Cardiac magnetic resonance (CMR) is becoming the imaging modality of choice in multicenter studies where highly reproducible measurements are necessary. The purpose of this study was to assess the effect of comprehensive initial training on reproducibility of quantitative left ventricular (LV) parameters estimated using strain-encoded (SENC) imaging. Thirty participants (10 patients with heart failure (HF) and preserved LV ejection fraction (HFpEF), 10 patients with HF and reduced LV ejection fraction (HFrEF) and 10 healthy volunteers) were examined using fast-SENC imaging. Four observers with different experience in non-invasive cardiac imaging completed comprehensive initial training course and were invited to perform CMR data analysis. To assess agreement between observers, LV volumes, mass, ejection fraction (LVEF), global longitudinal strain (GLS) and global circumferential strain (GCS) were estimated using dedicated software . To test intraobserver agreement data analysis was repeated after 4 weeks. SENC imaging and analysis were fast and were completed in less than 5 minutes. LV end-diastolic volume index (LVEDVi), LVEF and strain were significantly lower in HFpEF patients than in healthy volunteers . All LV functional parameters were further reduced in HFrEF. Excellent interobserver agreement was found for all LV parameters independently of the level of experience. The reproducibility of LV mass was lower, especially at the intraobserver level . LV volumetric and functional parameters derived using fast-SENC imaging, are highly reproducible. The appropriate initial training is relevant and allows to achieve highest concordance in fast-SENC measurements. Over the past decade cardiac magnetic resonance (CMR) has evolved into the reference standard to assess cardiac anatomy and function4. Because of its excellent endocardial border definition, cine CMR imaging is the accepted gold standard for quantification of ventricular volumes, mass and ejection fraction6. While important achievements in CMR techniques have reduced total scan time, quantitative volumetric analysis has not changed significantly and requires time and human resources8.In addition to clinical signs and symptoms, a detailed assessment of structural and functional cardiac parameters is considered to be essential and provides important diagnostic information in patients with heart failure (HF)9. Tissue-tracking techniques have enabled the non-invasive assessment of myocardial deformation and it appears that myocardial strain might be a more robust marker of the failing myocardium12. Strain-encoded magnetic resonance (SENC) imaging was developed on the concepts of myocardial tagging and first described in 200113. In line with other tissue tracking techniques, SENC provides quantitative information about myocardial mechanics and has been validated and applied in multiple experimental and clinical settings16. Fast-SENC technique is a real-time version of SENC that has shortened the scan duration to a single heartbeat17. The absence of contrast agent and free breathing during data acquisition are important advantages that make the technique desirable in daily routine. Moreover, recent achievements in fast-SENC data analysis tools have enabled quantification of conventional left ventricular (LV) volumetric and functional parameters with excellent accuracy and minimal educational efforts18.Growing evidence suggests that conventional functional parameters such as left ventricular ejection fraction (LVEF) may not be sensitive enough to detect subtle changes in ventricular function21; hence, interobserver and intraobserver variability may become an important source of bias. Although recommendations exist for CMR acquisition22 and data post-processing24, the lack of proper initial training of the observers may lead to significant measurement variance which becomes more apparent in multicenter studies. Indeed, appropriate education26 as well as repeated measurements27 might improve interobserver reproducibility for volumetric and functional measures of the left ventricle.More and more clinical decision making relies on CMR derived dataWe set up this study to investigate the effect of comprehensive initial training on reproducibility of LV volumes, mass, ejection fraction and strain derived using fast-SENC imaging. The main hypothesis was that appropriate initial training has an important impact in terms of cardiac imaging of the readers on the concordance of measurements.The study population comprised patients with heart failure and preserved LVEF , reduced LVEF  and healthy volunteers (n = 10). The study complies with the Declaration of Helsinki and was approved by the ethics committee board of the Charité-Universitätsmedizin Berlin. All participants provided written informed consent before entering the study.All CMR studies were performed on a 1.5 T MRI scanner  using a five-element phased array cardiac coil in supine position.17 real-time free breathing SENC imaging technique  based on the acquisition of two images with different frequency modulation was employed. Images were taken in three different LV long-axis  and three LV short-axis  views. The slices of different LV short-axis levels were identified as follows: basal level slice was considered and used for quantitative analysis if complete LV myocardium was visible throughout the entire cardiac cycle; mid-ventricular level slice was selected at the level of both papillary muscles; and apical level slice was considered if blood pool was still visible throughout the entire cardiac cycle (no obliteration of the LV cavity at end-systolic phase). Typical fast-SENC parameters were as follows: field-of-view = 256 × 256 mm2, slice thickness = 10 mm, voxel size = 4.0 × 4.0 × 10 mm3, single-shot spiral readout (3 interleaves) with acquisition time (TA) = 10 ms, flip angle = 30°, effective echo time (TE) = 0.7 ms, repetition time (TR) = 12 ms, temporal resolution = 36 ms, typical number of acquired phases = 22, spectrally selective fat suppression (SPIR), total acquisition time per slice < 1 s.A previously describedThe four observers with different knowledge and experience in CMR imaging were invited to perform analysis of acquired CMR data: (1) CMR expert (TL) ; (2) CMR beginner (VZ) (with basic knowledge and <3 months of experience in CMR imaging); (3) Echo expert (HHC)  and (4) Non-cardiac technician (JE) (fully-trained radiographer without any experience in data post-processing).Before starting the CMR data analysis, all observers were trained similarly by a representative of the software company with an emphasis on possible sources of error. A Quick-Reference Guide was given to each trainee before starting the training. The training consisted of a 2 to 4-hour training course designed to provide observers with the skills necessary to correctly use the dedicated MyoStrain software Fig. . A set oAll fast-SENC images were uploaded from the MRI scanner and analyzed using dedicated MyoStrain, version 4.2 software . LV end-diastolic (LVEDV), LV end-systolic volumes (LVESV) and LV mass (LVM) were quantified using manual planimetry of the endocardial and epicardial surface from three long-axis fast-SENC images and LVEF was calculated Figs . The quat test and the Mann-Whitney U test where appropriate. Interobserver and intraobserver variability was assessed by intraclass correlation (ICC)  and Bland-Altman analysis28. Agreement was considered excellent for ICC >0.74, good for ICC 0.60–0.74, fair for ICC 0.40–0.59, and poor for ICC <0.4029. A p value of <0.05 was considered statistically significant.Data were analyzed using IBM SPSS Statistics, version 21.0 software  for Windows. Continuous variables were expressed as mean ± standard deviation. The distribution of continuous variables was assessed using the Shapiro-Wilk test and comparisons between groups were performed with the 2-sample The local ethics committee (Charité-Universitätsmedizin Berlin) approved the research and consent was obtained for all study participants.All study participants were able to complete the entire study protocol. SENC imaging and analysis was fast with a 15 second scan time and a 3 to 5 minute post-processing time for complete quantitative assessment including LV volumes, mass, ejection fraction and global longitudinal and circumferential strain.2 vs. 75.20 ± 11.66 ml/m2, p = 0.019 for LVEDVi; 60.41 ± 5.57% vs. 55.96 ± 3.40%, p = 0.023 for LVEF; −20.45 ± 1.46% vs. −18.92 ± 0.84%, p = 0.004 for GLS and −21.25 ± 1.19% vs. −17.35 ± 1.89%, p < 0.001 for GCS). All LV functional parameters were further reduced in HFrEF patients compared with healthy volunteers or HFpEF. LV volumes and mass were significantly larger in HFrEF than in other study subjects. Table There was no significant difference in LVESV and LVM indices between healthy volunteers and HFpEF patients (p = 0.579 for LVESVi and p = 0.315 for LVMi), while LVEDVi, LVEF and strain values were significantly lower in HFpEF  . Tables LV volumetric and functional parameters can be precisely derived from fast-SENC images in a single short data analysis session.Appropriate initial training is important and has impact on the concordance in measurements among observers independently of their previous experience.Excellent interobserver and intraobserver agreement is present for all quantitative LV parameters, especially for GLS and GCS, whereas measures of LV mass appear less robust.The current study was designed to test whether comprehensive initial training has more relevant impact on the reproducibility of LV volumetric and functional parameters estimated using fast-SENC technique than observers experience. Our data analysis demonstrated that:32. It has been shown that this single measure is critical for diagnosis of HF and selection of optimal medical or device therapy33. However, there is evidence that advanced measures of myocardial performance, such as strain or torsion, are better predictors of outcome than LVEF or wall motion score index35. Tissue-tracking techniques such as speckle tracking echocardiography, CMR tagging, displacement encoded with stimulated echoes (DENSE) imaging or feature tracking appear very promising and have shown the ability to detect early changes in myocardial motion36. Historically, CMR tagging was the first technique implemented for the analysis of myocardial deformation37. However, time-consuming data acquisition and analysis remain important limitations of this standard of reference technique39.The assessment of LV function is probably the most important part of every cardiac imaging study. The majority of clinical decision making algorithms largely rely on quantitative variables such as LVEFet al., proposed a new method for measuring the myocardial strain orthogonal to the imaging plane, called SENC-MRI13. The method required the acquisition of two images and allowed straightforward and fast computation of longitudinal strain. Recent achievements in SENC technique have shortened the scan duration to a single heartbeat and eliminated the demand of multiple breath-holds40. Fast-SENC was validated against the conventional CMR tagging and excellent correlation between the methods was shown42. The ability to obtain accurate measurements in a short time is highly desirable, especially in severely ill patients and children. We successfully completed image acquisition and data analysis in less than five minutes, while participants were still in the MRI scanner. Such achievements make the implementation of this technique in the clinical realm very promising.In 2001 Osman 43. A lower level of variability permits detection of smaller changes and may reduce the necessary sample size for clinical trials45. Neizel et al., evaluated interobserver agreement in healthy volunteers and found very high reproducibility in SENC strain measurements (r = 0.87), which was superior to CMR tagging (0.81)42. Hamdan et al., reported similar findings in healthy volunteers scanned on a 3.0 T MRI system with ICC between observers and repeated studies ranging from 0.92 to 0.9846. Our findings are in line with the results of previous studies. We found excellent interobserver and intraobserver agreement of LV global longitudinal and circumferential strain. Moreover, for the first time we demonstrated excellent interobserver and intraobserver reproducibility of LV volumes and ejection fraction estimated using fast-SENC imaging. As reported previously, the agreement of LV mass measurements was lower, especially at the intraobserver level .The reliability and reproducibility of LV functional measures are of great importance for patient management, therapy monitoring and outcome studies47; therefore, inter-institutional agreement of derived measures must be recognized as a relevant source of error. Sample size calculation is an important aspect of study design and depends on the concordance of measurements. Much attention has been attributed to CMR scanning and data analysis guidelines24. However, little is known on whether knowledge, experience or appropriate initial training has more impact on the precision of measurements. Beerbaum et al., investigated the impact of interobserver variance between the institutions for volumetric and flow CMR data. Images were analyzed by experienced readers only. Inter-institutional agreement was assessed before and after a dedicated training course. Interestingly, in patients, on transverse planes, variation coefficient for LV volumes was significantly decreased by training (p < 0.007). For short-axis volumetry training also resulted in narrower limits of agreement. The reproducibility did not improve significantly with training in healthy volunteers. However, the highest variability after training in volunteers was found for LV mass 48.At present, CMR is becoming the imaging modality of choice in multicentric cardiovascular trialset al. evaluated the role of experience in the precision and validity of strain measurements derived using speckle tracking echocardiography. Their study revealed that although the group with the highest level of experience achieved better agreement than those with no experience, the ICC of the inexperienced observers was still very high 49. To examine the importance of initial training we selected four study observers with different knowledge and experience background but provided comprehensive and expert-guided training. Data analysis demonstrated that interobserver agreement was excellent independently of readers’ expertise. Nevertheless, it should be noted that LV mass measurements were more variable, especially at the intraobserver level , confirming that degree of experience might be also important and should not be underestimated. Despite higher variability, the concordance of LV mass measurements is still clinically acceptable (ICC 0.91).In a recent study, Negishi 50. Findings of this study are in line with previous studies and confirm that appropriate initial training might be more important to achieve highest concordance in CMR measurements. In the light of inadequate experience in CMR imaging fast-SENC technique would be highly desirable in non-expert CMR centers where precise quantitative LV analysis could be performed rapidly even by unexperienced readers.Our very recent study was conducted to evaluate the impact of proper training on the variability of myocardial strain measurements derived using different commercially available CMR feature tracking software packages. Study results demonstrated that dedicated training of the observer significantly improves reproducibility of LV GLS and GCSSeveral limitations of the current study should be noted. First, the population of this study was relatively small. Second, it was single center, single vendor, single software and single MRI lab protocol. Third, only fast-SENC imaging was used to investigate the performance of observers without reflection of other CMR tissue tracking techniques such as tagging, DENSE or feature tracking. We also did not compare fast-SENC images acquired by MRI scanners of different vendors. Lastly, we did not assess the variability of measurements before the training of the observers.Excellent reproducibility of LV volumetric and functional parameters makes fast-SENC a reliable imaging modality for future studies. Although level of experience is important, it appears that appropriate initial training has much more impact on the agreement of derived measurements. However, larger multicenter studies using MRI scanners and software packages from different vendors are necessary to confirm our findings.


Preeclampsia is one of the most common pregnancy complications, which is one of the major causes of fetal and maternal mortality.To compare the serum Brain Natriuretic Peptide (BNP) level in patients with severe preeclampsia and normal pregnancy and investigate associated cardiovascular complications.This case-control study was performed on 94 women with a singleton pregnancy  at Imam Reza Hospital in Mashhad, Iran. The venous blood samples were collected to evaluate the serum BNP level. All patients were subjected to echocardiography performed by a single cardiologist.ratio of the early transmitral flow velocity to the early diastolic tissue velocity (E/Em). However,the serum BNP level showed a significant correlation with EF , TAPSE , and E/Em ratio  in patients with severe preeclampsia.The mean pro-BNP levels were 480.36 It seems that BNP can be used as a predictor for some of the main cardiac functional indices  in severe preeclampsia patients.  It has been recently demonstrated that the patients with preeclampsia have an elevated BNP level as compared to those with normal pregnancy, which is indicative of subclinical vascular disorders in these patients (11). Furthermore, the previous studies have demonstrated a direct relationship between the BNP level and the severity of preeclampsia and obstetrical complications, such as preterm delivery (12). According to various studies, cardiovascular disorders, such as increased systemic vascular resistance and left ventricular pressure, decreased heart rate, left ventricular diastolic dysfunction, and increased left ventricular mass index are associated with the elevation of BNP in preeclampsia. However, these studies have included both severe and non-severe preeclampsia (12).Gestational hypertension and preeclampsia are among the most prevalent medical problems during pregnancy, which mostly occur in the young and nulliparous females . Preeclampsia is one of the main risk factors for maternal mortality along with maternal and fetal-neonatal complications (3). This condition complicates 5–8% of the pregnancies and has an unknown etiology (4). Preeclampsia occurs early in pregnancy through hidden pathophysiological changes that accelerate during pregnancy and ultimately becomes clinically apparent (2). Several investigations have been conducted to find the predictive factors of preeclampsia. However, there is no reliable, valid, and cost-effective method for predicting this condition. Preeclampsia can be diagnosed in its early stages only through the implementation of planned prenatal care (5). The first step in the prevention of preeclampsia is the early detection of women at risk of this complication. Therefore, the use of an appropriate diagnostic test that can help identify the patients at risk is of paramount importance. Such a test can play a significant role in the reduction of maternal and fetal mortality and morbidity (6). Severe cardiovascular dysfunctions are common in preeclampsia syndrome. These disorders increase the cardiac output due to high blood pressure and induce a significant negative impact on the cardiac input by the pathologic reduction of hypovolemia during pregnancy. The echocardiography of myocardial function and the clinical assessment of ventricular function should be considered when evaluating cardiac function in preeclampsia (7). Brain natriuretic peptide (BNP) is a polypeptide, which is secreted as a pre-pro BNP by the cardiac ventricle in response to With this background in mind, the present study aimed to compare the serum BNP level in patients with severe preeclampsia and normal pregnancy and investigating cardiovascular complications. The findings of this study may be helpful in introducing BNP as a marker for the identification of patients requiring cardiac evaluation.This case-control study was performed on 94 women with singleton pregnancy at Imam Reza Hospital in Mashhad, Iran from September 2015 to November 2016. The study population who were selected among referral patients were patients with preeclampsia and those with normal pregnancy. The sample size of this study was estimated as 45 patients in each group based on a study conducted by Hamad and colleagues (13) and the formula for comparing the two means with an alpha of 5%, power of 80%, and 10% for drop out. The inclusion criteria were women with severe preeclampsia which is defined as the presence of one of the following signs or symptoms in the presence of preeclampsia: (i) a blood pressure of A checklist containing maternal age, gravidity, gestational age, systolic and diastolic blood pressure, number of previous pregnancies, body mass index, and drug consumption was filled. To evaluate the serum BNP level, 2–4 cc venous blood samples were collected from the preeclampsia (before the administration of magnesium sulfate) and control groups in the biochemistry tube (gelled) stored at 4°C in the refrigerator and sent to the laboratory. After being exposed to ambient temperature for 30 min, pro-BNP was measured using VIDASⓇ NT-proBNP2 kit  and advanced enzyme-linked immunosorbent assay. In addition, to determine the electrocardiographic variations, all patients were subjected to a standard b-mode transthoracic echocardiography (Samsung V10 model) performed by a single cardiologist who was blind to the patient's status regarding blood pressure. The echocardiography was conducted before the administration of magnesium sulfate.This study was approved by the Research Chancellor of Mashhad University of Medical Sciences, Mashhad, Iran (940284). Ethical Committee of Mashhad University of Medical Sciences approved the ethical issues regarding the involvement of human subjects (IR.MUMS.fm.REC.1394.355). Informed consent was obtained from all participants.t-test, and Mann-Whitney U test. ANCOVA was used to control confounders. Furthermore, the correlation between the quantitative variables was estimated through Spearman's rank correlation coefficient. All tests were two-tailed and P-value less than 0.05 was considered statistically significant.Data analyses were performed using Statistical Package for the Social Sciences, version 16.0, SPSS Inc, Chicago, Illinois, USA (SPSS). The relationship between the qualitative and quantitative variables was evaluated using the student Overall, 94 pregnant women  were studied. Except for age and gestational age, there was no significant difference between the normal and preeclampsia groups (Table I). The mean pro-BNP levels in the women with preeclampsia  which is an index for the left ventricular diastolic function (Table II). Considering EF There was no significant difference between the two groups  in terms of the cardiac parameters, including EF, LVEDD and LVESD, TAPSE which is an indicator of the right ventricular systolic function, and The aim of this study was to compare serum BNP levels in the patients with severe preeclampsia and normal pregnancy group. We also determined the relationship of serum BNP level with the left ventricular systolic and diastolic dysfunction in the patients with severe preeclampsia. In the present study, the mean total pro-BNP level showed an increase in patients with severe preeclampsia in comparison to the normal pregnancy group. However, after adjusting for maternal and gestational age statistical differences was not seen. Additionally, some echocardiographic indices, such as E/Em ratio, LVEDD, and LVESD, had a positive correlation with BNP in patients with severe preeclampsia. These findings suggested that BNP can be used as a marker for the diagnosis of cardiac complications. On the other hand, EF and TAPSE had a negative correlation with BNP in patients with severe preeclampsia. It should be noted that the mean NT-pro BNP level obtained in the present study was higher than those reported in previous studies . However, there was no significant difference between the two groups in terms of underlying heart disease and renal function. The possible reason of obtaining a high mean BNP in the present study in comparison to those obtained in the other studies could be ascribed to high levels of BNP in two patients with preeclampsia who had left ventricular dysfunction and a significant reduction in EF ratio. These two patients had no known underlying heart disease, and we could not find any etiology for their condition during the investigation. Therefore, they were not excluded from the study, and it was assumed that high BNP and cardiac findings of these two patients might be affected by their preeclampsia severity.In a study conducted by Resnik and colleagues in 2005, the BNP levels of 25 healthy pregnant women with 34 preeclamptic women were compared. In the mentioned study, the median levels of BNP in the normal subjects and the patients with moderate and severe preeclampsia were 17.8, 21.1, and 101 pg/ml, respectively. "This finding indicated the significantly higher level of this hormone in the severe preeclampsia group than that in the mild preeclampsia group, which could reflect the ventricular stress or subclinical cardiac disorder associated with preeclampsia" (15).There are different studies examining the association of BNP with the severity of preeclampsia. For instance, Bakacak and colleagues conducted a study on 49 females with preeclampsia, 25 of whom had severe preeclampsia, and 27 pregnant women with normal blood pressure (16). "Their findings showed that serum NT-pro BNP level in the preeclampsia group was significantly higher than that in the control group. In addition, the NT-pro BNP level was significantly higher in the severe preeclampsia group than those in non-severe preeclampsia and control groups". Therefore, the mentioned study concluded the NT-pro BNP level as a useful marker for estimating the severity of preeclampsia (16).Hamad and colleagues also performed a study in 2009 on 35 pregnant women with preeclampsia and 30 females with normal pregnancy. They performed echocardiography and estimated the NT-pro-BNP, C-reactive protein, cystatin C, and troponin I level during pregnancy and 3–6 months after the delivery. The results demonstrated that the function and dimensions of the left ventricle and atria were significantly different between the two groups. In addition, they reported a significant increase in the septal and lateral E/Em ratio in the preeclampsia group. Also, the levels of NT-pro-BNP and cystatin C were demonstrated to significantly elevate in the preeclampsia group (13). However, we did not find a statistically significant difference between the two groups regarding cardiac indices which could be due to the period of exposure with preeclampsia . The results were indicative of the elevated level of BNP in the females with preeclampsia along with changes in the left ventricular diastolic function as compared with the females with normal pregnancy. Our results were similar to those reported by Fayers and colleagues (17) in terms of the enhancement of pro-BNP levels in the preeclampsia group. Nonetheless, the examination of cardiac parameters based on echocardiography revealed that the two groups of preeclampsia and normal pregnancy showed no significant difference in this regard. However, in the severe preeclampsia group, BNP levels had a significant correlation with EF, TAPSE, and E/Em. This could be indicative of the right and left ventricular systolic and diastolic dysfunction.In a systematic review conducted on 12 studies in 2013, the BNP level was reported to be significantly higher in the preeclampsia patients than that in normal pregnancies. Additionally, in the mentioned study, the high level of BNP was reported to be associated with cardiovascular complications and preterm delivery. However, the researchers of the mentioned study suggested performing more studies on the patients with preeclampsia in order to obtain more accurate findings in this regard (1).It is noteworthy that although there are some studies investigating BNP and preeclampsia, limited research has examined the relationship between cardiac parameters in preeclampsia and BNP levels. To the best of our knowledge, this was the first study to evaluate the correlation of BNP with cardiac indices in preeclampsia in the east of Iran. We also suggest to include pregnancy complications and neonatal outcome in future studies.In conclusion, the total mean Pro-BNP level was not statistically different in patients with severe preeclampsia in comparison to that in the normal pregnancy. However, E/Em had a statistically positive correlation with BNP and EF and TAPSE had a negative correlation with BNP in severe preeclampsia patients. So, BNP can be used as a predictor for at least some of the main cardiac functional indices in patients with severe preeclampsia.The authors declare that they have no conflict of interest.


Sodium glucose co-transporter 2 inhibitor (SGLT2i), a new class of anti-diabetic drugs acting on inhibiting glucose resorption by kidneys, is shown beneficial in reduction of heart failure hospitalization and cardiovascular mortality. The mechanisms remain unclear. We hypothesized that SGLT2i, empagliflozin can improve cardiac hemodynamics in non-diabetic hypertensive heart failure.The hypertensive heart failure model had been created by feeding spontaneous hypertensive rats (SHR) with high fat diet for 32 weeks . Half SHRs were randomized to be administered with SGLT2i, empagliflozin at 20 mg/kg/day for 12 weeks. After evaluation of electrocardiography and echocardiography, invasive hemodynamic study was performed and followed by blood sample collection and tissue analyses. Empagliflozin exhibited cardiac  and renal protection, while plasma glucose level was not affected. Empagliflozin normalized both end-systolic and end-diastolic volume in SHR, in parallel with parameters in echocardiographic evaluation. Empagliflozin also normalized systolic dysfunction, in terms of the reduced maximal velocity of pressure incline and the slope of end-systolic pressure volume relationship in SHR. In histological analysis, empagliflozin significantly attenuated cardiac fibrosis in both atrial and ventricular tissues. The upregulation of atrial and ventricular expression of PPARα, ACADM, natriuretic peptides (NPPA and NPPB), and TNF-α in SHR, was all restored by treatment of empagliflozin.Empagliflozin improves hemodynamics in our hypertensive heart failure rat model, associated with renal protection, attenuated cardiac fibrosis, and normalization of HF genes. Our results contribute some understanding of the pleiotropic effects of empagliflozin on improving heart function. Sodium glucose co-transporter 2 inhibitors (SGLT2i) are a new class of anti-diabetic drugs acting on inhibiting glucose and sodium resorption by the kidneys. Marketed compounds of SGLT2i include dapagliflozin, canagliflozin, empagliflozin, and ertugliflozin. Empagliflozin was approved in August 2014. In addition to efficacy for glycemic control on the HbA1c level, cardiovascular protective benefit from SGLT2i is remarkable, in terms of reduction of hospitalization for heart failure (HF) , and red2+ leak which are hallmarks of HF , and LV chamber dimensions (LVID) at end-diastole were determined from M-mode images. Left atrial size was determined from M-mode at end-systole. The ejection fraction (EF) and LV mass and end-diastole and end-systole volumes (LVEDV and LVESV) were calculated according to Teichholz et al. . For theRats were anesthetized with intraperitoneal injection of thiopental sodium (60–80 mg/kg ip). Right carotid artery was cut down to insert the microtip 2.0 F Pressure-Volume (PV) catheter . After arterial pressure was recorded, the catheter was advanced to the LV guided by pressure tracing waves as described previously . After sAfter hemodynamic study, venous blood was drawn from the inferior vena cava into collecting vials, and plasma was prepared and stored at − 20 °C pending further analysis. Plasma samples were used for the measurement by means of specific kits of the following parameters: fructosamine, triglycerides, total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density-lipoprotein cholesterol (HDL-C), blood urea nitrogen (BUN), creatinine and, aspartate amino-transferase (AST), alanine amino-transferase (ALT) activities, uric acid, and atrial natriuretic peptide (ANP).After venous blood collection, hearts were harvested and processed accordingly for subsequent tissue and molecular analyses. Rat hearts were blotted dry on tissue paper and weighed, then were fixed with 4% paraformaldehyde. Next, they were embedded in paraffin and sections were stained with Masson’s trichrome according to the manufacturer’s protocol as previously described. The whole hearts were scanned at 20-fold magnification on a high-resolution microscope by using TissueFAXS software . The fibrosis content was quantified by identifying and counting the number of blue-staining pixels as a percentage of the total left atrial or left ventricular tissue area using ImageJ software.2 SHG images with 512 × 512 pixels at pixel scanning rate of 30 kHz and had laser power of 22.4 mW on the specimen.Collagen deposition in cardiac sections were analyzed by the second-harmonic generation microscopy (SHG). Multiphoton imaging was performed using 10 μm thick acute slices without de-waxing and staining, and acquisitions were taken with a high numerical aperture (NA) objective lens  which enabled visualization of a major part of the slice. Visualization of micrometer or submicrometer collagen fibers that were heterogeneously distributed in the cardiac tissue at millimeter scale required both a large field of view and a good spatial resolution. The SHG signal was excited by a femtosecond Ti: Sapphire laser  adjusted to wavelength of 800 nm and a fluorescence filter  was specific chosen for SHG detection. We therefore acquired 200 × 200 μmSmall pieces of atrial and ventricular tissue were placed into liquid nitrogen for snap freezing and later stored in − 80 °C freezer until analysis. Four rats in each group were chosen for heart mRNA expression analysis. Total RNA was prepared using TRI Reagent , then reverse transcribed . Quantitative real-time RT-PCR was performed using an ABI 7500 real-time system  and TaqMan Universal Master Mix II with TaqMan probes : PPARα, Rn00566193_m1; ACADM, Rn00566390_m1; TNF-α, Rn01525859_g1; ANP, Rn00664637_g1 and BNP, Rn00580641_m1.Data were expressed as mean ± SD; n indicated the number of rats. One-way ANOVA and Tukey’s multiple comparisons test were used. Statistical significance was considered as a P value ≤ 0.05. Statistical analyses were undertaken using GraphPad Prism software .Table Few atrial and ventricular premature beats (APC and VPC) were observed in only hypertensive rats, with and without empagliflozin treatment Fig. . The numBeing fed with the same high-fat diet, cardiac systolic dysfunction was noted in hypertensive rats . Empagliflozin did not significantly improve the LV EF (67.1 ± 9.4%)  Fig. a, it sigTo determine the effects of empagliflozin on collagen deposition in SHR-induced cardiac fibrosis, SHG microscopy Fig.  was utilP = 0.0002) and SHR ventricular tissue  . For ACADM transcriptional expression, it was also significantly increased in SHR atrial  and SHR ventricular tissue  .We included two genes that are related to fatty acid metabolism in the real-time PCR experiment. PPARα is a nuclear receptor that is activated by long chain fatty acids to regulate transcriptional activation of genes of key enzymes in fatty acid uptake and oxygenation . The othP = 0.0064) and was remarkably upregulated in SHR ventricular tissue  . The effect of empagliflozin on atrial TNF-α was similar to the ventricle without a statistical significance .Cardiac TNF-α over-expression can induce apoptosis, progressive chamber dilation, and contractile dysfunction . CompareP = 0.0039; NPPB, 36.66 ± 9.32-folds to WKY, *P = 0.0001) and in the ventricular tissue    but the attenuation of NPPB gene was non-significant   are encoded by NPPA and NPPB genes and both affect the control of extracellular fluid volume and electrolyte homeostasis. NPPA and NPPB are downregulated in adult ventricular tissue and can increase predominantly in condition of heart failure and cardiac hypertrophy . In SHR,The beneficial effects of empagliflozin shown in this study include: (1) reduced systemic blood pressure, (2) improved renal function, (3) improvement in left atrial dilatation, (4) attenuated intra-cardiac fibrosis, (5) improved incline and decline dP/dt of left ventricle, and (6) modulated genes related to fatty acid metabolism (PPARα and ACADM) and restored upregulated genes in HF.Like findings in clinical trials , 11, empMyocardial systolic dysfunction was shown in 8-month-old SHR rats fed with Western-type diet . TherefoAnother SGLT2i, dapagliflozin significantly improved LV EF in a HF model that was creased by coronary artery ligation/reperfusion on high-fat diet-induced pre-diabetic Wistar rats. The biological mechanisms on cardioprotection of 4-week dapagliflozin were suggested from a combination of modulation of mitochondrial DRP1, caspase 3, and lipid peroxidation . The LV The effect of empagliflozin on plasma glucose had been examined in non-diabetes human subjects. Empagliflozin can reduce the threshold for glucose spillage into urine to a level below the fasting plasma glucose concentration (~ 30 to 40 mg/dL) . As a reThere were three hypothesis responding to the diabetes-independent cardiovascular protective effects of empagliflozin: diuretic , fuel 3 and thriThe absence of data on the effects of EMPA on myocardial redox aspects, apoptosis, metabolism, intramyocardial sodium and calcium regulation, and insulin sensitivity, is a limitation of this study. In addition, the animals were not housed in individual cages to collect urine that allowed to collect information about glucosuria, albuminuria, and urinary sodium excretion. The lack of a diuretic control group, with an anti-aldosteronic agent, is another study limitation –45.Empagliflozin exerted beneficial effects on systemic blood pressure, renal function, and ameliorated left atrial dilatation, intra-cardiac fibrosis, contraction and relaxation dysfunction in hypertensive heart failure rats. The potential application beyond type 2 DM for SGLT2i may include hypertension heart failure.


The need to diagnose RV dysfunction is evident. Because of itswide availability, echocardiography is the most frequently used imaging test in clinicalpractice to assess RV size and function. That assessment can be hindered by the complexRV anatomy; thus, important international societies of cardiovascular imaging haverecommended the routine and systematic addition of several echocardiographicmeasurements and techniques.3 That approach includes conventionalparameters, such as RV basal diameter  and tricuspid annularplane systolic excursion , as well as advancedparameters, such as the s wave of the RV free wall on tissue Doppler, ejection fraction on 3D echocardiography  and longitudinal strain of the RV free wall .The importance of the right ventricle in cardiovascular physiology has beenunderestimated for decades. Previously considered a mere conduit, the right ventricle iscurrently known to play a major role in maintaining global cardiac function intact. Inparallel, right ventricular (RV) systolic function has been shown to be an essentialdeterminant of clinical outcomes in several scenarios,1 Right ventricular longitudinal strain is a parameter lessdependent on the angle, with less intra- and interobserver variability, that canapparently detect early RV dysfunction. Its drawbacks include the high dependence onimage quality and the variability of the software of the equipment available in themarket.3 Recently aninternational consensus has been reached to standardize the use of 2D-STE to obtain RVstrain.4 The specific use ofright-ventricle-focused apical 4-chamber view is recommended for correct strainmeasurement. Extreme care should be taken to define the region of interest (ROI) of theendocardial border (suggested ROI: 5 mm), because of the RV shape and thin walls. Thepericardium should be excluded from the analysis, because of the risk of strainunderestimation.In this scenario, strain (systolic shortening percentage) and strain rate (shorteningrate), calculated by speckle tracking on two-dimensional echocardiography (2D speckletracking or 2D-STE), emerge as alternatives in the RV systolic function analysis. Thelongitudinal strain of the RV free wall, excluding the ventricular septum, showedprognostic value in patients with signs and symptoms of cardiopulmonary disease, such asheart failure, myocardial infarction, pulmonary hypertension, congenital heart diseases,RV arrhythmogenic cardiomyopathy and amyloidosis.5 published inthis issue of the Arquivos Brasileiros de Cardiologia, shows that theassessment of strain and strain rate by use of 2D-STE can detect early RV dysfunction inindividuals with systemic lupus erythematosus (SLE) associated with mild and subclinicalpulmonary hypertension [PH: systolic pulmonary artery pressure (SPAP) between 30 and 50mmHg]. It is worth noting that, considering the other conventional and nonconventionalparameters of RV size and systolic function, RV dysfunction was only diagnosed inindividuals with moderate to severe PH (SPAP ≥ 50 mmHg). It is necessary toacknowledge the little methodological limitation in estimating right atrial pressure, towhich only two values were attributed (8 or 15 mmHg) in the dynamic analysis of theinferior vena cava. This might have overestimated the SPAP in some patients, but thatbias does not invalidate the results of that study. Another study has reported that thesurvival rates of patients with SLE who develop PH seem lower than those of individualswith primary PH.6 The findings of thestudy by Luo et al.5 allow us tospeculate that RV dysfunction is the mediator of the high mortality risk in that groupof individuals. Those findings suggest that the use of strain to analyze RV systolicfunction in SLE can select patients in a subclinical phase who require carefulsurveillance and early therapy to prevent the development of RV failure andcardiovascular complications. Further studies are necessary to deepen thepathophysiological knowledge of RV dysfunction in the clinical context of SLE and toassess the role of intervention strategies to reduce mortality.The study by Luo et al.,


Isolated left ventricular noncompaction (LVNC) was described for the first time in 1984. It is a rare congenital disease, characterized by prominent trabecular meshwork pattern and deep intertrabecular recesses, communicated with the left ventricular chamber. Clinical presentation varies from asymptomatic patients, to those developing supraventricular and ventricular arrhythmias, thromboembolism, heart failure and sudden cardiac death. We present an unusual case, where the patient with Neurofibromatosis type 1 presented with a wide complex orthodromic atrioventricular reentrant tachycardia (AVRT) and a diagnosis of left posterior paraseptal accessory pathway in association with LVNC. A 21-year-old previously asymptomatic Caucasian man, presented to the emergency department with symptomatic wide complex sustained tachycardia that required cardioversion for termination. His personal history was positive only for the use of recreational drugs . He was diagnosed with mild form of genetic neurofibromatosis type 1 (NF1), Von Recklinghausen’s disease at 3 years old. His grandfather died from left atrial myxoma and heart failure at 74 years old.Physical examination: Cardiovascular examination results and blood pressure were normal. Centripetal obesity. The body mass index was: 32. Had a six cafe-au-lait spots, measuring between to 5 to 12 mm. Two Lisch nodules were found in the eyes, and the head size was larger than average. Electrocardiogram was performed  dilatation, apical, lateral, and inferior hypokinesia, multiple and prominent myocardial trabeculations that communicate with the chamber in the same segments, and noncompacted/-compacted myocardium ratio of >2.5. Fig. In the electrophysiologyical study, orthodromic atrioventricular (AV) reentrant tachycardia was induced using as the retrograde limb, a concealed left posterior paraseptal accessory pathway located at 5 o’clock position in mitral valve annulus as observed from the left anterior oblique projection. Anterograde conduction over the AV node was associated with the rate- dependent block in the right bundle branch. Radiofrequency catheter ablation eliminated the accessory pathway conduction but terminated the tachycardia Fig. .NF1 is usually diagnosed based on the presence of characteristic signs and symptoms. Specifically, physicians consider two or more of the following features to diagnose NF1. For the diagnosis six cafe-au-lait spots measuring >5 mm in all children and >15 mm in adults. Other signs and symptoms may include the following: (1) high blood pressure ; (2) bone abnormalities; (3) optic nerve tumors; (4) Lisch nodules; (5) learning disabilities, attention deficit hyperactivity disorder, and autism spectrum disorder; (6) larger than average head size; (7) and short stature. Our patient has a minor expression of NF1, as confirmed by a genetic diagnostic test [The frequency of congenital heart defects ranges from 0.4% to 6.4% in published series of NF1 patients . Is unclLVNC associated with congenital heart disease was reported for the first time in 1926 . Only inet al., who defined LVNC as a two-layer structure, with a thin layer, normally compacted (C) and a thicker, noncompacted (NC) (with an NC/C ratio >2), which were excessively prominent trabeculae and deep intertrabecular recesses measured at the end of systole in the short -axis parasternal projections. In hearts with prominent myocardial trabeculations due to other causes, the thickness ratio between trabeculated myocardium and normal ones does not reach >2. Moreover, trabeculated regions associated with LVNC tend to be segmentary instead of diffuse, because it occurs in the left ventricular hypertrophy [The echocardiographic criteria of LVNC include: (1) the presence of ≥4 prominent trabeculations and deep intertrabecular recesses; (2) appearance of blood flow from the ventricular chamber to intertrabecular recesses that can be visualized using color Doppler imaging; (3) segments of noncompacted ventricle mainly involving the LV apex, inferior, and lateral wall and typically show a two -layer structure with telesystolic ratio of >2 between the noncompacted subendocardial layer and the compacted subepicardial one; and (4) absence of coexisting cardiac anomalies. The most widely used and accepted classification is proposed by Jenni ertrophy , 11.Electrophysiological findings include supraventricular tachycardia (SVT), ventricular pre-excitation of the Wolff-Parkinson-White syndrome, particularly in the pediatric population (present in up to 7% in this age group) , but rarHerein, the patient characteristics associated with NF1 were confirmed by genetic testing. The patient also had LVNC, resulting in a wide complex orthodromic AV reentrant tachycardia due to aberrant conduction in the right bundle branch block pattern.This is a case of NF1 associated with LVNC. This association has not yet been reported previously and may only be casual. Therefore, prospective studies should be conducted to validate this association. In addition all patients with supraventricular tachycardia should be initially evaluated, to rule out structural heart disease, and as in the present case, a rare condition like LVNC should be carefully considered and closely followed up due to the potential for other complications related to cardiomyopathy.Supplementary DataClick here for additional data file.


Furthermore, 28 patients suffered from dissections, of which 14 had a type A dissection, 10 had a type B dissection, and 4 patients suffered from both. Of those who suffered from dissection, 64% (18 out of 28) had a dilatation of the PA, versus 39% (53 out of 134) in the patient group without a dissection (p < 0.05). There was a significant association between type B dissection and descending aorta diameter  and PA dilatation . In the multivariable analysis the final model for type B dissection, only systolic blood pressure  and PA dilatation were statistically significant  while descending aorta diameter was not. Conclusions: We report an association between progressive PA dilatation and type B dissection. Our findings encourage a renewed interest in PA dimensions in MFS.Objective: Marfan syndrome (MFS) is a connective tissue disorder associated with severe cardiovascular morbidity and mortality. It is unknown if aorta complications in MFS are associated with progressive pulmonary artery (PA) dilatation. Methods: We measured the PA diameter on routine magnetic resonance imaging in a population of MFS patients seen in our specialised centre with follow up of diameters as well as the outcome. Results: PA dilatation was defined as an increase in diameter of 2 mm or more, and 71 patients (44%) of our total cohort ( Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder, in which cardiovascular complications and more specific aortic dissections are associated with severe morbidity and mortality . Type A Medical interest in MFS is, thus, focused on the aorta, and although involvement of the pulmonary artery (PA) has been studied previously, it has lost clinical relevance. To illustrate this, in the revised Ghent nosology introduced in 2010, more diagnostic weight was given to fibrillin-1 mutation (FBN-1), as well as aortic root dimensions and ectopia lentis, while dilatation of the main pulmonary artery (PA) was excluded from the diagnostic criteria . The reaActual documentation and follow-up data of PA dilatation are, however, sparse. Yet, since the PA and aorta originate from the same common trunk but are exposed to other pressures and haemodynamics after birth, we hypothesised that the follow up of PA dimensions might be of clinical relevance since it may reflect tissue characteristics independent of blood pressure exposure and altered flow patterns . We, theOur centre is a tertiary referral centre for MFS. All patients are seen on an annual base as published previously, and consecutively prospectively entered in our database . All pat3) or gadolinium-enhanced MRA .All MRI images were acquired on a 1.5T clinical MRI scanner  using aortic diameter protocol without intravenous contrast or MRA protocol with intravenous contrast (gadolinium), all with a slice thickness of 8 mm. Aortic and PA diameters were measured on the axial and sagittal multislice balanced steady-state free precession images .Baseline descriptive patient characteristics were provided for the study group as a whole and per type of dissection. Data are presented as medians and interquartile ranges (IQR) for continuous variables or numbers and percentages for categorical variables. Possible explanatory factors were selected based on reasoning/hypothesis. For these factors, univariate correlations with PA growth were examined using logistic regression analyses in patients with a type A or B dissection or both as a reference category. All variables from the univariate associations were entered in a multivariable full model. Backward model selection was then performed wherein a At the moment of analysis, 181 patients were diagnosed with an FBN-1 mutation, of which 162 had undergone two or more MRI scans. The mean follow up time between two scans was 8.6 years (standard deviation (SD) ± 2.7 years).n = 162), 28 patients suffered from aortic dissections, of which 14 had a type A dissection , 10 had a type B dissection , and four patients suffered from both . A total of 76 (46.9%) patients underwent aortic surgery, of which 48 underwent elective surgery. No patients underwent PA surgery.In this cohort (n = 133) of the patients were treated medically with a beta-blocker , of which 2.3% (n = 3) were combined with an aldosterone receptor antagonist and 2.3% (n = 3) with a calcium antagonist. A total of 47.5% (n = 77) of the patients were treated with an angiotensin-1 receptor blocker  met this criterion. Of the patients who had a dissection, 64% (18 out of 28) had a growth of the PA, versus 39% (53 out of 134) in the patient group without a dissection. The median PA growth was 3.5 mm, and the interquartile range (IQR) was 1.5–5 mm in those who suffered from type B dissection, while the median growth was 1 mm (IQR 0–3mm) in those who did not .p-value = 0.50). For a type B dissection, the variables descending aorta diameter (OR 1.14) and pulmonary root dilatation  showed a significant association. In the group of patients with a dissection (both or either type A or B), the variables sex (OR 2.11), age (OR 1.03), systolic blood pressure (OR 1.03), aorta ascendens diameter (OR 1.13) and aorta descendent diameter (OR 1.27) showed significant associations. Again, pulmonary root dilatation was not significantly associated (p = 0.17). Data are shown in There was a significant association between type A dissection and the variables age , diameter of the ascending aorta (OR 1.15), and aorta dilatation rate (OR 0.31). PA dilatation was not significantly associated . The final model for the group with a dissection  contained systolic blood pressure , aorta descendens diameter  and pulmonary root dilatation . The R2, or explained variance, was highest for the model concerning all dissection types (R2 = 0.345). In the multivariable analysis, the final model for type A dissection did not contain pulmonary root dilatation. The model for type B dissection contained systolic blood pressure (OR 1.06) and pulmonary root dilatation (OR 1.85), which were both statistically significant (both Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder, in which cardiovascular complications and especially type A dissection are the most life threatening, thus gaining the most clinical interest.The first official definition of MFS was described in the Berlin criteria in 1986 and was based only on clinical phenotype such as skeletal, aortic, and pulmonary features . Hence, The prognosis in patients suffering from MFS has improved significantly since the introduction of the Bentall procedure  in 1968 because type A dissection can now be treated or prevented ,11. The Up until now, no longitudinal data on PA dilatation in adult patients with MFS are available. Nollen et al. showed significant higher PA dimensions in Marfan patients than in controls, and within the Marfan group, a significant larger pulmonary root in patients with aortic root replacement. Also, they found that the difference in diameter between the pulmonary root and the pulmonary bifurcation is larger in Marfan patients. They used the anterior-right diameter of the pulmonary root on MRI because this dimension showed the smallest variability . In contThe PA and aorta derive from the same embryological origin, the so-called ‘common trunk’ which is split in order to form the ascending aorta and the PA . This imSeveral limitations should be taken into account when interpreting this study. Firstly, our data are only observational, and it cannot be concluded from our data that descending aorta interventions in patients with progressive PA dilatation already should be performed earlier. Secondly, only patients with MFS with the FBN-1 mutation were used in this analysis. Therefore, data cannot be extrapolated to other connective tissue disorders or hypertension patients. Thirdly, PA measurements were not performed doubly oblique, but since all measurements were performed in the same manner as described above, the reported association remains valid. However, PA dilatation is an easily available diagnostic tool since all subjects with MFS undergo routinely aortic imaging, and by including PA dilatation in this follow up, physicians may better risk-stratify MFS patients.In conclusion, we now, for the first time, show a longitudinal follow up of PA dimensions in MFS. Progression of PA dilatation is associated with the occurrence of type B dissection, which might reflect tissue vulnerability. Further investigation is needed in order to stratify the clinical relevance of progressive PA dilatation, while we advocate measuring PA dimensions in routine follow up of aorta dimensions in MFS.What is already known about this subject?—Marfan syndrome has high cardiovascular morbidity, especially due to aortic dissections.What does this study add?—We describe that progressive pulmonary artery dilatation is associated with type B dissection, with a better odd’s ratio than all present predictors.How might this impact on clinical practice?—Measurement of the pulmonary artery, available at no extra costs in the routine work-up may help in better risk estimation in Marfan syndrome.We show for the first time a longitudinal follow up of PA dimensions in MFS. Progression of PA dilatation is associated with the occurrence of type B dissection, which might reflect tissue vulnerability.Further investigation is needed in order to define the clinical relevance of progressive PA dilatation, while we support measuring of PA dimensions in routine follow up of aorta dimensions in MFS.


Breast cancer (BC) radiotherapy (RT) can induce cardiotoxicity, with adverse events often observed many years after BC RT. Subclinical left ventricular (LV) dysfunction can be detected early after BC RT with global longitudinal strain (GLS) measurement based on 2D speckle-tracking echocardiography. This 6-month follow-up analysis from the BACCARAT prospective study aimed to investigate the association between cardiac radiation doses and subclinical LV dysfunction based on GLS reduction.The patient study group consisted of 79 BC patients  treated with RT without chemotherapy. Echocardiographic parameters, including GLS, were measured before RT and 6 months post-RT. The association between subclinical LV dysfunction, defined as GLS reduction > 10%, and radiation doses to whole heart and the LV were performed based on logistic regressions. Non-radiation factors associated with subclinical LV dysfunction including age, BMI, hypertension, hypercholesterolemia and endocrine therapy were considered for multivariate analyses.p = 0.01). For left-sided patients, mean heart and LV doses were 3.1 ± 1.3 Gy and 6.7 ± 3.4 Gy respectively. For right-sided patients, mean heart dose was 0.7 ± 0.5 Gy and median LV dose was 0.1 Gy. Associations between GLS reduction > 10% (37 patients) and mean doses to the heart and the LV as well as the V20 were observed in univariate analysis . In multivariate analysis, these associations did not remain significant after adjustment for non-radiation factors. Further exploratory analysis allowed identifying a subgroup of patients (LV V20 > 15%) for whom a significant association with subclinical LV dysfunction was found .A mean decrease of 6% in GLS was observed (− 15.1% ± 3.2% at 6 months vs. − 16.1% ± 2.7% before RT, This analysis indicated that subclinical LV dysfunction defined as a GLS decrease > 10% is associated with cardiac doses, but adjustment for non-radiation factors such as endocrine therapy lead to no longer statistically significant relationships. However, LV dosimetry may be promising to identify high-risk subpopulations. Larger and longer follow-up studies are required to further investigate these associations.NCT02605512, Registered 6 November 2015 - Retrospectively registeredClinicalTrials.gov:  Breast cancer (BC) radiotherapy (RT) reduces BC recurrence and improves survival . HoweverIn most of previous studies on early myocardial dysfunction post BC RT, a statistically significant decrease in GLS was observed among left-sided BC patients, ranging from 5 to 14% at different post-RT time points from few weeks to 14 months –16, wherKnowledge on the relationship between cardiac exposure and the decrease of strain is limited. A dose-related regional myocardial dysfunction in the acute phase after RT was found in left-sided BC patients with the greatest reduction in the apical part of the left ventricle, which received the highest radiation dose , but no Based on the BACCARAT prospective cohort of BC patients treated with 3D-CRT , we aimed to present a 6-month follow-up analysis of the association between radiation exposure to the whole heart and the left ventricle (LV) and the evolution of GLS from baseline to 6 months after RT, in particular for subclinical LV dysfunction defined as GLS reduction > 10%, a secondary endpoint of BACCARAT.n = 20). In addition, 6 patients without available cardiac dosimetry (see details below) were excluded. Finally, the patient study group consisted of 79 patients.This prospective, monocentric observational clinical study  initiallAfter the surgical treatment of BC, all patients were treated with 3D-CRT with 6 and 25 MV photon beams by tangential fields. The planning target volume dose was 50 Gy delivered in 25 daily fractions of 2 Gy over 5 weeks or 47 Gy delivered in 20 daily fractions of 2.35 Gy over 5 weeks for patients treated between January 2016 and May 2016 . For most patients, 6MV photons were used, except few cases of patients with big breast where 25 MV additional photons were used. Additional boost of 9–15 Gy could be applied to the tumor site using photon/electron beams with energies ranging from 6 MeV to 18 MeV. The treatment planning system (TPS) used to perform dose calculations was Eclipse™ with the Analytical Anisotropic Algorithm (AAA v13.6) . Each patient’s RT was planned such that the dose distribution was optimized and normalized to the International Commission on Radiation Units and Measurements (ICRU) reference point of the breast and to achieve QUANTEC dose constraints to organs at risk including the heart .The methodology of the complete evaluation of radiation doses in BACCARAT patients was previously described , 21. Onl− 1).A comprehensive 2D echocardiography study was performed at baseline before RT and 6 months after RT with a commercially available ultrasound Acuson S2000 , using a 3 MHz transducer. Image analysis was independently performed by a single blinded observer unaware of clinical data. LV ejection fraction (LVEF) was measured using the biplane Simpson’s method from apical two- and four-chamber windows. Myocardial function by longitudinal myocardial strain was calculated using two-dimensional speckle tracking echocardiography (2DSTE) and the automated function imaging technique for tracking of acoustic markers (speckles) . The 2DSt-test or Wilcoxon non-parametric test was used to compare continuous variables, adapted to paired samples for the comparison of echocardiographic variables  before RT and 6 months after RT. Percent change in GLS was defined as the ratio of the difference between RT + 6 months measurement and baseline measurement. A more than 10% decrease in the GLS is generally considered clinically relevant [p-value < 0.20 in univariate analysis. Finally, p-value < 0.05 was considered statistically significant. All statistical analysis was performed using SAS statistical software for Windows .Continuous variables are presented with mean and standard deviation or median and (interquartile) range values. Categorical values are presented with percentages. Student’s relevant –18 to deA total of 79 BC patients (64 left-sided and 15 right-sided) were included in the analysis. Baseline patients’ characteristics are shown in Table Radiation doses received by the heart and the left ventricle are detailed in Table p = 0.02) with a mean decrease of 6%. We observed subclinical LV dysfunction defined as GLS reduction > 10% in 37 patients corresponding to 48% of left-sided BC patients and 40% of right-sided BC patients. Moreover, 18 patients with a GLS increase > 10% were observed (27% among right-sided BC patients and 21% among left-sided BC patients).The results of echocardiography are summarized in Table p-value of less than 0.20 and were considered in further analysis (Table p = 0.04), was in particular significant for patients treated with anti-aromatase (OR = 4.52 (1.32–15.53)). In univariate analysis, laterality of BC was not significantly associated with the event GLS reduction > 10% (p = 0.55), in contrast with mean dose to the heart and to the left ventricle . In multivariate analysis, none of these associations remained significant after adjustment for BMI, hypercholesterolemia and endocrine therapy. The LV V20 was the closest from statistical significance . In further exploratory analysis of the LV V20, patients were grouped according to whether the LV V20 was 0%, less than 15%, or 15% or more. There was a 4-fold increase in the adjusted odds ratio for subclinical LV dysfunction for the most exposed category, as compared with the 0% category  .In this prospective study, we evaluated the association between cardiac exposure and subclinical LV dysfunction defined as GLS reduction > 10% from baseline before RT to 6 months after RT in BC patients treated with 3D-CRT without chemotherapy. The associations with mean doses to the heart and the LV as well as the heart and LV V20 were significant in univariate analysis. In multivariate analysis, these associations were no longer significant after adjustment for non-radiation factors including BMI, hypercholesterolemia and endocrine therapy. Further exploratory analysis allowed identifying a subgroup of patients (LV V20 > 15%) with a significant association with subclinical LV dysfunction which remained significant after adjustment.Decrease in longitudinal strain was previously observed in left-sided BC patients with follow-up ranging from few days to 14 months after RT , 26 and We considered a subclinical LV dysfunction defined as GLS reduction > 10% which has been considered clinically relevant  and whicR = 0.35, R = 0.22) [p = 0.04) but was no longer significant in multivariate analysis .Even if all previous studies concluded that longitudinal strain was decreased after RT for left-sided BC patients and not for right-sided BC patients, little was known on the association between cardiac doses and decrease in longitudinal strain. A modest correlation was observed between GLS reduction 6 weeks after RT and mean heart dose or V30 ( = 0.22) , 27, but = 0.22) . With a  = 0.22) . In our 2 vs. 3.3 Gy for patients with BMI > 25 kg/m2, p < 0.01), as previously observed [Contribution of factors apart from radiation dose on the risk of long term cardiac disease, such as age, hypertension, diabetes or preexisting cardiac diseases was previously observed  as they observed . Last, tobserved , 31. A sSome studies investigated more precisely the longitudinal strain changes based on the segmental evaluation within the LV . Lo et aResearch on radiation-induced changes in LV-function and association with cardiac exposure in patients treated with RT is not only relevant for BC patients. Patients treated for other organ with relevant heart doses like esophagus cancer, lung cancer or Hodgkin’s lymphoma are also of concerns. Some studies showed that, similarly to BC patients, these patients could receive high doses to the heart and its substructures  and GLS Even if we could observe associations between cardiac doses and the risk of subclinical LV dysfunction, our study showed the importance to consider also non-radiation factors such as BMI or endocrine therapy in the investigation of these association with doses as the results didn’t remain significant after adjustment. Our study is one of the largest ever published in this research area. However, with 79 patients, the size of the population involved a limited statistical power for odds ratios sub-analyses which may partly explain the absence of significant results in multivariate analysis. A large multicenter European study (MEDIRAD EARLY-HEART study) is ongoing and plan to include 250 patients which should provide results without this limitation . Some alThis is the first study to investigate the associations between BC RT-induced cardiac doses and subclinical LV dysfunction defined as a GLS reduction > 10%, 6 months after RT. This 6-month follow-up analysis indicated a significant association with mean heart dose, V20 of the heart, mean LV dose and V20 of the LV in univariate analysis. However, they didn’t remain significant in multivariate analysis in particular after adjustment for endocrine therapy. An exploratory analysis in our study allowed identifying a subgroup of patients (LV V20 > 15%) for whom a significant association with subclinical LV dysfunction was observed. LV dosimetry may be promising to identify high-risk subpopulations. Larger and longer follow-up studies are required to further investigate these associations.


Peripartum cardiomyopathy (PPCM) is a rare form of pregnancy-associated heart failure and is considered to be a diagnosis of exclusion. There are many hypotheses on the aetiology of PPCM; however, the exact pathophysiological mechanism remains unknown. It shows many resemblances to other conditions, such as familial dilated cardiomyopathy or myocarditis, and therefore it can be hard to make a definite diagnosis. We describe four cases of peripartum-onset heart failure in women who were suspected of having PPCM. We discuss the differential diagnosis, pathophysiological mechanisms and various diagnostic modalities. Peripartum cardiomyopathy (PPCM) is a rare form of pregnancy-associated heart failure and is considered to be a diagnosis of exclusion. Currently, the Heart Failure Association of the European Society of Cardiology Working Group on PPCM defines it as an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found.2PPCM may show resemblances to dilated cardiomyopathy (DCM), in clinical presentation as well as in genetic background, and it is associated with maternal and fetal mortality and morbidity.4Patients are treated with conventional heart failure medication. Recently, bromocriptine has been discovered as having positive effects on the outcomes and can be added to standard heart failure treatment. While evidence on the effectivity and safety of bromocriptine is scarce, its use has been associated with a decrease in morbidity and mortality rates in patients with PPCM and higher rates of left ventricular recovery.The diagnosis of PPCM is difficult to make, as it is a diagnosis of exclusion, with a considerable overlap with other conditions. Especially in women who present with acute heart failure at the end of pregnancy or directly post partum, thorough investigations and intensive follow-up may often lead to alternative diagnoses. We describe four cases of patients with peripartum heart failure at our centre who were initially diagnosed with PPCM, but in whom a different diagnosis eventually emerged. We discuss the differential diagnosis, pathophysiological mechanisms and the use of various diagnostic modalities.This 31-year-old primigravida woman with a history of pulmonary embolism and multiple deep venous thrombosis during the index pregnancy was admitted to the obstetric department with pre-eclampsia with severe hypertension of 160/100 mm Hg at 26 weeks of pregnancy. She had been taking vitamin K antagonists, which were switched to low-molecular-weight heparin, and she was treated with magnesium sulfate and intravenous antihypertensive drugs. A primary caesarean section under general anaesthesia was performed at 30 weeks of pregnancy due to fetal distress, delivering a growth-restricted, premature girl of 920 g. Postsurgery the mother developed severe postpartum haemorrhage with a total of 5000 mL blood loss, and treatment was complicated by her anticoagulation therapy. She received blood transfusions and was discharged from the hospital with a haemoglobin level of 77.3 g/L. Three days later she was readmitted with complaints of fatigue, severe dyspnoea and fever. She had pleural effusion and thrombocytopaenia. She was later transferred to the cardiac intensive care unit (ICU) due to deterioration of her condition, and echocardiographic examination revealed severe left ventricular dysfunction with mild dilatation of the ventricles. ECG showed a sinus tachycardia with low voltages in the extremity leads and a QS pattern in V1–V3 . CoronarBecause of the combination of multiple venous emboli, pre-eclampsia with proteinuria, pleural effusion and the thrombocytopaenia, the patient was referred to an immunologist, who diagnosed her with antiphospholipid syndrome and systemic lupus erythematosus (SLE). Her last echocardiogram showed only a mild impairment of left ventricular function.This 25-year-old primigravida woman with a history of childhood asthma and generalised anxiety disorder was admitted to a cardiology ward unit with progressive dyspnoea at 26 weeks of pregnancy. Her ECG revealed several abnormalities , and echThis 36-year-old woman with a history of unspecified palpitations and a family history of sudden cardiac death, who had once been assessed by a cardiologist because of suspected long-QT syndrome in her infant daughter, was admitted to the cardiology ward unit with complaints of dyspnoea and chest pain, 4 months after giving birth to her third child. Her N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was markedly elevated, and echocardiography revealed a DCM with a left ventricular ejection fraction of 15% and moderate to severe tricuspid insufficiency and a moderate to severe mitral insufficiency. She was diagnosed with PPCM and was treated with heart failure medication on which she slowly recovered. She was discharged home and seen by a cardiologist for regular follow-up. A 24-hour Holter ECG showed frequent, non-sustained ventricular tachyarrhythmias, and as part of her outpatient follow-up an MRI scan of her heart was made, which showed distinct tubular dilatation of the right ventricle, with less distinct dilatation of the left ventricle . HypokinThis 26-year-old primigravida woman in labour with an unremarkable medical history was urgently admitted to the obstetrics department with failure to progress in the second stage and the suspicion of an intrauterine infection. She underwent an emergency caesarean section, which was complicated by a severe postpartum haemorrhage with a blood loss of 2 L. She was treated with sulprostone and intravenous fluids and a blood transfusion, immediately after which she became severely dyspnoeic. Chest X-rays showed congestion, and echocardiography revealed severe left ventricular dysfunction with an estimated ejection fraction of 15% and only moderate wall motility in the basal septal region. There were no signs of ischaemia or coagulopathy (thereby excluding amniotic fluid embolism). The diagnosis of PPCM was suspected and she was intubated and transferred to the ICU, where she was treated with conventional heart failure medication. She could be extubated very quickly after initiation of therapy, and repeat echocardiography showed normalisation of left ventricular function with normal ventricular dimensions within a few days. She had experienced the caesarean section as very traumatic and has visited a psychologist to help her cope. In the outpatient clinic, the question rose whether she had suffered from PPCM or whether her acute heart failure was caused by a takotsubo cardiomyopathy. The urgent and complicated characteristics of the delivery, as well as the echocardiographic images of akinesia affecting the whole ventricle except the basal segments and the very rapid recovery of the ejection fraction, are suggestive of a takotsubo cardiomyopathy rather than a PPCM. She returned to the cardiologist a few years later with the wish to become pregnant again. Due to her recovered left ventricular function, there were no objections to a subsequent pregnancy and she has had several uncomplicated pregnancies since. Her left ventricular function has remained normal to date.We have described four women who presented during pregnancy or in the early postpartum period with signs of heart failure and echocardiographic signs of severely impaired left ventricular function. The peripartum onset makes the diagnosis of PPCM likely; however, features of the patients’ history and the results of specific investigations including histology suggested alternative diagnoses.Myocarditis in SLE is usually asymptomatic, and while cardiac problems in SLE are often related to coronary disease, which was ruled out in our patient, lupus myocarditis without coronary involvement is not uncommon.8Mitochondrial myopathies can be isolated to skeletal muscle, but can also affect cardiac muscle, presenting with a wide range of clinical problems.Other forms of cardiomyopathy, such as ARVC as diagnosed in our patient, have been misdiagnosed as PPCM when presenting in the peripartum period. In an article from 2011, mutations in the titin (TTN) gene were associated with ARVC, the same mutation as reported in both DCM and PPCM.In PPCM, many pathophysiological mechanisms have been suggested, but it is unlikely that there is one single mechanism. With respect to the pregnancy-associated aetiologies, many advances have been made in the angiogenic imbalance theory.16Another hypothesis that has been repeatedly proposed within the recent literature is the prolactin and oxidative stress theory.17–20The introduction of bromocriptine as treatment for PPCM is based on the theory of prolactin-mediated endothelial dysfunction; it seems to have beneficial effects on morbidity and mortality and is associated with higher rates of left ventricular recovery.Due to PPCM being a diagnosis of exclusion and the overlap with other syndromes, it is possible that many cases of PPCM are missed. On the other hand, the haemodynamic stress of pregnancy can reveal undiagnosed cardiac conditions such as DCM, or can give rise to conditions such as takotsubo cardiomyopathy, which could also mimic PPCM. It can also be hard to distinguish PPCM from pre-eclampsia and eclampsia, especially when they are complicated by pulmonary oedema. Furthermore, drugs administered for postpartum haemorrhage, like prostaglandin analogues, can cause coronary spasms and other severe cardiovascular reactions, mimicking PPCM.Around two-thirds of women with PPCM present post partum,26This identification of pathogenic mutations in other familial cardiomyopathies further highlights the possibility that many cases of PPCM might be due to genetic DCM revealed for the first time by the stress of pregnancy. Also, the higher incidence in specific ethnic groups and in defined areas of the world suggests a role of environmental and/or genetic factors.27Due to the difficulties in diagnosing heart failure manifesting during pregnancy or in the postpartum period and the limited availability of broad genetic tests, it is very likely that patients with genetic forms of DCM and other cardiomyopathies have been included in the published studies on PPCM over the past decades. This has the potential to fuel a cycle of overdiagnosis and ever increasing incidence of what might be a relatively rare condition. For example, the increases in incidence of PPCM in the USA (from 1 per 4350 in 1990–1993 to 1 per 2229 in 2000–2002)It is probable that a collection of pregnancy-related factors, which include haemodynamic stress and high prolactin levels, combined to varying degrees with an underlying genetic predisposition for cardiomyopathy, result in the prepartum or immediate postdelivery onset of heart failure, with the exact importance of each factor varying from case to case. As the exact pathophysiology remains largely unknown and as it displays very similar clinical, demographical and genetic characteristics to other forms of cardiomyopathy, it may be defensible to regard PPCM as a syndrome, rather than a distinct diagnosis—a syndrome of peripartum heart failure of unknown origin, characterised by a reduced left ventricular ejection fraction accompanied by symptoms of heart failure, elicited by peripartum-induced changes in haemodynamic, hormonal and/or homeostatic systems, in previously healthy women, women with a pre-existent (unknown) condition or women with a predisposition for developing (dilated) cardiomyopathy. As such, it remains a diagnosis of exclusion or a diagnosis made in the early stages of the disease, when more definite answers are still being sought.


Dear Editor,We report the case of a 63-year-old male, with a history of acute myocardial infarction(AMI) and angioplasty 10 years prior, who was asymptomatic at presentation. He statedthat he had not undergone routine clinical follow-up and was therefore submitted toechocardiography for functional evaluation. Moderate dilation and dysfunction of theleft ventricle (LV) were detected, although with limitation in the evaluation of theapex, without information on the presence of an aneurysm or thrombus. Coronary computedtomography angiography (CCTA) was performed in order to identify in-stent restenosis,and the images showed apparent subocclusion distal to the stent in the anteriordescending artery  and a la-4. It is defined as myocardial ventricular wall thinning anddilation, with distinct margins, leading to akinesia or dyskinesia of one or moremyocardial segments during ventricular contraction,2-5. It typically affects the anteroapical region of the LV,because the blood supply of the anterior wall is highly dependent on the anteriordescending artery,3. Ventricular aneurysm develops within two to ten daysafter AMI, becoming apparent in the first year after the infarction, with an incidenceof 30-35% in patients who have experienced AMI-6. As a secondaryfinding, intracavitary thrombus affects approximately 40-60% of patients and results from the inflammatoryprocess in the endocardial region affected by the AMI, being associated with thehypokinesia and hypercoagulability existing in the infarction, increasing the risk of athromboembolic event after the third month in patients with ventricular aneurysm. Thereis a broad range of symptoms in LV aneurysms, ranging from none to dyspnea, heartfailure, or angina, as well as severe manifestations such as acute pulmonary edema,thromboembolism, and ventricular rupture-7. In the treatment ofsevere refractory cases, surgical procedures, such as plication, excision/suture,imbrication, and patch interposition, are indicated. In the case presented here, despite the extensive area of leftventricular dyskinesia with aneurysm formation and adherent intracavitary thrombus, thepatient remained asymptomatic, an uncommon presentation in large aneurysms, which wasdiagnosed only through CCTA, a noninvasive method that not only allows the diagnosis tobe made but also provides accurate measurements and can be used in the postoperativefollow-up,4-6,9-11. Routinescreening tests, such as echocardiography, often fail to assess the apex of the LV, evenwith a good access window,2,7. In addition to allowing the diagnosis to be made, the CCTA findingspromoted patient adherence to the treatment.Ventricular aneurysm is a serious complication of transmural myocardial infarction(occurring in 5-38% of cases), being the most common mechanical complication, typicallyevolving to physical limitations and having a negative impact on quality oflife


R = 0.289, p = 0.034), severity on the Fazekas scale (p = 0.000), and with the size of subcortical (p = 0.002) and semiovale (p = 0.008) perivascular spaces. The PAI-1 level is not correlated with the t-PA level or MRI signs of SVD. The correlation between t-PA and the degree of WMH and perivascular spaces’ enlargement, without a correlation with PAI-1 and lacunes, is consistent with the importance of t-PA in BBB disruption and its role in causing brain damage in SVD.Cerebral small vessel disease (SVD) is one of the leading causes of cognitive impairment and stroke. The importance of endothelial dysfunction and high blood–brain barrier (BBB) permeability in pathogenesis, together with ischemia, is under discussion. The aim of this study was to clarify the relationship between tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1), and magnetic resonance imaging (MRI) signs of SVD. We examined 71 patients  with clinical and MRI signs of SVD, and 21 healthy volunteers with normal MRIs. All subjects underwent 3T MRI and measurements of t-PA and PAI-1 levels. An increase in t-PA level is correlated with the volume of white matter hyperintensities (WMH) ( Cerebral small vessel disease (SVD) is associated with age and vascular risk factors, and is one of the leading causes of cognitive impairment, and ischemic and hemorrhagic strokes . Given tThe aim of this study was to clarify the relationship between t-PA and plasminogen activator inhibitor (PAI-1) and MRI signs of cerebral SVD.The study included patients aged 46–70 years with cognitive and other cerebral complaints, presenting to the Center of Neurology  between January 2016 and December 2017, whose brain changes, as found by an MRI, were consistent with cerebral SVD  [The exclusion criteria were as follows: (1) severe dementia; (2) cognitive impairment due to probable Alzheimer’s disease according to the U.S. National Institute on Aging criteria ,21; (3) The control group consisted of volunteers with no clinical and neuroimaging evidence of cerebrovascular or degenerative pathology, matched in age and sex.According to the above criteria, 71 patients  and 21 volunteers  were included in the study.The study was approved by the Local Ethics Committee of the Center of Neurology. All subjects signed an informed consent form, agreeing to the examination and processing of personal data.All patients were asked about the appearance of general and neurological symptoms of the disease. Their physical status, major vascular risk factors , and neug at room temperature. The resulting supernatant was transferred to separate, labeled microcentrifuge tubes and frozen at −80 °C. The samples were thawed at room temperature before being examined. Solid-phase sandwich enzyme immunoassay, eBioscience  reagents and corresponding calibrators, and a Victor-2 microplate reader  was used. An ELISA assay was performed in duplicate using lyophilized control sera with low and high contents of the studied parameters.Blood samples for the subsequent measurement of t-PA and PAI-1 levels were obtained in the morning by cubital fossa venipuncture, on an empty stomach, in a Vacuette-tube  with a coagulation activator. The serum was separated from the blood cells by centrifugation for 10 min at 1500× 2; duration: 2 min 02 s); sagittal three-dimensional (3D) T2 FLAIR ; sagittal 3D T1-mpr ; diffusion MRI (DWI) using axial spin-echo echo-planar imaging sequence with two b-values (0 and 1000 s/mm2) ; axial susceptibility-weighted imaging (SWI) sequence with magnitude and phase images reconstruction .MRI data were acquired using a Siemens MAGNETOM Verio 3T scanner  with a standard 12-channel matrix head coil. To evaluate the STRIVE (Standards for Reporting Vascular changes on neuroimaging) criteria [Two neuroradiologists (E.K. and M.V.) evaluated the brain MRI studies in a standardized manner and blinded to clinical information. No STRIVE criteria were found in the control group. For the patient group, no acute or recent small lacunar infarcts were found based on DWI analysis. White matter and basal ganglia lacunes were graded on T2 FLAIR images depending on their amount . The Fazekas scale was used to quantify T2 FLAIR WMH (grades 0–3), as well as semi-automatic WMH segmentation using the LST toolbox for SPM8 , with fup < 0.05.Statistical analysis was performed using IBM SPSS 23.0  and R 3.4.3  software. The main parameters for categorical and ordinal variables were frequency and proportion (%), and median and quartiles for quantitative variables. In all cases, two-way statistical criteria were used. The null hypothesis was rejected if 2 test or Fisher’s exact test, according to the grouping variable levels.Qualitative parameters were compared using the χU test with Bonferroni correction. Spearman’s rank correlation was used to assess the relationship between the volume of WMH and t-PA and PAI-1 levels, as well as the relationship between these two blood parameters.Quantitative parameters were compared using the Kruskal–Wallis test with subsequent pairwise comparisons using the Mann–Whitney The main demographic data and risk factors in the examined patients and the control group subjects are presented in Clinical symptoms of SVD are presented in The main neuroimaging features of SVD are demonstrated in R = 0.289, p = 0.034; A direct relationship between the level of t-PA and degree of WMH was confirmed by comparing t-PA to the total volume of WMH (In this study, we established a link between the t-PA level and the volume and severity of WMH on the Fazekas scale, as well as the size of perivascular spaces. The patterns identified in the signs of SVD associated with increased BBB permeability ,27 indicThe identified correlation between t-PA level, WMH severity, and the size of perivascular spaces in patients with SVD—MRI signs of SVD associated with endothelial dysfunction, increased BBB permeability, and immune-mediated brain damage—correspond to the previously, experimentally established participation of t-PA in these pathological processes and their importance in the progress of SVD and its clinical manifestations. Further study of the parameters pathogenetically associated with t-PA and the development of SVD will expand our understanding of the mechanisms of small vessel and cerebral damage, with the ultimate goal of developing pathogenetically justified therapeutic approaches.


Background: Newborn piglets are commonly used in biomedical research. However, cardiovascular imaging of this species is quite challenging. For point of care diagnostics of heart function transthoracic echocardiography may be used, which appears to differ comparing newborn piglets with adult pigs. To date, there are few data or studies on the feasibility and quality of measurement of functional echocardiographic parameters in very small neonatal piglets.Objectives: To study the feasibility of transthoracic echocardiography in very small newborn piglets in supine position.Methods: In 44 anesthetized and intubated newborn piglets, positioned in supine position  transthoracic echocardiography was performed using a point of care ultrasound device , and a standard ultrasound transducer.Results: Using 2D- and M-mode-imaging left- and right-sided heart structures were accessible to transthoracic echocardiography in neonatal piglets. Diameters of the interventricular septum, the left ventricle, and the posterior wall were measured and ejection fraction and shortening fraction was calculated. Both left and right ventricular outflow tract could be imaged, and ventricular filling and systolic function could be evaluated. Furthermore, we were able to assess shunts of fetal circulation, such as patent ductus arteriosus, structure of the heart valves and congenital heart defects including ventricular septal defect.Conclusions: In summary, transthoracic echocardiography is feasible for assessment of cardiovascular function even in very small newborn laboratory piglets in supine position. Swine is one of the larger animal species commonly used in biomedical research. Many of their anatomical and physiological features are comparable to humans . TherefoDespite technical advance in recent years, functional imaging of the cardiovascular system in laboratory pigs, especially in neonatal piglets is still challenging. Magnetic resonance imaging (MRI) and computed tomography (CT) are often not readily available in every experimental setting. Furthermore, transport of anesthetized, catheterized and monitored animals to imaging facilities may affect study conditions and may influence results due to changes in body temperature or changes in ventilator or circulatory parameters. Therefore, using transthoracic echocardiography (TTE) may be a suitable option for point of care diagnostics.TTE is used to assess hemodynamic status in critically ill patients with sepsis  or shockIn contrast to humans, the swine has some important anatomic differences that affect acquisition of standard imaging planes and correct measurements. Its thorax configuration is rather “oval” in the anterior-posterior direction and the long axis of the heart is aligned perpendicularly to the long axis of the body . Due to All procedures conformed to the Society of Laboratory Animal Science (GV-SOLAS) as well as the National Animal Welfare Law. Following approval by the responsible government authority  the procedures were performed according to the guidelines of the Federation of European Laboratory Animal Science Association (FELASA).In the present study we performed transthoracic echocardiography in newborn piglets before, during and after asphyxia and hemorrhage. A detailed description on instrumentation/procedures is available in the original publication . Briefly©, FujiFilm SonoSite BV, Amsterdam, Netherlands) with an ultrasound transducer  was used. Animals were studied in supine position as mandated by the protocol of the original study. Before applying ultrasound gel, the skin was shaved. Additional procedures were not performed during TTE.Echocardiography was performed at Baseline, 2 h and 4 h after ROSC by the same examiner experienced in human neonatal TTE in order to minimize potential bias. A point of care ultrasound device , left-sided heart structures were visible in all imaging studies. Left atrium, the mitral valve, the muscular parts of the left ventricle (LV) and the left ventricular outflow tract (LVOT) with the aortic valve (AV) and parts of the ascending aorta (aAo) could be visualized. From the same view, functional imaging by M-mode was performed and measurements of interventricular septum (IVSd/s), left ventricular diameter (LVDd/s) and left ventricular posterior wall (LVPWd/s) were obtained. Left ventricular shortening fraction (SF) and ejection fraction (EF) were calculated . FurtherFor illustration From PLAX left-sided heart structures were imaged as described above. Using Doppler sonography we were able to show/measure inflow into the left ventricle (LV) across the mitral valve (MV) and outflow across the aortic valve (AV). Using the parasternal short axis view (PSAX) the right ventricular outflow tract (RVOT) and flow across the pulmonary valve (PV) into the main pulmonary artery (MPA) becomes visible. Flow across the valves can be visualized by pulsed wave (PW) or continuous wave (CW) Doppler. Measurement of heart rate, peak and mean gradients or velocity time integral (VTI) are also possible, although the insonation angle is not favorable for Doppler studies across MV and AV and the measurements may significantly underestimate true values . For illFrom PSAX we could regularly detect shunting across an open arterial duct using color and pulsed wave Doppler in newborn piglets .For illustration From PLAX detection of aortic insufficiency using color Doppler and 2D imaging was possible .For illustration From PLAX we were able to prove presence of a ventricular septal defect with a size of ~2.8 mm using 2D imaging and a bidirectional shunt using color Doppler .For illustration From PSAX detection of coronary arteries using color Doppler  was possFurthermore, Kerut et al. showed in 2004 that transthoracic echocardiography is a useful modality for the imaging of cardiac structures in anesthetized older pigs . The feaIn summary, cardiac imaging by TTE in the laboratory piglet is a feasible method also in very small neonatal piglets in supine position. In our study ventricular structures could be visualized in parasternal long axis and parasternal short axis planes and functional parameters based on M-mode images could be measured.The datasets generated for this study are available on request to the corresponding author.This study was carried out in accordance with the recommendations of the Society of Laboratory Animal Science (GV-SOLAS) as well as the National Animal Welfare Law. The protocol was approved by the responsible government authority  and the procedures were performed according to the guidelines of the Federation of European Laboratory Animal Science Association (FELASA).SS, MK, and MM conceived and designed the study and also performed the animal experiments. SS and MK interpreted the results obtained and contributed equally to this research work. SS and MM drafted the manuscript. MM and HH revised the manuscript. All authors read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work.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.