The purpose of this study was to evaluate the sex differences in myocardial structure, tissue characteristics, and myocardial function in type 2 diabetes mellitus (T2DM) patients.  A total of 62 T2DM patients and 40 controls were prospectively recruited for the study. All the participants were scanned using cardiovascular magnetic resonance (CMR) cine and underwent native and postcontrast T1 mapping to obtain left ventricular (LV) structure, function, and tissue characteristics. The differences between the control and T2DM patients were compared in males and females, respectively. p = 0.008) and thicker wall thickness  in females. For tissue characteristics, T2DM was associated with a similar T1 value, elevated extracellular volume fraction , and increased extracellular matrix volume index  in males. For myocardial function, in male, compared with control, T2DM was associated with decreased peak longitudinal diastolic strain rate .  For myocardial structure, T2DM was associated with a larger ratio of myocardial mass to end-diastolic volume (MVR, T2DM: 0.87 ± 0.20 vs. controls: 0.73 ± 0.14,  There might be sex differences in myocardial remodeling induced by T2DM, including LV structural concentric remodeling in female patients and extracellular matrix remodeling and subclinical diastolic dysfunction in male patients. Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases affecting health globally . T2DM paPrevious studies indicate that T2DM patients are associated with diffuse myocardial extracellular interstitial fibrosis , structuCardiovascular magnetic resonance (CMR) has been widely used to comprehensively evaluate tissue characteristics and the structure and function of the myocardium due to its advantages of high spatial resolution, good repeatability, a large field of vision, and multiparameter imaging. T1 mapping and the extracellular volume fraction (ECV) can be used to quantify the extracellular matrix of the myocardium . CMR cinTherefore, we used CMR techniques, including cine and T1 mapping, to evaluate sex differences in myocardial structure, tissue characteristics, and myocardial function in patients with T2DM vs. controls.2, and (3) other CMR contraindications. Controls were enrolled from the community with the following criteria: (1) no T2DM, (2) no hypertension, and (3) no history of cardiovascular disease or chest pain. In total, 62 T2DM patients and 40 controls were recruited for the study.This study was approved by the Ethics Committee of First Affiliated Hospital of Third Military Medical University , and all subjects given written informed consent. The study prospectively enrolled T2DM patients. The inclusion criteria were as follows: (1) an initial diagnosis of T2DM, according to World Health Organization criteria  and (2) As previously reported , the heiAs previously reported , CMR sca2; matrix, 179 × 256; TR/TE, 59.22/1.45 ms; and 25 reconstructed phases per cardiac cycle.An electrocardiogram-gated, breath-hold, balanced steady-state free-precession (bSSFP) sequence was used to obtain four-chamber long-axis cine images and short-axis cine images covering the entire LV, and the parameters were as follows: slice thickness, 6 mm; gap, 1.5 mm; field of view, 325 × 400 mm2; matrix, 256 × 166; TR/TE, 301.7/1.09 ms; flip angle, 35 degrees; and 6 mm thickness. Midventricular short-axis images were acquired before and approximately 15 min after the administration of 0.2 mmol/kg gadoteric acid meglumine  with a 5(3)3 and 4(1)3(1)2 sampling pattern for native and postcontrast T1 mapping, respectively. T1 maps were generated inline from the MOLLI images with motion correction (MOCO).An electrocardiogram-gated, breath-hold, MOdified Look-Locker Inversion recovery (MOLLI) prototype sequence was performed with the following parameters: a bSSFP readout; field of view, 400 × 300 mmAll the cine and T1 map images were analyzed offline using the cvi42 software . Endo- and epicardial contours on the cine images were manually traced to obtain the LV end-diastolic volume index (EDVi), end-systolic volume index (ESVi), stroke volume index (SVi), ejection fraction (EF), cardiac index (CI), myocardial mass index (MMi) with papillary muscle included in the LV lumen, and the ratio of MMi to EDVi (MVR). The wall thickness (WT) on the LV middle short-axis interventricular septum was measured. Two-dimensional feature tracking was performed on four-chamber long-axis cine images and midventricular short-axis cine images to obtain global longitudinal, circumferential, and radial strain and the peak systolic and diastolic strain rates.As previously reported , an ROI p < 0.05.The data were analyzed using SPSS  and GraphPad Prism software . The Kolmogorov–Smirnov test was used to test the normality of the variables. For continuous and normal variables, differences between the means were compared using one-way ANOVA and least significant difference (LSD) test was performed to evaluate post hoc comparisons. The intra- and interobserver variabilities of CMR indices were analyzed by determining the intraclass correlation coefficient (ICC) and mean difference. Statistical tests were two-tailed, and statistical significance was defined as The demographic and biochemical data are presented in p < 0.001) and smaller MVR  and larger ECV , larger circumferential strain , larger radial diastolic strain rate .For myocardial structure, female controls had thinner WT , similar MMi, larger MVR , and thicker WT  in females. In males, there were no significant differences in any of these indices between T2DM patients and controls , and increased ECMVi   .p = 0.030)  .In this study, we found that there was LV structural concentric remodeling in female T2DM patients and extracellular matrix remodeling and subclinical diastolic dysfunction in male T2DM patients.There was no change seen in MMi, but decreased EDVi, increased MVR, and thicker WT were noted in patients with T2DM, indicating LV concentric remodeling, which is consistent with previous studies , 11. LV Previous studies have shown myocardial extracellular matrix remodeling in patients with T2DM , 16. ThiThis study showed that there are sex differences in the above LV structure, tissue characteristics, and functional changes, including LV concentric remodeling in female T2DM patients and, in contrast, extracellular matrix remodeling and subclinical diastolic dysfunction in male T2DM patients. Previous studies have focused on the effects of sex differences on different myocardial remodeling patterns, including aortic stenosis  and tranThe results of the present study provide some reference information for different types of myocardial remodeling and the corresponding treatment strategies in different sex patients with T2DM. Previous studies , 22 have2, and the patients in the study received different treatments. Third, this study was a cross-sectional one, so there was no follow-up analysis of the above changes in patients with T2DM.Our study had several limitations. First, the overall number of subjects was relatively small. Second, we did not recruit patients with a GFR ≤ 30 mL/min/1.7 mIn conclusion, there might be sex differences in myocardial remodeling induced by T2DM, including LV structural concentric remodeling in female patients and extracellular matrix remodeling and subclinical diastolic dysfunction in male patients.


Acute myocardial infarction complicated by cardiogenic shock (AMICS), is characterized by critically low cardiac output and decreased myocardial contractility. In this situation, a treatment that unloads the myocardium and restores CO without increasing the myocardial oxygen demand is theoretically appealing. Axial flow pumps offer hemodynamic support without increasing myocardial oxygen consumption. Consequently, the use of axial flow pumps, especially the Impella devices, is increasing. It is likely that the SCAI C patient with predominantly left ventricular failure and without prolonged cardiac arrest is the best candidate for these devices. Registry data suggest that pre-PCI Impella may be advantageous to post-PCI placement. However, several gaps in knowledge exist regarding optimal patient selection, futility criteria, timing, weaning and escalation strategy, and until data from adequately sized randomized trials are available, immediate individual evaluation for mechanical circulatory support by a shock team is warranted when a patient is diagnosed with AMICS. Acute myocardial infarction (AMI), complicated by cardiogenic shock (AMICS), occurs in 5–10% of AMI cases. Even with immediate revascularization, pharmacological, and in selected cases, mechanical circulatory support, mortality often approaches 50% . ClassicImpella  is by far, the most frequently used transvalvular flow device, with options for mechanical circulatory support both for the left and right ventricle. Left-sided devices include the Impella 2.5 and CP with 13 or 14F percutaneous arterial access, and the Impella 5.0 and 5.5 devices that need surgical access. The Impella RP is a right-sided device that uses a percutaneous 22F venous access. These devices generate continuous flow. In AMICS, the Impella CP is often preferred in the acute setting, thus providing a continuous flow of up to 3.8 L/min [After coronary artery occlusion, contractility will decrease and eventually cease in the affected myocardial territory unless there are adequate collaterals. Even with the restoration of coronary flow, the recovery of contractility often takes several hours and continues to improve over days . TransvaCareful patient selection is a key factor in achieving acceptable outcomes in patients treated with axial flow pumps or other MCS systems. These complex invasive treatments are costly and with potentially serious complications. Thus, rigorous patient selection criteria are pivotal. AMICS is a heterogeneous condition that may be seen in ST-segment elevation AMIs as well as non-ST-segment elevation AMIs, and frequently, it is preceded by cardiac arrest . AlthougAMICS is also a spectrum of severity of disease that recently has been categorized into five classes by the Society for Cardiovascular Angiography and Interventions (SCAI) . SCAI clAbout 40% of AMICS patients will present with out-of-hospital cardiac arrest (OHCA) ,10. DespSome patients with AMICS will die regardless of MCS and immediate revascularization, and several risk models have been proposed for patients with cardiogenic shock, however, with moderate accuracy ,15. MostIn experimental studies, the placement of Impella during coronary occlusion, even when prolonging the ischemia time, has been demonstrated to lower wall stress and reduce myocardial oxygen consumption, leading to a reduction in the infarct size compared with immediate revascularization ,8. Regisn = 237) retrospective study with a propensity-matched comparison of patients fulfilling IABP-Shock 2 inclusion criteria but treated on a clinical basis with Impella 2.5 or CP vs patients from the IABP-Shock 2 trial [The evidence for the use of an axial flow pump in AMICS is low and based on two small randomized studies, conflicting retrospective case series and registry studies. The efficacy study of the LV Assist Device to Treat Patients With Cardiogenic Shock (ISAR-SHOCK) study was a feasibility study on 25 patients comparing the Impella 2.5 with the intra-aortic balloon pump (IABP) . ISAR-SH 2 trial . Impella 2 trial . Further 2 trial . As ther 2 trial  in a popThus, there is currently no strong evidence to support the routine use of axial flow pumps in AMICS, and further evidence should be gained from adequately powered randomized trials. The Danish-German Cardiogenic Shock study (DanGer shock) is an ongoing trial randomizing ST-segment elevation AMI CS patients not presenting with OHCA and mandatory lactate >2.5 mmol/L . The stuAfter placement of Impella CP in AMICS and revascularization, patients should be monitored for signs of inadequate circulatory support until recovery of native heart function. Escalation is usually done using more powerful Impella devices, such as Impella 5.0 and 5.5, a combination of Impella and VA-ECMO (ECMELLA), or in selected cases, Impella RP and CP in combination (BIPELLA), as shown in The possibility of weaning from the axial flow device in AMICS should be evaluated daily already from 24–48 h after imitating support. The evidence for the timing and the mode of weaning from an MCS device is very limited. In general, the patient must be stable with a pulsatile arterial waveform, on low-dose vasopressors, and with no or minimal inotropic support. Weaning should be guided by hemodynamic monitoring with a pulmonary artery catheter . There aThe use of axial flow pumps in critically ill patients is associated with access site complications and complications related to the flow pump, that even with careful access site management and continuing assessment of placement cannot be avoided. The most frequent access site-related complication is bleeding complications, where the registry-based study by Dhruva et al. reported a 31% rate of major bleeding according to the Chest Pain-MI Registry. Of these, 11% were reported as access site bleeding, which was significantly higher than in the IABP-treated patients (3% access site-related) . In the In a recent post hoc analysis, it has been demonstrated that a significant drop in hemoglobin in patients with acute coronary syndrome without overt bleeding was associated with mortality . Less thUnlike VA-ECMO, distal arterial protection is not readily feasible with Impella support and thus patients with existing peripheral arterial disease are at risk of limb ischemia. The reported risk of limb ischemia varies between 4% in NCSI and 12.6% in the IMP-IT registry ,34. Hemolysis is usually seen during the early course of management and is apparent as a rise in plasma-free hemoglobin, and in severe cases, a drop in hemoglobin. The risk of hemolysis increases dramatically with malposition of the devices and LV suction events. The presence of hemolysis should always prompt a reduction in P-levels until the problem is resolved, and should prompt immediate imaging to optimize the placement, and evaluate RV function, and volume status.In a situation such as AMICS associated with critically low cardiac output, decreased myocardial contractility and increased wall stress, a treatment that unloads the myocardium and restores CO without increasing myocardial oxygen demand is theoretically appealing. Likely, the SCAI C patient with predominantly LV failure without prolonged cardiac arrest is the best candidate for axial flow pumps. Registry data suggest that pre-PCI Impella may be advantageous to post-PCI placement. However, several gaps in knowledge exist regarding optimal patient selection, futility criteria, timing, weaning, and escalation strategy, and until data from adequately sized randomized trials are available, immediate individual evaluation for MCS by a shock team is warranted when a patient is diagnosed with AMICS; see


Left atrial enlargement (LAE) predispose to arrhythmias, atrial thrombogenesis and cardioembolic stroke. Whether LAE constitute a major risk among African hypertensive subjects is not well described. This study was aimed to describe the epidemiologic pattern of LAE among hypertensive subjects and determine their correlates.Clinical and demographic details of 414 hypertensive subjects used were taken. Echocardiography was done. LAE was defined as Left atrial dimension (LAD)>3.7 cm. Statistical analysis was done using SPSS 17.0.414 subjects including 258 (62.3%) males were recruited. The mean age was 56.8±16.8 years. LAE was present in 57.73% of hypertensive subjects. Those with LAE were likely to be older , had a higher waist circumference , left ventricular mass index  and a higher frequency of left ventricular hypertrophy (LVH)  respectively than those without LAE. LAD was significantly higher among those with LVH than those without LVH .LAE is common among Nigerian hypertensive subjects. Age, waist circumference, left ventricular wall dimension and mass index are the important correlates of LAE in hypertensive Nigerians. The left atrium is a conduit between the four pulmonary veins and the left ventricle allowing passive inflow of blood to the left ventricle (LV) during early diastole. The atrial systole accounts for about 20–30% of the LV inflow occurring in late diastole.This was a retrospective review of echocardiography done at the LadokeAkintola University of Technology Teaching Hospitals, Osogbo&Ogbomoso and Goshen Heart Clinic, Osogbo, all in South West Nigeria. Echocardiography was done as part of the cardiovascular risk assessment of hypertensive subjects. Echocardiography was done according to standardized protocols as recommended by the American Society of Echocardiography. Four hundred and fourteen consecutive hypertensive subjects who had echocardiography done and with complete data were recruited. The left ventricular mass index was calculated as3 +0.6 13LVM= 0.81 1.04  3 - Left atrial dimension was obtained in the M-mode derived echogram in the left parasternal long axis. The maximal left atrial dimension in diastole was taken. An average of three measurements was taken as the mean left atrial dimension. Adebiyi et al. from Ibadan suggested echocardiographic reference in normotensive Nigerians and also noted that sex specific definition of cardiac dimension may not apply to Nigerians.14LVM index (LVMI) was calculated as LVM/height in meters2.7. Correcting LVM for height 2.7 minimizes the effect of sex, race, age, and obesity on the validity of various parameters for the diagnosis of left ventricular hypertrophy.18Left ventricular ejection fraction (EF) was calculated using Teicholz's Formula.Data were summarized using means± standard deviation for quantitative variables and frequencies and percentages for quantitative variables. Comparism was done using students' t test and Chi square as appropriate when data was of normal distribution. Statistical analysis was done using the Statistical Package for Social Sciences (SPSS) 16.0. p<0.05 was taken as statistically significant. Institutional Ethical approval was obtained.The clinical characteristics of the study participants are shown in The clinical and echocardiographic parameters are shown in The association between left ventricular hypertrophy and LAE was studied. The clinical, demographic and echocardiographic characteristics between hypertensive subjects with LVH and those with normal left ventricular mass/index is shown in This study shows that left atrial enlargement is fairly common among treated hypertensive subjects in Nigeria. It also shows that left atrial abnormalities in treated hypertensive subjects are closely related to many clinical and echocardiographic variables. Left atrial enlargement is associated with increasing age and waist circumference in the present study. These are known conventional cardiovascular risk factors with potential for a geometric increase in cardiovascular risk when present. Echocardiographic variables associated with increased left atrial dimension in this study were left ventricular posterior and interventricular septal wall thickness, left ventricular mass and left ventricular mass index.Evidence suggests that increasing left atrial dimension is associated with higher cardiovascular risk.Left atrial dimension has also been shown to predict the all cause and cardiovascular mortality in the general population.23In this study, the mean left ventricular mass/index and the frequency of left ventricular hypertrophy were significantly higher among hypertensive subjects with left atrial enlargement than those without LAE. The wall dimensions and the other left ventricular parameters which are the major determinants of left ventricular diastolic function were significantly more associated with LAE in this study. This was even recently shown in a group of offspring of hypertensive subjects aged 15–25 years in Ilorin, Nigeria.Adebiyi et al. in Ibadan in Nigeria showed that the prevalence of LAE in a group of hypertensive subjects was 15.8% using a sex specific classification of LAD>4.2 cm in men or LAD>3.8 in women. They also showed that left atrial size in Nigerian hypertensive subjects is influenced by age, sex, left ventricular mass and left ventricular mass index.26The prevalence of LAE in this study is also significantly higher among studies from Caucasians. Cuspidi et al. reported a prevalence of 24.5% in women and 21.5% in men using sex specific definitions for LAE.LAE is associated with increased prevalence of atrial fibrillation, stroke and cardiovascular mortality.27This study shows that using the traditional definition for LAE obtainable from local population, left atrial enlargement is very common among hypertensive subjects in our environment and it is well related to left ventricular hypertrophy, waist circumference, age and left ventricular wall dimensions. Early identification may allow introduction of management options to reduce the prevalence among hypertensive Nigerian subjects. Further studies warranted to determine the clinical profile and consequence of left atrial enlargement among hypertensive Nigerians and to determine their clinical and pathologic significance.


In remote territories, there was a lower increment in subendocardial circumferential strain in the CRIC group than in controls . In summary, CRIC following P-PCI for STEMI is associated with improved longitudinal strain in infarct-related segments, and an attenuated increase in circumferential strain in remote segments. Further work is needed to establish whether these changes may translate into a reduced incidence of adverse remodelling and clinical events. Clinical Trial Registration: http://clinicaltrials.gov/show/NCT01664611.Late, repetitive or chronic remote ischaemic conditioning (CRIC) is a potential cardioprotective strategy against adverse remodelling following ST-segment elevation myocardial infarction (STEMI). In the randomised Daily Remote Ischaemic Conditioning Following Acute Myocardial Infarction (DREAM) trial, CRIC following primary percutaneous coronary intervention (P-PCI) did not improve global left ventricular (LV) systolic function. A post-hoc analysis was performed to determine whether CRIC improved regional strain. All 73 patients completing the original trial were studied . Patients underwent cardiovascular magnetic resonance at baseline (5–7 days post-STEMI) and after 4 months, with assessment of LV systolic function, infarct size and strain . At both timepoints, there were no significant between-group differences in global indices . However, regional analysis revealed a significant improvement in longitudinal strain in the infarcted segments of the CRIC group  but not in corresponding segments of the control group (from − 15.5 ± 4.0 to − 15.2 ± 4.7, p = 0.81; for change: − 2.5 ± 3.6 versus + 0.3 ± 5.6, respectively,  The decline in mortality following ST-segment elevation myocardial infarction (STEMI) is mirrored by an increasing number of survivors with residual heart failure, a condition whose prognosis has not improved significantly in the last two decades , 57. Then = 5401), RIC failed to reduce infarct size or improve 12 month clinical outcomes  ; in the control group, the sham device employed the same cycle durations with inflation to 10 mmHg. In both groups during inflation, the device made identical vibrating noises, and participants were not told of the level of inflation required to deliver active treatment and whether they were in the control group. Participants were instructed to apply the device at the same time of day and on the same arm. Participants were asked to keep a diary of use of the device and were removed from the trial if they returned an incomplete diary sheet, missed more than three treatment sessions or missed more than two consecutive days of treatments. Written informed consent was obtained from each patient prior to enrolment. The study was approved by the regional ethics committee (12/EM/0304) and registered with clinicaltrials.gov (NCT01664611). It was conducted according to the principles of Good Clinical Practice and according to the Declaration of Helsinki, under the oversight of the University of Leicester.Our study was based on a non-specified post-hoc analysis of 73 STEMI patients recruited in the multicentre, prospective randomised Daily Remote Ischaemic Conditioning Following Acute Myocardial Infarction (DREAM) trial, assessing the impact of CRIC on LV systolic function. Trial design and methodology are as previously reported . All subFollowing their index presentation with STEMI, participants underwent CMR imaging at 5–7 days (baseline) and at 4 months  ) nor improved the primary clinical endpoint  [n = 516), there was no reduction in infarct size with adjunctive RIC (based on 48 h troponin release) but the primary composite outcome of cardiac death and heart failure hospitalisation was significantly reduced  [n = 122) showed no reduction in infarct size but at 1 year, adverse remodelling was reduced, especially in those with microvascular obstruction [n = 696), combined RIC and postconditioning resulted in greater myocardial salvage than conventional PPCI alone, and with extended follow up (median 3.6 years), a reduction in cardiac death, reinfarction and new congestive cardiac failure  [p-0.41), and other postconditioning studies have also reported neutral outcomes [In the CONDI-2/ERIC-PPCI trial, remote ischaemic perconditioning neither reduced infarct size (as assessed by 48-h troponin release or by CMR [ months) , 18. How1 years) . Other struction . In the  = 0.04) . Howeveroutcomes . Nonethen = 200) and i-RIC (n = 4700) trials will incorporate CRIC following STEMI  [To our knowledge, ours is the only trial to evaluate CRIC post-STEMI: to date, no other clinical trial has evaluated late, repetitive RIC post-STEMI, though the CORIC-MI (tioning) , 63. Howtioning) . Importationing) , 62. Pretioning) . Our datNonetheless, if CRIC is beneficial, why was there no observed effect on LVEF or other volumetric indices of remodelling? Global volumetric indices integrate the function of infarcted and remote regions, and hence may be insensitive to regional dysfunction, particularly if compensatory mechanisms subsequently normalise global performance. Furthermore, gross volumetric change may only occur late in the remodelling process, in a maladaptive state beyond the point of no return. By contrast, strain imaging may prove more sensitive, identifying subtle, early and potentially reversible regional derangements in those at risk of at risk of adverse remodelling . ImpairmStrain analysis may also provide pathophysiological insights into STEMI-induced remodelling. The myocardium comprises a complex spatial orientation of fibres, with subendocardial fibres orientated in a right-handed helix and subepicardial fibres, in a left-handed helix, with mid-myocardial fibres arranged circumferentially , 49. ThiOur data show increased circumferential strain in remote as well as in infarcted segments. Studies using CMR diffusion tensor imaging have shown reorientation of fibres in remote myocardium post-MI , 58, 59.This study has several limitations. As CRIC was self-administered in participants’ homes, it was not possible to objectively verify correct application of the device and achievement of a satisfactory postconditioning stimulus. The present work was a non-prespecified post-hoc analysis and a small number of participants were involved: hence, the results should be interpreted with caution. The study was not powered to determine potential improvements in adverse remodelling, as defined by global parameters. However, as a proof-of-concept study it serves the purpose of hypothesis generation. Whether the observed changes in regional strain translate into a reduction in adverse remodelling and altered clinical outcome warrants exploration in larger-scale prospective studies. Our data do not elucidate the mechanisms underlying observed changes in strain, albeit demonstrating that these do not involve infarct size reduction or changes in haemodynamic parameters.Our analysis suggests that the beneficial effects of RIC may involve mechanisms distinct from infarct size limitation. This warrants further investigation in prospective studies as well as in analyses of imaging datasets acquired from previously studied RIC cohorts. Further study is required to determine whether a multi-target approach combining CRIC with ischaemic perconditioning interventions may afford a more effective, synergistic cardioprotective strategy.


A 12-lead electrocardiogram (ECG) and Holter ECG have been established as gold standards for detection of arrhythmias. Recently, wearable ECG monitoring devices have been available. Our purpose of the present study was to investigate whether a novel wearable electrode embedded in an undershirt is useful for ECG monitoring and detection of arrhythmias.We studied 31 consecutive hospitalized patients who underwent catheter ablation of tachyarrhythmias. Patients equipped a wearable electrode and a lead CM5 of Holter ECG simultaneously, and total heart beats, maximum heart rate (HR), mean HR, minimum HR, detections of arrhythmias, such as atrial fibrillation, non-sustained ventricular tachycardia, and premature ventricular contractions (Lown’s grade >II), were compared between the two methods using a Holter ECG analysis software.Median recording time of ECG by wearable electrodes was 12.6 hours. Strong correlations between the two methods were observed in total heart beats , maximum HR , mean HR , minimum HR  and QRS duration . Bland-Altman analysis showed excellent concordance between each parameter measured by two methods. In addition, the detection of atrial fibrillation (nine events), non-sustained ventricular tachycardia (two events), and premature ventricular contractions of Lown’s grade >II (five events) were concordant in two methods. In addition, there were no significant difference in parameters of time-domain and frequency-domain analyses of heart rate variability between the two methods.The usefulness of a novel electrode embedded in an undershirt is equivalent to that of a Holter ECG in monitoring the ECG and detection of arrythmias. A 12-The present study prospectively enrolled 31 patients who were hospitalized for catheter ablation of tachyarrhythmias at Fukushima Medical University Hospital between October 2020 and December 2020. The baseline characteristics of the patients are listed in ®, Mitsufuji Corp., Tokyo, A wearable single lead electrode embedded in an undershirt  simultaneously for comparison of ability for ECG monitoring and detection of arrhythmias . ECG wasTotal heart beats, maximum heart rate (HR), mean HR, minimum HR, QRS duration, QTc interval corrected by Bazett’s formula, detections of arrhythmias, such as atrial fibrillation, non-sustained ventricular tachycardia, and premature ventricular contractions (Lown’s grade >II) were compared between wearable electrodes and the lead CM5 of Holter ECG, using the same Holter ECG analysis software by experienced clinical technologists who were blind to the clinical data. In addition, the time-domain analysis  and frequency-domain analysis including low-frequency power , high-frequency power  and LF to HF ratio of heart rate variability were compared between the two methods. For heart rate variability analyses, patients with atrial fibrillation and/or premature cardiac complex above 1000 per total recording time were excluded. The results of the ECG analysis were interpreted by independent cardiologists.t-test. Non-normally distributed data were reported as median and interquartile range, and were compared with a Mann-Whitney U test. Differences in total heart beats, maximum HR, mean HR, minimum HR, QRS duration and QTc interval between wearable electrodes and Holter ECG were assessed with linear regression analysis and Bland-Altman analysis. The frequency-domain of heart rate variability was analyzed with two-way repeated measures analysis of variance, and the Huynh-Feldt ε correction was used to evaluate F ratios for repeated measures involving more than one degree of freedom. A value of P <0.05 was considered statistically significant. Statistical analyses were performed with the statistical software SPSS 28.0 .Normally distributed data were presented as mean ± standard deviation (SD), and were compared with a Student’s We could acquire ECG from all of study subjects without recording failure. As shown in 11, 286 = 0.430, P = 0.869, ε = 0.586), HF power  and LF to HF ratio .Of 31 patients, 17 patients with atrial fibrillation and/or premature cardiac complex above 1000 per total recording time were excluded. In 14 patients, the time-domain analysis during the hole recording time  showed tIn the present study, we verified the abilities of a novel wearable electrode embedded in an undershirt: measuring ECG parameters, detection of arrhythmias and assessments of heart rate variability. As a result, this promising wearable device demonstrated similar ability compared to Holter ECG. These results imply clinical utility of the device.Recently, early detection of arrhythmias is required for its therapy and prevention of complications ,2,13. ThIt is also important for wearable devices to be easy to use without any expertise skills . This noWe could verify the utility of a novel wearable electrode embedded in an undershirt for ECG monitoring and detection of arrhythmias, and this wearable device may be preferable for long-term use because of its user-friendly characteristics. Further studies may be required to evaluate the ability of the device to detect arrhythmias during a long-term period.First, the current study was performed in a single center, and the numbers of study population and events were relatively small. Second, wearable electrodes only have single lead and we selected only lead CM5 of Holter ECG to compare with, therefore, we could not fully assess the differences in abilities to record ECG between wearable electrodes and Holter ECG with all leads. Wearable electrodes and lead CM5 of Holter ECG are resembles to lead I and V5 of 12-lead ECG respectively. The difference in lead may led to lower T wave of wearable electrodes and longer QTc interval  in wearaA novel wearable electrode embedded in an undershirt demonstrated abilities comparable to those of Holter ECG for ECG monitoring and detection of arrhythmias. This wearable device possibly provides clinical utilities for long-term ECG monitoring and detection of arrhythmias.S1 Data(XLSX)Click here for additional data file.


Since transcatheter edge-to-edge repair (TEER) has become a valuable therapy in the treatment of both, mitral (MR) and tricuspid regurgitation (TR), the question of optimized patient selection has gained growing importance. After years of attributing rather little attention to the right ventricle (RV) and its function in the setting of valvular heart failure, this neglect has recently changed. The present review sought to summarize anatomy and function of the RV in a clinical context and aimed at presenting the current knowledge on how the RV influences outcomes after TEER for atrioventricular regurgitation. The anatomy of the RV is determined by its unique shape, which necessitates to use three-dimensional imaging methods for detailed and comprehensive characterization. Complex parameters such as RV to pulmonary artery coupling (RVPAc) have been developed to combine information of RV function and afterload which is primary determined by the pulmonary vasculature and LV filling pressure. Beyond that, TR, which is closely related to RV function also plays an important role in the setting of TEER. While mitral valve transcatheter edge-to-edge repair (M-TEER) leads to reduction of concomitant TR in some patients, the prognostic value of TR in the setting of M-TEER remains unclear. Overall, this review summarizes the current state of knowledge of the outstanding role of RV function and associated TR in the setting of TEER and outlines the unsolved questions associated with right-sided heart failure. The clinical importance of transcatheter mitral and tricuspid valve repair has steadily increased within the past two decades. Despite a growing number of transcatheter techniques, edge-to-edge valve repair (TEER) remains the most commonly used clinical procedure until today and has been proven to improve prognosis in case of mitral regurgitation (MR) , 2. The While the beneficial effect of mitral valve transcatheter edge-to-edge repair (M-TEER) has been proven in randomized controlled trials , 6, studHistorically, both the right ventricle (RV) and the tricuspid valve, often referred to as the “forgotten valve” have received less scientific attention than the left ventricle (LV). This could be partly explained by high procedural/perioperative and short-term mortality rates for right heart surgical procedures in this high-risk population. Another reason was the lack of comprehensive three-dimensional imaging models that could reflect the complex and irregular anatomy of the RV . As thisThe aim of this review was to provide a comprehensive overview about (1) RV anatomy, (2) RV function, and (3) the role of RV geometry and function in the context of mitral and tricuspid TEER.The RV is the most anteriorly located chamber of the human heart . Its shaThe TV separates the right atrium (RA) from the RV and consists of leaflets , the annulus, papillary muscles, and chordae tendineae , 17. ConTo describe RV function and its contraction patterns, it is crucial to understand the RVs myoarchitecture. The muscular wall of the RV is arranged in two layers. The outer  layer of cardiomyocytes is arranged circumferentially to the TV annulus. Toward the RV apex, the fibers turn slightly oblique and continue into the superficial layer of the LV myocardium . The deeThe overall systolic function of the RV is a complex interplay of preload (systemic venous return), contractility, and afterload (pulmonary pressure). Due to the large surface compared to the RV volume and a relatively thin wall, according to Laplace’s law, the RV can adopt to a broad spectrum of preload alterations but struggles with rapid changes in afterload . Rapid cThe TV annulus shows a unique saddle-shaped anatomic configuration with the most atrial located point in the antero-posterior direction and the most ventricular located point in the medio-lateral direction . It is aSince echocardiographic assessment of right ventricular function is challenging, routine RV function parameters  are subject to a variety of limitations. TAPSE is usually measured using the M-mode in an apical four chamber view and represents the longitudinal shortening of the tricuspid annulus and hence RV in one plane. Even though longitudinal contraction significantly contributes to the overall RV function, it does not consider shortening in the other two dimensions . FurtherRecently, a parameter called RV to pulmonary artery coupling (RVPAc) was introduced to quantify the close interdependency of the RV and its afterload , 28. UndEchocardiographically, RVPAc can be quantified as a ratio of, in principle, any RV functional parameter  and pulmonary artery pressure (PAP). In 2021, a large European multicentric registry of patients who underwent M-TEER for severe SMR found RVPA uncoupling as defined by a TAPSE/sPAP ratio <0.274 mm/mmHg to be associated with significantly impaired 2-year survival rates . A subanIn patients with severe MR, RVPA uncoupling, and thus biventricular failure is most likely the consequence of long standing regurgitant blood flow across the MV in systole and development of secondary pulmonary hypertension. In patients undergoing T-TEER for severe TR, RVPA uncoupling may occur if the etiology of TR is secondary to any kind of left sided disease.Recently, a large observational study identified RVPA uncoupling defined as TAPSE/sPAP ratio <0.406 mm/mmHg as independent predictor for 1-year all-cause mortality after T-TEER for severe TR . sPAP isRight ventricular contraction is a complex process in both spatial and temporal dimensions. Using up-to-date imaging protocols in echocardiography and cardiac magnetic resonance (CMR) have resolved the technical challenges in visualizing and adequately measuring RV function. These methods have provided important insights into the role of the RV for atrioventricular regurgitation.A recent study focused on the prognostic impact of RV contraction patterns in the setting of T-TEER for severe TR using CMR imaging . The autWithin the past few years, three-dimensional echocardiography (3DE) has emerged as state-of-the-art imaging technique, as it is better suited to the geometric and functional complexity of the RV than biplane methods  38). A . A 38). As recent data show, T-TEER treatment not only leads to a significant reduction in TR, but was also associated with RV reverse remodeling (RVRR) . RV dimeA crucial point in treatment planning and device selection in high-grade TR is the anatomy of the TV, which is often challenging due to the high variability. In 2021 Hahn et al. presented a systematic classification of different TV morphologies . In thisIn an additional study, the authors investigated the influence of this classification on outcome after T-TEER . They obDevelopment of pulmonary hypertension and right ventricular dysfunction (RVD) in patients undergoing M-TEER might be associated with concomitant TR. Recent studies focused on the change in TR severity after M-TEER by hemodynamic pulmonary circulatory relief after MR reduction. Successful M-TEER was associated with modest reduction in TR severity as early as 1 month after procedure , 47. NevFurthermore, it is controversial whether moderate or advanced TR has independent prognostic importance in patients undergoing M-TEER for severe MR. A subanalysis of the COAPT trial sought to assess on outcomes in patients with HF and severe secondary MR in both the treatment and control-group. Of note per protocol, patients with TR requiring surgery or transcatheter treatment were excluded. Overall, 15.4% presented with moderate and, 0.8% with moderate-to-severe and 0.2% with severe TR. Interestingly, TR ≥ 2+ was a significant independent predictor for the combined endpoint  in the GDMT, but not in the M-TEER group . Of noteThe “renaissance” of the RV and TV in cardiovascular medicine and research has clearly a significant impact on the dynamic field of transcatheter edge-to-edge repair. For both mitral and tricuspid valve repair, the RV is gaining importance in clinical decision making due to its eminent pathophysiologic and therefore prognostic role.The interplay of RV, MV, and TV and their respective extravalvular structures needs a detailed preprocedural multimodal imaging evaluation for treatment planning. This is of utmost importance for the TV, as anatomic and functional variability is high . Valve iOptimizing patient selection for T-TEER or combined M/T-TEER is an important question to be resolved in the future. Although some observational studies have addressed this issue, randomized data are urgently needed. In fact, randomized trials of T-TEER are underway, and will confirm or refuse the prognostic impact of e.g., proposed cut-off values of RV dysfunction , 39. ButFor combined M/T-TEER, it is currently unknown whether an approach similar to surgery has added benefit over isolated TEER or a staged procedure. In the surgical field, current guidelines recommend concomitant tricuspid surgery for severe TR when primary left-sided valve surgery is indicated. In case of mild or moderate TR, certain anatomic parameters have to be taken into account for this concomitant surgical approach. For the transcatheter approach, there is no such recommendation, as concise data is missing. Potentially, RV and LV function could give us the answer which patients needs concomitant, staged, or isolated treatment with a meaningful clinical benefit in each of the latter cases.Even though numerous retrospective studies were performed to shed light into the world of T-TEER, until today, there have been no randomized-controlled studies which have shown the benefit of T-TEER and optimal medical therapy (OMT) vs. OMT alone. Currently, four large, randomized trials are ongoing in order to close this gap in evidence . Beyond that, it remains unclear which patients with concomitant mitral and tricuspid regurgitation need to be treated simultaneously and in which patients’ treatment of MR alone might be sufficient.In conclusion, we believe that RV function is of key prognostic importance in patients undergoing TEER and its evaluation needs to be performed using state of the art 3DE technologies in order to comprehend the RVs anatomical and functional complexity. We believe that the journey toward a comprehensive understanding of RV function and hemodynamics has only begun but can further improve the quality of TEER treatment through optimized patient selection.LS and MatO wrote the preliminary version after conceptual development. CH, DB, JH, LW, MarO, MN, MW, PD, SM, and TS edited the text and figures according to their expertise. All authors contributed to the article and approved the submitted version.


Renal artery denervation (RDN) can treat hypertension and paroxysmal atrial fibrillation (PAF). Hypertension and PAF can affect cardiac diastolic function. The study aimed to evaluate the effect of RDN on cardiac diastolic function in patients with refractory hypertension and PAF.  190 consecutive patients with hypertension and PAF were recruited. The levels of NT-proBNP and metrics of echocardiography were measured before and after RDN in patients with refractory hypertension and PAF. The 190 patients were divided into the decreasing HR and nondecreasing HR group, the decreasing MAP and nondecreasing MAP group, the HFPEF group, and the normal diastolic function group, respectively. E/e′, e′. The diastolic function about the indices of NT-proBNP, E/e′, e′ was improved in the decreasing HR group, the decreasing mean arterial pressure (MAP) group, and the HFPEF group, correspondingly compared to the nondecreasing HR group, the non-decreasing MAP group, and the preoperative normal diastolic function group. In the multivariate analysis, the MAP and HR were the only two indicators significantly associated with the improvement of diastolic function.  Before RDN, the indices about cardiac diastolic function were out of the normal range. After RDN, the diastolic function improved in the indices of NT-proBNP,  RDN could improve the diastolic function in patients with refractory hypertension and PAF. Patients with HFPEF could receive benefits through RDN. It was speculated that RDN improved the diastolic function mainly through decreasing HR and MAP. In the treatment of refractory hypertension, renal artery ablation (RDN) has become the most important nonpharmaceutical treatment modality –3. By blHeart failure with preserved ejection fraction (HFpEF) was a common clinical disease, with an incidence rate as high as 50% in all heart failure cases –12. ManyThe patients with refractory hypertension and PAF simultaneously were common in clinical. RDN has a therapeutic effect on such patients. Theoretically, the RDN also has a certain effect on cardiac diastolic function in these patients. In this study, we studied the changes in diastolic function in patients with refractory hypertension and PAF before and after RDN.This was a single-center, prospective study. Patients were recruited for this study between January 2013 and December 2018 from the Department of Internal Medicine-Cardiovascular, the People's Hospital affiliated with Nanjing Medical University. Written informed consent was provided by all subjects before participation in study-related procedures. The study was approved by the Jiangsu Province People's Hospital Clinic Institutional Review Board, and the study was registered (NCT01418248). All patients were screened strictly before taking the study.Percutaneous femoral artery puncture with a modified Seldinger technique was performed under local anesthesia. Selective invasive left and right renal artery angiography was performed by using a JR4.0 catheter. Radiofrequency ablation was delivered using a cold brine temperature control ablation catheter through Z-shaped ablation from the left and right renal artery trunk to the proximal head. The ablation parameters were as follows: temperature (<45°C), impedance (<250 Ω), and power (10 W). The routine setting of the ablation energy was 10 W to start ablation. If the patient had difficulty tolerating pain in the process of ablation, the ablation energy would be reduced until the patient could tolerate it, and the target of energy and time were set as follows: 9.0–10 W for 60 s, 8.0∼9.0 W for 90 s, and < 8.0 W for 120 s. If the temperature exceeds 45°C or the impedance was over 250 Ω, the ablation was stopped and changed to the other suitable sites. The parameters of heart rate (HR) and MAP (1/3 systolic blood pressure + 2/3 diastolic blood pressure) were also recorded throughout the RDN.PAF is defined as atrial fibrillation (AF) episode recording by ECG or ambulatory electrocardiogram, lasting more than 5 minutes and less than 7 days, being reversed by medication or spontaneously. The secondary atrial fibrillation  was excluded. In this study, heart rate was monitored mainly via ambulatory ECG. The Holter test was performed before RDN and during the follow-up period.The resistant hypertension was defined based on the 2018 American Heart Association Scientific Statement . We defiE/e′ ≥13, and a mean e′ septal and lateral wall <9 cm/s [The typical symptoms or signs of HF included fatigue, weakness, dyspnea, orthopnea, and edema. The diagnosis of HFpEF was established in patients with the above typical symptoms or signs, NT‐proBNP >450 pg/ml (<50 years), or >900 pg/ml (>50 years), the parameter of transthoracic echocardiogram (TTE), including left ventricular ejection fraction (LVEF) ≥50%, plus an  <9 cm/s –16.A) were measured. Using the tissue Doppler technique, early mitral annulus velocity (e′) was measured at the lateral and septal annulus.The parameters included LVEF, left ventricular end-diastolic diameter (LVEDd), and left atrial diameter (LA). Two-dimensional Doppler and tissue Doppler echocardiography were performed according to guidelines by experienced sonographers , 16. UsiThe examination of echocardiography was performed before RDN and during the follow-up period. During the examination of echocardiography, the cardiac rhythm needed to be sinus rhythm. If the AF attacked, the examination would be delayed until the sinus rhythm was restored.All patients received follow-up six months and twelve months after RDN. Patients would be contacted by telephone or correspondence if the deadline of the follow-up exceeded more than seven working days. Patients were considered as loss to follow-up if the deadline exceeded more than 30 days.p < 0.05 was considered to be statistically significant. Numbers with percentages were used to summarize categorical variables. Mean and standard deviation was used to summarize the continuous variables, and the comparison between groups was performed by the t-test. Cox regression was used to determine risk factors for the change of diastolic function. All statistical analyses were carried out using Statistical Package for Social Sciences version 23.0  and GraphPad Prism version 6.All statistical tests were two-sided, and A total of 190 consecutive patients were enrolled in this study. During the follow-up period, 14 patients were lost to follow-up. All the patients' characteristics, comorbidities, and oral medications are described in E/e′, and e′. The number of patients with heart failure symptoms decreased, but there was no significant difference compared to preoperation. During the follow-up, with decreasing HR and BP, all types of oral medications reduced, and only the calcium-channel blockers and diuretics were statistically significant compared to preoperation.As shown in E/e′, and e′. However, no significant change in parameters was observed about diastolic function in the nondecreasing HR group before and after RDN  and the normal diastolic function group (120 patients). Compared to preoperation, the diastolic function in the HFpEF group was improved about the NT-proBNP, fter RDN .During follow-up, a total of 50 patients presented with an improvement of diastolic function. In the univariate Cox regression model, both MAP and HR were associated with the improvement of diastolic function. In the multivariate analysis, the MAP and HR remained to be significantly associated with the improvement of diastolic function .The two main findings from this study are as follows: First, the cardiac diastolic function in patients with refractory hypertension and PAF could decrease. Second, RDN could improve the diastolic function in these patients.etc [E/e′, and e′, could help to improve the positive rate of HFPEF.Previous research found that 10% of hypertension could cause a cardiac diastolic function decline , 18. Lonetc –24. ThusThe basic principle of RDN is to selectively destroy the renal sympathetic nerve fibers so as to decrease the peripheral norepinephrine secretion and play a hypotensive role. RDN inhibits the sympathetic nerve and RAAS activity, lowers the norepinephrine level, and decreases plasma AngII and aldosterone levels to play a role in the treatment of atrial fibrillation –28. By lRDN had no effect on patients with normal diastolic function, but it could improve the diastolic function in those who had already suffered from a diastolic dysfunction decline. This phenomenon can be explained that the cardiac function of patients with hypertension and AF was still in the compensatory stage before RDN. Through RDN, the therapeutic effect of lowering blood pressure and heart rate was achieved. However, the effect of improving cardiac diastolic function could not be reflected, because diastolic function was within the normal range before RDN. Therefore, it was reasonable to speculate that the improvement of diastolic function of patients through RDN was mainly concentrated on those who had already suffered from diastolic dysfunction.The cardiac diastolic function was improved in the decreasing HR group and the decreasing MAP group during the 6th month and 12th month follow-up. RDN could reduce both the HR and MAP simultaneously. As the heart rate is declining, the cardiac cycle and diastolic period prolonged, which could directly affect diastolic function. As MAP decreases, the left ventricular compliance and stiffness would improve. It was speculated that RDN improved the diastolic function mainly through decreasing the HR and MAP. In Cox regression analysis, only the MAP and HR remained to be significantly associated with the improvement of diastolic function.This was a single-center study with a small sample size. We did not take a sham-operated group as a control, because of the sample size, short follow-up time and the condition were limited. Patients with different baseline complications might also be involved in diastolic dysfunction. The diastolic function was evaluated mainly by NT-proBNP and echocardiography, instead of a more accurate invasive examination method, such as CAP, PCWP, and CO. We took the change of 10 bpm and 10 mmHg as the clinically significant boundaries in HR and MAP. The first reason was that similar indicators were used to evaluate the effect of RDN in the past. The other reason was that the sample size of this study was too small to have further group discussion. The evaluation was based on the patients with refractory hypertension and atrial fibrillation, but we did not discuss separately. Oral medications have a certain impact on heart function, such as BB and ACEI/ARB, which were mainly used to control blood pressure and heart rate. However, after RDN, only diuretics and CCB had statistical significance in reduced oral medications. Regression analysis also showed that the factor of oral medications was not related to diastolic function.RDN could improve the diastolic function in patients with hypertension and PAF. The patients with HFPEF could receive benefits through RDN. It was speculated that RDN improved the diastolic function mainly through decreasing HR and MAP.


Regression analysis showed that higher SHSES score, higher age, left ventricular hypertrophy, left ventricular diastolic dysfunction, and higher CAD-RADS are independent risk factors for lower peak of LV GLS values. On the contrary, the effective blood pressure control appeared to be independent protecting factor against lower peak of LV GLS values. In summary, there is an unfavorable weak relationship between ETS exposure estimated using the SHSES scale and LV GLS in hypertensive patients.Aim of the study was to assess the relationship between environmental tobacco smoke (ETS) and computed tomography-derived left ventricular global longitudinal strain (LV GLS) in patients with arterial hypertension. 103 non-smokers with AH were included in the study (age 67.73 ± 8.84 years). ETS exposure was assessed with the Second-Hand Smoke Exposure Scale (SHSES). LV GLS was measured on computed tomography using feature tracking technology. In accordance with SHSES scale patients were divided into subgroups: subgroup A—no ETS exposure, subgroup B—low ETS exposure, subgroup C—medium ETS exposure, and subgroup D—high ETS exposure. Peak of LV GLS was statistically significantly lower in subgroup D than in subgroup A. There was a negative correlation between the exposure to ETS expressed by the SHSES scale and peak of LV GLS ( Since 1990, there is a twofold increase in the number of cases of arterial hypertension (AH). AH is responsible for over 8 million deaths from stroke, ischemic heart disease, and others . TobaccoEnvironmental tobacco smoke (ETS) is a health hazard which includes second-hand smoking (SHS) and passive smoking. The degree of ETS exposure can be expressed using the Second-Hand Smoke Exposure Scale (SHSES) validated by Vardavas et al. . The scaA measure of tissue deformation is strain, which is defined as the change in length normalized to the original length. Strain rate describes the rate at which this change occurs. The strain is accurate in defining regional diastolic and systolic function in radial, circumferential, longitudinal, or torsional directions . Strain The aim of the study was to assess the relationship between ETS and feature tracking computed tomography-derived LV GLS in patients with AH.For this cross-sectional study, 103 non-smokers with AH were included. The group consisted of 49 females and 54 males with the mean age of 67.73 ± 8.84 years. Inclusion criteria were age ≥ 18, arterial hypertension pharmacologically treated ≥ 5 years, no history of smoking cigarettes , and indication to coronary CT angiography. The exclusion criteria were insufficient quality of the coronary CT angiography, secondary hypertension, previously diagnosed ischemic heart disease, previous stroke, type 2 diabetes, chronic kidney disease, and hyperthyroidism or hypothyroidism. Group characteristics are presented in Table The International Review Board (IRB) approval for this study was obtained. Study was performed in accordance with Good Clinical Practise (GCP) principles. Written informed consent was also obtained from all participants.The study protocol assumed: taking medical history, obtaining anthropometric features, collecting of blood samples to perform some laboratory blood tests, assessment in accordance with SHSES scale, transthoracic echocardiography, and coronary CT angiography.Study participants had several blood parameters assessed: total cholesterol concentration, LDL cholesterol, HDL cholesterol, triglycerides, and glucose. Lipid profile and fasting glucose concentration were measured using standard methods described in the instructions provided with the ordered reagent kits. The blood pressure was measured in accordance with clinical guidelines by Korotkov method. The effectiveness of blood pressure control was assessed based on the 24-h ambulatory blood pressure monitoring (ABPM) performed in the last 6 months.n = 48), subgroup B—low ETS exposure , subgroup C—medium ETS exposure , and subgroup D—high ETS exposure .ETS exposure was assessed with SHSES. In accordance with SHSES scale, patients were divided into subgroups: subgroup A—no ETS exposure , maximum late diastolic mitral flow velocity (A), deceleration time of E velocity (DT), and isovolumetric relaxation time (IVRT) were evaluated. Using tissue Doppler, early diastolic mitral annular velocity (E′) was evaluated. Left ventricular diastolic dysfunction (LVDD) was diagnosed when E/E′ ratio ≥ 15. When the value of E/E′ ratio was within the range of 8 to 15 accessory criteria were employed, based on evaluation of mitral inflow profile, left atrium volume index (LAVI), and left ventricular mass index (LVMI). LVDD was diagnosed when E/A ratio < 0.5 and DT > 280 ms or LAVI > 40 ml/m2 or LVMI > 122 g/m2 for females or LVMI > 149 g/m2 for men. Echocardiography was performed in all patients by a cardiologist with 20 years of experience.Transthoracic echocardiography was performed using the standard method. Using M-mode, left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), interventricular septum end-diastolic diameter (IVSEDD), and posterior wall end-diastolic diameter (PWEDD) were measured. Left ventricular ejection fraction (LVEF) was determined from the apical 4-chamber and 2-chamber view, with the biplane Simpson’s method. Left ventricular mass (LVM), left ventricular mass index (LVMI), and relative wall thickness (RWT) were calculated. Left ventricular hypertrophy (LVH) was diagnosed when RWT > 0.45 or LVMI > 125 g/mThe cardiac computed tomography (CCT) was performed using the standard coronary CT angiography (CCTA) protocol with dual-source 128-slice CT scanner SOMATOM Definition Dual-Source CT . The coronary artery disease severity was determined based on the Coronary Artery Disease–Reporting and Data System (CAD-RADS), where 0—documented absence of coronary artery disease (CAD), 1—minimal non-obstructive CAD , 2—mild non-obstructive CAD , 3—moderate CAD , 4—severe CAD , and 5—total coronary artery occlusion.The original CT images, obtained by means of retrospective ECG gating for the entire heart cycle, were processed using Medis Suite 3.2 software  into 2D cinematographic loops of 3 LAX cardiological projections, i.e., 2-chamber, 3-chamber, and 4-chamber. The following reconstruction parameters were used: slice thickness of 0.6 mm, a reconstruction increment of 0.4 mm, and temporal resolution of 10 phases per cardiac cycle in 10% increments from early systole (0% cardiac cycle) to end-diastole (90% cardiac cycle). The obtained secondary CINE reconstructions were used for the planimetric assessment of the left ventricular volume. The following volume parameters were calculated: left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), and left ventricular stroke volume (LVSV). Based on the “LVSV/LVEDV*100%” formula, the left ventricular ejection fraction (LVEF) was calculated.The obtained secondary cinematographic reconstructions were also used for the assessment of LV GLS. Using the Medis Suite LV Strain application , the feature tracking method, the parameters of the left ventricular myocardial longitudinal strain (LS) were calculated. Strain analysis was performed semi-automatically with manual correction. In the images along the short axis, points corresponding to the endocardium and epicardium were marked in each of the three locations in the basal-ventricular, mid-ventricular, and apex-ventricular layers. Based on the indicated points, the application drew outlines of the endocardium and epicardium, which were then analyzed and accepted or manually corrected by the researcher. The papillary muscle was considered part of the left ventricular lumen.Peak LS values were assessed for each of 16 segments of the left ventricle: 6 basal segments, 6 mid-chamber segments, and 4 apical segments. In the basal and mid-chamber layer, the anterior, antero-septal, infero-septal, inferior, infero-lateral, and antero-lateral segments were analyzed. By contrast, in the apical layer, the anterior, septal, inferior, and lateral segments were analyzed. Then, peak LS was assessed for the whole basal, mid-chamber, and apical layer. Global longitudinal strain (GLS) was assessed by averaging the peak strain values of 16 segments extracted from three LAX projections.Strain analysis was performed by one cardiovascular radiologist with 10 years of experience in cardiac CT evaluation, passed European Association of Cardiovascular Imaging cardiac computed tomography exam and national certification in the field of cardiovascular radiology research. For the reproducibility of the GLS assessment, a 10% group of 11 CCT studies was randomized in which the researcher re-analyzed the strain more than 6 weeks after the previous assessment. In this group of CCT studies, the strain was also assessed by a second researcher—a cardiologist with 20 years of echocardiographic experience and 5 years of experience in CCT evaluation. Strain analysis results were highly reproducible. The intra-observer reproducibility parameters were coefficient of variance 4.1%, intra-class correlation coefficient 0.98. On the other hand, the inter-observer reproducibility parameters amounted to coefficient of variance 7.3%, intra-class correlation coefficient 0.92.U test or the Kruskal–Wallis ANOVA test were used to test the hypotheses. Qualitative variables were presented as percentages. The χ2 test was used in the comparative analysis of qualitative variables. To establish the relationship between the studied variables, a correlation analysis and regression analysis were performed. The results at the level of p < 0.05 were considered statistically significant.Statistical analysis was performed with the application “Dell Statistica” . Quantitative variables were presented as arithmetic means ± standard deviations. The distribution of variables was determined by the Shapiro–Wilk test. For normally distributed quantitative variables, the t-test or ANOVA was used to test the hypotheses. For quantitative variables with no normal distribution, the Mann–Whitney In the study group, the mean SHSES value was 33.37 ± 3.96. The minimum SHSES value of 0 (meaning no exposure to ETS) was found in 48 patients, while the maximum SHSES value of 11 was observed in 4 patients. 55 patients (53.4%) were exposed to ETS, of which 16 patients (15.5%) had low exposure, 21 patients (20.4%) had medium exposure, and 18 patients (17.5%) had high exposure.In the study group, effective blood pressure control assessed based on the ABPM performed in the last 6 months was observed in 51.4% of patients, Table Based on the obtained CCTA images, coronary artery disease was excluded in 16.5% of patients. 59.2% of patients had non-obstructive CAD (18.4% CAD-RADS 1 and 40.8% CAD-RADS 2). The coronary stenosis requiring further diagnosis was visualized in 24.2% of patients . The assessed parameters of the CCTA test in the studied group of patients are summarized in Table In the study group the mean peak of LV GLS was 15.84 ± 3.85%, including 17.38 ± 4.15% for the basal layers, 17.42 ± 3.97% for the mid-chamber layers and 14.98 ± 2.78% for the apical layers. In the segmental analysis similar strain values were observed for different segments of the myocardium. The lowest value of the peak of LS was found for the anterior apical segment (13.87 ± 2.89%), while the highest value of the peak of LS was found for the infero-lateral basal segment (18.27 ± 3.95%), Table In a comparative analysis of subgroups differing in the degree of exposure to ETS heart rate during CT acquisition was statistically significantly lower in subgroup A than in subgroup D, Table In a comparative analysis of subgroups differing in the degree of exposure to ETS peak of LV GLS was statistically significantly lower in subgroup D than in subgroup A. Moreover, a peak of LV basal layer LS and peak of LV mid-chamber layer LS were statistically significantly lower in subgroup D than in subgroups A, B, and C, while peak of LV apical layer LS was statistically significantly lower in subgroup D than in subgroup A.By comparing the subgroups of patients differing in the fact of exposure to ETS , it was shown that both peak of LV GLS and peak of LV basal layer LS, peak of LV mid-chamber layer LS, and peak of LV apical layer LS, were statistically significantly lower in the subgroup B–D than in the subgroup A. The result of the comparative analysis is presented in Table r = − 0.35, p < 0.05). The correlation is presented in Fig. r = − 0.29, p < 0.05), between diastolic blood pressure and LV GLS , between LVMI in echocardiography and LV GLS , and between heart rate during acquisition CT and LV GLS .The correlation analysis showed the existence of a negative linear relationship between the exposure to ETS expressed by the SHSES scale and peak of LV GLS  velocity ratio. Exposure during adolescence or adulthood was associated with larger right atrial size, higher LVEF, and lower isovolumetric index. Worse LV GLS occurred in those exposed to tobacco smoke in both childhood and adulthood. The study suggests that exposure to tobacco smoke is associated with deterioration of systolic and diastolic cardiac function. Chronic exposure to tobacco smoke causes oxidative stress, endothelial damage, and increased blood pressure. The pattern of myocardial deformation in chronic tobacco smoke exposure is like early heart failure with preserved ejection fraction (HFpEF), abnormal diastolic function, and myocardial deformation mechanics but normal systolic function [The conducted study showed that patients with higher ETS exposure had statistically significantly lower LV GLS peak than patients with lower ETS exposure. ETS exposure, expressed quantitatively by SHSES score, was weakly negatively correlated with peak LV GLS. From regression analysis it was shown that a higher SHSES score is an independent risk factor for a lower LV GLS peak. These results complement the current knowledge regarding the relationship between exposure to tobacco smoke and left ventricular function. Study conducted by Yaman et al. indicate that chronic smokers have significantly lower LV GLS assessed by ECHO than non-smokers . This sufunction . Our stuApart from the main aim of the study, the obtained results indicate the existence of independent relationships between older age and lower LV strain values, between left ventricular hypertrophy and lower LV strain values, between left ventricular diastolic dysfunction and lower LV strain values, between higher severity of coronary artery disease and lower values of the LV strain, and between effective blood pressure control and higher LV strain values. Other researchers have obtained similar relationships so far.Healthy subjects without cardiovascular disease were shown to have decreasing GLS values with age, e.g., in a study by Stylidis et al. . An analExtensive research on the relationship between left ventricular hypertrophy, left ventricular diastolic dysfunction, and LV GLS in patients with arterial hypertension allowed to establish that GLS is particularly useful in revealing early subclinical LV systolic dysfunction in this group of patients . GalderiReduced GLS in patients with coronary artery disease was demonstrated, among others, by Biering-Sørensen et al. , Choi etThe usefulness of echocardiographic parameters of myocardial strain as good indicators for monitoring the effectiveness of treatment in patients with arterial hypertension was demonstrated by Imbalzano et al. . SimilarYingchoncharoen et al. conducted meta-analysis to estimate normal values of GLS, GRS, and GCS. The normative GLS, GRS, and GCS values in echocardiography were as follows: − 19.7% (95% CI − 20.4% to − 18.9%), 47.3% (95% CI 43.6% to 51.0%), and − 23.3% (95% CI − 24.6% to − 22.1%) . In the Our study has some limitations. There is small non-randomized study group. However, the applied statistical tests considered such a group size. The coexistence of many recognized factors lowering the left ventricular strain in the study group is another significant limitation. Non-effective blood pressure control, high heart rate, left ventricular hypertrophy, left ventricular diastolic dysfunction, and significant coronary artery disease have been associated with a reduction in left ventricular strain in many studies. The influence of potentially modifying factors on the studied relationship “exposure to ETS vs. LV GLS” was verified by regression analyses. The studied relationship is independent of other potentially influencing factors. Yet, another limitation in the study group is the absence of a non-hypertensive group. The control group  among patients recruited to the project to some extent may be patients with a score of 0 on the SHSES scale, with effective blood pressure control assessed based on ABPM. Efficiency blood pressure control as well as systolic blood pressure and diastolic blood pressure were considered in the regression analysis as potential variables influencing the assessed relationship. An important methodological limitation of the study is the use of the CT-derived strain as a method of myocardial contractility assessment instead of the echocardiographic method. The use of echocardiographic strain evaluation is obviously better documented in the literature than the use of CT-derived strain. Strain evaluation by echocardiography is also used in practice more often than by CT. However, the popularity of the CT-derived strain method is growing, and the methodology itself is standardized, as shown by recently published studies . StudiesThere is an unfavorable weak relationship between environmental tobacco smoke exposure estimated using the Second-Hand Smoke Exposure Scale and computed tomography-derived left ventricular global longitudinal strain in hypertensive patients.


Coturnix pectoralis in Victoria, Australia. Using distance sampling, the density and abundance of stubble quail was estimated at 79 sites across a range of habitat types in an agricultural setting, each with an active ‘quail caller’ station continuously broadcasting for 48 hours, and a control station (no broadcast). Quail detectability at the active stations (62.9%) far exceeded that at control stations (6.3%). Most (57%) detections occurred within 30 m of active ‘quail callers’. Stubble quail relative abundance was substantially greater when ‘quail callers’ were broadcasting. Cameras mounted near ‘quail callers’ identified the predatory red fox as a non-target predator, although rates of attraction appear similar between active and control sites. ‘Quail callers’ are highly effective at attracting stubble quail and concentrating them to a known area, raising questions in relation to sustainable hunting practices, indirect effects, and ethical implications. ‘Quail callers’ do, however, also offer a tool for estimating quail abundance and developing more accurate population size estimates.Hunting is a prominent feature of many human societies. Advancements in hunting technologies can challenge the ethics and sustainability of hunting globally. We investigated the efficacy of an electronic acoustic lure , in attracting the otherwise difficult-to hunt stubble quail  Hunting has been an integral aspect of human evolution and has co-evolved with human tool-use for hundreds of thousands of years –3. Over Deception is a key strategy used by hunters to gain proximity to their target species, particularly using lures to draw in or aggregate animals , 12. LurChen caerulescens caerulescens) were found to be highly vulnerable to EALs in the USA [EALs may increase a hunter’s harvest rate far beyond what has been historically possible, especially where the hunted species are cryptic, widespread at low densities, or both. For example, lesser snow geese  are a small (~100 g), cryptic, ground-dwelling grassland galliform species [Stubble quail  is currently legal for quail hunting in Victoria, with the use of the technology increasing rapidly . While uThis research was supported by the Deakin University Animal Ethics Committee (AEC) approval #B33-2020 and in accordance with Department of Environment, Land, Water and Planning Wildlife Act Research Permit No. 10009735.This research was undertaken in western Victoria, Australia, a primary production district with vast areas of privately owned agricultural land representing key habitat for stubble quail , 33, 39.Surveys were conducted during the hunting season of 2021 to establish the effect of ‘quail callers’ during the period when they are actually used in hunting. Seventy-nine sites on private land were selected across a range of habitat types including pasture crop (N = 27 sites), cereal and legume stubble (N = 21), native grasslands (N = 19), low open woodlands (N = 5), regenerative cover crops (N = 3), freshwater marshland (N = 2), and rocky outcrops (N = 2). Sites chosen for the study have been subjected to differing levels of agricultural disturbance , from minimal or no disturbance  to consistent heavy cultivation . Sites were selected based on three key criteria: 1) they had confirmed recent or historical presence of stubble quail; 2) our sampling would not impede agricultural practices; and 3) agricultural practices would not influence the presence of stubble quail. Sites were maintained at least 1 km apart to increase independence .At each site, a matched paired design was used where two 200 m transects, positioned in a north-south orientation, were established 300 m apart. Each transect was randomly assigned as either ‘active’ , or ‘control’ . The paired nature of this design enabled us to account for differences in habitat type, climatic and weather conditions throughout our surveys. A ‘quail caller’   was deplDistance sampling was conducted during daylight hours only and at 72% of sites  minutes at ~2.20 km/h) as it is known to be effective at estimating abundance for other species of quail , 41–43. in situ for two days and placed in a SE–SW direction. Cameras were initially used to establish a metric of stubble quail activity, although were quickly replaced with distance sampling when stubble quail detections were absent even though they were known to be in the area. Cameras, however, also enabled the assessment of non-target predators that may have been attracted to ‘quail callers’ [At the center point of each transect an infrared trail camera  was also deployed facing the ‘quail caller’, 20 m away. Cameras were set approximately 30 cm above the ground and were set on high sensitivity to take three consecutive images when triggered. Cameras were left callers’ , 45. CamWe first used a Generalised Linear Mixed Model (GLMM) in ‘lme4’  in the sTo investigate whether the relative abundance of quail differed between the treatments we used distance sampling in the ‘Distance’ package in ‘R’ . We firsVulpes vulpes) that was at least 15 minutes apart from another image of the same species. We compared the detections of predators (presence/absence) to each treatment (control/active) using a Chi-squared test of independence using a continuity correction.Detections on cameras were sorted to identify potential predators of stubble quail which may have equally been attracted to the ‘quail callers’. We defined a predator event as an image of a predator .A total of 228 transects were surveyed detecting 508 stubble quail. Thirteen quail were detected during pre-treatment surveys ; 495 stubble quail were detected during the post-treatment surveys 99% of which were at active sites. When stubble quail were detected at active sites, we found they were more likely to be detected closer to the location of the ‘quail caller’ . It was 2m = 0.401) of the data explained by the model fixed effects and 54% explained by the full model (R2c = 0.536).The presence of quail at a transect was influenced by treatment , the time period  and the interaction term between the two . The probability of detecting quail at a site during pre-surveys was 0.023 (95%CI: 0.005–0.110) and 0.037 (95%CI: 0.010–0.137) at active and control sites respectively. This increased during post-treatment surveys with the probability of detecting quail at active sites  being considerably higher than at control sites , and all uniform detection functions . This detection function demonstrated that most quail were detected within 10 m of the transect, declining sharply towards 20 m from the transect . Using tElectronic acoustic lures have proven to be an effective tool for attracting birds in a variety of environments , 49–51. Degree of attraction to EALs may vary with duration of exposure to calls , 53. ThuWhile annual total harvest levels are known in Victoria , 31, theRed foxes were the only possible predator of stubble quail to be detected more than once. Data were too few for a robust test of whether foxes are attracted to active ‘quail callers’. However, this does not mean that there is no response from predators to the devices–no detection does not mean that there was nothing to be detected . AdditioThe use of EALs, given their effectiveness, may provide an effective survey tool for assessing quail abundance and distribution, and underpin enhanced understanding of habitat usage, and landscape-scale features that correlate with stubble quail occurrence. Paradoxically, something that has the potential to compromise the sustainability of hunting may also provide a tool to develop more informed estimates of population size and therefore sustainable hunting regulations based on known population sizes.In addition to their regular spring-summer breed, stubble quail are known to breed in late-summer and autumn if conditions are favorable , 35. ThiIt was not possible in this study to determine whether stubble quail were attracted to the caller solely in response to its aural stimulus or whether visual or other stimuli also had an effect. It is possible that the sight or behavior of nearby conspecifics may have caused a ‘flocking effect’  which inWe demonstrate that ‘quail callers’ concentrate and aggregate stubble quail and as such have the potential to markedly increase the harvest rate of stubble quail, compromise the concept of fair-chase, and may cause indirect impacts, such as disturbance from foraging and other behaviors, that direct energy into responding to the ‘quail callers’–an area requiring further research. Consideration should be given to regulating their use, particularly in the context of a lack of rigorous stubble quail abundance estimates at present creating the potential for undetected unsustainable harvesting. ‘Quail callers’ could, however, if investigated further, be an advantageous tool for facilitating much-needed ecological research on this species.S1 File(CSV)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.


The IL-33/ST2 L signaling pathway is involved in the pathophysiological processes of several diseases and mainly exerts anti-inflammatory and antifibrotic effects. Soluble suppression of tumorigenicity 2 (sST2), which serves as a competitive inhibitory molecule of this pathway, is a member of the interleukin (IL)-1 family, a decoy receptor for IL33, thought to play a role in cardiac remodeling and the inflammatory process. However, the association between sST2 and coronary artery disease (CAD), one of the most common causes of heart failure, is still being explored. We therefore reviewed the research on sST2 in the field of CAD, including reflecting the atherosclerosis burden, predicting no-reflow, predicting prognosis, responding to myocardial remodeling, and guiding management, hoping to provide cardiologists with new perspectives. Suppression of tumorigenicity 2 (ST2) is a member of the interleukin 1 (IL-1) receptor family and is formally known as interleukin 1 receptor-like 1 (IL1RL-1). It was first described in 1989 but remained an orphan receptor mainly related to immune and inflammatory diseases for years . For insCoronary artery disease (CAD), especially acute coronary syndrome (ACS), is one of the most common causes of mortality throughout the world, despite technological improvements, new drugs, and an increasing level of awareness , 18. In The “inflammatory hypothesis” of atherosclerosis postulates that inflammatory cell signaling drives the formation, growth, and ultimately the instability of atherosclerotic plaques, setting up the substrate for the thrombotic response that causes myocardial damage or infarction . In the Pfetsh et al. observed a strong correlation between elevated sST2 levels and inflammatory markers (hs-CRP and IL-6) that may reflect the presence of chronic inflammation in the pathophysiology of atherosclerosis . In addiBased on the above studies, Luo et al. prospectively enrolled 120 patients to assess plaque vulnerability by coronary computed tomography angiography (CCTA) . Their sMeanwhile, the coronary artery calcium score (CACS) is a marker of atherosclerotic plaque burden and an independent predictor of coronary events. In the study by Oh et al. , researcp = 0.002). Furthermore, after adjustment for potential confounders, it was found that being in a high-sST2 group was one of the independent predictors of no-reflow .The no-reflow phenomenon is defined as insufficiency of myocardial perfusion despite the mechanically responsible lesion being opened. The no-reflow phenomenon rate can reach as high as 50% in ACS patients  and restP = 0.015]. It also had independent predictive value after adjusting for confounding factors . However, both studies were single-center studies, and the number of patients included was relatively small. More importantly, they only detected the sST2 level of patients at the time of admission but did not observe subsequent changes. Thus, more high-quality trials should be carried out to determine the relationship between sST2 and no-reflow.Since the above study showed that sST2 can predict the no-reflow phenomenon in STEMI patients, experts then turned their attention to non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Zhang et al.  revealedShimpo et al. demonstrated that sST2 levels can predict mortality and heart failure in MI patients by extracting sST2 from the serum of 810 AMI patients . Then, SAlthough many studies have confirmed that sST2 has a strong predictive effect on the prognosis of heart failure, the number of studies on sST2 and the prognosis of CAD, both in ACS and chronic coronary syndrome (CCS), is limited, and their findings are controversial. Therefore, more studies should be conducted in the future to further explore the prognostic effect of sST2 on CAD.Left ventricular remodeling (LVR) refers to changes in the shape and size of the whole left ventricle after acute myocardial infarction (AMI). Important pathological features of postinfarction LV remodeling include infarct expansion, myocardial hypertrophy, cardiac fibrosis, and ventricular dilation, which are mainly due to inflammatory responses and neuroendocrine activation , 41. TheMeanwhile, ST2 regulates the expression of proinflammatory cytokines from macrophages and prevents uncontrolled inflammatory reactions in the MI region. The sST2 level could be responsible for myocardial fibrosis and LVR, which could affect the prognosis after MI , 42. By Currently, mainly instrumental markers, such as the parameters of ECHO and CMR, are used to indicate the development of adverse LVR . The queMoreover, several studies have found a link between sST2 and circulating aldosterone, implying that the IL-33/sST2 signaling system and the RAAS are linked . This rapost-hoc analysis of the PROTECT study in which the group of patients who received high-dose beta-blockers with low sST2 levels had the best prognosis, suggesting that sST2 levels can assist cardiologists in selecting the best treatment option for patients with MI , the Postdoctoral Research Project, West China Hospital, Sichuan University (No. 2020HXBH048), and the Innovative Scientific Research Project of Medical Youth in Sichuan Province (No. Q20061).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.