAAS in RV dysfunction need to be clarified. The effects of beta blockers on RV function in PAH are being investigated in ongoing clinical trials, and it is hoped that will help elucidate the role of the SNS on RV function .Table 3RDevelopment of RV fibrosis may initially be an adaptive process to maintain RV shape, but during prolonged stress, RV fibrosis becomes maladaptive as it increases diastolic stiffness, alters cardiomyocyte excitation-contraction coupling, and depresses myocardial contraction , 63, 64.It is interesting that currently available antifibrotics do not effectively mitigate RV fibrosis in preclinical studies. However, multiple preclinical drug studies show reduction in RV fibrosis is associated with improved RV function, but all occur in the setting of reduced afterload , 68, 69.Current antifibrotic therapies do not mitigate RV fibrosis directly. For instance, pirfenidone, which reverses fibrosis in pressure overloaded LV , does noAlthough there are similar molecular mechanisms that trigger RV and LV fibrosis, fibrosis appears to have different roles in each ventricle. For instance, the RV can be subjected up to a 5-fold increase in afterload in PAH, whereas the LV afterload increase under pathological conditions is usually <1.5-fold . The heiIn summary, there are data that suggest excess RV fibrosis is pathological, but currently available therapies do not effectively reverse RV fibrosis. Of note, these results suggest the RV and LV have distinct fibrotic responses that will require further evaluation to determine how to target RV fibrosis effectively.Transverse (t)-tubules are cell membrane invaginations that penetrate into cardiac cells and enhance excitation-contraction coupling . In monoThere is emerging evidence that altered sarcomere function promotes RV dysfunction in PAH. In pulmonary artery-banded rats, RV myocardial stiffness is observed in both mild and severe dysfunction . In huma2+/calmodulin-dependent protein kinase II δ decreases activation of the nucleotide-binding oligomerization domain-like receptor pyrin domain-containing protein 3 (NLRP3) inflammasome, decreases macrophage accumulation, and improves LV function in mice , IL-6 (tocilizumab), and CD20 on B cells (rituximab) in PAH are completed , but notNumerous preclinical studies show biological sex and sex hormones are major determinants of RV function in RV pressure overload . Male SuIn patients with PAH, there is a sex paradox, as PAH is more prevalent in female patients , but malPreclinical studies imply there are ventricle-specific differences in estrogen signaling. In the dysfunctional rodent RV, the beneficial effects of estrogen are predominately mediated by estrogen receptor (ER)-α . ConversOf note, there are several ongoing clinical trials evaluating the effects of antagonizing estrogen , as highAlterations in metabolism during maladaptive RV remodeling have been extensively reviewed ,109. In There are multiple preclinical studies showing alterations in RV metabolism in PAH. Inhibition of fatty acid oxidation (FAO) with ranolazone and trimetazidine increases glucose oxidation, which is advantageous because glucose oxidation is more efficient than fatty acid metabolism , and resMore recent publications highlight additional metabolic deficiencies in the RV in PAH. There is alteration of RV FAO as patients with PAH have significant increases in RV free fatty acids but lower levels of acylcarnitines, which suggests the conversion of fatty acid to acylcarnitines is disrupted in the PAH RV . Of noteSeveral recent clinical trials studying the FAO inhibitors, ranolazine  and trimDuring maladaptive RV remodeling in PAH, RV ischemia results from decreased right coronary artery perfusion pressure or capillary rarefaction. Although the development of RV ischemia from reduced coronary perfusion pressure is well established , the rolA detailed review of the role of angiogenesis during RV failure was previously published . In summSeveral therapies that inhibit capillary rarefaction and restore RV perfusion in preclinical models improve RV function in PAH. The antioxidant Protandim  prevents capillary loss and fibrosis and augments RV function in Sugen-hypoxia rats . In addiThe differences in perfusion between the LV and RV may limit expolating LV findings on the mechanisms of ischemia to the RV. In addition to the RV normally being perfused during both systole and diastole , it has Epigenetic processes are defined as molecules and mechanisms that modulate gene expression independent of changes in DNA sequence . Recent Murine studies have shown baseline differences in the expression of miRNAs between the RV and LV , and mulHistones are chromatin proteins that pack DNA . HistoneAlthough largely unexplored in the RV, DNA methylation differences are observed in the diseased human LV ,152. HowThe proteasome is a multicatalytic complex that regulates protein homeostasis via protein degradation . The proThe causes of impaired exercise capacity in PAH are multifactorial, likely caused by a combination of cardiac , pulmonary , skeletal muscle, and other systemic limitations  . HoweverPhosphodiesterase-5 (PDE5) inhibitors increase exercise capacity in patients with PAH , and somCertainly, further research is needed to understand the mechanisms by which exercise improves RV function in PAH and other PH subgroups. Several ongoing clinical trials are investigating the role of exercise on RV function ; it is hMultiple clinical trials have investigated or are currently investigating the targets of RV dysfunction discussed in this review . HoweverRV dysfunction is the strongest predictor of mortality in PAH , 2, 3, bDr. Prisco is funded by National Institutes of Health (NIH) grant T32 HL144472, a University of Minnesota Clinical and Translational Science award (NIH UL1 TR0029494), and a University of Minnesota Medical School Academic Investment Educational Program grant. Dr. Prins is funded by NIH K08 HL140100, the Jenesis Award from United Therapeutics, a Lillehei Heart Institute Cardiovascular Seed Grant, and the Cardiovascular Medical Research and Education Fund; and has served as a consultant for Actelion and receives grant funding from United Therapeutics. Dr. Thenappan has served as a consultant for Actelion and Gilead. The content of this article is solely the responsibility of the authors and does not represent the official views of the NIH or any other funding sources. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.


Highly trained athletes running 42 km or more demonstrate elevated cardiac biomarkers, ventricular dysfunction, and decreased glomerular filtration rate (GFR). Whether similar changes occur in the much larger population of recreational runners following half‐marathon distance running is unclear.Recreational runners exhibit changes in myocardial and renal biomarkers, including ventricular strain, after a half‐marathon treadmill run.10 recreational subjects (mean age 36.5 ± 6.5 years) ran 21 km on a treadmill (mean completion time 121.6 ± 16.1 minutes). Serum high‐sensitivity troponin T (hsTnT), amino‐terminal pro‐brain natriuretic peptide (NT‐proBNP), creatinine, and neutrophil gelatinase‐associated lipocalin (NGAL) were measured prior to, 1 hour post‐, and 24 hours post‐exercise. Pre‐ and post‐exercise echocardiograms were performed.P < .05), NT‐ProBNP by 26.2 ± 22.8 pg/ml (P < .05) and NGAL by 29.5 ± 37.7 ng/ml (P=NS). By 24 hours post‐run, these biomarkers declined toward baseline levels. Right ventricle (RV) free wall and left ventricle global longitudinal strain decreased by 5.5% and 1.8%, respectively (P < .001). Changes in NGAL correlated well with changes in serum creatinine  and GFR . Faster 21 km completion times, and a larger reduction in post‐exercise RV strain, were associated with higher NGAL levels:  and , respectively.All biomarkers increased 1 hour post‐exercise: hsTnT by 8.5 ± 8.5 pg/ml (A 21 km run in recreational runners is associated with transient ventricular stunning and reversible changes in myocardial and renal biomarkers. Whether repeated bouts of similar activity contributes to chronic cardiac or kidney dysfunction deserves further evaluation. However, participants of the full marathon distance (42.125 km) and above are a minority compared with those of shorter distance events. Over the last 15 years, the number of half‐marathon (21 km) participants globally has increased more than 5‐fold from under 500 000 in 2003 to more than 2 million in 2018. The 21 km distance had twice the number of participants as the full marathon distance and was second only to the number of 5 km runners (2.9 million).In this pilot study, we investigated changes in peripheral blood biomarkers of myocardial injury, haemodynamic stress, and renal injury with right and left ventricular strain in recreational runners completing a 21 km treadmill run.22.1Study participants were recruited from a local recreational running club. Eligible subjects were recreational runners 21 years or older with a weekly training distance of under 50 km.Training history was ascertained for all participants including average running distance per week, number of years of running, and number of half‐ and full‐marathons completed. Measurements of height, weight, peripheral blood pressure, and resting heart rate were obtained prior to the run. Holter monitors were attached to all runners for the duration of the run to track their exercise heart rates. Maximum heart rate for each participant was calculated by subtracting their age from 220. Level of intensity was then calculated by dividing average heart rate during activity by maximum heart rate. Based on the American College of Sports Medicine (ACSM) guidelines, a range of 30% to 49% of maximum heart rate corresponds to “light” intensity, 50% to 69% to “moderate” and 70% to 89% to “hard”.All subjects completed an indoor 21 km run at their own pace within an air‐conditioned gymnasium on a commercial grade treadmill  with full manual settings. Isotonic beverages and plain water were made available throughout the run and participants were encouraged to hydrate liberally. Fluid intake of the subjects was not monitored. Transthoracic echocardiography (TTE) was performed pre‐run and within an hour of completing the 21 km run. Peripheral blood samples were obtained pre‐run, within 1 hour post‐run and within 24 hours post‐run.The protocol was approved by the local institutional review board ethics committee and all subjects gave written informed consent prior to study participation.2.2Serum creatinine was measured by the Enzymatic Creatinine 2 method using the Advia 2400 analyzer . The reference range for this assay is 9‐2652 umol/L, and upper limit of normal is 125 umol/L and 90 umol/L in males and females, respectively. Estimated glomerular filtration rate (GFR) was then calculated using the Modification of Diet in Renal Disease (MDRD) equation.High‐sensitivity troponin T (hsTnT) and NT‐proBNP were measured using electrochemiluminescence immunoassays on a cobas e411 analyzer . For hsTnT, the 99th percentile for normal subjects is 14 pg/ml. For NT‐ProBNP, the upper limit of normal in subjects 75 years of age and below is considered to be 125 pg/ml.Serum neutrophil gelatinase‐associated lipocalin (NGAL) was quantified using enzyme‐linked immunosorbent assay with the Quantikine Human Lipocalin‐2 immunoassay  and absorbance values measured on the Enspire Microplate Reader . The normal range for healthy individuals is 42‐177 ng/ml (mean 119 ng/ml ± 35.6).2.3Subjects underwent M‐mode, two‐dimensional (2D) and doppler TTE using a Vivid 7 Dimension ultrasound system  equipped with a 2.5 MHz probe, in accordance with American Society of Echocardiography (ASE) guidelines.Left ventricular (LV) ejection fraction and stroke volume were measured using the biplane method of disks. Fractional shortening was calculated using the difference in LV end‐diastolic and end‐systolic diameters via M‐mode. Pulsed wave tissue doppler imaging was performed to obtain peak early (e') and late (a') myocardial velocities and the ratio of early diastolic transmitral flow velocity to e' (E/e').Indices of myocardial deformation obtained by speckle‐tracking analysis using the EchoPac software . LV global longitudinal strain (GLS) was obtained as the average segmental value based on three apical imaging planes.Right ventricular (RV) free wall strain was assessed along the length of the free wall from apical 4‐chamber images. Other measures of RV systolic function that is, 2D fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE) and myocardial performance index (via pulsed tissue Doppler) were also obtained.2.4Data for continuous variables are presented as mean ± SD. Repeated measures analysis of variance (ANOVA) was used to compare changes in the biomarkers for all 3 time points . A 2‐sided P value of <.05 was considered statistically significant.33.12. Participants had 4.25 ± 3.1 years of running experience, and ran 29 ± 9.1 km weekly. Mean pre‐exercise values for systolic and diastolic blood pressure and heart rate were 120 ± 11.6 mmHg, 72.8 ± 8.4 mmHg and 59 ± 6.7 beats per minute respectively. All participants were free of modifiable cardiovascular risk factors.The study population consisted of 10 subjects  with mean age of 36.5 ± 6.5 years and mean body mass index of 21.9 ± 1.7 kg/mParticipants completed the 21 km treadmill run in an average time of 121.6 ± 16.1 minutes . These timings correspond to the 60 to 70th percentile and 30 to 40th percentile for recreational male and female runners respectively, and 40 to 50th percentile overall.3.2P = .01) and returned toward baseline 24 hours post‐run . In 5 runners , the 1‐hour post‐run hsTnT was elevated beyond 14 pg/ml. There was no correlation between running intensity or run duration and hsTnT level.Baseline hsTnT levels ranged from 3 to 8 pg/ml. Within 1 hour of completing the run, hsTnT increased to 12.2 ± 9.8 pg/ml (P < .01) within 1 hour post‐run. In no subject was the upper limit of normal exceeded. As with hsTnT, levels of NT‐proBNP declined at 24 hours post‐run to 26.8 ± 17 pg/ml (P = .06). There was no correlation between NT‐proBNP and hsTnT.Mean NT‐proBNP at baseline was 13.5 ± 10 pg/ml and increased to 39.7 ± 29 pg/ml (P < .05). At 24 hours post‐run, mean NGAL dropped to 73.4 ± 31.8 ng/ml (P = .1), consistent with the other biomarkers. At baseline, serum creatinine was 92.1 ± 11.6 umol/L and increased to 123.1 ± 30.2 umol/L (P < .01). Pre‐run estimated GFR (73 ± 10 ml/min/1.73m2) declined by 25% to 55 ± 18 ml/min/1.73m2 (P < .01) at 1 hour post‐run. NGAL levels correlated with both serum creatinine  and GFR . Shorter 21 km completion time was associated with higher NGAL 24 hour post‐exercise .Mean NGAL pre‐run was 67.1 ± 18.4 ng/ml and increased 1 hour post‐run to 96.6 ± 47.1 ng/ml (3.3P < .05) and 3.2 ± 1.4% (P = .05), respectively. The septal E/e' ratio remained stable pre‐ and post‐exercise, while the lateral LV E/e' ratio declined by 1.1 ± 0.8 (P < .01). At 1 hour post‐run, RV FAC decreased by 11.5 ± 2.6% (P < .01), TAPSE decreased by 3.2 ± 2.8 mm (P < .01) and mPAP increased by 7.2 ± 2.9 mmHg (P < .05). RV annular systolic velocity and RV myocardial performance index did not change significantly. RAP, IVC dimension, and other surrogate measures of RV filling, including RV diastolic area, tricuspid E/e' and hepatic vein systolic velocity, showed no statistically significant differences before and after exercise.Baseline echocardiographic parameters were within normal limits in all subjects. Post‐exercise, LV ejection fraction, end diastolic volume, and cardiac index were unchanged, whereas LV stroke volume and fractional shortening decreased, falling by 5.7 ± 2.4 ml (3.4P = .05), as well as 24‐hour post‐exercise NGAL , but did not correlate with running time or the extent of increase in PASP. In the four subjects who had higher NT‐proBNP level at 24 hours than at 1 hour post‐exercise, there was a greater reduction in RV strain compared with those in whom NT‐proBNP declined .Biventricular strain showed statistically significant reductions following endurance exercise. There was no difference in the magnitude of reduction in LV GLS between runners with post‐run hsTnT above versus below the 99th percentile. The percentage reduction in RV free wall strain showed a positive relationship with peak  a transient and reversible elevation of hsTnT and NT‐proBNP, (b) increased NGAL and reversible reduction in estimated GFR, and (c) myocardial stunning as evidenced by reduced biventricular strain. In addition, NGAL showed good correlation with the degree of ventricular stunning.A meta‐analysis of 26 studies showed that 47% of endurance athletes had elevation in cardiac troponin post‐exercise.Independent studies utilizing magnetic resonance imaging in competitive lifelong athletes have shown an association between long‐term endurance activity and the presence of myocardial fibrosis, with reported prevalence rates as high as 17%.Our study showed a statistically significant reduction in LV GLS, in keeping with previous work on athletes participating in prolonged endurance activity.Although fluid intake was not restricted throughout the run, dehydration and reduced preload could account for the right ventricular changes. While fluid balance was not directly quantified, comparison of multiple surrogate measures of RAP and RV filling pressure showed no statistically significant differences pre‐ and post‐run. Moreoever, LV dimensions  did not change significantly post‐run. Taken together, this suggests that the observed reduction in RV strain was predominantly related to transient myocardial stunning rather than altered load.In our study, pre‐run estimated GFR declined by 25% at 1 hour post‐run, fulfilling stage 1 of the RIFLE  classification system for AKI.NGAL is a novel highly sensitive biomarker for AKI.2max) of study participants was not available, hence, the ACSM guidelines were used as a surrogate for maximum heart rate and subsequent calculation of exercise intensity.Limitations of our study included its small sample size, making generalisability an issue. Additionally, cardiac magnetic resonance, the current imaging gold standard, was not utilized for more accurate assessment of cardiac volumes and function due to operational constraints. However, each subject served as their own control, and any inaccuracies in echocardiographic assessment should be systematic. We did not perform a 24‐hour post‐run echocardiographic assessment, which would have provided more information on the reversibility of the observed changes in ventricular strain. Objective baseline cardiopulmonary fitness via maximum oxygen uptake .


Pathologic Q waves are the classic ECG sign of myocardial infarction. Prior studies have shown cardiac MRI is a more sensitive tool to detect myocardial necrosis. However, it is unclear whether pathologic Q waves on ECG always correlate with ischemic pattern of delayed enhancement. We tested the hypothesis that Q waves always indicate the presence of myocardial scaring on contrast enhanced cardiac Magnetic resonance imaging.We included 41  consecutive patients with pathologic Q waves on ECG who underwent contrast enhanced cardiac MRI (1.5 T) for various clinical reasons. Imaging protocols included cine SSFP sequence and post double dose contrast delayed imaging. Q waves were considered pathologic if the total Q wave voltage is more than one third of the QR voltage. Left ventricular myocardial scar was evaluated qualitatively using the AHA recommended 17 segment model by 2 readers who were blinded to the clinical and ECG data.A total of 29/41 (69%) patients had evidence of myocardial scar in coronary pattern, 18 (44%) of which were transmural. The presence of a Q only pattern (absence of R or S waves) did not improve the accuracy of ECG in identifying myocardial delayed enhancement on MRI. However, Q waves only modestly localized the scar. Anterior Q waves (64%) have the best correlation with the presence of scar in the anterior segments with lateral and inferior being 41% and 40% respectively. In addition, the Q only pattern did not improve the localizing accuracy of ECG.The presence of pathologic Q waves on ECG is not always associated with the presence of prior myocardial infarction on cardiac MRI. In addition, Q waves appear to modestly correlate with the location of the prior MI. Further studies should evaluate the potential causes of pathologic Q waves in patients without prior myocardial infarction.


Cardiac dysfunction is increasingly recognized in patients with liver cirrhosis. Nevertheless, the presence or absence of structural alterations such as diffuse myocardial fibrosis remains unclear. We aimed to investigate myocardial structural changes in cirrhosis, and explore left ventricular (LV) structural and functional changes induced by liver transplantation.n = 33) and 1 year after transplantation (n = 19).This study included 33 cirrhosis patients listed for transplantation and 20 healthy controls. Patients underwent speckle-tracking echocardiography and cardiovascular magnetic resonance (CMR) with extracellular volume fraction (ECV) quantification at baseline (LV-EF) and echocardiographic LV global longitudinal strain (LV-GLS) demonstrated hyper-contractile LV in cirrhosis patients . No significant differences in LV size, wall thickness, mass index, and diastolic function between cirrhosis patients and healthy controls were seen . Only one of the cirrhosis patients showed late gadolinium enhancement. However, cirrhosis patients showed a higher ECV  than healthy controls. ECV showed a positive correlation with Child-Pugh score . Electrocardiogram-based corrected QT interval was prolonged in cirrhosis (P < 0.001). One-year post-transplantation, echocardiographic LV-GLS  and ECV  moved to the normal ranges. Corrected QT interval decreased after transplantation .CMR-based LV ejection fraction (CMRMyocardial extracellular volume expansion with augmented resting LV systolic function was characteristic of cirrhotic cardiomyopathy, which normalizes 1-year post-transplantation. Thus, myocardial extracellular expansion represents a structural component of myocardial changes in cirrhosis. Liver cirrhosis is associated with chronic dysfunction in the cardiovascular system –4. CardiCardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) is a widely utilized non-invasive imaging protocol for myocardial tissue characterization. However, a drawback of LGE is its insufficient sensitivity in detecting reversible, early stage diffuse interstitial fibrosis or DMF , 11. Rec2), documented history of cardiovascular diseases including coronary artery disease, and other forms of myocardial disease, and acute liver failure without cirrhosis. All patients underwent computed tomographic coronary angiography or invasive coronary angiography as a routine preoperative assessment. The absence of a significant coronary artery disease  was verified. Electrocardiogram (ECG), transthoracic echocardiography, and CMR were performed at baseline (n = 33) and repeated at 1 year after transplant (n = 19). Clinical data on baseline characteristics were collected. Liver cirrhosis severity was categorised according to the Child-Pugh score. For comparison, 20 subjects without any cardiovascular disease or cardiovascular disease risk factors were included as healthy controls. This study was conducted according to the principles of the Declaration of Helsinki and approved by the Institutional Review Board of our institution. Written informed consent was obtained from all participants.From March 2016 to December 2017, 36 patients with liver cirrhosis of various etiologies who were listed on the transplant waitlist were prospectively enrolled, of whom three (8.3%) were excluded as they failed to undergo CMR due to acute clinical deterioration. All included patients had been referred to the cardiology department for cardiac evaluation before transplantation. Liver cirrhosis was confirmed based on clinical, laboratory, and ultrasonographic findings –17. PatiEchocardiographic and ECG examinations were conducted as part of the preoperative cardiac evaluation. Echocardiographic data were obtained with commercially available equipments . Conventional echocardiographic parameters were measured by experienced sonographers. Left ventricular (LV) ejection fraction (LVEF) was calculated in accordance with the American Society of Echocardiography guideline . To asseOn ECG QT interval was measured from the start of the Q wave to the end of the T-wave in lead II. To adjust for the heart rate, corrected QT (QTc) interval was calculated by dividing the QT interval by the square root of the R-R interval.CMR was performed using a 3 T CMR system  equipped with six-channel phased-array coils . After amyocardium post - 1/T1myocardium pre]/[1/T1 blood post - 1/T1blood pre]  .To evaluate irreversible myocardial fibrosis, the presence or absence of LGE was assessed. LGE images were acquired 10 min after intravenous gadolinium administration , immediately followed by 20 mL saline flush. The protocol for obtaining LGE images was as follows: slice thickness, 6 mm; interslice gap, 4 mm; TR, 9.1 msec; TE, 42 msec; flip angle, 13 degrees; and in-plane resolution, 1.4 × 1.9 mm. LGE images from the same image planes as those in the cine images were acquired using inversion recovery segmented spoiled-gradient echo and phase-sensitive inversion recovery sequences. The most appropriate inversion time was set to null the normal myocardium, which was typically between 250 and 300 msec, in both pre- and post-transplant CMR examinations. LGE CMR images were analyzed by an experienced radiologist (E-A Park), who was blinded to the patients’ information.At the last stage of this study, myocardial T2 mapping data was acquired in 6 patients using adiabatic T2-prepared fast low-angle shot (FLASH) technique. Three single-shot FLASH images with different T2 preparation times were acquired as follow: echo time (ms): 0, 30, 55 respectively; slice thickness 6 mm; TR, 2.4 msec; TE, 1.0 msec; flip angle, 12 degrees; receiver bandwidth 1184 Hz/pixel; field of view, 288 × 360 mm; and matrix, 144 × 192.P-value < 0.05 was considered statistically significant.Baseline characteristics are described as number and percentages for categorical variables, and mean ± standard deviation for continuous variables. Patient characteristics were compared between groups using a chi-square or Fisher’s exact test for categorical variables, and Student’s t test or Mann-Whitney U test for continuous variables, as appropriate. Changes in echocardiographic, ECG, and CMR parameters between pre- and post-transplant were compared using paired t-test or Wilcoxon signed rank test. Pearson’s correlation coefficient was used to evaluate the relationship between the relevant parameters and Child-Pugh score. A partial correlation analysis between ECV and Child-Pugh score was performed while controlling for cardiac index. All statistical analyses were performed using SPSS . A n = 23, 69.7%) were in Child-Pugh class C and their heart rate was higher than that of patients with Child-Pugh class A/B (P = 0.002). There were no significant differences in the prevalence of hypertension and diabetes mellitus and in the levels of hemoglobin and creatinine between the Child-Pugh class A/B and Child-Pugh class C groups. No significant difference in cardiovascular medications at the time of CMR except for beta-blockers was noted.A total of 33 patients were analyzed in the final analysis. The patients’ baseline characteristics are summarized in Table P = 0.049), indicating a hyper-contractile state in cirrhosis. Resting hyper-contractile state in cirrhosis was corroborated by a significant augmentation in GLS . LAVI and E/e’ ratio were significantly higher in cirrhosis patients than in the normal controls, suggesting impaired LV diastolic function in cirrhosis patients. No significant difference in E/A ratio and deceleration time was found. LV diastolic function in cirrhosis patients could not be classified into one category in 15 patients (45.5%) when the 2016 guideline was applied [P = 0.040). As expected, QTc interval was significantly prolonged in cirrhosis patients (P < 0.001). Most ECG and echocardiographic parameters between Child-Pugh class A/B and Child-Pugh class C showed no statistical differences. A significant positive linear correlation was observed between QTc interval and Child-Pugh score .Comparisons of echocardiographic and ECG parameters are shown in Table  applied . In addiP = 0.027), mainly driven by a larger EDV, rather than by a smaller ESV. Moreover, LV stroke volume  and cardiac index  were greater in cirrhosis patients, again supporting hyper-dynamic circulation in cirrhosis [P = 0.073). With Child- Pugh score as a continuous variable, a positive trend in relation to cardiac index was observed . There were no significant differences in terms of LV mass index and LV mass/LV EDV ratio between cirrhosis patients and the healthy control group.CMR-based hemodynamic parameters are shown in Table P = 0.001; Table P = 0.87). Cirrhosis patients had a significantly higher ECV . The pre-transplant native T2 values measured in 6 patients at the last stage of this study were within normal range in all 6 patients (100%), whereas pre-transplant ECV was more than 30.0% in 4/6 patients (66.7%) . Although CMR LVEF showed no significant changes 1-year post-transplant (P = 0.382), LV GLS . E/e’ ratio was significantly decreased, as well .A total of 28 patients underwent transplant, of which four 14.3%) died after transplantation. Three patients died of sepsis-associated heart failure within 6 months after transplant, and 1 patient died of heart failure 9 months after transplant. Patients who died after transplant were older, and had a lower pre-transplant CMR cardiac index  and an increase of blood volume in splanchnic bed . In thisLiver transplantation is the only curative treatment and has been believed to reverse structural, hemodynamic, and functional cardiac alterations in cirrhosis. However, only two prospective studies investigated transplant-induced cardiac changes. In the first study, 19 patients were evaluated with echocardiography before and 6 to 12 months after transplant. The authors found that transplant resulted in LV wall thickness regression, and a decrease in cardiac index and LVEF, but no change in LV diastolic function indexes . The secAugmented GLS at rest in cirrhosis could be explained by the resting recruitment of LV contractile reserve to maintain hyper-dynamic circulation . RestingWe observed a stepwise increase in ECV from healthy subjects, Child-Pugh class A/B, to Child-Pugh class C, suggesting that ECV quantification can be clinically used to track myocardial health in relation to cirrhosis severity. Detection of this unique cardiomyopathy pre-transplant is clinically relevant and important given that up to 25% of cirrhosis patients were reported to experience cardiac death after transplant . Of noteFirstly, patients were enrolled in a prospective manner, but we had to exclude patients who could not undergo CMR, i.e. poor renal function or patients with acute clinical deterioration. Thus, our results could not be generalized to all terminally decompensated cirrhosis patients. Secondly, we did not demonstrate potential associations between CMR findings and long-term clinical outcomes. Finally, this study cannot provide definite clinical management directions to reduce the risk of cardiovascular events peri-operatively.Myocardial extracellular expansion with augmented resting LV systolic function was a characteristic finding in cirrhotic cardiomyopathy. This cardiac change was reversible 1 year after liver transplantation, suggesting that hepatic decompensation itself should be a culprit for the cause of the observed myocardial structural and functional changes. Thus, myocardial extracellular expansion represents a structural component of myocardial change in cirrhosis.Additional file 1: Table S1. Comparison of baseline clinical characteristics of patients who died versus survived after transplantation Table S2. Comparison of baseline echocardiographic and electrocardiographic parameters of patients who died versus survived after transplantation. Table S3. Comparison of baseline cardiac magnetic resonance parameters of patients who died versus survived after transplantation.