Rates of 1-year death  and MACE  were higher for the FMR group, as compared to the DMR group. After correcting for variables, FMR independently predicted rates of MACE  and had a non-significant effect on one-year mortality . In our experience, worse overall 1-year composite MACE outcomes were observed after TEER in patients with FMR as compared to patients with DMR.Current guidelines support the use of transcatheter edge-to-edge repair (TEER) for patients with both primary and secondary mitral regurgitation. We aimed to compare the prognoses of TEER in degenerative mitral regurgitation (DMR) vs. functional mitral regurgitation (FMR). A total of 208 consecutive patients who underwent TEER over a ten-year period were analyzed. Primary endpoints included rates of all-cause death and major adverse cardiac events . A total of 148 (71%) patients were identified with FMR, while 60 (29%) were identified with DMR. Patients in the FMR group were younger (77.2 ± 8.4 vs. 80.2 ± 7.2,  Mitral regurgitation (MR) is the most common heart valve disease in the global population . Even whIn this prospective registry, included were all patients undergoing TEER at the Rabin Medical Center, Petah-Tikva, Israel and the Città della Salute e della Scienza Hospital, Turin, Italy for the first time using the MitraClip percutaneous mitral valve repair  between January 2012 and May 2021. All patients suffered from severe symptomatic MR. The data is continuously entered into an ongoing prospective registry for purposes of recording and monitoring patient-related parameters, clinical events, and angiographic findings. Exclusion criteria were immediate conversion to surgery due to technical failure, unavailability of echocardiographic data after discharge, concomitant transcatheter tricuspid repair, active malignancy, systemic infection, or cardiogenic shock at baseline. The study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki and was approved by the ethics committees of both medical centers.As recently validated and adopted in several medical centers worldwide ,12,13, at-test (paired or unpaired), whereas those not following a normal distribution are presented as median and interquartile range and were compared using the Mann–Whitney U test. Categorical variables are reported as counts and percentages and were compared using the chi-squared or Fisher’s exact test, as appropriate.The Kolmogorov–Smirnov and Shapiro–Wilk tests were used to investigate the normality of the distribution of continuous variables. Continuous variables following a normal distribution are reported as mean ± standard deviation and were compared using the Student’s p < 0.25 on univariate analysis were included in the final multivariable model. Each result is expressed as a hazard ratio (HR) and a corresponding 95% confidence interval (CI). A 2-sided p value of < 0.05 was considered statistically significant for all analyses. All statistical analyses were performed using SPSS version 28.0 .The survival rate free from clinical endpoints was estimated using the Kaplan–Meier method, and the differences between groups were calculated using the log-rank test. A Cox regression analysis was performed to identify the multivariable predictors of mortality and MACE at 12 months. Variables with A total of 226 patients had undergone TEER over the study period (2012–2021), of whom 18 were excluded due to conversion to surgery and missing echocardiographic data for the complete follow-up period .p = 0.02), suffered more frequently from coronary artery disease (CAD) , and atrial fibrillation/flutter , as compared to the DMR group.Of the remaining eligible 208 patients, 148 (71%) were identified with FMR, while 60 (29%) were identified with DMR. Baseline characteristics of DMR vs. FMR are shown in p = 0.04), higher left ventricular end systolic diameter (LVESd) , lower left ventricular ejection fraction (LVEF) , lower MR volume , and higher pulmonary artery pressure , as compared to the DMR group.Baseline echocardiographic characteristics are shown in p = 0.04), MACE , and hospitalizations for heart failure,  were all significantly higher in the FMR group after 1 year as compared to the DMR group.Clinical outcomes during study follow-up are shown in Kaplan–Meier analysis for death and MACE are shown in p = 0.04) emerged as an independent risk factor for mortality at 1 year, while higher LVEF  was found to be an independent protective factor for mortality at 1 year. Although not statistically significant, FMR etiology  displayed a numerical trend towards higher 1-year mortality.The results of the Cox regression analysis for death are shown in p = 0.02), FMR etiology , and post-procedure MR  emerged as independent risk factors for 1 year events, while higher LVEF  was found to be an independent protective factor.For MACE , after aThe Kaplan–Meier curves for the adjusted death and MACE are shown in According to our decade-long clinical experience with TEER for both FMR and DMR, we observed higher rates of both death and MACE at 1 year in the FMR group, as compared to the DMR group. Following adjustment, FMR was independently associated with excess MACE but had a marginal, non-significant effect on 1-year mortality following TEER—probably due to the relatively small number of mortality events. Multivariable analysis identified age as an independent risk factor for both mortality and MACE at 1 year, whereas higher LVEF was found to be an independent protective factor for both mortality and MACE at 1 year. In addition, FMR etiology and post-procedural residual MR emerged as independent risk factors for MACE at 1 year.Our findings are consistent with earlier research. As was shown by Sorajja et al. , patientSeveral reasons may explain these findings: First, there are fundamental anatomical and pathophysiological differences between the valve characteristics of patients suffering from DMR and FMR. DMR may be caused by perforation or cleft (Carpentier type I) or leaflet/chordal thickening diseases (Carpentier type IIIA). Compared to patients with FMR, patients with DMR have a larger regurgitant volume, moderate cardiac remodeling, a normal stroke volume index, and mildly elevated pulmonary pressure. On the other hand, the two main etiologies of FMR are annular dilation or atriogenic MR (Carpentier type I) and leaflet tethering from a ventricular disease (Carpentier IIIB). Second, FMR due to LV dilation and systolic dysfunction, often with concomitant mitral annular dilation, is a common consequence of either ischemic or nonischemic cardiomyopathies. A number of mechanisms may contribute to malcoaptation of the mitral valve leaflets in FMR: (1) global and/or regional LV dilation/dysfunction that decreases the closing forces of the leaflets; (2) displacement of the papillary muscles with tethering of the leaflets into the ventricular cavity, which outweighs the closing forces; 3) dilation and dysfunction of the annulus; and (4) inadequate leaflet adaptation to ventricular or atrial enlargement. In the setting of DMR, the left ventricular end diastolic volume (LVEDV) increases, which results in increased left ventricular (LV) wall stress, a stimulus for eccentric hypertrophy. Initially, the reduced afterload is associated with an increased LV ejection fraction (LVEF). However, prolonged hemodynamic overload ultimately leads to myocardial decompensation. Reduction of MR abolishes the hemodynamic burden responsible for the deterioration in LV function and may restore it if it is already depressed. The anatomic features associated with these mechanisms thus predict the severity of MR and recurrence after surgical or transcatheter repair [ dilationWhile initial landmark trials focused mostly on patients with DMR , real-woThe field of transcatheter mitral valve repair is rapidly evolving. In addition to the well-established TEER techniques, there is also growing evidence for therapeutic strategies targeting the different parts of the mitral apparatus  . As more2 and a regurgitant volume of ≥45 mL [This study has several limitations. First, although all data were collected prospectively, the observational design of the study has inherent limitations associated with a non-randomized comparison. Second, out of the 208 patients, only 60 29%) suffered from DMR. Lastly, we have begun collecting data before the 5-point scale, which includes massive and torrential sub-categories within the previous definition of severe TR . We havef ≥45 mL ,29.% suffereOur study suggests worse overall outcomes for FMR, as compared to DMR, following the TEER procedure. Higher rates of both death and MACE were observed in the FMR group, mainly driven by heart failure hospitalizations. These findings further strengthen the importance of optimal GDMT after interventional procedures. Large, randomized studies, with extended follow-up, are needed to fully understand the effects of TEER on these two very different MR etiologies.


Fabry disease (FD) is a rare, X-linked lysosomal deposition disease characterized by multi-system symptoms. The accumulation of globotriaosylceramide in various organs, such as the kidneys and heart, as well as the nervous system, has been speculated to be the mechanism involved in tissue damage, including vascular impairment with thrombotic events.Here, we describe a 72-year-old male patient diagnosed with FD, who first presented with acute myocardial infarction, left ventricular thrombosis, and pericardial effusion, accompanied by cardiac hypertrophy.GLA gene, which induce p.R301Q (p.Arg301Gln), confirming a diagnosis of FD (Fig. A physical examination showed that he was hemodynamically stable and an electrocardiogram showed ventricular tachycardia Fig. A. The si FD Fig. .Orally administered drugs included rivaroxaban, sacubitril valsartan, beta blockers, dapagliflozin, and mineralocorticoid receptor antagonist. Cardiac resynchronization therapy with an implanted defibrillator was implemented to prevent sudden death.At present, he is still in follow-up and there have been no adverse events.Our case suggests that clinicians should consider the possibility of FD in patients with acute myocardial infarction and cardiomyopathy. A detailed analysis of subtle historical clues would help promote earlier diagnosis of FD. FD presents with multisystemic signs and symptoms, including angiokeratoma, acroparesthesia, diaphoresis abnormalities, cornea verticillata, and chronic or episodic pain, as well as cardiovascular, cerebrovascular, and renal disorders, such as cardiomyopathy, arrhythmia, stroke, and proteinuria, resulting in limited life expectancy. In the heart, glycosphingolipide position causes progressive left ventricular hypertrophy that mimics the morphological and clinical characteristics of hypertrophic cardiomyopathy.,4 Here we report a case of an older male patient with FD, acute myocardial infarction, left ventricular thrombosis, and pericardial effusion.Fabry disease (FD) is an X-chromosome-linked inherited disorder of glycosphingolipid metabolism caused by deficient or absent lysosomal alpha galactosidase A activity, which results in progressive build-up of globotriaosylceramide in the cells of various tissues.2GLA gene, which induce p.R301Q (p.Arg301Gln), confirming a diagnosis of FD  showed ventricular tachycardia Fig. . Speckle FD Fig. . Myocard3 The case presented here appears to fall into the latter category. The main clinical manifestations of cardiac type FD are myocardial hypertrophy; however, the first symptoms in our patient were myocardial infarction, accompanied by left ventricular thrombosis and pericardial effusion.FD is a hereditary disorder linked to the X chromosome, meaning that men have a severe form of the disease and transmit it to all of their daughters, but not to their sons. Fabry disease can manifest as an earlier onset form that effects multiple organ systems or a later onset form that usually dominated by single organ system, which is often the heart.The patient had typical chest pain and dynamic myocardial enzyme changes and, combined with the results of coronary angiography and echocardiography, this led to a diagnosis of myocardial infarction with non-obstructive coronary artery disease. FD cardiomyopathy include myocyte hypertrophy and fibrosis, which cause raised coronary vascular resistance and increased myocardial oxygen demand.,8 However, LVT is rarely observed in FD. LVT is a common complication of myocardial infarction and can also occur because of hypertrophic cardiomyopathies, nonischemic dilated cardiomyopathies, and malignancies, among other causes. We speculate that the reasons underlying LVT in our case were related to acute myocardial infarction, low ventricular ejection fraction, and hypercoagulable state, all caused by FD.Patients with FD have risk of clinically relevant thromboembolic events, which occur at an incidence rate of 15%, including arterial thrombosis, deep vein thrombosis, and pulmonary embolism, which can be aggravated by concurrent factor V Leiden. The presence of lysosomal Gb3 and related globotriaosylsphingosine in pericardial fluid from patients with FD and elevated IL-6 and IL-18 levels in pericardial fluid and plasma, are markers of FD-associated cardiomyopathy severity. Our patient had moderate hemodynamically stable effusion; therefore, we did not conduct pericardiocentesis.Pericardial effusion is a rare manifestation of FD. These findings suggest that stored glycosphingolipids may alter ion channel expression and/or cell membrane trafficking, altering the electrical properties of cardiomyocytes. Namdar et al proposed increased conduction velocity in atrial and ventricular myocardium as possible causes of electrocardiographic abnormalities in FD, including a short PR interval, with no evidence of an accessory pathway. Hence, both tachycardia and conduction block can occur in patients with FD. Our case had a PR interval of <120 ms, and non-sustained ventricular tachycardiadue to enhanced sodium and calcium channel function. Further, the patient had an intraventricular conduction block, possibly related to cardiac fibrosis.Birket et al demonstrated enhanced sodium and calcium channel function that resulted in higher and shorter spontaneous action potentials in FD cardiomyocytes derived from induced pluripotent stem cells.; however, the case presented here has blood group AB, so it is difficult to explain his relatively mild clinical manifestations.Male patients with late-onset FD have higher residual a-Gal A activity than those with classic FD, although values are far below normal, as in the case described here. Our male patient of 72 years old with only heart involvement in FD is very rare. Patients with FD and type B or AB blood groups often have early onset severe disease, because these two blood groups also carry two other sugar sphingolipids (B and B1 sugar sphingolipids). When α-galactosidase A is deficient, molecular terminal α-galactose residues cannot dissociate, and B and B1 sugar sphingolipids are also deposited in organs and tissues. Since patients with blood groups B or AB have more sugar sphingolipid deposition than those with blood groups O or A, their condition is more serious Several studies have shown that ERT provides optimal benefit when it is started at an early disease stage, before extensive fibrosis or other irreversible tissue damage occurs.–19ERT has been shown to benefit various Fabry-related symptoms and organ manifestations.Here we report a patient with late-onset FD presenting with acute myocardial infarction, left ventricular thrombosis, and pericardial effusion. This is a 72-year-old man, only heart involved, and have no symptom of heart failure. That means the process of FD maybe slower than young patient. Although he did not receive ERT, we think maybe he will get benefit from cardiac resynchronization therapy with an implanted defibrillator.The authors would like to thank the patient and her family for granting us their permission to publish this case report.Following-up: Hang Li.Investigation: Xiaocong Wang.Supervision: Hui Xu.Visualization: Xiaocong Wang.Writing – original draft preparation, reviewing: Shanshan Zhou.Writing – reviewing & editing: Liping Zhang.


The development and translation of regenerative medicine approaches for the treatment of hypoplastic left heart syndrome (HLHS) provides a promising alternative to the current standard of care. We review the strategies that have been pursued to date and those that hold the greatest promise in moving forward. Significant challenges remain. Continued scientific advances and technological breakthroughs will be required if we are to translate this technology to the clinic and move from palliative to curative treatment.  Hypoplastic Left Heart Syndrome (HLHS) is a critical congenital cardiac anomaly defined by a hypoplastic left ventricle, mitral and aortic valve stenosis/atresia, and a diminutive ascending aorta . It is gRegenerative medicine is a multidisciplinary endeavor that attempts to leverage our cells’ innate capacity to multiply and self-organize into functional units or neotissues. The resulting neotissues can be used to surgically repair or replace tissues that are either diseased, damaged, or congenitally absent. Since its inception, regenerative medicine has held promise for advancing the field of congenital heart surgery under the premise that regenerative medicine techniques could be used to create autologous cardiovascular neotissues, which, in turn, could be used to repair or replace malformed or congenitally absent tissues such as those associated with HLHS . While some promising early preclinical studies highlighted the potential to use tissue-engineering methods to create cardiovascular patches, vascular conduits, and replacement heart valves, the development and translation of this technology to the clinic have been slow . The firMore recently, results of clinical trials evaluating the use of autologous tissue-engineered constructs developed using either cell-seeded or unseeded scaffolds, which provide sites for cell attachment and space for neotissue formation while also serving as a template to direct neotissue formation, have moved beyond being the first in human studies, and into late-stage clinical trials in Europe and the United States ,10. FurtFinally, the creation of living neotissues with growth capacity enables the avoidance of somatic overgrowth, a significant concern in all major congenital heart operations, especially in those performed in the newborn period . Recent In vivo cell-based therapies to regenerate damaged myocardial tissue in response to myocardial ischemia have generated significant interest in preclinical and clinical studies . VariablThe general treatment paradigm promotes favorable right ventricular remodeling, which structurally and functionally did not evolve to support the systemic circulation and must function within the foreign hemodynamic environment of Fontan palliation and multiple prior exposures cardiopulmonary bypass and cardioplegia through staged surgical palliation. Similar to the adult experience, only modest improvements in ventricular function and size have been demonstrated ,20. FutuOne potential method for the treatment and prevention of HLHS includes transcatheter fetal intervention with the delivery of current scaffold-based tissue-engineering techniques described above to leverage the unique features of the fetal environment. Early clinical fetal valvuloplasty studies demonstrated that approximately one-third of patients with severe midgestational aortic stenosis that are at risk for progression to hypoplastic left heart syndrome (HLHS) could be converted to biventricular anatomy by performing fetal aortic valvuloplasty, thus restoring flow through the left ventricle and preventing the left ventricular hypoplasia . BuildinThe holy grail of regenerative medicine strategies applied to patients born with HLHS or patients with HLHS and Fontan failure includes the creation of autologous pulsatile cardiac tissue to supplement the diminutive left ventricle and autologous replacement donor hearts.Early preclinical studies using decellularization-recellularization tissue-engineering methods demonstrated the concept of using regenerative medicine techniques to create whole organs, including the heart . When coWhile the promise of iPSC methods for creating autologous cells for regenerative medicine applications is great, so too are its complexities. Fundamental biological questions such as which cell types are required to make functional pulsatile cardiac tissues of adequate purity that will stably integrate into the host remain to be answered . SuccessDeveloping strategies to directly connect or enable inosculation into the host vasculature are also areas of focus and advancement. The application of bioprinting coupled with advancements in bioreactors have demonstrated promise in early preclinical studies for assembling, maturing, and preserving these tissue-engineered constructs before implantation but is at an early stage of development ,30. SignContinued scientific advances and technological breakthroughs will be required if we are to move beyond the palliative and towards curative treatments for critical cardiac anomalies. The development and translation of regenerative medicine approaches for the treatment of HLHS provides a promising potential approach towards achieving this goal, but significant challenges and enormous amounts of research will be required if we pursue this approach. We recently celebrated the 50th anniversary of the first successful heart transplant, an amazing feat built upon a half-century of research . Where w


Left-to-right shunt congenital heart disease is more likely to induce recurrent respiratory infections in the patients which exacerbate pulmonary hypertension and thereby impairs cardiac function. It is urgent to explore a non-invasive and accurate diagnostic method that can show the cardiac anatomy and associated malformations in clinical research.To determine the diagnostic value of peripheral mucin domain protein-3 (Tim-3), N-terminal pro-brain natriuretic peptide (NT proBNP), sestrin2 testing in patients with the left-to-right shunt congenital heart disease and heart failure.Fifty-two neonates with with left to right shunt congenital heart disease and 30 healthy neonates were enrolled. Blood samples were collected within 24 h of admission from newborns for determining the content of TiM-3, NT proBNP, and Sestrin2. Analyzing the ROC curve provided insight into the diagnostic accuracy. Both a Spearman’s rank correlation test and a logistic regression analysis were carried out.P < 0.05). There were significant differences in LVEF and LVFS among the three groups (P < 0.05). When used to diagnose heart failure in conjunction with left-to-right shunt congenital heart disease, TiM-3, NT proBNP, and Sestrin2 exhibited sensitivity of 58.3, 58.3, and 83.3%, respectively, and specificity of 85.0, 72.5, and 70.0%. ROC curve analysis showed that the AUCs of Tim-3, NT proBNP, and sestrin2 in predicting the outcome of left-to-right shunted congenital heart disease combined with heart failure were 0.744 , 0.608 , respectively 0.744 (95% CI 0.592 to 0.896).TiM-3, NT proBNP, and Sestrin2 levels in peripheral blood were statistically different in the three groups (Tim-3, NT proBNP, and sestrin2 can accurately differentiate heart failure from non-combined heart failure from left-to-right shunt congenital heart disease. Congenital heart disease is very common among birth defects and a leading cause of infant mortality or disability. Children with congenital heart disease are prone to serious complications such as heart failure and pulmonary infections. Shunt left-to-right congenital heart disease is distinguished by the presence of abnormal channels between the left and right chambers of the heart, resulting in a blood shunt from left-to-right. If not treated correctly and promptly, this type of congenital heart disease will eventually develop a “right-to-left” shunt, which is characterized by increased blood volume in the pulmonary circulation and decreased blood volume in the body circulation, and patients with this disorder are prone to recurrent respiratory tract infections . RepeateMucin domain protein-3 (Tim-3), a Th1(T helper 1) lymphocyte marker molecule that regulates T lymphocyte subset function through corresponding ligands, is involved in the disease progression of autoimmune diseases and closely related to the development of congenital heart disease . Studiesn = 16) and non-combined heart failure group (n = 36). The group with heart failure with all left to right shunt: 8 males and 8 females, age (4.34 ± 0.12) days; In the group without left-to-right shunt, 19 were male and 17 were female, age (4.25 ± 0.12 days). Inclusion criteria: (1) All cases with heart failurewere diagnosed by echo examination; (2) The diagnosis of heart failure complies with the diagnostic criteria of the 5th edition of Practical Neonatology:left heart failure with varying degrees of dyspnea and pulmonary rales, right heart failure with jugular vein signs, hepatomegaly, edema and heart failure with gallop rhythm and murmurs in the valvular region.; (3) Informed consent of guardians of newborns in this study; (4) Comply with Diagnostic Standard of Left-to-Right Shunt Congenital Heart Disease, 5th edition of Practical Neonatology. Exclusion criteria: (1) Combination of other cardiovascular diseases than Congenital heart disease; (2) Abnormal function of liver and kidney; (3) accompanied by diseases of the central nervous system and malignant tumors. At the same time, 30 healthy newborns in our hospital were selected as the control group, including 15 males and 15 females, aged (4.33 ± 0.11 days). Inclusion criteria: (1) All newborns were excluded from cardiovascular diseases by echo examination; (2) Informed consent of guardians of newborns in this study; (3) Exclude abnormal functions of liver and kidney, diseases of the central nervous system, and malignant tumors. There was no statistical difference in the general data of each group (P > 0.05). This study was approved by the Hospital Ethics Committee. Standard for normal neonates: ① Normal breathing: after birth, cry several times, and then start pulmonary respiration. In the first 2 weeks of life (when quiet), the breathing rate is 40–50 times per minute; ② Normal pulse: 120 ~ 140 times per minute at rest; ③ Normal temperature: the normal temperature of the newborn is 36 ~ 37.5 °C; ④ Normal weight: the weight of normal newborn is 3000-4000 g; ⑤ Normal stool: the baby’s stool is dark green, thick and tasteless, and is called meconium after 1–2 days of birth. After feeding, stool gradually turns yellow or golden (breast feeding) or light yellow (milk feeding). The baseline information was listed in Table All methods were carried out in accordance with relevant guidelines and regulations or Declaration of Helsinki. Fifty-two newborns with left-to-right shunt congenital heart disease admitted to our hospital from January 2020 to July 2022 were selected and divided into combined heart failure group with all left to right shunt n = 6 and none routine newborn examination within 24 hours after being admitted to the same room of mother and infant to detect the levels of TiM-3, NT proBNP, and Sestrin 2.The control group received biochemical blood samples for thTiM-3 detection method: TiM-3-PE 20 μl was added to the test tube after blood collection and anticoagulation respectively. Erythrocyte lysate was add after incubation at room temperature for 30 min. After continue incubation for 10 min, the superarant was collected through centrifugation. After washing with 200 μl PBS, the cells were resuspended cells and subjected to flow cytometer analysis . The reagent is Tim3 recombinant antibody purchased from Aikangde Biomedical Technology (Suzhou) Co., Ltd. In these QC, both intra group and inter group CVs were < 10%. Data processing and quality control are completed by the clinical laboratory of our hospital.Nt proBNP detection method: use the American VITROS that can be used for clinical diagnosis in our hospital® 5600 automatic biochemical immune analyzer and its supporting reagents. After instrument debugging and calibration, use the matched quality control to conduct quality control measurement and conduct sample testing after passing. Take 4 mL of whole blood, centrifugate and directly measure it with serum. All operations strictly follow the operating specifications of the instrument..Vitros® Johnson & Johnson, USA)). The instrument is Gemini XPS full-wavelength enzymatic label provided by Mercury Molecular Instruments (Shanghai) Co., Ltd.. In these QCs, their intra- and inter-assay CVs were < 10–15%. Data processing and QC were done by our hospital clinical lab.Sestrin2 detection method: after the blood is resting, take the supernatant and place it in the C1650R-230 V micro-high-speed refrigeration centrifuge provided by Leipter Scientific Instruments (Beijing) Co., Ltd. at 4 °C, 3000 r/min, 15 min centrifugal, 10 cm centrifugal radius. The supernatant was storedin the Freezerat − 80 °C. The serum Sestrin 2 level was detected by Sestrin-2 ELISA Kit (To determine left ventricular ejection fraction (LEVF), DC-28 color Doppler ultrasonic system. With the probe set to 3.5 ~ 5.0MHZ  was used to detect left ventricular ejection fraction (LEVF), left ventricular short axis shortening rate (LVFS), A peak E flow rate ratio (E/A).2 inspection; Pearson correlation test was used between dependent and independent variables. The sensitivity and specificity of TiM-3, NT-proBNP, and Sestrin2 detection in peripheral blood for left-to-right shunt congenital heart disease with heart failure was analyzed by ROC curve, with P < 0.05 as the significant difference.SPSS22.0 statistical software was used to analyze and process the data. Data are presented as mean ± standard errors. Normal distribution of the data was demonstrated by the Kolmogorov–Smirnov test. Metrology data are expressed as mean standard deviation, the t-test is used for comparison betweentwo groups, and one-way ANOVA is used for comparison between three groups. Counting data used χP < 0.001), Table P < 0.05), and the levels of the above indicators in the combined HF group were higher than those in the non-combined and control groups, as shown in Table Both HF groups had higher levels of all 3 biomarkers compared to healthy newborns. HF + left to right shunt group was higher than HF alone group (P < 0.05), and the levels of the above indicators in the combined HF group were lower than those in the non-combined HF and control groups, while there was no statistical difference in E / A comparison among the three groups (P > 0.05), see Table There were significant differences in LVEF and LVFS among the three groups (P < 0.05) and are shown in Table The levels of Tim-3, NT proBNP, and sestrin2 in peripheral blood were all correlated with the occurrence of heart failure in the child . However, whether they have diagnostic value remained unknown in combined heart failure with left-to-right shunt congenital heart disease. Our data showed that that It has been shown that sestrin2 exerts antioxidant effects through the hestrin2 / kelh like ECH associated protein 1 / nuclear erythroid related factor 2 pathway and thereby play an important role during the pathogenesis of heart disease . YingcunIn summary, the levels of Tim-3, NT proBNP, and sestrin2 in peripheral blood would be increased and LVEF and LVFS would be decreased in children with the left-to-right shunt congenital heart disease and heart failure, and the levels of Tim-3, NT proBNP and sestrin2 would have a better diagnostic value of left-to-right shunt congenital heart disease. The prospective, multi-centered, large-scale studies are warranted. Additionally, other clinical parameters in diagnostics of heart failure from non-combined heart failure from left-to-right shunt congenital heart disease should be considered.


In this study, we evaluate its correlation with clinical reference mapping techniques in patients with a range of cardiovascular diseases (CVDs) and compare image quality and inter- and intra-observer repeatability. Multimapping consists of an ECG-triggered, 2D single-shot bSSFP readout with inversion recovery and T2 preparation modules, acquired across 10 cardiac cycles. The sequence was implemented at 1.5T and compared to clinical reference mapping techniques, modified Look-Locker inversion recovery (MOLLI) and T2 prepared bSSFP with four echo times (T2bSSFP), and compared in 47 patients with CVD . In diseased myocardial segments (defined as the presence of late gadolinium enhancement), there was a high correlation between Multimapping and MOLLI for native myocardium T1 (r2 = 0.73), ECV (r2 = 0.91), and blood T1 (r2 = 0.88), and Multimapping and T2bSSFP for native myocardial T2 (r2 = 0.80). In healthy myocardial segments, a bias for native T1 , post-contrast T1 , ECV , and native T2  was observed. The image quality for Multimapping was scored as higher for all mapping techniques  compared to the clinical reference techniques. The inter- and intra-observer agreements were excellent  for most measurements, except for inter-observer repeatability of Multimapping native T1 (ICC = 0.87), post-contrast T1 (ICC = 0.73), and T2bSSFP native T2 (ICC = 0.88). Multimapping shows high correlations with clinical reference mapping techniques for T1, T2, and ECV in a diverse cohort of patients with different cardiovascular diseases. Multimapping enables simultaneous T1 and T2 mapping and can be performed in a short breath-hold, with image quality superior to that of the clinical reference techniques.The Multimapping technique was recently proposed for simultaneous myocardial T Patients referred for CMR at Linköping University Hospital between June and November 2021 were considered for inclusion in this study. In total, 47 patients were recruited. Datasets from three patients were excluded, two because no late gadolinium enhancement (LGE) images were acquired and one due to excessive fold-over artifacts. Clinical characteristics of the remaining patients can be seen in st and 5th cardiac cycles to improve T1 sensitization. The inversion pulse used a hyperbolic secant shape, had a duration of 8.4 ms, and a B1 amplitude of 13.5 μT. A previous study has shown that similar settings yield an inversion efficiency of approximately 0.89  during a breath-hold. Native Multimapping was acquired in all 47 patients, and post-contrast Multimapping was performed in 31 patients approximately 15 to 20 min after contrast agent administration (0.2 mmol/kg gadobutrol). Due to clinical prioritization, the post-contrast Multimapping was performed after the acquisition of post-contrast MOLL and LGE.All scans were performed on a 1.5T Philips clinical CMR scanner  using a 28-channel torso coil. The Multimapping pulse sequence and post-processing steps are illustrated in ely 0.89 , which w1 and T2 maps using MATLAB R2021b . The MATLAB code used to generate the maps, including example Multimapping source images from one subject, is available at https://github.com/Multimapping/Matlab_files. Since blood samples were not available for all patients, Multimapping synthetic ECV maps were generated using synthetic hematocrit values, based on the native MOLLI left ventricular blood pool measurements, as previously outlined  to generate Toutlined . Image r2bSSFP was acquired in 45 patients, in the same slice as Multimapping and used as clinical reference techniques for T1 and T2 mapping, respectively. All imaging parameters for the reference techniques  were the same as for Multimapping, except for the flip angle which was 35°. MOLLI was acquired with the 5 (3s) 3 scheme and used the same adiabatic inversion pulse as Multimapping. T2bSSFP was acquired with four images at different T2 preparation echo times  and used 3 pause cardiac cycles between each image. Furthermore, T2bSSFP used the same RF pulse types for the T2 preparation module as Multimapping. The reference maps were reconstructed on the scanner using vendor-provided inline mapping algorithms, except for the ECV maps which were generated offline using MATLAB. Similar to Multimapping, synthetic ECV maps were generated using a synthetic hematocrit value derived from the left ventricular blood pool T1 measured in the native MOLLI image. As for Multimapping, image registration was applied to native and post-contrast MOLLI T1 maps before ECV was calculated. LGE imaging parameters were TR/TE = 5.6/2.0 ms, flip angle = 25°, FOV = 350 × 350 mm2, spatial resolution = 1.8 × 1.8 mm2.MOLLI was acquired in all 47 patients and T1 (native and post-contrast), T2 (native), and ECV measurements were made by drawing manual regions of interest (ROIs) in all datasets. To compare Multimapping to the clinical reference techniques, two sets of myocardial measurements were performed, one targeting any diseased myocardium and one targeting healthy myocardium. For the measurements of diseased myocardium in all maps, ROIs were drawn in the area corresponding with the most prominent positive LGE findings of each patient. Since only a subset of patients had positive LGE findings in the imaged slice, this resulted in 21 measurements for native T1 and T2 and 12 measurements for post-contrast T1 and ECV. For the measurements of healthy myocardium in all maps, ROIs were drawn in the area remote of any LGE abnormality and preferentially in the interventricular septum if it was free of abnormal LGE. Patients were excluded from this analysis if there were indications suggestive of global or diffuse myocardial disease. The measurements in the healthy myocardium were performed in a total of 19 patients for native T1, 12 patients for T1 post-contrast and ECV, and 18 patients for T2.T1 (native and post-contrast), ROIs were drawn in the left ventricular blood pool (avoiding any papillary muscles) in the Multimapping T1 and MOLLI images.Measurements were performed in all patients by one observer . To allow intra-observer variability analysis, measurements were repeated in 23 patients by the same observer 2 weeks later. For inter-observer variability analysis, the same 23 patients were measured by two additional observers . Furthermore, to compare blood T1 (native and post-contrast), T2 (native), and ECV separately using the different mapping techniques, and this analysis was performed in 20 patients. The visual scoring was performed by consensus of two blinded observers (CJ and CJC).The image quality of the acquired maps was qualitatively compared using a Likert scale as devised by Jaubert et al.  with thet-tests were performed to compare Multimapping to MOLLI for native T1, post-contrast T1, and ECV, and Multimapping and T2bSSFP for native T2. For the remote measurements, all parameters tested positive for normality using a Shapiro–Wilk test. Bland–Altman and correlation plots were used to evaluate the agreement and correlation, respectively, between Multimapping and the reference techniques of the measurements in diseased myocardium for native T1, post-contrast T1, ECV, and native T2. To investigate any heart rate dependency for the mapping techniques, the measurements of the remote myocardium were correlated with the heart rate at the time of the scan. Similarly, dependency on T2 for T1 (and vice versa) was evaluated by correlating remote T1 with T2 for both Multimapping and the reference techniques, and testing for statistical significance. To account for multiple comparisons, Bonferroni correction was performed on the threshold for all significance tests. Since four comparisons were performed , a threshold of 0.05/4 = 0.0125 was used. Intra-observer repeatability and inter-observer repeatability were assessed with intraclass correlation coefficient (ICC) analysis. ICC was calculated using absolute agreement two-way mixed model. Statistical analysis was performed using IBM SPSS Statistics, version 27.0.Continuous variables are expressed as mean ± SD. Categorical variables are expressed as counts and percentages. For the remote measurements, two-tailed Student's paired https://github.com/Multimapping/Patient_study/raw/main/MapReconstructions.pdf.Representative parameter maps acquired with Multimapping, reference techniques, and LGE in a patient with no cardiovascular disease findings are shown in 1 was 1,116 ± 21 ms and for MOLLI 1,002 ± 21 ms, resulting in a statistically significant bias of 114 ms (P < 0.001). Multimapping post-contrast T1 was 479 ± 31 ms and for MOLLI 426 ± 27 ms, yielding a bias of 53 ms which was statistically significant (P < 0.001). Multimapping ECV was 21.5 ± 1.9%, and MOLLI ECV was 23.7 ± 2.3%, resulting in a bias of −2.2% which was statistically significant (P = 0.001). Multimapping native T2 was 48.0 ± 3.0 ms while T2bSSFP was 53.9 ± 3.5 ms, a statistically significant bias of –.9 ms (P < 0.001) (The Multimapping native T< 0.001) .1 and T2 for neither Multimapping nor MOLLI and T2bSSFP. Multimapping T1 (native and post-contrast), T2, or ECV and MOLLI T1 (native and post-contrast) or ECV did not correlate with heart rate either. However, T2bSSFP showed a correlation with heart rate (P < 0.001) (There was no correlation between native T< 0.001) .r2 > 0.7) for most variables (r2 > 0.5) was found between Multimapping and MOLLI for myocardial T1 post-contrast (r2 = 0.66) and blood T1 post-contrast (r2 = 0.53).In general, the correlation between Multimapping and the clinical reference techniques was very strong (ariables . A stron1 measurements of the blood pool for inter-repeatability showed good to excellent repeatability (ICC > 0.92).The myocardial measurements and measurements of the left ventricular blood pool for intra-repeatability assessment showed excellent repeatability  . The myo2bSSFP (P < 0.001), MOLLI native T1 (P = 0.007), MOLLI post-contrast T1 (P < 0.001), and MOLLI ECV (P < 0.001)  .1 and T2 mapping was compared to the clinical reference mapping technique in a cohort of patients with cardiovascular disease. We found a strong to very strong correlation between the methods for all measured parameters , while the image quality was considered better using the proposed Multimapping technique compared to the reference methods. Furthermore, intra- and inter-observer variability of Multimapping parameter measurements were in general low and similar to those obtained with the clinical reference techniques.In this study, a new method for simultaneous T1 of 1116 ms using Multimapping, more than 100 ms higher than for MOLLI. However, MOLLI is known to significantly underestimate T1 when compared to more accurate methods such as SASHA  compared to MOLLI (427 ms). Although post-contrast T1 values are more difficult to compare between studies due to differences in contrast agents and the timing of acquisition after injection, previous studies have shown underestimation of post-contrast T1 for MOLLI compared to more accurate techniques such as SASHA  parameter did not show any particular dependency for Multimapping in this regard. However, T2bSSFP appeared to be inversely correlated with heart rate. This suggests additional delayed cardiac cycles may be required to yield less biased T2 values for high heart rates. Conversely, Multimapping may be a more robust approach for T1 and T2 mapping at higher heart rates as no additional modification of the pulse sequence is required.In segments of healthy/remote myocardium, we measured a mean native Tas SASHA , which t at 1.5T , 27. The1,114 ms . For posas SASHA , 29. The1 (blood and myocardium), T2, and ECV. While correlations for post-contrast T1 (blood and myocardium) were more moderate, this may be explained by the confounding factor of time after injection, which affect the T1 measurements. Furthermore, measured post-contrast T1 in this study had a narrower range for both Multimapping and MOLLI compared to native T1 which can contribute to a weaker correlation between techniques. Nevertheless, a very strong correlation between Multimapping and reference techniques for native T1, T2, and ECV indicates that Multimapping is a useful technique that can be used to detect disease.In the measurements of myocardial segments with disease, we found a high correlation between Multimapping and the clinical reference techniques for native T1 overestimation as inflowing spins have seen fewer RF pulses and are therefore less saturated. This can explain the observed overestimation of blood (particularly native) T1 relative to MOLLI. However, it should also be noted that, due to the strong correlation for native blood T1 blood between Multimapping and MOLLI, the Multimapping technique can likely still capture variability in blood T1  with a similar sensitivity as MOLLI.Dictionary-based mapping techniques such as Multimapping typically assume that there is no through-plane motion, which is not the case for flowing blood. Such through-plane motion leads to T2bSSFP which both use a flip angle 35°, with otherwise identical imaging parameters to Multimapping. A higher flip angle for bSSFP-based mapping techniques leads to a higher signal-to-noise ratio which typically contributes to improved image quality. The shorter duration of Multimapping (10 beats) compared to both MOLLI (11 beats) and T2bSSFP (16 beats) means that Multimapping is less prone to respiratory motion-induced misalignment, which may also contribute to a better image quality. While the Multimapping and MOLLI pulse sequences are very similar (both inversion recovery with bSSFP readouts), Multimapping benefits from phase-sensitive inversion recovery post-processing step which has been shown to improve T1 map image quality compared to fitting with magnitude images , post-contrast T1 mapping is primarily used to generate ECV maps, and here, Multimapping and MOLLI yielded near identical ICC values of 0.94 and 0.93, respectively.The intra- and inter-observer repeatability analysis showed an excellent repeatability for most measurements using both Multimapping and reference techniques. While Multimapping post-contrast myocardial T1 and T2 mapping techniques have been proposed over the last years, comparable to Multimapping. Published studies using similar methods in healthy volunteers are summarized in 1 and T2 mapping techniques, requiring 10 beats, which is also shorter than both MOLLI and T2bSSFP. As many patients with cardiovascular diseases struggle to hold their breath for an extended period, reducing the scan time of mapping techniques is important and has been the focus of several studies  than MOLLI  or the most comparable simultaneous T1 and T2 mapping studies, Blume et al. .This study has several limitations: no respiratory motion correction was performed. Correcting for respiratory-induced image misalignment is important even for breath-held scans and can be achieved using image registration . Althoug1 and T2 values show high correlations with clinical reference mapping techniques in a diverse cohort of patients with different cardiovascular diseases. Multimapping enables simultaneous T1 and T2 mapping and can be performed in a short (10 cardiac beats) breath-hold, with image quality superior to that of the clinical reference techniques.Multimapping Thttps://github.com/Multimapping/Patient_study/raw/main/MapReconstructions.pdf.The dataset presented in this study can be found in online at: The studies involving human participants were reviewed and approved by Linköping Regional Ethics Committee. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.MH and C-JC conceived of the study. MH developed the methods, acquired the data, and performed image reconstruction and processing. MH, CJ, and C-JC analyzed the data. All authors participated in revising the manuscript, read, and approved the final manuscript.The research leading to these results has received funding from the Swedish Medical Research Council [2018-02779], the Swedish Heart and Lung Foundation [20170440], ALF Grants Region Östergötland [LIO-797721], and the Swedish Research Council [2018-04164].The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Functional tricuspid regurgitation (TR) usually decreases after atrial septal defect (ASD) closure; however, it may persist and cause heart failure that requires treatment. We aimed to investigate clinical and echocardiographic factors predicting persistent TR after ASD closure.Among 348 adults who underwent isolated ASD closure between January 2010 and September 2020, 91 (26.1%) patients with significant TR (at least moderate degree) before ASD closure were included. Persistent TR was defined as significant TR on echocardiography at 6 months to 1 year after ASD correction. We comprehensively analyzed the echocardiogram before ASD closure, including speckle-tracking imaging. Right ventricular (RV)–pulmonary arterial (PA) (RV–PA) coupling was assessed by the ratio of RV global longitudinal strain (RV GLS) and tricuspid annular S' velocity to PA systolic pressure (PASP).p = 0.030) and |RV GLS|/PASP . ROC curves analysis showed that |RV GLS|/PASP's best cut-off for persistent TR was 0.46 .Persistent TR was observed in 22 (24.2%) patients. Patients with persistent TR were significantly older and had larger TR jet areas and lower RV–PA coupling parameters than those without persistent TR. On multivariable regression, persistent TR was independently associated with age [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.01–1.14, Persistent TR after ASD closure is not rare. Old age and RV–PA uncoupling could be associated with persistent TR after ASD closure. In older patients with abnormal RV–PA coupling, careful evaluation and concomitant or subsequent TR intervention may be considered. Atrial septal defect (ASD) is a relatively common congenital heart disease in adults. The left-to-right shunt causes right ventricular (RV) volume overload and changes in pulmonary vasculature resulting in RV pressure overload . FinallyNon-invasive estimation of RV–pulmonary arterial (PA) coupling, a load-independent measure of RV performance, using a ratio of RV systolic functional parameters and RV afterload (PA systolic pressure), has been validated as a prognostic marker in patients with PA hypertension, heart failure, and adult congenital heart disease , 10. In n = 222); (2) concomitant valve surgery or congenital cardiac defects (n = 21); (3) severe pulmonary hypertension [right ventricular systolic pressure (RVSP) ≥ 70 mmHg] (n = 8); (4) ASD closure with fenestration type (n = 6); and (5) absence of echocardiography between 6 months and 1 year after ASD closure (n = 78). Finally, 91 (26.1%) patients with significant TR (at least moderate degree) before ASD closure were included  surgical or percutaneous closures without combined structural abnormality between January 2010 and September 2020 at a single tertiary hospital. In patients with ASD closure, echocardiography was routinely performed at baseline, before ASD closure, and at 6 months or 1 year after ASD closure. The exclusion criteria included the following: (1) no or mild TR at baseline echocardiography  with a 2.5–3.5 MHz probe. Standard echocardiographic measurements were performed according to the recommendations from the American Society of Echocardiography guidelines . AssessmSpeckle tracking echocardiography was performed by an experienced cardiologist blinded to clinical data, using a vendor-independent software package . All echocardiograms were uploaded in the Digital Imaging and Communications in Medicine format to the software package. For myocardial deformation analysis, the endocardial border was traced on the end-systolic frame in each selected image. The end-systolic frame (≥ 50 frames per second) was defined by the QRS complex or based on the smallest ventricular volume during a cardiac cycle. The software automatically tracked speckles along the endocardial border and myocardium throughout the cardiac cycle. The myocardium of the right ventricle was divided into six segments  of the RV free wall and septum. For the assessment of RV strain, we evaluated the average value of the longitudinal peak systolic strain from all segments of the free and septal walls of the right ventricle (RV GLS) in the RV-focused apical view. For the assessment of left ventricular global longitudinal strain (LV GLS), the value for LV GLS was obtained by averaging all segmental strain values from the 18 LV segments in the apical four-, three-, and two-chamber views. The absolute value of RV GLS and LV GLS was expressed as |RV GLS| and |LV GLS|, respectively.RV–PA coupling was estimated non-invasively using the conventional echocardiographic parameters and RV strain. Conceptually, RV–PA uncoupling occurs when RV contractility cannot rise further to match RV afterload –11. RV cEchocardiography was routinely performed at 6 months to 1 year after ASD closure. Persistent TR was defined as a significant TR (at least moderate degree) even after ASD correction on echocardiography. Clinical outcomes were defined as a composite of cardiovascular death, HF admission, urgent hospital visits due to HF aggravation, and up-titrated diuretics.t-test  or the Mann–Whitney U-test . Categorical variables are presented as absolute numbers and percentages and were analyzed using the chi-square or Fisher's exact test. Kaplan-Meier survival analyses and log-rank tests were used to compare the clinical outcomes between patients with persistent TR and those with resolved TR during the follow-up period. The cut-off values for parameters were determined as the values that maximized the sum of the sensitivity and specificity for persistent TR after ASD closure in the receiver operating characteristic (ROC) curve analysis. Logistic regression analysis was performed to determine the relationships between clinical and echocardiographic variables and persistent TR after ASD closure. The variables selected for entry into the multivariate analyses were those with a p < 0.10 in the logistic univariate analysis. The multivariate analyses focusing on RV function were performed in model 1. In model 2, the analyses including RV–PA coupling parameters were performed. A two-sided p < 0.05 was considered statistically significant. All analyses were performed using IBM SPSS Statistics for Windows, version 25.0 .Continuous variables are presented as a mean ± standard deviation (SD) or median (interquartile range) and were compared using paired Student's p < 0.001), had more hypertension , and had a higher prevalence of atrial fibrillation (AF)  compared to patients with resolved TR. There were no significant differences in ASD size, Qp/Qs, and type of intervention between patients with persistent TR and those with resolved TR.The baseline characteristics of the study population, according to the presence of persistent TR, are presented in Transthoracic echocardiography was performed at a median of 195 days (range 174–245 days) after ASD closure. The echocardiographic parameters were significantly changed after ASD closure . CompareE/e' were not different between the two groups. Right cardiac chamber size was similar between the two groups. In RV functional parameters, TV annular S' and |RV GLS| were significantly lower in patients with persistent TR than in those with resolved TR, but RV FAC was not different. In terms of RV–PA coupling, both TV annular S'/PASP ratio and |RV GLS|/PASP ratio illustrated significantly lower values in patients with persistent TR compared with those with resolved TR. TR jet area was significantly larger in patients with persistent TR, but other TV parameters were not significantly different between the two groups.Echocardiographic parameters of the resolved TR and persistent TR groups after ASD closure are described in p = 0.116). During follow-up, the diuretics dose was significantly higher in patients with persistent TR compared to the patients with resolved TR . Kaplan-Meier analysis showed that the event-free survival rate was worse in patients with persistent TR than in those with resolved TR  (During the follow-up duration (median: 22 months), there were no cardiovascular death and HF admission in patients with resolved TR and those with persistent TR. One (1.4%) of the 69 patients with resolved TR and 2 (9.0%) of the 22 patients with persistent TR were urgent visits due to HF aggravation. The diuretics dose was up-titrated in four (18.1%) patients with persistent TR and one (1.4%) patient with resolved TR. There was no significant difference in diuretics (furosemide) dose in patients with resolved TR and persistent TR  .Persistent TR after ASD closure was observed in 22 (24.1%), including 17 (19%) with moderate TR and 5 (5%) with severe TR . In univp = 0.003; cut-off value: 0.32; |RV GLS|/PASP: area under the curve = 0.789; p < 0.003, cut-off value: 0.46) (p < 0.012). |RV GLS| was also a good cut-off value, but the area under the ROC curve value of |RV GLS|/PASP was statistically significantly higher than that of |RV GLS| [area under the curve: 0.729 (0.607–0.81)]   . In a co: 0.043) . TR jet The principal findings of this study are as follows: (1) Persistent TR after ASD closure is not uncommon; (2) Old age and abnormal RV–PA coupling are associated with persistent TR after ASD closure; (3) Among the RV–PA coupling parameters, |RV GLS|/PASP < 0.46 depicts the most satisfactory predictive performance for persistent TR after ASD closure.There is a growing interest in functional TR, which is associated with poor prognosis , 14. DilWith regard to the factors associated with persistent TR after ASD closure, previous studies showed varied results , 15. TheInterestingly, in this study, RV–PA coupling parameters were independent factors of persistent TR after ASD closure. Chronic volume overload of the right side of the heart leads to dilatation of the right atrium and right ventricle and effects such as right heart failure and pulmonary hypertension . FurtherRV remodeling is frequently associated with secondary TR, which may accelerate RV–PA uncoupling . RV–PA cMoreover, in our study, the included patients were relatively old. Old age was a significant factor contributing to persistent TR after ASD closure. This may suggest that long-standing remodeling of the right heart and pulmonary vasculature affects RV myocardial function and pulmonary circulation. Therefore, it may be suggested that concurrent or subsequent TR interventions should be considered in elderly patients and patients with RV–PA uncoupling. TR interventions could reduce RV volume overload ; therefon = 52) in this study.There are several limitations to this study. First, this was a single-center, retrospective study with small sample size. Furthermore, the number of patients with persistent TR after ASD closure was small. Second, the severity of TR was evaluated using the semi-quantitative method in this study. Recent guidelines of TR showed that the grading of TR using quantitative methods, such as the PISA method or volumetric method, to evaluate the severity of TR. Third, we did not evaluate invasive hemodynamic data of RV–PA coupling. Thus, further validation of non-invasively measured RV–PA coupling parameters is needed. Last, TAPSE/PASP, the most validated parameter of RV–PA coupling, could not be analyzed due to small numbers .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Metformin, the first-line drug in type 2 diabetes mellitus, elicits cardiovascular protection also in obese patients via pleiotropic effects, among which the anti-oxidant is one of the most investigated. The aim of the present study was to assess whether metformin can acutely mitigate oxidative stress in atrial tissue harvested from overweight non-diabetic patients. Right atrial appendage samples were harvested during open-heart surgery and used for the evaluation of reactive oxygen species (ROS) production by means of confocal microscopy (superoxide anion) and spectrophotometry (hydrogen peroxide). Experiments were performed after acute incubation with metformin (10 µM) in the presence vs. absence of angiotensin II , lipopolysaccharide , and high glucose . Stimulation with AII, LPS, and high Gluc increased ROS production. The magnitude of oxidative stress correlated with several echocardiographic parameters. Metformin applied in the lowest therapeutic concentration (10 µM) was able to decrease ROS generation in stimulated but also non-stimulated atrial samples. In conclusion, in a pilot group of overweight non-diabetic cardiac patients, acute incubation with metformin at a clinically relevant dose alleviated oxidative stress both in basal conditions and conditions that mimicked the activation of the renin–angiotensin–aldosterone system, acute inflammation, and uncontrolled hyperglycemia. Metformin, a biguanide synthetized at the beginning of the past century, is nowadays the first-line pharmacotherapy for type 2 diabetes mellitus (T2DM) due to its remarkable capability to control plasma glucose levels, primarily via decreased hepatic glucose production/output associated with enhanced insulin sensitivity and increased peripheral glucose uptake ,2. In thSeveral randomized controlled trials that have been conducted in non-diabetic patients with atherosclerosis/high cardiovascular risk aimed at providing evidence for the long-term benefits of metformin; both positive or neutral effects on the cardiovascular outcome have been reported, as recently reviewed . At vari2+-sensitivity [Oxidative stress represents one of the most significant insults disrupting cardiomyocyte homeostasis that has been reported to occur in most cardiovascular pathologies . In the sitivity , which lsitivity . Currentsitivity  since misitivity . The grositivity . Metformsitivity .Data literature regarding the acute effect of micromolar doses of the biguanide on human samples are scarce. As such, the present pilot study was double aimed (i) to assess whether metformin applied in a clinical relevant concentration can acutely mitigate the oxidative stress in atrial tissue harvested from cardiac non-diabetic overweight patients, in the presence vs. absence of angiotensin II (AII), lipopolysaccharide (LPS) and high glucose (Gluc), respectively, and (ii) to investigate whether the magnitude of oxidative stress assessed in atrial samples correlates with atrial and/or ventricular echocardiographic parameters.The study was conducted in accordance with the principles of the Declaration of Helsinki and the protocol was approved by the Committee for Research Ethics of “Victor Babeș” University of Medicine and Pharmacy of Timișoara, Romania (no. 04/28.02.2020 and 04p/17/12/2020). Written informed consent was obtained from all patients prior to surgery.2) and diagnosed with heart failure with mid-range ejection fraction (HFmrEF) according to the left ventricular ejection fraction (LVEF = 47.10 ± 1.59%). Fifteen (75%) patients were diagnosed with severe valvular lesions that required surgical intervention. Among these, 7 (35%) patients presented severe mitral regurgitation, 6 (30%) patients had severe aortic valve stenosis, 4 (20%) patients had severe tricuspid regurgitation, 2 (10%) patients had severe aortic regurgitation, and 1 (5%) patient had severe mitral stenosis. Eleven (55%) patients were diagnosed with severe coronary lesions. Regarding the type of surgery, 3 (15%) patients underwent aortic valve replacement, 1 (5%) patient had mitral valve replacement, 4 (20%) patients had mitral valve replacement and tricuspid valve plasty, 1 (5%) patient underwent aortic valve replacement and mitral valve annuloplasty, 5 (25%) patients underwent aorto-coronary bypass graft, 4 (20%) patients had aortic valve replacement and aortocoronary bypass graft, and 2 (10%) patients had aorto-coronary bypass surgery and mitral valve annuloplasty. Postoperative atrial fibrillation was documented in 3 (15%) patients and was converted to sinus rhythm with drug therapy (amiodarone). As for comorbidities, fourteen (70%) patients presented preoperative hypertension which was controlled  in all cases and thirteen (65%) patients had dyslipidemia which was controlled (with statins) in most cases.The study group included 20 non-diabetic cardiac patients  who were overweight . The atrial samples were further transferred to the laboratory for all the experimental procedures. Each sample was divided in 8 pieces which was randomly assigned to one of the following groups: (1) Control, (2) Control + Metfomin, (3) AII, (4) AII + Metformin, (5) LPS, (6) LPS + Metformin, (7) GLUC, and (8) GLUC + Metformin.n = 20) are listed in The characteristics of the included patients (2O2 assessment in spectrophotometry with the Ferrous Oxidation-Xylenol Orange (FOX) assay according to a method described in ref. [Atrial tissue samples were cleaned and incubated for 12 h at 37 °C in a culture medium  in the presence or absence of AII (100 nM), LPS (1 μg/mL), and high Gluc (400 mg/dL) with or without metformin (10 µM). Subsequently, the tissue was embedded in Tissue-Tek for the superoxide assessment in confocal microscopy with dihydroethidium (DHE) or used for H in ref. .2+ to Fe3+ ions at acidic pH. The Fe3+ ions will form a colored adduct with xylenol orange, which is quantified spectrophotometrically at 560 nm according to a method described in refs. [Hydrogen peroxide production was assessed in human atrial tissue samples using the FOX assay . The principle of the assay is that peroxides oxidize Fein refs. ,19,20.Superoxide generation in human atrial samples was determined using the dihydroethidium (DHE) probe as previously described ,20. Briep < 0.05 were considered statistically significant.Statistical data processing was performed with the GraphPad Prism software version 9.3.1 . Data are presented as mean ± SEM and were analyzed using one-way ANOVA. Pearson’s linear correlation was used to determine correlations between oxidative stress and echocardiographic parameters. Values of 2O2 generation were significantly increased in conditions that mimicked the activation of the renin–angiotensin–aldosterone system (RAAS), acute inflammation, and uncontrolled hyperglycemia, respectively. Importantly, the effect of metformin was also present in the control (CTL), non-stimulated samples incubated overnight with the drug, thus suggesting a potential beneficial role in the prevention of cardiovascular oxidative stress regardless of its magnitude  with AII (100 nM), LPS (1 μg/mL), and high glucose (400 mg/dL) and measured the ROS levels by two methods. As demonstrated by the DHE staining  and FOX agnitude .2O2 measured by FOX assay) in the analyzed samples. We observed a positive correlation between the ROS levels and LA diameter, LV end-diastolic diameter, and RV diameter. At variance, a negative correlation was noticed between ROS and LVEF  and the degree of oxidative stress , the cornerstone therapy for T2DM, has widely reported beneficial effects in numerous other pathologies such as cardiovascular, liver, and renal diseases as well as various types of cancer  via pleiWe have here assessed the acute effects of the drug on both superoxide and hydrogen peroxide generation in human atrial samples harvested from overweight patients with no diabetes applied at 10 µM concentration (close to the steady-state plasma concentration) in conditions that mimic the renin–angiotensin–aldosterone system (RAAS) activation, acute inflammation, and uncontrolled hyperglycemia. The first important finding is the acute beneficial effect of the drug on the diseased atrial samples, including in basal conditions, at variance from its well known chronic cardiac protection.Metformin has been earlier reported to decrease the AII-induced ROS generation in cardiac fibroblasts by inhibiting the activation of the PKC-NADPH oxidase pathway . Of notePlasma concentrations of metformin in long-term-treated humans range between ~1 µM and ~40 µM and the vast majority of in vitro studies aimed at elucidating its mechanisms of action have been performed with supratherapeutic drug concentrations ,31. Of nMitochondria are the main ROS sources, in particular when the ETS becomes dysfunctional and complex I can produce superoxide via both forward and reverse electron fluxes, depending on the substrates used. Metformin specifically decreased the superoxide generation driven by the reverse electron transfer but without increasing ROS generation through the forward direction . HoweverThe observations that mitochondrial ROS production is central to the deleterious effects of hyperglycemia and that the protective properties of the drug administration are related to its mitochondrial effects have been reported more than two decades ago . Thus, HWe report here the capability of metformin to decrease both the basal and stimulated ROS (superoxide and hydrogen peroxide) production in a pilot group of overweight cardiac patients with neither diagnostic nor treatment for diabetes. This observation is in line with our results that previously reported the effect of the same dose of metformin  on cardiac samples harvested from rats with diet-induced obesity and prediabetes. In the animal model, the acute anti-oxidant effect was not related to a scavenger activity of the drug . Importa2O2 at the outer mitochondrial membrane as ancillary product of the oxidative deamination of biogenic amines, mainly catecholamines in the heart. In heart samples harvested from the obese animals, metformin also mitigated the degree of oxidative stress as shown by both DHE staining and FOX assay. In order to assess whether the drug interferes with MAO expression in healthy animals, control samples were incubated overnight with serotonin (10 μM) in the presence vs absence of metformin and the amount of H2O2 was measured. Interestingly, the addition of the MAO substrate increased the H2O2 generation but metformin did not influence this process in the non-obese animals [Targeting mitochondrial dysfunction is nowadays an innovative therapeutic approach in the management of heart failure. A small double-blind, placebo-controlled, ascending-dose trial with elamipretide, a novel peptide which reduces the mitochondrial ROS production, acutely administered in patients with HF with reduced EF (≤35%) in a single 4 h infusion, demonstrated favorable changes in the left ventricular volumes that correlated with its peak plasma concentration . Whether animals . The acu animals . In both animals ,20.Oxidative stress is not only a promotor of cardiac and vascular damage but also a promotor of inflammation in the cardiovascular system . Both ox2O2 production, the lower the LV ejection fraction, suggesting that oxidative stress is likely to early contribute to the onset of contractile impairment in the evolution of heart failure. It has been reported a decade ago by the group of Fabio Di Lisa that oxidative changes of actin and tropomyosin were significantly increased in LV biopsies from explanted hearts harvested from patients with end-stage HF (NYHA class IV) and were inversely correlated to LVEF [In this pilot group of overweight patients with mid-range ejection fraction (HFmrEF), the second important finding is that the magnitude of oxidative stress assessed in the right atria positively correlated with the cavity changes in left atria and ventricles, with the highest correlation for the left ventricle. Since the correlation was also present with the ventricular echographic parameters, it is tempting to speculate that changes in the atria might be a relevant proxy for ventricular abnormalities in cardiac patients with HF in early stages. It has been recently reported that the life-course cumulative burden of BMI is positively and significantly associated with the development of left ventricular hypertrophy in midlife . Whether to LVEF . Current to LVEF . HoweverEarly mitigation of acute oxidative stress represents an unmet therapeutic goal in the setting of heart failure , particuMetformin in a clinically relevant concentration mitigated oxidative stress in human atrial samples harvested from overweight non-diabetic patients undergoing revascularization therapy. The magnitude of oxidative stress positively correlated with the LA diameter, LV end-diastolic diameter, and RV diameter and negatively with the LVEF. Whether the acute administration of the biguanide prior to open-heart surgery could elicit beneficial effects on cardiovascular outcomes warrants further investigation.


Reply to the Editor:The authors reported no conflicts of interest.Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.The We appreciate the insightful comments on our paper from Dr Andrushchuk and his colleagues.We agree that left ventricle (LV) remodeling is a concept beyond change in LV wall thickness. Our study showed that the overall LV myocardial volume decreased beyond the extent of resection after septal resection during the relatively short median observation period of 2.5 months. Simultaneously, both LV end-diastolic diameter and end-systolic diameter increased . With more increase in end-systolic volume relatively to end-diastolic volume, postoperative LV ejection fraction became lower than preoperatively, albeit it remained within the normal range. Previously, such change in ejection fraction was believed to be related to improvement in LV hypercontractile state and diastolic function.We also admire the remarkable clinical outcomes of their surgical myectomy. While we believe our outcomes are in line with the literatureThe concept of the septal band is fascinating to us. Technically speaking, it may be best visualized through a “heat map,” in which point cloud of the endocardium  and the epicardium  are depicted using the LV end-diastolic segmentation as well as the wall thickness at each point is color encoded on each point . Based o


Overt left ventricular (LV) dysfunction and congestive heart failure are known entities in Takayasu arteritis (TA). Subclinical LV dysfunction may develop in these patients despite normal LV ejection fraction (LVEF). Moreover, effect of treatment of aortic or renal artery narrowing in such patients is unknown.This study included 15 angiographically confirmed TA patients undergoing aortic and/or renal intervention. A comprehensive clinical, biochemical and echocardiographic  evaluation were done at baseline, 72 h, and six months post intervention.p = 0.001), E/e’ ratio decreased from 15.15 ± 3.19 to 10.8 ± 2.56 (p = 0.005) and median NT pro BNP decreased from 1673 pg/ml (970–2401 pg/ml) to 80 pg/ml (40–354 pg/ml) (p = 0.001) at 6 months after interventional procedure. In patients with baseline normal EF, median NT pro BNP decreased from 512 pg/ml (80–898.5 pg/ml) to 34 pg/ml (29–70.8 pg/ml) (p < 0.01), mean GLS improved from −8.80 ± 0.77% to −16.3 ± 0.78% (p < 0.001) and mean E/e’ decreased from 12.93 ± 2.63 to 7.8 ± 2.73 (p = 0.005) at 6 months follow up.Six patients (40%) had reduced LVEF (<50%) at baseline while rest 9 (60%) patients had reduced global longitudinal strain (GLS) but normal EF. Diastolic filling pattern was abnormal in all the patients. In patients with baseline reduced EF, mean EF improved from 24.62 ± 12.14% to 45.6 ± 9.45% (LV dysfunction is common in patients with TA and obstructive lesions in aorta or renal arteries. GLS can be used to assess subclinical systolic dysfunction in these patients. Timely intervention can improve LV dysfunction and can even reverse the subclinical changes. All patients underwent a detailed clinical assessment including symptomatology, determination of baseline clinical and biochemical parameters including estimated glomerular filtration rate (GFR), serum creatinine, inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) and N-Terminal Pro brain Natriuretic Peptide (NT pro BNP). Additionally, CT aortogram as well as conventional angiography of the aorta and its branches were performed to determine the extent of the lesions. All these patients were on oral corticosteroids along with methotrexate once weekly pre and post intervention.This was a single-center prospective observational study wherein consecutive patients with TA diagnosed as per the American College of Rheumatology (ACR) criteriaAortic intervention was done in symptomatic cases of aortic obstruction with a mean gradient greater than 20 mm Hg  and renaBasic echocardiographic measurements and speckle tracking echocardiography:Transthoracic echocardiography was performed by an independent observer blinded to the intervention group using EPIQ 7 C  system. E/e’ ratio was calculated using tissue doppler imaging. LV ejection fraction (LVEF) was determined by modified Simpson's biplane method.2.2t-test was used for continuous variables and the Chi-square test for categorical variables. A p value of <0.05 was considered statistically significant. SPSS version 24.0  software were used for statistical analysis. A written informed consent was taken from each patient. The study protocol was cleared by the Institutional Ethics Committee (IRB number: F.No.17/IEC/MAMC/2018/49).Continuous data was expressed as mean ± standard deviation (SD) and categorical data as proportions. To test for differences in various characteristics, Student's 3During the study period of 18 months, a total of 30 patients with TA and aortic and/or renal involvement were screened, of whom 15 were excluded in view of the poor echocardiographic window.3.13.2Percutaneous transluminal balloon angioplasty with stenting (Boston Scientific Express Vascular and Epic Vascular Self Expanding Stent) was done to descending thoracic aorta in three, thoracoabdominal aorta in four, and abdominal aorta in two patients. One patient underwent redo balloon angioplasty of previously stented abdominal aorta. Bilateral renal artery balloon angioplasty was done in two patients and unilateral renal artery balloon angioplasty in three patients. All patients who underwent aortic intervention had residual peak systolic gradient less than 20 mm Hg. After renal balloon angioplasty, none of the patients had residual stenosis more than 20%.3.3Both average systolic and diastolic blood pressure decreased significantly at 72 h post intervention and a further decrease was seen at six months follow up . Of the 3.4p = 0.001), E/e’ ratio decreased from 15.15 ± 3.19 to 10.8 ± 2.56 (p = 0.005). There was a significant improvement in serum creatinine levels pre and post intervention . Similarly, eGFR values had significantly improved post intervention . In the normal LVEF group, both GLS and E/e’ were deranged indicating subclinical LV systolic and diastolic dysfunction. NT pro BNP was also elevated though not to the extent seen in the reduced LVEF group. Post-intervention, median NT pro BNP decreased from 512 pg/ml at baseline (80–898.5 pg/ml) to 34 pg/ml (29–70.8 pg/ml) at 6 months (p < 0.01), mean GLS improved from −8.80 ± 0.77% to −16.3 ± 0.78% at 6 months (p < 0.001) and mean E/e’ decreased from 12.93 ± 2.63 to 7.8 ± 2.73 (p = 0.005) at 6 months follow up.Subgroup analysis was performed by dividing patients intotwo groups based on LVEF (a) reduced LVEF (<50%) and normal LVEF (>50%). 4,,p = 0.001) at six months follow up. However, in one patient, there was no improvement in LV ejection fraction and the LV cavity remained dilated at six months despite disease remission. This could be related to the onset of irreversible LV dysfunction due to diffuse and prolonged disease process. This underscores the concept of early detection of LV dysfunction and timely intervention before the irreversible damage.Left ventricular dysfunction in TA is multifactorial with both inflammation and hemodynamic factors being implicated. Findings of our pilot study revealed significant improvement in LV function determined using conventional and speckle tracking echocardiography following aortic/renal interventions in TA. Observational studies have reported relatively high prevalence of LV dysfunction in TA of 15–50%.p < 0.001). To the best of our knowledge, there is no published data regarding the role of GLS in patients with TA patients. GLS has the potential to identify Takayasu arteritis patients who might benefit from early intervention in order to preserve the LV function.Conventional echocardiography generally detects LV dysfunction following prolonged disease process when dysfunction is overt while GLS obtained by STE is a sensitive and validated method for detection of subclinical LV dysfunction.p < 0.01) and a further decrease was seen at 6 months (p = 0.005) indicating significant improvement in diastolic function. On subgroup analysis,the reduced LVEF group though showed significant improvement in mean E/e’ ratio, though it didn't reach normal value (<8). This suggests that there may be a subset of patients in whom pressure load has lead to myocardial changes, including hypertrophy and myocardial fibrosis, as well as alterations in active relaxation that are less reversible. To the best of our knowledge, there is no literature available on post-intervention change in diastolic function in Takayasu arteritis patients. These findings could be extrapolated from data onpatients with congenital AS.Diastolic dysfunction was present in all patients irrespective of the systolic function. E/e’ ratio decreased significantly at 72 h (The potential limitations of the our study was a small sample size with shorter duration of follow up. However, this was a pilot study in a small group of patients demonstrating the feasibility of STE in TA. This calls for future studies in larger patient sub-groups in order to validate these findings. Additionally, cardiac MRI or endomyocardial biopsy was not carried out to rule out myocarditis in these patients.5Overt LV dysfunction and congestive heart failure are known entities in Takayasu arteritis. Hemodynamic factors by increasing the afterload have important role in LV dysfunction. Timely correction of these hemodynamic factors by appropriate endovascular/surgical intervention can lead to symptomatic as well as objective improvement in myocardial contractile performance/myocardial systolic function indices. 2D STE is a useful modality to assess subclinical systolic dysfunction in these patients. Early intervention can improve hypertension, ejection fraction, diastolic function and prevent subclinical LV dysfunction to convert into overt dysfunction.None.Authors have no conflict of interest to disclose.


Radiotherapy for breast cancer can induce radiation-induced coronary artery diseases many years after RT. Long before the onset of clinical signs of these diseases, increase in coronary artery calcium (CAC) score is a good predictor of the risk of coronary disease in patients who may be asymptomatic. In order to improve knowledge for the prevention of radiation-induced coronary artery diseases, our study aimed to evaluate whether there was an association between early CAC increase and cardiac exposure. Based on a population of 101 breast cancer patients with CAC score measured before and 2 years after RT, CAC increase was observed in 28 patients presenting higher cardiac exposure than others. Calcifications were mainly localized in the left anterior descending coronary, the most exposed coronary artery. This study suggests that minimizing cardiac exposure could limit the risk of early CAC increase and therefore the longer-term risk of coronary artery diseases.p = 0.04). LAD exposure marginally explained increased CAC in the LAD . Conclusion: The risk of early CAC progression may be associated with LV exposure. This progression might primarily be a consequence of CAC increase in the LAD and its exposure.Background: Radiotherapy (RT) for breast cancer (BC) can induce coronary artery disease many years after RT. At an earlier stage, during the first two years after RT, we aimed to evaluate the occurrence of increased coronary artery calcium (CAC) and its association with cardiac exposure. Methods: This prospective study included 101 BC patients treated with RT without chemotherapy. Based on CAC CT scans performed before and two years after RT, the event ‘CAC progression’ was defined by an increase in overall CAC score (CAC RT+ two years—CAC before RT > 0). Dosimetry was evaluated for whole heart, left ventricle (LV), and coronary arteries. Multivariable logistic regression models were used to assess association with doses. Results: Two years after RT, 28 patients presented the event ‘CAC progression’, explained in 93% of cases by a higher CAC score in the left anterior descending coronary (LAD). A dose–response relationship was observed with LV exposure (for Dmean LV: OR = 1.15,  Breast cancer (BC) is the most common cancer in women, with more than two million new cases and almost 685,000 deaths in 2020 worldwide . DespiteAmong these cardiovascular complications, coronary artery disease (CAD) is the most common manifestation of radiation-induced heart disease , and it Baseline measures of coronary artery calcification (CAC), as quantified by cardiac computed tomography (CT), have been shown to predict future cardiovascular events, in particular CAD, in multiple populations . In the Although baseline CAC might reflect prior coronary atherosclerotic plaque burden, CAC progression might provide insight into current disease activity . The impBased on the BACCARAT study (BreAst Cancer and CArdiotoxicity Induced by RAdioTherapy) , a prospThe BACCARAT study is a monocentric prospective cohort of 118 female volunteer patients treated for BC from 2015 to 2017 in the Clinique Pasteur, Toulouse, France [This study received ethical approval from the French South West Committee for Protection of Persons (ID: CPP2015/66/2015-A00990-69) and from the National Agency for Medical and Health products Safety (Reference: 150873B-12). All patients enrolled in the study provided their written informed consent.At first, all the BC patients underwent surgical treatment (mastectomy or lumpectomy). Afterwards, patients were treated with 3D-CRT with or without irradiation of supraclavicular or internal mammary lymph nodes. Patients were positioned on a breast board with both arms above the head. The planning target volume dose was 50 Gy delivered in 5 weeks with 25 daily doses of 2 Gy or 47 Gy delivered in 5 weeks with 20 daily doses of 2.35 Gy over 5 weeks for patients treated between January 2016 and May 2016. This hypo-fractioned dose administration decision was made due to technical problems in one of the 3D-CRT machines during this period and due to the need to slightly limit the number of sessions per patient. Six MV photons were used for most of the patients, with the exception of the few cases of patients with big breast sizes where 25 MV additional photons were delivered. An additional boost of 9 to 15 Gy could be applied to the tumor site with electron/photons beams, with energies ranging from 6MeV to 18 MeV on a case-by-case basis. Eclipse™ Treatment planning system (TPS) and the integrated software Analytical Anisotropic Algorithm (AAA v13.6)  were used to conduct whole heart dose calculations. The resulting doses of all irradiated volumes were considered. The RT was planned for each patient so that the distribution was normalized and optimized based on the International Commission on Radiation Units and Measurements (ICRU) point of reference for the breast and to obtain QUANTEC dose constraints to organs at risk, e.g., the heart [The methods used for the evaluation of radiation doses distribution to the whole heart, left ventricle, left main coronary artery (LMCA), left anterior descending artery (LAD), circumflex artery (Cx), and right coronary artery (RCA) in BACCARAT patients are described elsewhere ,17. In sThe CAC CT scans were carried out before treatment and two years after RT. CAC was measured using ECG-Gated Ct exams without contrast injection acquired on a SIEMENS dual-source CT . The noninvasive CT scan was performed within 10–15 min, with a 3-mm reconstructed slice thickness. A calcified lesion was defined as more than three contiguous pixels with a peak of attenuation of at least 130 Hounsfield units (HU). The overall CAC score was calculated according to Agatston et al. , using aFor all patients, we had measurements of the overall CAC and CAC in each coronary artery before RT and two years after RT. Several definitions exist for quantification of the progression of the CAC scores ,20, and p-value < 0.05 in univariate analysis. The analyses of the data were conducted with Stata 14.2 STATA corp. p-values < 0.05 (two-sided) were considered statistically significant.The descriptive analyses were expressed as means and standard deviations (SD), medians and interquartile ranges (IQR) for quantitative variables, absolute numbers (n), and relative percentages (%) frequencies for qualitative variables. The comparisons were performed using the non-parametric Wilcoxon test for continuous data (dosimetry data 3 and CAC scores) and Mac Nemar or Chi2 for categorical data (proportions and percentages). We analyzed the associations between the endpoint CAC progression (yes/no) and radiation and non-radiation factors in univariate analysis based on logistic regressions (odds ratios (ORs), 95% confidence intervals (CI), p-values). Cardiac radiation exposure factors included the laterality of BC, Dmean, D2 and V2 and V5 of the heart, the left ventricle, and coronary arteries. Non-radiation factors included covariates known to have a potential impact on coronary atherosclerosis development and progression such as age, body mass index (BMI), smoking, hypertension, diabetes, dyslipidemia, endocrine therapy, cardiovascular treatment (including statins use), and baseline CAC score (zero/non-zero) . BecauseOverall, 101 BC patients (84 left-sided and 17 right-sided) were included in this analysis. Baseline patients’ characteristics are shown in p < 0.001), except for the RCA dose, which was higher in patients treated for right BC compared to the left one. The LAD was the most exposed coronary artery with a mean dose of 16.0 Gy for left-sided BC. Detailed information on cardiac doses is provided in p = 0.06) and 28 patients (27.7%) had CAC progression: 5 patients had zero baseline CAC value  and 23 patients had non-zero baseline value CAC , p < 0.001. A significant increase in mean overall CAC was observed . Among 28 patients with CAC progression, 89% of patients had increased CAC in LAD , and the proportion of non-zero values for CAC in LAD significantly increased from 19.8% to 25.7% (p = 0.03), in contrast with other coronary arteries.The CAC values evaluated at baseline and two years after RT are described in p < 0.00001). This baseline CAC status was thus a major risk factor of CAC progression that needed to be taken into account for further multivariable dose–response analysis. Moreover, age, hypertension, diabetes, and use of cardiovascular treatment reached statistical significance (p < 0.05) and were considered in multivariable analysis.Based on univariate logistic regression analysis, we evaluated the association between the occurrence of CAC progression and baseline cardiovascular risk factors (intrinsic factor and endocrine therapy) . Patientp = 0.04 for heart; 4.50 Gy vs. 6.93 Gy, p = 0.005 for LV). No other cardiac substructure doses differed significantly between both groups. A comparison of doses according to the CAC progression status is presented in p = 0.12). We focused dose–response analysis on cardiac structures previously identified with significant difference in mean dose distribution (p > 0.05), except D2 of the heart . Several left ventricle exposure parameters were significantly associated with CAC progression, in particular mean LV dose, D2, V2, and V5. Given the limited size of the study and the strength of the association between baseline CAC and CAC progression , or adjusted on baseline CAC status (zero/non-zero) and age (Model 2). In Model 1, we observed that the risk of CAC progression was associated with the mean LV dose with an increased risk of 15% per additional Gy  and the risk increased by 4% per additional Gy in the near maximum dose D2 . In Model 2, similar findings were observed with strengthened associations. Results on the association between CAC progression and cardiac exposure are detailed in ribution : heart ap = 0.029.The analysis of CAC progression according to the mean LV dose category (divided in 25th percentile of mean dose distribution) , which ap = 0.006 for mean LV dose; OR = 1.04, p = 0.008 for V2 of LV) in univariate analysis, and the association with V2 remained significant even after adjustment on age, diabetes hypertension, and cardiovascular treatment use . Regarding the LAD exposure, only the near maximum dose was significantly associated with increased CAC in LAD , but this association was only marginally significant (p = 0.07) in multivariate analysis.As previously indicated, CAC in the LAD was increased in 89% of patients with CAC progression. We further investigated the association between these localized increased CAC in LAD and dose to the heart, the left ventricle, and the LAD . We coulIn this prospective study of 101 BC patients treated with 3D-CRT without chemotherapy, 28 patients had CAC progression characterized by an increase > 0 in CAC value from baseline to RT+ two years measurements. Non-zero CAC at baseline was a major risk factor of CAC progression, as well as age, hypertension, diabetes, and use of cardiovascular treatment (including statins). We observed a significant dose–response relationship between the risk of CAC progression and mean or near maximum LV dose, which remained significant even after adjustment on these intrinsic cardiovascular risk factors. This progression might primarily be a consequence of CAC increase in the LAD and its exposure. p = 0.16). However, some other studies did not observe significant difference in CAC before and after RT, which may be explained by a short follow-up (< 1 year) [Both cardiac exposure and pre-treatment CAC, in BC patients treated with RT, have been shown to be associated with the risk of coronary artery disease several years after RT ,9,10,11. 1 year) ,25.p = 0.11), which may illustrate that radiation exposure could also be involved in the initiation process. This remains to be further investigated.Among these previous studies, none provided a precise evaluation of the dose–response relationship between cardiac exposure and CAC progression, which is the best approach to enhance knowledge on causality association between exposure and radiation-induced cardiac endpoint. Our study was the first to present results on CAC progression evaluated two years after RT and combined with a precise evaluation of cardiac exposure, including left ventricle and coronary arteries. A dose–response relationship between mean LV dose and the occurrence of CAC progression was observed, and this result is concordant with previous study, indicating a dose–response relationship between LV exposure and the occurrence of acute coronary event . InteresWe observed that in nearly all cases of CAC progression after RT, calcifications were localized in the LAD. In BC RT context, this is not surprising for several reasons. First, the LAD is the most exposed coronary artery that can receive hot spot doses > 40 Gy  and may Some studies proposed cut-off values to define CAC progression as a strong predictor of coronary event or mortality , but litThis study has several limitations. Our study was relatively small, but it is one of the largest ever published on CAC progression in BC RT population, and we could observe a statically significant dose–response relationship. Our definition of endpoint CAC progression was based on very sensitive thresholds (>0) for arithmetical difference in CAC scores at baseline and RT+ two years, which probably resulted in overestimation of clinically significant progression of CAC, but this may have involved underestimation of OR. As a consequence, the significant association observed with LV exposure can be considered as relevant. We included patients having received RT without chemotherapy, allowing us to specifically analyze radiation-induced CAC progression without potential bias due to combination with chemotherapy. A large multicenter European study (MEDIRAD EARLY-HEART study) is ongoing and included 250 patients, which should provide results without this size limitation ,31. WithOur study focused on CAC CT Scan and CAC scores. However, the absence of measured CAC (CAC = 0) does not absolutely rule out the absence of atherosclerotic plaques, including other forms of non-calcified plaques such as unstable plaques and soft plaques. With a zero CAC, there is, however, a low probability of significant luminal occlusion . FurtherThe study found an association between LV exposure and the risk of CAC progression within two years after BC RT, even after adjustment on intrinsic cardiovascular risk factors. Whether such a progression is mainly the consequence of CAC increase in the LAD and its exposure is suggested but remains to be confirmed. These results prompt further investigation of the early- and mid-term development of radiation-induced calcifications and their later consequences.