Heart failure has been singled out as an emerging epidemic, which could be the result of increased incidence and/or increased survival leading to increased prevalence. Knowledge of the responsibility of each factor in the genesis of the epidemic is crucial for prevention. Population-based studies have shown that, over time, the incidence of heart failure remained overall stable, while survival improved. Therefore, the heart failure epidemic is chiefly one of hospitalizations. Data on temporal trends in the incidence and prevalence of heart failure according to ejection fraction and how it may have changed over time are needed while interventions should focus on reducing the burden of hospitalizations in hear failure. Knowledge of the respective responsibility of each of these factors in the genesis of the heart failure epidemic is crucial for prevention strategies. To identify studies for this review, we searched the Medline database for literature with the subject headings “heart failure, epidemiology prevalence, incidence, trends” between 2005 and present. We identified 612 articles from which we selected the ones that form the basis of this article after reviewing the abstracts for relevance to the topic.Heart failure has been singled out as an emerging epidemic . The Mer2.The 2005 American Heart Association/American College of Cardiology guidelines [2.1.Several criteria have been proposed, including the Framingham criteria , the Boset al. [It is important to note that the European Society of Cardiology criteria  require et al.  were broet al. . The Caret al. . The comet al. . Altoget2.2.Once the diagnosis of heart failure is established, further classification requires the understanding of the parameters of left ventricular function to understand the physiology of the heart failure syndrome in each patient.The first step is the assessment of left ventricular ejection fraction to classify heart failure into heart failure with preserved or reduced ejection fraction.While a reduced ejection fraction identifies systolic heart failure, different thresholds to define preserved ejection fraction have been recommended by different groups as shown in versus echocardiography-Doppler to define diastolic heart failure remains controversial [Conversely, heart failure with an ejection fraction of 50% or greater in the absence of major valve disease defines heart failure with preserved systolic function . Using toversial ,23,28–30Invasive measurements with conductance catheters have historically been considered the gold standard to measure filling pressures . HoweverRegardless of the measurements consideration, the mechanistic link between the elevation of filling pressures and the disease process is also controversial. Indeed, the causal role of intrinsic diastolic dysfunction (impaired relaxation and increased diastolic stiffness)  was chal3.i.e., lack of validation and sole use of inpatient data. They, however, prompt the question of whether the stabilization of the heart failure hospitalization rates could be offset by increasing out patient care practice. Data from the Henry Ford Health system, a managed care organization [As measured by Vital Statistics, the burden of heart failure and its societal cost are enormous, thereby epitomizing a public health problem as underscored in guidelines from the American Heart Association and American College of Cardiology . Indeed,nization , indicatnization  and the nization  indicatenization  or even nization . It shounization . The Franization ,70. Datanization .4.The prognosis of heart failure is poor with reported survival estimates of 50% and 10% at 5 and 10 years, respectively –73, and Regardless, these data resonate with clinical trial data that indicated that angiotensin converting enzyme inhibitors, while associated with large reductions in the relative risk of mortality, resulted in more modest (5.7%) absolute event-rate difference. Conversely, the administrative data from the Henry Ford Health system, which include outpatient encounters, reported a median survival of 4.2 years without any discernible improvement over time . These lAs discussed above, the data available suggest that the proportion of heart failure with preserved ejection fraction increased over time. As the survival of heart failure with preserved ejection fraction remained unchanged , its pre4.1.versus coronary disease (43%) for subjects with reduced ejection fraction. The proportion of cardiovascular deaths decreased from 69% in 1979–1984 to 40% in 1997–2002 (p = 0.007) among subjects with preserved ejection fraction contrasting with a modest change among those with reduced ejection fraction  [While the causes of death in heart failure can be challenging to ascertain, there is evidence that, in the community and within the context of stable overall survival, cardiovascular deaths were less frequent among subjects with preserved ejection fraction. Indeed, in Olmsted County, Minnesota, among 1063 persons with heart failure, the leading cause of death in subjects with preserved ejection fraction was non-cardiovascular (49%) 5.As reviewed above, there is evidence that the incidence of heart failure has remained stable over the past 2 decades while survival has improved ,67,68. TAs hospital admissions are event-based, this allows multiple hospitalizations for the same individual to be counted. Thus, this information, while crucial to assess the health care implications of heart failure, does not measure hospitalizations experienced by individual patients. Further, in administrative data, the diagnoses are not validated using standardized criteria, and shifts in hospital discharge diagnoses preferences after the introduction of the Diagnosis-Related Groups payment systems have been demonstrated ,56. As mre-admissions. Yet, a large proportion of incident heart failure cases are diagnosed in outpatient settings such that the numbers reported do not pertain to the entire spectrum of patients with heart failure [All studies pertain to hospitalized cases and measure  failure . Further failure . Those t failure ,86. Impo failure . In the  failure . It is i failure –91. Thes6.The guidelines underscore the challenge of assigning a cause to heart failure . The etiThe etiology of heart failure and how it may have changed over time is not defined. It is conceivable that the increasing burden of heart failure as measured by hospital admissions relates in part to changing etiology, the analyses of which should thus be part of the investigation of the heart failure epidemic and integrated with the analysis of coronary disease and hypertension trends.While research has focused on coronary disease and hypertension as the etiology of heart failure , the obvEstimates of the prevalence of coronary disease in studies of heart failure vary considerably. Fox , using aData from the first National Health and Nutrition Examination Survey (NHANES I) indicate that coronary disease had the largest population attributable risk for heart failure at 62% compared to the other risk factors analyzed  . The att7.Despite the staggering impact of heart failure as measured by Vital Statistics and administrative databases, validated longitudinal data on the incidence and outcome of heart failure remain sparse. The available data indicate that the incidence of heart failure is overall stable in the predominantly white populations in which it was studied.Survival, which remains poor, is nevertheless improving over time. This results in an increase in the prevalence of heart failure and an increase in the number of individuals at risk for multiple hospitalizations. Future epidemiology research should investigate the heart failure epidemic in diverse populations and examine the burden and determinants of hospitalizations in heart failure.


Cardiovascular magnetic resonance (CMR) has excellent capabilities to assess ventricular systolic function. Current clinical scenarios warrant routine evaluation of ventricular diastolic function for complete evaluation, especially in congestive heart failure patients. To our knowledge, no systematic assessment of diastolic function over a range of lusitropy has been performed using CMR.Left ventricular diastolic function was assessed in 31 subjects (10 controls) who underwent CMR and compared with Transthoracic echocardiogram (TTE) evaluation of mitral valve (MV) and pulmonary vein (PV) blood flow. Blood flow in the MV and PV were successfully imaged by CMR for all cases  while TTE evaluated flow in all MV  but only 21/31 PV (68%) cases. Velocities of MV flow (E and A) measured by CMR correlated well with TTE , but demonstrated a systematic underestimation by CMR compared to TTE (slope = 0.77). Bland-Altman analysis of the E:A ratio and deceleration time (DT) calculated from each modality showed excellent agreement . When assessing morphology using TTE, CMR correctly identified patients as having normal or abnormal inflow conditions.We have shown that there is homology between CMR and TTE for the assessment of diastolic inflow over a wide range of conditions, including normal, impaired relaxation and restrictive. There is excellent agreement of quantitative velocity measurements between CMR and TTE. Diastolic blood flow assessment by CMR can be performed in a single scan, with times ranging from 20 sec to 3 min, and we show that there is good indication for applying CMR to assess diastolic conditions, either as an adjunctive test when evaluating systolic function, or even as a primary test when TTE data cannot be obtained. Congestive heart failure (CHF) is the third most prevalent form of heart disease with as many as 5 million patients currently under treatment in United States . Approxidp/dt) as a function of LV relaxation has fallen out of favor, as non-invasive methodologies have become widely available. Currently, TTE is almost exclusively used to assess diastolic function, but in this application it is used to assess flow as opposed to volumetric conditions. Pulsed wave Doppler is applied to assess early MV diastolic filling velocity (Evel), late atrial systolic filling velocity (Avel), and deceleration time (DT). Similarly, the PV systolic 'S' wave and diastolic 'D' wave velocities have been used to confirm MV diastolic disturbances [Use of angiography for routine assessment of diastolic function by measuring the LV pressure decline over time  ,11. The D manner ,13. As tIn vitro validation of CMR-PC data was conducted by measuring pulsatile flow through a straight pipe generated by a pump under computer control . The mitral valve Evel, Avel, DT and pulmonary vein S and D wave velocities obtained by CMR were compared with similar indices obtained using TTE pulsed Doppler. By design, all subjects underwent TTE evaluation by a research echocardiographer (CT) using American Society of Echocardiography (ASE) guidelines within two hours of the CMR examination [A total of 31 subjects  were studied, which included 21 patients with mean age of 60 ± 14 yrs. and 10 controls with mean age of 33 ± 9 yrs. Patients were recruited if they had prior evidence of diastolic dysfunction, either due to hypertensive heart disease, ischemic heart disease, cardiomyopathy or pericardial disease. All subjects were in normal sinus rhythm at the time of study. The study was approved by the institutional review board of Allegheny General Hospital and all subjects provided informed consent. The study design was a double blind evaluation of diastolic indices of MV and PV flow. All subjects underwent PC imaging using a GE CV/i 1.5 T MRI scanner . Subjects were imaged in the supine position and signal reception was accomplished using a 4-channel phased-array cardiac coil. The ECG signal was used to trigger the acquisition. Localization scout images were acquired and used to identify the LV in the long axis four-chamber views. Cine images were acquired using Fast Imaging Employing STeady-state Acquisition (FIESTA) to permit visualization of the tips of the mitral valve leaflets. The right superior pulmonary vein was identified and imaged 1 cm proximal to the ostium. All PC data sets were acquired with velocity encoding in three orthogonal directions and velocity sensitivity set at 200 cm/s for each direction. The maximum velocity was calculated using the vector sum of the three individual velocity directions. To capture cross-sectional MV flow, an imaging plane was planned parallel to the mitral annular plane at the level of the mitral leaflet tips . Regions of interest were manually drawn on one frame to encircle the entire cross section of MV leaflets or PV on the short axis images and propagated using a semi-automated contouring mode with manual override, yielding velocity CP et al . On the 2) [The transthoracic echocardiogram was performed on a Philips Sonos 5500 with 3.0 MHz probe . The exam was performed with the subject supine in the left lateral position. In the four-chamber view, the MV inflow was localized and the Doppler sample volume was placed at the level of the tip of the MV leaflets and the pulsed wave Doppler was recorded under free breathing conditions. Similarly, for the PV flow the sample volume was placed 1 cm inside the right superior pulmonary vein. The right upper pulmonary vein was chosen due to its ease of location by the echocardiographer and to provide continuity between CMR and echocardiographic data. Data were post-processed offline following ASE guidelines for the calculation of maximum E and A velocities, DT and pulmonary vein S and D velocities. A mean of 4 consecutive data sets was used for data analysis. Absolute velocity was converted to pressure gradient using modified Bernoulli equation (ΔP = 4 V2) ,20.t test was used to analyze paired data and regression analysis was used for correlation of CMR with TTE for corresponding variables. A p value of < 0.05 was taken as significant. Bland Altman analysis was performed to assess agreement between the CMR and TTE.After passing the, Kolmogorov-Smirnov normality test to assure parametric nature of acquired data, the student's There was no significant difference in the summed acquisition and offline processing time for either technique (CMR mean time = 15 ± 2 min vs. TTE mean time = 13 ± 1 min). All 31/31 (100%) of MV and PV were imaged using CMR-PC in a mean duration of 2 ± 0.5 min each. All MV's were imaged by TTE. However, only 21 out of 31 (68%) PV were imaged by TTE and were not included in further analysis.in vivo measurements of the mitral valve peak Evel and Avel velocities by CMR-PC were slightly lower than TTE but correlated well   Figure . SimilarThe 31 subjects demonstrated diverse diastolic physiology: 11 impaired relaxation, 3 restrictive, 2 pseudonormalized, 3 EA fusions and the remainder were assessed as normal using TTE MV flow data. Morphology was assessed by the standard classification of the graphical representation of flow velocities. In each case, the CMR representation of diastolic flow velocities was similar to the TTE, allowing identical morphologic classifications Figure .A comprehensive clinical evaluation of ventricular function for CHF requires assessment of both LV systolic and diastolic function. Conventionally, echocardiographic Doppler measurements of MV flow conditions are used to assess diastolic function. However, CMR-PC imaging allows quantitative assessment of blood velocity, with the advantage that the tomographic plane of interest can be positioned optimally, permitting measurement in 3D space compared to the "ice pick" assessment of flow allowed by echocardiography.Flow velocity based diagnosis of diastolic function requires an accurate representation of changes throughout the diastolic time of mitral inflow. Indeed, our most important finding was that morphologically the CMR data had 100% correlation with the TTE data, and further we have demonstrated its practical utility. Additionally, quantitative CMR measurement of variables including Evel, Avel, E:A ratio and deceleration time were highly correlated with TTE measurements. Despite excellent correlations, Evel and Avel measured by CMR were systematically lower compared to TTE. However, the CMR acquisition of velocities in a pulsatile flow phantom accurately correlated with pump determined flow values. This may reflect the differences in the nature of acquisition by each technique. TTE obtains data within each cardiac cycle and is thus influenced by changes that occur over short time scales, whereas CMR data are effectively averaged over several cycles, thus damping sensitivity to intra-cycle variation. Importantly, this did not result in any misclassification of diastolic flow abnormalities between modalities. As CMR progresses towards real-time modes, these areas of difference are expected to diminish.Our results are in concordance with the previous, but limited, studies ,19. A coA similar approach was used by Karwatowski et al in 1995, studying 19 patients with known coronary artery disease . The tecWe imaged MV and PV in the short axis orientation, perpendicular to the major direction of flow, and using 3D encoding of velocity, allowing interrogation of the complete cross-section of the plane to comprehensively assess diastolic flow, irrespective of the location and vector. The velocity window of 200 cm/s was used to avoid aliasing of the Evel and was not significantly different to values used in prior studies. Pixel by pixel evaluation of 3D velocity data obtained by CMR revealed that most peak velocities reside in the anterolateral or inferoseptal location away from the center of the mitral valve where we typically sample by TTE. This finding should be confirmed in larger series of patients to give us a direction into newer insights of diastolic mitral flow evaluation.In summary, our study was conducted to establish the feasibility of routinely performing evaluation of MV flow to assess diastolic function using CMR. We were able to obtain clinical variables including E:A ratios and deceleration times, which were in agreement with those obtained using TTE.The diastolic flow indices are limited by the pressure gradients, heart rate and hydration status of the patient. This source of variability is not technique dependent, and standard precautions were observed to minimize these influences. To obviate this limitation, intramyocardial properties ideally should be assessed, but this investigation is beyond the scope of the work presented here. While a diastolic strain analysis can be performed, this too is not generally considered clinically feasible due to the protracted post-processing required and the inability to compare directly with clinical assessments obtained using echocardiography.Block Regional Interpolation of Segmented k-space), the breathholds can be applied to PC imaging thus improving signal to noise and reducing variability due to respiratory effects and slice selection [Non-breathhold imaging was performed for CMR-PC. As rapid, sparse sampling techniques mature, such as BRISK (election ,25. PostThis study highlights certain key points for the LV diastolic function assessment by CMR. Firstly, it is clinically feasible to accurately obtain the LV diastolic flow data and systolic function data in a single examination, wherein current clinical practice application of CMR is largely limited to systolic function evaluation. Secondly, the image quality, patient tolerability, ease and time to obtain the data match the TTE examination, and only adding an average of 4 minutes to the CMR examination, allowing CMR to provide comprehensive ventricular assessment. Thirdly, the data obtained are morphologically and quantitatively similar to that obtained using TTE, and are thus easily interpretable by a general cardiologist, requiring no further physician education for the interpretation of CMR results. The added ability to interrogate flow in 3D manner is an improvement to prior studies and has the potential to provide more accurate diastolic flow evaluation, given the great variety of physiologic conditions that can prevail, providing variables that include flow profiles and mean trans-valvular flow.In conclusion, we have shown for the first time that there is good agreement between the CMR and TTE evaluation of diastolic function. The 3D CMR acquisition of one slice at the mitral valve leaflets provides reproducible and reliable flow data, without a time penalty compared to TTE, and is clinically feasible on current commercial CMR scanners.CHF: Congestive heart failure; CMR: Cardiovascular magnetic resonance; TTE: Transthoracic echocardiography; PC: Phase contrast; LV: Left ventricle; MV: Mitral valve; PV: Pulmonary vein.VKR conceived and designed the study, analyzed data and drafted the manuscript. MD carried out the phantom experiments in MRI and helped draft the manuscript. JY and RBW operated the MRI scanner, organized and stored the data. KC participated in analyzing the MRI data. CT perfomed the transthoracic echocardiograms. DV performed the statistical analysis. RWWB participated in study design, coordination and scientific input. All authors read and approved the final manuscript.


The respiratory variation in pulse pressure (PP) has been established as a dynamic variable of cardiac preload which indicates fluid responsiveness in mechanically ventilated patients. The impact of acute changes in cardiac performance on respiratory fluctuations in PP has not been evaluated until now. We used cardiac resynchronization therapy as a model to assess the acute effects of changes in left ventricular performance on respiratory PP variability without the need of pharmacological intervention.In 19 patients undergoing the implantation of a biventricular pacing/defibrillator device under general anesthesia, dynamic blood pressure regulation was assessed during right ventricular and biventricular pacing in the frequency domain  and in the time domain .2 versus -0.66 ± 1.48 ln mm Hg2; p < 0.01); the geometric mean of respiratory PP variability increased 1.8-fold during cardiac resynchronization. PP variation, assessed in the time domain and expressed as a percentage, showed comparable changes, increasing from 5.3%  during right ventricular pacing to 6.9%  during biventricular pacing .PP increased slightly during biventricular pacing but without statistical significance . Respiratory PP fluctuations increased significantly (logarithmically transformed PP variability -1.27 ± 1.74 ln mm HgChanges in cardiac performance have a significant impact on respiratory hemodynamic fluctuations in ventilated patients. This influence should be taken into consideration when interpreting PP variation. The respiratory fluctuations of stroke volume and its surrogate, pulse pressure (PP), in mechanically ventilated patients are an expression of the relationship between changes in left ventricular preload and stroke volume. Several studies have found a significant correlation between PP variation or stroke volume variation and the increase in cardiac output caused by fluid loading -3. ThereHowever, preload is only one determinant of cardiac performance (besides ventricular contractility and afterload properties). Whereas the influence of changes in preload on the variation of stroke volume, PP, or systolic blood pressure (SBP) has been investigated in detail, the extent to which these dynamic measures are modified by changes in ventricular performance is not yet clear. This might be due to the fact that the treatment with inotropic drugs also modifies heart rate and vascular tone, thus making it impossible to study the isolated effect of changes in cardiac performance on dynamic cardiovascular measures.We used cardiac resynchronization therapy as a model to study the effect of changes in cardiac performance on the variation of hemodynamic variables. Cardiac resynchronization therapy is an accepted therapeutic approach for improving cardiac performance in patients with heart failure associated with an intraventricular conduction disorder -7. In thAfter obtaining the approval of the local ethics committee and written informed consent, we studied 19 patients  with New York Heart Association class III (18 patients) and class IV (1 patient) heart failure and dyssynchrony between right and left ventricular contractions who were scheduled for the implantation of a combined biventricular pacing/defibrillator device .The patients underwent routine monitoring by means of electrocardiogram (ECG), pulse oximetry, and non-invasive blood pressure monitoring . Additionally, the R-R intervals and plethysmographic blood pressure measurement were continuously registered .The patients were prehydrated with 3 ml/kg of an isotonic crystalloid solution, followed by 2 to 3 ml/kg per hour. Anesthesia was induced with 10 to 20 μg of remifantanil and etomidate until loss of consciousness, and tracheal intubation was facilitated by rocuronium 0.6 mg/kg. Anesthesia was maintained by remifantanil 2.5 μg/kg per minute and propofol 0.05 to 0.06 mg/kg per minute as clinically required.2  of 35 mm Hg at an FiO2 (fraction of inspired oxygen) of 0.5 throughout the entire study period.The patients were mechanically ventilated with a constant tidal volume of 7 to 8 ml/kg, a positive end-expiratory pressure of 5 millibars, an inspiratory/expiratory ratio of 1:1, and a respiratory rate of 10 to 12 per minute to maintain an end-tidal pCOA norepinephrine infusion was administered if required to maintain an SBP of 90 mm Hg.Bipolar electrode catheters were placed in the right atrial appendage, the right ventricle, and via the coronary sinus in a posterior or lateral venous branch.Three-minute recordings of ECG and arterial blood pressure were performed in a hemodynamic steady state during right ventricular and biventricular pacing. ECG and blood pressure were sampled at 1,000 Hz and stored on the hard disk of a personal computer.Frequency-domain analysis of SBP and PP variability was performed in accordance with the suggestions of the Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology . SignalsAdditionally, time-domain analysis of PP was performed. The three-minute data files were divided into 7.5-second periods. The difference between the minimum and maximum values of PP, normalized by the mean of the two values and expressed as a percentage, was calculated in each window. The results of the 24 periods were subsequently averaged.t test for paired data or the Wilcoxon signed rank test, as appropriate. An α error of 0.05 was considered significant.Statistical analysis was performed using commercially available software . The data were checked for normal distribution by means of the Lilliefors modification of the Kolmogorov-Smirnov test. The results of spectral power analysis were normally distributed after logarithmic transformation. Data are presented as mean ± standard deviation or as median . Data were compared using the Student p = 0.08).Demographic data and the characteristics of the patients are presented in Table p < 0.01) during biventricular pacing, with a 1.5-fold increase in the geometric mean of SBP variability  and a 1.8-fold increase in the geometric mean of PP variability . The analysis of PP variation in the time domain, determined as the difference between the highest and lowest values and normalized by the mean value, revealed a 1.3-fold increase from 5.3% to 6.9% during biventricular pacing (p < 0.01).Exemplary registrations of PP, recorded during right ventricular and biventricular pacing, and their related power spectra are demonstrated in Figure Respiratory fluctuations in PP during mechanical ventilation are an expression of respiratory changes in left ventricular stroke volume: due to a decrease in right ventricular preload and an increase in right ventricular afterload, right ventricular stroke volume decreases during inspiration. Left ventricular stroke volume decreases with a delay of one to two heartbeats and is additionally modified by a variety of factors, such as a decrease in left ventricular afterload during inspiration -12.Most studies dealing with PP variation have focused on the influence of the volume status on respiratory fluctuations: an increase in preload is related to a rightward shift of the cardiac operating point on the Frank-Starling curve with the consequence that a patient who is operating on the steep portion of the curve may operate on the flat portion. This change in the position on the Frank-Starling curve is related to a decrease in the respiratory fluctuation of PP.In contrast to previous studies, we did not focus on the influence of the intravascular volume on the position of the cardiac operating point on the Frank-Starling curve, but on the influence of cardiac performance on the slope of the preload/stroke volume relationship. A decrease in ventricular contractility decreases the slope of the relationship between end-diastolic volume and stroke volume . Thus, tOur results confirm this physiological model. The respiratory fluctuations of PP increased significantly during biventricular pacing in our patients with severely impaired myocardial function.In previous studies, PP variation derived by time-domain analysis was markedly decreased when compared to patients with normal or moderately impaired myocardial function ,14. ReutIn addition to time-domain analysis, we assessed blood pressure variability by spectral analysis and were thus able to analyze the influence of ventilation on blood pressure at the specific frequency of respiration. Respiratory fluctuations in SBP are less closely related to changes in stroke volume than are respiratory fluctuations in PP ,12. NevePreviously, in adults anesthetized with propofol, we observed that the respiratory fluctuations of blood pressure were superimposed by major fluctuations, which were located at a significantly lower frequency component than the mechanical ventilation or the Mayer waves . In thesThe interaction of respiratory changes in stroke volume and intrathoracic and transpulmonary pressures is of major importance when interpreting respiratory fluctuations of blood pressure . A previmax as a measure of isovolumic systolic function and in PP as a surrogate of stroke volume during biventricular pacing in patients with heart failure and intraventricular conduction delay [Several studies reported an improvement in dP/dton delay ,22. Conson delay . The PP on delay . Howeveron delay ,22. It ion delay ,24,25. BThe absence of invasive measurement of cardiac output for the above-mentioned reason may be a limitation of the study. We measured beat-to-beat blood pressure by a finger plethysmographic method, which is calibrated by the oscillometric measurement of blood pressure . This methodology showed satisfactory precision in the assessment of blood pressure changes compared to intra-arterial measurement ,27. PinnOur findings indicate that changes in cardiac performance have a significant influence on respiratory fluctuations in PP. This interaction should be considered when interpreting PP variation in the clinical setting. Our results suggest, furthermore, that respiratory PP variability is a parameter that is much more sensitive to an improvement in systolic cardiac performance than changes in the mean value of PP in mechanically ventilated patients with heart failure associated with an intraventricular conduction disorder. Whether this parameter might be helpful in guiding the positioning of electrodes and optimizing the configuration of biventricular stimulation in mechanically ventilated patients remains to be determined.• Cardiac performance has a considerable impact on the respiratory fluctuations of pulse pressure in mechanically ventilated patients with heart failure.• Cardiac resynchronization therapy is associated with minor changes in blood pressure but with major changes in respiratory fluctuations of pulse pressure in mechanically ventilated patients.ECG = electrocardiogram; PP = pulse pressure; SBP = systolic blood pressure.The authors declare that they have no competing interests.CK designed the study, processed and analyzed the data, and wrote the manuscript. JS contributed to the study design and interpretation of data. SL collected the clinical data and revised the manuscript critically. KS contributed to the acquisition of data. JS-R collected the clinical data and contributed to data interpretation. CW was involved in data interpretation and drafting the manuscript. All authors read and approved the final manuscript.


We sought to evaluate the geometric changes of the mitral leaflets, local and global LV remodeling in patients with left ventricular dysfunction and varying degrees of Functional mitral regurgitation (FMR).Functional mitral regurgitation (FMR) occurs as a consequence of systolic left ventricular (LV) dysfunction caused by ischemic or nonischemic cardiomyopathy. Mitral valve repair in ischemic MR is one of the most controversial topic in surgery and proper repairing requires an understanding of its mechanisms, as the exact mechanism of FMR are not well defined.136 consecutive patients mean age of 55 with systolic LV dysfunction and FMR underwent complete echocardiography and after assessing MR severity, LV volumes, Ejection Fraction, LV sphericity index, C-Septal distance, Mitral valve annulus, Interpapillary distance, Tenting distance and Tenting area were obtained.There was significant association between MR severity and echocardiogarphic indices . Severe MR occurred more frequently in dilated cardiomyopathy (DCM) patients compared to ischemic patients, (p < 0.001). Based on the model, only Mitral valve tenting distance (TnD)  and Interpapillary muscle distance (IPMD),  had significant associations with MR severity.Mitral annular dimensions and area, C-septal distance and sphericity index, although greater in patients with severe regurgitation, did not significantly contribute to FMR severity.Degree of LV enlargement and dysfunction were not primary determinants of FMR severity, therefore local LV remodeling and mitral valve apparatus deformation are the strongest predictors of functional MR severity. Functional Mitral Regurgitation (FMR) defined as a regurgitation that seen with structurally normal valve leaflets. It occurs as a consequence of systolic LV dysfunction caused by ischemic or nonischemic cardiomyopathy. Functional MR occurs in roughly 20–25% of patients following MI and 50% of those with CHF ,2. Any dThis study was conducted in Rajaei cardiovascular medical and research center, Tehran, Iran, where is one of the major referral center of cardiovascular diseases in the country.136 patients (mean age (SD) 55 (13.5) years, 85 (63%) male) with systolic LV dysfunction (mean EF (SD) 20% (8.7%)) and functional MR were enrolled. This study was approved by the ethics committee of Rajaei cardiovascular medical and research center. Inclusion criteria were: (1) systolic LV dysfunction (LVEF less than 50%); (2) structurally normal cardiac valves; (3)adequate 2D image for quantification of LV remodeling and mitral apparatus deformation; and (4)sinus rhythm. Exclusion criteria were (1) clinical or echocardiographic evidence of other cardiac diseases, such as organic valvular, pericardial, congenital, or infiltrative heart disease; (2) more than trace aortic regurgitation; (3) acute myocardial infarction; (4) suboptimal echocardiographic windows, leading to incomplete quantification of FMR or anatomic assessment; and (5) atrial fibrillation or flutter.All patients underwent complete transthoracic echocardiography for assessing MR severity and measuring the indices of global and local LV remodeling as well as mitral deformation indexes. All exams performed using Vivid seven (GE Vingmed ultrasound), with a 3S probe.14.ERO and MR volume assessed by PISA and VC methods . In patients with lesser degree of MR (less than mild to moderate) assessment of PISA wasnot done due to lesser accuracy in these patient. Measurements of LV indices: LV dimensions was measured at diastole and systole  in parasternal long axis view. LV volumes and EF were obtained by biplane Simpson's method. Patterns of regional wall motion abnormalities were assessed according to a 16 segment model [ERO ≥ 0.2 cmnt model . LV spheC-Septal distance was measured at mid-systolic parasternal long-axis view; The distance was measured between septum at hinge point of aortic valve cusp and coaptation point of mitral valve leaflets Figure .Mitral valve annulus was measured at mid-diastolic four-chamber and parasternal long-axis views. Mitral annular area was measured by formula; (MA area = d1 × d2 × π/4).Interpapillary distance was measured at diastolic mid parasternal short-axis view as a distance between two papillary muscles tips.Mitral Deformation Indexes: Tenting distance was measured as a distance between coaptation point of mitral leaflets and annular plane of MV at mid-systolic parasternal long axis view. Tenting area was measured as an area enclosed between leaflets and annular plane. Figure .One-way ANOVA (and Bonferroni post-hoc test) and chi-square tests were used for comparison of data among the groups. P-value < 0.05 considered as statistically significant. An ordinal logistic regression (OLR) model was fitted to study the adjusted association between severity of FMR and other echocardiogarphic and background determinants. The variables selected based on theoretic considerations and their statistically significant associations in bivariate analysis. STATA™/SE 8  was used for data analysis.Of total 136 patients enrolled in this study, 85 (63%) were male. Mean (SD) age was 55(13.5) years. 51 patients (37.5%) presented with mild regurgitation, 39 patients (28.7%) with moderate and 46 patients (33.8%) with severe functional mitral regurgitation.104 (77%) patients categorized as ischemic cardiomyopathy (ICM) by documented history of infarction and/or coronary angiography and 32 (24%) of them as dilated cardiomyopathy (DCM). All of them had LV systolic dysfunction (mean (SD) EF = 23% (9%), range 10% to 50%). Mean (SD) of end-systolic diameter (ESD), end-systolic volume (ESV), end-diastolic diameter (EDD) and end-diastolic volume (EDV) of LV were: 5.50 (0.89) cm, 128.19 (53.22) ml, 6.49 (0.75) cm and 166.99 (57.71) ml, respectively. Mean volume (SD) of LA was 72.71 (26) ml. Also, the mean pressure (SD) of pulmonary artery (PAP) was 45 (15) mmHg.Associations between these characteristics and severity of FMR are shown in table All echocardiogarphic measurements of LV remodeling and mitral valve deformation are shown in table Based on OLR model, we estimated the values for tenting distance index, as an important predictor of FMR severity, in pre-defined probabilities of FMR. It can be seen that tenting distance 0.45 cm predicts mild FMR and 2.35 cm predicts severe FMR with 80% probability.The present study shows that mitral deformation in patients with systolic dysfunction provides reliable suggestion of valves subject to functional regurgitation, with a graded relationship between valve deformation indices and FMR severity. In early experimental studies, FMR has been attributed to global LV dilatation or sphericity. Later, animal studies have suggested complex alterations of spatial relationship between left ventricle and mitral apparatus to induce functional MR ,15. In pThe papillary muscles which are normally parallel to the LV long axis, displaced as a result of ischemia or heart failure, drawing the leaflets into the ventricle and restricting their motion toward closure ,8. In thWe sought that interpapillary muscle distance contributed independently to functional MR severity. Other studies also showed interpapillary distance and displacement of papillary muscles as a reliable indicator of FMR, correlated with regurgitation severity ,15-18. YWe didnot have gold standard to quantify MR severity. The limitations of PISA for quantitative MR assessment were previously reported, but were minimized in this study because we used both PISA and vena contracta methods for assessing MR severity.FMR: Functional mitral regurgitation; LV: Left ventricular; DCM: Dilated cardiomyopathy; ICM: Ischemic cardiomyopathy; IPMD: Interpapillary muscle distance; TnD: Tenting distance; TnV: Tenting volume; 2D: 2-Dimensional; PISA: Proximal isovelocity surface area; ERO: Effective regurgitant orifice; VC: vena contracta.


Brain natriuretic peptide (BNP) was a marker for heart failure and cardiac wall tension. We analysed the trend of BNP after predischarge testing in order to get non-invasive details about the cardiac stress during predischarge testing.4-5 days after ICD implant we measured BNP, myoglobin, cardiac troponin I and creatine kinase in 20 patients before and 1, 5, 10, 20, 40, 60, 80, 100, 120 minutes and at the next day after predischarge testing. We evaluated actual values and percentage alterations of BNP.BNP significantly increased with a maximum after 5 minutes  and in terms of the percentage values  compared with baseline BNP. BNP decreased after that with the last significantly increased BNP value after 20 minutes . We excluded a cardiac necrosis during predischarge testing because of similar values of myoglobin, cardiac troponin I and creatine kinase during the 2-hour follow-up.Our data showed a great increase with a doubling of BNP after 5 minutes as a result of induced ventricular fibrillation during predischarge test. This increase was not generated by myocardial necrosis but rather caused by an acute cardiac failure as a consequence of induced ventricular fibrillation in predischarge testing. Clinical trials showed the efficacy of implantable cardioverter defibrillators (ICDs) for prevention of sudden cardiac death ,2. AfterBrain natriuretic peptide (BNP) is a powerful neurohormonal predictor of the left ventricular function and prognosis and could reflect the pulmonary capillary wedge pressure ,9. In adHence, BNP is an appropriate parameter for the evaluation of cardiac stress during predischarge testing because of its physiology and timing release. Thus the purpose of our prospective study was to evaluate the trend of BNP after predischarge testing 4-5 days after ICD implant in an experimental study.We included 20 consecutive patients  with different ICDs during predischarge testing in an experimental study. All were patients admitted electively in our hospital for implantation of an ICD. Patients with a serum creatinine ≥ 1.5 mg/dl were excluded because of possible influence of BNP values . The traThe BNP values  were measured directly before (baseline) and 1, 5, 10 and 20 minutes after predischarge testing. Furthermore BNP was measured for five half-life's  after predischarge testing and at the next day in the morning.In addition myoglobin, cardiac troponin I and creatine kinase were also measured with Triage Meter Plus®. The normal values were 0 - 4.3 ng/ml for creatine kinase (detection limit 1.0 ng/ml), 0 - 107 ng/ml for myoglobin (detection limit 5 ng/ml) and 0 - 0.4 ng/ml for troponin I (detection limit 0.05 ng/ml). Blood was taken from a peripheral intravenous catheter.The local medical ethics committee approved the study protocol and all patients gave written, informed consent before entering the study.Short-term anaesthesia was performed with propofol and midazolam in all patients. The patients were fasting and received no intravenous diuretic in the morning. Ventricular fibrillation was induced by T wave shock. The duration of ventricular fibrillation was defined as interval between the induction of ventricular fibrillation and the termination of ventricular fibrillation with a biphasic shock of the ICD. The programmed post shock pacing was not changed. All patients with CRT were tested in paced rhythm in biventricular mode. Patients with single or dual chamber ICD were tested with intrinsic QRS. We included only patients who were successfully defibrillated with the first initial delivered shock energy in order to consist the same condition for all patients in our study.All data are presented as mean values ± standard deviation. Datasets were tested for normal distribution. The real BNP values showed a skew distribution. Here, the Mann-Whitney U test was employed. We calculated the percentage alterations of BNP for the reduction of standard deviation of the measurements because of the high standard deviation of real BNP values. The BNP value before predischarge testing was equated with 100% for evaluation of percentage alterations. For comparisons of the follow-up myoglobin, BNP (%),  cardiac troponin I and creatine kinase the two-sided Friedman ANOVA test was performed. A measure of the linear association between two variables was evaluated using Pearson's correlation coefficient; all statistical tests were two-tailed. A multivariate Cox regression analysis was performed on variables regarded as significant predictors (P < 0.1) with a univariate analysis. For all variables with at least a moderate level of association we estimated the individual odds ratios with confidence intervals. A P value < 0.05 was considered statistically significant. The statistical package that we used was SPSS 12.0 for Windows.The demographic data are presented in The results of predischarge testing are shown in The mean baseline BNP value was 475.7 ± 629.5 pg/ml (range 43.8 - 2860 pg/ml). The BNP five minutes after predischarge testing was significantly higher  than baseline BNP . The lasBNP was doubled after 5 minutes in terms of the percentage values . We also observed an increase of BNP in terms of the percentage values followed by a consistent decrease of BNP compared with baseline BNP .The cardiac markers namely myoglobin, cardiac troponin I and creatine kinase showed no significant increases after predischarge testing .We did not observe any correlation  or an independent predictor  for the rise or the trend of BNP, myoglobin, cardiac troponin I, creatine kinase, cycle length of ventricular fibrillation, duration of ventricular fibrillation, defibrillation threshold, serum creatinine and left ventricular ejection fraction.In our study we observed an increase of BNP after predischarge testing with a doubling of BNP values after five minutes. After reaching the maximum we found a consistent decrease of BNP with the last significantly increased BNP value after 20 minutes. A myocardial necrosis could be excluded by similar values of myoglobin, cardiac troponin I and creatine kinase. We did not find a correlation between the BNP trend and other parameters.In the present study we documented a short-term increase of BNP after predischarge testing with a maximum after 5 minutes followed by a consistent decrease of BNP. As far as we know this is the first study, in which a trend of BNP for two hours after predischarge testing was examined.Unlike prior studies ,12, our Ventricular fibrillation causes a hypotension, a reduction of the left ventricular ejection fraction as well as a dilation of the right and left ventricle -16. The Although our enzyme data excluded a myocardial necrosis during predischarge ICD test, we could not exclude a contributory role of acute ischemia during ventricular fibrillation induction in accounting for the transient rise in BNP because of high detection limit of 0.05 ng/ml for troponin I.During the two hour follow-up we found similar values of myoglobin, cardiac troponin I and creatine kinase. An increase of myoglobin, cardiac troponin I and creatine kinase was observed in other studies -21. TherThe blood samples were taken from a peripheral intravenous catheter in our study. Therefore we could not exclude a dilution of our BNP values in contrast to the studies of Fromer et al  and CoheA doubling of BNP was detected after 5 minutes of predischarge testing as a result of induced ventricular fibrillation. This increase was generated by ventricular fibrillation and is not caused by myocardial necrosis. Through this a strong cardiac wall tension was detected indirectly with BNP as a result of induced ventricular fibrillation. But it is unclear how far a modified post-shock pacing can alter the trend of BNP. Therefore a randomized study has to be performed with different post-shock pacing intervals.


The combination of early transmitral inflow velocity and mitral annular tissue Doppler imaging (E/Em ratio) is widely applied to noninvasively estimate left ventricular (LV) filling pressures. However E/Em ratio has a significant gray zone and its accuracy in patients with heart failure is debated. Left atrial (LA) deformation analysis by speckle tracking echocardiography (STE) was recently proposed as an alternative approach to estimate LV filling pressures. This study aimed at exploring the correlation of LA longitudinal function by STE and Doppler measurements with direct measurements of LV filling pressures in patients with heart failure.A total of 36 patients with advanced systolic heart failure (ejection fraction ≤35%), undergoing right heart catheterization, were studied. Simultaneously to pulmonary capillary wedge pressure (PCWP) determination, peak atrial longitudinal strain (PALS) and mean E/Em ratio were measured in all subjects by two independent operators. PALS values were obtained by averaging all segments , and by separately averaging segments measured in the 4-chamber and 2-chamber views.Not significant correlation was found between mean E/Em ratio and PCWP (R = 0.15). A close negative correlation between global PALS and the PCWP was found . Furthermore, global PALS demonstrated the highest diagnostic accuracy (AUC of 0.93) and excellent sensitivity and specificity of 100% and 93%, respectively, to predict elevated filling pressure using a cutoff value less than 15.1%. Bland-Altman analysis confirmed this close agreement between PCWP estimated by global PALS and invasive PCWP (mean bias 0.1 ± 8.0 mmHg).In a group of patients with advanced systolic heart failure, E/Em ratio correlated poorly with invasively obtained LV filling pressures. However, LA longitudinal deformation analysis by STE correlated well with PCWP, providing a better estimation of LV filling pressures in this particular clinical setting. Accurate noninvasive estimation of left ventricular (LV) filling pressures is a clinical valuable tool to predict the severity of different heart diseases and to decide therapeutic strategy, particularly in patients with heart failure . In factForty-eight consecutive patients with symptomatic chronic (> 6 months) systolic heart failure (ejection fraction ≤ 35% and New York Heart Association class III to IV symptoms), who underwent a right heart catheterization, in the cardiac catheterization laboratory (n = 34) or in the intensive care unit (n = 14), because of concerns about hemodynamic derangements and/or to a staging of patients listed for heart transplantation, were enrolled. All were in sinus rhythm, hemodinamically stable and had simultaneous right heart catheterization and transthoracic echocardiographic imaging. A previous cardiac resynchronization therapy with defibrillator (CRT-D) was not an exclusion criteria. Patients were excluded if they had nonsinus rhythm, mechanical ventilation, severe mitral regurgitation, any mitral stenosis, any prosthetic mitral and/or aortic valve, heart transplantation or an insufficient imaging quality of the LA endocardial border. All subjects gave their written informed consent for the participation to the study. All work was in compliance with the declaration of Helsinki and it was performed with the approval of local ethics committee.Readings of invasive cardiac pressure measurements were performed by an investigator blinded to all echocardiographic data. The pressure transducers were balanced before data acquisition with the zero level at mid-axillary line. Pulmonary artery (PA) catheters were used to measure PA pressures, mean right atrial pressure and mean PCWP. The wedge position was verified by fluoroscopy, phasic changes in pressure waveforms and oxygen saturation. Cardiac output and cardiac index were derived by the thermodilution technique (average of 5 cardiac cycles with < 10% variation) and by the Fick equation through sampling of a mixed central venous blood gas taken in the pulmonary artery and of an arterial blood gas.Echocardiographic studies were performed using a portable echocardiograph , equipped with a 2.5 MHz transducer. Subjects were studied in a supine position during the heart catheterization. Measurements of left ventricular and left atrial dimensions, LV ejection fraction, and diastolic LV filling velocities were made in accordance with current recommendations of ASE . LV ejecLV longitudinal function was explored by pulsed Tissue Doppler imaging, placing the sample volume at the level of mitral lateral and septal annulus from the apical four-chamber view . Mean peFor speckle tracking analysis, apical four- and two-chamber views images were obtained using conventional two dimensional gray scale echocardiography, during breath hold and with a stable ECG recording. Care was taken to obtain true apical images using standard anatomic landmarks in each view and not foreshorten the left atrium, allowing a more reliable delineation of the atrial endocardial border. We also avoided visualization of the LA appendage in the apical 2-chamber view to minimize its effect on LA strain measurements. Three consecutive heart cycles were recorded and averaged. The frame rate was set between 60 and 80 frames per second.The analysis of files recorded was performed off-line by a single experienced and independent echocardiographer, who was not directly involved in the image acquisition and had no knowledge of hemodynamic mesasurements, using a commercially available semi-automated two-dimensional strain software . As previously described , LA endoTo assess the reproducibility of global PALS, 10 patients were randomly selected: Bland-Altman analysis was performed to evaluate the intra- and interobserver agreement by repeating the analysis 1 week later by the same observer and a second independent observer. Bland-Altman analysis demonstrated good intra- and interobserver agreement, with small bias not significantly different from zero. Mean differences ± 2 standard deviations were 0.4 ± 2.1% and 0.6 ± 3.4%, for intra- and interobserver agreement, respectively.Data are shown as mean ± SD. A P value < 0.05 was considered statistically significant. Pearson's correlation coefficients were calculated to assess the relationships between continuous variables. On the basis of similar previous studies -25, a PCOf 48 patients screened, 36 patients  met eligibility criteria during the study period. The admitting diagnosis were coronary artery disease (29 patients) and non-ischemic cardiomiopathy (7 patients). All patients were classified as New York Heart Association class III to IV with a mean LV ejection fraction of 26.1 ± 5%. Five were excluded for nonsinus rythm; 3, for severe mitral valve disease, 3 for poor echocardiographic window; and 2, for difficulties in heart catheterization. Table Conventional Doppler and tissue-Doppler indices showed increased mitral E , mitral E/A ratio  and mean E/Em ratio  in the patients with PCWP ≥18 mmHg, instead no differences between groups were found for mitral Em. Regarding novel atrial STE measurements, among a total of 432 segments analyzed, the software was able to correctly track 411 (95.1%) segments. Global PALS was significantly lower in patients with PCWP ≥18 mmHg . Similar results were obtained in PALS measured in four-chamber view  and in two-chamber view . No significant differences of TPLS values were detected between two groups.A strong inverse correlation was observed between PCWP and global PALS  Figure , instead2. Mean E/Em ratio presented limited diagnostic accuracy (AUC = 0.69)  curve analyses. Area under the curve (AUC), optimal cutoff values and corresponding sensitivities and specificities to predict PCWP 18 mmHg or greater are presented in Table ) Figure . Bland-A) Figure .In this study we analyzed for the first time the correlation with PCWP of a novel speckle tracking index, the LA longitudinal strain, comparing it with other Doppler indices, in particular the E/Em ratio, in patients with advanced systolic heart failure referred for right heart catheterization. Using simultaneous measured echocardiographic and invasive hemodynamic variables, we found in this particular group of patients a strong correlation between global PALS and PCWP, in contrast with the weaker and not significant correlation showed by mean E/Em ratio. Furthermore, global PALS demonstrated the highest diagnostic accuracy (AUC of 0.93) and excellent sensitivity and specificity of 100% and 93%, respectively, to predict elevated filling pressure using a cutoff value less than 15.1%. ROC curve analysis indicated that, by using this cutoff value of 15.1%, although the relative limited sample size, no one patient in the group of elevated PCWP was misdiagnosed. Bland-Altman analysis confirmed this close agreement between PCWP estimated by global PALS and invasive PCWP. The atrial reservoir phase is essential for LV filling by storing energy during ventricular systole, that is released after MV opening ; in our Regarding Doppler indices, mitral E and E/A ratio were significantly higher in the patients with elevated PCWP, but their diagnostic accuracy were relatively poor . Similarly, mean E/Em ratio appeared unable to adequately predict elevated filling pressure (AUC of 0.69). According to our results, that are confirmed by previous studies ,29-31, wThe measurement of global PALS requires more capability and is contingent on the presence of adequate apical views. However, in this study, which included supine patients on the cardiac catheterization table or in the intensive care unit, the feasibility was excellent at 94%. Considered the close dependence of STE with the single-cardiac cycle strain analysis, it was not possible to conduct the study even in patients with non-sinus rhythm. Regional wall motion abnormalities in severely dilated and/or ischemic ventricles might have altered mitral Em acquisition. However, instead of analyzing only the septal or the lateral Em, we considered the average of both walls . No invaAlthough there was a limited sample size, we were able to show novel findings. Nonetheless, larger prospective validation studies using these novel indices are of utmost importance.In patients with advanced systolic heart failure mean E/Em ratio may not be a useful index to estimate filling pressures; the measurement of global PALS, instead, provides a close prediction of PCWP and could be considered a promising noninvasive index to assess LV filling pressures in this particular clinical setting.The authors declare that they have no competing interests.MC, ML, MP, CT and SB were responsible for the collection of data; MC drafted the manuscript and performed the statistical analysis; SM and MM were responsible for the design of the study and revised the manuscript for important intellectual content. PC also revised the manuscript for important intellectual content. All authors read and approved the final manuscript.


Echocardiography is a non-invasive, relatively cheap and useful imaging technique for the evaluation of cardiac diseases. The procedure has reliable levels of accuracy.Echocardiography commenced at the Federal medical centre Abeokuta on September 9, 2005.The aim of this study is to report our experience with the procedure, and to define the clinical cases seen in our setting.This is a retrospective analysis of a prospectively collected data. Echocardiography was performed using Aloka SSD 1,100 echocardiograph equipped with 2.5–5.0 MHz transducerDuring the period of 18 months under review (September 2005–February 2007), 1629 procedures were performed. The reports of 188 echocardiograms were excluded due to poor echo-window, repeated procedure or incomplete report. 1441 reports were reviewed for demographic parameter, indications for the procedure and the main echocardiographic diagnoses.The mean age of the 1441 individuals studied was 54 +/- 14.3 years (15–90). There were 744 men and 697 women. Eight hundred and seventeen subjects (56.7%) had hypertensive heart disease, 53 subjects (3.7%) had rheumatic heart disease while 44(3.0%) had dilated cardiomyopathy. Pericardial diseases, cor-pulmonale, ischaemic heart disease, congenital heart diseases, diabetic heart disease, thyroid heart disease, sickle cell cardiopathy were present in 26(1.8%), 23(1.6%), 9(0.6%), 6(0.4%), 6(0.4%), 6(0.4%), 1(0.1%), and 1(0.1%) respectively. Four hundred and forty nine (31.2%) subjects had normal study.Hypertensive heart disease was found to be the most prevalent cardiac condition in this study. The relatively frequent diagnoses of rheumatic heart disease, cardiomyopathies and pericardial diseases reflect the impact of infections and infestations on the cardiovascular health of adult Nigerians.We suggest that prevention and treatment of cardiac diseases in our setting should among other things focus on blood pressure control and early treatment of infections causing heart diseases. Epidemiological studies have shown that heart diseases are on the increase worldwide especially in low income countries and developing economies where non-communicable diseases are emerging Cardiovascular disease now constitute major heath problem in developing nations. Over 80% of global morbidity and mortality from cardiovascular diseases now occur in these countries.Knowledge of the prevalent and patterns of heart diseases in any environment is important in health care planning and in the provision of health care services.th anniversary of the original demonstration of cardiac ultrasound by Edler and Hertz.Echocardiography has grown to become the most widely used cardiac imaging technique worldwide. In 2003, the medical world marked the 50Although the procedure had an unheralded beginning, it has become a powerful tool in the diagnosis of cardiac diseases and in epidemiological studies.In 2003, it was estimated that over 20 million procedures were performed in the United States of America alone [th day of September 2005.At the Federal Medical Centre Abeokuta, Nigeria, M-mode and 2-dimentional echocardiography commenced on the 9The aim of this study is to report on our experience with the procedure, and to describe the different clinical cases diagnosed with this tool over a period of 18-months.This is retrospective and descriptive study of a prospectively collected data. The study was carried out at the Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria between September 2005 and February 2007.The centre is a relatively young tertiary one, established in 1993 by the Federal Government of Nigeria to cater for the health need of the people of Ogun State and its environs in Southwestern Nigeria. The state has a population of about 3.2 million and a land area of about 16,409.26 square kilometers.Echocardiography is performed at our centre on a twice weekly basis except in emergency situations.Ethical approval was obtained from our institution's ethical review committee.Baseline clinical and demographic characteristics were obtained from the subjects. These included: date of birth, age, gender and indication for echocardiogram.Two-dimensional guided M-mode echocardiography with the use of commercially available echo-machine  and a 2.5–5.0 MHz linear array transducer was performed on each subject in the partial decubitus position. All measurements were made according to the American Society of Echocardiography (ASE) leading edge to leading edge convention . EchocarOne experienced cardiologist performed all the echocardiography. In our laboratory, the intra-observer concordance correlation coefficient and measurement error have been reported. .All the echocardiographic diagnoses were based on standard criteria.2.7), and dilated left atrium, a surrogate of impaired LV filling .Hypertensive heart disease was diagnosed in the presence of any or combination of the following abnormalities: left ventricular systolic dysfunction (ejection fraction < 50%), left ventricular hypertrophy  were documented based on the following:i. Mitral stenosis: – presence of thickened and calcified mitral valve leaflets, loss of the classic M-shaped pattern of a normal mitral valve, diastolic dooming and restriction of the mitral valve leaflet motions.ii. Mitral Regurgitation: Poor coaptation of the mitral valve leaflets in systole, thickened leaflets, dilated and hyperdynamic left ventricleiii. Aortic stenosis: Presence of calcified aortic valve, reduction in aortic cusp separation, highly echo reflectant aortic valve leafletsiv. Aortic regurgitation: Poor coaptation of the aortic cusps in diastole dilated left ventricles and fine fluttering of the anterior mitral valve in diastole.Dilated cardiomyopathy was diagnosed when there are dilated heart chambers with normal or decreased wall chambers as well as impaired LV systolic function .Endomyocardial fibrosis (EMF) was documented in the presence of clinical features coupled with dilated atria and thickening of the endocardium especially at the apices of the ventricles .Pericardial effusion was diagnosed when there is echo free space between the visceral and parietal pericardium. Cor-pulmonale was present when there is dilated and hypertrophied right ventricle (RV), evidence of increased RV systolic pressure (D-shaped LV in diastole (diastolic flattening of the LV septum)Data management and analysis were performed with SPSS software version 11.0. . Continuous variables were expressed as mean ± SD (standard deviation) and categorical variables expressed as percentages. Differences in categorical variables were assessed by Chi-square analysis.A 2-tailed p value < 0.05 was considered to be significant.During the 18 months period 1,629 echocardiograms were performed. The data of 188 subjects were excluded in the analysis due to poor echo-window, repeated procedure in the course of the management of the patient, or incomplete data.One thousand, four hundred and forty one (1441) subjects were analyzed.Table The mean age of all the subjects was 54.4 ± 14.3 years and range 15–90 years.Table Eight hundred and seventeen subjects (56.7%) had hypertensive heart disease, 53 subjects (3.7%) had rheumatic heart disease while 44(3.0%) had dilated cardiomyopathy. Pericardial diseases, Cor-pulmonale, ischaemic heart disease, congenital heart diseases, diabetic heart disease, thyroid heart disease, sickle cell cardiopathy were present in 26(1.8%), 23(1.6%), 9(0.6%), 6(0.4%), 6(0.4%), 6(0.4%), 1(0.1%), and 1(0.1%) respectively. Four hundred and forty nine (31.2%) subjects had normal study . This is followed by pure mitral stenosis (8 cases), and 7 cases of mixed rheumatic heart disease. Three cases of primary mitral valve prolapse were documented.The commonest form of pericardial disease was effusive-constrictive pericarditis (13 cases) followed by effusive type (8 cases) and constrictive pericarditis (4 cases)Idiopathic dilated cardiomyopathy was the commonest form of cardiomyopathy (constituting 34 of the 44 cases seen)There were 6 cases of adult congenital heart disease.Figures This echocardiographic based study shows that the common heart diseases in adult Nigerians in Abeokuta are hypertensive heart disease, valvular heart disease (mostly rheumatic), dilated cardiomyopathy, pericardial diseases, and cor-pulmonale. Ischaemic heart disease and adult congenital heart disease were infrequently diagnosed Table .Hypertensive heart disease is by far the commonest heart disease in this study. It is well established that this condition forms the bulk and is the foundation of cardiovascular disease in Africa.The relatively frequent diagnoses of rheumatic heart disease, cardiomyopathies and pericardial diseases reflect the impact of infections and infestations on the cardiovascular health of adult Nigerians.The large number of normal findings at echocardiography in this study is similar to some previous studies in Nigeria . This caOur findings are similar to previous similar studies from other parts of Nigeria.Table In a review of 275 echocardiograms performed in Zaria over a 12-month period 1976–1977), Adesanya et al  reported76–1977, Ukoh et al  in BeninFurther analysis of the 817 hypertensive patients in this study shows that left ventricular hypertrophy (LVH) either concentric LVH or eccentric LVH was present in 53%. The frequency of LV geometry is as follows in the order of decreasing frequency: concentric LVH (40.2%), concentric remodeling (30.2%), normal LV geometry (16.8%) and eccentric LVH (12.8%).About forty percent (39.6%) including 49.1% of women and 30.1% of men had dilated left atrium while about twenty percent (19.5%) had impaired LV systolic function.The spectrum of chronic rheumatic heart disease in this study is similar to earlier finding in the country with mitral regurgitation being the commonest valve lesion.We found dilated cardiomyopathy as the commonest form of cardiomyopathy in Abeokuta similar to other reports. However, peripartum cardiomyopathy (PPCM) is relatively uncommon compared to reports from the Northern part of the country. Endomyocardial fibrosis (EMF) was diagnosed infrequently in our study compared to reports in the 60s and 70s.The low frequency of hypertrophic cardiomyopathy is similar to reports from the country. Our report also demonstrated the low prevalence of ischaemic heart disease in the country as reported by previous authors -13.Echocardiography  has been shown to be a useful tool in establishing cardiac diagnosis and in evaluating the performance of the heart in various disease conditions.In resource poor setting like ours, it is ideal because it is non-invasive.Worldwide the tool has been shown to be a very useful in clinical patient care and research.th year of existence of the tool), one can identify more papers using the search term "echocardiography "than in the first 25 years after Edler's initial description combined.In 2003 alone .It also shows the increasing burden of non-communicable diseases in the country coupled with the impact of infective conditions on the heart such as tuberculosis.There is therefore need for strategies to control cardiovascular risk factors such as hypertension, obesity, and physical inactivity.There is also need for improvement in housing and environmental sanitation as well early detection and treatment of throat infectionThe authors declare that they have no competing interests.OSO and GWA conceived the study. JOA, AAA, ROA, RFO and JKO participated in its design. OSO performed the echocardiographic examinations. OIU, JOA, and AAA participated in the recruitment of subjects and collated the data. OSO, OIU and GWA managed the data, performed statistical analysis. OSO drafted the manuscript. All authors read and approved the final manuscript.


Quantification of ventricular volume by Steady State Free Precession (SSFP) cardiovascular magnetic resonance is accurate and reproducible. Normal values exist for adults, but are lacking for children.We sought to establish normal values for left and right ventricular volumes, mass and function in healthy children by using SSFP.Fifty children  without cardiovascular disease were evaluated. Median age was 11 years (range 7 months – 18 years), weight 35 kg (range 7–77 kg), height 146 cm (range 66–181 cm). Thirty-six examinations were performed with breath holding, 14 in freely breathing sedated children.Ventricular volumes and mass were measured in the end systolic and end diastolic phase on SSFP cine images acquired in a short axis plane as a stack of 12 contiguous slices covering full length of both ventricles.bnormal value = a*BSA). Normative curves for males and females are presented in relation to BSA for the enddiastolic volume, endsystolic volume and mass of both ventricles. Intra- and interobserver variability of the measurements was within the limits of 2% and 7% respectively, except for right ventricular mass (10%).Regression analysis showed an exponential relationship between body surface area (BSA) and ventricular volumes and mass (The exponential equation for calculation of normal values for each ventricular parameter and graphical display of normative curves for data acquired in healthy children by SSFP cardiovascular magnetic resonance are provided. Cardiovascular magnetic resonance (CMR) is nowadays considered an essential tool for advanced assessment of congenital heart disease (CHD). Besides anatomical information, CMR can provide reliable quantification of various functional cardiac parameters. CMR measurements of ventricular volumes, mass and function have been validated in vitro and in vivo, demonstrating excellent accuracy and reproducibility of the method ,2. Thus The Steady State Free Precession (SSFP) cine sequence is the technique used in most centres for single-slice multi-phase acquisitions ,7. The sNormal values for the left and the right ventricle in the adult population have been published ,10, but The aim of our study was to establish normal values for left and right ventricular volumes, mass and function in healthy children by using CMR with SSFP sequences.rd or above the 97th percentile of the normative values for the Swiss population, represented an additional exclusion criterion [Fifty-two subjects were recruited for the study among physically normally developed children without cardiovascular disease, undergoing magnetic resonance imaging for evaluation of peripheral and local anomalies, typically orthopaedic disease. Inclusion criteria were age between 0 and 18 months and no evidence of cardiovascular disease. Exclusion criteria consisted of presence of disease affecting the chest or the cardiovascular system, acute infections, arterial hypertension, arrhythmias, anaemia, neoplasm, and use of any drug. An abnormal body size for the age, defined as bodyweight or length below the 3riterion . Two chiWritten informed consent for participation in the study was obtained from the parents in all cases and from the child whenever possible. The patients demographic data as well as bodyweight and height where collected at the same day of the examination.The ethics board of our institution approved the study protocol.The magnetic resonance examination was performed on a 1.5 Tesla scanner . CMR was performed after completion of the clinical MR examination by using an 8-channel phased-array cardiac coil for larger children and a quadrature head coil for smaller children. Cine imaging was performed with a two dimensional retrospectively cardiac gated SSFP sequence (2D FIESTA) using following parameters: TR 3.5–4.2 ms, TE 1.5–1.8 ms, flip-angle 45°, bandwidth ± 125 kHz, matrix 224 × 224, number of excitations 1 (breath hold) or 2 (free breathing), field of view 250–350 mm, field of view in phase direction 75%, slice thickness 5–8 mm with a gap of 0–2 mm depending on body size and targeting 12 slices to be acquired. If Gadolinium based contrast medium had been previously given for the clinical study, the flip angle was raised to 60° in order to optimise the contrast between blood and myocardium.The degree of k-space segmentation (views per segment 4–12) and number of images reconstructed per cardiac cycle (20 – 30) was adjusted to the heart rate in order to achieve a true temporal  resolution in the range of 21–45 ms, for accurate definition of the end-systolic and end-diastolic phase,15. ThusAfter obtaining sagittal, coronal and axial localizers, SSFP cine images were acquired first in the vertical and horizontal long axis planes for planning the subsequent stack of at least 12 contiguous slices in the short axis plane covering both ventricles in their entire length. The short axis images were obtained from the base to the apex of the heart, with the most basal slice positioned parallel to and across the plane of the atrioventricular valves ,16.Non-sedated children were instructed on how to hold their breath prior to the examination, and the images were acquired during end-expiratory breath holds. In children examined under sedation the images were acquired during free breathing.All images were analysed on a commercially available off-line workstation . Measurement of ventricular volumes and myocardial mass was performed using the MASS+ Software package .The end-systolic and the end-diastolic phase were first identified visually on a movie loop of a midventricular slice. The endocardial contours were then traced manually on the images of the estimated end-systolic and end-diastolic phase, as well as on the two previous and following phases, for a correct detection of the minimal (end-systolic) and maximal (end-diastolic) volume. Stroke volume was calculated as the difference between the end-diastolic volume (EDV) and the end-systolic volume (ESV) and ejection fraction (EF) was defined as EDV-ESV/EDV.The epicardial contours were traced in the end-systolic and in the end-diastolic phase for calculation of the ventricular mass. The myocardial volume was calculated as the difference of the epicardial and the endocardial volumes and multiplied by the specific density of the myocardium 1.05 g/ml) for obtaining the value of myocardial mass. For cal.05 g/ml For correct identification of the most basal slice, i.e. if the slice was located in the atrium or in the ventricle, cavities surrounded by at least 50% of their circumference by myocardium were considered as ventricular . In addi2 tube and CO2 sampling tube . Deep sedation was continued with propofol 10 mg/kg/h given as continuous intravenous infusion, following our institutional protocol. Routine monitoring of capnography with respiratory rate and end-tidal carbon dioxide concentration, oxygen saturation, heart rate, electrocardiogram and blood pressure, was assessed continuously .Anaesthesia was induced either intravenously with propofol 2 mg/kg and further doses of 1 mg/kg as necessary to tolerate positioning, or by inhalation with sevoflurane 4–8% in oxygen/nitrous oxide (1:1) until an intravenous line was established . Meticulous care was taken to maintain spontaneous breathing. 2 L/min Oxygen was applied with a nasal cannula with separate ODemographic data are expressed as median and range. Body surface area was calculated from the Mosteller formula.b, Y = ax2+bx+c and Y = ax3+bx2+dx+c, where Y is the predicted value and x is BSA. For exponential functions, a logarithmic transformation of the measurements was performed before fitting of the regression models for the purpose of stabilize variances. The best fitting model was defined by a large R2, i.e by a high percentage of the variability of the data that is explained by the association between variables, and analysis of residuals for each regression equation. The resulting equations and parameters were then retransformed to a linear scale. Significance of gender, previous administration of contrast-medium, and acquisition of the images during free-breathing or breath holding were tested by introducing a factor accounting for each of these variances in the regression model. A p < 0.05 was considered statistically significant. Intra- and interobserver variability were evaluated in two observers blinded to each other by using Bland-Altman analysis in 10 randomly selected patients[Several regression models were used to examine the allometric relationship between ventricular parameters and BSA. We tested the following equations: Y = ax+c, Y = ax patients Statisti50 normotensive children  were included in the study. Demographic data are shown in table In 36 children image acquisition was performed during breath holding; 13 were examined in deep sedation and images acquired during free breathing; one child was unable to hold his breath and images were acquired in free breathing as well.b best described the relationship between ventricular parameters and BSA. Thus the final normative equation for all ventricular parameters was: bnormal value = a*BSA.The regression model y = axAll values for each ventricular parameter are described in table Figure Intra- and interobserver variability is summarized in Table This study provides normal values for the left and right ventricular volumes, myocardial mass, and ejection fraction in children and adolescents measured by using the SSFP sequence. These data are an update to previously published normative values which were collected only in small paediatric sample sizes and had been acquired with the gradient-echo cine sequence, which is not being commonly used any more ,16. Mace2 for the left ventricular EDV and of 4 ml/m2 for the right ventricular EDV. Additionally, following characteristics of the data has been found by both groups: gender modifies the relationship between volumetric data and BSA, so that gender needs to be added as separate variable in regression models; ejection fraction remains constant throughout growth and does not differ significantly between boys and girls; a good R2 points out a strong relationship between BSA and ventricular volumes; SSFP images yield to larger volume measurements than gradient echo cine images, as previously demonstrated [2, RVEDV +14 ml/m2), resulting in a difference in stroke volumes less than 1 ml.Our data can be compared with those of a very recent publication. Robbers-Visser et colleagues established volumetric normative data in a similar number of healthy children . They usnstrated ,24. If wnstrated , we founb) with an exponent for BSA of 1.385 for calculation of LVEDV, measured by 2D echocardiography [1.4 (1.3–1.5) for determination of LVEDV[2 (≥ 0.95 for volumetric data) obtained in our study by using an exponential equation for BSA and introducing an additional factor for gender, demonstrate that the fitting model is appropriate and more accurate than others used in different studies [Finding the correct allometric relationship is crucial for exact description of growth of the human heart in relation to BSA . We usediography . Lange eiography . Finally of LVEDV. The hig studies .On the base of all these data demonstrating that cardiac volumes have a non-linear relation to body surface area, and since the exponential values are different for different cardiac parameters, it would not be appropriate to provide normal values simply indexed to BSA in a table . TherefoThe correct definition of the endocardial contours has a major impact on the accuracy of volumetric measurements. It has been shown that delineation along the border of the compact myocardium has better reproducibility than delineation along the fine endocardial trabeculations . SieversThe intra- and inter-observer variability in our study are within the variability range previously described in the literature confirming the good reproducibility of the CMR volumetric measurements ,23,28. SSmall children recruited for the study (n = 14) were examined under sedation with propofol and the images were acquired while freely breathing. Due to respiratory motion, the image quality was not as good as when acquired during breath holding. Nevertheless, the cardiac borders were perceived well enough for allowing tracing of the contours in all children. The image quality and accuracy of volume measurements can be improved in small children by performing the CMR exam under general anaesthesia with controlled ventilation allowing image acquisition in breath hold. Due to obvious ethical reasons, we could not intubate any young child solely for investigational purposes. When performing studies in sedation or general anaesthesia, investigators need to be aware that anaesthetic drugs may have some minor influence on cardiac functionIn our study group we could not find any statistical significant difference between the regression curves of subjects studied during free breathing (sedation) and those who were able to held their breath; therefore the two groups are presented in the same normative curve.More detailed analysis of the effects of gender, BSA, weight, height, and conditions of image acquisition, such as breath hold or free breathing, sedation or mechanical ventilation, on the ventricular volumetric values, requires a larger number of subjects studied. In the field of paediatric cardiology, these results may be achieved by planning a large multi-centre study.This study provides the normal values for left- and right ventricular volumes, mass and function in children, determined by SSFP CMR. As the relationship between cardiac volumetric data and BSA is not linear, the data are displayed graphically in form of normative curves and the appropriate equations for calculation of the expected value are provided for each gender and parameter. These data are of significant clinical and research utility for centres assessing children with congenital or acquired heart disease by CMR.The authors declare that they have no competing interests.EVB conceived and designed the study and gave a major contribution to the draft of the manuscript and its revision. TK carried out subject's recruitment, image acquisition and analysis and drafted the manuscript. CJ was involved in data analysis and advanced statistical calculation. AS was responsible for children's sedation, helped in coordinating the study and contributed to the manuscript draft. CJK helped in designing the study, image acquisition and participated in the revision of the manuscript.All authors read and approved the final manuscript.