Eosinophilic myocarditis (EM) is a rare condition characterized by myocardial eosinophilic infiltration due to various underlying etiologies. The patient with EM may benefit from appropriate use of mechanical circulatory support (MCS) that acts as a bridge to myocardial recovery in response to effective immunosuppressive therapy. A 16-year-old boy presented with cardiogenic shock due to fulminant myocarditis, for which a percutaneous ventricular assist device (PVAD) was immediately inserted. Based on the histological diagnosis of EM, immunosuppressive therapy was immediately commenced, leading to improvement of left-ventricular ejection fraction (27% to 47%). The PVAD was successfully removed on day 7. Cardiac magnetic resonance imaging and dual-tracer myocardial scintigraphy suggested limited extent of irreversible myocardial damage. For fulminant EM, the short-term use of PVAD, together with immunosuppressive therapy guided by an immediate histological investigation, may be an effective bridging strategy to myocardial recovery. Eosinophilic myocarditis (EM) is a rare condition characterized by myocardial eosinophilic infiltration due to various underlying etiologies –4. AlthoWe present the case of a young boy who survived fulminant EM with successful short-term MCS using PVAD as a bridge to myocardial recovery in response to histology-guided immunosuppressive therapy.2) was transferred to our cardiac institution with a 9-day history of a sustained high fever complicated by diarrhea and abdominal pain. He had no history of allergic disease such as bronchial asthma, or known drug allergies. He had received oral cefdinir for a few days for suspected bacterial enterocolitis two weeks previously. His symptoms had been resistant to the antibiotics and antipyretic medications given in the prior tertiary center. Upon arrival at our center, he exhibited cardiogenic shock with a body temperature of 40.5°, heart rate 107 beats/min (irregular), systolic pressure 90, and diastolic pressure ranging from 30 to 75 mmHg , and respiratory rate 48/min. He was mostly conscious but occasionally stuporous. No jugular distension, limb edema, or skin rash was observed. His peripheral body was cold despite his body trunk being warm. On auscultation, he had regularly irregular muffled heart sounds without a significant murmur, and some rales bibasally. The electrocardiogram revealed tachycardia, sinus rhythm, right axis deviation, nonspecific ST-T change, and clockwise rotation (3/μL with neutrophils 93% and eosinophils 1.5% and serum C-reactive protein 29 mg/dL), mild hepatic failure , and almost unimpaired renal function (blood urea nitrogen 26 mg/dL [20 mg/dL] and creatinine 1.2 mg/dL [1.08 mg/dL]). The myeloperoxidase-anti-neutrophil cytoplasmic antibody was below the detectable range.A previously healthy, athletic 16-year-old boy  endomyocardial biopsy (EMB) via the right internal jugular. Intact coronary arteries were subsequently confirmed by coronary angiography. Chest radiography after Impella placement showed alleviated pulmonary edema  togetherμg/kg/min and of dopamine 1.5 μg/kg/min on days 1 and 2).Within 48 h after admission, eosinophilic myocarditis was diagnosed based on the histological findings . Immunosμg/kg/min each) to avoid sudden hemodynamic deterioration immediately after removal of the MCS. He was extubated on day 8, followed by initiation of antiheart failure medications  to prevent further remodeling. The follow-up EMB, performed 2 weeks after his admission, revealed improved infiltration of eosinophils and lymphocytes and some degree of fibrosis  dual-tracer myocardial scintigraphy 3 weeks after admission showed a patchy deficit of perfusion at the anterolateral wall and a discordantly larger deficit of fatty acid metabolism (perfusion-metabolism mismatch), suggesting regional myocardial damage with potential reversibility -123 sibility .Cardiac 1.5-T magnetic resonance imaging (CMR) 4 weeks after admission showed no high-intensity areas on T2-weighted imaging or late-gadolinium enhancement (LGE), but prolonged native T1 mapping at papillary muscle level, indicating myocardial edema .At discharge from the hospital, follow-up chest radiography revealed diminishing cardiomegaly with no pulmonary congestion . At the At the time of presentation to our hospital, we recognized that our patient had complicated acute myocarditis (LVEF <50%), which is associated with a worse prognosis and therefore important to identify on presentation . The patThe proposed underlying etiologies of EM include hypersensitivity reactions , 14, autPeripheral eosinophilia may be absent in 25% of patients –28. The The use of VA-ECMO is an attractive MCS option for patients in severe cardiogenic shock –10. HoweThe Impella 2.5 is a percutaneously inserted device equipped with a miniature, nonpulsatile, axial-flow Archimedes-screw pump that propels it from the left ventricle to the ascending aorta. By unloading the left ventricle and supporting flow, it reduces the total mechanical work, subendocardial ischemia, myocardial oxygen demand, pulmonary capillary wedge pressure, and end-organ malperfusion , 34–40. Several previous publications have reported successful results in patients with fulminant myocarditis using the LV Impella, including a 13-year-old boy without a histological diagnosis  , a 44-yeOur case is specific in that the EMB-driven histological diagnosis played a crucial role in initiating early immunosuppressive therapy, which led to immediately improved myocardial function, allowing us to wean the patient off the Impella. The CMR findings in our case indicated increased extracellular volume  but not apparent myocardial fibrosis, as represented by the LGE , also suCombinations of the LV PVAD with other MCS may be effective in various clinical scenarios. For instance, patients with cardiogenic shock accompanied by severely impaired oxygenation may benefit from a combination of LV PVAD and V-A ECMO, by oxygenating and flow-supporting while unloading the left ventricle –48. AnotFor fulminant EM, the short-term use of PVAD, together with immunosuppressive therapy guided by an immediate histological investigation, may be an effective bridging strategy to myocardial recovery.


Elevated left atrial (LA) pressures are associated with poor prognosis in heart failure (HF). Invasive monitoring of LA-pressures and direct mechanical LA-decompression are associated with functional improvement in patients suffering from HF both with reduced and preserved ejection fraction. We aim to review the current available percutaneously implantable sensors for haemodynamic telemonitoring of LA-pressures . Heart failure (HF) is a leading cause of mortality and morbidity worldwide. Despite major advances in pharmacological and device therapy, hospitalisation rates due to cardiovascular causes in patients with HF remain high and did not show any significantly improvement over the last decades, 2. IndeWe aimed to review the knowledge regarding currently available implantable devices for direct and indirect haemodynamic telemonitoring of LA pressures in patients with chronic HF.LA pressures (LAP) represents the best hemodynamic parameter to estimate the left ventricular filling pressures. However, in absence of a relevant mitral valve stenosis as well as in absence of precapillary pulmonary arterial hypertension, the pulmonary capillary wedge pressure (PCWP) closely correlates with end-diastolic arterial pulmonary pressure and can be used in spite of the hardly measurable LAP. Similarly, in absence of relevant pulmonary valve dysfunction, the right ventricular (RV) pressures closely remark the pulmonary artery pressures (PAP). AccordiThe HeartPOD device  was developed to be implanted in the left atrium and direct measure LA pressure, potentially providing more accurate assessment of left ventricular filling pressures, without potential confounding factors deriving from pulmonary vascular abnormalities.The HeartPOD left atrial sensing device consists of an implantable sensor coupled with a subcutaneous antenna coil and a patient advisory module (PAM). The sensor system is implanted into the atrial septum oriented to the LA and is fixed in the interatrial septum through two nitinol anchors; it included a 3×7mm sensor module hermetically sealed with a titanium pressure sensing membrane and circuity to measure LAP, temperature and intracardiac electrogram. LAP is obtained by subtracting the absolute pressure measured by the sensor from the atmospheric one measured by a pressure sensor located in the PAM. Measurement and calibration are performed through the skin by wireless transmissions from the PAM. The acquired waveforms are simultaneously stored in the PAM-memory.The device is implanted through a right heart catheterization . Transseptal atrial puncture is performed and an 11-F sheath is placed in the left atrium. The sensor system is advanced under fluoroscopic guidance until the distal anchor unfolds and contacts the left side of the interatrial septum; then, the sheath is withdrawn to release the sensor module. The antenna coil is connected to the proximal end of the sensor lead and placed in a subcutaneous pocket specifically created . After implantation, in patients not taking oral anticoagulants, dual antiplatelet therapy with acetylsalicylic acid (ASA) and Clopidogrel is recommended for a minimum of six months, followed by ASA-monotherapy lifetime. Measurement acquisitions are made by placing the PAM in proximity (< 5 cm) of the subcutaneous pocket.The safety and feasibility of the HeartPOD device in human settings were evaluated in the HOMEOSTASIS  trial, a prospective, multicentre, observational open-label registry enrolling patients with chronic, symptomatic HF (HFrEF or HfpEF) and a history of acute decompensation. In the pilot HOMEOSTASIS study, the devThe first implantable devices aiming to provide an invasive hemodynamic monitoring of patients with chronic HF were developed in the 1990 and estimated left ventricular filling pressures by hemodynamic parameters measured in the right ventricle.The right-ventricular pressure sensor mostly used in the clinical research is the Chronicle  device. It is composed by a transvenous lead with a pressure-sensor at the tip and a programmable device to process and store information. It is implanted similar to a single-lead pacemaker, with the lead positioned transvenously in the right ventricular outflow tract or septum and the device positioned in a subcutaneous pocket created in the pectoral area. The Chronicle system continuously monitors and stores several information including heart fate, body temperature, patient activity, right ventricular systolic and diastolic pressures, change in right ventricular pressure, right ventricular pre-ejection and systolic time and estimated pulmonary arterial diastolic pressure (ePAD). This latter has been showed to be strongly correlated with actual pulmonary artery pressures, independently from loading conditions. Chronicle device and representative measurement images are shown in A pilot study includinThe CardioMEMS Heart Failure Sensor  consists of three components: the implantable HF sensor, the delivery catheter and an external electronic monitoring unit connected with an external antenna. The implantable HF sensor is a miniature electrical circuit composed from a three-dimensional coil and a pressure-sensitive capacitor hermetically sealed and enclosed in a fused silica capsule. The device is 15-mm long and 3-mm wide and contains two nickel-titanium wire loops attached to each end that ensure a stable sensor position in the pulmonary artery. Pressure changes in the implantable sensor environment result in correlated changes to the circuit’s resonant frequency. The coil allows for electromagnetic coupling to the sensor by an external antenna, which is held against the patient’s chest approximately in the area of sensor deployment. The antenna provides power to the device and allows for continuous measurement of its resonant frequency, which is converted in a real-time pressure waveform on the electronic monitoring unit. The electronic unit is used by the physician to calibrate the HF sensor during implant and, after implantation, to take readings of hemodynamic data. The haemodynamic data provided are the following: PA pressure waveform; systolic, diastolic and mean PA pressure; heart rate. These data are transmitted to a secure Internet database where they are stored and made available for later reading.The implantable HF sensor is connected to a tether wire within a hydrophilic delivery catheter and is implanted during a right heart catheterization. Femoral venous access is routinely used, although a jugular access may be preferred in case of severe obesity. After venous cannulation with an 11-French sheath, a Swan-Ganz catheter is advanced into the left or right pulmonary artery tree under fluoroscopic guidance and a selective pulmonary angiography is performed in order to identify an appropriate target artery. Thereafter, a 0.018-inch guidewire is placed in the target vessel, the Swan-Ganz catheter is retired, and a 12-French sheath is advanced over the guidewire, allowing the introduction of the CardioMEMS delivery catheter. Once the target site is reached, the HF sensor, which is connected to the end of the delivery catheter, is released into the target artery. A selective angiography is indicated to test the correct position of the device and the presence of distal blood flow. The delivery system is removed and exchanged again with the Swan-Ganz catheter; pulmonary artery pressures are acquired through the Swan-Ganz catheter and used to calibrate the sensor. Full anticoagulation is recommended during the procedure to prevent catheters and devices’ thrombosis. Patients not taking oral anticoagulants are recommended to undergo dual platelet therapy with ASA and Clopidogrel for a month after procedure, followed by ASA-monotherapy lifelong. Patients on oral anticoagulant therapy are recommended to continue their treatment. Device components and representative acquired waveforms are shown in The CHAMPION  study was a prContinuous monitoring of LAP through implantable devices placed in left atrium, in right ventricle or in the pulmonary artery represents a promising strategy to dynamically optimize pharmacological therapy and prevent acute decompensation in these patients. Currently, only pulmonary artery pressure sensor (CardioMEMS) has been found to improve symptoms and significantly decrease rate of cardiac hospitalization and its use may be considered in clinical practice to prevent decompensation in symptomatic HF patients. On the same pathophysiological basis, the interventional creation of a restrictive atrial communication to improve symptoms and ameliorate loading condition in patients with chronic HF is currently under investigation.


The speckle tracking method allows one to quantify the temporal and spatial characteristics of myocardial contraction. Importantly, it does not depend on a scanning angle and allows one to record the movement of speckles in 2D mode in any direction, unlike tissue Doppler imaging. This examination is non-invasive, safe for patients, and economically more beneficial in comparison with other modern methods of assessing heart contractility: MRI and scintigraphy. Diagnostic thresholds are suggested for obtaining peak values of all types of global strains and strain rates by sampling a healthy group, which can reveal early signs of left ventricle contractility failure. Correlation relationships of deformation parameters between themselves and with left ventricular hemodynamic indices, as well as anthropometric parameters in healthy subjects highlight the features of heart contraction biomechanics. However, currently this method is scarcely studied because no generally accepted normal range of strain values exists.•It is necessary to have sufficient qualification and skills in dealing with the XStrain™ Esaote software to obtain optimal values of myocardial deformation.•The study results expand the database of this software for users and determine the normal range of the left ventricular contractility parameters.•The revealed interrelationships of strain values in healthy individuals are relevant for understanding how the contractility mechanisms are altered in patients, and open up the prospect of studying the heart’s compensatory possibilities. Studying tissue deformation is a new diagnostic method in cardiology that makes it possible to quantify the regional contractility of the myocardium using two-dimensional echocardiography .This technology allows one to record a unique pattern of gray scale spots, generated by ultrasound passing through myocardial tissues. Displacement of the gray scale spot (set) picture reflects the movement of the myocardium during systole and diastole, and displacement between the spots, respectively, the deformation of the myocardium . This meThis technique has a number of advantages, in particular, its independence from a scanning angle, in contrast to tissue Doppler imaging . Thus, iWhen using “speckle tracking”, no tethering effect exists because the strain is evaluated directly by the motion of gray scale spots of a certain area of the myocardium . This teThis study is non-invasive, safe for patients and economically more beneficial, compared with other modern methods of assessing heart contractility, namely, MRI and scintigraphy.However, wide clinical application of this method is limited by the considerable variability of strain indices when using different software packages .2. Blood pressure (BP) was measured in all participants immediately before the echocardiographic examination. Height and weight were measured using a calibrated stadiometer and scale, and body surface area was calculated according to the Dubois and Dubois formula. Body mass index was calculated by dividing the weight in kilograms by the height in meters squared (kg/m2). This study was approved by the local ethics committee of Penza State University, and written informed consent was obtained from all volunteers before they were screened for study eligibility.A large-scale prospective study of 104 healthy volunteers (53 women and 51 men) was conducted . ProspecEchocardiography was carried out on the left side position with an ultrasonic scanner MyLabEsaote, a 2.5–5.5 MHz multidimensional sensor with a synchronized ECG from the extremities. The video clips were registered to the short-axis contours at the level of the mitral valve and papillary muscles, from the apical position of 5-, 4-, and 2-chamber images with respiratory arrest. Incorrect frames, such as intermediate positions between the long and short axes from parasternal access, as well as the absence of the apex or any wall of the LV were considered inadmissible. The computer analysis was based on the processing of digital signals of dynamic images of the heart with a frame rate in the range of 40–60 frames per second, using X-Strain software , which allows one to estimate the longitudinal, circumferential, and radial myocardial strain and strain rate. The software algorithm tracks the frame-by-frame shift of the gray scale spots and extracts information about the strain and the strain rate of a specific myocardial segment in a given geometric position.For each patient, an initial image was selected at the end of diastole, which coincided with a QRS peak on ECG . Good viThe anatomy of the analyzed segments should correspond to the LV scheme specified by the software, with the possibility of manual selection. The boundaries of the endocardium and epicardium were traced as a sequence of dots in the semi-automatic mode, with visual correction by the investigator. They should not be projected onto the papillary muscles and the aorta. Proper determination of endocardial borders is the most important condition for qualitative post-processing, requiring an examiner to have appropriate skills and sufficient experience in echocardiography. The parameters governing the myocardial deformation characteristics were evaluated in 16 segments. For each point, the strains and strain rates were automatically calculated, shown as vectors added to a two-dimensional image. Based on the dynamics of the cardiac cycle’s digital values, the software generates strain curves for each segment. We obtained strain values in the phase of interest in the cardiac cycle on the panel of these graphs. In addition, the strains and strain rate values for each segment were represented using color graphics .Fig. 4FoThe global spatial and velocity indices were calculated as the arithmetic mean value of all segments . The peaRegional deformation (strain) is a dimensionless value associated with changing the length of an object and is expressed as a percentage of its initial form. For one-dimensional objects, the deformation can be represented by elongation or shortening .The rate of deformation (the strain rate) is the rate at which deformation occurs per unit time (c-1). The strain rate, as well as the definition of deformation allows one to estimate the degree of myocardial deformation .From the echocardiographic parameters observed, the following were analyzed: the end-diastolic volume (EDV), the end-diastolic volume index (EDVI), the end systolic volume (ESV), the end systolic volume index (ESVI), the end diastolic LV dimension (EDD), the relative wall thickness (RWT), the stroke volume (SV), the LV ejection fraction (EF) by Simpson at the four chamber level, along the long axis of the left ventricle from the apical position, the left ventricular myocardial mass index (LVMI).We constructed correlation models to determine the relationship between the contractile parameters of the left ventricle and its hemodynamic parameters, as well as anthropometric parameters, thus contributing to our understanding of heart biomechanics.The correlation analysis methods with the Pearson coefficient (r) were used to determine the relationship between the variables. The distribution normality was established using the Kolmogorov-Smirnov test. The sensitivity of the selective Pearson coefficient for the corresponding index was determined as the probability of detecting connection tightness (1-β) in the general population.Determining the descriptive characteristics of the left ventricular contractile function will contribute to refining the strain values, recorded on a MyLabEsaote scanner using XStrain™ Esaote software among healthy subjects. Among all deformation characteristics, the largest value of the mean is the radial strain, followed by longitudinal and circumferential strains, which makes it possible to quantify the contribution of individual muscle types to the overall contractility. However, the radial strain index is characterized by high variability, which may limit its practical application. In contrast, owing to their small variability and low standard error, GLS and GCS can provide a more accurate estimate of the rate of contractility of the left ventricle. On this basis, we analyzed in detail the GLS score in healthy subjects in order to optimally determine the limits of its normal range. In addition, it has been established that a decrease in the global longitudinal deformation of LV is a sensitive marker of myocardial ischemia, which affects the cardiomyocytes’ contractile function at the subclinical stage of the disease .The table also shows the values of all strains and strain rate types corresponding to the fifth, tenth, fifteenth, and twentieth percentiles. The mean values and standard deviations of the global deformation parameters obtained in this study can serve as a guideline for developing the normal range, taking into account the desired accuracy and reliability of the confidence intervals.Only 5% of healthy individuals have GLS values below 16.71%; 10% below 17.75%; 15% below 18.71%, and 20% below 18.67%. The median value of 20.68% indicates that half of patients have GLS values that are both larger and smaller.It is recommended to define cut-off values to distinguish between healthy and sick individuals to determine the normal range, taking into account the optimal “sensitivity-specificity” ratio. This method, with high sensitivity, is useful for excluding the diagnosis, if the result is negative. However, a method with high specificity is useful for including the diagnosis, along with other possible factors if there is a positive result  Fig. 5)Fig. 5).FAccording to the table, the closest relationship is observed at pairwise comparison of GLS and GCS, with similar strain rate parameters, which is associated with a single structural-physiological mechanism underlying the magnitude and the time of contraction. In addition, high correlation coefficients are observed between GLS and GCS. This is due to the structural features of the two layers of the myocardium: the external and internal ones, respectively .Fig. 6GrThe external oblique and the internal longitudinal muscles are represented by the same fibers, which start from the valve fibrous rings, go top-down, form a “vortex” at the apex of the heart and return to the fibrous rings already as a component of the inner longitudinal layer .Fig. 7A The smallest correlation values of radial deformation with other types of strains and strain rates can be explained by the peculiarities of the distribution of the middle layer fibers, at right angles to the subepicardial and subendocardial layers and, consequently, the independence of these fibers’ contraction. Nevertheless, the reliable dependence of the majority of the revealed deformation characteristics indicates a well-coordinated cardiac contraction.In analyzing the correlations presented in However, in the healthy population, there was a significant moderate direct relationship between GRS and LVMI. On the one hand, this dependence must be interpreted with caution, since GRS has the greatest variance. On the other hand, this regularity is justified, since the main thickness of the wall is the circumferential muscle, whose contraction causes radial deformation. In addition, the significant dependence of GRSR on the anthropometric characteristics  could be explained by the fact that a larger muscle size should contract in less time for effective cardiac output. The above-described interrelationships between the radial strain indicators and anthropometric data in healthy individuals are also reflected in other studies , which rA correlation relationship (ρ), which exists within the entire population, with a probability of at least 98%, was detected for a sample size of n = 104.In order to obtain the optimal values of left ventricular myocardial deformations by a MyLab90 Esaote ultrasound scanner, one must know how to work effectively with the XStrain ™ Esaote software and how to monitor all obtained deformations, with the possibility of manual correction at all stages of information retrieval offered by this software package. Therefore, we have introduced specific practical guidelines intended for specialists.The correlations of the strain indices in healthy individuals, revealed in this study, have not been found in any available professional literature. The correlation patterns of deformation parameters were obtained from a small group of patients, which is a limitation of this study. Therefore, the relative reliability and high sensitivity of the obtained data, along with the correlation sensitivity coefficient, were used for optimal interpretation and interpolation of these results for the general population.The correlation relationships of certain types of strains and the strain rates between them highlight the features of cardiac contraction biomechanics, which is relevant for understanding how the contractility mechanisms are altered in patients. It also opens up the prospect of studying the heart’s compensatory possibilities with optimal therapeutic and diagnostic correction. The other reliable correlations that were revealed, in particular, the signficance of the radial strain parameters in healthy individuals, indicate the dependence of cardiomyocyte contraction on body weight, which can predict the expended myocardial resources and the extent of their compensatory possibilities.Determining the normal range of various physiological factors is a difficult task when a new technique is introduced into practical medicine. The problem of choosing the threshold values of contractility by the speckle tracking method has been solved in here only in part, since its sensitivity can be determined by examining the population of patients with confirmation of the left ventricular contractility disturbance by other investigative methods. Therefore, we are planning a large-scale study on deformation characteristics in patients with CHD using the results obtained in this study.All conclusions are mathematically justified, the application conditions and the results of the correlation analysis were verified, and exploratory regression analysis was performed.When using the new “speckle tracking” method it is necessary to acquire reliable data on various parameters of cardiac deformation. This will enable one to establish an algorithm for obtaining the specific deformation values needed to reveal heart biomechanics regularities in healthy subjects, in order to determine the normal values of these parameters for subsequent use in the diagnosis of various heart diseases.


Cardiovascular dysfunction in cirrhotic patients is a recognized clinical entity commonly referred to as cirrhotic cardiomyopathy. Systematic inflammation, autonomic dysfunction, and activation of vasodilatory factors lead to hyperdynamic circulation with high cardiac output and low peripheral vascular resistance. Counter acting mechanisms as well as direct effects on cardiac cells led to systolic or diastolic dysfunction and electromechanical abnormalities, which are usually masked at rest but exposed at stress situations. While cardiovascular complications and mortality are common in patients undergoing liver transplantation, they cannot be adequately predicted by conventional cardiac examination including transthoracic echocardiography. Newer echocardiography indices and other imaging modalities such as cardiac magnetic resonance have shown increased diagnostic accuracy with predictive implications in cardiovascular diseases. The scope of this review was to describe the role of cardiac imaging in the preoperative assessment of liver transplantation candidates with comprehensive analysis of the future perspectives anticipated by the use of newer echocardiography indices and cardiac magnetic resonance applications. The effects of end stage liver disease in the function of the cardiovascular system are a recognized clinical entity frequently referred to as cirrhotic cardiomyopathy (CCM) . CCM is However, CCM often remains unrecognised when using traditional cardiovascular imaging modalities  and hearCardiac manifestations in patients with advanced cirrhosis are a result of heart remodeling to compensate for the high output state and of the direct effects in the cardiac cell .Changes in systematic circulation have been related with changes in hepatic blood flow and portal pressure . DysfuncDirect effects on the cardiac cells of cirrhotic patients are mediated mainly through the down-regulation and desensitization of b-adrenergic receptors . EndocanAccording to the Montreal Criteria introduced in 2005 , CCM is According to an inspection of 639 autopsies of cirrhotic patients compared to over 17,000 autopsies of the general population, myocardial infarction was about four times lower in cirrhotic patients (4.9%) when compared to other populations (20.2%) . These fQuantification of cardiac chamber dimensions using standard two-dimensional (2D) echocardiography has revealed an increase of left ventricular end diastolic volume and left atrial volume index in cirrhotic patients which is correlated with the disease severity and the Model for End stage Liver Disease (MELD) score . Right hBecause of the high output state and reduced afterload, systolic function, as can be assessed using left ventricular ejection fraction (LVEF), is found normal or even increased in most patients . LVEF isTraditional indices of diastolic dysfunction such as early diastolic mitral inflow velocity/ late diastolic mitral inflow velocity (E/A ratio), isovolumetric relaxation time and deceleration time have been used as diagnostic criteria of cirrhotic cardiomyopathy . E/A ratHeart failure in LT recipients is believed to be the result of non-ischemic systolic dysfunction . A decreMyocardial Performance Index (MPI/Tei index) is defined as the ratio of isovolumetric contraction time plus isovolumetric relaxation time to the ejection time and has found to be increased in heart failure patients . It has Speckle tracking echocardiography (STE) is based on the generation of small myocardial footprints and frame by frame identification of their relative displacement which enables quantification of myocardial deformation . Global Except from GLS, STE can be useful in the diagnosis of diastolic dysfunction. Strain rate during isovolumetric relaxation and early diastole are related with LV filling pressure and wedge pressure and may be sensitive markers of impaired LV relaxation . To our Three dimensional (3D) echocardiography is helpful when quantifying volume and function of cardiac chambers, is considered more accurate and more reproducible than 2D echocardiography and may also permit more accurate measurement of LV mass . Those aContrast echocardiography utilizing contrast agents and low mechanical index imaging modalities (left ventricular opacification-LVO) can offer many advantages on the evaluation of cardiac dysfunction in cirrhotic patients. Differentiation of ventricular cavity to myocardium enables accurate detection of endocardial borders and recognition of segmental wall-motion abnormalities . FurtherA distinctive feature in CCM is the inability to increase cardiac work at stress. Thus, stress echocardiography (SE) is used first to reveal the blunted response to adrenergic stimulation and secondly to diagnose CAD. Several studies have been published using either exercise test or dobutamine induced stress to evaluate the diagnostic and prognostic role of SE in cirrhotic patients and/or LT candidates.Blunted response to adrenergic stimulation is translated into lower peak heart rate, lower increase in LVEF and cardiac index in cirrhotics compared to controls during peak exercise . These fAccording to a meta-analysis which evaluated the diagnostic accuracy of dobutamine SE in diagnosing hemodynamically significant coronary artery stenoses, there is a high heterogeneity among studies, demonstrating low sensitivity of 28% and high specificity of 82% . HoweverExtended use of beta blockers and autonomic dysfunction attenuates the ability of dobutamine to increase heart rate and accomplish a diagnostic SE. Even though there are limited data showing that the maximum heart rate achieved may inversely correlate with adverse events , the proDuring vasodilator studies, ischemia is induced by coronary steal of blood flow away from the stenotic artery  and thusWhen performing dobutamine SE with contrast agents, myocardial perfusion can be evaluated with quantitative or semi-quantitative methods using a combination of high and low mechanical index imaging modalities . This caDiastolic SE with supine bicycle reveals worsening of diastolic dysfunction in patients with reduced diastolic reserve and can possibly exacerbate symptoms of heart failure when they are masked at rest . During Hepatopulmonary syndrome (HPS) is caused by intrapulmonary vasodialation or arteriovenous communications and leads to hypoxia because of ventilation/perfusion (V/Q) mismatch . Common Contrast echocardiography with the use of saline (bubble test) is the most common method to diagnose HPS in patients with cirrhosis and/or portal hypertension and blood gas abnormalities . Saline-−5). Traditionally, PPH is graded as mild when mPAP is 25–35 mmHg, moderate when mPAP is 35–45 mmHg and severe for mPAP values ≥ 45 mmHg [Portopulmonary hypertension (PPH) is the increase of mean pulmonary artery pressure (mPAP) in a patient with portal hypertension after other causes of pulmonary hypertension and especially elevated left ventricular filling pressure (mean pulmonary capillary wedge pressure (PCWP) > 15 mmHg) have been excluded . Contrar 45 mmHg . However 45 mmHg . Because 45 mmHg . When in 45 mmHg .Pulmonary transit time, the time-lapse of the blood to leave right ventricle and reach left atrium, has been shown to be lower in cirrhotic patients with HPS . EchocarMany parameters can be determined by echocardiography  for a satisfactory differentiation between pre- and post-capillary pulmonary hypertension but most of those indices have not been examined in cirrhotic patients . BecauseCMR measures ventricular volumes and ejection fraction noninvasively and without contrast agent . Due to CMR can detect ischemia by two different ways. First with observation of wall motion abnormalities  using the stress factor dobutamine. Compared to stress echo, stress CMR using dobutamine has better sensitivity (86% vs. 74%) and specificity (86% vs. 70%) . Second,CCM is characterized by an impaired cardiac pharmacological response that can be detected with magnetic resonance myocardial stress testing. Krag et al. showed that inotropic response to stress is normal in patients with early cirrhosis . CMR def3 of tissue, substantially less than other in vivo methods, such as conventional echocardiography and nuclear techniques even when only the subendocardium is involved [Following acute ischemic injury, the myocardial distribution volume of gadolinium is increased, due to sarcrolemmal rupture and abnormal wash-out kinetics. This method is referred in the literature as late gadolinium enhanced CMR (LGE) and is the gold standard for the in vivo assessment of myocardial scar . CMR caninvolved ,124. Theinvolved  and patiinvolved . Howeverinvolved .In case of CCM, late gadolinium enhancement has a diffuse myocardial distribution in CMR images with the pattern of myocarditis . High LG“T2-star” technique, assessed by CMR, is a non-invasive method for measuring liver and cardiac iron deposition . Values 1 and T2 mapping techniques. Quantitative T1 imaging, in particular, can be used to calculate the myocardial extracellular volume fraction (ECV), a measure of microscopic myocardial remodeling that has been associated with underlying diffuse fibrosis [CMR has the capability to characterize myocardial tissue using Tfibrosis . ECV wasfibrosis . ECV in fibrosis . These fLimitations of CMR include lack of availability, high cost, high expertise level needed for accurate diagnosis, awareness of referring physicians about the applications of the technique, claustrophobia, metallic clips, pacemakers (unless CMR compatible) and defibrillator . Even thCardiovascular dysfunction in cirrhotic patients without a preexisting cardiac disease is usually referred to as CCM, a condition characterized by high cardiac output and usually preserved systolic function at rest. Careful evaluation of diastolic function and identification of blunted response to adrenergic stimulation may unmask this clinical condition. Newer imaging modalities such as STE, as well as CMR may contribute to improved diagnostic approach of cirrhotic patients, but they are not used in the clinical practice nor are they included in the diagnostic criteria. More data are needed to investigate their clinical utility and limitation for the LT candidates. Given the increased prevalence of metabolic syndrome, NASH associated cirrhosis has become more frequent increasing the proportion of cirrhotic patients with CAD. Standard protocols have low sensitivity for CAD, giving prominence to the need for evaluation of the prognostic significance of mixed stress echo protocols and stress CMR. Other cardiovascular abnormalities in LT candidates include HPS and PPH, which are usually diagnosed with conventional echocardiography. We believe that a multidisciplinary team including both hepatologists and cardiologists can take advantage of the multimodality imaging approach to improve clinical outcomes of LT candidates. Such approach should be reflected in future diagnostic criteria and guidelines.


Although diabetes mellitus (DM) and insulin resistance associate with adverse cardiac events, the associations of left ventricular (LV) remodeling and function with compromised glucose metabolism have not been fully evaluated in a general population. We used cardiovascular magnetic resonance (CMR) to evaluate how CMR indices are associated with DM or insulin resistance among participants before developing cardiac events.We studied 1476 participants who were free of clinical cardiovascular disease and who underwent tagged CMR in the Multi-Ethnic Study of Atherosclerosis (MESA). LV shape and longitudinal myocardial shortening and torsion were assessed by CMR. A higher sphericity index represents a more spherical LV shape. Multivariable linear regression was used to evaluate the associations of DM or homeostasis model assessment-estimated insulin resistance (HOMA-IR) with CMR indices.p < 0.05); torsion was greater in treated DM  after full adjustments. Among participants without DM, greater log-HOMA-IR was correlated with greater LV mass  and LV mass-to-volume ratio , and lower sphericity index . Greater log-HOMA IR was associated with lower longitudinal shortening  and circumferential shortening . Torsion was positively correlated with log-HOMA-IR until 1.5 of log-HOMA-IR .), and tended to fall once above 1.5 of log-HOMA-IR . The sphericity index was associated negatively with LV mass-to-volume ratio  and torsion .In multiple linear regression, longitudinal shortening was lower in impaired fasting glucose than normal fasting glucose (NFG) .Multi-Ethnic Study of Atherosclerosis (MESA): A full list of participating MESA investigators and institutions can be found at The online version of this article (10.1186/s12968-018-0472-9) contains supplementary material, which is available to authorized users. Type 2 diabetes mellitus (DM) is a group of metabolic diseases; insulin resistance is a condition characterized by the failure to respond appropriately to insulin. Chronic hyperglycemia may impair myocardial energy metabolism, induces cardiomyocyte systolic dysfunction and eventually cell death , 2. EpidLeft ventricular (LV) structure, shape and myocardial shortening  have been shown to have incremental predictive value for cardiovascular events beyond the traditional LV ejection fraction measures –10. AlthThe Multi-Ethnic Study of Atherosclerosis (MESA)—a prospective study sponsored by the National Heart Lung and Blood Institute (NHLBI) of the National Institutes of Health—is a large cohort study of ethnically diverse individuals free of cardiovascular disease at baseline, and was primarily designed to study the progression of subclinical cardiovascular disease . MESA isMESA evaluated the mechanisms that underlie the development and progression of subclinical cardiovascular diseases among asymptomatic individuals. Details of the MESA study design have been previously described . In brieLV end-systolic volume and end-diastolic volume (LVEDV), LV mass, and LV ejection fraction were obtained -gated fast low angle shot pulse sequence , smoking status , heart rate, systolic blood pressure, total cholesterol, use of medication for hypertension and dyslipidemia, estimated glomerular filtration rate, walking in METs per week, and alcoholic status . Significant nonlinearity was present between the torsion and HOMA-IR with a knot at 1.5 of log-HOMA-IR. Therefore, we used a linear spline model to estimate the relationship as a piecewise linear function with adjustments for the same covariates, as described above. Standardized values were defined by dividing the differences between the observed values and the sample means by the corresponding standard deviations. Statistical analyses were performed using the Stata statistical software package . A two-sided p-value < 0.05 was considered statistically significant.Summary statistics were presented using median  for continuous variables, and percent for categorical variables. The chi-square test was used for comparison of categorical variables. Wilcoxon’s rank-sum test was used to test the differences to compare each DM fasting glucose state. Multivariable linear regression models were used to compare CMR indices by DM fasting glucose criteria. We also used multivariable linear regression to evaluate the associations of HOMA-IR with CMR indices. Potential covariates included age, gender, race, height, obesity  had DM and 262 (18%) had IFG.p < 0.05). Use of lipid-lowering medication was common in treated DM .Baseline characteristics according to DM fasting glucose criteria are shown in Table p = 0.077) and mass-to-volume ratio  with a lower longitudinal shortening  after adjustments for all prespecified confounders (Table p < 0.05) than NFG after full adjustments  and torsion  after full adjustments  in the whole study population, and did not differ among DM fasting glucose criteria. Compared to NFG, treated DM tended to have greater LV mass  and mass-to-volume ratio , and with lower sphericity index  after full adjustments. Greater log-HOMA IR associated with lower longitudinal shortening  and circumferential shortening  after adjustments. These relationships were confounded by hypertension  and obesity. The association between torsion and HOMA-IR was nonlinear , and tended to fall once above 1.5 of log-HOMA-IR  after full adjustments  participants with treated DM had greater LV concentric remodeling and greater torsion compared to participants with normal fasting glucose (NFG); (2) insulin resistance (non-DM) was related to a more conical LV shape and concentric remodeling with impaired systolic longitudinal myocardial shortening, but torsion was higher in advance with insulin resistance and was mirrored in a somewhat parallel manner with higher LV mass-to-volume ratio and conical shape. These observations suggest that DM or impaired insulin resistance are associated with adverse LV concentric remodeling, conical LV shape, and impaired systolic function. Increased torsion may be a key compensation mechanism to maintain global systolic function despite the alteration of myocardial shortening and structure due to compromised glucose metabolism in the general population Fig. .Fig. 3SuIn the present study, subjects with treated DM had a more concentric LV than those with NFG subjects. In the Strong Heart Study, DM patients had increased LV mass and wall thickness by conventional echocardiography than normal glucose tolerance . AccordiAlthough the effect of LV sphericity shape has been described in LV severe systolic dysfunction  or in woIn the present study, torsion was not enhanced in the untreated DM group. It has been noticed in a clinical practice that the direct pathway from DM to dilated cardiac failure (increased LV sphericity and eccentricity change) can occur without a myocardial infarction . ChronicIn our data, longitudinal and circumferential shortening were impaired with insulin resistance despite the relations being confounded by obesity and hypertension. In the Strong Heart Study, DM had lower fractional shortening by echocardiography than normal glucose tolerance . Others LV torsion and myocardial strain are a principle for quantification of LV function which is also feasible with speckle-tracking echocardiography. Global LV torsion may be used to identify subclinical systolic dysfunction in patients with DM in addition to myocardial shortening. Although LV torsion has yet not been included in clinical practice guidelines, it is likely to become a useful application when evaluating patients with heart failure symptoms. Therefore, future studies should investigate if LV torsion may be useful marker of the predicting heart failure.Our study has several limitations. First, because of the cross-sectional design, we cannot establish causal relations between glucose metabolism disorders and LV indices; however, MESA is the largest CMR tagging study to evaluate these associations so far, allowing unique investigation of cardiac mechanics at the population level. Second, the small number of untreated DM participants affects the power to detect differences in LV indices compared to NFG. This might be a factor explaining why torsion was not increased in the untreated DM group.Although some investigators have also expressed torsion as the representing the shear deformation angle, wich torsion normalized by twist angle and LV radius , we did Glucose metabolism disorders are associated with LV concentric remodeling, less spherical shape, and reduced systolic myocardial shortening in the general population. Although torsion is higher in participants who are treated for DM and impaired insulin resistance, torsion was increased only with less severe insulin resistance. Increased torsion may be a key compensation mechanism to maintain global systolic function despite impaired myocardial shortening, and be explained by the changes in LV concentric remodeling with less spherical shape due to compromised glucose metabolism.Additional file 1:Methods; CINE Cardiovascular magnetic resonance/ Torsion and Myocardial Strain Analysis/ Left ventricular indices/ Risk factor measures. (DOCX 636 kb)


Percutaneous mitral valve repair is an important procedure for patients at high risk of surgical mitral valve repair. Multi-modality Cardiac Imaging plays a key role in these procedures. MitraClip is the first and most utilized percutaneous mitral repair device and experience is has grown to treat not only typical but atypical and complex lesions. Cardioband is an emerging percutaneous annuloplasty system with promising early results. This review will focus on the comprehensive multi-modality cardiac imaging for patient selection and intra-procedural guidance of the MitraClip and Cardioband systems. Mitral regurgitation (MR) is one of the most common valvular diseases in the world. Percutaneous technologies have been increasingly investigated as an alternative to open heart surgery in high-surgical risk patients. Several mitral repair systems have been approved in the United States or Europe. The Mitraclip  percutaneous edge-to-edge repair device has received Conformité Européenne (CE) mark approval for degenerative and functional MR in Europe as well as Food and Drug Administration (FDA) approval for degenerative and more recently functional MR in the United States. Cardioband  percutaneous annuloplasty system has received CE mark approval for functional MR in Europe. Cardiac imaging pre-procedural assessment and intra-procedural guidance are crucial for procedural success and will be reviewed here.2, regurgitant volume of ≥60 cc and regurgitant fraction of ≥50%. Importantly for chronic MR, the left ventricle (LV) should be dilated.Multiple Societal guidelines , 2 recom2, regurgitant volume of ≥60 cc. Although current European Society of Cardiology guideline (which uses a lower cut-off) (2 (2), with LV dilatation (LV end-systolic dimension ≤ 70 mm) and LV ejection fraction >20%. Guidelines are expected to change based on the results of the randomized trial and these new indications.The recent ACC/American Heart Association guideline update  as well -off) (2 . FDA app-off)  . Case reports, observational studies, and clinical experience have since shown the possibility of successful therapy outside of these original criteria  (33). A recent paper studying treatment of degenerative MR suggested that higher baseline left-ventricular end-diastolic diameter and mitral annular diameter predict greater than mild residual MR after mitraclip  definitions of “device success” measured at 30 days are listed in  = 0.04) . Sorajja = 0.04) . The oricriteria –16. Luboitraclip . In curritraclip . Hahn etitraclip  18). Se. Sep = 0itraclip –21. ThusFor patient anatomic TEE screening, mitral anatomy should be completely described, including etiology of mitral regurgitation, specific scallop location(s) of mitral regurgitant jet(s), and leaflet qualities at these locations  . A biplaIntra-operative imaging guidance for MitraClip is predicated upon 2D and 3D TEE imaging. The procedural plan based on screening and intra-operative diagnostic TEE, including location and numbers of clips proposed, should be discussed between the interventional imager and interventional cardiologist. A qualitative and quantitative re-evaluation of the mitral regurgitation intra-procedurally, prior to MitraClip placement, is needed to establish a baseline for comparison at the end of the case. A step-by-step overview of imaging-based procedural steps is outlined in Recent guidelines delineate the many pitfalls of routine measures of MR severity following percutaneous edge-to-edge repair . ImportaMitral and pulmonary vein inflow patterns, change in forward stroke volume, and continuous wave jet profile. The primary quantitative parameter still valid following an edge-to-edge repair is three-dimensional color Doppler direct planimetry of the vena contracta areas , 29, 30.Similarly to the pre-procedural evaluation, residual mitral valve orifice area should be planimetered on 3D multiplanar reconstruction, with each orifice area measured and added to evaluate the total orifice area. If significant mitral stenosis is present by planimetered mitral valve orifice area or transmitral gradient while the clip is attached to the delivery system, the clip can then be released, repositioned and/or withdrawn.After clips are released from the delivery system, tissue grasp should be reconfirmed, and residual regurgitation, mitral valve orifice area, and transmitral gradient by continuous-wave Doppler should be evaluated. Complications should be monitored on TEE imaging during and after the procedure, including pericardial effusion, clip detachment, and damage to the leaflets or subvalvular apparatus.p < 0.01) immediately post-procedure, which was maintained at 1 year follow-up  as well as MDCT. Mitral regurgitation etiology and severity should be assessed on TEE imaging as previously described. Preprocedural anatomic planning is primarily based on MDCT. MDCT analysis for Cardioband requires a dedicated software module such as those found on 3mensio . Posterior mitral annulus perimeter (excluding trigone-to-trigone distance) should be measured using a cubic-spline interpolation measurement from a semi-automated workflow . The lenIntra-procedural Guidance of mitral Cardioband is based on 2D and 3D-TEE, and fluoroscopy. Intracardiac echocardiographic imaging may play an increasing role as technology improves. As with Mitraclip, an initial intra-procedural baseline assessment of mitral regurgitation severity, mitral valve orifice area, and transmitral gradients should be performed for direct comparison post-implant. Additionally, baseline mitral annulus dimensions should be recorded for direct post-implant comparison. Transseptal puncture should be 3.0–4.5 cm above the mitral annular plane, and entering the atrium across the anteroseptal commissure on 3-dimensional TEE surgical (en-face) view. The first anchor is implanted as anterior as possible to the lateral commissure near the trigone. The positioning of the guide toward the first anchor location can be performed using 3D-TEE . Once thThe newly established percutaneous mitral valve repair technologies rely heavily on multimodality cardiac imaging for pre-procedural patient selection, as well as for intra-operative imaging guidance. Cardiac imaging will continue to play a critical role in the success of these procedures.OK reports speaker fees from Edwards Lifesciences; consulting for Jenavalve and Cephea Valves. RH reports speaker fees from Boston Scientific Corporation and Baylis Medical; consulting for Abbott Structural, Edwards Lifesciences, Gore & Associates, Medtronic, Navigate, Philips Healthcare and Siemens Healthcare; non-financial support from 3mensio and GE Healthcare; is Chief Scientific Officer for the Echocardiography Core Laboratory at the Cardiovascular Research Foundation for multiple industry-sponsored trials, for which she receives no direct industry compensation.OK and RH both conceived the design of the document and approved the final document. OK drafted the document with significant edits and additions made by RH.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Patients were dichotomized by presence of elevated ECV. High-sensitivity cardiac troponin T (hs-cTnT) and N-terminal B-type natriuretic peptide (NT-proBNP) were measured using serum samples acquired and stored at time of CMR scan, and patients were categorized into 3 groups for each blood marker based on recommended cutoff values. Subsequent heart failure admission and any death were ascertained. Relationships with ECV, hs-cTnT, and NT-proBNP were examined separately and as a composite with Cox proportional hazard models. Of 1,604 serial patients referred for a clinical CMR with myocardial T1 maps, 331 were eligible after exclusions and had blood available and were followed over a median 25.0  months. After adjustments for age (mean 57.3 ; p = 0.02) and NT-proBNP . Similar trends were seen for lower category levels of blood markers, but did not persist with minimal covariate adjustments. Elevated measures of ECV by CMR are associated with incident heart failure outcomes in patients with high hs-cTnT and NT-proBNP levels. This imaging marker may have a role for additional heart failure risk stratification.Measures of serum cardiac troponins and natriuretic peptides have become established as prognostic heart failure risk markers. In addition to detecting myocardial fibrosis through late gadolinium enhancement (LGE), extracellular volume fraction (ECV) measures by cardiac magnetic resonance (CMR) have emerged as a phenotypic imaging risk marker for incident heart failure outcomes. We sought to examine the relationship between cardiac troponins, natriuretic peptides, ECV and their associations with incident heart failure events in a CMR referral base. Mid short axis T1 maps were divided into 6 cardiac segments, each classified as LGE absent or present. Global ECV was derived from T1 maps using the area-weighted average of only LGE-absent segments. ECV was considered elevated if measured >30%, the upper 95% bounds of a reference healthy group without known cardiac disease ( Elevations in measures of natriuretic peptides and cardiac troponins have previously been established as markers of poor heart failure prognosis not only in patients with established heart failure  but also in patients without established disease 7. The detection of elevated natriuretic peptides through B-type natriuretic peptide (BNP) and its propeptide N-type proBNP (NT-proBNP) has entered clinical use in diagnosing and guiding management of patients with or at risk for heart failure, and for risk prognostication in patients with chronic heart failure per guideline recommendations8. Assays for measuring cardiac troponins have improved in the last several years with newer commercial assays that enable lower limits of measurements using high sensitivity techniques.Non-invasive measures of extracellular volume fraction (ECV) by cardiac magnetic resonance techniques (CMR) have been histologically validated as surrogates of the myocardial interstitial volume, have been shown to be altered in various heart diseases, and have emerged as potential imaging risk markers for subsequent heart failure events9. Limited data exist on the association between such imaging and blood markers and would be essential to formulating future research strategies and clinical recommendations for improving heart failure risk stratification using such biomarker combinations. In this study, we sought to examine the relationships between ECV, NT-proBNP, high-sensitivity cardiac troponin T (hs-cTnT) and incident heart failure outcomes in a population referred for CMR.Epidemiologic studies have established a strong association between troponin levels detected at lower levels with subsequent adverse cardiovascular events in various populations10. Written informed consent was obtained from all participants prior to enrollment. Subjects were serially recruited from patients referred to the cardiovascular magnetic resonance (CMR) laboratories of Houston Methodist Hospital, a tertiary center for routine CMR imaging from June 2011 through January 2015, as part of an ongoing prospective cohort study designed to examine the relationship of myocardial extracellular volume fraction (ECV) with heart failure events. All patients were approached during this time period by the CMR staff on arrival to the waiting area, at which point the study was discussed and the consent form was provided. When patients were brought the holding area for safety screening and final preparations before the CMR scan, they were given the opportunity to ask questions about the study and to choose to participate.The study was approved by the local institutional review board of the Houston Methodist Research Institute and conducted in accordance with Good Clinical Practice guidelines2), had no contraindications to CMR, and completed the full imaging protocol which included, cine-CMR, late gadolinium enhancement (LGE), and T1 mapping procedure . Exclusion criteria included any missing relevant demographic data, refusing or missing blood samples, technical issues with imaging, and any infiltrative cardiomyopathy or any cardiac tumors by clinical history or detected on CMR. Three hundred thirty one participants were selected for analyses after application of inclusion and exclusion criteria , or contact with the referring clinic through December 31, 2016. The primary outcome of the first major heart failure event was a composite of heart failure hospitalization and death from any cause. Individual outcome types were examined separately as secondary outcomes. As established in the 2014 American College of Cardiology/American Heart Association (AHA) Cardiovascular Endpoints Data Standards, heart failure hospitalization events were defined as any hospitalization with a primary diagnosis of heart failure where the patient had a length of stay of at least 24 hours, symptoms or objective evidence of new or worsening heart failure, and initiation or intensification of heart failure therapies17.Patients underwent CMR scans on either a 1.5-Tesla or a 3.0-Tesla clinical scanner  with phased-array receiver coil systems. Imaging protocols consisted at a minimum of an electrocardiography (ECG)-gated cine section and LGE imaging as previously described, and each of these protocol sections was followed with modified Look-Locker inversion recovery (MOLLI) sequences for T1 mapping just prior to and ~15 minutes after contrast administration18.Briefly, cardiac cines were acquired with a steady-state free precession sequence (SSFP) over 25–30 cardiac phases with in-plane spatial resolutions of 1.7 to 2.0 mm by 1.4 to 1.6 mm using sequential short-axis stacks  with 10-mm increments  and standard cardiac long-axis views . Cardiac chamber parameters were measured by level III trained CMR readers and indexed for body surface area20.LGE images were acquired over slice positions matched to cines about 10–15 minutes following intravenous gadolinium-based contrast administration  with in-plane spatial resolutions of 1.8 mm by 1.3 mm and slice thicknesses of 6–7 mm with 3–4 mm gap. LGE images were obtained using inversion-recovery gradient echo sequences with inversion times set to null myocardial tissue signal (inversion time [TI] 250–350 msec)21. For each myocardial segment, the extent of regional LGE was scored according to the spatial extent of LGE within each segment . The total scar burden for the entire left ventricle was expressed as a percentage of LV myocardial volume and derived by averaging the score for all 17 segments.The presence and extent of myocardial LGE, considered synonymous with replacement fibrosis or scar tissue, was assessed using the AHA 17-segment model by level III trained CMR readersAn ECG-gated MOLLI sequence with SSFP image readout with motion correction was performed at a representative mid short-axis view of the left ventricle at two distinct time points within a CMR scan: once following cine imaging but prior to contrast administration (pre-contrast), and once ~15 minutes following LGE imaging (post-contrast). The mid short-axis was chosen due to concerns with partial volume due to through-plane cardiac motion near the base and near the apex. Technical details of the MOLLI sequence setup can be found in the Supplemental Material.42 software, Circle Cardiovascular Imaging, Calgary, Canada; Supplemental Material). The LGE image corresponding to the T1 maps was reviewed for LGE presence. Myocardial segments with LGE were classified as coronary artery disease (CAD) or non-CAD type LGE for subsequent exclusion from ECV calculations.A single reader – blinded to the clinical history, other CMR images, and clinical outcomes – post-processed all cases in randomized order and abstracted the T1 values for ECV calculations. Intra- and inter-reader reproducibility of ECV measures were separately assessed in a selected sub-group, which was re-randomized for each reader . ECV was assessed for the 6 myocardial segments of the mid short axis using post-processing image analysis tools  × (ΔR1myocardium/ΔR1blood), where Hct is the hematocrit level and ΔR1 represents the change in T1 relaxivity (R1 = 1/T1) before and after gadolinium-based contrast administration. Myocardial segments with any artifacts or LGE were excluded from the ECV calculation used for the main analyses. Segments with LGE were excluded because LGE has been determined to increase ECV and to be independently associated with adverse cardiovascular outcomes. A global scar-free ECV was then calculated, average-weighted for the size of each usable myocardial segment.For each of the 6 myocardial segments, myocardial ECV was derived using pre- and post-contrast T1 values of myocardium and blood pool as previously described in other worksBlood was drawn in ethylenediamine tetraacetic acid tubes, mixed and placed on ice, or into serum separator tubes, which were allowed to stand for 30–45 minutes at room temperature. These tubes were sent within the hour to the onsite research core laboratory for further processing. Tubes were centrifuged at 3000 rpm for 15 minutes at ambient temperature. The plasma or serum was transferred from the tubes with a sterile pipette into three 1 mL aliquots for storage. Samples were frozen and stored at − 80 °C.A 1 mL aliquot for each eligible study participant with available blood samples was transferred to the Atherosclerosis Clinical Research Laboratory (ACRL) at the Baylor College of Medicine and thawed to ambient temperature prior to use. Plasma levels of cardiac troponin T were measured using a high-sensitivity assay  on a Cobas e411 automated analyzer. The hs-cTnT assay has a inter-assay coefficient of variation (CV) of 5.2% at a mean hs-cTnT concentration of 13.5 ng/L. Plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP levels) were measured by electrochemoluninescence immunoassay (ECLIA)  on a Cobas e411 automated analyzer on the same sample set. The NT-proBNP assay has an inter-assay coefficient of variation (CV) of <4.6.All statistical analyses were conducted using Stata 15.1 . From the 28 healthy volunteers, the upper 95% cutoff or mean + 2 standard deviations (SD) of ECV was determined to be 30.2% on the 1.5-Tesla scanner and 31.1% on the 3.0-Tesla scanner. The main cohort was dichotomized into low (≤mean + 2 SD) vs. high (>mean + 2 SD) ECV categories based on ECV values and scanner type. It was also separated into three categories of hs-cTnT  and into three categories of NT-proBNP . We elected to present results using categories for the imaging and blood biomarkers because the few number of heart failure events limited our power to examine their associations with events as continuous variables. The power calculation for our study sample was calculated for the difference in mortality, heart failure hospitalization and composite of mortality or heart failure hospitalization between the low and high ECV groups. The power calculated was based on the 2-sided chi-square test for two proportions. Analyses of the markers as continuous variables are included in the supplemental.25.Baseline characteristics and CMR parameters were described. All statistical tests were two-sided with significance set at p < 0.05. Nominal variables were compared among ECV and scar groups using Chi-squared or Fisher’s exact testing as appropriate. Normality of continuous variables was assessed using Shapiro-Wilk testing. Because continuous variables were predominantly non-normally distributed, non-parametric comparison among ECV and scar groups were conducted for all continuous variables using Kruskal Wallis testing. Correlations between continuous ECV measures and blood biomarkers were assessed using Spearman’s rank correlation coefficients. Associations between blood biomarkers and binary ECV categories were further assessed using multivariable logistic regression. We examined a parsimonious logistic regression model, developed using Bayesian model averaging to select out only significant predictors of elevated ECV26, we employed a base multivariable model with stepwise addition of covariate clusters (imaging and blood markers) to assess whether scar-free ECV categories contributed to the model for prediction of incident heart failure events. This multivariable model included age, sex, black ethnicity, current and former smoking status, heart rate, body mass index, history of hypertension, history of diabetes, and history of prior myocardial infarction.Time to first composite event of either heart failure hospitalization or any death event were depicted using Kaplan-Meier survival curves. Differences between groups was compared by the log-rank test. Potential risk factors associated with the composite event were determined by and univariable and multivariable Cox proportional hazard risk models examining ECV as a binary variable . Based on a previously validated heart failure prediction model from the Atherosclerosis Risk in Communities Study (ARIC)27.Harrell’s C-statistic was used to compare the diagnostic performance of the predictive models. The incremental benefit of scar-free ECV categories when added back to the multivariate models was evaluated using the post-hoc linear combinations of estimatorsOverall, the cohort had a median age of 59.7 (interquartile range 47.4 to 67.8) years with a male predominance Tables  and 2. TElevated scar-free ECV measures and scar presence were also more prevalent with elevated levels of blood biomarkers. Both blood biomarkers were modestly, positively correlated with elevated ECV  and scar presence   hs-cTnT and NT-proBNP levels have modest associations with elevated ECV, more so with scar presence, that persist despite adjustments for relevant covariates in this population; and b) elevated ECV was associated with increased risk for first composite events for patients in the highest category levels for both blood biomarkers and for intermediate levels of hs-cTnT. For first composite events, a trend for significance was observed with elevated ECV for intermediate levels of NT-proBNP and the lowest category levels of both blood biomarkers.4. Prior investigators have also examined the associations of CMR-derived imaging markers with hs-cTnT and NT pro-BNP levels. Chin et al. observed that patients with aortic stenosis had elevated hs-cTnT levels with mid-wall LGE present vs. those without LGE and also with increasing ECV values in fully adjusted models. In contrast, BNP levels were not associated with either CMR imaging marker in their cohort after adjustments28. In a study of patients with hypertrophic cardiomyopathy, Goh et al. also found that elevated hs-cTnT levels were similarly associated with mid-wall LGE presence vs. those without LGE and also with increasing interstitial volume after adjusting for covariates. Unlike their previous cohort with aortic stenosis, the same investigators found a similar relationship between these CMR-derived imaging markers and BNP in their cohort with hypertrophic cardiomyopathy, persisting after adjustments29. Our findings that these CMR imaging markers are associated with cardiac troponin and natriuretic peptide levels are consistent with both works by the same group of investigators but in a more general CMR referral base in a clinical setting.Non-invasive quantification of ECV has been histologically validated in various small studies of patients with cardiac diseases5. Schelbert et al. have shown that ECV measures were strongly associated with log-transformed BNP levels in a subcohort of patients (n = 397) with heart failure with preserved ejection fraction or at risk for heart failure (univariable β linear regression coefficient = 0.338 [standard error (SE) 0.050], p < 0.001; multivariable β = 0.254 5. Although Kammerlander et al. also observed an association between NT-proBNP and heart failure outcomes  in their Austrian cohort (n = 473), this association did not persist in a multivariable model inclusive of ECV measures, which itself remained a significant predictor. Our univariable and multivariable models echo the findings of both observational studies, with elevated ECV persisting as a predictor of incident heart failure events. Additionally, when we examined improvement statistics, we found ECV to have significant improvement for detecting first composite heart failure events when added to a full heart failure prediction model plus LV EF and myocardial mass, hs-cTnT and NT pro-BNP, and myocardial scar. To our knowledge, few studies have also examined the relationship of ECV measures on CMR with troponin levels measured with high sensitivity assays.To date, only a few large single center studies have established the association of ECV values with incident heart failure events8. For natriuretic peptides, the writing group recognized in their 2017 focused update that these markers may also have utility in screening populations for incident heart failure as well. Cardiac troponin levels using conventional assays were similarly commented by the writing group to be suggestive of cardiomyocyte injury or necrosis and should be interpreted within a given clinical context. However, authors of a recent meta-analysis of high sensitivity troponin measures in 154,052 individuals suggest other causes, such as atrial fibrillation, subclinical coronary ischemia, and even neurohormonal stressors may also play a role in their elevation9.Authors of the American College of Cardiology Foundation/American Heart Association Guideline for the Management of Heart Failure recognized the utility of various biomarkers for assessing patients with congestive heart failureThe same heart failure guideline writing group also identified several emerging blood biomarkers of interest associated with myocardial tissue activity such as soluble ST2 and galectin-3 for possible roles in heart failure risk stratification and management. Except for assessing potential etiologies of heart failure such as cardiac ischemia or infiltrative cardiomyopathies, the writing group did not consider noninvasive imaging markers beyond ventricular morphology and function for further heart failure management. More pointedly, the writing group endorsed the consideration of additional biomarkers for myocardial injury or fibrosis for additive risk stratification as a class IIB recommendation. Further, a need was identified for future multicenter studies that employ strategies combining multiple biomarkers for guiding heart failure therapies. Our study would be among the first to examine an imaging marker of myocardial fibrosis in the context of established blood markers of myocardial stress and injury in relation to the prognostic risk of heart failure outcomes. The work also provides a premise for framing ECV with such blood markers in future heart failure studies.The study was not without limitations. As an observational cohort study, we included many demographic variables associated with heart failure outcomes at baseline, but unanticipated variables associated with heart failure outcomes may not have been captured at initial enrollment. Every reasonable effort was made to determine the vital status of participants and to contact participants regarding interval clinical events. However, outcomes of interest may still be missed despite our best efforts. The number of events were also small. Thus, we may not have been sufficiently powered to detect differences in outcomes associated with lower levels of blood biomarkers and ECV. Our findings should be construed as hypothesis-generating and would require further validation in a cohort with larger, sufficient event numbers. We also applied a model developed for a general population to a CMR referral base. Despite this issue, we still found that the ARIC heart failure risk model to have a reasonable discriminative ability for future heart failure outcomes in our population with c-statistics >0.70 for all studied outcomes, even before the addition of any additional risk markers to the risk models. Lastly, we used a CMR referral base at a tertiary care center, which may have a selection bias not only for more prevalent cardiac pathologies but also for less severe renal disease, because of the requirement for gadolinium contrast use. Thus, our study population may be less generalizable to other populationsElevated noninvasive measures of extracellular volume fraction on cardiac magnetic resonance imaging are associated with incident heart failure outcomes in patients with higher troponin T levels on high sensitivity assays and with higher N-terminal pro B-type natriuretic peptide levels. This imaging marker may have a role in providing additional risk stratification in patients at risk for heart failure and should be considered in future studies combining heart failure risk markers.Supplementary Information


Although previous studies have examined the impact of slice position in volumetric measurements in Cardiovascular Magnetic Resonance (CMR) imaging, very limited data are available today comparing T1 and Extra-Cellular Volume (ECV) measurements from short and long axis acquisitions. The purpose of this study was to investigate the impact of slice position and orientation on T1 and ECV measurements using the MOdified Look-Locker Inversion recovery (MOLLI) and Saturation recovery single-shot acquisition (SASHA) sequence in patients with myocardial infarction and in healthy volunteers.Eight (8) healthy volunteers with no medical history and eight (8) patients with myocardial infarction were included in this study. MOLLI and SASHA were utilized and short-axis and long-axis images were acquired. T1 and ECV measurements were performed by drawing same size regions of interest on the myocardium as well in the blood pool at the intersections of the short axis and long axis images.In healthy volunteers, there were no statistically significant differences in native T1 and ECV values between short axis and long axis acquisitions using MOLLI  and SASHA (three-chamber). In patients, there were no statistically significant differences in native T1 and ECV values between short axis and 3-chamber long axis acquisitions in both remote and affected myocardium using MOLLI and SASHA.Long axis measurements of myocardial T1 and ECV using MOLLI and SASHA exhibit good agreement with the corresponding short axis measurements allowing for fast and reliable myocardial tissue characterization in cases where shortening of the overall imaging acquisition is required. In the field of Cardiovascular Magnetic Resonance (CMR) imaging, quantitative measures of myocardial and blood T1 before and after contrast injection enabled the calculation of myocardial extracellular volume fraction (ECV), an important myocardial biomarker . SeveralMyocardial and blood T1 values are most often determined on short-axis images of the left ventricle of the heart, usually including one apical, one midventricular and one basal slice. Recent advancements in the field of cardiac T1 mapping have allowed for fast generation of a single-slice T1 map within a single breath-hold acquisition. Today, the most commonly used T1 mapping technique in CMR is the MOdified Look-Locker Inversion recovery (MOLLI)  whereas It has previously been shown that several factors affect the performance of MOLLI and SASHA on T1 and ECV mapping in terms of accuracy and precision . DiffereEight (8) healthy volunteers with no medical history  and eight (8) patients  with myocardial infarction and without any renal impairment were included in this study. The study was approved by the regional ethics committee and all subjects provided written informed consent . Blood for hematocrit analysis was sampled from a peripheral vein from the subjects approximately 30 min after lying down, just before Gd-contrast administration.All subjects underwent CMR on a MAGNETOM Aera 1.5 T scanner  using a 30-channel coil (body array and spine array). In healthy volunteers, a prototype MOLLI sequence was used to acquire a single midventricular short-axis image and three long-axis images  whereas a prototype SASHA sequence was used to acquire a midventricular short-axis image and a single long-axis (three-chamber) image. Pre-contrast MOLLI T1 mapping was performed using an acquisition scheme of 5s(3s)3s whereas post-contrast MOLLI T1 mapping was performed using an acquisition scheme of 4s(1s)3s(1s)2s. The SASHA scheme remained the same before and after contrast administration. Previous studies , 8 have http://segment.heiberg.se) [2) as well in the blood pool (ROI area: 0.8 cm2) at the intersections of the short axis and long axis images  . T1 measp-value < 0.05 were considered to be statistically significant. Bland-Altman plots were also used to compare the short-axis native T1 and ECV values against the T1 values and ECV values extracted from the corresponding long-axis image.Graphpad Prism version 7.03  was used to perform statistical analysis. Values are presented as mean ± SD. Student’s two tailed t-test for paired data was utilized for comparison of different acquisitions. Differences with a p > 0.05) using MOLLI acquisitions. Figure n = 16, p = 0.46), 963 ± 35 ms vs. 950 ± 51 ms  and 973 ± 41 ms vs. 981 ± 46 ms . The corresponding Bland-Altman plots for native T1 measurement in SAX view against the 3-chamber and 4 chamber LAX views are shown in Fig. n = 16, p = 0.59), 24.9 ± 4% vs. 24.2 ± 3.4%  and 26.2 ± 3.2% vs. 26.3 ± 3.4% . The corresponding Bland-Altman plots for ECV measurement in SAX view against the 3-chamber and 4 chamber LAX views are shown in Fig. In healthy volunteers, there were no statistically significant differences in native T1 and ECV values between short axis and long axis acquisitions p > 0.0 using MOn = 16, p = 0.35) for MOLLI whereas the corresponding mean T1 values for SASHA were 1181 ± 38 ms vs. 1215 ± 83 ms . The mean ECV values were 24.9 ± 4% vs. 24.2 ± 3.4%  for MOLLI whereas the corresponding mean ECV values for SASHA were 22.8 ± 2.5% vs. 21.2 ± 2.6% . The corresponding Bland-Altman plots for ECV measurement in SAX view against the 3-chamber LAX view using SASHA is shown in Fig. Native T1 and ECV measurements in SAX and 3-chamber LAX views using MOLLI and SASHA acquisitions are presented in Figs. p > 0.05). The mean native T1 values extracted from ROIs placed in remote myocardium were 982 ± 79 ms vs. 981 ± 99 ms  for MOLLI whereas the corresponding mean T1 values for SASHA were 1083 ± 147 ms vs. 1154 ± 145 ms . The mean ECV values from the same ROIs placed in remote myocardium were 24.4 ± 3.9% vs. 24.6 ± 3.8%  for MOLLI whereas the corresponding mean ECV values for SASHA were 20.2 ± 3.1% vs. 20.1 ± 5.3% . In affected myocardium, the mean native T1 values were 1212 ± 106 ms vs. 1199 ± 113 ms  for MOLLI whereas the corresponding mean T1 values for SASHA were 1407 ± 87 ms vs. 1416 ± 139 ms . The mean ECV values from the same ROIs placed in affected myocardium were 46.2 ± 8.9% vs. 50.6 ± 14.7%  for MOLLI whereas the corresponding mean ECV values for SASHA were 44.3 ± 11.7% vs. 41.3 ± 10.2% . Figures In patients, there were no statistically significant differences in native T1 and ECV values between short axis and 3-chamber long axis acquisitions (p < 0.05) in T1 measurements between remote and diseased myocardium in both MOLLI and SASHA for both short axis and 3-chamber long axis acquisitions . However, there was no statistically significant difference (p > 0.05) between the MOLLI-based T1 measurements of diseased myocardium and the SASHA-based T1 measurements of remote myocardium for both short axis (p = 0.06) and 3-chamber long axis (p = 0.26) acquisitions.Lastly, as Fig. This study investigates T1 and ECV quantified from long-axis acquisitions compared to short-axis acquisitions using MOLLI and SASHA in healthy volunteers and patients. Long-axis acquisitions showed no statistically significant differences in native T1 and ECV values compared to short-axis acquisitions using both MOLLI and SASHA methods. The two-chamber long axis acquisition presented the lowest agreement with the short-axis acquisition compared to the other two long axis acquisitions. Both MOLLI and SASHA showed similarly tight limits of agreement when comparing the ECV measurements taken with short axis and three-chamber long axis acquisitions although SASHA showed larger bias than MOLLI. Lastly, the statistical hypothesis testing presented in Fig. In the last several years, CMR parametric mapping has been used as a non-invasive tool for quantifying myocardial tissue alternations in myocardial disease. Recently, the Society for Cardiovascular Magnetic Resonance (SCMR) endorsed by the European Association for Cardiovascular Imaging (EACVI) published a consensus statement with recommendations on T1 and ECV mapping . The guiThis study adds on the research that other groups have already performed in order to investigate the impact of slice position in CMR imaging. In particular, comparison of short and long axis methods had been the focus of other previous studies in CMR for volumetric measurements. Harizolan et al.  showed tIn the field of T1 and ECV mapping, results of the current work were similar to results previously reported in the literature. Nacif et al.  showed tCompared to the previous two studies , 16, theIn this study, some limitations apply. The number of subjects is small in both groups. Larger scale studies are required to detect potential subtle differences between different acquisition techniques in T1 and ECV measurements. Moreover, the design of the current study does not allow for a direct comparison between MOLLI and SASHA on the inter-slice variability of the T1 and ECV estimates using the two-chamber and four-chamber LAX images since these images were not acquired neither in healthy volunteers nor in patients. Lastly, the post contrast myocardial T1 values were not presented in this study. Post contrast T1 mapping is considered more variable and depend on several factors such as time elapsed between contrast agent administration and renal clearance .In conclusion, long axis measurements of myocardial T1 and ECV using MOLLI and SASHA exhibit good agreement with the corresponding short axis measurements allowing for fast and reliable myocardial tissue characterization. This may be of high importance in clinical cases where shortening of the overall imaging acquisition is required. Moreover, the ROI-based design of the current study may be utilized in other studies that are focused on myocardial tissue characterization in order to evaluate the differences between different slice orientations, especially in cases with focal native T1 abnormalities.


Correct selection of patients involves – (1) patients with advanced HFto which the risk of MCSD implantation surpasses mortality risk for current disease; (2) patients with moderately advanced HF,i.e., implantation of MCSD would not increase patient’s morbidity and mortality dueto increased complication rate; (3) no contraindications for MCSDimplantation.5Perioperative renal failure, pre-existing right HF, liver dysfunction, mechanicalventilation in the pre-operative period, low weight or overweight and reoperationhave been related to worse clinical outcomes after MCSD implantation.The main scores for risk prediction in MCSD implantation are described in Evaluation of patients candidates for MCDS should include a transthoracicechocardiogram (TEE) complemented by a transesophageal echocardiography (TEE).10The effects of MCDS on right ventricular function depend on the balance between thebenefits of decompression of the left chambers (reduction of the left ventricularafterload) and greater volumetric load to the right atrium . Decompression of left chambers also cause changes in thegeometry of the right chambers, such as leftward shift of interatrial (IAS) andinterventricular septum (IVS), structural changes of tricuspid annulus, which canaggravate a pre-existing tricuspid insufficiency (TI) and right ventricularoverload.11Considering that right ventricular cardiac output determines left ventricularpreload, a significant reduction in right ventricular function results in decreasedoutput by the MCSD. It is estimated that approximately 30% of patients with leftventricular assist device develop limiting right ventricular dysfunction. For thesereasons, a careful evaluation of right ventricular function is mandatory before MCDSimplantation. In the presence of moderate-to-severe dysfunction, the requirement ofa permanent biventricular support cannot be ruled out.12 tricuspidannular plane systolic excursion (TAPSE) determined by M mode, peak systolicvelocity of lateral tricuspid ring, measured by tissue Doppler (s’), and rightventricular performance index.14In the assessment of right ventricular function before MCSD implantation, it isrecommended the measurement of the right ventricle, as well as a semiquantitativeassessment of right ventricular longitudinal and radial contractility combined withquantitative parameters, including fractional area change ,15Right ventricular dysfunction is multifactorial and includes an increase inpreload, ventricular ischemia and mechanical interdependence of ventriculargeometry. It is one of the most severe complications of left ventricular assistdevice, observed in up to 30% of cases and associated with a six-fold increasein morbidity and mortality (increased risk in up to 67%).Risk factors and the main risk score for right ventricular dysfunction after MCSDimplantation are described in 21Implantation of a MCSD in the left ventricle should be performed with caution inpatients with important right ventricular dilation, moderate-to-severe tricuspidinsufficiency, tricuspid valve annulus > 45 mm and CVP > 15 mmHg. By thismeans, hemodynamic variables directly reflect a preload or afterload increaseand right ventricular contractility reductions, whereas venous congestion andorgan hypoperfusion, consequence of right ventricular dysfunction, indicatehepatic and renal dysfunctions2.Positive hemodynamic indicators of adequate right ventricular function that mightreduce the risk of post-MCSD implantation dysfunction are: CVP ≤ 8 mmHg;PCP ≤ 18 mmHg; CVP/PCP ≤ 0,66; pulmonary vascular resistance (PVR)< 2 wood units and right ventricular work index ≥ 400mL/mTemporary MCSD can be used for hemodynamic and clinical stability restoration,aiming at improvement of cardiac function and transplantation. Three strategies(which may be overlapped) can be defined:Bridge to decision: should be considered in severely illpatients, who requires immediate hemodynamic support due to highrisk of cardiac failure. It may occur in different situations – lackof neurological recovery, multiple organ failure, hemodynamicstabilization and requirement of other devices – in which the finalstrategy of therapy cannot be established during device implantation(e.g. after cardiorespiratory arrest).22Bridge to recovery: situation in which support device isremoved for ventricular function recovery, such as ventriculardysfunction following acute myocardial infarction, Takotsubocardiomyopathy and myocarditis.23Bridge to transplantation: situations in which thepatient is in progressive severity and heart transplantation cannotbe performed in a short term. Support devices may providehemodynamic support and clinical stability until transplantation isperformed.24Main characteristics of temporary MCSDs available in Brazil are described inAlthough temporary MCSDs are primarily indicated for patients INTERMACSlevels 1 and 2, INTERMACS level 3 patients, dependent of high doses ofinotropes or at high risk of hemodynamic instability may also be consideredeligible.Contraindications for temporary MCDS include limiting clinical situationsthat require individualized approach and involvement of other professionals(e.g. oncologist for establishment of cancer prognosis).The mechanism of action of the IABP is aortic counterpulsation, whichincreases diastolic pressure at aortic root, promoting an increase incoronary perfusion, afterload reduction, and consequently an increment incardiac output by 15%.Although IABP is still used in the clinical practice especially in youngerpatients with less severe cardiogenic shock, the efficacy of the methodshould be carefully evaluated based on improvement of objective parametersof tissue microperfusion. Lack of improvement of these variables in a shorttime period (hours) justifies the selection of more invasive devices.26Percutaneous circulatory devices enable active support without requiring asynchronism with the cardiac cycle. The main benefits are maintenance oftissue perfusion, improvement of coronary perfusion, and reduction ofmyocardial oxygen consumption, filling pressures and ventricular wallstress, providing a circulatory support in cardiogenic shock.27Impella device is composed of a continuous axial flow pump, that aspiratesblood directly from the left ventricle and directs it to the aorta (works inseries with left ventricle). It allows the flow of 2.5 L/min(Impella® 2.5), 4.0 L/min (Impella® CP) or 5.0 L/min(Impella® 5.0). The model currently available in Brazil isImpella® CP.27TandemHeart™ system is composed of a centrifugal extracorporeal pump,a femoral cannula, a transseptal cannula and a control console. It pumpsblood from the left atrium through a transseptal cannula to the ileo-femoralarterial system. Both TandemHeart™ and the left ventricle work inparallel and contribute to aortic blood flow.Extracorporeal membrane oxygenation (ECMO) is an invasive temporarymechanical support that provides partial or total cardiopulmonary supportfor patients with cardiogenic shock and/or acute respiratory insufficiency.There are two types of ECMO – venoarterial and venovenous. With quickinstallation technology, ECMO promotes rapid reversal of circulatory failureand/or anoxia.Paracorporeal circulatory support devices are surgically implanted pumps thatpromote hemodynamic support in individuals with refractory cardiogenic shockwith high mortality risk.24A CentriMag® is a continuous flow, magnetically levitated centrifugalblood pump. It provides up to 10 L/minute of blood flow and low shearstress, promoting low thrombogenicity, moderate anticoagulation levels andminimum hemolysis during support.Berlin Heart EXCOR® is a pulsatile-flow pump that provides up to 8L/min of blood flow, with batteries connected to a transport system,allowing an up to ten hours of patient’s mobility.Other conventional centrifugal pumps may be used with the same purpose.Due to technological progress, advances in long-term MCSD models haveoccurred during the last years, regarding pumping system and flow type,enabling its reduction in size, greater efficiency and lower complicationrates .The long-term MCSDs available in Brazil are described in In making decision process for long-term MCSDs, some important factors shouldbe considered. In case of bridge to transplantation, transplant waiting timeshould be taken into account; for waiting time shorter than 30 days, therewould be a low benefit-cost ratio. Also, the use of these devices inINTERMACS level 2 patients may have unfavorable results.Patients eligible for MCSD should be evaluated for the presence of factorsthat may contraindicate or negatively influence patients’ survival aftertransplant. Main contraindications are listed in Bridge to decision: long-term MCSDs may be indicated forpatients with clinical conditions that contraindicate hearttransplantation, but if modified, patients may become eligible fortransplant (for example: pulmonary hypertension and curablecancers).Bridge to transplant: Situations in which MCSDs mayprovide hemodynamic support and clinical stability until hearttransplant, in patients with progressive severity and when ashort-term transplant is not possible.Destination therapy: Situations in which MCSDs mayprovide hemodynamic support and clinical stability in patients withrefractory heart failure with contraindication for cardiactransplant, promoting higher survival and better quality of life ascompared with clinical treatment with drugs.28 Its diagnostic criteria are – signs andsymptoms for persistent right ventricular dysfunction; CVP > 18 mmHg withcardiac index < 2,0 L/min.m2 in the absence of ventriculararrhythmias or pneumothorax; requirement of ventricular support devices; orrequirement for inhaled nitric oxide or inotropic therapy for more than oneweek after device implantation.29Right ventricular failure is still one of the main factors that affectpatients’ survival after MCSD implantation.29Implantation of a MCSD increases cardiac output and consequently causes anincrement in venous return to the right ventricle. To counteract thispreload increase, right ventricular compliance should improve with reductionof its afterload . However, leftward shift of IVS may occur incase of excessive left ventricular emptying.30In addition to its contractility, optimization of right ventricular preloadand afterload is crucial to prevent right ventricular failure in theperioperative period. CVP and systolic pulmonary pressure should bemaintained lower than 16 mmHg and 65 mmHg, respectively. For maintenance ofcoronary perfusion, use of inotropes that cause pulmonary vasodilation(milrinone or dobutamine) and maintain adequate systemic pressure is recommended. In addition, the use of specific pulmonaryvasodilators, such as nitric oxide should be considered .30The main complications related to long-term MCSD implantation are describedin With increasing number of MCDSs, this document proposes a change in theprioritization criteria for patients in the cardiac transplant waiting list.These new criteria are described in