Reversible left ventricular dysfunction, also termed Takotsubo cardiomyopathy, is rarely reported in Addison’s disease after initiation of hormone replacement therapy. The pathogenesis of this cardiomyopathy is unknown.A 41-year-old white woman with a history of autoimmune Hashimoto thyroiditis diagnosed 3 years earlier and acute adrenal insufficiency diagnosed 3 weeks earlier presented with new onset of heart failure New York Heart Association class IV, which had started shortly after initiation of hormone replacement therapy with hydrocortisone 20 mg/day and fludrocortisone 0.3 mg/day. Nine days before admission she had collapsed because of dizziness and had a cerebral concussion and open fracture of her nasal bone, however, no further investigations were carried out at that time.5 and V6 and a corrected QT interval of 590 ms. Echocardiography revealed a reduced left ventricular systolic function with an ejection fraction of 30 %, and septal, apical, and anterior wall akinesia. Cardiac magnetic resonance imaging showed relative enhancement of gadolinium, indicating hyperemia and capillary leakage, and no myocardial scars. Because of the improvement in her cardiac function, lack of cardiovascular risk factors, and lack of signs for ischemia on magnetic resonance imaging, no coronary angiography was carried out. The results of sellar and renal magnetic resonance imaging were normal. Her troponin T was slightly elevated. Bisoprolol and ramipril were started. Her fludrocortisone dose was reduced to 0.05 mg/day. Her electrocardiogram and systolic function, documented by echocardiography and magnetic resonance imaging, normalized within 6 months.A physical examination revealed leg edema, tachycardia, tachypnea, bilateral basal crepitations, and blood pressure 110/70 mmHg. An electrocardiogram showed sinus tachycardia, low voltage, negative T-waves in VAlthough we could not exclude coronary artery disease by coronary angiography, her clinical course and instrumental findings suggest Takotsubo cardiomyopathy of the apical type. Fludrocortisone overdosage and increased myocardial vulnerability due to cortisol deficiency might be pathogenetic factors, whereas myocarditis is unlikely. When hormone replacement in patients with Addison’s disease is initiated, cardiac function should be monitored by electrocardiogram and echocardiography. Heart failure in Addison’s disease has been described mainly in older patients with ischemic, valvular, or hypertensive heart disease . ReversiA 41-year-old white woman presented in December 2014 to our cardiology department with new onset of heart failure New York Heart Association (NYHA) class IV. She reported that she had gained 8 kg weight in the last 4 weeks.She had a history of a surgically removed uncomplicated ovarian cyst 17 years ago. In 2011, autoimmune Hashimoto thyroiditis was diagnosed and substitution therapy with levothyroxine was started. In November 2014, she was hospitalized in another hospital because of generalized weakness, weight loss of 19 kg, and abdominal pain. Adrenal insufficiency was suspected and confirmed by a positive Synacthen test  of 590 ms , tachypnea of 30 breaths/minute, bilateral basal crepitations, and leg edema. Her oxygen saturation was 90 % at rest, without oxygen. An ECG revealed a sinus tachycardia, low voltage, negative T-waves in VTherapy with bisoprolol and ramipril, and furosemide administered intravenously was initiated. Her fludrocortisone dose was reduced to 0.05 mg/day. Under that therapy, her clinical condition improved, her BNP levels regressed Table , echocarIn our case, heart failure occurred 3 years after the diagnosis of thyroiditis, 3 weeks after the diagnosis of Addison’s disease and initiation of the hormonal therapy, and 9 days after her collapse, when her condition was slowly normalizing. According to previous reports and her history, there were no indications for preexisting cardiovascular disorders.The pathogenesis of reversible systolic dysfunction in Addison’s disease, resembling Takotsubo cardiomyopathy (TTC), is unknown. There are several speculations about the pathophysiologic mechanism of heart failure after initiation of hormone therapy in Addison’s disease. One speculation assumes that once mineralocorticoid replacement therapy is commenced, renal adaptation to chronic water and sodium loss leads to overshooting of water and sodium retention with ensuing heart failure . DevelopAlso without preexisting cardiovascular disease, mineralocorticoid overdose has been implicated in ventricular dysfunction in Addison’s disease Table  2, 4, 7, 74, 7. However, her clinical presentation was not compatible with pure volume overload. She showed ECG changes similar to those of myocardial ischemia, albeit the absence of cardiovascular risk factors, her clinical course, and her normal levels of creatine kinase with only slight elevations of troponin and no indications for myocardial ischemia on repeated cardiac MRIs virtually ruled out this possibility. The findings and her clinical course resemble apical TTC, characterized by symptoms and ECG signs of acute myocardial infarction, transient left ventricular dysfunction but without angiographic evidence of coronary stenosis . Since cRegarding the pathomechanism of TTC in Addison’s disease, there are only animal data available. Studies in adrenalectomized animals suggest that cardiac function may be markedly impaired when stress is superimposed, and increased catecholamine levels are toxic to a myocardium that is unprotected by glucocorticoids . GlucocoMyocarditis could be another explanation for the transient left ventricular dysfunction. However, neither history, nor blood tests, nor MRI were indicative of myocarditis . A furthThe reason for her collapse that occurred 9 days before her actual admission remains unclear. Since her serum potassium level was low at the actual admission Table , it can Limitations of the presented case are that no coronary angiography was carried out to establish the diagnosis of TTC and no myocardial biopsy was carried out to definitively exclude myocarditis, thus the case does not fulfill all the diagnostic requirements for TTC according to the Mayo Clinic diagnostic criteria . FurtherPatients with Addison’s disease should be monitored for cardiac abnormalities during therapy for acute adrenal insufficiency. If they develop symptoms suggestive for arrhythmia, their serum electrolytes should be measured and an ECG should be recorded. If they develop heart failure or left ventricular dysfunction, hormonal therapy should be considered to be a possible iatrogenic trigger.


Magnetic resonance imaging (MRI) is a useful non-invasive tool for evaluating abnormalities of intervertebral discs. However, there are few studies which applied functional MRI techniques to investigate degenerative changes in cervical and cervicothoracic junction (CTJ) spine among adults. The aim of this study was to compare T2 relaxation time measurement evaluation with morphological grading for assessing cervical and CTJ intervertebral discs (IVD) in the patients suffering neck, shoulder, and upper back pain.Sixty-three patients (378 IVDs) and 60 asymptomatic volunteers (360 IVDs) of the cervical and CTJ discs were assessed using a 3.0 T magnetic resonance imaging (MRI) protocol, including an sagittal T2 relaxation time protocol. The relaxation time values of the nucleus pulposus (NP) were recorded and all discs were visually graded according to Pfirrman’s grading system. The correlation between T2 relaxation time values and qualitative clinical grading of degeneration, patient age, sex and anatomic level were analyzedP < 0.05). However, grade V was not observed in the CTJ. Linear correlation analysis revealed a strong negative association between T2 values of the NP and Pfirrmann grade  of C2-7 and C7T1. Age were also significantly correlated NP T2 values  for patients and volunteers. Moreover, the receiver operating characteristic analysis for average measures in a range from 0.70-0.79 (C2-7) to 0.84-0.89 (C7T1) for patients.There is a clear trend of decreasing mean T2 values of the NP associate with increasing Pfirrmann grades (C2-T1) for both patients and asymptotic volunteers. Significant T2 differences were seen among grades I-V (T2 quantitation provides a more sensitive and robust approach for detecting and characterizing the early stage of IVD degeneration and age-associated disc changes.The online version of this article (doi:10.1186/s12880-017-0182-z) contains supplementary material, which is available to authorized users. Cervical intervertebral disc (IVD) degeneration changes range from 5% to 10% in people between the ages of 20 and 30 years, to more than 50% by 45 years of age. Approximately, 90% of men over the age of 50 and 90% of women over the age of 60 have radiographic evidence of cervical spondylosis [Magnetic resonance imaging (MRI) is a promising non-invasive examining tool for evaluating abnormalities of IVD. Age and degeneration can be reflected by signal variation of the discs on T2-weighted images (T2WIs), which allows for the determination of degree of disc degeneration . SpecifiRecently, several quantitative MRI techniques for evaluation of IVD have been used for evaluating disc degeneration –9. In paTherefore, the purpose of this study was to use the quantitative T2 relaxation time measurement of 3.0 T MRI to evaluate the degree of cervical and CTJ degenerative IVDs, comparing with Pfirrmann grading in a larger cohort of young-to-middle-aged patients with neck, shoulder, and upper back pain.The study was approved by the institutional review board of the First Affiliated Hospital, Wenzhou Medical University and all participants provided written informed consent prior to enrollment. This study involved 63 patients  and 60 asymptomatic volunteers  in our initial study, who accepted MRI scan of their cervical spine from C2 to T1. They were consecutively recruited and evaluated from September 2014 to May 2015. The subjects were excluded if they had diabetes mellitus, major systemic disease, serious illness , back surgery, spinal fractures, or osteoporosis. They consisted of patients with back pain and/or brachial plexus neuralgia. The following inclusion criteria was applied: the patients had significant neurological symptoms, which were defined as upper back pain for > 2 weeks and severe enough to require physician consultation or treatment, including neck or arm weakness, numbness, or tingling .A GE Signa HDx 3.0 T MRI machine  with a spine coil was used for MRI scanning. All MR images in this study were obtained in the afternoon to minimize the diurnal variation of T2 values in the IVDs . Sagitta2 to cover the NP using the software. All of data was measured by three times in order to reduce error. The exemplary Pfirrmann grades were shown in Fig. Evaluation of all morphological images were performed by two radiologists in consensus, one with more than 10 years of experience and a special interest in musculoskeletal radiology, and the other one with more than 20 years of experience in orthopedic radiology. Though challenging to appraise cervical or lumbar MRI , no obviThe intra- and interobserver variability of the ROI evaluation was assessed. Two central sagittal slices of T2 map were evaluated as already described. The evaluation was performed by two independent observers with different skill levels . In addition, observer A and B performed the same analysis twice, with an interval of one month, to test intraobserver agreement.k ≥ 0.7; moderate consistency, 0.7 ≥ k > 0.4; and weak consistency k ≤ 0.4. One-way ANOVA and Student Newman-Keuls test were used to detect the statistical differences of T2 values between different Pfirrmann grades. Additionally, Receiver operating characteristic (ROC) curves were plotted to test the sensitivity and specificity of T2 measures in assessment of Pfirrmann grade. Areas under the ROC curves were calculated. The statistical difference of T2 measures used to evaluate Pfirrmann grade was determined by U-test. All tests above were considered significant with P < 0.05.Statistical analysis and graph drawing were performed using SPSS 19.0 . Descriptive statistical data are given as mean ± standard deviation (Mean ± SD). To evaluate the reliability of Pfirrmann grading, intraobserver and interobserver agreements were graded through Kappa statistics. The degree of internal consistency was considered as: strong consistency, Tables k values ranging from 0.826 (p = 0.000) to 0.793 (P = 0.000), whereas the interobserver test produced k values of 0.757 (P = 0.000).Regarding the Pfirrmann grading reproducibility by the 2 readers, the intraobserver test yielded P < 0.01, Table r = −0.588; P = 0.000; r = −0.808, P = 0.000) of C2-7 and C7T1. Furthermore, significant correlation between age and T2 value of NP was demonstrated both in patient group  and volunteer group  . The overall mean value of T2 relaxation time of volunteer group was 59.65 ± 9.55 ms, which was significantly larger than its counterpart of patient group . Similarly, the mean value of T2 value of the 315 discs from patient group was significantly lower than that from volunteer group . At the same degeneration grade, the T2 values of patients were relatively smaller comparing to the T2 values of volunteers. As shown in table 4, the significant differences of sensitivity, specificity, area under the ROC curve (AUC) and T2 cut-off value between different Pfirrmann grades of C2-7 and C7T1, were demonstrated respectively (P < 0.05) by conducting U-test.The mean value of T2 relaxation time at different regions of each Pfirrmann grade are presented in table In this prospective study, we developed and investigated an MRI method, applicable for conventional 3.0 Tesla units, for sagittal T2 mapping of cervical and CTJ IVDs in symptomatic patients and asymptomatic volunteers and then compared against the Pfirrmann grades which can be used in a clinical set-up. The results of this study suggest that negative correlations between T2 values and disc degeneration grades. More important, the results indicate that the IVDD of CTJ exist, range from grade I to IV. To the best of our knowledge, the present study is the first who use asymptomatic volunteers and symptomatic population to investigate the correlation between T2 values and Pfirrmann changes in the inner portion of cervical IVDs. This study suggests that T2 relaxation time can be sensitive to early degenerative changes in cervical IVDD.MRI is commonly used in the clinical setting for examination of the degeneration of bone, cartilage and other tissues , 13, 14.Most previous studies emphasized T2 changes in the lumbar IVDD without consideration of cervical and CTJ . Only ouA degeneration IVD can also occur in CTJ. Strictly speaking, CTJ should contain the C7 vertebra, the disc between C7 and T1, and attachment of ligaments . C7T1 diSome previous studies showed no significant difference in T2 values between grade IV and V , 13 of lIt is important to realize that the correlation coefficients of T2 values of NP referring to grades and T2 values obtained in this study range between moderate and strong. This might be attributed to the relative large sample size. Moreover, the results also explained that the T2 value in the IVD is known to be sensitive to the composition of the collagen network structure and water content. Previous study reported that the T2 values are influenced by both rotational and translational motion which result in dipole-dipole interaction of water molecules in the collagen matrix .Sekhon et al. confirmed a good to excellent correlation of T2 values, water content and PG content in IVD tissue . MoreoveThe T2 maps can be generated and measured immediately after MRI scan, and the ROI analysis takes about 3 min for each patient. Moreover, an automated segmentation of the IVDs may facilitate acquiring promising initial data attribute to ongoing efforts in the future. Therefore, quantitative information reflecting the biochemical composition of IVDs can be provided without extensive increase in time.ROC between each grade of the NP generated cut-off values obtaining from area under the curve (AUC) values for disc degeneration quantification via T2 SI. In this study, it was in consistent with previous study , 13 thatNaturally, this study has some limitations. Firstly, the major limitation of our study is no histological or biochemical analysis of IVDs performing. Secondly, partial volume effects still existed attributing to subjectivity and bias of ROIs selection. Thirdly, we did not compare some other imaging techniques such as T1p, T2*(star) or ADC and so on to results of T2 relaxation time , 30, 31,In summary, our results proved a negative correlation between T2 values of cervical and CTJ IVDs and the Pfirrmann grades regarding IVDD. What should be highlighted is that we proposed the distinct cut-off values of the classification based on quantitative evaluation. Thus, the T2 value-based measurements of IVD water content and PG may be useful for estimating cervical and CTJ degenerative disc diseases.


Many non-invasive methods, such as imaging tests, have been developed aiming toadd a contribution to existing studies in estimating patients’ prognosis aftermyocardial injury. This prognosis is proportional to myocardial viability, whichis evaluated in coronary artery disease and left ventricular dysfunctionpatients only.While myocardial viability represents the likelihood of a dysfunctional muscle(resulting from decreased oxygen supply for coronary artery obstruction),hibernation represents post-interventional functional recovery itself.This article proposes a review of pathophysiological basis of viability,diagnostic methods, prognosis and future perspectives of myocardial viability.An electronic bibliographic search for articles was performed in PubMed, Lilacs,Cochrane and Scielo databases, according to pre-established criteria.The studies showed the ability of many imaging techniques in detecting viabletissues in dysfunctional areas of left ventricle resulting from coronary arteryinjuries. These techniques can identify patients who may benefit from myocardialrevascularization and indicate the most appropriate treatment. Thesetests highlight the importance of a correct evaluation of this condition for anappropriate risk stratification and selection of patients considered eligible formyocardial revascularization. Since cardiac function is not a dichotomous variable,some of its aspects measured by imaging techniques may not be measurable by anothermethod. Useful parameters to guide therapeutic strategies include ejection fraction,scar size, ischemia and remodeling extension, as well as duration of cardiacdysfunction.3 showed higher values for these variables, which wereanalyzed in combination, providing a more reliable characterization of myocardialfunction. However, due to the lack of larger studies, imaging tests based onmultimodal approach are not recommended yet. It is worth pointing out that eventhough the presence of a viable myocardium in a large heart area is important forrevascularization, the decision for this procedure should be based on patient’sclinical status, evidence of ischemia, coronary anatomy and left ventricular globaland regional function.4Using a multimodal approach of viability, a pilot study5 This isparticularly important in cases when myocardial revascularization is considered, dueto high mortality rate and perioperative morbidity in these patients.6Determination of myocardial viability is a common and clinically relevant challenge,that may be necessary in post-infarction patients receiving thrombolytic therapy.Also, it may be helpful for surgeons and cardiologists in choosing the best therapyfrom interventionist strategy, angioplasty and myocardialrevascularization.7In viability studies, while nuclear medicine techniques have high sensitivity, thetechniques used to evaluate contractile reserve have higher specificity. Imagingmethods, such as computed tomography (CT), positron-emission tomography (PET),myocardial scintigraphy, echocardiography with dobutamine and cardiac magneticresonance (CMR) have been exhaustively investigated in attempt to establish the bestmethod for myocardial study.8  and myocardial dysfunction. Annual mortality rate in thegroup of patients with myocardial viability and in drug treatment was 16%, incontrast with 3.2% in the group that underwent revascularization.11In CAD patients, left ventricular dysfunction may be caused by areas of viablemyocardium and fibrotic areas combined. Assessment of cardiac muscle usingimaging methods enables the localization, quantification of viability indysfunctional myocardium and possibility of anatomical revascularization, whichis essential for treatment planning of these patients.This article proposes a review of pathophysiological bases of myocardialviability, diagnostic methods available, prognosis and risk for this condition.A bibliographic search was performed on the electronic databases PubMed, Lilacs,Cochrane and Scielo, based on pre-established criteria.To achieve the objectives and results proposed, a descriptive review of scientificliterature was conducted of studies on diagnostic accuracy of imaging tests used forthe measurement of myocardial viability. We included both studies showing thesuperiority of certain method and those comparing the efficacy of the methods fromthe perspective of other authors.Types of study: as “review articles”, we included studies aimed to demonstratethe efficacy of imaging tests in measuring myocardial viability afterischemia.Population: heart disease patients with history of myocardial infarction.Studies that did not provide a detailed description of the protocols of thediagnostic methods or of data statistical analysis, and studies that did notmeet the inclusion criteria were excluded.PubMed/MEDLINE: North-American database, one of the largest inhealth, with no limits of date.The following descriptors were used for the search on Pubmed: Myocardialviability; PET; CT; SPECT; Resonance Magnetic myocardial;Echocardiography.LILACS: database that integrates the BIREME system and includesseveral scientific journals, dissertations and books.The following terms were used: Myocardial Viability ANS viabilitystudies.COCHRANE: database focused on systemic reviews. The terms used inthis database were: Myocardial viability.20 with lowincidence of significant events21 .22 Thismethod has favorable sensitivity (77-89%) and specificity (68-93%) not onlyin the post-infarction phase,24 but alsoin the chronic phase , as shown by Marzullo etal.25The use of dobutamine stress echocardiography for detection of myocardialviability is an efficient and safe method in both acute and chronic phasesof CAD,99mTc-Sestamibi is a widely available method for assessment ofmyocardial viability. The use of nitrates enables the improvement of bloodflow in narrowed and collateral vessels, responsible for irrigation ofhypoperfused areas, which potentiates the ability of the method to detectviable tissues, especially when combined with99mTc-Sestamibi.11 This is assured by the fact that both absorptionand retention of sestamibi depend on perfusion, cell membrane integrity andmembrane potential , which hence constitute themarkers of viable tissue.27 SchinkelAF et al.28 reported a 81%sensitivity and 69% specificity of nitrate-enhanced99mTc-Sestamibi scintigraphy to detect viability, which is lowerthan those reported with the use of PET-18F-FDG.28 In 99mTc-Sestamibi in the detection of myocardial fibrosis andviability.Myocardial perfusion scintigraphy using nitrate-augmented99mTc-Sestamibi scintigraphy,two patterns of images are commonly obtained: rest images andnitrate-enhanced images. Reversibility of the lesion (by filling) isindicative of viability. Sciagra et al.29 studied 105 patients with chronic CAD and leftventricular dysfunction who underwent baseline-nitrate sestamibi perfusionimaging and showed that the most powerful prognostic predictors of eventswere the number of nonrevascularized dysfunctional areas with viability insestamibi imaging29 , which is the hallmark of myocardial viability.35In fasting conditions, myocardium uses preferentially free fatty acids as energysource, whereas in post-prandial phase, its metabolism is shifted to glucose(with increased levels of circulating insulin).18F-FDG has meansensitivity of 92% and specificity of 63% in assessing the likelihood offunctional improvement of the muscle in the after revascularization. Manystudies have used comparative data of perfusion and 18F-FDG uptake,defining myocardial viability as hypoperfused areas with preserved glucosemetabolism.34 (PET with olism.34 .18F-FDG. Left ventricular ejection fraction (LVEF) improves from 37%to 47%  in patients with myocardial viability detected by18F-FDG PET after revascularization. In patients without viablemyocardium, LVEF remained almost unchanged (39% x 40%).39Overall improvement of left ventricle may also be evaluated by42CT is the most recent and widely used method for coronary angiography. Threetechniques are currently used for cardiac CT - coronary angiography, CT withiodinated and non-contrast CT - and all of them can provide information onmyocardial viability.42CT coronary angiography has high negative predictive value (> 95%) inexcluding epicardial CAD, with increasing role in the assessment of chest pain.It may also provide valuable information in the evaluation of patients with leftventricular systolic dysfunction, with suspected congenital heart disease orcoronary anomaly.42Delayed enhancement CT uses a similar principle to gadolinium-based magneticresonance (MR) imaging for imaging studies of myocardial scarring. In CT, theuse of iodinated contrast causes an increase in Hounsfield units in contrastedtissues, due to attenuation of X-rays, allowing the visualization of cardiacmuscle in the early arterial phase, and discrimination of macro andmicrovascular obstruction. When evaluated 5-10 minutes after injection ofiodinated contrast and increased enhancement, the obstruction is suggestive ofinfarction, due to extracellular contrast accumulation.42Finally, non-contrast CT can reveal calcified aneurysms in the left ventricle,for showing similar images to those obtained during attenuation correction scansor calcium scoring.43Some advantages of cardiac CT include the possibility of being performed incombination with coronary CT, requiring only the addition of some minutes to theangiography protocol; its high spatial resolution, being of great importance inevaluation of small infarctions; near-isotropic resolution and reliable 3D datareconstruction for the small slide thickness; possibility of inclusion ofpatients with pacemakers and other metallic devices. As disadvantages, we canmention the necessity of higher radioactive emission for acquisition ofadditional images following coronary images, and poorer localization ability andtransmurality as compared with CMR.26 and has played an importantrole in the clinical practice. It has also been considered a gold standardmethod in the assessment of left ventricular function. MR allows assessment ofleft ventricular dysfunction associated with chronic ischemic disease byevaluation of contractile reserve using dobutamine at low dose and, mostimportantly, evaluation of fibrosis by late gadolinium enhancement. In ametanalysis, Romero et al.44concluded that MR with low-dose dobutamine has high sensitivity and specificity, whereas late gadolinium enhancement MR has 95%sensitivity and 51% specificity, and high accuracy in determining someparameters, including ejection fraction, left ventricular volume, regional wallmotion, and myocardial thickness.46 Leftventricular wall thickness at end diastole is important to excludeviability.MR is a highly efficient method for myocardial viability study47The most notable characteristic of MR is its high spatial resolution, and, forthis reason, the method stands out for its high imaging quality and capacity todiagnose ischemic areas that would not be detectable by other methods. MR mayalso be particularly useful in the assessment of myocardial blood flow at restin hibernating areas of narrowed coronary artery and improvement of localmyocardial contractility after coronary revascularization.48 Gadolinium has a low risk of nephrotoxicity, except forpatients with end-stage renal disease, in which the risk of systemic toxicity isreal. Although chelated-gadolinium compounds are distributed in theextracellular space, and do not penetrate in intact cells, they may accumulatein myocytes with ruptured cell membrane  andfibrotic areas10 Tc-Sestamibi, and observed that thenumber of these segments was significantly greater than those showing acontractile response to dobutamine. Hence, due to its greater accessibility,echocardiography may be the method of choice in the screening for the presenceof viability, and in a second line of investigation, a nuclear method could beused.56For practical purposes, the most appropriate methods for viability assessment arethose in which the clinician or the institution have the highest experience.Echocardiography with dobutamine has, in general, high positive predictivevalue, and thus, is relatively more specific whereas nuclear medicine techniquesare more sensitive to diagnosis, with a significative negative predictive value,as can be seen in the study by Panza et al.,(99m)Tc-Sestamibi has been used as an alternative to201Tálio for its higher quality combined with lower exposureto radiation. In cases when (99m)Tc-Sestamibi imaging are notconclusive, or when greater viability is still clinically possible, the use of201Tálio is indicated for its higher detection rate,especially in severe hypoperfusion areas.2518F-FDG PET, for its higher sensitivity in detecting dysfunctional,but viable, myocardium. Although a sensitivity of 93% was shown for thistechnique in a metanalysis,35other authors reported a lower specificity (58%).59An excellent method for assessment of hibernating myocardium is201Táliorest-redistribution showed an agreement of 83% and 75%, respectively.60 Klein et al.51 showed a good agreementbetween contrast MR and 18F-FDG PET; in patients with CAD and severely reduced LVEF, MRimaging can identify fibrotic areas with results similar to those obtained byPET measurements, provided by comparison of flow and glucose metabolism. MR alsoprovides other parameters of tissue viability, such as wall thickness,contractile reserve and delayed enhancement.62With respect to MR and nuclear medicine techniques, comparison of contrast MRimaging, with dobutamine echocardiography and 41 may be an alternative test toMR for patients with pacemakers, implantable cardioverter defibrillator ormechanical cardiac valve. In addition, in comparison with CT, MR has higher contrast resolution for softtissues, without requiring radiation exposure. CT and PET66Observational studies have suggested that the presence of viable myocardium isdirectly associated with favorable progress of left ventricular function andgood prognosis after revascularization. Patients who seem to benefit more fromsurgical revascularization are those with ischemic symptoms and severe leftventricular dysfunction. A significant perioperative risk should be consideredin relation to long-term benefits on mortality.Today, there is little evidence of randomized studies on this theme, withconflicting results.67 In the myocardial viability study, 298 patients wererandomly allocated to receive conservative treatment plus surgicalrevascularization, and 303 patients to receive pharmacological therapy alone.Median follow-up period was 56 months (12 months - 100 months).67 No statistically significantbenefit of surgical intervention on mortality, or of assessment of myocardialviability on surgical intervention, suggesting that investigation of a viablemyocardium do not differentiate patients who would benefit fromrevascularization from those who would benefit from medical therapyalone.67Randomized, multicenter study involving 1,212 patients, 601 assessed formyocardial viability by dobutamine echocardiography (130 patients), SPECT (321patients) or both (150 patients).67Despite its limitations and biases, the STICH trial is, so far, the largest studyon the influence of myocardial viability on clinical outcomes in patients withischemic heart disease. Also, it is the first study to evaluate differentialresults of revascularization and pharmacological therapy.18F-FDG PET in patients withleft ventricular dysfunction, by risk stratification and identification of those whowould benefit from myocardial revascularization. A total of 430 patients with LVEF< 35% and CAD were allocated into two groups - standard care (n = 212) andtreatment assisted by 18F-FDG PET (n = 218).68Study designed to evaluate the efficacy of 68At one year, the PARR-2 trial did not show a significant difference between thegroups in the primary outcomes that included death for cardiac causes, acutemyocardial infarction or hospital stays for cardiac cause (30% vs. 36% p = 0.15). InPET group, however, there was a significant decrease in primary outcome over thefollow-up period .Myocardial viability is still a subject of clinical importance and a focus ofclinical trials and translational science. Pathophysiological basis of leftventricular ischemic dysfunction seems to be correlated with myocardialstunning, hibernation or myocardial necrosis. Imaging methods used forassessment of viable muscular tissue have their own operational characteristicsand should be appropriate to the patient’s individual characteristics. Thedetection of myocardial viability may be a valuable predictor of the response torevascularization and long-term prognostic and, thereby, contribute to thedecision-making in the medical practice.18F-FDG PET and CMR are considered first-choice methods for detectionof viability due to their high sensitivity and specificity rates, whereas bothechocardiography and myocardial scintigraphy considered acceptable methods fortheir wide availability and accessibility. With respect to the impact on medicalpractice, there are no definite studies showing the benefits of myocardialviability assessment on patients’ prognosis, which reinforce the necessity oflarger studies, considering the great relevance of the theme.


Fifteen patients drank coffee within 4 h of CMR (<4H caffeine group), and 10 patients had coffee the day before (>8H caffeine group). Comparison was made to patients without self-reported coffee intake: 50 with normal CMR (control group), 18 with myocardial ischemia, and 12 with myocardial infarction. The national review board approved the study; all patients gave written informed consent. The <4H caffeine group showed inverted ∆T1 of −7.8 % . The >8H caffeine group showed reduced T1 reactivity  compared to the controls , p < 0.0005. Ischemic and infarcted myocardium showed minimal T1 reactivity . Caffeine intake inverts the adenosine effect during stress perfusion CMR as measured by T1 mapping. T1 reactivity can assess the adequacy of adenosine-induced stress in perfusion CMR.Caffeine intake before adenosine stress myocardial perfusion imaging may cause false negative findings. We hypothesized that the antagonistic effect of caffeine can be measured by T1 relaxation times in rest and adenosine stress cardiac magnetic resonance imaging (CMR), as T1 mapping techniques are sensitive to changes in myocardial blood volume. We prospectively analyzed 105 consecutive patients with adenosine stress perfusion CMR on a 1.5-T MRI system. Rest and stress T1 mapping was performed using Modified Look-Locker Inversion recovery. T1 reactivity was defined as difference in T1 Myocardial stress perfusion cardio magnetic resonance (CMR) imaging is state of the art in the diagnosis of myocardial ischemia . AlthougNative (non-contrast) T1 mapping is a CMR technique used to quantify myocardial water content, closely related to MBV . Native All subjects gave written informed consent to participate in the study and the national ethical committee granted all study procedures. Between August and December 2015 we prospectively enrolled 172 consecutive patients referred for stress perfusion CMR because of suspicion of myocardial ischemia in our institution. All patients avoided potential adenosine agonists for at least 24 h before CMR, and all anti-anginal medication was stopped 4 days before the examination. Dypiridamole had to be stopped and, if not possible, was considered a contraindication. At arrival in the CMR facility patients were specifically interviewed on the use of coffee. Patients were excluded from analysis based on general CMR contraindications  and tech2; slice thickness 8 mm; acquisition matrix, 192 × 128; in plane spatial resolution, 1.4 × 1.4 mm2; bandwidth, 1085 Hz/pixel; flip angle, 35° and parallel imaging acceleration factor, 2. T1 maps were acquired at rest and during peak dose adenosine stress (140 µg/kg/min) in 3 short-axis slices . Stress-only perfusion imaging was performed as previously described, according to conventional methods [A 1.5T system  was used in all patients. After the standard cine images, an investigational Modified Look-Locker Inversion Recovery (MOLLI) based T1–mapping sequence (WIP780B) was performed at rest and in stress. A 5(3)3 sampling scheme of the heart was performed, including 8 images in 11 heartbeats. For the MOLLI acquisition an initial Inversion time of 110 ms was used with an 80 ms increment. A pixel-wise T1 map of the myocardium was acquired in short-axis view with inline motion correction. The images were generated using a single-shot steady-state free-precession readout. Typical parameters were: field of view, 300 × 256 mm methods . In brieThe T1 maps, generated on the imaging console, were analyzed on commercially available software . Short-axis T1 maps were manually contoured using conservative septal sampling , and sperest and T1stress), and, if appropriate, ±standard deviation (SD). Categorical data were presented as percentages. Difference in T1rest and T1stress was expressed as percentage (∆T1 (%) = (T1stress− T1rest)/T1rest × 100). Differences between two groups were tested by independent samples t test, and differences in T1 values between ischemic/infarcted myocardium and normal myocardium by paired t test. Differences between three or more groups  myocardium group, infarct (and remote) myocardium group) were assessed using one-way analysis of variance (ANOVA) including proper post-hoc testing based on the homogeneity of variances per measured variable. Values of P < 0.05 were considered statistically significant. SPSS Statistics version 22 was used.All statistical analysis was performed using SPSS Statistics 23 . Continuous values were presented as mean values  was similar to the <4H and >8H caffeine group , and to the ischemia group (979 ± 64 ms). The native T1rest in the infarct group was significantly higher (1039 ± 49 ms) than in controls (P = 0.001). The ∆T1 was significantly lower in the <4H caffeine group as compared to all other groups , including the >8H caffeine group (1.8 %) and the control group (4.3 %)  a much higher dose of adenosine (266 ml/h instead of 210 ml/h), which resulted in a ∆T1 of −16.5 %. In the repeated study the ∆T1 normalized to 2.5 %.This study demonstrates that the increase of MBF of adenosine during myocardial stress perfusion is not only blocked, but inverted by coffee intake as measured by T1 mapping. We studied the short-term impact of caffeine consumption on T1-mapping and found that the ∆T1 values in the <4H caffeine group were significantly lower than all other ∆T1 values for all other groups in this study. Moreover there were no overlapping ∆T1 values between the <4H caffeine group and all other groups. This imaging biomarker is able to identify patients during the adenosine stress CMR study who are stressed inadequately due to caffeine, which may lead to false-negative perfusion test outcomes. ∆T1, or T1 reactivity, can be used as a benchmark for the adequacy of stress induction by adenosine at stress perfusion CMR studies and should be reported in the results.rest for caffeine groups versus the control group, which is comparable to studies that analyzed the effect of caffeine on MBF and MFR [We found no significant increase in T1 and MFR , 18. The and MFR . Caffein and MFR , 21. Fur and MFR .In this study -in the absence of an infarction—an almost zero local ∆T1 was indicative for myocardial ischemia. Basic research has shown that the regulation of a constant capillary hydrostatic pressure precedes myocardial oxygen transfer . Myocardrest values of the infarct group as reported in this study (1039 ms) were lower than reported recently (1442 ms) [The T11442 ms) . These l1442 ms) .The three patients who were imaged twice showed a tremendous recovery of ∆T1 after avoiding coffee for the stress test, which are in line with the main findings in this study. The results in this study supports the guidelines . So, mosThe hemodynamic data in this study showed no significant difference in rate-pressure products between the normal patients and the patients who consumed coffee. It is known that peripheral hemodynamic parameters during adenosine are poor indicators of changes of the MBF , which wA major strength of evaluating T1 reactivity by CMR, is the quantitative measure of response to adenosine. This allows more detailed assessment of the effect of adenosine than visual analysis of perfusion defects as used f.e. in SPECT. In fact, based on nuclear MPI-based studies there is debate about whether or not caffeine even exerts an effect on adenosine response , 26. In The investigational MOLLI-based T1 mapping technique used in this study revealed a substantial number of motion artefacts, which could be overcome by using shorter independent heart rate T1 sequences. New applications of the used software may also correct these motions artefacts in the future.In conclusion, rest-stress T1 mapping CMR can identify and quantify the antagonistic effect of caffeine on myocardial blood volume in patients stressed with adenosine. ∆T1 can be used as a benchmark for the validity of the stress induction by adenosine at cardiac MR perfusion studies. The results of this study are applicable on all types of adenosine myocardial perfusion imaging.


To investigate the association between diabetic retinopathy (DR) and myocardial dysfunction in patients with type 2 diabetes and dilated cardiomyopathy (dCMP).Data were collected retrospectively from 89 patients with dCMP (46 with type 2 diabetes and 43 without diabetes) and no evidence of coronary artery disease. Echocardiographic parameters and laboratory data, including lipid profiles and fundus findings, were obtained from medical records. A left ventricular ejection fraction (LVEF) less than 40% was considered impaired systolic function, while an E/E′ ratio greater than 15 was considered elevated left ventricular (LV) filling pressure.P = 0.022). Logistic regression analysis revealed that statin use lowered the risk of impaired systolic dysfunction in all patients (odds ratio (OR) 0.33, 95% confidence interval (CI) 0.12–0.92, P = 0.034) and in patients with diabetes , while the presence of DR was associated with a higher risk of elevated LV filling filling pressure in patients with diabetes .Baseline characteristics show that LVEF was not significantly different between patients with and without diabetes or between diabetic patients with and without DR. Among the diastolic function parameters, patients with DR exhibited higher E/E′ ratios (left ventricular filling pressures) than patients without DR  contains supplementary material, which is available to authorized users. Cardiovascular disease (CVD), including coronary artery disease and stroke, is the leading cause of death in patients with diabetes and directly related to atherosclerosis , 2. AlthDilated cardiomyopathy (dCMP) is defined by the presence of left ventricular systolic dysfunction in the absence of an abnormal loading condition or significant coronary artery disease . EndocriThe presence of DR in diabetic patients suggests that microvascular complications are manifested clinically. Accordingly, we performed a retrospective clinical study to investigate the association of diabetes or DR with myocardial function in patients with type 2 diabetes with non-ischemic dCMP compared with that in patients without diabetes.The medical records of patients diagnosed with cardiomyopathy between 1994 and 2015 and followed by the Ophthalmology and Cardiology departments of Ajou University Hospital  were retrospectively reviewed. This study complied with the Declaration of Helsinki and was approved by the Institutional Review Board of Ajou University Hospital (#AJIRB-MED-MDB-16-542). Patients were excluded if fundus examinations revealed any retinal vascular diseases other than diabetic retinopathy; without records of fundus findings and echocardiographic results; or with myocardial dysfunction related to secondary causes. Detailed exclusion criteria were as follows: the presence of significant coronary artery disease (>50% stenosis of at least one major coronary artery) confirmed by coronary angiography or non-performed angiography, or myocardial dysfunction resulted from significant valvular disease , and medications including anticoagulants, β-blockers, angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), calcium channel blocker (CCB), diuretics and statins. Those without diabetes were defined by HbA1c <6.5%, fasting blood glucose <126 mg/dL, and lack of antidiabetic agents, verified from medical records. Fundus findings and echocardiographic parameters were also obtained from medical records. The collected echocardiographic data included left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS), left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic dimension (LVESD), left ventricular mass index (LVMI), posterior wall thickness at end-diastole (PWd) and at end-systole (PWs), relative wall thickness (RWT), peak early diastolic mitral inflow velocity (E), and peak late diastolic mitral inflow velocity (A). The early diastolic mitral annular velocity (E′) was averaged from the two measurements at septal and lateral sides of mitral annulus. The presence and severity of DR were obtained from medical records of ophthalmology department, based on the traditional Early Treatment Diabetic Retinopathy Study (ETDRS) grading system using fundus photos and fluorescence angiography of patients by an experienced retina specialist.t test, Mann–Whitney test, or Kruskal–Wallis test. Logistic regression analysis was performed to evaluate factors associated with impaired systolic function or elevated left ventricular (LV) filling pressure. Systolic dysfunction was defined as LVEF <40%, while elevated LV filling pressure was defined as E/E′ ratio >15 [P < 0.05 were considered statistically significant.Statistical analysis was performed using SPSS software . Shapiro–Wilk test was used for the assessment of the Gaussian distribution, and nonparametric tests were applied if the assumption of normality was violated. Categorical variables were compared using the Chi square test, and continuous variables were compared using independent atio >15 –14. P < 89 patients with dCMP were included in this study, and their demographic characteristics are summarized in Table P = 0.021 and P = 0.022, respectively). These parameters were also significantly different when compared among those without diabetes, those with diabetes but no DR, and those with DR  . Altogether, the presence of retinopathy rather than nephropathy could be used as a clinical feature to determine whether patients with diabetes are likely to have elevated LV filling pressure in dCMP (Fig. The presence of DR suggests that the patient is experiencing microvascular complications. DR, one of the major microvascular complications in patients with diabetes, has been investigated as a potential predictor for cardiovascular diseases , 30, 31.Among the systemic medications, statin use was associated with a lower degree of systolic dysfunction in patients with dCMP. There are several experimental studies that have reported the protective effect of statin use on diabetic cardiomyopathy , 34, whiThe present study has also other limitations with regard to the retrospective design; more detailed assessment of diastolic profiles such as pulmonary venous flow, left atrial volume, or tricuspid regurgitation pressure gradient was not available. Furthermore , the measurement of LV end-diastolic pressure by catheter examination would be informative, which was not available in this retrospective study. Cohort studies with larger numbers of subjects may be needed for further investigation of diabetes, DR, and cardiomyopathy. Some large ranges of 95% CI in the logistic regression analyses, which were especially common in the subgroup of patients with diabetes, may be narrowed with statistical significance if analyzed with a larger number of patients.In conclusion, DR was associated with diastolic dysfunction in patients with dCMP. DR may not only represent microvascular long-term complications in patients with diabetes but may also be associated with more advanced form of diastolic dysfunction among diabetic patients with cardiomyopathy. Based on our findings, dCMP patients with DR should be encouraged to increase the frequency of cardiovascular follow-up, and intensive health education on life style modification and special attention to medication adherence are needed to avoid worsening the condition.


Heart failure related to cardiac siderosis remains a major cause of death in transfusion dependent anaemias. Replacement fibrosis has been reported as causative of heart failure in siderotic cardiomyopathy in historical reports, but these findings do not accord with the reversible nature of siderotic heart failure achievable with intensive iron chelation.Ten whole human hearts  were examined for iron loading and fibrosis . Five had died from heart failure, 4 had cardiac transplantation for heart failure, and 1 had no heart failure (death from a stroke). Heart samples iron content was measured using atomic emission spectroscopy. Interstitial fibrosis was quantified by computer using picrosirius red (PSR) staining and expressed as collagen volume fraction (CVF) with normal value for left ventricle <3%.The 9 hearts affected by heart failure had severe iron loading with very low T2* of 5.0 ± 2.0 ms (iron concentration 8.5 ± 7.0 mg/g dw) and diffuse granular myocardial iron deposition. In none of the 10 hearts was significant macroscopic replacement fibrosis present. In only 2 hearts was interstitial fibrosis present, but with low CVF: in one patient with no cardiac siderosis  and in a heart failure patient (CVF 2%). In the remaining 8 patients, no interstitial fibrosis was seen despite all having severe cardiac siderosis and heart failure (CVF 1.86% ±0.87%).Replacement cardiac fibrosis was not seen in the 9 post-mortem hearts from patients with severe cardiac siderosis and heart failure leading to death or transplantation, which contrasts markedly to historical reports. Minor interstitial fibrosis was also unusual and very limited in extent. These findings accord with the potential for reversibility of heart failure seen in iron overload cardiomyopathy.NCT00520559ClinicalTrials.gov Identifier:  The transfusion dependent anaemias cause a substantial burden of morbidity and mortality, of which thalassaemia is the commonest single gene disorder worldwide . The traTen hearts were studied from 5 centres, with 9 from patients with beta thalassaemia major and 1 from a patient with sideroblastic anaemia. A separate report associating myocardial T2* to myocardial iron in these hearts has been published . Six of The left ventricle (LV) was cut into 5 short axis ventricular slices and ex-vivo CMR was performed on each slice, as described below. After imaging, each slice was divided into 6 sectors and 3 layers  making a total of 90 left ventricular samples per heart. Transmural samples were also taken of the right ventricle and both atria, and additional samples of the conduction tissue and valves. All samples were transported to a specialist lab for iron analysis in Perth, Australia. Each sample underwent lyophilization and acid digestion. Tissue iron concentration was measured using inductively coupled plasma atomic emission spectroscopy. Iron concentration values for the left ventricle samples showed only minor variation within each heart , and areWhole blocks for histology were taken contiguous to the samples taken for iron analysis. Fifty blocks in each case was examined. The tissue blocks were fixed in formalin and dehydrated and embedded in paraffin wax. Sections were cut and stained with Picrosirius red (PSR) a stain which highlights collagen , 21. Per2 (ventricular) or 0.3 mm2 . The images were analysed using dedicated computer software (Nikon NIS elements) which enabled a direct measurement of the myocardial tissue volume and PSR staining volume. The fraction of PSR staining within the myocardium was defined as the collagen volume fraction (CVF). Three studies published using this technique have shown a mean ± SD value of CVF for the left ventricle of 2.1 ± 0.45% [After visual inspection, a representative digitized image was acquired from each slide of up to 1.8 mm ± 0.45% –26, and  ± 0.45% , 25. UsiCardiovascular magnetic resonance (CMR) T2* imaging is an established technique for assessing myocardial iron loading , 27–29. Nine hearts had severe iron loading with a mean ex-vivo LV T2* of 5.0 ± 2.0 ms and a mean LV iron concentration of 8.5 ± 7.0 mg/g dw  and a mThe normal finding of PSR staining of collagen surrounding adventitia of blood vessels in the interstitium and the division of trabeculae was noted. Overall, the collagen volume fraction in all hearts was 2.28% ± 1.49%. No heart with cardiac siderosis had increased overall CVF Fig. . There wFibrosis above the normal range was demonstrated in one heart by PSR staining (heart 1) with an overall CVF of 5.9 ± 2.8%, but this was considered too mild to cause heart failure. The donor had died from a stroke and had a long history of atrial fibrillation, but with no cardiac iron loading . The heart weighed 380 g with moderate left ventricular hypertrophy. Minimal fibrosis was noted in the mid left ventricular inferoseptal wall and basal anteroseptal wall. Mild patchy interstitial fibrosis was also seen which was predominantly subepicardial . This suggests that deferoxamine might impair the development cardiac fibrosis that occurs with myocardial siderosis. This is plausible as deferoxamine is known to stabilise liver fibrosis in association with reduced liver iron loading , 35 but Although the use of deferoxamine seems the most likely factor distinguishing the historical from our modern cardiac findings, other possibilities exist. Another change in treatment of thalassemia major patients is the use of increased numbers of blood transfusions per year since the 1970’s, which suppresses ineffective erythropoiesis and bony abnormality. A typical modern regime for an adult includes the transfusion of up to 50 units of blood per year  . Engle dFurther possible factors that might influence the difference in cardiac fibrosis over time are: 1) the occurrence of diabetes in thalassaemia major, which has association with the presence of cardiac fibrosis and development of heart failure . HoweverThe absence of in-vivo CMR does not allow the comparison of late gadolinium enhancement with the histological findings. The technique of T1 mapping was likewise not possible in-vivo in this population . This isSevere myocardial siderosis causes a toxic dilated cardiomyopathy which can be reversed if aggressive chelation is commenced early. In the current study, the direct histological examination of hearts from patients with terminal heart failure has shown no significant replacement myocardial fibrosis. This suggests that the cause of left ventricular impairment seen in cardiac siderosis is a direct result of myocardial iron toxicity and not due to fibrosis. The discrepancy of these findings in comparison with historical reports of extensive fibrosis in cardiac siderosis is most probably explained by the use of iron chelation treatment, although other factors may play a role including increased transfusions.


The aim of the study was to determine whether segmental interactions, as expressed by postsystolic shortening (PSS), affects RV mechanics and are connected with impaired systolic and diastolic function in rTOF children. Patients and Methods: 55 rTOF adolescent (study group), and 34 healthy volunteers (control group) were examined using classical Doppler flow (Doppler), Tissue Doppler Imaging (TDI) and Speckle Tracking Echocardiography (STE). PSS was found to occur when time to peak (TTP) was longer than pulmonary valve closure time (PVCT). TTP and strain were derived from RV lateral segments—basal (BL), medial (ML) and apical (AL) in STE. PVCT was measured from the beginning of QRS complex in the ECG to the termination of Doppler flow at the pulmonary valve. TDI was obtained at the lateral tricuspid annulus site and the systolic (S′), early (E′) and late diastolic (A’) peak velocities were measured along with isovolumic contraction (IVCT), and relaxation (IVRT) time. PW was used to measure early tricuspid inflow velocity (E) for calculating the E/E’ ratio. The TDI data in patients with PSS presence (TTP>PVCT) and those in whom it did not occur (TTP≤PVCT) were compared. Results: PSS in BL, ML and AL were observed respectively in: 27, 9 (18%), and 8  patients. Mean values of TTP in BL, ML, and AL were respectively: 420.6±55.5ms, 389.8±50.0ms and 366.7±59.0ms. PVCT mean value was 396.6±33.5ms. In the study group, the mean E’ in TTP>PVCT was significantly lower (4.8±1.8 cm/s) compared to mean E’ in TTP≤PVCT (8.4±2.6 cm/s), p<0.01. The average E/E’ was significantly higher in TTP>PCVT than in TTP≤PVCT, respectively 21.6±7.3 vs 12.2±5.1, p<0.05. IVRT was significantly prolonged in TTP>PVCT compared to IVRT in TTP≤PVCT, respectively 95.9±38.7 vs 77.0±35.1, p<0.05. Furthermore, in TTP>PVCT, significantly higher strain in BL (-28.8±8.7%) was observed when compared to that parameter in TTP≤PVCT (-35.3±13.1%), p <0.05. Conclusions: Tissue Doppler Echocardiography and Speckle Tracking Echocardiography are useful techniques for detecting regional systolic and diastolic dysfunction in children after Tetralogy of Fallot surgical repair. Postsystolic shortening in the basal lateral segment is commonly seen in children after the Tetralogy of Fallot surgical repair, and is associated with altered right ventricular systolic and diastolic function. An increasing number of patients after Tetralogy of Fallot surgical repair (rTOF) has led to a growing adolescent population with postoperative cardiac sequels.  PulmonarWe thus hypothesized, those segmental interactions, as expressed by postsystolic shortening, affects RV mechanics and are connected with impaired systolic and diastolic function in rTOF children.Study subjects were 55 consecutive rTOF patients, aged 8–18 years (average 13.7±3.3 years). The control group was comprised of 34 healthy volunteers aged 8–18 years, (average 13.6±2.9 years). The data on surgical treatment in the study group were obtained from medical documentation. Anthropometrical parameters were measured in the study and control group.In all patients, resting ECG was performed to evaluate the shape and duration of the QRS complex.Echocardiography: patients and controls were examined using a standardized protocol by the iE 33 ultrasound system (Philips); being in the left lateral decubitus position with a phased-array transducer S5-1. The RV focused apical 4-chamber view (RV AP4Ch) was used to calculate end-systolic (ESA) and diastolic (EDA) areas. These were adjusted to body surface area. The right ventricular fractional area change (RVFAC) was calculated by: EDA-ESA/EDA x100%. RV AP4Ch was also used to assess transannular plane systolic excursion in M-mode. Classical Doppler flow was obtained at the pulmonary valve and tricuspid valve. Tissue Doppler Imaging (TDI) was measured at the lateral tricuspid annulus site at a frame rate of at least 90 Hz from the RV AP4Ch. Gray-Scale images for RV speckle tracking echocardiography (STE) were acquired at frame rates of 50 to 90 Hz also from the RV AP4Ch. At least 5 cardiac cycles were stored for offline analysis (“QLAB Advanced Quantification” Philips). Tracking was automatically generated by the software and was only accepted if visual inspection indicated adequate covering of the myocardium throughout the whole cardiac cycle. Strain curves were generated at the basal, mid, and apical RV lateral wall. Patients in whom STE was inadequate in more than 1 segment were excluded.The forward pulmonary flow and pulmonary regurgitation (PR) were assessed in continuous wave Doppler. The maximal and mean systolic pressure gradient between the right ventricular outflow tract and main pulmonary artery were measured. The ratio between the duration of PR and total diastole, referred to as PR index, was used to assess the degree of PR as previously described in the literature The tricuspid valve flow and regurgitation was assessed in the apical 4-chamber view. Pulse wave Doppler was used to measure a maximal early (E) and atrial (A) tricuspid inflow velocity along with E deceleration time. The E/A ratio was calculated. Tricuspid regurgitation was assessed in color Doppler flow and was considered significant when the ratio of regurgitant jet area to total right atrial area was at least 40% with an optimal setting of color Doppler gain and, additionally, when evidence of retrograde flow in the inferior vena cava in PW was registered.TDI was obtained at the lateral tricuspid annulus site and the systolic (S′), early diastolic (E′) and late diastolic (A’) peak velocities were measured along with isovolumic contraction (IVCT) and relaxation (IVRT) time. The E/E’ ratio was thence calculatedIn STE, time to peak (TTP) and maximal value of longitudinal strain (ε) were automatically derived from each of the three RV segments. The early prestretch, defined as a segmental elongation (stretch) before shortening, was recorded. PSS was found to occur when the TTP was longer than the pulmonary valve closure time (PVCT). PVCT was measured from the beginning of QRS complex in the ECG to the termination of flow at the pulmonary valve in pulse wave Doppler flow. The duration of deformation after pulmonary valve closure, i.e. the postsystolic shortening time (PSST), was calculated by: PSST = TTP–PVCT, whilst the postsystolic shortening time index (PSSTi), was obtained by: PSSTi = PSST/PVCP x 100%, where PVCP is the pulmonary valve closure period. PVCP was defined as the time between termination and beginning of pulmonary flow in pulse wave Doppler. Strain at the moment of pulmonary valve closure (εPVC) was measured manually and postsystolic shortening strain was calculated, , using the formula: εPSS = ε—εPVC. The postsystolic shortening strain index (εPSSi) was also determined by: εPSSi = εPSS/ ε. ECG was registered during the whole examination. Maximal accepted difference in mean values of RR intervals between the ECG’s in the 2-dimensional images and the Pulse Wave Doppler was 5%. The study received approval from the Bioethics Committee, Medical University of Warsaw No: KB/18/2009. All study subjects’ parents/guardians signed written informed consent form; additionally the study participants aged above 15 years old also signed written informed consent form. The Bioethics Committee, Medical University of Warsaw, approved all these documents.supporting information files.All data underlying the findings described in our manuscript are fully available as The numbers and rates of patients and healthy children with and without postsystolic shortening were counted. Data were presented as a mean ± SD. The Shapiro-Wilk test was used to verify a normal distribution. Comparison between the controls and the study group were determined by using the Mann-Whitney U test. 2x2 tables were analyzed using the exact Fisher test. Correlations were determined according to the Spermann rank order correlation. The statistical analysis was not performed if the number of patients was less than 10. A p<0.05 was taken as being statistically significant.The mean patient age at the time of surgical correction was 12±8.9 months. The trial was performed 12.9±3.3 years after reparative surgery. Three patients of the study group (none of the controls) were excluded from the trial, when tracing was inadequate in more than 1 segment. For the further analysis 52 patients were considered. Eleven (21.1%) patients received a transannular patch during initial surgical repair. Nine patients (17.3%) underwent Blalock-Taussig shunt before corrective surgery whilst one (1.9%) underwent reoperation for a residual ventricular septal defect. Both study and control groups had statistically similar body mass, height and body surface area .The complete right bundle branch block was found in 48 (92%) children of the study group and none for children in the control group. The average value of the QRS duration was statistically significantly longer (p<0.01) in patients after the tetralogy of Fallot correction  compared with QRS duration in the control group .In study group patients, severe pulmonary regurgitation was seen in 17(32.7%), moderate in 24 (46.1%), and mild in 11 (21.1%). There was no diagnosis of moderate and severe pulmonary regurgitation in healthy children. Three (3.6%) of the study patients had severe tricuspid valve regurgitation but none in healthy volunteers.Results of the remaining of echocardiographic parameters in the control and study group are summarized in The early prestretch was seen in 49 (94.2%), 12 (23%), 7(13%) patients of the study group and in 3 (8%), 2  and none of healthy children in basal, medial and apical lateral segments respectively. PSS occurred also more frequently in the study group than controls for all segments measured in the right ventricle . PatientThe mean value of maximum E’ wave velocity was significantly lower in PSS+ patients compared to PSS- children from the study group p<0.01. The average E/E’ value was significantly higher in PSS+ than in PSS- patients, p<0.01. The IVRT was significantly prolonged in PSS+ compared to PSS- rTOF children, p<0.05. Furthermore, in PSS+ patients, a significantly lower total deformation in basal lateral segment was observed when compared to rTOF PSS- children. There was no significant difference in QRS duration between PSS+ (139.0±17.4ms) and PSS- (129.3±35.9 ms) children of the study group. Maximal and mean pressure gradient between right ventricular outflow tract and main pulmonary artery did not differ significantly in the PSS+ and PSS- patients and were respectively in PSS+ 23.0±12.6 mmHg and 12.3±7.0 mmHg and in PSS- 23.2±14.0 mmHg and 12.4±7.9 mmHg. Severe pulmonary regurgitation was seen in 12 (44.4%) PSS+ and in 5 (20%) PSS- patients but this difference was not statistically significant. All 3 patients with severe tricuspid regurgitation were PSS+. There were no significant differences between any of the remaining parameters of right ventricular function for PSS+ and PSS- patients. In PSS+ rTOF children, the mean filling time was 324.5±101.7 ms, the PVCT was 379.2±44.1 ms. No significant differences in the mean durations of the cardiac cycle between PSS+ patients and controls were found, where the mean PVCP was 354.7±26.2 ms and PVCT 356.5±27.6 ms. The mean TTP level in the BL for the study group was 452.5±53.0 ms whilst that for healthy children was significantly less at 365.0±29.3 ms (p<0.01).The PSST and PSSTi, in the basal lateral segment were both significantly higher in children after rTOF compared to controls; respectively 73.4 ± 29.8 ms and 24.4 ± 11.1% versus 8.5 ± 4.0 ms and 2.3 ± 1.1% (p<0.01). In PSS+ children the mean ε and εPVCT in the BL for the study group were significantly higher than for controls; respectively -27.7±8.6% and -24.6±9.0% versus -40.9±11.5% and -36.8±11.1% (p<0.01). Likewise, in those PSS+, the mean εPSS and εPSSi in a given segment were not significantly different between patients and controls. In rTOF children, such values were found to be respectively -3.0±1.7% and 12.4±8.2% compared to -4.1±1.6% and 11.0±5.6% for healthy children.r = 0.44; P<0.05), the ESA/BSA  and EDA/BSA  correlated positively whilst TAPSE correlated negatively with PSSTi . No correlations were observed between PSSTi and other functional parameters such as: RV FAC, maximal and mean systolic pressure gradient between right ventricle and main pulmonary artery.In PSST+ rTOF patients, the QRS duration  universally driving to right ventricular elevated filling pressure. In our study we found a significant decrease in myocardial early diastolic velocity (E’) and isovolumic relaxation time prolongation (IVRT) within the right ventricle in patients in whom postsystolic shortening was detected when compared with the remaining subjects of the study group. Hitherto, in the literature, there have been no descriptions of diastolic dysfunction when determined by Tissue Doppler Imaging in rTOF patients with postsystolic shortening. Some trials show, prolonged IVRT upon TDI testing, decrease early maximum diastolic velocities (E’) and increases the E/E’ ratio reflects high end-diastolic pressure and/or right ventricular stiffness in selected patient groups. –21. HoweThe presented study for the first time demonstrates some link between PSS and decreased local deformation. We found reduced strain in the basal lateral segment of the right ventricle in those patients for whom postsystolic shortening was detected as compared to the remaining rTOF children.We suggest that PSS influences local deformation and does not affect global systolic function of the right ventricle. RV FAC was unrelated to PSS in our study. A negative correlation between PSSTi duration and TAPSE, in our circumstances, most likely confirms local contractile dysfunction in the basal lateral segment of the right ventricle where the parameter is typically measured. According to the trials TAPSE does not reflect global systolic function in children after TOF correction .Except the intrinsic myocardial impairment, there are other mechanisms considered to be responsible for the presence of PSS. Hui et al. suggest  postsystNevertheless, we found that PSSTi was significantly correlated to parameters such indexed end-systolic and end-diastolic areas of right ventricle, indicating that the volume overload does also have some link with PSS. On the other hand, the magnitude of pulmonary valve regurgitation has been shown to be less related to PSS; both in our study and work by Hui et al . It thusBased on our results, right ventricular pressure overload did not affect PSS. There was no difference in the maximum and average systolic pressure gradient within the right ventricular outflow tract between patients with PSS + and PSS-. The systolic pressure gradients within right ventricular outflow tract also poorly correlated with PSST. However, once should note that the values of the pressure gradients were low in our study group, the average value of mean pressure gradient was 12.3 mmHg and only in 2 patients the maximum pressure gradient exceeded of 50 mmHg.As it was presented in previous studies the time to peak parameter might become extended after the moment when the arterial valve closes in healthy ones ,23. LighParsai et al [Prolonged deformation after aortic valve closure in the left ventricle is fairly well understood. It is of prognostic value in patients with myocardial infarction. Recognizing this symptom in patients suffering from myocardial infarction directly after revascularization, improves the prognosis in the reversion back to normal contractile function. However, when this occurs in patients with arterial hypertension or dilated cardiomyopathy, then it is associated with impaired diastolic function, as detected by Tissue Doppler Imaging or Speckle Tracking Echocardiography –12. In pai et al  found reBy extrapolating study data from the left ventricle, it might be assumed that the postsystolic shortening findings obtained from within the right ventricle might provide useful information in qualifying patients for therapeutic interventions following Tetralogy of Fallot correction. However, there is no evidence on whether pulmonary valve replacement, (due to severe regurgitation) or cardiac resynchronization, could significantly improve mechanical function of the disturbed right ventricle due to postsystolic shortening in rTOF patients.The lack of data about long-term clinical implications is a major limitation of our study. Besides, measuring the pulmonary pulse wave Doppler profile and 2D images for strain were not simultaneous, but possibly heart rate variability might influence postsystolic shortening time. We therefore performed the measurement only if the heart rate in PW and 2D 4 chamber views were similar  as described previously in the literature. We also calculated the postsystolic shortening index to avoid any risk of inadequately assessing postsystolic shortening connected with heart rate changes. We did not assess right ventricular systolic pressure because of insufficient tricuspidal regurgitation, so pressure overloading was based only on the gradient between the right ventricle and the main pulmonary artery.We also consider that at present there are many questions that remain unanswered  MRI, histopathology and exercise studies might provide the answers, which were not performed on our subjects. The follow-up of PSS assessment could also explain the issue of by how much PSS is an indicator of long-term myocardial damage.Tissue Doppler Echocardiography and Speckle Tracking Echocardiography are useful techniques for detecting regional systolic and diastolic dysfunction in children after Tetralogy of Fallot surgical repair.Postsystolic shortening in the basal lateral segment is commonly seen in children after the Tetralogy of Fallot surgical repair, and is associated with altered right ventricular systolic and diastolic function.S1 Fig(PDF)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.S3 Fig(PDF)Click here for additional data file.S4 Fig(PDF)Click here for additional data file.


Following femur fracture, medullary fat enters the systemic circulation and altered pulmonary haemodynamics may contribute to pulmonary complications. This study evaluated the association between right ventricular (RV) function and pulmonary complications in patients with femur fracture.Patients with a femur fracture who had undergone pre-operative echocardiography that included RV peak global longitudinal strain (RV GLS) were evaluated retrospectively between March 2015 and February 2016. Pulmonary complications were defined as the development of pneumonia or pulmonary thromboembolism during the first postoperative month.Among 78 patients, pulmonary complications developed in eight (10.3%). The RV GLS value of all patients was lower than the normal range. In addition, the RV GLS value of patients with pulmonary complications was significantly lower than that of patients without pulmonary complications. Multivariate regression analyses found that worse RV GLS values independently predicted pulmonary complications . Receiver operating characteristic curve analysis found that a RV GLS value of –14.85% was the best cut-off value to predict pulmonary complications; sensitivity: 75.0%; specificity: 62.9%. Moreover, patients with RV GLS values > –14.85% had significantly lower pulmonary complication-free survival.In patients with femur fracture, RV GLS values could help predict pulmonary complications. Therefore, patients with RV GLS values > –14.85 should be monitored closely before and after surgery for femur fracture. Following femur fracture, a long-bone trauma, medullary fat enters the systemic circulation and altered pulmonary haemodynamics may contribute to pulmonary complications.Pulmonary vascular resistance (PVR) is an important component of pulmonary haemodynamics and a critical determinant of right ventricular (RV) systolic function.The aim of this study was to evaluate the association between pulmonary complications and RV function in patients with femur fracture.Data from 100 consecutive patients who visited a hospital for femur fracture between March 2015 and February 2016 and also underwent transthoracic echocardiography were retrospectively analysed. Among these, 22 patients were excluded from the study because the echocardiographic image quality was inadequate for quantitative analysis.The study was approved by the institutional review boards of the hospitals, and was conducted according to the Declaration of Helsinki. Written informed consent was exempted by the institutional review boards.2)] was calculated. In addition, length of hospital stay was recorded.Patients’ demographic and clinical characteristics were reviewed using electronic records. The following demographic and clinical characteristics were extracted: age, gender, height, weight, systolic blood pressure, diastolic blood pressure, current smoking status, and history of hypertension, diabetes, dyslipidaemia, coronary artery disease, and atrial fibrillation. Each patient’s body mass index [BMI . Left ventricular (LV) systolic function was assessed by calculation of LV ejection fraction (EF) using M-mode echocardiography.RV systolic function was assessed from the following parameters: tricuspid annular plane systolic excursion (TAPSE), tissue Doppler-derived tricuspid lateral annular systolic velocity (RVs′), and RV fractional area change (FAC).The endocardial border of the RV myocardium was delineated manually on an end-systolic frame, after which the software automatically drew the epicardial border. Manual adjustment was done for matching the actual borders of the regions of interest. Then the RV myocardium was traced frame by frame, and the longitudinal strain of the basal, middle and apical segments of the RV free wall and septum were obtained separately.By averaging all segmental values, RV peak global longitudinal strain (RV GLS) was calculated using this software with two-dimensional speckle-tracking echocardiography.The primary outcome was the development of a clinically apparent pulmonary complication during the one-month postoperative period. We defined a pulmonary complication as a composite outcome: development of either pneumonia or pulmonary embolism during the first postoperative month. Pulmonary embolism was confirmed by computed tomographic pulmonary angiogram.13To assess the inter-observer variability of RV GLS, a second experienced independent investigator re-evaluated 20 randomly selected images using the same software. Intra-observer variability was evaluated: the first investigator who was blinded to the former results analysed RV GLS for each randomly selected image again at one month after the initial analysis.All categorical data are summarised as frequencies and percentages, whereas statistics for continuous variables are presented as means and standard deviations. The Pearson chi-squared test was used to compare categorical variables. The Student’s t-test was used to compare continuous variables and the Mann–Whitney U-test was used when the sample size of at least one group was less than 30.Univariate analysis was followed by multivariate logistic regression analyses to evaluate potential risk factors for pulmonary complications with adjustment for other risk factors. Variables with a p-value less than 0.1 in univariate analysis were selected for inclusion in the multivariate regression model.RV GLS was analysed as a continuous variable in univariate and multivariate models. We investigated the optimal cut-off value of RV GLS to predict pulmonary complications in patients with femur fracture using receiver operator characteristic (ROC) curve analyses. In addition, Kaplan–Meier survival analyses and log-rank tests were used to compare clinical event-free survival rates between groups stratified by the RV GLS cut-off value.Then, to evaluate the consistency of results according to the identified cut-off value, RV GLS was analysed as a dichotomous variable in univariate Cox analysis. The inter- and intraobserver agreements were described by calculating the intra-class correlation coefficient (ICC). A p-value of less than 0.05 was considered statistically significant. All analyses were performed using SPSS 18.0 .Seventy-eight patients with femur fracture were included; their mean age was 80.1 ± 9.1 years, and 59 (75.6 %) patients were female. Patients’ baseline characteristics are presented in Eight patients (10.3%) developed pulmonary complications during the first postoperative month. One patient (1.3%) developed pulmonary embolism and the other seven developed pneumonia. Among these, two patients (2.6%) died. The patients who developed pulmonary complications had significantly longer hospital stays than the patients who did not develop pulmonary complications .Similarly, RV FAC, RVs′ and TAPSE values, known as measures of RV function, did not differ significantly between the two groups. In univariate analyses , worse RROC curve analysis identified RV GLS of –14.85% as the best cut-off value for predicting pulmonary complications; this value had a sensitivity of 75.0% and a specificity of 62.9% . Fig. 2 The inter-observer agreement of RV GLS was excellent . The degree of intra-observer agreement  was similar to that of the inter-observer agreement.Pneumonia and pulmonary embolism are important complications in older patients with femur fracture. Our findings indicate that pulmonary complications develop often, at a rate of 10.3%, in patients with femur fracture. Lower RV GLS values and longer hospital stay were good predictors for detecting pulmonary complications. In addition, our findings document that patients with impaired RV GLS values > –14.85% had significantly lower clinical event-free survival rates than patients with better RV GLS values.After long-bone trauma, medullary fat enters the systemic circulation and fat emboli pass through the pulmonary capillaries, causing altered pulmonary haemodynamics and a systemic inflammatory reaction.4Previous studies have demonstrated that when increased pulmonary vascular resistance is caused by vascular obstruction from fat emboli, RV afterload may increase and RVEF will decline.RV dysfunction has been shown to predict adverse clinical outcomes in patients with heart failure or myocardial infarction,22Although the imaging quality has improved, delineation of the endocardial border for the measurement of RV FAC has variable reliability depending on the experience of the operator. In addition, velocity and displacement-based analyses, such as TAPSE, can be affected by tethering and cardiac translation and respiratory variation.Two-dimensional strain echocardiography quantifies both regional and global myocardial function.27The reference value of RV GLS in normal subjects is about –28%,A previous study revealed that RV GLS value ≥ –15.5% was associated with adverse clinical events and death in patients with inferior ST-segment elevation myocardial infarction (STEMI).It is notable from our analysis that the subclinical changes in RV function identified as decreases in RV longitudinal strain could be detected using two-dimensional strain analysis; these findings provide additional information to predict pulmonary complications in compromised pulmonary haemodynamics after acute long-bone trauma. Likewise, RV strain may help to further our understanding of pulmonary haemodynamic changes.Some limitations of this study should be considered. First, this study was a retrospective observational study. Moreover, it was a single-centre experience with a relatively small sample size. Because quantitative analysis could have been affected by the quality of stored images, we excluded patients with inadequate echocardiographic image quality. Although a prospective study with more patients and a longer postoperative observation period may help identify additional factors, impaired RV GLS in patients after the acute trauma of long-bone fracture was significantly associated with more short-term clinical events and may provide useful information to manage trauma patients in real-world clinical situations.In patients with femur fracture, the short-term pulmonary complication rate was 10.3% and this was increased by worse RV GLS values and longer hospital stays. Because of the high incidence of pulmonary complications in femur fracture, patients with RV GLS values > –14.85% should be monitored closely before and after surgery to detect pulmonary events.


Notwithstanding all the advantages of the cine bSSFP there are certain limitations, especially in sedated patients, patients with impaired breath-holding capacity, and those with cardiac arrhythmias. Any respiratory motion due to unsteady breath-hold during data acquisition causes motion artifacts, sacrificing endocardial border definition. In this study we clinically validate a RT-SSFP sequence for free breathing acquisition of cardiac cine images.3; SENSE factor = 1.3-1.9; temp res 40-50 ms; imaging time : 6-8 RR intervals/slice) for LV function evaluation in 22yrs) and 21yrs) consecutive patients undergoing clinically indicated cardiac MR. The image quality was scored by blinded reviewer for blood to myocardial contrast, endocardial edge definition, and motion artifacts  at two independent institutes . A real-time adaptive RT-SSFP sequence synchronizing the drive to SS with respiratory cycle along with retrospective cardiac gating was implemented. We note that a vast majority of subjects in this study were good breathholders (BA plot), and RT-SSFP images were of equivalent image quality. Inclusion of more difficult clinical cases in comparison study may reveal the added value of free breathing cine SSFP alternative. The free breathing RT-SSFP sequence generates diagnostic cine MR images with contrast and spatio-temporal resolutions that are comparable to BH SSFP sequence at the expense of modest sacrifice in image quality in patients able to perform reasonable breath hold. Global LV functional parameters obtained from the two sequences were in good agreement. Thus, FB RT sequence may be a robust alternative for evaluating global LV function in patients with impaired breath-holding capacity.


The final therapy of ‘end-stage heart failure’ is orthotopic heart, lung or heart-lung transplantation. However, these options are not available for many patients worldwide. Therefore, novel therapeutical strategies are needed. Based on pathophysiological insights regarding (1) the long-term impact of an obstructive pulmonary outflow tract in neonates with congenitally corrected transposition of the great arteries, (2) the importance of a restrictive versus a non-restrictive atrial septum in neonates born with a borderline left ventricle and (3) the significance of both, a patent foramen ovale and/or open ductus arteriosus for survival of newborns with persistent pulmonary hypertension, the current review introduces some therapeutical strategies that may be applicable to selected patients with heart failure. These strategies include (1) reversible pulmonary artery banding in left ventricular-dilated cardiomyopathy with preserved right ventricular function, (2) the creation of restrictive interatrial communication to treat diastolic (systolic) heart failure, (3) atrioseptostomy or reverse Potts shunt in pulmonary arterial hypertension and (4) return to a fetal, parallel circulation by combining atrioseptostomy and reversed Potts shunt with or without placement of a bilateral pulmonary artery banding. While still being experimental, it is hoped that the procedures presented in the current overview will inspire future novel therapeutic strategies that may be applicable to selected patients with heart failure. End-stage heart failure is the cause of death or need for heart transplantation (HTx) in many cardiovascular conditions.supplementary video 1a–c10.1136/heartjnl-2015-309110.supp1supplementary video 1a10.1136/heartjnl-2015-309110.supp2supplementary video 1b10.1136/heartjnl-2015-309110.supp3supplementary video 1cIn summary, left heart-dependent PH might be misinterpreted by focusing exclusively on TPG; the calculated value might be misinterpreted in consideration of the reversibility of PH or in the setting of decision-making for heart or heart-lung transplantation. Therefore, as already emphasised by several other authors,In LV-dilated cardiomyopathy (DCM), stroke volume remains preserved by LV dilatation on the expense of a high-end systolic volume; the physiopathology of a borderline left ventricle (BLV) and even restrictive cardiomyopathy (RCM) is characterised by CpcPH; the precapillary pulmonary component prevents pulmonary oedema. The properly adapted RV is able over quite some time to maintain filling and pumping. Thus, systemic, or sometimes suprasystemic, pulmonary artery pressures can develop, which correspond to a pulmonary artery banding (PAB) effect that preserves RV systolic function, in particular in the setting of a congenitally restrictive LV-cardiomyopathy  or placement of an LV assist device or biventricular assist device, a repertoire of novel therapeutic surgical interventional options is available that might reduce the need for such procedures.LV-DCM is characterised by reduced LV ejection fraction (EF), but preserved RV-EF. Idiopathic LV-DCM is the predominant form in infants and young children, while ischaemic DCM predominates in adults. DCM is a myocardial disease with systolic cardiac dysfunction and dilatation.8Box 11. Increase of RV contractility (Anrep effect), wall stress and isovolemic contraction2. Stimulation of RV hypertrophy and matrix remodelling3. Improvement of RV diastolic inflow characteristics4. Leftward shift of the IVS and restoration of electromechanical RV-LV synchrony5. Reduction of LVED volume with reshaping from spherical to ellipsoid morphology6. Reduction of LV-filling dynamics (preload) and subsequent LVED pressure7. Improvement of LA–LV interaction by reduction of left atrial volume overload8. Restoration and improvement of MV regurgitation and LV ejection fraction9. LV reverse remodelling (co-hypertrophy) by favouring endogenous repair potentialsIVS, interventricular septum; LA, left atrium; LV, left ventricle; LV-DCM, left ventricular-dilated cardiomyopathy; MV, mitral valve; PAB, pulmonary artery banding; RV, right ventricular.Considering patients with a systemic RV, the long-term outcome is directly related to a balanced ventricular interaction and the competence of the systemic atrioventricular valve.supplementary video 2a,b10.1136/heartjnl-2015-309110.supp4supplementary video 2a10.1136/heartjnl-2015-309110.supp5supplementary video 2aThe current results, partially published,Heart failure with preserved ejection fraction is attributed to diastolic dysfunction, which ranges from discrete failure of myocardial relaxation to significant anatomical limitations of the size of the systemic ventricle.Considering our currently only partially published institutional experience of percutaneous left atrial decompression,A reverse Potts shunt has been described as an alternative for lung transplantation in selected children with suprasystemic idiopathic PAH.28Based on the experience with ‘Hybrid approach’ in neonates with a morphologically hypoplastic left heart,Although speculative at present, ‘Hybrid strategies’ might have a survival benefit even in adolescents with a severe diastolic left-heart failure. Timing of such a comprehensive approach in the setting of a dysfunctional global circulation might, however, be difficult. We argue that a disproportionate postcapillary PH and ensuing RV failure necessitating listing for heart-lung transplantation might be one criterion, favouring a hybrid approach that includes percutaneous atrioseptostomy with or without device implantation and a surgically created or transcatheter-created reversed Potts shunt, in some together with bilateral pulmonary banding, although this approach has to be still regarded as experimental at present.In conclusion, this article provides insight into some novel methods for managing selected patients with heart failure. These procedures have still to be regarded as experimental and should only be regarded as a potential adjunct to management in accordance to the current heart failure guidelines.