Introduction: Myocardial remodeling due to large atrial septum defect (ASD) is macroscopically characterized by dilation of the right-sided cardiac cavities secondary to volume overload, the cellular mechanisms of which are not yet understood. We postulated that inflammation, fibrosis, and cell death are actors of right atrial remodeling secondary to ASD.Patients and Methods: In 12 children with large ASD (median age: 63 months), expression of genes coding for proteins involved in the response to cell stress and -protection, inflammation, growth and angiogenesis, fibrosis, and apoptosis was assessed by RT-PCR in right atrial myocardial biopsies taken during cardiac surgery. The presence of cytokines in myocardial cells was confirmed by immunohistochemistry and effective apoptosis by TUNEL assay.Results: In all patients investigated, a cellular response to early mechanical stress with the initiation of early protective mechanisms, of inflammation (and its control), -growth, and -angiogenesis, of fibrosis and apoptosis was present. The apoptotic index assessed by TUNEL assay averaged 0.3%.Conclusions: In children with large ASD, macroscopic right atrial remodeling relates to cellular mechanisms involving the expression of numerous genes that either still act to protect cells and tissues but that also harm as they initiate and/or sustain inflammation, fibrosis, and cell death by apoptosis. This may contribute to long term morbidity in patients with ASD. Atrial septal defect (ASD) is a common congenital heart disease responsible for inter-atrial left-to-right shunt and for volume overload of the right cardiac cavities and their dilation. Hemodynamic overload initiates myocardial remodeling that comprises changes in tissue properties secondary to the activation of different signal cascades such as inflammatory-, growth- and death signaling pathways. Consecutive cardiomyocyte loss due to cell death or phenotype transformation in cardio-myofibroblasts ends up in myocardial fibrosis and finally in systolic and/or diastolic myocardial dysfunction. In patients with ASD, right atrial remodeling may elicit late supra-ventricular arrhythmias.Mechanisms of myocardial remodeling are complex and have principally been studied in models of ischemic myocardial injury or pressure overload, in particular in systemic hypertension . In infaThis study was therefore designed to investigate mRNA expression of genes coding for factors involved in mechanical stress (ANF), cell protection , inflammation , growth and angiogenesis , fibrosis of the extracellular matrix , and regulation of apoptosis  in children with volume overload of the right atrium due to atrial septal defect.According to the current recommended strategy, the large majority of patients undergo nowadays percutaneous- instead of surgical ASD closure. Because only few patients are still scheduled for surgical closure we recruited those matching the criteria for entering the study from our two institutions where the myocardial samples were processed and analyses performed. For that reason, data of both patient groups were not pooled but presented separately.Inclusion criteria were (1) pre-pubertal state in children aged <10 years of age; (2) the presence of an isolated ASD with hemodynamic relevant left-to-right shunt requiring closure. Exclusion criteria were (1) syndromic affection; (2) genetic disorder; (3) infectious or inflammatory state.N = 7 , Institution I, median age: 78.8 months; Group 2, n = 5 , Institution II, median age: 49.6 months.The ethics committees of the University Hospital Aachen (Institution I) and the University Hospital Leuven (Institution II) gave their agreement, respectively. Parents gave their informed and written consent. A total of 12 children were enrolled, divided into 2 groups according to the institution of origin. Group 1, ostium secundum but one who had an ASD type superior sinus venosus. All patients showed significant left-to-right shunt as shown by clinical examination , electrocardiography (right ventricular hypertrophy) and echocardiography . Left-to right shunt was calculated by applying the Fick formula during heart catheterization that was performed under general anesthesia at least 4 weeks before surgery in 5 patients of group I who were initially scheduled for interventional ASD closure.All patients had an ASD type 3) was taken from the right atrial appendage immediately before institution of cardiopulmonary bypass, during right atriotomy.In all cases and in both institutions, conventional general anesthesia consisted of midazolam, fentanyl sulfate, and pancuronium bromide. A biopsy , according to the manufacturer's recommendation.Isolated RNA was reverse transcribed to complementary DNA (cDNA) using iScriptTM cDNA Synthesis Kit . A standard for each primer set was generated for quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR) by cloning PCR products in pBluescript and the identity was verified by sequencing. A 2 μl cDNA sample was incubated with 20 μl QuantiTect Mix containing fluorescence dye SYBR Green (QIAGEN Hilden® Germany) and 0.6 μmol/l of each primer pair. PCR amplification was performed after initial denaturation at optimized annealing temperatures for each primer pair using MJ Research Opticon 2 (Biozym). Melting curves were acquired by stepwise increase of the temperature from 55° to 95°C. Threshold cycles (CTs) of real-time PCR curves were determined by Opticon® Monitor software . The difference of the CTs (ΔCT) of targets and 18S-RNA housekeeping control gene reflected the amount of target mRNA in each sample. Target mRNA was quantified according to standard curve and normalized to levels of 18S-RNA.In Group II RNA was also isolated by using the RNeasy kit according to the manufacturers recommendations . Total mRNA concentration was assessed by photometric analyses by measuring absorbance at 260 nm, using a NanoDrop 2000-C apparatus .RNA (2 μg) was reverse-transcribed to complementary deoxyribonucleic acid (DNA) with random hexamers. Two microlitre of cDNA samples were incubated with 20 μl of Quanti Tect Mix containing fluorescing SYBR Green  and in each case 0.6 μl of the primer pairs. The real-time cycler conditions consisted of an initial activation PCR step of 15 min at 95°C, and then 40 cycles of 15 s at 94°C, 30 s at 55°C, and 30 s at 72°C. Three replicas were performed for each analyzed sample, and positive and negative controls were tested on each plate.−ΔCT. Primers used in both groups are listed in SYBR Green served as the DNA dye to quantify the PCR products. Expression was normalized to levels of actin-mRNA and calculated with 22O for 5 min). Epitope unmasking was achieved by incubating the sections in a humidified chamber with proteinase K  for 15 min at room temperature. Endogenous peroxidase activity was then blocked by incubating the sections in a humidified chamber for 15 min at 23°C in 3% H2O2 and incubated for 40 min at 23°C with blocking solution (PBS + 10% serum). The sections were then incubated at 23°C for 1 h with either anti-CT-1 (MAB2602. R.D Systems) (5 μg/ml) and or anti-IL1β (ab8320. Abcam) washed in PBS , and incubated further at 23°C for 1 h with secondary antibody . After washing in PBS (5 min. x 3), the sections were counterstained with hematoxylin for 2 min and DAPI for 1 min respectively. After dehydration through graded ethanol solutions and xylenes, glass coverslips were mounted on slides in Permount (Sigma).In group II, frozen sections of 4 μm were mounted on polylysine-coated glass slides. Sections were rehydrated through graded ethanol  according to manufacturer's instructions.TUNEL assay was performed with the p < 0.05 was considered significant. Data were analyzed with statistical Package for Social Science (IBM SPSS Software 20.0).Results are expressed as median value and interquartile range or as mean value ± SEM. Correlation of independent parameters was assessed by the Pearson correlation test. A Demographic and clinical patient data are summarized in In patients in whom cardiac catheterization was performed before surgery, the amount of left-to-right shunt and mean right atrial pressure were not correlated with the mRNA-expression of genes of interest, respectively.In each patient group, expression of mRNA coding for genes implicated in cell protection, growth, angiogenesis, apoptosis but inflammation generally correlated with each other –5.p = 0.029).In all patients tested of group II, mRNA expression of TGFβ negatively correlated with that of Bcl-xL (Pearson correlation coefficient: −0.92, Immunohistochemistry showed the presence of IL 1β and CT-1 in right atrial cardiomyocytes in all patients tested , 7.TUNEL positive cardiomyocytes were clearly detected in all patients with ASD . ApoptotIn this series, we assessed mRNA-expression of genes implicated in myocardial remodeling in the volume overloaded RA of children with large ASD.In all patients tested, the mRNA expression pattern indicated a cellular response to mechanical stress, the initiation of early protective mechanisms, of inflammation, growth, and angiogenesis, of fibrosis and apoptosis. The presence of the non-constitutive inflammatory cytokine IL-1β and of the major growth factor CT-1 in the cardiomyocytes was confirmed at protein level by immunohistochemistry and the execution of apoptosis by the detection of DNA degradation products, respectively.The expression of ANF-mRNA in our patients reflects the immediate biological response to mechanical stress of the volume overloaded RA-myocardium secondary to the large inter-atrial left-to right shunt. Accordingly, several studies have reported increased intra-myocardial and also circulating levels of ANF in patients with ASD . ANF posIL-6 is the major regulator of the systemic inflammatory response that plays a protective role in the acute injured myocardium by preventing apoptosis, while it depresses contractility in chronically exposed myocardium . In a moCT-1 is another member of the IL-6 family of cytokines and the most potent growth factor involved in myocardial hypertrophy . In receThe presence of IGF-1-mRNA in the RA myocardium of our patients indicates a possible protective role against fibrogenesis as it has been shown in an animal model of partial IGF-1 deficiency .Mechanical stretch due to increased wall expansion activates several pathways as discussed above, among others stretch-activated channels and the phosphatidylinositol 3-pathway. These latter are responsible for the increase of the HIF-1α subunit of HIF-1 that initiates in turn the expression of its target gene VEGF via the activation of the ERK /c-Fos signaling pathway . The preMyocardial apoptosis has been documented in response to a variety of cardiac stresses, including ischemia-reperfusion injury, and heart failure –38. In oCardiac surgery itself is a source of inflammatory signaling as we have demonstrated previously . HoweverThe small number of patients included in this descriptive study is a limitation factor as is the absence of correlation between the expression pattern of mRNA coding for genes involved in myocardial remodeling and clinical outcome variables. The rarity of surgeries for ASD closure motivated us to include patients the myocardial tissue of whom was processed in 2 different institutions. Their results were therefore not pooled. The fact that similar results were obtained in both patient groups may however be considered strength of the study.Our results show that in children with ASD, myocardial remodeling of the RA involves inflammatory-, growth- fibrogenic- and apoptotic signaling pathways that are likely to be activated in response to cellular stress. Besides the expression of harmful mediators such as pro-inflammatory cytokines, protective mediators are also expressed that may delay the apparition of irreversible tissue remodeling. With this respect, the predominance of anti-apoptotic over pro-apoptotic regulators in children could be understood as an intrinsic myocardial protection allowing lesion reversibility after ASD-closure.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.The studies involving human participants were reviewed and approved by Ethical Committee of the University Hospitals Leuven and Aachen. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.HR and M-CS conceived and designed the study. HR, AG, NF, RH, and JV-J contributed to the data acquisition, data analysis, and interpretation. HR and M-CS drafted the manuscript. All authors revised the manuscript critically and approved it finally before publication and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Hypertension and/or myocardial infarction are common causes of heart failure in Type 2 diabetes. Progression to heart failure is usually preceded by ventricular dysfunction, linked to matrix metalloproteinase (MMP) mediated extracellular matrix changes. We hypothesise that the minor allele of genetic variant rs3918242 in the promoter region of the MMP-9 gene is associated with hypertension and/or myocardial infarction, with resultant progression of dysfunctional cardiac remodelling in patients with diabetes without symptomatic heart failure.We genotyped 498 diabetes patients participating in the St Vincent’s Screening TO Prevent Heart Failure (STOP-HF) follow-up programme for the rs3918242 single nucleotide polymorphism and investigated associations with the co-primary endpoints hypertension and/or myocardial infarction using a dominant model. We also evaluated resulting cardiometabolic phenotype and progression of ventricular dysfunction and cardiac structural abnormalities over a median follow-up period of 3.5 years.p = 0.026] over a median follow-up of 3.5 years . Conversely, rs3918242 was not associated with hypertension, blood pressure, pulse pressure or left ventricular mass index at baseline or over follow up.The CT/TT genotype comprised 28.1% of the cohort and was associated with a twofold higher risk of myocardial infarction (17.9% vs 8.4%), a reduction in ejection fraction and greater left ventricular systolic dysfunction progression [adjusted OR = 2.56 , Diabetes patients with the minor T allele of rs3918242 in the STOP-HF follow up programme have greater risk of myocardial infarction, lower ejection fraction and greater progression of left ventricular systolic abnormalities, a precursor to heart failure. These data may support further work on MMP-9 as a biomarker of ventricular dysfunction and the investigation of MMP-9 inhibitors for heart failure prevention in diabetes, particularly in the post-infarction setting.ClinicalTrials.gov Identifier: NCT00921960 The growth of cardiovascular disease in diabetes, including hypertension, myocardial infarction and diabetes-related cardiomyopathy, is a persistent global public health problem , 2. In phttps://www.ncbi.nlm.nih.gov/snp/?term=rs3918242) near the promoter region of the MMP-9 gene has been associated with increased circulating levels of MMP-9 and with higher frequencies of vascular disease, especially in type 2 diabetes . There were no differences between the two groups in terms of LVDD, LVD or LVD and structural cardiac abnormality progression. There was also a significant difference between both groups in the proportion of patients demonstrating progression of LAVI , although this did not remain significant when adjusted for age and sex.Furthermore, over a median follow-up of 3.5 years  there was a significant difference in LVSD progression ; death or MACE or LVD progression ; death or MACE or LVD or structural cardiac abnormality progression .Although myocardial infarction occurred in only 11% of the total population, the majority of patients with LVSD at baseline (54%) or with LVSD progression (58%) had a history of MI. Due to the strong association between the minor T allele, myocardial infarction and reduced LVEF in our study, we carried out a post-hoc analysis of patients with a history of myocardial infarction to see if severity of cardiac damage, denoted by reduced LVEF, was greater in this subset. We compared clinical characteristics, medications and Doppler echocardiography of the patients with myocardial infarction according to CC or CT/TT genotype  allele of rs3918242 we observed a twofold risk of prior myocardial infarction, but no associated risk of hypertension. We also found significantly lower ejection fraction at baseline in CT/TT genotyped patients and greater progression of left ventricular systolic dysfunction over a median 3.5 year follow up period, suggesting higher risk of the future development of HF. Consistent with these observations, in propensity-matched, sub-group analyses of patients with a history of myocardial infarction, CT/TT genotype patients had significantly reduced ejection fraction compared to CC controls, with greater reduction in ejection fraction compared to T allele patients in the overall cohort. As MMP-9 is an inducible gelatinase and rs3918242 C > T in the promoter region of the gene is known to augment expression of MMP-9, these data may support the use of MMP-9 as a biomarker of ventricular dysfunction and the investigation of MMP-9 inhibitors for HF prevention in diabetes, particularly in the post-infarction setting.–8 and consequently identify only a minority of gene variants associated with disease risk. Moreover, GWAS may lack deep phenotypic characterisation and many of the variant candidates emerging from GWAS to date have uncertain functional significance [The observational nature of this study means that causality between rs3918242, myocardial infarction and ejection fraction cannot be definitively established. In addition, the population is exclusively Irish Caucasian, and our results may not hold in populations with different ethnicities, where minor allele frequencies differ. The work is also limited by relatively low patient number and potentially biased by the absence of a matched non-diabetic cohort to investigate whether this relationship applies only in the context of diabetes. Furthermore, while the minor T allele of rs3918242 is associated with coronary artery and cerebrovascular diseases in large clinical studies and a recent meta-analysis, , 27, 28 ificance . A pragmificance , 30.The main strength of this study is the detailed clinical, biochemical and deep-phenotyping with sequential Doppler echocardiography to highlight the association of myocardial infarction, asymptomatic left ventricular dysfunction and progression of left ventricular systolic dysfunction amongst carriers of the rs3918242 T allele. The data may be important in the context of concerns about the burden of heart failure in diabetes and support the potential of MMP-9 as a diagnostic marker and/or therapeutic target post-MI in order to prevent heart failure in this setting. Our study is also consistent with a large population based study of coronary artery disease patients, which showed that the rs3918242 T-allele associated with the risk of clinical events only in patients with metabolic syndrome . ChronicIn contrast, we did not find any association of rs3918242 with baseline prevalence of hypertension, blood pressure and pulse pressure. This is unlike previous studies showing MMP-9 is associated with arterial stiffness in patients with diabetes . In an eAlternatively, the present study may support a hypothesis that over-expression of MMP-9 is most associated with the evolution of, and cardiac response to, myocardial infarction in diabetes. The magnitude of EF difference at baseline, while significant, was considerably smaller in the total population rather than the prior MI subset and the majority of patients that demonstrated LVSD progression over time had prior MI. This relationship may be complex, involve the innate immune response and have important temporal features. For example, in accordance with our study, maximal plasma MMP-9, seen early in the first 12 h post-MI, is independently related to lower EF and increased circulating leukocytes . On one Future avenues of research could build on these data with a view to individualizing care. For example, excess MMP-9 activity associated with the minor allele of rs3918242 may be a therapeutic target in post-MI diabetes patients. To date, MMP inhibitors have produced mixed results when evaluated clinically in cardiovascular disease patients including post-MI, which may relate to temporal issues described above, as well as a lack of selectivity of inhibitors for pathophysiological MMP isoforms . HoweverDiabetes patients with the minor T allele of rs3918242 in the STOP-HF follow up programme have greater prevalence of myocardial infarction, reduced ejection fraction at baseline and greater progression of left ventricular systolic dysfunction over a median 3.5-year follow-up period. The reduced ejection fraction is lower in subsets of post-myocardial infarction patients with the CT/TT genotype. In contrast, we did not find any association of rs3918242 with baseline prevalence of hypertension, blood pressure and pulse pressure. These data may support further work on MMP-9 as a biomarker of ventricular dysfunction and the investigation of MMP-9 inhibitors for HF prevention in diabetes, particularly in the post-infarction setting.Additional file 1. Supplementary Data File.


Anorexia Nervosa (AN) is a complex psychiatric disorder that can lead to specific somatic complications. Heart abnormalities are frequently reported, while their frequency and associated factors in severely malnourished AN patients remain poorly defined.This study aimed to characterize echocardiographic abnormalities in severely malnourished AN patients and to assess associated clinical, biological and related body composition features.Between January 2013 and January 2015, all severely malnourished adult patients with AN  were included in a monocentric study performed in in a highly specialized AN inpatient unit. Electrocardiogram (ECG) and echocardiography were used to assess both heart rhythm and function. All inpatients underwent a Doppler echocardiography procedure after undergoing combined blood volume adjustment, micronutrients deficiencies supplementation and electrolyte disorders correction. Right Ventricular (RV) and Left Ventricular (LV) systolic and diastolic functions were collected and compared to 29 healthy normal subjects in a control group.2 were included. Ninety patients (73%) had been diagnosed with AN Restrictive type (AN-R), 34 (27%) an AN Binge eating/Purging type (AN-BP). Eighteen patients (15%) disclosed an abnormal Left Ventricular Ejection Fraction (LVEF) . LVEF impairment was associated with AN-BP patients (p < 0.017) and hypertransaminasemia (AST and/or ALT ≥2 N) (p < 0.05). Left Ventricular mass (LV mass) and Left Ventricular End Diastolic Diameter (LVEDD) were significantly reduced in patients . Left and right ventricular tissue Doppler Imaging Velocities (TDI) peak were reduced in patients: Septal and Lateral LV Sm velocities peaks respectively 10 ± 2 cm/s , 12 ± 3 cm/s , basal RV Sm velocity peaks at 14 ± 3 cm/s . Additionally, LV and RV diastolic velocity peaks were reduced: LV septal and lateral velocity peaks were respectively 13 ± 3 cm/s (vs 18 ± 2 cm/s p < 0.001), 12 ± 3 cm/s  and RV diastolic velocity peaks at 14 ± 3 cm/s (vs 21 ± 4 cm/s p < 0.001). LV diastolic velocity TDI peaks were significantly associated with hypertransaminasemia (p < 0.05) and tended to be associated with a low all body Fat-Free Mass Index (FFMI)  (HOLOGICQDR 4500) (p = 0.056). Thirty-four patients (27%) had a pericardial effusion and were significantly associated with a decreased all body FFMI (p < 0.036).One hundred and 24 patients (119 (96%) women, 5 (4%) men) with a mean age of 30.1 ± 11 years old and an average Body Mass Index (BMI) of 12 kg/mHeart abnormalities are frequent in malnourished patients with AN, particularly in AN-BP type. Both liver enzymes and body composition abnormalities tended to be associated with heart dysfunction (non-significant association). Prospective studies are needed to better characterize and describe the evolution of cardiac abnormalities during the refeeding period and subsequent weight restoration. AN is a complex and severe eating disorder that affects 1–2.2% of young women. Its mortality rate is high, up to 12 times compared that of the general population. AN is defined as either an inability to maintain adequate dietary intakes associated with an intense fear of gaining weight or becoming fat, or a persistent behavior preventing weight gain and causing interference with body image.Dietary restriction can cause undernutrition and serious medical complications such as heart abnormalities, which are frequent yet poorly defined.We aimed to characterize echocardiographic abnormalities in severely malnourished patients suffering from AN and to assess associated clinical, biological and related body composition features. Results support that heart abnormalities are frequent in malnourished patients with AN (BMI < 12), particularly in the AN-BP type. Liver enzyme levels were associated with heart dysfunction. Body composition abnormalities tended to be associated with heart dysfunction. Our outcomes suggested that echocardiography may be performed in all severe malnourished AN-BP type patients on presentation, in order to diagnose and manage heart-related abnormalities, thereby reducing potential complications.Prospective studies are needed to describe the evolution of these abnormalities after weight recovery.Anorexia Nervosa (AN) currently affects 1% of young women , AN is cSerious medical complications have been reported, including electrolyte disorders, hematologic disorders , severe In this study, we aimed to characterize echocardiographic abnormalities in extremely severe malnourished patients suffering from AN and to assess associated clinical, biological and related body composition features.We conducted a retrospective study of all malnourished patients with AN (according to DSM IVr)  hospitalData were collected for the time period between January 2013 and January 2015 and included patients with the following criteria: AN patients aged ≥16 years-old, BMI < 16  with eitDuring the first 48 h after admission, all patients underwent standard progressive enteral feeding, using standard polymeric enteral nutrition products, combined with initial intravenous supplementation of vitamins, phosphorus and trace elements. This therapeutic protocol was initially recommended by the NICE  in the UK  and was In cases where the BMI was below 12 and the patient exhibited hypophosphatemia at admission, patients were fasted, hydrated intravenously and given micronutrient supplements for the first 24 h. After the hydration period, enteral nutrition was initiated according HAS (France) and NICE (UK) recommendations, to avoid the occurrence of refeeding syndrome (RS) .Enteral feeding was started gradually with the administration of 10 kcal / kilogram of body weight / day, followed by a gradual increase depending on clinical status and phosphatemia , 18. No For each patient the following clinical data were collected at admission: age, gender, AN types, height and weight. Blood biological parameters collected were as follows: Aspartate Transaminase (AST), Alanine Transaminase (ALT), Gamma Glutamyl- Transpeptidase (GGT), Alkaline Phosphatase (ALP), Prothrombin Rate (PR), and other biological parameters, such as: serum electrolytes, Urea, Creatinine, Phosphorus, Calcium, Magnesium, Calcifediol (25- OHD3), Thyroid-Stimulating Hormone (TSH) free Thyroxine (T4), Triiodothyronine (T3), Brain Natriuretic Peptide (BNP), Selenium, Thiamine, total Cholesterol and LDL (Low Density Lipoprotein), Triglycerides (TG), Albumin, Thransthyretin (TTR) and C-Reactive Protein (CRP).Body composition Fat Mass (FM), Fat-Free Mass (FFM) and calculated Fat-Free Mass Index (FFMI) were studied using Dual-energy X-ray Absorptiometry (DXA) (HOLOGIC QDR 4500) measurements collected at admission.> 25) volunteers were excluded. Controls did not undergo DXA or blood tests.Healthy normal weight (BMI between 18.5 and 25) volunteers were enrolled consecutively after a medical interview, among hospital’s medical and paramedical staff. Past and actual overweight  by an experienced AF, with a specialization in childhood and adult myopathic diseases, during the. Heart parameters were determined and interpreted according to the guidelines issued by the American Society of Echocardiography . We recoRV systolic dysfunction was defined if TAPSE < 17 mm or peak RV systolic velocity (RV Sm) < 9.5 cm/s .Study results were analyzed using SPSS 11.0  software.t test, chi-square test and Fisher’s test were used for univariate analysis. The risk factors identified using univariate analyses were tested using a multivariate logistic regression. A p value lower or equal to 0.05, was considered statistically significant.Student’s 2 (BMI: 18.5–24.9 kg/ m2). Clinical and biological characteristics of the study population are summarized in Table One hundred and 27 inpatients were screened, 3 patients were excluded for concomitant comorbidities . One hundred and 24 were ultimately enrolled: 119 women (96%) and 5 men (4%). Ninety patients (73%) were suffering from AN-R type as defined by the DSM-IVr, while the other 34 (27%) presented AN with associated purgative behaviors (AN-BP). The mean age of patients was 30.1 ± 11 years old, with an average BMI of 12.3 ± 2.5 kg/mp < 0.05). LV mass and LVEDD was reduced in patients . Left and right ventricular TDI systolic velocity peaks were significantly reduced in patients: LV septal and lateral Sm velocity peaks respectively 10 ± 2 cm/s (vs 14 ± 2 cm/s p < 0.001), 12 ± 3 cm/s vs 16 ± 3 cm/s p < 0.001), basal RV Sm velocity peak 14 ± 3 cm/s (vs 19 ± 3 cm/s). In addition, LV and RV diastolic velocity peaks were both reduced: septal and lateral LV Ea velocity peaks respectively 13 ± 3 cm/s (vs 18 ± 2 cm/s p < 0.001), 12 ± 3 cm/s  and RV Ea diastolic velocity peak at 14 ± 3 cm/s (vs 21 ± 4 cm/s p < 0.001). TAPSE was significantly reduced in patients compared to controls   [A comparison of patients’ heart parameters and controls is presented in Table females)  Table 3p < 0.05.p < 0.017). Patients with LV systolic dysfunction frequently displayed hypertransaminasemia in comparison to patients with normal systolic function (p < 0.05). Using multivariate analysis, hypertransaminasemia and AN-BP were independently associated with LVEF alteration . LV TDI diastolic peak velocities  were significantly associated with hypertransaminasemia (p = 0.05); there was an additional trend toward an association with FFMI, (p = 0.056). TDI Right ventricular diastolic velocity peaks (RV Ea peak) were above the lower limit of normal in all AN patients. Considering an elevated BNP value (> 100 pg/ml) as a parameter indicative of altered left ventricular function, abnormal BNP values (> 100 pg/l) were significantly associated with older age  and with hypertransaminasemia (p = 0.001). A decreased FM was significantly associated with pericardial effusion .Using univariate analysis, patients with AN-BP had a higher incidence of LV dysfunction compared to patients with AN-R . The Doppler-echocardiographic analysis was the most thorough compared with all others studies, focusing not only on the LVEF but also on subclinical systolic and diastolic function assessment. Our study was thus able to identify risk factors for subclinical heart alterations . One of the major risk factors identified in this study was AN-BP type which is characterized by vomiting and laxative misuse potentially leading to hypokalemia, hypomagnesaemia and metabolic alkalosis. However these electrolyte disorders were not observed in our study because they were corrected intravenously in the early days of hospitalization, before refeeding. One can suppose that chronic metabolic disorders may alter myocardial fibers and that the damage remains even after micronutrient deficiency correction and subsequent recovery. This hypothesis was supported by both Romano et al. and Oflaz et al. [Rautou et al reported on the liver biopsy of 12 malnourished AN patients with acute liver insufficiency, hepatocyte autophagia, liver hypoxia and decreased portal pressure. These microscopic abnormalities were associated with heart output. This low heart output appeared to be related to heart muscle atrophy and heart arrhythmia, which had been enhanced by electrolyte disorders, leading to hypokalemia and hypocalcaemia, and inducing QT prolongation and impairment of the autonomic nervous system [Characterization of heart abnormalities may lead to a better understanding for anticipating morbi-mortality in the future; though to our knowledge, no studies so far have focused on heart function  in AN patients. As for other disease settings, myocardial function may be altered in the context of metabolic disorders, such as acid-base disorders, hyperkalemia, hypomagnesaemia and hypocalcaemia . These a studies , 26 discer et al  carried z et al. , 26. It s system . HypertrOur study found a relationship between the level of severe undernutrition and heart alterations, highlighting the potential specific association between muscle mass and hepatic and cardiac impairment as a consequence of severe undernutrition.The results of our study suggest that cardiac assessment for AN patients with hypertransaminasemia may be warranted prior to refeeding  in order to prevent complications such as heart failure.Heart abnormalities are frequent in severely malnourished AN patients. LV function can be altered especially in AN-BP patients. Subclinical heart abnormalities are also frequent and tend to be associated to body composition abnormalities. Prospective studies are needed to determine and to describe the evolution of these heart abnormalities during refeeding and after weight restoration.


Cardiotoxic effects of anthracycline therapy are a major cause of morbidity for childhood cancer survivors. The aim of this retrospective evaluation is to assess the efficacy of Tissue Doppler Imaging in the early detection of myocardial alterations in these patients.P-value < 0.05 was considered statistically significant. Statistical analysis was performed using STATA 7.0.A population of 50 childhood cancer survivors  who have been treated with anthracyclines was evaluated by standard and TDI echocardiographic examination of the basal and median region of the interventricular septum , of the left ventricular posterior wall , and of the mitral annulus; the results were compared with those obtained from a population of 50 healthy age-matched and sex-matched controls by using the Student test. The clinical and echocardiographic data of the two groups were compared also with the independent samples t-test. All data were expressed as mean ± standard deviation. A two-tailed p < 0,05) between the patients and the controls values. The systolic performance of the patients was normal  and LVFS ). Statistically significant differences between patients and controls were found for diastolic function measurements obtained with PW Doppler such as IVRT , DT , E , A , even if E/A ratio was not altered. TDI analysis also show significant differences between patients and controls in both LVPW and IVS ; E/E’ ratio and E’/A’ ratio did not vary significantly. Linear Regression and multivariate analysis showed that Hematopoietic Stem Cell Transplantation had the highest impact on our measurements.The case-control analysis showed statistically significant differences  contains supplementary material, which is available to authorized users. Anthracycline-induced cardiotoxicity represents the most important therapeutic limitation for both children and adults with neoplasia . ChildhoPulsed-wave Tissue Doppler Imaging (TDI) is a non-invasive tecnique for the evaluation of myocardial tissue velocities; this study aims to evaluate the role of TDI in the early detection of the mild subclinical dysfunction induced by anthracyclines.A retrospective evaluation was performed on survivors of childhood cancer treated with anthracyclines at the Pediatric Hematology-Oncology Unit of the S.Orsola-Malpighi Clinic. All children were evaluated with standard echocardiography and Tissue Doppler Imaging (TDI) using iE 33 xMatrixs Echo system . The results were compared with those obtained from a population of healthy age-matched and sex-matched controls.2. They were treated for leukemia (n = 31), lymphoma (n = 15), and other solid tumors (n = 4), with a median cumulative dose of 219,6 (range 83–780) mg/m2 of anthracyclines. The mean age at the start of chemotherapy was  years, with a median follow-up period of 24 months (4–127 months) after the anthracycline treatment was completed. Among these, 14 children  underwent haematopoietic stem cell transplantation and 11 children received mediastinal irradiation . The control population includes 50 subjects  with a mean age of 11,5  years and mean body surface area of 1,31 .The patients cohort includes 50 children , mean age of 11,7  years, with mean body surface area (BSA) of 1,35  mThe cumulative doses of anthracyclines were converted into Doxorubicin (DOX) equivalents, using conversion factors of 0,83 (Daunorubicin), 5,0 (Idarubicin) and 4,0 (Mitoxantrone) [An expert pediatric cardiologist and a trained pediatrician performed the transthoracic echocardiographies. All measurements were performed on 3 consecutive cardiac cycles. The pediatric cardiologist reviewed all the images acquired. The analysis included standard left ventricle chamber measurements , blood flow velocity through the mitral valve (pulsed-wave doppler) and tissue peak velocities for the interventricular septum and left ventricle parietal wall (pulsed-wave TDI).The variables measured on 2D M-mode ultrasonography were: interventricular septum thickness in diastole (IVSd) and systole (IVSs), left ventricle end-diastolic diameter (LVEDD or LVIDd), left ventricle end-systolic diameter (LVESD or LVIDs), left ventricle posterior wall in diastole (LVPWd) and systole (LVPWs). Shortening fraction (SF) and ejection fraction (EF) were calculated from M-mode measurements of LV dimensions at the level of mitral valve leaflet using parasternal long axis view. The EF was considered normal when ≥55% and mildly abnormal between 54 and 45% . LVFS waPulsed-wave Doppler was used to evaluate the diastolic function: mitral inflow wave velocity in the early diastole (E) and in the late diastole (A), left ventricle isovolumic relaxation time (IVRT) and E deceleration time (DT) were measured. Sample volume was placed between the leaflets of the mitral valve. The Diastolic function was considered normal when E/A ratio ranged between 0.9 and 1.5, abnormal with delayed relaxation pattern if E/A ratio < 0.9 and with restrictive pattern if E/A ratio > 2. Pulsed-wave Tissue Doppler Imaging (TDI) was used to add information on both systolic and diastolic performance. The apical four chamber view was used to assess peak myocardial velocities of the LV during systole (S′), early diastole (E’) and late diastole (A’). E’/A’ index and E/E’ index were calculated. The sample volume was placed at the basal and median segments of the interventricular septum  and left ventricular posterior wall . We did not include the evaluation of LV apical segments because myocardial velocities decreases toward the apex of the heart, resulting in unreliable and less significant measurements in this segment . The samTotal cumulative dose of anthracyclines the patients’ cohort was divided into 3 subgroups according to the literature [2; 2)medium-risk: 150–300 mg/m2; 3)high-risk: > 300 mg/m2. We compared the low-risk class with patients at medium- and high-risk, and the high-risk class with patients at low- and medium-risk. B) Gender C) Medistinic Irradiation D) Haematopoietic stem cell transplantation (HSCT): the results obtained from the children who underwent HSCT at the Pediatric Hematology-Oncology Unit of the S.Orsola-Malpighi Clinic were compared with those who didn’t receive such procedure during their therapy. E) Oncologic diagnosis. F) Follow-up duration at the time of the evaluation: we compared the patients evaluated within 12 months after the end of therapy with those evaluated after 12 months after the end of therapy. The same comparison was carried out using also a 24 months cut-off.The patient’s cohort was divided into sub-groups according to risk factors for anthracycline cardiomyopathy , 4: A) Tterature : 1)low-rp value < 0.05 was considered to be statistically significant.Analysis of variance was used to assess differences in the mean value of the normally distributed variables between groups, while the Student Test was used for within-group post-hoc analysis. A p value < 0.05 was considered to be statistically significant. The clinical and echocardiographic data between the two groups were compared by the independent-samples t-test. All data were expressed as mean ± standard deviation. A two-tailed P-value < 0.05 was considered statistically significant. Statistical analysis was performed using STATA 7.0.The statistically significant measurements of the case-control analysis were analyzed by linear regression analysis; multivariate analysis was also performed to determine the influence of the risk factors on each parameters. The independent variables considered were 1) time from end of therapy to TDI evaluation, 2) time from diagnosis to TDI evaluation, 3) gender, 4) BSA (body surface area), 5) anthracycline equivalent dose, 6) Hematopoietic Stem Cell Transplantation procedure, 7) Tumor Type. A p = 0,0000) and systole  of the treated children. LVPWd showed a significant thickness increment  as opposed to LVPWs. The patients cohort showed a significant decrement of both LVSF  and LVEF , but values remained in the normal range . Z-score for the M-mode values of the patients showed that both IVSd  and LVPWd  were higher than the European children population reference values, while LVIDd  was lower and LVIDs  was in line with the reference values. The PW Doppler analysis of the transmitral blood flow revealed that the E deceleration time of the patients was significantly reduced  as well as E  and A  peak velocities values. IVRT was significantly higher in patients  while E/A ratio was lower, but with a p value > 0,05. TDI analysis of the LVPW middle segment showed a significant reduction of both E’  and A’  among patients, while S  was increased. Both E’/A’ ratio increment  and E/E’ ratio decrement  were not significant. LVPW basal segment revealed a similar profile, with higher S , lower E’  and lower A’  values compared to controls. E’/A’ ratio and E/E’ ratio didn’t show statistically significant alterations. E’ showed a statistically significant reduction  in the IVS middle segment only, while the IVS basal segment analysis revealed a significant reduction of S , E’ and A’ . E’/A’ ratio and E/E’ ratio values alterations were not significant. Mitral annular displacement measures showed significant alterations of both E’  and A’ . Both our standard PW Doppler and TDI measurements revealed significant diastolic alterations in the patients’ cohort, but they did not reflect any typical diastolic dysfunction pattern; in fact E/A, E/E’ and E’/A’ (8), didn’t vary significantly between patients and controls.Table p = 0,0433) on the LVPW basal segment . No statistically significant difference of TDI values was found comparing the gender groups  of the basal segment of LVPW. Also the IVS analysis showed significant middle segment  and basal segment  alterations, while mitral annular displacement values were not significant  than those evaluated before  than those evaluated before  and multivariate analysis     . Anthracyclines equivalent dose was another important risk factor, with significant influence on the E’ wave of the LVPWb    and multivariate analysis   had mild alterations on the left ventricular posterior wall  supporting the results of the analysis. (DOCX 145 kb)Additional file 2:Tables of linear regression analysis and multivariate analysis. Due to the large amount of data which would have been impractical to attach to the end of this manuscript, the authors provides this file with seventeen detailed tables (from “Table 10” to “Table 26”) supporting the results of the analysis. (DOCX 46 kb)


The burden of pregnancy-related heart disease has dramatically increased over the last decades due to the increasing age at first pregnancy and higher prevalence of cardiovascular risk factors such as diabetes, hypertension, and obesity. Pregnancy is associated with physiological changes in the cardiovascular system, including hemodynamic, metabolic, and hormonal adaptations to meet the increased metabolic demands of the mother and fetus. It has been postulated that pregnancy may act as a cardiovascular stress test to identify women at high risk for heart disease, where the inability to adequately adapt to the physiologic stress of pregnancy may reveal the presence of genetic susceptibility to cardiovascular disease or accelerate the phenotypic expression of both inherited and acquired heart diseases, such as peripartum cardiomyopathy (PPCM). PPCM is a rare and incompletely understood clinical condition. Despite recent advances in the understanding of its pathogenesis, PPCM is not attributable to a well-defined pathological mechanism, and therefore, its diagnosis still relies on the exclusion of overlapping dilated phenotypes. Cardiac imaging plays a key role in any peripartum woman with signs and symptoms of heart failure in establishing the diagnosis, ruling out life-threatening complications, guiding therapy and conveying prognostic information. Echocardiography represents the first-line imaging technique, given its robust diagnostic yield and its favorable cost-effectiveness. Cardiovascular magnetic resonance is a biologically safe high-throughput modality that allows accurate morpho-functional assessment of the cardiovascular system in addition to the unique asset of myocardial tissue characterization as a pivotal piece of information in the pathophysiological puzzle of PPCM. In this review, we will highlight current evidence on the role of multimodality imaging in the differential diagnosis, prognostic assessment, and understanding of the pathophysiological basis of PPCM. This According to the international guidelines –8, PPCM PPCM is a rare disease with a generally accepted incidence of nearly 1 in 1,000–4,000 live births in western countries . However4).Along with patients' medical history, physical examination, electrocardiogram (ECG), and B-type natriuretic peptide assessment , cardiacAuthors performed a narrative review and searched Medline from January 1966 through August 2019 for potentially relevant articles using the following search terms: (peripartum cardiomyopathy OR pregnancy) AND (echocardiography OR cardiovascular magnetic resonance OR computed tomography OR nuclear OR cardiovascular imaging). References of selected papers were screened, searching for other potentially relevant publications. Websites, including escardio.org and ResearchGate, as well as reference lists of all identified articles, including hand-searching of reviews and previous meta-analyses, were also appraised for additional relevant studies. Four authors screened a list of potentially relevant articles based on title, abstract, and full-text review. A selection of the most relevant papers was finally included in the review according to authors' opinion.Pregnancy produces prominent cardiovascular adaptations that become particularly evident in the last trimester and peripartum period. These changes include increase of LV mass, dilation of cardiac chambers, increase in cardiac output, and elevation of LV filling pressure due to fluid volume overload , 22. ForAlthough LV systolic dysfunction is observed in the vast majority of PPCM patients, as reduced LVEF is a major criterion for the diagnosis , severalStrain has been validated as an important echocardiographic parameter with diagnostic and prognostic utility in various cardiac conditions. In this context, myocardial strain analysis would be the ideal tool for unmasking early myocardial impairment associated with various degrees of myocardial inflammation, oxidative stress, and fibrosis eventually driving the transition to overt HF. Accordingly, in a single-center experience, global longitudinal strain (GLS) was significantly lower in PPCM patients compared with healthy peripartum women regardless of LVEF values . This hoLV thrombosis is a common finding in PPCM, due to the coexistence of multiple predisposing factors. Although CMR has been proven to be superior to both transthoracic and transesophageal echocardiography in the detection of LV thrombi , echocarDespite PPCM-related outcome appearing to be favorable compared with other cardiomyopathies , with moThe results of the Investigations of Pregnancy-Associated Cardiomyopathy (IPAC) study, a prospective multicenter study on 100 PPCM patients, highlighted that baseline LVEF <30% and LV dilatation with a left ventricular end-diastolic diameter (LVEDD) >60 mm were strongly associated with lower rates of both 12-month event-free survival and LV functional recovery . SimilarPPCM is associated with risk of recurrence during subsequent pregnancies and requires adequate counseling . SeveralThe role of pharmacological stress testing during pregnancy is currently limited, with conflicting data on the prognostic value of LV contractile reserve assessment by dobutamine stress echocardiography (DSE). In a series of seven patients, the presence of inotropic contractile reserve—defined as the improvement of wall motion score in ≥2 segments—was a better predictor than resting LVEF of LV functional recovery during follow-up . ConversRV involvement identifies a PPCM phenotype with worse outcome. Echocardiography is a cost-effective alternative to CMR for RV function assessment in PPCM patients, particularly in those countries where PPCM is relatively more frequent and with limited economic resources . In the Echocardiography is useful for counseling purposes and for risk stratification of PPCM women undergoing a subsequent pregnancy, individuating those that may benefit more from strict follow-up and timely treatment, also in the case of apparent full recovery of global LV systolic function .In the last decade, CMR has emerged as the gold standard technique for cardiac chamber quantification and flow assessment, but the key advantage of CMR is its unique ability to provide information about the tissue composition by myocardial tissue characterization with high spatial resolution, excellent accuracy, and reproducibility . AccordiThe first case of CMR assessment of PPCM was described in 2008 . AuthorsIn another case series, CMR could identify neither LGE nor signs of myocardial edema in the entire study cohort. However, it should be acknowledged that CMR was performed beyond 2 weeks from HF onset in most patients, and nearly 40% of the study population presented with pregnancy-induced hypertension, hence not entirely meeting PPCM diagnostic criteria .Supporting the hypothesis of the time dependence of detection of tissue composition alteration, both diffusely increased T2 and early gadolinium enhancement ratios  have been documented at the initial evaluation of women with PPCM . LGE wasIn a series of 10 patients with established PPCM, CMR revealed LGE with non-ischemic distribution in 40% of cases. LGE was associated with higher risk of HF hospitalization and HF exacerbation during subsequent pregnancies . An elevIn a larger CMR study enrolling 34 PPCM women, most patients presented with LVEF <35%, LV dilatation, and regional wall motion abnormalities . The obsCMR is also useful in the detection of intracardiac thrombosis. LV thrombosis is a serious complication of PPCM with potentially devastating consequences. The reported prevalence of LV thrombosis is highly variable, ranging between 10 and 30% . PPCM coCurrent evidence suggests that the utility of phenotyping PPCM by CMR imaging is manifold and should be aimed at establishing a correct diagnosis, improving risk stratification, detecting thrombotic complications, and planning appropriate follow-up , 4. FurtIonizing radiation exposure during pregnancy may be harmful for both mother and fetus. In pregnant or lactating women, the risk profile of radiation exposure is similar to that of non-pregnant women, with the exception of breast tissue. Given pregnancy-induced proliferation, it has been postulated that breast tissue of such patients is more sensitive to radiation, although the entity of this effect remains unclear . The conNon-ionizing imaging methods should be preferred whenever possible, and if radiographic or nuclear techniques are necessary, the risk/benefit profile must be carefully evaluated on an individual basis without exposing patients to potentially life-threatening consequences of delayed diagnosis.Chest x-ray represents the initial radiographic imaging method in the evaluation of the vast majority of pregnant women with HF when other radiation-free techniques are unable to clarify symptoms . Both maThe role of other radiographic and nuclear imaging methods in PPCM is limited, and these techniques are usually not required. However, computed tomography (CT), ventilation/perfusion (V/Q), scan or invasive coronary angiography (ICA) may be necessary in order to establish a differential diagnosis between ppCM and other diseases with acute HF presentation, such as pulmonary embolism (PE), amniotic fluid embolism, and acute coronary syndromes (ACSs).PE is a well-known complication of pregnancy-associated hemodynamic and metabolic changes and represents a relevant cause of maternal death , 77. It Although pregnancy is associated with an increased risk of ACS compared with age-matched non-pregnant women, ACSs are relatively uncommon during pregnancy . In addiIn the setting of suspected chronic coronary syndrome related to obstructive coronary artery disease (CAD), the choice of the optimal non-invasive diagnostic test should be guided by pre-test probability (PTP) and patient characteristics . CoronarA correct diagnosis of PPCM is key to start early treatment, plan appropriate follow-up, and provide adequate counseling. Recent data support the use of specific drug therapy with the prolactin inhibitor bromocriptine, although most studies are small-sized and with short-term follow-up. Future studies are needed to clarify the clinical importance and prognostic relevance of subclinical cardiac dysfunction at different stages of the disease by means of advanced echo modules including tissue Doppler imaging, speckle strain analysis, 3-D, contrast, and stress echocardiography. Further, 3-D echocardiography holds promise toward early detection of subclinical RV dysfunction and improved sensitivity for imaging of intracardiac thrombosis. Finally, the prognostic value of echocardiographic parameters other than LVEF or LV size requires further evaluation , 3.Although LGE is a robust outcome predictor in several non-ischemic cardiomyopathies, available evidence for PPCM highlighted conflicting results on scar prevalence in the absence of any specific scar pattern. This might be secondary to the small number of subjects enrolled, the heterogeneity of study design, and the poorly defined pathophysiology underlying PPCM that may be different across specific patient subgroups. Advanced tissue characterization by native and post-contrast parametric mapping and MR fingerprinting may provide valuable information about specific disease process underlying PPCM and should be the objective of future investigations . Given tFR: conceptualization, literature review, and writing—original draft. CD, EV, LC, CM, CP, FI, SGab, and AD'A: literature review and writing—original draft. MK, NA, MC, GR, ED, and SP: review and editing. SGal: conceptualization, project administration, and supervision.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Left ventricular non-compaction (LVNC) is a complex clinical condition with no diagnostic gold standard. At present, there is trepidation about the accuracy of the diagnosis, the correlation to clinical outcomes and the long-term medical management. This article reviews the current imaging criteria, the limitations of echocardiography and cardiac magnetic resonance and the consequences of LV hypertrabeculation in athletes.  Left ventricular non-compaction (LVNC) is an unclassified cardiomyopathy characterized by an abnormally thick trabeculated non-compacted myocardial layer with adjacent deep intra-trabecular recesses and a thin compacted myocardial layer . AlthougHeightened awareness and improved imaging techniques has led to inaccurate diagnosis, clinical challenges and unwarranted restriction from competitive sport ,13. At pThis review highlights the strengths and weaknesses of the current diagnostic criteria, the future directions of evaluating LV hypertrabeculation and the implication for athletes.Due to its low cost and widespread availability, 2D-echo is usually the first investigation in the evaluation of LV hyper-trabeculation. Presently, there are four 2D-echo-based criteria that are commonly used, but none are considered as the gold standard . The firDespite the widespread use of 2D-echo in the evaluation of hyper-trabeculation, the current criteria have several limitations. First, 2D-echo has limited spatial resolution and a poor ability to image the entire left ventricular cavity, making it difficult to differentiate non-compacted from compacted myocardium. For example, the LV apex, which is a commonly affected segmented can be difficult to visualize and differentiate from benign LV trabeculation . The lim2, a non-compacted to compacted myocardial ratio ≥3:1 in segments 1–3 or 7–16 excluding the apex and a non-compacted to compacted myocardial ration ≥2:1 in segments 4–6. The final criterion was proposed by Captur and colleagues using a method of quantifying complex geometric patterns in biological structures called fractal analysis [CMR is generally used to supplement and confirm 2D-echo findings by providing better spatial resolution in all LV segments, detailed visualization of cardiac morphology, robust volumetrics and the ability to identify fibrosis with late gadolinium enhancement (LGE). There are currently four validated CMR-based criteria but, again, no gold-standard has been established; analysis . The autanalysis  and can analysis . Several concerns have been highlighted about CMR and the current criteria. First, the four criteria are based on small cohorts and the data are not prospectively derived. Even though the criteria have been shown to accurately differentiate LVNC from other cardiomyopathies, none of the criteria have been correlated with clinical outcomes. In fact, only one study showed a strong association between end-systolic measures of LVNC and adverse events such as congestive heart failure . In addiIn the evaluation of athletes, echocardiographic studies have demonstrated a high prevalence of LV hypertrabeculation, fulfilling at least one of the diagnostic criteria. The authors of the PESA  study assessed the relationship between LVNC phenotype on CMR imaging and accelerometer-measured physical activity and found that the prevalence of an LVNC phenotype according to several CMR criteria was significantly higher in those with the highest physical activity quintile . The assManaging LVNC presents a significant clinical challenge given the variability in manifestations and the limited long-term efficacy of specific treatments. Although most patients with LVNC remain asymptomatic, it is important to review patients regularly with cardiac imaging, as some may be at risk of heart failure, stroke and/or sudden cardiac death. In particular, those with reduced LV function should be reviewed frequently and treated with evidence-based, guideline-directed pharmacologic therapy. As per guidelines, an intracardiac defibrillator should be offered to those who survive an episode of sustained ventricular tachycardia (VT) or sudden cardiac arrest . SuccessIn the evaluation of hyper-trabeculation, the diagnosis of LVNC is limited by the lack of standardized imaging criteria and poor correlation with clinical outcomes, leaving clinicians to rely on small single-center studies. We know from previous data that criteria based on morphological parameters alone are inadequate to prognosticate patients. As a result, assessments have shifted away from static single-plane, two-dimensional measurements towards the quantification of trabeculated volume or mass ,20. The In an effort to improve the overall diagnostic accuracy, a clinical algorithm has been developed to help guide clinicians in the assessment of patients with suspected LVNC . The autLVNC is a heterogenous condition with no universally accepted diagnostic criteria or gold standard. In the evaluation of patients and athletes with LVNC, it is important to take a comprehensive history, rely on more than one diagnostic method and include LV parameters such as LV function and LGE. In those with clinical suspicion of LVNC, echocardiography remains the first imaging modality; however, once hypertrabeculation has been identified, CMR should be used to evaluate LV ejection fraction and assess for LGE. For those with impaired LV function and/or LGE, prohibiting vigorous sports activities should be considered and management goals should be based on clinical symptoms such as ventricular arrhythmias, syncope or thromboembolic events.


Immune checkpoint inhibitors (ICIs) are highly effective in treating cancer; however, cardiotoxicity can occur, including myocarditis. Cardiac magnetic resonance (CMR) imaging is useful for evaluation of myocarditis, although it has not been well studied in ICI cardiotoxicity.We identified patients referred for CMR evaluation of ICI cardiotoxicity from September 2015 through September 2019. We assessed structural and functional parameters, feature tracking (FT) left ventricular and atrial strain, T2- weighted ratios and quantitative late gadolinium enhancement (LGE). We also applied the Updated Lake Louise Criteria for diagnosis of myocarditis.s = −0.64, p 0.002). Sixteen patients (80%) had presence of LGE (14 non-ischemic pattern and 2 ischemic). Percent LGE did not correlate with any CMR parameters and notably did not correlate with LVEF  or GLS , highlighting the value of tissue characterization beyond functional assessment. Nine patients (45%) met full Updated Lake Louise Criteria and 85% met at least one criterion, suggestive of myocarditis in the correct clinical context. Thirteen patients (65%) were treated for ICI-associated myocarditis and, of these, 54% (n = 7) had recovery of LVEF to normal. There was no correlation between LVEF (p = 0.47), GLS (0.89), or % LGE (0.15) and recovery of LVEF with treatment.Of the 20 patients referred, the median left ventricular ejection fraction (LVEF) was 52.5% ± 19.1 and 50% had a normal LVEF (≥53%). FT strain analysis revealed an average abnormal global longitudinal strain (GLS) of −9.8%± 4.2%. In patients with a normal LVEF, the average GLS remained depressed at −12.3%± 2.4%. In all patients, GLS demonstrated a significant negative correlation with LVEF (rIn patients with suspected ICI cardiotoxicity, CMR is an important diagnostic tool, even in the absence of overt left ventricular dysfunction, as abnormalities in left ventricular strain, T2 signal and LGE can identifying disease. Recent advances in immunotherapy have improved survival in cancer patients. The two FDA-approved classes of immune checkpoint inhibitors (ICIs) inhibit T-cell activation by targeting cytotoxic T lymphocyte antigen 4, programmed cell death protein-1 or programmed cell death ligand 1. ICIs have revolutionized the field of immuno-oncology, as many patients have seen immediate and lasting beneficial effects, and the number of trials utilizing ICIs is growing rapidly . CardiotCurrently there is no standard for the diagnosis and management of patients with ICI cardiotoxicity. Cardiac magnetic resonance (CMR) imaging is a well-established tool for diagnosis of myocarditis in general and provides detailed tissue characterization, in addition to functional data, which can increase the sensitivity for detection of myocarditis , 8. MyocMyocardial strain by echocardiography and CMR has been extensively studied in chemotherapy associated cardiotoxicity –12. AddiCMR is well established in the diagnosis of myocarditis; however, the recent study using only qualitative CMR data in ICI myocarditis suggests that CMR may not be reliable for evaluation of this clinical scenario . HoweverA clinical database search was performed to identify all patients referred for clinical CMR imaging for an indication of ICI cardiotoxicity from September 2015 to September 2019. We included all patients on ICIs with clinically diagnosed ICI cardiotoxicity based on symptoms who also had at least one of the following objective markers: either an increase in troponin, a decrease in LVEF on echocardiogram, or a new pericardial effusion. All patients referred for CMR exam met these criteria and therefore none were excluded.Medical chart review was performed on all patients and included: demographics, cancer diagnosis, cancer treatment, cardiovascular risk factors, relevant laboratory tests , electrocardiogram, cardiac catheterization, endomyocardial biopsy, treatment for myocarditis, other immune-related adverse events (irAEs) , and vit3 resolution) with retrospective ECG gating was acquired in the two-chamber, three-chamber, and four-chamber views, and in contiguous short axis slices of the left ventricle. Short axis T2W black-blood fast spin echo images were used . T2W mapping used T2W-prepared balanced steady-state free precession (bSSFP) single shot images acquired in 9 heart beats  with FOV = 360 mm x 270 mm, slice thickness = 8 mm, FA = 30°, parallel imaging = generalized autocalibrating partially parallel acquisition (GRAPPA 2), bandwidth = 1395Hz/pixel). The T2W maps were automatically generated using an exponential fit (image resolution 1.5mm×1.5mm x 8mm). LGE evaluation was performed 8–10 min after administration of 0.2 mmol/kg gadolinium contrast agent. After performing an inversion scout sequence, LGE imaging was obtained using inversion recovery gradient echo .All CMRs were performed in a single center on a 1.5 T clinical scanner  using standard clinical protocols. Steady state free precession (SSFP) cine imaging [repetition time (TR) = 3 ms, echo time (TE) = 1.5 ms, flip angle (FA) = 60°, 30 cardiac phases, 1.4x 1.4 x 8 mm42 (version 5.10.1). Analysis for volumes and function was performed using semiquantitative threshold detection technique, with manual adjustments. Trabeculations and papillary muscles were included in the left ventricular (LV) mass.All CMRs were independently re-processed in a uniform manner by the authors  using Circle Cardiovascular Imaging Inc. CMRLeft ventricular GLS, global radial strain (GRS), and global circumferential strain (GCS) analysis was performed using SSFP cine short axis stack, four chamber, three chamber, and two-chamber views using CMR42 feature tracking. This software tracks image feature displacement over successive frames, similar to speckle tracking used in echocardiography , 19. RepT2 myocardium/SIT2 skeletal muscle. A ratio of ≥2 in the septum or lateral wall was considered positive for edema8. For T2W mapping, a T2>52ms was considered abnormal [Myocardial edema was assessed by measuring T2 myocardium to skeletal muscle ratio (T2 ratio) . Myocardabnormal . LGE wasPatients were categorized according to the 2018 Updated Lake Louise Criteria for myocardial inflammation [Descriptive statistics were expressed as median and interquartile range or number and percentage. Spearman’s rank correlation coefficient was used to describe the relationship between continuous variables and Mann-Whitney U-test was used for ordinal variables. A p-value of <0.05 was considered significant. Statistical analysis was performed using SPSS Version 26.Twenty patients were included in the analysis. Baseline characteristics and initial clinical evaluation are reported in The median time from starting checkpoint ICI therapy until presentation was 94 days (IQR 43–228 days) . A preseFunctional analysis is summarized in s = −0.85, p <0.001). There was a moderate correlation between LV GRS and cardiac index, RVESVI, RVSVI, and RVEF.Feature tracking analysis revealed a median LV GLS of −11.1% (IQR −7.2− −12.6%), LV GCS of −14.4% (IQR −10.7 − −15.5%) and LV GRS of 23.0% (IQR 14.6–29.2%). There was a moderate association between GLS and left ventricular end systolic volume index (LVESVI), LVEF, and cardiac index. There was a strong correlation between LV GCS and LVESVI, LVEF, and RVEF and a moderate correlation between LV GCS and cardiac index, right ventricular end systolic volume index (RVESVI), and RV stroke volume index (RVSVI). There was a strong correlation between LV GRS and LVESVI and LVEF , LV GLS , LV GRS , and LV GRS . Left atrial GLS(R) was not correlated with left atrial size .Left atrial longitudinal strain analysis was possible for 13 patients (GLS(R) n = 13, GLS(E) n = 10, GLS(A) n = 10). The median left atrial GLS(R) was 24.5% (IQR 20.8–28.0%), GLS(E) was 11.2% (IQR 9.9–12.4%) and GLS(A) was 13.5% (IQR 10.1–14.4%). Left atrial GLS(R) was correlated with LVEF  . T2 ratio did not correlate with any CMR parameter and notably did not correlate with LVEF (r = 0.25) . Eight os = −0.29, p = 0.22) or GLS  (Sixteen patients (80%) had LGE (14 non-ischemic pattern and 2 ischemic pattern). In patients with LGE, the mean percent LGE was 9.3%. Mid-myocardial right ventricular insertion site LGE was common, and occurred in 75% of patients (n = 15), and three patients had isolated RV insertion site LGE. Percent LGE did not correlate with any other CMR parameters  and notably did not correlate with LVEF (r = 0.67) .A LVEF ≥53% was considered normal  and halfUsing the Updated Lake Louise Criteria, 9 patients (45%) were positive for definite myocardial inflammation based on having concomitant abnormal T2W imaging and LGE in a non-ischemic distribution. Representative CMR images of a patient with checkpoint inhibitor myocarditis are displayed in Histology was available on 7 patients, and of these, 2 patients had confirmed myocarditis (both on autopsy), 3 had inconclusive pathology (on biopsy), and 2 patients had negative pathology (on biopsy) for myocarditis. Six patients were diagnosed with concomitant pericarditis. Representative images of one patient with myopericarditis are displayed in Fourteen patients were treated for ICI myocarditis, and the most common treatment was steroids (100%). Other additional treatments included: infliximab (n = 3), IVIG (n = 1), mycophenolate mofetil (n = 1), tacrolimus (n = 1) and thymoglobulin (n = 1). Patients were categorized based on their clinical presentation into the following categories: treated clinical myocarditis/pericarditis (n = 14); subclinical, non-treated (n = 1); clinical, not treated (n = 3); and ischemic (n = 2). The decision to not treat those diagnosed with myocarditis was made by the treating physicians and patients in the context of their goals of care and as part of an overall risk versus benefit discussion. Of patients treated for checkpoint inhibitor myocarditis or pericarditis, 50% (n = 7) had improvement in LVEF with treatment. Of the 6 patients not treated for myocarditis, 2 had a normal LVEF at time of presentation, 3 had improvement in LVEF from abnormal to normal, and 1 did not have repeat imaging. There was no correlation between LVEF, GLS, GRS, GCS, LV volumes or % LGE and recovery of LVEF with treatment. Further, there was no correlation with presence of increased T2W signal, atrial strain, or atrial volumes and recovery of LVEF. The median follow-up time was 24 months (IQR 17–29 months), and vital status was definitively available on 17 patients. Of those, eleven patients were confirmed deceased, and of these, 4 died of cardiac causes, 6 died of cancer progression, and 1 died of multi-organ system failure due to influenza. Of the four patients who died of cardiac causes, three were treated for ICI cardiotoxicity.To our knowledge, our study is the first to evaluate CMR strain, quantitative LGE, and T2-ratios in patients with ICI-associated cardiotoxicity. In this study of twenty patients with comprehensive CMR evaluation for ICI cardiotoxicity, abnormalities by CMR were detected in both patients with a depressed and with a normal LVEF, highlighting the importance of CMR for diagnosing cardiotoxicity. Specifically, in patients with a normal LVEF (≥53%), GLS was reduced at −12.1% (IQR −10.8− −12.9%) and tissue characterization (T2-ratios and quantitative LGE) was frequently abnormal.This study also demonstrated that clinical presentation, including time to presentation and presenting symptom, is variable, as has been shown in other studies . The diaWe found that strain parameters correlated well with LV function; however, even in patients with normal LVEF, strain imaging was abnormal. There is some variability, due to method and software used, in normal values for CMR strain using FT . Howevers = −0.29, p = 0.22) or GLS , but showed a modest trend in correlation with troponin . This is contrary to a previous study which showed that quantitative LGE had a significant, albeit weak, inverse correlation with LVEF in acute myocarditis [s = −0.29, p = 0.25). These findings are important, as LVEF, particularly by echocardiogram, is used as a screening tool for diagnosis of myocarditis. LVEF alone may miss more subtle tissue abnormalities that precede overt cardiac dysfunction. Overall, almost half of the patients in our study met full criteria for acute myocarditis based on the Updated Lake Louise Criteria, and 85% met one main criterion, which is supportive of the diagnosis of acute myocarditis in the correct clinical context [Late gadolinium enhancement and abnormal T2W imaging are established criteria for the diagnosis of myocarditis by CMR , 8. Furtcarditis . It is pRegarding the pattern of LGE, we found that most patients had a non-ischemic distribution, but two patients were diagnosed with ischemic disease based on pattern of LGE. One of these patients had diffuse increase in T2 ratio outside of the area of the ischemic pattern LGE, suggestive of myocarditis and prior infarct. The second patient clearly had acute infarct as with concomitant increased T2 signal mostly within the area of LGE and subtle patchy increased signal outside of the area of infarct. Neither of these patients were given a diagnosis of definite myocarditis by CMR in our study, due to the presence of ischemic LGE. Acute coronary plaque rupture  and non-We also found that RV insertion site LGE was common. Right ventricular insertion site LGE can be seen in other non-ischemic cardiomyopathies (NICM), and is frequently seen in patients with hypertrophic cardiomyopathy , and an One patient with myocardial tumor infiltration from metastatic disease did demonstrate evidence of myocardial inflammation by T2W mapping, positive LGE, and positive troponins  on the majority of patients. This is in concordance with contemporary clinic practice, where a non-invasive assessment and diagnosis of myocarditis is most often initially pursued in lieu of EMB, as discussed by Friedrich MG specifically in the context of ICI associated myocarditis . FurtherLastly, while we cannot exclude prior chemotherapy as a contributing factor to the abnormalities in tissue characterization, all patients had no known cardiac dysfunction prior to ICI therapy. However, the lack of routine baseline cardiac function assessment and monitoring in this cohort is a limitation to our study.In this study, we performed a comprehensive CMR evaluation of patients with ICI cardiotoxicity and demonstrated the value of LV strain and tissue characterization for diagnosis. Importantly, patients with a normal LVEF demonstrated abnormal left ventricular strain, increased T2W signal, and abnormal LGE imaging. ICI cardiotoxicity requires a high level of suspicion and CMR is a sensitive tool to detect changes in myocardial tissue and function. The utilization of CMR for detection of ICI cardiotoxicity should be considered when making this challenging diagnosis in clinical practice, even in the setting of preserved LV systolic function on echocardiography. Future prospective CMR studies would be of value in this patient population and should include quantitative techniques, such as strain analysis and parametric mapping techniques, for sensitive detection of ICI cardiotoxicity.S1 Table(DOCX)Click here for additional data file.S2 Table(PDF)Click here for additional data file.


Therapeutic hypothermia has been used for treating brain injury after out-of-hospital cardiac arrest. Its potential benefit on minimizing myocardial ischemic injury has been explored, but clinical evidence has yet to confirm positive results in preclinical studies. Importantly, therapeutic hypothermia for myocardial infarction is unique in that it can be initiated prior to reperfusion, in contrast to its application for brain injury in resuscitated cardiac arrest patients. Recent advance in cooling technology allows more rapid cooling of the heart than ever and new clinical trials are designed to examine the efficacy of rapid therapeutic hypothermia for myocardial infarction. In this review, we summarize current knowledge regarding the effect of hypothermia on normal and ischemic hearts and discuss issues to be solved in order to realize its clinical application for treating acute myocardial infarction. The impact of temperature on human biology has been researched extensively and a number of experimental studies have shown that lowering body temperature is capable of protecting tissues from injury –7. To taA decrease in heart rate is the most consistently reported electrophysiological change associated with TH in both normal and ischemic hearts –15. In aThe J wave is a characteristic ECG change found in some hypothermic patients. Up to 30% of patients after OHCA presented with J waves during TH and its prevalence was found to be higher in patients with STEMI . In caseP = 0.07)  trial, TH was not associated with the incidence of atrial fibrillation in patients with new-onset STEMI  compared to the control group  . Using n = 0.07)  found thet STEMI . Combineet STEMI . Within et STEMI , 24, a fet STEMI . Taken tet STEMI , carefulex vivo studies reproducibly showed that hypothermia increased cardiac contractility  and alleviate ischemia progression. TH can also affect cardiac metabolism. Whole body metabolism and oxygen consumption decrease substantially as the temperature decreases . The relIn vitro studies using cardiomyocyte cell lines indicate that apoptosis of these cells at reperfusion following oxygen/energy deprivation is suppressed by TH  and control (n = 26)  . The stu(n = 26) . In a re(n = 26) . The aut03447834  accessed03447834 , 104, wh03447834 , 98, 10603447834  combined03361995  accessedAlthough blood temperature is expected to correlate with cardiac temperature, direct monitoring of ischemic myocardial temperature in STEMI setting is challenging. Moreover, cooling speed of the heart and other organs varies depending on the employed method . TherefoAvailable evidence suggests that TH has the potential to reduce myocardial ischemic injury in humans. However, randomized clinical trials have yet to prove promising results in preclinical studies. Compared to the large number of studies focusing on TH for post-resuscitation brain injury or myocardial protection for surgery, that of alleviating myocardial reperfusion injury remains much less. Accordingly, there remain many questions that are only vaguely answered. These include: (1) Optimal target temperature for STEMI application; (2) Optimal TH method; (3) Whether target temperature needs to be achieved prior to reperfusion; (4) Optimal duration of hypothermia; (5) Mechanisms of myocardial protection; (6) Optimal target patient population; and (7) Optimal protocol for rewarming. Emergence of new devices that allow faster cooling may help to better define some of these questions and lead to positive results in forthcoming clinical trials.KI drafted the manuscript. All other authors critically edited the manuscript and provided key information on this review article. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Left ventricular systolic function evaluation has always been one of the main attributions of echocardiography. The degree of ventricular systolic dysfunction is an important predictor of outcome for a large number of diseases, including ischemic heart disease, cardiomyopathy, valvular heart disease, and congenital heart disease. In this area, the ejection fraction has been sovereign for many decades, but despite being a parameter that can, in most cases, inform the real state of global ventricular function, in many situations it may be normal in the presence of evident systolic or diastolic dysfunction.Known clinical examples are the several cases of heart failure with preserved ejection fraction (HFpEF) or patients with hypertrophic cardiomyopathy, among others. For this reason, an index that can identify early ventricular dysfunction that is not connected with the ejection fraction has been sought for a long time.2 In 2004, we had already demonstrated the presence of incipient systolic dysfunction in patients with the indeterminate form of Chagas disease using this technique.3 Later, in 2006, the speckle tracking technique appeared, which quantifies myocardial deformation by two-dimensional echo and does not depend on the insonation angle (a limitation of the prior technique).4This technique has advanced to the present day and allows measuring the longitudinal, radial and circumferential deformation of the several myocardial segments (strain). The mean value of the percentage of longitudinal deformation of each segment is what we call the global longitudinal strain (GLS) and this index has shown to be an excellent parameter for systolic function evaluation, which is sensitive enough to detect incipient impairment when the ejection fraction is still normal and has a higher prognostic value than EF in many clinical situations.7Myocardial deformation evaluation by echocardiography emerged with the strain and strain rate techniques, still derived from tissue Doppler, which was developed at the Norwegian University of Science and Technology in Trondheim, Norway, approximately twenty years ago.8 It was observed that GLS values were significantly lower in infected individuals than in control ones, regardless of whether or not they were undergoing treatment. All of them had normal ejection fraction and the only group with abnormal GLS (less than -18%) was that of infected individuals without treatment. Their findings demonstrate the high sensitivity of this echocardiographic parameter in detecting incipient systolic dysfunction, which leads us to think that treatment must decrease myocardial aggression by the virus. Early systolic dysfunction was also found by Mendes et al.,9 in a similar group.In this issue of the Brazilian Archives of Cardiology, Dr. Ronaldo Campos Rodrigues presents us with an excellent work, in which left ventricular systolic function was assessed by quantifying GLS in HIV-positive patients, with and without antiretroviral therapy, compared with a control group.These and other studies point to a paradigm shift in the study of ventricular function. I believe that soon, cardiologists will not be satisfied with the value of the ejection fraction alone but will also require the value of GLS for a deeper and more accurate assessment of ventricular systolic function.


In HFrEF patients, despite a long history of the disease, the introduction of sacubitril/valsartan provides a rapid global  RR in >25% of cases, both at standard and advanced echocardiographic evaluations.Sacubitril/valsartan reduces mortality in heart failure with reduced ejection fraction (HFrEF) patients, partially due to cardiac reverse remodeling (RR). Little is known about the RR rate in long-lasting HFrEF and the evolution of advanced echocardiographic parameters, despite their known prognostic impact in this setting. We sought to evaluate the rates of left ventricle (LV) and left atrial (LA) RR through standard and advanced echocardiographic imaging in a cohort of HFrEF patients, after the introduction of sacubitril/valsartan. A multi-parametric standard and advanced echocardiographic evaluation was performed at the moment of introduction of sacubitril/valsartan and at 3 to 18 months subsequent follow-up. LVRR was defined as an increase in the LV ejection fraction ≥10 points associated with a decrease ≥10% in indexed LV end-diastolic diameter; LARR was defined as a decrease >15% in the left atrium end-systolic volume. We analyzed 77 patients  with 76 (28–165) months since HFrEF diagnosis. After a median follow-up of 9 (interquartile range 6–14) months from the beginning of sacubitril/valsartan, LVRR occurred in 20 patients (26%) and LARR in 33 patients (43%). Moreover, left ventricular global longitudinal strain (LVGLS) improved from −8.3 ± 4% to −12 ± 4.7% ( Cardiac adverse remodeling is associated with poor outcome in patients affected by heart failure with reduced ejection fraction (HFrEF) ,2. It isRecently, sacubitril/valsartan has been shown to reduce cardiovascular mortality and hospitalizations in HFrEF patients compared to enalapril and also to decrease ventricular arrhythmias and appropriate implantable cardioverter defibrillator (ICD) shocks ,8. Howev1)Diagnosis of symptomatic HFrEF (<40%) despite OMT according to ESC guidelines .2)Availability of a follow-up evaluation at 3 to 18 months including a multi-parametric echocardiographic evaluation. Considering the observational character of our study, the timing of the follow-up evaluation was established by the physician who followed the patient. In case of two echocardiographic evaluations during the follow-up period the last one was considered.3)Absence of cardiac resynchronization therapy during the study observation and within 12 months before the enrolment From January 2016 to January 2018 we prospectively enrolled HFrEF patients under optimal medical therapy (OMT) who started sacubitril/valsartan at Heart Failure Clinic of the University Hospital of Trieste. Inclusion criteria were:The up-titration of the sacubitril/valsartan dosage was performed every two weeks, if tolerated. Changes in doses of other medications were allowed when appropriate. In order to standardize the doses of ACE-i and antagonist of angiotensin receptors (ARB) the following conversion were adopted: Enalapril 40 mg = Ramipril 10 mg, Losartan 100 mg = Ramipril 10 mg. About beta blockers the following conversion were adopted: Carvedilol 50 mg = Bisoprolol 10 mg, Metoprolol 200 mg = Bisoprolol 10 mg.Echocardiographic studies were performed in left lateral decubitus position using iE33 xMATRIX , Vivid E9 or Vivid E95 imaging devices . Data were digitally stored and analyzed offline using a vendor-independent software . All images were acquired at a frame rate of at least 50 frames/sec.Echocardiographic analysis was performed by operators blinded to other patient’s details.Left ventricular (LV) dimensions and function were assessed according to the international guidelines .In particular, LV volumes and LVEF were calculated by Simpson’s biplane method. Left atrium (LA) parameters were obtained from an optimized apical four-chamber view, avoiding foreshortening of the atrium. LA volumes were determined using the area-length method. Total LA emptying fraction (TLAEF) was calculated as /maximal LA volume X 100%).Diastolic function was evaluated according to international guidelines . In partFor speckle tracking analysis, endocardial borders of LV and LA were traced using a chamber-specific tool. End-diastole and end-systole were defined by both ECG and visual assessment of 2D images. The software  automatically tracked speckles along the endocardial border of each chamber throughout the cardiac cycle providing the left ventricular global longitudinal strain (LVGLS) and the peak atrial longitudinal strain (PALS). All measurements were obtained from the mean of 3 beats (patients in sinus rhythm) or 5 beats ).2) at follow-up evaluation [LVRR was defined as an increase in the LVEF ≥ 10% (or LVEF > 50%) associated with a decrease ≥10% in indexed left ventricular end-diastolic diameter (LVEDD) or . Unpaired and paired Student’s p values are two sided and were considered significant when <0.05.Univariable and subsequent possible multivariable logistic regression modelling was performed to assess the effect of the clinical variables LVRR. Intra and Inter observer variability was determined by the ICC (Intraclass Correlation Coefficient) computed respectively on the repeated measurements at 2 different times by 1 experienced reader (M.C.) in 23 randomly selected patients. Then, a second experienced reader (V.N.) performed the analysis in the same 23 patients, providing the interobserver measurements data. This allowed us to achieve 80% power to detect an ICC of 0.80 under the null hypothesis of ICC = 0.50, by using an F-test at a significance level of 0.05 .The agreement between measures for the assessment of LV and LA strain were further explored using Bland-Altman analysis. .All the analyses were performed using IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY, USA: IBM Corp.During the study period a total of 101 patients were enrolled. Among them, 7 patients discontinued the drug due to side effects, 15 were excluded because poor acoustic echocardiographic windows and finally 2 underwent cardiac resynchronization device implantation. Finally, the study population was composed of 77 HFrEF patients with a mean duration of heart failure of 76 (28–165) months. The main characteristics of the patients are described in 2, left ventricular end-diastolic volume indexed (LVEDVi) 101 ± 36 mL/m2, left atrial end-systolic volume (LAESV) 110 ± 50 mL. LVGLS and PALS were compromised consistently with the chambers remodelling .At baseline, a conspicuous cardiac remodeling was present: mean LVEF was 28 ± 6%, LVEDDi 34 ± 5 mm/mAfter a median follow up of 9 (6–14) months from sacubitril/valsartan introduction, no patient died or experienced any other relevant clinical event. In total, 47% of the population was taking the highest dose of sacubitril/valsartan, 40% the intermediate dose and 13% the lowest dose . No signp < 0.001). Furthermore, a significant cardiac reverse remodelling emerged: 20 patients (26%) showed a LVRR and 33 (43%) a LARR. At clinical-echocardiographic follow-up evaluation, there was a significant improvement of the mean functional status , LVEF increased 28 ± 6% to 35 ± 10% (p < 0.001). Regarding LA, LEASVi dropped from 57 ± 26 to 48 ± 21 mL/m2 (p < 0.001). Concerning advanced echocardiographic parameters, LVGLS improved from −8.3 ± 4% to −12 ± 4.7% (p < 0.001). Similarly, TLAEF increased from 28.2 ± 14.2% to 32.6 ± 13.6% (p = 0.013) and PALS from −10.3 ± 6.9% to -13.7 ± 7.6% (p < 0.001), , .p = 0.01). Therefore, a multivariable analysis was not performed.At univariable analysis , only thThis is the first report to consider a comprehensive evaluation of LV and LA using both advanced and standard echocardiographic parameters in this setting, documenting that the improvement of both variables was consistent and conferring value to advanced echocardiographyFurthermore, to the best of our knowledge, no previous study reported the proportion of patients reaching LVRR and LARR according to accepted definitions ,10Finally, the results provided by our study are of particular interest considering the rapid effect showed by sacubitril/valsartan both on LVRR and on LARR despite the long-lasting diseased patients includedRecently, there is an increasing body of data about the effect of Sacubitril/Valsartan on LVRR. In this filed, our analysis adds important elements of novelty, possibly useful in the management of HFrEF patients:The findings of the Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor with an Angiotensin Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM HF) trial have been revolutionary for HFrEF management . Indeed,Recently, sacubitril/valsartan has been shown to cause a cardiac RR on the top of OMT , which cIn this scenario, our experience adds meaningful findings to the current literature. To the best of our knowledge, this is the first study which considers a multi-parametric standard and advanced echocardiographic assessment demonstrating a global cardiac further RR  induced by sacubitril/valsartan on the top of OMT. Importantly, RR was demonstrated in >25% of patients and the effect of sacubitril/valsartan was quite rapid , despite a mean long-lasting HFrEF under OMT . These results claim for a confirmation in larger populations because they raise possible important clinical implications in the management of HFrEF patients, such as a more precise definition of the best timing for switching from ACE-i to sacubitril/valsartan.We found LVRR in 26% and LARR in 43% of patients, after switching to sacubitril/valsartan. It is important to remark that the positive cardiac RR was likely to be totally due to sacubitril/valsartan, considering that patients undergoing cardiac resynchronization therapy during the study observation were excluded and the remaining HF medications did not significantly change during the follow-up period. Interestingly, it is possible that these results are even underestimated. Indeed, in previous experiences, a LVRR induced by optimal medical therapy has been described from 12 to 24 months of OMT , whilst Concerning advanced echocardiographic evaluation, LVGLS, PALS and TLAEF showed a parallel significant improvement to traditional LV and LA functional parameters. In other settings, LVGLS has been reported to show earlier changes in the LV function compared to LVEF . It mighTo the best of our knowledge, the results on PALS and TLAEF are completely new and need further confirmation. However, they should be part of LA assessment, that could be strongly useful for the early detection of RR under therapy in HFrEF patients.Interestingly, the only parameter negatively associated to the LVRR was a long-standing history of HFrEF . It appears clear that a long-standing disease already in OMT might be less responsive to switching therapy because of a more consolidated and irreversible adverse cardiac remodeling. Nonetheless, it is noteworthy that patients with a duration of symptoms and OMT longer than 48 months, still exhibited LVRR adding sacubitril/valsartan on top of OMT, highlighting the great potential of the drug.On the other hand, in our population we did not found any factor associated with LARR after beginning therapy with sacubitril/valsartan .Finally, important considerations on ICD implantation in primary prevention could be raised from the present results. The significant effect of sacubitril/valsartan on all the considered parameters evaluated in this study, also in long-standing diseases, could be consistent with a demonstrated decreased burden of ventricular arrhythmias and ICD appropriate interventions induced by the drug ,22. It eSome limitations need to be acknowledged. This is not a randomized study, neither we had a matched control population available. We considered a relatively small population, although no previous reports are available on global cardiac RR by standard and advanced echocardiographic evaluation in larger samples. Furthermore, in our analysis follow-up LVEF and GLS evaluations were performed at the same time. In future experiences, it would be definitely important to explore if speckle tracking analysis might allow an earlier detection of LVRR compared to standard echocardiographic evaluation. Finally, we did not have available cardiac magnetic resonance data in our patients while this method can be useful to more precisely characterize the myocardial tissue and to investigate the effect of the drug also on the LV fibrosis. Moreover, sample plasmatic heart failure biomarkers concentrations were not systematically available for many patients.In conclusion, when applied to daily clinical practice, our study highlights the usefulness of the switching to sacubitril/valsartan in stable HFrEF, despite long-standing diseases. In fact, consistent rates of LARR and LVRR, both at standard and advanced echocardiographic evaluation, could be observed.