Endothelial dysfunction, associated with depressed nitric oxide (NO) bioavailability, is a well-recognized contributor to both accelerated atherogenesis and microvascular complications in type 2 diabetes (DM). However, growing evidence points to the comorbidities-driven endothelial dysfunction within coronary microvessels as a key player responsible for left ventricular (LV) diastolic dysfunction, restrictive LV remodeling and heart failure with preserved ejection fraction (HFpEF), the most common form of heart failure in DM. In this review we have described: (1) multiple cellular pathways which may link depressed NO bioavailability to LV diastolic dysfunction and hypertrophy; (2) hemodynamic consequences and prognostic effects of restrictive LV remodeling and combined diastolic and mild systolic LV dysfunction on cardiovascular outcomes in DM and HFpEF, with a focus on the clinical relevance of endothelial dysfunction; (3) novel therapeutic strategies to improve endothelial function in DM. In summary, beyond associations with accelerated atherogenesis and microvascular complications, endothelial dysfunction supplements the multiple interwoven pathways affecting cardiomyocytes, endothelial cells and the extracellular matrix with consequent LV dysfunction in DM patients. The association amongst impaired endothelial function, reduced coronary flow reserve, combined LV diastolic and discrete systolic dysfunction, and low LV stroke volume and preload reserve—all of which are adverse outcome predictors—is a dangerous constellation of inter-related abnormalities, underlying the development of heart failure. Nevertheless, the relevance of endothelial effects of novel drugs in terms of their ability to attenuate cardiovascular remodeling and delay heart failure onset in DM patients remains to be investigated. Endothelial dysfunction entails depressed bioavailability of nitric oxide (NO), a short-living mediator generated from L-arginine by endothelial NO synthase (eNOS) in response to blood flow-induced shear stress and multiple chemical stimuli . NO diffHowever, in addition to on-going modulation of systemic arterial resistance, NO exerts antioxidant, anti-inflammatory, anti-platelet and anti-thrombotic effects, as well as inhibits migration and proliferation of vascular myocytes, being a key endogenous anti-atherogenic molecule . EndotheSeveral mechanisms of reduced NO bioavailability in hyperglycemia and DM have been proposed, evolving from eNOS downregulation by advanced glycation end-products (AGE) ,7,8,9 inAmong potential mechanisms of eNOS uncoupling in DM, the oxidation of the eNOS cofactor tetrahydrobiopterin by reactive oxygen species (ROS) appears predominant ,18, withAdditionally, DM is associated with increased activity and expression of endothelial arginase I, which decreases the availability of L-arginine to eNOS . FurtherThus, a variety of mechanisms contribute to reduced NO bioavailability in DM. Consequently, long-lasting endothelial dysfunction in epicardial coronary arteries of diabetic subjects precedes the development of atherosclerotic plaques which underlie the vast majority of acute coronary syndromes ,30.Regardless of the relevance of ROS overproduction and endothelial dysfunction for both accelerated atherogenesis and microvascular diabetic complications ,12,31, gAlthough myocardial infarction appears to be a likely cause of systolic left ventricular (LV) dysfunction in DM patients with coronary artery disease (CAD) , overt CFinally, the prevalence of DM in major HF trials was similar in HFrEF and HFpEF, averaging 30–40%, despite the fact that a history of myocardial infarction is usually more common in HFrEF compared to HFpEF ,47. TherThis review is focused on the clinical importance of endothelial dysfunction in DM patients for restrictive left ventricular (LV) remodeling and diastolic dysfunction, predisposing to subsequent development of HFpEF.Diabetes mellitus-related myocardial dysfunction and consequent HF can traditionally be considered as a two-faced disorder, corresponding to two different phenotypes of LV remodeling, dilated or restrictive . Almost Nevertheless, although that original report  correspoTherefore, as proposed by Paulus and Dal Canto , the simAlthough HFpEF and HFrEF can be clearly differentiated from each other by the well-established criteria reflecting either a restrictive or dilated phenotype of LV remodeling, diastolic and discrete systolic LV dysfunction frequently coexist in DM, thereby suggesting some overlapping of the two phenotypes.Faden et al.  and GiorWith regard to systolic LV dysfunction, it was defined as an EF ≤ 50% or LV midwall fractional shortening (mwFS) ≤ 15% in the DYDA study , whereasIn contrast to EF, calculated by tracing of LV endocardial borders by means of the biplane method, mwFS—estimated in the SHOCKWAVE and DYDA studies—represents systolic shortening of the LV short axis at the midwall level. The calculation of mwFS takes into account the migration of midwall myocardial fibers during systole towards the epicardium from the middle line between the endocardium and epicardium, thereby avoiding EF overestimation in patients with concentric LV geometry . AdditioThe relevance of the complex estimation of LV function could also be concluded from an earlier work by Andersson et al. . They deHence, keeping in mind the central role of endothelial dysfunction in the novel paradigm for HFpEF ,33, the In contrast to direct cardiomyocyte damage, underlying the dilated phenotype of LV remodeling and HFrEF, multiple comorbidities, including obesity, metabolic syndrome and DM, induce a systemic proinflammatory state with consequent endothelial dysfunction within coronary microvessels. This proinflammatory state appears to be a key player responsible for LV diastolic dysfunction, restrictive LV remodeling and HFpEF ,33. MultThe above described abnormalities enhance restrictive LV remodeling, i.e., a small and stiff ventricle with a consequent fall in stroke volume (SV) in DM ,35,36,53Importantly, low stroke volume index (SVI)  was associated with an increase of over 80% in the incidence HF among the Strong Heart Study participants , includiTherefore, the link between endothelial dysfunction and restrictive LV remodeling with decreased SV might also imply an association between impaired endothelial function and the risk of developing symptomatic HF. Moreover, as even mild coexistent systolic dysfunction further decreases SVI, the low SVI‒HF risk association could even be strengthened by the coincidence of diastolic and discrete systolic LV dysfunction. Concomitant subtle systolic LV dysfunction was observed in 30‒61% of diabetics with LV diastolic dysfunction in the SHOCKWAVE and DYDA studies ,56, whilNotably, as early as 2008, Kistorp et al.  describeAccordingly, the association among reduced CFR, impaired endothelial function, LV diastolic and discrete systolic dysfunction and low SVI—all of which are adverse CV outcome predictors ,73,79,80Among the candidate mechanisms of this association, it can be proposed that they are likely to be shared by the pathways implicated in both LV diastolic and systolic dysfunction, responsible for the development of HFpEF and HFrEF, respectively, as elegantly reviewed by Paulus and Dal Canto . AccordiLikewise, lipid overload and lipotoxicity—dependent on excessive accumulation of triglycerides, diacylglycerols and ceramides, ROS formation, mitochondrial respiratory dysfunction and impaired calcium handling—can lead to cardiomyocyte cell death and HFrEF ,83,84,85Furthermore, in insulin-resistant DM subjects, increased delivery of free fatty acids further suppresses glucose oxidation—in agreement with the Randle cycle-mediated competition between free fatty acids and glucose oxidation—and potentiates insulin resistance which, in turn, contributes to oxidative stress, reduced NO bioavailability and cardiomyocyte hypertrophy ,84,85,86Finally, coronary microvascular rarefaction, i.e., reduced capillary density relative to cardiomyocyte surface area, might facilitate both diastolic dysfunction (via reduced NO availability) and systolic impairment through exacerbated subendocardial ischemia ,36,53.In addition to intrinsic myocardial abnormalities and limited LV preload reserve, the depression of LV performance in DM can be enhanced by excessive afterload. Beyond hypertension, frequently coinciding with obesity and DM, large artery stiffening may also contribute to increased afterload. Due to decreased arterial compliance, the arterial pulse wave travels faster, which allows the reflected wave to return to the aorta earlier, thereby increasing central systolic pressure and lowering diastolic pressure. Among mechanisms accountable for arterial stiffening in DM, augmented collagen synthesis and cross-linking due to AGE accumulation appear of paramount importance . NotablyThe similarity of abnormalities at the vascular and cardiac level might also contribute to common associations of cardiac and vascular changes in DM irrespective of concomitant diseases. Indeed, about 20 years ago, Strong Heart Study investigators observed both depressed systemic arterial compliance and subtle LV systolic dysfunction despite preserved EF in 1810 diabetic American Indians compared to their 944 nondiabetic counterparts . MoreoveStatins and inhibitors of the renin-angiotensin axis have demonstrated the capability to prevent eNOS uncoupling, improve NO bioavailability and attenuate endothelial dysfunction ,97,98. ARecently, sodium-glucose cotransporter-2 inhibitors, known to potently and rapidly reduce the risk of developing HF and HF-related events in DM ,106,107,Among possible future treatment targets aimed at the correction of endothelial dysfunction in DM, arginase I appears potentially attractive. As mentioned previously, arginase I upregulation in RBC of DM patients may lead to eNOS uncoupling in RBC with consequent ROS formation, which can translate into the dysfunction of adjacent endothelium ,26,27,28Finally, clinical reports also suggest potential benefits of arginase inhibition in DM. First, arginase blockade improved endothelial function in DM patients ,114,115.Beyond associations with accelerated atherogenesis ,38, micr


One out of seven patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) may be affected by transthyretin cardiac amyloidosis (ATTR-CA), mostly presenting with low-flow low-gradient AS with mildly reduced ejection fraction. The complex interaction of these two pathologies poses specific diagnostic and management challenges. The prognostic implications of this clinical intersection are not defined yet. Moreover, whether TAVR may have a prognostic benefit in ATTR-CA patients with symptomatic severe AS remains unclear, posing doubts on the best management strategy in this increasingly recognized subset of patients.We present a case of an 87-year old man with low-flow low-gradient severe AS, for whom a diagnosis of ATTR-CA was suspected based on clinical and echocardiographic criteria specific to coexisting AS and ATTR-CA. The diagnosis was eventually confirmed by positive bone tracer scintigraphy imaging. Following in-depth Heart team discussion, integrating frailty and prognostic information from combined cardiomyopathy states, a decision was made to manage the patient’s severe AS conservatively.In the presented case, we deemed the natural history of ATTR-CA amyloidosis to negatively affect both the patient’ prognosis and procedural risk, adversing TAVR indication despite symptomatic severe AS. No clear evidence is currently available to guide decision making in this setting, advocating for prospective studies to clarify if TAVR may have a prognostic benefit in ATTR-CA - and which ATTR-CA - patients. One out of seven patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) may be affected by transthyretin cardiac amyloidosis (ATTR-CA), mostly presenting with low-flow low-gradient AS with mildly reduced ejection fraction . The comA 87-year old man with a presenting diagnosis of hypertensive cardiomyopathy, orthostatic hypotension, moderate aortic stenosis, permanent atrial fibrillation, left bundle branch block and preserved ejection fraction (EF)  was admitted to our Clinic with Canadian Cardiovascular Society III angina, New York Heart Association (NYHA) III functional class and signs of pulmonary and systemic venous congestion Fig. .Fig. 1a2) with severe concentric remodeling , mildly reduced EF (50%), severely depressed global longitudinal strain (− 3.1%) with no relative apical sparing pattern and an average mitral annular Tissue Doppler S′ of 5.5 cm/sec. Second degree diastolic disfunction and severe biatrial dilatation were also apparent. A low QRS voltage-to-LV mass ratio by Sokolow-Lyon criteria was observed. Aortic valve evaluation revealed low flow-low gradient severe aortic stenosis (AS) , confirmed by computed tomography scan .Cardiac ultrasound documented left ventricle (LV) hypertrophy .Based on the low-flow low-gradient AS phenotype in the background of severe concentric hypertrophy, biatrial dilatation, S′ wave depression, conduction abnormalities, low QRS-voltage-to-LV-mass ratio and history of orthostatic hypotension, a diagnosis of amyloid cardiomyopathy was suspected. Bone tracer scintigraphy was performed revealing high diffuse myocardial uptake (Perugini score 3), diagnostic - in the context of an absent monoclonal protein on serum and urine exams  - for transthyretin cardiac amyloidosis (ATTR-CA)  The patient was unsuitable for ATTR-CA specific treatment because of current national reimbursement policies.A Heart Team evaluation was carried. In consideration of the high procedural risk (EuroSCORE II 11.4%) transcatheter aortic valve replacement (TAVR) appeared indicated for severe AS treatment. However, considering the patient frailty , hypoalbuminemia (1 point), lower-extremity muscle weakness (2 points) ), the prATTR-CA is a common under recognized condition among patients with severe AS, mostly presenting with low-flow low-gradient AS with mildly reduced EF . A high In this context, no solid evidence is currently available to inform the diagnostic strategies for ATTR-CA among patients with severe AS and, more importantly, whether and in which ATTR-CA patients TAVR (and which with TAVR device ) may havIn the presented case, a comprehensive heart team evaluation deemed the natural history of ATTR-CA to negatively affect both the patient’s prognosis and procedural risk, leading, along with consideration of patient preferences, to a lack of indication to TAVR during the index hospitalization despite severe AS. At mid-term follow-up, the patient was clinically stable without ensuing decompensation episodes, accordingly, clinical follow-up is ongoing. This management strategy, despite based on objective functional, laboratoristic and imaging parameters along with patient preferences, was based on a subjective weight of the numerous elements taken into considerations, as solid data regarding risk stratification and management of severe AS in patients with ATTR-CA are currently lacking. Indeed, no clear guidance to orientate decision making in this setting is available, advocating for prospective studies to clarify if TAVR may have a prognostic benefit in ATTR-CA - and which ATTR-CA-patients.


Introduction: Mitral valve prolapse (MVP) is the most common anomaly of the mitral valve. Several studies have shown prevalence of MVP in atrial septal defect (ASD) especially secundum types (II). The aims of this study is to show the potential role of 3D echocardiography in improving the diagnosis of MVP and to depict the relationship between reverse remodeling of the right and left ventricles  and MVP after transcatheter closure of ASD II.Methods: Sixty patients underwent transcatheter closure of ASD II and completed follow up by 2D and 3D echocardiography in Cairo University Children Hospital before the procedure and at 24 hours, 1 and 6 months after the procedure.Results: 3D echocardiography was more accurate than 2D echocardiography in detecting MVP frequency in ASD II patients (75% vs. 50%). Maximum statistically significant remodeling was detected by 3D echocardiography 1 month after the procedure  while 2D echocardiography was delayed in detecting biventricular reverse remodeling. 3D derived RV: LV ratio was accurate in detecting MVP status with a sensitivity of 88%.Conclusion: MVP in ASD II may be related to Biventricular remodeling; 3D echocardiography is accurate in the detection of reverse remodeling as well as MVP in ASD II patients before and after device closure. ASD accounts for 10% of all congenital heart diseases as it is detected in 1 child per 1500 live births.3Mitral valve prolapse (MVP) is the commonest anomaly of the mitral valve apparatus. It is defined as the superior systolic displacement of mitral leaflets ≥2 mm above annulus with coaptation point at, or superior to the annular plane. There is increasing evidence that relates the presence of MVP to ASD type II with significant volume overload. The incidence reported for the association between both lesions is 40%-45%.4Several postulations have been made to explain this association with no general consensus reached as of yet. Most studies point towards the distortion in LV geometry as a result of compression by remodeled RV from prolonged volume overload.5Right ventricular eccentric remodeling is a well-known complication of ASD type II, accounting for most of its chronic complications. The dilated RV also compresses the LV leading to its distortion and that of its incorporated mitral valve apparatus leading to MVP.6Right ventricular remodeling, once thought to be a late event after ASD Transcatheter closure, seems to occur earlier than expected; within few hours after ASD closure. However, a major drawback of 2D Echocardiography is that it depends for RV volumes calculations on a geometric assumption which may give the impression of a delayed reverse remodeling after Transcatheter ASD closure.7Cardiac MRI remains the standard method for assessment of RV and LV volumes; however, since 2010 increasing evidence point towards low variability between 3D derived and CMR volumetric assessment of LV and RV.The aim of this study is to assess the status of MVP after Transcatheter closure of ASD type II and to determine whether or not reverse biventricular remodeling can be correlated with MVP status.8 and follow up in Congenital Heart Disease Clinic of Cairo University Children Hospital and Benha University Children Hospital between January 2016 and January 2018 were enrolled for the study. Sixty-two patients had successful device closure and were included in the study. All patients underwent trans-esophageal echocardiography (TEE) to assess their suitability for the device closure. Transcatheter closure of ASD was performed using an appropriately sized Amplatzer-type septal occluder device [St Jude]  in catheter laboratory under TEE guidance. Two patients had lost to follow-up. Sixty patients had completed the study including 1 and 6-months follow-up. Patients with depressed right and/or left ventricular function, severe valvular disease, chronic obstructive pulmonary disease, cardiomyopathy, and residual shunt after percutaneous closure and patients with significant rhythm and conduction disturbances  were also excluded.Sixty-four patients with ASDs indicated for closure according to guidelinesTransthoracic echocardiography was performed before ASD closure, 24 hours, 1 month and 6 months after ASD closure as follows:2D echocardiography was digitally acquired using a standard protocol. RV/LV ratios were obtained offline from the apical 4 chamber view at end-diastole and end-systole, the basal diameter of RV and LV basal diameters were obtained to calculate the respective end –diastolic and end-systolic RV:LV ratios using the same adopted technique by Akula et al.9Presence or absence of MVP was assessed according to standard definitionby 2D and 3D echocardiography; three-dimensional billowing height with a cutoff value of 1.0 mm and billowing volume with a cutoff value 1.15 mL was considered diagnostic of MVP by 3D echocardiography.1011Transthoracic examination was carried out with the patient lying in the left lateral recumbent position. Echocardiographic images were stored digitally for offline analysis using Tom Tec software . On the basis of the initial view adjustment and the landmarks, the software automatically calculated the RV and lv end–diastolic and end-systolic volumes which were used to calculate the respective end-diastolic and end-systolic RV:LV volume ratio.Data were analyzed using IBM© SPSS© Statistics version 23 .t test. Paired comparisons for normally distributed numerical data were done using the paired t test. Categorical variables were presented as number (%). Receiver-operating characteristic (ROC) curve analysis was used to examine the value of 3D and 2D derived RV: LV ratio in predicting MVP status one month after the procedure. A P value <0.05 was considered statistically significantNormally distributed numerical variables were presented as mean and SD; inter-group differences were compared using the unpaired Transcatheter closure of ASD type II was performed on 60 patients, with an average hospital stay of 26 ± 2 hours with 0% mortality. All patients had one device implanted; Amplatzer Septal Occluder in 50% of patients, and Occlutech septal Occluder in the rest of patients.The baseline clinical, demographic and echocardiographic data of the patients were listed in 12ASD type II is the third commonest congenital heart disease and the commonest congenital heart disease persisting into adulthood. The longstanding left to right shunt through this defect during diastole causes significant RV remodeling. The RV progressively distends causing bowing of the interventricular septum to the left and subsequent shrink of the LV. This mechanism has been regarded as the cause of the common association (45%) between MVP and ASD type II.13 This also reflects the need for 3D reconstruction for accurate assessment of MVP status in ASD type II patients.In our study subjects, the prevalence of MVP among ASD type II patient was higher than previously reported (75%) when assessed by 3D echocardiography. This may be due to more accurate assessment of prolapsing segments by 3D echocardiography. This may reflect that the prevalence of MVP among ASD type II patients may be underestimated.14Transcatheter device closure has become the standard method for closure of ASD type II. Its low profile of postoperative complications gives it the upper hand over closed heart surgery. In our study subjects the 60 patients undergoing the procedure had no reported complications with an average duration of hospital stay of 26±2 hours which is greatly below the expected duration of hospital stay after surgical closure of ASD type II.15 as well as electrocardiographic,17 functional,22 and volumetric reverse remodeling26; none of which have correlated remodeling to MVP status.There is conflicting data on the duration needed for gradual reverse remodeling of RV in patients after Transcatheter closure of ASD type II. Many papers have focused on this issue from different aspects. These aspects included the hemodynamic status25 suggested that maximum noticeable reverse remodeling occurs 1 month after Transcatheter closure of ASD type II while Santoro et al23 and Yılmazer et al26 noted earlier reverse remodeling within 24 hours after the procedure.Du et al23 and Yılmazer et al26 which both succeeded in showing reduction in RV dimensions by 2D echocardiography. This may be attributed to the larger size of defects in our patients (16.6 ± 2.1) compared to Yılmazer et al (12.24±5). The different size of ASD type II has been reflected as well on the average RV: LV ratio whether by 2D or 3D echocardiography which was pretty higher in our study group.In our study subjects, 2D Echocardiography failed to show reverse remodeling within 24 hours after device closure, this is contradictory to both Santoro et al273D echocardiography at end systole showed an early significant remodeling 24 hours after device closure. However, maximum remodeling has been depicted by 3D echocardiography 1 month after the procedure, while by 2D Echocardiography maximum statistical significance of remodeling has been shown at 6-month post closure. This lag between results of 3D and 2D Echocardiography may be attributable to the tendency of 2D Echocardiography to overestimate ventricular dimensions.28Another striking finding in our study was the discrepancy between the remodeling extent observed at end-systole and that seen at end-diastole. End-diastolic volumes by 3D echocardiography did not show significant reverse remodeling at either 24 hours post-catheterization or after 1 month; to our knowledge our series is the first to examine the reverse remodeling after ASD type II Transcatheter closure at end-systole. An increasing body of evidences in other pathological contexts, point to the fact that reverse remodeling starts at end-systole due to improvement of contractile function of the heart following the abolishment of either volume or pressure load.To our knowledge this is the first paper to determine the status of MVP following transcatheter ASD closure and to correlate it to Biventricular reverse remodeling. In our patients, significant agreement has been depicted between results of biventricular remodeling as measured by 3D RV: LV ratio and MVP status. None of our patients have shown any change in MVP status 24 hours after the procedure. While 1 month after the procedure 30% of patients showed resolution of MVP, this was also the point at which the maximum change in RV LV ratio by 3D echocardiography has occurred.Our study points to a certain delay (1 month) in the occurrence of biventricular reverse remodeling after ASD type II transcatheter closure. Early (after 24 hours) reverse remodeling may be seen in smaller defects with less volume load. It also shows a tight relationship between biventricular reverse remodeling and the improvement of MVP after transcatheter closure of ASD type II, which may mean that the initially observed MVP was attributable to biventricular remodeling. Finally, the study demonstrates that the 3D echocardiography offers a faster and more accurate way in detection of both MVP and biventricular reverse remodeling.None.The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant National Egyptian guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008, and has been approved by the institutional Committees of the Faculty of Medicine, Cairo University.We want as authors to thank our patients for their priceless trust, but also we want to thank all our students, interns and residents for the viral passion they have. These young colleagues ignite by their enthusiasm our passion and every day seeing them around and working hand in hand with them has the potential ton revive our will to keep up the good work. Last but not least we wanted to send our deepest gratitude to Dr. Rahma A.Menshawey for her valuable advices in English Editing. This outstanding young researcher has substantially helped us.


Strain echocardiography highlighted a 24%-increase (p****) in the ejection fraction mean value in TD-treated (n = 12) versus Ctrl mice (n = 17) during the 6 month-period. Improved cardiac performance was associated to a 54%-decrease (p**) in left ventricular fibrosis at 6 months in TD (n = 16) versus Ctrl (n = 20). In conclusion, targeting the extrinsic pathway with TD peptide at the onset of reperfusion provided long-term cardioprotection in a mouse model of myocardial IR injury by improving post-MI cardiac performance and preventing cardiac remodeling.Reperfusion therapy during myocardial infarction (MI) leads to side effects called ischemia–reperfusion (IR) injury for which no treatment exists. While most studies have targeted the intrinsic apoptotic pathway to prevent IR injury with no successful clinical translation, we evidenced recently the potent cardioprotective effect of the anti-apoptotic Tat-DAXXp (TD) peptide targeting the FAS-dependent extrinsic pathway. The aim of the present study was to evaluate TD long term cardioprotective effects against IR injury in a MI mouse model. TD peptide (1 mg/kg) was administered in mice subjected to MI , 5 min prior to reperfusion, and were clinically followed-up during 6 months after surgery. Plasma cTnI concentration evaluated 24 h post-MI was 70%-decreased in TD (n = 16) versus Ctrl (n = 20) mice ( The overall mortality related to myocardial infarction (MI) has largely decreased over the years due to effective procedural therapy and secondary prevention. Unfortunately, for the patients that survive after MI, the morbidity leading to heart failure (HF) is rising leading to increased cost burden on the healthcare system. Moreover, according to the World Health Organization, this burden will be worsened since CVD are predicted to stay at the first rank until 2030 because of an aging population and an exponential growing number of diabetic patients4. However, reperfusion therapy leads to deleterious side effects, namely ischemia–reperfusion (IR) injury, adding to ichemic injury and limiting myocardial salvage5. Upon the abrupt restoration of blood flow, cardiac cells endangered by ischemia die after activation of intracellular cascades of complex events such as calcium overload, the loss of ion homeostasis and the production of oxygen free radicals leading to apoptotic processes. Importantly, lethal IR injury arise when apoptosis is triggered by reperfusion in cells that have survived ischemia7. Because infarct expansion due to IR injury concerns 25 to 50% of the total infarct, new cardioprotective strategies applicable at the onset of reperfusion are urgently needed.Acute MI occurs as a consequence of the abrupt occlusion of a coronary artery leading to ischemic injury and subsequent necrosis. Resulting infarct size is correlated to the duration of ischemia and is a determinant of post-MI mortality. Limitation of infarct size by reperfusion of the culprit artery as early as possible (thrombolysis or primary angioplasty) is the only treatment providing myocardial salvage and improving patient prognosis12. Until now, all clinical trials targeting the mitochondrial intrinsic apoptotic pathway involved in IR injury have not been successful. Even if inhibition of the mitochondrial permeability transition pore (mPTP) opening using Cyclosporin A (CsA) provided encouraging results in many animal models and also in a proof-of-concept study in patients38, large-scale clinical trials provided negative results showing neither long-term protection nor decreased mortality or prevention of early multiple organ failure 40.Thus, targeting an apoptotic cascade activated at the time of reperfusion appeared as a promising and innovative therapeutic strategy to prevent IR injury and limit infarct size6. In this context, the death domain associated protein (DAXX) has been identified as a key element involved in IR injury in many organs including the heart15. The DAXX protein has a dual function depending of its subcellular localization. DAXX in the nucleus acts as a transcription regulator with a main anti-apoptotic contribution16. However, triggered by various stimuli such as oxidative or ischemic stresses, DAXX is relocalized into the cytosol upon the Apoptosis signal-regulating kinase 1 (ASK1)-shuttling21. Cytosolic pro-apoptotic DAXX protein binds to the intracellular part of the First Apoptosis Signal (FAS) death-receptor and activates the downstream apoptotic signaling pathway22.Therefore, we have capitalized on the pro-apoptotic key role of the FAS death receptor in the extrinsic pathway since elevated Fas Ligand in the blood of AMI patients activates FAS receptor13. In order to translate this genetical into a pharmacological approach, we have developed the anti-apoptotic peptide Tat-DAXXp (TD) composed of the association of a FAS:DAXX interfering peptide DAXXp with the Tat cell-penetrating peptide. After a single intraveneous administration prior to reperfusion, TD-treatment provided a 48%-decrease in infarct size and an inhibition of apoptosis by the same extent in a short-term murine myocardial IR in vivo model compared to a non-treated control group23.In a previous study, we have identified FAS:DAXX interaction as a key player during myocardial IR injury using the DAXX-dominant negative mice model exhibiting a drastic decrease in infarct size (45%)23  compared to the non-treated IR condition. In addition, this treatment allows activating pro-survival proteins (ERK and AKT) from the RISK pathways. Finally, TD treatment was associated with DAXX re-localization from the cytosol to the nucleus (where it is reported to play anti-apoptotic functions) probably as a consequence of the inhibition of HSP70-mediated proteotoxic stress. This suggests that TD plays a key role in early cardioprotection by strongly inhibiting apoptosis specifically induced by IR injury. Importantly, 24 h after TD administration, the peptide is completely degraded in vitro and eliminated in vivo avoiding possible side effects. Therefore, anti-apoptotic TD peptide is fully active and necessary only at the onset of reperfusion within a 30 min-therapeutic time window, corresponding to the apoptotic burst in the subacute phase of AMI23.Fluorescent labeled TD peptide shows a cytoplasmatic localization in cardiomyocytes in vitro and in vivo. Within the cell, TD peptide ensures cardioprotection by inhibiting both extrinsic and intrinsic apoptotic cascades, reducing JNK, Caspases 8, 9 and 3 activation, and decreasing FADD and BAD expression. TD-induced caspase 8 inhibition was not associated with any switch to necroptosis24, a moderate IR murine model was used, as a more relevant study model to mimic the majority of AMI patients benefiting from culprit coronary artery revascularization. Moreover, mild injury in the cardiac tissue is compatible with a therapeutic reversion24. TD was administrated 5 min before reperfusion (bolus of 1 mg/kg) compared to two placebos, a pharmacological and a surgical one (three-arms study) in a double-blind manner as usual in a clinical trial. Cardiac injury was evaluated by measuring the plasmatic cardiac troponin I (cTnI) biomarker and cardiac function by echocardiography during 6 months after MI. Finally, fibrosis was quantified in the left ventricle (LV) of the mice by histological coloration.The aim of our present study was to evaluate the long-term cardioprotection provided by one bolus injection of TD in mice submitted to 40-min myocardial infarction followed by 6-month reperfusion. In order to optimize the translation into the clinical settingOur study was designed to evaluate the long-term effects of the TD peptide in mice subjected to mild myocardial IR. The studied mice population included the SHAM n = 18) and the IR groups (n = 49)  group . At 1, 2, 3 and 6 months, cTnI levels were close to zero in all study groups  is a well-established biomarker for infarct size with reliable prognostic value both in the clinical setting and in small animalspgroup** = 0.0012) and end-systolic volume  measurements. Indeed, 10% and 17% decreased mean values were observed in the TD-treated mice compared to Ctrl, respectively, for LVES area  and for LVESV . At 6 months, LVEDV was increased by 18% in the Ctrl group versus SHAM (p* = 0.0317). TD treatment allowed a 9%-decrease for this parameter versus Ctrl to recover mean values close to those of SHAM (p# = 0.7753) without reaching significance . Importantly, TD treatment induced a large 54% reduction in fibrosis formation compared to non-treated Ctrl hearts .Since structural changes occur in the left ventricular (LV) myocardium after the IR insult in patients, the LV anatomy was evaluated by echocardiography during the post-MI period. Significant LV changes were observed among groups as assessed for both end-systolic area  for EF which is the main parameter reflecting systolic function  and more importantly, mean values were close to those recorded in the SHAM group . A similar result was observed for FS (pgroup**** < 0.0001) exhibiting a drastic 40%-increase upon TD treatment compared to non-treated Ctrl mice  and fractional shortening , which are considered as reliable assessments of LV functionion Fig. A. Indeed30. In our study, TD treatment significantly improved strain properties that were strongly impaired after IR injury . Indeed, a 25%-increase in the longitudinal strain average  was observed in the TD group compared to Ctrl  but TD treatment was not able to fully restore this strain property  injury, the long-term cardioprotective effects of the anti-apoptotic Tat-DAXXp (TD) peptide injected as an intravenous bolus (1 mg/kg body weight). The results of this study performed in a double-blind manner demonstrate that TD-treatment enhanced the beneficial effect of reperfusion up to 6 months following injection in a relatively mild model of IR injury. TD-treatment applied as a bolus, 5 min before reperfusion, reduced both cardiac injury (cTnI level) and remodeling (fibrosis). Accordingly, left ventricle (LV) global function of the myocardium was significantly improved along the 6-month period as showed by a significant higher ejection fraction . These new data further expand and provide relevance for clinical translation to our previous results showing short-term cardioprotective effects associated to reduced mortality rates measured at 24 h post-MI31. In addition, due to a partial inhibition of caspase 8, we did not observe a switch to necroptosis that could bypass the effect of the treatment . Furthermore, inhibition of the mitochondrial apoptotic pathway was also evidenced (decreased activation of caspase 9) due to the crosstalk between the two main apoptotic cascades. This therapeutic strategy allows an upstream inhibition of regulated cell death mechanisms.The TD peptide was designed to specifically act on the FAS:DAXX apoptotic pathway that is activated specifically during myocardial reperfusion injury. In mechanistic terms, our previous study evidenced that short-term cardioprotection was related to a potent anti-apoptotic effect by targeting the FAS receptor-downstream pathway (decreased activation of caspases 8 and 3) associated with an activation of RISK survival kinases33. Results obtained in the present study confirm that decreasing IR injury, specifically when reperfusion starts, provides long term protection of the myocardium by decreasing cardiac injury in the early post-MI period and preventing subsequent heart remodeling.Decreasing infarct size in patients allows the prevention of post-ischemic heart failure (HF) and the improvement of survival. LV remodeling is dominated during the myocardial infarction (MI) acute phase by an early dilatation of the ventricle (a key marker of the evolution and prognosis of the disease) followed by deposit of scar fibrosis to replace the injured tissue and hypertrophy in non-infarcted remote areas. Therapeutic strategies for MI patients must be implemented as early as possible to avoid ventricular dilatation. As described in the literature, the duration and extent of MI must be reduced by rapid heart revascularization, and IR injury resulting from both apoptosis and inflammation must be treated26. cTnI dosage in patients with acute coronary syndrome allows the early recognition of those with an increased risk of death34. In murine models, cTnI is also a prognostic value for infarct size27. Determination of plasma levels at 24 h was reported to be an early predictor of infarct size in mice with either permanent or transient ligation of the left ascending coronary artery36 and described as a biomarker of cardiotoxicity in preclinical models37. In the present study, cTnI plasma levels was decreased to 70% in TD-treated IR mice (TD group) compared to the Ctrl (non-treated IR) group  is considered as a diagnostic and prognostic biomarker for cardiac pathology as well as an essential indicator of the risk stratification of acute MIpost mortem at the end of the protocol, was drastically decreased in the TD-treated hearts. Myocardial fibrosis is a major parameter of remodeling after MI38. During this process, injured myocardial wall becomes thinner and the left ventricle dilates. The non-infarcted myocardium is also altered by the deposit of interstitial fibrosis together with cardiomyocyte hypertrophy. These structural alterations lead to cardiac dysfunction, which could progress to heart failure (HF).Following myocardial infarction leading to the death of cardiac cells, macrophages remove necrotic tissue, which is then replaced by granular tissue to provide a fibrotic scar. In our mouse model of ischemia–reperfusion injury, the amount of fibrosis was increased as evidenced in the Ctrl group. We did not observe any impact of the deposit of fibrosis on the diastolic stiffness of the LV as attested by our echocardiography study using the pulse-waved Doppler mode clearly showing that the mitral valve E/A ratio considered as a clinical marker of diastolic dysfunction was similar upon IR stress. Our results gave evidence that the enhanced fibrosis in Ctrl versus SHAM left ventricles upon myocardial injury, as investigated 40. In our study, echocardiographic evaluation of end-systolic area (LVES area) and LVESV during the 6-month period after MI revealed the expected LV dilatation in the non-treated Ctrl group compared to SHAM, which was prevented by TD-treatment from the first month after MI  used in clinical practice for LV remodeling41. There was a trendancy for TD treatment to decrease LVEDV mean value at 6 months, which allows to prevent post-MI LV remodeling. A bad prognosis for patients is correlated with both increased end-systolic and end-diastolic volumes but LVESV is considered as a stronger predictor of adverse outcomes and the primary predictor of survival after MI42. In our study, we have not observed any differences in the survival rates during the 6 month-period, in particular by comparing the Ctrl and the SHAM groups, since we have choosen a mild injury model in accordance with the recommendations provided to translate cardioprotection into the clinical setting. Nowadays, it has been widely discussed that obtaining positive results in clinical trials depends on the recruitment of patients who have truly a chance to benefit from adjunct cardioprotection24. Indeed, patients with severe injury (with long ischemic period) has less chances to benefit of an effective therapeutic-based cardioprotection that can be additive to reperfusion treatment. In addition, severe injury is associated with strong necrosis induction that could not be reversed by any cardioprotective therapeutic strategy. According to this idea, we have adapted our study mouse model by inducing myocardial IR injury without progression to heart failure and used a functional investigation technique as in humans (Strain echocardiography to detect subtle changes) in order to facilitate the translation from bench to bedside. In addition, compared to permanent LAD ligation, our IR model is more clinically relevant because most of the AMI patients nowadays benefit from revascularization of their culprit coronary artery. In particular, criteria for patient selection should be short ischemic stress (< 2–3 h), large area-at-risk (> 30–40% of LV) and no significant collaterality, which corresponds to our mouse IR model24. In addition, no hypertrophy was detected in the hearts and no mouse died of cardiovascular cause beyond the immediate post-infarction critical period (first 24 h of recovery). In accordance, absence of significant changes in LVED volume and area  were observed in Ctrl mice from 1 to 6 months compared to SHAM mice. These results show that the study model of 40 min myocardial ischemia followed by 6-month reperfusion is characterized by the absence of bad prognosis, which is usually reported in mouse models of permanent LAD (Left Anterior Descending) artery ligation leading to heart failure and high mortality rates.As a direct result of systolic dysfunction related to cardiac remodeling, end-systolic left ventricle enlarges and LVESV (LV end-systolic volume) changes are considered as prognostic values in cardiac remodeling MI Fig. . A the e43. As expected, the early reduction in cardiac injury reflected by reduced cTnI plasmatic levels (marker of infarct size) after TD-treatment observed in our study was followed by a marked improvement in LV systolic performance. The ejection fraction  parameter is considered as the main marker of cardiac performance and is widely used to easily assess global LV function. In addition, EF evaluation allows to predict mortality and plays a critical role in clinical decisions including device implantation and valve surgery44. In the present study, EF was measured from the bi-dimensional mode by two different methods using the LV trace module and the area-length method45. A higher EF mean value was observed in TD-treated mice at each time point compared to those of Ctrl mice showing a clear treatment-related long-term improvement of cardiac performance after MI  using the two-dimensional strain (2D-strain) method, which is angle-independent and less subject to artefacts48. Strain analysis evaluates cardiac performance, which depends on three factors: ventricular geometry, myocardial fiber orientation  and wall elasticity28. In patients with previous MI, strain imaging allows prediction of clinical outcome better than LVEF parameter49. In particular, decreased longitudinal strain predicts mortality in high-risk MI patients50. In mice, a previous study reported that longitudinal strain was correlated with infarct size and that this correlation was greater than for radial strain51. In addition, longitudinal strain was also described as a highly sensitive parameter to early detect myocardial dysfunction after MI as well as beneficial cardioprotective effects30. Thus, we used strain echocardiography for a more detailed investigation of myocardial function. We confirmed that in our model of coronary occlusion longitudinal strain values were more significantly impacted (p****) than those for circumferential strain (p*) versus SHAM in agreement with the higher sensitivity to ischemia of the longitudinal fibers located in the endocardial and subendocardial tissues than the circumferential ones. In addition, we did not detect significant changes among groups for the radial strain parameter as previously described51. Interestingly, our results show an improvement of 2D longitudinal strain in TD-treated versus non-treated Ctrl mice  mice. All the results for plasma cTnI levels, fibrosis amount and functional echocardiography show that a single dose of the anti-apoptotic TD peptide administered systemically prior to reperfusion constitutes an effective treatment against LV remodeling after myocardial infarction with a persistence of the cardioprotective effect over a 6-month period.31. Therefore, TD-treatment appears as a promising therapeutic molecule to prevent post-MI reperfusion injury which should be tested in a clinical situation.In conclusion, a single dose of TD peptide prior to reperfusion decreases infarct size assessed by cTnI quantification and induces a restoration of cardiac performance together with a prevention of post-MI LV remodeling. Importantly, we did not detect behavorial changes during the 6-months period or abnormalities such as tumor development and organ hypo- or hypertrophy among mice at the end of the study protocol, suggesting the safety of this potential new therapeutic tool. In addition, specifically targeting the burst of apoptosis involving FAS:DAXX interaction at the onset of reperfusion is safe because TD peptide is administrated as a single bolus and it has a short life time as reported in our previous studyOur study was performed using young adult male mice in order to avoid the influence of the cardioprotective female hormons. However, we need to consider that in the clinical setting, women are also a population at risk of cardiovascular disease. In addition, for a future preclinical study, we need also to take into account that animal studies should be performed on old animals with co-morbidities and medications usually prescribed in high cardiovascular risk patients for an optimal clinical translation.Charles River laboratory, l'Abresle, France) in accordance with the European Communities Council directive of November 1986 and conformed to the “Guide for the Care and Use of Laboratory Animals” published by the US National Institutes of Health . The study protocols were approved by the “Comité d’éthique pour l’expérimentation animale Languedoc-Roussillon” (CEEA-LR) with the authorization number CEEA-LR-12107 for experiments to be realized on the site of experimentation that obtained authorization number A 34-172-41.All experiments were carried out on C57BL/6 J mice  were anaesthetized by an anaesthetic preparation (intramuscular injection) composed by xylazine , ketamine  and chlorpromazine . Mice were placed under mechanical ventilation through a tracheal intubation on a rodent respirator . A thermo-regulated table  allowed maintaining the body temperature between 36.8 and 37 °C during the surgery. Ketamine  and xylazine  were injected to fully induce anesthesia before opening the chest by a left lateral thoracotomy and placing a reversible coronary artery snare occluder around the left coronary artery. During the surgical protocol, anesthezia and pain analgesia were controled by pinching the toes of the posterior legs. All mice experienced an ischemic injury of 40 min. The coronary reperfusion was obtained by loosening the silk knot. Then, the chest was sutured after administration of lidocaine  subcutaneously. Postoperative awakening was achieved with oxygen supply and controlled humidity in an emergency care unit maintained at 28 °C where mice were allowed to recover during 24 h. Then they were transferred in a ventilated cabinet where they were maintained during all the study.Investigations conform to the Directive 2010/63/EU of the European Parliament. C57Bl6J male mice were subjected to a surgical model of acute myocardial ischemia and reperfusion as previously describedSHAM: sham operation for surgery placebo was performed without coronary artery ligation .Ctrl (non treated IR mice): 40 min ischemia—6 months reperfusion with an I.V. injection of physiological serum 5 min before the onset of reperfusion .TD (TD-treated IR mice): 40 min ischemia—6 months reperfusion with an I.V. injection of TD peptide (1 mg/kg) 5 min before the onset of reperfusion. Mice subjected to the IR protocol were randomly allocated to the two groups of treatment Ctrl or TD (blind to the experimentor).Various protocols were applied:Intavis AG, Germany) was solubilized in physiological serum  to a final concentration of 1 mg/kg. Pharmacological treatments with 15 µL of the peptide solution or physiological serum  were given blindly to the surgery experimentor, who administered them intravenously in the tail vein of the anaesthetized mice 5 min prior to reperfusion.Tat-DAXXp  at various time points . After centrifugation at 4 °C, the plasma was collected and stored at -80 °C.High sensitivity mouse cardiac Troponin-I Elisa immunoassay kit  and an Infinite M 200 plate reader . The assay was performed in duplicates for each mouse after having collected all samples of the long-term study.Cardiac troponin I (cTnI) levels were quantified at various time points in the plasma using the 53. Cardiac anatomy and function in vivo were measured non-invasively using a high-frequency, high-resolution echocardiographic system consisting of a VEVO ultrasound machine (1100) equipped with a 22–55 MHz (MS-550D) bifrequencial transducer . Anesthetized with 1–1.2% isoflurane , mice in supine position were placed on an homeothermic stage (body temperature at 37 °C) equipped with electrocardiographic electrodes allowing heart rate monitoring during image acquisition .Transthoracic echocardiographic recordings were realized at 1, 2, 3, 4, 5 and 6 months in post-MI miceon Table . High-re2) and LV end-diastole area , end diastolic  and end-systolic LV volumes , ejection fraction  was calculated. Global longitudinal and radial strains were measured from the bidimensional long axis view of the left ventricle using the Vevostrain software and the speckle tracking imaging. Circumferential and radial strains were measured from the bidimensional short axis view and these measured values were used to calculate STI-derived ejection fraction   and xylazine  and maintained on a surgical table under ventilation. Euthanasia was performed by harvesting the heart after opening of the chest. After rinsing the heart with a PBS solution, the right ventricle and the atria were removed. Cardiac chambers were weighted and the left ventricle processed for fibrosis quantification (see below).At the end of the complete protocol, mice were weighted and anesthetized by administrating (intramuscular injection) a solution composed of ketamine  were fixated in a 4%-PFA solution (Electron Microscopy Sciences) during 48 h and embedded in paraffin before slicing . 3 µm-sections were stained with Picrosirius red . Fibrosis revealed by Picrosirius staining was quantified by measuring the extent of fibrotic area in each LV cross-sections using an ImageJ macro developed by MRI platform . For each slice, total fibrosis area was corrected to the total LV area. The amount of total fibrosis in each LV was obtained by averaging the percentage of fibrosis of all the slices across the whole LV. Finally, fibrosis values from Ctrl and TD LVs were corrected by subtracting the value measured in the SHAM group corresponding to the perimeter fibrosis. This allows to exclude the unspecific fibrosis of adherence resulting from post-surgery healing of the heart without pericardium in the chest.Fiji is just ImageJ, version 2.1.0/1.53c; https://imagej.net/Fiji).Hematoxylin & eosin staining was performed on 3 µm-sections (at the papillary muscle level) and mean cardiomyocyte cross-sectional area was measured for 180 random cells in the non-infarcted region of each LV using Fiji software  allowed scanning of the stained slides using a × 20 magnification for Picrosirius red and × 40 for HE staining. All the measurements were performed in a blind-manner.www.graphpad.com).Data (mean ± SEM) were analyzed statistically using GraphPad Prism software  in order to evaluate sources of variation among groups. Supplementary Information.


The beta-O-linkage of N-acetylglucosamine  to proteins is a pro-adaptive response to cellular insults. To this end, increased protein O-GlcNAcylation improves short-term survival of cardiomyocytes subjected to acute injury. This observation has been repeated by multiple groups and in multiple models; however, whether increased protein O-GlcNAcylation plays a beneficial role in more chronic settings remains an open question.Here, we queried whether increasing levels of cardiac protein O-GlcNAcylation would be beneficial during infarct-induced heart failure.Oga, the gene responsible for removing O-GlcNAc from proteins. Here, we generated mice with cardiomyocyte-restricted, tamoxifen-inducible haploinsufficient Oga gene. In the absence of infarction, we observed a slight reduction in ejection fraction in Oga deficient mice. Overall, Oga reduction had no major impact on ventricular function. In additional cohorts, mice of both sexes and both genotypes were subjected to infarct-induced heart failure and followed for up to four weeks, during which time cardiac function was assessed via echocardiography. Contrary to our prediction, the Oga deficient mice exhibited exacerbated—not improved—cardiac function at one week following infarction. When the observation was extended to 4 wk post-MI, this acute exacerbation was lost.To achieve increased protein O-GlcNAcylation, we targeted The present findings, coupled with our previous work, suggest that altering the ability of cardiomyocytes to either add or remove O-GlcNAc modifications to proteins exacerbates early infarct-induced heart failure. We speculate that more nuanced approaches to regulating O-GlcNAcylation are needed to understand its role—and, in particular, the possibility of cycling, in the pathophysiology of the failing heart. Ogt) and O-GlcNAcase , and the proteins they encode are OGT and OGA, respectively. OGT adds the O-GlcNAc modification to serine/threonine residues and OGA is the only known enzyme that removes the O-GlcNAc modification. Changes in protein O-GlcNAcylation have been implicated in a variety of pathophysiological processes, including diseases of the cardiovascular system . Cardiomyocytes where chosen based on their circularity and whether they had centrally located nuclei. Circularity was calculated using the Shape Factor feature in NIS-Elements AR 4.0. Cardiomyocytes were chosen based on a Shape Factor between 1.0 and 0.895 (radius ratio of 1:1 to 1:1.4).Griffonia simplicifolia Lectin I; Vector Labs) and imaged as described previously [2).Cardiac sections were stained with 40 μg/mL isolectin B4  was used on LV sections according to the manufacturer’s instructions. Sections were also stained with DAPI to identify nuclei. Sections were imaged using an epi-fluorescence microscope (Nikon Eclipse Ti) using a 20x objective. TUNEL positivity was calculated by dividing the total number of TUNEL positive cells by the number of nuclei.Well-characterized de-identified human myocardial tissue samples were obtained from the Transplantation Biobank of the Heart and Vascular Center at Semmelweis University, Budapest, Hungary , 35. Folt test, when appropriate. A chi-squared test was used to determine statistical differences in patient demographics. Differences were considered statistically significant if p<0.05.Results are shown as mean or mean ± SD. Statistical analysis (GraphPad 8.0.2(159)) was conducted using a two-tailed Student’s Ogt [Oga deficient mice. Mice with one Oga floxed allele were crossed with α-MHC MCM mice to generate icmOga+/- and icmOga+/+ littermates. and icmOga+/- (n = 15) were subjected to echocardiography after 1 wk post-MI. Indices of left ventricular cardiac function were assessed. No significant changes were observed in left ventricular inner systolic diameter (LVIDs), left ventricular inner diastolic diameter (LVIDd), fractional shortening (FS), left ventricular posterior wall thickness in diastole (LVPWd), left ventricular posterior wall thickness in systole (LVPWs), and left ventricular anterior wall thickness in diastole or systole . An unpaired Student’s t-test was used to determine significance between icmOga+/+ and icmOga+/- groups.Tamoxifen treated male icmOga reduction altered regulation of O-GlcNAcylation, we queried whether OGA and OGT protein expression was different in icmOga+/- and icmOga+/+ hearts 1 wk post-MI. We probed for OGT, OGA, and protein O-GlcNAcylation via immunoblot  between icmOga+/- and icmOga+/+ hearts were not significantly different . Infarcted icm post-MI . InteresOga dysregulated protein O-GlcNAcylation, we queried whether OGT protein expression and overall protein O-GlcNAcylation was different in icmOga+/- and icmOga+/+ hearts at 4 wk post-MI. Although OGT protein expression was also not different  were also similar  hastens the severity of infarct-induced heart failure.Our previous work indicated the requirement for  failure . Our obsIt is worth noting that despite similarities between our mouse and human data, there were qualitative differences between the two species. Here and previously , we founC. elegans, deletion of ogt-1(ok430) or oga-1(ok1207) resulted in similar alterations in metabolism, macronutrient storage and intracellular signaling [So, how do we reconcile our present results with our previous complementary study in which we ablated OGT in cardiomyocytes? That is, in our previous investigation of OGT deletion in heart failure, we found that the mice did worse—similar to the present observations. Without careful consideration of the aggregate results of the present work focusing on OGA haploinsufficiency and our previous work focusing on OGT deletion , it woulignaling , 42. ThuOga mRNA. Through a series of reporter assays we provided evidence that miRNA-539 negative regulates OGA expression in vitro [Ogt and Oga [E2f1 could attenuate post-infarction ventricular remodeling by alleviating repression of O-GlcNAc cycling enzymes [E2f1 did attenuate ventricular remodeling, it did not exert an appreciable effect on O-GlcNAcylation. Thus, the regulation of O-GlcNAcylation in the failing heart remains enigmatic and is likely to be multifactorial.There are several unanswered questions regarding how OGT, OGA, and O-GlcNAcylation are regulated. Little work has been done in this area; however, some insights have emerged. We have identified candidates that may regulate OGT and OGA expression: miRNA-539  and the in vitro . In a se and Oga . Despite enzymes . AlthougOgt [Oga—which have opposite effects on global O-GlcNAc levels—culminates in exacerbation of heart failure. In our model, haploinsufficiency of Oga was sufficient to affect cardiac function even in naïve conditions following extended observation. Interestingly, there is a link between excessive O-GlcNAcylation and cardiac dysfunction [Oga-deficient mice with significantly elevated O-GlcNAc levels displayed no further exacerbation in cardiac function after 1 wk. These collective observations suggest that identifying specific O-GlcNAc-modified protein targets may not be the most proximal question to address.Although the O-GlcNAc modification does not occur via a canonical consensus sequence, many proteins harboring this modification have been identified; however, the level of evidence for such O-GlcNAc modified proteins (particularly site-specific identities) varies widely. To determine whether a specific O-GlcNAc site is responsible for a given effect on the function of a protein, a classical approach would be to perform site-directed mutagenesis. Unfortunately, because the O-GlcNAc modification occurs on serine/threonine residues, investigators are often frustrated by the potential impact  of interfering with phosphorylation—a concern that does not seem to affect investigators of phosphorylation sites . One may still wonder why the present study did not focus on the protein targets of O-GlcNAcylation that could explain the observed effects. Although this may be fruitful in limited circumstances, the more immediate need was to understand the overarching phenomenon before becoming lost in the minutiae. Thus, our approach was to take a system-wide view to determine whether simple increases or decreases in O-GlcNAcylation predicted (or were associated with) the outcome in heart failure. Indeed, had the reduced-function OGA mouse (with increased O-GlcNAc levels) shown improvement in EF during heart failure, the urgency to identify protein targets would be clear; however, we observed that either deletion of Ogt  or reducfunction . Indeed,function . In contThe results of these studies question the uncomplicated view of simply directionally changing O-GlcNAc levels, i.e., more or less O-GlcNAc is good or bad. Instead, our previous and present work provide evidence that blocking the ability of cycling O-GlcNAc exacerbates heart failure. It is possible that O-GlcNAcylation, like a thermostat, requires the ability to constantly change. In other words, O-GlcNAcylation can be temporarily increased or decreased; however, blocking either side of the equation for extended periods of time likely disrupts homeostasis, or, given sufficient time, may actually serve as the nidus for disease.S1 FigOga floxed mice (A). PCR products of the floxed Oga appear at 850 bp and the wild-type Oga PCR product appears at 792 bp. To generate mice capable of tamoxifen-induced, cardiomyocyte-specific, heterozygous deletion of Oga (icmOga+/), we crossed Ogafl/+with MCM+/- mice to generate Ogafl/+ MCM+/- mice (B). The Oga floxed strain was described previously [Genotyping results of wild-type and heterogenous eviously . Timelin(TIFF)Click here for additional data file.S2 FigOga+/+ and icmOga+/- mice. Immunoblot for OGA protein in skeletal muscle (A), lung (B), and kidney (C) tissue.To determine if ablation of OGA was limited to the heart we isolated protein from skeletal muscle, lung, and kidney from icm(TIFF)Click here for additional data file.S3 FigOga+/- and icmOga+/+ heart sections (C). Cardiomyocyte cross-sectional area was measured in the area bordering the infarct (BZ), in the infarct zone (IZ), and remote (RZ) from the infarct (D). Capillary density in border (BZ), infarct (IZ), and remote zone (RZ) (E). An unpaired Student’s t-test was used to determine significance between icmOga+/- and icmOga+/+groups.Gene expression of markers of cardiac hypertrophy 1 wk post-MI(A). Gravimetric analysis of heart size; heart weight to tibia length (B) Representative images of WGA and isolectin-stained icm(TIFF)Click here for additional data file.S4 FigBcl2 (A). Representative TUNEL-stained sections (B). Quantification of TUNEL positive cells (C). An unpaired Student’s t-test was used to determine significance between icmOga+/- and icmOga+/+groups.Gene expression of apoptosis marker (TIFF)Click here for additional data file.S5 Fig+/- mice. By 4 wk, the ejection fraction of the icmOga+/+ mice resembled that of the OGA-deficient mice (A). An unpaired Student’s t-test was used to determine significance between icmOga+/+ and icmOga+/- groups.A separate cohort of mice was subjected to extended observation after 1 wk MI. Cardiac function of the left ventricle was assessed at both 1 and 4 wk post-MI. Left ventricle Ejection fraction was significantly lower at 1 wk in the icmOga(TIFF)Click here for additional data file.S6 FigBcl2 (A). Representative TUNEL-stained sections (B). Quantification of TUNEL positive cells (C). An unpaired Student’s t-test was used to determine significance between icmOga+/- and icmOga+/+groups.Gene expression of apoptosis marker (TIFF)Click here for additional data file.S7 Figt-test was used to determine significance between NF and HF groups.Cardiac tissue from non-failing  and failing hearts  was used to assess the expression of overall O-GlcNAcylation. Western blot of protein O-GlcNAcylation (A) and subsequent densitometric analysis (B). An unpaired Student’s (TIFF)Click here for additional data file.S1 TableOga floxed and MCM mice.Primer sequences used for genotyping (TIFF)Click here for additional data file.S2 TablePrimer sequences used for RT-PCR.(TIFF)Click here for additional data file.S3 TableOga+/-  and their icmOga+/+  littermates treated with tamoxifen were subjected to echocardiography. Cardiac function of the left ventricle was assessed. Naïve icmOga+/- mice demonstrated a lower left ventricular ejection fraction (EF) compared to icmOga+/+ mice. No changes in left ventricular end-diastolic volume (EDV), left ventricular end-systolic volume (ESV), heart rate (HR), stroke volume (SV), cardiac output (CO), left ventricular inner systolic diameter (LVIDs), left ventricular inner diastolic diameter (LVIDd), fractional shortening (FS), left ventricular posterior wall thickness in diastole (LVPWd), left ventricular posterior wall thickness in systole (LVPWs), and left ventricular anterior wall thickness in diastole or systole . An unpaired Student’s t-test was used to determine significance between icmOga+/+ and icmOga+/- groups.Naïve, 10–18 wk-old male and female icm(TIFF)Click here for additional data file.S4 TableOga+/+ (n = 13) and icmOga+/- (n = 13) were subjected to echocardiography after 1 wk post-MI. Cardiac function of the left ventricle was assessed. No changes were observed in left ventricular end-diastolic volume (EDV), left ventricular end-systolic volume (ESV), ejection fraction (EF), heart rate (HR), stroke volume (SV), cardiac output (CO), left ventricular inner systolic diameter (LVIDs), left ventricular inner diastolic diameter (LVIDd), fractional shortening (FS), left ventricular posterior wall thickness in diastole (LVPWd), left ventricular posterior wall thickness in systole (LVPWs), and diastolic or systolic left ventricular anterior wall thickness in diastole or systole . An unpaired Student’s t-test was used to determine significance between icmOga+/+ and icmOga+/- groups.Tamoxifen-treated female icm(TIFF)Click here for additional data file.S5 TableOga+/+ (n = 9) and icmOga+/- (n = 7) were subjected to echocardiography after 4 wk post-MI. Cardiac function of the left ventricle was assessed. No changes were observed in left ventricular end-diastolic volume (EDV), left ventricular end-systolic volume (ESV), left ventricular ejection fraction (EF), heart rate (HR), stroke volume (SV), cardiac output (CO), left ventricular inner systolic diameter (LVIDs), left ventricular inner diastolic diameter (LVIDd), fractional shortening (FS), left ventricular posterior wall thickness in diastole (LVPWd), left ventricular posterior wall thickness in systole (LVPWs), and diastolic or systolic left ventricular anterior wall thickness in diastole or systole . An unpaired Student’s t-test was used to determine significance between icmOga+/+ and icmOga+/- groups.Tamoxifen-treated male icm(TIFF)Click here for additional data file.S6 TablePatient demographics of de-identified human samples. A chi-squared test was used to determined significance between NF and HF demographics.(TIFF)Click here for additional data file.S1 Raw images(PDF)Click here for additional data file.


However, it is technically challenging to acquire high-quality T1 and ECV maps in small animals for preclinical research because of high heart rates and high respiration rates. In this work, we developed an electrocardiogram (ECG)-less, free-breathing ECV mapping method using motion-resolved CMR Multitasking on a 9.4 T small animal CMR system. The feasibility of characterizing diffuse myocardial fibrosis was tested in a rat heart failure model with preserved ejection fraction (HFpEF).Extracellular volume fraction (ECV) quantification with cardiovascular magnetic resonance (CMR) T1 Multitasking scans before and after gadolinium injection, were performed on each rat. It allows a cardiac temporal resolution of 20 ms for a heart rate of ~ 300 bpm. Myocardial ECV was calculated from the hematocrit (HCT) and fitted T1 values of the myocardium and the blood pool. Masson's trichrome stain was used to measure the extent of fibrosis. Welch’s t-test was performed between control and HFpEF groups.High-salt fed rats diagnosed with HFpEF (n = 9) and control rats (n = 9) were imaged with the proposed ECV Multitasking technique. A 25-min exam, including two 4-min TP = 0.0010). A moderate correlation between the ECV and the extent of fibrosis was found .ECV was significantly higher in the HFpEF group (22.4% ± 2.5% vs. 18.0% ± 2.1%, Motion-resolved ECV Multitasking CMR can quantify ECV in the rat myocardium at high heart rates without ECG triggering or respiratory gating. Elevated ECV found in the HFpEF group is consistent with previous human studies and well correlated with histological data. This technique has the potential to be a viable imaging tool for myocardial tissue characterization in small animal models. Combinefibrosis –6.1 and ECV maps in small animals because of their high heart rates (often > 300 bpm) and high respiration rates (around 60 cpm). Therefore, CMR quantification of ECV is still not well established despite the important unmet needs in research. Several studies have been done to improve CMR T1 mapping and/or ECV measurement in small animals. Coolen et al. proposed a 3D T1 mapping method of the mouse heart using variable flip angle (VFA) analysis [1 inhomogeneity, and the long scan time (more than 20 min) makes it impractical to be used in pre- and post-Gd studies. Messroghli et al. acquired myocardial T1 and ECV maps in rats from a single (unsegmented) dataset using a small animal Look-Locker inversion recovery (SALLI) method [1 maps, and showed the feasibility to detect diffuse myocardial fibrosis, while the spatial resolution was limited due to signal-to-noise ratio (SNR) consideration. Segmented multi-shot FLASH methods were then proposed to acquired images with higher resolution [Rodent models are widely used in preclinical studies of myocardial diseases because of the short development period, availability of genetically modified disease models, and low cost. However, it is technically challenging to acquire high-quality Tanalysis . The met) method , 9. It wsolution , 11.In all previous studies with a Look-Locker scheme , 13, eleECV Multitasking) on a 9.4 T small animal CMR system. It allows continuous acquisition without ECG triggering or respiratory gating. The pre- and post-Gd data were acquired separately but reconstructed jointly, to allow image co-registration and direct ECV mapping. The feasibility of characterizing diffuse myocardial fibrosis was tested in a rat hypertensive heart failure model with preserved ejection fraction (HFpEF), which has been shown to have increased left ventricular (LV) interstitial fibrosis [In this study, we developed a ECG-less, free-breathing ECV mapping method using CMR Multitasking , 17  rats can develop hypertension followed by HFpEF on a high-salt diet , 19. In Control rats  and HS fed rats diagnosed with HFpEF  were imaged. Imaging experiments and all measurements were done between the age of 14 weeks and 15 weeks. After the imaging study, animals were euthanized, and the hearts were excised. Mid-ventricular heart tissues of the control rats (n = 9) and HFpEF rats (n = 9) were sectioned and stained with Masson’s trichrome staining.1 Multitasking sequence was implemented in Paravision 5.1 by modifying the built-in FLASH sequence.All CMR data were acquired on a 9.4 T preclinical system  using a single-channel volume coil. The TThe rat was anesthetized before the scan, and the tail vein was cannulated for later Gd injection within the scan. During the scan, anesthesia was maintained by ventilation with 1.5% isoflurane-oxygen. After the scan, hematocrit (HCT) level was measured for ECV calculation.1 Multitasking sequence [1 Multitasking sequence was repeated on the same slice using identical imaging parameters. The total exam time was ~ 25 min.Figure sequence   pulses) = 2.9 s. In each T1 Multitasking module, 85 IR preparation pulses were applied, resulting in a total scan time of 4 min 10 s.Imaging parameters were: matrix size = 128 × 128, FOV = 40 × 40 mm1 Multitasking sequence were reconstructed and analyzed jointly, as described in the following sections. The joint pre- and post-Gd reconstruction can improve respiratory and cardiac binning and promote image co-registration in native and post-Gd T1 fitting.Data acquired from pre- and post-Gd T1 recovery time 1 recovery temporal basis functions, respectively; Images from the proposed ECV Multitasking protocol are represented as a high-dimensional image eparable , i.e.1\ectively .Equation  permits  (HOSVD) , 27. Wit sensing .A detailed description of the basic image model and reconstruction scheme used in CMR Multitasking can be found in previous work , 17, 29.1 recovery process is modeled by Bloch simulations to determine 1 recovery curves were jointly simulated as shown in Fig. 1 recovery modeling is available in The inversion recovery (IR)-prepared Tentclass1pt{minima1 values ranging from 100 to 3000 ms  image was first generated for motion identification:The real-time temporal basis 1 recovery model in 1 recovery [Different time points of recovery .1 recovery index. A 4-way training data tensor After cardiac and respiratory binning, each readout time point was assigned three temporal indices: cardiac phase, respiratory phase, and T, fully determining After entclass1pt{minima1 and ECV map generation, corresponding to end-expiration and end-diastole respectively. A joint pre- and post-Gd T1 recovery model was also used in pixel-wise T1 fitting. By fitting this joint model . In each section, the extent of myocardial fibrosis was quantified by the percentage of total fibrosis area, which was calculated as the number of blue-stained pixels divided by the total number of pixels in the ventricular area  [Masson's trichrome staining was used to measure the extent of fibrosis. Mid-ventricular heart tissues were sectioned and stained following the manufacturer’s protocol . Quantitative histological analysis was done with ImageJ 1.52a  , 30. ForP < 0.05 was considered to be statistically significant. Statistical graphs were generated using GraphPad Prism 8  and Excel .Welch’s t-test was performed to compare ECV values between the control group and HFpEF group. The Pearson coefficient was measured to evaluate the correlation between ECV values and quantitative fibrosis percentages. A two-tailed value of 1 of the phantoms measured by RARE-VTR ranged from 333 to 2433 ms, with a corresponding R1 range from 0.41 to 3.00 s−1. Figure 1 values measured by Multitasking and RARE-VTR, in which a strong linear relationship can be found .The reference T1 recovery process, and (4) post-Gd T1 recovery process are also available in Additional file Five respiratory bins and ten cardiac bins were used for respiratory and cardiac binning, corresponding to a cardiac temporal resolution of 20 ms for a heart rate of ~ 300 bpm. Figure mentclass2pt{minim1 maps from the control group and heart failure with preserved ejection fractino (HFpEF) group. T1 maps were smooth and homogeneous within the left ventricular (LV) myocardium, except for areas in the inferior and lateral walls with imperfect fitting results  were 1662 ± 152 in the HFpEF group . Figure 1 fitting, because of the signal loss resulting from LV inflow in this single slice setup; and the septal myocardium areas selected for P = 0.0010, Fig. Figure 1 Multitasking sequence was run 10 min after the Gd injection, with identical imaging parameters. ECVs were also calculated using this separate post-Gd T1 measurement. Figure 1 (ECV15) and the 10-min post-Gd T1 (ECV10). The interclass correlation coefficient (ICC) was 0.817. The root-mean-square within-subject standard deviation was 1.4, yielding a coefficient of variation of 6.7%. There was no significant difference between ECV15 and ECV10 (P = 0.66).In eight rats (4 control + 4 HFpEF), an additional post-Gd TP < 0.001) Fig. R = 0.59, P = 0.0098).Figure 1 and ECV characterization of patients with HFpEF in recent years. Several publications showed elevated ECV in HFpEF patients versus control subjects. Su et al. reported that patients with HFpEF had elevated ECV compared with control subjects  [P < 0.01) [P < 0.001) [1 mapping in all of these studies. In the present study, ECV characterization was performed for the first time in a HFpEF rat model. The elevated ECV we found with HFpEF  is consistent with previous human studies. Though so far only tested in the DSS rat model for HFpEF diagnosis [We developed a novel ECV Multitasking protocol which can map ECV at high heart rates without ECG triggering or respiratory navigation. To test its feasibility to characterize diffuse myocardial fibrosis, a HFpEF rat model was chosen in this study. Although ECV has not previously been measured in a HFpEF rat model, there has been increasing clinical interest in T < 0.01) , and Mor< 0.001) . A modifiagnosis , this neiagnosis .1 values were 1534 ± 151 ms and ECV values were 18.0% ± 2.1% . Previous rodent studies have reported variable myocardial T1 values, depending on field strength and T1 encoding schemes, both of which are known to affect T1 estimates. At 7.0 T, T1 values were reported as 1620 ms  and 1638 ms  [1 values ranged from ~ 1200 ms to 1764 ms  [1 encoding scheme, allows more direct comparison. In healthy rats, myocardial ECV was previously reported as 16% [In the control group, native T et al.) , 32. At  et al.) , 34. ECVd as 16% , 18% [36d as 16% , and 15.1 recovery. This has two primary benefits. First, it allows the respiratory and cardiac binning to be done in the concatenated pre- and post-Gd data. In this way, the data with a similar motion state—no matter whether from pre-Gd or post-Gd—will be clustered into exactly the same respiratory or cardiac bin, removing the need for respiratory co-registration between pre- and post-Gd T1 maps. Second, it can improve the robustness of T1 fitting by constraining pre- and post-Gd images to share the same thermal equilibrium magnetization One major technical novelty of this work compared with previous CMR Multitasking work is the joint reconstruction of pre- and post-Gd data and the paired modeling of the pre- and post-Gd T1 fitting results showed a strong linear correlation with the RARE-VTR reference. If calibrated using the linear correlation  and slope (1.166) of the linear transformation The phantom study found that the Multitasking based TR = − 0.44, P = 0.06) was found between the septal SNR of the ECV map and the heart rate  treatment of HFpEF [Future work will include optimizing the number of cardiac bins, expanding spatial coverage with 3D volumetric imaging, as well as addressing Bof HFpEF .1 recovery model to generate ECV maps. Elevated ECV found in the HFpEF group agrees well with previous human studies and shows a moderate correlation with the histological data. This technique can serve as a viable CMR imaging tool for myocardial tissue characterization in small animal models.We developed an ECG-less, free-breathing CMR Multitasking ECV mapping method at high heart rates. The pre- and post-Gd data were concatenated and reconstructed using a joint TAdditional file 1: Page 1. The four videos show reconstructed results of (1) steady-state images from five respiratory bins, (2) steady-state images from ten cardiac bins, (3) native inversion recovery process, and (4) post-Gd inversion recovery, respectively. Page 2: The scatterplot between the SNR of the ECV map and the heart rate. The SNR was measured as mean/std of the ECV map within the septal area. A nearly-significant negative correlation  can be found between the SNR and the heart rate.


Right ventricular (RV) morphology and function is essential in the evaluation of different cardiac diseases. It has prognosis significance and influence everyday clinical decision making. Routine RV assessment is done by means of echocardiography. Visual estimation of RV morphology and function is normally performed, using RV function echocardiographic indexes only in selected populations. This approach may lead to inaccurate RV assessment especially in cases with mild RV dilatation/impairment. Cardiac magnetic resonance (CMR) has emerged as the gold standard for biventricular volume and function quantiphication.The aim of the study was to analyze in a clinical setting, the utility of CMR in the evaluation of RV morphology and function, comparing it to routine echocardiography examinations reports.96 patients with RV volume and function assessed with CRM were initially included. Reports form echocardiography performed to these patients were reviewed. Patients in whom the echocardiography was performed more than one year from the CRM study were excluded, as well as patients in whom specific echocardiography RV information was lacking. Study population consisted of 72 patients, mean age 48 years, men 55, 6%. Main indication for CRM study was as follows: viability assessment 7% dilated cardyomyopathy 11, 1% and right ventricular dysplasia evaluation 7%. All CMR exams were performed at 1,5 T  scanner. Breath-hold, electrocardiographically triggered steady state free precession cine images were acquired in four chamber long axis view and short axis view from base to apex. Cine images were analyzed with CMR tools . RV end diastolic, end systolic volume and ejection fraction were calculated using Simpson method. Volumes and ejection fraction were then classified as normal/abnormal in accordance to patient age and sex using published reference values. Based on echocardiography reports RV was considered dilated or not and RV ejection fraction normal or decreased in a binary manner. Statistical analysis was performed using SPSS program, version 12.72 patients were included. Mean RVEDV was 133,21 ml, RVESV 56,68 ml and RVEF 58,94. According to CRM 11, 1% patients had increased end diastolic RVV with 25% having increased end systolic RVV. Right ventricular dysfunction was present in 25%. Echocardiography studies described RV dilatation in 15, 5 patients and RV dysfunction in 5, 6% patients. Agreement index between both methods were 0,33  for RV volume and 0,19  for RV ejection fraction.Routine echocardiography evaluation of RV in different cardiac diseases compared to gold standard CRM lack accuracy. Thus, in cases where RV assessment is essential other echo Doppler indexes or CRM should be considered in order to provide accurate RV evaluation.


Advanced cardiovascular surgery in structural heart disease require accurate pre-operative evaluation. Most of non-invasive imaging technologies remain limited in two-dimensional and show insufficiency of visualization for procedural planning. The aim of this study was to discuss the value of patient-specific 3-dimensional (3D) printing in treatment of hypertrophic cardiomyopathy (HCM).Patient-specific 3D-printed models were constructed preoperatively in 12 consecutive HOCM patients which come to Beijing Anzhen Hospital for surgical treatment from October 2016 to March 2017. Image files were extracted from multi-slice computed tomography images, 3D models were constructed by the Mimics 19.0 software and generated by Objet350 Connex3 3D printer. The 3D-printed models were made with soft material that can be surgically performed. The modified Morrow myectomy of the model was performed before the operation. Clinical characters and echocardiographic parameters were recorded.There was no significant difference in tissue volume between the models and specimens. Preoperative and postoperative echocardiography showed the septal thickness was reduced from 18.8±4.5 mm to 12.7±3.3 mm (p<0.001), the left ventricular outflow tract obstruction was adequately relieved , and the SAM disappeared completely after the operation. Cardiac function was improved in all patients .The proposed optimal 3D-modelled septal myectomy allows intraoperative monitoring of the shape and volume of the myocardium resection to achieve the ‘ideal’ interventricular septum. It eliminates obstruction in the LVOT and SAM, resulting in LV remodeling with an increase in LV end-diastolic volume and diameter at early follow-up. Hypertrophic cardiomyopathy (HCM) is an inheritable cardiovascular disease characterized by unexplained left ventricular hypertrophy, left ventricular outflow tract (LVOT) obstruction, and systolic anterior motion (SAM) of the mitral valve, with a prevalence of approximately 1:500 in the general population.Three-dimensional (3D) printing is an emerging technology that has been widely used in the medical study. Previous studies had reported that, in cardiovascular fields, 3D-printed has been used for congenital heart disease.Twelve consecutive HOCM patients who came to Beijing Anzhen Hospital for surgical treatment from October 2016 to March 2017 were included in the study. All patients were diagnosed by echocardiography and CT scan. They were eligible for surgical procedure and met the following two criteria: (1) a LVOT gradient of ≥50 mmHg at rest or with physiological provocation; (2) unresponsive to maximum pharmacological therapy, including dyspnoea with New York Heart Association (NYHA) functional class II to IV. Patients who met the following criteria were not recommended to undergo operation: (1) aged more than 70 years (2) the presence of an additional risk for on-pump cardiac surgery, which may lead to early postoperative death. The study was approved by The Ethics Committee of Anzhen Hospital (No.AZ00305), and all patients signed informed consent.Each patient was scanned by 64-slice spiral computed tomography (CT) scanner  in the supine position. The scan settings were as follows: a voltage of 120 kV, a current of 180–220 mA, and a slice thickness of 1 mm. The CT scan data of the heart were saved as DICOM files. Multilayer images were input into Mimics 19.0  to perform region reconstruction for 3D image segmentation. The models were reconstructed by the printer. After cleaning and drying of the prototype, a 1:1 ratio left heart prototype was obtained . Detaile8The day before operation, the operating surgeon (Lai) performed myectomy on the 3D model. This was done in a laboratory operating room furnished with operating table and surgical lighting. Septal Myectomy of the 3D model was performed through the aorta. The 3-dimensional print before and after operative rehearsal, and its myectomy specimens from the actual myectomy specimen from same patient are shown in After a median incision with sternotomy, cardiopulmonary bypass was performed using ascending aortic cannulation and venae cava cannulation. Septal myectomy on patients was performed through a transverse aortotomy extended into the noncoronary sinus after cardiac asystole induced with cold crystalloid cardioplegia. The left-right sinus and right nonsinus commissures were elevated and retracted with 5-0 Prolene suture. Auxiliary light and loupe magnification were used to achieve better inspection of the left ventricular cavity. The resection ranges were as follows: The upper end was located below the aortic ring; the lower end was extended to the apex of the left ventricle; from the right side, the myectomy was started slightly rightward to the nadir of the right aortic cusp; and to the left, resection was terminated near the mitral anterior commissure.9A 25 mL glass graduated flask was filled with 15 mL of water and placed on the table. The part of resection from the 3D model were put into the flask and the fluctuation in level was recorded. The same graduated flask was used similarly to measure the volume of cardiac muscle resected from the patient the next day. Following operation, the 3D model and patient specimens were placed together and photographed for comparison. Since the resected 3D model and muscle specimens both sank to the bottom of the flask, the elevation in milliliters of the water level is nearly equal to the volume of the specimens regardless of any differences in density.10Echocardiography was rountinely performed before and after operation. The view below the xiphoid were used to measure LVOT velocity by continuous-wave Doppler. Peak gradients of LVOT velocity were computed by optimal spectral Doppler envelopes and velocities computed according to the formula 4V.2Clinical status was obtained through phone interview with patients or family members at least yearly six months after septal myectomy. Echocardiographic data were collected during the latest clinic visits.The baseline clinical variables of HOCM patients are shown in 3D print prototypes were used for left heart reshaping pre- and post- operation for all patients. Represent , 2 The lSeptal myectomy was performed in all patients. The mean weight of resected muscle sample was (7.9±3.8) g and the mean cross-clamp time is (80.2±32.2) min. Septal thickness and peak gradient were (12.7±3.3) mm and (8.7±6.5) mmHg, respectively. SAM disappeared in all patients, and mitral valve regurgitation was no or trivial in five cases and mild in one patient postoperatively. The volume of resected muscle and models were similar  Completeness of septal myectomy is of great importance and the key to surgery. Many imaging techniques, including echocardiography, computerized tomography (CT) and magnetic resonance imaging (MRI), can construct two-dimension structures of the heart. Recently, an emerging technology that allows better visualization of the spatial anatomical of organs in our body from 2-dimension to 3-dimension. This new technology makes cardiothoracic surgery step further, meanwhile providing cardiac surgeon a chance for patient-specific deliberate practice of septal myectomy. This technology advances allow surgeons to evaluate surgery more accurate, however, they are just a virtual 3 dimension. Operative rehearsals with patient-specific 3D models may instruct the young surgeon a preferred septal myectomy approach, and to avoid potential pitfalls.Previous studies had revealed that 3D printing technology can be used in congenital heart disease and aortic dissection. Shafkat et al., introduce four examples of complex congenital heart diseases using 3D technology.14We have reconstructed the 3D models of heart of HOCM patients.Mitral valvular and sub-valvular abnormalities are popular in this patient cohort and often aggravate LVOT obstruction,Although 3D models can print the structure of the heart of HCM patients, it can’t simulate the changes of haemodynamics. In future studies, we will try to construct the hydrodynamic model and combine the two models together to better guide the myectomy.This preliminary study is limited to only 12 HOCM patients. The 3D model in our study was reconstructed by the data derived from CT scan. The fine structures, such as chordal and mitral valve can’t simulate correctly because of lower resolution. In addition, the relationship of 3D models anatomy and hemodynamic results recorded by echocardiography will be investigated in our further study.Our investigation illustrates 3D-printed models derived from CT scans are feasible in patients with HOCM. The proposed optimal 3D-modelled septal myectomy allows intraoperative monitoring of the shape and volume of the myocardium resection to achieve the ‘ideal’ interventricular septum. It eliminates obstruction in the LVOT and SAM, resulting in LV remodeling with an increase in LV end-diastolic volume and diameter at early follow-up.YQ Lai; Conception and design. YQ Lai; Administrative support. YQ Lai, Y Wang; Provision of study materials or patients. HC Guo, KM Liu: Collection and assembly of data. YQ & YW: Are responsible and accountable for the accuracy or integrity of the work.