Background and Objectives: Chronic severe aortic valve disease is associated with important changes in left ventricle (LV) performance associated with eccentric or concentric LV hypertrophy. We aimed to assess the immediate prognostic implications of the type of the LV diastolic filling pattern (LVDFP) compared with LV systolic performance in patients with severe aortic regurgitation (AR) undergoing aortic valve replacement (AVR) and to define the independent echographic predictors for the immediate and long-term prognoses. Materials and Methods: We performed a prospective study enrolling 332 AR patients undergoing AVR, divided into two groups: Group A—201 pts with normal LV systolic function, divided into two subgroups (A1: 129 pts with a nonrestrictive LVDFP and A2: 72 pts with restrictive LVDFP), and Group B—131 pts with LV systolic dysfunction (LV ejection fraction LVEF < 50%), divided into two subgroups (B1: 83 pts with a nonrestrictive LVDFP and B2: 48 pts with restrictive LVDFP). Results: The early postoperative mortality rate was higher in patients with a restrictive LVDFP (11.12% in A2 and 12.5% in B2) compared with normal LV filling , regardless of the LVEF. The restrictive LVDFP—defined by at least one of the following echographic parameters: an E/A > 2 with an E wave deceleration time (EDt) < 100 ms; an isovolumetric relaxation time (IVRT) < 60 ms; or an S/D ratio < 1 in the pulmonary vein flow—was an independent predictor for early postoperative mortality, increasing the relative risk by 8.2-fold. Other independent factors associated with early poor prognosis were an LV end-systolic diameter (LVESD) > 58 mm, an age > 75 years, and the presence of comorbidities (chronic obstructive pulmonary disease-COPD or diabetes mellitus). On a medium-term, an unfavorable evolution was associated with: an age > 75 years (RR = 8.1), an LV end-systolic volume (LVESV) > 95 cm3 (RR = 6.7), a restrictive LVDFP , and pulmonary hypertension (RR = 8.2). Conclusions: The presence of a restrictive LVDFP in patients with AR undergoing AVR is associated with both increased early and medium-term mortality rates. The LV diastolic function is a more reliable parameter for prognosis than LV systolic performance (RR 9.2 versus 2.1). Other independent predictors for increased early postoperative mortality rate were: an age > 75 years, an LVESD > 58 mm, and comorbidities , and for unfavorable evolution at 2 years postoperatively: an age > 75 years, an LVESV > 95 cm3, and severe pulmonary hypertension. Chronic severe aortic valve disease is associated with important changes in LV performance associated with eccentric or concentric LV hypertrophy. Diastolic dysfunction has been demonstrated to precede the alteration in systolic function in these patients .In patients with severe chronic aortic regurgitation (AR), chronic volume overload is suggested to be more harmful for the ventricle because of the increased end-diastolic and end-systolic volumes; thus, AR is more harmful than mitral regurgitation or aortic stenosis. On the other hand, LV systolic dysfunction is usually initially reversible with surgery, but diastolic dysfunction needs more time to ameliorate .The diastolic dysfunction severity is closely related to the type and severity of the underlying valvular lesion. The presence of a restrictive LV diastolic filling pattern (LVDFP) determines a less-favorable prognosis. In addition, the change or lack of change in LV volume and systolic or diastolic performance within the first year after AVR seems to be an important predictor of long-term prognosis .The medical literature evaluating the effects and efficacy of AVR in severe AR is composed of relatively small-population heterogeneous studies. The studies have a limited applicability in trying to formulate a unitary management of these patients, because they vary considerably in terms of the patient selection, surgical intervention, outcomes evaluated, and postoperative follow-up timing.Some studies tried to establish the early, intermediate, and late consequences of AVR on LV size regression and the LVEF; whether the LV can return to normal dimensions; and how rapidly the myocardial hypertrophy dimensions and LV dysfunction regress after AVR ,5,6.In addition, the influence of the LVDFP on early postoperative evolution in patients with AR undergoing AVR has been evaluated in a few previous studies , but in However, short-term or long-term studies on the effects of AVR on the LV systolic and diastolic performance and the relation between LV dilatation reversal and the increase in LV systolic function have not been reported.To address these issues, the first aim of our study was to investigate whether the diastolic or systolic performance of the LV predicts the outcome after AVR in patients with chronic severe AR. We aimed as well to assess the immediate and medium-term prognostic implications of the LVDFP in patients with AR undergoing AVR and to define the echographic parameters related to diastolic function that can be taken into consideration as independent predictors of the immediate and long-term evolution in these patients and their adjusted value for preoperative risk evaluation.We conducted a prospective study that enrolled 332 patients with AR undergoing AVR in the “C.C. Iliescu” Emergency Institute for Cardiovascular Diseases in three consecutive years. Informed consent was obtained from all subjects and the local ethical committee approved the study.Selected patients were divided in two main groups, depending on their LV systolic dysfunction: Group A included 201 patients with normal LV systolic performance with an LVEF ≥ 50% and the second group, Group B, included 131 patients with LV systolic dysfunction with an LVEF < 50%. Taking into consideration the LV diastolic function, we subsequently divided each group into two: Group A was divided into Subgroup A1, with 129 patients with a nonrestrictive diastolic filling pattern , and Subgroup A2, comprising 72 patients with a restrictive diastolic filling pattern (severe diastolic dysfunction). Similarly, patients from Group B were divided into Subgroup B1, comprising 83 patients with a nonrestrictive diastolic filling pattern, and Subgroup B2, comprising 48 patients with a restrictive diastolic pattern .-Acute AR;-Acute endocarditis;-Associated severe aortic stenosis;-Associated or previous mitral or tricuspid valve replacement or repair;-Aortic dissection;-Previous aortic valve surgery;-Congenital diseases unrelated to AS;-Coronary significant lesions (more than 50% coronary stenosis);-Postoperative prosthesis mismatch;-Permanent atrial fibrillation;-Presence of a pacemaker;-Left or right bundle-branch block.The exclusion criteria were as follows:Patients undergoing concomitant procedures such as associated ascending aortic surgery with AVR were not excluded. At the moment of enrollment, all patients were in sinus rhythm. Most of the patients were male (71%), the mean age of the whole group was 62 ± 16 years, and the mean LV ejection fraction (LVEF) was 52 ± 5%. Both groups were similar regarding age, sex, and comorbidities , AVR with a biological prosthesis (76 pts), or AVR combined with ascending aorta replacement .The follow-up included both a clinical and echocardiographic evaluation (including TDI) before surgery and postoperatively at 10 days; 1, 3, and 6 months; and yearly for 4 years postoperatively. The clinical exams included the NYHA functional classification and quality-of-life scores.We used a Philips Affinity30 or portable General Electric VIVID machine, with a 3.5 MHz probe for all echocardiographic examinations with techniques and calculations in accordance with the European and American Society of Echocardiography recommendations .At each visit, the echographic parameters assessed included: the LV systolic and diastolic function (with complete TDI parameter measurements), the left atrium dimensions and indexed volume, and the LV end-systolic and end-diastolic dimensions (including the LV end-diastolic volume (LVEDV) and the LV end-systolic volume (LVESV)). Preoperatively, we evaluated the AR severity and postoperatively, we evaluated the parameters related with aortic prosthesis functionality.The LV systolic performance was determined using a calculation of the LVEF using the volumetric Simpson method.Transmitral flow: measurement of transmitral flow parameters, including the early (E) and late (A) diastolic filling velocities, the E/A ratio, the E wave deceleration time (DT), and the isovolumetric relaxation time (IVRT) from an apical four-chamber view with a conventional pulsed-wave Doppler;Pulmonary venous flow: assessment of diastolic (D) and “forward” systolic (S) velocities into the left atrium, and the “backwards” late diastolic A reversal wave, which corresponded to the atrial contraction;Flow propagation velocity (Vp): measured using the color Doppler M mode from the apical four-chamber view with the M mode beam aligned parallel to the LV inflow and a calculation of the E/Vp ratio;Tissue Doppler imaging: assessment of LV relaxation rate by recording longitudinal velocities at the mitral annulus with the sample volume (2–5 mm) placed at the septal or lateral border of the mitral annulus in the apical four-chamber view for an estimation of the LV filling pressures using an average of the lateral and septal E/Ea ratio.The assessment of diastolic function was based on a comprehensive echocardiographic study integrating all available two-dimensional and Doppler data ,10:TransEDT < 150 ms, E/A ratio > 2, and E/Vp > 1.5;S/D < 1;IVRT < 60 ms with elevated filling pressures (E/Ea > 12);Ea/Aa < 1 .We considered restrictive diastolic filling to be present if either of the following echographic findings were found :EDT < 15Additionally, we preoperatively performed coronary arteriography in all patients over 35 years and for patients under 35 years old with angina pectoris. We did not include patients with associated significant coronary artery disease (more than 50% reduction in any coronary artery diameter). In addition, we used brain natriuretic peptide (BNP) titration for patients with a preserved LVEF and symptoms suggestive of heart failure (considering that diastolic heart failure was likely at a BNP > 100 pg/mL) .The main endpoints tested were: NYHA class, LVDFP type, quality of life , and death.For the evaluation of life quality, we used a self-reported questionnaire with two parts: a mental score (MCS) and a physical one (PCS), both being continuous from ten to zero . We also asked the patients to report their perception of their quality of life during the follow-up at 30 days. The question asked, “How would you rate your quality of life now?” for both mental and physical aspects, with choices between “better than before your procedure,” “the same as before your procedure,” and “worse than before your procedure.”-LV systolic dysfunction and restrictive LVDFP are independent predictors for unfavorable postoperative evolution in patients with AR undergoing AVR;-The presence of a restrictive LVDFP in preoperative risk evaluation in patients with AR undergoing AVR is more important than LV systolic dysfunction.The main null hypotheses tested were:t-test and for three groups with ANOVA. In order to compare the two groups, a univariate logistic regression analysis was used. In addition, the association between preoperative data and the magnitude of postoperative change in LV dimensions and function was tested using a linear regression analysis.All calculations were performed with the Statistical Package for the Social Sciences version 23 (SPSS 23) program. Numerical data were synthesized as a mean ± standard deviation, and qualitative data were recorded as percentages. Qualitative data were tested using the Pearson chi-squared test, likelihood ratio, and Fisher’s exact test and quantitative data were tested between the two groups with an independent samples A multivariate logistic regression analysis was performed to identify predictive factors for mortality.p < 0.05 was considered statistically significant.The area under the receiver operating characteristic (ROC) curve and the Hosmer–Lemeshow goodness-of-fit statistic test were calculated to assess the discrimination and calibration of the model, respectively. To evaluate the goodness of fit of the model, the Cox and Snell/Nagelkerke value was calculated. A value of p < 0.005, likelihood ratio). At 30 days postoperatively, 59.70% of the patients from Group A reported a better postoperative SR QOL score, compared with only 34.35% in Group B with preoperative LV systolic dysfunction .We calculated the overall percentage of patients whose self-reported quality-of-life scores (SR QOL score) changed. A total of 39.8% of the patients from Group A had a preoperative SR QOL score less than 5, compared to 84.734% of the patients from Group B (p = 0.06) and a significant improvement in Group A (p = 0.002). The postoperative end-diastolic and end-systolic dimensions decreased significantly in both groups (The postoperative echocardiography showed a trend towards an improvement in the LVEF in Group B (h groups .p < 0.0001). After 1 year postoperatively, the mortality rate was also influenced by the LV systolic performance . The cumulative incidence of death at 1 year from cardiovascular causes was 2.98% in Group A and 4.58% in Group B. Extracardiac causes  were associated with a cumulative 1-year mortality of 1.99% in Group A, and 1.58% in Group B. Patients that experienced an intraoperative death were not included in the database. Approximately 1/5 of the patients  had severe LV systolic dysfunction (LVEF < 35%) and a severely enlarged LV with an LVESD > 58 mm, being at the borderline indication for surgery, which can explain the high mortality rate.Following surgery, the early mortality rate (defined as death within 1 to 365 days after the date of the AVR surgery) was different in patients with a restrictive LVDFP compared to those with a nonrestrictive LVDFP. Thus, the early postoperative mortality rate was significantly higher in patients with an abnormal LVDFP (11.12% in Subgroup A2 and 12.5% in B2) compared with patients with normal LV filling (2.32% in A1 and 4.82% in B1), regardless of the LV systolic performance ;A restrictive LVDFP ;A severe LV systolic dysfunction with an LVEF of less than 35% ;Severe pulmonary hypertension with a mean PAP > 50 mmHg ;A patient age of more than 75 years ;The presence of preoperative AR ;Comorbidities  .A severely dilated LV with an LVES diameter > 58 mm and LVES volume > 200 mL/mEarly postoperatively, a multivariate logistic regression analysis revealed that the main independent predictors for the evolution of the patients with AR undergoing AVR were:At 2 years postoperatively, the relative risk of death associated with the parameters known to increase the mortality rates in patients undergoing AVR  were hip = 0.001). In these patients, the only independent predictor for increasing the risk of death was LV dilatation with an LVESD > 58 mm (RR 7.3)  and an age > 75 years markedly increased the risk of death . Systolic dysfunction had a moderate influence on mortality, with an increase in the relative risk from 1.5 to 2.8. The presence of a restrictive LV diastolic filling pattern homogenized the relative risk values. In patients with this type of filling pattern, the postoperative risk of death significantly increased, regardless of the LV systolic performance (RR 5.3 versus 5.9), patient’s age (RR 6.1 versus 6.9), or presence of LV dilatation with an LVES diameter between 45 and 58 mm (RR 4.8 versus 5.6), proving an independent predictor value for severe diastolic dysfunction ((RR 7.3) .2), and the presence of comorbidities such as diabetes mellitus or COPD. The parameters of the LV systolic function, end-diastolic diameters, and volumes, as well as the presence of pulmonary hypertension, were not correlated with a significant increase in early postoperative mortality rate in these patients. Thus, the restrictive LVDFP turned out to be an independent predictive factor for an increasing early mortality rate in these patients (p = 0.001), regardless of the LV dimensions and systolic function, the patient’s age, comorbidities, or pulmonary hypertension  < 130 msec with an E/A ratio > 2, an isovolumetric relaxation time (IVRT) < 60 ms, and a systolic per diastolic wave ratio < 1  in the prtension .p < 0.01), severe LV dilatation , a restrictive LVDFP , and severe pulmonary hypertension . The end-diastolic diameter, the volume of LV, and the LV systolic performance did not significantly influence the mortality rate at 2 and 4 years postoperatively in these patients  were twice as likely to be in the group with nonrestrictive diastolic dysfunction, regardless of their LV systolic performance at both the 2- and 4-year follow-ups .Severe AR leads to an increase in both preload (volume overload) and afterload, which in turn causes a combination of chamber dilation and hypertrophy, usually eccentric, that is generally associated with the worsening of diastolic function. The LVEF is often initially within normal limits, and many patients with severe AR and subclinical myocardial dysfunction are asymptomatic or have only mild symptoms. However, when the compensatory mechanisms are exhausted, the changes in LV geometry and anatomy become irreversible, with negative consequences for survival and increased postoperative morbidity .On the other hand, both the systolic and diastolic performance of LV have an important influence on the postoperative evolution of patients with AR undergoing AVR, which is why they should be investigated before the onset of irreversible LV dysfunction. In the majority of patients with chronic severe AR that receive AVR, usually within the first few months after surgery, there is a substantial reversal of LV dilatation that is associated with a significant increase in the LV systolic performance . HoweverThe echocardiographic evaluation of the diastolic performance in severe AR can be challenging. The regurgitation jet can interfere with the recording of mitral inflow velocities; therefore, the careful positioning of the sample volume is needed in order to avoid contamination with the AR jet. There are limited data on the accuracy of the estimation of LV filling pressures in chronic severe AR. This explains why, in these patients, it is important to take into account the presence of LA enlargement and the average E/Ea ratio in order to support the presence of increased LV filling. In patients with severe AR, whether acute or chronic, the premature closure of the mitral valve, diastolic MR, LA enlargement, and an average E/Ea ratio > 14 are consistent with elevated LV filling pressures. An invasive measurement of the LV filling pressure was well correlated with the echocardiographic findings .After AVR, the LV systolic and diastolic performances are influenced by the LV contractility, the LV and left atrium dimensions and architecture, the LV afterload, and the extent of irreversible interstitial fibrosis. Thus, in order to prevent severe and irreversible LV function deterioration and to better predict postoperative outcomes, it is important to search for other parameters besides a low LVEF that are associated with a poor prognosis.Because it is highly dependent on the left ventricular loading conditions, the primary relevance of the preoperative LVEF in patients with AR may not accurately reflect the intrinsic LV performance, and it is not a very good marker for the determination of optimal timing for surgical intervention and for postoperative course prediction.On the other hand, the importance of diastolic dysfunction on the postoperative evolution in patients with AR is still underestimated. Severe diastolic dysfunction correlates well with other comorbidities known to increase mortality, such as diabetes mellitus, age, and secondary pulmonary hypertension ,19. The Moreover, patients with greater abnormalities in their LV filling pattern have a progressive increase in their risk of major cardiac events, and the stage of diastolic dysfunction correlates better than the LVEF with exercise impairment. In addition, in patients with heart failure, restrictive diastolic dysfunction is a stronger predictor of mortality than the LVEF ,24,25. TIn addition, the left ventricular function late postoperatively cannot be accurately predicted by routine measurements of the preoperative LVEF and LV dimensions, and a complete evaluation of the LVDFP should be more frequently used in clinical decision making and for recommending surgery in patients with severe AR.In patients with severe AR, persistent diastolic dysfunction with a maintained LV systolic performance was observed late after successful AVR and can be explained by the incomplete regression of the extracellular matrix four years after the valve replacement . In patiIn the majority of patients with chronic severe AR, AVR results in a substantial reversal of LV dilatation within the first few months after the operation, which is associated with a significant increase in LV systolic performance. Importantly, numerous studies have indicated that a depressed LV systolic performance may improve and, in some patients, normalize after the reversal of the volume overload by AVR . These cThere is still a lot of uncertainty regarding whether to operate on a patient when the diastolic function is already severely depressed. There is no clear limit for a marked reduction in the LV diastolic function in surgical aortic disease, either by stenosis or regurgitation, and our knowledge is still limited regarding the outcome for patients with a restrictive LVDFP. The most recent guidelines underscore these limits when AVR is recommended in patients with a restrictive LVDFP .The transition from a compliant (chronic compensated AR) to a rigid (decompensated AR) LV is due to the upregulation of fibroblast genes, with consequent remodeling of the extracellular matrix (ECM) of the heart . The amoWe hypothesized that the operative and postoperative risk would be smaller in patients with milder LV diastolic dysfunction compared to patients with severe AR with a restrictive LVDFP. We also hypothesized that the rates of cardiovascular morbidity and mortality after surgery would not be so high and that AVR would improve the clinical outcome of most of these patients.In general, the recognition of diastolic heart failure in the postoperative heart and its treatment remains difficult and often unsatisfactory. This condition often occurs in conjunction with some degree of systolic dysfunction. As the conditions under which diastolic dysfunction occurs vary between patients, straightforward therapeutic algorithms are not easy to provide for an individual. Although there are many studies on diastolic dysfunction, there are very few data about diastolic dysfunction in the postoperative cardiac surgical patient.Although diastolic dysfunction is an important cause of heart failure, it remains underreported in the postoperative heart. We tried to find the criteria that could be applied to help diagnose it in this group of patients in the intensive care setting where cardiac surgical patients are usually managed in the immediate postoperative period. Since both systolic and diastolic heart failure share a similar clinical picture, it is important to recognize the difference between these two entities. Unfortunately, there is still very little evidence on how to treat diastolic dysfunction.The clinical benefit for patients with mild diastolic dysfunction after AVR is significantly higher than for patients with advanced diastolic dysfunction. The deceleration time and E/A ratio are independent predictors of postoperative improvement in the LV systolic and diastolic performance and the LV dimensions in patients with severe AR and LV systolic dysfunction. The diastolic function has an increased sensitivity for defining a patient’s prognosis due to the alterations in the compliance and stiffness of the LV caused by irreversible remodeling. The complete assessment of diastolic function with tissue Doppler echocardiography is a noninvasive, simple, and reliable preoperative method that can be used to predict the short- and long-term outcomes after AVR and may help in the management of postoperative treatment in patients with severe AR undergoing AVR.In our study, for the echographic evaluations, we did not use three-dimensional speckle-tracking, which is known as a very good technique for assessing the LV systolic function using echocardiography. This was because of technical limitations (only one ultrasound device available at this facility) and also because the required examination time was dependent on a good acoustic window, quality data sets, and on patient cooperation for breath-holding, limiting its feasibility in postoperative patients.In addition, for the assessment of diastolic performance, only a small number of patients underwent an invasive determination of the LV filling pressures. However, the echocardiographic examinations included all the parameters indicating increased LV-filling pressures in patients with valvular heat disease, taking into account their limitations. The restrictive pattern was considered only when three parameters were modified. For the same reason, we didn’t include patients with atrial fibrillation in our study.All the patients in our study benefited from surgical AVR without having a comparison with a possible control group in which transcatheter implantation was performed. For the data analysis, we did not take into account the duration of the surgery and intraoperative complications, but all operations were scheduled, not urgent. In addition, we did not analyze the causes of in-hospital deaths, but most of them occurred in the ICU by severe LV dysfunction or multiple systemic organic failure.In our study, we found that the global LVEF had only a borderline predictive value in multivariable models that included restrictive diastolic filling pattern. This may be due to the fact that systolic function was preserved in many patients and because the prognostic data obtained from depressed systolic function may be obtained from other covariates that were included in the multivariate model. In addition, most of our patients with low EF had only mild or moderate systolic dysfunction (mean EF = 50% ± 2).We recognize that the quality of the data regarding the causes of death is dependent on the quality with which the physicians certified the cause of death. Additionally, although the data quality in this study was high and the follow-up was complete, the cause-specific death rates in the study cohort were not established. Furthermore, although we did not examine mortality and causes of death, we examined other aspects of health following AVR, such as quality of life and the HF evolution. A lower early survival after AVR was explained by an increased relative risk of cardiovascular death, probably because of a too-late surgical indication and operating on patients with terminal heart failure. Future studies should focus on the role of earlier surgery in patients with asymptomatic aortic regurgitation and on optimizing the treatment and follow-up after AVR.The presence of a restrictive LVDFP in patients undergoing AVR for AR was associated with an increased mortality rate early after surgery. Compared to LV systolic function, the LV diastolic function was a more reliable prognostic parameter.2.The independent predictors for an increased early postoperative mortality rate early after surgery were: an age > 75 years, comorbidities , a restrictive diastolic filling pattern , an LV end-systolic diameter > 58 mm, and an LV end-systolic volume > 200 mL/m2.The major independent predictors for an unfavorable evolution at 2 and 4 years after surgery were: an age > 75 years, severe pulmonary hypertension, a restrictive LVDFP, an LV end-systolic diameter > 58 mm, and an LV end-systolic volume > 200 mL/m


Phase angle (PA) constitutes a bioelectrical impedance measurement, indicating cell membrane health and integrity, hydration, and nutritional status. Handgrip strength (HS) has been also associated with body composition, nutritional status, inflammation, and functional ability in several chronic diseases. Although their prognostic significance as independent biomarkers has been already investigated regarding the outcomes of a cardiac surgery, our study is the first one to assess the combined predictive value of preoperative PA and HS.HS and PA measurements were performed preoperativelyin 195 patients undergoing cardiac surgery. The association ofthe combination of HS and PAwith all-cause mortality rates was the primary study outcome, while its association with the intensive care unit (ICU) length of stay (LOS) was the secondary one.p < 0.005) and negatively with EuroSCORE II (r = − 0.306 p < 0.005). The combination of PA < 5.15 and HS < 25.5 was associated with higher one-year all-cause mortality  compared to patients with PA > 5.15 and HS > 25.5, respectively. Patients with combined lower values of PA and HS (PA < 5.15 and HS < 30.7) were at higher risk of prolonged ICU LOS  compared to those with higher PA–HS (PA > 5.15–HS > 30.7). The combination of PA–HS was also significantly linked with EuroSCORE II.PA was positively correlated with HS (r = 0.446, The combination of low preoperative PA and HS values was significantly associated with higher risk of all-cause mortality at 12 months and prolonged ICU LOS; thereby it might serve as a clinically useful prognostic biomarker after cardiac surgery procedures.The online version contains supplementary material available at 10.1186/s13019-022-01970-z. Predicting post-procedural morbidity and mortality remains challenging despite the development of many scoring systems and prognostic algorithms in cardiac surgery , 2. HencThe latest international guidelines support a more individualized patient management based on group discussion among cardiac specialists (i.e. “heart team”) and on the utilization of novel biomarkers such as frailty tests .IndicatoIn this prospective study enrolling patients undergoing selective open-heart surgery, we examined whether the combination of PA and HS values was associated with higher rates of one-year mortality, early morbidity and higher intensive care unit (ICU) stay. Our aim was to investigate the role of PA and HS in predicting clinical outcomes and enhancing pre-operative risk stratification in cardiac surgery patients.The study population comprised adult patients undergoing scheduled selective coronary artery bypass grafting (CABG) surgery, individual valve replacement or repair, or any combination of these procedures at the Cardio-Thoracic Surgery Department of AHEPA University Hospital between December 2018 and October 2019.The exclusion criteria were: i. age < 18 years, ii. hemodynamic instability requiring urgent surgery, iii. urgent surgery for aortic dissection, iv. any major adverse intra-operative outcome, v. congenital heart disease, vi. recent cardiac surgery during the prior three months, and vii. presence of any implantable device. The study protocol has been approved by the Scientific Board of AHEPA University Hospital as well as by Ethics Committee of the Aristotle University of Thessaloniki. Written informed consent was obtained pre-operatively from every participant.On admission, demographic, anthropometric and clinical data  were recorded for each individual. Hospitalization data such as cardiopulmonary bypass (CPB) time, duration of mechanical ventilation, occurrence of post-operative complications, length of stay in the Intensive Care Unit (ICU) and postoperative length of hospital stay were also noted.PA was measured using bioelectrical impedance method on the first pre-operative day by a blinded researcher trained in this technique. A simple quadrupole measurement was applied to the right side of the body using four-surface electrodes . Thereby, resistance (restriction of current flow) and reactance (capacitance of cell membranes to block current) were measured. The primary 50 kHz resistance and reactance data were used to calculate PA .HS was also assessed preoperatively using a portable hydraulic dynamometer . The HS test was performed in the sitting position, having their elbow flexed at 90°, whilst pressing the dynamometer with the dominant hand at full force for three seconds. After three repetitions of the test with an interval of one minute to avoid fatigue, the best performance was recorded in kilograms (kg).Primary study outcome was deemed all-cause mortality, as assessed at last available telephonic follow-up or as determined by electronic medical health records. The length of ICU stay was considered as the secondary study outcome.Continuous variables are presented with mean and standard deviation (SD) or with median and intra-quartile range (IQR) depending on data normality. Categorical variables are presented with frequencies (n) and percentages (%). Regularity of data distribution was checked using the Kolmogorov–Smirnov test.The correlation of PA and HS with outcomes of interest was performed via t-test or Mann Whitney test for independent samples. Logistic regression was performed to detect the independent effect of demographic and clinical indicators on the outcomes of interest. The predictive value of PA and HS was evaluated through receiver operator characteristics (ROC) analyses and calculated Areas Under the Curve (AUC). Cut-off points of PA and HS that maximize sensitivity and specificity for risk stratification were evaluated via calculating Positive Predictive Value (PPV) and Negative Predictive Value (NPV). Due to the non-standardization of PA and HS values, statistical tests of collinearity were executed for each one of the performed multivariate analyses to investigate if there is any source of collinearity which could decrease the value of the independent effect. All statistical analyses were performed with the statistical package SPSS version 21 . The p-value of less than 0.05 was defined as the level of statistical significance.p < 0.005) and negatively with EUROSCORE II (r = − 0.306 p < 0.005) (Table Our study included 195 patients with a mean age of 67 years (SD: 9 years) of whom 150 were men (76.9%) and 45 women 23.1%). Of included patients, 90 suffered from coronary artery disease (46.2%), 87 (44.6%) from valvular disease and 18 from both (9.2%). Median EuroSCORE II was equal to 2.6%(0.6–15.5). Demographic and clinical characteristics of the overall study population and of the patients who survived compared to those who died during follow-up, are presented in Tables 3.1%. Of p = 0.009, HS: AUC (95% CI) 0.659 (0.5–0.78); p = 0.008, and their combination: AUC (95% CI) 0.671 (0.56–0.78); p = 0.004  died from any cause after one-year follow-up. PA, HS and their combination had a significant yet fair predictive value for all-cause mortality; PA: AUC (95% CI) 0.657 0.54–0.77); –0.77; p p = 0.009]. Patients with PA < 5.15 and HS < 25.5 were 5 times more likely to die  when compared to those with PA > 5.15–HS > 25.5 ; p = 0.003] and the combination of PA–HS [p = 0.005] had an independent effect on mortality. Regarding the PA–HS combination, patients with PA < 5.15 and HS < 25.5 were 9.3 times more likely to die  in relation to those with PA > 5.15–HS > 25.5 ; p = 0.001] in comparison with those having PA > 5.15 and HS > 30.7  = 0.586 (0.51–0.67); p = 0.040, and their combination: AUC (95% CI) = 0.597 (0.52–0.68); p = 0.019 ; p < 0.005], left ventricular ejection fraction  and the combination of PA–HS [p = 0.038] were independent predictors. Regarding the combination of those indicators, patients with PA < 5.15 and HS < 30.7 were found to be 4 times more likely to stay in the ICU for more than 1 day  compared to those with PA > 5.15–HS > 30.7 ; 3; p = 0.Α multivariate regression model for the prediction of ICU stay using PA and HS as continuous variables was also performed and is presented in Additional file In order to observe the relationship between the PA–HS combination and the standard EuroSCORE II risk index, an analysis of variance (ANOVA) was performed, showing a statistically significant difference in EuroSCORE II values among individuals with PA < 5.15–HS < 25.5 compared to those with PA > 5.15–HS > 25.5 in mortality Table .Table 9EStatistical tests of collinearity were also performed for each one of the multivariate analyses to investigate if there is any source of collinearity which could decrease the value of the independent effect  study enrolling 277 patients undergoing major cardiac surgery in Canada, PA can independently predict early and midterm mortality after major cardiac surgery . A PA cuThe measurement of HS is the most commonly used indicator for muscle function in several clinical conditions, as it is considered a strong indicator of functional capacity of the muscles as well as an indicative point of a patient’s nutritional status. The correlation between nutritional status and HS is well documented , 14. PreNevertheless, our study is subject to several limitations. Τhe small sample size, the limited follow-up and the monocentric study design restrict the generalizability of our findings. Secondly, we could not precisely record the dates of patients’ deaths and, therefore, survival analyses could not be performed. Furthermore, major adverse cardiovascular events and re-admissions were not documented in our database. Additionally, PA was not standardized for its direct determinants: age, gender and BMI, which could affect our results; however, we have adjusted our multivariate analyses for age and gender, while BMI was not univariately associated with either mortality or ICU LOS. Nevertheless, PA standardization prior to statistical analyses might be considered in future studies , 21. MorIn this prospective observational study, the combination of low preoperative PA and HS values was significantly associated with higher risk of all-cause mortality at 12 months and prolonged ICU stay. Hence, these clinical biomarkers could serve as prognostic tools for assessing adverse clinical course after cardiac surgery procedures. Larger studies and randomized-controlled trials are needed to confirm these results.Additional file 1: Supplementary tables S1, S2, and S3.


Percutaneous coronary intervention of chronic total occlusion (CTO PCI) is a challenging procedure with high complication rates and, as not yet fully understood long-term clinical benefits. Ischemic symptom relief in patients with high ischemic burden is to date the only established clinical indication to undergo CTO PCI, supported by randomized controlled trials. In this context, current guidelines suggest attempting CTO PCI only in non-invasively assessed viable CTO correspondent myocardial territories, with large ischemic areas. Hence, besides a comprehensive coronary angiography lesion evaluation, the information derived from non-invasive cardiac imaging techniques is crucial to selecting candidates who may benefit from the revascularization of the occluded vessel. Currently, there are no clear recommendations for a non-invasive myocardial evaluation or choice of imaging modality pre-CTO PCI. Therefore, selecting among available options is left to the physician’s discretion. As CTO PCI is strongly recommended to be carried out explicitly in experienced centers, full access to non-invasive imaging for risk-benefit assessment as well as a systematic institutional evaluation process has to be encouraged. In this framework, we opted to review the current myocardial imaging tools and their use for indicating a CTO PCI. Furthermore, based on our experience, we propose a cost-effective systematic approach for myocardial assessment to help guide clinical decision-making for patients presenting with chronic total occlusions. Chronic total occlusion (CTO) of coronary arteries represents an advanced form of atherosclerotic coronary artery disease, which is currently prevalent in circa one-fifth of patients presenting for diagnostic coronary angiography . CTO is Due to the lack of randomized trials, the hard-outcome benefits of CTO PCI are not yet fully elaborated. However, the HORIZONS-AMI trial observed that the presence of a CTO in patients undergoing PCI for ST-elevation myocardial infarction was associated with worse early and late clinical outcomes .CTO PCI is a challenging procedure with increased technical complexity and a need for appropriate operator experience. Through recent advancements and the development of dedicated methods and devices in the last few years, success rates of CTO PCI have increased significantly. However, they remain lower than non-CTO PCI–#, with successful revascularization of CTO vessels ranging from 60–70% of patients in inexperienced operating centers and 90–95% in some highly experienced centers ,12,13,14The European Society of Cardiology (ESC) guidelines on myocardial revascularization suggest choosing patients for CTO PCI in a similar manner to those who need treatment for non-CTO lesions, and explain that clinical benefits are analogous among these patient groups–hence, the rationale and criteria for decision-making in the revascularization of stable CAD should apply to the CTO subset . As statMost importantly, CTO PCI is currently recommended by the ESC in selected patients with angina symptoms resistant to medical therapy   Table 2Table 2. Pre-interventional evaluation of CTO lesions has indeed to be well elaborated as the main characteristics of this specific lesion subset, such as collateral vessels and complete antegrade flow impairment, restrict diagnostic availability or alter the interpretations for clinical indication. For example, the use of the broadly recommended FFR or the novel CT-FFR measurements is not routinely possible in CTO vessels . Thus, nIn this context, suitable candidates to undergo CTO PCI should be carefully identified and selected taking into consideration diverse clinical factors and supported by appropriate cardiac imaging techniques evaluating viability and ischemia.Guided by current recommendations and clinical practice, we opted to review the available evidence on benefits of CTO PCI and shed light on pre-interventional requirements for the consideration of revascularization. Throughout our review, we used the term revascularization to reference PCI as our primary focus, if not stated otherwise. Furthermore, we summarised the available non-invasive imaging methods that support the physician to guide the patient selection process.In patients with coronary artery disease and normal ventricular function without regional wall motion abnormalities assessed by echocardiography, intact myocardial viability can be presumed . In thesn = 205) investigated the left ventricular recovery in terms of wall thickness and ejection fraction and found no differences between CTO patients who underwent revascularization and those who received optimal medical therapy alone. However, the results were limited by the low rates of ventricular dysfunction at baseline and the revascularization of diseased donor vessels in the control group [On the other hand, the clinical benefit of revascularization in patients with left ventricular dysfunction is still ambivalent. A considerable proportion of CTO patients manifest heart failure with a reduction of left ventricular function  but it iol group . Howeverol group . This stol group ,23. Howeol group . A viabiol group . On the ol group .It seems that revascularization in ventricular dysfunction has prognostic benefits, but it has been long debated if this implication depends on the revascularization method. Indeed, in the general CAD population, the recent FAME-3 trial reported a non-inferiority of functionally-guided PCI vs. CABG in 1-year follow-up. However, patients with left ventricular dysfunction were underrepresented with ca. 18% in both treatment arms .Recently, one randomized trial recently addressed the evidence gap. The REVIVED trial investigated patients with viable dysfunctional left ventricles undergoing PCI and reported no benefit in survival or cardiac events in 3 years compared to the control group which received optimal medical therapy alone. Moreover, the trial showed no improvement in left ventricular ejection fraction after PCI . HoweverOn the other hand, non-randomized data suggest PCI survival benefits in left ventricular dysfunction: Gerber et al., reported a higher 3-year survival in patients with severe left ventricular dysfunction and viable myocardium who received revascularization. Overall, the study reported similar 3-year mortality as the REVIVED trial . AlthougIn patients with ventricular dysfunction, PCI benefits may be found mostly in the presence of hibernation. An observational study on 648 patients reported that an extent of hibernating myocardium exceeding 10% was associated with the benefits of revascularization . PhysiolRevascularization of ischemic but viable myocardium aims to minimize residual ischemia and subsequently improves symptoms and prognosis. Patients with a large ischemic burden (more than 10%) are considered to benefit the most from PCI . This stNowadays, invasive functional assessment of coronary artery stenoses can derive information related to the extent of ischemia in the distal supply region. Treatment of functionally significant stenoses, as assessed by fractional flow reserve, has been proven to be superior to revascularization guided by anatomical evaluation alone. The FAME trial reported better 2-year MACE rates after revascularization of ischemic myocardium, as assessed invasively with FFR . HoweverIndeed, CTO-related myocardium can be an ischemic area even in well-developed collaterals. Werner et al., reported a sufficient collateral flow in only 5% of CTO patients with preserved left ventricular function . When paWe reviewed the currently available non-invasive diagnostic tools that can help to set the clinical indication for revascularization in CTO patients and described how they can help properly characterize this patient group by investigating quantitative and qualitative parameters . The avaResting transthoracic echocardiography (TTE) is a widely available diagnostic method in heart disease and provides an incremental value in characterizing the effects of coronary artery disease on myocardial anatomy and function. As such, it is a fast and efficient way to investigate possible myocardial conditions following a suspected or confirmed coronary artery disease ,46. TTE Dobutamine echocardiography, on the other hand, enables a dynamic assessment of the improvement in contractile function (contractile reserve) in dysfunctional areas and indicates preserved viability. A biphasic response in myocardial wall motion alterations after injection of dobutamine (motion enhancement at low doses and downgrading at high doses) indicates hibernating myocardium and preserved viability . DobutamEchocardiography represents a valuable non-invasive imaging method, but in general it can be limited by reduced image quality in patients with difficult acoustic windows, high interpreter variability, as well as low sensitivity to quantify persistent and stress-induced defects using wall motion assessment.Single Photon Emission Computer Tomography (SPECT) detects myocardial perfusion defects by deriving myocardial radiotracer uptake distribution . DiverseA classic stress myocardial perfusion imaging protocol is performed after physical or pharmacological stress using vasodilators such as dipyridamole, adenosine, or regadenoson, followed by radiotracer injection. A resting study precedes or follows  depending on the selected protocol . ReversiLimitations in SPECT perfusion imaging have been outmatched by the use of more precise positron emission tomography (PET) imaging modalities. The concept is to assess myocardial perfusion  and metabolism (using F-18-FDG) .FDG is actively transported into the inside of cells by the glucose transporters . In areaDynamic PET myocardial perfusion assessment enables quantitative information on myocardial blood flow (MBF) and myocardial perfusion reserve (MPR) ,71,72. SFunctional cardiac magnetic resonance tomography (CMR) with late gadolinium enhancement (LGE) is a highly sensitive imaging method for the evaluation of myocardial viability . GadolinWhile stress-rest SPECT may underestimate viability, the LGE stress and rest CMR can better assess scar, ischemia and hibernating myocardium . Stress CTO patients are often multimorbid patients with coexisting medical conditions that could alter diagnostics and clinical decisions, which calls for a dedicated patient evaluation in an outpatient clinical setting . For thiSupported by robust evidence, viability has a pivotal role in predicting short and long-term revascularization benefits. In patients with extended scarring in the CTO region, revascularization benefits are not warranted, while in those with smaller regional defects, the extent of viability could be interpreted along with angiographic information, to finally derive the binary labels of significant viability vs. non-viable CTO region. CMR delivers more accurate information in this context, as it can quantify both the regional extent and thickness of LGE enhancement. SPECT imaging for viability and ischemia is widely accessible and affordable; new CZT cameras and adapted protocols expose patients to less radiation. Thallium-201 SPECT rest-redistribution imaging provides better viability assessment compared to technetium-99 m stress-rest SPECT; in case of doubt, FDG-PET might be performed additionally. In the same manner, ischemia can be underestimated in some cases in the classic segmental semi-quantification . HoweverIschemia assessment is a more complex process in CTO patients, which requires careful angiography integration. Due to the development of collaterals, the CTO region and donor vessel are interconnected, thus influencing hemodynamic parameters and myocardial perfusion distribution. The collateral circulation and myocardial “steal” have been long described in the literature and recently tested in FFR studies, implicating two main effects: firstly, collaterals are rarely sufficient to provide enough flow to CTO regions; blood flow is further reduced in hyperemia due to coronary steal . SecondlSymptom improvement is the primary indication for CTO PCI with the strongest evidence to date. For this reason, ischemic symptoms and the will to accept the peri-interventional risks for improvement of life quality should stay on the plateau of the information cluster when conducting the pre-interventional evaluation. Secondly, the prognostic benefits of CTO PCI can be evaluated and taken into consideration, as stated in the European guidelines (CTO in left anterior descending or left main coronary artery, multi-vessel disease, reduced ejection fraction—Our proposed systematic workflow is presented in In conclusion, in the context of the lack of established patient evaluation algorithms including recommendations of specified cardiac imaging methods, this review has to be read as a suggestion according to the literature and the experience of the authors. Indeed, the evaluation process workflow is currently left to the physician’s discretion. However, patient evaluation should be conducted by physicians who are familiar with imaging techniques, complex coronary angiography and CTO PCI.


Aims: This study explored the advantages and limitations of novel series of three-dimensional (3D) echocardiographic techniques and summarized their application methods for congenital heart diseases (CHDs).Method and result: Two-dimensional (2D), traditional 3D echocardiography, and TrueVue plus light and/or Glass novel 3D technologies were performed on 62 patients with CHD, and a clinical survey was designed to judge whether the novel 3D images were more helpful for understanding the cardiac condition and guide treatment than traditional 3D images. TrueVue increased the visual resolution and simulated the true texture of cardiac tissue, significantly improving the display ability of abnormal anatomical structures in CHDs. TrueVue Glass displayed the blood channel and the internal structure of cardiac cavity more intuitively, indicating a new observation aspect not shown by conventional echocardiography. The clinical survey results showed that the new 3D imaging methods effectively increased the diagnostic confidence of echocardiographers, enabled surgeons to better understand the details of lesions, promoted efficient communication, and improved the confidence of both doctors and patients in treatment.Conclusion: The combined application of TrueVue, TrueVue Light, and TrueVue Glass more closely simulated real anatomical features, showed more comprehensive and subtle blood flow in the lumen, not only increased the visual effect but also provided more useful diagnostic information, improved the accuracy of evaluation and treatment of CHD when compared to traditional imaging techniques, indicating that this combined application has significant clinical value. Congenital heart disease (CHD) may be caused by developmental disorders during the cardiac embryonic period or unclosed channels after birth and is an important cause of death for children and adults . Real-tia priori approval by the institution’s human research committee.This study included 62 patients, who underwent echocardiographic evaluation in our hospital for cardiac-related clinical symptoms or signs and were diagnosed with CHD from August 2020 to May 2021, including 30 males and 32 females, with a mean age of 15.56 ± 14.71 years (range: 3 days to 56 years). This study does not establish strict exclusion criteria, even if the quality of the 2D image is not very satisfactory. For the original 2D image quality is not ideal, we also try to compare the imaging effect and the improvement of the diagnostic value after the conversion to the new 3D imaging mode, in order to objectively evaluate the actual value of these new imaging technologies. Therefore, TTE was performed in 41 cases and TEE was performed in 21 cases. TEE examiners excluded contraindications. All patients or their legal guardians signed an informed consent form. This study was approved by the Ethics Committee of China Medical University. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in Imaging was obtained via Philips EPIQ system, CVx equipment , with the appropriate 3D probes, including X5-1 or X7-2 for transthoracic echocardiography (TTE) or X8-2t for TEE. Each imaging mode was set to store continuous four cardiac cycles. After the 2D image was satisfactorily obtained, traditional 3D acquisition modes were initiated, such as Live 3D, Full Volume, or 3D Zoom to obtain real-time 3D images , and sixWe randomly selected 10 sonographers (the average age is 35.6 ± 10.73 years) as the echocardiographer group, eight doctors (40 ± 8.9 years) who specialize in cardiac intervention or thoracotomy surgery as the cardiac surgeon group , six cardiologists specializing in CHD interventional techniques , and 20 patients with CHD (or a parent of a child under 14 years) who underwent the novel 3D echocardiographic examinations to fill out a short questionnaire evaluating their experience, they were all provided score [using Likert score system ] the elet-test. Non-Gaussian data were compared using the Mann-Whitney test. Comparisons among the participant groups were performed using analysis of variance, the Kruskal-Wallis test, or the Chi square test as appropriate, and p < 0.05 was considered statistically significant.Using SPSS 25.0 software , categorical data are expressed as number of cases (percentage), for analysis of the Likert responses to the question design, data were tested for normality using the Kolmogorov–Smirnov test. Results are reported as mean ± standard deviation and median  for normally distributed and non-normally distributed data, respectively. Continuous normally-distributed data were compared using Student’s The advanced novel 3D echocardiography classified the 62 patients as follows: 18 (29.0%) with ventricular septal defect (VSD); 17 (27.4%) with atrial septal defect (ASD); 9 (14.5%) with patent ductus arteriosus (PDA); 5 (8.1%) with aortic valve malformation; 4 (6.5%) with mitral valve cleft; 3 (4.8%) with pulmonary artery stenosis; 2 (3.2%) with complete atrioventricular septal defect (CAVSD); 2 (3.2%) with double orifice mitral valve (DOMV); and one case (1.6%) each of pulmonary artery sling, and ventricular diverticulum. Of the total patients, 55 (88.7%) underwent cardiac surgery, including conventional thoracotomy or interventional cardiac procedures, wherein the results of the ultrasound diagnosis were confirmed.For patients undergoing innovative 3D imaging, 55 cases (88.7%) obtained satisfactory TrueVue images, and 59 (95.2%) obtained satisfactory TrueVue Glass images. For patients who underwent TTE, the overall satisfaction ratio with 3D images was 87.8% (36/41). For TEE, the overall satisfaction ratio was 100% (21/21). The standard for satisfactory image quality is to provide a clear and obvious evidence for diagnosis. Dissatisfaction with the quality of transthoracic ultrasound images is mainly due to obesity or excessive lung gas. During the TrueVue imaging of the patients with VSD, placing the light source below the defect made the shape and edge of the defect extremely eye-catching when compared with that of traditional 3D ultrasound, especially for the diagnosis of a small perimembranous ventricular defect . While ip < 0.0001)  .TrueVue is a new, high definition 3D rendering mode whose spatial image gradually transitions from light-pink to orange-red to represent the surface to deep structures and simulate the real texture of heart tissue, enabling a hierarchical and realistic view of a variety of structures . On the Although traditional 3DE can display some congenital malformations, there remain shortcomings in the resolution of small structures and the display of deeper organizational structures . TherefoAlthough the diagnostic value of traditional 3DE has been confirmed for relatively common septal defects , TrueVueFor malformations of the thin cardiac valves, traditional 3D images are closely dependent on the quality of 2D images; however, while they are often used to evaluate the relatively large and morphologically regular mitral valves , their dThis is exactly the issue with 3D rendering techniques: they often “look good” but misrepresent the anatomic details; especially with thin structures. The new Glass imaging mode has obvious visual enhancement effects on the ability to display thin structures, such as the atrial septum and thin valves, to a certain extent, improving the problem of false echo loss in traditional ultrasound.Rare pulmonary artery sling imaging has certain difficulties in 2D and traditional 3DE, usually need time-consuming and laborious to confirm the diagnosis through the 3D reconstruction of enhanced computed tomography (CT), and the children under examination are not easy to cooperate well . TrueVueBecause the content and features of the diagnostic concerns of different diseases are significantly different when applying ultrasound imaging, we will ask more targeted questions for different diseases during the questionnaire process, also because the diagnostic advantages of these new 3D imaging technologies will be more obvious for certain types of CHD. At the same time, considering that the patient’s feelings are equally important in the evaluation and treatment of CHD, including a full understanding of the characteristics and extent of their disease and the surgical procedure explained by the doctor, we ask some of the patients or their guardians to observe the conventional and new 3D display of the lesion through the doctor’s explanation of the characteristics of their disease. However, since they are not professionally trained in medicine, they will only answer a small part of the questions related to their medical procedure.Although the true resolution of the above-mentioned new series of 3D images has not been improved digitally, these new imaging modes plus light and shadow effects have significantly improved the visual effects and diagnostic efficiency of the characteristics of CHDs. Although traditional 2D and 3DE can also help us complete most of the ultrasonic diagnosis of CHD, it is time-consuming and labor-intensive, especially in some special diseases. The innovative TrueVue combined with Light and Glass 3D imaging technology provides us with more reliable reference information. In particular, the layered sense by the photorealistic light source addition, and the outer contour imaging of the heart cavity displayed by the application of Glass (such as the shape of the left atrial appendage  and the The TrueVue, TrueVue Light, and TrueVue Glass series of 3D cardiac ultrasound technologies have achieved satisfactory results in some research fields, but there are some limitations and deficiencies. This innovative series of 3DE improved the visual clarity of image details to a certain extent, but in cases where the 2D image was very dissatisfied displayed, it was still difficult to obtain a satisfying 3D image, especially in TrueVue mode. Moreover, the application of TrueVue plus light and Glass have requirements for the operator, who should have mastery of the overall and partial anatomy of the heart and be able to apply the tools of the machine for image processing. It also requires the operator to be an “artist,” able to flexibly use the visual effects produced by the light source to display the abnormal anatomical structure. Therefore, a certain learning curve to obtain optimal rendered images is required, and for doctors with traditional 3DE operation experience, it is easy to master the methods and skills of the new series of 3DE operations. Furthermore, the extensive post-processing increases the possibility of artificial creation or loss of defects based on variations in both scan quality and post-processing technique. At present, as the 3DE of the TrueVue series, especially TrueVue Glass, is a recently launched novel tools, there are few published reports about them. In addition, although our research is one with the largest sample size reporting on the application of the above-mentioned new tools, it discusses limited types of CHDs. Therefore, further studies are needed to explore their application value and experience.This study showed the excellent applicability of TrueVue, TrueVue Light, and TrueVue Glass as diagnostic tools for patients with suspected CHD. Compared with 2D and traditional 3DE, the TrueVue, TrueVue Light, TrueVue Glass series of novel 3DE technologies’ display of abnormal structures in patients with CHD more closely simulate real anatomical features and make the outer contours of the heart chambers, the thin valves and blood flow in the lumen more comprehensive and clearer. These technologies provide us with a wealth of evidence for the diagnosis and treatment of CHD and are a revolution in the ultrasonic diagnosis method of CHD.


Background: The subcutaneous implantable cardioverter defibrillator (S-ICD) was developed as an alternative to the transvenous ICD, to prevent lead-related complications associated with the latter. The absence of intravascular or intracardiac components offers potential advantages to pediatric patients. Aims: The aim of the study is to present an overview of our experience with S-ICDs in the pediatric center that, currently, has performed the largest number of implantations in children in Poland. Methods: Retrospective analysis of data from medical history, qualification, implantation procedure, and S-ICD post-implantation observations in 11 pediatric patients were performed. Results: S-ICDs were implanted in 11 patients, 8 boys and 3 girls, aged 12–17 years. The S-ICD was implanted for primary prevention in seven patients: four with hypertrophic cardiomyopathy (HCM), two with dilated cardiomyopathy (DCM), and one with arrhythmogenic right ventricular cardiomyopathy (ARVC). It was implanted for secondary prevention in four patients: two with sudden cardiac arrest (SCA) in the course of idiopathic ventricular fibrillation (IVF), one with long QT syndrome (LQTS) after probable SCA, and one with Brugada syndrome after SCA. In all patients, the device was implanted intramuscularly. One patient did not have a defibrillation test performed due to the presence of an intracardiac thrombus. In one patient, during screening, it was decided to implant an electrode on the right side of the sternum. There were no early or late complications with any of the procedures. So far, no inadequate discharges have been observed. Conclusions: Our results prove the efficacy of the S-ICD treatment option along with technically simple surgery, which supports its further and more widespread application in children. Prevention of sudden cardiac death (SCD) is of major concern in cardiology. The development and spread of implantable cardioverter defibrillators (ICDs) have resulted in a breakthrough in treatment and prevention in patients at high risk of SCD. Currently, ICD implantations are considered routine procedures in cardiology departments in developed countries. To date, the majority of high-voltage devices are represented by transvenous leads. Less frequently, epicardial defibrillation patches are used, mainly in the pediatric population ,2. The mIn this retrospective study, we present a 4-year single-center experience with the use of S-ICDs. The aim of the study was to provide an overview of early experience with S-ICDs in the pediatric center.Patients: 11 pediatrics patients, 8 boys and 3 girls, aged from 12 to 17 years were analyzed.An S-ICD was implanted for primary prevention in 7 patients: 4 with hypertrophic cardiomyopathy (HCM), 2 with dilated cardiomyopathy (DCM), and 1 with arrhythmogenic right ventricular cardiomyopathy (ARVC). An S-ICD was implanted for secondary prevention in 4 patients: 2 with sudden cardiac arrest (SCA) in the course of idiopathic ventricular fibrillation (IVF), 1 with long QT syndrome (LQTS) after probable SCA, and 1 with Brugada syndrome after SCA. None of the patients had an absolute indication for permanent pacing.Data from medical history, qualification, implantation procedure, and S-ICD post-implantation observations in 11 pediatric patients were analyzed. All patients were informed of the characteristics of the new system, indications, and potential complications. Informed consent was obtained from each patient. Prior to the procedure, patients were screened with a manual screening tool to assess the applicability of this technology. All patients were screened in accordance with currently applicable procedures and standards.An electrophysiology expert participated in all the procedures. All procedures were performed under general anesthesia. Proctor Prof. Joachim Winter, a cardiac surgeon at the Medical University of Dusseldorf, participated in the first implantation procedure. The subcutaneous or intramuscular implantation technique and pocket placement developed by Professor Winter is considered to offer good aesthetic results, especially in young people, as well as to reduce local complications associated with the implant . In all The results are summarized in A 17-year-old male patient with hypertrophic cardiomyopathy with left ventricular outflow tract obstruction (HCM with LVOTO). Echocardiography revealed the following: significant degree of concentric myocardial hypertrophy, LVOTO with maximal systolic pressure gradient LV-Ao 108–112 mmHg, and mean pressure gradient 55 mmHg.A 17-year-old male patient with heart failure in the course of dilated cardiomyopathy, with gradually worsening left ventricular function and coexisting complex ventricular arrhythmia (VT episodes up to 170/min) and ventricular tachycardia (VT) with celiac disease, congenital IgA deficiency, and history of renal failure episode. The patient was qualified for heart transplant and LVAD (left ventricular assist device). A HeartMate 3 was implanted for left ventricular support as a bridge for heart transplantation. At the time of publication, the patient has not yet received a heart transplant. He is doing well, helps with lighter household chores, meets with friends, has a girlfriend, and describes his quality of life as satisfactory .A 17-year-old male patient with hypertrophic cardiomyopathy, obesity, insulin resistance, and arterial hypertension. Echocardiography revealed asymmetric LV hypertrophy and LV outflow tract obstruction with systolic pressure gradient LV-Ao up to 70 mmHg and complete obliteration of LV lumen during systole, hyperkinesis of both ventricles, mitral insufficiency, and left atrial enlargement. Non-sustained ventricular tachycardia (nsVT) was recorded in Holter ECG monitoring. During screening, correct sensing parameters were obtained for the electrode located on the right side of the sternum .The S-ICD was implanted for primary prevention in seven patients:Despite obesity and the need to implant the electrode at a greater distance from the defibrillator, there were no procedure-related complications.4.A 17-year-old male patient with dilated cardiomyopathy and severe heart failure, who was qualified for heart transplant. In echocardiography, significantly enlarged LV with impaired global myocardial contractility—LV EF 10–25%—and enlarged LA were found. CMR showed no signs of active or previous myocarditis, decreased left ventricular (EF 13%) and right ventricular (EF 16%) contractility, and myocardial fibrosis. In addition, imaging examinations revealed thrombus in the apical part of the left ventricle and treatment with low-molecular-weight heparin was introduced at a therapeutic dose, which led to regression of the lesion. Due to lack of thrombus in follow-up examination, defibrillation testing (DFT) was performed. Ten months after S-ICD implantation, the patient died of circulatory failure in the course of COVID-19 pneumonia. At the parents’ request, the device was not collected after the boy’s death. Reading was not possible due to epidemiological reasons.5.A 17-year-old female patient with hypertrophic cardiomyopathy and pre-excitation in ECG (after two-fold RF ablation—radiofrequency catheter ablation), treated with Sotalol, in whom genetic testing revealed heterozygous deletion in the LAMP2 region typical for Danon disease. The findings of the echocardiographic examination were as follows: features of hypertrophic cardiomyopathy, LV diastolic dysfunction, borderline size of LA, and normal LV contractility. CMR showed the presence of a parietal LV thrombus, LV myocardial fibrosis, mixed hypertrophic cardiomyopathy, and LV myocardial noncompaction with normal LV contractility. ECG monitoring reported episodes of ventricular tachycardia and multiple narrow QRS complex tachycardias. Due to the presence of thrombus, no defibrillation test was performed.6.A 16-year-old male patient with hypertrophic cardiomyopathy, whose echocardiographic examination showed extreme concentric left ventricular hypertrophy and almost complete obliteration of the ventricular lumen in systole. In CMR, visible signs of edema within LV myocardium and diffuse areas of myocardial fibrosis/necrosis of non-ischemic etiology were revealed. Self-limiting ventricular tachycardia and prolonged QT with a mean QTc 460 ms were recorded in Holter monitoring.7.2, EF < 40%) in CMR were fulfilled.A 17-year-old male patient with complex ventricular arrhythmia and arrhythmogenic right ventricular cardiomyopathy. Holter monitoring revealed PVCs with increasing tendency . Positive family history—the boy’s brother died suddenly at age 13 years and the boy’s father died at age 40 years. In echocardiography, RV within the upper limit of normal, convex RV free wall, thick septo-marginal trabecula and increased trabeculation of the apical part of the right ventricle, and preserved systolic function of the right ventricle were found. The main criteria for the diagnosis of arrhythmogenic right ventricular cardiomyopathy  after outpatient cardiac arrest. The incident took place in a mall while shopping. Ventricular fibrillation was documented in AED records. Imaging examinations (ECHO) showed normal morphology of the heart structures. Diagnostic tests toward channelopathy were performed: no signs of prolonged QT were found in a series of ECG tests. Exercise stress test was negative—there was no arrythmia during the test and QTc in the 4th minute of rest was normal. Subsequently, a drug provocation test was conducted with adrenaline and ajmaline—both were negative. Therefore, idiopathic ventricular fibrillation was diagnosed. Beta-blocker treatment was introduced with good drug tolerance. The patient was very slim and implantation was technically difficult, but the cosmetic effect was very good .9.A 12-year-old female patient with long QT syndrome , confirmed by genetic testing, treated with propranolol. While playing in a pool , the girl lost consciousness for about 2 min. The loss of consciousness was sudden and was not preceded by palpitations or a feeling of weakness, visual disturbances, or dizziness. During the period of unconsciousness, the girl first presented with tautness; she was pale, limp, and did not respond to stimuli. After being taken out of the pool, she was still unconscious, without a pulse. After consciousness returned, there was no confusion or excessive sleepiness. Since then, QTc 0.46–0.5 s has been observed. The girl’s older brother is also a patient of the Clinic; he was diagnosed with LQTS, which was genetically confirmed. During the course of diagnosis of both children, their mother was also diagnosed with prolongation of QT interval, as well as their grandmother. During the girl’s exercise stress test, QTc at the 4th minute after exercise was 0.49 s. Due to her very slim body structure and low weight (38 kg), the procedure was technically difficult, but it was possible to create an intramuscular pocket. The procedure was performed using a two-incision technique. There were no complications. On day 2, the patient was mobilized, and after about a week during a control visit, she presented without pain with almost the entire range of left-hand movement was recovered .10.A 16-year-old male patient with sudden cardiac arrest that occurred at school during a sports lesson—the child collapsed without any warning symptoms after having performed physical activity. The teacher started CPR. At the scene of the incident, paramedics diagnosed the boy with ventricular fibrillation and performed defibrillation three times, restoring the sinus rhythm. Family history of SCD was negative. ECG showed normal sinus rhythm, with normal QTc and early repolarization features in leads II, III, aVF, V5, and V6. Holter monitoring ECG showed no arrhythmia. ECHO showed normal LV size and contractility. An exercise treadmill test was performed—no arrhythmia was observed with normal QTc at 4 min of rest. ECG with high right ventricular leads and provocative test with flecainide were performed and were both negative. Angio CT of the coronary arteries revealed a muscular bridge over the course of the left anterior descending coronary artery without narrowing in coronarography with nitroglycerines, with no ischemic features and no myocardial edema in CMR.11.A 16-year-old male patient diagnosed with Brugada syndrome, implanted with an ICD system, qualified for S-ICD implantation due to battery depletion and increasing defibrillation lead resistance. He had a history of several episodes of unconsciousness up to the age of 3 years and, at age 9 years, during an episode of SCA, the boy lost consciousness on the beach; he was assisted by a cardiologist present there, who started CPR. During hospitalization after the episode, he was diagnosed with Brugada syndrome. He was implanted with an ICD and one year after implantation, there was an episode of adequate defibrillation. It was decided that the transvenous system would be temporarily left and an S-ICD device implanted and, after healing, a decision would be made on the intracardiac lead removal.S-ICD was implanted for secondary prevention in four patients:There were no early or late complications related to the procedure in any of the patients .S-ICD constitutes a new treatment perspective for patients with primary electrical or structural heart disease, preventing them from SCD, while the heart and vessels remain unaffected. Its advantages to young patients are aesthetically pleasing results. The S-ICD system diminishes the risk of the lead insulation damage because of its multistrand cable core lead design and no lumen and no systolic and diastolic cyclic friction within the heart. Implantation of the S-ICD using anatomical landmarks reduces the X-ray dose significantly. The risk of lead-related infective endocarditis, cardiac perforation, and pneumothorax is eliminated. Advanced experimental trials are being conducted to develop a smaller and lower-energy pulse generator system with a miniaturized lead. It is estimated that 35 J of energy should be sufficient for this purpose in small children of 5–10 kg weight . The maxIt is reported that the overall rates of complications in adults after S-ICD are similar to those of transvenous systems ,13,14. TUse of the S-ICD is indicated in patients who are ineligible for a transvenous system, patients with difficult venous access to the heart due to thrombosis, or congenital anatomical anomalies, after transvenous electrode removal and as a procedure of choice in young patients. It is extremely important to emphasize that, in the event of infection or damage to the S-ICD electrode, its removal and replacement is much easier and safer and with minimal risk of severe complications compared to transvenous electrode removal and replacement. This is an important argument in favor of the S-ICD as the first-choice method in young patients over the TV-ICD . As thisThere were 11 patients in our group, 8 boys (72.7%) and 3 girls (27.3%), aged from 12 to 17 years, mean 15.5 years. In the monitoring so far, none of our patients have suffered from inadequate defibrillation. To date, we have not observed late complications. The largest study published to date described 115 children and adolescents from 15 centers in the United States. For comparison, the cited study comprised 115 patients with a median follow-up of 32 (19 to 52) months. Their median age was 16.7 years (14.8 to 19.3 years); 29% were female and 71% were male. Fifty-five per cent had a primary prevention indication. The underlying disease substrates were cardiomyopathy (40%), structural heart disease (32%), idiopathic ventricular fibrillation (16%), and channelopathy (13%). The complication rate was 7.8% at 30 days and 14.7% at 360 days. Overall, inappropriate shocks occurred in 15.6% of patients. At implant, 97.9% of patients had successful first-shock conversion with 96% requiring ≤65 J. Appropriate therapy was delivered to 11.2% [A study from another center in Poland was published in 2020, which covered a group of 80 patients with ICDs implanted over a period of 22 years (13). In the study, a group of children, adolescents, and young adults aged 6–21 years with different types of implanted devices was analyzed. S-ICDs were implanted in eight patients, whose average age was 18 years (15–21 years). The exact number of pediatric patients under the age of 18 years with an S-ICD implantation is not clearly stated.At the time of publication, there are two more patients who have been successfully qualified in our center for the S-ICD procedure: two girls with hypertrophic cardiomyopathy and high risk of SCD. The parents previously refused consent to a venous ICD, so the only option being considered is the S-ICD.Our results prove the efficacy of the S-ICD treatment option along with technically simple surgery, which supports its further widespread application in children.We are convinced that the safety, short term of the procedure, good cosmetic effect, even in slim patients, and the absence of intravascular or intracardiac components offer potential advantages to pediatric patients and those with congenital heart disease.


To measure native T1 values, a marker of diffuse fibrosis, by usingcardiac MRI (CMR) in young adults born prematurely.t test. Associations between T1 values and othervariables were analyzed by using linear regression and multivariateregression.This secondary analysis of a prospective cohort study included youngadults born moderately to extremely preterm and age-matched, term-bornparticipants. CMR was performed with a 3.0-T imager that included cineimaging for the quantification of left ventricular (LV) and rightventricular (RV) volumes and function and native saturation recovery T1mapping for the assessment of diffuse myocardial fibrosis. Valuesbetween preterm and term were compared by using the StudentP = .0019). Native T1 values appeared to bepositively associated with indexed LV end-diastolic and end-systolicvolumes , the RV end-diastolic volume index, and the LV mass index . Higher T1 values may be associated withreduced cardiac systolic strain measures and diastolic strain measures.Five-minute Apgar scores were inversely associated with native T1values.Of the 50 young-adult participants, 32 were born preterm  and 18 were born at term . Native T1 values were significantlyhigher in participants born preterm than in participants born at term(1477 msec ± 77 vs 1423 msec ± 71, respectively;unadjusted Young adults born moderately to extremely preterm exhibited significantlyhigher native T1 values than age-matched, term-born young adults.Keywords: MRI, Cardiac, Heart, Left Ventricle,CardiomyopathiesClinical trial registration no. NCT03245723Published under a CC BY 4.0 licenseSupplemental material is available for thisarticle.  Young adults born moderately to extremely preterm exhibited significantly highernative T1 values than age-matched, term-born participants, suggesting thatdiffuse myocardial fibrosis may be present in adults born prematurely and may beassociated with adverse cardiac function.LV], 1477.4 msec± 76.8; mean T1 value for a 1-cm2 region of interestin the septum [T1septum], 1487.0 msec ± 67.4;P = .019 and .003, respectively) compared withterm-born participants .■ Significantly higher native T1 values were observed in youngadults born prematurely  can help characterize thechanges in myocardial tissue in a variety of pathologic conditions. Interstitialfibrosis affects the longitudinal proton relaxation times following a preparationpulse and can be quantified by using T1 mapping sequences . This isThe primary aim of this study was to compare native T1 values derived at CMR, amarker of diffuse interstitial fibrosis, in young adults born extremely preterm(≤32 weeks’ gestation) with those in age-matched, term-born controlparticipants. Our primary hypothesis was that native T1 values are elevated in youngadults born preterm. Secondary, exploratory aims of this study were to investigatethe relationships between myocardial T1 values and measures of cardiac function andneonatal circumstances.This cross-sectional cohort study was approved by the University ofWisconsin–Madison Institutional Review Board and was in compliance withthe Health Insurance Portability and Accountability Act. Prior to all studies,participants gave written informed consent. Young-adult (≥18 years)participants born preterm were recruited from the Newborn Lung Project , a cohorFor the participants born preterm, neonatal records were reviewed for thefollowing: gestational age (in weeks); birth weight (in grams); 1-minute and5-minute Apgar scores (0–10); days on mechanical ventilation, continuouspositive airway pressure, and supplemental oxygen; days in the neonatalintensive care unit; the administration of maternal steroids and the presence ofmaternal preeclampsia (yes or no); the diagnosis of bronchopulmonary dysplasia(yes or no); the administration of neonatal steroids, surfactant, or totalparenteral nutrition (yes or no); and the type of feeding during infancy. This is a secondary analysis of data acquiredprospectively between 2016 and 2020 .ClinicalTrials.gov identifier: NCT03245723).The trial was registered with the United States National Library of Medicine and LV size and function were assessedwith multiplanar, cineangiographic, prospectively gated, balanced steady-statefree precession imaging performed during end expiration. Parameters for thecineangiographic, balanced steady-state free precession were 3.1-msec repetitiontime, 1.1-msec echo time, array spatial sensitivity encoding technique factor =two; 2350 × 350–mm2 field of view, 1.4 ×1.4–mm2 in-plane spatial resolution, and 7-mm sectionthickness.Non–contrast-enhanced CMR was performed with a 3.0-T combined PET/MRimager  ,11. ParaLV) and themean T1 value for a 1-cm2 region of interest in the septum(T1septum) of the same mid-LV section. For the LV, end-diastolicvolume (EDV), end-systolic volume (ESV), stroke volume (SV), EF, cardiac output,and mass were calculated. For the RV, EDV, ESV, SV, EF, and cardiac output werecalculated. EDV, ESV, SV, cardiac output, and mass were indexed to body surfacearea calculated by using the Mosteller method.Analysis of ventricular volumes, EF, mass, and native T1 values was performed bya single reader with more than 10 years of CMR experience (C.J.F.) and by usingcommercially available software . T1 values were calculated by using a three-parameter fit, taking themean native T1 value for the entire mid-LV section (T1http://segment.heiberg.se)  with 5 yearsof CMR experience and by using commercially available software  . Peak glt test with equalvariance. Secondary volumetric and strain measures were compared for meandifferences between participants born at term and participants born preterm byusing the Student t test; adjusted P valueswere calculated by using Hochberg methods to control for false discovery rate(FDR)   . Other cIn participants born preterm, associations between T1 values and neonatalmeasures were evaluated by using linear regressions for continuous measures andadjusted for FDR. In addition, we investigated the effects of birth measures oncurrent T1 values in a multivariate regression model, including gestational age,birth weight, the Apgar score at 5 minutes, and any ventilation  used.P values presented forsecondary volumetric and strain measures were adjusted for FDR.The significance level was determined a priori at the .05 level, and all testswere two-tailed. Data are presented as means ± SDs or as medians andranges, unless otherwise noted. P = .75). For the pretermcohort, the gestational age was 29.2 weeks ± 2.5, and the birth weightwas 1225.4 g ± 397.Participant demographics are summarized in n =32) and in all but two participants born at term (n = 16). Intwo participants born at term, native T1 mapping was not included because CMRwas performed with a different MR imager (n = 1) or becausebanding artifacts precluded quantification of T1 values (n =1). Native T1 values were higher in participants born preterm  and1412.2 msec ± 80.7 (P = .003) in participants born atterm, respectively. We found no evidence of a difference in mean native T1values between men and women.Native T1 mapping imaging  wassucc preterm , Table 2LV and T1septum values of 58.3 msec(P = .02) and 73.4 msec (P = .004),respectively .In multivariate models adjusting for current age, sex, body mass index, andsystolic blood pressure, participants born preterm had higher mean T1 valuesthan did participants born at term; participants born preterm demonstratedT1−1 ± 11.3 compared with −11.4% ±2.9  and −42.5sec−1 ± 12.1 , respectively). For the RV,peak GCS and peak systolic and diastolic GCS rate were generally of greatermagnitude in participants born preterm than in participants born at term. FollowingFDR adjustment for multiple testing, the RV peak GCS was found to besignificantly different between term and preterm groups.LV and RV structure and function parameters for participants born at term andparticipants born preterm are summarized in LV and T1septumvalues, adjusting for preterm status, are summarized in LV values appearedto be associated with a higher LV EDV index , ESV index ,mass index , and RV EDV index .Higher T1septum values were observed with a higher LV EDV index, SV index , and RVSV index . In four participants bornpreterm with T1LV values greater than 2 SDs above the meanT1LV values in participants born at term, the LV EF appearedlower than in those with T1LV values within 2 SDs of the meanT1LV values in participants born at term . In threeparticipants with T1septum values greater than 2 SDs above the meanT1septum values in participants born at term, we found noevidence of a difference in the LV EF relative to those with T1septumvalues within 2 SDs of the values of participants born at term .Associations among CMR parameters and T1LV values were observed with a lower-magnitude LV peak GRS and GCS , peaksystolic and diastolic GRS rate ,peak diastolic GCS rate , and RV peak diastolic GCSrate . Higher T1septumvalues appeared to be associated with a lower-magnitude LV peak systolic GRSrate .Higher T1LV values and Apgar scores at 5 minutes, with lower Apgarscores being associated with higher T1 values, but no neonatal values wereassociated with T1LV values following adjustment for FDR. Weaker orno associations were present between native T1LV values andT1septum values and other neonatal variables. Of the 31participants with known ventilation use at birth, only seven (23%) did notrequire continuous positive airway pressure or mechanical ventilation.With regard to neonatal variables in participants born preterm , the strP = .003 for T1LV and P =.03 for T1septum; Tables E3,E4 [supplement]). Gestational age, birthweight, and use of ventilation were not associated with T1 values.In multivariate models investigating the association of birth measures and T1values, Apgar score remained the most highly associated with T1 values, witheach unit increase in an Apgar score being associated with a reduction in the T1value  than in age-matched, term-birthparticipants .Higher native T1 values appeared associated with larger LV and RV volumes, greaterLV mass, and abnormal LV and RV strain values. Of the various neonatal variablesrecorded in the preterm adults, 5-minute Apgar scores showed the strongestassociation with T1 values.In this study, we found that native T1 values derived at CMR were higher in adultsborn prematurely , several reflect cardiac function and are reduced ininfants with cardiac depression at births requiring resuscitation efforts. Low Apgarscores can predict short-term prognosis and the need for more cardiopulmonaryresuscitation in the first 6–8 hours of life  and may This study had several limitations. First, the relatively small size of the cohortlikely contributed to the low number of significant associations. Many of theoriginal participants in the Newborn Lung Project cohort, recruited from 1988 to1991, have been lost to follow-up. However, we have not observed any differences incharacteristics of participants born preterm from the original Newborn Lung Projectcohort and those recruited de novo for this study. In addition, the absence ofimaging after the administration of intravenous gadolinium-based contrast agents didnot allow us to assess areas of replacement fibrosis or calculate extracellularvolume. Without longitudinal data, it is not possible to determine whether theelevated native T1 values are constant or whether they change over time. Althoughvery high temporal resolution is required to accurately measure strain rates,particularly systolic strain rates, we observed significant differences in LV peakdiastolic GLS rate and RV peak systolic and diastolic GCS rates. Future studiesusing echography or higher temporal resolution strain imaging are necessary toconfirm the presence of abnormal strain rates in those born preterm.In conclusion, young adults born moderately to extremely preterm (≤32weeks’ gestation) demonstrated evidence of diffuse interstitial myocardialfibrosis based on CMR native T1 mapping. The diffuse fibrosis may be associated withcardiac chamber size and function, providing additional evidence of a distinctcardiomyopathy associated with premature birth. In our analysis, lower 5-minuteApgar scores appeared to be most associated with higher native T1 values. Youngadults born prematurely, particularly those with lower Apgar scores, warrant closefollow-up to monitor for adverse cardiovascular outcomes.