The remodeling of gap junctions may affect their conduction properties and contribute to the maintenance of atrial fibrillation. The significance of the role of angiotensin-II receptor blockers (ARBs) in upstream therapy is not clear. This study was performed to investigate the effects of ARBs on atrial remodeling in a heart failure model. A model of heart failure was established or sham surgery performed in 24 Sprague-Dawley male rats. The rats were divided into sham, heart failure and heart failure-ARB groups. In the ARB group, 30 mg/kg of losartan was administered each day for 4 weeks. Echocardiography was performed at the baseline and 4 weeks following the surgery. An atrial fibrillation induction study and histological and immunohistochemical evaluation were performed 4 weeks after surgery. The increase in the left atrial diameter of the heart failure-ARB group was smaller than that of the heart failure group (P=0.028). The atrial fibrillation inducibility and duration of induced atrial fibrillation were not different between the heart failure and heart failure-ARB groups. Masson’s trichrome staining revealed less fibrosis in the heart failure-ARB group compared with the heart failure group. Immunohistochemical staining and western blot analysis for connexin 43 showed a lower expression level in the heart failure-ARB group compared with that in the heart failure group. In a rat model of ischemic heart failure the ARB losartan had structural and histological atrial reverse-remodeling effects. However, its role as an electrical stabilizer requires further study. They are effective in left ventricular dysfunction and have reno-protective effects in the reduction of proteinuria and atrial reverse-remodeling effects as electrophysiological stabilizers . Studieset al  demonstret al . Electriet al  weighing ∼260 g were used in the experiments. Each rat was isolated and housed individually in a ventilated microisolator-cage rack system, in which day and night were set at 12 hourly intervals. The rats were fed with standard rodent provender and distilled water. The experiments were performed in accordance with the guidelines of the Chonnam National University Hospital Animal Subject Institutional Review Board . The amount of provender for each subject was estimated for 5 days of adaptation. The ground medicine was mixed into the ground provender, which was congealed for one day at 35°C.A total of 38 rats were divided into sham (n=8), heart failure (n=15) and heart failure-angiotensin-II receptor blocker (ARB) (n=15) groups. Due to 14 rats not surviving surgery, each group ultimately contained 8 rats. Losartan potassium (30 mg/kg) was administered to the heart failure-ARB group for 4 weeks .The ischemic heart failure model was induced using the method reported by Johns and Olson . AnestheEchocardiography was performed under anesthesia using an intramuscular injection of ketamine (50 mg/kg) and xylazine (5 mg/kg) prior to surgery and 4 weeks after surgery. A 15 MHz linear probe  was used to perform transthoracic echocardiography. The left ventricular end systolic diameter (LVESd), left ventricular end diastolic diameter (LVEDd), left atrial diameter (LAD) in the parasternal long axis view and left ventricular ejection fraction (LVEF) were measured . All echAfter follow-up echocardiography, atrial fibrillation induction was performed under anesthesia. Following a 10-min equilibration period after anesthesia, a 4F electrode catheter  was inserted into the esophagus and positioned to ensure constant atrial capture. A BLOOM 215B DTU stimulator, Prucka recording system, Grass S-8800 2-channel stimulator , MP150 and ECG100C ×2  were used for stimulation and recording. Atrial pacing was performed at twice the diastolic threshold , using 2 poles on the pacing catheter . To induce atrial fibrillation, burst stimulation at a frequency of 25 msec intervals was performed for 35 sec in each of the rats . The rat®).Following the atrial fibrillation induction test, all rats were sacrificed. For 5 of the 8 rats in each group, the hearts were fixed using 10% formaldehyde perfusion into the abdominal aorta. Following formaldehyde perfusion, the hearts were excised immediately. The excised hearts were fixed in 10% formaldehyde. Hematoxylin and eosin (HE) and Masson’s trichrome staining, as well as immunohistochemical staining for connexin 43  were performed. Fibrosis and connexin expression were quantified using automatic computer graphics software  was used as the lysis buffer. Protein extracts (50 μg) were used. Connexin 43 was detected using rabbit polyclonal anti-C×43 antibody .For the western blot analysis of connexin 43, the two atria from 3 of the 8 rats in each group were excised following sacrifice via CO®. Mann-Whitney tests were used for comparisons between the groups. Intra-group analysis was performed using paired t-tests. P<0.05 was considered to indicate a statistically significant difference.Statistical analysis was performed using the SPSS 15.0 software for WindowsThe rats were divided into sham (n=8), heart failure (n=15) and heart failure-ARB groups (n=15). After left anterior descending artery ligation, 14 rats died. A total of 8 rats were successfully maintained in each group for 4 weeks following surgery. There was no significant difference in weight gain between the heart failure and heart failure-ARB groups for all 4 weeks .The baseline LVEFs in the sham, heart failure and heart failure-ARB groups were 56.6±2.78, 62.6±8.28 and 59.3±4.13%, respectively. The follow-up LVEFs were 58.2±2.08, 43.0±3.82 and 47.4±6.76%, respectively. The reduction in the LVEF of the heart failure-ARB group was significantly smaller than that in the heart failure group (P= 0.024; The atrioventricular block cycle lengths in the sham, heart failure and heart failure-ARB groups were 107±8.3, 124±11.4 and 116±11.4 msec, respectively . The indThe gross sizes of the excised hearts in the heart failure and heart failure-ARB groups were larger than those in the sham group. The area of infarction was pale and thin .In the HE staining  of the hThe Masson’s trichrome staining revealed severe fibrosis of the infarcted ventricular area and more fibrosis of the atria in the heart failure group . The lefThe immunohistochemical staining revealed that connexin 43 protein was present in the intercalated discs in the sham group . AbundanWestern blotting for connexin 43 showed that the connexin 43 bands of the heart failure group were more marked than those of the sham group and the heart failure-ARB group had weaker connexin 43 bands compared with the heart failure group .Atrial fibrillation is highly associated with atrial remodeling. It is a relatively common arrhythmia, which may be paroxysmal and persistent. It develops with or without underlying heart diseases. Atrial fibrillation has clinical significance due to probable hemodynamic instabilities and thromboembolic events. The multiple-wavelet hypothesis has been the accepted theory for the mechanism of atrial fibrillation, whereby multiple wavelets conflict and collide, then create small wave-lets repeatedly .Atrial fibrillation is induced by initial abnormal electrical activity and is maintained in the atrium with irregular reentry. These irregular electrical reentries are associated with structural and electrical remodeling. The ion channel-like protein connexin appears to be important in remodeling . This reAtrial systolic function may not be recovered even when cardioversion is performed chemically or electrically. We suggest that the cause of this phenomenon is that structural and electrical remodeling of the atrium may not be reversed quickly. The fact that persistent atrial fibrillation induces chronic hibernation-like changes in the atrial myocardium may explain the slow reversal . Inhomoget al (Thomas et al  reportedIn the present study, connexin 43 exhibited an abundant plasmalemmal distribution in the heart failure group and a smaller connexin 43-stained area in the heart failure-ARB group. Additionally, western blotting showed that the connexin 43 bands of the heart failure group were more marked than those of the heart failure-ARB group. We hypothesize that the change in the quantity and distribution of connexin 43 is the result of changes in dephosphorylated connexin 43 levels in myocardial infarction or ischemic heart failure. Connexin 43 has multiple electrophoretic isoforms, including a non-phosphorylated and phosphorylated form. Phosphorylation regulates the assembly, degradation and gating of connexin 43 . During et al (et al (et al (Certain studies have reported the changes in connexin quantity or arrangement of various species  and the et al  reportedl (et al  reportedl (et al  reportedet al. Regardless of the connexin results, it is important for physicians to know whether ARBs have potential as an upstream therapy in atrial fibrillation. However, in the present induction study of atrial fibrillation, it was not possible to not identify a significant difference between heart failure and heart failure-ARB groups. Certain studies have reported that candesartan is able to prevent atrial fibrillation, and thus inhibit atrial structural remodeling (The results of the present study are compatible with the results of Rucker-Martin modeling . In a camodeling . The 201modeling . The guimodeling .The present study had several limitations. Losartan potassium is lipid-soluble, so if it is dissolved in water, an uneven distribution may be expected. However, ground medicine and provender were mixed for each rat individually. Also, whether the rats had eaten all their provender was checked daily.Echocardiography is a sonographer-dependent technique. As such, there is a probability of inter-observer variation or open labeling. In the present study, all echocardiography was performed in a blinded state to attenuate such concerns.The fact that an angiotensin converting enzyme inhibitor is able to inhibit left ventricular dilatation in patients with ventricular dysfunction following myocardial infarction has been well established by animal experiments and clinical trials ,28. In tIn conclusion, ARBs have a small preventive effect in atrial fibrillation if there is no underlying heart disease such as heart failure. However, ARBs also have an atrial reverse remodeling effect. It was revealed that, in a rat ischemic heart failure model, the ARB losartan had structural and histological atrial reverse-remodeling effects. It should be kept in mind that atrial fibrillation is a result of complex molecular, mechanical and electrical remodeling. Thus, we suggest that gap junctions may not be surrogate targets for atrial remodeling. The role of ARBs as electrical stabilizers requires further study.


The aim of this study was to compare two methods of myocardial edema imaging: DWI and T2-TIRM.Recent studies, performed with the use of a commercially available diffusion weighted imaging (DWI) sequence, showed that they are sensitive to the increase of water content in the myocardium and may be used as an alternative to the standard T1 - the contrast between edema and healthy myocardium and CNR2 - the contrast between edema and intraventricular blood pool. The area of edema was measured for both TIRM and DWI sequences and compared with the infarct size in LGE images.The study included 91 acute and post STEMI patients. We applied a qualitative and quantitative image analysis. The qualitative analysis consisted of evaluation of the quality of blood suppression, presence of artifacts and occurrence of high signal (edema) areas. On the basis of edema detection in AMI and control (post STEMI) group, the sensitivity and specificity of TIRM and DWI were determined. Two contrast to noise ratios (CNR) were calculated: CNR2-TIRM, whereas in the DWI sequence in 85%. An analysis of the image quality parameters showed that the use of DWI sequence allows complete blood signal suppression in the left ventricular cavity and reduces the occurrence of motion artifacts. However, it is connected with a higher incidence of magnetic susceptibility artifacts and image distortion. An analysis of the CNRs showed that CNR1 in T2-TIRM sequence depends on the infarct location and has the lowest value for the inferior wall. The area of edema measured on DWI images was significantly larger than in T2-TIRM.Edema occurred more frequently in the DWI sequence. A major difference was observed in the inferior wall, where an edema-high signal was observed in 46% in TDWI is a new technique for edema detection in patients with acute myocardial infarction which may be recommended for the diagnosis of acute injuries, especially in patients with slow-flow artifacts in TIRM images. Evaluation of AMI  with magnetic resonance imaging, allows detection of reversible and irreversible injury of the myocardium . Cardiov2 weighted sequences are commonly applied to detect myocardial edema [2 images allow the quantification myocardial salvage index and to distinguish between acute and chronic injure [1 and T2 times (e.g. edematous myocardium). Despite all the advantages of T2 imaging, the above technique has some limitations. One of the main shortcomings of this breath-hold technique are motion artifacts, which blur the image in the case of non compliant patients. Partial blood suppression in the area of slow flow leads to a “slow flow artifact” resulting in high signal, which is often confused with sub-endocardial edema [Tal edema -7. Combic injure ,8. Turboc injure -7,9. Inval edema . Dark-blDiffusion Weighted Imaging (DWI) is a well known technique in neuroradiology owing to its ability to detect ischemic regions in brain tissue . Rapid d2 turbo inversion recovery, black blood sequences - TIRM.The aim of this study was to assess myocardial edema with diffusion weighted imaging in patients with acute myocardial infarction and to compare it with commonly used (routinely in our lab) TWe screened 125 consecutive patients with STEMI admitted to the Department of Cardiology, University of Medical Sciences in Poznan, between June and December 2011. STEMI was defined as the presence of continuous chest pain for at least 30 min, ST-segment elevation in 2 or more contiguous ECG leads , elevated markers of myocardial necrosis (troponin I–TnI or creatinine kinase MB– CK-MB), the presence of coronary artery occlusion or significant stenosis with visible thrombus on initial coronary angiogram. All patients were treated with primary PCI in accordance with current STEMI guidelines. We excluded patients with STEMI and previous myocardial infarction, patients in critical clinical condition , patients with acute or chronic renal failure (contraindication to gadolinium contrast), or with other contraindications to CMR . The final group numbered 91 patients.•control group - patients who were subjected to magnetic resonance imaging at least 6 months after myocardial infarction, n = 20;•AMI group - patients who were subjected to magnetic resonance imaging not later than 7 days after myocardial infarction, n = 71.All patients expressed a written consent to participate in the examination and a protocol was approved by the Bioethical Committee of the University of Medical Sciences in Poznan.2 triple inversion recovery (TIRM) and DWI sequences were applied before contrast administration for detection of myocardial edema. Both sequences were acquired at the same location. Details of the compared sequences are shown in Table CMR was performed on 1.5 Tesla scanner  with the use of a six-channel phased-array body coil combined with a six-channel spine matrix coil. The study protocol consisted of the following sequences: scout images in coronal, sagittal and transverse planes performed to locate the anatomical axes of the heart. Steady State Free Precession (SSFP) cine imaging was performed for wall motion and left ventricular function assessment in 2-, 3-, 4-chamber and short axis planes. TAll CMR images were analysed on a dedicated workstation  by two separate observers. Analysis of left ventricular ejection fraction was performed using Argus software and volumetric method.Initially, both AMI and control group patients were screened for the presence or absence of edema. To avoid interpretation bias, TIRM and DWI images were presented to the observers separately in random order. Moreover, in order to achieve blinding, the reviewer did not know patients’ clinical and angiographic data, or the assessment provided by the other observer. Sensitivity and specificity of TIRM and DWI were determined on the basis of the edema detected in AMI and control groups. Each patient in the AMI group was assumed to show an increased signal in the infarct area, while in the control group an increased signal should not be present.Next, a detailed qualitative and quantitative image analysis was performed in AMI group (n = 71). For this purpose matching short axis slices were compared across SSFP, TIRM, DWI and LGE images.The qualitative analysis consisted of evaluation of the quality of blood suppression, presence of motion and other artifacts  and the occurrence of high signal (edema) areas.For the quantitative analysis, endo- and epicardial borders were manually outlined and signal intensity with standard deviation for four areas was measured: healthy muscle, the area of edema, left ventricular cavity and the background. Normal myocardium was defined as segments with normal regional wall thickening in retro images and the absence of contrast enhancement in LGE images. For TIRM and LGE images, a high signal of edema/infarction was defined as a myocardial signal intensity exceeding the mean value + 2 × standard deviation (SD) of noninfarcted, normal myocardium ,16. In o1 - the contrast between edema and healthy myocardium and CNR2 - the contrast between edema and intraventricular blood pool. The area of edema was measured for both TIRM and DWI sequences and compared with the infarct size in LGE images in the same slice position. Results are presented as a percentage of the left ventricle slice area.For quantitative evaluation of DWI and TIRM images in AMI group we used the method described by Deux . Two conWe also examined the correlation between the area of edema in TIRM and DWI sequences with the area of fibrosis measured in LGE images. In order to visualize the area of edema that was smaller than the area of fibrosis, we applied the line of identity which denoted edema equal to fibrosis. Points located below the line of identity represent cases in which the designated area of edema was smaller than the area of fibrosis.DW images with b-value 50 s/mm2 were chosen for all the calculations as they showed the highest signal intensity for edema and healthy myocardium Figure .Because of the differences in the sequence parameters between DWI and TIRM the measurements of the signal intensity in TIRM was multiplied by a factor of 0.93 ,17.The consensus of the observers’ assessments and the mean measurement value estimated by them were analyzed. Values of continuous variables are expressed as a mean (±SD) and a median (range). Normality was confirmed or excluded using the Shapiro-Wilk test. Continuous variables were compared using Mann Whitney or Wilkoxon test and noncontiguous data using chi-square test. Statistical significance was defined as p < 0.05.The study included 91 patients, 71 in AMI and 20 in the control group. Groups did not differ regarding basic clinical data  than TIRM sequence (60.6%) with the same specificity of 90%. The negative predictive value was found to be higher in the DWI sequence (60.0%) than in TIRM images (39.1%). Both sequences had the positive predictive value of approximately 96%.The analysis of the quality parameters of TIRM and DWI of the AMI group showed a significant difference in signal suppression of the left ventricle blood signal. In TIRM sequence, suppression was accomplished in 50 out of 71 patients, while in DWI in all cases. The occurrence of motion artifacts was significantly higher in the TIRM images 24%, relative to DWI 3%. There was also a significant difference in the frequency of susceptibility artifacts . Most significant, high signal of myocardial edema was detected in 43 (58%) of the patients in TIRM and 59 (80%) in DWI (Table 1) and the contrast ratio between the area of edema and blood inside the left ventricle (CNR2) did not differ between DWI and TIRM sequences  in TIRM sequence (p = 0.0442). The highest value of CNR1 occurred in the area supplied by the left descending coronary artery (CNR1 = 21.4 ± 7.1), while the lowest in the area supplied by the right coronary artery (CNR1 = 15.4 ± 6.3) . For TIRM, the values were r = 0.39, p = 0.01. In TIRM images, in 8 patients edema was smaller than fibrosis in LGE images. In DWI this difference was observed in two patients only . Abel-Aty et al. reported 91-94% and 92-100% , differentiating between the acute and chronic myocardial infarction with T2-TIRM and LGE [2-TIRM allows detection of acute myocardial infarction with 100% sensitivity and specificity [2-TIRM and ACUT2E and found that only in 61% of cases T2-TIRM allowed proper identification of infarct-related artery. The sensitivity was 96% and specificity of detection of the anterior wall edema and not more than 35% [Our study indicates that diffusion weighted imaging detects areas of increased myocardial signal in patients with acute myocardial infarction with high sensitivity and specificity (83.1% and 90.0% respectively). DWI may also be used to differentiate chronic from acute injury. Other authors have reported the presence of edema in DWI in all patients in the acute phase of myocardial infarction ,13. Howecificity . Payne ethan 35% . In this1 in TIRM depended on infarct location  and b value (high). However, in this study b = 50 mm2/s was used, therefore the role of T2 relaxation in DWI signal intensity is significant. Also high signal intensity in the infarction area reflects the perfusion disorder in myocardium. Diffusion-weighted imaging performed in a well-vascularized tissue results in attenuation of signal observed at low b values (e.g. 0–100 s/mm2), as the capillary blood flow analyzed in a voxel scale, may be mistaken for a type of diffusion. Since all AMI patients had abnormal microvascular perfusion due to acute myocardial infarction, we cannot exclude that this effect influenced the detection of the increased signal. Further, it cannot be excluded that DWIs provided some false positive results due to the bulk motion artifact. Diffusion imaging using EPI is sensitive to several artifacts, of which geometric distortions are most frequent. Those distortions, induced by magnetic susceptibility differences across the imaging tissues and bulk motions appearing during the application of the diffusion gradients, may lead to inhomogeneous signal attenuation artifacts  in DWI [1 and T2 values as is the case in single diffusion weighted images. However, since the impact of all factors on myocardial signal intensity in patients with acute myocardial infarction has not yet been fully examined, the analysis of ADC maps is beyond the scope of this paper.We also found that the mean size of edema-high signal measured in DWI was significantly larger than in TIRM images. This difference may be due to the fact that the signal in the DWI sequence is influenced by two factors: relaxation time of water in the area of edema and the cardiac perfusion. Because the DWI is a T) in DWI . These a2-TIRM and DWI correlates with the area of fibrosis in LGE images. The correlation is much stronger for DWI sequence (r = 0.67 vs r = 0.39 in T2-TIRM). In addition, the analysis showed that in T2-TIRM in 8 patients, the area of edema was smaller than that of fibrosis. In DWI this difference occurred only in two patients. Since the area of edema should always be greater than, or equal to, the area of fibrosis, it must be recognized that the application of T2-TIRM will more frequently underestimate the area of edema.We have also shown that the area of edema measured in TThis study has three main limitations:In our study the minimum pPCI to CMR time in the control group was 235 days. Previous studies showed that in some patients, small edema lesions might still be present 6 or even 12 months after AMI -24. Cons2 imaging has a higher diagnostic accuracy than application of TIRM in AMI [2-prepared SSFP. However, since T2-TIRM continues to be widely used in most centers and has acceptable reproducibility [TIRM sequence was used as a reference method for DWI although recent studies have shown that bright blood TM in AMI -27. AlsoM in AMI ,29 are acibility , the metThis study evaluates two different methods for edema imaging. In such a study full blindness is cumbersome to achieve due to the specific characteristics of the images which are practically impossible to conceal. This has a negative effect on the qualitative analysis while the quantitative analysis, based on objective parameters, is less affected.2-TIRM. The sensitivity of the DWI sequence, in contrast to the T2-TIRM, does not depend on the infarct location, provides total suppression of the blood signal and reduces the occurrence of motion artifacts. DWI may be recommended for the diagnosis of acute injuries, especially in patients with “slow-flow” artifacts in TIRM images. The results of our study require further investigation, especially in light of a relatively few papers on diffusion imaging of the heart. It should also be remembered that the diffusion weighted imaging is more challenging and demanding for the technical staff. It is more time consuming and requires manual adjustment of the acquisition window, depending on the patient heart rate. However, these obstacles can be eliminated by introducing a diffusion sequence dedicated to cardiac imaging, thus allowing automatic adjustment of the acquisition window.Diffusion weighted imaging is a new technique for edema detection in patients with acute myocardial infarction and has a higher sensitivity in the detection of myocardial edema than TACU2E: Acquisition for cardiac unified T2 edema; ADC: Apparent diffusion coefficient; AMI: Acute myocardial infarction; CMR: Cardiovascular magnetic resonance; CNR: Contrast to noise ratio; DWI: Diffusion weighted imaging; EPI: Echo planar imaging; FoV: Field of view; LAD: Left coronary artery; LCX: Left Circumflex Artery; LGE: Late gadolinium enhancement; LV: Left ventricle; NSTEMI: Non ST elevation myocardial infarction; PACE: Motion under control with prospective acquisition correction; PAT: Parallel acquisition technique; pPCI: Primary percutaneous coronary intervention; RCA: Right coronary artery; SD: Standard deviation; SNR: Signal to noise ratio; SSFP: Steady state free precession; STEMI: ST elevation myocardial infarction; T2-TIRM: T2 turbo inversion recovery with magnitude display; TE: Echo time; TR: Repetition time.The authors declare that they have no competing interests.AK was involved in developing the sequence, collecting and analysing the data, drafting and submitting the manuscript. MP was involved in designing the study, revising and submitting the manuscript. KK was involved in designing the study and developing the sequence. MŁ, AS MJ were involved in evaluating the patients studies. SG was involved in overseeing the study. All authors have read and approved the final manuscript.


However, the effect of iron overload with cardiac T2* magnetic resonance imaging (MRI) on cardiac repolarization remains unclear yet. We aimed to examine relationship between repolarization parameters and iron loading using cardiac T2* MRI in asymptomatic β-TM patients. Twenty-two β-TM patients and 22 age- and gender-matched healthy controls were enrolled to the study. From the 12-lead surface electrocardiography, regional and transmyocardial repolarization parameters were evaluated manually by two experienced cardiologists. All patients were also undergone MRI for cardiac T2* evaluation. Cardiac T2* score <20 msec was considered as iron overload status. Of the QT parameters, QT duration, corrected QT interval, and QT peak duration were significantly longer in the β-TM group compared to the healthy controls. Tp − Te and Tp − Te dispersions were also significantly prolonged in β-TM group compared to healthy controls. (Tp − Te)/QT was similar between groups. There was no correlation between repolarization parameters and cardiac T2* MRI values. In conclusion, although repolarization parameters were prolonged in asymptomatic β-TM patients compared with control, we could not find any relation between ECG findings and cardiac iron load.Previous studies have demonstrated impaired ventricular repolarization in patients with  Although QT prolongation was demonstrated in patients with β-TM [β-TM and found no correlation of QT parameters with both serum ferritin levels and liver iron concentration. Interestingly, two experimental models have found that iron does not cause arrhythmias in guinea pig model and gerbil [β-TM [β-TM patients and examine the relation of these repolarization parameters with cardiac T2* MRI value.Conventional QT parameters and transmyocardial repolarization parameters including myopathy –7. Thereith β-TM –10, therith β-TM , 12. Chrith β-TM –16. Ulgeith β-TM  investigd gerbil , 18. Card gerbil . Cardiacil [β-TM . Howeverβ-TM and 22 age- and gender-matched healthy subjects were prospectively enrolled to the study. Included patients gave their verbal and written consent for participation in the study. The study was approved by the local ethical committee. The diagnosis of TM was made on hemogram, blood smear, hemoglobin electrophoresis, and clinical evaluation. The patients had been regularly transfused (every 3-4 weeks), and everyone received chronic chelation therapy (deferoxamine or deferiprone). Exclusion criteria were diabetes mellitus, history of coronary artery disease, congestive heart failure, congenital or acquired arrhythmia syndromes, use of drugs that lengthen the QT interval, current AF, bundle branch block, atrioventricular blocks, and unmeasurable T waves (<0.15 mV) on surface ECG. This is a cross-sectional case control study which was conducted at the Hematology department, Selcuk University, in Konya, Turkey. Twenty-two  with diagnosis of Surface 12-lead standard ECGs were recorded from each patient with a 50 mm/s paper speed at 10 mm/mV amplitude. Timing of electrocardiographic measurements was adjusted to the last blood transfusion, so ECG was performed at least two weeks later after blood transfusion. The ECGs were scanned at a 600 dpi resolution and analyzed manually by two experts who were blinded to the clinical status of the study population. Three consecutive ECG complexes were analyzed and given averaged measures for each lead. The QT intervals were measured from the onset of the first deflection of the QRS complex to the end of T wave in all 12 leads. If the T wave was flat or the end of the T wave was difficult to define, or if the T wave amplitude was <0.15 mV, the lead was excluded from measurement. The end of the QT interval was defined as the intersection of the terminal part of the T wave and the isoelectric line. If a U wave interrupted the T wave before it returned to baseline, the end of the QT interval was defined as the nadir between T and U waves.Corrected QT interval (cQT) was calculated using Bazett's formula Tp − Te interval was defined as the interval between QT and QT peak (Tp − Te = QT − QTp). The difference between maximum Tp − Te and minimum Tp − Te was defined as Tp − Te dispersion (Tp − Te to QT duration (Tp − Te/QT) was also calculated. Intra- and interobserver variablities for Tp − Te were determined of 6.7% and 8.3%, respectively.spersion . The rathttp://www.cmrtools.com/) for quantification. Iron loading in the heart was evaluated with MRI T2*. MR images were acquired for all patients with a single imager equipped with a 1.5 T magnet . Body phased array coil to image a single 10 mm midventricular short axis slice at eight echoes times  with ECG gating and breath hold was also utilized. A gradient-echo sequence was used . Double inversion recovery pulses were applied to suppress the blood signal and data was acquired every other cardiac cycle. The monoexponential decay model and the nonlinear curve fitting algorithm were used to fit the curve to obtain T2 measurement. We used CMR Tools software (U test was used for nonparametric comparison of two groups. A Spearman correlation test was used to assess linear association. The data were expressed as mean ± standard or median (inter quartile range) deviation according to the distribution properties, and P value under 0.05 was considered statistically significant.The statistical analysis was performed with the help of the Statistical Package for Social Sciences (SPSS for Windows) software (version 15.0) . The relation between the categorical variables was determined by the chi-square test. The distribution of the variables was analyzed with the Kolmogorov-Smirnow test. The Mann-Whitney β-TM patients were not different from the control group in age, gender, body-mass index, or blood pressure levels. The mean cardiac T2* value of patients with β-TM was 21.7 ± 9.0 ms. Hemoglobin (Hb) and hematocrit (Hct) levels were significantly lower in β-TM group than in the control group  (ol group . Heart r= 0.004) . Mean caβ-TM patients presented with increased QT duration , QTc , and peak QT duration  . Tp − Te and (Tp − Te)d were significantly higher in β-TM group than that in controls  (Tp − Te/QT ratio (P = 0.32) and T-wave amplitude (P = 0.39). Heart rate was significantly increased in patient group compared to control group   . QTd and, resp.) . No stat, resp.) . ECG findings were similar in those patients with cardiac T2* < 20 msec and those with cardiac T2* ≥ 20 msec . Both coTp − Te, and (Tp − Te)d were significantly prolonged in patients with β-TM compared to healthy subjects. Neither conventional QT parameters nor transmyocardial repolarization parameters were correlated with cardiac T2* MRI values. To the best of our knowledge, the present study is a first time study, where the relation between cardiac T2* MRI values and transmyocardial repolarization parameters was investigated.The present study demonstrated that repolarization parameters including QT, QTc, QTp, β-TM patients [β-TM patients is indicated for reduction of morbidity and mortality. The toxicity of iron was attributed to the following mechanisms: (a) excessive intracellular iron interferes with electrical function of the heart [+ channels [ Cardiac complications, including arrhythmias, are among the leading causes of morbidity and mortality of transfusion-dependent, iron-overloaded patients . Patientpatients . Early dhe heart , (b) cathe heart , and (c)channels . Furtherchannels .β-TM patients. The results of these studies were conflicting. Some of them found prolonged QT, QTc, QTd, and cQTd in β-TM patients compared to controls [β-TM patients and controls [β-TM. Evaluation of conventional QT parameters was previously performed in controls –10. In tcontrols , 12. In β-TM patients. There is only a study where Magri et al. [ The relationship between QT parameters and iron overload measured by serum ferritin level was investigated previously. Ulger et al.  found noi et al.  demonstrTp − Te, (Tp − Te)d, and (Tp − Te)/QT ratio. Therefore we think that myocardial iron overload may contribute to creating transmyocardial nonhomogeneity and these ECG parameters may better demonstrate the relation between iron overload and repolarization parameters than conventional QT parameters. However, the data in Tp − Te are very scarce in β-TM patients. There is only a study where Kocharian et al. [Tp − Te and (Tp − Te)d in patients with β-TM. Nevertheless, they did not investigate (Tp − Te)/QT ratio. We also found higher transmyocardial repolarization parameters except for (Tp − Te)/QT ratio in β-TM patients compared to the healthy subjects. In contrast to conventional QT parameters, there is no study investigating the relation between transmyocardial repolarization parameters and both ferritin levels and cardiac iron load. For the first time, we investigated the relation of transmyocardial repolarization parameters with cardiac T2* values. In our study, we found no difference in transmyocardial repolarization parameters in patients with T2* < 20  msec and those with T2* ≥ 20 msec. In addition, there was no linear relation between transmyocardial repolarization parameters and cardiac T2* values. These results support the theory that fibrosis as a cause of iron overload may be more deleterious than iron itself. Iron alone is not sufficient to cause arrhythmia and other comorbid conditions can contribute to arrhythmias. This issue was observed in nonhuman models [Regarding transmyocardial repolarization, there are three layers in the myocardium: the endocardial, the M-cell, and the epicardial layer. The myocardial layers are at different repolarization phases creating transmyocardial nonhomogeneities, which become substrates for reentry causing malignant arrhythmias . These tn et al.  demonstrn models , 18. In n models . Taken tβ-TM patients, (b) we did not perform cardiac MRI in control group because of cost. In addition, because of controversial results in the literature, we aimed to evaluate whether repolarization parameters are impaired in patients with β-TM or not, (c) β-TM patients were under chelation therapy and this type of therapy may blind results of the study. Therefore our results may not be applicable to patients not undergoing this kind of therapy, (d) because of speculations that fibrosis as a cause of iron load may impair repolarization parameters, we think that investigation of noninvasive markers of fibrosis, such as metalloproteinase, procollagen type I, and procollagen type III needs to be investigated in future.A few limitations deserve mention: (a) this study is a cross-sectional study with small sample size and large prospective randomized studies are needed to clarify the relationship between the both impaired regional and transmyocardial repolarization parameters and subsequent cardiac events in β-TM patients and it was unrelated with cardiac T2* MRI values. Thus it needs to well-designed randomized investigations in this area.The present study demonstrated that repolarization parameters are impaired in asymptomatic


Stress-related cardiomyopathies can be observed in the four following situations: Takotsubo cardiomyopathy or apical ballooning syndrome; acute left ventricular dysfunction associated with subarachnoid hemorrhage; acute left ventricular dysfunction associated with pheochromocytoma and exogenous catecholamine administration; acute left ventricular dysfunction in the critically ill. Cardiac toxicity was mediated more by catecholamines released directly into the heart via neural connection than by those reaching the heart via the bloodstream. The mechanisms underlying the association between this generalized autonomic storm secondary to a life-threatening stress and myocardial toxicity are widely discussed. Takotsubo cardiomyopathy has been reported all over the world and has been acknowledged by the American Heart Association as a form of reversible cardiomyopathy. Four "Mayo Clinic" diagnostic criteria are required for the diagnosis of Takotsubo cardiomyopathy: 1) transient left ventricular wall motion abnormalities involving the apical and/or midventricular myocardial segments with wall motion abnormalities extending beyond a single epicardial coronary artery distribution; 2) absence of obstructive epicardial coronary artery disease that could be responsible for the observed wall motion abnormality; 3) ECG abnormalities, such as transient ST-segment elevation and/or diffuse T wave inversion associated with a slight troponin elevation; and 4) the lack of proven pheochromocytoma and myocarditis. ECG changes and LV dysfunction occur frequently following subarachnoid hemorrhage and ischemic stroke. This entity, referred as neurocardiogenic stunning, was called neurogenic stress-related cardiomyopathy. Stress-related cardiomyopathy has been reported in patients with pheochromocytoma and in patients receiving intravenous exogenous catecholamine administration. The role of a huge increase in endogenous and/or exogenous catecholamine level in critically ill patients  to explain the onset of myocardial dysfunction was discussed. Further research is needed to understand this complex interaction between heart and brain and to identify risk factors and therapeutic and preventive strategies. Neurocardiology has many dimensions, namely divided in three categories: the heart's effects on the brain ; the brain's effects on the heart ; and neurocardiac syndromes, such as Friedreich disease . The preThe first description of suspected SRC was reported by W.B. Cannon in 1942 cited by Engel et al. [It is now widely admitted that this autonomic storm, which results from a life-threatening stressor, can be observed in the four following situations that induce left ventricle (LV) dysfunction :- Takotsubo cardiomyopathy or apical ballooning syndrome - Acute LV dysfunction associated with subarachnoid hemorrhage - Acute LV dysfunction associated with pheochromocytoma and exogenous catecholamine administration - Acute LV dysfunction in the critically ill Emotional and physical stress can induce an excitation of the limbic system. Amygdalus and hippocampus are, with the insula the principle brain areas, implicated in emotion and memory ,10. ThesWittstein et al. compared plasma catecholamine levels in patients with SRC to those observed in patients with Killip class III myocardial infarction . They reThe mechanisms underlying the association between this generalized autonomic storm secondary to a life-threatening stress and myocardial toxicity are widely discussed. Three mechanisms have been reported. Some authors have suggested that multivessel epicardial coronary artery spasm could supervene, but angiographic evidence of epicardial spasm was not reported by Wittstein et al. . CoronarJapanese authors reported in the nineties the first cases of reversible cardiomyopathy precipitated by acute and severe emotional stress in postmenopausal women ,17-20. TUsually seen in postmenopausal women, the clinical presentation of Takotsubo is similar to that of an acute coronary syndrome with typical chest pain and ECG abnormalities. Reported emotional stress included for example death of a family member, traffic road accidents, financial loss, and disasters, such as earthquakes ,23,24. ITypically, echocardiography showed apical and midventricular wall motion abnormalities and hyperkinesis of the basal myocardial segments . These wWhen performed, LV angiography confirmed these wall motion abnormalities Figure  with theMany morphological LV variants of Takotsubo have been reported: isolated midventricular and basal dysfunction with apical sparing, isolated basal hypokinesis, named inverse Takotsubo ,26. The Bybee and Prasad suggested four "Mayo Clinic" diagnostic criteria for Takotsubo: 1) transient LV wall motion abnormalities involving the apical and/or midventricular myocardial segments with wall motion abnormalities extending beyond a single epicardial coronary artery distribution; 2) absence of obstructive epicardial coronary artery disease that could be responsible for the observed wall motion abnormality; 3) ECG abnormalities, such as transient ST-segment elevation and/or diffuse T-wave inversion associated with a slight troponin elevation; and 4) the lack of proven pheochromocytoma and myocarditis [Patients with suspected and/or proved Takotsubo must be monitored in intensive care. Because massive catecholamine release was observed in Takotsubo-induced stunned myocardium, beta agonists and vasopressors might be avoided whenever possible even in acute circulatory failure and mechanical circulatory support preferred if necessary. Sympathetic activation suggested the use of beta blocker therapy as soon as LV failure was corrected. The presence of a dynamic obstruction in the LV outflow precluded the initiation of an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or diuretic treatment because of a possible potentiation. Anticoagulation with heparin was required to prevent left ventricle thrombus formation ,24,27.Echocardiographic examination will be regularly performed after hospital discharge to evaluate the resolution of LV dysfunction, which is complete in the majority of the patients after 1 to 3 months. A favorable prognosis has been widely reported in the more recent literature .ECG changes and LV dysfunction occur frequently after subarachnoid hemorrhage and ischemic stroke. This entity, referred as neurocardiogenic stunning, was called neurogenic SRC . Four inEchocardiography shows hypokinesis involving basal and midventricular portion of the left ventricle, i.e., inverse Takotusbo. These findings are more usual than those observed in patients suffering from Takotusbo. Bybee and Prasad have suggested an algorithm for the evaluation of patients with subarachnoid haemorrhage and LV dysfunction associated with ECG abnormalities . SimilarLV dysfunction has been reported in the case of endogenous or exogenous over production of catecholamines. Pheochromocytoma is a rare neuroendocrine tumor located in the adrenal medulla that secretes catecholamines and particularly norepinephrine. Many case reports have suggested the onset of reversible LV dysfunction mimicking neurogenic SRC and rarely Takotusbo ,26. ThisAcute LV failure occurs in approximately one-third to one-half of critically ill hospitalized patients. As reported by Chockalingam et al., determination as to whether the LV dysfunction is the cause, effect, or a coincidental finding has to be made and revisited periodically . One of If a previously undiagnosed dilated cardiomyopathy is excluded, global LV dysfunction can be partly explained by a relative contribution of direct catecholamine myocardial toxicity in the following situations: tachycardia-induced cardiomyopathy, hypertensive crisis, sepsis, multiorgan dysfunction, and postcardiac arrest syndrome. In these situations, a high incidence of myocardial injury assessed by cardiac troponin I levels was demonstrated despite the lack of acute coronary syndromes on admission to the intensive care unit ,32. QuenTachycardia-induced cardiomyopathy has been defined as a global systolic LV dysfunction secondary to atrial or ventricular tachyarrhythmias that reversed with rhythm control ,34. StudMild troponin elevations, ischemic ECG changes, and LV dysfunction can be observed in patients with uncontrolled hypertension, for example, in patients suffering from neuroendocrine tumors, such as pheochromocytoma. Rapid blood pressure lowering was required with vasodilators, i.e., nitroglycerin infusions and/or oral administration of ACE inhibitors and angiotensin receptor antagonists, to prevent the onset of acute LV dysfunction and cardiogenic shock ,35,36.Myocardial dysfunction, which is characterized by transient biventricular impairment of myocardial contractility, is commonly observed in patients suffering from severe sepsis and septic shock ,38. LV dBy contrast, some authors consider sepsis-induced myocardial depression an adaptative and at least partially protective process ,43. TheyThus, to keep adrenergic stimulation of the heart at the minimum level, some recently published papers suggested a place for beta-blockers to favor the enhancement of the decatecholaminization in septic critically ill patients ,43,46. OPrengel et al. reported that severe stress, such as that occurring with cardiac arrest and cardiopulmonary resuscitation, activates the sympathetic nervous system and causes a rise in plasma catecholamine concentrations, which could play a role in the onset of post cardiac arrest myocardial dysfunction . This po1-adrenergic actions [The time to recovery appeared to be between 24 and 48 hours and complete for a wide majority of the patients. Laurent et al. reported that cardiac arrest survivors have reduced cardiac output 4 to 8 hours later . Cardiac actions -52. ThisIn conclusion, SRC can occur after an acute physical or psychological stress, subarachnoid hemorrhage, pheochromocytoma crisis, acute medical illness, such as severe sepsis, and after the administration of exogenous catecholamine administration. The presence of contraction band necrosis in the myocardial biopsy specimen suggests a catecholamine-mediated mechanism even if other pathophysiological mechanisms have been suggested. Further research is needed to understand this complex interaction between heart and brain and to identify risk factors and therapeutic and preventive strategies.The author declares that they have no competing interests.


Journal of Cardiovascular Magnetic Resonance (JCMR) in 2011, which is an 11% increase in the number of articles since 2010. The quality of the submissions continues to increase. The editors had been delighted with the 2010 JCMR Impact Factor of 4.33, although this fell modestly to 3.72 for 2011. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, we remain very pleased with the progress of the journal's impact over the last 5 years. Our acceptance rate is approximately 25%, and has been falling as the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors feel it is useful to summarize the papers for the readership into broad areas of interest or theme, which we feel would be useful, so that areas of interest from the previous year can be reviewed in a single article in relation to each other and other recent JCMR articles [1]. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality manuscripts to JCMR for publication.There were 83 articles published in the  CMR is reasonably mature for assessment of cardiac function, with categorization by age decile, gender and body surface area for normal values for the left ventricle (LV) , right vPatients with the metabolic syndrome are often found to have left ventricular hypertrophy and raised LV mass . ThiazolIncreased left atrial size is a marker of left ventricular diastolic dysfunction and is a direct result of raised left ventricular end-diastolic pressure. It is a strong prognostic predictor of outcomes in patients with diastolic dysfunction but less is known about the prognostic significance of atrial contractile function. Over a median follow-up period of 19 months, Kaminski studied 210 patients with chronic hypertension who underwent a clinically indicated CMR scan for assessment of left ventricular function, myocardial ischemia or viability . Left atIt is without doubt that one of the major advantages of CMR over other imaging techniques is the robust measurement of myocardial volumes and mass. High interstudy and interobserver reproducibility makes the technique ideally suited for longitudinal follow-up and can dramatically reduce sample size required for clinical trials . Childs This paper was a report of the CMR tagging substudy of the Autologous Stem Cell Transplantation in Acute Myocardial Infarction trial (ASTAMI), exploring the regenerative effects of intracoronary delivery of autologous mononuclear bone marrow stem cells . Grid taThe differentiation of restrictive cardiomyopathy from pericardial constriction can be challenging as both conditions may have similar imaging features but require a very different management strategy. Patients with surgically documented pericardial constriction (n-23), restrictive cardiomyopathy (n = 22) and normal subjects (n = 25) were included in this study . Cheng eCMR myocardial feature tracking is a new technique which attempts to track myocardial motion at voxel level from standard steady-state-free-precession cine acquisitions. The technique generates values for circumferential and radial strain, and is not currently validated or in clinical use. Schuster et al performed feature tracking on 10 normals at 1.5 T using the 4 chamber view . StudiesCardiac resynchronization therapy (CRT) is of proven benefit in advanced heart failure, but an important subset do not respond. CMR has been increasingly used to study patients requiring CRT . AlpenduThe capability of CMR to measure cardiovascular flow contributes greatly to the versatility of CMR in clinical practice, and development of baseline flow corrections , and aut2 = 0.48, p < 0.001), left ventricular outflow tract (LVOT) diameter  and left ventricular ejection fraction (LVEF)  and a moderate correlation in terms of aortic valve area (AVA) . CMR generally tended to report larger values than TTE for all measurements. Bland-Altman analysis indicated that the 95% limits of agreement between TTE and CMR ranged from -5.6 mm to + 1.0 mm for annulus size, from -0.45 mm to + 0.25 mm for LVOT, from -0.45 mm2 to + 0.25 mm2 for AVA and from -29.2% to 13.2% for LVEF. CMR represents a viable complementary imaging method to TTE in elderly patients being considered for TAVI.Correlation and agreement between transthoracic echocardiography (TTE) and CMR in the assessment of aortic root dimension and LV morphology and function were studied in 49 patients undergoing transcatheter aortic valve implantation (TAVI) . There wThis is an interesting case report of a pseudoaneurysm of the left ventricle following trans-apical TAVI approach in an elderly lady with severe aortic stenosis . A 23 mmThere are currently a number of commercially available devices for left atrial appendage (LAA) closure to prevent the formation of thrombus and risk of stroke in atrial fibrillation. However, imperfect device placement or suboptimal ‘fit’ causing a residual ‘leak’ into the LAA has the potential to allow thrombus to form. This would mandate that the patient remains on long-term anticoagulation medication, thereby negating the potential benefit from device implantation. Mohrs’ pilot study of 7 patients with three different device occluders  assessed the feasibility of using CMR to detect residual leaks around the devices . First-pThis manuscript describes a follow-up study to the multi-vendor, multi-centre study by Gatehouse in which they measured offsets in phase contrast velocity mapping studies . In thisCongenital heart disease remains a major indication for CMR, and makes particular contribution in the assessment of the major vessels , shunt aQuantification of right ventricular myocardial function and any changes of it over time are important issues in congenital heart disease. Volumetric calculation of right ventricular (RV) ejection fraction is time consuming to acquire and analyse, and inter-study reproducibility is suboptimal. In this study, a linear tag orientated perpendicular to the basal free wall of the RV was used to measure long axis systolic displacement . The metThree dimensional echo is a relatively new technique which promises to offer a rapid alternative to CMR for the examination of the right heart. In this study, comparison of 3D echo with CMR measurements of RV volumes and function was undertaken in patients with varying degrees of RV dysfunction resulting from congenital heart disease . The echSurgical anastomoses of pulmonary veins are prone to re-stenosis, especially if attempted in the small, delicate veins of infants. For this reason, atrio-pericardial anastomosis uses a pericardial pouch to create a large communication between the left atrium and the pulmonary veins. It avoids direct suturing of the pulmonary veins during the repair of various congenital malformations. This study reviewed CMR assessments of this approach, performed in 31 of the 103 patients undergoing the procedure . FindingFontan surgery, performed for children with only one effective ventricle, involves reconnection of the systemic venous returns to the pulmonary arteries so that the one effective pump delivers flow to the systemic and then the pulmonary vasculature in series. The procedure requires careful pre-operative planning. After reviewing the investigations performed and their findings in 44 patients undergoing Fontan surgery, the authors of this paper propose a pre-procedure investigative-diagnostic algorithm . They foCMR is rapidly coming to be regarded as an indispensible imaging and investigative modality in paediatric cardiology. However, imaging small children with congenital heart disease is challenging. This paper provides an authoritative and clearly written review of the technical adjustments, imaging protocols and applications of CMR in the paediatric population .Those who routinely image patients with dilated and/or pressure loaded RVs are likely to have noticed signs of prolonged systole of the RV relative to that of the LV. This study used phase contrast velocity mapping to record the time course of tricuspid and mitral flow in 31 children with repaired tetralogy of Fallot . The autCMR study of an expectant mother’s haemodynamics is feasible and acceptable during mid to late pregnancy. It may be more comfortable in a left lateral than the supine position. This study of healthy pregnant women, 6 in mid pregnancy and 8 late in pregnancy, compared haemodynamic parameters and the effects of position on them . It concThis study compared CMR and echocardiographic approaches to assessments of aortic stenosis (AS) using the continuity approach that incorporates calculations of volume flow at left ventricular outflow tract (LVOT) level, and the post stenotic jet velocity time integral . CMR shoThis study used phase contrast CMR to record pulmonary artery flow in groups of patients with and without pulmonary embolus detected by computed tomography (CT) about 6 months previously . Both grTetralogy of Fallot is one of the commonest and most important congenital heart conditions whose management after surgical repair calls for serial follow up by CMR. The author gives a comprehensive and thoughtful review of the methods and interpretation of CMR studies in relation to the pathophysiology of condition . This reFour dimensional (4D) phase contrast velocity mapping is a relatively novel and impressive CMR technique. It entails the acquisition of all 3 directional components of velocity for voxels distributed in all 3 dimensions of space, triggered over many heart cycles to represent multiple phases of the cardiac cycle. This paper reviews and illustrates the methods used for the acquisition, visualization, and quantification of 4D velocity datasets, which typically takes ten or more minutes . AlthougSecinaro reported the use of CMR in a series of 6 patients at Great Ormond Street Hospital, London with clinical suspicion of ischemia following surgical repair for anomalous left coronary artery to pulmonary artery connection (ALCAPA) . The meaSince the first data on myocardial T2* CMR published in 2001 , there hThis paper analyzes the importance of increases in ejection fraction during treatment with iron chelators for myocardial siderosis on the future likelihood of developing heart failure, which is the most dangerous complication of multiple transfusions as the historical mortality is high once heart failure develops . The preThe CMR sequence used to measure myocardial T2* has gone incremental improvement since the first use of a non-breathold sequence which was influenced by tissue T1 in 2001. A single breathold multi-echo sequence was introduced in 2003 and was shown to be reliable and reproducible . HoweverPost-mortem reports in the 1960s and 1970s showed that patients dying of myocardial siderosis had severe replacement myocardial fibrosis. If this were the case today, it would be expected that heart failure related to myocardial siderosis would be irreversible. However, recent studies with aggressive intravenous iron chelation  have shoConsiderable attention has been paid to the effect of iron overload on the left ventricle, but little to its effects on the right ventricle. Recent work has shown normal right ventricular function in thalassemia , and itsAlthough myocardial T2* has been successfully introduced into clinical practice, it is not as available as it needs to be in lower income countries where thalassemia is prevalent. Seldrum examines CMR tagging as a possible alternative measure to detect myocardial iron . In 10 pCMR of patients with cardiomyopathy has become a leading referral over the last 5 years and there has been considerable interaction with cardiovascular geneticists as CMR offers high fidelity phenotyping , that auHypertrophic cardiomyopathy (HCM) is often described as associated with a reduced exercise capacity, perhaps best demonstrated by a reduced peak VO2. It is also often considered that in patients with unexplained LV hypertrophy, a suboptimal VO2 is a hallmark of HCM rather than hypertensive disease. This case study reports an asymptomatic male athlete with 25 years of ultra-endurance competition, with genetically confirmed HCM phenotypically manifesting with LVH, a small LV cavity together with repolarisation abnormalities suggestive of HCM . The autIn concert with major developments in genetic techniques an important group of patients are those that are gene positive and phenotypically negative, particularly in HCM. What is controversial is determining early markers of disease before the phenotype has manifested. In this study of 17 HCM mutation carriers, and normal wall thickness, using tissue tagging it was observed that there was increased LV torsion as well as endocardial circumferential strain and torsion-to-endocardial-circumferential-shortening ratio, which reflects the transmural distribution in contractile function . FurtherDetection of interstitial fibrosis is one of the most exciting fields in CMR at present. There is still much controversy over sequence types, and in particular whether slow infusion carries significant advantage over the more practical bolus option. In this study of 10 volunteers, serial Ve measures were compared across the 2 methods . ImportaLate gadolinium enhancement (LGE) has been the standard of reference for detecting focal myocardial fibrosis in clinical however, it relies on the differences in signal intensity between scarred and adjacent normal myocardium to generate image contrast. T1 mapping, is a promising quantitative method for detecting diffuse myocardial fibrosis. It has potential to provide significant insights into myocardial function. In this study, after validation of MOLLI sequences at 3 T in Phantoms, the authors present values for myocardial and blood T1 pre and post gadolinium contrast at 3 T . At 3 T,Takotsubo cardiomyapthy, also known as a stress-induced cardiomyopathy, refers to the transient LV apical ballooning observed after some form of stress that usually resolves. Part of the diagnosis assumes unobstructed coronaries. There is controversy over the presence of fibrosis. In this study, they observe that in 8 patients scanned serially in the sub-acute and late phase (1.5 and 6 months later), the presence of LGE in the subacute phase was associated with greater disease severity and more prolonged recovery . These fWet Beriberi is one of four clinical syndromes associated with Thiamine (Vitamin B1) Deficiency. Wet beriberi has varying degrees of cardiovascular involvement. In its most fulminant form, it is characterized by hypotension, tachycardia and lactic acidosis. If untreated, patients die within hours from circulatory collapse and pulmonary edema. This condition often goes unrecognized since it is easily confused with other illnesses. This is the first report demonstrating the CMR finding of myocardial edema associated with wet beriberi and uses a T2 mapping technique to gauge quantitative assessment . Whilst Limb-girdle muscular dystrophy (LGMD) comprises a group of genetically-heterogeneous disorders that present with variable skeletal and cardiac muscle involvement. LGMD produces progressive weakness of proximal shoulder-girdle or pelvic muscles with a wide range of phenotypic expression, severity, and age of disease onset. What is less clear is the extent and degree of cardiac involvement. In this study, consecutive patients with genetically-proven LGMD types 2I (n = 7) and 2B (n = 9) and 8 control subjects were enrolled . All subThe lamin A/C gene (LMNA) is so far the most significant disease gene identified clinically for dilated cardiomyopathy (DCM). It has been estimated that LMNA mutations cause up to 10% of familial DCM. The penetrance of the LMNA mutations causing cardiomyopathy is nearly complete. It is associated with an increased risk of sudden death and heart-failure. The main aim of this study was to characterise myocardial fibrosis, regional wall motion abnormalities, ventricular dilatation, longitudinal LV systolic function and global function with LGE CMR in asymptomatic or mildly symptomatic carriers of LMNA mutations causing DCM . They alCardiac resynchronization therapy has become an important mainstay in the management of patients with heart-failure. Unfortunately, about 30% of patients do not seem to show a clinical response. As a relatively expensive form of treatment, there is a need for better stratification of Patient selection and also to deploy better methods of optimizing lead placement at the time of implantation. In this study, the authors assessed whether the use of late gadolinium enhancement CMR scan to guide deployment of the LV lead in a non-scarred segment of the LV free wall leads to a better long-term outcome from CRT than using a conventional implantation approach . This isOne of the main challenges confronting CMR is the burgeoning number of patients with conventional pacemakers/devices implanted. Whilst under certain restricted conditions, some sites are proceeding with CMR in these patients, and where there is an overwhelming benefit to risk balance, most sites remain conservative in their approach. For this reason, there has been great interest in MR-conditional devices. In this interesting case report, Quarta and colleagues describe how the management of a Patient with sarcoid and such a device, was facilitated by being able to perform CMR on the heart and secondly the impact of their findings . Image qManoeuvres to improve outcomes following a ventricular fibrillation (VF) arrest are likely to improve the current suboptimal outcomes. In this study of 14 swine randomised to normothermia or hypothermia, the latter reduced the early LV dilatation typically seen and importantly, delayed the onset of stone heart thereby extending a known, morphologic limit of resuscitability . These fThis excellent review assesses the impact of T2-weighted imaging in the assessment of acute cardiac disease . ApplicaWhilst it is well recognised that Duchenne muscular dystrophy (DMD) carries an increased risk of cardiac morbidity, treatment of this cohort of patients suffers from a lack of systematic prospective clinical trials. In this study, the authors identified patients for inclusion in one of two treatment groups . Group ADuchenne muscular dystrophy (DMD), is the most common of the muscular dystrophies. It has an incidence of 1 in 3,500 males. It is an X-linked recessive disorder resulting from a disabling mutation of the gene encoding dystrophin, a sarcolemmal protein found in skeletal and cardiac muscles. There is progressive skeletal muscle weakness with loss of ambulatory ability in the teenage years. Death is usually due to cardiac or respiratory failure, and distinctive pathologic findings have been noted. As noted by the authors, with improvements in overall management and respiratory treatment, there has been increasing focus on the prevention and treatment of cardiac disease in this condition. In this study, strain using myocardial tagging and fibrosis patterns were determined in a cohort of 16 patients with DMD . There wAs noted above, DMD carries a high morbidity and mortality rate with cardiac dysfunction an important cause. In this large study of 236 Patients with DMD, dysynchrony was assessed based on timing of CMR derived circumferential strain (ecc) . The calCMR is well suited to characterising the atherosclerotic arterial wall. Research has been focussed on early detection ,94, pathThis is an elegant prospective observational study in 35 patients with first time spontaneous cervical artery dissection to determine the age of vessel wall hematoma using multiple-weighted CMR on a 3 T scanner . The manThis study investigates the use of magnetization transfer contrast (MTC) for atherosclerotic plaque characterization at 11.7 T . High-reThis review article addresses renal MRA and advanced renal MR techniques which is an interesting and important subject . The curThis paper describes the use of lumen curvature measurements obtained from MR images to characterize healing of ruptured plaque in individuals who have recently suffered from a transient ischemic attack . PatientThis study compares CMR and B-mode ultrasound in monitoring changes in plaque burden over 6 months of statin therapy . In 26 sThis paper reports serial measurements of aortic dimensions in Turner syndrome patients and provides some insight into the degree of aortic growth and its associated risk factors . The autThis is an excellent review that covers all aspects of magnetic resonance angiography in some depth . The oveThe authors use a well-known model to derive theoretical values for aortic pulse wave velocity (PWV) from CMR-assessed data, and compared these with CMR-assessed values for PWV in the aortic arch . CMR datThis is a well-written study on the use of an albumin binding contrast agent for assessment of endothelial integrity in a pig model of coronary injury . The autAlthough inflammation plays a key role in the progression of atherosclerotic plaques, it is the prediction of the next ‘culprit’ or ‘hot’ lesion with the potential to rupture giving rise to an acute coronary syndrome which is a major challenge in patients with coronary artery disease. Pedersen looked at edema in the proximal left anterior descending coronary artery in pigs following balloon injury using T2-weighted short tau inversion recovery (STIR) and conventional T2-weighted spin echo sequences . STIR siTo date, most of the CMR studies looking at vascular parameters have focused on patients presenting with carotid disease ,112. KylPerfusion CMR has grown into a clinically important examination and is challenging established referral patterns for nuclear based techniques . New steAdenosine perfusion CMR is well established in chronic coronary disease, but its role in acute coronary disease is less well tested especially in the detection of non-culprit lesion ischemia. Wong et al studied 59 patients 3 days after acute ST-elevation myocardial infarction with 41% anterior infarctions and 100 non-culprit vessels . The accThe dual bolus protocol for gadolinium injection for myocardial perfusion CMR enables accurate quantification but has disadvantages for complicated set-up. Ishida et al propose a simpler dual bolus regime which may have greater clinical utility . The regIn contrast to Gadolinium chelates, manganese-containing agents are intracellular and manganese chloride is rapidly taken up into myocytes. Fernandes published preliminary safety and efficacy data regarding the use of manganese chloride in 17 healthy volunteers . A signiCMR research in acute coronary syndromes has been stimulated by visualisation of pathological processes that are difficult  or imposThe concept of myocardial area at risk and salvage in acute myocardial infarction is of major interest and key importance for clinical trials looking at interventions to reduce infarct size. Lønborg performed a comparison of two different T2-weighted CMR protocols to assess the myocardial area at risk and salvage index in 91 patients with acute ST-elevation myocardial infarction treated with primary percutaneous coronary intervention . A seconThe use of late gadolinium enhancement (LGE) has transformed the investigation and clinical practice of chronic coronary disease, and recently yielded new insights into infarction, viability, medical treatment  and revaDobutamine stress CMR is effective in the identification of myocardial ischemia, but often in the research setting. Gebker et al report a large study of 1532 patients to determine the value of the technique in the routine clinical setting . PatientIschaemic heart disease is a common cause of left ventricular systolic dysfunction which can lead to chronic heart failure. The role of revascularisation for potentially hibernating areas of myocardium remains unclear but previous studies of heart failure patients with evidence of significant viability have been neutral in terms of hard endpoints and have not included late gadolinium CMR for assessment of viability -138. It Previous authors have noted the utility of adding a low-dose dobutamine stress protocol to conventional scar imaging in order to improve the potential predictive value of CMR for assessment of hibernation prior to revascularisation . GlaveckIschaemic preconditioning (both in the myocardium and in remote organs) has been shown to mitigate ischemia-perfusion injury, thereby reducing infarct size following coronary artery occlusion ,143. UsiIn contrast to CMR which has a high sensitivity and specificity for detecting myocardial infarction using LGE imaging, other non-invasive imaging techniques can miss subtle subendocardial infarcts . KrittayThe editors of JCMR continue to support publication of new CMR techniques involving new sequences -149, appThe fundamental understanding of cardiac structure and function requires structural models of the heart, but little is known about interspecies structure variation. Using diffusion tensor imaging (DTI), which was recently reviewed in JCMR , Healy sThis paper describes the development and implementation of a 3D cine DENSE pulse sequence on a 7 T small-bore scanner for the study of micromechanics in mice . This hiThis paper represents the latest development in methods for measurement of arterial pulse wave velocity (PWV) . The MR The outcome of the research described in this manuscript was an integrated study of flow and oxygen saturation for improved assessment of vascular disease . The autDespite a number of advantages a particular problem with phase contrast velocity mapping of the myocardium is the long acquisition times. This manuscript describes a study to assess the impact of using frame-by-frame SENSE to accelerate the acquisition of such maps and therefore make them more clinically applicable . The worThis manuscript describes the application of a recently developed 3D T1 mapping technique in the mouse to study myocardial infarction and to measure differences in myocardial T1 before and after injection of a liposomal contrast agent . This waThis manuscript is a validation of quantitative in vivo cardiac 4D flow measurements where the acquisition has been accelerated with parallel imaging and k-t BLAST at 1.5 T and 3 T . These tThere is a general problem of long acquisition and analysis times for measurement of cardiac function in mouse models. In this study guide-point modelling was used with reduced slice numbers reducing acquisition times for the determination of left ventricular function parameters in the infarcted mouse . The stuThis manuscript describes another development of improved cardiac imaging in the small animal rodent model . In thisThe authors present a study on first-pass perfusion in a small animal model, stating that perfusion and infarct size may predict severity of impairment . PerfusiThis excellent well referenced review describes in an extremely thorough way all the tagging sequences, their advances and how the different approaches interrelate primarily from a technical perspective but also with an interesting historical context . The figThis manuscript describes a systematic study of the impact of k-t BLAST on the measurement on myocardial function by tissue phase mapping . MyocardThere is a well recognised source of referrals which is simply put as unusual pathology, or cases where other imaging has failed to yield a definitive diagnosis. These include for example pericardial disease, tumours , and infAdvances in cardiac device technology have led to the first generation of MR conditional devices. This timely paper reviews the current state of the art, the likely future of new devices and the problems in development .Long acquisition times and complex breathing patterns limit the clinical applicability of whole heart 3D coronary MR angiography. Ishida et al designed and tested a tight abdominal belt in 15 Japanese and 15 English patients, to determine whether the belt could improve diaphragmatic position . The autAntony et al conducted a survey of 60 National Health Service providers of CMR in the UK and obtained replies from 88% . There wMoro et al measured coronary sinus flow during cold pressor stress to determine whether gender differences could be found reflecting coronary endothelial function . The autACEI: Angiotensin converting enzyme inhibitor; ARB: Angiogtensin receptor blocker; AVA: Aortic valve area; BOLD: Blood oxygen level dependent; CMR: Cardiovascular magnetic resonance; CRT: Cardiac resynchronisation therapy; CT x-ray: Computed tomography; DCM: Dilated cardiomyopathy; DMD: Duchenne muscular dystrophy; DTI: Diffusion tensor imaging; EF: Ejection fraction; ECV: Extracellular cardiac volume; HCM: Hypertrophic cardiomyopathy; IP: Intraplaque hemorrhage; JCMR: Journal of cardiovascular magnetic resonance; LGE: Late gadolinium enhancement; LGMD: Limb-girdle muscular dystrophy; LV: Left ventricle; LVOT: Left ventricular outflow tract; MTC: Magnetisation transfer contrast; MRA: Magnetic resonance angiography; PCr: Phosphcreatine; PWV: Pulse wave velocity; RV: Right ventricle; SSFP: Steady state free precesson; STIR: Short tau inversion recovery; TTE: Transthoracic echo; TAVI: Transcatheter aortic valve implantation; VF: Ventricular fibrillation; 3D: 3 dimensional; 4D: 4 dimensional.The authors declare that they have no competing interests.All authors contributed to the writing of this review article. All authors read and approved the final manuscript


In response to pressure overload the left ventricle (LV) remodels to compensate for the increased workload. Initially this adaptation is beneficial to maintain pump function, but eventually the heart may loose its battle to cope with the increased workload resulting in heart failure (HF). In this study the evolution of global LV function was characterized in a relevant mouse model of LV pressure overload during the development of HF using MRI.C57BL/6 mice  underwent a transverse aortic constriction to induce LV pressure overload. Animals were subjected to a mild  or severe constriction . Age-matched littermates were used as controls (n=4). MRI measurements acquired at 9.4T were performed starting 1 week post surgery until the age of 22 weeks. Global LV function was characterized from cinematographic MR images (15-18 frames per cardiac cycle) using a respiratory gated and cardiac triggered FLASH sequence (Fig.Mice subjected to a mild constriction showed a small increase in LV mass normalized to tibia length as compared to controls Fig. , p<0.01.Mice subjected to a mild constriction of the transverse aorta develop a compensated stage of LV hypertrophy. Mice subjected to a severe constriction show progressive LV hypertrophy accompanied by a decline in LV function. Lung edema and depressed right ventricular EF in this group suggests that these animals develop end stage heart failure. Future work will focus on the imaging of different aspects of adverse remodelling of the LV using MRI.


Supravalvar aortic stenosis (SVAS) in patients with Williams' syndrome is often accompanied by coronary, pulmonary, and even myocardial lesions and therefore associated with increased perioperative morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) provides reliable short-term mechanical circulatory support to patients, especially young, in acute postoperative cardiac failure when conventional means are ineffective. The incorporation of centrifugal pumps in these systems has made their use more efficient and less traumatic. We describe our experience of using the Levitronix CentriMag pump in two patients with Williams' syndrome who underwent surgical correction of supravalvular aortic stenosis. Supravalvar aortic stenosis (SVAS) is commonly found in patients with Williams' syndrome. The association of SVAS and pulmonary artery stenosis with mental retardation and distinctive facial features is known as the Williams-Beuren syndrome , 2. PromAlthough low cardiac output is not uncommon following surgery for congenital heart disease in the paediatric population, conventional methods of treatment prove that efficient and postcardiotomy mechanical support is, therefore, rarely required. Extracorporeal membrane oxygenation (ECMO) constitutes an effective and essentially the only available short-term circulatory support for acute postoperative severe cardiopulmonary failure in the paediatric population following cardiac surgery. Nonetheless, it has been associated with increased risk of complications including bleeding, thromboembolism, plasma leakage, and infection , 7.An 8-month-old boy with Williams' syndrome and supravalvular aortic stenosis was admitted to our department for surgical treatment. Repair was achieved by extended aortoplasty with incision of noncoronary and right coronary sinuses and implantation of an inverted Y-shaped Dacron patch. Failure to wean from cardiopulmonary bypass (CPB) due to postcardiotomy cardiac failure resulted in the institution of extracorporeal membrane oxygenation (ECMO). Reexploration for bleeding was required the first day. The patient was successfully weaned off ECMO support 70 hours later. ICU and total hospital stay was 9 and 16 days, respectively. The patient is alive at 5-year follow-up with excellent cardiac function.A 13-month-old girl with the Williams-Beuren syndrome and supravalvular aortic and pulmonary stenosis was admitted to our department for surgical treatment. Repair technique included patch enlargement, extended aortoplasty with incision of the noncoronary and right coronary sinus, and implantation of an inverted Y-shaped Dacron patch. Inability to wean from CPB due to postcardiotomy cardiac failure led to the institution of ECMO for 44 hours. The patient remained in ICU stay for 30 days and the hospital for a total of 39 days. In the postoperative course she developed pneumothorax after the removal of the chest drain tubes and was treated accordingly. The patient is alive at 5-year follow-up with excellent cardiac function.The ECMO system, in both cases, was instituted utilizing the original CPB cannulae. The circuit included a Levitronix CentriMag  centrifugal pump, a hollow fibre membrane gas exchanger, and heparin-bonded tubing. Conservative systemic heparinization was used until mediastinal bleeding was well controlled; adequate anticoagulation was thereafter achieved by heparin sodium administration at a dose of 20–40 u/kg/hr in order to maintain an activated clotting time (ACT) of 140–180 sec. Mean ECMO flow was maintained at 150 mL/kg/min (range 60–250 mL/kg/min) depending on cardiac function, serum lactate levels, and mixed venous oxygen saturation. Minimal inotropic maintenance was continued during mechanical support  to facilitate left ventricular (LV) emptying against increased afterload and prevent overdistension. Ventilation  was maintained to keep the lungs inflated and avoid alveolar collapse. Weaning from ECMO was accomplished by maximising inotropic support and gradually decreasing flow rates similarly to weaning from CPB. Once the patient was completely off support, haemodynamic stability was monitored and tissue perfusion was assessed by arterial blood gases with serum lactate and base deficit values. Cannulae were subsequently removed. Both patients made a full recovery and were discharged from hospital in excellent clinical condition . Five yeLocalization of the stenosis at the level of the commissures of the aortic valve in patients with SVAS has important implications for both aortic valve function and the coronary circulation. Coronary orifices can be obstructed by the thickened aortic or sinus wall and these patients should be considered at risk of myocardial ischemia. Furthermore, the coronary arteries are subjected to the elevated prestenotic systolic pressure, resulting in dilatation and tortuosity , 5. SuddExtracorporeal membrane oxygenation for circulatory support is established via venoarterial and, in the case of postoperative cardiac failure, intrathoracic and central (right atrium and aorta) routes. A suitable level of anticoagulation has to be maintained, which increases the risk of bleeding. Other reported complications include thromboembolism, haemolysis, renal failure, sepsis, or vascular complications , 7, 9. TThere was no evidence of clots in the pump head, tubing, or cannulae after their removal in our patients. The other markers of blood trauma including serum bilirubin and lactate dehydrogenase (LDH) remained within the normal range. The devise was not demanding to handle and easy to monitor. The Levitronix CentriMag device provided successful mechanical support in our young patients with acute postcardiotomy heart failure with minimal anticoagulation. Larger studies are required to further elucidate the efficacy of this device and help draw guidelines regarding anticoagulation.Although it is difficult to draw firm conclusions from just 2 patients, yet in conjunction with other reported cases, SVAS patients should receive special attention to their coronary circulation, which in our cases was probably responsible for poor myocardial preservation during cardiac surgery.


Cardiac disease is the most common cause of death in patients with end-stage renal disease. It is assumed that the high rate of cardiovascular mortality is related to accelerated atherosclerosis. Patients with chronic renal insufficiency have an increased prevalence of coronary artery disease, silent myocardial ischaemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, annular mitral and aortic valve calcification, and enlargement of the left atrium, than patients with normal renal function. It is also well known that haemodialysis is associated with cardiovascular structural changes and rapid fluctuations in electrolyte levels.In this study, we sought to estimate left atrial size by means of echocardiography and to determine any correlations between different echocardiographic measurements in patients with end-stage renal disease.t-test were performed, with levels of significance of p < 0.01 and p < 0.05.We analysed data from 123 patients who were on regular haemodialysis, by means of traditional transthoracic echocardiographic examination. The usual statistical parameters, correlations and the Student’s The most presented age group was 60 to 69 years old, with a predomination of females (56.1%). We found dilated left atrium in 26.02% of the study patients and a high statistical correlation between different methods of measurement and calculated volumes of the left atrium.Evaluation of left atrial size should be determined by several different measurements, and left atrial enlargement should be seen as a risk factor for advancing disease. Cardiovascular morbidity and mortality are high in patients with end-stage renal disease. These patients have an increased prevalence of coronary heart disease, silent myocardial ischaemia, ventricular and supraventricular disturbances in heart rhythm,6The repercussions of high blood pressure are apparent in the heart as increased volume and hypertrophy of the left ventricle. The size of the left atrium is also a predictor of cerebrovascular insults and atrial fibrillation,8Diastolic dysfunction of the left ventricle plays an important role in the pathogenesis of symptoms in patients with hypertrophic cardiomyopathy. Abnormal filling of the left ventricle11A significant correlation has been found between several methods of echocardiographic (ECG) measurement of the left atrium, but size of the body and thorax were not found to affect the data. Evaluation of atrial size should be done with ECG measurements obtained from different viewpoints.13The aim of our study was to assess left atrial size in patients with end-stage renal disease and determine the correlation between dimensions taken from different views using transthoracic echocardiography.The study population consisted of all patients on regular haemodialysis at the University Clinical Cente of Kosova in the first six months of 2007. We analysed data from transthoracic echocardiographic examinations performed with Doppler.This was a cross-sectional study including all patients  who underwent haemodialysis on a regular basis at the time of the study. Patients were divided randomly into two groups. Echocardiography was performed in one group prior to haemodialysis and in the other group after haemodialysis. The examination was done on the day the patients arrived for haemodialysis. The echocardiographic readings were performed on all patients by the same two operators.A nurse took all blood pressure measurements using a mercury sphygmomanometer. The patients were asked to take their usual antihypertensive medications. Brachial blood pressure was measured twice in a sitting position after the patient had rested for more than 10 minutes. Blood pressure measurement was carried out in the contralateral arteriovenous fistula arm. Phase I and V of the Korotkoff sounds were taken as systolic and diastolic blood pressure, respectively, and averaged for two measurements. Classification of blood pressure was done according to the seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.14Exclusions from this study were patients undergoing acute haemodialysis and those who presented with congenital or acquired valve disease. Patients with evidence of ischaemic heart disease as detected by changes in the ECG prior to enrolment in the study were also excluded.Transthoracic echocardiography with Doppler was carried out in the long-axis view, short-axis view, apical four-chamber view, and apical two-chamber view. Apart from these standard measurements, the left atrium was examined from the anteroposterior long axis, orthogonal apical four-chamber, orthogonal apical two-chamber, and orthogonal short-axis views. The area was calculated for each orthogonal dimension separately and the total was averaged. The left atrial volume (LAV) was calculated using the formulae:LAV=0.85 ×A1 ×A2Lwhere A1 is left atrial area in the apical four-chamber view, A2 is left atrial area in the apical two-chamber view, and L is orthogonal  left atrial dimension in the apical fourchamber view.LAV=D1 ×D2 ×D3 ×0.523where D1 is the anteroposterior left atrial dimension in the longaxis view, D2 is the orthogonal  left atrial dimension in the apical four-chamber view, and D3 is the orthogonal  left atrial dimension in the apical four-chamber view.The total number of patients examined was 123 with a mean age of 56.39 (± 13.86) years and 56.1% were female. The most representative age group was 60 to 69 years (38.2%) The mean period of haemodialysis was 5.4 (± 3.4) years; 65% of the patients had been on dialysis for less than five years, and 29.3% for six to 10 years r = 0.60) between left atrial size and atrial volume using formula 1 r = 0.89) between left atrial size and volume using the ellipsoid method (formula 2) In our study there was a significant medium correlation . Correlation between the values obtained with the four-chamber apical view and the two-dimensional method was r = 0.97. The mean difference between these two methods was 5.0 ± 12 ml (± 2 SD), which is very acceptable. The authors of this study concluded that measurements of left atrial size using M-mode echocardiography were not as representative as those determined by two-dimensional methods. M-mode measurements should therefore be used with caution or not at all.15The correlation coefficient for calculations of left atrial volume using M-mode and two-dimensional approaches was et al. in their study found a significant correlation between measurements of the left atrium from the parasternal and apical views, but values from the apical view were higher. They found large variations in the dimensions of the left atrium between different subjects and no correlation between these measurements and body and chest size, or diagnosis. They recommended that measurements be taken from both parasternal and apical positions, and that the upper limit of left atrial size from the apical view should be 45 mm.12Gradin r = 0.88) and apical four-chamber views from one side (r = 0.62), and the two-chamber view from the other side (r = 0.62).In our study, there was a high correlation between the different measurements of the left atrium for the total patient population and the correlation was also gender related. A moderate correlation resulted from measurements in all patients from the parasternal long-axis (Studies have compared different methods and approaches to measuring the left atrium using two- and three-dimensional echocardiography,13A dilated left atrium was found in almost one-third of the study population, with a larger number of these cases presenting with up to 10 years of disease duration. There was a high correlation between the size of the left atrium and its volume, calculated by area and the ellipsoid formula, respectively, with gender.A high correlation was found between left atrial dimensions resulting from the two parasternal views. A moderate correlation was seen between left atrial dimensions from the parasternal long-axis view and the apical four- and two-chamber views. The highest values for left atrial size resulted from the apical fourchamber view. Evaluation of left atrial size should therefore be based on several measurements taken from different echocardiographic views.The study assessed atrial dimensions in patients on haemodialysis using additional, non-conventional methods, and determined the relationship between these dimensions in order to better evaluate atrial size. We correlated these measurements of the left atrium, but did not include the eventual changes in atrial size caused by factors such as ongoing disease. An analysis of the latter may follow in another article.