The COVID-19 Case Collection highlights the impact of coronavirus disease 2019 (COVID-19) on the heart as demonstrated on CMR. Each case in series consists of the clinical presentation and the role of CMR in diagnosis and guiding clinical management. The cases are all instructive and helpful in the approach to patient management. We present a digital archive of the 2021 Cases of SCMR and the 2020 and 2021 COVID-19 Case Collection series of nine cases as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar literature search engine.The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). “Cases of SCMR” is a case series hosted on the SCMR website (The online version contains supplementary material available at 10.1186/s12968-022-00872-2. This year, we have the privilege to present also, SCMR’s 2020 and 2021 COVID-19 Case Collection. Coronavirus disease 2019 (COVID-19) has had a significant impact worldwide, and it is important to recognize its impact on the heart. The presentation of the COVID-19 cases differ a little to that of Cases of SCMR. The presentations focus on the main clinical findings and features on cardiovascular magnetic resonance (CMR) as opposed to the more complex Cases of SCMR with a more detailed discussion and perspective sections. As previously in Cases of SCMR, we have an international representation of cases, from the United States and Europe, and pleasingly, a case from Mexico. There was a mixture of adult and pediatric cases for Cases of SCMR, demonstrating the broad utility of CMR in assessing and diagnosing cardiovascular disease. We present unexpected and rare diagnoses by CMR and therefore highlighted important information in guiding clinical management. Cases appropriate for Cases of SCMR are those that demonstrate the role of CMR in context of clinical presentation, diagnosis and management; and the way it complements other imaging modalities , estimated glomerular filtration rate (eGFR) 38 mL/min/1.73m2  suggestive of at least moderate aortic stenosis (AS). She had pulmonary artery hypertension with estimated RV systolic pressure of 60 mmHg. An invasive cardiac evaluation was recommended but the patient opted for a conservative strategy with medical management. Upon her request, palliative care team was consulted and she elected to have a do not resuscitate (DNR) / do not intubate (DNI) status. She was medically managed and discharged home after 14 days of hospitalization with aspirin, clopidogrel, metoprolol succinate, atorvastatin, and furosemide. Angiotensin converting enzyme inhibitor was held for hypotension.On TTE, the LV size was normal and systolic function was moderately decreased, LVEF 35% with significant regional wall motion abnormalities consistent with inferior MI. The mitral valve leaflets were bilaterally tethered, resulting in severe mitral regurgitation Fig. . The aorAs her shortness of breath worsened, she returned to the emergency room 9 days after her initial discharge requesting full treatment options including invasive procedures. Invasive coronary angiography showed severe multi-vessel coronary disease with chronic occlusion of the dominant right coronary artery (RCA) filling retrograde through contralateral collaterals, subtotal thrombotic occlusion of a small caliber left circumflex (LCx) artery with thrombolysis in myocardial infarction (TIMI) 1–2 flow, and probable significant disease in the proximal left anterior descending (LAD) artery and proximal large diagonal Fig. . LV end-Ischemic cardiomyopathy was considered as the major contributor for her severe mitral regurgitation and recurrent HF. Cardiothoracic surgery team was consulted for possible coronary artery bypass grafting (CABG), aortic valve replacement (AVR) and mitral valve repair/replacement. The surgical team was of the opinion that she was a high surgical risk, being especially concerned about her frailty. CMR was ordered to assess myocardial viability as part of her risk stratification (and to plan for the surgery).CMR was performed at 1.5 T . Cine imaging showed that the LV was severely dilated (LVEDVI 130 mL/m2) and systolic function was severely decreased LVEF 34%) replacement was deemed unfavourable. The structural heart disease team considered her not to be a good candidate for transcatheter mitral valve replacement (TMVR). The option of transcatheter aortic valve replacement (TAVR) has been offered but patient decided not to pursue it.The option of percutaneous coronary intervention (PCI) for the LCx and LAD disease was considered. However, revascularization of the presumed non-viable territory perfused by the small LCx was deemed to be of questionable value. PCI of the LAD was considered very challenging due to anticipated difficulty of wiring the diagonal branch and the associated concern of occluding it with stenting only of the LAD. In addition, the clinical impression was that her presentation was related to a significant degree to her valve disease(s) and addressing just the myocardial ischemia had an uncertain risk/benefit ratio. Her medical therapy was optimized by adding low dose losartan and ivabradine as the low dose metoprolol had to be held due to hypotension. At 2-week outpatient follow up she had adequate symptomatic control, albeit at a low, but acceptable for the patient, level of physical activity.This case emphasizes the critical role of CMR in decision making for patient’s clinical management. We presented a case with heart failure related to non-ST-elevation myocardial infarction (NSTEMI) in the setting of coexisting AS and MR. Based on the results of TTE and cardiac catheterization, high-risk CABG and AVR were considered. However, CMR clarified the complex clinical picture leading to a unanimous agreement among the members of the heart team regarding the viable options for patient’s management, and possibility of TMVR was entertained instead of CABG and AVR. The absence of myocardial viability in 2 of the 3 coronary territories for which revascularization was planned, in addition to the other concerning clinical features , resulted in the surgical team considering the patient too high risk for CABG and AVR.Transmural extent of LGE is a well-established method to predict reversibility of myocardial dysfunction. EspeciaCMR has been considered as the gold standard in assessment of ventricular and atrial volume and function , 33. TheManagement of this case was complicated by coexistence of both AS and MR in addition to ischemic cardiomyopathy. Per the guideline for the management of patients with valvular heart disease, AVR is a class 2b recommendation for patients with moderate AS who are undergoing cardiac surgery . In the https://www.cloudcmr.com/6257-1973-9318-0151/).The CMR of Case 4  by a positive reverse transcriptase PCR. Troponin-I was elevated at 13 ng/mL, and the D-dimer and other inflammatory biomarkers were elevated. She had a normal ECG with normal sinus rhythm, normal intervals, and no ST-T wave changes. TTE showed moderately decreased LV systolic function with global hypokinesis and mild RV dilation and mildly decreased systolic function.Moderately reduced LV systolic function  thirteen years prior revealed no perfusion abnormalities and LVEF 44%) presented with fever, myalgias, abdominal pain, and shortness of breath. CT abdomen/pelvis with contrast was performed revealing no acute abnormalities in the abdomen but was notable for focal peripheral consolidation in the lungs Fig. . An ischCMR was obtained to evaluate for acute myocarditis. Cine bSSFP images revealed mildly dilated LV with moderately decreased global systolic function with LVEF 33% and dyskinesis of the inferolateral wall . The CMR facilitated in diagnosing the patient’s infarct and intracardiac thrombi. He was started on goal directed medical therapy for HF as well as anticoagulation therapy and discharged on COVID-19 clinical trial medication. He was scheduled to see a cardiologist in one-week post discharge at which time they would decide a further treatment plan.A 52 year old male with no significant past medical history had been having intermittent fevers, chills, dry cough, left scapular and pleuritic chest pain associated with exertional dyspnea for more than one month. He had three prior hospitalizations since his symptoms began. He was initially diagnosed with right middle lobe pneumonia when hospitalized at an outside facility, treated with antibiotics and had subsequent mild symptom relief on discharge. He was hospitalized twice again for the same complaints at the outside institution. CT angiography of the chest was done on both admissions and showed no evidence for pulmonary embolism or pneumonia, but demonstrated a pericardial effusion and small left pleural effusion. His SARS-CoV-2 PCR test was negative but his SARS-CoV-2 antibody was positive. He was given a short course of antibiotics during one of those hospitalizations without benefit.Despite previous treatments, he again had a relapse of symptoms and was admitted to our facility. Social history revealed his mother had contracted SARS-CoV-2 and died from COVID-19 pneumonia about 2 months prior to his presentation. He was febrile to 102.7F on admission with a mildly elevated white blood cell count of 11.5 K. Initial blood work showed elevated inflammatory markers  and mild troponin elevation to 0.1 ng/mL. Chest X ray showed clear lungs and chest CT did not show pneumonia. Blood cultures remained without growth. ECG showed sinus tachycardia with non-specific ST abnormalities in leads V4-V6 . The patient had full recovery after treatment with colchicine and upon follow up 6 months later, he has remained asymptomatic and active.There have been several studies evaluating cardiovascular complications from COVID-19 early in the pandemic–39. MyocSeveral cases of myocarditis related to COVID-19 have been documented in the literature –49. The An evaluation of myocardial tissue characteristics by CMR in previously hospitalized patients with COVID-19 in China revealed 54% with myocardial edema (elevated T2) and 31% with myocardial fibrosis (positive LGE). All of The pathogenesis of hypercoagulability has been commonly explained through Virchow’s triad of stasis, endothelial injury, and a hypercoagulable state. Severe infection with SARS-Co-2 virus causes a proinflammatory state and elevation of levels of several prothrombogenic factors. The infSeveral studies have shown a strong association between risk factors for CAD such as diabetes, hypertension, prior CAD and the severity of COVID-19 infection . Severe The importance of using CMR despite TTE findings in adult patients with COVID-19 is highlighted by Case 9. The patient’s TTE mistakenly demonstrated a LVEF of 35–40%, leading to inappropriate therapy with metoprolol and losartan for “acute systolic congestive heart failure”. Of note, the patient’s NT-pro BNP was 48 pg/mL with a non-obese BMI (26 kg/m2). The patient possibly had recurrent post infectious COVID-19 pericarditis as manifested by his symptom course and persistently positive SARS–CoV-2 antibody. He is also at high risk for further recurrence as manifested by pericardial LGE . In the Additional file 1. Case 1 Movie 1. Transthoracic echocardiogram (TTE) parasternal long axis view. There was pericardial thickening and a circumferential pericardial effusion present.Additional file 2.Case 1 Movie 2. Cine SSFP four chamber and mid short axis views. There was normal biventricular systolic function, a moderate circumferential pericardial effusion, brief right atrial (RA) compression, and mild pericardial thickening present.Additional file 3.Case 2 Movie 1. Four A and two chamber B cine bSSFP images. Septal and anterior LV hypertrophy and myocardial crypts of the basal anterior and anterolateral walls.Additional file 4.Case 3 Movie 1. Apical four chamber TTE. There is normal LV systolic function, mild tricuspid valve insufficiency, and the right ventricle is not well seen.Additional file 5.Case 3 Movie 2. Four chamber cine bSSFP stack. Dilated RV with RV dyskinesia and irregularity noted in the LV lateral wall.Additional file 6.Case 3 Movie 3. Two chamber right A and left B cine bSSFP. RV microaneurysms along the free wall consistent with the “accordion sign” and normal LV systolic function present.Additional file 7.Case 3 Movie 4. Short axis cine bSSFP stack. Dilated RV with globally mildly reduced systolic function present. Mild LV dilation with normal systolic function and no regional wall motion abnormalities present.Additional file 8.Case 4 Movie 1. Two chamber (A), three chamber (B), four chamber C cine bSSFP. Severely dilated LV with severely decreased systolic function, aortic valve stenosis, and mitral valve stenosis and regurgitation.Additional file 9.Case 5 Movie 1. Two chamber (A), three chamber (B), and four chamber C cine bSSFP. There is moderately decreased left ventricular systolic function.Additional file 10.Case 6 Movie 1. Three chamber A and short axis stack B bSSFP cine images. These images show a dilated LV, dyskinesis of inferolateral wall and decreased global systolic function.Additional file 11.Case 7 Movie 1. Single shot bSSFP axial stack. No evidence of pulmonary consolidations and no pleural or pericardial effusions present.Additional file 12.Case 7 Movie 2. Two chamber (A), three chamber (B), four chamber (C), and mid short axis D cine SSFP. Normal LV volumes, wall thickness, and ejection fraction without wall motion abnormalities.Additional file 13.Case 7 Movie 3. Short axis stack LGE. Likely patchy mid-myocardial LGE affecting the mid anterior and mid to apical anteroseptal walls.Additional file 14.Case 8 Movie 1. Contrast enhanced TTE four chamber and short axis views. TTE showed multiple wall motion abnormalities as well as the presence of LV masses.Additional file 15.Case 8 Movie 2. Cine bSSFP two chamber (A), short axis (B), and three chamber views (C). The LV was severely dilated with severely reduced systolic function. The basal and mid inferior and inferolateral walls were thin, aneurysmal with a large mass present, and the entire apex was thin and akinetic with another mass present.Additional file 16.Case 8 Movie 3. First pass perfusion four chamber A and short axis B views. There is no uptake of contrast in either mass.Additional file 17.Case 9 Movie 1. Four chamber (A), mid short axis (B), and three (chamber) cine balanced bSSFP images. Low normal biventricular systolic function and marked pericardial thickening with a moderate left pleural effusion.Additional file 18.Case 9 Movie 2. Real time four chamber A and mid short axis B cine. No evidence of interventricular dependence present.


To investigate the effect of the phantom-based correction method for standardizing myocardial native T1 and extracellular volume fraction (ECV) in healthy subjects.Seventy-one healthy asymptomatic adult (≥ 20 years) volunteers of five different age groups  were prospectively enrolled in three academic hospitals. Cardiac MRI including Modified Look - Locker Inversion recovery T1 mapping sequence was performed using a 3-Tesla system with a different type of scanner for each hospital. Native T1 and ECV were measured in the short-axis T1 map and analyzed for mean values of the 16 entire segments. The myocardial T1 value of each subject was corrected based on the site-specific equation derived from the T1 Mapping and ECV Standardization phantom. The global native T1 and ECV were compared between institutions before and after phantom-based correction, and the variation in native T1 and ECV among institutions was assessed using a coefficient of variation (CoV).p = 0.002), but the mean ECV did not . After phantom-based correction, the global native T1 and ECV were 1289.7 ± 32.4 ms and 25.0 ± 2.7%, respectively, and CoV for native T1 between the three institutions decreased from 3.0 to 2.5%. The corrected native T1 value did not significantly differ between institutions , and neither did the ECV .The global native T1 value significantly differed between the institutions (1198.7 ± 32.1 ms, institution A; 1217.7 ± 39.9 ms, institution B; 1232.7 ± 31.1 ms, institution C; The phantom-based correction method can provide standardized reference T1 values in healthy subjects.After phantom-based correction, the global native T1 of 16 entire myocardial segments on 3-T cardiac MRI is 1289.4 ± 32.4 ms, and the extracellular volume fraction was 25.0 ± 2.7% for healthy subjects.• After phantom - based correction was applied, the differences in the global native T1 among institutions became insignificant, and the CoV also decreased from 3.0 to 2.5%.• The online version contains supplementary material available at 10.1007/s00330-022-08936-8. Myocardial tissue characterization by T1 mapping and estimation of native T1 and extracellular volume (ECV) by cardiac magnetic resonance imaging (CMR) are important for diagnosing and predicting the prognosis of various cardiovascular diseases . AssessmTherefore, the consensus statement from the society of cardiovascular magnetic resonance recommends that a local reference range from healthy controls or patients without other signs or history of myocardial disease should be primarily used for native T1 mapping , z-scoreTherefore, we aimed to investigate the effect of the phantom-based correction method for standardizing myocardial T1 measurement in healthy subjects from multiple institutions and provide standardized reference values of myocardial native T1 and ECV.2), and family history of cardiovascular disease (acute coronary syndrome or coronary revascularization in first - degree relatives < 65 years old). For screening, all subjects underwent ECG and blood sampling with measurement of estimated glomerular filtration rate , hematocrit, cholesterol, and N-terminal pro - brain natriuretic peptide prior to inclusion. Exclusion criteria were (1) any evidence of heart disease as indicated by clinical history or physical examination, (2) presence of abnormal ECG or hyperlipidemia  on screening, (3) pregnancy, (4) contraindications to CMR or expectation of having degraded CMR image quality , or contraindications to injection of gadolinium-based contrast agent , and (5) diabetes. After 96 healthy Korean subjects were screened, 20 subjects were excluded due to screening failure , and 5 subjects withdrew their informed consents after study participation. The final population consisted of 71 participants , with 14 subjects  per age group between 20–29 and 50–59 years and 15 subjects  in the age group of 60–79 years.This prospective study was approved by the institutional review boards of the participating hospitals. Subjects were enrolled after obtaining written informed consent to participate in this study. From December 2019 to April 2021, healthy asymptomatic adult ( ≥ 20 years) volunteers of five different age groups  were prospectively enrolled in three academic hospitals . The CMR acquisition parameters for cine imaging and T1 mapping are described in Supplementary Material. To assess left ventricular (LV) myocardial function and mass, short-axis images of the LV were acquired using a cine balanced steady-state free precession (bSSFP) sequence [At all three participating institutions, CMR was performed using a 3-Tesla (T) system  of the T1MES phantom in each institution, the inversion-recovery prepared turbo spin-echo [GT) of this T1MES phantom was regarded as the T1 described in the manual by the manufacturer.To measure the gold-standard T1  was calculated with the T1 on MOLLI (T1ML) and T1GT. Last, an internal reference T1-based correction function (IC) was calculated with the T1ML and the T1GS. In particular, the MC and IC methods were subdivided according to whether the RR interval (RRI) of the subject was considered. When the RRI of each subject was considered (adaptive RRI), the correction function was calculated using a T1ML with an RRI close to the RRI of the subject (Supplementary Table ML with an RRI of 900 ms (static RRI) was used  who were blinded to the clinical data. Cine imaging and T1 map images were analyzed using commercial software  (Supplementary Methods).On cine bSSFP images, the endocardial and epicardial contours of the LV were semi-automatically drawn with manual adjustments when needed. LV end-diastolic volume (EDV) and end-systolic volume (ESV) were calculated using the modified Simpson method and were indexed to body surface area. LV ejection fraction was calculated as (EDV-ESV)/EDV.s(t) = a – b exp. (t/T1*), and T1 = T1*((b/a−1), where a and b are constants, t is time, and s(t) is the signal intensity at time t. On T1 map images, endocardial and epicardial contouring of the LV was performed semi-automatically, and manual adjustments were applied when needed. Native and post-contrast blood T1 times were measured on a region of interest drawn in the center of the blood pool. Native and post-contrast T1 values were measured in 16 AHA segments in the short-axis view of LV [Native and post-contrast T1 map images were generated by fitting pixels to the equation ew of LV . The myoew of LV :\documeNative T1 and ECV fraction were analyzed as the mean of the 16 entire segments  and mid septum, after the exclusion of segments with image artifacts  that caused significant deterioration in T1 measurement.th to 75th percentile, and categorical variables are shown as counts and percentages. Categorical variables were compared using the χ2 or Fischer’s exact test. Continuous variables were compared among groups using ANOVA for normally distributed data and the Kruskal-Wallis test for non-normally distributed data. T1 mapping results were excluded from the analysis if measured T1 values were estimated as outliers by the Tukey method [Statistical analyses were performed using MedCalc for Windows version 19.1.0.0  and R . Continuous variables are expressed as the mean ± standard deviation or median with 25y method , 22. VarThe baseline characteristics of the 71 subjects are shown in Table The CMR examination was successfully completed in all subjects, but 2 patients  were excluded from the analysis of T1 mapping because their measured T1 values were estimated as outliers due to image artifacts. All participants had normal LV function on cine imaging (Supplementary Table 2 method (second-order correction equation with MC method) with static RRI was used for the correction of native and post-contrast T1 map images because the method showed the greatest decrease in the CoV of native T1 map in healthy human subjects among various correction methods , but ECV was not significantly different between the institutions . After phantom-based correction, the global native T1 was not significantly different between the three institutions , and ECV was also not significantly different between the institutions . The mean of the corrected native T1 and ECV in 69 subjects were 1289.4 ± 32.4 ms and 25.0 ± 2.7%, respectively. After phantom-based correction, the CoV for the native T1 between the three institutions decreased from 3.0 to 2.5%.The mean global native T1 and ECV fraction in 69 subjects are shown in Table p = 0.004) before phantom-based correction, but ECV was not significantly different between the institutions . After phantom-based correction, the mean native T1 of the mid septum was not significantly different between the three institutions , and ECV was also not significantly different between the institutions . After phantom-based correction, the CoV for the native T1 between the three institutions decreased from 3.0 to 2.6%.In the measurement of the mid septum, native T1 was significantly different between the three institutions . As ethnicity may affect the myocardial T1 and ECV similarly as it affects the LV volume and mass [n < 30) for comparison against patients with cardiovascular disease. Second, this is a multi-institutional study conducted in three different institutions with different scanner types and provides standardized normal native T1 and ECV by using the phantom-based correction method. After phantom-based correction was applied, the differences in the mean native T1 among institutions became insignificant, and the CoV also decreased. Our results suggest that the phantom-based correction method is effective for the standardization of myocardial T1 achieved by reducing measurement variation.Compared to previous studies regarding the reference T1 on CMR, our study has two main strengths. First, we reported the myocardial T1 in healthy Korean subjects with a sufficient sample size  subjects, which might have diminished the reliability of ECV calculation . We assuIn conclusion, the standardized reference value of myocardial native T1 and ECV in healthy Korean subjects can be provided using the phantom-based correction method as it reduces variation in T1 measurement. Our phantom-based correction method may allow standardization of myocardial T1, which can facilitate the application of T1 mapping in multi-institutional, large-scale clinical trials.ESM 1(DOCX 56 kb)


The bi-atrial surgical technique of heart transplantation is associated with postoperative atrial dysfunction, sinus node dysfunction, valvular dysfunction, and bi-atrial enlargement predisposing to atrial arrhythmia with thrombus formation. This report deals with a very late thrombus formation in the neo-atrium of a heart transplanted using the bi-atrial technique. The absence of arrhythmia and absence of any history of intake of prothrombotic medications make it noteworthy.The online version contains supplementary material available at 10.1007/s12055-022-01362-x. The bi-atrial surgical technique of heart transplantation is one of the standard options for orthotopic heart transplants. This technique takes less time than the bi-caval technique, which is, however, now more commonly practiced than the bi-atrial one since the latter has been associated with postoperative problems including atrial dysfunction, sinus node dysfunction, valvular dysfunction, and bi-atrial enlargement predisposing to atrial arrhythmia with thrombus formation. The precise incidence of bi-atrial thrombus formation after orthotopic heart transplantation is not clear, and only few cases have been reported in the literature.2), moderate mitral and aortic regurgitations, and a normal inferior vena cava. She remained pauci-symptomatic (New York Heart Association (NYHA) functional class II) until July 2020, when she attended the yearly cardiologic follow-up. A transthoracic echocardiography showed a huge extended neo-left atrium  with evidence of spontaneous echo contrast and intracavitary thrombus , severe pulmonary hypertension (estimated systolic pulmonary artery pressure 60 mmHg), and a mildly dilated inferior vena cava. A transesophageal echocardiogram was then performed, confirming the presence of a double heterogeneous formation localized onto the left atrial posterior wall, and principally extended to the septal and lateral walls (thickness 2.8–3 cm), with a small pedunculated component and not involving the four pulmonary veins’ ostia  diabetes mellitus, renal failure, and hyperuricemia. In January 2020, the patient was admitted to the General Surgery Unit for surgical treatment of a sigmoid colon perforation following a complicated endoscopic polypectomy, and underwent laparoscopic bowel suturing and temporary ileostomy. The peri-operative cardiologic evaluation with echocardiography described normal left ventricular geometry and systolic function with grade II diastolic dysfunction, a dilated right ventricle with preserved pump function and mild pulmonary hypertension (estimated systolic pulmonary hypertension 45 mmHg), an extremely dilated left atrium  scan study was therefore performed, confirming the presence of a giant thrombotic formation in the left neo-atrium, posteriorly to the suture lines Fig. . At paceprimum movens of thrombus formation after 17 years from heart transplant. There were no symptoms or thromboembolic events in the past. In literature, most of the other cases reported were identified early after heart transplantation (mean 3–31 months) [Atrial masses are a rare complication in heart transplant recipients. They are usually diagnosed accidentally on routine transthoracic echocardiography, and other imaging techniques should be performed to assess the masses’ size, morphology, and precise localization. Standard orthotopic heart transplantation produces important anatomic and functional atrial alterations, with subsequent thrombotic risk. Left atrial thrombosis in heart transplant recipients is not a rare finding, particularly with the bi-atrial rather than the bi-caval technique, because larger neo-atria predispose also to supraventricular arrhythmias –4. The i months) , 4 and o months) .The main pathophysiological issues to be considered are the components of the Virchow’s triad, mostly referring to abnormal blood flow due to massive chamber dilation caused by the orthotopic technique, atrial scars following cardiac surgery, and a prothrombotic state related to abdominal surgery. Conventional cardiac transplantation using the bi-atrial technique alters atrial integrity, geometry, and possibly function. This can lead to enlarged atria, which can be hemodynamically impaired despite the presence of a sinus rhythm. Differently from some previous reports, the novelty of this case relates to the absence of other known factors favoring the development of cardiac thrombosis and the long time frame from heart transplantation. The patient maintained a constant sinus rhythm and was not on mammalian target of rapamycin (mTOR) inhibitors as immunosuppressant, which have prothrombotic properties. Accordingly, the novelty of this case relates to the knowledge of a reliable cause for the thrombotic phenomenon, namely the surgical intervention, given that the thrombus had never been reported before it.Video 1Transoesophageal echocardiography showing left atrial thrombotic formation. (MP4 2659 kb)Video 2Transoesophageal echocardiography showing left atrial thrombotic formation. (MP4 2634 kb)Video 33D transoesophageal echocardiography showing left atrial thrombotic formation. (MP4 244 kb)


All participants had objective evidence of reversible myocardial ischemia in technetium sestamibi scan, LV ejection fraction (LVEF) ≥35%, and no significant valvular disease. Primary pulmonary hypertension was excluded when appropriate.NCT01566175).All underwent full echocardiographic evaluation at baseline and 4 to 6 months following Reducer implantation. Impaired RV function was defined as the presence of ≥2 of the following: RV fractional area change (RV FAC) <35%, tricuspid annulus plane systolic excursion (TAPSE) <16 mm, peak systolic lateral tricuspid annular velocity (S') <10 cm/s and myocardial performance index (MPI) >0.44. All measurements were done in accordance with the American Society of Echocardiography Guidelines for the Echocardiographic Assessment of the Right Heart in Adults.P = 0.63), sex , LVEF , right coronary artery (RCA) involvement , regional LV ischemic distribution, diastolic function, and cardiovascular risk profile. Following Reducer implantation, a similar degree of angina relief was observed in patients with and without RV dysfunction.Enrolled were 25 patients. Mean age was 67 ± 9 years, 84% men, mean CCS (Canadian Cardiovascular Society) 3.4 ± 0.8. Baseline RV dysfunction was present in 14 patients (56%). Patients with and without RV dysfunction had similar baseline characteristics in terms of age  (P for interaction = 0.6). However, lateral LV wall ischemia was associated with an improvement in several RV function indices .Improvement in RV function indices after Reducer implantation was shown in the entire cohort but reached statistical significance in the subgroup of patients with baseline RV dysfunction  . The imp,Though physiological differences in afterload, wall stress, and myocardial perfusion allow the RV to better recover from ischemic injury,Our study is limited by its small size, the use of 2-dimensional echocardiography as a single method for RV function evaluation and the lack of direct assessment of RV ischemia. Therefore, our results should be seen as hypothesis-generating and warrant repeated investigation in a larger cohort and using other methods for evaluating RV ischemia and function. Nevertheless, our findings suggest that in this small group of severe CAD patients, coronary Reducer implantation was associated with RV function improvement, a result that might contribute to patients’ clinical stabilization.


Certain cerebrovascular events can induce electrocardiography (ECG) abnormalities and cardiac dysfunction. The most frequent patterns reported are nonspecific ST-T change, inverted or broad T wave, prolongation of QT interval as well as ST-segment depression or elevation. Here we present a case of intracerebral hemorrhage (ICH) with transient J wave-like ST-segment elevation accompanied by myocardial lesion.A 58-year-old woman was admitted to our hospital and diagnosed with right basal ganglia region cerebral hemorrhage. The ECG recorded on the second hospital day showed transient J wave-like ST-segment elevation accompanied by increased myocardial troponin I and myocardial enzyme.The J wave-like ST-segment elevation may be not a specific ECG signs for primary ischemic heart diseases as it also could be found in ICH patients. We believe that the follow-up ECGs can be used in conjunction with repeated myocardial enzyme analysis and echocardiography to differentiate ICH-ralated J wave-like ST-segment elevation from acute myocardial infarction (AMI), thus avoiding unnecessary cardiac catheterization. Certain cerebrovascular events, such as intracerebral hemorrhage (ICH), subarachnoid hemorrhage and intracranial hypertension, can be the cause of electrocardiography (ECG) abnormalities and cardiac dysfunction . The mosA 58-year-old woman was admitted to our hospital, because of sudden unconsciousness 1 h earlier. The patient had hypertension, and past medical history didn’t mention diabetes or heart disease. On admission, she was in the state of coma and Glasgow Coma Scale score was only 3. The prompt cranial computed tomography (CT) scan revealed right basal ganglia region cerebral hemorrhage  of 3.44 ng/ml , a creatine kinase (CK) of 185 U/L  and a creatine kinase isoenzyme MB (CK-MB) of 31U/L . On the second hospital day, the ECG exhibited J wave-like ST-segment elevation in the inferior lead  and anterolateral lead . Prominent J waves could be noted in leads V5 and V6 (Fig. Previous studies have demonstrated that cerebrovascular events are often accompanied by transient myocardial damage that may manifest as ST-segment elevation on the ECG and coinstantaneous release of cardiac troponin . The J wAs for our case, although the increased myocardial enzyme profile and cardiac troponin implied myocardial lesion, the manifestation of the transient J wave-like ST-segment elevation without an appearance of pathological Q wave on the ECG may suggest ICH-related ST-segment elevation rather than AMI. The surge of circulating catecholamine concentration and neurological stress, could be possible mechanisms responsible for such ECG changes in patients with ICH . SeveralAs a part of ICH, the concentration of plasma catecholamine were increased at the very onset. Following the incident, the concentration of epinephring and norepinephrine decreased gradually according to the study by Espiner et al. . SubsequAlthough the presence of J wave-like ST-segment elevation is generally regarded as highly specific manifestation for primary ischemic heart diseases, it can also happen in patients with ICH. We believe that the follow-up ECGs can be used in conjunction with repeated myocardial enzyme analysis and echocardiography to diffferentiate ICH-ralated J wave-like ST-segment elevation from AMI, thus avoiding unnecessary cardiac catheterization.


To analyze the correlation between metanephrine and normetanephrines (MNs) and subclinical myocardial injuries (SMI) diagnosed by low left ventricular global longitudinal strain (LV GLS) in patients with pheochromocytoma and paraganglioma (PPGL).Seventy-six patients who underwent surgery for pheochromocytoma or paraganglioma from September 2017 to April 2022 were examined. All the patients enrolled had normal left ventricular ejection fraction (LVEF) and myocardial injury biomarkers including cardiac troponin I and B-natriuretic peptide. Univariate analysis and multivariate analysis were performed to evaluate the association of MNs and subclinical myocardial injury (SMI)(defined as LV GLS<18).LV GLS of 13(17.11%) PPGL patients was less than 18. The percentage of patients with elevation of single hormone  or any one of MNs was not significantly correlated with SMI . All MNs elevation was associated with SMI . After adjusting for age, All MNs elevation was significantly correlated with SMI .MNs might be an important factor influencing myocardial function. All MNs elevation might indicate SMI. If all MNs elevated, LV GLS measurement was recommended for PPGL patients to detect SMI in the absence of decrease LVEF or other heart disease in clinical practice. Pheochromocytomas and paragangliomas (PPGL) are catecholamine-producing neuroendocrine tumor and surgery is the only curative therapy at present. One of the main causes of perioperative complications and death in PPGL patients is myocardial injury, including stress cardiomyopathy, hypertrophic myocardiopathy, dilated cardiomyopathy and myocardial ischemia . TherefoPatients who underwent surgery for PPGL from September 2017 to April 2022 in Peking University First Hospital and tested for plasma MNs (including metanephrine (MN), normetanephrine (NMN), 3-methoxytyramine (3-MT)) before surgery were initially enrolled as potential participants (N=262). A retrospective study design was used. The patients who met any of the following criteria were excluded (1): surgery involving non-tumor organs (2); incomplete data abstracted from the electronic medical records (3); missing echocardiography images before surgery or poor image quality  segments during offline strain analysis); (4) complicated with heart disease including catecholamine cardiomyopathy (CC) or LVEF <50%; (5) elevation of cardiac troponin I or hypersensitive troponin I or BNP before surgery. Finally, 76 patients were enrolled. The study protocol was approved by the ethics committee of Peking University First Hospital. Written informed consent for participation was not required and the study was conducted in accordance with the Declaration of Helsinki.For each patient, we reviewed the medical records to collect information including patient demographics, medical history, the highest systolic blood pressure (SBP) and diastolic blood pressure (DBP) before surgery, biochemical test, and tumor size in postoperative pathologic examination. All biochemical test values were defined to be positive if beyond the upper limit of the normal range. Patients were divided into two groups: no myocardial injury (defined as LV GLS≥18) and SMI (defined as LV GLS<18) .All patients’ echocardiographs before surgery were digitally recorded and remeasured for LV function following the echocardiography core laboratory protocol based on American Society of Echocardiography guidelines , with st15 randomly selected patients’ LV GLS were remeasured by the same observer blinded to previous measurements with 1 week interval, and by a second observer blinded to the first one’s results to assess intra- and inter- observer variability.2 test. Univariate analysis and multivariate analysis were performed to evaluate the association of MNs and LV GLS. Covariates were included as potential confounders in the adjusted model if P ≤ 0.1. All P values were two-sided and were considered statistically significant if less than 0.05. All analyses were performed with statistical software (Empower(R), www.empowerstats.com; X&Y solutions, Inc., Boston, MA, USA; R [http://www.R-project.org].v4.2.0).Continuous variables were presented as mean ± standard deviation or median . Categorical variables were presented as number with percentage(%). Differences between the two groups were compared using Student’s t-test or the χIn this retrospective study, the average age was 46.34 ± 15.04 years and 34 (44.74%) of the patients were male. LV GLS in 13(17.11%) patients was less than 18. Additionally, 39 (51.32%) had history of hypertension, 18 (23.68%) had history of diabetes, and 4 (5.33%) had history of stroke. LV GLS in two group were 21.94 ± 2.45 , 14.90 ± 1.81 (SMI), respectively. Elevation of single hormone  was no different in the groups . However, the rate of elevation of all MNs was 1.59% and 15.38% (P=0.020). And there were no differences in other factors among the groups Table 1.Univariate correlations of LV GLS included demographic parameters , elevation of hormone  and tumor condition (tumor size and ectopic tumor) Table 2.Overall, elevation of single hormone  or any one of MNs was not associated with SMI . However, compared with patients with no elevation of MNs, the OR for patients with all MNs elevation was 11.27 (P= 0.056).Given that age was related to LV GLS  OR: 0.9Table 3.The intra- and inter- observer intraclass correlation coefficient (ICC) for LV GLS was 0.968 (95%CI: 0.911 -0.989) and 0.982 (95%CI: 0.949 - 0.994), respectively.As a severe complication of PPGL, CC was a specific cardiomyopathy disease, influencing the cardiac structure and function due to the circulating catecholamine (CA) beyond physical dosage. It was reported that CA had direct effects on the systolic function of LV myocardium and 8-11% of PPGL patients would develop CC –8. MortaSymmetric LV hypertrophy was the main pathological characteristic of CC. Myocarditis was found in about 50-60% of PPGL patients at autopsy, with degeneration, contraction band necrosis, inflammatory cells infiltrating and fibrosis during later period. And sarcomere excess contraction, mitochondria swelling and endoplasmic reticulum dilatation could also be observed clearly under electronic microscope, which were entirely different from coagulative necrosis in myocardial infarction . AlthougWe used TOMTEC in LV GLS measurement in the current study and an absolute number of 18% as the cutoff value according to published literature –5. LV GLAlthough CA was reported to be associated with myocardial injury in PPGL patients in previous research or hypothesis of mechanism, it was still controversial what risk factors increased the probability of injury. In a 15 cases study, there was no correlation between plasma epinephrine or noradrenaline level and LV structural parameters of echocardiography in 6 LV hypertrophy patients . HoweverIn general, CA could cause myocardial injury through chronic and continuous exposure, overexcitation of receptors and desensitization of beta receptors. Large amounts of studies showed that the mechanisms of different CA acting on myocardial injury seemed to be various. Norepinephrine could augment myocardial oxygen demand, cell death and injury and attenuate cardiac performance, thus leading to systolic heart failure and dilated dilated cardiomyopathy . The adrSome limitations could not be ignored in the study. Firstly, inevitable bias existed in the retrospective study. Secondly, based on a small sample, LV GLS<18 patients were few in number. Moreover, lack of postoperative follow-up and echocardiography made it impossible to compare the changes of LV GLS. Lastly, qualitative analysis rather than quantitative analysis was used in the elevation of MNs.In summary, MNs might be an important factor influencing myocardial function. All MNs elevation might indicate SMI. If all MNs elevated, LV GLS measurement was recommended for PPGL patients to detect SMI in the absence of decrease LVEF or other heart disease in clinical practice.doczhz@aliyun.com.The datasets presented in this article are not readily available because The data that support the findings of this study are available from the corresponding author upon reasonable request after the request is submitted and formally reviewed and approved by the ethics committee of Peking University First Hospital. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by the ethics committee of Peking University First Hospital. Written informed consent from the participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.ZZ and YiY: conception and design. YY, CC and WH: acquisition of data and critical revision of the manuscript for important intellectual content. YY and CC: analysis and interpretation of data, drafting of the manuscript. ZZ, YZ and YiY: supervision. All authors contributed to the article and approved the submitted version.This work was supported by the National High Level Hospital Clinical Research Funding  (2022CX08).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Conventional transthoracic (TTE) and transoesophageal echocardiography (TEE) parameters assessing right ventricle (RV) systolic function are daily used assuming their clinical interchangeability. RV longitudinal shortening fraction (RV-LSF) is a two-dimensional speckle tracking parameter used to assess RV systolic function. RV-LSF is based on tricuspid annular displacement analysis and could be measured with TTE or TEE.TTE and RV-LSFTEE measurements were interchangeable in the perioperative setting.The aim of the study was to determine if RV-LSFProspective perioperative TTE and TEE echocardiography were performed under general anesthesia during scheduled cardiac surgery in 90 patients. RV-LSF was measured by semi-automatic software. Comparisons were performed using Pearson correlation and Bland-Altman plots. RV-LSF clinical agreement was determined as a range of −5 to 5%.TTE was 20.4 ± 4.3 and 21.1 ± 4.1% for RV-LSFTEE. The agreement between RV-LSF measurements was excellent, with a bias at −0.61 and limits of agreement of −4.18 to 2.97 %. All measurements fell within the determined clinical agreement interval in the Bland-Altman plot. Linear regression analysis showed a high correlation between RV-LSFTTE and RV-LSFTEE measurement .Of the 114 patients who met the inclusion criteria, 90 were included. The mean preoperative RV-LSFTTE and RV-LSFTEE measurements are interchangeable, allowing RV-LSF to be a helpful parameter for assessing perioperative changes in RV systolic function.RV-LSFhttps://www.clinicaltrials.gov/ct2/show/NCT05404737.NCT05404737.  Echocardiography is a non-invasive, simple, and helpful technique in patients undergoing interventional cardiology procedures, cardiac surgery, high-risk non-cardiac surgery, and for diagnosing intra- or post-operative complications . Two-dimIn interventional cardiology procedures, TEE is used to guide device placement and assess the periprocedural changes of RV systolic function . During lat) and septal (TADsep) portion of the tricuspid ring toward the RV apex. RV-LSF can be measured by TTE or TEE  is a two-dimensional speckle tracking echocardiography (2D-STE) parameter based on the longitudinal tricuspid annular displacement (TAD) that assesses the global RV systolic function . RV-LSF E or TEE . In TTE,E or TEE  or threeE or TEE , than coE or TEE .TTE and RV-LSFTEE. In TEE, several factors could affect RV-LSF measurement and, therefore, its interchangeability: TEE view is foreshortened and does not fully display the apical portion of the RV, which is crucial for ROI placement. Besides, the dynamic and non-planarity of the tricuspid annulus could also affect the measurement of TADlat and TADsep.However, to our knowledge, RV-LSF values measured by TTE and TEE have not been compared. Mainly, there are no data assessing the interchangeability of RV-LSFTTE and RV-LSFTEE measurements could be considered interchangeable in the perioperative setting. The second aim was to study the interchangeability of the two components of RV-LSF (TADlat and TADsep).The first aim of the study was to determine whether RV-LSFThis prospective interventional study was conducted at Amiens university hospital  between August 2021 and April 2022. We prospectively included all adult patients (>18 years old) hospitalized for a scheduled cardiac surgery under cardiopulmonary bypass that required intraoperative TEE. Exclusion criteria were patients with a contraindication to TEE performance , a poor echogenicity on TEE, a TTE not allowing evaluation of RV-LSF, and patients with a rapid supraventricular rhythm disorder at the time of TEE and TTE.This is a single-center, prospective and interventional study of patients hospitalized at Amiens University Hospital for scheduled cardiac surgery under cardiopulmonary bypass (CPB). The study was approved by the Amiens University Hospital IRB  and by an institutional ethics committee . Oral and written information was provided to the patients.Echocardiography images were obtained using high-quality commercially available probes  and ultrasound systems . To assess the interchangeability of RV-LSF, TTE and TEE exams, respectively, were performed in patients under general anesthesia immediately after induction of anesthesia, oral intubation, and muscle blockade. The procedures for general anesthesia and mechanical ventilation were standardized for all patients. The TEE and TTE echocardiography protocols followed the American Society of Echocardiography and the European Society of Cardiology recommendations for assessing RV systolic function , 15.lat), (2) the displacement between the interventricular septum and the RV apex (TADsep), and (3) the RV-LSF. RV-LSF was calculated as the maximum end-systolic displacement (LES) of the mid-annular point from the measured annular motion and is expressed as a percentage of the end-diastolic RV longitudinal dimension (LED): 100 × (LED–LES)/LED. The software automatically selected the mid-annular point.RV-LSF was measured using dedicated software . For RV-LSF analysis, three regions of interest (ROI) were used to initialize the first diastolic frame in a mild-esophageal four-chamber (ME-4CH) view  for the RV-LSF was analyzed in a single beat, and the reported value was the average of 3 measurements. All TTE and TEE RV-LSF measurements were analyzed offline (separately and randomly) by an expert sonographer 2 weeks after the inclusion period.In TTE, conventional RV systolic parameters were measured according to international guidelines: tricuspid annular plane systolic excursion (TAPSE) was measured using M-mode with a cursor placed at the junction of the lateral tricuspid leaflet and the RV free wall. RV-S' wave was measured in the apical four-chamber view using Doppler tissue imaging mode. RV systolic and diastolic areas were measured in the apical four-chamber view in 2D mode. RV-fractional area change was calculated by subtracting the end-systolic area from the end-diastolic area and dividing this value by the end-diastolic area. The following variables were recorded: age, gender, body weight, personal medical history, logistic EuroSCORE II, type of cardiac surgery, preoperative plasmatic creatinine, and hemoglobin.RV − LSF and TEERV − LSF measurements was quantified using Pearson's coefficient. Bland-Altman (BA) analysis was performed to assess the level of agreement between RV-LSFTTE and RV-LSFTEE.Continuous variables were expressed as mean and 95% confidence interval or standard deviation. Categorical variables are presented as absolute numbers and percentages. The correlation between TTElat − TTE, TADlat − TEE, TADsep − TTE, and TADsep − TEE.Assuming a common standard deviation equal to 5 points for each of the RV-LSF values (TTE and TEE), the standard deviation of the difference between the two measures is estimated to be 3.87 if a correlation coefficient (ρ) of 0.7 is assumed between the two RV-LSF measures. Thus, according to Bland and Altman , at leasLimits of clinical relevance for RV-LSF: given that the mean RV-LSFTTE from healthy volunteers was 25.6 ± 4.8% . The threshold for statistical significance was set to p < 0.05. To analyze the discrepancy between the different measures, we performed a Spearman correlation and a calculation of the intra-class coefficient (ICC). All statistical analyses were performed with R software (version 4.0.4).6 ± 4.8% , we expen = 74/90) were men with an average age of 63 ± 11 years. The average logistic EuroSCORE II was 4.3 ± 4, and valve repair/replacement was the main cardiac surgical procedure .From August 2021 to February 2022, 201 consecutive patients were hospitalized for scheduled cardiac surgery under cardiopulmonary bypass. Among the 114 patients who met the inclusion criteria, 90 patients were included, and 24 patients were finally excluded: 18 patients for poor TTE image quality, five patients due to a failed ROI placement, and one for rapid rhythm disorder  and with an excellent model fit . The 2.44 mm bias corresponded to 12.8% relative bias compared to the overall TADlat measurements with LOA from −21.6 to 47.3%. A good correlation was found between TADlat − TTE and TADlat − TEE  TEE underestimated TADsep measurement.The main findings of the present study can be summarized as follows: (1) RV-LSF measurements using TTE and TEE techniques were interchangeable, (2) TADClinicians need interchangeable RV parameters between TTE and TEE because an accurate assessment of RV systolic function is of utmost importance for perioperative RV monitoring and precise diagnosis of RV dysfunction during postoperative follow-up. The most used TTE RV systolic parameters were RV-FAC and TAPSE, which are assumed to apply to TEE. In TEE, TAPSE measurement is challenging due to a problematic M-mode alignment. Hence, modified methods were proposed for assessing tricuspid systolic excursion with controversial results . RV-FAC In this study, we demonstrated that RV-LSF measurements were interchangeable between TTE and TEE. The graphical Bland-Altman analysis showed a limited bias and LOA between the two ultrasound techniques. This is the first study to report an excellent agreement between TTE and TEE techniques using a clinical significance agreement (−5 to 5%) for a 2D-RV global systolic function parameter . Severallat and TADsep measurement interchangeability. We found that TTE and TEE TADsep measurements were poorly correlated (r = 0.5) and not interchangeable. We observed a good correlation (r = 0.7) between TTE and TEE TADlat measurements. However, the graphical Bland-Altman analysis showed that both TADlat measurement were underestimated, and the LOA between the two methods were too broad for reasonable clinical interchangeability. The underestimation of the TEE measurement was probably because the TEE ME-4CH view may not represent the true long axis of the interventricular septum and causes a “foreshortening” view. Foreshortening view is a frequent problem in 2D echocardiography examinations. It occurs when the ultrasound beam does not cut through the true apex, leading to geometric distortion of the image. Therefore, the long axis of the ventricle appears shorter. Previous studies on LV function identified similar findings about underestimation of volumes due to foreshortening of the transesophageal imaging plane .This is the first study that reported data about TADng plane . The impBesides, as in our study, these results are probably related to using the RV apex as the reference point. Selection of RV apex can be challenging because TEE only partially reveals the apical portion of the RV, which is truncated or shortened; this leads to underestimating the measured parameters. The use of 3D echocardiography for assessing the RV systolic function is the best approach to avoid a foreshortening view and an underestimation of ventricle size or volumes .Our results were close to that of other studies which assess the interchangeability between the longitudinal displacement analysis of the lateral portion of the tricuspid annular and TAPSE. Markin et al. compared TTE TAPSE by M-mode and TEE TAPSE by speckle tracking in 84 patients. They found that TAPSE by M-mode was correlated with TAPSE by speckle tracking in the ME-4CH view (Pearson r = 0.62), but they did not analyze the agreement between the two methods. In the study by Mauermann et al., TAD lateral (named speckle tracking TAPSE) was assessed in TEE and compared to TTE TAPSE. The authors found a significant correlation (r = 0.59) but with large LOA (−9.4 to 8.4 mm) .TEE and RV-LSFTTE were calculated from loops recorded in a supine position, possibly resulting in a foreshortened apical view in TTE. To limit the impact of a foreshortening apical view on RV long-axis measurement due to supine position, we measured RV-LSF in an RV-focused apical four-chamber view as recommended (TEE in four patients with large aortic root. Hence, the use of RV-LSF appears to be limited for monitoring RV systolic function in aortic root surgery. Finally, as with many 2D-STE parameters, the software version is a potential limitation. It is possible that RV-LSF values measured by the Philips QLAB version 15.0 may not reflect results from another version of the same software (This study had several strengths. First, this study prospectively acquired TTE and TEE images under identical clinical situations in mechanically ventilated patients under general anesthesia. Secondly, we performed a sample size calculation to assess clinical agreement between the two techniques to avoid underpowered analysis. Nevertheless, this study admits some limitations. First, RV-LSFommended . Second,ommended  because software , 21.TTE and RV-LSFTEE measured in the operating room for patients undergoing cardiac surgery exhibited excellent clinical agreement, and thus were interchangeable. RV-LSF could be helpful in assessing RV systolic function during and after high-risk surgery.In this study, we showed that RV-LSFThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comité de Protection des Personnes Ile de France VIII, ID-RCB 2021_A000908-33. The patients/participants provided their written informed consent to participate in this study.Study conception and manuscript drafting: CB, OA-A, DM, and YM. Clinical data collection: PV, FL, CD, PH, BA, GT, and TC. Statistical analysis: BR and DM. Manuscript revision: CB, HD, and YM. All authors approved the final version of the manuscript.


Triglyceride glucose index (TyG index) is a novel marker of insulin resistance. Studies have shown that TyG index is closely associated with the occurrence of hypertension and cardiovascular disease. However, little is known about the correlation between TyG index and the occurrence of heart failure with preserved ejection fraction (HFpEF) in hypertensive patients.Our study assumes that TyG index strongly correlates with occurence of HFpEF in hypertensive patients.This research enrolled 559 hypertensive patients (273 patients with HFpEF and 286 without HFpEF) admitted to the Department of Cardiology of Jiading Branch of Shanghai General Hospital from 2020 to 2021 as the study subjects. Gender, age, diastolic blood pressure, systolic blood pressure (SBP), and heart rate (HR) were recorded at admission. Medication history and fasting blood samples were harvested after admission to detect laboratory index. Cardiac function and ventricular structure index were measured by echocardiography. Pearson correlation analysis was conducted to identify the correlation of TyG index with cardiac function and ventricular structure. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of TyG index in HFpEF with hypertension.HFpEF patients had higher diuretic use frequencies, fasting plasma glucose, NT‐proBNP, triglycerides, TyG index, left atrial diameter (LAD), left ventricular mass index (LVMI), the ratio of peak E‐velocity of mitral orifice to peak velocity of early diastolic mitral annulus (E/e′), and SBP but lower ratio of peak E of early diastolic maximum blood flow velocity to peak A of late diastolic maximum blood flow velocity of mitral orifice (E/A) and average e′ than non‐HFpEF patients. Moreover, TyG index was correlated with LAD, left ventricular ejection fraction (LVEF), LVMI, average e′, E/e′, and NT‐proBNP. The multivariate regression analysis suggested that TyG index, E/e′, and NT‐proBNP were independent risk factors for HFpEF in hypertensive patients. Compared with E/e′ and NT‐proBNP, the area under the ROC curve  was the largest for TyG index.TyG index is higher in HFpEF patients than in non‐HFpEF patients and related to cardiac diastolic function, which strongly correlates with occurrence of HFpEF in hypertensive patients. A total of 559 hypertensive patients admitted to the inpatient ward of the Department of Cardiology of Jiading Branch of Shanghai General Hospital from 2020 to 2021 were selected as the research subjects, including 291 males and 268 females. Their average age was 70.76 ± 12.13 years old.2.2Hypertension was diagnosed based on the standard definition of the 2020 International Society of Hypertension Global Hypertension Practice Guide.2 or the left ventricular mass index [LVMI] ≥ 115 g/m2 for males and 95 g/m2 for females) or functional features of diastolic dysfunction  normal or slightly abnormal left ventricular ejection fraction (LVEF) ≥50% and not enlarged left ventricle;Inclusion criteria are as follows: (1) signs or symptoms of heart failure; (2) elevated B‐type natriuretic peptide (BNP) levels (BNP > 35 pg/ml or NT‐proBNP >125 pg/ml); (3) evidence of cardiac structural alterations ; (12) drugs affecting blood glucose and blood lipids used before admission.Exclusion criteria are as follows: (1) white coat hypertension, defined as elevated blood pressure in the clinic despite mean ambulatory BP monitoring or consistent home BP readings <135/85 mmHg; (2) secondary hypertension ; (3) congenital heart disease ; (4) severe heart valve disease ; (5) restrictive cardiomyopathy; (6) hypertrophic cardiomyopathy; (7) pericardial diseases (acute pericarditis and constrictive pericarditis); (8) heart failure due to noncardiogenic factors ; (9) thyroid dysfunction (hyperthyroidism and hypothyroidism); (10) severe liver damage ; (11) heavy renal impairment , medication history , and fasting blood samples were collected after admission to measure laboratory indicators: N‐terminal B‐type brain natriuretic peptide precursor (NT‐proBNP), uric acid, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), high‐density lipoprotein cholesterol (HDL‐C), low‐density lipoprotein cholesterol (LDL‐C), total cholesterol (TC), triglyceride (TG), and fasting blood glucose (FBG).2.4TyG index is calculated with the following formula: TyG index = Ln (serum TG [mg/dl] × FBG [mg/dl]/2).2.53 − LVEDD3) − 13.6; LVMI (g/m2) = LVM/body surface product , among which BSA  = 0.0057 × height (m) + 0.0121 × body weight (kg) + 0.0882 and BSA  = 0.0073 × height (m) + 0.0127 × body weight (kg) − 0.2106.All patients underwent routine echocardiography examination after admission. The following indicators were observed and recorded for all patients: left ventricular ejection fraction (LVEF), left ventricular end‐diastolic diameter (LVEDD), interventricular septal thickness (IVST), left ventricular posterior wall thickness (LVPWT), left atrial diameter (LAD), septal peak early diastolic mitral annulus velocity , lateral wall early diastolic mitral annulus velocity , average e′ = , the ratio of peak E‐velocity of mitral orifice to peak velocity of early diastolic mitral annulus (E/e′), and the ratio of peak E of early diastolic maximum blood flow velocity to peak A of late diastolic maximum blood flow velocity of mitral orifice (E/A). Left ventricular mass (LVM) was calculated according to the Devereux formula: LVM (g) = 1.04 × ([IVST + LVPWT + LVEDD]2.6x ± s). The t‐test was utilized for comparisons between the two groups. Data without normal distribution were expressed as M , and the nonparametric test was applied for comparisons between the two groups. Count data were displayed as an example (%), and the rank‐sum test was adopted for comparisons between the two groups. Pearson or Spearman correlation analysis was selected depending on whether the data were normally distributed. Logistic regression was used to analyze the relationship between HFpEF and various variables in patients with hypertension. The diagnostic efficiency of TyG index for HFpEF in hypertensive patients was evaluated using the receiver operating characteristic (ROC) curve. All tests were performed using the two‐sided test, with the test level set as p < .05.SPSS 26.0 software was employed for statistical analysis. All measurement data were first tested for normality, and the data conforming to normal distribution was represented by (33.1p < .05) , the liver and kidney function, HDL‐C, and LDL‐C. A statistically significant difference was observed for SBP, the percentage of diuretics used, NT‐proBNP, FBG, TG, and TyG index between these two groups (5) Table .3.2p < .05)  Table .3.3p < .05)  Table .3.4p < .05). Therefore, TyG index, E/e′, and NT‐proBNP were independent risk factors for HFpEF in patients with hypertension . The independent variables were assigned to diuretic or not (yes = 1 and no = 0), and the remaining continuous numerical variables were substituted with actual values. The analysis results exhibited that LVEF, TyG index, E/e′, and NT‐proBNP were influential factors for HFpEF  for NT‐proBNP, and 0.778 (95% CI: 0.707–0.849) for TyG index . It was first proposed by Guerreo Romero as a surrogate indicator of IR.The mechanism of TyG index in heart failure is not clear. According to the existing research, TyG index is considered to be related to IR. So far as we know, ventricular fibrosis has been proven to be one of the key intermediate links in the pathogenesis of heart failure.TyG index is a simple and economic indicator of IR, which is useful to help clinicians early screen out the “high‐risk group” prone to HFpEF in hypertensive patients and can be routinely monitored during the management of patients. It is recommended to add TyG index to the routine evaluation model of hypertensive population.5Our study shows that the TyG index strongly correlates with the occurrence of HFpEF in hypertensive patients.6There exists several limitations in this study. First, this study is a single‐center retrospective study with a small sample size, selection bias, and no long‐term follow‐up of patients. In the future, multicenter studies with larger sample sizes are warranted to further confirm our conclusions. In addition, this study can only infer from our data that TyG may be implicated in the occurrence of HFpEF in hypertensive patients. The mechanism has not been clarified through relevant experiments. Finally, research is merited to further analyze the relationship between TyG index and the prognosis of heart failure in hypertensive patients with heart failure.The author declares no conflict of interest.


Cardiac power-to-left ventricular mass (power/mass) is an index reflecting the muscular hydraulic pump capability of the heart, and the E/e’ ratio is a specific indicator for identifying increased left ventricular filling pressure. Limited data exist regarding the prognostic value of incorporating power/mass and E/e’ ratio in heart failure with preserved ejection fraction (HFpEF).In total, 475 patients with HFpEF from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial with complete baseline echocardiography data were included in our analysis. Patients were categorized into four groups according to power/mass and E/e’ ratio. The risk of outcomes was examined using Cox proportional hazards models and competing risk models.P = 0.001; hospitalization for heart failure: HR 3.27; 95% CI: 1.60–6.67; P = 0.001; and primary endpoint: HR 3.07; 95% CI: 1.73–5.42; P < 0.001).Patients with low power/mass and high E/e’ were more likely to be males (60.5%), with higher waist circumference, and had a higher prevalence of diabetes (52.1%), atrial fibrillation (50.4%), and lower estimated glomerular filtration rate (eGFR). Combined resting power/mass and E/e’ have graded correlations with left ventricular (LV) dysfunction and clinical outcomes in patients with HFpEF. After multivariable adjustments, an integrative approach combining power/mass and E/e’ remained to be a powerful prognostic predictor, with the highest HRs of clinical outcomes observed in patients with low power/mass and high E/e’ (all-cause mortality: HR 3.45; 95% CI: 1.69–7.05; In patients with HFpEF, an echo-derived integrated approach incorporating resting power/mass and E/e’ ratio remained to be a powerful prognosis predictor and may be useful to risk-stratify patients with this heterogeneous syndrome.https://clinicaltrials.gov], identifier [NCT00094302].[ Heart failure with preserved ejection fraction (HFpEF) accounts for approximately half of the patients with heart failure (HF) in the community and leads to substantial morbidity and mortality . AlthougIn HFpEF, a normal LVEF may be associated with reduced cardiac output and/or increasing LV filling pressure, which is the intrinsic characteristic of this heterogeneous syndrome. Therefore, a combined assessment of both systolic and diastolic LV functions might be a better approach to decipher pathophysiological mechanisms and determine the prognosis of HFpEF, beyond the simplistic evaluation by LVEF. In recent years, novel hemodynamic classifications taking into account both LV anterograde flow and filling pressure have been proposed in the general HF population and patients with heart failure with reduced EF (HFrEF) , 9. HoweWe used data from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial obtained from the National Heart, Lung, and Blood Institute (NHLBI). The principles and procedures of the TOPCAT trial have previously been described . In brieIn this study, we performed a retrospective analysis in the TOPCAT trial and further excluded patients with inadequate information regarding baseline echocardiographic measures including E/e’ ratio  and the variables required for calculating power/mass, as well as potential clinical confounders . Finally, a total of 475 patients were included in our analysis. This study was approved by the Medical Ethical Committee of The First Affiliated Hospital, Sun Yat-sen University and conformed with the principles outlined in the Declaration of Helsinki.In the TOPCAT trial, standard measurements of the echocardiographic study were performed according to the recommendations of the American Society of Echocardiography and analyzed at a dedicated core laboratory blinded to randomized treatment assignment and clinical information, as previously described , 12. TheK = 0.222 (a conversion constant to W/100 g of LV myocardium). Mean arterial pressure (mmHg) was calculated as: Mean BP = [(systolic blood pressure−diastolic blood pressure)/3] + diastolic blood pressure. According to the median of power/mass (0.362 W/100 g) and a septal E/e’ ratio threshold of 15 at baseline, patients were categorized into four groups:Cardiac power-to-LV mass (in W/100 g) was calculated using the following equation: Power/mass = mean arterial pressure (mmHg) × stroke volume (L) × heart rate (bpm) × K/LV mass, where HP-NF): power/mass > median (0.362 W/100 g) and E/e’ ratio ≤ 15,High cardiac power with non-increased filling pressure (LP-NF): power/mass ≤ 0.362 W/100 g and E/e’ ratio ≤ 15,Low cardiac power with non-increased filling pressure (HP-HF): power/mass > 0.362 W/100 g and E/e’ ratio > 15,High cardiac power with increased filling pressure (LP-HF): power/mass ≤ 0.362 W/100 g and E/e’ ratio > 15.Low cardiac power with increased filling pressure  according to the distribution. Categorical variables were presented as numbers with proportions (%). Baseline characteristics and echocardiographic parameters among the pre-specified four groups were compared using ANOVA or Kruskal–Wallis test for continuous variables and using chi-square tests or Fisher’s test for categorized variables as appropriate. Kaplan–Meier curves were constructed to assess the unadjusted cumulative incidence estimates of each outcome stratified by median power/mass and an E/e’ threshold of 15 for the cohort and compared using log-rank tests or gray’s test as appropriate. The prognostic relevance of combined power/mass and E/e’ ratio for all-cause mortality, hospitalization for HF, and primary endpoints were assessed using crude and multivariable-adjusted Cox regression models (reference group: high power/mass with low E/e’ ratio). The risk of cardiovascular and non-cardiovascular death associated with each group was assessed using univariable and multivariable competing risk regression models. Model 1 was adjusted for age, sex, race, region of enrollment (Americas vs. Russia/Georgia), and randomization group. Model 2 was additionally adjusted for NYHA functional class, stroke, atrial fibrillation, heart rate, creatinine, and LVEF. The associations of power/mass or E/e’ ratio with outcomes were also analyzed by crude and multivariate regression analysis with adjustment for the same aforementioned covariates. All the statistical analyses were performed using the R statistical software (R version 4.0.3), and statistical significance was defined as a two-tailed Among the 475 patients with HFpEF  included in this analysis, the median of power/mass was 0.362 W/100 g, and 48% had a septal E/e’ ratio higher than 15. There were 129 (27.2%) patients with high power/mass with low E/e’, 118 (24.8%) with low power/mass with low E/e’, 109 (22.9%) with high power/mass with high E/e’, and 119 (25.1%) with low power/mass with high E/e’.2) in patients with low power/mass and high E/e’. As for medication prescription, diuretics were more frequently prescribed (92.4%) in the LP-HF group.The baseline clinical characteristics according to the pre-specified four groups are presented in During a median follow-up of 3.0 years, 88 (18.5%) deaths occurred, of which 57 (12.0%) were adjudicated as cardiovascular deaths. In total, 87 (18.3%) experienced HF hospitalizations and 127 (26.7%) primary endpoints.P < 0.05 except for left ventricular end-systolic volume (LVESV)]. Objective evidence of LV diastolic dysfunction (LVDD) was found in 90.5% of patients with HFpEF in this study, of which significant LVDD (classified as moderate to severe) accounted for more than one-half of the patients. Although LVDD existed both in the overall patients of HP-HF group (high power/mass with high E/e’) and LP-HF group (low power/mass with high E/e’), the distribution of LVDD grade was distinct between the two groups. Moderate LVDD was more frequent (accounting for 61.3%) in the HP-HF group, while moderate and severe LVDD were both more common in the LP-HF group , which indicated a trend toward the deterioration of LVDD from HP-HF group to LP-HF group. Besides, the Left atrial volume (LAV) value of patients in the LP-HF group was significantly greater than that of the other three groups (P < 0.001). There were increasing trends of peak E wave velocity to peak A wave velocity (E/A ratio) and peak tricuspid regurgitation velocity from the HP-NF group to the LP-HF group (P < 0.001).The baseline echocardiographic characteristics according to the four groups are shown in P = 0.023) and primary endpoint   , whereas= 0.020) . In mult= 0.020) .P = 0.001). Similar association patterns were also observed with HF hospitalization and primary endpoint (P = 0.001) than those with high power/mass with low E/e’ (P < 0.001)  .P = 0.013), compared with the HP-NF group (P = 0.032) as compared with the HP-NF group.For cardiovascular death, the incidence rate in the LP-HF group  was more than three times higher than that in the HP-NF group  . LikewisNF group , whereasIn this study, we proposed an integrated risk-stratification approach incorporating resting CP-to-LV mass and E/e’ ratio, which allowed effective prognostication in HFpEF. In general, we found that patients with low power/mass and high E/e’ had substantially higher crude rates of poor outcomes than patients with high power/mass and low E/e’. After adjustment for clinical covariates, combining power/mass and E/e’ ratio had a graded relationship with LV dysfunction and clinical outcomes in patients with HFpEF. The predictive value of the integrated approach was stronger than that of the individual variables contained in the approach alone.An appropriate HF categorization not only should be associated with pathophysiological mechanisms but also have a prognostic significance. A recent study demonstrated that HF phenotypes categorized by LVEF (HFrEF and HFpEF) do not match the pathophysiological perspective of HF . Althoug2 as the threshold for low output) and E/e’ ratio  is useful in predicting survival. A similar pathophysiological stratification approach based on an assessment of cardiac hemodynamics (ventricular forward flow and filling pressure) has also been proposed in patients with cardiogenic shock  . As the An integrated hemodynamic approach that incorporates resting power/mass and E/e’ has graded correlations with LV dysfunction and clinical outcomes in patients with HFpEF. In particular, the prognosis is worst in the presence of low values of resting power/mass and high values of E/e’ ratio in patients with HFpEF. These findings suggest the potential value of an echo-derived integrated approach for risk stratification and prognosis prediction in patients with HFpEF.The original contributions presented in this study are included in the article/The study was approved by the institutional review board at all participating institutions, and all participants provided written informed consent at enrollment.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.