This study was investigated the role that endothelial function and systemic vascular resistance (SVR) play in determining cardiac function reserve during exercise by a new ambulatory radionuclide monitoring system (VEST) in patients with heart disease. The study population consisted of 32 patients. The patients had cardiopulmonary stress testing using the treadmill Ramp protocol and the VEST. The anaerobic threshold (AT) was autodetermined using the V-slope method. The SVR was calculated by determining the mean blood pressure/cardiac output. Flow-mediated vasodilation (FMD) was measured in the brachial artery to evaluate endotheilial function. FMD and the percent change f'rom rest to AT in SVR correlated with those from rest to AT in ejection fraction and peak ejection ratio by VEST, respectively. Our findings suggest that FMD in the brachial artery and the SVR determined by VEST in patients with heart disease can possibly reflect cardiac function reserve during aerobic exercise. Lipid abnormalities, hypertension, diabetes, smoking, and obesity are the traditional atherosclerotic risk factors. These risk factors cause endothelial dysfunction, inflammation, and altered biological pathways –3 which Flow-mediated vasodilation (FMD) in the brachial artery is one of the most widely used noninvasive diagnostic modalities , 5 for cHowever, recent advances in technology have enabled us to measure dynamic SVR and cardiac function during exercise at the same time. Recently, a new type of ambulatory radionuclide monitoring (VEST) system has been developed, which can be connected to computerized ambulatory-electrocardiogram monitoring using an IC card . This VEThe purposes of the present study were (1) to investigate the role that peripheral endothelial function and dynamic changes in SVR during exercise have on left ventricular performance during exercise and (2) to clarify the relationship between peripheral endothelial function and SVR during exercise in patients with heart disease by using the new VEST system combined with cardiopulmonary function testing.The study population consisted of 32 men (63 ± 14 years old); 25 had coronary artery disease , 3 had dilated cardiomyopathy, and 4 were diagnosed with hypertensive heart disease. Patients were excluded if they had acute myocardial infarction or decompensated heart failure within the last three months or severe valvular heart disease. All cardiac medications were discontinued for at least five half-lives before the study. All subjects were aware of the investigative nature of the study and gave their informed consent. The research protocol was approved by the Ethics Committee of our institute that follows the Declaration of Helsinki.All patients had ECG-gated blood-pool scintigraphy. After an injection of 740 MBq (20 mCi) of 99mTc-labeled human serum albumin into an antecubital vein, equilibrium radionuclide ventriculography was done at rest in the 45° left anterior oblique projection. The images were obtained using a gamma camera . The imaging data were taken in a 64 × 64 matrix with a 2.0 zoom, and were acquired for an average of 300 counts per pixel in the cardiac region of interest, with 24 frames per cardiac cycle using a computer system. The left ventricular ejection fraction was computed from the global time-activity curve using the single semiautomated method.To measure the serial changes in left ventricular function during cardiopulmonary stress testing, we used the newly developed VEST system . This system consists of two radiation detectors and an ambulatory electrocardiographic recording system. The method employed when using this technique has been previously described . BrieflyAfter completion of cardiopulmonary stress testing, the patients were placed in front of the gamma camera and another 30-second static image was done to confirm that the VEST detector had not moved during the recording interval. Left ventricular function and the electrocardiogram were subsequently analyzed in a blind manner using the data recorded by the instrument.2), carbon dioxide release, and ventilation were measured. Calibration of volumes and gases were carefully done prior to each test.After radionuclide ventriculography in the supine position, the patients assumed the upright position for symptom-limited cardiopulmonary stress testing using a Ramp treadmill protocol . Left ventricular function was assessed using the VEST system. Using a respiromonitor RM-300 and a gas analyzer MG-360 , breathing patterns were analyzed and oxygen uptake /3. The double product was obtained by multiplying the systolic blood pressure by the heart rate. Before cardiopulmonary stress testing, baseline measurements were taken while the subjects stood for 5 minutes. Then, the patients underwent cardiopulmonary stress testing wearing the VEST system. After peak exercise, the recording was continued until the heart rate returned to the baseline rate. The end points for terminating exercise testing included: typical angina, dyspnea, extreme fatigue, or exercise-induced ST-segment depression >2 mm.2 at rest, AT, and peak exercise were recorded, and the measured VO2 was divided by the body weight.The anaerobic threshold (AT) was autodetermined using the V-slope method and a personal computer (NEC PC-9801) . An analAll ultrasound studies were done in a temperature-controlled room (25°C) with the subject in a fasting, resting, and supine state at approximately 08:00. Heavy meals, including a high-fat diet and caffeine-containing beverages, were prohibited from the night before the study. Blood pressure and heart rate were recorded from the left arm every 3 minutes with an automatic sphygmomanometer  during the ultrasound procedure. A 7.5 MHz high-resolution ultrasound  was used to measure brachial artery diameter.πD2)/4; D indicates the luminal diameter of the brachial artery) derived from the brachial artery diameter using the formula: brachial blood flow (ml/min) = average peak velocity (cm/s)/2 × πD2 × 0.15. Reactive hyperemia was defined as the relative increase in the brachial blood flow calculated as the maximal flow measured immediately after cuff deflation divided by the flow obtained at rest (baseline). Finally, after a 15-minute interval, nitroglycerin-induced vasodilation (NTG-D) was performed. Baseline measurements of brachial artery diameter and flow velocity were again obtained, and 0.3 mg of sublingual nitroglycerin was then administered. Three minutes later, the brachial artery diameter was recorded. NTG-D was defined as the percent change relative to the baseline diameter. All images were recorded on super VHS videotape for later analysis. All ultrasound study and parameter measurements were performed by an investigator who was blinded to the other clinical information. A previous study in our laboratory showed that the intra- and interobserver variabilities (coefficient of variation) for repeated measures of diameter before and after reactive hyperemia in the brachial artery were <3% [FMD was then measured by a previously validated technique . Brachiawere <3% .With respect to the VEST recordings: The beat-to-beat data were taken over 30-second intervals, from which the end-diastolic volume, the end-systolic volume, the stroke volume, the left ventricular ejection fraction, the cardiac output, the left ventricular peak ejection ratio, and the left ventricular peak filling ratio were calculated. The background factor was corrected to obtain the best correlation with measurements taken with the gamma camera. The VEST system does not permit absolute measurements; end-diastolic volume data obtained at the beginning of the study were considered to be 100%, and subsequent measurements were expressed relative to this initial value. The SVR was calculated by dividing the mean blood pressure by the cardiac output obtained using the VEST measurements.In order to assess the VEST parameters, changes from the values at 2 minutes after standing on the treadmill system (rest) to those at the AT point were calculated for the left ventricular ejection fraction, the left ventricular peak ejection ratio, and the SVR using the following formulas: changes in the left ventricular ejection fraction from rest to AT (%) = (left ventricular ejection fraction at AT − left ventricular ejection fraction at rest); changes in the left ventricular peak ejection ratio from rest to AT (%) = ((left ventricular peak ejection ratio at AT − left ventricular peak ejection ratio at rest) / left ventricular peak ejection ratio at rest × 100); changes in the SVR were also calculated using the same formulas as those for the left ventricular peak ejection ratio.P value of less than 0.05 was considered statistically significant. All analyses were done on a personal computer with the statistical program Statview, Version 5.0 .Continuous variables are presented as the mean value ± standard deviation. Analysis of variance for repeated one-way ANOVA was applied to the data obtained at rest and during cardiopulmonary stress testing. When making multiple comparisons, significant probability values were defined and adjusted using the Bonferroni method. The relationships between variables were determined by doing simple linear regression analysis. A 2 showed similar changes to the heart rate (All patients exercised beyond AT (16.3 ± 3.3 mL/min/kg) until exhaustion without any ischemic ST-segment changes on electrocardiography. Heart rate and systolic blood pressure significantly increased from rest to AT or peak exercise. The double product and the body weight-corrected VOart rate .The sequential data obtained using the VEST system are shown in P < .05; blood flow, from 15 ± 13 mL/sec to 65 ± 21 mL/sec, P < .05). From these data, the calculated FMD was 2.5% ± 2.0%, which was below the normal range obtained in our laboratory [The FMD measurement results showed a significant increase of brachial artery diameter and calculated brachial artery blood flow . Thus, when patients on ACE-inhibitor treatment were excluded from the analysis, the FMD significantly correlated with both the left ventricular ejection fraction and the left ventricular peak ejection ratio change that occurred from rest to AT ; their use may confound the relationship between these various parameters , 15. Whest to AT . In addist to AT .The present study has demonstrated that: (1) peripheral endothelial function possibly contributes to left ventricular performance during exercise; (2) SVR during exercise can determine left ventricular performance in response to aerobic exercise; and (3) peripheral endothelial function may partly contribute to SVR during aerobic exercise in patients with heart disease.r value and the influence of ACE-inhibitors were considered, the definite role of peripheral endothelial function on left ventricular performance during exercise should be confirmed by duplicated larger cohort study of our observation.The correlation coefficient obtained in this study supports the possible presence of a significant relationship between peripheral endothelial function and left ventricular performance during aerobic exercise when patients on ACE-inhibitors were excluded. As well, a significant relationship between SVR and left ventricular performance was confirmed. In addition, peripheral endothelial function tended to correlate with the SVR obtained during aerobic exercise. Before reaching the anaerobic threshold, exercise is considered to be aerobic if no ischemia exists. In this study, no ischemic ECG changes were observed at the AT points in any of the patients studied. Thus, all of the patients were exercising aerobically when the contributions of peripheral endothelial function and SVR on left ventricular performance were observed. However, when the relatively low correlation coefficient By using a combination of the VEST system and blood pressure measurements , we coulThe findings in this study give a new insight into the exercise physiology of patients with heart disease. Cardiac performance is closely associated with dynamic SVR during exercise obtained using the new VEST system. Cardiopulmonary stress testing in combination with the VEST system can be more widely applied in clinical practice to help manage heart disease. Using this modality, we can evaluate the efficacy of a new medication or a new therapeutic option, such as biventricular pacing, in patients with heart failure. Furthermore, the mechanisms of action of new treatments can also be elucidated.β adrenergic responsiveness [2) in the failing heart [Peripheral endothelial function contributes not only to resting cardiac function but also to the dynamic cardiac function change that occurs during exercise. One could speculate that direct and indirect mechanisms are responsible for this phenomenon. However, the present study's findings cannot help clarify these mechanisms. While in one study nitric oxide aggravated cardiac function in patients with heart disease , other rsiveness , and nitng heart , 24. Theng heart . With reng heart . A preving heart . Exercisng heart –32. BracIn our study, brachial  endothelial function tended to correlate with the systemic vascular response that occurred during exercise. However, this tendency was only observed when patients on ACE-inhibitors were excluded from the analysis, as ACE-inhibitors have potent effects on endothelial function even after having been discontinued for 24 hours , 15. TheStudy limitations: this study has several limitations. First, the study population was not homogeneous; thus, different baseline characteristics might have confounded the main findings of the present study. This study should be duplicated with more homogeneous populations. Second, endothelial function during exercise could not be measured due to technical problems. If a new technology that measures endothelial function during exercise could be developed, the role of endothelial function in systemic vascular resistance and left ventricular function during exercise would be further elucidated. Third, since recently statisticians criticize investigators for utilizing the correlation analysis between the changes in two measured values  and recoDespite these limitations, we can conclude that peripheral endothelial function and vasomotion, including SVR, might play a significant role in determining cardiac performance during exercise in patients with heart disease. This information provides a new insight into the understanding of the exercise physiology of patients with heart disease.


Heart failure from adverse ventricular remodeling follows myocardial infarction, but the contribution of periinfarct and remote myocardium to the development of cardiomyopathy remains poorly defined. 2D strain echocardiography (2DSE) is a novel and sensitive tool to measure regional myocardial mechanics. The aim is to quantify radial strain in infarcted (I), periinfarct (PI) and remote (R) myocardial regions acutely and chronically following anterior infarction in rats.The left anterior coronary artery of male Sprague-Dawley rats (270–370 g) were occluded for 20–30 minutes and 2DSE was performed in the acute setting  and in the chronic setting . Using software, radial strain was measured in the mid-ventricle in short axis view. The ventricle was divided into 3 regions: I , PI –  and R – (inferior). Infarct size was measured using triphenyl tetrazolium chloride in the acute group.Following infarct, adverse remodeling occurred with progressive increase in left ventricular size, mass and reduced fractional shortening within 6 weeks. Radial strain decreased not only in the infarct but also in the periinfarct and remote regions acutely and chronically . Reduced radial strain in periinfarct and remote regions occurred despite minimal or absent necrosis .Following left anterior coronary occlusion, radial strain decreased at 60 minutes and up to 6 weeks in the periinfarct and remote regions, similar to the reduction in the infarct region. This demonstrates early and chronic myopathic process in periinfarct and remote regions following myocardial infarction that may be an under recognized but important contributor to adverse left ventricular remodeling and progression to ischemic cardiomyopathy. Left ventricular remodeling from myocardial infarction is a leading cause of heart failure and death in the United States -3. FolloThe trial design is an observational cohort study. Male Sprague-Dawley rats (270–370 g) were used, 10 for the acute and 14 for the chronic experiment  was used with 11 MHz M12L linear array transducer. The parasternal short axis view of the mid left ventricle was used for the study because of the easy reproducibility of this view in this species for serial studies owing to well-defined anatomic landmarks (prominent papillary muscles and the anterior and posterior insertion of the right ventricle). Image depth was 2–2.5 cm with 234–256 frames per second acquisition using second harmonic imaging. Electrocardiographic gating was used. The images were sent to a workstation with software  for analyses.The left ventricle was divided into 6 segments as defined by the American Society of Echocardiography . The met3-LVID3}]+0.6 +0.6 . Three cFollowing TTC injection, the heart was sectioned in 1 mm thick short axis slices similar in orientation as the echocardiography slices. The midventricular section with corresponding papillary muscle as landmark was chosen. The slice was divided radially into 6 equal segments with the orientation adjusted to correspond to the echocardiographic images using the papillary muscles and the insertion points (anterior and posterior) of the right ventricle to the left ventricle as markers. Pale areas (lack of TTC stain) corresponding to areas of infarct were measured using software .Data are expressed as means ± standard deviation. Continuous variables measured serially were compared using 2 way repeated measures analysis of variance followed by pairwise multiple comparison procedures (Holm-Sidak method) . Pearson's correlation was used to describe the relationship between radial strain in the infarcted and periinfarct/remote regions. A significant p value was set at 0.05.Following reperfusion, there was no significant change in left ventricular diastolic dimension but there was a trend towards increased end-systolic diameter Figure . As a reOcclusion of the left anterior coronary artery produced necrosis in the anteroseptal, anterior and to a lesser degree in the anterolateral region Figure . There wBased on the TTC findings, the left ventricle was divided into infarct, periinfarct and remote regions. In the acute group, there was significant reduction in radial strain 60 minutes following ischemic injury in all 3 regions Figure . The chaAs a measure of regional diastolic function, the early diastolic radial strain rate showed progressive reduction with time and was significantly reduced by 6 weeks in the infarct and the periinfarct region compared to baseline and the remote region  versus intrinsic myocardial dysfunction in the region (a true reduction). However, several lines of evidence suggest that a true reduction in radial strain is occurring. First, the significant reduction in radial strain in the contralateral remote region is difficult to explain by the passive effects of tethering. Second, progressive dilatation in all regions and not just in the infarcted region cannot be explained by passive effects from infarct region. Third, ischemic injury in the LAD territory that did not result in infarction (therefore there was absence of akinetic infarcted tissue to produce passive tethering) similarly caused reduction in strain in both radial and circumferential directions in the periinfarct and remote regions in a similar rat model of injury . An addiThe study demonstrates that abnormal radial strain signifying myocardial dysfunction occurs within 1 hour and persists up to 6 weeks in periinfarct and remote myocardial regions following occlusion of the left anterior coronary artery in rats. The degree of myocardial dysfunction in periinfarct and remote regions is closely related to the dysfunction in the infarct region. This is the first study that we know of that demonstrates abnormal function not only in the periinfarct borderzone but also in remote regions, both acutely and chronically. The persistent myocardial dysfunction in the periinfarct and remote regions together with the dysfunction in the infarct region were associated with progression of left ventricular enlargement and adverse remodeling. The mechanism underlying this observation may be important in attenuating adverse remodeling following myocardial infarction and preventing heart failure.The authors declare that they have no competing interests.RQM, XZ, MZ conceptualized the study, carried out the studies, analyzed the data and participated in manuscript preparation. MM, TB and MB participated in data analysis and participated in manuscript preparation. All authors read and approved the final manuscript.


The time course of regional functional recovery following revascularization with regards to the presence or absence of infarction is poorly known. We studied the effect of the presence of chronic non-transmural infarction on the time course of recovery of myocardial perfusion and function after elective revascularization.Eighteen patients  prospectively underwent cine magnetic resonance imaging (MRI), delayed contrast enhanced MRI and rest/stress 99m-Tc-tetrofosmin single photon emission computed tomography (SPECT) before, one and six months after elective coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).Dysfunctional myocardial segments  were classified according to the presence (n = 164) or absence (n = 173) of infarction. Infarct transmurality in dysfunctional segments was largely non-transmural . Quantitative stress perfusion and wall thickening increased at one month in dysfunctional segments without infarction (p < 0.001), with no further improvement at six months. Despite improvements in stress perfusion at one month (p < 0.001), non-transmural infarction displayed a slower and lesser improvement in wall thickening at one (p < 0.05) and six months (p < 0.001).Dysfunctional segments without infarction represent repetitively stunned or hibernating myocardium, and these segments improved both perfusion and function within one month after revascularization with no improvement thereafter. Although dysfunctional segments with non-transmural infarction improved in perfusion at one month, functional recovery was mostly seen between one and six months, possibly reflecting a more severe ischemic burden. These findings may be of value in the clinical assessment of regional functional recovery in the time period after revascularization. Revascularization of dysfunctional but viable myocardium in patients with chronic ischemic heart disease (CIHD) may offer both functional improvement of myocardium and prognostic benefit . The pat99mTc-tetrofosmin single photon emission computed tomography (SPECT) over a six month period after revascularization.Delayed contrast enhanced magnetic resonance imaging (DE-MRI) has shown to be valuable for predicting regional functional improvement after revascularization . FurtherThe study was approved by the ethics committee on human research at Lund University Hospital. All patients provided written informed consent. Patients were prospectively enrolled between December, 2001 and May, 2005. The inclusion criterion was clinical selection for first time elective revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Following revascularization, changes in medication were determined by the caring physician. Patients were imaged with cardiac MRI and rest/stress SPECT prior to revascularization and one and six months after revascularization. A schematic diagram of the timeline of the study is presented in Figure ®, gadopentetate dimeglumine, Gd-DTPA, Schering Nordiska AB, Järfälla, Sweden). This approach has been shown to enhance non-viable myocardium [Left ventricular function and viability were imaged in the short-axis plane during breath hold using a 1.5T system . Global and regional function was imaged using an ECG-triggered cine gradient echo sequence  or a retrospectively vector-ECG-triggered cine steady-state free precession sequence . Infarct imaging was undertaken using a segmented inversion recovery turbo fast low-angle shot sequence  in eitheocardium  due to aocardium .99mTc-tetrofosmin . The same dose was used for rest and stress. For stress imaging, 5 mg/ml adenosin  was infused at a rate of 140 μg/kg/min for 3 minutes before tracer injection, and continued for 2 minutes following injection. For those instances where a subject mistakenly had consumed caffeine in the 24 hours prior to stress imaging, exercise stress was performed using a bicycle ergometer with a minimum required increase of 85% of the maximum predicted heart rate. For both rest and stress imaging, the subject was imaged in the supine position with a dual head camera  using standard methods [Rest and stress SPECT imaging were performed on separate days, 30 minutes after intravenous injection of a body weight adjusted dose (500-700 MBq) of  methods .http://segment.heiberg.se [All studies were quantitatively analyzed using a 48-segment model with 4 midventricular short-axis slices and 12 segments per slice. All images were analyzed using software developed in-house, including the freely available software Segment version 1.661 berg.se , as descberg.se . In summberg.se . For MR th and 75th quartile of the data. All other data are presented as mean ± SD unless stated otherwise. Variations between data were tested by paired t-test and independent t-test as appropriate. P < 0.05 was considered statistically significant. Power analysis was calculated retrospectively to determine the difference in wall thickening which one could detect with a power of 0.90 using p < 0.05 (two-tailed), a measurement variability (SD) of 1 mm, and given the number of myocardial segments involved in the comparison.Time course data are presented as mean ± SEM. The number of days between imaging and revascularization are presented as median and interquartile range (IQR), defined as the range between the 25Patient characteristics including times of imaging in relation to revascularization and baseline medications are described in Table DE-MRI was possible in all patients resulting in 864 segments for analysis. Myocardial segments that were dysfunctional before revascularization n = 337, 39%) were classified according to the presence (n = 164) or absence (n = 173) of infarction. Figure 37, 39% wRetrospective power analysis showed that given a comparison of 164 myocardial segments, there was a power of 0.90 for detecting a change in wall thickening of 0.25 mm. Figure Figure Figure Figure To our knowledge, this is the first study to have serially and quantitatively examined the time course after revascularization of regional recovery of perfusion and function according to presence of infarction by DE-MRI. The major findings can be summarized as follows. Dysfunctional segments without infarction gained the greatest improvement in both perfusion and function within one month after revascularization. In contrast, segments with infarction, which was predominantly <50% transmural, showed a slower functional recovery which was obvious first at six months, despite improvements in perfusion already at one month.18F-2-deoxyglucose (FDG) uptake using SPECT [Several studies have examined functional recovery at single time points following revascularization based on the extent of infarction assessed by DE-MRI ,19,20. Sng SPECT . HoweverLate improvements in function assessed visually by echocardiography have been associated with pre-operative histological and scintigraphic measures of ischemic burden, defined as a prolonged duration, greater extent or greater severity of ischemia -9. Such Surprisingly, segments without baseline dysfunction showed a reduction in wall thickening at one month regardless of presence of infarction. The reason for this pattern of remodelling is not known. Although we found changes in regional function in different regions within the left ventricle, we found no change in net global function (ejection fraction) following revascularization in our population. Similar to our findings, stent revascularization of chronic total coronary occlusion has been shown to increase wall thickening in dysfunctional segments, but decrease wall thickening in remote segments, with no net change in ejection fraction . Also, vThe current study agrees with previous findings that scintigraphically assessed regional perfusion at rest improves soon after surgical and percutaneous revascularization .et al [The current study also agrees with previous findings showing an improvement in scintigraphically assessed stress perfusion at single examinations after revascularization. This has been shown soon after percutaneous revascularization  and bothet al , showed The difference between rest and stress perfusion may represent stress induced ischemia. Previous studies have examined the extent of reversible perfusion defects that exceed a certain severity cut-off value . To our When comparing the distribution of infarct transmurality in relation to baseline dysfunction, the current study showed, as expected, that there was a greater prevalence of infarction among segments with baseline dysfunction. The distribution of infarction in the population was largely non-transmural. However, it is noteworthy that there existed segments without baseline dysfunction which had as much as 100% infarct transmurality. This may seem counterintuitive. However, this represents very few myocardial segments (n = 2), and can be explained by tethering to adjacent segments. For example, it has been shown that myocardial segmental function is influenced moreso by the function of neighbouring segments than by infarct transmurality as such .The number of patients is limited, however, power analysis showed that the study was adequately powered to assess differences in regional function. The number of segments with different degrees of transmurality did not permit an adequate separate analysis for infarction of different transmuralities. Although care was taken to achieve maximal alignment of slices between modalities and time points, misalignment due to fundamental differences in the imaging modalities is also a potential limitation.This study has demonstrated that dysfunctional segments without infarction, also known as hibernating or repetitively stunned myocardium, improved in both perfusion and function within one month after revascularization. Although segments with predominantly non-transmural infarction improved in rest and stress perfusion at one month, functional recovery was slower and clearly seen first at six months. Despite lack of change in ejection fraction, remote myocardium showed a decreased wall thickening suggesting relief of compensatory contractile work. This may be of value in the clinical assessment of regional function and suggests that evaluation of the coronary revascularization procedure with regards to regional function should be performed first 6 months or later after the intervention in patients with previous infarction. Further studies are warranted to elucidate the pathophysiological mechanism behind these findings.18F-2-deoxyglucose; Gd-DTPA: gadolinium diethylene triamine pentaacetic acid; IQR: interquartile range; MRI: magnetic resonance imaging; PCI: percutaneous coronary intervention; SPECT: single photon emission computed tomography; Tc: technetium.CABG: coronary artery bypass surgery; CIHD: chronic ischemic heart; DE: delayed enhancement; ECG: electrocardiogram; FDG: The authors declare that they have no competing interests.MU participated in design, performed data acquisition and image analysis, data analysis and wrote the manuscript. PC participated in design, data analysis, and writing the manuscript. JP and PJ participated in design and revised the manuscript for important intellectual content. HA conceived of the study, designed the study and participated in data analysis and writing the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/10/4/prepub


Transthoracic echocardiography left ventricular wall thickness is often increased in master athletes and it results by intense physical training. Left Ventricular Hypertrophy can also be due to a constant pressure overload. Conventional Pulsed Wave (PW) Doppler analysis of diastolic function sometimes fails to distinguish physiological from pathological LVH.The aim of this study is to evaluate the role of Pulsed Wave Tissue Doppler Imaging in differentiating pathological from physiological LVH in the middle-aged population.we selected a group of 80 master athletes, a group of 80 sedentary subjects with essential hypertension and an apparent normal diastolic function at standard PW Doppler analysis. The two groups were comparable for increased left ventricular wall thickness and mass index . Diastolic function indexes using the PW technique were in the normal range for both.Pulsed Wave TDI study of diastolic function immediately distinguished the two groups. While in master athletes the diastolic TDI-derived parameters remained within normal range , in the hypertensive group these parameters were found to be constantly altered, with mean values and variation ranges always outside normal validated limits , and with E' and E/E' statistically different in the two groups (p < .001).Our study showed that the TDI technique can be an easy and validated method to assess diastolic function in differentiating normal from pseudonormal diastolic patterns and it can distinguish physiological from pathological LVH emphasizing the eligibility certification required by legal medical legislation as in Italy. Left ventricular wall thickness and mass at transthoracic echocardiography are often increased in master athletes, a growing population of trained subjects observed in Sports Medicine. These modifications induced by intense physical training (athlete's heart) result from cardiac remodelling which is characterized by normal left ventricular performance and normal or increased capillary density with little or no fibrosis ,2. IncreTwo-dimensional echocardiography and conventional Pulsed Wave (PW) Doppler analysis of the diastolic function sometimes fails to distinguish the two aspects of left ventricular mass increase.Pulse Wave-Tissue Doppler Imaging (PW-TDI) is a relatively new echocardiographic technique for analysing myocardial tissue movement -7. PreviAim of this study is to evaluate the role of Pulsed Wave Tissue Doppler Imaging (PW-TDI) in differentiating normal from pathological diastolic patterns in the middle-aged population (athletes and hypertensives) with a mild-moderate LVM increase .2 for mild, 132 - 148 g/m2 for moderate and ≥149 g/m2 for severe hypertrophy [From January 2004 to May 2006, 2573 master athletes (aged more than 40 years) and 1010 hypertensive patients were consecutively observed at our Non-invasive Cardiac Laboratory - Medicine Centre Sport, University of Florence. Among the master athletes we selected 80 regularly trained subjects (Group A), mean age 50 years, all practising agonistic competitive sports (cycling and running). They were matched for age, sex and body mass index with 80 sedentary hypertensive subjects (Group B) under pharmacological treatment and with a good control of the blood pressure daily profile. Inclusion criteria for both groups were mild-moderate LVM increase and an "apparent "normal diastolic pattern at echocardiographic evaluation. The reference limits defined in ASE guidelines for LVM are lower than those published in some previous echocardiographic studies and are virtually identical to those based on direct necropsy. Therefore, abnormal LVM increases were defined in mild, moderate and severe. Reference limits in men are 116 - 131 g/mertrophy  that defHypertensive subjects with an evident pathological diastolic pattern , as impaFor both groups other exclusion criteria were the presence of ischemic heart disease, major brady or tachy-arythmias, regional and/or global systolic ventricular dysfunction, pulmonary hypertension, pericardial and/or significant valvular heart disease and other major cardiovascular disease. In the athletes group, the presence of hypertension in medical history or check-in clinic, was considered an exclusion criteria. The study was approved by the Local Ethics Committee and all subjects enrolled gave their informed written consent.Echocardiographic studies were performed by four experienced ultrasonographer cardiologists using GE Vivid 7 equipped with 2.5 MHz and 3.3 MHz transducers. The following measurements were obtained in parasternal long-axis view, according to American Society of Echocardiography recommendations : left veDiastolic function was previously evaluated with traditional ultrasound PW Doppler of transmitral flow applied in a four-chamber apical view Fig.  and 2. IThere is a grading system for diastolic dysfunction based on the progression of disease patterns according a scale of I to IV grades. In the early stage of dysfunction, impaired relaxation of the left ventricle predominates. In "abnormal relaxation pattern" there is a low E velocity, prolongation of the deceleration time and increased A velocity (grade I). With disease progression, there is a "pseudonormal pattern" consist in a further increase of the E velocity and a shortening of deceleration time (grade II). In more advanced disease can occur a "restriction to filling pattern" characterized by increase of E velocity and shortening of DT .Pulsed wave TDI was performed by activating TDI function in the same machine Fig.  and 4. AFrom the combination of traditional and TDI PW indexes, we then obtained another parameter (E/E' ratio), which was found in previous studies to be directly correlated with impaired diastolic function -23.Data were analysed by SPSS 13 and presented as means ± standard deviation and submitted to statistical analysis with Student's two-tailed unpaired test (p < .01).There wasn't any significant difference in general data between two groups Table .Both groups showed a mild-moderate increase in LVM index (LVMI) without significant differences between the two groups (LVMI 134.4 ± 19.7 in athletes vs. 134.5 ± 22.1 in hypertensive subjects). Left Atrium (LA) and posterior wall were higher in hypertensive subjects. RWT in hypertensive ones was significantly higher than athletes and it was compatible with concentric hypertrophy. In both, left ventricular systolic function was normal ; E/E'  was significantly different too.LV dimensions, volumes and wall thicknesses are echocardiographic measurements widely used in clinical practice and research. Methods for quantification of LV size and mass using 2-dimensional imaging have been validated and cross-checked 	with 3-dimensional data. Calculation of Relative Wall Thickness (RWT) permits categorization of an increase in LV mass as either concentric (RWT ≥ 0.42) or eccentric (RWT ≤ 0.42) hypertrophy and allows identification of concentric remodelling . In according to wall thickness values we can distinguish, in agreement with ASE recommendations, three groups in men: 11-13 mm indicates a mild LVH, 14-16 mm correspond to a moderate LVH and > 17 mm are values indicative of a severe LVH.In this study we analysed two different groups of subjects (master athletes and hypertensive subjects) who were both characterized by a mild-moderate LVM and left ventricular wall increase and an apparently normal diastolic pattern at traditional PW Doppler analysis. The Valsalva maneuver reduces preload and can unmask a diastolic disfunction in subjects with an apparent normal diastolic pattern. In our study we didn't evaluate transmitral flow during a Valsalva maneuver in order to differentiate a normal from a pseudonormal pattern because of this method is mainly limited by induction of reflex tachycardia, which could result in a partial fusion of the E and A waves .PW-TDI technique instead, in combination with the traditional PW Doppler analysis, was found to be useful in distinguishing physiological from pathological remodelling. In our study in fact all the 80 hypertensive subjects showed an apparent normal diastolic function by traditional PW Doppler but values out of the normal range by PW-TDI technique. This means that their diastolic pattern, analysed with PW Doppler, was a "pseudonormal pattern". The prevalence of "pseudonormal diastolic pattern" in general hypertensive population was about 7,9%. All hypertensive subjects of our study had this particular diastolic pattern but this is not surprising because we enrolled only hypertensive subjects with increased wall thickening and apparent normal diastolic function excluding those with an impaired relaxation by PW Doppler. Our findings confirmed the intrinsic limits of PW-Doppler-derived parameters to study diastolic function. TDI was useful to distinguish between normal and pseudonormal diastolic pattern.E/E' ratio is an important parameter derived from a combination of traditional PW Doppler and PW-TDI. It's directly correlated with diastolic abnormality, in agreement with previous studies -27,1.Sometimes evaluating diastolic function only by PW-Doppler could be not so easy. Patterns of transmitral diastolic flow change mainly with the age and it also depends on the variation of pre- or after-load conditions. In certain subset of patients , the diastolic function is more difficult to interpret. Sinus tachycardia and first-degree AV block can result in partial or complete fusion of E and A waves and DT may not be measurable. In atrial fibrillation the Doppler estimation is limited by the variability in cycle length and the absence of organized atrial activity.Among different diastolic dysfunction patterns, the pseudonormal one is the hardest to interpret. The development of a new echocardiographic technique like PW Doppler TDI appears to be very important, helping us better understand and evaluate diastolic ventricular function.LVM increase and LVH induced by a pathological state, such as hypertension, are associated to diastolic dysfunction that can occur even in early stages and are correlated with an increase in cardiovascular risk and mortality -30.The evaluation of diastolic left ventricular function must be particularly accurate in middle-aged people, who are an ever-growing population involved in competitive sports. They had some systemic hypertension which, although in asymptomatic subjects, may lead to a diastolic dysfunction and an increase in mortality as compared to asymptomatic subjects with normal diastolic function ,27,32.The PW-TDI analysis is a more simple, inexpensive and immediate method to assess hypertrophic hearts than others methods like magnetic resonance. Therefore, it may become a useful instrument in distinguishing the physiological from the pathological LVH and increase of LVM, particularly when sport eligibility certification is required by legal medical legislation, as in Italy.In our study we selected a particular subset of a middle-aged population; characterized by mild left ventricular increase mass and apparent normal diastolic pattern at conventional Doppler. The number of studied subjects was limited and the data should be confirmed on a large scale. Would be interesting in the future to compare our data with others methodologies (in e. DE-CMR), to confirm the hypothesis of the study.The authors declare that they have no competing interests.GG: concived of the studyLT: concived of the study, provided research, contributed to writing the articleFDF: provided research, provided statistical analysis, contributed to writing the articleLS: provided researchBC: provided researchADL: provided research, contributed to translate and formatting articleMCRV: provided research.All authors read and approved the final manuscript.


To assess left ventricular (LV) strain and displacement and their relations to LV geometry in patients with aortic stenosis (AS).2.7 ≥46.7/49.2 g/m2.7 in women/men and concentric LV geometry if relative wall thickness ≥0.43. LV geometry was assessed from LV mass/height2.7 and relative wall thickness in combination.Cross-sectional echocardiographic study in patients with AS. Peak circumferential, radial and longitudinal strain, and radial, longitudinal and transverse displacement were measured by 2D speckle tracking. Severity of AS was assessed from energy loss index (ELI). LV hypertrophy was present if LV mass/heightDepartment of Heart Disease, Haukeland University Hospital, Bergen, Norway.70 patients with AS .None.Association of regional and average LV myocardial strain and displacement with LV geometric pattern and degree of AS.2=0.72). When relative wall thickness was replaced with LV mass, lower longitudinal strain was also associated with higher LV mass  (R2=0.73).Average longitudinal strain was lower in the hypertrophy groups and correlated with higher LV mass index and relative wall thickness, lower stress-corrected mid-wall shortening and smaller ELI . Average strain and displacement in other directions did not differ between geometric groups. In multivariate regression analysis, lower average longitudinal strain was associated with higher relative wall thickness (β=0.15), lower ejection fraction (β=−0.16), systolic blood pressure (β=−0.16) and energy loss index (β=−0.20)  (RIn patients with AS, lower average longitudinal strain is related to higher LV mass, concentric geometry and more severe AS. In patients with aortic stenosis (AS), it has been demonstrated that increased left ventricular (LV) load induces changes in LV geometry in order to allow preservation of a normal ejection fraction in spite of reduced long-axis excursion by M-mode echocardiography,Strain and displacement can be derived from LV deformation analysis offering direct measurement of myocardial deformation  and thus enabling assessment of regional or global myocardial function.13The aim of this study was to assess the impact of LV geometry on LV strain and displacement in patients with degenerative AS.This study was prospectively planned for all patients with degenerative AS who had conventional and 2D speckle tracking echocardiography undertaken at the echocardiography laboratory, Haukeland University Hospital, Bergen, Norway as part of prospective clinical trial protocols in the time period April 2006–October 2007. A total of 70 patients were identified, and all agreed to participate in this study. Forty patients had asymptomatic AS and came for scheduled study echocardiograms in the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) study at the Haukeland University Hospital study centre.Concomitant hypertension was defined as a history of hypertension reported by the attending doctor. Blood pressure was measured at the end of the echocardiographic examination by an arm-cuff sphygmomanometer.All patients gave written informed consent to participate in the study, which was approved by the regional ethics committees.All examinations were performed using a Vivid 7 echocardiograph  equipped with a phased-array transducer following the previously published standard SEAS echocardiographic protocol.152.7. LV hypertrophy was considered present if LV mass/height2.7 ≥46.7 g/m2.7 in women and ≥49.2 g/m2.7 in men, respectively. Relative wall thickness was calculated from posterior LV wall thickness/LV internal radius ratio at end-diastole and considered increased if ≥0.43.18LV dimensions were measured in parasternal long-axis view according to the American Society of Echocardiography guidelines.LV endocardial systolic function was assessed by biplane Simpson's ejection fraction202/m2.22Doppler assessment of AS included measurement of peak and mean transvalvular velocities and gradients; aortic valve area by the continuity equation, indexed for body surface area; and pressure recovery adjusted aortic valve area ) calculated by a previously validated formula.Recordings of five consecutive heart cycles were used to analyse regional deformation on grey-scale images2 test was used to compare categorical variables and full-factorial two-way analysis of variance with Sidak's post hoc test to compare continuous variables, as appropriate. Univariate correlates of strain and displacement were identified by Pearson's correlation for normally distributed data. Predictors of higher peak strain were assessed in multiple linear regression analyses using an enter procedure with collinearity diagnostics. Results are presented as multiple R2 for the model and β coefficients for significant covariates. Two-tailed p<0.05 was considered significant both in univariate and multivariate analyses.Data management and analysis were performed using SPSS 15.0 software. Data are presented as mean±SD for continuous variables and as percentages for categorical variables. The λThe study population included 54% women, 46% hypertensive and 50% overweight patients . Clinica2/m2). Comparing the LV geometric groups, there were significantly more patients with severe AS in the concentric LV hypertrophy group  had severe AS . LV ejection fraction was low in one patient with eccentric LV hypertrophy who had an ejection fraction of 49% .From a total of 840 analysed segments, 12 parasternal segments and six apical segments were excluded owing to suboptimal myocardial tracking and poor image quality.Average LS and TD differed significantly between the LV geometric groups. Average LS was lower in the hypertrophy groups, in particular in patients with concentric LV hypertrophy , while aIn univariate analyses, lower average LS was associated with higher LV mass index (r=0.40) and relative wall thickness (r=0.33) (both p<0.01), and with smaller scMWS  and ELI  . In a subsequent model, replacing relative wall thickness with LV mass, lower longitudinal strain was also associated with higher LV mass  . Further, replacing average LD with scMWS among the covariates, lower scMWS remained the only significant covariate of lower average LS  . Age, presence of angiographic coronary artery disease, concomitant hypertension or mitral regurgitation were not significant covariates when added to these models.In multiple regression analysis, lower average LS was associated with higher relative wall thickness, lower LV ejection fraction, systolic blood pressure and ELI, independent of gender, diastolic blood pressure or average LD (multiple Rp<0.001) . When thIn the total study population, LS increased while LD decreased from base to apex both in the septum and in the lateral wall . These results need further confirmation in future studies to determine if they are related to the AS itself or to other factors like LV structure or the position of the heart.In conclusion, in patients with AS, changes in LV geometry, including increased LV mass and higher relative wall thickness, are associated with reduced LV regional and global myocardial deformation assessed by 2D speckle tracking, in particular in the longitudinal direction. Longitudinal peak myocardial strain is also progressively reduced with increasing severity of AS. LS is furthermore significantly related to previously validated and prognostically important measures of myocardial systolic function, such as scMWS. Our findings suggest that 2D speckle tracking may be used in clinical assessment of LV function in patients with AS to detect subclinical LV myocardial dysfunction which cannot be diagnosed by conventional echocardiographic measures of systolic function like LV ejection fraction. However, the prognostic implications of our findings remain to be assessed in future longitudinal studies.The definition of LV geometry was based on conventional parasternal measures of LV dimensions and wall thicknesses assuming the site of measurements to be representative for the whole ventricle. In spite of its limitations, this method is in accordance with current LV quantification guidelines, and has proven prognostic value in hypertensive patients.24Myocardial strain and displacement are load-dependent measures of LV function. However, all patients included in the present analyses were asymptomatic and in stable haemodynamic condition at rest. 2D speckle tracking is dependent on image quality and high frame rate which were both high in the present study population as only 2% of the LV segments had to be excluded from analysis, and the average frame rate was >80 frames/s.9The thirty symptomatic AS patients recruited at the screening visit of the Mosaic Ultra versus Perimount Magna study underwent additional coronary angiography. However, the 40 patients recruited from the local SEAS study did not undergo coronary angiography or stress echocardiography as part of the protocol. We can therefore not exclude that some patients in this latter group had subclinical coronary artery disease. However, they did not present symptoms of obstructive coronary disease.Antihypertensive treatment was not standardised in the study, but left to the discretion of the cardiac surgeons and general practitioners managing the individual patients. Thus, impact of antihypertensive treatment on deformation parameters could not be assessed in this study.The present cross-sectional study could not evaluate whether LV ejection fraction, scMWS or longitudinal strain is the better marker of subclinical myocardial dysfunction. This important clinical question needs to be addressed in future prospective studies.


A 35 year-old asymptomatic Caucasian female with a family history of hypertrophic cardiomyopathy (HCM) was referred for cardiologic evaluation. The electrocardiogram and transthoracic echocardiogram were normal. Cardiovascular magnetic resonance (CMR) was performed for further assessment of myocardial function and presence of myocardial scar. CMR showed normal left ventricular systolic size, measurements and function. However, there was extensive, diffuse late gadolinium enhancement (LGE) throughout the left ventricle. This finding was consistent with extensive myocardial scarring and was highly suggestive of advanced, non-ischemic cardiomyopathy. Genotyping showed a heterozygous mis-sense mutation (275G>A) in the cardiac troponin T (TNNT2) gene, which is causally associated with HCM. There have been no previous reports of such extensive, atypical pattern of myocardial scarring despite an otherwise structurally and functionally normal left ventricle in an asymptomatic individual with HCM. This finding has important implications for phenotype screening in HCM. There was extensive, diffuse, poorly demarcated LGE throughout the LV ventricle, predominantly involving the basal lateral, basal anteroseptal and mid-inferior walls , including sudden cardiac death of unknown cause in one son and HCM in two other children, was referred for cardiologic consultation. The electrocardiogram and transthoracic echocardiogram had revealed no abnormalities. Cardiovascular magnetic resonance (CMR) was performed for further assessment of myocardial function and detection of myocardial scar. Two-, three- and four-chamber CMR cines were obtained using steady-state free precession and inversion-recovery imaging was used to assess late gadolinium enhancement (LGE). CMR showed normal left ventricular (LV) systolic function , but more advanced forms include dense replacement scars throughout the ventricle . MyocardWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.BS wrote drafted the manuscript. VA interpreted the cardiovascular magnetic resonance images and was responsible for the idea for the manuscript, performed sequence alignment of the manuscript and, helped write and rewrote the manuscript. RS was the pediatrician for the patient's children and subsequently conducted genetic testing on them. CG conducted genetic counseling and testing on the patient, and interpreted the significance of those results. DS and RM prescribed, performed and interpreted the various sequences during cardiovascular magnetic resonance imaging of the patient. AM was the patient's cardiologist and had been responsible for the patient's care, referral for further testing, manuscript revision and for echocardiographic assessments. All authors read and approved the final manuscript.


Despite ample evidence that right ventricular function is a critical determinant of the clinical response to a spectrum of cardiovascular diseases, there has been only a limited analysis of the unique and distinguishing physiologic properties of the RV under normal circumstances and in response to pathologic insults. This review highlights some of these features and underscores the fact that rational therapy in RV failure should acknowledge this physiology and ought to be chamber specific. Early cardiovascular investigators also recognized that the RV was structurally, geometrically and mechanically distinct from the LV, and that its response to disease states was likewise quite different. Despite this, comparatively little attention has been paid to the basic physiology and biology of the RV  and the general assumption has been that the laws that define cardiac mechanics, and therapies that improve cardiac performance are equally applicable to the RV and the LV. This is only partly true. Ever since the 17Given the increasingly nuanced appreciation of the cell biology of cardiac  adaptation as well as increasingly sophisticated biophysical and imaging tools, it seems as if a reexamination of the structure and function of the RV is now in order , 2. IndeI.Anatomically the two most striking features of the right ventricle (relative to the left) is its complex shape which defies easy geometric approximation – it appears triangular when viewed from the side and crescentric when viewed in cross-section with a relatively thin free wall . The mus1 .2 requirement compared to the LV both at rest and during exercise. Consistent with the lesser work of the RV, the resting RV coronary blood flow is lower than left coronary flow. Additionally, at rest, the RV extracts only ~50% of the O2 supplied by the coronary flow whereas the LV extracts ~75%. The lower coronary flow in the RV coupled with reduced O2 extraction provides both a flow reserve and a large O2 extraction reserve for the RV. In the LV, increases in O2 demand are primarily met by increased coronary flow [2 demands either through increases in coronary flow or by increased O2 extraction [2 demand are met primarily by increases in O2 extraction whereas increases in O2 demand induced by acute pulmonary hypertension are met primarily by increased coronary flow [Energetically, the lower systolic pressure in the RV, and hence, the lower wall stress leads to lower Oary flow , 13. Howtraction , 13. Intary flow .et al. [Two other related factors that impact global RV dysfunction are worth comment: loss of atrial systole and loss of synchronicity. The former has been appreciated for many years and in fact maintenance of sinus rhythm is felt to be a key therapeutic maneuver in right ventricular infarction , 16. A net al.  who demoet al. . WhetherThe regulation of RV contractility, like that of the LV, is a function of heart rate, Frank-Starling mechanisms and autonomic input. As mentioned above, within the limits of normal filling pressures, heart rate and pre-load influences on RV function are not distinct from those of the LV, although once these limits are exceeded, factors such as pericardial constraint may play a role. In so far as autonomic input is concerned, there is a differential effect on function of the inflow and outflow regions and overall adrenergic and cholinergic receptor density is generally felt to be slightly higher in the RV than in the LV . Vagal iOn the cellular level, few distinctions between right ventricular cardiomyocytes and left ventricular cardiomyocytes have been described. However, there have been a number of reports showing that force generation of RV papillary muscle per unit mass is less than that of LV papillary muscle, although the shortening velocity of isolated RV muscle is greater than that of the LV , 24. AddIt is possible that the difference in contractile velocities between the RV and the LV is, in part, due to differences in myosin heavy chain isozyme expression as it has been demonstrated that there is significantly more of the α-myosin heavy chain (V1) isozyme (which is associated with a higher ATPase activity) in the RV compared to LV in both rats  and in rII.When clinicians and cardiovascular researchers refer to “heart failure” they are invariably describing a symptom complex that is linked to impaired left ventricular performance. This has been subcategorized as “ischemic” versus “dilated” and “systolic” versus “diastolic” and rarely is the function of the right ventricle commented on, except as it reflects collateral damage from left ventricular processes. This overall calculus is not completely inappropriate and in fact does reflect the incidence and prevalence of disease in western society. However it does not do justice to the facts that right ventricular dysfunction (in any setting) has profound prognostic significance and that the right ventricle evidences different biologic responses to complex pathologic loads than the LV so that therapy that is appropriate for LV dysfunction is not necessarily ideal for RV dysfunction. et al. [vs. 71% with a normal RV, irrespective of LV EFx). This same finding was confirmed more recently by several other groups [The observation that right ventricular dysfunction is a strong and independent predictor of survival in the context of LV failure dates back to the early 1980s when Polak et al.  showed tr groups , 29 and r groups -32. Evenr groups . While t2, below, which provides a list of pathophysiologic categories rather than a comprehensive list of disease entities.It is not our intention to comprehensively review the causes and mechanisms of right heart failure but rather to highlight some unifying principles that define the pathophysiology of RV HF. However, it is worth outlining the spectrum of diseases that impact on right ventricular function in order to provide a framework for a more mechanistic overview. This is detailed in table The right ventricular response to a pathologic load is complex and reflects the nature, severity and chronicity of the insult. In addition, the timing of the insult  is important and insults that are initiated early in life  tend to be better tolerated than those imposed during adulthood. This is an interesting phenomenon and likely reflects the fact that the normal RV is relatively hypertrophic during fetal and neonatal life  and RV hypertrophy normally regresses during infancy as it accommodates to a lower resistance pulmonary circulation , 35. WheAs mentioned above, the RV is generally felt to tolerate volume overload better than the LV. Mechanically this probably reflects improved muscle compliance and clinically is evidenced by the fact that RV systolic function remains well preserved even in the face of long-standing volume overload secondary to an atrial septal defect (ASD) or tricuspid regurgitation . What evet al. [In contrast, the adult RV appears to tolerate acute increases in afterload poorly. This was very nicely demonstrated by MacNee et al.   failure. However, not only is there still much controversy over the mechanism of the functional change in the failing myocyte, the nature of the functional change is still unclear. There are reports that in skinned fiber preparations from spontaneously hypertensive heart failure prone (SHHF) rats, the myofilament function  of RV trabeculae is reduced , increasIt is well accepted that in cardiac myocytes, calcium regulates contraction by binding to the thin filament regulatory protein troponin C which in turn causes a conformational shift in the other troponin subunits, troponin I and T, allowing myosin binding to actin, and in general, the velocity and strength of contraction are regulated by either changes in available calcium or by the calcium sensitivity of the contractile apparatus. There are undoubtedly differences in calcium handling in failing myocytes and as demonstrated by the changes in myofilament function in skinned preparations, and there are likely changes in the calcium sensitivity of the myofilaments. In samples from the hypertrophic RV, correlations between expression levels  of numerous proteins and the degree of hypertrophy have recently been described . The majWhile the most common cause of RV failure is LV failure, it is probably more instructive to dissect the RV response and therapeutic options available to treat RV decompensation in the setting of pulmonary hypertension. Of course many of the same principles hold for the treatment of combined RV and LV failure but the focus (appropriately) in this circumstance is on the LV. In pulmonary hypertension, the RV is primarily and predominantly affected so the physiology and therapy is more chamber specific. While the classification of pulmonary hypertension is extensive and the pathogenesis is complex, none the less the unifying feature of the disease complex is that the RV is exposed to a progressive pressure load. While the initial adaptive response is myocardial hypertrophy (much like the LV when exposed to a pressure load), this is generally not adequate to normalize wall stress and progressive contractile dysfunction and chamber dilation occurs . This isTreatment of right ventricular dysfunction in this setting is largely empirical  although an appreciation of right ventricular physiology would seem to support certain fundamental principles. First, since the primary insult is a pressure load with an associated increase in wall stress, a stimulus which is very poorly tolerated by the RV, afterload reduction is a primary therapy. A spectrum of vasodilators have been employed and it is quite clear that acute responsiveness to pulmonary vasodilators (regardless of class) has prognostic significance , 55. Of et al. [et al. [Therapies which are of obvious benefit in LV failure, such as beta-blockade and angiotensin converting enzyme inhibition have not demonstrated clinically significant benefit in RV failure and studies in animal models have suggested both a biologic basis for this as well as possible distinct targetable pathways. For example, Rouleau et al.  have shoet al. . In someet al. , 63. Fan [et al. . It is a [et al. . Given this, it is clear that the failing RV presents a qualitatively different substrate than the failing LV and pharmacotherapy should be tailored accordingly.Maintenance of atrial systole and AV synchrony as well as synchronous RV contraction are also clearly important for the reasons articulated above and it is certainly true that progressive RV dilation secondary to a superimposed pressure load is commonly associated both with atrial arrhythmias and with the development of bundle branch block. In a large series of patients with surgically corrected congenital heart disease with RV involvement, such as Tetralogy of Fallot, Epsteins’s anomaly or those following a Fontan procedure, the incidence of atrial arrhythmia is ~50%  and in pIn summary, two themes emerge: the first is that the right ventricle, by virtue of its geometry and its cell biology, behaves quite differently from the left ventricle, both in normal and pathologic circumstances, and the second is that deterioration of right ventricular function strongly predicts clinical outcomes in a variety of circumstances. Thus it is imprudent to ignore the RV any longer. Understanding its physiology and developing therapeutic strategies that are chamber specific will almost certainly have broad clinical benefit.


Noncompaction of the ventricular myocardium is a rare cardiomyopathy due to an arrest of myocardial morphogenesis. The characteristic echocardiographic findings are prominent myocardial trabeculations and deep intertrabecular spaces communicating with the left ventricular cavity. The clinical manifestations include heart failure (HF) signs, ventricular arrhythmias, and cardioembolic events. We describe an illustrative case of noncompaction of the ventricular myocardium associated with bicuspid aortic valve, a 42-year-old male presenting a refractory acute heart failure successfully treated by emergency heart transplantation. Noncompaction of the ventricular myocardium (NVM) is a recently described cardiomyopathy. It is an anomaly of myocardial morphogenesis that leads to persistent prominent ventricular trabeculations and deep intertrabecular recesses communicating with the ventricular cavity . The proA 42-year-old man was referred in for evaluation of progressive dyspnea. He had a history of aortic bicuspid valve, with a poor medical followup. A transesophageal echocardiography demonstrated the aortic bicuspidy with grade III aortic insufficiency. The left ventricle was dilated with an ejection fraction of 40%. A surgical valve repair was proposed though the patient refused surgery. After 3 months, the patient was admitted to hospital emergently with congestive heart failure. Diuretic and dobutamine infusions were started, as well as amiodarone after an episode of ventricular fibrillation. Despite this medical treatment, his condition worsened and he was transferred to our cardiac surgical intensive care unit.μg/kg/min. The patient's oxygen saturation was 99% on room air. The transthoracic echocardiography showed severely depressed left ventricular systolic function with an ejection fraction of 25%. The left ventricle was dilated with a severe functional mitral regurgitation  is a rare cardiomyopathy recently categorized as a primary genetic cardiomyopathy . This abThe disease involves the left ventricular myocardium, but right ventricular involvement is not uncommon . NoncompThe clinical manifestations include systolic and diastolic dysfunction associated with heart failure signs, ventricular arrhythmias and cardioembolic events . SymptomDiagnosis can be made by two dimension and color Doppler echocardiography. Four morphological criteria have been defined: (1) absence of coexisting cardiac abnormalities (to define an isolated NVM), (2) maximal end systolic ratio of noncompacted to compacted layers superior to 2, (3) predominant localisation of the pathology to mid-lateral, apical, and mid-inferior areas, 4) colour Doppler evidence of deep perfused intertrabecular recesses . Magneti colour DUnfortunately, as demonstrated in our case, NVM is often misdiagnosed since it is not a prevalent disease. Frequently, during routine echocardiographic evaluation, the disease is identified as an incidental finding, which leads to the diagnosis being made several months to years after the onset of symptoms. Szymanski et al. published a case of NVM revealed by a ventricular arrhythmia; such arrhythmias can justify implantation of a cardioverter-defibrillator. This patient diagnosed with idiopathic cardiomyopathy, has been managed for many years with nonspecific treatment . The management of NVM is not specific. Anticoagulation is warranted in presence of thromboembolic complications . StandarNoncompaction of the ventricular myocardium is a rare disease often unrecognized because not widely known. Nevertheless, this cardiopathy can be accompanied by three major cardiac risks: heart failure, ventricular arrhythmias, and endocardial clot with systemic embolization. Our case report emphasizes the need for practitioner to recognize this disease not to miss a potential life-threatening pathology.


We present and characterize an original experimental model to create a chronic ischemic heart failure in pig. Two ameroid constrictors were placed around the LAD and the circumflex artery. Two months after surgery, pigs presented a poor LV function associated with a severe mitral valve insufficiency. Echocardiography analysis showed substantial anomalies in radial and circumferential deformations, both on the anterior and lateral surface of the heart. These anomalies in function were coupled with anomalies of perfusion observed in echocardiography after injection of contrast medium. No demonstration of myocardial infarction was observed with histological analysis. Our findings suggest that we were able to create and to stabilize a chronic ischemic heart failure model in the pig. This model represents a useful tool for the development of new medical or surgical treatment in this field. Ischemic cardiomyopathy plays a predominant part in the etiology of patients with heart failure . DespiteMale pigs, 2 months aged weighing 15 to 20 kg were used for this procedure. These animals came from an animal supply facility where they are housed pre- and postoperatively and where the rules of good practice with regard to the management of animals for research are met. This study was conducted in accordance with both institutional guidelines and those in force in the European community for experimental animal use (L358–86/609/EEC).Details of the design are given in The animals were pre-medicated with an intramuscular injection of Calmivet . They were then transferred to the operating room. A catheter was placed in the vein at the level of the left ear (cathlon 22 gauge) which enabled induction of anaesthesia, combining Imalgène (30 mg/kg-ketamine) and Rompun (1 mL/kg-xylazine). The pig was then intubated with a no. 7 reinforced tube using a large right blade laryngoscope. Ventilatory parameters were as follows: frequency 15–20/min, Volume 8–10 mL/kg. The pig was placed in the dorsal recumbent position. Homeostasis was maintained using a heated operating table, controlled by a temperature probe.per os for 10 days in association with Cordarone (200 mg/day).An incision was made into the thorax at the level of the left fifth intercostal space. The pericardium was opened radially on contact with the left atrium. This was then reclined, the dissection continuing towards the dihedral angle between the atrium and the pulmonary artery. The distal part of the left trunk then appeared as well as the division between the circumflex coronary artery and anterior descending branch. The proximal circumflex coronary artery was then exposed and the first ameroid constrictor placed around it  just above the first lateral branch . The desA Vivid 7  was used to acquire echocardiographic data with a 4-MHz transducer. All the evaluations were performed at rest. To determine the percentage of thickening, the method was performed using the following formula TeleDiastolic Diameter—TeleSystolic Diameter/TeleDiastolic Diameter. Results were expressed in percentage. To study Wall motion score, the LV was divided into 12 segments assigned to coronary artery supply. Image analysis was performed by an experienced echocardiographer unaware of swine disease, who analyzed stored 2D cine loops in random order. Quad-screen display was used to view the 2D parasternal long-axis and short-axis views and apical 4-chamber, 2-chamber, and long-axis views at baseline. Wall motion score was assessed using a side-by-side visual assessment. The development of new or worsening resting LV wall motion abnormalities in >1 contiguous segment of the same vascular territory was considered a sign of inducible ischemia. Segmental wall motion was scored as follows: 1 = normal or hyperkinetic, 2 = hypokinetic, 3 = akinetic, and 4 = dyskinetic. For myocardial function, a conventional echocardiogram of the ejection fraction was carried out. Briefly, the Simpson's formula was used (TeleDiastolic Volume—TeleSystolic Volume/TeleDiastolic Volume) and results were expressed in percentage.at rest with calculation of perfusion flow-rate in real-time mode together with a flash sequence. A microbubble solution of the type Sonovue* (BRACCO) was given by central intravenous infusion to show the level of perfusion at the level of the myocardial wall [y = A(1 − ebt−), where y is SI at any given time, A is the SI plateau that reflects microvascular cross-sectional area or myocardial blood volume, and b is the slope of the refilling curve that reflects myocardial microbubble velocity. The product of A and b (A∗b) reflects the myocardial blood flow.To study myocardial perfusion, we used contrast echocardiography ial wall . MyocardTools for quantifying 2-dimensional strain (speckle tracking) enabled us, through a recording of conventional black and white images in the various zones, to obtain the parameters of myocardial deformation. These deformations depending on the orientation of acquisitions were expressed in the form of circumferential, longitudinal, and radial components closest to the orientation of the myocardial fibres. These components were exploited at rest as described in . The def Coronary angiography was used to monitor the progressive evolution of stenosis of the coronary arteries, to assess the intensity of flow through the stenoses, and to check collaterality from the right coronary artery. It was carried out through the femoral artery using a 4 Fr. catheter.After sacrifice, various fragments from the anterior, lateral ischemic zones, as well as the healthy zones were harvested, then fixed in methanol as well as cryopreserved. These various fragments were stained with Masson's trichrome stain. Analysis of inflammatory reaction was carried out by labelling with myeloperoxydase, with CD 45, and with CD 3. Capillary density was performed by immunostaining of endothelial cells with CD 31 .t-test was carried out. A value of P < .05 was considered to be significant.The results are expressed in mean ± standard deviation. All the analyses were carried out using the relevant software (Statview 5–1). Comparisons of the continuous variables between 2 groups were carried out using ANOVA. If a statistical difference was found, a Twenty-seven pigs were operated for this study. Two died during the procedure for implanting the constrictors . Ten died during the follow-up period. Six died (25%) from congestive heart failure and 4 died from cardiac rhythm disorder  caused suddenly. We were able to assess 15 animals for the present study. Total mortality rate was 40%. In a preliminary study and in the absence of programmed sacrifice , all the animals died at three months.The degree of stenosis was assessed by immediate postoperative coronary angiography, and at 1 and 2 months. No stenosis was seen in the immediate postoperative examination. At 1 month, the stenoses observed both on the circumflex and on the anterior descending branch were approximately 90%. The flow was scored TIMI 2, except for 1 case where the circumflex was thrombosed. Similar results were observed at 2 months with no worsening of the already existing stenoses. In contrast, in our hand, we were never able to demonstrate any collateralization on the follow-up angiographies with a specific analysis from the right coronary artery.P <.05). A significant decrease in percentage of thickening (P < .01) as well as substantial alteration of the mean wall motion score was found . The circumferential and radial strain were obtained in the parasternal short-axis view. Apical views were used to measure longitudinal strain as well as in the anterior, lateral, and inferior wall. Echocardiographic analysis consisted of measurement of the peak of strain in the end-systolic phase within the ischemic and the healthy zone (P < .01) and circumferential deformations  alike, both on the anterior and lateral surface of the heart, with compensation marks on the inferior  surface . These anomalies in function were coupled with anomalies of perfusion observed in echocardiography after injection of contrast medium. As shown in P <.05) compared to the healthy zone  corresponding in a significant decrease in myocardial blood flow.At 1 month, with identical results at 2 months, there was significant alteration in left ventricular function of around 30% to 35%. As shown in thy zone . QuantifAfter sacrifice, the hearts were collected for histological analysis. Staining with Masson's trichrome stain enabled elimination of the presence of infarction . ImmunosIschemic heart failure is a major cause of morbidity and mortality in developed countries. Much progress has been made, both in understanding the pathophysiological processes involved and in the medical and surgical management of these patients. However, many problems remain and require the development of new concepts to improve the prognosis for our patients. In this sense, cardiac surgeons, in association with all the actors in health and research who are involved in heart failure, play an essential role in trying to manage this disease better. Developing experimental models for ischemic heart failure is an important part in the progression of research in this field. Our object was to develop and define a preclinical model for ischemic heart failure in a large animal. Our choice focused on the pig because of the possible extensions for surgical treatment which could be developed. In the literature, there is no model, to date, for heart failure secondary to chronic ischemia. Many models have been developed with the aim of making a ventricle deficient but they do not pertain to a process of chronic ischemia. Whether they are models for infarction by ligature, by embolization, by endocoronary balloon, by injection with toxins, or by rapid rhythm electrical stimulization, permanent myocardial ischemia cannot be superimposed on any of them . In our However, the study presented some several limitations. First at all, we observed an important rate of mortality during the follow-up. This mortality was probably dependant on the model but this high incidence of sudden death or end stage heart failure represented a severe limitation to improve our understanding of pathophysiology. Second, we have not performed hemodynamic study and we could not evaluate LVEDP which would be an important target in this model. The LV filling pressures were only analyzed echographycally with the ratio E/Ea. Finally, all the measurements were performed at rest without dobutamine infusion. Histological analysis had never demonstrated necrosis and myocardial infarction in the area at risk traducing the anatomical integrity of the myocardial wall (viable myocardium). If 2-dimensional strain analysis has clearly demonstrated its role in the evaluation of our model at rest, our results could be strengthened at stress.We have therefore created a stable model for ischemic heart failure and developed tools to define it. This model could be used to assess new medications, new procedures for echocardiographic analysis, to implement new procedures for biventricular stimulation, or more specifically for surgeons as a basis for new techniques for surgical management of ischemic heart failure.All the authors do not have a direct financial relation with the commercial identities mentioned in the present paper that might lead to a conflict of interests.


The aim of this prospective study was to assess the diagnostic value of NT-proBNP and the concordance with Tissue Doppler Echocardiography  in diastolic and systolic heart failure.137 consecutive clinically stable patients were included . In diastolic heart failure, basal septal strain was reduced . In all patients with preserved systolic function, septal basal longitudinal displacement was impaired in patients with increased left-ventricular filling pressures  parallel to NT-proBNP elevation . In ROC analysis, NT-proBNP could detect patients with reduced left ventricular systolic function (LVEF ≥ 55%) with a good diagnostic accuracy. However, the diagnostic accuracy of NT-proBNP to detect diastolic dysfunction was lower.Subtle changes of longitudinal myocardial function begin in diastolic heart failure and are further increased in systolic heart failure. In patients with preserved LV function, a complex approach with the integration of multiple parameters including Tissue Doppler echocardiography and NT-proBNP is necessary to classify patients. The prevalence of both systolic and diastolic heart failure is high and the prognosis is comparably poor. The prevalence of diastolic heart failure is increasing and the survival rates remain low, whereas the survival rates of systolic heart failure have improved in recent years. Diastolic heart failure is characterized by abnormal myocardial relaxation and increased passive stiffness and is hard to distinguish from systolic heart failure by clinical examination alone -8.It was suggested that there is no isolated diastolic dysfunction, but that there is a continuum from normal to impaired diastolic and then systolic dysfunction (concept of "single syndrome"). The impairment of the longitudinal systolic function measured by Tissue Doppler Imaging (TDI) in patients with diastolic dysfunction supports this concept -11. In cThe non-invasive methods to diagnose heart failure include echocardiography and cardiac biomakers. Increased left-ventricular filling pressure is believed to induce myocardial wall-stress, the release of natriuretic peptides and increased E/E'-ratio. Diastolic heart failure is unlikely if E/E' is < 8, an E/E' 8–15 is suggestive of but not diagnostic of diastolic heart failure ,14.In addition to myocardial velocity measurements, new sensitive TDI-derived measurements of systolic function were introduced recently: Strain and longitudinal displacement . Strain Natriuretic peptides  are significantly elevated in systolic and in less so in diastolic heart failure -22. NT-pThe aim of this study was to assess the diagnostic value of NT-proBNP and the concordance with Tissue Doppler Echocardiography  in diastolic and systolic heart failure. We postulate that the integration of these parameters improves the severity estimation of systolic and diastolic heart failure.In this prospective monocentric study (enrolment 2004–2005), 137 consecutive clinically stable out- and in-patients with a clinical indication for echocardiography from medical and surgical departments were included. Exclusion criteria: atrial fibrillation, relevant valvular heart disease exceeding mild mitral or aortic valve disease, prosthetic heart valves, pulmonary hypertension, myocardial infarction < 3 months prior to study inclusion, terminal renal failure, creatinine > 2.5 mg/dl, pregnancy, age < 18 years. The blood for NT-proBNP measurements  , E/E' > (group 1), diastolic heart failure with preserved left ventricular function , systolic heart failure .The patients were classified as normal controls Statistics were calculated by SPSS . Descriptive statistics of parametric variables are expressed as mean (± SD). Nonparametric variables are expressed as median .2-test. The level of significance was p = 0.05.The comparison of echocardiographic parameters between groups was calculated by Wilcoxon test for non-parametric data. The Dunnett test was used for comparison to normal findings . DichotoROC (Receiver Operator Characteristics) analysis was performed to calculate sensitivity, specificity, negative and positive predictive values and an optimal cut-point of NT-proBNP to detect systolic or diastolic dysfunction. The optimal cut-off point was assessed according to Youden .137 patients were included. 42 patients had normal systolic and diastolic function (group 1), 43 patients had diastolic dysfunction (group 2), 52 patients had systolic dysfunction with an EF < 55% (group 3).The baseline characteristics of the patients are listed in table The ROC analysis to discriminate between normal LVEF (n = 88) and reduced LVEF (n = 49) had an area under the curve of 0.844, which indicates a good diagnostic accuracy. The best cut-off for this discrimination was 489 pg/ml . The ROC analysis to discriminate between normal echocardiography (n = 42) and impaired diastolic and/or systolic function (n = 95) had an area under the curve of 0.763, which indicates a fair diagnostic accuracy. The best cut-off for this discrimination was 97 pg/ml  (figure Dividing the patients with preserved systolic LV function (groups 1 and 2) by E/E' (cut-point = 8) showed that there were significant differences in NT-proBNP levels , p = 0.01). Classifying these patients by E/E' < 8, E/E' 8–15 and E/E' > 15 according to  revealedA division by E/A  or E'/A'  was not associated with significantly different NT-proBNP levels. This indicates that increased E/E' is most closely linked to elevated NT-proBNP.There was a correlation of peak systolic velocities (S') and longitudinal displacement with NT-proBNP throughout the spectrum of our patients (Spearman correlation coefficient was -0.578 (p < 0.0001) for longitudinal displacement and -0.605 (p < 0.001) for S').The main finding of this study is that patients with diastolic and systolic myocardial dysfunction have significantly reduced basal left ventricular septal and lateral strain compared to healthy controls. Patients with normal LVEF and elevated left ventricular filling pressures (E/E' > 15) have significantly reduced longitudinal displacement and significantly elevated NT-proBNP. NT-proBNP can detect patients with a reduced left ventricular systolic function (LVEF < 55%) with a good diagnostic accuracy in accordance with previous studies -24.In the patients with normal LV function and an elevated E/E' (8 – 15), the measurement of NT-proBNP does not add a significant diagnostic information. Therefore, the diagnostic accuracy of NT-proBNP to detect diastolic dysfunction in these patients is low. Our findings do not fully support the algorithm recently published consensus statement for the diagnosis of diastolic heart failure that emphasized E/E' and NT-proBNP .In the grey zone of mildly elevated NT-proBNP and/or an E/E' between 8 and 15, it remains difficult to diagnose diastolic heart failure. This could be due to the weak correlation of invasively measured LA filling pressures and E/E' in this grey zone. The majority of patients with normal LVEF and invasively measured elevated LA filling pressures had an E/E' between 8 and 15 .This underlines the importance of integrating multiple echocardiographic parameters and an individual interpretation by experienced cardiologists. Especially in the case of elevated NT-proBNP of non-cardiac causes , the diagnostic work-up has to rely on echocardiography alone. In these borderline cases, invasive measurements by a conductance catheter should be considered to exclude relevant diastolic dysfunction .Why is NT-proBNP not significantly elevated in diastolic dysfunction compared to healthy controls, but correlates to filling pressures (E/E')? We speculate that diastolic dysfunction is a process that includes a variety of mechanisms . The trigger for NT-proBNP release from cardiomyocytes is primarily wall stress, which is functionally reflected by filling pressures (E/E').Our findings support the "single syndrome" theory of heart failure. Subtle changes of longitudinal myocardial function  begin in diastolic heart failure and are further increased in systolic heart failure. However, the study by Yip  has seenThe cut-off values of LVEF, NT-proBNP and E/E' need to be discussed, because the different studies have used different cut-offs. The definition of a normal LVEF > 50% in the ESC Guidelines  is somewThe NT-proBNP values physiologically increase with age ; therefoIn conclusion, we found that in patients with systolic and diastolic heart failure, E/E', NT-proBNP as well as Strain and longitudinal displacement add important incremental information for the severity estimation of heart failure. In patients with isolated diastolic dysfunction, Strain is significantly reduced and with increased fillings pressures longitudinal displacement is impaired, paralleled by an increase of NT-proBNP. But in a substantial subset of patients with borderline NT-proBNP and E/E', an individual analysis of all available data has to be performed.We have excluded patients with atrial fibrillation because of the difficulty to assess certain diastolic function parameters . We have only measured NT-proBNP and not BNP, because recent head-to-head studies found that BNP and NT-proBNP can be used comparably [41]. We have not classified diastolic dysfunction according to restrictive, pseudo-normal or impaired relaxation. But previous studies have shown that NT-proBNP is strongly elevated in patients with pseudo-normal and restrictive filling patterns . In the NT-proBNP: N-terminal-pro-Brain Natriuretic Peptide; PPV: Positive Predictive Value; NPV: Negative Predictive Value; ROC: Receiver Operator Characteristic; LVMI: Left Ventricular Mass Index; BMI: Body Mass Index.The authors declare that they have no competing interests.FK, SE, MB and ACB have designed the study and have acquired the data. SS, VR, SE, IS, MB participated in contributions to conception and, or analysis and interpretation of data. FK has written the manuscript. GB has supervised and commented the study. ACB was the supervisor of echo examinations, is head of the echo lab, contributed by revising the manuscript critically. All authors read and approved the final manuscript.TDI image of the interventricular septum. Acquisition of a TDI image in the apical four chamber view.Click here for fileHow to perform the TDI analysis. Illustration of the correct acquisition a TDI region of interest (= ROI) in the basal left-ventricular septum. The size of the ROI is adjusted to the septal diameter and then, the ROI is traced manually in each frame to avoid artifacts. This acquisition applies to Velocity, Strain Rate and Displacement.Click here for file