Background. The aim of this study is to show whether the septal E/(E′ × S′) ratio assessed by tissue Doppler echocardiography can predict left ventricular remodeling after first ST segment elevation myocardial infarction treated successfully with primary percutaneous intervention. Methods. Consecutive patients (n = 111) presenting with acute anterior myocardial infarction for the first time in their life were enrolled. All patients underwent successful primary percutaneous coronary intervention. Standard and tissue Doppler echocardiography were performed in the first 24-36 hours of admission. Echocardiographic examination was repeated after 6 months to reassess left ventricular volumes. Septal E/(E′ × S′) ratio was assessed by pulsed Doppler echocardiography. Results. Group 1 consisted of 33 patients with left ventricular (LV) remodeling, and Group 2 had 78 patients without LV remodeling. E/(E′ × S′) was significantly higher in Group 1 . The optimal cutoff value for E/(E′ × S′) ratio was 2.34 with 87.0% sensitivity and 82.1% specificity. Conclusion. Septal E/(E′ × S′) values measured after the acute anterior myocardial infarction can strongly predict LV remodeling in the 6-month follow-up. In the risk assessment, the septal E/(E′ × S′) can be evaluated together with the conventional echocardiographic techniques.  E/E′) is one of the most well-known evaluation methods. The E/E′ ratio has been proposed to be the single best Doppler predictor for evaluating LV filling pressure and is a good predictor of cardiac death  predicts left ventricular (LV) filling pressure in different populations [Mornos et al. studied an index including the ulations . In anotulations . We inveThis study was designed as a prospective study. One hundred and eleven patients with acute anterior myocardial infarction enrolled in the study between January 2014 and December 2015. Written, informed consent was taken from all patients. We obtained approval from local ethical committee. Fourteen patients were excluded due to poor echocardiographic assessment. Acute myocardial infarction was defined as >2 mm ST elevation in precordial leads or new onset LBBB in electrocardiography in patients with a history of 30 minutes to 12 hours of chest pain. The diagnosis was confirmed with troponin levels. Troponin T (Tn T), creatine kinase (CK), and MB fraction of CK (CK-MB) were measured at baseline and at the end of 6th and 24th hours. The major exclusion criteria were a history of other heart muscle and valvular diseases , systemic diseases affecting left ventricular systolic and diastolic functions, serious arrhythmias including atrial fibrillation, permanent pacemaker implantation history, and patients with poor acoustic window in echocardiography. According to these criteria, 111 patients were enrolled and 24 patients were excluded. Patients were divided into two groups according the remodeling at the end of the 6th month.E) and atrial (A) diastolic filling and E wave deceleration (DT) were measured, and the E/A ratio was calculated. The LV ejection fraction (LVEF) and LV volumes were determined using modified biplane Simpson's method. All measurements used for statistical analysis were averaged from five consecutive beats. The LV was divided into 17 segments, evaluated, and scored . The global wall motion score index (WMSI) was calculated for each TTE examination. More than 20% increase in the diastolic volume and/or systolic volume was defined as left ventricular remodeling [Echocardiography was performed with a Vivid 3 ultrasound system  by cardiologist between 24 and 36 hours after primary PCI. All participants were examined using conventional two-dimensional echocardiography and pulsed-wave Doppler tissue imaging (DTI) according to standardized protocols. All echocardiograms were stored and analyzed by two cardiologists. The LV dimensions  were obtained from parasternal long axis view. The pulsed-wave sample volume is placed between the tips of the mitral leaflets ensuring parallel alignment of the Doppler beam with blood flow. Peak velocities of early (E′), and peak mitral annular systolic velocity (S′) was measured. The E/E′ and E/(E′ × S′) values were recorded from septal and lateral mitral annulus [Transmitral flow patterns were recorded from apical four-chamber windows with 4-5 mm pulsed-sample Doppler volume placed between mitral valve tips in diastole during five consecutive cardiac cycles. Care was taken to obtain the smallest possible angle between the direction of transmitral flow and the ultrasound beam. The measurements were recorded during the expiratory apnea and the mean value of five consecutive measurements obtained. Pulsed Doppler signals were recorded at a horizontal sweep of 100 mm/s. The TDI program was set in pulsed-wave Doppler mode. Motion of mitral annulus was recorded in the apical four-chamber view at a frame rate of 80 to 140 frames per second [Baseline characteristics including gender, age, hypertension, diabetes mellitus, hyperlipidemia, smoking, family history, and body mass index of the patients who presented with acute myocardial infarction were evaluated. In addition, blood urea, creatinine, uric acid, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, troponin peak CK-MB and hemoglobin, platelet count (PLT), and neutrophil-leucocyte levels were analyzed. Angiographic parameters including multivessel disease, procedures for the treatment , antiplatelet therapy, and TIMI flow grade before and after procedure were recorded.Primary PCI procedures were obtained according to international guidelines. 300 mg chewable aspirin as well as clopidogrel, prasugrel, or ticagrelor was given with certain loading doses. 10000 U unfractionated heparin was used during the procedure. GPIIb/IIIa antagonist agents were used if necessary. Multivessel disease is defined as two- or three-vessel disease with complexity of the lesions. Anti-ischemic, antiplatelet, and lipid lowering therapy after the procedure was given and continued according to guidelines. Two invasive cardiologists assessed the coronary angiograms. TIMI thrombus grade scales were evaluated and patients with high thrombus scale were identified , 10. SynAll echocardiographic measurements including TDI parameters were recorded at the end of the 6th month, and patients were divided into two groups according to left ventricular remodeling using the left ventricular systolic and diastolic volumes.t-test was used for the comparison of echocardiographic parameters between two groups. Receiver operating characteristic analysis (ROC) was used for the determination of predictive value. A p value <0.05 was considered significant.Measured values are reported as the mean ± standard deviation, and statistical comparisons were performed using SPSS11.0. The normality of the distribution of the groups was compared using a Kolmogorov-Smirnov test, and categorical variables were analyzed using a chi-square test. A p = 0.016).Hundred and eleven patients  were included in the study at the end of the 6th month. Group 1 consisted of 33 (29.7%) patients with positive remodeling, and the rest of the patients without remodeling were defined as Group 2. Baseline characteristics of the study population are shown in The pain-balloon time was high in the remodeling group when the groups were compared according to clinical characteristics. However the difference was not statistically significant. Similarly, the comparison of two groups according to syntax score and TIMI thrombus scale was not significant. Peak troponin and CK-MB levels were similar between the two groups despite the higher values in Group 1 .E velocity and the E/A ratio between two groups was similar. Septal E′ and S′ values in Group 1 were significantly lower than Group 2. The septal E/E′ ratio was significantly higher in patients with positive remodeling . Similarly, E/(E′ × S′) was significantly higher in Group 1 . The initial LVEF was lower  when WMSI was higher  in patients with positive remodeling. The end baseline diastolic and systolic volume indexes in Group 1 were high but not statistically significant. On 6-month follow-up, the EDVI was significantly higher in Group 1  and ESVI was higher in Group 1 as well . In the first 24–36 hours of admission, the deceleration time (DT) and isovolumetric relaxation time (IVRT) were shorter in Group 1 but not significant  at discharge to predict remodeling. The optimal cutoff value for E/(E′ × S′) ratio was 2.34 with 87.0% sensitivity and 82.1% specificity  value predicted the cardiac mortality in patients with heart failure. In this study, Mornos et al.thought that the E/E′ ratio was insufficient for the prediction of the LV end diastolic filling pressure and indicated the restrictions when E/E′ ratio was between 8 and 15 in healthy individuals. The relationship between systolic performance and diastolic function is not clear. Conceptually, it is very difficult to separate relaxation from contraction, and it is better to consider them together as a part of a continuous cycle [E/(E′ × S′) was evaluated and found to be strong predictor in patients with regional wall motion abnormality when compared with E/E′ ratio [E/(E′ × S′) was found to be an important index that evaluates both the diastolic and systolic parameters via a systolic parameter S′ value.Mornos et al. demonstrated that the us cycle . SystoliE′ ratio . Here, wMyocardial infarction causes complex changes in the infarct related area. This change is defined as ventricular remodeling and affects the ventricular functions and prognosis. Remodeling after myocardial infarction is related to adverse cardiac events and mortality. The maintenance of the normal flow in the infarct related artery reduces the ventricular remodeling even in the late period. However, remodeling may be seen even after successful primary coronary intervention . We aimeE/(E′ × S′) index after primary PCI was 87% sensitive and 81.2% specific. The E/(E′ × S′) index can be easily measured in echocardiographic examination and will have important usage because the E/E′ ratio is commonly used in clinical practice.We found remodeling in 29.7% of the patients successfully treated with primary PCI. The S′ and E′ values predict adverse cardiac events in a study published in 2014 [E/(E′ × S′) index predicts ventricular remodeling in our study. We considered the successful usage of advance Doppler echocardiographic parameters for the prediction of ventricular remodeling in the literature [E/(E′ × S′) index is easier and more practical for predicting remodeling—this is what differentiates our study from the others. E/(E′ × S′) values >2.34 can be used in the clinical practice according to ROC curve analysis.Biering-Sørensen et al. investigated the color Doppler parameters in patients treated with primary PCI and found the terature . HoweverThe study consisted of a small number of patients and was statistically significant. We did not use advanced Doppler parameters because they are not useful in clinical practice.The invasive parameters were not compared in this study. This is another limitation of the study. Mornos et al. proved the correlation of this parameter with invasive end diastolic volumes of the measurements in their study. Therefore, we cited this article as a reference and we did not want to prove it again. Another limitation of the study is that Mornos et al.'s study has been the only study done on that. Finally, our study is a single center study, and its reproduction in other centers or by multicenter studies could further confirm its validity.E/(E′ × S′) index may predict left ventricular remodeling at the end of the 6th month in patients successfully treated with primary PCI. E/(E′ × S′) value >2.34 predicts positive remodeling independent of LVEF.The


Heart failure (HF) is a condition characterized by increased filling pressures in the left ventricle due to altered cardiopulmonary blood flow. However, there are no clinically available non-invasive quantitative methods to measure filling pressures in HF. The pulmonary blood volume variation (PBVV) indexed to stroke volume (SV) by cardiac magnetic resonance (CMR) could be a novel non-invasive measure of HF. However, the relationship between PBVV/SV and increased filling pressures has not been validated. We have previously shown that the effect of increased filling pressures and redistribution of pulmonary blood flow can objectively be quantified using perfusion gradients derived from ventilation/perfusion single-photon emission computed tomography (V/P SPECT). V/P SPECT perfusion gradients have a high positive predictive value to diagnose decompensated HF.The aim of this study was therefore to investigate the relationship between the PBVV/SV and perfusion gradients in patients with heart failure.Fifteen patients with HF  were included. All patients underwent CMR at 1.5T and V/P SPECT. Four patients were under consideration for heart transplantation and 11 patients were candidates for cardiac resynchronization therapy. By measuring the blood flow in the pulmonary trunk and in one pulmonary vein, the PBVV was calculated, defined as the maximum cumulative difference in pulmonary blood volume over one heart beat. The SV by CMR was measured as the integral of the flow measurement over one heart beat in the pulmonary trunk. Dorso-ventral perfusion gradients (%-counts/cm) were automatically derived from V/P SPECT images using a user independent algorithm previously developed and validated in our department.There was a positive relationship between PBVV/SV and perfusion gradients Figure  suggestiPBVV/SV measured by CMR, as well as perfusion gradients by V/P SPECT have the potential to serve as non-invasive measures of HF. Further validation work with comparison to invasive pressure measurements are needed to assess the accuracy of the methods.


No unified method exists to effectively predict and monitor progression of pulmonary arterial hypertension (PAH). We assessed the longitudinal relationship between a novel marker of cardiopulmonary reserve and established prognostic surrogate markers in patients with pulmonary vascular disease.n = 14) or at high risk (n = 6) for PAH underwent cardiovascular magnetic resonance (CMR) at baseline and after ~6 months of guideline-appropriate management. Ten PAH participants underwent RHC within 48 h of each CMR. RHC  and phase-contrast CMR  measurements were taken at rest and during continuous adenosine infusion (70/140/210 mcg/kg/min). Initial meanPAvel’s (rest and hyperemic) were correlated with validated surrogate prognostic parameters , a measure of pulmonary arterial stiffness (elastic modulus) and volumetric estimation of RV ventriculoarterial (VA) coupling. Changes in meanPAvel’s were correlated with changes in comparator parameters over time.Twenty participants with confirmed , whereas meanPAvel at peak hyperemia correlated significantly with PVRI, RVEF, RVESVI, 6MWD, elastic modulus and VA coupling . Neither resting or hyperemia-derived meanPAvel correlated with NTpBNP levels. Initial meanPAvel at rest correlated significantly with RVEF, RVESVI, CI and VA coupling at follow up assessment  and initial meanPAvel at peak hyperemia correlated with RVEF, RVESVI, PVRI and VA coupling . Change in meanPAvel at rest over time did not show statistically significant correlation with change in prognostic parameters, while change in meanPAvel at peak hyperemia did show a significant relationship with ΔRVEF, ΔRVESVI, ΔNTpBNP and ΔCI .At initial assessment, meanPAvel at rest correlated significantly with PVRI (inversely), CI (positively) and elastic modulus (inversely) (MeanPAvel during peak hyperemia correlated with invasive, non-invasive and clinical prognostic parameters at different time points. Further studies with predefined clinical endpoints are required to evaluated if this novel tool is a marker of disease progression in patients with pulmonary vascular disease. Pulmonary arterial hypertension (PAH) is characterised by a pathological increase in the resistance of the pulmonary circulation secondary to arterial wall remodelling, vasoconstriction and in situ thrombosis . Progressive obliteration of the pulmonary vascular bed eventually leads to right ventricular (RV) failure and premature death. Therapeutic advances have contributed to better long-term outcomes but disease progression remains difficult to predict and objectively monitor necessitating new methods.We previously demonstrated proof-of-concept for a novel non-invasive method to assess ‘cardiopulmonary reserve’ as it pertains to PAH by measuring the average pulmonary arterial blood flow velocity (meanPAvel) at rest and during standardised intravenous (IV) adenosine infusion using phase-contrast cardiovascular magnetic resonance (CMR) . This apAs a marker of cardiopulmonary reserve and with the advantage of ameliorating the impact of unrelated systemic processes on variables measured at rest, we hypothesised that meanPAvel at peak hyperemia may provide prognostic information at initial assessment and during follow up. To evaluate this, we investigated the association of meanPAvel at rest and during peak hyperaemia with accepted RHC-derived, CMR-derived, biomarker and clinical prognostic surrogate markers in a cohort of patients with confirmed PAH or at high risk for incident PAH. Specifically, we hypothesised that relative to meanPAvel at rest, meanPAvel at peak hyperaemia at initial assessment would be more closely associated with comparator parameters at initial and follow-up assessments, and that changes in meanPAvel at peak hyperemia would correlate more closely with changes in these prognostic markers over time.We prospectively recruited participants with known or suspected PAH and a clinical indication for a right heart catheter (RHC) through a single tertiary-referral centre over a 14-month period 2013–2014). Patients were ineligible if they were <18 years old; pregnant; had known or suspected PAH due to congenital heart disease with left-to-right shunt, or portopulmonary hypertension; or, had a contraindication to CMR or IV adenosine. Right heart catheterization for suspected PAH was deemed clinically indicated by pulmonary hypertension experts following a comprehensive review of clinical status and ancillary investigations, in accordance with guidelines [013–2014.At initial assessment, all participants underwent a RHC and CMR with IV adenosine within 48 h, with PAH confirmed by hemodynamic criteria . Participants with mPAWP > 15 mmHg were excluded and did not undergo vasoreactive testing. Patients with PAH were invited to undergo repeat RHC and CMR with vasoreactivity testing and participants with suspected but excluded PAH (high-risk for incident PAH) invited to undergo repeat CMR with vasoreative testing approximately 6 months after their initial study. Between assessments, patients were administered guideline-appropriate management.Right heart catheterization was performed via the right femoral vein with a 7 F Swan-Ganz thermodilution pulmonary artery catheter . Systemic arterial pressures were monitored by arm cuff. Complete resting hemodynamic assessment was performed in accordance with current guidelines. Intravenous (IV) adenosine  was infused via peripheral vein at three increasing doses: 70-, 140-, and 210mcg/kg/min, and repeat hemodynamic assessment (mPAP/mPAWP/CI/PVR) conducted after a minimum of two minutes’ infusion at each dose.CMR was performed with a 1.5 T magnet  with images obtained at end-expiration. Volumetric and functional analyses were performed using steady-state free procession (SSFP) sequences of the atria and ventricles. Flow imaging through the main pulmonary artery was performed 1.5-2 cm above the pulmonary valve using a velocity-encoded gradient echo sequence with an upper velocity limit of 150 cm/s, temporal resolution of 39 ms and spatial resolution of 1.8x1.8x6mm  CMR-derived: right ventricular ejection fraction (RVEF) and right ventricular end systolic volume index (RVESVI); 2) Biomarker: NT-proBNP levels; 3) RHC-derived: pulmonary vascular resistance index (PVRI) and cardiac index (CI); 4) Clinical: six-minute walk distance (6MWD). In addition to these validated serial prognostic parameters, two other physiologically-relevant parameters were assessed: a marker of pulmonary arterial stiffness , and volumetric estimation of VA coupling .Comparator surrogate prognostic parameters for initial and serial analyses were defined P value of <0.05 considered statistically significant.Normally distributed continuous variables were expressed as means ± standard deviations. Normality was assessed using the Shapiro-Wilk normality test. Scatterplots of univariate associations were reviewed and, where appropriate, Pearson correlation coefficients were used to explore the strength of linear relationships between meanPAvel at rest and during hyperemia with comparator prognostic parameters and Spearman correlation coefficients were used to explore the strength of relationships that were curvilinear and where there was a significant departure from a Gaussian distribution. More specifically, meanPAvel measured at rest and during hyperemia at the initial assessment were correlated with initial and follow up comparator parameters; and changes in meanPAvel at rest and during hyperemia were correlated with changes in comparator parameters between initial assessment and follow up. Statistical analyses were performed using a software package , with a two-sided n = 19; suspected but excluded PAH: ‘High Risk’ n = 12) of which 5 were ineligible . 20 underwent repeat investigations  after a median period of 8 months and 21 days  and were included in the present study. Ten of the 14 PAH participants had both repeat CMR and RHC and 4 had CMR only (declined repeat RHC n = 4). Demographic and clinical characteristics of participants are presented in Table n = 6) and ‘borderline’ abnormal resting hemodynamics (n = 2 with rest mPAP of 21-24 mmHg) [Thirty-one participants were recruited . There was minimal intra-observer and interobserver variability for meanPAvel measures  at all doses.The hemodynamic and meanPAvel changes in response to adenosine are shown in Figs. Correlation coefficients are presented in Table R = 0.60, P = 0.005 and R = 0.65, P = 0.002 respectively) and minimum PVRI  during adenosine challenge. This is consistent with earlier work demonstrating close correlation between meanPAvel and invasively-derived hemodynamics at rest and during adenosine infusion [Given the weaker association between CI and meanPAvel at peak hyperemia, compared to meanPAvel at rest, we assessed the relationship between meanPAvel’s and hemodynamic measurements made during hyperemia. In this regard, meanPAvel at rest and during hyperemia correlated closely with the maximum CI (vs. 0.59 for meanPAvel at rest vs. peak hyperemia), 6MWD and NTpBNP. Correlation coefficients are presented in Table MeanPAvel measured at rest showed moderate strength statistically significant correlation with RVEF Fig. , RVESVI n = 14 vs. n = 10). In contrast, change in meanPAvel measured at hyperemia correlated moderate-strongly with all comparator prognostic parameters except 6MWD, PVRI and VA coupling . Similar trends were seen when only confirmed PAH participants were analysed. Correlation coefficients are presented in Table There were no statistically significant associations between change in meanPAvel measured at rest and change in comparator prognostic parameters, although statistical power was reduced with regard to RHC-derived parameters owing to fewer follow-up invasive procedures , with registry data showing a decline in 6MWD confers a worse prognosis but a rise in 6MWD has no impact on survival [N = 9) in the present study, correlation with change in meanPAvel at hyperemia improved but statistical significance was not met  possibly due to the low sample size.Despite its routine use, 6MWD has many limitations as a serial prognostic marker , stress (e.g. NTpBNP), and functional adaptation  all provide independent prognostic information. In isolation however, each parameter tends to provide a limited picture of the state of the ‘cardiopulmonary’ unit as a whole. In our study, meanPAvel at peak hyperemia correlated significantly with measures of RV afterload (e.g. PVRI and elastic modulus), RV functional adaptation (e.g. RVEF/RVESVI) and VA coupling , suggesting a capacity to simultaneously interrogate the pulmonary vasculature, the RV, and their interaction in a simple, non-invasive fashion. The capacity to assess the RV and pulmonary vasculature as a collective unit may translate to improved ability to discriminate changes in ventricular function, arterial load, or both when compared to, for example, RVEF, a serial CMR measure that conveys consistent prognostic information in PAH patients [PAH is principally defined by the plexogenic pulmonary vasculopathy that underlies its genesis, increasing RV afterload and stress. These two compartments (the RV and pulmonary vasculature) are integrally related and not surprisingly therefore, measures of RV afterload  and the capacity of the RV to increase blood flow in response to downstream circulatory recruitment (‘RV reserve’: chronotropic/inotropic). We postulate that the generally closer association found between meanPAvel at peak hyperemia with validated prognostic parameters, compared with meanPAvel measured at rest, was due to the capacity to assess the cardiopulmonary unit as whole and its’ reserve while ameliorating the impact of unrelated systemic processes.N = 10) or, as earlier discussed, the impact of unrelated systemic factors on resting measures that may compound with serial assessment. No correlation between change in meanPAvel at peak hyperemia and change in 6MWD over time may reflect the inherent limitations of serial 6MWDs and is in keeping with registry data showing a decline in 6MWD is prognostically relevant whereas an increase is not [n = 9: R = 0.59, P = 0.22) is in keeping with our other findings, acknowledging that statistical significance was not met, likely due to a small sample size.Acknowledging the above, not all validated prognostic comparators correlated significantly with meanPAvel at peak hyperemia. Most notably, NTpBNP levels measured at initial assessment did not correlate with meanPAvel measured at the same assessment or at follow-up, although the relative change in NTpBNP correlated with the change in meanPAVel at peak hyperemia over time. Previous studies have demonstrated association between baseline NTpBNP levels, resting hemodynamics, lung function, peak VO2 and prognosis, CMR-derived measures of RV function, and association between change in NTpBNP over time and survival –19. The The major limitations are the small sample size, single centre study design, and lack of clinical outcome data. Findings from this study should be considered hypothesis generating. Repeat vasoreactivity testing via invasive or non-invasive protocols is novel, with this study designed to explore its potential clinical utility by assessing relative strength of association across a range of validated prognostic parameters. Whether meanPAvel provides independent prognostic information cannot be determined. Evidence for potential clinical utility of repeat standardised vasoreactivity testing using this protocol is provided by the combination of physiologically appropriate correlation across a range of relevant CMR-derived, RHC-derived, biomarker and clinical variables; and correlation of generally greater strength at hyperemia compared to rest. Larger studies are required to confirm these findings.Mean pulmonary arterial blood flow velocity measured using CMR during non-invasive standardised pulmonary vasoreactive testing correlated moderate-strongly with a range of CMR-derived, RHC-derived, biomarker and clinical prognostic variables at initial assessment and at follow up. Change in meanPAvel at peak hyperemia on repeat vasoreactivity testing correlated with change in these variables over time, although correlation was generally weaker. Compared with meanPAvel measured at rest, correlation was generally stronger with meanPAvel measured at peak hyperemia. The novel parameter of meanPAvel at peak hyperemia may provide prognostic information by simultaneously interrogating the pulmonary vasculature and RV functional capacity whilst ameliorating the impact of unrelated systemic processes, although larger trials are required to confirm these findings.


Multiple regression analysis revealed that LVDd and septal e′ were significantly associated with cardiac index (CI) and stroke volume index at rest. Among the exercise capacity markers evaluated, TAPSE, TRPG, and LVDd were significantly correlated with peak oxygen uptake . Multiple regression analysis showed that TAPSE was significantly associated with peak oxygen uptake (VO2). In PAH and CTEPH patients, LVDd and septal e′ were significantly associated with CI at rest, whereas TAPSE was significantly associated with peak VO2. Echocardiographic parameters may predict the prognostic factors of PAH and CTEPH patients.Little is known regarding a correlation of hemodynamics at rest or exercise capacity with echocardiographic parameters in patients with pulmonary hypertension (PH). To clarify these potential correlations, we performed transthoracic echocardiography, right heart catheterization, and cardiopulmonary exercise testing in 53 patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Left ventricular end-diastolic dimension (LVDd), early diastolic velocity of the septal mitral annulus , tricuspid regurgitation peak gradient (TRPG), and tricuspid annular plane systolic excursion (TAPSE) were significantly correlated with cardiac index  contains supplementary material, which is available to authorized users. Several specific therapies have been introduced for the treatment of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), and patient conditions have been assessed repeatedly in detail. –6 Noninv2), which is assessed through cardiopulmonary exercise testing (CPET), are established prognostic factors of PAH  × BSA; females, VO2 (mL/min/m2) = [138.1 − (17.04 × logeage) + (0.378 × HR)] × BSA. Pulmonary vascular resistance (PVR) was calculated using the standard formula: PVR = 80 × (mean PAP − mean PAWP)/cardiac output.All patients underwent right heart catheterization via right internal jugular vein with a 6-French Thermodilution catheter  to obtain the pulmonary arterial wedge pressure (PAWP), PAP, RV, and right atrial (RA) pressures. Mixed venous oxygen saturation and arterial oxygen saturation were measured in blood taken from each main PA and radial artery. Cardiac output was calculated by indirect Fick method and estimated VO2), VO2, and minute ventilation (VE) were measured continuously on a breath-by-breath basis using an Ergospirometry Oxycon Pro .All 53 patients underwent exercise testing at a progressively increasing work rate to maximum tolerance on a cycle ergometer. The test was performed according to the American Thoracic Society guidelines . SpecifiTwo-dimensional, M-mode, Doppler echocardiographic images were acquired  and examined according to the guidelines of the American Society of Echocardiography , 26. Pat2. Variables including clinical and laboratory findings, and hemodynamic and echocardiographic parameters were selected on the basis of a significant univariate relation (P < 0.05). A P value of < 0.05 was considered to be statistically significant. All statistical analyses were conducted by using the SPSS statistical software program .Categorical variables are presented as numbers and percentages (%). Continuous variables are presented as mean ± standard deviation or medians. Pearson correlation was used to assess the strength of the relationship between two variables. We performed stepwise multiple regression analysis to evaluate factors that affected CI, stroke volume index (SVI), and peak VOTable The mean TRPG and TAPSE in 53 patients were 74.1 mmHg and 17.3 mm, respectively, highly indicative of severe PH Table . As patiCorrelations of echocardiographic parameters and hemodynamics at rest are shown in Fig. 2 was excluded from the analysis because it was included in the formula of Fick method. The result indicated that LVDd and septal e′ were significantly associated with CI at rest , mean PAP, E, septal e′, LVDd, TAPSE, and TRPG. We also included heart rate (HR) as an independent variable for clinical importance. SvOst Table .Table 3IIn addition, we analyzed SVI which is an important determinant of CI. Stepwise multiple regression analysis was performed incorporating same independent variables used in CI analysis, except HR. The result indicated that LVDd, septal e′, and BNP were significantly associated with SVI, which was compatible with the result of CI Table .Table 4I2 indicated severe exercise intolerance in these patients , BNP, heart rate, CI, mean PAP, SvO2, LVDd, TAPSE, and TRPG. Among those, TAPSE and SvO2 were significantly associated with peak VO2  measured at rest and after dobutamine stress were strongly correlated with peak VO2. [2. These previous results and our results together indicate that RV function is strongly associated with exercise capacity and that assessment of RV systolic function using echocardiography is informative regarding exercise capacity in patients with PAH and CTEPH.Peak VOpatients . In the eak VO2.  AdditionOur study had several limitations. Because it was carried out in the context of current clinical practices, we were unable to perform echocardiography, right heart catheterization, and CPET all on the same day. Right heart catheterization was performed within a median 15 days before and after echocardiography and median 17 days before and after CPET, and each patient received the same drugs with the same dose throughout all examinations. In addition, we evaluated lateral e′, total RV linear measurements, fractional area change, Doppler tissue imaging-derived tricuspid lateral annular systolic velocity wave, RV index of myocardial performance, and longitudinal strain only in limited patients. Therefore, although septal e′ is an established relaxation marker in left-sided heart failure, its usage as a marker for the abnormal LV relaxation, specifically in patients with PAH and CTEPH, remains unclear. Furthermore, because we excluded PH patients with left heart disease, chronic lung disease, or congenital heart disease, future studies are warranted to evaluate whether our results could be applied to PH patients with these comorbidities. Finally, we evaluated patients only at the time of their first admission to our hospital. How each echocardiographic parameter changes as a consequence of patient’s condition remains to be assessed in future.2. Our results indicate that evaluating both LV and RV functions is important in PAH and CTEPH patients. Furthermore, echocardiography—particularly several simple parameters measured frequently in clinical practice—is useful in predicting CI obtained through invasive techniques at rest and peakVO2 during exercise obtained by great physical effort.In conclusion, we demonstrated that, in patients with PAH and CTEPH, LVDd and septal e′ were significantly associated with CI, whereas TAPSE was significantly associated with peak VOSupplementary material 1 (DOC 33 kb)Supplementary material 2 (DOC 49 kb)Supplementary material 3 (DOC 34 kb)Below is the link to the electronic supplementary material.


Objective. To compare T2⁎ value of healthy and diseased Achilles tendons (AT) with a recently introduced three-dimensional ultrashort echo time (3D-UTE) sequence and analyze the correlation between T2⁎ value and clinical scores. Methods. Ten patients with symptomatic Achilles tendon and ten healthy volunteers were investigated with 3D-UTE sequence on a 3T magnetic resonance (MR) scanner. T2⁎ values of four regions in Achilles tendons were calculated. The clinical outcomes of patients were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) score and Achilles Tendon Rupture Score (ATRS). An independent sample t-test was used to compare the differences of T2⁎ value and clinical scores between two groups. The Pearson correlation coefficient between clinical scores and T2⁎ values was assessed. Results. The T2⁎ values of Achilles tendon were statistically significantly different between patients and volunteers. The Pearson correlation coefficients between T2⁎ and AOFAS or ATRS scores of patients were r = −0.733 and r = −0.634, respectively. Conclusion. The variability of T2⁎ in healthy and pathologic AT can be quantified by UTE-T2⁎. T2⁎ may be a promising marker to detect and diagnose AT tendinopathy. UTE-T2⁎ could give a precise guidance to clinical outcome.  Tendinopathy, a syndrome with tendon pain, tenderness, and swelling that limited the tendon function, is one of the most common injures in both athletic and nonathletic populations , 2. Nowa⁎-mapping for short-T2⁎ components [⁎ values of AT and thus can be caught and quantified with UTE sequences [As a noninvasive and credible diagnostic tool, magnetic resonance imaging (MRI) has been widely used to evaluate the pathological changes of AT. But highly organized AT with very short T2 appear dark on conventional MRI sequences, for only tissues with long T2 relaxation times could be visualized , 9. Thusmponents –12. Biocequences .⁎ in evaluating diseased AT and analyze the correlation between T2⁎ value and American Orthopaedic Foot and Ankle Society (AOFAS) score or Achilles tendon Total Rupture Score (ATRS). We hypothesize that the pathologic AT would show increased T2⁎ value while comparing with matched healthy samples and T2⁎ value may be correlated with clinical score.Therefore, the aim of this study was to investigate the capability of quantitative 3D-UTE-T22) with pain or abnormalities in the AT and ten healthy volunteers matched for sex, age, and BMI  participated in the study. Participants were excluded if they had significant tendon rupture or any contraindication for MR.The study was approved by the institutional review board of our hospital and all participants' informed consents were obtained. Ten patients  were acquired. The parameters were set as follows: sagittal orientation, FOV = 140 × 140 mm, slice thickness = 2.0 mm, flip angle = 18, and number of excitations (NEX) = 1. Fat-saturated proton-density weighted turbo-spin echo (PD-TSE) sequence was underwent to acquire morphological assessment with the parameters: sagittal orientation, TR 2843.0 ms, FOV 180 × 180 mm, slice thickness 2.0 mm, flip angle 142, and number of excitations (NEX) = 2.All the participants were examined on a 3T MR scanner  to get monoexponential calculation of T2For clinical evaluation, AOFAS scoring system and ATRS were used to evaluate the patients' clinical outcome .⁎ sequence were analyzed by software in the work station of GE. The AT was segmented and divided into three parts equally according to length: insertion (INS), middle (MID), and muscle-tendon junction (MTJ)  . These tay model .t-test was used to compare the differences of T2⁎ values between two groups. Pearson's correlation coefficient was used to analyze correlations between clinical scores and T2⁎ values of patients. The difference would be statistically significant if P value < 0.05.All statistical analyses were performed in SPSS 20.0 . An independent sample ⁎ value for bulk ROIs was significantly higher in patients than that in volunteers  . The difference in INS region is greater than that in MID and MTJ. In patients, the mean AOFAS and ATRS were 70.6 ± 5.58 and 52.8 ± 8.27, respectively. The T2⁎ value for bulk region was negatively correlated with AOFAS as well as ATRS score   . Separat= 0.049) .⁎ relaxation time in pathologic and healthy AT was measured using UTE-T2⁎ sequence and a significant higher T2⁎ value was observed in all four regions of diseased AT. Besides, T2⁎ value of all bulk of AT in patients was found to be negatively correlated with AOFAS and ATRS score.In this study, T2⁎ mapping, a novel quantitative technique, could catch the short-T2⁎ relaxations from AT that are not well captured by standard T2 mapping [⁎ mapping is sensitive to these changes; thus it could be a useful tool to detect tendon disease in an early stage [⁎. The increasing of T2⁎ value may due to disorganization of collagen structure and increasing of water content in tendons. What is more, the difference in INS region is greater. The reason could be that the enthesis is mostly involved in overuse injuries of AT [⁎ relaxation time in symptomatic tendons compared with control tendons. In a study by Juras et al., they compared mono- and biexponential T2⁎ analysis using variable-echo time sequence (vTE) and found that increased T2⁎ in all parts of diseased AT with monoexponential analysis [⁎ [⁎ relaxation times and off-resonance saturation ratio, Grosse et al. also observed statistical significant differences between the patients with tendinopathy and controls [UTE-T2 mapping . In the  mapping , which c mapping . UTE-T2⁎ly stage . The reses of AT , 17. Gares of AT  applied analysis . Juras econtrols .⁎. Juras et al. [⁎ reflects the changes of Achilles tendinopathy more accurately than the monoexponential T2⁎ [We applied monoexponential calculation of UTE-T2s et al.  found thtial T2⁎ . Howevertial T2⁎ .⁎ value and clinical score. Both AOFAS and ATRS scores are widely used in clinical practice and validated in many studies [⁎ value of the bulk region in patients was correlated with AOFAS and ATRS score, which suggests that T2⁎ could give a precise guidance to clinical outcome of patients with Achilles tendinopathy. Juras et al. got a similar correlation between ATRS score and the monoexponential T2⁎ [To the best of our knowledge, only a few studies analyzed the correlation between T2 studies , 21. Thetial T2⁎ .⁎ reflects the mean value of all the components of relaxation time, which may lead to an underrate of T2⁎, especially in diseased tendons [There are also some limitations in the study. Firstly, a small number of patients which would lead to increased statistical deviation. The patient cohort would be enlarged in our next study. Secondly, monoexponential calculation of T2 tendons .⁎ in healthy and pathologic tendons could be observed by UTE-T2⁎. As the preliminary patient data suggest, UTE-T2⁎ is an acute marker to detect AT tendinopathy in the early stage and it gives a precise guidance to clinical outcome. By further investigation in larger cohort of patients, different terms of follow-up after treatments are required to define the exact role of UTE-T2⁎ for monitoring the change of AT.In conclusion, the differences between T2P-value > 0.05 each.SPSS software and Shapiro-Wilk method are used to test the distribution of samples, for the sample sizes are less than 2000. A normal distribution of our data was shown with the


Right ventricular (RV) dysfunction is an important predictor of long-term outcome in heart failure patients undergoing surgical ventricular restoration (SVR). RV assessment is therefore a pivotal step in the selection of patient candidates for SVR and during follow up. While the impact of SVR on left ventricle (LV) is currently described in terms of both functional and morphological parameters, RV changes are usually considered only from a functional point of view because of the complex chamber shape.We aim to combine a morphological parameter, RV remodeling index (RV mass/volume ratio), with functional evaluation in order to describe and understand RV adaptation after SVR and the resulting impact on clinical outcome.A total of 32 patients  with previous myocardial infarction underwent Cardiac Magnetic Resonance (CMR) (1.5T) before and 6 months after SVR. RV and LV morpho-functional evaluations were performed by CMR. Doppler estimation of systolic pulmonary artery pressure (PAPs) was considered. Changes in NT-proBNP values, dosed before and 6 months after surgery at the time of scanning, were considered as markers of outcome.Statistical significance of parameters changes after surgery was evaluated using Paired T-test or Wilcoxon Matched Pairs Signed-Ranks test as appropriate. Six months after SVR there was a significant reduction in NT-proBNP values compared with pre-surgical evaluation . LV EDV and LV ESV were significantly reduced , while LV ejection fraction was significantly increased . LV stroke volume did not show significant changes . In the face of these results there was no significant variation in RV remodeling index . RV mass remained unchanged  despite a slight increase in RV EDV , probably due to the loss of the compressive effect exerted by the dilated/aneurismal LV. Mean pre-surgical RV EF was 57% ± 11 and did not show significant variation after SVR . Echocardiographic estimation of PAPs remained unchanged . Correlations between variables were studied using Spearman Rank Correlation test. Changes in NT-proBNP levels were positively correlated with variations of PAPs. There was no correlation between changes in NT-proBNP levels and changes in RV ejection fraction , LV ejection fraction , RV stroke volume  and LV stroke volume .In patients with preserved RV systolic function undergoing SVR, there are no significant changes in RV structure and function after surgery. RV seems to behave as a ‘bystander’ in front of clinical improvement and LV modifications. Selection of patients with a ‘healthy’ RV is crucial for clinical success of SVR.


Clinical results of ischemic left ventricular free-wall rupture show high mortality rates.We reviewed studies published after 1993 on PubMed.A sutureless technique using fibrin glue sheets or patches with/without fibrin glue might contribute to improved clinical results. However, some technique limitations remain for blowout-type ruptures, and the possibility of a pseudoaneurysm formation at the repair site after surgery should be considered.The sutureless technique can be a promising strategy for the treatment of ischemic rupture, but serial echocardiographic studies should be mandatory for diagnosing a left ventricular pseudoaneurysm formation thereafter. Cardiac rupture after acute myocardial infarction, which includes ventricular free wall rupture, septal rupture, and papillary muscle rupture, could result in lethal complications. Post-infarction ventricular septal defects develop in approximately 1%-3% of patients prior to the advent of thrombolytic therapy and percutaneous coronary artery interventions. Thereafter, the frequency is substantially reduced to less than 0.5% of patients with acute myocardial infarction [Mitral valve regurgitation caused by rupture of a papillary muscle presents in 1%-3% of patients. The posteromedial papillary muscle ruptures in about 75% of these patients and the anterolateral muscle in about 25%, although complications are less common given the widespread use of thrombolytic and percutaneous intervention therapy [These life-threatening complications mainly occur within 7 days after myocardial infarction. Free-wall rupture of the left ventricle is another mechanical complication that can occur after acute myocardial infarction. However, its clinical outcomes are poorly studied because of the rarity of the condition. Here, the author reviews surgical results of the ischemic free-wall rupture of the left ventricle, particularly after sutureless repair.As conventional procedures, direct suture closures of rupture sites are employed under cardiopulmonary bypass. Because of the rapid deterioration of these patients with free-wall rupture, the mortality rate within the first week is very high if left untreated. Patients can extend their 5-year survival rates to 65% with conventional surgical corrections including infarctectomy with patch reconstruction, direct closure with or without patch covering, and endoventricular patch repair under cardiopulmonary bypass . HoweverReardon and colleagues reported that free wall rupture was a complication after myocardial infarction in 4% to 24% of patients and that it was the second most common cause of death (pump failure being the most common cause), accounting for 12% to 21% of deaths after myocardial infarctions . Repair We reviewed studies written in English published after 1993 on PubMed, including studies written in non-English with English abstracts as of the end of 2015. Studies were searched for using following key words: ischemic left ventricular rupture, sutureless repair, left ventricular pseudoaneurysm, left ventricular repair, and sutureless repair.®  and TachoSil® .Thirteen articles matched the key words, and they were reviewed. Patients’ profiles, operative procedures, and outcomes are summarized in Tables Padró et al. reported 13 successful cases treated by sutureless repair . They apFollowing the sutureless procedures, several studies have reported on pseudoaneurysm formation of the left ventricle. Kimura et al. described a case with such a complication, who developed a left ventricular pseudoaneurysm 7 days post-surgery . The pseFollowing the sutureless procedures, several studies have reported on pseudoaneurym formation of left ventricle –22. The Nasir et al. reviewed articles that analyzed the outcomes related to conservative and surgical approaches and the effects of cardiopulmonary bypass under systemic heparinization . They coSutureless procedures are somewhat different among investigators, and materials applied to myocardial lesions have been changed. Typically, the heart is accessed through a standard sternotomy and pericardiotomy, and several layers of fibrin glue sheets or patches with or without fibrin glue are applied to the rupture site including the infarcted area. The oozing surface is then compressed for several minutes to confirm complete hemostasis. Many surgeons perform this procedure without the need for cardiopulmonary bypass.Ischemic rupture can occur at any portion of the left ventricle Table . PericarPatch materials vary from an expanded polytetrafluoroethylene membrane such as Teflon to an equine collagen sponge coated with a solid component of fibrin glue such as TachoComb. TachoComb should be applied to myocardium covering infarcted myocardium and healthy myocardium surrounding to reduce the shear stress of the infarcted myocardium. Many surgeons repeated this procedure several times and they applied additional glue drops to the area of myocardial rupture. The sutureless technique, which employs surgical glue sheets such as TachoComb, has become widespread.After sutureless repair of ischemic cardiac rupture, a pseudoaneurysm of the left ventricle can be encountered. The pseudoaneurysm can spontaneously occur after myocardial infarction. Surgical mortality and long-term survival rate are poor due to underlying ischemic cardiomyopathy . PseudoaThe sutureless procedure is an attractive and simple treatment strategy for ischemic left ventricular rupture, but surgeons should be aware that it has a potential risk of pseudoaneurysm formation after surgery. Large fibrin glue sheets covering the entire infarcted myocardium could reduce the wall stress of the left ventricular lesion. Avoiding cardiopulmonary bypass might also contribute to successful results. Management after repair, including intra-aortic balloon pumping which decreases the afterload of the left ventricle, and other mechanical supports help to reduce the preload of the left ventricle, hopefully leading to better clinical results . AdditioThe sutureless technique can be a promising strategy for the treatment of ischemic rupture, but serial echocardiographic studies should be mandatory for diagnosing a left ventricular pseudoaneurysm formation thereafter.


Vector flow mapping, a novel flow visualization echocardiographic technology, is increasing in popularity. Energy loss reference values for children have been established using vector flow mapping, but those for adults have not yet been provided. We aimed to establish reference values in healthy adults for energy loss, kinetic energy in the left ventricular outflow tract, and the energetic performance index (defined as the ratio of kinetic energy to energy loss over one cardiac cycle).Transthoracic echocardiography was performed in fifty healthy volunteers, and the stored images were analyzed to calculate energy loss, kinetic energy, and energetic performance index and obtain ranges of reference values for these.Mean energy loss over one cardiac cycle ranged from 10.1 to 59.1 mW/m , with a reference range of 10.32 ~ 58.63 mW/m. Mean systolic energy loss ranged from 8.5 to 80.1 (23.52 ± 14.53) mW/m, with a reference range of 8.86 ~ 77.30 mW/m. Mean diastolic energy loss ranged from 7.9 to 86 (30.41 ± 16.93) mW/m, with a reference range of 8.31 ~ 80.36 mW/m. Mean kinetic energy in the left ventricular outflow tract over one cardiac cycle ranged from 200 to 851.6 (449.74 ± 177.51) mW/m with a reference range of 203.16 ~ 833.15 mW/m. The energetic performance index ranged from 5.3 to 37.6 (18.48 ± 7.74), with a reference range of 5.80 ~ 36.67.Energy loss, kinetic energy, and energetic performance index reference values were defined using vector flow mapping. These reference values enable the assessment of various cardiac conditions in any clinical situation. Blood flow in a healthy human left ventricle forms an energetically efficient vortex , 2. ThisSeveral intracardiac flow visualization technologies have emerged recently, among which is vector flow mapping (VFM), a novel echocardiographic technology –15. VFM The study was approved by the institutional review board (ERB-C-437) of Kyoto Prefectural University of Medicine, Kyoto, Japan, and written informed consent was obtained from all participants. The participants were 42 and 12 healthy men and women, respectively, aged 20 to 44 years, with no particular medical history or chronic disease and a structurally normal heart and sinus rhythm, who volunteered to participate in the study between November 2015 and June 2016. Exclusion criteria were poor quality echocardiographic images, and heart valvular disease or wall motion abnormality on echocardiographic examination.TTE was performed using an ultrasound machine, Prosound F75 Premier  with a 2.5 MHz sector probe, in accordance with the recommended method of the American Society of Echocardiography . Two-dimClinical data including sex, age, height, body weight, and body surface area (BSA) were collected. The echocardiographic measurements collected included heart rate (HR), left ventricular end diastolic diameter, left ventricular end systolic diameter, left ventricular fractional shortening (LVFS), peak blood flow velocity at the mitral valve during early diastole (E) and late diastole (A), the E/A ratio, and peak myocardial velocity at the septal mitral annulus during early diastole (e’) and late diastole (a’) and the E/e’ ratio.The stored ultrasound images from the Prosound F75 Premier were transferred to a computer for analysis with VFM software. The one cardiac cycle image for analysis was selected using two consecutive QRS complexes of the electrocardiogram as the beginning and end points. Whenever the aliasing phenomenon was recognized, the aliased areas were manually corrected with phase shift. The left ventricular endocardial boundary was manually traced to detect left ventricular wall motion by speckle tracking. Based on the VFM images, intracardiac EL values and the KE in the left ventricular outflow tract (LVOT) were calculated. There are three types of intracardiac EL: mean EL over one cardiac cycle (ELcycle), mean systolic EL (ELsys), and mean diastolic EL (ELdia). All three types of EL were calculated. Intracardiac EL values and the mean KE over one cardiac cycle in the LVOT (KEcycle) were averaged over three cardiac cycles.VFM enables the evaluation of intracardiac flow and calculation of intracardiac EL and KE. This technology uses both color Doppler images and speckle tracking images. The velocity vectors of each pixel can be calculated using a continuity equation from the left and right side boundaries. The calculated velocity vectors are integrated according to a weight function , 17.Intracardiac EL can be calculated from the following equation :\documenu and v are velocity components along the Cartesian axes (x and y), and A is the area of the unit of the grid.where μ is the viscosity of the blood, As the equation indicates, EL is the total of squared differences between neighboring velocity vectors. It increases at points where the size and direction of velocity vectors change. For example, EL is likely to increase due to turbulent flow, such as at a site after aortic stenosis. The EL values are expressed in W/m because VFM images are two-dimensional.The KE in the LVOT can be calculated from to the following equation:3), v is the velocity vector of the blood flow, and dL is an increment of the cross-sectional line.where ρ is the density of the blood . The significance level was set at p < 0.05.Continuous variables are expressed as mean ± standard deviation. Reference ranges for each energetic parameter were calculated from the 2.5% and 97.5% values. Correlations between ELcycle, ELsys, ELdia, and KEcycle and age, height, weight, BSA, HR, and echocardiographic measurements were evaluated using Pearson’s correlation coefficients. Stepwise multivariate linear regression analyses were performed to analyze the independent variables that correlated with EL and KE. The analyzed variables were age, height, weight, BSA, HR, LVFS, E, A, and e’. Interaction between the independent variables was analyzed by stepwise multivariate linear regression analysis, setting the level of significance to TTE was performed in 54 volunteers. However, four women were excluded due to the poor quality of their echocardiographic images, leaving 50 volunteers to be included in this study. Their demographic and echocardiographic data are shown in Table A normal vortex pattern as shown in Fig. r = 0.448, p = 0.001) and HR  (Table p < 0.0001) and HR (p < 0.0001), with the following regression equation:A typical graph of EL over a cardiac cycle is shown in Fig. R2 0.4211, p < 0.0001). and LVFS  (Table p = 0.00733), E (p = 0.159), and LVFS (p = 0.148), with the following regression equation:ELsys, the mean value of systolic phase EL, is a useful parameter for assessing the pathological cardiac condition at the systolic phase, such as systolic anterior motion, mitral regurgitation, and aortic stenosis. The range of ELsys was from 8.5 to 80.1 mW/m   (Table p < 0.0001), HR (p = 0.00037), and age (p = 0.147), with the following regression equation:ELdia, the mean value of diastolic phase EL, is a useful parameter for assessing cardiac condition that is pathological during diastolic phase, such as with mitral stenosis or aortic regurgitation. The range of ELdia was from 7.9 to 86 mW/m   (Table p = 0.0013), with the following regression equation:KEcycle, the mean value of KE over one cardiac cycle, is a useful parameter for assessing the ejection of blood flow from the left ventricle into the left ventricular outflow tract. The range of KEcycle was from 200 to 851.6 mW/m  (Table (adjusted 3) Table .EPI, the ratio of KEcycle to ELcycle, is a useful parameter for assessing the energetic efficiency of the heart, especially in evaluating the success of cardiac surgery. The range of EPI was from 5.3 to 37.6  of ELcycle and KEcycle were 0.953 and 0.978, respectively, for intra-observer measurements . For inter-observer measurements, the ICCs of ELcycle and KEcycle were 0.943 and 0.947, respectively, . Bland-Altman plots for each variability are shown in Fig. By using VFM, we were able to confirm in this study the normal pattern vortex in the left ventricle, and to define reference values for each type of EL, KE, and EPI in healthy volunteers. In future, left ventricular function and load can be assessed with regard to energetics in the perioperative period by referring to the values obtained in this study. In addition, if the reference values of the energetic parameters were established with transesophageal echocardiography, energetic values can be calculated in a few minutes by online real-time VFM and the result of surgery can be evaluated with regard to energy even during the operative period.It is natural in the human left ventricle that there are a strong clockwise vortex under the anterior mitral leaflet and a weak counterclockwise vortex under the posterior mitral leaflet during early diastole. In our analysis, although the weak counterclockwise vortex quickly diminished, the strong clockwise vortex continued until the isovolumic contraction phase, as reported previously , 20–23. The correlations of ELsys with HR and LVFS are reasonable because the main factor in EL generation is flow acceleration during systole, as shown in Figs. A factor of EL generation during diastole is flow dissipation, as shown in Figs. Because ELcycle combines both ELsys and ELdia, it is affected by the factors of both the systolic and diastolic phases.As discussed earlier, the preload provides left ventricular contractility according to the Frank–Starling law. Thus, during the main portion of diastolic flow, E is correlated with KEcycle.EPI is useful for assessing patients with various heart diseases and for evaluating cardiac surgery performance. Because EL and KE are susceptible to hemodynamic condition, either can sometimes be problematic for assessing cardiac condition. However, EPI enables the diagnosis of cardiac condition, such as hyperdynamic, overloaded, impaired, or decompensated. EPI is a new index, and data about EPI will need to be collected across a range of cardiac conditions.In practical situations, there are various indicating parameters for operative therapy. For example, peak aortic valve velocity, mean pressure gradient, symptoms and left ventricular ejection fraction in the case of aortic stenosis, while vena contracta, regurgitant volume, symptoms, left ventricular ejection fraction, left ventricular diastolic diameter, and left ventricular systolic diameter in the case of aortic regurgitation. The most appropriate timing for operative therapy can be challenging using these parameters, particularly in mixed pathological conditions such as aortic stenosis combined with aortic regurgitation. However, assessing EL allows the estimation of the cardiac workload with ease as a single parameter. Like EL, KE plays an important role in assessing left ventricular function , 34. In Recently, good outcomes of early surgery have been reported, suggesting that a surgical intervention should be performed before cardiac function deteriorates –38. PeriThe participants of the study were potentially different from the general population because they volunteered to participate in the study and had differing characteristics from those who did not volunteer. Indeed, the mean participants’ age was approximately 30 years, and 84% of the participants were male. The values of energetic parameters may have been affected by both age-related decrease in cardiac function and gender differences.The sample size of the present study was small for reference ranges that were calculated using 2.5% and 97.5% values. Although the present study is the first to report reference ranges for each energetic parameter using VFM, further studies are required.2 values than those in the study of children by Hayashi et al. [The regression equations of this study showed lower adjusted Ri et al. . This isAs an example of intraoperative energetic parameters calculation, we describe the case of an 80-year-old woman who underwent trans-catheter aortic valve replacement due to severe aortic valve stenosis. The procedure was performed under general anesthesia from a right femoral approach with the successful implantation of a 26-mm Sapien XT . We performed TTE in the operation room before and after the procedure. The transaortic valve flow maximum velocity was 4.8 m/s and the left ventricular wall motion before the procedure was diffuse hypokinesis. After the procedure, the transprosthetic valve flow maximum velocity was 2.3 m/s, and the left ventricular wall motion was normal. Before the procedure, ELcycle, KEcycle, and EPI were 9.5 mW/m, 63.9 mW/m, and 5.76, respectively. After the procedure, these changed to 40.7 mW/m, 458.3 mW/m, and 11.26, respectively. ELcycle increased after the procedure because the flow stagnation due to the stenotic aortic valve was released. However, KEcycle increased more than ELcycle, thus improving the energetic efficiency (EPI) (Fig. EL, KE, and EPI reference values were defined using VFM. These reference values enable the assessment of a range of cardiac conditions in any clinical situation. EPI is useful for assessing patients with various heart diseases and for evaluating the success of cardiac surgery. However, further investigation of EPI is required to validate its efficacy.


Papillary muscles (PMs) were reported to be origin of ventricular arrhythmia (VA). Radiofrequency (RF) ablation was reported to be acutely effective in eliminating VA. However, the recurrence rate is high. Recently, cryoablation guided by intracardiac echocardiography, 3-dimensional mapping system, and image integration was introduced as alternative strategy for this challenging ablation. We present a case of ventricular tachycardia originating from anterior PM of left ventricle treated by cryoablation guided only by intracardiac echocardiography. Papillary muscles (PMs) were reported to be origin of ventricular arrhythmia (VA). Radiofrequency (RF) ablation was reported to be acutely effective in eliminating VA . HoweverA 75-year-old woman was admitted because of wide complex tachycardia with right bundle branch block pattern and right inferior axis. She was treated with adenosine and verapamil with no effect. Sinus rhythm was achieved by DC shock. Transthoracic echocardiography revealed normal systolic function without wall motion abnormalities, moderate concentric hypertrophy, and severe aortic stenosis. Coronary angiography showed nonsignificant stenosis of left anterior descending artery.The patient underwent electrophysiological study. The procedure was performed under conscious sedation. Standard multielectrode catheters were placed in the His bundle region, coronary sinus, and RV apex through the right and left femoral veins. Ventricular tachycardia (VT) resembling the clinical tachycardia was easily induced by programmed electrical stimulation from the RV apex. The arrhythmia was nonsustained and became sustained after isoproterenol infusion. Spontaneous changes in QRS morphology were observed . 6 mm crCatheter ablation of PM VAs is challenging compared with the other VA in the LV . The comn = 19) patients, transthoracic and intracardiac echocardiography and left ventriculography revealed that the successful ablation sites were localized at the base of the PMs in the LV. Additional ablation targeting a relatively wide area around the first RF lesion was required to completely eliminate the VAs in all patients. Multiple QRS morphologies were seen spontaneously and after the ablation in 47% of patients. RF lesions on both sides of the PMs were required in these patients. During the follow-up, VAs recurred in 58% of patients.Yamada et al.  reportedRivera et al.  performeP = 0.08). Catheter stability was achieved in all patients treated with cryoenergy and only in 25% patients treated with RF (P = 0.001). Incidence of multiple VA morphologies was observed in 77.7% patients treated with RF, whereas none was observed in those treated with cryoenergy (P = 0.001). VA recurrence at 6 months' follow-up was 0% for cryoablation and 44% for RF (P = 0.03).In another study, Rivera et al.  comparedThe acute and long-term advantage of cryocatheter over RF catheter is stability during energy application. Keeping good contact of RF catheter with tissue during the whole period of RF application is very difficult because of contractility of both LV and PM. In addition, ablation of wide area on both sides of the PMs might be required to completely eliminate VA as changes in QRS morphology and a shift in the breakout site to the opposite side of the PM can occur spontaneously and after the ablation . During The uniqueness of our case is that cryoablation was guided by ICE without 3D mapping system or CT image integration. Cryocatheter can be integrated with the NavX system but not with the CARTO system. So we could not use 3D mapping system as we have only the CARTO system in our laboratory. Many centers have only 1 3D mapping system. In addition, ICE can help to localize the origin of arrhythmia, although differentiating ventricular arrhythmias originating from the papillary muscle and the fascicles is challenging and not always possible . It can In summary, cryoablation guided only by ICE of VA originating from papillary muscle is feasible and should be considered as alternative strategy in this challenging condition.


The multi-contrast assessment of the carotid artery wall has become an important diagnostic tool for the characterization of atherosclerotic plaque and vessel wall thickening. For providing the required T1-, T2-, and proton density weighted contrast, multi-slice turbo spin echo (TSE) techniques are normally applied. The straightforward extension of the TSE techniques to volumetric imaging of large sections of the carotid arteries is limited by the resulting long acquisition times. Where the acquisition of a T1-weighted contrast can be accelerated by applying a T1-weighted fast gradient echo technique, acceleration of the T2-weighted contrast is not as straightforward.In this work, the combination of a T2 preparation and a conventional fast gradient echo technique (T2P-3DGE) was evaluated for rapid acquisition of a T2-weighted image contrast. Acquisition parameters were optimized in an initial in vitro study in direct comparison to the conventional T2-weighted TSE (T2W-3DTSE) technique. Subsequently, the T2P-3DGE technique was evaluated in vivo.In direct comparison, the T2P-3DGE sequence provided similar T2 contrast as the respective T2W-3DTSE sequence. After correction of an observed intensity offset, most likely caused by the additional T1-weighting of the T2P-3DGE sequence, no significant difference between the two T2-weighted sequences were observed in phantom data. The good correlation of the image contrast between the two sequences was confirmed in the initial in-vivo study, proving a potential reduction of the scan time for T2P-3DGE to 25% of the respective T2W-3DTSE technique.The in vitro as well as the in vivo results clearly indicate the potential of the T2P-3DGE technique for providing similar T2 image contrast as in the conventional techniques. Thereby, the acquisition times could be substantially reduced to about 25% of the respective 3D-TSE technique. Stroke is one of the leading causes of morbidity and mortality worldwide. Atherosclerotic carotid artery narrowing is currently a relevant clinical risk factor for developing stroke . HoweverMost commonly, plaque imaging has been achieved by combining a double-inversion recovery black-blood preparation  with twoFor volume coverage, most studies so far have combined TSE imaging with multi-slice 2D acquisitions to measure the required volume-of-interest (VOI). A major limitation of these approaches results from their non-isotropic spatial resolution and the rather long acquisition times. The straight extension of the TSE techniques to three-dimensional (3D) coverage of large sections of the arteries of interest  has beenIt is the objective of this study to investigate the potential of T2-prepared three-dimensional spoiled gradient echo (T2P-3DGE) techniques for providing T2 contrast in reasonable acquisition time.TP being the T2P preparation time, and α the excitation flip angle. By choosing a sufficiently short TE, T2* effects can be almost neglected and the resulting signal is governed by the T2 decay of the tissue superimposed by some additional T1 relaxation.The application of a T2-preparation module (T2P) is well known from MRI coronary angiography for improving the contrast between blood and e.g. the myocardium , 22. AssA schematic diagram of the T2P-3DGE sequence is provided in Fig. −1 and maximum slew rate of 200 T m−1 s−1.All imaging was performed on a 3T whole-body system  equipped with a high-performance gradient system capable of a maximum gradient amplitude of 40 mT mP, the acquisition duration TGE (number of gradient echoes per shot times TR) and the excitation flip angle α. All data were acquired with an 8-element head coil. Coil sensitivity patterns and receiver gain settings were corrected before image analysis. The resulting image intensities of a certain T2P-3DGE parameter set were quantitatively compared to the T2W-3DTSE reference scan (Table For optimization of the T2-prepared fast gradient echo sequence (T2P-3DGE), an agarose gel phantom containing several insets with different concentrations of iron oxide particles was used. Depending on the iron concentration, the resulting T2 values ranged from roughly 18.9 to 96.3 ms as mapped by a conventional multi-spin echo technique with subsequent fitting of a mono-exponential T2 decay curve to the multi-echo data. The optimization of the acquisition parameters included shot interval ∆T , the preparation time TAfter optimization of the T2P-3DGE acquisition parameters, the proposed technique was evaluated in 10 patients , scheduled for a conventional MRI investigation of the carotid artery wall. The MR protocol was approved by the Ethic Committee of University Hospital of Ulm with signed written informed consent obtained from all patients before data acquisition.The comprehensive MRI investigation included a fast survey, followed by a coil sensitivity map for homogenization of the images and for parallel imaging reconstruction. An additional inflow angiogram was acquired for accurate planning. Vessel wall images were obtained by three-dimensional TSE (3DTSE) techniques with proton density (PDW-3DTSE), T1 (T1W-3DTSE), and T2 (T2W-3DTSE) image contrast and a fast three-dimensional gradient echo technique with (T2P-3DGE) and without (3DGE) T2 preparation. Black-blood image contrast was obtained by double inversion recovery (3D-TSE) or a driven-equilibrium motion-sensitized preparation . For T22 each.All data were acquired utilizing a dedicated two segment four-element carotid coil . Either segment comprises two independent coil elements with spatial extent of 65 × 50 mmCNR was calculated as S being the signal intensity and σ being the respective standard deviation. The outer and inner vessel areas were calculated according to manually drawn contours, and the vessel wall area calculated as the respective difference. All analyses were performed in a slice located in the ACC, identified manually 10 mm caudal to the bulbus.All patient data was transferred to a medical workstation . For SNR measurements, a region-of-interest (ROI) was manually placed in the vessel wall and the vessel lumen, and the SNR was calculated as the fraction of the mean signal intensity and the standard deviation of the respective ROI. The http://www.real-statistics.com).A nonparametric two-tailed Mann–Whitney U test was performed for assessment of the significance of the results. P values below 0.05 were considered significant. All statistical analyses were performed with the real statistics package for Excel  of the T2W-3DTSE and T2P-3DGE image intensities. However, an offset, most likely caused by the additional T1 weighting of the T2P-3DGE sequence, can be appreciated. Furthermore, a slight increase of the intensity differences can be observed for the T2P-3DGE approach [IT2W-TSE = 0.95 (IT2P-3DGE – IT2P-Offset)]. After correction for the offset no significant (p = 0.72) differences between the two approaches were observed.The in vitro study revealed that choosing the T2P-3DGE sequence parameters as: ∆T = 1000 ms, TThe imaging protocol could be completed in all patients. One patient had to be excluded due to severe motion artifacts in all images. Acquisition time per slice for the T2W-3DTSE technique resulted to 23 s. Respective acquisition time for the T2P-3DGE approach resulted to 5.4 s. To match signal to noise in both techniques, three signal averages were used in most patients for the T2P-3DGE approach yielding a realistic acquisition time per slice of 16.2 s. Navigator efficiency resulted higher than 95% in all cases and respective prolongation of the acquisition time could be neglected.Qualitative comparison of the 3DGE technique Fig. c with thFor the T2 prepared gradient echo technique, a significant (p < 0.05) increase in SNR for the vessel wall and lumen, and a clear trend (p < 0.06) to improved wall-lumen CNR were observed  is commonly used in coronary magnetic resonance angiography (MRA) to improve the CNR between blood (long T2) and myocardium (short T2), hence improving vessel conspicuity. Further application of T2P includes the rapid generation of images with multiple T2 weightings for T2 mapping of the myocardium. In this study, T2P was combined with rapid three-dimensional gradient echo imaging (T2P-3DGE) for providing T2 contrast in carotid artery wall imaging.CNR in the T2P-3DGE technique, which provides a better delineation of the vessel wall. Whether these contrast differences and slight differences in the vessel wall area will cause diagnostic consequences must be proven by further clinical evaluation.The study shows that by proper adjustment of the acquisition parameters, the T2P-3DGE provides similar contrast as the conventional T2-weighted turbo spin echo (T2W-3DTSE) technique. Differences result from the additional T1 weighting of the T2P-3DGE sequence, which cause signal enhancement especially from short T1 species like fat. A slight underestimation of the vessel wall area is observed. This may be attributed to the superior SNR and CNR in the T2P-3DGE techniques show the potential for further reduction of the measurement time. In combination with high field-strength or improved coil designs, the related increased SNR may even enable full utilization of the theoretical gain in acquisition speed. But even for the current setup, the application of the T2P-3DGE technique in combination with multiple signal averages appears promising for increasing the volume coverage by a factor of three without any prolongation of the overall acquisition time. Furthermore, when keeping the covered volume constant, the required signal averages can be applied for further reduction of motion artifacts caused by swallowing or pulsatile motion of the arteries.The main motivation of applying the T2P-3DGE sequence is the shortening of acquisition time in lengthy 3D acquisitions. In our case, the acquisition time per slice could theoretically be reduced to 25% without obvious changes in the resulting lesion contrast. However, due to the intrinsic lower SNR in T2P-3DGE, in our current setup three signal averages are required for ensuring sufficient SNR, whereas in the T2W-3DTSE a single signal average appears sufficient. Thus currently, the acquisition time gain is 25%, only. The currently superior The TSE-based as well as GE-based sequences tested here, have been optimized regarding providing sufficient SNR while maintaining scan times in reasonable limits. Potential further reduction of acquisition time may rise from using variable flip angle TSE approaches enabling longer echo trains and by exploiting parallel imaging techniques for T2P-3DGE.The T2-prepared gradient echo approach can be applied for providing similar T2-weighted contrast as known from the conventional T2W-TSE imaging technique in shorter image acquisition time. The impact of the slight contrast variations introduced by the intrinsic T1 weighting of the 3DGE sequence on the diagnostic accuracy has to be evaluated in further clinical studies.


High level of androgens found in congenital adrenal hyperplasia (CAH) seems to have a deleterious effect on heart function. We therefore evaluate cardiac function of children with CAH in comparison with a healthy group.We carried out a case-control study in the single endocrinology unit of the Mother and Child Center of Chantal Biya’s Foundation. Cases were matched for age and genotypic sex to 2 healthy controls. We analyzed the ejection fraction (LVEF), fractional shortening and left ventricular mass; output and cardiac index; E and A waves velocities, E/A ratio and the mitral deceleration time and diameter of the left atrium; tricuspid annular plane systolic excursion and pulmonary artery systolic pressure were also measured.We included 19 patients with a median age of 6.26 ± 3.75 years and 38 controls stackable distribution. The left ventricular mass of cases was greater than that of controls. A case of reversible cardiomyopathy on hormone replacement therapy was found.For the cases, the average ejection fraction was 71.95 ± 7.88%; the average fractional shortening was 40.67 ± 7.02%. All these values were higher than those of controls, although the difference was not statistically significant. Diastolic left ventricular function was more impaired among the cases.Right ventricular function was similar in both groups. These abnormalities were highly correlated to the late age at diagnosis and duration of treatment.This study shows an altered cardiac function in CAH compared to healthy control and highlights importance of an early diagnosis of cases, a tight control of androgens levels and a regular monitoring of cardiac function. Children with Congenital Adrenal Hyperplasia (CAH), are exposed to high levels of androgens  leading This was a matched case-control study, performed over a 9 months’ period (October 2015 to July 2016). We included all recorded children affected with CAH in the national registry and followed in the single service of pediatric endocrinology of the country: the Mother and Child Center of the Chantal Biya Foundation (MCC/CBF). Cases aged 10 months to 15 years were matched for age and genotypic sex to 2 healthy controls. We used paired and unbalanced sampling (1 case per 2 controls) to increase the potency of the results and to limit the bias related to the sample size. The controls were recruited in children coming for a routine visit or vaccination. We excluded controls with another chronic condition, a known cardiovascular disease or acute illness modifying cardiac function .After an informed consent obtained from parents and assent from children aged >12 years, diagnosis circumstances, morphology  and lab results  at diagnosis were noted. Height and weight were measured to the nearest 0.1 cm and 0.1 kg. Three blood pressures were measured and the mean noted for each case and control, with an electronic sphygmomanometer . The blood pressure was derived in percentile for height and genotypic sex. A general cardiac examination was done by a senior cardiologist.Thereafter, a standard echocardiography in time mode motion, two-dimensional and Doppler , 13 was For the left ventricle: ejection fraction, fractional shortening, stroke volume and left ventricular mass; cardiac output and index; the E and A waves velocities, the E/A wave ratio and the mitral deceleration time;For the right ventricle: tricuspid annular plane systolic excursion (TAPSE). The pulmonary artery systolic pressure was also measured.The variables analyzed were:2.7 (in meters) has been validated as an indicator of lean body mass and has been recommended for indexing LVM. Use of height2.7 to index LVM also minimizes the effect of age, gender and race [Heightand race –17. Stroand race .p value <0.05 was statistically significant.Statistical analyses were done using Microsoft® Excel 2013 and SPSS 20 software from IBM. Average and proportions served to describe quantitative and qualitative data. Comparison was done with the T test of Student  and a suitable non-parametric test Kruskall Wallis. Multivariate analysis was done to evaluate correlation between variables (Spearman). A The study received ethical approval from institutional board review of Faculty of medicine and biomedical sciences of Yaounde..We included 19 cases and 38 controls aged 10 months to 15 years with an average age of 6.26 ± 3.75 years. The most represented age was 4 years, with a proportion of 21% of cases. Among cases, 5 were boys and 14 girls. After the karyotype, only one was actually genotypically male (XY). As diagnosis circumstances, abnormal genitalia was the most represented (84.2%).The average age at diagnosis was 3.7 years (1 month to 12 years) , 78.9% of cases. Achondroplasia was found in 2 cases and one patient present with dilated cardiomyopathy diagnosed at 1 year of life, reversible on hormone replacement therapy (Table p = 0.025)  Figs.  and 2.Fi2 and 43.15 ± 10.83 ml/m2 in cases and controls, respectively. The average cardiac output of cases was 3.76 ± 1.54 L/min. Mean cardiac index was 4.40 ± 1.07 L/min/m2 for cases and 4.38 ± 0.94 L/min/m2 for controls. Although cases values were above controls, the differences were not statistically significant  was 71.95 ± 7.88%, VS 69.29 ± 7.95% in controls. The average fractional shortening (LVFS) was 40.67 ± 7.02% and 37.25 ± 5.64% for cases and controls respectively. In addition, mean stroke volume (SV) was 47.56 ± 13.58 ml/mDiastolic left ventricular function was more impaired among the cases. Thus, we found an average E wave velocity of 0.80 ± 0.32 m/s, lower than that of controls; an A wave velocity of 0.76 ± 0.35 m/s, higher than that of the controls, an average E/A ratio of 1.38 ± 0.96 less than the value of controls and a longer deceleration time, 147.58 ± 42.81(milliseconds) ms  of cases and controls. In contrast, pulmonary pressures were within normal values while significantly higher in controls. However, we noted a case of CAH with a systolic pulmonary arterial hypertension Table .Table 5C2.7. The end diastolic and systolic diameters of the left ventricle and the left atrium were almost identical in the two groups (Table The left ventricular mass index (LVMI) of cases was statistically greater than that of controls with an average value of 46.02 ± 17.14 g/mp = 0.00)  Table . The dur0) Table .Table 7COur study focused on the evaluation of cardiac function among Cameroonian children with congenital adrenal hyperplasia. The aim was to evaluate through standard echocardiography the most common settings for heart function and compared it to a group of healthy children matched for age and sex. With a sample of 57 children (1 case for 2 controls), we found an impaired diastolic function in cases compared to controls and increased values of systolic function in cases. Right cardiac function was similar in the 2 groups.This pilot study was monocentric but included all patients diagnosed and followed in the country. The lack of references curves of echocardiographic values in the literature for black children , 13 makeI.General characteristicsOur study population was younger than that of Sowande and al in Nigeria 2009 , in 30% Concerning diagnosis circumstances, the most frequent reason for consultation was abnormal genitalia (clitoris hypertrophy). Sowande and al in 2009 in Nigeria, in their retrospective study on disorders of sexual differentiation, had 6 cases attributed to the CAH and all had as a dominant clinical presentation, clitoromegaly [The average age at diagnosis was greater than that of Rodrigues and al (2 months) . AwareneOn initial clinical presentation, advanced bone age found in all the patients is related to the late age at diagnosis. Garcia and al in Brazil in 2013 , had advThe most found type of enzyme deficiency was 11β-OH in 78.9%, which is in contradiction to literature where the deficit in 21-OH (21 Hydroxylase) is recognized as the most common, with a prevalence more than 90% , 26. IndA child in our study had dilated cardiomyopathy diagnosed at 1 year and a clinical improvement was observed upon initial hormone replacement therapy. A similar case was described in Kuwait. Al Jarallah and al in 2004 , publishII.Blood pressure and Cardiac functionBlood pressure was higher in cases than controls, either systolic or diastolic. Various studies found similar results: Rodrigues and al  and SubbSystolic function of the left ventricleThe variables studied to assess left ventricular systolic function were all within normal values for average, but higher in cases than in controls. Although the differences were not statistically significant. The small differences in means between controls and patients could be potentially due to differences in body composition or fitness level. Metwalley and al in Egypt in 2015  studied LVEF expresses the degree of emptying of the left ventricle. It quantifies the capacity of it and arteries to maintain adequate cardiac output under changing load conditions and / or contractility . Its proDiastolic function of the left ventriclep < 0.001. In our study this difference was not statistically significant probably because our children were younger. This situation resulted from longer exposure to androgens whose stimulatory activity on the heart was seen with the rise of systolic settings, an abnormal relaxation of the most sought muscle [The E wave velocity and E / A ratio were higher in controls than in cases. In contrast the A wave velocity was higher in cases than in controls. There was no statistically significant difference. The cases deceleration time varied between 78 and 228 ms, which is higher than the controls. This reflects an impaired relaxation function of the left ventricle of cases compared to controls. Metwalley in Egypt, found similar results : an E / t muscle , 35.Right ventricular functionIn our study it was assessed mainly by systolic excursion of the plan of the tricuspid annulus. No differences were found between cases and controls for TAPSE. Systolic pulmonary pressure was statistically higher in cases than controls with a mean of 19.86 ± 3.44 mm. Alteration of right ventricular function is usually secondary to left heart failure. However, it can be isolated when it is due to certain lung diseases, right heart or pericardial diseases. Assessment of right ventricular function is, in terms of daily practice, extrapolated over the measures taken left . The echCardiac cavitiesThe left ventricle mass index of the cases was statistically higher than controls. This reflects left ventricular hypertrophy which could be explained by the recognized trophic effect of androgens on cardiomyocytes. All this leading also to an abnormal relaxation of the cardiac muscle , 37.Reasons for increase in cardiovascular risk of CAH patients are not totally elucidated. Could high levels of androgens have a vasoconstrictor effect? –31. MoreIII. Correlation between cardiac function parameters and disease determinantsp = 0.00. This could be due to a vasodilator effect at high doses of androgens established in some studies [A strong correlation was found between the diameter of the left atrium and age at diagnosis. A delayed age at diagnosis, lead to a prolonged exposure to high levels of androgens with their hypertrophic effect on the myocardium , 37. The studies .Through inhibition of depolarizing calcium influx, it has been established that in humans, their injection at physiological and supra physiological concentrations induces expansion (up to 4.5%) of the coronary artery and improves coronary flow (up 17.5%) in subjects with arteriosclerotic coronary lesions .A negative significant correlation would have been expected between the duration of the treatment and the cardiac mass, but it is not the case in our study. This highlights the importance of treatment compliance and patients being controlled, for better assessment of the relationship between treatment duration and cardiac mass.Nonetheless the present study brings relevant data among this particular population.This study showed that the cases had a greater systolic function than the controls, consequently increasing contractility. It also showed an increased left ventricular mass among cases leading to an altered relaxation of the left ventricle. These abnormalities were highly correlated to the late age at diagnosis and duration of treatment. This hence the necessity to introduce systematic neonatal screening for CAH to ensure early diagnosis and treatment, along with regular monitoring of heart function in children with CAH.