P < 0.05. The standardized regression coefficients of the three groups were 0.32, 0.41, and 0.47, respectively, P < 0.05, which indicated that the greater the coronary artery stenosis rate, the higher the diagnostic coincidence rate of left anterior descending limb (LAD), left circumflex branch (LCX), and left coronary artery (RCA). The conformity of ECT imaging in the LCX group for diagnosis of myocardial ischemia was higher than that of UCG, P < 0.05. To sum up, the ECT technology based on the FBP reconstruction algorithm had a good application prospect in the diagnosis of cardiac function recovery in AMI patients after PCI.This study aimed to explore the application value of emission computed tomography (ECT) imaging technology based on filtered back projection reconstruction algorithm (FBP) in cardiac function examination after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Eighty patients with myocardial infarction diagnosed by medical history, electrocardiograph (ECG), and myocardial enzyme admitted to hospital from February 2018 to February 2019 were selected as the research objects. All patients underwent PCI seven days after the onset of myocardial infarction. ECT was performed for all patients before and after surgery. In addition, all ECT images were processed by the FBP reconstruction algorithm. On this basis, preoperative and postoperative cardiac surgery function and ischemia of the patients were diagnosed. Then, the diagnostic results were compared with the results of coronary angiography and echocardiogram. The results showed that all patients had a total of 541 segments before PCI surgery. ECT examination revealed 294 abnormal segments of the ventricular wall, with a total score of 585 points. A total of 100 segments were scored with 1 point, a total of 194 segments were scored with 2 points, and a total of 50 segments were scored with 3 points. After PCI, the number of abnormal segments was reduced to 58, with a total score of 193. There were 6 segments with a score of 1, 44 segments with a score of 2, and 5 segments with a score of 3. The left ventricular diastolic volume (EDV), left ventricular systolic volume (ESV), stroke volume (CO), and ejection fraction (EF) of the patients before the operation were 148 ± 16 mL, 77 ± 14.5 mL, 4.29 ± 0.37 L/min, and 41.9 ± 8%, respectively. The EDV, ESV, CO, and EF of the patients after surgery were 132 ± 16 mL, 62 ± 13 mL, 4.89 ± 0.71, and 53 ± 6%, respectively. Significant changes occurred in various systolic function parameters before and after surgery,  In recent years, with the aggravation of the aging of the population in China and the increasing pressure on people's life, the prevalence and mortality of cardiovascular diseases are rising. Among them, coronary atherosclerotic heart disease (CAD) has become one of the primary cardiovascular diseases threatening the life and health of Chinese people . CoronarRadionuclide emission computed tomography (ECT) is a computer aided technique, which uses isotopes to label drugs, thereby measuring the concentration intensity of isotopes in various organs in the body and its change with time based on the principle of human body synthesis. In this way, the visual shape of the organs is displayed, and the functional image information of their physiological process and metabolism is reflected . ECT tecECT examination is mainly classified into functional image examination and anatomical structure image examination, but the image resolution collected by functional image examination is very low and lacks anatomical information. To solve this problem, image fusion is proposed. At present, CET and CT can be organically combined to provide high-quality images with anatomical localization. To a certain extent, the quality of ECT images is provided . HoweverIn this study, patients with acute heart infarction were taken as the research objects. ECT examination was performed before and after PCI. FBP algorithm was used to process the obtained images, and on this basis, the efficacy of PCI in MAI was evaluated, to provide reference and basis for clinical use of ECT, PCI, and FBP algorithm in treatment and diagnosis of AMI.A total of 80 patients admitted to the hospital from February 2018 to February 2019 who were diagnosed with AMI by medical history, ECG, and myocardial enzyme were selected. There were 55 male patients and 25 female patients, with an average age of 61.6 ± 11.2 years. Exclusion criteria are as follows: patients with onset less than twelve hours or longer than one month; patients suffering from cerebrovascular diseases or severe liver and kidney dysfunction or hyperthyroidism; patients suffering from malignant arrhythmia, congenital heart disease, cardiac hypertrophy, and myocarditis resulting in cardiac insufficiency; patients with a history of respiratory dysfunction, malignant tumor, or active bleeding; and patients who were long-term bedridden and unable to perform ECT examination. All studies had obtained patients' informed consent and met the requirements of medical ethics.All the subjects underwent percutaneous coronary intervention (PCI) seven days after myocardial infarction. All patients were examined with radionuclide emission computed tomography (ECT) before and after surgery. All ECT images are processed by filtering back projection reconstruction algorithm. On this basis, the preoperative and postoperative cardiac operation function and ischemia were diagnosed. The diagnostic results were compared with coronary angiography and ultrasound ECG.The inspection instrument was Siemens symbia-1, the imaging agent was 9mTc-MIBI, and the radiochemical purity was >95%. All patients were routinely given antiplatelet aggregation, anticoagulants, beta-blockers, nitrates, ACEI drugs, and statins after admission. 99mTc-MIBI was intravenously injected on the morning of the 7th day of admission, in the fasting and resting state, with a dose of 925∼1110 MBq (25∼30 mCi). Half an hour later, the patient was fed a fried egg or 250 mL of pure milk. Resting-gated myocardial perfusion imaging was performed 1.5 to 2 hours later. ECT was equipped with a parallel hole low energy and high-resolution collimator. The R wave of ECG was the trigger wave. The patient lied on the examination bed with his head outwards. ECG gating device was opened, and the ECG electrodes were connected correctly. The starting angle of probe 1 was −45°, and the starting angle of probe 2 was 56°. The angle between probes was 101°, one position per 3D, running 1050 in total, and 36 individual positions were collected. Eight frames were collected per cardiac cycle, and the acceptable heart rate range was ±20% of the mean heart rate. The matrix was 64 × 64, and the acquisition time was 30 seconds/section. The energy peak was 140, and the magnification (ZOOM) was 1.33.ECT results were classified into four grades: normal (grade 0), decreased perfusion (grade 1), substantially decreased perfusion (grade 2), and perfusion defect (grade 3). The calculation of wall thickening rate was automatically graded into normal wall thickening rate , reduced , substantially reduced , and substantially reduced or no exercise .The back projection reconstruction algorithm usually introduces star artifacts, which will lead to image distortion after reconstruction. This problem can be solved by rate-wave processing of the image before reconstruction.f is given by the 1D Fourier transform of an image pϕ(xr) projected at the angle ϕ of view f. The slice and the axis w1 intersect at an angle ϕ and pass through the origin of the coordinate. The specific schematic diagram is shown in f in the direction ϕ gives a slice of the 2D Fourier transform of f, and the position of the slice passes through the origin and forms an angle ϕ with w1.The projection theorem is the basis of image reconstruction. The specific content is as follows. A slice of the 2D Fourier transform ϕ of view and the rotation coordinates  and  is as follows.The relationship between the projection angle w1, w2 are not independent but bound bya; then, its 2D Fourier transform is pϕ(xr) of the projection of a under different viewing angles, which is expressed as follows.FBP reconstruction is as follows. The image to be built is The image to be built is as follows.Then, there is The second integral of equation  is as foxr as follows.The above equation is rewritten as the inverse Fourier variant with the spatial variable Equation  is substp measured under the fixed viewing angle ϕ1 is filtered to obtain the filtered projection gThe projection ϕi, g is projected back on all points  on the ray satisfying xr=r  cos(θ − ϕi)For each ϕ < π) in the second step are integrated to get the reconstructed imageAll the back projection values , and A(N)=O(N  log2  N). The calculation amount of the first step of filtering is real number multiplication and addition of A(2N) times. The calculation amount of the second step is real number multiplication of 2N times. The calculation amount of the third step is the same as that of the first step. Therefore, to complete the filtering of azimuth projection data, the amount of calculation required is expressed as follows.The required calculation is used to evaluate the reconstruction effect of the algorithm proposed in this study and the traditional algorithm. The lower the amount of calculation, the better the reconstruction effect. The specific calculation process is as follows. It is supposed that the one-dimensional calculation of The calculation steps required by the traditional algorithm are the same as those of the new method as follows.All patients underwent PCI seven days after AMI. 6F guiding catheter was placed at the opening of the diseased vessel. The guidewire was inserted to the distal end of the stenosis and the occlusion. Balloon angioplasty was performed on the lesion site through balloon insertion along the guidewire. Then, according to the diameter and length of the lesion, the appropriate stent was selected for intracoronary stent implantation, and the balloon pressure of the stent was preexpanded and the balloon pressure of the stent was released regarding the characteristics of the lesion. All patients received 9mTc-MIBI resting-gated myocardial perfusion two days after PCI, using the same method as before. The myocardial perfusion and cardiac function improvement were evaluated. The imaging method was the same as before. To ensure the comparability of myocardial images, the activity of the imaging agent, the instrument, and the position of the patient were as consistent as possible before and after stent implantation in the same patient.x ± s) was how measurement data were expressed, and the t-test was used to test the significance of patients' data before and after the operation. Percentage (%) was how count data were expressed, and the χ2 test was used to test the significance. The pairwise comparison was performed by analysis of variance. The difference was statistically considerable with P < 0.05.SPSS 11.0 was employed for data statistics and analysis. Mean ± standard deviation , and in each direction, only the pixels in the positioning part need positioning operations, the calculation amount of multiplication in the new method operation is 3N[M/4]/2 approximately, and the calculation amount of other operations can be deduced by analogy. Therefore, the required calculation of the new method is only 1/8 of the traditional method.The comparison of myocardial perfusion in patients before and after PCI operation is shown in P < 0.05.The comparison of the cardiac function parameters of the patients before and after PCI is shown in F = 4.39, P < 0.05, which was statistically considerable. In the LCX group, F = 8.21, P < 0.05, which was statistically considerable. In the RCA group, F = 11.36, P < 0.05, which was statistically considerable. The standardized regression coefficients of the three groups were 0.29, 0.42, and 0.48, respectively, and the significance of the three groups was P < 0.05, which indicated that the greater the coronary artery stenosis rate, the higher the diagnostic coincidence rate of the three groups of LAD, LAD, and RCA.According to the classification of coronary artery disease, the patients were rolled into three groups of left anterior descending limb (LAD), left circumflex artery (LCX), and left coronary artery (RCA), to perform regression analysis of ECT diagnosis coincidence rate and coronary artery stenosis rate. From P=1. The conformity of ECT imaging in the LCX group for diagnosis of myocardial ischemia was higher than that of UCG, and the difference was considerable, P < 0.05. The conformity of ECT imaging in the RCA group for diagnosis of myocardial ischemia was higher than that of UCG, but the difference was not considerable, P > 0.05.The comparison results of myocardial ECT imaging and UCG diagnosis are shown in AMI refers to the rapid reduction and interruption of the blood supply of the coronary artery when the coronary artery disease occurs, and then, the relevant myocardium presents continuous ischemia and then leads to myocardial necrosis . As the At present, coronary angiography is still the gold standard for the diagnosis of AMI. With the continuous development of nuclear medicine and imaging technology, radionuclide ECT has also been applied in the diagnosis of heart diseases . ECT is Image reconstruction is an important research branch in image processing. It refers to the reconstruction of images based on the data obtained from object detection. Its significance lies in obtaining the image of the internal structure of the detected object without causing any physical damage to the object. Due to its considerable advantages, it has shown unique importance in various application fields –19. For P < 0.05. The standardized regression coefficients of the three groups were 0.32, 0.41, and 0.47, respectively, P=0.05, indicating that the greater the coronary stenosis rate, the higher the diagnostic coincidence rate of LAD, LAD, and RCA. The diagnostic conformity of ECT images in the LCX group for myocardial ischemia was higher than that of UCG, P < 0.05, which showed that the results of ECT examination after PCI showed that the patient's cardiac perfusion and cardiac systolic function were greatly improved. The coincidence rate of the ECT examination based on the filtered back projection reconstruction algorithm for the cardiac function examination results and the coronary angiography examination results increased with the increase of the coronary artery stenosis rate. Compared with cardiac ultrasound, the ECT examination based on the filtered back projection reconstruction algorithm had a higher degree of agreement between the results of the cardiac function examination and the results of coronary angiography. In summary, the ECT technology based on the filtered back projection reconstruction algorithm had a good application prospect in the examination of cardiac function after PCI in AMI patients. However, due to the limited sample size and space, the study was not comprehensive and in-depth enough. In future studies and work, the sample will be further expanded and further studied.In this study, the diagnostic effect of ECT image features based on the FBP reconstruction algorithm on the recovery of cardiac function in patients with AMI after PCI surgery was explored. The results showed that all patients had a total of 541 segments before PCI. ECT examination showed 294 abnormal segments of the ventricular wall, with a total score of 585. A total of 100 segments were scored as 1 point, a total of 194 segments were scored as 2 points, and a total of 50 segments were scored as 3 points. After PCI, the abnormal segments were reduced to 58 segments, with a total score of 193. Six segments scored 1 point, 44 segments scored 2 points, and 5 segments scored 3 points. The preoperative EDV, ESV, CO, and EF were 148 ± 16 mL, 77 ± 14.5 mL, 4.29 ± 0.37 L/min, and 41.9 ± 8%, respectively. The EDV, ESV, CO, and EF of the postoperative patients were 132 ± 16 mL, 62 ± 13 mL, 4.89 ± 0.71, and 53 ± 6%, respectively. All systolic function parameters changed significantly after the operation, This study investigated the diagnostic effect of ECT image features based on the FBP reconstruction algorithm on cardiac recovery after PCI in AMI patients. The results showed that the patients' visceral function recovered significantly after PCI, and ECT based on the FBP reconstruction algorithm had better performance in cardiac function examination than cardiac ultrasound. This study provides a reference and basis for the application of PCI, FBP reconstruction algorithm, and ECT in the diagnosis and treatment of AMI patients. However, due to the limited sample size and space, this study still has some limitations and deficiencies. In future studies and work, we will expand the sample size to further study this problem.


Thirty four-year-old male with history of D-transposition of the great arteries (D-TGA) who underwent Mustard operation at 14 months of age presented in cardiogenic shock secondary to severe systemic right ventricular failure. Catheterization revealed significantly increased pulmonary pressures. Due to the patient's inotrope dependence and prohibitive pulmonary hypertension, he underwent implantation of a Heart Ware HVAD® for systemic RV support. Within 4 months of continuous flow ventricular assist device (VAD) implantation complete normalization of pulmonary vascular resistance (PVR) was achieved. He ultimately underwent orthotopic heart transplantation with favorable outcomes. This is the second report of complete normalization of PVR following VAD implantation into a systemic RV in <4 months. We conducted a thorough literature review to identify Mustard patients that received systemic RV VAD as a bridge to a successful heart transplantation. In this article, we summarize the outcomes and focus on pulmonary hypertension reversibility following VAD implant. Systemic right ventricular (RV) failure is a well-known sequel in the decades following atrial switch for D-transposition of the great arteries (D-TGA). As patients who underwent these procedures are now entering adulthood, at times reaching their 4th and even 5th decade of life, the disease burden can only be expected to grow. Cardiac transplantation is a well-accepted therapy for systemic RV failure, but the complication of secondary pulmonary hypertension may often be prohibitive. We herein report a case of severe systemic RV failure and pulmonary hypertension, with subsequent complete normalization of pulmonary vascular resistance (PVR) following continuous flow ventricular assist device (VAD) implantation.2. Due to the patient's inotrope dependence and prohibitive elevation in PVR (> 4 WU), he underwent implantation of a Heart Ware HVAD® for systemic RV support. He tolerated the procedure very well. VAD flows were titrated with echocardiographic monitoring, RV chamber size decreased from 6.2 cm at low VAD speed  to 5.3 cm at high VAD speed   and increasing RV end diastolic volume (RVEDV 221 ml in 2007 to 423 ml in 2013) . Cardiac80 rpms) . He was B-type natriuretic peptide decreased markedly post VAD implantation. Cardiac MRI could not be repeated due to the presence of the VAD, but chest x-ray showed significant decrease in RV size between post-operative day 1 and 10 months postoperatively . The patBecause of normalization of pulmonary resistance, he was ultimately listed for cardiac transplantation (UNOS status 1B). A suitable donor was identified in February 2017. He underwent VAD extraction and orthotopic heart transplantation (OHT) at that time. Surgical course was complicated by significant blood loss, requiring multiple units of blood products. Otherwise, he tolerated the transplantation very well. Immune suppression was induced with anti-thymocyte globulin, then transitioned to a regimen consisting of tacrolimus, mycophenolate mofetil, and prednisone. Symptoms continued to improve at 3 years post-transplant (New York Heart Association class I) and the patient's quality of life improved given that he is more active. Myocardial biopsies showed no signs of rejection and prednisone was weaned successfully.The Mustard procedure is one of the two atrial switch operations initially performed in the 1960s to correct D-TGA. During this operation, a synthetic material is used to construct a two-way baffle. This generates a discordant atrioventricular connection on the existing discordant ventriculoarterial connection . FailingHeart transplantation is the definitive long-term option for a failing systemic RV. There are few case-reports that describe VAD implantation for RV failure in patients with prior history of atrial switch as a bridge to a successful heart transplantation. Therefore, we conducted a thorough literature review using PubMed, Ovid/Medline, Cochrane Library to identify Mustard patients that received systemic RV VAD as a bridge to a successful heart transplantation between 1988 and 2020. A total of 13 published cases –12 were The average age of the patients at VAD implantation was 33 ± 9 years of age. 9 patients were male and four were female. The most common indication for VAD implantation was cardiogenic shock, noted in 5 cases. Heart mate II was implanted in 7, HVAD in 4 and Heart mate I in two of them. The average time on VAD prior to heart transplant was 17 ± 17 months. Drive line infection was reported in 5 patients, of which one required device exchange  and 30 ± 9 mmHg (n = 5) after implant . The median of the PA pressure was 55 ±  mmHg before and 30 ±  mmHg after VAD implant. 4 out of 6 patients decreased their PVR to <3 WU after VAD support. None of the five patients reported by Maly et al. (Pulmonary hypertension (PHT) is a complication that is increasingly seen 3–18%) in this population . PHT may% in this55 ± 50, 7 mmHg bey et al.  reportedIn general, patients with CHD have higher perioperative and one-year mortality after heart transplant. However, Pigula et al. showed that the results of heart transplantation in ACHD were comparable to those of adults without a CHD . Among tAs demonstrated, ventricular assist devices may be a safe and viable option to serve as a bridge to transplant/bridge to decision, in Mustard patients with systemic RV failure and secondary pulmonary hypertension. Additionally, we found that VAD therapy can reduce pulmonary pressure and decrease the PVR to normal ranges in a relatively short amount of time. Finally, VADs may serve this group of patients who are not immediately able to be transplanted due to donor supply shortage or hemodynamic instability. In the future, this can possibly be expanded to failing systemic right ventricles in patient with other types of complex congenital heart disease.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.RB took the lead in writing the manuscript. All authors cared for the patient, provided critical feedback, and helped shape and edit the final manuscript.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.


LS accuracy was lower than that of CS at baseline , and was increased at follow-up . Changes in myocardial perfusion reserve from baseline to follow-up were significantly associated with those in LS but not in CS. Conclusions: Use of 2D-STE may allow the non-invasive evaluation of patients undergoing CTO-PCI to assess the indication before the procedure and treatment effects at follow-up.Background: As percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) gains wider acceptance as a therapeutic option for coronary artery disease, the importance of appropriate patient selection has increased. Although cardiovascular magnetic resonance imaging (MRI) allows segmental and quantitative analyses of myocardial ischemia and scar transmurality, it has limitations, including contraindications, cost, and accessibility. This study established a non-invasive method to evaluate patients undergoing CTO-PCI using two-dimensional speckle-tracking echocardiography (2D-STE). Methods: Overall, we studied 55 patients who underwent successful CTO-PCI. Cardiovascular MRI and 2D-STE were performed before and 8 ± 2 months after CTO-PCI. Segmental findings of strain parameters were compared with those obtained with late gadolinium enhancement and stress-perfusion MRI. Results: With a cutoff of −10.7, pre-procedural circumferential strain (CS) showed reasonable sensitivity (71%) and specificity (73%) for detecting segments with transmural scar. The discriminatory ability of longitudinal strain (LS) for segments with transmural scar significantly improved during follow-up after successful CTO-PCI in the territory of the recanalized artery (area under the curve (AUC) 0.70 vs. 0.80,  Chronic total occlusion (CTO) is commonly encountered among patients referred for coronary angiography, with a reported prevalence of 20–30% . The sucThe clinical benefit of revascularization for CTO depends on the myocardial ischemia status and scar transmurality of the perfusion territory of the CTO lesion. With its excellent spatial resolution, cardiovascular magnetic resonance imaging (MRI) allows us to measure myocardial ischemia quantitatively , assess In contrast, two-dimensional speckle-tracking echocardiography (2D-STE) is a non-invasive method with no contraindications. It provides quantitative measurements of myocardial systolic function more objectively than visual wall motion analysis, with high reproducibility .This study established the use of a non-invasive assessment method using 2D-STE, combined with cardiovascular MRI quantitative measurements of the ischemic burden and the extent of chronic infarction, in patients undergoing CTO-PCI. Therefore, the aim of the present study was two-fold: (1) to determine how echocardiographic strain parameters relate to cardiovascular MRI as a surrogate for viability in decision-making and planning of CTO-PCI, and (2) how to use strain echocardiography as a more objective and sensitive method compared with visual wall motion analysis to identify left ventricular segmental improvements following revascularization.This single-center, prospective study included patients with a CTO lesion suitable for recanalization based on coronary angiographic findings. CTO was defined as a coronary obstruction with thrombolysis and myocardial infarction (TIMI) flow grade 0 for >3 months (estimated). All patients had symptomatic angina and/or a positive ischemia study. In patients with multivessel disease, revascularization for non-CTO lesions had to have been achieved. Exclusion criteria included atrial fibrillation, general contraindications to MRI , contraindication to gadolinium contrast agents , contraindication to adenosine administration , insufficient echocardiographic image quality, and significant valvular heart disease. The 16-segment model (American Society of Echocardiography) was used to assess regional systolic function. It divides the left ventricle into six segments for the left anterior descending artery, five for the right coronary artery, and five for the left circumferential artery. Our institutional review board approved this study. All patients provided written informed consent to participate in the study.Echocardiographic studies were performed using a Vivid E9 system . Parasternal long-axis and short-axis views  and three standard apical views  were obtained at 56–92 frames/s. Left ventricular (LV) ejection fraction was determined by manually tracing end-systolic and end-diastolic endocardial borders using Simpson’s biplane method. Segmental wall motion was determined on a scale of 1–4: 1, normokinetic; 2, hypokinetic; 3, akinetic; 4, dyskinetic.The echocardiographic strain measurements were performed before CTO-PCI and 8 ± 2 months afterward. For circumferential strain (CS) analysis, three short-axis views  were analyzed. For longitudinal strain (LS) analysis, three standard apical  views were analyzed according to the 16-segment model. Strain analysis was performed with offline dedicated software , which allows the analysis of peak systolic segmental CS from short-axis views and of peak global and segmental systolic LS from apical views based on detecting natural acoustic markers. The markers are equally distributed in the myocardium and can be identified and followed frame-to-frame in consecutive images. This system calculates the mean strain values for predefined LV segments. For global strain analysis, peak strain values from each of the 16 segments were averaged. Strain evaluation results were defined by the consensus of two observers. The analytic system automatically determined tracking quality. Segments of suboptimal quality were excluded. End-systole was defined as aortic valve closure in the apical view and was applied to all other views. Ten studies were randomly selected to evaluate intra-observer and inter-observer reproducibility for strain measurements.Before CTO-PCI and 8 ± 2 months afterward, cardiovascular MRI studies were performed using a 1.5-T MRI scanner  with 32-channel cardiac coils. After 4 min of adenosine infusion (140 g/kg/min) and 15 min after the intravenous injection of gadolinium diethylenetriamine pentaacetic acid (0.20 mmol/kg) , 8 mm short-axis slices were acquired using a prospective electrocardiogram-gated gradient-echo sequence. Finally, first-pass rest perfusion images were acquired >20 min after stress perfusion imaging.LGE MRI images and rest–stress first-pass myocardial perfusion MRI images were transferred to a workstation and analyzed with dedicated software . LGE-affected areas were defined as those with signal enhancement ≥ 5 standard deviations from the signal intensity of non-enhanced myocardium. The LGE extent was calculated as the percentage of the contrast-enhanced volume relative to the total myocardial volume of the segment . Myocardial segments were allocated to three categories : 0%, 1–5PCI and stent implantation were performed according to standard practice. Drug-eluting stents were used in all angioplasty procedures. Heparin was administered to maintain an activated clotting time of >250 s. CTO-PCI was performed with modern techniques, such as bilateral injections, specialized hydrophilic, tapered-tip, and stiff wires, parallel-wire techniques using microcatheters or double-lumen catheters, intravascular ultrasonography-guided techniques, and a retrograde approach when possible . After tt-test for normally distributed values and Mann–Whitney U-test for skewed variables. Receiver operating characteristic (ROC) curves for segmental peak systolic strain were determined to detect segments with transmural LGE > 50% on the preprocedural MRI. ROC analyses and area under the curve (AUC) comparisons were performed according to Delong et al. [p < 0.05 were considered to indicate statistical significance. Reproducibility of strain measurements was expressed by the intra-class correlation coefficient.Data were statistically analyzed using SPSS Statistics version 24  and the Medcalc 18.6 statistical program . Data are expressed as means ± standard deviation. Categorical data are presented as frequencies and percentages. Normality was evaluated using the Shapiro–Wilk test. Changes in echocardiographic parameters between baseline and follow-up were tested using the paired g et al. . UnivariOf the 65 patients initially recruited, 55 completed the study  . Five paPatient characteristics are shown in Angiographic and procedural characteristics of the patients are shown in From baseline to follow-up, the enhanced area percentage did not change. All 880 segments were evaluable for the presence/absence of late enhancement by LGE MRI. Among the 284 segments of the CTO territory, 92 (32.4%) had no late enhancement , 130 (45.8%) showed delayed enhancement with transmural extent of 1–50%, and 62 (21.8%) showed delayed enhancement with a transmural extent of 51–100%.p < 0.001) (p < 0.001). MPR after revascularization was similar between the CTO territory and a remote territory . There were no differences in the MPR in the remote territory before and after PCI.At baseline, MPR in the CTO territory was lower than that in a remote territory  , but it p = 0.004). Following CTO-PCI, the global LS , global CS , and wall motion score (WMS) index  were significantly improved.p = 0.048) or WMS . With a cutoff value of −10.7, the sensitivity, specificity, and accuracy of pre-procedural CS for detecting segments with LGE > 50% were 71%, 73%, and 79%, respectively. The discriminatory ability of LS for segments with a transmural extent of LGE >50% was significantly improved during the follow-up period after successful CTO-PCI in the recanalized artery territory  vs. 0.80 (0.75–0.85), p < 0.001), whereas that of CS or WMS did not change from baseline to follow-up. At follow-up, CS identified segments of LGE > 50% better than WMS  but not better than LS .Intra-observer and intra-class correlation coefficients for LS and CS were 0.93 and 0.92 respectively, and the inter-observer and intra-class correlation coefficients were 0.86 and 0.84, respectively.There were three major findings of this study: (1) With a cutoff value of −10.7, pre-procedural CS showed reasonable sensitivity (71%), specificity (73%), and accuracy (79%) for detecting segments with transmural scar. (2) The discriminatory ability of LS for segmental scar transmurality assessment improved significantly in the territory of the recanalized artery during follow-up after successful CTO-PCI. The accuracy of LS was lower than that of CS at baseline, but increased at follow-up. (3) Reduction of the myocardial ischemic burden using CTO-PCI was significantly associated with changes in LS (but not in CS) from baseline to follow-up.In line with previous reports, the CS assessment allowed the better differentiation of segments with transmural scar than LS before CTO-PCI, indicating the greater value of using CS for preprocedural assessment of CTO-PCI indications. In contrast, LS was sensitive to the reduction in ischemic burden by CTO-PCI, suggesting that it might be helpful for monitoring the effect of CTO revascularization. The differences in utility among strain parameters could be partly explained by differences in the sensitivity to the myocardial ischemic burden.CS has shown a greater ability than LS to differentiate segments with transmural or non-transmural scars, via a mechanism related to the function of subepicardial and mid-wall myocardial fibers ,17. If tIn the present study, changes in quantitative measurements of the myocardial ischemic burden from baseline to follow-up were significantly associated with changes in the LS but not in the CS. Moreover, the discriminatory ability of LS for segmental scar transmurality assessment significantly improved during follow-up after successful CTO-PCI in the perfusion territory of the recanalized artery, and increased to a level similar to that of CS during the follow-up. In contrast, the discriminatory ability of CS did not change from baseline to follow-up. LS is the most sensitive strain parameter to detect subtle impairments of contractile function in coronary artery disease ,21 and oWith CTO-PCI gaining wider acceptance as a therapeutic option for coronary artery disease, the importance of valid patient selection has increased. On the basis of the recent increase in the importance of physiological assessment for coronary artery disease, quantitative measurements of the myocardial ischemic burden are frequently performed before coronary interventions. However, it would not be practical to manipulate a pressure wire to the distal sites of CTO lesions for preprocedural assessment for indications of CTO-PCI. Approximately 40% of CTO patients have had a previous myocardial infarction, a rate twice that of patients without CTO lesions . FurtherWith its excellent spatial resolution, cardiovascular MRI provides detailed, segmental, quantitative analyses of myocardial ischemia and scar transmurality. However, it also has limitations, including contraindications, cost, accessibility, and side effects from the contrast medium or adenosine administration. We previously showed that the optimal cut-off value of the extent of LGE MRI was 50% for functional recovery after CTO-PCI . In the PCI is rapidly becoming a valid option for complex high-risk (and indicated) patients . Some coThere were several limitations in this study. First, it was a single-center, observational study. Second, myocardial strain could not be automatically analyzed via echocardiography because of poor image quality in 5.6% of the segments. However, this value is comparable to those of previous reports. Third, the rate of non-LAD-CTO was 80% in the current study. Accordingly, it would be challenging to show a prognostic benefit conferred by successful CTO-PCI in this study cohort with relatively preserved contractile function. However, according to guidelines for stable coronary artery disease, LAD-CTO impacts the selection of treatment strategies, especially for patients with multivessel disease, decreasing the likelihood of PCI. This is a bias inherent in observational studies. Moreover, we think that improving survival is not the only potential benefit of CTO-PCI. Improvements also exist related to clinical outcomes, including improved left ventricular systolic function and significant reductions in angina burden after CTO-PCI. These potential benefits may also justify attempted CTO-PCI despite a lack of significant improvements in survival. Fourth, the rate of the retrograde approach in the current study was relatively high in comparison to recently standardized procedures. Some universal algorithms regarding CTO-PCI strategy were recently developed . HoweverAlthough cardiovascular MRI, which allows segmental and quantitative analyses of myocardial ischemia and scar transmurality, is useful for assessment of CTO patients, it has limitations, including contraindications, cost, and accessibility. However, 2D-STE may overcome these limitations for cardiovascular MRI. Application of 2D-STE for CTO-PCI might noninvasively provide appropriate patient selection, sensitive and objective information regarding clinical benefits conferred by successful results, and wider use of the treatment procedure in clinical practice.


S = −0.397, p < 0.001). In multivariable linear as well as binary logistic regression analysis , CRPv was independently associated with LVEF  and LVEF ≤ 40% , respectively. The combined predictive value of peak cardiac troponin T (cTnT) and CRPv for LVEF ≤ 40%  was higher than it was for peak cTnT alone . CRPv was independently associated with early LV dysfunction, as measured by the CMR-determined LVEF, revealing an additive predictive value over cTnT after acute STEMI treated with primary PCI.C-reactive protein velocity (CRPv) has been proposed as a very early and sensitive risk predictor in patients with ST-elevation myocardial infarction (STEMI). However, the association of CRPv with early left ventricular (LV) dysfunction after STEMI is unknown. The aim of this study was to investigate the relationship between CRPv and early LV dysfunction, either before or at hospital discharge, in patients with first STEMI. This analysis evaluated 432 STEMI patients that were included in the prospective MARINA-STEMI  cohort study. The difference of CRP 24 ± 8 h and CRP at hospital admission divided by the time (in h) that elapsed during the two examinations was defined as CRPv. Cardiac magnetic resonance (CMR) imaging was conducted at a median of 3 (IQR 2–4) days after primary percutaneous coronary intervention (PCI) for the determination of LV function and myocardial infarct characteristics. The association of CRPv with the CMR-derived LV ejection fraction (LVEF) was investigated. The median CRPv was 0.42 (IQR 0.21–0.76) mg/l/h and was correlated with LVEF (r Despite significant progress in the management of ST-elevation myocardial infarction (STEMI), left ventricular (LV) systolic dysfunction is the most common consequence after STEMI and has significant implications on short- and long-term prognosis ,2,3. EarElevated peak C-reactive protein (CRP) levels are associated with reduced LV ejection fraction (LVEF) , more seCRP velocity (CRPv), which displays CRP level changes over time, has been suggested as a very early and more sensitive parameter for more serious outcomes following STEMI ,20,21,222, and any other contraindication to CMR examination  [This study is based on the “Magnetic Resonance Imaging In Acute ST-Elevation Myocardial Infarction (MARINA-STEMI)” trial , a prospective observational study recruiting acute STEMI patients, that were treated with primary PCI, at the coronary care unit of the Medical University of Innsbruck. The following inclusion criteria were applied for the present analysis: first STEMI according to the European Society of Cardiology/American College of Cardiology committee criteria , revascuolinium) .® 8000 modular analyzer (Roche Diagnostics®), and cTnT measurements were conducted by applying a validated enzyme immunoassay . CRP and cTnT levels were assessed at hospital admission, 6 ± 2 h, 12 ± 4 h, 24 ± 8 h, and then daily until day 4 after PCI or discharge [For the determination of hs-cTnT and hs-CRP, peripheral venous blood samples were performed and analyzed as described previously . In brieischarge . The difischarge ,21.The primary objective of the current study was the association between CRPv and LVEF as determined by CMR imaging. The secondary objective was to assess the potential additive value of CRPv over cTnT for the prediction of LV dysfunction. The value of LVEF categorization ≤40% to define LV dysfunction is derived from the latest guidelines  and is bPrior to study inclusion, all participants gave written informed consent. The study was designed and conducted in accordance with the Declaration of Helsinki and received approval by the research ethics committee of the Medical University of Innsbruck.CMR examinations were performed in the supine position on a 1.5 Tesla clinical MR scanner  within the first week after treatment with primary PCI. The detailed standardized imaging protocol of our research group has been published previously . High-reStandard software  was used for post-processing analyses with the semi-automatic detection of LV endo- and epicardial borders . Papilla®, Bayer Vital GmbH, Leverkusen, Germany), with short-axis slices covering the entire LV [®, Agfa HealthCare, Bonn, Germany) was used for IS quantification, whereas “hyperenhancement” was defined as +5 standard deviations above the signal intensity of remote LV myocardium [An ECG-triggered, phase-sensitive inversion recovery sequence was used to obtain late gadolinium enhancement (LGE) images 15–20 min after the application of 0.2 mmol/kg of Gd-DO3A-butriol  with LVEF and LVEF ≤ 40%, respectively, in univariable analysis were inserted into the multivariable model. There were no missing values. Z-scores were calculated to present odds ratios (OR) per 1 standard deviation increase. Receiver operating characteristic (ROC) curve analysis was performed to depict the area under the curve (AUC) for the prediction of LVEF ≤ 40%. Comparisons of the ROC curves were conducted according to DeLong et al. [p-value of <0.05 was defined as significant.SPSS Statistics 27.0.1  and MedCalc v19.0.7  were used for the statistical analyses. Continuous data are depicted as median with interquartile range (IQR), and categorical variables are expressed as numbers with corresponding percentages. The differences in the continuous and categorical variables between two groups were assessed by the Mann–Whitney U-test and Chi-square test, respectively. Correlations between continuous variables were tested with Spearman’s rank test. For multivariable testing, linear and binary logistic regression analyses were used to reveal the independent associated markers of LVEF and LVEF ≤ 40%, respectively. Parameters indicating significant association  as well as separately for patients with LVEF > 40%  and LVEF ≤ 40%  at CMR are depicted in p = 0.010) and smoking (p = 0.002). Total ischemia time was 178 (IQR 120–262) min and did not differ between patients with LVEF ≤ 40% and> 40% (p = 0.407). Patients with LVEF ≤ 40% had anterior infarcts more often (p < 0.001) as well as lower TIMI flows pre (p = 0.018) and post-PCI (p = 0.006). No patient had symptomatic heart failure before STEMI. Patients with LVEF ≤ 40% had Killip class II more often (p < 0.001).A total of 432 STEMI patients were included in this analysis. Baseline characteristics of the overall cohort (p < 0.001) , 12.4 (IQR 6.9–20.1), and 22.5 (IQR 11.7–45.5) mg/L, respectively. The median CRPv was 0.42 (IQR 0.21–0.76) mg/L/h and was significantly higher in patients with LVEF ≤ 40% (< 0.001) .The median time from PCI to CMR was 3 (IQR 2–4) days. S = −0.397, p < 0.001). In multiple linear regression analysis, CRPv , peak cTnT , TIMI flow pre-PCI , TIMI flow post-PCI , and current smoking  were significantly related to LVEF (p = 0.004) and peak cTnT  remained independently associated with LVEF ≤ 40% (p < 0.001), CRPv , peak CRP , and peak cTnT  emerged as strong predictors of LVEF ≤ 40%. The best cut-off value of CRPv in predicting LVEF ≤ 40% was >0.59 mg/l/h, with a sensitivity of 70% and a specificity of 75%. According to C-statistics, the AUCs of CRPv and peak CRP  and CRPv and peak cTnT  did not differ. The combination of peak cTnT and CRPv  resulted in a higher AUC than peak cTnT alone for the prediction of LVEF ≤ 40%  .CRPv was correlated with LVEF (r to LVEF . After bEF ≤ 40% . In ROC = 0.009) . The staThe present study investigated the association of CRPv with LV dysfunction as assessed by CMR in patients with acute STEMI treated with primary PCI for the first time. The major findings can be summarized as follows: (a) Patients with elevated CRPv levels had significantly lower LVEF. (b) In the first week following acute STEMI, the association of CRPv and LV dysfunction remained significant after adjustment for clinical  and angiographical parameters . (c) The predictive value of CRPv for LVEF ≤ 40% was strong and additive to peak cTnT. Taken together, these data indicate that CRPv represents a sensitive risk stratification tool in daily clinical practice, that is available in the very early phase after STEMI. Moreover, further studies could explore whether patients with increased CRP levels could benefit from individualized therapeutic strategies targeting the post-STEMI inflammatory response.Among several inflammatory markers in the setting of myocardial infarction, CRP represents the most intensively explored marker. As an acute phase protein, CRP is released by hepatocytes after the stimulation of cytokines, primarily interleukin-6, about 6 h after the beginning of ischemic injury and peaks at day 2–3 thereafter . InterleChanges in CRP concentrations during myocardial infarction are considered to play a crucial role regarding adverse cardiovascular events, including death  and LV dDynamics in inflammatory processes during myocardial infarction, as measured by CRPv, have recently been shown to predict microvascular pathology , which iAnother important research question is whether CRP is only an associate or a mechanistic  driver of LV dysfunction after STEMI. Indeed, the modulation of inflammatory processes have recently moved more and more into focus in the treatment of STEMI. The recently published CAMI-1 study  revealedTo summarize, CRPv could help in the characterization of the dynamic inflammatory mechanism in the setting of acute STEMI as a time-dependent parameter and has important implications on myocardial infarct characteristics and outcome , as wellIn this study, only stable STEMI patients with Killip class < 3 and a delay < 12 h were included . The majCRPv is independently associated with LV dysfunction, as determined by CMR, before or at hospital discharge in patients with acute STEMI treated with primary PCI. CRPv might help to identify patients who are at an increased risk for LV dysfunction at a very early stage after STEMI.


Irisin is a myokine derived from the cleavage of fibronectin type III domain-containing 5. Irisin regulates mitochondrial energy, glucose metabolism, fatty acid oxidation, and fat browning. Skeletal muscle and cardiomyocytes produce irisin and affect various cardiovascular functions. In the early phase of acute myocardial infarction, an increasing irisin level can reduce endothelial damage by inhibiting inflammation and oxidative stress. By contrast, higher levels of irisin in the later phase of myocardial infarction are associated with more cardiovascular events. During different stages of heart failure, irisin has various influences on mitochondrial dysfunction, oxidative stress, metabolic imbalance, energy expenditure, and heart failure prognosis. Irisin affects blood pressure and controls hypertension through modulating vasodilatation. Moreover, irisin can enhance vasoconstriction via the hypothalamus. Because of these dual effects of irisin on cardiovascular physiology, irisin can be a critical therapeutic target in cardiovascular diseases. This review focuses on the complex functions of irisin in myocardial ischemia, heart failure, and cardiac hypertrophy. Irisin is a myokine with 112-amino acid, glycosylated protein hormone. It is a cleavage product of the polypeptide from fibronectin type III domain-containing 5 (FNDC5), a transmembrane protein of skeletal muscle. Peroxisome proliferator-activated receptor-γ coactivator 1α (PGC-1α) mediates exercise-related effects by stimulating an increase in the expression of FNDC5 and the release of irisin. This process can activate mitochondrial energy regulation, glucose metabolism, fatty acid oxidation, and fat browning. Exercise influences various organs, such as the brain, heart, muscles, adipose tissue, and liver. Irisin is a multifunctional hormone acting on metabolism, diabetes mellitus, and cardiovascular diseases. In this regard, irisin, FNDC5, and PGC-1α are therapeutic targets of metabolic and cardiovascular disease.Exercise increases irisin abundance, which can fine-tune body composition in individuals with obesity. Irisin regulates appetite by the expression of brain-derived neurotrophic factor (BDNF) and neuronal activity . Irisin However, many irisin studies have shown conflicting results between irisin levels and associated prognostic value in cardiovascular diseases ,14,15,16Acute myocardial infarction is the leading cause of death and morbidity in cardiovascular diseases . MyocardIn mice, irisin suppresses neointima formation and attenuates the development of atherosclerotic aortic lesions . Irisin Irisin is highly expressed in the myocardium. Irisin abundance is significantly correlated with different stages after myocardial infarction and cardiac repair ,25,26. CIn the acute phase of myocardial infarction, coronary blood supply, and myocardial demand imbalance cause cardiomyocyte damage and energy depletion. Therefore, decreasing cell damage and improving cardiac function are essential for cardiomyocyte survival. The myocardial injury, including mitochondrial dysfunction and reactive oxygen species (ROS) influences the myocardium repair and remodeling processes. Irisin is critical in mitochondrial homeostasis in myocardial infarction. After an ischemic injury, irisin interacts with the mitochondrial uncoupling protein ,32, prevIn early-stage ischemia, hypoxemia impairs endothelial cell function to increase permeability and leukocyte infiltration . AutophaThe abundance of irisin changes dynamically after acute myocardial infarction. Irisin increases after 8 h of myocardial infarction, then gradually decreases on day three in patients with acute ST-segment elevation myocardial infarction . This paIn the late phase of myocardial infarction, the inflammatory response is tapered and resolves after 3 to 5 days. The myocardium begins the repair process, which necessitates cell remodeling and ROS production. Immune regulation and myofibroblasts are activated for the repair mechanisms. These processes contribute to neovascularization, scar formation, and cardiac repair. The immunomodulation and anti-inflammatory effects last up to 14 days. The cardiomyocytes secrete several paracrine signals, including islet-derived 3β, to regulate macrophages and inhibit inflammation . DepletiA clinical study extensively examined the level of irisin 1 month after myocardial infarction . The myoIn short, different mechanisms may underlie irisin abundance after myocardial infarction . More evHeart failure is the terminal stage of many cardiovascular diseases with high mortality . The mol+) to NAD + hydrogen, and increases ROS [The mitochondria in cardiomyocytes are dynamic and responsive to various physiological or pathological conditions . Exercisases ROS . All thiases ROS . PGC-1α ases ROS . Fine-tuases ROS ,48. Pathases ROS ,48. Hearases ROS ,55. Decrases ROS . PGC-1α FNDC5 mRNA expression and irisin are abundant and associated with high energy expenditure [Irisin was identified as a PGC-1α–dependent myokine . Irisin enditure ,32,62. Eenditure . Increasenditure ,9. Howevenditure . These eIrisin could improve cardiac remodeling by inhibiting oxidative stress and attenuating Akt signaling activation ,66. In rPGC-1α and FNDC5 expression from skeletal muscle biopsy samples correlation with a better functional capacity [The first study in patients with heart failure revealed high capacity . High aecapacity . In paticapacity . Cachexicapacity . By contcapacity .Heart failure with a preserved ejection fraction has a more complex mechanism than that with a reduced ejection fraction does. It affects both systolic and diastolic function of the heart and is related to cardiac hypertrophy and myocardial fibrosis . The traTo date, research in irisin and heart failure is still insufficient. Whether irisin is a biomarker for heart failure or the exact mechanistic signaling of heart failure is unclear. Heart failure has different stages, including acute heart failure, chronic heart failure, or chronic heart failure with acute decompensation. In the different stages of heart failure, the role of irisin might have multiple functions. In acute ischemic injury with heart failure, higher irisin could waste more energy and increase oxidative stress and ROS . A higheFNDC5 expression in the placenta has a positive correlation with blood pressure [Hypertension is the most prevalent cardiovascular disease . Uncontrpressure . In patipressure . In hypepressure ,80. Irispressure ,81. In opressure . Irisin pressure .Hypertension can influence cardiac function. High blood pressure causes pressure overload and myocardial hypertrophy, and a hypertrophic heart leads to heart failure . This meIn patients with diabetes, the risks of coronary artery disease, hypertension, and myocardial infarction are increased . The terBased on current studies of irisin, blood pressure, and cardiac hypertrophy, many signaling pathways were associated with irisin in cardiovascular effects.  From a cIrisin has multiple functions in diabetes, obesity, and cardiovascular disease. Irisin induces the browning of adipose tissue to promote energy expenditure which prevents obesity and metabolic syndrome . ExercisThe adequate therapeutic level of irisin in myocardial infarctionThe optimal timing of irisin administration during heart failureThe role of irisin as a biomarker in acute myocardial infarction and heart failureThe mechanism of irisin during heart failure repair (trigger or consequence)The further response of irisin in vascular disease and hypertensionThe function of irisin in the cardiovascular field is gaining interest, and many laboratories have been investigating the therapeutic roles of irisin. The following areas could be further investigated:Further research is warranted to identify more of the essential mechanisms and therapeutic effects of irisin in cardiovascular disease. The disparities in irisin study results indicate the unknown aspects of irisin on the cardiomyocyte. With more evidence, irisin might be found to have an essential regulatory role in myocardial infarction, heart failure, and hypertension.


Mitral valve prolapse (MVP) is a common cause of valvular heart disease. Although many patients with MVP have a benign course, there is increasing recognition of an arrhythmic phenotype associated with ventricular arrhythmias and sudden cardiac death (SCD). Pathophysiologic mechanisms associated with arrhythmias include cardiac fibrosis, mechanical stress induced changes in ventricular refractory periods, as well as electrophysiologic changes in Purkinje fibers. Clinically, a variety of risk factors including demographic, electrocardiographic, and imaging characteristics help to identify patients with MVP at the highest at risk of SCD and arrhythmias. Once identified, recent advances in treatment including device therapy, catheter ablation, and surgical interventions show promising outcomes. In this review, we will summarize the incidence of ventricular arrhythmias and SCD in patients with MVP, the association with mitral annular disjunction, mechanisms of arrhythmogenesis, methods for arrhythmic and SCD risk stratification including findings with multimodality imaging, and treatments for the primary and secondary prevention of SCD. Mitral valve prolapse (MVP) is the abnormal systolic excursion of mitral valve leaflets into the left atrium. First described clinically in the 1960s with cine-angiocardiography ,3,4. MVPPathologically, MVP is a spectrum of anatomical abnormalities ranging from the classic form (Barlow’s Disease) with thickened redundant leaflets to a non-classic form (fibroelastic deficiency) with thinner leaflets ,7. In clMVP is related to but distinct from mitral annular disjunction (MAD). The mitral annulus is an anatomically “D”-shaped structure, into which the anterior and posterior mitral valve leaflets insert ,12. MAD The long-term outcome of patients with MVP is heterogenous ,5,28. WhIn this review, we will summarize the mechanisms of arrhythmogenesis, incidence of SCD in patients with MVP, methods for SCD risk stratification including novel findings with multimodality imaging, and treatments for the primary and secondary prevention of SCD.While poorly understood, the current understanding of arrhythmogenesis in MVP involves the development of a substrate for arrhythmias (cardiac fibrosis) combined with a trigger for arrhythmias . The anaIn addition to a substrate, a trigger is typically necessary for sustained VA. Two key theories for triggers involve abnormal mechanical stretch and Purkinje tissue. In animal models, papillary muscle traction prolonged the ventricular functional refractory period locally . Given tMAD has also been associated with VA both in the presence and absence of MVP. This has led some authors to suggest that MAD is the inciting factor in the cascade that involves altered valvular mechanics, valvular degeneration, leaflet prolapse, myocardial fibrosis, and finally arrhythmias. This has been labeled the Padua hypothesis , and whiThe majority of patients with MVP have a benign course. However, there are subgroups at higher risk for complications. Studies are difficult to generalize due to a variety of cohorts studied. In a large study of Olmstead Countypatients, those with asymptomatic MVP had a 10-year cardiovascular morbidity and overall mortality of 30% and 19%, respectively . AnotherSudden cardiac death (SCD) and VA occur at a low rate in patients with MVP, about 0.14 per 100 patient years in community-dwelling patients ,40,41,42There is a growing body of evidence identifying those with MVP at higher risk for SCD. The following section will describe known risk factors for SCD and describe an approach to risk stratification. Relatively little is known about the demographic factors predisposing MVP patients to SCD. Classically, SCD patients found to have MVP are younger than patients with SCD from other causes . HoweverMost patients with MVP have no clearly identifiable resting ECG abnormalities. However, several ECG abnormalities correlated with MVP and SCD have been known since the 1970s ,47,48. OIndividual studies produced conflicting results on whether patients with MVP with arrhythmias have longer corrected QT intervals ,30,39,50QT dispersion  has been shown to be higher in patients with MVP than those with normal hearts and has been correlated with VA, MVP severity, and complex ventricular ectopy in MVP patients ,52,53,54Ventricular ectopy (VE) is common in patients with MVP . Typicalp value < 0.001) for complex VA  compared with segmental or single leaflet prolapse [Several anatomic characteristics of the mitral valve (MV) leaflets themselves have been associated with VA and SCD . The preprolapse . Longer prolapse ,49,54,59prolapse , but an prolapse . A largeprolapse . The degree of regurgitation appears to be associated with SCD, although patients with minimal regurgitation may still experience SCD ,60. The Advances in echocardiographic techniques have led to the identification of several abnormalities associated with VA. As described below, these advances include the mitral annular tissue Doppler velocity, global longitudinal strain, mechanical dispersion, and post-systolic shortening. While these new imaging findings are promising, most have only been demonstrated in small studies and require further validation prior to mainstream utilization. Pickelhaube sign: In one study of 21 patients, a spike in the mitral annular tissue-Doppler velocity of >16 cm/sec was associated with VA . This spSpeckle-tracking echocardiography: Changes in speckle-tracking echocardiography imaging can precede more classic changes in cardiac function  and have been associated with arrhythmic outcomes in hypertrophic cardiomyopathy . PatientMechanical dispersion is defined as the standard deviation of the time to peak longitudinal strain in all LV segments. A larger number correlates with mechanical dyssynchrony. Increased mechanical dispersion correlates with myocardial fibrosis and arrhythmic risk in hypertrophic cardiomyopathy and ischemic cardiomyopathy ,69. ArrhOther speckle-tracking echocardiography techniques such as circumferential or radial strain, and post-systolic shortening may be associated with MVP with VA, but further validation is required ,67,70.p = 0.001) in a meta-analysis [Cardiac magnetic resonance (CMR) is a powerful technique to assess cardiac structure and function, including cardiac fibrosis. In addition to evaluation of valve structure and regurgitation, contrast enhanced CMR with delayed imaging can demonstrate late gadolinium enhancement (LGE), a marker for replacement myocardial fibrosis . LGE is analysis . Areas oanalysis ,75,76. A recent histopathologic analysis of MVP with SCD also suggested that MVP patients may have a more diffuse type of fibrosis compared with controls . This dip < 0.0001) [As described above, MAD is defined as mitral annular detachment from the basal LV myocardium with an abnormal systolic excursion of the mitral valve hinge point into the left atrium . It is p 0.0001) . Given limited multicenter prospective data, arrhythmic risk stratification for MVP must be individualized and cost-effectiveness should be considered. Our specific approach is outlined in In general, MVP patients with significant valvular heart disease and arrhythmias are treated according to standard guidelines for arrhythmias, valvular heart disease, and heart failure . To dateThe role of electrophysiology study (EPS) in risk stratification for patients with MVP is unclear. During an EPS, ventricular burst pacing or ventricular extra-stimulus testing can be utilized to assess the risk of future sustained VA and the potential need for an implantable cardiac defibrillator (ICD). As discussed above, there are multiple known risk factors for increased risk of ventricular arrhythmias, although formal indications for EPS in MVP patients do not exist. One study of MVP patients undergoing ablation showed that 5/5 patients of those that had sustained VA after an ablation experienced sustained VT during EPS prior to first ablation . This suThere is relatively little data regarding the efficacy of anti-arrhythmic drugs for VA specifically related to MVP. Due to their relative safety, medical therapy is often first line. PVC suppression by anti-arrhythmic drug therapy  in one small study was not efficacious . There iThe use of ICDs should follow standard guidelines. Patients with sustained ventricular tachycardia or fibrillation should be considered for secondary prevention ICD. The role of primary prevention ICD is unclear. As mentioned above, an electrophysiology study may be helpful for risk stratification, but currently there are no robust data to support primary prevention ICD in any other specific populations and no formal risk calculators. If arrhythmic MVP is being considered, a cardiac MRI prior to device implantation may be helpful.Catheter ablation in patients with MVP is typically carried out for frequent symptomatic ventricular ectopy, sustained ventricular fibrillation/tachycardia (including PVC triggered), or recurrent appropriate ICD discharges refractory to anti-arrhythmic drug therapy. Of note, in one prior series where the ablation of PVCs triggering VF was performed, one patient had incessant VF in the first 24 h post ablation .As discussed above, MVP-related PVCs often originate from the papillary muscles and from Purkinje fibers. Other sources include the mitral valve annulus, right ventricular outflow tract, septum, LV lateral wall, or other locations  ,57,79,80Given the predisposition to papillary muscle arrhythmias, ablation can be challenging in MVP patients . The anaFor ablation, the papillary muscle structure makes catheter engagement and stability more difficult. Steerable sheaths may be helpful. Intra-cardiac echocardiography (ICE) is a useful adjunct to confirm anatomic position and stability. High energy is often necessary to create adequate injury given the poor contact. In papillary muscle PVC cases refractory to radiofrequency ablation, cryoablation should be considered as it may result in improved catheter stability during ablation  84,85,8,885,86.PVC ablation has been shown to reduce ventricular ectopy burden, prevent ICD shocks, and improve systolic function (in patients with PVC cardiomyopathy) ,35,56. ISurgical indications for mitral valve repair in the setting of MVP depend on the severity of mitral regurgitation; the role of surgery and intraoperative ablation for the prevention of SCD is unknown. Historically, multiple case reports and series, typically with fewer than ten patients with MVP and VA, showed a reduction in VA after mitral valve surgery, even when the regurgitation was insignificant ,88,89. MOnly a small proportion of patients with MVP and MAD will suffer from VA, but given the relative prevalence of MVP and MAD worldwide, it is a significant cause of SCD. Over the last decade, retrospective research studies have identified risk factors for SCD, including abnormalities in electrocardiography, echocardiography, and cardiac MRI. Initial research suggests that electrophysiologic studies can accurately predict the need for ICD in well-selected patients and that catheter ablation of VA is efficacious when indicated. Future prospective research is needed to further delineate optimal methods for SCD risk stratification and treatment.


Left atrium enlargement is very common in patients with valvular heart disease and atrial fibrillation but an extremely dilated left atrium is a very rare condition and rarely reported in the literature. It is a risk factor for ischemic cerebrovascular accidents due to blood stasis as the cavity diameter increases. We are reporting a case of rarely seen severely dilated left atrium with a normal functioning prosthetic mechanical mitral valve with a cerebrovascular accident on anti-vitamin K and aspirin. The patient had a left atrium diameter of 12.7 cm, an area of 200 cm square, and a volume of 2000 cc. We elected to keep the international normalized ratio (INR) slightly above the therapeutic range in order to decrease the risk of ischemic events. It might be necessary to do the same for patients with a similar condition to decrease the stroke rates. The left atrium is an important structure in the heart, as it receives oxygenated blood from the lungs by the pulmonary veins and participates in left ventricular filling. When opposed to high afterload and high pressure or when the heart electrical activity is irregular in case of atrial fibrillation, the left atrium will increase in size to compensate for the high afterload . This ocOur patient was a 60-year-old male with a history of long-standing hypertension, dyslipidemia, and permanent atrial fibrillation. He underwent mechanical mitral valve replacement 10 years ago with no major complications. His medications were bisoprolol, aspirin, warfarin, spironolactone, and furosemide. He presented for acute onset of slurred speech and right upper limb weakness associated with hypertension (175/120 mmHg), with a heart rate of 75 beats per minute. ECG showed atrial fibrillation with normal ventricular rate and all laboratory tests were within normal range but he had a subtherapeutic international normalized ratio (INR) of 2.1. Chest X-ray showed massive cardiomegaly . We elected to keep the INR above 3.0 and replaced aspirin with clopidogrel to decrease the risk of gastrointestinal bleeding and ischemic brain events. The combination of VKA and antithrombotics was also shown to decrease the risk of ischemic events, with a moderate increase in bleeding events. It might be warranted to do the same in the future for patients with extremely large left atrial size prior to the occurrence of a cerebrovascular ischemic accident.


Leadless pacemaker is indicated in patients with symptomatic bradycardia as an alternative therapy when transvenous pacemaker implantation is considered difficult or at high risk. The experience of implanting leadless pacemaker in patients with dextrocardia and situs inversus is limited. A 94-year-old male was transferred to our hospital due to advanced atrio-ventricular block with episode of syncope. Chest radiograph and computed tomography revealed dextrocardia with situs inversus. Emergency cardiac catheterization was performed and a temporary pacemaker was inserted, but the patient removed it due to delirium. So, a leadless pacemaker was implanted to him. Shorter time of bed-rest after the implantation and shorter hospital stay would be beneficial of implanting a leadless pacemaker. Precise anatomical evaluation would be important to perform implantation efficiently and safely. Permanent cardiac pacing is a gold standard therapy for symptomatic bradycardia. A leadless intracardiac transcatheter pacing system is also available with advantages of fewer lead problems and less chance of device infections. Dextrocardia with situs inversus is a rare condition in which the heart and major visceral organs are positioned on the right side of the body. The incidence of dextrocardia with situs inversus is estimated to be 0.0125% in the general population [A 94-year-old male was transferred to our hospital due to malaise, loss of appetite, and bradycardia with a heart rate of 30 beats per minute. He experienced syncope a few months prior to presentation. He had been treated with an angiotensin II receptor blocker for hypertension by his family doctor. At the age of 70 years he underwent a gastrectomy for gastric cancer. He received an operation for lumbar spinal stenosis at an age of 90. An electrocardiogram (ECG) demonstrated 2:1 atrio-ventricular block with a ventricular rate of 34 bpm Figure . Chest rThe patient received an emergency cardiac catheterization since the cardiac troponin T was positive. Coronary angiography showed no significant stenosis in the coronary arteries. A temporary pacemaker was inserted from the right internal jugular vein for treatment of symptomatic bradycardia. His symptoms and pulmonary congestion improved after VVI pacing at 70 bpm, and an elective implantation of the permanent pacemaker was scheduled. Echocardiography demonstrated a normal left ventricular function and no significant valve dysfunction or other cardiac anomalies. On the next day after admission, the patient removed the pacing lead of temporary pacemaker unintentionally due to delirium during the daytime. His daily cognitive ability was normal. We discussed the treatment option as to whether to insert a temporary pacemaker again and implant a transvenous pacemaker electively or to implant a leadless pacemaker directly. The medical team explained the family members about the possible repetition of removal of the temporally pacemaker before implantation of transvenous pacemaker. Although, in patients with atrio-ventricular block lacking atrial fibrillation, dual-chamber pacing, not single-chamber pacemaker, is recommended, his family requested to implant a leadless pacemaker.The implantation of a leadless pacemaker was performed under fluoroscopy after the right ventriculography Figure , 2B. The3, length of 25.9 mm, and weight of 2.0 g. Its functionality and features are similar to those of existing VVI(R) pacemakers with a longevity of 12.5 years [The leadless pacemaker  is a single-chamber ventricular pacemaker with a volume of 0.8 cm.5 years .Dextrocardia with situs inversus is a rare condition that is characterized by abnormal mirror image positioning of the heart and other organs. Although majority of affected individuals are asymptomatic, some individuals may have congenital heart anomalies or ciliary dyskinesia referred to Kartagener syndrome. Device implantations sometimes are complicated by anatomical anomalies of the heart. During the leadless pacemaker implantation, implanting tools are not made for those conditions and the procedures using existing delivery systems are challenging.So far, successful implantation of leadless pacemakers in patients with dextrocardia and situs inversus has been rarely reported. To the best of our knowledge, Regibus et al. reported one case of a leadless pacemaker implantation in a 36-year-old male patient with dextrocardia and situs inversus . A transWe implanted a leadless pacemaker for symptomatic high-degree atrio-ventricular block in an elderly patient with dextrocardia and situs inversus. Shorter time of bed-rest after the implantation and shorter hospital stay would be beneficial to elderly patients with a risk of delirium. However, a precise anatomical evaluation by fluoroscopy, venography, and right ventriculography would be important for grasping accurate anatomy and performing the procedure of implantation efficiently and safely.


Exercise therapy is considered preferential treatment for patellar tendinopathy (PT). However, there is conflicting evidence for structural patellar tendon adaptation in response to exercise therapy and its association with symptoms is weak.2* relaxation times and symptom severity; 2) baseline T2* and clinical outcome; and 3) longitudinal T2* changes and clinical outcome in athletes with PT performing exercise therapy.To assess the association between 1) TRandomized controlled clinical trial.Seventy‐six athletes (18–35 years) with clinically diagnosed and ultrasound‐confirmed PT.3D gradient echo sequence (3.0 T).2* relaxation times were quantified using mono‐exponential and bi‐exponential models. T2* analysis was performed in three patellar tendon tissue compartments representing: aligned collagen, degenerative tissue, and interface.Patients were enrolled in a randomized trial of progressive tendon‐loading exercises (PTLE) versus eccentric exercise therapy (EET). Symptoms were assessed using the Victorian Institute of Sports Assessment (VISA‐P) questionnaire. 3D‐Ultrashort echo time (UTE)‐MRI was acquired at baseline, 12 and 24 weeks. Voxel‐wise TAdjusted general linear, mixed‐linear models, and generalized estimating equations.2* relaxation times were significantly associated with VISA‐P in degenerative and interface tissues of the patellar tendon. No association was found between baseline T2* and VISA‐P after 24 weeks (P > 0.29). The estimated mean T2* in degenerative tissue decreased from 14 msec (95%CI: 12–16) at baseline to 13 msec (95%CI: 11–15) at 12 weeks and to 13 msec (95%CI: 10–15) at 24 weeks. The significant decrease in T2* from baseline to 24 weeks was associated with improved clinical outcome.We included 76 patients with PT ; 38 in the PTLE‐group and 38 in the EET‐group, of which 57 subjects remained eligible for analysis. T2* relaxation times, identified with 3D‐UTE‐MRI, decreased significantly in athletes with patellar tendinopathy performing exercise therapy and this decrease was associated with improved clinical outcome.Tissue‐specific T1Stage 4 Patellar tendinopathy (PT) is a common disorder due to tendon overuse injury in athletes.The pathophysiology of PT is largely unknown but involves characteristic degenerative changes at the latter stages.2* relaxation components, such as collagen.Imaging of tendons using MRI with conventional pulse sequences is typically limited by the fast free induction decay of collagen, commonly only visualizing increased signal intensity in the proximal patellar tendon, which may reflect increased water content.2* tissues such as tendons, which can be used to infer tendon hydration state by voxel‐wise T2* quantification.2* analysis reflects signal from protons in different water pools within the patellar tendon, consisting of collagen‐bound water pools (shorter T2* relaxation times) and free water pools (longer T2* relaxation times).2* fitting models have shown the best reliability, bi‐exponential models allow differentiating voxels in highly organized collagen compartments from degenerative tissue compartments within the patellar tendon.Ultrashort echo time (UTE) MRI facilitates the detection of signal from short T2* relaxation times.2* changes in PT within specific tissue compartments has not been performed. Moreover, associations with symptoms have not been studied. We hypothesized that temporal changes in T2* can be detected using UTE‐MRI and might be associated with clinical outcome in athletes with patellar tendinopathy performing exercise therapy.Previous studies on UTE in tendinopathy have consistently shown increased T2* relaxation times within different tissue compartments of the patellar tendon and symptom severity. The second aim was to investigate the association between baseline T2* and clinical outcome after exercise therapy. The third aim was to evaluate the association between longitudinal T2* changes and changes in severity of symptoms in athletes with PT.The first aim of this study was to investigate the association between TClinicalTrials.gov ID: NCT02938143). Inclusion criteria were age 18–35 years; history of knee pain in the patellar tendon region associated with training and competition; playing sports ≥3 times a week before injury onset; tenderness on palpation of the proximal patellar tendon; structural tendon changes on grayscale ultrasound and/or increased tendon vascularity on power Doppler; Victorian Institute of Sports Assessment (VISA‐P) score < 80/100. Exclusion criteria are presented in the trial register. Activity level was measured using the Cincinnati Sports Activity Scale (CSAS).Ethical approval was obtained by the institutional review board and all participants provided written informed consent. Participants enrolled in the JUMPER‐study, a randomized controlled trial investigating the effect of progressive tendon‐loading exercises (PTLE) vs. eccentric exercise therapy (EET) for PT  with 10 years' experience. Subsequently, grayscale ultrasound  and power Doppler ultrasound (PDUS) were performed by the main investigator, a radiologist‐in‐training with 5 years' experience (S.B.) under supervision of a senior musculoskeletal radiologist with 16 years' experience (E.O.) to confirm the clinical diagnosis PT. Ultrasound was regarded conclusive for PT when structural changes to normal parallel ordered collagen fibers and/or hypoechoic changes and/or tendon thickening (anterior–posterior diameter > 6 mm) were confirmed and/or presence of intratendinous Doppler flow was detected on PDUS.The intervention group performed progressive tendon‐loading exercises (PTLE) within limits of acceptable pain, consisting of four consecutive stages .Clinical and imaging outcomes were collected at baseline, 12 and 24 weeks by the main investigator (S.B.). Patients were included in the primary analysis when there was at least one follow‐up measurement available.Symptom severity was assessed using the validated Victorian Institute of Sports Assessment (VISA‐P) questionnaire prior to image acquisition at every visit.Imaging was performed at 3.0 T  using a 16‐channel flexible coil  and a fixation device. The knee was positioned in 30° flexion, using a cylindrical tube and foam padding.3, number of slices = 60, number of excitations (NEX) = 1, bandwidth 125 kHz, flip angle = 17°, and two excitations per fat saturation. Echoes were scanned in interleaved order using four fat saturated multiecho UTE‐acquisitions with a total scan time of 53 minutes. The full acquisition protocol is described elsewhere.2* quantification.Using a research prototype 3D‐UTE‐Cones sequence , 16 echoes  were acquired using four multi‐echo sequences with a constant repetition time of 83.4 msec.Image registration was performed to facilitate spatial one‐to‐one mapping of voxels across longitudinal UTE‐acquisitions, using in‐house developed tools  and Matlab software .2* analysis, mono‐exponential and bi‐exponential models were fitted to registered UTE‐images, using maximum likelihood estimation incorporating the Rician noise model.Image analysis was performed by the main investigator, a radiologist‐in‐training with 5 years' experience (S.B.) under supervision of a postdoctoral researcher specialized in image analysis with 14 years' experience (D.P.) using an in‐house developed Matlab script. For quantitative T2* data within this mask were categorized into three groups, by selecting voxels based on the average over visits of the percentage of short T2* components from the bi‐exponential model .2* (60%–100% short), 2) mostly long T2* (0%–30% short), and 3) an interface that separated the two (30%–60% short). The subregions were considered to represent aligned collagen, degenerative tissue, and an interface, respectively and were based on histogram analysis of the T2* frequency distribution in previous work.2* relaxation times were used, in these selected voxel groups that were constant over visits, to calculate T2* relaxation times for each voxel group (patellar tendon subregion) accordingly. Thus, the selected voxel groups that delineated the regions of interest used for analysis were defined on the baseline scans and propagated to follow‐up scans to assess temporal changes in T2* on subsequent scans (after 12 weeks and 24 weeks). The mono‐exponential T2* relaxation times were fitted voxel‐wisely in the entire registered scan volume from three separate visits.Second, the T2* relaxation times and VISA‐P score were assessed using multiple linear regression analyses. Adjusted general linear models were used to assess associations between baseline T2* and clinical outcome after 24 weeks. Longitudinal data were analyzed using adjusted generalized estimating equations (GEE) models, to estimate population‐averaged effects. Whole group analyses were performed and between‐group differences in relation to the time course of the dependent variables were evaluated using an interaction term “study arm*visit” in the GEE model, where the visit defined baseline, 12 weeks or 24 weeks. Bonferroni corrections were applied in the GEE‐models for the following comparisons: 1) baseline vs. 12 weeks, 2) 12 weeks vs. 24 weeks, and 3) baseline vs. 24 weeks. Associations with clinical outcome were evaluated using adjusted mixed linear models. All models were adjusted for predefined potential confounding factors, including age, sex, BMI, CSAS, and symptom duration. All analyses were performed following an intention‐to‐treat principle. Imputation of missing data was not performed. Instead, posthoc sensitivity analyses using the last observation carried forward (LOCF) approach were performed when the amount of missing data exceeded 5% of the total number of observations.P‐value < 0.05.Normality of data was assessed using the Shapiro–Wilk test and homogeneity of variances was tested using the Levene test. Associations between T2* analysis. Furthermore, eight subjects could not be included in the primary analysis due to missing data. Demographic characteristics of the study population are listed in Table Athletes were consecutively enrolled between January 2017 and June 2019. A total of 76 included athletes  with clinically diagnosed and ultrasound‐confirmed PT were included of which 38 were randomized to PTLE and 38 to EET . The significant adjusted mean between‐group difference of the VISA‐P score at 24 weeks was 9 points (95% CI: 1–16), in favor of the PTLE group, indicating an improved clinical outcome in athletes performing progressive tendon‐loading exercises (PTLE).Among all athletes, the estimated mean VISA‐P score improved significantly from 57 (95% CI: 53–61) at baseline to 72 (95% CI: 67–76) at 12 weeks and 80 (95% CI: 76–84) at 24 weeks follow‐up. In the PTLE group, the estimated mean VISA‐P score improved significantly from 56 (95% CI: 52–61) at baseline to 84 (95% CI: 79–89) at 24 weeks and in the EET‐group it improved significantly from 57 (95% CI: 53–62) to 75 (95% CI: 69–82). The parameter estimate for the “study arm2* relaxation times in both degenerative tissue and in the interface between aligned collagen and degenerative tissue .Baseline T2* was found in the voxels that represented the degenerative tissue of the patellar tendon, from 14 ± 3 msec at baseline to 13 ± 4 msec at 24 weeks (adjusted mean difference [95% CI] = 1 msec [1–2]). The change in T2* was not significant at 12 weeks . For voxels that represented aligned collagen and voxels that represented the interface between aligned collagen and degenerative tissue, the adjusted mean differences were not statistically significant  . An example of the longitudinal T2* change is illustrated in Fig. Among all athletes, a significant decrease in T2* decrease in the degenerative tissue compartment was significantly associated with the improvement in severity of symptoms as measured with the VISA‐P score , Fig. P = 0.77) and interface (P = 0.06) tissue compartments.The significant T2* decrease in degenerative tissue between baseline and 24 weeks follow up remained significant . The association with clinical outcome was significant  when the most recent preceding T2* value was carried forward to substitute all missing values. There were no significant T2* changes in voxels that represented aligned collagen  and the voxels that represented the interface  between aligned collagen and degenerative tissue.Twenty one of the 195 UTE‐MRI acquisitions (11%) were missing .2* in a remodeling anterior cruciate ligament graft 6 months post‐surgery. Forth, a change in the MR acquisition protocol during the trial was required to optimize SNR for better fitting of T2* data, which unfortunately lead to exclusion of 11 patients in the final analyses. Moreover, the unbalanced loss of follow‐up between the exercise groups (one in the PTLE group and seven in the EET group), could suggest that the eccentric exercises were less easy to sustain, which seems logical due to the fact that these exercises should be performed with pain.2* after 24 weeks was associated with clinical improvement in our study participants, it is important to note that the validity of the T2* parameters in tendinopathy (with tissue histopathology as reference standard) is currently unknown.We proposed a method to quantify T2* relaxation times identified with 3D‐UTE‐MRI are associated with symptom severity in athletes with patellar tendinopathy. Decreasing T2* relaxation times in the degenerative tissue of the patellar tendon are associated with improved clinical outcome after exercise therapy for patellar tendinopathy, while it is unsuitable as a single predictive measurement at baseline for clinical outcome. While the change in T2* was small and the technique has limitations to use in clinical practice, our findings indicate that the hydration state of the patellar tendon is able to change in response to conservative exercise therapy.Tissue‐specific T


A major clinical concern is the continuous increase in the number of patients diagnosed with advanced coronary artery disease, ischemic heart failure, and refractory angina, and one of the most promising treatment options for these conditions is stem cell-based therapy. The aim of this study was to assess the functional improvement following intramyocardial injection of adipose-derived stromal cells, using cardiac magnetic resonance. p = 0.025) and stroke volume index , a statistical trend toward an increase in left ventricle ejection fraction , and cardiac output improvement  was observed in the patient postprocedure. Enhanced relative regional thickening was noted in the segments with adipose-derived stromal cell implantation.  Thirteen patients with ischemic heart failure, reduced left ventricular ejection fraction, refractory angina, and who have been disqualified from any form of direct revascularization were enrolled in the study with transthoracic autologous adipose-derived stromal cell implantation. All patients underwent cardiac magnetic resonance prior to the procedure and after 12 months of follow-up. A significant increase in stroke volume (83.1 ± 8.5 mL vs 93.8 ± 13.8 mL,  Intramyocardial adipose-derived stromal cell implantation is a promising therapeutic option for selected, symptomatic patients with ischemic heart failure, who have preserved myocardial viability despite being unsuitable for direct revascularization. Ischemic heart disease, caused by the reduction of blood supply in the myocardium, has been a major clinical burden of the recent years. Cardiovascular diseases have contributed to the highest number of years of life lost in patients across the world , 2. ObstIschemic heart failure (IHF) is characterized by typical symptoms of breathlessness, ankle swelling, and fatigue, with CAD as the underlying cause . CurrentBased on current treatment guidelines, novel therapies, including promotion of collateral growth, transmural redistribution of blood flow, and neuromodulation of the cardiac pain syndrome, are considered for these individuals, and among these, stem cell-based therapies are the most promising treatment strategy . The forNevertheless, evidence regarding the clinical effectiveness of stem cell-based therapies is still limited . In the Fifteen patients with IHF were enrolled in this study in accordance with a previously published study protocol , 18.2), unexplained hematological abnormalities, existing valvular heart disease, requirement of surgery, congenital heart disease, severe arrhythmias, contraindications for general anesthesia, and inability to perform CMR imaging .Briefly, the inclusion criteria were symptomatic IHF with or without reduced left ventricular ejection fraction (LVEF) (NYHA class II or III), stable angina (CCS class II or greater), and ineligibility for direct revascularization (PCI or CABG) as assessed by the local Heart Team. Exclusion criteria included LVEF less than 20%, acute myocardial infarction within 6 months before enrollment, history of malignancy, renal dysfunction  prior to the procedure. All patients had previous myocardial infarction; before enrollment, 5 of the 13 patients (38%) had undergone PCI, and 3 of the 13 patients (23%) had undergone CABG .6.The ADSC implantation site was determined by the position of the mid-left anterior descending (mid-LAD) artery. The harvested stem cell suspension was then immediately delivered with a PHOENIX combined delivery system , and 1 mL of suspension was applied around each single channel created using the laser. No perioperative complications were reported, and the patients were discharged home on postoperative day 7. The detailed protocol for ADSC implantation has been described previously [Patients were placed under general anesthesia, and fat tissue (liposuction) was collected from the abdominal area; automatic suction was not used to collect body fat. Subsequently, the adipose tissue was subjected to purification using the Celution® 800/CRS System , according to the manufacturer's instructions, to obtain ADSCs, and 5 mL of concentrated stem cell suspension was obtained from the patients. For cell purification, we used dedicated medical equipment that enables reliable and reproducible isolation of ADSCs from the fat tissue . The anteviously , 18.Breath-hold, ECG-gated CMR was performed using the 1.5 T scanner Magnetom Sonata Maestro Class  equipped with a cardiac phased array coil. Cine and morphologic imaging was performed in the left ventricular two-chamber, four-chamber, apical long-axis, and short-axis view, encompassing the entire left ventricle (LV). Cine imaging was performed using a balanced steady-state free precession gradient echo technique . Ten minutes after intravenous infusion of 0.15 mmol/kg body weight gadobutrol , late gadolinium-enhanced (LGE) imaging was performed using T1-weighted segmented inversion-recovery pulse sequence .Cine and LGE images were assessed offline using dedicated software  by an independent observer, blinded to the clinical data.Cine images: endocardial and epicardial LV borders were outlined using the short-axis images to calculate end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), myocardial mass, and EF.LGE images: qualitative assessment for the presence and location of hyperintense lesions in contrast to hypointense viable myocardium was performed using the LGE images. The number of affected segments was calculated, and the transmurality of myocardial wall thickness was scored using the LGE images as follows: 0 (no LGE), 1(1–25%), 2 (26–50%), 3 (51–75%), or 4 (76–100%).Health status was evaluated on the basis of the Short Form Health Survey (SF-36), which is commonly used in cardiac rehabilitation studies . Scores t-test or Wilcoxon signed-rank test, when appropriate. The Friedman test was used to analyze changes in quality of life over the observation period. For categorical variables, McNemar's test was applied. Statistical analysis was performed using STATISTICA 13.3 . A p value <0.05 was considered statistically significant.Quantitative findings are presented as the mean ± standard deviation or median (interquartile range) when appropriate. Qualitative findings are presented as raw numbers and/or percentages. Statistical tests performed for related samples were paired This study was funded by the Polish National Science Centre (contract number UMO-2011/03/B/NZ5/01437). This article was supported by the science fund of the John Paul II Hospital, Cracow, Poland (no. FN5/2021 to J.K.K.), and Jagiellonian University Medical College. The study was approved by the Bioethics Committee at the regional medical chamber in Krakow, Poland .p = 0.025) and stroke volume index , which is the ratio of PER to EDV of the LV, peak filling rate index (PFRi), which is the ratio of PFR to EDV of the LV, and peak ejection time . Myocardp < 0.001), BP (p < 0.001), and GH (p < 0.001)  required hospital readmissions due to cardiac causes . The quality of life improved over the 12 months after the procedure in terms of PF (< 0.001) .CMR is extremely efficacious in evaluating myocardial ischemia and myocardial function in patients with heart failure (HF) and CAD . AlthougDespite the small sample size, a significant improvement in the LV systolic function was noted . AdditioThe observed enhanced myocardial thickening and left ventricle function correspond with initial 6 months results reported for this trial . PreviouMoreover, hospital readmissions in patients with HF remain a great health care problem, reaching the annual rate of 41% based on the recently published data for the Polish population . In our Undoubtedly, stem cell-based therapies are still evolving and require further investigation. However, as no adverse events related to ADSC implantation were reported within 12 months follow-up in this study, the proposed procedure can be considered a safe treatment option for highly symptomatic patients. ADSCs have been previously investigated in the Athena Trial; however, the percutaneous delivery protocol was associated with neurological complications, resulting in premature termination . The traSeveral stem cell lines have been previously investigated, and the results from the mesenchymal stromal cell therapy in heart failure (MSC-HF) trial have been recently published . The MSCThe major limitations of our study include small sample size and lack of a control group. It should be noted that all subjects received optimal medical therapy at least 12 months before the operation and continued treatment throughout the follow-up period. Therefore, the study design does not allow for definite conclusions regarding the effectiveness of the applied treatment. Nevertheless, the study provides novel information, including successful implementation of the CMR myocardial viability assessment protocol.In conclusion, an appropriate qualification protocol with CMR-assessed viability can aid the selection of the best candidates for indirect revascularization treatments, in terms of safety and efficacy. Symptomatic patients with IHF, ineligible for direct revascularization, selected using a CMR-based assessment, can consider transthoracic ADSC injection as a safe alternate treatment option for angina symptoms and improvement in LV viability.