Electrical disparity can induce inefficient cardiac performance, representing an uncoordinated wall motion at an earlier activated ventricular wall: an early shortening followed by a systolic rebound stretch. Although regional contractility and distensibility modulate this pathological motion, the effect of a morphological factor has not been emphasized. Our strain analysis in 62 patients with single ventricle revealed that those with an activation delay in 60–70% of ventricular wall area suffered from cardiac dysfunction and mechanical discoordination along with prolonged QRS duration. A computational simulation with a two-compartment ventricular model also suggested that the ventricle with an activation delay in 70% of the total volume was most vulnerable to a large activation delay, accompanied by an uncoordinated motion at an earlier activated wall. Taken together, the ratio of the delayed ventricular wall has a significant impact on the pathophysiology due to an activation delay, potentially highlighting an indicator of cardiac dysfunction. Electrically and mechanically synchronous wall motion is essential for efficient cardiac performance. Dyssynchronous contraction and relaxation reduce the cardiac output, eventually leading to adverse myocardial remodeling and heart failure . The disIn an anatomically normal left ventricle, the left bundle branch block (LBBB) can induce an uncoordinated septal motion known as a septal flash, which is characterized by an early shortening during the isovolumic contraction period followed by a rebound stretch during the ejection period. Patients with LBBB have a worse prognosis than those with non-specific intraventricular conduction delay or with right bundle branch block , 4, whicBesides the anatomically normal left ventricle, we have reported that a characteristic motion similar to the septal flash could be detected at the earlier activated ventricular wall in pediatric patients with functional single ventricle . In thatIn this study, we hypothesized that the ratio of the ventricular wall exhibiting delayed contraction has a pivotal impact on ventricular dysfunction because of the widened time delay of activation onsets. To test this hypothesis, we analyzed ventricular strain in patients with single ventricle with prolonged QRS duration. Further, we developed a two-compartment ventricular model in a zero-dimensional platform, which allows simple characterization of cardiac mechanics, taking no account of pressure and flow wave dynamics across ventricles and vascular trees afforded by higher dimensional model. The hemodynamic simulation study was performed to obtain a deeper understanding of the results of the clinical study.The clinical study complied with the principles outlined in the Declaration of Helsinki and was approved by the institutional review board . A total of 62 consecutive patients with single-ventricle anatomy were retrospectively identified and included according to the following inclusion criteria: a postoperative state after bidirectional Glenn or Fontan operation, the presence of conduction disturbance defined as QRS duration Z-score ≥ 2 , 14, and−2). We estimated ventricular contractility by ventricular elastance at end-systole  using the following equation:dic is the dicrotic notch pressure at the ascending aorta.All patients underwent diagnostic cardiac catheterization with angiography under mild procedural sedation as previously described . CentralAll echocardiograms were obtained between April 2013 and March 2017 using a Philips iE33 ultrasound system  by a single observer (Y.H.). The frame rates were maximized at 52–100 frames/s to provide the highest possible temporal resolution. The timings of the atrioventricular and aortic valve opening and closure from QRS onset were measured from pulse-wave Doppler flow sampled in the ventricular inflow or outflow tract and served as cardiac event timing markers. An off-line myocardial strain analysis was performed based on two-dimensional speckle tracking using QLAB 9.1 software .delayed) is calculated as the length of the delayed wall divided by the global base-to-base longitudinal length. An area ratio of the delayed wall (ARdelayed) was then derived from LRdelayed as follows  derived from two strain values (%) during the isovolumic contraction period and ejection periods; Rstrains = (100 + Strainejection)/(100 + Strainisovolumic) [strains was measured based on a hemiglobal longitudinal strain at three segments on the earlier activated side among seven segments of the global ventricular wall  was measured and used as an index of ventricular mechanical stress. This surrogate marker was reported to be an independent predictor of all-cause mortality in patients with single ventricle .delayed was varied. The volume ratio of the delayed compartment was equal to ARdelayed under the assumption of identical curvatures . An atrioventricular interval was fixed, whereas ΔT varied from 0 to 90 ms in steps of 5 ms. The ΔT of 90 ms corresponds to 10 standard deviations of the QRS elongation observed in our patient study. We also varied the volume of the delayed compartment in the two-compartment model from 5 to 95% of the total end-diastolic ventricular volume in steps of 5%. Corresponding to the increase in the ratio of the delayed compartment, the volume in the earlier activated  compartment would decrease from 95 to 5% of the total end-diastolic ventricular volume. In the setting of the ventricle separated into 20 units, ventricular parameters were thus given for one unit . Cardiac and vascular characteristics of the simulation study were tuned to yield typical postoperative hemodynamics of a 40-kg body after Fontan operation, which was comparable to the hemodynamic data at our institute [We specified a time delay of the activation onset at a delayed ventricular wall by Δnstitute  and thisOur simulation provided two volumetric values of earlier activated and delayed ventricular compartments as a function of time. When earlier activated and delayed ventricular compartments are connected with a sagittal plane perpendicular to the base of the hemisphere, a longitudinal strain can be measured using a coronal cut-plane through the vertex of the hemisphere. This view is analogous to an apical four chamber-like view in the anatomy with single ventricle that includes earlier activated and delayed walls Fig. . In accop value < 0.05. To analyze the combined effects of ARdelayed and an activation delay in clinical study, we drew a response surface for plasma BNP levels or estEes using a second-order polynomial model.All statistical analyses were performed using JMP 12.0.1 . Categorical variables were expressed as frequencies and percentages, whereas continuous variables are expressed as the median and interquartile range. Spearman’s correlation analysis was used to assume relationships between continuous variables. Statistical significance was accepted at Subject characteristics in the patient study are summarized in Table delayed, and ventricular function evaluated by plasma BNP levels or estEes in this cohort. Figure delayed on the horizontal axis. The relationships in the response surface were evaluated using a second-order polynomial model. As shown in Table delayed . Similarly, the estEes showed a negative association with QRS duration Z-score  and a U-shaped association with ARdelayed , although the association between the estEes and a quadratic term of ARdelayed was not statistically significant. According to contour plots exhibiting iso-response lines of BNP and estEes shown at the bottom row in Fig. delayed of 62% and 68%, respectively  are summarized in Tables T and the ratio of the delayed compartment affect the ventricular mechanics  are shown in Fig. Relative changes in simulated cardiac output and ventricular contractility (ΔEes) with respect to each baseline value . However, when the ratio of the delayed compartment was large enough, the first peak became small (green arrow). A similar uncoordinated double-peaked shortening was also observed at an earlier activated ventricular wall in a patient with single ventricle , which can be measured both in clinical strain measurements and in our simulated strain curves.Figure T = 0), the amount of reverse flow from the delayed to the earlier activated compartment during systole (expressed in percentage of the baseline output), the difference in time to peak strain between earlier and delayed hemiglobal strain curves, and Rstrains calculated in the earlier activated hemiglobal strain curve. As shown in Fig. strains predicted reduced ventricular contractility.Furthermore, we sought the best predictor of decreased ventricular contractility (negative ΔEes) among the following four simulated hemodynamic parameters: the change in the maximal derivatives of ventricular pressure (ΔdP/dt max) relative to its baseline value  and a negative association with estEes .Finally, we evaluated the local wall strain at earlier activated three segments irrespective of an insertion point of the septum and calculated Rcle Fig. . The Rstdelayed, in addition to an electrical delay. We demonstrated that the ventricular morphology with ARdelayed of 60–70% in the patient study and approximately 70% in the simulation study was most vulnerable to a prolonged activation delay, representing an uncoordinated motion at an earlier activated ventricular wall (an increase in Rstrains).To the best of our knowledge, this is the first study to analyze the detrimental hemodynamic effect of mechanical discoordination, highlighting the importance of the ratio of the delayed wall, ARdelayed was the secondary determinant  free wall is activated late by a gradually propagating impulse originating from the right ventricle. As for patients with accessory atrioventricular pathways and those under resynchronization therapy (LV pacing), earlier and delayed conductions propagate independently and meet at the middle of the left ventricle. Hence, the ventricle is functionally separated into earlier activated and delayed compartments with various wall area ratios. When the earlier activated compartment is large enough but less than half of the ventricular wall, the ventricle ought to be vulnerable to the widened time difference between two activation onsets. For instance, clinical evidence of patients with the preexcitation syndrome suggests that patients with right-sided septal or paraseptal accessory pathways, but not patients of preexcitation at the LV free wall, suffer from ventricular dysfunction , 25. TheAs for patients with single-ventricle anatomy, despite diverse anatomical variants, those with a codominant-type single ventricle  would be most vulnerable to an activation delay and reveal an uncoordinated motion at an earlier activated wall. The ratio of the delayed ventricular wall had a significant impact on mechanical discoordination associated with an activation delay, potentially highlighting an indicator of cardiac dysfunction. Further study is warranted to confirm this interpretation.Additional file 1: Appendix A. Estimation of a wall area ratio. Appendix B. Hemodynamic simulation of single-ventricle physiology. Appendix C. Strain measurement from the simulation. Figure S1. Estimation of a wall area ratio based on a hemispherical ventricular model. Figure S2. Hemodynamic simulation with a two-compartment ventricular model after total cavopulmonary connection (Fontan circulation). Figure S3. Strain measurement from a two-compartment ventricular model. Figure S4. Change in pressure rise depending on an activation delay and the delayed compartment volume ratio.


Stable angina develops during physical activity or stress, and it is typically an aspect of Coronary Heart Disease (CHD) that can lead to arrhythmia, heart failure and even sudden death. ANRIL, an Antisense Noncoding RNA gene in the INK4 Locus, is associated with multiple disorders including CHD; however, expressional levels of ANRIL in between patients with stable angina and myocardial infarction, one of the acute coronary syndrome, have not been clarified yet.The authors enrolled 62 patients with myocardial infarction and 59 with stable angina before primary percutaneous coronary intervention, as well as 48 healthy volunteers. Their peripheral blood was collected for analysis of ANRIL and cardiac troponin I, a traditional diagnostic index of CHD by real-time PCR.The data showed that ANRIL is a better diagnostic indicator than cardiac troponin I in patients with stable angina and that the levels of ANRIL are higher in patients with stable angina than those with the myocardial infarction.The levels of ANRIL in peripheral plasma could be used as a good biomarker for stable angina. A major characteristic of atherosclerosis is the formation of artery plaque that can narrow arteries and lead to Coronary Heart Disease (CHD). Stable angina is the clinical feature of the early stage of CHD, whereas myocardial infarction, one of acute coronary syndrome, is a late stage of CHD.,,13The long noncoding RNA (lncRNA), an important class of regulatory molecule involved in a myriad of biological processes,ANRIL is associated with CHD, but whether there is a difference in its expression in patients between stable angina and myocardial infarction remains elusive. The present investigation showed that ANRIL in the plasma of patients with stable angina increased more remarkably than the traditional index: cardiac troponin I, suggesting ANRIL can be used as a diagnostic biomarker for stable angina.,62 patients with myocardial infarction, 59 patients with stable angina, and 48 healthy volunteers (without apparent signs of cardiovascular disease) were enrolled in the third affiliated hospital of Central South University from September 2015 to May 2016. 5 mL blood was collected in anticoagulant tubes before any medical treatment; the blood was then centrifuged at 3000 rpm/min for 20 min, and the supernatant as plasma was carefully transferred into an RNase-free tube for RNA extraction.This study followed the ARRIVE guidelines and was approved by the Central South University ethics review board, all the patients and volunteers were informed and consented, and the study was performed to conform to the declaration of Helsinki. The approval number for the scientific research project by the Medical Ethics Committee of Xiangya Third Hospital, Central South University is 2014-S093.Total RNA was isolated using RNA serum/plasma kit according to the manufacturer's instructions. In brief, 1 mL of QIAzol Lysis Reagent to 400 μL of serum was added, mixed well, and then incubated at room temperature for 5 min (min). Subsequently, 400 μL of chloroform was added and vortexed vigorously for 15 s (s). After incubation at room temperature for an additional 3 min, the samples were centrifuged at 12,000g for 15 min at 4°C. The upper aqueous phase was transferred to a new EP tube with 1.5 times the volume of ethanol (anhydrous) and mixed well. 700 μL of the mixture was transferred to an RNeasy MinElute spin column for centrifugation at 8000g for 15s. The liquid part was then discarded, and the centrifugation step with the remaining mixture was repeated. 700 μL of buffer RWT to the column was added for centrifugation at 8000g for 15s, and the supernatant was discarded.Next, 500 μL of Buffer RPE to the column was added for centrifugation at 8,000g for 15s, the pellet was kept for 500 μL of 80% ethanol, centrifugation at 8000g for 2 min. The RNeasy MinElute spin column was centrifuged again at 8000g for 5 min to ensure thorough drying of the membrane and then dried at the air at room temperature for 3 min.The RNeasy MinElute spin column was then placed in a new 1.5 mL EP tube, and 14 μL of RNase-free H2O was added to the center of the membrane, and incubated at room temperature for 10 min. Finally, the column was centrifuged at 12,000g for 1 min to obtain the RNA.TM Reverse Transcription System, and real-time PCR was performed using GoTaq® qPCR Master mix. The primers used in this study were as the followings: ANRIL: 5′-CTGGGACTACAGATGCACCAC-3′(forward), 5′-GGAGGGAGCATG TCTGTTTCT-3′(reverse); GAPDH : 5′-GGGAGCCAAAAGGGTCAT-3′(forward), 5′-GAGTCCTTCCACGATACC AA-3′(reverse). The expression level of ANRIL was normalized to GAPDH using the 2−ΔΔCT method. Each specimen underwent PCR testing three times,To analyze ANRIL, RNA was reverse transcribed with GoScript,Low Density Lipoprotein (LDL), High Density Lipoprotein (HDL), Triglyceride (TG), Creatine Kinase-MB (CK-MB), cardiac troponin I, and blood glucose were measured using a Hitachi 7600-010 fully automatic biochemical analyzer.p < 0.05 considered to indicate statistical significance. The Receiver Operating Characteristic (ROC) curve was established to evaluate the predictive power of circulating ANRIL between the health and CHD subjects. To evaluate the prognostic value of lncRNAs, Receiver Operating Characteristic (ROC) curves were constructed, and the Area Under the ROC Curve (AUC) was determined. Reclassification analyses were performed to determine the additive value of lncRNAs to clinical parameters and other biomarkers.,Data is described as means ± Standard Deviation (SD) and median for general characteristics of subjects. Spearman rank correlation was used to evaluate the association between levels of lncRNAs and continuous variables, all statistical analyses were performed using the SPSS 18.0 software. Differences between different groups were assessed using the One-Way ANOVA comparison method. A value of This study was approved by Central South University ethics review board, all the patients and volunteers were informed and consented, and the study was performed to conform to the declaration of Helsinki.p < 0.05).p < 0.01). The cTnI level in the blood of stable angina patients was significantly lower than that of acute myocardial infarction patients, 3.273 ± 2.85 ng/mL (p < 0.01). These results suggest that cTnI is more effective in diagnosing late-stage coronary heart disease  compared to early-stage detection.,p < 0.05, p < 0.05) between ANRIL and cardiac troponin I in both patients with angina patients and myocardial infarction. Notably, ANRIL increased much more than cardiac troponin I in patients with stable angina, but cardiac troponin I increased more than ANRIL in patients with myocardial infarction. These results indicate the levels of cardiac troponin I are a better index for a late stage of CHD, whereas the levels of ANRIL are a better biomarker for an early stage of CHD.ANRIL is highly expressed in the early stage of atherosclerotic plaques and may regulate the NF-κB pathway by acting as an antisense regulator to the CDKN2B-CDKN2A gene.To evaluate the predictive power of ANRIL for CHD in the plasma of patients, the authors performed ROC analysis for 121 patients with CHD. As shown in This study found a significant increase in the expression of ANRIL in the plasma of Coronary Heart Disease (CHD) patients compared to the control group. Among CHD patients, stable angina patients had a higher level of ANRIL in their plasma. ANRIL may serve as a potential circulating biomarker for the early diagnosis of CHD.Coronary heart disease is a complex disease caused by the interaction of environmental and genetic factors. Although epigenetic changes play an important role in the development of atherosclerosis under various genetic and modifiable risk factors, data on specific gene targets of epigenetic modifications are still limited. Single molecular markers are insufficient for the diagnosis or prognosis of coronary heart disease. Given the close association between abnormal expression of ANRIL and endothelial cell injury, smooth muscle cell proliferation, migration, aging, and apoptosis, monocyte adhesion and proliferation, lipid metabolism disorders, and DNA damage, as well as its critical role in the development of atherosclerosis, ANRIL provides further insights for clinical diagnosis and prognosis. The focus of this study is to identify potential circulating biomarkers for the rapid and accurate diagnosis and monitoring of coronary heart disease through combined detection including myocardial injury markers and LncRNA.,An increasing number of studies in the literature indicate that long non-coding RNAs (lncRNAs) play important roles in many physiological and pathological processes, and several circulating lncRNAs have been applied as biomarkers for the diagnosis and prognosis of cancer.This study detected the plasma circulating levels of stable angina, myocardial infarction, and healthy volunteers, and found that the circulating ANRIL levels in the plasma of coronary heart disease patients were higher than those of healthy individuals. Interestingly, the circulating ANRIL levels of patients with stable angina and myocardial infarction were significantly different: the circulating ANRIL levels in the plasma of patients with stable angina were higher than those with myocardial infarction. In addition, the authors compared the diagnostic ROC curves of circulating ANRIL levels with the traditional indicator cTnI. As a diagnostic indicator for stable angina in coronary heart disease, the AUC of circulating ANRIL was 0.875, and the AUC of cTnI was 0.858. As a diagnostic indicator for myocardial infarction in coronary heart disease, the AUC of circulating ANRIL was 0.765, and the AUC of cTnI was 0.938. As a diagnostic indicator for coronary heart disease, the AUC of circulating ANRIL was 0.825, and the AUC of cTnI was 0.898. The ROC analysis showed that ANRIL in plasma provided a more accurate diagnostic rate in the stable angina stage, suggesting that ANRIL in plasma may be more sensitive and specific for the diagnosis of early coronary heart disease.However, there are still some limitations to this study. Firstly, a relatively small and single ethnic sample was used. Therefore, a larger sample size is needed to validate the current findings. Secondly, only the expression of ANRIL in plasma was detected, and testing for other biomarkers and/or LncRNAs may provide additional information.In summary, the present research findings suggest a positive correlation between the expression of ANRIL in plasma and the severity of early-stage coronary heart disease.ANRIL is increased in the plasma of patients with stable angina and myocardial infarction and is a good biomarker for stable angina, an early stage of CHD.Yunjuan Jiao: Formal analysis, Investigation, Project administration, Writing – original draft. Fanming Meng: Investigation. Gaoen Ma: Investigation, Funding acquisition, Writing – review & editing. Hetian Lei: Conceptualization, Funding acquisition, Writing – review & editing. Junwen Liu: Investigation, Conceptualization, Funding acquisition, Writing – review & editing.The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Hetian Lei reports financial support was provided by National Natural Science Foundation of China.


Left-ventricular (LV) end-diastolic diameter (LVED), LV end-systolic diameter (LVES), right atrial, left atrial (LA) area, thickness of interventricular septum (IVS) and posterior wall, LV ejection fraction (LVEF), and right ventricular outflow tract end-diastolic area (RVOT EDA) of CABG and non-cardiac patients  were determined by echocardiography, and LV mass was calculated (cLVM). Results: Positive correlations were found between Hcy levels of plasma and PF, tHcy levels and LVED, LVES and LA, and an inverse correlation was found between tHcy levels and LVEF. cLVM, IVS, and RVOT EDA were higher in CABG with elevated tHcy (>12 µM/L) compared to NCP. In addition, we found a higher cTn-I level in the PF compared to the plasma of CABG patients , which was ~10 fold higher than the normal level. Conclusions: We propose that homocysteine is an important cardiac biomarker and may have an important role in the development of cardiac remodeling and dysfunction in chronic myocardial ischemia in humans.Background: Homocysteine (Hcy) is involved in various methylation processes, and its plasma level is increased in cardiac ischemia. Thus, we hypothesized that levels of homocysteine correlate with the morphological and functional remodeling of ischemic hearts. Thus, we aimed to measure the Hcy levels in the plasma and pericardial fluid (PF) and correlate them with morphological and functional changes in the ischemic hearts of humans. Methods: Concentration of total homocysteine (tHcy) and cardiac troponin-I (cTn-I) of plasma and PF were measured in patients undergoing coronary artery bypass graft (CABG) surgery ( Ischemic heart disease, including coronary artery disease, is the leading cause of death worldwide . ImpaireHomocysteine (Hcy) is a sulfur-containing amino acid, which is metabolized via re-methylation by converting Hcy back to methionine, and trans-sulfuration by converting Hcy to cysteine and taurine amino acids . AlthougDespite earlier reports, as of today, there is still no consensus regarding the reference limits for plasma homocysteine levels. Studies focusing on various parts of the population suggest that the upper limit of 15 µmol/L is too high in normally nourished people without vitamin deficiencies. Additionally, it seems that each 5 µmol/L increase in Hcy level increases the risk of CHD  by about 20% and that a continuum exists with the subsequent risk. Some reports suggest that a level around 6 µmol/L Hcy should be considered normal . A systeIndeed, elevated plasma levels of Hcy play an important role in the development of cardiovascular diseases, such as coronary artery disease and atherosclerosis, which may further exacerbate cardiac ischemia/infarction and fibrosis ,19. SuppCardiac ischemia in humans—in many cases—is resolved by successful coronary bypass graft surgery (CABG) . BecauseBased on the aforementioned facts, we hypothesize that the levels of Hcy in the plasma and pericardial fluid correlate with cardiac remodeling of the ischemic heart of patients undergoing CABG treatment. Thus, we collected samples of the plasma and PF of patients undergoing CABG surgery and measured their total Hcy and cTn-I concentrations and correlated them with the morphological and functional characteristics of their hearts.In the present study, subjects were recruited at the Heart Institute of the University of Pécs Medical School, Hungary. This is a cross-sectional investigation of 14 subjects with coronary artery disease and 10 non-cardiac patients (NCP) as a control for echocardiographic measurements. Non-cardiac patients underwent physical examination with no cardiac surgery. All patients with coronary artery disease underwent elective CABG surgery. Age- and sex-matched subjects with mild to moderate arterial hypertension were selected for the study. Written informed consent was obtained from all individuals before participation in the study. The investigation and consent documents were approved by the Ethics Committee of the Medical School of the University of Pecs (RKEB-4123/20110). The investigation conforms to the principle outlined in the Declaration of Helsinki. Blood plasma and PF samples were collected from the patients after median sternotomy.Pericardial fluid samples were collected by pericardiocentesis, together with blood samples, simultaneously from CABG patients in heparinized vacutainer tubes during CABG surgery, and centrifuged at 3000 rpm for 10 min. Supernatants were then kept at –80 degrees for further use. cTn-I was measured by Microparticle Enzyme Immunoassay, and tHcy was measured by Fluorescence Polarization Immunoassay on an Abbott Axsym immunochemical automated analyzer , according to the manufacturer’s instructions ,26.Morphological characteristics of CABG patients’ hearts were assessed with 2-D transthoracic echocardiography. Two-dimensional (2-D), M-mode, and Doppler echocardiography with automated border detection were carried out using Hewlett-Packard Sonos 5500 echocardiograph with a 2.5 MHz transducer . Two-dimensional echocardiographic measurements were performed according to European guidelines. In order to minimize the variability and bias, echocardiographic measurements were carried out by the same cardiologist (blinded to the patient’s identity) with an expert license in transthoracic echocardiography. All images were recorded and analyzed offline. The following parameters were measured: left ventricular end-diastolic diameter (LVED), left ventricular end-systolic diameter (LVES), the thickness of interventricular septum (IVS) and posterior wall (PW), right ventricular outflow tract end-diastolic area (RVOT EDA), and right atrial (RA) and left atrial (LA) area. The biplane Simpson method using the end-diastolic and end-systolic apical 4- and 2- chamber views for estimation of LV volume and calculation of the ejection fraction (LVEF)  was applt-test. For comparison of echocardiographic parameters of CABG patients with non-cardiac patients (NCP), two-tailed independent t-test was applied. Left ventricular mass (LVM) was calculated using the American Society of Echocardiography (ASE) convention: VM = 0.8 (1.04 ([LVED + PW+ IVS]3- [LVED]3)) + 0.6 g, where PW is posterior wall thickness [p < 0.05.Correlations between tHcy levels and echocardiographic parameters were performed using Pearson’s correlation analysis. Because we found a very high correlation between PF and plasma values of Hcy for correlation analysis plasma and PF, tHcy levels (plasma + PF)/2 were averaged. Plasma and PF tHcy and cTn-I levels were compared with a two-tailed independent hickness . StatistDescriptive statistics of the patients are summarized in p = 0.2628) (p < 0.0001)  A. In add 0.0001) B.According to previous a publication  the optiWe found that the LVED and LVES of CABG patients with tHcy higher than 12 µM/L were greater than that of lower tHcy. The LA of CABG patients with elevated tHcy is higher than that of CABG patients with lower tHcy. In CABG patients with elevated tHcy, the cLVM was higher than that of CABG patients with lower tHcy. The LVEF, PW, and RA were similar between the two groups .p < 0.01) (p < 0.01) (p < 0.01) (p < 0.05)  A, LVDS ( < 0.01) B, and LA < 0.01) C and inv < 0.05) D.p < 0.001)  .The salient findings of the present study are as follows: (1) There is a positive correlation between plasma and pericardial fluid Hcy levels. (2) The echocardiographic parameters, namely, end-diastolic (LVED), end-systolic diameter of the left ventricle (LVDS), the left atrial (LA) area, calculated left ventricular mass (cLVM), right ventricular outflow tract end-diastolic area (RVOT EDA), and thickness of the interventricular septum (IVS) were significantly higher in CABG patients with tHcy above 12 μM/L compared to non-cardiac patients. (3) There are positive correlations between tHcy levels and the structural changes in LVED, as well as LVDS, LA, and an inverse correlation between tHcy levels and left-ventricular ejection fraction (LVEF) in CABG patients. (4) The level of cardiac troponin-I was significantly higher in pericardial fluid than plasma.CABG surgery is a widely used surgical solution for myocardial ischemia due to infarction or narrowing of the large coronary arteries. The persistent myocardial ischemia before CABG surgery causes injury to the myocardium, initiating simultaneous compensatory mechanisms that lead to changes in the size of cardiac chambers . Indeed,Plasma tHcy level considered to be normal between 5–15 μmol/L, and its elevation can contribute to coronary artery disease in humans ,12. HighCardiac troponins have been found to have high sensitivity as indicators of myocardial injuries, such as in myocardial ischemia. Cardiac troponin level in the plasma is <0.004 ng/mL or <0.005 ng/mL . In the The Framingham Heart Study showed that Hcy levels in the plasma of cardiac patients are positively related to changes of the left ventricular structure and function, such as left ventricular wall thickness . In the Interestingly, we have previously found in rats with elevated homocysteine that increases in flow elicit constrictions of isolated arterioles, instead of dilation, which were attributed to enhanced production of reactive oxygen species known to decrease the bioavailability of nitric oxide (NO).The lack of NO could contribute to hypoxia and inflammation ,33, and Previously, we found elevated asymmetric dimethylarginine (ADMA) levels in cardiac ischemic and valve diseased patients, which showed positive correlation with indices of cardiac hypertrophy . We haveHypoxia and inflammation can initiate fibrotic processes in which the heart undergoes structural remodeling, with consequent functional changes . The iniAll of these molecular pathomechanisms can lead to changes in cardiac substrate utilization , reducedIn Our data suggest that it is important to measure homocysteine level in patient populations with ischemic heart disease, because higher but still normal levels of homocysteine may represent risk factors for morphological and functional remodeling of the heart in this condition. On the basis of our findings in The higher level of Hcy may be due to—among other factors—low vitamin B6, B12, and folate levels, which, however, can be corrected with appropriate therapy in most cases . The norIt is of note that the long-term administration of glucose-lowering drugs such as metformin may attenuate cardiac hypertrophy and improve cardiac function, as suggested by clinical and animal studies ,49,50. HAs in most human studies, there are no appropriate controls; thus we used findings from experimental  studies to draw our conclusions regarding the underlying mechanisms. In this human study, we were limited by the amount of coronary bypass graft surgery (CABG) performed at our institution. Due to the great advances in percutaneous intervention (PCI), fewer patients need this type of open chest surgery. In addition, we were limited regarding the number of patients available in our clinic, which fall into the category of our investigation. Nevertheless, the homogeneity of patients allowed for the statistical analysis of data. For this reason, more data are necessary to support our conclusions regarding the role of homocysteine metabolism in cardiac remodeling due to long-lasting ischemia. In addition, it is of note that the anti-diabetic medication may influence the homocysteine levels of these CABG patients .In conclusion, the findings of the present investigation suggest that in chronic ischemic cardiac patients—as indicated by the increased troponin level in the pericardial fluid—the higher levels of homocysteine  in the pericardial fluid and plasma contribute to the development of cardiac remodeling and contractile dysfunction. Thus, in this special patient population, plasma homocysteine levels should be measured, considered, and lowered with appropriate therapy.


Cardiac dysfunction is a well-established risk factor for contrast-associated acute kidney injury (CA-AKI). Nevertheless, the relationship between cardiac remodeling, as assessed by echocardiography, and CA-AKI remains uncertain.A total of 3,241 patients undergoing coronary angiography (CAG) with/without percutaneous coronary intervention (PCI) were enrolled in this retrospective study. Collected echocardiographic parameters were normalized by body surface area (BSA) and divided according to quartile, including the left ventricular internal end-diastolic diameter index (LVIDDI), left ventricular internal end-systolic diameter index (LVIDSI), and left ventricular mass index (LVMI). Logistic regression analysis was conducted to ascertain the association between structural parameter changes and CA-AKI. Further investigation was performed in different subgroups.2: OR = 1.953, 95%CI (1.459 to 2.615), P < 0.001], LVIDDI , and LVMI  in quartile were positively associated with CA-AKI risk in general . These associations were consistent when stratified by age, left ventricular ejection fraction, estimated glomerular filtration rate, and N-terminal brain natriuretic peptide . The presence of eccentric hypertrophy  and the coexistence of hypertrophy and dilation  carried a higher CA-AKI risk.The mean age of the participants was 66.6 years, and 16.3% suffered from CA-AKI. LVIDSI [≥22.9 mm/mThe presence of cardiac remodeling, assessed by echocardiography, is associated with a higher risk of CA-AKI. The incCA-AKI has been ranked as the third most common cause of nosocomial acute kidney injury in the United States, with a 30% rate among patients undergoing CAG/PCI . PatientCardiac dysfunction commonly accompanies cardiac remodeling, which involves both functional and structural changes. Cardiac remodeling occurs in both cardiovascular and non-cardiovascular diseases in compensatory response to the overload . More thAccordingly, the current retrospective research was conducted to figure out the association of cardiac remodeling with CA-AKI risk in a cohort of CAG patients undergoing CAG/PCI. With the help of an echocardiogram, certain structural parameters were measured to evaluate cardiac remodeling . Further2.2.1.Conforming to the STROBE  guidelines, this cross-section study was conducted to explore the association of structural and functional cardiac remodeling on an echocardiogram with the risk of CA-AKI . A largeThis retrospective study has been authorized by the Ethics Committee of the Sir Run Run Shaw Hospital (No. 20201217-36) and performed following the Helsinki statement. Given the nature of a retrospective cross-section study, informed consent could be skipped.2.2.According to the ESUR  guidelines, CA-AKI was set as the primary endpoint, and diagnosing by the Scr level increased by ≥44 μmol/L (0.5 mg/dl), or the proportion increased by ≥25% compared to the level on admission .The secondary outcome was considered the percentage of the Scr elevation, which was evaluated by the difference of the Scr level after the CAG/PCI divided baseline Scr level [the percentage of Scr elevation = (postoperative Scr—baseline Scr)/baseline Scr].2.3.Certain echocardiographic parameters were measured to detect the presence of cardiac structural remodeling during the perioperative period (within 3 days before or after the CAG/PCI). All of the echocardiographic parameters were collected during the hospitalization by the clinical operators with long-term specialized training. The criteria of reference for analysis were from the 2015 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) document for chamber quantification .3– LVIDD3] + 0.6 g. Relative wall thickness (RWT) was calculated as 2 × LVPWD divided by LVIDD to depict left ventricular (LV) geometry.Left ventricular (LV) geometry and ejection fraction (EF) were assessed using two-dimensional (2D) echocardiography. All measurements were standardized to body surface area. LVM was calculated according to the Devereux formula: 0.8 × 1.04 × , P = 0.038, in P = 0.008]. Then, recruited patients were roughly categorized into three statuses: normal LV geometry, the existence of LVH or dilation, and the coexistence of LV hypertrophy and dilation. Multivariable logistic regression was performed to verify the correlation between abnormal LV geometry and CA-AKI risk, which demonstrated that the coexistence of LV hypertrophy and dilation carried the highest risk of CA-AKI .In the current study, abnormal LVMI and LVIDDI signified LV hypertrophy and dilation. Compared with the patients without structural remodeling, the two abnormal LV geometries were found to possess a significant relationship with CA-AKI risk in the multivariable logistic analysis  patients suffered from CA-AKI. Patients with higher LVMI, LVIDDI, and LVIDSI carried a higher risk of CA-AKI and abnormal LVMI associated with the CA-AKI risk, especially in patients with preserved LVEF. In other words, the presence of cardiac remodeling, namely, left ventricular hypertrophy and dilation, was significantly associated with the CA-AKI risk. The coexistence of LV hypertrophy and dilation possessed the highest risk of CA-AKI among different remodeling patterns, and subjects with eccentric hypertrophy confronted a higher CA-AKI risk.The development of cardiac remodeling involves alterations in cardiac size, shape, and function . An abnoOne of the leading culprits for cardiac remodeling is hypertension . Under tPatients with cardiac remodeling often carry more potential risk factors than others, such as diabetes mellitus, anemia, and renal dysfunction. Similar patterns of relationships were also found in the current study for patients with structural remodeling, with a higher CA-AKI risk compared to patients without remodeling. It is conceived that cardiac structural remodeling often relates to decreased stroke volume and worse diastolic function, later showing more severe deterioration in the impaired kidney function than in the systolic function –26. The Of note is that not only does the presence of cardiac remodeling increase the CA-AKI risk but also the different patterns of cardiac remodeling show different risks. To be specific, patients with both LV hypertrophy and dilation confront the highest risk. Yamanaka et al. also argued that the combination of LV dilation and hypertrophy has the worst prognosis compared with other structural patterns among patients with heart failure with preserved ejection fraction . The CASThere are also certain limitations in this retrospective research. First, the authority of the conclusions is inevitably limited by the nature of retrospective cross-section research. Therefore, large-scale prospective research is required in the future to further confirm the association of cardiac remodeling with CA-AKI risks. Second, there was a shortage of the calculation for LVM. The linear method was likely to overestimate LVH, but as the most widespread echocardiographic method to evaluate LV geometry, its usefulness in a tremendous number of clinical trials has been verified . TherefoIn conclusion, the present study established a significant association of cardiac remodeling, detected by echocardiogram, with the risk of CA-AKI among CAD patients receiving CAG/PCI. Abnormal structural echocardiographic parameters were correlated with CA-AKI, showing that patients with abnormal cardiac structure should take timely protective measures, even those with LV hypertrophy but preserved LVEF.


Introduction: Left ventricular (LV) strains are measures of deformation that reflect LV function quantifying the rate of LV contraction, providing information in three directions in space: radial (RS), longitudinal (LS) and circumferential directions (CS). The LV moves around its longitudinal axis in a special movement called LV rotational mechanics. The present study aimed to assess associations between three-dimensional speckle-tracking echocardiography (3DSTE)-derived LV rotational mechanics and LV strains in healthy adult subjects. Methods: The present study consisted of 174 healthy adults . Complete two-dimensional Doppler echocardiography and 3DSTE were performed in all subjects. Results: While LV-gRS and LV-gLS did not show associations with increased basal LV rotation, the lowest LV-gCS was seen in the presence of the highest LV basal rotation. An increase in basal LV rotation and consequential LV twist were not associated with apical LV rotation. While LV-gLS was not associated with the increase in apical LV rotation, LV-gRS and LV-gCS showed a trend towards increasing values. An increase in LV-gRS was associated with an increasing trend towards apical LV rotation, LV twist and LV-gCS and the preservation of basal LV rotation. LV-gLS also increased but only up to a certain value. An increase in LV-gCS was associated with a tendency towards a decrease in basal LV rotation and a tendency towards an increase in LV-gRS and LV-gLS. The highest LV-gCS was associated with the highest apical LV rotation and LV twist. The highest apical LV rotation, LV twist and LV-gCS were seen in the presence of the highest LV-gLS, while basal LV rotation and LV-gRS were not associated with increasing LV-gLS. Conclusions: Basal LV rotation has been shown to have an inverse relationship with LV-gCS, but without being related to LV-gRS and LV-gLS, while apical LV rotation is associated with LV strains in all directions, but to a different extent, suggesting a complex relationship between LV rotational mechanics and LV strains in healthy adults. During the heart cycle, the left ventricular (LV) wall not only contracts but also twists at the same time, maximizing its functional effectivity, intracavitary pressure and stroke volume and minimizing myocardial oxygen demand ,6,7,8,9.The present study comprised 174 healthy adults . Volunteers without any known disorders or pathological states were involved between 2011 and 2015. They underwent physical examination, laboratory assessments, standard 12-lead electrocardiography (ECG) and 2D Doppler echocardiography, which was followed by 3DSTE. All tests ended with negative results, which were within the normal reference range. None of the participants was an athlete or obese or took regular medication. The analysis carried out in this study is part of the ‘Motion analysis of the heart and great vessels by three-dimensional speckle-tracking echocardiography in healthy subjects’  study, which has been organized to examine physiological relationships under healthy circumstances (‘Magyar’ means ‘Hungarian’ in the Hungarian language). This investigation was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The Institutional and Regional Human Biomedical Research Committee at the University of Szeged, Hungary (registration number: 71/2011 and updated versions) approved the study. Informed consent was given by all volunteers.TM echocardiographic machine  was used in all healthy subjects, attached to a PST-30BT (1–5 MHz) phased-array transducer.During the 2D echocardiographic studies, we followed the accepted professional guidelines . AccordiTM echocardiographic tool , but using a 3D-capable PST-25SX matrix-array transducer. ECG gating was used for all subjects who were in sinus rhythm, during six cardiac cycles; one wedge-shaped subvolume per cardiac cycle was acquired to achieve the best image quality. The software stitched them together, creating a pyramid-shaped full-volume 3D echocardiographic dataset called an ‘echocloud’ [Immediately after the 2D echocardiographic examination, 3DSTE was performed. All 3DSTE analyses followed our standard protocol. Firstly, in healthy subjects in the left lateral decubitus position, 3D echocardiographic data acquisitions were performed from an apical window following image optimizations  with the same Toshiba Artidahocloud’ ,15,16,17Secondly, at a later date, 3D echocardiographic datasets were analysed offline with 3D Wall Motion Tracking software . The aim of the analysis was to create a 3D model/cast of the LV for same-time determination of LV strains and rotational parameters. During the analysis, the software automatically created a five-division figure with apical longitudinal four-chamber (AP4CH) and two-chamber (AP2CH) views and basal, midventricular and apical cross-sectional views. For the creation of the LV 3D cast, septal and lateral mitral annular (MA)-LV edges and the apical endocardial surface of the LV were defined, after which a sequential analysis was performed ,15,16,17The following LV rotational parameters were provided: apical and basal LV rotations, LV twist and time-to-peak LV twist .○LV radial strain (LV-gRS)—for characterizing thinning/thickening of the myocardial tissue.○LV longitudinal strain (LV-gLS)—for characterizing lengthening/shortening of the myocardial tissue.○LV circumferential strain (LV-gCS)—for characterizing widening/narrowing of the myocardial tissue.The following global LV strains, featuring the whole LV were measured :○LV radThirdly, using this 3D LV model, several functional LV properties were calculated :The folln (%) formats were used for data presentations, as appropriate. Significance was determined when p was less than 0.05. Depending on whether the data were continuous or categorical, Student’s t-test, Bonferroni method following one-way analysis of variance (ANOVA) and Fischer’s exact test were used, where appropriate. Statistical analyses were performed with SPSS version 22  software.Mean ± standard deviation and 2 and 24.5 ± 2.3 kg/m2, respectively.The most important clinical parameters were within the normal ranges, including systolic (122.3 ± 5.1 mm Hg) and diastolic (75.7 ± 4.6 mm Hg) blood pressures and heart rate (71.9 ± 2.8 1/s). The mean height, weight, calculated body surface area and body mass index were 170.5 ± 7.6 cm, 72.1 ± 10.9 kg, 1.87 ± 0.13 mRoutine 2D echocardiographic parameters proved to be normal: left atrial diameter assessed in parasternal long-axis view (36.5 ± 3.9 mm), LV end-diastolic and end-systolic diameters , LV end-diastolic and end-systolic volumes , interventricular septum (9.0 ± 1.5 mm) and LV posterior wall (9.1 ± 1.6 mm) and LV ejection fraction (65.9 ± 4.9%). Mean transmitral flow velocities measured in diastole were 79.3 ± 17.5 cm/s and 63.4 ± 19.3 cm/s, respectively. None of the participants had larger than grade 1 valvular regurgitation or showed valvular stenosis on any valves.Using the same 3D cast of the LV, the following LV parameters were calculated: LV-EDV, LV-ESV, LV-EF, LV mass, basal and apical LV rotations. LV-gRS, LV-gCS and LV-gLS proved to be 86.2 ± 23.1 mL, 36.3 ± 10.5 mL, 58.2 ± 5.6%, 158.2 ± 31.8 g, −4.10 ± 2.07 degree, 9.31 ± 3.79 degree, 25.4 ± 9.3%, −27.6 ± 5.0% and −16.1 ± 2.5%, respectively. 3DSTE-derived maximum, pre-atrial contraction and minimum left atrial volumes proved to be 40.5 ± 12.5 mL, 27. 5 ± 10.9 mL and 19.1 ± 7.8 mL, respectively.Subgroups were created based on mean ± SD of basal and apical LV rotations and LV-gRS, LV-gCS and LV-gLS. Subjects were classified into these subgroups according to the lower  and upper  values of the above-mentioned variables.While LV-gRS and LV-gLS did not show any associations with the increase in basal LV rotation, the lowest LV-gCS was seen in the presence of the highest LV basal rotation. An increase in basal LV rotation and consequential LV twist were not associated with apical LV rotation. While LV-gLS was not associated with an increase in apical LV rotation, LV-gRS and LV-gCS showed a tendency towards an increase .An increase in LV-gRS was associated with an increasing trend towards apical LV rotation, LV twist and LV-gCS and the preservation of basal LV rotation. LV-gLS increased, but only up to a certain value. An increase in LV-gCS was associated with a tendency towards decrease in basal LV rotation and a tendency towards an increase in LV-gRS and LV-gLS. The highest LV-gCS was associated with the highest apical LV rotation and LV twist. The highest apical LV rotation, LV twist and LV-gCS were seen in the presence of the highest LV-gLS, while basal LV rotation and LV-gRS were not associated with an increase in LV-gLS .Adequate evaluations could be carried out in 174 out of 298 subjects (58% success ratio).The structure of the heart muscle is very specialized. Numerous experimental and clinical studies have clarified its structure ,28,29,30However, LV not only twists during the heart cycle but also performs a contracting–relaxing motion. Moreover, in real life, LV rotational mechanics cannot be separated from this complex form of LV movement, which occurs in coordination simultaneously. While the LV muscle contracts and thickens radially, there is a shortening in the longitudinal and circumferential (in other words narrowing) dimensions in systole. The myocardial fiber orientation and LV contraction pattern allow the determination of three simple unidimensional-unidirectional strains: longitudinal (LV-LS), circumferential (LV-CS) and radial (LV-RS) strains. Note that modern imaging techniques such as 3DSTE can also compute complex strains calculated as a combination of simple strains, such as area strain  and 3D strain . The above-mentioned LV radial thickening in systole is represented by LV-RS (positive strain), while longitudinal and circumferential shortening and narrowing are represented by LV-LS and LV-CS, respectively (negative strains) ,8,13.In recent decades, cardiovascular imaging has undergone tremendous technical advancement. Methods such as cardiac computer tomography and magnetic resonance imaging have become part of the daily clinical routine, making it possible to diagnose diseases that could not be examined fully or at all until then. But ultrasound technology has also undergone outstanding development. In just over 25 years, completely new cardiovascular ultrasound methods have appeared and spread , and certain parameters  have been included in professional guidelines. Developments have resulted in the ability to analyse the chambers and valves of the heart non-invasively, in a relatively short time, in an easy-to-learn way. Although the emergence of these methods requires a new approach and takes some time to learn, when used in conjunction with previously widespread techniques, they have significantly complemented diagnostic possibilities. Three-dimensional echocardiography has made volumetric measurements more accurate by taking into account the exact shape of the heart cavities using spatial models, while STE allows the contractility of the walls of a heart cavity to be objectified using strain parameters. From a theoretical point of view, a 2D examination of a 3D organ should lead to the loss of certain information. This is where 3DSTE can help, combining the advantages of 3D echocardiography and STE. Although current recommendations do not consider 2DSTE suitable for quantitative characterization of LV rotational mechanics , 3DSTE iAll these abilities give us an examination method that is suitable for performing clinical physiological examinations without harming the interests of our patients; moreover, they can receive detailed information about their cardiac statuses in a non-invasive way. We have the opportunity to compare physiological parameters under healthy conditions. Although the aim of the present study was only to compare the deformation and rotational functional parameters of LV, within the framework of the MAGYAR-Healthy Study, the examination of the relationships of other cavities and valves of the heart and their significance was partly confirmed ,26. BaseIn recent studies, the dependence of LV rotations on LV volumes has already been demonstrated, together with a complex pattern of LV strains in the presence of higher/lower LV volumes ,26. The Although healthy individuals were included in the study and there were no known factors that could have influenced the findings, it cannot be ruled out 100% that they had some kind of subclinical latent disease. Further laboratory and imaging tests could have ruled them out.An important technical problem that still exists today is 3DSTE image quality, which is worse than that of 2D echocardiography due to technical reasons  ,15,16,17In the present study, only LV data were analyzed. However, 3DSTE-derived (left and right) atrial analysis could have been performed at the same time, as demonstrated in recent studies .The investigators did not validate 3DSTE-derived LV strains and rotational parameters due to the fact that this sort of measurement has already been validated ,21,22,23Similarly, the determination of 3DSTE-derived normal reference values of LV rotational parameters and strains was not aimed in this paper because they are already defined ,36.Although there may be debate about which chamber the ventricular septum is part of, it was clearly considered part of the LV in the present investigation.Three-dimensional STE allows the determination of complex/multidimensional LV strains as well, such as 3D and area strains, which are formed from unidimensional LV strains. However, due to their complex nature, these parameters were not examined.LV dimensions and volumes were not involved in the analyses. However, relationships between LV rotational mechanics and strains and LV volumes have already been examined in the frame of the MAGYAR-Healthy Study ,26.The relationship between global LV strains and rotational parameters determined only by 3DSTE was studied. The presentation of other morphological abnormalities of LV, the measurement of the diameters or areas of LV in a particular selected plane or the analysis of segmental or regional strain and rotational parameters of the LV were not the aim of this study.This study is a retrospective study, which limits the value of the conclusions that can be drawn.The following important limitations have to be mentioned regarding this study:Basal LV rotation has been shown to have an inverse relationship with LV-gCS, but without being related to LV-gRS and LV-gLS, while apical LV rotation is associated with LV strains in all directions, but to a different extent, suggesting a complex relationship between LV rotational mechanics and LV strains in healthy adults.


After the Mustard/Senning procedure, the amount of interstitial fibrosis was significantly higher , remarkably more in the subpulmonary left ventricle (LV) than in the systemic right ventricle (RV). In TGA-ASO, an increased amount of fibrosis was found in one adult specimen. The amount of innervation was diminished from 3 days after ASO (0.034% ± 0.017) compared to uncorrected TGA . In conclusion, in these selected postmortem TGA specimens, diffuse interstitial fibrosis was already present in newborn hearts, suggesting that altered oxygen saturations may already impact myocardial structure in the fetal phase. TGA-Mustard/Senning specimens showed diffuse myocardial fibrosis in the systemic RV and, remarkably, in the LV. Post-ASO, decreased uptake of nerve staining was observed, implicating  myocardial denervation after ASO.In the transposition of the great arteries (TGA), alterations in hemodynamics and oxygen saturation could result in fibrotic remodeling, but histological studies are scarce. We aimed to investigate fibrosis and innervation state in the full spectrum of TGA and correlate findings to clinical literature. Twenty-two human postmortem TGA hearts, including TGA without surgical correction (n = 8), after Mustard/Senning (n = 6), and arterial switch operation , were studied. In newborn uncorrected TGA specimens (1 day–1.5 months), significantly more interstitial fibrosis (8.6% ± 3.0) was observed compared to control hearts (5.4% ± 0.8,  Transposition of the great arteries (TGA) is a complex congenital heart malformation and affects approximately 3 in 10,000 live births . AlthougRecognition of myocardial remodeling is of great importance as previous studies in non-congenital heart disease reported that diffuse myocardial fibrosis is associated with worsening ventricular function and increased ventricular stiffness ,4. PreviFurthermore, TGA patients are nowadays corrected using the ASO and may be denervated due to the transection of the nerves along the great arteries and reimplantation of the coronary arteries. As innervation might influence myocardial maturation , partialThe aim of the current study was to perform a histological assessment of myocardial fibrosis, myocardial structure, and myocardial innervation in uncorrected TGA postmortem, post-Mustard/Senning and post-ASO hearts and to correlate these findings to current literature.This postmortem study was performed in accordance with the local biobank and ethics committee of the Leiden University Medical Center and with Dutch regulations for proper use of human tissue for medical research purposes. Postmortem heart specimens from the Leiden Collection of Congenital Malformations, that is part of the Biobank Congenital Heart Disease of the Leiden University Medical Center, were included in this study. The Leiden Collection of Congenital Malformations is part of the institutional Biobank Congenital Heart Disease, that is approved by the Medical Ethical Committee Leiden-Den Haag-Delft. The local scientific committee and Medical Ethical Committee Leiden-Den Haag-Delft approved the working protocol of the current study (protocol number RP23.006).Specimens were selected based on age, sex, and, in case of operation, duration of survival after operation . As we aimed to investigate the presence of myocardial fibrosis in newborn TGA patients and during aging, we included pediatric TGA postmortem hearts without surgical intervention (uncorrected TGA) of various ages. We also included one available uncorrected adult TGA postmortem heart (20 years). Secondly, we included postmortem TGA hearts who survived at least six months after atrial switch operation (TGA-Mustard/Senning) to investigate the impact of physiological correction on the presence of fibrosis in the subpulmonary LV and systemic RV. Finally, we included all available TGA specimens after arterial switch operation (TGA-ASO) to investigate the presence of fibrosis and whether histological denervation occurs after transection of the great arteries and reimplantation of the coronary arteries. Histological findings from TGA specimens were compared with postmortem hearts without congenital heart defects (control group). Hearts from the control group  that on further inspection showed signs of heart failure or ventricular overload, were excluded. From each postmortem heart, transmural tissue blocks were obtained at the following sites: RV basal anterior segment, LV basal anterior segment, and septal basal posterior segment See E. DependBiopsies were embedded in paraffin, and 5 μm sections were mounted on KP-Silane adhesive glass slides (Klinipath). Sections were stained with primary antibodies, followed by a second incubation with an antibody coupled to peroxidase. For detection, we used 3-30diaminobenzidine tetrahydrochloride (DAB). To examine myocardial structure and organization, sections were stained with cardiac troponin-I F, and weMyocardium was defined as normal if myocardial collagen was seen at the epicardial surface, at the endocardial surface, and around blood vessels with the distribution of linear collagen parallel to cardiomyocytes, not entirely surrounding the cardiomyocytes  Figure A. TransmIn all biopsies stained with Picrosirius Red, the amount of fibrosis was quantified using custom software (Python 2.7), as previously described . Each piIn tissue blocks stained to detect βIII-tubulin, photomicrographs were taken in areas around cross-sectioned coronary vessels, visually assessed, and compared between TGA-ASO and carefully matched sections in uncorrected TGA postmortem hearts. The amount of βIII-tubulin-positive nerves was quantified using custom software (Python 2.7). A threshold for brown color was set, and the percentage of brown pixels was calculated by dividing the number of brown pixels by the total amount of pixels within the tissue block.To correlate the findings of our study with current literature, a comprehensive literature review with the subjects 1. myocardial fibrosis in TGA and 2. myocardial innervation in TGA post-ASO was performed in PubMed, Embase, Web of Science, Cochrane Library, and Emcare. Two separate search strategies were executed with the following keywords: Search strategy 1: Transposition of the great arteries, Mustard/Senning operation, arterial switch operation, myocardial fibrosis. Search strategy 2: arterial switch operation and innervation . Normally distributed variables were reported as mean ± standard deviation and not normally distributed variables as the median and interquartile range (IQR1–IQR3). Where appropriate, differences between continuous data were compared by Student’s t-test or Mann–Whitney U test. A Four subgroups of postmortem hearts were included in the Leiden Collection of Congenital Malformations. Subgroup 1: TGA hearts (n = 8) without surgical correction (uncorrected TGA) consisting of seven pediatric hearts (age range: 1 day–5.0 years) and one adult postmortem heart (20 years). Subgroup 2: TGA-Mustard/Senning postmortem hearts (n = 6), including five pediatric hearts (age range: 1–5.0 years) and one adult TGA-Mustard/Senning postmortem heart (age 33 years). Time until surgical correction (Mustard or Senning procedure) was 12 ± 6.8 months, and the median time between surgical correction and death was 3 years (range 6 months–33 years). Subgroup 3: TGA hearts after ASO (n = 8). Of these, seven pediatric postmortem hearts (age range 1 day–4.5 years) survived only a short time after ASO (time range: 1 day–15 days), and one adult postmortem heart survived 19 years after ASO. Subgroup 4: Pediatric control hearts (n = 3) without congenital heart disease (age range: 1 day–1.5 years). In these 25 postmortem hearts, a total of 75 tissue blocks were taken for further analysis. Characteristics of the TGA postmortem hearts are summarized in All three postmortem hearts in the control group were devoid of interstitial or patchy fibrosis at the visual inspection A–C. The p = 0.016). In uncorrected TGA, myocardial fibrosis was 9.1% ± 5.2 in the subpulmonary LV, 10.2% ± 3.7 in the systemic RV, and 11.7% ± 6.7 in the interventricular septum for all specimens combined (n = 8) and was significantly higher compared to controls (p = 0.009)  of the uncorrected TGA specimens. Of interest, the localization of diffuse interstitial fibrosis in 5 (63%) specimens was more pronounced in subendocardial/midventricular areas. The uncorrected TGA specimen at the age of 1 day old showed normal myocardium in the subpulmonary LV E but inc= 0.009) H. The mep = 0.002). Categorized upon age, the amount of fibrosis at the age of 1 year, 1.8 years, 2.5 years, 3.5 years, 5 years, and 33 years was 27.3% ± 8.2, 12.9% ± 3.4, 15.7% ± 2.6, 21.5% ± 4.8, 19.6% ± 2.7, and 21.9% ± 4.4, respectively (p = 0.001)  L. Inters= 0.001) M and int= 0.001) N and IVS= 0.001) O. TGA sup = 0.059  was operated at the age of 1 month and died 15 days after ASO. Sirius red staining showed diffuse interstitial fibrosis in the subpulmonary RV R and IVS = 0.059 T. The se = 0.059 U and int = 0.059 W, wherea = 0.059 V showed Control hearts showed that in both the left and right ventricle, cardiomyocytes were well aligned with a proper banding pattern and a homogeneous distribution of capillaries and cardiomyocytes A–C. Withp = 0.451) (p = 0.036)  B,D. Howe= 0.451) F,H,J,L, = 0.036) To correlate our findings with the literature, we systematically reviewed current literature related to TGA with respect to the subjects of our study. The literature search on myocardial fibrosis identified a total of 321 studies. After abstract screening and full text assessment, the majority of studies were excluded as they did not focus on TGA patients See . After cEight CMR studies  have beeOnly three histological studies in TGA-Mustard/Senning were identified ,12,13 inIn the TGA-ASO cohort, three CMR studies focusing on cardiac fibrosis have been performed. Most studies did not find LGE in the LV or RV, whereas one study reported LGE in either the inferior or superior septal-free wall, which was, in the majority, a small focal enhancement. Although higher ECV values with CMR were found post-ASO in both LV and RV compared to controls, this was not associated with any specific area . No hist11C]meta-hydroxyephedrine uptake in childhood and also during adulthood, indicating impaired myocardial innervation after ASO. Regional uptake was seen more frequently found at the left ventricle anterior site compared to the lateral site. No histological studies on cardiac innervation post-ASO were found. The included studies and the main results are summarized in The literature search on innervation post-arterial switch identified a total of 56 papers. After abstract screening and full text assessment, 53 papers were excluded. Most of these publications were excluded because no TGA-ASO patients were included or the focus was not on cardiac innervation. We included three studies that reported on cardiac innervation after the arterial switch operation see . These sIn this study, we systematically described the myocardial alterations in the full spectrum of TGA in uncorrected specimens as well as after surgical correction (Mustard/Senning or ASO). The key finding of our study is that interstitial myocardial fibrosis is already present in young uncorrected TGA hearts in both the systemic RV and subpulmonary LV. More fibrosis was observed in older uncorrected TGA patients. Furthermore, after TGA-Mustard/Senning correction, specimens showed various patterns of mild and severe interstitial fibrosis, which was remarkably more pronounced in the subpulmonary LV compared to the systemic RV. In TGA-ASO specimens, we found that the amount of βIII-tubulin-positive nerves was significantly decreased from three days after ASO, which may be related to denervation during the ASO. In the current study, the amount of interstitial fibrosis was increased in TGA neonates compared to the control group, suggesting that altered hemodynamics and saturations in TGA may induce fibroblast activation, which could already start in utero. In utero remodeling in the setting of congenital heart disease is supported by a study by Zwanenburg et al.  that alsTGA-Mustard/Senning postmortem specimens showed interstitial fibrosis, the amount varying from mild to severe. This finding is in line with a previous histological study in alive TGA-Mustard/Senning patients in which endomyocardial biopsies were obtained during cardiac catheterization at a mean age of 16.9 years and interstitial fibrosis in both the systematic RV as well as in the subpulmonary LV was found . HoweverIn our study, analyses of the presence of fibrosis in TGA-ASO were limited and performed in only two specimens due to the limited availability of specimens surviving at least two weeks after ASO. These two specimens died 15 days (age 1.5 months) and 19 years (age 19 years) after ASO. The specimen that died 19 years after ASO remarkably showed a severe amount of patchy fibrosis in the IVS and LV and diffuse interstitial fibrosis in the RV. Detailed clinical data were not available for clinical correlation, although no history of LV disease had been reported. Previous clinical studies with the inclusion of TGA-ASO patients and speckle-tracking strain imaging reported altered ventricular function in TGA patients. Klitsie et al.  reportedThe decreased number of βIII-tubulin-positive nerves that were found in specimens who survived at least 3 days after ASO could implicate that denervation starts shortly post-ASO. From a mechanistic point of view, this seems plausible as the cardiac plexus located at the myocardial outflow tract is acutely dissected during the ASO. This is in line with findings reported by Kondo et al. , in whicSeveral limitations should be acknowledged. First, this study is performed in selected postmortem specimens from the Leiden Collection of Congenital Malformations , and therefore per definition, in patients with a detrimental outcome. Findings should be, therefore, interpreted with caution as they may not be representative of myocardial structure and organization in patients with a more favorable outcome. Histological findings described, however, do correlate with findings in clinical studies reported to date, potentially representing patients at higher risk of complications/events. As TGA is a rare defect and short-term outcome has dramatically improved, the number of specimens in this study was dictated by the availability of postmortem TGA specimens in our biobank that met our inclusion criteria. Nevertheless, to the best of our knowledge, this is the largest histological study reported in postmortem TGA specimens to date. Although our results indicate a potential development of myocardial fibrosis already in utero, we did not examine fetal specimens in the current study. Most available specimens were from previous decades and had been stored for a significant time in conservative solutions. Some specimens did not retain antigen for myocardial structure (NCAD) or vascularization (PECAM), possibly caused by the long storage duration, and were excluded from sub-analysis. Only a limited number of TGA-ASO specimens with the survival of at least five days after the correction was available; therefore, this group was underrepresented to draw valid conclusions with regard to fibrosis patterns over time. Nevertheless, innervation patterns could be studied, and this group of ASO hearts represents the first to be described in histological detail to the best of our knowledge. Histological assessment in a selected group of postmortem TGA hearts showed diffuse interstitial myocardial fibrosis in uncorrected TGA newborns in the systemic RV as well as in the subpulmonary LV. This suggests that myocardial remodeling in TGA may already occur at the fetal stage. Furthermore, in TGA hearts after the Mustard/Senning operation, an increased amount of diffuse interstitial fibrosis was found in both systemic RV and, remarkably, even more so in the subpulmonary LV. Specimens of TGA patients who survived at least three days after ASO showed a decreased amount of autonomic nerves, which may be caused by  denervation during the ASO. Although data from the current study support a careful follow-up of TGA patients, these data should also be interpreted with caution as they are derived from a selected group of patients with detrimental outcomes. Long-term follow-up will likely shed light on the potential clinical implications of increased fibrosis, disturbed innervation patterns, and myocardial disorganization in the clinical group of TGA patients.