Apical hypertrophic cardiomyopathy is an uncommon variant of hypertrophic cardiomyopathy, with hypertrophy mainly affecting the apex of the left ventricle. We hereby describe a case of an octogenarian female patient who was randomly diagnosed with AHCM due to other comorbidities. Apical hypertrophic cardiomyopathy (AHCM) is a relatively rare morphologic form of hypertrophic cardiomyopathy (HCM), in which the hypertrophy of the myocardium predominantly implicates the apex of the left ventricle (LV), involving mostly Asian population –3. We coAn 85-year-old Caucasian, smoker, and hypertensive female under chronic medical therapy with digitalis due to known permanent atrial fibrillation (AF) presented complaining of dizziness, nausea, and angina-like chest discomfort. The patient also reported episodes of syncope during the past but without any further investigation. Her electrocardiogram (ECG) showed bradyarrhythmia with a high degree atrioventricular block, due to digitalis toxicity .Transthoracic echocardiography indicated left atrium enlargement, a small LV with hyperdynamic contractility, and excessive hypertrophy of the apical wall of 33 mm, while contrast injection was elusive for apical AHCM .Coronary arteriography showed no significant stenosis. The left ventriculography revealed a typical “spade” shape ventricle  with obstruction during systole confirming the diagnosis of AHCM Figures .Seven days after digitalis withdrawal, the ECG findings were AF with normal axis deviation and T wave inversion most prominent in the midprecordial leads . A 24-hoOur case underlines the unusual features of AHCM. This variant of nonobstructive HCM represents up to 25% of the entire HCM population in Japan and 1% to 10% in non-Asian population, while its prevalence in the elderly people remains uncertain .Compared to all other forms of HCM, patients with AHCM tend to be much older, less symptomatic, and usually characterized by less hypertrophy. The typical features of AHCM consist of giant negative T waves on ECG and a “spade-like” configuration of the LV cavity at end-diastole on left ventriculography. Data from ECG-CMRI (cardiac magnetic resonance tomography) studies demonstrate a good correlation between negative T waves amplitude and the ratio between apical and basal septal wall thicknesses  –7. HowevIn this context, a weak correlation between the degree of apical thickness and the maximal T wave negativity has also been reported. Of note, Caucasian patients tend to have less localized involvement of the distal apex resulting in a lower frequency of the pathognomonic sign of “ace of spade” on the left ventriculography , 9. ConvThe apical variant has a more benign prognosis than other forms of HCM as the patient in our case, but it is still associated with adverse outcome mainly in the elderly in the presence of AF. Adverse events include thromboembolic stroke, progressive heart failure myocardial infarction, and arrhythmias. AHMC in Western population patients is not frequently associated with sudden cardiac death in terms of cardiovascular mortality ranging around 0.1% , 12.Small number of cases and studies documented the delayed onset of the AHCM phenotype at any age in life, resulting in late-appearing apical LV hypertrophy. Hypertension, whose prevalence is higher in the elderly cohort than the general population, has been reported that could play an added role as a trigger of AHCM. Meanwhile, this clinical entity often remains underappreciated and misdiagnosed due to lack of awareness of the condition, especially in this cohort of patients , 12.AHCM is an uncommon clinical type of HCM. Recent data suggest that it is less benign than previously suspected, especially in Caucasian elderly women that might also present without the giant T waves on ECG. Careful care along with serious consideration of all related comorbidities and medications is needed.


Pregnancy represents a physiological adaptation to the transient load changes of maternal heart. This study aimed to investigate maternal left ventricle (LV) performance during normal pregnancy by three-dimensional speckle-tracking echocardiography (3D STE) parameters considering LV loading and shape.Sequential two-dimensional echocardiography (2DE) and 3D STE were performed on 68 women during each pregnancy trimester and 6 to 9 weeks after delivery, while thirty age-matched, healthy, nonpregnant women served as controls. Global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS) and global radial strain (GRS) were measured.Increased cardiac index and progressive eccentric hypertrophy was detected, which subsequently recovered postpartum. In late pregnancy, GLS, GCS, GAS and GRS significantly decreased (P < 0.05) accompanied by a slight reduction of LV ejection fraction (EF) (P < 0.05), and these values returned postpartum to baseline level. All 3D strain indices correlated well with gestation age (P < 0.01), while compared to other components, GAS exhibited the strongest association with 3D EF (r = 0.549) and sphericity index (r = 0.328), and was the only parameter that correlated well with LV mass index (r = 0.22).This study gives normal ranges of 3D STE indices in pregnancy. 3D STE demonstrated modified myocardial deformation and changes in maternal LV structure and function during the gestation period. During pregnancy, there are important hemodynamic variations which result in a physiological situation of transient changes preload and afterload in the maternal heart. Those changes are necessary for the progression of a successful pregnancy, but which may also impose further load on the heart. Moreover, heart disease is the leading cause of nonobstetric mortality during pregnancy , and theDespite many reports on maternal cardiac adaption being published, there is controversy about the change in left ventricular (LV) performance during pregnancy. Although it is reported that an increased cardiac output (CO) is paralleled by a decreased peripheral vascular resistance, the documents on the enlargement of chamber size, LV wall thickness and mass are inconsistent , 4. MoreRecently, two-dimensional echocardiographic (2DE) indices of myocardial longitudinal deformation, strain imaging, have been shown decreased significantly in late pregnancy while the traditional parameters did not reflect those functional changes . HoweverAll women with singleton pregnancy were recruited consecutively as cases, and thirty age-matched, healthy, nonpregnant women served as controls after informed consent and with approval from the Third Affiliated Hospital of Zhengzhou University Ethics Committee. Enrolled criteria of healthy pregnant women was that they were without medical diseases, such as cardiovascular disorders, renal disease etc., and without obstetrical complications, such as gestational diabetes mellitus or pregnancy-induced hypertension. Subjects who had poor echo quality or any fetal abnormalities were excluded from the study. A total of 68 patients were entered into the study. Four visits were planned during the study: trimester 1, 12–14 weeks; trimester 2, 24–26 weeks; trimester 3, 36–38 weeks and 6–9 weeks after delivery. The pregnancy trimester was confirmed by ultrasound scanning in the first half of pregnancy. At each visit, the normal course of pregnancy was confirmed by an obstetric assessment, weight and blood pressure were measured, and an echocardiographic examination was performed.Standard 2D echocardiographic examinations, including parasternal and apical views with pulsed Doppler evaluation, were performed with subjects in the left lateral decubitus position using a commercially available ultrasound machine and transducer . The long axis views of the left ventricle were obtained at the apical four-chamber, two-chamber, and long-axis planes, while three short-axis views were acquired at the basal, midventricular and apical level. The following parameters were performed by M-Mode in the parasternal long-axis view as recommended: interventricular septum (IVSd), posterior wall (PWd), left ventricular end-diastolic (LVEDd) and end-systolic (LVEDs) diameters. LVEF and stroke volume (SV) were calculated as previously described . RelativA full-volume scan was acquired by a matrix-array transducer . Consecutive three-beat electrocardiographically gated subvolume acquisition was performed from the apical approach during apnea to generate the full-volume data set. Frame rate (in volume per second) higher than 40% of the individual heart beat was used in order to increase the possibility that the ‘speckles’ could be recognizable in successive frames. A12-slice display mode available on the machine was selected to ensure the entire LV cavity and walls were included in the full volume. When the acquisition was considered suboptimal, the data set was re-acquired. All data sets were stored digitally in a raw-data format and exported to separate workstations equipped with commercially available quantitative software.Three-dimensional full-volume data sets were analyzed using the 4DAutoLVQ package (EchoPAC PC version 110.1.8). A quad view, which displayed at end-diastolic frame, was used for manual alignment of the axis and the mitral valve leaflet. Then, in each of the three apical views, three points were indicated manually, including both sides of mitral annular corners and one apical point. Automated border detection followed the endocardium throughout the whole cardiac cycle; subsequently, a frame-by-frame point-and-click correction was manually performed by the operator to adjust the tracking of the endocardium for all segments. After that, end-diastolic volume (EDV), end-systolic volume (ESV), SV, CO, EF and sphericity index (SpI) were automatically calculated Figure . Global All imaging data was analyzed by one observer in random order. To test intraobserver variability, a single observer analyzed the data twice on occasions separated by an interval of 1 month. To test interobserver variability, a second observer analyzed the data without knowledge of the measurements of the first observer.t tests. 3D strain data were compared with 2D approach by paired t test. Pearson correlation coefficient was used to analyze the relationship between two parameters. Reproducibility was assessed as the mean percentage error (absolute difference divided by the mean of the 2 observations). We used SPSS version 17.0  statistical software. P < 0.05 was considered to indicate statistical significance.Descriptive data are shown as means ± SD. ANOVA for repeated measures was used to compare data between sequential studies in the pregnant group. Pregnancy data were compared with controls using independent sample P not significant).From the initially enrolled 87 participants, those with poor-quality images (5 participants), lacking at least 2 visits during pregnancy (6 participants), and those pregnancy-related pathology  and with fetal abnormalities (2 participants) were excluded from the analysis. Finally, sixty-eight pregnant women were involved in the study. Their mean age was 29.6 ± 4.2 years (range 26 ~ 33 years). The mean age of the 30 participants of the control group was 30 ± 5.1 years  and GCS .3D echocardiography assessment of LV structure and function is reported in Table For 3D STE measurements, intraobserver and interobserver variability were 7. 2% and 8.4% for LV EDV measurements; 6.8% and 7.6% for 3D EF measurements; 9.1% and 9.8% for LVMi measurements; and 8.1% and 8.6% for SpI measurements, respectively. Meanwhile, for deformation parameters, intraobserver and interobserver variability were 8.0% and 8.9% for GLS measurements, 9.0% and 9.6% for GCS measurements, 7.1% and 8.4% for GAS measurements as well as 9.4% and 11.2% for GRS measurements, respectively.The present study examined LV structure and systolic function in healthy pregnant individuals by 3D STE assessment of LV volumes, mass and cardiac motions. To the best of our knowledge, this is the first study to use this quantitative approach as an alteration to standard echocardiograph on normal pregnancies. Similar to previous studies , increasIn current clinical practice, 2DE is the first-choice technique to diagnose changes of LV geometry, and LVEF is a widely used and prognostic important indicator of LV systolic function. However, these parameters are inextricably linked with and influenced by the load and the geometry of heart and, therefore, only reflect the ventricular function indirectly. In this regard, several studies have successfully shown that 3D STE has better accuracy than 2DE in comparison with reference techniques, such as cardiac magnetic resonance imaging . MoreoveIn the present study, the changes of global directional strain with 3D STE, including longitudinal, circumferential and radial, were assessed. Although the values between the first and second trimester showed mild but no significant reduction in strain, these components decreased significantly from the second to third trimester and increased again postpartum. This finding is different from the previous 2D STE study that reported only LV longitudinal systolic deformation showed a significant decrease in late pregnancy while circumferential and radial strain showed no changes during the study . FurtherAnother new and important finding of our study is represented by the evidence of varied GAS during normal pregnancy. GAS is a novel 3D STE index which corresponds to the percentage of deformation in LV endocardial surface area. Since it has integrated longitudinal and circumferential deformation, Seo et al. inferred that GAS might decrease the tracking error and emphasize synergistically the magnitude of deformation . SeveralBy using 3D method, GLS, GAS, GRS showed small, but significant decreases between the second and third trimester, while EF showed no significant changes at the same time. These data are in concordance with other studies that strain measurements detect subtle changes more sensitively than EF , 22. AllWe reasoned that the variation of strain during uncomplicated pregnancy could be due to a combination of mechanisms: preload/afterload of ventricle, wall thickness and chamber size.To produce the same stroke volume, there is an inverse relationship between heart size and strain . BetweenIn contrast, despite an increasing stroke work, the values of 3D STE appeared significantly reduced in the late term accompanied by a slight drop of 3D EF. Hypertrophy is commonly seen as a primary mechanism of the heart to reduce stress on the ventricular walls . From thThere are several limitations in this study that should be addressed. Firstly, we did not use a non-echocardiographic method for EF estimation to verify the accuracy of 3D measurements, but 3D echocardiography has been validated against cardiac magnetic nuclear resonance imaging . SecondlThis study provides reference data concerning physiological changes in LV structure and systolic function during normal pregnancy and presents normal range of maternal cardiac motion with 3D STE. Cardiac hypertrophy in pregnancies was observed. We could show that the subtle reduction of myocardial deformation appears as an adaptive response to changes of preload, afterload and LV geometry, and consequently contribute to the modest decrease of EF in late pregnancy. In future clinical use of 3D STE for the early detection of pregnant complications, normal values would require to be adjusted to the gestational age or considering LV geometry and load.


Chagas’ heart disease is an important public health problem in South America. Several aspects of the pathogenesis are not fully understood, especially in its subclinical phases. On pathology Chagas’ heart disease is characterized by chronic myocardial inflammation and extensive myocardial fibrosis. The latter has also been demonstrated by late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR). In three clinical phases of this disease, we sought to investigate the presence of LGE, myocardial increase in signal intensity in T2-weighted images (T2W) and in T1-weighted myocardial early gadolinium enhancement (MEGE), previously described CMR surrogates for myocardial fibrosis, myocardial edema and hyperemia, respectively.Fifty-four patients were analyzed. Sixteen patients with the indeterminate phase (IND), seventeen patients with the cardiac phase with no left ventricular systolic dysfunction (CPND), and twenty-one patients with the cardiac phase with left ventricular systolic dysfunction (CPD). All patients underwent 1.5 T CMR scan including LGE, T2W and MEGE image sequences to evaluate myocardial abnormalities.p < 0.0001). Myocardial increase in signal intensity in T2-weighted images (T2W) was present in 77.8 % of all patients, in 31.3 % of the IND, 94.1 % of the CPND and 100 % of the CPD patients (p < 0.0001). T1-weighted myocardial early gadolinium enhancement (MEGE) was present in 73.8 % of all patients, in 25.0 % of the IND, 92.3 % of the CPND and 94.1 % of the CPD (p < 0.0001). A good correlation between LGE and T2W was observed .Late gadolinium enhancement was present in 72.2 % of all patients, in 12.5 % of IND, 94.1 % of the CPND and 100 % of the CPD patients (Increase in T2-weighted (T2W) myocardial signal intensity and T1-weighted myocardial early gadolinium enhancement (MEGE) can be detected by CMR in patients throughout all phases of Chagas’ heart disease, including its subclinical presentation (IND). Moreover, those findings were parallel to myocardial fibrosis (LGE) in extent and location and also correlated with the degree of Chagas’ heart disease clinical severity. These findings contribute to further the knowledge on pathophysiology of Chagas’ heart disease, and might have therapeutic and prognostic usefulness in the future. Trypanosoma cruzi infection is responsible for the Chagas’ disease (CD) [ase (CD)  and it iase (CD) , with anase (CD) . Chagas’ase (CD) , 5. ChagT. cruzi DNA can be detected by polymerase chain reaction during the chronic phases of Chagas’ heart disease in association with inflammatory infiltrate [T. cruzi in combination with moderate to severe inflammation was demonstrated with the technique of immunohistochemistry [Myocardial fibrosis has been described in some studies with advanced Chagas’ heart disease subjects, using histologic confirmation , 7. T. cfiltrate –10. The hemistry . Myocardhemistry .Myocardial fibrosis in Chagas’ heart disease has also been demonstrated by cardiovascular magnetic resonance (CMR) using late gadolinium enhancement (LGE) technique, by few studies –15. Addi2 and a contraindication to perform CMR. All patients underwent a brief interview prior to the MRI exam, which included information on height, weight, medical history and previous exams. We enrolled three subgroups at different stages of disease progression based on a classification of Chagas’ disease and grouped by the outpatient clinic: 1) a group of 16 patients without evidence of cardiac involvement by ECG, chest radiography and echocardiography called indeterminate phase of Chagas’ disease (IND), 2) a group of 17 patients who had cardiac phase without left ventricular systolic dysfunction (CPND), determined by ejection fraction equal or superior to 55 % by a routine clinical echocardiography analysis and electrocardiographic abnormalities (right bundle branch block with left anterior hemiblock) or 3) a group of 21 patients with the cardiac phase with left ventricular systolic dysfunction determined by ejection fraction inferior to 55 % by echocardiography analysis (CPD). The use of echocardiography for the definition of the left ventricular dysfunction and for the classification of chagasic cardiopathy phase followed the recommendation of the current guidelines for Chagas heart disease [In this cross-sectional study, we enrolled 54 patients with Chagas’ heart disease to undergo CMR. Patients with serologic confirmed Chagas’ disease diagnosis were referred to the study from our cardiomyopathy outpatient clinic. Exclusion criteria were history of myocardial infarction or coronary artery disease, more than two risk factors for CAD or diabetes mellitus , valvular heart disease, previous viral myocarditis, other phases of cardiomyopathy, creatinine clearance below 30 ml/min/1.72 mCMR was performed in all patients with a Philips 1.5 T scanner . Images were acquired and coupled to the ECG during breath-hold, at left ventricle long and short axis, in the exact same location in the different image sequences. This allowed a precise comparison between cardiac function and regional myocardial structure. Cine images were acquired using SSFP sequence with TR 3.5 ms, TE 1.5 ms, flip angle 60 °, receiver bandwidth ± 125 kHz, field of view (FOV) of 35 × 35 cm, 256 × 148 matrix, temporal resolution 35 ms, 8.0 mm slice thickness, with 2 mm gap between the slices.The detection of T2W was performed with a triple inversion-recovery pulse fast spin-echo (FSE) and long TE , with breath-hold, in short axis view of the left ventricle, which was carefully prescribed in order to guarantee the presence of an adequate skeletal muscle area for reference. In this sequence, we used the volumetric body coil acquisition to guarantee volume homogeneity and avoid signal dropout, as usually occurs with the surface coils. The parameters were: TR 2RR interval, TE 80-120 ms, Echo train length 24 (ETL), TI 140 ms, slice thickness 10 mm, with no gap (keeping the same center slice as for cine and LGE sequences) field of view 34 × 38 cm, matrix 128 × 128. MEGE acquisitions were performed pre and immediately post-gadolinium injection, with the same scanner parameters and calibrations. We applied a spin-echo free breathing sequence, in axial plane tipped inferiorly towards the left to align with the inferior wall of the left ventricle, with no change in acquisition parameters before and immediately after intravenous injection of 0.1 mmol/kg gadolinium based contrast , at a 2 ml/sec rate, followed by 10 ml of saline. The sequence began immediately after injection and lasted 3 to 4 min; the images reflect a gadolinium enhancement for an average time of 2 min. The sequence parameters were the following: Field of view should be adjusted to include the left upper arm, echo train length 2 to 4, slice thickness of 8 to 10 mm, 128 y-lines, and four signals averages.Following the acquisition of spin-echo images, an additional dose of gadolinium-based contrast (0.1 mmol/kg) was injected for LGE acquisitions, using a typical inversion-recovery prepared gradient-echo acquired 10 to 20 min after the contrast, with the following parameters: TR 7.1 ms, TE 3.1 ms, flip angle 20°, cardiac phases 1, views per segment 16 to 32, matrix 256 X 192, slice thickness 8 mm, gap between slices 2 mm and field of view 32 to 38 cm, inversion time 150 to 350 ms, receiver bandwidth 31.25 kHz, number of excitations 1, acquisition every other heart beat. Additionally, we performed another sequence as described above but with an inversion time TI of 600 ms for further characterization of cardiac thrombus.The tests were analyzed in workstation with the CMR-42 software version 4.0.3 . The analyses were performed by an experienced professional blinded to the clinical classification and LGE results, randomly assigned using the Lake Louise criteria for myocarditis by CMR . End-sysLate gadolinium enhancement patterns were classified as subendocardial, midwall, subepicardial, or transmural. The analysis included the number of LV segments involved by late gadolinium enhancement and an assisted automatic quantitative analysis to estimate LGE mass by a thresholding technique with pixel signal intensity 3 standard deviation above the mean of normal myocardial considered as myocardial fibrosis. In Chagas cardiomyopathy, heterogeneous and patchy myocardial fibrosis is the most frequent pattern, which challenges the use of Full Width at Half Maximum (FWHM) technique, where it is crucial to define a clear homogenous myocardial fibrosis area as a reference. By our knowledge, no definition on ideal threshold for detecting myocardial fibrosis in LGE images of Chagas cardiomyopathy patients is available. The authors performed a pilot analysis and felt that 3 standard deviation (SD) cutoff above normal myocardial signal intensity had the best agreement with visual LGE in a range of Chagas cardiomyopathy severity, which led the authors to choose in this study the 3SD threshold instead of 5SD (used in some studies involving hypertrophic cardiomyopathy). Quantification of late enhancement in the left ventricular myocardium used CMR42 software .t test and one-way analysis of variance with Bonferroni test for multiple comparisons. The Fisher exact test was used for proportions comparisons. The nonparametric test for discrete variables and non-normal continuous variables was Kruskal-Wallis rank test. Normality was determined by Shapiro-Francia W’ test. Simple linear regression was used between the MF mass and LVEF, end-diastolic volume, and end-systolic volume. Stata 8.0  was used, and p < 0.05 (two-tailed) considered statistically significant. Given the exploratory nature of the study, formal calculations of sample size were not performed. Based on an article published by our group [Comparisons of normally distributed continuous variables were performed by the Student ur group , which iWe have analyzed 54 patients, and 47 (87 %) had coronary angiography indicating absence of obstructive lesions , The seven remaining patients had no history for coronary artery disease or presence of more than one risk factor. The mean age was 55.53 ± 11.11 years. The minimum age was 35 years and maximum 84 years. The population had similar age within the three phases of the disease. Regarding gender distribution, our sample showed no significant difference, however, there is an unequal distribution in the disease severity between genders, men are in more advanced stages of disease than women and with more LGE and T2W . The CPND showed an average LVEF of 35.8 ± 10.8 %, CPD and the indeterminate phase had 54.0 ± 12.0 % and 65.0 ± 5.7 %, respectively (<0.001). All with statistical differences by post HOC analysis (Bonferronni). The indexed end diastolic volumes of the left ventricle were progressively increased, along with the severity of the clinical phase. CPD showed an average of 137.0 ± 44.0 ml/m2 (Table p < 0.001), functional class (p < 0.001), LVEF (p < 0.001), and left ventricular diastolic volume (p < 0.001)  Tables .Table 3Pp < 0,0001)  of the indeterminate phase Fig. , 21 pati1) Table .Fig. 1App < 0,0001)  indeterminate phase  within the indeterminate phase, twelve (92.3 %) in CPND patients and sixteen 94.1 %) of the CPD patient group, .1 % of tp < 0.001)  were identified with myocardial fibrosis, of which 204 (83.6 %) had segmental dysfunction. In 138 (15.0 %) segments T2W was detected, of which 102 (73.9 %) had segmental dysfunction. The coexistence of fibrosis and T2W was seen in 99 segments . Segmental dysfunction was detected in 363 segments. Presence of T2W did not perform as an independent factor to predict dysfunction when the segment had myocardial fibrosis, but it showed a significant chance for predicting segmental dysfunction within segments without myocardial fibrosis (Figs. .6 % wereCMR stands out amongst imaging techniques in the identification and quantification of myocardial fibrosis in Chagas’ heart disease, as has been described previously , 14. Thein vivo with a noninvasive tool, such as CMR, in patients with Chagas’ heart disease. The techniques applied in this study were well established in some important studies of myocarditis [This is the first study to investigate T2W and MEGE carditis , 17, 19 carditis .The natural history of indeterminate phase is to evolve to the cardiac phase in up to one third of this group or stay a benign condition without considerable deterioration of the myocardial status. Presence of positive criteria for T2W and MEGE in the indeterminate phase could have prognostic power to predict the evolution to the cardiac phase. The CPND is of great interest, considering that there is already a cardiac involvement, especially in the electric pathway, without significant systolic myocardial dysfunction. This phase may have also an unpredictable evolution and, therefore, it could become a valid maker for etiologic therapy, which is still controversial and awaiting for results of larger trials. Identifying myocardial abnormalities in phases of the disease with none or minor cardiac damage seems to be a reasonable alert to physicians of witch groups are at greater risk to develop systolic dysfunction and clinical heart failure. It also represents a major advance in understanding this disease, besides having therapeutic and prognostic importance.T. cruzi could be demonstrated using PCR and immunohistochemistry associated with inflammation [T. cruzi and human myocardial fibers, and they serve to sustain the autoimmune theory [in vivo CMR evidence that the inflammation of Chagas’ disease is perpetuated for an extended period after the acute phase.The presence of myocardial abnormalities in patients with Chagas’ heart disease is not surprising and has been demonstrated on prior histological studies. Evidence suggests that parasites persist in the myocardium and the inflammatory and immune reactions are primarily responsible for the pathology. The presence of ammation –11. Othee theory , 27. Thie theory , and mayGutberlet et al. demonstrated the presence of persistent inflammation, confirmed by biopsy in 59 % of a group of patients with chronic viral myocarditis. This result differs of that found in this group of chronic Chagas myocarditis, where 74 % of the individuals had positive criteria for inflammation. This difference may be explained by the greater severity of myocardial damage found in chagasic myocarditis, where the mean LVEF was 50.2 % for all patients, 54.0 % for CP patients and 35,8 % for CPND patients, while in a chronic viral myocarditis group the LVEF was found within normal limits .in vivo in patients with Chagas’ heart disease. Therefore we have faced some novel technical and clinical challenges. Our study had no control group, since we found concerning to enroll health subjects to contrast injection, however we used a very well established criteria for the detection of LGE, T2W and MEGE, with published historical controls. The edema and hyperemia criteria were extensively experimented on prior studies, compared with normal myocardial [Our study represented the first to attempt an inflammatory characterization ocardial , 17, 19.in vivo by CMR in patients within all clinical phases of Chagas’ heart disease, not only in the advanced phases but also in the early indeterminate phase. Moreover, those findings demonstrated a good biological correlation with the severity of Chagas’ heart disease, NYHA functional class, left ventricular ejection fraction, and with the presence of myocardial fibrosis.CMR enables identification, location and quantification of myocardial fibrosis, T2W and MEGE on Chagas’ heart disease, adding potential information on disease severity. T2W and MEGE can be detected


Non response to cardiac resynchronisation therapy (CRT) may be related to the position of the coronary sinus lead.We studied the acute haemodynamic response (AHR) from alternative left ventricular (LV) endocardial pacing sites in clinical non-responders to CRT. AHR and the interval from QRS onset to LV sensing  from four different endocardial pacing sites were evaluated in 24 clinical non-responders. A rise in LVdP/dtmax ≥ 15 % from baseline was considered a positive AHR. We also compared the AHR from endocardial with the corresponding epicardial lead position.The implanted system showed an AHR ≥ 15 % in 5 patients. In 9 of the 19 remaining patients, AHR could be elevated to ≥ 15 % by endocardial LV pacing. The optimal endocardial pacing site was posterolateral. There was no significant difference in AHR between the epicardial and the corresponding endocardial position. The longest Q-LV interval corresponded with the best AHR in 12 out of the 14 patients with a positive AHR, with an average Q-LV/QRS width ratio of 90 %.Acute haemodynamic testing may indicate an alternative endocardial pacing site with a positive AHR in clinical non-responders. The Q-LV interval is a strongly correlated with the optimal endocardial pacing site. Endocardial pacing opposite epicardial sites does not result in a better AHR. Cardiac resynchronisation therapy (CRT) has become an important treatment for patients with heart failure and left ventricular (LV) dyssynchrony –3. HowevWe studied the acute haemodynamic response (AHR) of the implanted system and alternative left ventricular endocardial pacing sites in patients clinically not responding to CRT .We asked patients who remained in New York Heart Failure class III or IV despite at least 6 months of CRT and adequate medical therapy and with no therapeutic options left to undergo an acute haemodynamic study in search of improving existing CRT, as previously described , 9. TwenIn 23 patients, a 6F multipurpose angioplasty guiding catheter was introduced into the LV after a standard transseptal catheterisation. In one patient, the guiding catheter was introduced through the radial artery following coronary angiography. Through this guiding catheter, endocardial pacing and measurements of LVdP/dtmax were accomplished by roving a Medtronic 6416 temporary bipolar screw-in lead  and a RADI pressure wire  inside the LV cavity.Initially the atrioventricular and interventricular intervals of the implanted system were optimised to obtain the maximal LVdP/dtmax. LV pacing was performed from basal posterolateral, mid-posterolateral, LV apical and LV septal locations, and optimal AHR obtained after optimisation of the CRT system for all positions. If none of the 4 endocardial positions were opposite the position of the coronary sinus lead, an additional measurement was done at this location. A rise in LVdP/dtmax ≥ 15 % from baseline was considered to be a positive haemodynamic response.In all patients with an AHR of ≥ 15 % during LV endocardial pacing, the interval between the onset of the QRS complex and the intrinsic activation at the LV electrode  was measured and the ratio between Q-LV/QRS width interval calculated. This ratio expresses the relation between Q-LV interval and QRS width, which is a better indicator for late or early LV sensing than the absolute value of Q-LV.Notwithstanding that all patients were clinical non-responders, in 5 patients LVdP/dtmax with the implanted coronary sinus system increased ≥ 15 % after optimisation: average 30.2 %, 15.6–44.5 %  with LBBB, the AHR could be increased above the 15 % level by LV endocardial pacing. The average AHR with the coronary sinus system was 9.6 % (5.8–14.9 %) and at the LV endocardial optimal position 25.8 % (19.0–34.3 %). The average QRS width in these patients was 169 ms (135–198 ms) and the average Q-LV at the optimal LV endocardial pacing site 157 ms (128–176 ms), resulting in a Q-LV/QRS ratio of 93 %. The position of the original coronary sinus lead was apical in 3, anterolateral in 1 and mid-posterolateral in 1 patient . The average QRS width in these patients was 176 ms (149–209 ms) and the average Q-LV 136 ms (100–174 ms), resulting in a Q-LV/QRS ratio of 83 %. The coronary sinus lead position was posterolateral in all 4 patients.Four patients did not have LBBB. Of these, only one patient with RBBB, combined with left anterior hemiblock, showed an increase in the AHR, from − 9.1 %  to 25.8 % at an endocardial basal posterolateral position. Two of the other patients had an RBBB pattern Fig. ; one hadThree out of the 6 patients with RV pacing became haemodynamic responders  increased to 21.8 % 16.6–24.8 %)). Coronary sinus leads were in an apical, anterolateral and mid-posterolateral position. In the other 3 patients the average AHR increased from 2.9 % (1.1–4.0 %) to 9.7 % (7.8–11.4 %). In 2 patients the coronary sinus lead was in a mid-posterolateral position, one in an apical position. Individual details are summarised in Table .7 % incr.8 %). Cop = 0.37).When pacing endocardially, opposite the epicardial coronary sinus lead, we found that LVdP/dtmax did not differ significantly for any of the patients: LVdP/dtmax from the coronary sinus averaged 1046 ± 292 mmHg/s vs. 1068 ± 296 mmHg/s from the corresponding LV endocardial site . PL-best had a rise to 30.2 ± 13.6 % in LVdP/dtmax, basal posterolateral 27.7 ± 15.2 %, mid-posterolateral 24.6 ± 12.6 %, LV apical 14.8 ± 9.1 % and LV septal 17.0 ± 11.2 %.We also found that in 12 out of the 14 patients (85 %) with an AHR ≥ 15 %, the LV endocardial site with the longest time interval between the onset of the QRS complex and LV sensing  resulted in the best haemodynamic response . The aveTen patients were considered possible candidates for LV endocardial pacing: 9 patients in whom a rise in LVdP/dtmax ≥ 15 % level was only obtained by endocardial pacing, and the patient that showed a substantial additional rise in AHR with LV pacing compared with coronary sinus pacing (patient 15). One patient died from progressive heart failure before the endocardial implant could be performed.Of the remaining 9 patients, and after deliberation with the patients about the possible benefits and risks, 5 of them finally agreed to LV endocardial implant at the optimal LV site as indicated from the acute study [One patient with a positive AHR from endocardial pacing also improved significantly after changing stimulation from the distal to the proximal electrode with a more basal position, and became a clinical responder after optimisation of the atrioventricular and interventricular interval.In one patient, the deterioration of his condition after initial improvement proved to be the result of a blunted chronotropic response after increasing beta-blocker dosage following an episode of atrial fibrillation resulting in an inappropriate ICD shock. Activation of sensor driven pacing restored his clinical status to the former level.This observational study showed that endocardial LV pacing, guided by acute haemodynamic studies, could improve clinical outcome in patients not responding to conventional CRT. It also demonstrated the importance of lead location, as the clinical response improved with a posterolateral position of the lead instead of the original apical or anterolateral lead location. Conversely, none of the patients who already had a coronary sinus lead in a posterolateral position improved sufficiently with endocardial pacing at any site during the acute haemodynamic study to justify endocardial lead implant. This is in line with the MADIT-CRT trial, where the apical and anterior positions of the LV lead had a lower clinical response .Noteworthy, and similar to what has previously been reported, endocardial pacing opposite the coronary sinus pacing site did not improve the AHR in our study –13. ThisTherefore, although not examined in this and other studies, one either might speculate that epicardial pacing opposite the optimal endocardial sites, via the coronary sinus or surgically by thoracoscopy, might have resulted in similar benefits. If feasible, this might be a good alternative to avoid the uncertainty of thromboembolic complications with LV endocardial pacing .Our observational study also showed some limitations in the use of acute haemodynamic studies to predict clinical outcome. First, five clinical non-responders showed a clear AHR according to the accepted criteria  but failed to respond clinically .Still, when a substantial further increase in LVdP/dtmax from endocardial pacing at a posterolateral position compared with the apical coronary sinus lead (66 vs. 19.7 %) was obtained in one patient, endocardial lead implantation resulted in a positive clinical response. This illustrates the limitation of cut-off values in CRT studies of the 15 % level as surrogate for differentiating between clinical response and non-response, and that what is considered a positive haemodynamic response can still be significantly improved in the presence of an anterior or apical lead position . A similTo err on the safe side, we therefore proceeded to a permanent LV endocardial implantation when the final increase in AHR was at least 25 %. There was no clinical evidence for the choice of this percentage.The best AHR correlates well with the longest time interval between onset QRS and LV sensing in relation to the QRS width in the individual patient .The results of the group of patients with non-LBBB are in line with what could be expected according to the literature . The absThis observational study showed that a temporary acute haemodynamic study could be useful in non-responders to establish the chance of improvement with alternative pacing sites before embarking on complex procedures as endocardial LV pacing. It remains, however, uncertain what the optimal cut-off value for increase in LVdP/dtmax is before the improvement justifies intervention. The longest Q-LV interval is a reliable indicator for the optimal electrode position in the individual patient.Endocardial pacing opposite epicardial sites does not show acute haemodynamic improvement, so epicardial pacing at the optimal site may be a good alternative for endocardial LV lead placement. Although all patients who had a LV endocardial system implanted after a positive AHR improved clinically, larger randomised series are necessary to justify this technique before definitive conclusions can be drawn.B.M. van Gelder has received training and education on Pacing and CRT from St Jude Medical, is a consultant with RADI pressure wire systems, a St Jude Medical company, and consultant for Pacing and CRT with Sorin Group CRM SAS.R. Nathoe, F.A. Bracke: None declared.


Non-heart-beating donation, in the situation where a patient cannot be diagnosed as dead using brainstem criteria, may be an alternative to overcome shortage of donors. Preclinical studies showed that functional recovery of hearts after circulatory determination of death (DCDD) were similar to that of hearts from brain-dead donor. However, there are several experimental methods of simulating DCDD conditions such as exsanguination and hypoxic cardiac arrest both followed by warm ischemia.We aimed to compare two non-heart beating models in rat heart transplantation in which grafts were retrieved under exsanguination- or apnea-induced non-heart-beating conditions.Donor hearts were either left in situ for 10 min after cardiac arrest, which was induced by rapid exsanguination  or subjected to hypoxic cardiac arrest followed by 10 min of warm ischemia . Additionally, a control group, in which heart grafts were retrieved from heart beating donors, was used (n = 6). Then, hearts were perfused with a cold preservation solution (Custodiol), explanted, stored at 4°C in Custodiol for 1h and heterotopically transplanted. We evaluated left-ventricular graft function and assessed protein expression 1.5h after transplantation.After transplantation, significantly decreased systolic function  was observed in both exsanguinations- and apnea-groups compared to controls. Additionally, apnea-group showed further impaired diastolic function when compared with the exsanguination-group . Protein levels of caspase-3, tumor necrosis factor alpha, cyclooxygenase-2, nuclear factor KappaB, inducible nitric oxide synthase, cytochrome-c and SERCA-2 (assessed by Western Blot) did not differ between the groups.Our results showed that both models appear to be useful for investigating functional and molecular characterization of potential use of hearts after DCDD.


Duchenne muscular dystrophy (DMD) is an x-linked neuromuscular disorder in which cardiopulmonary disease leads to death in the third to fourth decade of life. Diaphragm and myocardium suffer progressive damage. While abnormalities in pulmonary and left ventricular function have been independently described, the relationship between pulmonary function and the right ventricle has not been evaluated.Thirteen males with DMD enrolled in an ongoing clinical trial underwent CMR with multislice short axis cine imaging, using either breathhold segmented steady-state free precession or real-time acquisition techniques. Offline analysis of right ventricular volumes and ejection fractions was performed by a single reviewer blinded to PFT results using endocardial contour delineation and Simpson's rule. Forced vital capacity (FVC%) was recorded from PFTs acquired within 10 weeks of CMR examination, and serum brain natriuretic peptide levels were measured. Subjects were classified into two groups based on having at least 80% predicted FVC.2; p=0.026, Figure). There was no significant difference in the LVEF between two groups .There was no correlation between indices of right ventricular size and systolic function and BNP levels.Of the 13 subjects aged 17.5± 6.5 years (mean ± SD) who underwent CMR and concurrent FVC assessment, 11 were non-ambulatory and all subjects were on chronic oral corticosteroids at the time of imaging. Left ventricular ejection fraction (LVEF) was normal in the study group (56.9±5.3%). The right ventricular indexed stroke volume was reduced in subjects who had less than 80% predicted FVC compared to patients who had more than 80% predicted FVC (25.2±4.9 vs. 32.4±5.3 mL/mVariable RV systolic function and pulmonary function were demonstrated in boys with DMD and normal LV systolic function as assessed by CMR. Abnormal pulmonary function is correlated with reduced RV stroke volume in boys with DMD and preserved LV systolic function. Further studies are needed to ascertain the prognostic significance and the influence of ventilatory support on these findings.This work was supported by BallouSkies.


A 35-year-old woman with long-lasting accelerated idioventricular rhythm (AIVR) exhibited palpitation and dyspnea on exertion and mild left ventricular (LV) dysfunction during followup. Symptoms appeared 10 years after the AIVR was first noted, and she underwent catheter ablation for curative therapy of AIVR after 12 years. Radiofrequency ablation of the anteroseptal site of the LV at the earliest activation terminated rhythm. An echocardiogram, taken 1 month after discharge, subsequently revealed that the left ventricular wall motion had normalized. This is a rare case of long-lasting AIVR with mild LV dysfunction. Accelerated idioventricular rhythm (AIVR) is a ventricular rhythm consisting of three or more consecutive monomorphic beats with 50–100 beats per minute. AIVR emerges and terminates gradually. It generally manifests in acute myocardial infarction, digitalis toxicity, and valvular disease . In partThis 35-year-old woman had been informed of electrocardiogram (ECG) abnormalities that showed continuous idioventricular rhythm (heart rate 75 bpm) after a physical examination at age 23. Subsequently, similar ECG findings were noted during routine annual medical examinations. From the age of 32, she became aware of palpitation and dyspnea on exertion. Beta-blockers were ineffective. At age 35, the ECG showed AIVR, with a heart rate of 103 bpm and a QRS width of 100ms , and HolAfter obtaining informed consent from the patient, the electrophysiological study and catheter ablation were performed. Multipolar electrode catheters were positioned at the high right atrium (HRA), His bundle recording area, and the right ventricular apex (RVA), via the right femoral vein. One 4 mm tip deflectable 7 Fr catheter (Navister) was inserted via the right femoral artery for mapping and ablation. We found constant atrioventricular conduction during HRA pacing (cycle length 650 ms). The AIVR was not terminated by rapid RVA pacing. The activation map of the left ventricle (LV) during AIVR using an electroanatomical mapping system  revealed the focus of the AIVR  at the aWe have encountered cases of mild heart dysfunction and symptoms in patients with long-lasting AIVR. The QRS waveforms of AIVR show a broader QRS width than sinus rhythm. Ventricular automaticity usually occurs at 30–40 beats/min. AIVR is clearly faster than ventricular automaticity and obviously slower than ventricular tachycardia. The definition of heart rate has been reported differently . In thisAIVR usually manifests in acute myocardial infarction, digitalis toxicity, and valvular disease –3. It isThe cause of cardiac dysfunction in this case was not clear. In most cases, AIVR is an ectopic ventricular rhythm with ≥3 consecutive ventricular premature beats with a rate faster than the normal sinus rhythm, but slower than ventricular tachycardia (less than 100/min). It is uncommon that AIVR lasts for a long time, as in this case. One cause of cardiac dysfunction might be the long-lasting rhythm. Tachycardia-induced cardiomyopathy (TICMP) can be considered as a cause of impaired cardiac function. TICMP is characterized by ventricular dysfunction resulting from an increased ventricular rate , 7. TICMAIVR patients generally have a good prognosis. It is rare to discover left ventricular dysfunction in a patient with AIVR during followup. However, in such cases the long-lasting symptoms might appear or AIVR may cause cardiac dysfunction. The long-lasting AIVR in this case should be considered for catheter ablation therapy. In any case, further study is necessary in consideration of cases with AIVR.


Background. Maze procedure aims at restoring sinus rhythm (SR) and atrial contractility (AC). This study evaluated multiple aspects of AC recovery and their relationship with SR regain after ablation. Methods. 122 mitral and fibrillating patients underwent radiofrequency Maze. Rhythm check and echocardiographic control of biatrial contractility were performed at 3, 6, 12, and 24 months postoperatively. A multivariate Cox analysis of risk factors for absence of AC recuperation was applied. Results. At 2-years follow-up, SR was achieved in 79% of patients. SR-AC coexistence increased from 76% until 98%, while biatrial contraction detection augmented from 84 to 98% at late stage. Shorter preoperative arrhythmia duration was the only common predictor of SR-AC restoring, while pulmonary artery pressure (PAP) negatively influenced AC recuperation. Early AC restoration favored future freedom from arrhythmia recurrence. Minor LA dimensions correlated with improved future A/E value and vice versa. Right atrial (RA) contractility restoring favored better left ventricular (LV) performance and volumes. Conclusions. SR and left AC are two interrelated Maze objectives. Factors associated with arrhythmia “chronic state” (PAP and arrhythmia duration) are negative predictors of procedural success. Our results suggest an association between postoperative LA dimensions and “kick” restoring and an influence of RA contraction onto LV function. AF presents with different frequencies in patients affected by structural heart diseases requiring surgery, showing a peak incidence of up to 60–80% in mitral subjects . It causThe original Maze was designed with three specific goals in mind: (1) the permanent AF ablation, 2) the restoration of atrioventricular synchrony, and (3) the preservation of atrial transport function  the rest, 6, the Despite its relevant role for judging Maze comprehensive success, biatrial contractility restoration and its clinical importance have not been deeply investigated. In more detail, a parallel deep analysis and comparison of possible determinants of both surgical ablation tied goals (AC and SR achievement) is still lacking. In the present study, we describe 2-year results of concomitant modified RF Maze in a homogeneous population of mitral patients, focusing onto common predictors of SR and AC restoring and their time-course appearance and possible relationship with cardiac chambers dimensions and function evolution.We analyzed a total of 122 consecutive patients with mitral valve disease scheduled for cardiac surgery who underwent a modified RF Maze procedure between January 2005 and June 2012 at our center . There w2. Mean basal PAP was 33 ± 15 mmHg. Patients experiencing mitral repair with residual regurgitation higher than 1 degree  were excluded from the study.Mean preoperative LA dimensions were 56 ± 12 mm and 34 ± 7 cmPreoperative clinical and echocardiographic variables are showed in This study was approved by our institution's ethical committee/institutional review board.RF energy was used to create continuous endocardial and epicardial lesions mimicking most of the left atrial incisions set as described in the Cox-Maze III procedure . We did Cardiopulmonary bypass was used with standard aortic cannulation, bicaval cannulation, and moderate hypothermia. After epicardial isolation of both pulmonary veins and of the left atrial appendage performed before aortic cross-clamping, some of the additional LA incisions sets currently used in the “cut and sew” technique were replaced by RF ablation lines, in particular represented by a double union line between the left and right pulmonary islands and a lesion connecting the right pulmonary one to the posterior annulus of the mitral valve at P2 or P3 portion (according to circumflex artery anatomy). In all patients the LA appendage was internally or externally closed.After completion of the RF ablation, mitral valve repair or replacement was performed .Postoperative general care was similar to routine cardiac surgical procedures. Modality of amiodarone prophylaxis protocol treatment was the same in all patients, represented by iv amiodarone 1200 mg/24 h in the first postoperative day, followed by 200 mg per os every 8 hours until hospital discharge and then 200 mg daily for six months. In case of amiodarone intolerance or contraindications, propafenone was employed.Patients showing SR or an ectopic atrial rhythm with rate inferior to 70 bpm in the first 48–72 postoperative hours were treated with temporary atrial pacing fixed at 80 bpm with the aim of avoiding supraventricular ectopic beats occurrence and consequently AF onset and of favoring atrial electrical activity recovery. Postoperative atrial tachyarrhythmias recurrences not responsive to medical treatment were submitted to direct-current (DC) shock; in this case, a loading dose of amiodarone was administrated before and until 24 hours after DC shock and then interrupted.Early postoperative rhythms were checked daily by standard 12-channel surface electrocardiogram. Follow-up 24-hour Holter monitoring was checked postoperatively at 3, 6, 12, and 24 months after the intervention.Contemporary to clinical follow-up, all patients were evaluated with 2-dimensional transthoracic echocardiography by the same cardiologist at 3, 6, 12, and 24 months in order to specifically monitor the evolution of cardiac chambers dimensions and systolic performance and to record left and RA contractility presence. In more detail, biatrial transport function was checked in all patients, independently from the original  AF type.All echocardiographic examinations were performed with a Philips ultrasound system . LA diameter was measured at the time of aortic valve closure on the M-mode echocardiogram in the parasternal long-axis view. End-diastolic and end-systolic internal LV diameters were determined from the M-mode echocardiogram and fractional shortening was obtained.Systolic PAP was calculated by adding transtricuspid pressure gradient to mean right atrial pressure estimated from inferior vena cava diameter and motion during respiration as follows: mean right atrial pressure was estimated to be 5 mmHg if there was complete collapse of a normal inferior vena cava during inspiration, 10 mmHg if a normal inferior vena cava collapse was >50%, 15 mmHg if a dilated inferior vena cava collapsed by >50% with inspiration, and 20 mmHg if there was no visible evidence of dilated inferior vena cava collapse.Transmitral flow velocity was measured with pulsed Doppler echocardiography, with a sample volume positioned at the level of the mitral tip in the apical four-chamber view, and was recorded on a strip chart at a paper speed of 100 mm/s. Peak velocity and the time-velocity integral of the early filling wave (E wave) and of the late filling wave (A wave) were determined. A/E ratio, representing atrial contribution to ventricular diastolic filling, was obtained. Each measurement was obtained as an average of 6 to 8 consecutive beats. We considered that a peak A wave velocity ≥10 cm/s indicated echocardiographic evidence of effective atrial contraction .λ2 analysis and Student's t-tests when indicated. A multivariate Cox proportional hazard model  was used to determine the independent predictors of AC recuperation and of AF reappearance. A multiple events Cox model was applied too for taking into account the chance of multiple arrhythmia and transport loss recurrences.Data were collected and managed in Microsoft Excel 2003 and analyzed with SPSS 12.0 software . Continuous variables were presented as mean ± SD and categorical variables as percentages or numbers. Seventeen variables were evaluated univariately to identify predictors of arrhythmia recurrence and of AC restoration. Univariate analysis was performed for all relevant categorical variables by means of λ2 test and Spearman rank correlation coefficient.Categoric and continuous variables associations were, respectively, investigated with McNemar test was employed for evaluating LA and RA contractility concordance.p less than 0.05 was considered statistically significant.A value of Mean aortic cross-clamp and cardiopulmonary bypass time were, respectively, 95 ± 38 and 121 ± 43 minutes. In all patients who underwent mitral valve repair, a residual valvular regurgitation lower than 1 degree  was achieved.One patient (0.8%) died in the Intensive Care Unit for unresponsive cardiac failure. Postoperative complications included major ischemic strokes  and reoperation for bleeding  whose origin was not related to Maze lesions.79 patients (65%) were discharged from the hospital in SR, 29 (24%) presented with stable AF, and 5 showed an atrial flutter while 9 patients had an atrial ectopic rhythm with heart rate superior to 70 bpm.2-year clinical follow-up was achieved in all patients. There were 2 (1.6%) late deaths (1 progressive congestive heart failure and 1 extra-cardiac cause). Stable SR was achieved in 96 patients (79%), while 18 (15%) experienced AF recurrence; most of them  were persistent arrhythmias resistant to pharmacological or electrical shock, and the others had AF episodes responsive to medical treatment or DC shock. No patients presented postincisional tachycardia. In the whole study population, 7 patients (5.7%) underwent permanent pacemaker implantation.At early follow-up (3 months), only 76% of patients showing a stable SR presented with a corresponding efficacious left AC. Nevertheless, such percentage of coexistence increased progressively, joining about 98% two years after the operation .LA contraction failed to be accompanied in every case by a corresponding RA contraction, since, at 3 months of follow-up, only in 84% of patients with an “A” wave both atria efficaciously contracted , while 2 years after the intervention the percentage of bilateral “kick” coexistence reached 98% (McNemar Kappa coefficient 0.87) .In patients who remained in persistent SR without known arrhythmia recurrence , left A/E ratio slightly augmented until a mean value of 2.65 at 24 months of echocardiographic follow-up .The univariate analysis of the predictive factors of freedom from AF recurrence at 2-years of follow-up is shown in Due to uniformity of antiarrhythmic prophylaxis and treatment in case of arrhythmia recurrence the item “amiodarone use” was not included in the statistical analysis of risk factors of Maze failure.In order to better evaluate the theoretical possibility of several AF recurrences, a multiple events Cox model was applied, again revealing the protective role played by a shorter preoperative arrhythmia duration and by early AC regain.p value 0.005, 0.05, and 0.017, resp.) and basal PAP for 3 and 6 months of contractility . 3- and 24-month results are shown in Tables The same features used for uni- and multivariate analysis for freedom from AF recurrence  were entered into the statistical model in order to evaluate possible predictive factors for absence of left AC recovery. At multivariate analysis, significant predictors for absence of LA transport function restoring were preoperative arrhythmia duration for 6–12 and 24 months of follow-up (p = 0.005) and by higher PAP (p = 0.029)  .minor LA dimensions were related with improved future A/E value and consequently with more pronounced LA contractility;3-month augmented left A/E favored greater improvement of LA diameter evaluated 1 and 2 years after surgery;3 and 24 months of better RA contractility corresponded to minor contemporary decrease of LVEF with respect to basal values;12-month greater right A/E ratio was associated with decreased 24-month LV volumes and better LVEF.Some statistically significant associations were retrieved between cardiac chambers dimensions and function and biatrial A/E ratios (considered as markers of contractility presence) evaluated at different follow-up times; in more detail ,minor LAThe association between AF and mitral valve disease is present in almost 60% of cases needing surgical correction. For more than 20 years, Cox-Maze procedure has been the gold standard for treating AF surgically ; despiteIf arrhythmia abolition has represented the most important goal of the procedure, it was even specifically conceived for allowing the entire atrial myocardium to be activated preserving postoperative atrial transport function . The impBased upon such considerations, we decided to focus our attention onto biatrial transport function behavior in a relatively homogeneous sample of patients affected by mitral valve disease and concomitant AF in whom RF modified left Maze procedure obtained 2-year arrhythmia abolition in about 80% of cases, in agreement with what is reported in medical literature.Previous studies retrieved that restoration of both SR and atrial contraction varies from 21% to 95%, depending on AF etiology –25. In mIn our trial, AC restoring was a dynamic and raising process, a finding that perhaps translates into the practical advice of persisting in serially controlling by echocardiography also patients that early experience SR reestablishment few months after the procedure, because in about three-quarters of cases LA is still “stunned.” This consideration may assume a great empirical role, since it discourages from interrupting anticoagulant and antiarrhythmic treatment too early, even in presence of detected stable SR and low CHADS2 score.Another element that could support this prudent attitude is the evidence of progressive increase of atrial contribution entity. A/E ratio time-course after Maze is a discussed question, as some authors  describeStarting from the assumption that SR and AC recovery represent two inseparable arms of the same question, we tried to deeply examine possible predictors of restoration and maintenance of atrial transport function at different intervals, with the objective of screening patients who could fully benefit from the procedure. Moreover, we applied a supplementary statistical tool addressed at also evaluating the intrinsic arrhythmia nature consisting in its chance of several recurrent episodes. In fact, it is well known that many subjects experience repeated heart rhythm changes  above all in the first postoperative months, probably due to recovery process, to postprocedural inflammation status, or to altered neurohumoral mechanisms .The only shared negative predictive factor for both SR and left AC restoring highlighted by our analysis was preoperative AF duration, with a cut-off identified at 36 months. If the role of longstanding arrhythmia largely emerged in medical literature , 32, othThe discouraging role played by basal PAP onto future atrial transport function recuperation was previously reported only by Reyes et al. , but witMedical literature extensively addressed the problem of identifying predictors able to discourage the surgeon to perform ablation, including old age, larger LA diameter, lower amplitude of p-wave, having a rheumatic mitral valve disease, permanent AF, and lesion sets of Maze procedures , 34. In Nevertheless, in our analysis, LA dimensions did not represent a negative predictor of SR-AC restoring; however, such absence of relationship is partially mitigated by the finding of a bidirectional association between LA size and chance of future AC recovery or, at the opposite, between early atrial “kick” recuperation and more marked future atrial diameter and area decrease. To the best of our knowledge, this is the first demonstration of a strength link between these two elements which are logically and theoretically related but whose modality of respective behavior was not completely clear.Moreover, we found that the atria seem to differently regain contraction after Maze. Available data addressing the question show various rates of RA function recovery , 33. AltAn important study limitation is represented by the limited sample size which does not allow drawing definitive conclusions; we believe that our preliminary results should be confirmed in larger trials including “more ancient” mitral and fibrillating patients, in order to better describe the negative influence of longstanding arrhythmia onto Maze objectives.We serially assessed biatrial function after RF Maze procedure in patients affected by mitral valve disease.In the early postoperative phases, a regular rhythm with P-waves was accompanied by a coexisting atrial transport function only in three quarters of cases, but concordance joined about 100% at two years of follow-up. Once LA contraction was resumed, its degree augmented progressively and was associated with a corresponding RA transport function in an increasing percentage of cases at late follow-up.A strict interaction was detected between LA chamber postoperative evolution and LA contractility recovery, as a decrease of LA size favored atrial “kick” reappearance and vice versa.SR and AC appear to be two intimately linked objectives of the Maze procedure, since early atrial transport function recuperation favors future stable freedom from arrhythmia recurrence.Our study highlighted the deleterious influence of arrhythmia “chronic state” onto procedural success and the importance of the cardiac right side, an entity somehow overlooked: even if these data need further investigation in order to elucidate a possible clinical implication too, we retrieved that, first, preoperative arrhythmia duration and, more interesting, pulmonary hypertension (an element that could be associated with a latent right ventricular dysfunction) play a role in predicting Maze failure in terms of SR-AC restoring and, second, RA contractility has an influence on LV contractile performance recovery and volumes decrease.


Diabetic cardiomyopathy is an increasingly prevalent health issue, with no specific management options. We examined the impact of weight loss with sleeve gastrectomy on diabetic cardiomyopathy.Eight obese patients with type 2 diabetes undergoing sleeve gastrectomy had left ventricular (LV) systolic and diastolic function assessed by global longitudinal strain (GLS) and septal early diastolic velocity (e’) using echocardiography, before and 9 months after surgery.2 (p < 0.001). Glycaemic control improved with glycated haemoglobin (HbA1c) improving from 9.2 % at baseline to 6.7 % at follow-up (p = 0.002), with a corresponding improvement in LV GLS from −13.2 ± 3.7 to −19.7 ± 2.2 % (p < 0.001), and LV ejection fraction from 60 ± 5 to 70 ± 4 % (p < 0.001). Improvement in GLS was associated with the amount of weight lost . LV septal e’ velocities increased, and LV filling pressures decreased after surgery.Following surgery, mean weight loss was 28.0 ± 16 kg; body mass index (BMI) decreased from 44 ± 9 to 35 ± 6 kg/mWeight loss with sleeve gastrectomy in obese patients with type 2 diabetes is effective in improving glycaemic control in subjects with type 2 diabetes and results in significant improvement in both systolic and diastolic myocardial function. Obesity and type 2 diabetes mellitus (T2DM) are prevalent health issues in both the developed and developing worlds. Patients with obesity and T2DM have an increased risk of developing left ventricular (LV) dysfunction and heart failure, independent of other traditional vascular risk factors. While diabetic cardiomyopathy is increasingly being recognised, specific treatment is still elusive. Diabetic cardiomyopathy may range from LV diastolic dysfunction in the early stages to overt severe global systolic dysfunction in the advanced stages of this disease. Smaller observational studies have shown that improved glycaemic control can improve LV diastolic dysfunction and suggest that cardiac abnormalities are potentially reversible . HoweverRecent advances in echocardiography have allowed for more sensitive and accurate assessments of even subtle impairments in LV diastolic and systolic dysfunction. Tissue Doppler imaging (TDI) is a well accepted technique to assess myocardial tissue velocities; the measurement of the early diastolic velocity, e’, in combination with early (E-wave) and late diastolic (A-wave) mitral inflow pulsed-wave Doppler velocities allows for reliable assessment of LV filling pressures and diastolic function . Two-dimIn recent years, bariatric surgery has evolved as a successful management option for weight and glycaemic control in obese patients with poorly controlled T2DM. Buchwald et al.  found thLaparoscopic sleeve gastrectomy is a safe and accepted treatment for obesity that involves removal of the fundus and most of the antrum of the stomach, thereby creating a gastric tube or sleeve that restricts oral intake. This technique has become increasingly popular due to its relative technical simplicity, preservation of the pylorus, and avoidance of postoperative malabsorption –13. Few The study population comprised obese patients with T2DM who were recruited and referred from a collaborative local weight loss centre. Patients with type 1 diabetes, current pregnancy, valvular or coronary artery disease (CAD), severe hypertension (systolic pressure >200 mmHg and diastolic pressure >120 mmHg at rest), left bundle branch block or non-sinus rhythm were excluded. Significant coronary artery disease was excluded by either coronary angiography or by stress echocardiography performed within 2 months of the study. All patients gave written informed consent. The study was conducted in accordance with National Health and Medical Research Council (NHMRC) guidelines and was approved by the hospital Human Research Ethics Committee.All patients were assessed at study entry. Patients’ age, height, weight, waist and hip circumference, Medical Research Council (MRC) dyspnoea scale, cardiac risk factors, duration of DM, medications and the presence of macrovascular and microvascular complications were recorded. Metabolic data including glycated haemoglobin (HbA1c), serum creatinine, estimated glomerular filtration rate (eGFR), total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides and spot urinary albumin-to-creatinine ratio were measured.All patients underwent 2D transthoracic echocardiography at baseline. This was performed on patients in the left lateral decubitus position using commercially available ultrasound equipment  Medical Systems, Milwaukee, WI). Images were stored for offline analysis . Complete M-mode, 2D, colour, pulsed and continuous-wave Doppler examination was performed according to standard techniques at rest to assess chamber thickness, volumes and valvular morphology. Mitral inflow E and A wave velocities, mitral septal annulus e’ velocities and LV mass were measured.Two-dimensional speckle-tracking analyses were used to measure LV global longitudinal strain (GLS). During these analyses, the endocardial border was manually traced at end-systole and the region of interest width was adjusted such that the entire myocardium was included. The software then tracks and accepts segments of good tracking quality and rejects poorly tracked segments. The observer is also able to manually accept and reject regions based on visual assessments of tracking quality. The mean GLS was calculated from the average of three global longitudinal strain curves of the three apical views Fig. . All DopPatients were assessed by a bariatric surgeon for suitability for laparoscopic sleeve gastrectomy. All patients adopted a preoperative very low calorie diet with an exercise program for 3 weeks supervised by an exercise physiologist, a dietician, and a psychologist. All patients underwent laparoscopic sleeve gastrectomy by a single surgeon. Postoperatively, diet included liquid diet for 3 weeks, then puree for 2 weeks, soft diet for 2 weeks, followed by progression to solid foods. After a 3-day stay in hospital, patients were seen postoperatively by the surgeon at 3-week, 3-month, 6-month and 1-year time points.All patients underwent repeat clinical and biochemical assessment and echocardiographic studies 9 months after surgery.t tests. Categorical variables were compared with the chi-square test. Linear regression was performed to identify relationship between improvement in GLS and e’ with changes in HbA1c with follow-up with Pearson’s or Spearman’s correlation coefficients (ρ). A two-sided p value <0.05 was considered significant. Statistical analyses were performed using STATA v12 .Continuous variables were presented as mean ± 1 SD unless otherwise stated. Continuous variables before and after surgery were compared with the paired student’s Eight patients, two men and six women, with a mean age of 56 ± 7 years, were included. The baseline clinical and metabolic characteristics are presented in Table Mean excess weight loss preoperatively was 4 % and from surgery until 9-month follow-up was 47 %. Surgery resulted in a significant decrease in body weight, body mass index and body surface area following surgery Fig. . Howeverp = 0.008).Insulin requirements were reduced by sleeve gastrectomy. Five patients required insulin therapy prior to surgery, but only one patient remained on insulin at follow-up. Patients took an average of five different medications preoperatively and only three postoperatively . However, there was no correlation between improvement in GLS and the decrease in HbA1c .The echocardiographic data for the patients at baseline and follow-up are presented in Table r = −0.66, p = 0.07) and with the amount of weight loss . Septal E/e’ ratio at follow-up was correlated with final HbA1c  and with the amount of weight loss .There was also a significant improvement in LV diastolic function measured by the septal e’ velocities and a reduction in LV filling pressures measured by the E/e’. There was no significant change in LV mass index. There were borderline correlations between the septal e’ velocities at follow-up with the final HbA1c (Patients reported improvements in symptoms of shortness of breath as measured by the MRC dyspnea scale Table . All patObese patients with T2DM have impairment of LV systolic and diastolic function. In this study, despite a normal LV ejection fraction of 60 % at baseline, our patients had significant impairment of LV systolic function as evident by a GLS of only −13 %. They also had impaired LV diastolic function with mean e’ velocities of 6 cm/s despite a mean patient age of only 56 years. LV filling pressures estimated by the E/e’ ratio were elevated in our patients. Sleeve gastrectomy led to significant weight loss as well as improvement in glycaemic control, but our study is novel in showing that this also resulted in significant improvement in both LV systolic and diastolic functions and a decrease in LV filling pressures in obese patients with T2DM. The more weight the patients lost after surgery, the larger the improvement in LV systolic function was. The improvement in LV systolic function was independent of the decrease in HbA1c with surgery. The lower the final HbA1c was and the more weight patients lost, the better their LV diastolic function at follow-up was. Similarly, the LV filling pressures were lower with lower final HbA1c or if there was larger amount of weight loss. Sleeve gastrectomy, combined with diet and lifestyle measures, resulted in significant weight loss and was associated with proportional improvements in both LV systolic and diastolic functions and a decrease in LV filling pressures.Improvements in GLS following surgery have previously been shown in two non-randomised studies on obese patients without T2DM, but those studies did not demonstrate any changes in LVEF or E/e’ ratio , 15. TheOther studies have also demonstrated improvements in the E/A ratio in obese patients without T2DM after bariatric surgery including sleeve gastrectomy and Roux-en-Y gastric bypass . The curReduction in LV mass has previously been shown in various studies. The meta-analysis by Cuspidi et al.  combinedOne of the main limitations of the study was the small sample size and that no control group was included for this study. The patients were followed up for 9 months following surgery, and a longer follow-up period could see further improvement in the patients’ glycaemic control and myocardial function.As far as we know, this is the first study to demonstrate that weight loss with sleeve gastrectomy is effective in improving glycaemic control in subjects with type 2 diabetes and results in significant and proportional improvement in both LV systolic and diastolic myocardial functions. While further research and larger studies are necessary to validate these findings, our study suggested that bariatric surgery not only has an important role in the management of obese patients with type 2 diabetes, it may also alter their progression of diabetic cardiomyopathy.


There is growing evidence on the value of left atrial function assessment in cardiac magnetic resonance (CMR) in patients with heart failure. However, there is paucity of data regarding the value of left atrial function in CMR to predict left ventricular remodeling in patients with ST-segment elevation myocardial infarction (STEMI).One hundred one  patients, who underwent CMR 3-5 days and 6 months after first STEMI treated with primary percutaneous coronary intervention, were enrolled. Cine, T2-weighted STIR and late gadolinium enhancement (LGE) CMR images were assessed off-line using dedicated software . Feature tracking cine-sequence based left atrial strain were measured using Diogenes CMR  in 2- and 4-chamber views. Segmental strain values were averaged from two views to obtain average reservoir, conduit and contractile strain. Logistic regression analysis was performed in stepwise forward fashion to determine CMR predictors of LV remodeling. The outcomes were expressed by odds ratio (OR) with corresponding 95% confidence interval (CI).52 subjects had anterior and 49 inferior STEMI. LV remodeling (increase in LV end-systolic volume by 15% in 6 months after STEMI) was present in 29 subjects. Comparing subjects with and without LV remodeling the former tended to have larger extent of LVLGE , larger extent of microvascular obstruction (MO) within LGE , higher maximal levels of troponin I , CPK-MB , CPK , and had lower values of average left atrial reservoir strain , left atrial conduit strain  and left atrial contractile strain . The univariative predictors of LV remodeling were the extent of MO within LGE , maximal levels of troponin I , CPK-MB , CPK , and average left atrial reservoir strain , left atrial conduit strain  and left atrial contractile strain . Of those in multivariative analysis the independent predictors were CPK  and left atrial contractile strain .LV remodeling is frequent after STEMI. The average left atrial contractile strain is the independent predictor of LV remodeling in 6 months observation.N/A.


Cardiac magnetic resonance (CMR) is considered a primary tool for the diagnosis of acute myocarditis, due to its unique potential for non-invasive identification of the various hallmarks of the inflammatory response, with relevant impact on patient management and prognosis. Nonetheless, a marked variation in sensitivity and negative predictive value has been reported in the literature, reflecting the intrinsic drawbacks of current diagnostic criteria, which are based mainly on the use of conventional CMR pulse sequences. As a consequence, a negative exam cannot reliably exclude the diagnosis, especially in patients who do not present an infarct-like onset of disease. The introduction of new-generation mapping techniques further widened CMR potentials, allowing quantification of tissue changes and opening new avenues for non-invasive workup of patients with inflammatory myocardial disease.CMR sensitivity varies in AM, reflecting its clinical polymorphism and the intrinsic drawbacks of LLc.• Semiquantitative approaches such as EGEr or T2 ratio have limited accuracy in diffuse disease forms.• T1 mapping allows objective quantification of inflammation, with no need to normalize measurements.• A revised protocol including T2-STIR, T1 mapping and LGE could be hypothesized to improve sensitivity.•  Acute myocarditis (AM) is a “multifaceted disease” characterized by a large variety of acute manifestations, potentially followed by unpredictable sequelae ranging from dilated cardiomyopathy to recurrent arrhythmias , 2. AlthIn this complex scenario, cardiac magnetic resonance (CMR) was immediately perceived as a potentially “revolutionary” non-invasive tool –9, with Current diagnostic criteria  are based on the application of a recommended standardized protocol that aims to identify typical signs of the inflammatory cascade, which consist of oedema, regional hyperemia, and cellular death . These cThis document analyses lights and shadows of CMR imaging in the diagnostic and prognostic assessment of AM and evaluates the improvement provided by the introduction of T1/T2 mapping techniques into clinical routine.The spectrum of currently available sequences for CMR study of myocarditis is summarized in Table myocardial oedema detected by T2-weighted techniques;myocardial hyperemia detected by early gadolinium enhancement (EGE) techniques;myocardial damage with non-ischemic pattern detected by late gadolinium enhancement (LGE) techniques.According to the LLc , CMR diaOEDEMA and INFLAMMATORY INFILTRATION:Interstitial or intracellular accumulation of water, together with serological biochemical markers, represents the most reliable sign of active inflammation , 16.Currently, the most widely used and validated technique for “oedema-weighted” imaging is based on the application of T2-weighted short-tau inversion recovery sequences (T2w-STIR) , 17, 18.Definition:T2w-STIR sequences must be performed using the same prescription of SSFP images in short-axis views and in three long-axis planes . However, a body coil is recommended to avoid signal heterogeneity as compared to SSFP.The presence of tissue oedema may be detected visually or, as suggested in the LLc, using a semiquantitative method. Regional oedema is defined as region of at least 10 adjacent pixels with signal intensity more than 2 standard deviations above the mean value of normal tissue, evident in two orthogonal planes .Diffuse oedema is quantified as the ratio of myocardial to skeletal muscle (T2 ratio) by drawing two distinct regions of interest in the same slice; a ratio ≥ 1.9 is considered positive and reflective of global myocardial oedema . An examLimitations:T2w-STIR images usually allow reliable visual identification of oedema in patients with a focal pattern of myocardial involvement, although the limited contrast-to-noise ratio (CNR) may impede the detection of subtle tissue changes in a significant minority of patients.Other weaknesses may prevent the interpretation of T2w-STIR images under certain conditions. First, signal heterogeneity related to coil sensitivity profiles can produce both false-negative and false-positive results, and thus the use of reliable surface coil intensity correction filters or body coils is of pivotal importance. Second, the dark blood preparation pulse may introduce regional signal loss in the LV wall, especially in the posterior and posterolateral wall, caused by through-plane cardiac motion. Third, incomplete dark blood preparation may lead to bright rim blood artefacts along the endocardium, especially in patients with impaired ventricular function .Another limitation is the qualitative nature of T2w-STIR images, which implies the need for reference tissue for interpretation. In the case of suspected diffuse oedema, the reference tissue is the skeletal muscle, although a concomitant signal change within skeletal muscles, such as that in patients with coexisting myositis, may adversely affect diagnostic performance , 22.Finally, a cut-off value of 1.9 was defined using clinical criteria  as a reference standard for establishing a diagnosis, without histological validation .Current diagnostic criterion:Myocardial oedema in AM often proceeds from a focal meso- and subepicardial distribution, which is observed in only about 30 % of patients, to a global pattern of ventricular involvement.HYPEREMIA:Definition:The technique used to assess myocardial hyperemia in the context of LLc was originally proposed by Abdel-Aty et al. in 2005. A free-breathing black blood fast spin echo (FSE) T1w sequence with an acquisition time of 3–4 min is acquired in four identical axial slices, both before and after (without any change in the parameters in between) intravascular injection of 0.1 mmol of gadopentetate dimeglumine (Gd-DTPA) .Sequence parameters should be adjusted to maximize T1 weighting; in particular, an echo train length of less than 4 is desirable. According to LLc, diffuse hyperemia can be detected by calculating the early gadolinium enhancement ratio (EGEr): endocardial and epicardial contours should be traced on both pre- and post-contrast images, and a reference region of interest (ROI) should be placed on the skeletal muscle located within the same slice. The myocardial enhancement should be normalized on the skeletal muscle enhancement, and an EGEr ≥ 4 is considered positive for myocardial inflammation .Limitations:EGE imaging is generally considered the least robust of the three components of the LLc, as FSE sequences originally proposed  are limiSecond, the acquisition of only 3–4 subsequent slices limits anatomic coverage of the left ventricle, impeding a panoramic assessment of the myocardial wall.Third, the cut-off value is validated with one standard-relaxivity contrast medium (Gd-DTPA) and may be not acceptable if higher relaxivity agents are used . Therefore, a redefinition of thresholds is needed for agents with higher relaxivity, as has already been reported in a similar model of breast MRI .Fourth, signal normalization may be hampered by coexisting skeletal muscles disease. Hence, in patients with an increase in skeletal muscle signal intensity ≥ 20 %, as well as in patients with a recent history of muscular pain, an increase of > 45 % in absolute myocardial signal intensity between pre- and post-gadolinium images is suggested as a threshold consistent with myocarditis, rather than normalized EGEr .An interesting alternative method for fast assessment of myocardial hyperemia in AM was recently reported, which relies on SSFP sequences acquired soon after contrast administration (ceSSFP) . This apCurrent diagnostic criterion:The identification of myocardial hyperemia is the second step of the diagnostic workup, according to the LLc. Endothelial dysfunction and increased vasopermeability have been considered the pathophysiological mechanisms for abnormal diffusion of gadolinium from the vascular compartment to the interstitial space. The tissue hyperemia is evaluated with a technique commonly defined as EGE , 16.CurrMYOCYTE DEATH and FIBROSISMyocyte necrosis with extracellular space expansion followed by replacement fibrosis occurs in AM as a consequence of either direct viral cellular damage or cell-mediated immunological injury. Both tissue changes lead to an increase in delayed gadolinium accumulation, with subsequent positive LGE. Typical disease patterns are characterized by mid-wall or subepicardial LGE distribution, with patchy or linear areas of high signal intensity . The infSeveral sequences are available today for the assessment of LGE, including the two-dimensional (2D) and three-dimensional (3D) inversion recovery gradient echo sequences (IR-GRE), the 2D and 3D inversion recovery SSFP sequences (IR-SSFP), and the phase-sensitive inversion recovery sequences (PSIR-GRE or PSIR-SSFP) that eliminate the need for a precise null time for normal myocardium. This sequence uses phase-sensitive detection to remove the background phase while preserving the signal of the desired magnetization during IR .Definition:LGE is considered positive if at least one focal area of high signal intensity with non-ischemic pattern of distribution is outlined in at least two orthogonal planes .Suggested LLc protocol recommends the application of conventional segmented two-dimensional breath-hold IR-GRE pulse sequence.Application of a fat-saturation pre-pulse may also be helpful for discriminating epicardial fat from pathological subepicardial LGE foci.Any quantitative approach for LGE quantification was recommended in the LLc, although semi-automated standard deviation (SD)-based thresholding techniques are commonly used today in different clinical settings, primarily in the assessment of acute myocardial infarction (AMI) .Limitations:LGE has been extensively validated as a robust and reproducible technique for detecting myocardial fibrosis and myocyte necrosis in patients with AM , 29, 30.However, LGE detection relies on differences in gadolinium concentration between pathological and “normal” segments. Such differences may not exist if the process is diffuse, or may be insufficient to create contrast in the presence of mild focal involvement.Recent data have demonstrated a limited sensitivity of the LGE technique, mainly in patients with less common disease onset such as arrhythmic or cardiomyopathic presentations . These rCurrent diagnostic criterion:Figure These three criteria are considered in addition to steady-state free precession (SSFP) sequences for the assessment of biventricular volumes and global/regional function Fig. .Fig. 2CoClinical studies investigating the diagnostic performance of LLc  in AM wePooled analysis of results Table  confirmeThe acute presentation of myocarditis is highly variable, ranging from asymptomatic or mildly symptomatic forms to sudden cardiac death (SCD). AM has been reported to be responsible for at least 5 % of outpatient SCD , and thiThe long-term prognosis is usually favorable, but a significant percentage of patients affected by AM experience progressive left ventricle dysfunction and dilatation. Prospective studies have suggested that AM causes at least 10 % of dilated cardiomyopathy , and thaMahrholdt and colleagues found that left ventricular end-diastolic volume (EDV), the presence of LGE in the interventricular septum, and the total amount of LGE at initial CMR were the strongest independent predictors of impaired ventricular function and ventricular dilatation at follow-up in a cohort of patients with parvovirus B 19 (PVB19) and/or human herpesvirus 6 (HHV6) infections . MoreoveThe wide and expanding use of CMR in the clinical setting of AM is attributable to its unique capacity to comprehensively evaluate the various components of myocardial inflammation cascade.Significant variations in sensitivity and negative predictive values have been reported in the scientific literature, reflecting both the syndromic nature of the disease and the technical drawbacks of conventional CMR sequences, with evidence that a negative CMR exam cannot reliably rule out a diagnosis of AM.Patients presenting with acute chest pain, positive troponin test results, and typical ST segment abnormalitiesIn the setting of symptomatic patients, for chest pain with typical ST elevation, increased troponin, and preserved LV function, CMR is pivotal in the diagnosis of AM.The first role of CMR is the exclusion of alternative diagnoses with similar clinical presentations, such as takotsubo or AMI with non-obstructive coronary artery disease –47.If the CMR is positive for AM according to LLc, appropriate management needs to be carefully evaluated, taking into account the clinical course and the CMR results, particularly the extent, location, and distribution of LGE . ExcelleEMB is generally not indicated in this specific clinical scenario, according to the scientific statement regarding the role of EMB in the management of cardiovascular disease published by the American Heart Association (AHA), the American College of Cardiology (ACC), and the European Society of Cardiology (ESC) . HoweverPatients with new onset of heart failure syndrome of unknown etiology .Fig.Fig50].FPost-myocarditis forms, however, are not always recognizable in this specific setting due to a prolonged subacute myocardial inflammation preceding clinical manifestations, and leading to progressive water reabsorption with less evident signal changes .EMB remains the primary alternative for these patients  due to tPatients presenting with sudden occurrence of palpitations/lipothymia-hypotension related to the presence of previously unknown ventricular arrhythmiasIn this clinical scenario, CMR may help to identify AM as the underlying cause of clinical presentation , althougCMR plays a role in the identification of other potential causes of previously undiagnosed ventricular arrhythmias, such as arrhythmogenic right ventricular dysplasia, non-compaction disease, atypical forms of hypertrophic cardiomyopathy, and unknown chronic myocardial scars . CMR canIndication of EMB is not well established in these patients: EMB should be considered only in exceptional cases of unexplained ventricular arrhythmias , but it Diagnostic pathways based on the three main clinical scenarios of AM can be suggested as evidence of the recent literature on the diagnostic accuracy and prognostic value of CMR.The major limitations of current LLc are the qualitative (LGE depiction) or semiquantitative (T2 ratio and EGEr) nature of the diagnostic criteria, which significantly affects the sensitivity of the CMR technique in the characterization of global myocardial processes.To overcome many of these limitations, current research has developed absolute quantitative approaches such as T1 and T2 mapping techniques.1 relaxation times encoded in each pixel of any region of the heart, without the need to normalize measurements to a reference standard tissue [Measurement of native myocardial longitudinal relaxation time (T1 mapping) has emerged as a novel quantitative approach to enable the depiction of diffuse inflammatory processes. It is based on the generation of parametric maps representing the Td tissue , 53, 54.The basic principle of this technique relies on the concept that pixel signal intensity depends on the relaxation of hydrogen nuclei protons in a static magnetic field, which varies in the presence of oedema, fat infiltration, and fibrosis .1 relaxation time in AM is related to an increase in both total and relative water content in the intra- and extracellular space due to tissue oedema and expansion of intercellular space [Specifically, the prolongation of Tar space . A seconar space . An initar space .More recently, Luetkens et al. convincingly demonstrated the importance of a CMR multiparametric approach . Native Notably, a marked variation in diagnostic thresholds among normal subjects has been reported in the literature . This vaExtracellular volume fraction (ECV) provides a direct measurement of the size of the extracellular space. ECV map generation is based on a pixel-wise co-registration and comparison of native and post-contrast T1 maps, adjusted for the patient’s hematocrit . In AM, 2 relaxation time (T2-rt) lengthening, is a well-known MR sign of cardiac and skeletal muscle damage, reflecting heterogeneous phenomena such as oedema and inflammation. Qualitative assessment of T2-weighted imaging is limited by signal intensity heterogeneities and by the absence of the “perfect” reference tissue for signal normalization. Direct measurement of T2-rt accurately reflects inflammation in the skeletal muscles [An increased signal in T2-weighted images, which is linked to T muscles  and also muscles . Hence, A T2-prepared steady-state free precession (T2p-SSFP) technique has been described as a means of minimizing the problems associated with current cardiac T2W imaging methods, and of providing an accurate assessment of myocardial oedema . This T2Since the publication of the JACC White Paper entitled “Cardiovascular Magnetic Resonance in Myocarditis” in 2009, the relevance of CMR as a component of the clinical workup in AM has increased dramatically. Several years of application of LLc have allowed for a better understanding of their value and limits, revealing flaws in providing wishful diagnostic results in some clinical situations. The EGE seems to be the weakest point of LLc, both with respect to the presence of ambiguity and, more importantly, with the strong artefacts that very frequently affect this technique. T2w-STIR sequences, although potentially affected by artefacts in some patients and limited in the assessment of mild and diffuse forms of myocardial involvement, may provide an intuitive and rapid means of ascertaining active inflammation in focal forms of disease. LGE is primarily affected by low sensitivity, but has significant value in differential diagnosis and prognostic evaluation. New perspectives in the diagnostic potential of CMR were highlighted by the recent introduction of mapping sequences, which provide insight into quantitative assessment of inflammatory myocardial changes. New scientific evidence supports the value and robustness of T1 mapping techniques in the diagnosis of AM, with the chief advantage of increasing CMR sensitivity. However, larger multicenter trials are needed to develop a standardized T1/T2 mapping technique and to define widely accepted normal thresholds values. On the other hand, a step-by-step simple CMR protocol including T2w-STIR, T1 mapping, and LGE Fig.  could be