Muscular dystrophy (MD) is a progressive disease with predominantly muscular symptoms. Myotonic dystrophy type II (MD2) and facioscapulohumeral muscular dystrophy type 1 (FSHD1) are gaining an increasing awareness, but data on cardiac involvement are conflicting. The aim of this study was to determine a progression of cardiac remodeling in both entities by applying cardiovascular magnetic resonance (CMR) and evaluate its potential relation to arrhythmias as well as to conduction abnormalities.83 MD2 and FSHD1 patients were followed. The participation was 87% in MD2 and 80% in FSHD1. 1.5 T CMR was performed to assess functional parameters as well as myocardial tissue characterization applying T1 and T2 mapping, fat/water-separated imaging and late gadolinium enhancement. Focal fibrosis was detected in 23% of MD2) and 33% of FSHD1 subjects and fat infiltration in 32% of MD2 and 28% of FSHD1 subjects, respectively. The incidence of all focal findings was higher at follow-up. T2 decreased, whereas native T1 remained stable. Global extracellular volume fraction (ECV) decreased similarly to the fibrosis volume while the total cell volume remained unchanged. All patients with focal fibrosis showed a significant increase in left ventricular (LV) and right ventricular (RV) volumes. An increase of arrhythmic events was observed. All patients with ventricular arrhythmias had focal myocardial changes and an increased volume of both ventricles (LV end-diastolic volume (EDV) p = 0.003, RVEDV p = 0.031). Patients with supraventricular tachycardias had a significantly higher left atrial volume (p = 0.047).We observed a remarkably fast and progressive decline of cardiac morphology and function as well as a progression of rhythm disturbances, even in asymptomatic patients with a potential association between an increase in arrhythmias and progression of myocardial tissue damage, such as focal fibrosis and fat infiltration, exists. These results suggest that MD2 and FSHD1 patients should be carefully followed-up to identify early development of remodeling and potential risks for the development of further cardiac events even in the absence of symptoms.Trial registration ISRCTN, ID ISRCTN16491505. Registered 29 November 2017 – Retrospectively registered, http://www.isrctn.com/ISRCTN16491505 Muscular dystrophy (MD) is a group of genetic and progressive diseases with primary symptoms of skeletal muscle pain and weakness. In some MD, such as Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD), cardiac involvement is well known. Myocardial fibrosis detected by cardiovascular magnetic resonance (CMR) enables the prediction of cardiac events in DMD/BMD patients independently when compared with reduced left ventricular (LV) ejection fraction (LVEF). Interestingly, in patients with preserved LVEF, there is added value of focal fibrosis –3. FocalMyotonic dystrophy type II (MD2) and facioscapulohumeral muscular dystrophy type 1 (FSHD1) have gained an increasing awareness during the last years. There is a suspicion that MD2 as well as FSHD1 could be underdiagnosed due to frequently mild symptoms and slower progression in females. Late onset and a slower progression seem to lead to a rate of 20% misdiagnosed patients . MD2 andMD2 is an autosomal dominant inherited multisystemic muscle disease. The mutation frequency constitutes 1:1830 . PatientFSHD1 is an autosomal dominant disorder and the third most common inherited muscle disease with an incidence of 1: 8.000–1: 20.000 .Arrhythmias in both patient groups are known but its relation to myocardial injury as well as evidence for progression of myocardial changes still remains unknown. Trevisan et al. reported arrhythmic events in 12% of FSHD-patients , whereasIn our pilot studies, we were able to identify myocardial injury, like fat infiltration and focal fibrosis, in over 26% of MD2 and FSHD1 patients with preserved LVEF , 13.Due to individual predispositions, even mild initial dysfunction may lead to severe heart failure over months to years , 15. HowThe aim of this study was to investigate a potential progression of the cardiac remodeling processes, including focal myocardial injury and function, in patients with MD2 and FSHD1 by applying serial CMR. Furthermore, we evaluated its relation to arrhythmias and conduction abnormalities.Follow-up was performed in 83 patients with genetically confirmed diagnosis of MD2 and FSHD1 who had previously participated in our studies , 13.A detailed medical history was recorded including symptoms related to cardiovascular diseases, medication and cardiovascular risk factors. Known myocardial infarction or myocarditis were considered as exclusion criterion to avoid an overlap with myocardial injury due to a different cause. Blood pressure was taken before and after CMR. Assessment of heart rhythm abnormalities was based on a 12-lead electrocardiogram (ECG) and on 24 h ECG-monitoring. Patients were also considered at risk of SCD according to the Groh-criteria: no sinus rhythm, PR interval ≥ 240 ms, QRS duration ≥ 120 ms, second- or third-degree atrioventricular block .Significant arrhythmias were defined as frequent premature ventricular contractions (PVC ≥ 1000 /24-h), episodes of non-sustained ventricular tachycardia (NSVT), runs of supraventricular tachycardia (SVT) and 2nd/3rd degree atrioventricular (AV) block.The local university ethical board approved the study (EA1/042/17) and all subjects gave written, informed consent.CMR was performed on a 1.5 T scanner  using a 32-channel surface coil.3) as well as a short axis (SAx) package  to cover the LV.Cine imaging was performed applying a balanced steady state free precession (bSSFP) sequence to determine the global cardiac performance. We acquired the following long axis views for the LV: four chamber (4Ch), three chamber (3Ch) and two chamber (2Ch) views and for the right ventricle (RV) a single long axis view (echo time (TE) 1.2 ms; repetition time, 33 ms; voxel size 1.8 × 1.8 × 6.0 mmFor myocardial tissue differentiation parametric T1- and T2-mapping, fat/water-separated imaging and focal fibrosis imaging  were acquired. An overview of the scan protocol is provided in Fig. A multi-echo sequence was used for fat/water-separation  in 4ch vWe used the same contrast agent as in the previous studies (0.2 mmol/kg body weight of gadoteridol for MD2 and 0.15 mmol/kg body weight of gadobutrol for FSHD1). , 13.LGE was performed in the same slice position as cine imaging in 4Ch, 3Ch, 2Ch views and SAx orientations  10–15 min after administration of contrast agent.T2- and T1-mapping were performed in basal, mid and apical slices as described , 18. CalMotion-corrected T1 mapping based on Modified Look-Locker Inversion Recovery (MOLLI) technique was performed before and 15 min after contrast media application using for T1 native: 5 s(3 s)3 s and for T1 post-contrast: 4 s(1 s)3 s(1 s)2 s pattern in 4Ch view and three SAx views with basal, mid-ventricular and apical slices (imaging parameters: TR = 281.64 ms (4ch) and 332.67 ms (SAX), TE = 1.12 ms, slice thickness 6.0 mm, GRAPPA acceleration factor 2).In the first paper (2016) we used cvi42 . The analysis of the MD2 cohort at follow-up was performed in 2018/2019. At that timepoint, we switched to cvi42 . Because of potential influences and possible inconsistencies between different software versions, a quality assurance test was performed . There were no significant differences between the quantitative results. For the FSHD1 group we used the same version of Circle software  for both baseline and follow up evaluations.SAx cine images were used to determine LVEF and right ventricular (RV) ejection fraction (RVEF), volumes and LV mass by drawing endo- and epicardial contours (papillary muscles as part of the mass) at the end of the systolic and diastolic phases .We quantified the left atrium (LA) area based on the biplanar approach using 2- and 4ch. For right atrium (RA) quantification 4Ch view cine images in LV systole were used. Furthermore, LA volume and ejection fraction were quantified based on the biplanar approach .The quantitative analysis of mapping was performed as average value for slice as well as for each segment. The region-of-interest ROI was defined by the delineation of the endocardial and epicardial border of the myocardium. To ensure that blood or extra myocardial tissue were not included, endo- and epicardial offset of 5% was used. The segments were defined following the American Heart Association (AHA) segment model. The qualitative survey implied the exclusion of segments in case of artifacts  or wrong motion correction.The visual evaluation of the LGE images was performed by two independent, experienced readers (SCMR Level III) to assess presence, number and location of focal scars.Quantification of LGE was performed with the established semi-automated signal threshold versus reference mean (STRM) method . On all LGE was defined as myocardial signal intensity plus 3 standard deviations (SD) above remote, normal-appearing myocardium. The automated LGE detection could be manually corrected by the reader for a specific location to exclude obvious artifacts. After segmentation, myocardial and scar tissue (in %) were calculated , 22.Fibrosis volume and the total cell volume were derived using extracellular volume fraction (ECV) and the following formulas :\documenFat/water-separation imaging was analyzed using pre-defined criteria. A suspected region was considered positive if the intramyocardial fat was detectable (a) in the fat-separated image (hyperintense) and in the water-separated image (hypointense) or (b) detected in one of the separated images as well as in the cine imaging and LGE. Within the LV segmental analysis was performed following the AHA segment model .Global longitudinal strain (GLS) using CMR feature tracking was assessed from the 4Ch, 3Ch, and 2Ch images. Endo- and epicardial contours were manually drawn in end-diastolic phase, defined as the phase with the largest LV volume. Trabeculae, papillary muscles, pericardium, and epicardial fat were consequently excluded from contouring .The statistical analysis was performed using SPSS® . All results are shown as mean ± standard deviation. Normal distribution was analyzed graphically using the Kolmogorov–Smirnov test. For comparing FSHD1/MD2 patients before and after the follow-up period we used the Mann–Whitney-U test. A p value < 0.05 was considered to indicate a statistically significant difference. Intra- and inter-observer reproducibility was analyzed using intra-class correlation coefficient (ICC) and 95% confidence interval (CI). ICC was classified as poor (ICC < 0.4), good (ICC = 0.4–0.75) or excellent (ICC > 0.75). Images were analyzed twice by blinded readers.Follow-up was available for 27 of 31 MD2 (87%) patients (follow up 3.9 ± 0.3 years) and 41 of 52 (80%) FSHD1 patients (follow up 2.0 ± 0.1 years). Six patients refused follow-up CMR. Twenty-two patients with MD2 and 40 subjects with FSHD1 underwent CMR with contrast. Baseline characteristics of patients at follow-up are shown in Tables Individual and mean changes between both baseline and follow-up groups are displayed in Fig. baseline 68 ± 6% vs LVEFFU 62 ± 6%, p = 0.001). After a mean observational period of four years, MD2 patients presented with significantly lower and mildly impaired RVEF compared to their baseline examinations . Both ventricles showed no significant changes in volume during the course of time (LV end-diastolic volume (LVEDV) p = 0.605 and indexed LVEDV (LVEDVI) p = 0.275, RVEDV p = 0.444 and RVEDVI p = 0.456.) , however it still remained in normal ranges. LVEDV and LVEDVI did not change at follow up .At follow up patients with focal fibrosis showed significantly lower LVEF , however LA volume showed no significant changes (for LAEDV p = 0.275 and for LAEDVI p = 0.288) , but ECV dropped significantly . T2 decreased significantly as well .While the cell volume remained constant, patients at follow-up presented with lower fibrosis volume   at follow up. It was located in the basal segments of the inferolateral and inferoseptal wall. At follow-up, an increase of focal fibrosis was observed. In total 6/22 27%,3 women) MD2 patients had focal fibrosis , mostly located in the apical part of the interventricular septal wall Fig. . OverallMD2 LGE (-) baseline -17.9 ± 1.0% vs. GLSMD2 LGE (-) at follow up -16.8 ± 4.0%, p < 0.01). LGE ( +) patients were excluded to avoid the influence of known focal fibrosis.GLS was significantly lower in MD2 patients at follow in comparison to baseline . New episodes of SVT occurred in 7 patients while a new AV block type 2 was detected in only 1 patient. Two patients displayed new conduction abnormalities, specifically right bundle branch block and left anterior hemiblock. Positive Groh-criteria (AV block type 1) could be identified in only one patient. Arrhythmias or conduction disturbances were observed in all seven patients with fatty infiltrations and 4 of 6 patients with focal fibrosis. See Table Individual and mean changes between baseline and follow-up in both groups are displayed in Fig. baseline 63 ± 5% vs LVEFFU 60 ± 3%, p = 0.762). There was no significant progression of RV dysfunction, however RVEF in FSHD1 patients was mildly impaired . Volume in both ventricles stayed within normal range during the course of time, however LVEDVI increased significantly at follow-up  as well as LA volume (for LAEDV p = 0.271 and for LAEDVI p = 0.227).We observed a significant progression of both LA and RA areas . ECV dropped significantly within three whole slices . T2 mapping values decreased significantly similarly as in MD2 patients . Interestingly, we observed the same phenomenon to that in MD2 patients regarding the cell and fibrosis volume. While the cell volume remained constant, patients at follow-up presented a statistically lower volume of fibrosis . We included detailed information in the table with the CMR parameters Table .In the FSHD1 group, new focal fibrosis was detected in 2 of 40 patients 6%, male). The fibrosis was located inferolateral and inferoseptal. Overall, in 15 of 40  patients focal fibrosis could be identified. The pattern of the fibrosis was non-ischemic with an intramural and subepicardial distribution , as well as in LVEDV and LVEDVI .At follow up, patients with focal fibrosis showed no significant changes in LVEF . Majority was located in the apical part of the interventricular septal wall. In one patient the infiltration was found in the inferior wall Fig. . IntramyFSHD1 LGE (-) baseline -18.3 ± 1% vs. GLSFSHD1 LGE (-) at follow up -16.4 ± 1%, p < 0.01).To avoid the influence of known focal fibrosis, after exclusion of LGE ( +) patients, GLS was significantly lower in FSHD1 patients at follow in comparison to baseline  with the diagnosis of FSHD1. The lack of data was due to patient related reasons.New arrhythmic events were recorded in 10 of 34 patients (29%). NSVT was detected in one patient, runs of SVT in eight patients. Groh-criteria could not be identified. Holter was not available in 5/34 patients with focal fibrosis and/or fat infiltration. Ventricular arrhythmias (PVC > 1000) were observed in 8 patients with focal fibrosis and 3 patients with fat infiltration. SVTs were present in 5 patients with fatty infiltrations and 3 patients with focal fibrosis . We have further discussed progressive fat infiltration as a possible explanation, as one could expect especially in this disease, further remodeling in this direction. However, we refused this possibility because T2 decreased. The explanation remains speculative, but an influence of anti-remodeling medications and myocardial deoxygenation could explain the observed mapping variations. We assume, that the decrease of T2 can be explained by T2* effects and may reflect a deterioration of myocardial oxygenation that may play a role in the further development of fibrosis. It was previously shown, that lower T2* mapping values are related to alterations in the myocardial microcirculation. Manka et al. showed that BOLD CMR (blood oxygen level dependent) at rest revealed significantly lower T2* values for segments supplied by > 50% stenosed vessels . FriedriWe assume that the decrease of ECV at follow-up is probably related to a change of therapy between the two time points. The cardioprotective medication was optimized including ACE inhibitors. This may play a role in regards to the myocardial tissue changes within the whole group. Interestingly, Raman et al. could further show, that ACEI and mineralocorticoid receptor antagonists have an influence on fibrosis in MD . There iQuantification of myocardial deformation is of growing interest in CMR. Although relatively new, CMR feature tracking has been performed in various myocardial diseases like cardiomyopathies, aortic valve diseases or myocardial infarction. It allows quantification of global and regional myocardial deformation offering additional information beyond ejection fraction and has the potential to detect subclinical myocardial dysfunction in patients with non-ischemic heart disease even in preserved ejection fraction and without wall motion abnormalities , 42.In our cohort, GLS was significantly lower at follow up although global LV function was preserved. That could also be shown in patients without focal myocardial injury. It seems that a volumetric approach using LVEF may be less reliable during the first years of follow-up regarding the early phase of subclinical LV remodeling.In our study we observed a remarkably fast progressive decline of the cardiac morphology and function as well as a progression of rhythm disturbances including arrhythmias, even in asymptomatic patients see Fig. . Both veFurther multi-center follow-up studies are needed to understand the relation between cardiac remodeling in MD and the outcome. However, regular use of CMR for follow-up in these patients may provide a valuable risk stratification tool in the future.Our sample size is relatively small, but both cohorts are recognized as rare diseases and this is the first follow-up study in this cohort. It was not possible to perform ECG-monitoring in all patients due to logistical reasons. This is an observational prospective cohort study, therefore there was no randomization into different treatment groups. Nevertheless, there is a potential impact of many other factors like progressive fat infiltration as well as the received therapy during the follow-up period, which should be taken into consideration. Currently, there are not enough data to report outcome analysis.Patients with MDs gain an increasing awareness in cardiology. We observed a remarkably fast progressive decline of cardiac morphology and function as well as a progression of rhythm disturbances including arrhythmias, even in asymptomatic patients. These changes occurred within a short period of time. It seems that a potential association between an increase of arrhythmias and progression of myocardial tissue damage such as focal fibrosis and fat infiltration exists. Our data suggest that these patients should be carefully followed to identify early development of remodeling and potential risks for the development of furthers cardiac events even in the absence of symptoms.Longitudinal multi-center trials with a larger sample size will help to define the impact of our findings as well as further demonstrate a correlation between myocardial injury and arrhythmias in regards to long-term prognosis and therapeutic decision-making.


Background: subclinical pulmonary and peripheral congestion is an emerging concept in heart failure, correlated with a worse prognosis. Very few studies have evaluated its prognostic impact in an outpatient setting and its relationship with right-ventricular dysfunction. The study aims to investigate subclinical congestion in chronic heart failure outpatients, exploring the close relationship between the right heart-pulmonary unit and peripheral congestion. Materials and methods: in this observational study, 104 chronic HF outpatients were enrolled. The degree of congestion and signs of elevated filling pressures of the right ventricle were evaluated by physical examination and a transthoracic ultrasound to define multiparametric right ventricular dysfunction, estimate the right atrial pressure and the pulmonary artery systolic pressure. Outcome data were obtained by scheduled visits and phone calls. Results: ultrasound signs of congestion were found in 26% of patients and, among this cohort, half of them presented as subclinical, affecting their prognosis, revealing a linear correlation between right ventricular/arterial coupling, the right-chambers size and ultrasound congestion. Right ventricular dysfunction, TAPSE/PAPS ratio, clinical and ultrasound signs of congestion have been confirmed to be useful predictors of outcome. Conclusions: subclinical congestion is widespread in the heart failure outpatient population, significantly affecting prognosis, especially when right ventricular dysfunction also occurs, suggesting a strict correlation between the heart-pulmonary unit and volume overload. Heart failure (HF) is a clinical syndrome with current or prior symptoms and/or signs, caused by a structural and/or functional cardiac abnormality, confirmed by elevated natriuretic peptide levels, and objective evidence of cardiogenic pulmonary or systemic congestion . Congest2 ; poor acoustic window; patients treated by HF telemedicine or treated with periodic or continuous inotropic infusions; recent hospitalization for HF (in the previous 30 days); acute coronary syndromes or myocardial revascularization in the previous 3 months; cardiac surgery in the previous 6 months; isolated right ventricular dysfunction and isolated tricuspid insufficiency; constrictive pericarditis; idiopathic pulmonary hypertension; severe pulmonary disease; BMI > 40; pregnancy.We screened 110 consecutive outpatients’ data, included in the HF electronic database , from December 2018 to June 2019; only patients whose echocardiographic evaluation was performed immediately after the clinical evaluation were included in the screening. Inclusion criteria were as follows: age >18 years, previous diagnosis of HF (regardless of LVEF and etiology of heart disease); recent blood tests (previous 3 months or the following month), including creatinine, urea, hemoglobin, hematocrit, NTproBNP, sodium, potassium. Exclusion criteria were as follows: estimated glomerular filtration rate <15 mL/min/1.73 m2 using MDRD formula.A previous history of myocardial infarction or angiographic evidence of significant coronary artery disease defined the existence of ischemic heart disease. A prior medical history of hypertension defined arterial hypertension. Diabetes was considered as comorbidity in the presence of a previous diagnosis of type 1 or type 2 diabetes mellitus. Atrial fibrillation was defined as a clinical history of sustained atrial arrhythmias . Anemia was defined by a hemoglobin level of <12 g/dL in females and of <13 g/dL in males. Chronic kidney disease was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 mThe study conforms to the principles outlined in the Declaration of Helsinki and was approved by the local ethics committee.The PE was performed by two cardiologists experienced in HF. PE was systematically performed for each patient to identify clinical signs of congestion and elevated central venous pressure; the presence of these clinical signs was not graduated and was analyzed as a dichotomic classification with regard to jugular vein distention (JVD), hepato-jugular reflux (HJR), peripheral oedema (OED) and rales. JVD was systematically inspected in the supine position, at 30°–45°, on both sides of the neck, with a careful evaluation of the internal jugular venous waveform. HJR was considered as positive when a sustained increase in JVD, during 10 s of continuous pressure on the abdomen was identified, with an immediate drop after the pressure was released. A detailed clinical history, electrocardiogram and PE with vital signs were always collected before a transthoracic echocardiogram (TTE). TTE was performed in a blinded fashion by an experienced cardiologist, using a Vivid E9  and a Philips IE33 , equipped with a cardiac probe (2.5–3.5 MHz); all measures were collected according to current guidelines. A systematic evaluation of the inferior vena cava (IVC) diameter and its collapsibility degree was performed whereby the IVC diameter was measured at end-expiration by a subxiphoid view, approximately 2 cm from venous ostium, and its collapse was estimated following deep inspiration. The RAP was estimated as 3 mmHg when an IVC diameter ≤ 21 mm and a collapsibility of > 50% were assessed; IVC diameter > 21 mm with a collapse < 50% arbitrary estimated a RAP of 13 mmHg; 8 mmHg was estimated for intermediate values of the IVC diameter and collapsibility degree. The right ventricular systolic function was assessed through a multiparametric evaluation, composed of fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE) and a systolic S’ wave, using the tissue Doppler technique. TAPSE < 17 mm, FAC < 35% and S’ < 9.5 cm/s were considered pathologic values. The tricuspid regurgitation degree has been classified by qualitative estimation as trivial, mild, moderate or severe, respectively. The systolic Pulmonary Artery Pressure (PAPS) was derived by the peak tricuspid jet velocity plus the estimated RAP; 36 mmHg was considered the upper normal range. The TAPSE/PAPS ratio was assumed as a surrogate of right ventricular–arterial coupling; values of > 0.57 were considered normal. The presence of at least two pathologic criteria among TAPSE, FAC and S’ were considered as RVD.The composite outcome was represented by HF rehospitalization and Emergency Department admission due to HF symptoms requiring diuretics and cardiovascular mortality.The outcome data were obtained by scheduled visits and Emergency Department admissions using the local electronic database. All missing outcome data were obtained directly by the patients by phone call and scheduled visits. To avoid interference in the outcomes, March 2020 was considered as the end of the follow-up period, which is when the Covid-19 pandemic began.p < 0.05 was considered statistically significant.Normally distributed continuous variables are presented as means ± standard deviation, or median and confidence intervals in case of a non-Gaussian distribution. Between-group differences were compared by a Chi square test, an Analysis of Variance test (ANOVA) and Student–Newman–Keuls, as appropriate. A Kaplan-Meier curve analysis was used to assess the event rate and for the graphic representations of outcomes. The accuracy data were expressed by area under curve  and by inter-rater agreement analysis. The associations between the echographic and clinical variables were tested using multivariate logistic regression models. The correlation between variables is expressed using the Pearson correlation coefficient. A value of Statistical analyses were performed using Medcalc software.110 consecutive patients were screened from December 2018 to June 2019; 6 patients met the exclusion criteria and were removed from the final analysis.(1)“Control” group, i.e., patients without clinical signs of peripheral edema nor US estimated RAP ≥ 13 mmHg;(2)“SubC”  Group i.e., patients with US estimated RAP ≥ 13 mmHg without peripheral edema;(3)“Edema” group i.e., patients with peripheral edema irrespective of US findings.Three groups of patients were defined:Patient characteristics are summarized in p < 0.01); no significant age difference was detected between the “Control” and “SubC” groups.From the analysis of the population characteristics, it was found that patients in the “Edema” group had a significantly higher mean age than the “Control” group (p < 0.01).Significant differences regarding the etiology of heart disease were found: idiopathic cardiomyopathy was prevalent in the “Control” group while in the “SubC” and “Edema” groups ischemic and valvular heart disease were prevalent (p < 0.001).The prevalence of both history of atrial fibrillation (AF) and permanent AF gradually increased from the “Control” group to the “Edema” group (p < 0.01). The inter-rater agreement analysis showed a significant correlation between the circulating levels of NTproBNP and IVC diameters and collapsibility . The baseline blood sample results are summarized in No significant differences in blood chemistry were observed except for the hemoglobin parameter, which was significantly reduced in the group with clear signs of congestion  in 29% of the patients. Clinical or instrumental congestion was detected in 26% of the patients. In this subgroup, 12 out of 27 patients (44%) only had subclinical congestion.p < 0.001) and FAC (p < 0.05) were significantly reduced in the congested groups compared to the group without instrumental and clinical congestion. Results of PE and TTE evaluations are summarized in RVD was found in 29% of the population and the TAPSE/PAPS ratio was reduced  in 46% of patients. The values of TAPSE (p < 0.001), the results of which are summarized in The end-diastolic right chambers’ volume and TAPSE/PAPS showed significant difference between the congested groups compared to the group with no signs of instrumental or clinical congestion  and an ROC area under the curve of 0.727 .The correlation analysis showed a strong correlation between both the right chamber size and ventricular/arterial coupling with US congestion. The right atrium size and TAPSE/PAPS resulted in the most significant correlations with IVC diameters and the collapse ratio.The main findings are summarized in the distribution graphs below .p < 0.01). Pathological values of TAPSE/PAPS ratio correlated with a significant reduction of event-free survival . RVD affects early prognosis, resulting in a 2-fold increase in events .During a follow-up of 370 days (IQR 259–448), the following 17 events occurred: 3 deaths due to cardiovascular causes and 14 Emergency Department admissions/hospitalization due to HF. Both clinical congestion, identified by PE, and instrumental congestion affect prognosis (p < 0.05).The combination of a multiparametric evaluation of RVD and US signs of congestion corroborates the above-mentioned findings, i.e., RVD and instrumental congestion significantly affect prognosis, which is even worse when both are present (OR 4.3, Finally, by comparing the three main groups according to the presence of overt or subclinical congestion, the former is associated with the worst event rate and the latter affects prognosis even in the absence of signs of clinical congestion. According to the US and PE data analyses, the estimated survival analysis is as shown in Our study evaluated an outpatient HF population to analyze the relationship between RVD and congestion, the accuracy of PE and the prognostic impact of clinical and US variables commonly used to assess congestion in outpatient HF settings. The main population characteristics were comparable to previous HF registries ,9 exceptPE is the cornerstone of outpatient evaluation, however it often lacks accuracy compared with other instrumental evaluations ,14, poteSeveral studies described subclinical congestion in outpatient settings: B-lines ,17, JVD The prevalence of a pathological IVC diameter and of collapsibility in our population ranges from 26% to 47% according to its grading, which is similar to other recent studies , highligData from the literature identifies RVD as a strong predictor of outcomes in the HF population, irrespective of LVEF ,23. GhioFinally, in agreement with previous observations, the presence of subclinical congestion allows us to identify a group of patients at high risk of events, even in the absence of clinical signs of congestion; this group is identifiable only by instrumental examination, presenting very similar ultrasound characteristics to patients with clinically overt signs of congestion. Due to the poor prognosis of the “SubC” cohort, it is mandatory to implement subclinical congestion detection methods in the HF outpatient population.Despite the fact that congestion represents an important therapeutic target and prognostic factor in HF outpatients, PE has a low sensitivity for identifying congestion, resulting in a significant proportion of subclinical congested patients. Subclinical congestion is a negative prognostic factor, strongly correlated with the right heart structure and ventricular/arterial coupling, amplifying RVD negative outcomes. When congestion coexists with RVD, it dramatically impacts prognosis, even if it is subclinical. An integrated, focused US approach provides accurate prognostic information and could allow physicians to empower the clinical patient risk assessment, potentially guiding future therapeutic approaches, according to patients’ characteristics. Further analyses are necessary to evaluate whether tailored therapy in subclinical congested patients could have a favorable impact on prognosis in an outpatient setting.The main limitations of the study are its small sample size, the lack of external validation of the data acquired in the US laboratory, the lack of a control group without HF and the absence of the invasive validation of US measurements. Furthermore, the presence of pulmonary congestion has not been systematically evaluated by US examination.The sample size was mainly limited by the requirement to enroll patients who had an adequate observation period with a deadline of February 2020, when the Covid-19 pandemic started, as this would have interfered with the primary endpoints. The sample size calculation obtained before starting enrollment estimated the range of patients to be enrolled between 81 and 120; therefore, the 104 enrollments made it possible to obtain a statistically significant result for almost all the data analyzed. The analysis of the literature has shown that the correlation between US, clinical and hemodynamic data is already well established; for this reason it was not considered necessary to acquire the data of control patients nor to carry out invasive measurements. Moreover, clinical congestion revealed by the PE has not been graded as it has been in recent studies, although it has been identified dichotomously, which could affect the accuracy and the odds ratio analyzes. However, this study aimed to analyze the correlation between instrumental congestion and RVD, both graded in tertiles according to previous studies, which has not been influenced by PE grading. Finally, systematic data on tricuspid regurgitation severity and liver function were insufficient and were therefore omitted from the analysis.


The right and left ventricles have traditionally been studied as individual entities. Furthermore, modifications found in diseased left ventricles are assumed to influence on right ventricle alterations, but the connection is poorly understood. In this review, we describe the differences between ventricles under physiological and pathological conditions. Understanding the mechanisms that differentiate both ventricles would facilitate a more effective use of therapeutics and broaden our knowledge of right ventricle (RV) dysfunction. RV failure is the strongest predictor of mortality in pulmonary arterial hypertension, but at present, there are no definitive therapies directly targeting RV failure. We further explore the current state of drugs and molecules that improve RV failure in experimental therapeutics and clinical trials to treat pulmonary arterial hypertension and provide evidence of their potential benefits in heart failure. Pulmonary arterial hypertension (PAH) is an incurable life-limiting disease characterized by increased pulmonary hypertension secondary to pulmonary vasculature remodeling . The incThe heart is a muscular pump whose primary function is to supply blood to the body, allowing oxygen and nutrients to reach each cell while removing carbon dioxide and metabolic waste. The ventricles propel blood from the heart to either high-pressure systemic circulation by the thick-walled conic-shaped LV or pulmonary circulation by the thin-walled, crescent-shaped RV, which is capable of maintaining low pressure levels even under changes in volume , 11. BotPITX2) gene, which determines left and right asymmetry [HAND1 and HAND2) genes, which influence the development of the left and right ventricles, respectively, [Embryonic development of the human cardiovascular system occurs between the third and eighth weeks of gestation . Specifisymmetry , and thectively, . Contrarctively, . Likewisctively, .An organ's structure serves its function; thus, differences in the pressure of pulmonary and systemic circuits determine several structural differences between ventricles. Noting the anatomical muscle arrangement in both ventricles helps to understand how blood is pumped through different parts of the circulatory system. Most of the muscle fibers in the RV free wall are transverse fibers with a small portion of subendocardial longitudinal fibers . HoweverAnatomical differences between the ventricles are also reflected in their perfusion system. The lower pulmonary arterial pressure and pulmonary vascular resistance are 20% and 10% of systemic arterial pressure and systemic vascular resistance, respectively , leading2+) transient by initial membrane depolarization, through the action potential (AP), to myofilament contraction in response to increased intracellular Ca2+. The initial AP promotes the entry of extracellular Ca2+ through voltage-dependent Ca2+ channels at the plasma membrane or sarcolemma, which promotes the release of Ca2+ from the sarcoplasmic reticulum (SR) in a process known as calcium-induced calcium release (CICR), causing a significant transient increase in intracellular Ca2+ [2+ in a highly energy-dependent process [2+ handling in myocytes, and energetic and mitochondria-dependent process in excitation energetic coupling.The cardiac muscle's functional unit is the cardiomyocyte, whose primary function is to accomplish the cell contraction-relaxation cycle, leading to synchronized organ contraction and relaxation . This sylar Ca2+ , which i process . This se+) and Ca2+ inward currents and different potassium ion (K+) outward currents are described in this section. Differences in AP form and duration (APD) are explained by changes in the expression and function of these ions' channels (INa) through voltage-sensitive Na+ channels. Higher INa densities and larger Na+ currents have been found in the LV than in the RV. In the LV, Na+ channels also have more negative steady-state inactivation, V1/2, and slower recovery from inactivation than in the RV, without changes in the activation threshold [INa density causes a slower conduction time in the RV, resulting in a lower upstroke velocity [+ channel expression has been reported.By definition, AP involves a reversible change in membrane potential due to the sequential activation and inhibition of several ionic channels, which allow ions to flow in favor of their electrochemical gradient through the cell membrane . Sodium channels .  Figurehreshold . The lowvelocity . Despitevelocity  or unchavelocity  Na+ chan+ channels after the initial Na+ inward current [+ current density [Ito) in the RV than in the LV [+ repolarization currents can explain the shorter APD present in the RV. The RV's steeper repolarization phase's significant contribution is partially due to a higher density in the RV of the slowly activating component (IKs) of the delayed rectifier K1 current [IKr), the inward rectifier current (IK1), and the sustained current (ISS) do not show changes in expression, density, or inactivation [+ current (IKATP) has been identified as a determinant factor of APD in ischemia, and its expression is higher in the LV than in the RV [The movement of different ions through the cell membrane shapes the AP, organizing it in well-defined membrane depolarization and repolarization phases. The main difference between LV's and RV's AP is during phase 1, which corresponds to the synchronized opening of K current , 29. The density , 30, 31.n the LV , 30–32. n the LV  or in thn the LV –36, evenn the LV . Howevern the LV , and 2-9n the LV . The K+ tivation . The ATPn the RV .2+ transient and differences observed between the APs of the LV and RV may influence intracellular Ca2+ dynamics. The initial membrane depolarization triggers the activation of L-type Ca2+ channels (LTCC), allowing an inward current of Ca2+, which, in turn, promotes the release of Ca2+ from the SR through the ryanodine receptors (RyR) by CICR, originating the Ca2+ transient [2+ transient.Changes in AP duration and shape may be considered since the cardiac AP's immediate consequence is the generation of an intracellular Caransient .  Figure2+ transient is the LTCC. There is a clear difference between the AP in both ventricles; however, the initial phase of the Ca2+ transient is not affected by these changes. Indeed, while some reports show an increase in LTCC protein expression in the RV [2+ currents (ICa) do not show differences between ventricles [The link between the initial membrane depolarization and the Can the RV , others n the RV . Moreoventricles .2+ concentration for half-maximal activation, the Hill coefficient, caffeine-sensitive ryanodine binding, or current density [Regarding RyR, there are no differences in Ca density . However density . More st2+ between the right and left ventricles [2+ transient amplitude during systole in the LV [2+ release by the SR due to primary Ca2+ content [2+ release, the greater the contraction force. However, two previous studies found no changes in sarcomere shortening in rats [2+ sensitivity in RV myofilaments [α-chain-containing myosin isozyme in the RV compared to the LV, which has a larger proportion of the slower β-chain [At rest, there is no difference in diastolic Cantricles , 41. Hown the LV , 42, ind content  and grea content , 41, 43, in rats , 45, wit in rats . On the  in rats , which iilaments –48. Howeilaments , 50 and  β-chain . All the2+ must decline, and the sarco/endoplasmic reticulum Ca2+-ATPase (SERCA) pump is the primary removal mechanism [2+ transient has been reported in RV myocytes than in LV myocytes [2+ in the RV [2+ removal mechanisms, leading to lower Ca2+ availability in the SR. This phenomenon might explain the decreased transient amplitudes and SR content [For relaxation to occur during diastole, intracellular Caechanism . As illumyocytes , 42, accmyocytes , 42 and n the RV . Phosphon the RV . A previn the RV . The dec content  than in  content  and expr content , 42 betw2+ removal mechanism in cardiomyocytes is the Na+/Ca2+ exchanger (NCX). Higher NCX protein expression has been found in RV than in LV [2+ availability, resulting in a decreased Ca2+ transient amplitude without changes in SERCA activity. However, regardless of its expression, NCX is more active in LV than in RV [2+ overload in the SR during the rest-potentiation phenomenon, which is more prominent in the LV than in the RV [2+ entry and SR loading in the right and left ventricles. Notably, the mitochondrial Ca2+ uniporter and mitochondrial NCX contribute to Ca2+ handling in cardiac cells [Another important Caan in LV   can occur when there is occlusion of the right coronary artery (RCA), proximally to the takeoff of RV branches . The RVMThe term RV infarction may be somewhat misleading since acute RV ischemic dysfunction frequently has a faster recovery than LV infarction. Indeed, there is a deep contrast between the effects of ischemia and reperfusion in RV and in LV, in which prolonged ischemia often leads to myocardial infarction. Levin and Goldstein proposed diverse reasons to explain LV's lower vulnerability to infarction. First, oxygen demand is undoubtedly lower in the RV than in the LV, because of its much smaller muscle mass and lower afterload. Second, in the absence of severe RV hypertrophy or pressure overload, the coronary artery flow in the RV is given in both diastole and systole. Third, chronic RV failure attributable to RV myocardial infarction is infrequent. Fourth, there is greater availability of blood perfusion in the RV through the collateral flow from the left to right coronary arteries . HoweverCardiac hypertrophy is defined as an increase in cardiac mass manifested by increasing size, as well as morphological and functional alterations attributed to a physiological or pathological stimulus. Physical exercise is an example of a physiological stimulus, while a pathological stimulus is found in hypertension, diabetes, myocardial ischemia, and other conditions . Cardiacα (HIF1α) and the suppression of angiogenesis, inducing chronic ischemia in the RV [Concentric hypertrophy is generally accompanied by remodeling to adapt to pressure overload and maintain a stable cardiac output. Next, remodeling progresses from an adaptive to a maladaptive phenotype, with altered contractility that leads to cardiac failure . Differen the RV , 65. Morn the RV . Addition the RV .Furthermore, mechanical stress on the ventricular wall due to pressure overload stimulates fibroblasts to differentiate into myofibroblasts that produce type II and III collagen in the LV and RV, contributing to cardiac failure , 68. Howβ, Rho-ROCK, and MAPKs. However, differences in signaling have been observed in MAPKs [β and ventricular dysfunction; however, hypertrophy and changes in proinflammatory genes are not mediated by p-p38 MAPK [α, has been also described as a mediator of fibrosis and hypertrophy, but conversely, interleukin-6 is involved as a probable pathway to induce hypertrophy [Studies have shown shared molecular pathways to hypertrophy and fibrosis between the LV and RV, such as TGF-in MAPKs , 65. Phop38 MAPK . In the ertrophy . Furtherertrophy –77, the ertrophy .Difference between RV and LV responses also depends on the stimulus. ROCK signaling mediates hypertrophy induced by metabolic alterations in the LV and by hypoxia in the RV , but alsOn the other hand, activation of proteasome has been observed in LVs exposed to pressure overload, which produces hypertrophy , similarEpigenetic mechanisms have also been identified in cardiac hypertrophy. Class I histone deacetylase inhibitors (HDACs) induce hypertrophy in the LV and RV , 92, wheThe inflammatory response also plays an essential role in heart failure progression by the activation of proinflammatory cytokines . The incThe increase in LV afterload by an overload of pressure or volume is considered a determining cause of left heart failure (LHF). In contrast, pulmonary hypertension, pulmonary stenosis, chronic obstructive pulmonary disease, and tricuspid valve pathology produce similar consequences on the right side, inducing right heart failure (RHF) –102. RHFAs a further example of the interconnection between both ventricles, the prevalence of RV dysfunction increases with LHF progression , and RV Furthermore, in patients with LHF, the development of pulmonary hypertension and RV dysfunction is common, and they play an essential role in disease progression, morbidity, and mortality. The diagnosis of pulmonary hypertension aggravates the prognosis in HFpEF and HFrEF patients, and pulmonary hypertension is observed in approximately 75% of patients with HFpEF. Thereby, this prevalence is higher than in patients with HFrEF , 110. InThe requirements of oxygen, glucose absorption, and the glycolytic rate increase in both the LV and RV, reducing fatty acid metabolism . An incrMitochondrial dysfunction is an important and crucial mechanism in the development of heart failure . Hypertr2+ release from the SR. These changes were also described in RV failure, where loss of T-tubules, smaller and slower intracellular Ca2+ transients, reduction and disorganization of the RyR2 network, and reduction of SERCA have been observed in severe hypertrophy caused by MCT-PAH [In LV and RV failure, alterations in ECC and relaxation are observed. In the LV, diastolic dysfunction with a slower contraction-relaxation kinetic is produced, as well as loss of T-tubules, reduced SR density, and altered Ca MCT-PAH . However MCT-PAH . PAH-RV  MCT-PAH .2+ signaling has been well demonstrated. Ca2+ binds to calmodulin (CaM), which activates calcineurin, a phosphatase that dephosphorylates NFAT in the cytosol, allowing its nuclear translocation to regulate the expression of prohypertrophic genes, such as the β-myosin heavy chain (β-MHC). Additionally, Ca2+/CaM activates Ca2+/CaM kinase II (CaMKII), which induces the nuclear export of histone deacetylase 5 (HDAC5), derepressing the prohypertrophic transcription factor Mef2 [β and its signaling pathway as a molecular switch has also been reported [The role of Cator Mef2 . Mef2 hator Mef2 . In the reported .2+-antagonists, endothelin receptor antagonists, and nitric oxide) target vascular abnormalities. Therefore, the amelioration of RV remodeling and dysfunction may represent an essential aspect of PAH therapy, but unfortunately, current therapies do not improve RV function.As mentioned previously, patients with PAH develop RV remodeling due to the progressive increase in pulmonary vascular resistance and pulmonary artery pressure, leading to RV failure. Although RV failure is the leading cause of death in PAH patients, most PAH treatments  technique and RV free wall thickness and contractility and decreased RV fibrosis and cardiomyocyte area and volume, caused by the low mRNA expression of BNP, Tnnc1, and Col1a1, as well as increased IL-10 and SIRT1 mRNA levels [in vivo model. Rol et al. observed a decrease in RV hypertrophy and collagen content, accompanied by reduced mRNA levels of Col1a1, BNP, and OPN [in vivo model [After treating of PAH caused by an MCT ecreased . SimilarA levels . These m and OPN . Furthervo model .in vivo model, Rai et al. observed the preservation of RV function by the attenuation of the increase in RV end-diastolic/systolic volume and collagen content after C57Bl/6J mice were treated with riociguat or sildenafil [TGFβ1 in vitro. Therapy with macitentan also improved RV function and hypertrophy caused by PAB in Wistar-Tokyo rats [On the other hand, in a PAB ldenafil . These ckyo rats .In a hypoxia-induced PAH model, Schmuck et al. observed that mesenchymal stem cells had a protective effect on RV function. A reduction in RV hypertrophy was observed, with an attenuated RV stroke volume and cardiac output, maintained RV contractility, reduced RV collagen content, and slowed cardiomyocyte enlargement .β-cyclodextrin (HPβCD) to treat PAH induced by MCT in vivo, Lacerda et al. observed an increase in GSH concentrations and GSH/GSSG ratio, accompanied by restored glutathione reductase, glutathione-S-transferase, and glutaredoxin enzyme activity [in vivo model, Türck et al. observed increased GSH/total glutathione ratio, decreased NADPH oxidase activity, and increased RV SERCA and RyR protein content [2+ handling mechanisms may represent valuable targets to treat PAH.Poststress conditions could increase ROS in the RV, a determinant factor in many diseases' progression and severity. Pterostilbene complexed with hydroxypropyl-activity . This tr content . The resin vivo [Col1a1 markers [As mitochondria play a key role in heart pathophysiology, Lee et al. investigated the effect of cyclosporine A (CsA) in MCT-PAH in vivo . Despitein vivo  showed t markers . The resVarious clinical trials have been conducted to better understand or more effectively treat PAH. However, most of them managed cardiac improvement secondary to reduced pulmonary artery pressure instead of managing it as a primary objective. Clinical trials aimed at RV function have studied functional and structural improvement by measuring various parameters. NCT03273387), 10.4% after six months of carvedilol (NCT00964678) oral treatment, 10.14% after six months of macitentan (NCT02310672) oral treatment, 7.65% and 5.8% after six months of ranolazine  oral treatments, and 7.54% after six months of treprostinil inhalations combined with oral tadalafil treatment (NCT01305252). Besides, some clinical trials describe changes in TAPSE such as 7% from baseline after three months of anastrozole treatment (NCT01545336), a decrease from 1.88 to 1.79 cm after four months of QCC374 therapy (NCT02927366), and a decrease from 2.2 to 1.65 cm after nine months of tadalafil and ambrisentan combinational treatment (NCT01042158). These changes reported in RVEF and TAPSE suggest an improvement of the RV function.Among the therapeutic compounds studied for PAH treatment at clinical trials are anti-ischemic agents , vasodilators , endothelin receptor antagonists , beta-blockers , stem cells , and others. Some of these clinical trials report improvements in RVEF at different percentages: 3.9% after three months of trimetazidine treatment (NCT02310672); besides, treatment with carvedilol caused a difference of 22.6 mL in RVESV (NCT00964678); these results were observed after six months of treatment with each compound. Along with these changes, improvements in RV mass were reported. Treatment with macitentan for six months caused a reduction of 10.10 g in RV mass (NCT02310672). Similarly, the combinatorial treatment with tadalafil and ambrisentan caused a change in RV mass from 32.5 to 28 g after nine months of treatment (NCT01042158), indicating an improvement in right ventricular remodeling.Changes in RV volume parameters were also observed in different clinical trials. Treatment with macitentan caused changes in RVSV of 15.17 mL, RVEDV of -6.22 mL, and RVESV of 16.39 mL , collagen type I carboxy-terminal telopeptide (CITP), and procollagen type I N-terminal propeptide (PINP), which might serve as surrogate estimates in approximating the intensity of fibrosis in the myocardium. PIIINP may also be a good indicator for right ventricular (SRV) remodeling , 137. FuAdditionally, cardiac troponin T (cTnT) is used less frequently but has been identified as an independent marker of mortality in patients with PAH ; cTnT leAdditional research is needed to identify new biomarkers that can further improve diagnostic accuracy. It is important to define standard operating procedures for blood and tissue collection, processing, and storage, as well as miRNA analysis, to ensure precise quantification. Additionally, it is necessary to correlate all emerging biomarkers with right ventricular function for robust validation.The ventricles have commonly been studied as individual entities; however, each ventricle must adapt its function to perform its respective role in coordination with each other. Structural differences between ventricles determine their physiological differences in function at the organ level. LV contraction involves radially constricting and longitudinally shortening the septum, while RV contraction is more passive since the RV's free wall lies flat against the septum when LV contracts. The prolonged AP in the LV and the slower contraction velocity in the RV may be a mechanism to coordinate whole-organ contraction. Changes in ECC may compensate for the differences in muscle thickness and ejection pressure to allow ventricles to synchronize at the end of the systole. Furthermore, the discrepancies reported in changes at different stages of the ECC may be due to the heterogeneity within and between ventricles , 31, 153Advances in RV dysfunction diagnostics and therapeutics are needed to improve the early detection of the disease and improve prognosis. The determination and validation of new, less-invasive, and more accurate biomarkers is an important research area that has been strengthened by the description of ventricle differences in dysfunction. Additionally, the search for new therapeutic approaches that target RV has been fueled by the variation in response between the two ventricles. Some diverse therapeutic strategies could be beneficial in improving current treatments , but the


No differences were found in secondary endpoints. (4) Conclusions: TAVI has an early beneficial impact on the left ventricular diastolic and right ventricular function. However, the extent of cardiac damage at baseline significantly affects the risk of mortality at 1-year after the procedure.(1) Aims: We sought to assess the impact of the extent of cardiac damage on survival among real-world patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). (2) Methods: A staging classification was applied to 262 patients from the EffecTAVI Registry at baseline and re-assessed within 30-days after TAVI. The primary endpoint of the study was all-cause mortality at 1-year. Secondary endpoints included cerebrovascular accident, myocardial infarction, permanent pacemaker implantation, endocarditis, and re-hospitalization for all causes. (3) Results: At baseline, 23 (8.7%) patients were in Stage 0/1 (no cardiac damage/left ventricular damage), 106 (40.4%) in Stage 2 , 59 (22.5%) in Stage 3  and 74 (28.3%) in Stage 4 (right ventricular damage). At 30-days after TAVI, a lower prevalence of advanced stages of cardiac damage than baseline, mainly driven by a significant improvement in left ventricular diastolic parameters and right ventricular function, was reported. At 1-year, a stepwise increase in mortality rates was observed according to staging at baseline: 4.3% in Stage 0/1, 6.6% in Stage 2, 18.6% in Stage 3 and 21.6% in Stage 4 ( Degenerative aortic stenosis (AS) is the most common heart valve disease among people ≥ 65 years in developed countries, with an increasing prevalence due to population ageing ,2. AS coA recently proposed staging classification of AS is based on the assumption that there is a continuum in the pathophysiology of LV structural and functional changes induced by AS. Such a system showed prognostic ability among patients from the PARTNER 2 trial as well as in asymptomatic subjects with moderate to severe AS, thus challenging the current management of the disease ,8.The aim of our study was to assess the prognostic performance of this staging classification in a real-world cohort of patients undergoing transcatheter aortic valve implantation (TAVI) and to investigate the eventual impact of the procedure on the extent of extra-aortic valve cardiac damage.2  and/or a peak aortic jet velocity ≥ 4 m/s [n = 275) received echocardiographic evaluation before TAVI. However, for the present analysis we only considered those with a complete dataset including variables needed for staging cardiac damage according to the system proposed by Gènèreux [https://www.redcap.unina.it). The EffecTAVI registry has been approved by the local ethics committee and written informed consent was obtained for all patients for participation. All study-related procedures were carried out in accordance with the Declaration of Helsinki and this analysis was approved by the institutional review board.All consecutive patients with severe symptomatic AS undergoing TAVI between 2014 and 2019 at our institution were enrolled in the EffecTAVI registry. Severe AS was defined according to current guidelines as a mean aortic valve gradient ≥ 40 mmHg and/or aortic valve area < 1.0 cm2 for women, >115 g/m2 for men) [2) and/or moderate to severe mitral regurgitation and/or atrial fibrillation; Stage 3, pulmonary vasculature and/or tricuspid valve damage as defined by the presence of systolic pulmonary hypertension  and/or moderate/severe tricuspid valve regurgitation [The following criteria for staging classification of cardiac damage were applied at baseline (within 1 month before TAVI) and after the procedure (within 30-days): Stage 0, no extra-aortic valve cardiac damage; Stage 1, LV damage as defined by the presence of LV hypertrophy (LV mass index > 95 g/mfor men) , severe gitation ,13; and gitation ,11,14,15To improve the identification of subclinical LV dysfunction, we added the LV global longitudinal strain (GLS) to Stage 1, using a cutoff value of <−20% to define impaired LV-GLS . PatientAfter hospital discharge, follow-up was performed by clinical or phone visits at 30-days and 1-year after TAVI. All adverse events were systematically collected and classified according to the definitions of the Valve Academic Research Consortium-2 . The prip-values were <0.10 in the univariable model. The univariable model was built by using the Student’s t-test or Wilcoxon–Mann–Whitney test for continuous variables and the chi-square test or Fisher exact test for categorical variables as appropriate. Statistical analyses were performed with Stata software version 14.2 .Continuous data are reported as mean ± standard deviation (SD) and categorical data are reported as frequencies and percentages. Kaplan–Meier curves were constructed to show the rate of mortality up to 1-year across the cardiac damage groups. The association between the extent of cardiac damage and the risk of all-cause mortality at 1-year was assessed by using a Cox-regression multivariable model including all variables associated whose Among patients included in the EffecTAVI registry between 2014 and 2019, 262 received a detailed echocardiographic assessment at baseline and were included in this analysis. Patients were categorized by the presence and extent of extra-aortic valvular cardiac damage. At baseline, 4 (1.4%) patients were in Stage 0 (no cardiac damage), 19 (7.2%) patients were in Stage 1 (LV damage), 106 (40.4%) patients were in Stage 2 , 59 (22.7%) patients were in Stage 3  and 74 (28.3%) patients were in Stage 4 (RV damage). Given the small number of patients in Stage 0 and Stage 1, they were merged in a single group, Stage 0/1. The prevalence of cardiac damage stages and the distribution of their individual components are presented in p = 0.059). Similarly, GLS significantly improved from baseline to follow-up . E/e′ ratio, a marker of diastolic dysfunction, showed a peculiar trend: from a mean value of 17.04 ± 4.4 at the baseline, it increased to 20.2 ± 5.7 at discharge and then decreased at 30-days after TAVI with a mean value of 12.19 ± 7.2 (p = 0.192). LA volume was significantly reduced  as well as systolic pulmonary artery pressure . Finally, improvement in RV function was demonstrated by an increase in TAPSE .The echocardiographic evaluation of the overall population is reported in p = 0.008) (p = 0.012).Clinical outcomes at 1-year after TAVI stratified by stage of cardiac damage are presented in = 0.008) . Death fNo differences were found for secondary endpoints including cerebrovascular accident, myocardial infarction, permanent pacemaker implantation, endocarditis, and re-hospitalization for all causes at 1-year after the procedure. In addition, periprocedural complications did not increase the risk of major clinical outcomes.p = 0.006) and frailty class 4/5  were significantly associated with all-cause mortality at 1-year follow-up  and demonstrated incremental value over other traditional risk markers [The identification of clinical and anatomic factors that affect clinical outcomes of patients with severe AS represents an important unmet need. Several scoring systems that account for baseline features and measures of frailty have been proposed for counselling AS patients ,18. Howe markers .However, our analysis is the first to assess the impact of TAVI on the extent of extra-aortic valve cardiac damage. We found that the procedure triggers an early (within 30-days) re-classification of the stages owing to significant changes in measures of LV diastolic and RV function. LV hypertrophy and collagen abnormalities develop in patients with severe AS and impair diastolic function. Indeed, objective evidence of variable degrees of LV diastolic dysfunction has been reported in up to two-thirds of patients undergoing TAVI . SimilarThe main clinical implication of the results of our study is the need to rethink the optimal timing of intervention in patients with AS. Multiple lines of evidence indicate that the greater the extent of cardiac damage before TAVI, the higher the probability of worse outcomes after the procedure. Moreover, irreversible structural cardiac changes induced by longstanding AS neutralize the beneficial impact of TAVI on some functional parameters. From this perspective, anticipating the intervention might have the potential advantage of obtaining the full reversibility of cardiac function and improving survival to a greater extent.Our study has several limitations. It is a retrospective analysis of data collected at a single center; thus, it is subject to inherent flaws related to that design and the sample size may not provide enough power to make definite conclusions. A comprehensive assessment of echocardiographic parameters after TAVI was not performed in the overall population, affecting the completeness of our observations. The parameters used for staging the extent of cardiac damage are those obtained in the context of the routine echocardiogram of TAVI patients and are potentially subject to measurement errors and variability. We did not assess the potential modifying effect of paravalvular aortic regurgitation on echocardiographic and clinical outcomes after TAVI. Moreover, we could not evaluate whether adding cardiac biomarkers might ameliorate the prognostic role of the staging classification as they are not routinely measured in our clinical practice.The staging classification confirms its utility as an additive clinical tool to enhance risk stratification and therapeutic decision making in patients with AS. Timely intervention  might reverse functional cardiac changes associated with AS; however, survival at medium-term is mainly related to the baseline grade of the extent of cardiac damage. Further and larger studies are needed to assess the value of the staging classification in the post-procedural setting.


Significant differences between groups were observed in the retrodiscal tissue, medial pterygoid muscle and bone marrow. The pulp short T2 component showed a trend toward statistical significance. The segmentation reliability was excellent (93.6%). The relationship between disk displacement and quantitative MRI features of stomatognathic structures can be useful in the combined treatment of articular disk displacement, pterygoid muscle tension and occlusive reconstruction.In this study, we aimed to assess the potential impact of temporomandibular disk displacement on anatomical structures of the stomatognathic system using biexponential T2 magnetic resonance imaging (MRI) maps. Fifty separate MRI scans of the temporomandibular joints (TMJ) of 25 patients were acquired with eight echo times. Biexponential T2 maps were created by weighted reconstruction based on Powell’s conjugate direction method and divided into two groups: the TMJ without (32 images) and with (18 images) disk displacement. The disk, retrodiscal tissue, condylar bone marrow, masseter muscle, lateral and medial pterygoid muscles and dental pulp of the first and second molars were manually segmented twice. The intrarater reliability was assessed. The averages and standard deviations of the T2 times and fractions of each segmented region for each group were calculated and analysed with multiple Student’s  The stomatognathic system is a set of functionally connected anatomical elements comprising the teeth, maxilla, mandible, temporal bone, muscles for mastication, temporomandibular disk and other associated soft tissues. One of its most common pathologies, after caries and periodontitis, is temporomandibular disk displacement . The aetThe clinical evaluation of patients with temporomandibular joint (TMJ) disorders is used to determine the relationship between disk displacement and complaints originating from other tissues, such as muscle tenderness or tooth sensitivity . HoweverQuantitative T2 mapping is an MRI technique for measuring the transverse relaxation time ,14. The Quantitative MRI studies have shown that monoexponential analysis of the T2 time can be useful for assessing the regeneration and recovery of cartilage, tendons and muscles. Attempts have been made to assess the correlation between disk dislocation and the surrounding tissues on monoexponential maps, however, without significant results  ,18,19. ITherefore, the aim of this research was to assess the potential impact of temporomandibular disk displacement on other anatomical structures of the stomatognathic system using biexponential T2 maps. The T2 times of segmented regions in patients with and without disk displacement were compared. Moreover, the reference T2 times and standard deviations of each anatomical structure with no disk displacement are presented. Future studies considering the presence of pathology will be able to refer to the reference T2 times given here.Fifty MRI scans of the TMJ of 25 patients without TMJ pain or mandibular mobility difficulties were included in this study. The inclusion criteria were as follows: age above 18 years; no metallic foreign bodies or artifacts in the assessed region; and no severe osteoarthritis or signs, such as severe articular surface flattening, bone spurs and osteophytes. Examinations were performed from January 2019 to May 2021. Patients  were positioned in the maximum intercuspation position during imaging . The stu2; matrix = 560 × 560 voxels; and average acquisition time = 5 min 32 s.The MRI examinations were performed using a 1.5-T MRI unit (Philips Achieva) with an eight-channel head coil (eight -channel SENSE Head coil). The turbo spin echo sequence was employed for T2 map acquisition. The following parameters were set: eight echo times = {13, 26, 39, 52, 65, 78, 91, 104 ms}; repetition time = 2000 ms; eigth slices; field of view = 160 × 160 mmThe examinations were performed separately on the left and right sides, resulting in 50 separate images of the TMJ. MR images were oriented parallel to the plane of the ramus of the mandible and covered the head of the mandible, which was in the field of view. No motion artifacts were found. Patients were positioned in a comfortable, stable position.The images were divided into two groups: TMJ without disk displacement (32 studies) and TMJ with disk displacement (18 studies). Disk displacement was assessed separately by a radiologist with 25 years of experience and by a dentist with 10 years of experience in maxillofacial radiology. The interrater reliability was measured with Cohen’s kappa coefficient (κ).Biexponential T2 map reconstruction was performed with a quantitative, weighted reconstruction based on Powell’s conjugate direction method implemented on the VisNow T2 Map Plugin library and available for use with the VisNow platform . The maiThe reconstruction consisted of two T2 maps (one for short and one for long time components) and two amplitude maps of the short and long time components. Amplitude maps were used to calculate short and long fraction maps as the ratio of the appropriate amplitude to the sum of the amplitudes. Detailed characteristics of the biexponential analysis were provided by Chang et al. .Biexponential T2 maps were tested in terms of the adequacy of reconstruction regarding whether the reconstructed voxels were considered biexponential. The voxel was monoexponential or degenerative when at least one relaxation time component was zero, when the difference between the time components was less than 1 ms, when one amplitude was equal to zero or when the mean squared error of fit (MSE) of the monoexponential reconstruction was less than the MSE of the biexponential reconstruction. In such cases, the voxel was considered to be monoexponential and was not taken into further assessment.The temporomandibular disk, retrodiscal tissue, condylar bone marrow, masseter muscle, lateral pterygoid muscle medial pterygoid muscle, and dental pulp of the first and second molars were manually segmented by the dentist. The segmentation was performed twice at an interval of two months, with manual contour tracing using the VisNow Plugin Medical library  Figure . Segmentt-tests were performed to compare values in each region between the groups. In order to assess the effect of age, the Pearson correlation coefficients between the T2 components, fractions and age for each structure were calculated. Potential relationships of sex with T2 times and fractions and of missing molars with T2 times were analysed with Student’s t-test. Bonferroni’s correction was used to counteract the multiple comparisons problem (p < 0.0125) caused by apossible relation between the short and long T2 components and their fractions. The results with p-values less than 0.0125 were significant, and p-values less than 0.05 showed a trend toward statistical significance. Normality was checked with the Shapiro–Wilk test. Statistical analysis was performed using Statistica software .The average and standard deviation of the T2 time and fraction for each segmented region in each group were obtained. Multiple Student’s The mean and standard deviation of the temporomandibular disk, retrodiscal tissue, bone marrow of the condyloid process of the mandible, masseter muscle, lateral pterygoid muscle and medial pterygoid muscle and pulp of the first and second molars are presented in p < 0.0001) short fraction (p = 0.0050) and long fraction (p = 0.0049), the medial pterygoid muscle short T2 component (p = 0.0025) as well as the bone marrow long T2 component (p = 0.0030) and short T2 component (p = 0.0116), indicating the relationship between disk displacement and quantitative MRI features of stomatognathic anatomical structures. The pulp short T2 component showed a trend toward statistical significance (0.0125 < p < 0.0500). Sample T2 maps are presented in Statistically significant differences were observed between the displaced and nondisplaced disk groups in the retrodiscal tissue short T2 component (p = 0.0001) and long T2 component  as well as the masseter muscle short T2 component  and long component . There were no significant relationships between sex, missing molars and T2 times (p > 0.05).The correlation coefficients between age and short and long T2 components were not significant for the stomatognathic structures except from the lateral pterygoid muscle short T2 component .This study confirms the thesis that, at the same time, the alteration of different structures of the stomatognathic apparatus are present when a disk dislocation is present. Statistically significant results show the relationship between disk dislocation and morphological changes in structures both close to  and far from  the disk and that such changes might have an impact on changes in the pulp of the molars; however, further research is required to confirm statistical significance.An explanation of this phenomenon might be associated with the function of the analysed regions. Disk dislocation leads to the redevelopment of retrodiscal tissue and its adaptation to new functions (replacing the dislocated disk). This can also increase masticatory muscle tension (which is mostly visible in the pterygoid muscle), thus, causing changes in the fibre orientation and water compartments ,22. The Juras et al.  showed aThe T2 changes in overloaded stomatognathic structures demonstrated in this paper are similar to those seen in degenerated tendons. The retrodiscal tissue, bone marrow and medial pterygoid muscle showed significant increases in the short T2 time, and the masseter muscle, temporomandibular disk and pulp showed insignificant increases in the short T2 time in patients with disk displacement as in degenerated tendons. This difference in significance of the results between the muscles of mastication might be associated with their different load in joints with and without disk displacement. The load of the medial pterygoid muscle is associated with the contralateral excursion of the mandible which can be affected by disk displacement. The medial pterygoid is the strongest muscle responsible for shifting of the mandible towards the contralateral side . Duman eTherefore, the mechanism of overload of the pterygoid muscle and collagen III synthesis might explain the prolongation of the short T2 time of the stomatognathic structures of patients with disk displacement. However, the complex interplay between significant differences in T2 times or fractions and physical explanations for biological phenomena and the clinical consequences of these differences merits additional research that includes a shorter time echo and multiexponential, quantitative sequences . The comThe effect of age on the T2 times of the pterygoid and masseter muscles does not alter the results of disk displacement. Neither muscle showed a significant difference in the displacement analysis. However, further research in a larger population is required to dispel doubts about the feasible relationships between disk displacement and T2 times in both muscles in different age groups.p > 0.05, Student’s t-tests). The fact that no other statistically significant results were found using the monoexponential fit both in our dataset and in the literature indicates that monoexponential reconstruction does not adequately describe the complex structures of most of the examined tissues. The structural complexity of these tissues requires at least biexponential reconstruction. Furthermore, the monoexponential reconstruction showed a higher MSE compared with the biexponential reconstruction , which provides accurate results even for images with a low signal-to-noise ratio.This study has several limitations. First, a larger studied group could show significance of degenerative pulp changes, which, in our study, presented a trend toward statistical significance. Secondly, our studies were performed on a 1.5T MRI system. As the field strength in MRI affects the spatial and contrast resolution, a similar study performed on a 3T system would supply additional information. In our in vivo studies, no histological confirmation of the structure of the retrodiscal tissue or muscles could be obtained. In conclusion, the retrodiscal tissue, condylar bone marrow and medial pterygoid muscle showed statistically significant differences in the biexponential T2 times between patients with and without disk displacement. The T2 time of the molar pulp showed a trend toward a significant difference between the groups. These results confirmed the morphological impact of disk displacement on stomatognathic tissues. Reference values for long and short T2 times are presented and may be of use in further studies.


Left atrial strain (LAS) is the most promising technique for assessment of diastolic dysfunction but few data are available in neonates. Our aim was to assess feasibility and reproducibility, and to provide reference ranges of LAS in healthy neonates in the first 48 h of life. We performed one echocardiography in 30 neonates to assess feasibility and develop a standard protocol for image acquisition and analysis. LAS reservoir (LASr), conduit (LAScd) and contraction (LASct) were measured. We performed echocardiography at 24 and 48 h of life in an unrelated cohort of 90 neonates. Median (range) gestational age and weight of the first cohort were 34.4 (26.4–40.2) weeks and 2075 (660–3680) g. LAS feasibility was 96.7%. Mean (SD) gestational age and weight of the second cohort were 34.2 (3.8) weeks and 2162 (833) g. Mean (SD) LASr significantly increased from 24 to 48 h: 32.9 (3.2) to 36.8 (4.6). Mean (SD) LAScd and LASct were stable: −20.6 (8.0) and −20.8 (9.9), −11.6 (4.9) and −13.5 (6.4). Intra and interobserver intraclass correlation coefficient for LASr, LAScd and LASct were 0.992, 0.993, 0.986 and 0.936, 0.938 and 0.871, respectively. We showed high feasibility and reproducibility of LAS in neonates and provided reference ranges. Echocardiographic assessment of left ventricle (LV) filling pressure is an essential step in the assessment of diastolic dysfunction ,2. Most In adult patients, two-dimensional (2D) speckle tracking echocardiography (STE) has been applied to assess left atrium (LA) function and left atrial strain (LAS) has recently been proposed as novel technique to be used in clinical practice . LAS meaLAS is the most promising technique for direct evaluation of LA function and non-invasive assessment of LV diastolic function in adults . DiffereTo the best of our knowledge, few data on LAS are available in neonates and no data are available in the first days of life, also known as ‘transitional period’, when the transition from intrauterine to extrauterine circulation occurs ,10.LA function has been conventionally divided into three phases timed to the ventricular QRS complex. During ventricular contraction, LA acts as reservoir by storing incoming pulmonary venous blood. During early ventricular relaxation, blood flows passively into the ventricle and LA acts as conduit between the pulmonary veins and LV. In the last phase, LA contracts and actively pumps blood into LV .In neonates, there is evidence of an early diastolic dysfunction in the transitional period, particularly when born prematurely ,13,14. MThe first aim of our study was to assess feasibility of LAS in healthy preterm and term neonates in the first 48 h of life and to develop a standard protocol for image acquisition and postprocessing analysis. The second aim was to provide reference ranges of LAS measurements in healthy preterm and term neonates in the first 48 h of life, to assess LAS reproducibility and to explore associations with other echocardiographic parameters of left systolic and diastolic function.This was a multicenter prospective observational cohort study conducted at the neonatal intensive care unit (NICU) and postnatal ward of Careggi University Hospital of Florence  and University Hospital of Verona . The study was divided into two phases.In the first phase, we developed an LAS protocol for image acquisition and postprocessing analysis and we assessed its feasibility in a cohort of 30 healthy neonates. Every infant underwent one echocardiography in the first 48 h of life.1 = 24 ± 2 h and T2 = 48 ± 2 h), to assess the association of LAS measurements with other echocardiographic parameters and to assess LAS intraobserver and interobserver reproducibility. Ethics approval was obtained from research ethics committees of University Hospital of Florence  and University Hospital of Verona (49/2016 and 2132CESC respectively). Parents or guardians of babies were approached in the NICU or postnatal ward and gave their written informed consent prior to enrollment.In the second phase, in an unrelated cohort of 90 healthy neonates, we applied this protocol to provide reference ranges of LAS at two timepoints  as follows: 10 term neonates with GA ≥ 37 weeks; 10 preterm neonates with GA between 32 and 37; and 10 preterm neonates with GA ≤ 32 weeks.In the second phase, from April 2019 to April 2020, we prospectively recruited 90 healthy neonates divided as follows: 30 term neonates with GA ≥ 37 weeks; 30 preterm neonates with GA between 32 and 37; and 30 preterm neonates with GA ≤ 32 weeks.2 < 0.3 was accepted, as previously reported [Inclusion criteria were informed parental consent and cardio-respiratory healthiness. The latter was defined as follows: no need for supplemental oxygen and/or respiratory support, except for babies with GA ≤ 32 weeks, in whom non-invasive respiratory support with a FiOreported ,17. Excl-LASr = strain during reservoir phase, calculated as the difference of the strain value at mitral valve opening minus ventricular end-diastole ;-LAScd = strain during conduit phase, calculated as the difference of the strain value at the onset of atrial contraction minus mitral valve opening ;-LASct = strain during contraction phase, calculated as the difference of the strain value at end-diastole minus onset of atrial contraction  ,20.All echocardiography examinations were performed using a Philips Epiq 7 system with 12 MHz probe . Images were acquired according to the recommendations of the American Society of Echocardiography . ElectroClinical characteristics of the enrolled neonates were collected at the time of scanning. We evaluated possible options in image acquisitions and postprocessing. Adult recommendations suggest assessing monoplane LAS from a single apical 4-chamber view but computation of biplane LAS, from both apical 4- and 2-chamber views, may be an option. We assessed feasibility of the monoplane LAS and biplane LAS as well as their agreement. A standard protocol for LAS was developed.1 and T2). LAS measurements were carried out according to the protocol developed in the first phase. LV global longitudinal strain (GLS) and strain rate (SR) were calculated as previously reported [Clinical characteristics of the enrolled neonates were collected at the time of scanning at the two timepoints .Data are expressed as mean and standard deviation (SD) for parametric variables, median (range) for non-parametric variables and percentage for categorical variables. Reference ranges of LAS measurements were reported as mean ± 2 SD. Normality was assessed using the Kolmogorov–Smirnov test. A paired-samples 23 scans . AgreemeMedian (range) gestational age and weight of the 30 neonates recruited in the first phase of the study were 34.4 (26.4–40.2) weeks and 2075 (660–3680) g respectively. Clinical characteristics of the three sub-cohorts of neonates divided according to GA are detailed in Monoplane LAS from a single apical 4-chamber view and biplane LAS from both a 4- and 2-chamber view were calculated. Quality of 29 out of 30 apical 4-chamber view images was rated as excellent or good, with a resulting feasibility of 96.7%, whereas only 26 out of 30 apical 2-chamber view images were rated excellent or good with a resulting feasibility of 86.7% .There was excellent agreement and correlation between monoplane and biplane LAS measurements . We deve1 and T2 in the three groups of neonates (p > 0.05).Mean (SD) gestational age and weight of the 90 neonates recruited in the second phase of the study were 34.2 (3.8) weeks and 2162 (833) g respectively. Clinical characteristics of the three sub-cohorts of neonates divided according to GA are shown in Quality of 171 out of 180 apical 4-chamber view images was rated excellent or good with a resulting feasibility of 95% .We observed excellent intraobserver reproducibility and slightly inferior interobserver reproducibility .1 and T2: 32.9 (3.2) to 36.8 (4.6). However, mean (SD) LAScd and LASct did not show statistically significant differences between the two timepoints: −20.6 (8.0) and−20.8 (9.9) and −11.6 (4.9) and−13.5 (6.4) respectively. In all 90 neonates, mean (SD) LASr significantly increased from TReference ranges (mean ± 2SD) of LASr, LAScd and LASct in the three groups of neonates divided according to GA are shown in 1 to T2. LAScd did not show statistically significant differences between T1 and T2 in all groups, whereas we found a statistically significant difference between LASct at T1 and T2 only in neonates with GA between 32 and 37 weeks.In each of the three groups of neonates LASr significantly increased from T1 and T2 are presented in Echocardiographic parameters of left systolic function, left diastolic function and LVO at T1 and T2 and between LAScd and E/e’ at T1.  with and without hsPDA, defined as mentioned above (see Methods section). Nine neonates (30%) had hsPDA. LASr and LASct were significantly different in neonates with and without hsPDA, whereas LAScd did not show any statistical significance. Other variables of systolic (GLS) and diastolic function  did not show statistically significant differences .To the best of our knowledge, this is the first study that longitudinally assessed LAS measured by 2D STE in term and preterm neonates in the first 48 h of life, during the transition from intrauterine to extrauterine circulation. We standardized image acquisition and postprocessing analysis and demonstrated high feasibility and reproducibility of LAS measurements. Finally, we provided reference ranges in healthy preterm and term neonates during the transitional period, that can be used as reference data for future research on diastolic dysfunction in neonates with heart failure and/or volume overload.A major challenge to widespread clinical application of LAS is the lack of standardization of image acquisition and postprocessing analysis, different software packages and parameters to be measured. A recent consensus document tried to standardize definitions and techniques for using LAS in adults. The same would be needed in neonates, given the fact that the current available data were obtained with different types of software and different modalities of both image acquisition and postprocessing analysis ,9,10,30.Firstly, it is essential to use software with a dedicated LA option. Cantinotti et al. presented data on LAS measurement in children using software with a left ventricular option, but they excluded the neonatal subgroup because the feasibility was very low in neonates .On the contrary, we showed that LAS had an optimal feasibility, as previously reported in neonates outside the transitional period and in children, when software with a dedicated LA option was used ,10.In the first phase of the study, we developed an LAS protocol for image acquisition and postprocessing analysis. The recent consensus statement recommended that LAS should be computed using a monoplane algorithm from an apical, non-foreshortened, 4-chamber view or, if available, from a biplane algorithm, which includes the apical 4-chamber and 2-chamber views, whereas assessment of LAS from an apical 3-chamber view should be avoided because the ascending aorta is difficult to separate from the atrial wall . De WaalIn our cohort of neonates, we found excellent agreement between biplane and monoplane LAS, and from a practical perspective, they seem to be interchangeable. Due to the fact that feasibility of the apical 4-chamber view was superior compared to the apical 2-chamber view, we chose to include only a calculation of monoplane LAS from an apical 4-chamber view in our protocol.In conclusion, in our opinion, computing LAS only from an apical 4-chamber view is preferrable due to its superior feasibility, accuracy and time-efficiency.We demonstrated excellent intraobserver reproducibility for LASr, LAScd and LASct and slightly inferior interobserver reproducibility. We feel that this was achieved by developing a standard protocol for image acquisition and postprocessing analysis. Our data on reproducibility are similar to that reported by De Waal et al. and Kutty at al. and confirm that within and between observer differences in LAS measurements may not be clinically relevant ,10.Although LAS is currently the best available non-invasive technique to directly assess LA function and indirectly assess LV diastolic function in adults, few data on LAS are available in neonates, particularly if born prematurely. Two pediatric studies presented normal values of LAS in term neonates and older children. Kutty et al. and Ghelani et al. reported reference values of LAS in subjects with an age ranging from 3 days to 20 years and from 4 days to 20.9 years, respectively . HoweverWe reported reference values for the components of LAS in the first 48 h of life in a cohort of preterm and term neonates. We showed a significant increase in LASr in the first 48 h of life. During the transitional period, lung aeration and distension lead to a dramatic reduction in pulmonary vascular resistance and a subsequent increase in pulmonary blood flow and LV preload ,32. We hIn our cohort of neonates, we confirmed that atrial and ventricular function are closely interdependent. Although the association is weak, GLS was the major determinant of LASr. In fact, longitudinal shortening of LV contributes to atrial stretching during systole and subsequent atrial longitudinal strain (LASr) . EnlargeMoreover, LV diastolic function or compliance may influence LV filling pressure and therefore both atrial reservoir and conduit functions. This is confirmed by the associations we found between E/e’, LASr and LAScd . We coulFinally, our data on preterm neonates with hsPDA confirmed the findings by De Waal et al. . In neonOur study has several limitations. First, the number of subjects in the three group of neonates is relatively small to establish normal ranges. Further studies are needed to confirm our findings. Secondly, the main limitation of 2D STE can be partial displacement of the speckles outside the imaging plane. Data on LAS measured by 3D echocardiography were recently reported in children, but no preterm neonates were included .Thirdly, we did not explore differences in LAS measurements related to the two different reference points for strain curve: QRS and P wave. According to data in adults, using QRS as reference point leads to slightly superior feasibility and is less time consuming . MoreoveFourthly, we did not assess scan–rescan echo repeatability. However, a number of other studies on neonatal echocardiography presented reproducibility data only from off-line analyses ,28,36.Lastly, we did not investigate any association between LAS measurements and clinically relevant outcomes, because the latter is outside the scope of the current study. Further studies are required to explore the role of LAS in neonates with heart failure and volume overload.This study demonstrates the high feasibility of LAS measurements by 2D STE in preterm and term neonates in the first 48 h of life and provides a protocol for image acquisition and postprocessing analysis that reduces measurement variability to a clinically insignificant level. In addition, reference ranges of LAS measurements have been presented. Further studies are required to confirm our findings and to explore the clinical utility of LAS in this population prior to implementation of LAS in clinical practice.