Remote monitoring and control of heart function are of primary importance for patient evaluation and management, especially in the modern era of precision medicine and personalized approach. Breaking technological developments have brought to the frontline a variety of smart wearable devices, such as smartwatches, chest patches/straps, or sensors integrated into clothing and footwear, which allow continuous and real-time recording of heart rate, facilitating the detection of cardiac arrhythmias. However, there is great diversity and significant differences in the type and quality of the information they provide, thus impairing their integration into daily clinical practice and the relevant familiarization of practicing physicians. This review will summarize the different types and dominant functions of cardiac smart wearables available in the market. Furthermore, we report the devices certified by official American and/or European authorities and the respective sources of evidence. Finally, we comment pertinent limitations and caveats as well as the potential answers that flow from the latest technological achievements and future perspectives. Heart rhythm disorders are dominant public health issues, affecting more than 2% of the adult population. Their incidence is comparable to that of other major cardiovascular diseases, such as stroke, acute myocardial infarction and non-ischemic cardiomyopathy , 2. CardAtrial fibrillation (AF) is the most common cardiac arrhythmia, affecting approximately 46.3 million people worldwide. According to recent studies, in 2017, 10 million Europeans were suffering from AF, while, in the United States the number of the patients is expected to rise from 6 to 16 million, by 2050 , accountOther rhythm disturbances, such as conduction disorders, bradyarrhythmias, supraventricular and ventricular tachycardias, induce significant morbidity and mortality, with related socioeconomic impact. These types of arrhythmias often result in patient hospitalization, while affected patients may experience severe symptoms, such as fatigue or syncope, as well as life-threatening events, or even sudden cardiac death .Based on the above, early detection of cardiac arrhythmias is of paramount importance, in order to improve patient management. Timely diagnosis allows the implementation of appropriate interventions, either pharmacological or interventional, in order to prevent adverse effects, reducing morbidity and mortality. In the recently issued guidelines for the management of AF, the European Society of Cardiology recommends opportunistic screening in individuals aged ≥65 years to detect asymptomatic AF . TraditiRecently, rapid technological advances have led to the development of wearables with built-in micro-detectors, that can provide real-time monitoring of the vital signs and heart rate. Such devices can detect cardiac arrhythmias , 15, witThe purpose of this review is to provide thorough insights into “smart” wearables, capable of cardiac rhythm monitoring, presenting the latest data derived from major clinical trials. The devices certified by the United States Food and Drug Administration (FDA), or CE-marked by the European Union authorities, are summarized, contributing to a comprehensive perception of the existing knowledge. Finally, legitimate concerns, based on literature evidence and future perspectives, are discussed, highlighting the limitations that need to be addressed and the aspects of potential development during the following years.The comprehensive review of the literature was achieved through screening of the Pubmed, Google Scholar and ClinicalTrials.gov databases from 1989 to January 2022, focusing mainly on articles published over the last decade. The searching procedure was based on several key terms regarding devices (“smart wearable devices” OR “smartwatches” OR “patches” OR “wristbands”) and heart conditions (“arrhythmia monitoring” OR “heart rhythm disorders” OR “cardiac diseases”), combined with Medical Subject Headings (MeSH). The first evaluation of the literature was based on the title and the abstract of each paper, while all the articles written in language other than English, or having included animal subjects, were dismissed. The reference section of the detected review articles was also probed and assessed, contributing to the overall selection of the literature. Finally, the Healthskouts Solutions Library for certified apps was used, as an additional source of certified smart wearable devices.Technological advancements have allowed heart rate sensors to be incorporated into numerous commercially available wearables. The spectrum of these devices ranges from smart accessories to sensors embedded into clothing and shoes. Patches, in particular, are leadless, wearable devices, that are attached to the patient's chest and provide ambulatory ECG monitoring over several days to weeks –21. FitnWearable devices rely on photoplethysmography (PPG) or single lead ECG tracings to detect heart rate. PPG is a non-invasive, optical technique that detects beat-to-beat alterations in the skin capillary bed volume . It utilThe accuracy of the various wearables to monitor heart rate and detect cardiac arrhythmias is highly dependent on both the type of the device and the method of detection in use. In general, PPG-based heart rate measurements from wrist-worn devices show high agreement with those derived from simultaneous ECG tracings , althougSmartwatches and wristbands are the most popular type of wearable devices, holding the dominant share of the global market, with a projected compound annual growth rate of 20% until 2026 . InevitaThe Apple Heart Study was one of the primary and most important studies regarding ambulatory ECG monitoring with the use of a wearable device . By recrRecently, The Fitbit Heart Study  demonstrFitbit and Apple smartwatches have also been compared with the standard ECG, concerning the accuracy of the PPG technology to estimate heart rate. Two studies that included 102 and 32 participants, respectively, recorded a total of more than 91,000 heart rate values and showed that both devices underestimate heart rate during AF, especially when a rapid ventricular response of 100 beats per minute or faster occurs , 60. In Many other companies have also launched smartwatches capable of heart rhythm detection, using either a PPG sensor or a combination of PPG and single-lead ECG. Two recent studies have shown high reliability of the AF detecting algorithms embedded into Samsung smart devices , 73. AccOther wearables are able to track dominant factors of cardiovascular function, associated with arrhythmia initiation and development, even though they do not feature specific AF detection algorithms. The E4 wristband and EmbracePlus smartwatch by Empatica, in particular, assess the heart rate variability, a measure of the autonomic nervous systems related to AF development , 84. SchWearable ECG patch monitors are appealing for AF detection, given their potential to store ECG tracings for a longer time, compared to conventional 24-h ECG Holter monitors. In general, patches provide an attractive alternative to conventional ambulatory Holter ECG monitoring for AF detection. They are easy to use and apply , less cuThe ZioPatch  is a leadless, adhesive cardiac monitor, that is placed on the anterior chest wall by a technician, or easily self-applied by the patient, to provide up to 14 days of continuous ECG monitoring . After tThe Carnation Ambulatory Monitor  is an adhesive patch monitor that is placed along the sternum for optimized P-wave capture. Improved P-wave clarity is associated with more accurate rhythm identification, compared to standard Holter monitoring . In a smThe Mobile Continuous Outpatient Telemetry (MCOT)  consists of a sensor, an adhesive patch and a monitor and can be used for medium-term heart rhythm monitoring. The sensor is attached on the patch, which is then placed on the patient's chest. Each patch lasts for approximately 5 days, before it is replaced by a new one, until the desired monitoring period is complete. The sensor captures a two-lead ECG tracing, using the patch embedded electrodes. Data are transmitted via Bluetooth to the monitor, which constantly analyses the ECG, using algorithms based on pre-specified criteria. If a heart rhythm disorder is detected, or the patient marks a symptom, the monitor instantly transmits the ECG tracing to the central monitoring station and the referring physician is notified . Thus, tThe CardioSTAT  is a single-lead device, worn on the upper chest to provide up to 14 days of heart rhythm monitoring through a lead I–like electrode configuration. In a validation study by Nault et al., the agreement between CardioSTAT and Holter monitor readings on AF detection was very high . In patiThe WiPatch sensors  are worn on the upper left part of the chest and record a two-lead ECG, for up to 72 h. Data are automatically transmitted to a connected mobile device and then uploaded to a cloud server for storage and analysis. Similar AF detection rates were reported in ambulatory patients monitored for 24 h, simultaneously by both a Holter ECG and a WiPatch .The VitalPatch  is another peel-and-stick device, capable of real-time heart rate monitoring. The device consists of a patch and a relay device (either a tablet or a phone). A single-lead ECG tracing is continuously recorded by a biosensor embedded in the patch, which is worn on the upper-left chest. Acquired data are transmitted to the relay device, analyzed and then sent to a central workstation. Apart from heart rate and single-lead ECG, VitalPatch also records data regarding heart rate variability, respiratory rate, body temperature and body motion, while it can also detect falls, providing a holistic telemonitoring of physiological measurements and body activity . RecentlThe integration of heart rate sensors into textiles and accessories has led to the development of a wide variety of devices, that can track heart rate and/or record ECG. Accessories, such as rings , 28, heaAlthough all the large-scale studies conducted on the use of smartwatches as diagnostic and monitoring tools focus on AF, data in the literature demonstrate their potential contribution to the detection of arrhythmias other than AF . The speBradyarrhythmias and tachyarrhythmias can be identified with the use of smartwatches . The AppApart from AF, patches that monitor heart rhythm can identify a series of other clinically significant arrhythmias, being a useful tool in the diagnostic work-up of patients with symptoms such as palpitations, syncope or presyncope. Supraventricular tachycardia was the most common rhythm disorder identified in a large cohort of individuals monitored with the ZioPatch , 52, as Among participants actively monitored in the mSToPS trial, the detection of significant pauses and high degree atrioventricular block, along with runs of non-sustained VT, resulted in increased rates of pacemaker and implantable defibrillator implantations . In compDespite the variety of benefits associated with wearable technology, several limitations have to be overcome in order to establish their role as medical devices for cardiac rhythm monitoring and diagnosis, in everyday clinical practice. Smartwatches and wristbands are practical and able to track heart rhythm during every possible physical activity, using a semi-continuous PPG sensor, with or without intermittent ECG tracings, when available. Consequently, they lack the ability of continuous rhythm monitoring and require the cooperation of the user in order to achieve a reliable recording and capture the required data . Due to On the other hand, wearable patches provide continuous rhythm recording during the application period, without requiring the active involvement of the user. Nonetheless, they manifest caveats that also restrict their applicability. Some patients may experience skin irritation, which is the most common adverse reaction of adhesive patch monitors , 63, 87.The integration of sensors into garments overcomes some of the drawbacks listed above, such as the need for the user to operate certain devices. On the other hand, incorporating electronics into fabric results in bulky, inflexible pieces of clothing. Moreover, the lifespan of smart clothing may be limited, affected by low durability and washing susceptibility.Most of the wearables that capture ECG tracings provide data equivalent only to one of the 12 leads of the traditional ECG, thus limiting their value in detecting more complex arrhythmias and cardiac disorders . FurtherWearable devices have evidence-based credentials that establish their role as a screening tool for the detection of cardiac arrhythmias, especially AF, affecting decision making in patient pharmacological treatment. However, the benefit derived from the initiation of anticoagulation, based on AF diagnosis by wearable devices screening, has not been confirmed. In fact, despite the increased diagnostic rate of AF episodes, in high-risk individuals, in the STROKESTOP trial , 118 andUndoubtedly, novel technologies bear the potential to shift the paradigm of disease diagnosis and patient management. The ideal wearable device for heart rhythm monitoring should be easy to use, even by the elderly and less familiarized patients, not interfere with daily activities and provide continuous and accurate real-time heart rhythm monitoring. Most commercially available wearables are capable of continuous monitoring for several days, providing they have sufficient power. Use of self-powered technology would, theoretically, allow for uninterrupted, extended use of cardiac monitoring devices . WearablFurther improvement of the diagnostic accuracy has the potential to transform wearables, such as smartwatches, from screening and pre-diagnostic tools to diagnostic modalities. The integration of artificial intelligence algorithms in basic medical tools, such as the 12-lead ECG, has demonstrated promising results, regarding the early and accurate detection of structural heart disorders, thus extending beyond the field of arrhythmia diagnosis , 122. ThAs wearable devices become more affordable and reach an increasingly number of consumers, a plethora of sensitive health data are anticipated to be generated. There is a clear necessity for an integrated system to collect and safely store personal information, in a way that will ensure users' privacy. Clear legal regulations, along with an ethical framework, under which personal data are collected and handled, are essential . Data prWearable devices are a new reality in monitoring and management of cardiac arrhythmias. Pertinent caveats, such as signal quality, connectivity issues, battery life limitations, sub-optimal diagnostic accuracy and data security and storage, need to be addressed, in order to enable their full utilization as medical devices. However, advanced technological developments contribute to rapid improvement and accomplishment of future intentions and are expected to establish the role of smart wearables as important tools in the emerging era of telehealth, remote patients' control, personalized and precision medicine.ST, AX, VS, DA, and PV: conception of the theme and design. AX and VS: data collection and preparation of the draft manuscript. ST: editing. ST and PV: final revision and supervision. All authors approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We aimed to evaluate the relationship between mitral annular disjunction (MAD) severity and myocardial interstitial fibrosis at the left ventricular (LV) base in patients with mitral valve prolapse (MVP), and to assess the association between severity of interstitial fibrosis and the occurrence of ventricular arrhythmic events.In MVP, MAD has been associated with myocardial replacement fibrosis and arrhythmia, but the importance of interstitial fibrosis remains unknown.In this retrospective study, 30 patients with MVP and MAD (MVP–MAD) underwent cardiovascular magnetic resonance (CMR) with assessment of MAD length, late gadolinium enhancement (LGE), and basal segments myocardial extracellular volume (ECVsyn). The control group included 14 patients with mitral regurgitation (MR) but no MAD (MR-NoMAD) and 10 patients with normal CMR (NoMR-NoMAD). Fifteen MVP–MAD patients underwent 24 h-Holter monitoring.LGE was observed in 47% of MVP–MAD patients and was absent in all controls. ECVsyn was higher in MVP–MAD , even in MVP–MAD patients without LGE . MAD length correlated with ECVsyn , but not with LGE extent. Four patients had history of out-of-hospital cardiac arrest; LGE and ECVsyn were equally performant to identify those high-risk patients, area under the receiver operating characteristic (ROC) curve 0.81 vs 0.83, p = 0.84). Among patients with Holter, 87% had complex ventricular arrhythmia. ECVsyn was above the cut-off value in all while only 53% had LGE.Increase in ECVsyn, a marker of interstitial fibrosis, occurs in MVP–MAD even in the absence of LGE, and was correlated with MAD length and increased risk of out-of-hospital cardiac arrest. ECV should be includedin the CMR examination of MVP patients in an effort to better assess fibrous remodelling as it may provide additional value beyond the assessment of LGE in the arrhythmic risk stratification.The online version contains supplementary material available at 10.1186/s12968-021-00797-2. With a prevalence of about 2% in the western population, mitral valve prolapse (MVP) is a relatively common condition, associated with a good overall prognosis –3. HowevMyocardial extracellular volume (ECV) quantification by T1 mapping has emerged as an accurate tool to detect ECV expansion, a quantitative marker of diffuse myocardial fibrosis in ischemic and non-ischemic cardiomyopathies , 14. MosHerein, we aimed to evaluate the relationship between MAD severity and myocardial interstitial fibrosis at the LV base quantified by T1 mapping in patients with bileaflet MVP. In addition, we sought to assess the association between a history of out-of-hospital cardiac arrest (OHCA) and the extent of interstitial myocardial fibrosis, as well as the relation between myocardial fibrosis and the occurrence of VA on holter monitoring in MVP patients.From the CMR registry of the Lausanne University Hospital, we retrospectively included patients with a bileaflet MVP and MAD between January 2011 and October 2019. MVP was defined as a systolic excursion of the mitral leaflets > 2 mm behind the mitral annular plane in the long axis view, i.e. a displacement of > 2 mm into the left atrium (LA) . MAD wasElectrocardiogram (ECG)-gated CMR imaging was performed using a 1.5T CMR system  with a 32-channel phased-array surface receiver coil. Cine images were acquired using a breath-hold balanced steady-state free precession sequence (bSSFP) in long-axis  and short-axis views . Breath-hold ECG-triggered phase contrast velocity sequences for ascending aortic flow evaluation were acquired to estimate the aortic forward flow and calculate the regurgitation fraction. For pre-contrast T1 mapping, we used the ECG-triggered modified Look-Locker inversion recovery (MOLLI) sequence (using the scheme 3(3)3(3)5) on a single short-axis basal LV slice. The basal slice was defined as the slice position of the most basal cine bSSFP slice, where a complete ring of myocardium was visible throughout diastole and systole. Ten minutes after the administration of a 0.2 mmol/kg intravenous bolus of Gadobutrol , LGE images were acquired using a 2D breath-hold phase-sensitive segmented inversion-recovery gradient echo pulse sequence in the same orientations as cine images. Inversion-time was individually optimized to null normal myocardium. Post-contrast T1-mapping was acquired following LGE imaging  using a MOLLI sequence (4(1)3(1)2 scheme). As previously reported in literature , pre andAll CMR examinations were analyzed blinded to clinical characteristics and outcome using the Syngo.via software  to calculate LV volumes, LV mass and LVEF by delineating endocardial and epicardial borders in the stack of short-axis cine images. The presence of myocardial LGE was visually evaluated and its extent was semi-quantitatively reported according to the American Heart Association 17 segments model . In the Pre- and post-contrast T1 mapping images were first visually reviewed to assess quality, and myocardial T1 relaxation times were then measured using the GTVolume software . After manual tracing of the endocardial and epicardial borders, the basal slice of the LV was automatically divided into 6 equal segments and the mean T1 relaxation time was calculated for each segment   at the basal LV myocardium and the length of MAD in MVP patients with and without a recent history of unexplained resuscitated OHCA. As a secondary objective, we assessed the relation between the severity of myocardial fibrosis and the incidence of PVC and of complex PVC (grade 4 or 5 according to Lown classification) in a subgroup of 15 patients with suspected arrhythmic MVP, who performed a 24 h Holter monitoring.2 test. Correlation analysis was performed using Spearman’s correlation. Receiver operating characteristic (ROC) analysis was used to determine the optimal cut-off value of selected CMR parameters (LGE and ECVsyn) associated with arrhythmic endpoints. Considering the inhomogeneous distribution of pre-contrast T1 relaxation times and ECVsyn, with the highest values typically located in the inferior and inferolateral region , the average values of the basal inferior and inferolateral segments were used for association analyses with arrhythmic endpoints.Continuous variables were expressed as mean ± SD or median [interquartile range] where appropriate, and categorical variables as numbers and percentages  respectively. Gaussian distribution was determined with the skewness and kurtosis test for normality. Differences in continuous variables between two groups were analysed with the independent-sample Student’s t test in case of normal distribution or the Mann–Whitney test in case of non-normal distribution. Comparisons between three groups were performed by ANOVA with post-hoc Bonferroni correction. Comparison of categorical variables was performed with the χReproducibility analyses for the measurement of myocardial pre-contrast T1 and ECVsyn were performed using Pearson’s correlation and Bland–Altman statistics. All statistical analyses were performed using STATA 16.0 . A p < 0.05 was considered statistically significant.A total of 38 patients with MVP and MAD were identified. Five patients with complex congenital heart disease and 3 patients who already underwent mitral valve repair were excluded leaving 30 patients in the MVP–MAD group. Thirty-eight patients with various degrees of MR detected by echocardiography and without MAD where selected as controls. Four patients were excluded because of poor image quality, 6 patients because of previous myocardial infarction and 4 patients because of myocarditis. Among the remaining 24 patients, 14 had mild to severe MR (MR-no MAD) and 10 had no or only a trace MR (no MR-no MAD).2 vs 81 ± 17 ml/m2, p = 0.018, and vs 82 ± 16 ml/m2, p = 0.048 respectively), but there was similar LVEF (Table Mean age was 50 ± 19 years and similar across the three groups (p = 0.82), and 43% were females. LV end-diastolic volume index was higher in the MVP–MAD group than in the MR-No MAD and the No MR–No MAD groups , moderate in 14 (36%) and severe in 4 (14%) patients.LGE was present in 14 MVP–MAD patients (47%) and was absent in the two other groups. In LGE-positive patients, the median LGE extent was 3 [3–4] segments, and LGE was most frequently detected in the basal to mid-ventricular inferior and inferolateral walls  compared with the anterior and antero-lateral walls  and the antero-septal and infero-septal walls   and No MR-No MAD   and No MR-No MAD   or between MAD length and pre-contrast native T1  but a moderate to high correlation was found between MAD length and ECVsyn  Fig. .Fig. 5ReAmong the 27 MVP–MAD patients with echocardiographic quantification of MR severity, no significant difference was observed among the three MR severity grades for MAD length , LGE extent , T1 relaxation time  and ECVsyn .Among the 30 MVP–MAD patients, 4 (13%) were referred for evaluation following OHCA. None of the patients had evidence of coronary heart disease on coronary angiogram. The clinical characteristics of the 4 patients with history of OHCA are presented in Table Of note, MR was mild in 3 and moderate in one OHCA patient. The mean MR severity grade in OHCA tended to be lower than in patients with no previous OHCA , but the difference was not significant.The baseline characteristics of the 15 patients investigated with a Holter monitoring are presented in Table Intra-observer  and inter-observer  reproducibility for pre-contrast T1 relaxation time was good. Both intra-observer  and inter-observer  reproducibility were excellent for ECVsyn calculation  MVP–MAD patients had a higher ECVsyn indicative of a higher amount of interstitial fibrosis even in the absence of detectable LGE, (2) MAD length was best associated with a higher ECVsyn but not with a higher native T1 or LGE extent, and (3) the presence of LGE and a basal posterior ECVsyn > 33.5% identified MVP–MAD patients with history of OHCA with similar accuracy.MVP is a relatively frequent clinical condition with a good overall prognosis. However, VA and SCD may occur with an incidence of 0.2% to 0.4% per year in this population , 9, 26. In patients with MVP and MAD, increasing evidence supports an association between prolapse severity, curling motion of the basal posterior myocardium and structural changes of the myocardium. The continuous mechanical stretch applied by the MVP has been suggested to induce a fibrotic remodelling of the basal inferior LV wall and the papillary muscles , 38, wheThe association between MVP and interstitial fibrosis, and its relation to VA has seldom been investigated. In a series published by Pradella et al. patients with MVP had higher native and lower post-contrast T1 myocardial values, but no association with complex VA was found . Bui et Given the retrospective nature of the study, synthetic haematocrit was used to calculate the ECV, as previously described in literature , 40, 41.The present study has several limitations. First, it is an observational, retrospective study, including a limited number of patients. Although our population was comparable in terms of arrhythmic MVP. Complex arrhythmia were detected in almost all of them, an evidence of a likely selection bias toward higher arrhythmic risk. Fourth, although we used high resolution bright-blood LGE-CMR and images were interpreted by expert operators, routine evaluation of the presence of fibrosis in the papillary muscles area could prove challenging in routine and was not part of our analysis. Fifth, MR severity was not systematically evaluated during CMR examinations and we cannot assess the influence of MR severity on risk prediction. Sixth, no histologic confirmation of interstitial or replacement fibrosis could be obtained and all our results are based on indirect CMR markers of myocardial fibrosis. Finally, patients underwent to CMR examination in two different scanners (Siemens Aera and Siemens Sola); however local calibration of synthetic haematocrit was performed for both scanners, aim at to obtaining a reliable estimation of the synthetic haematocrit and ECVsyn.In patients with MVP–MAD, remodelling of the LV occurs and both focal replacement and interstitial myocardial fibrosis can be detected by CMR. Compared to LGE extent, ECVsyn of the basal LV segments had a stronger association with MAD severity, and a similar association with OHCA. Our data suggest that ECVsyn should be part of the CMR examination of MVP patients in an effort to better assess fibrous remodelling as it may provide additional value beyond the assessment of LGE in the arrhythmic risk stratification.Additional file 1: Figure S1.  Relationship between haematocrit (%) and R1 blood pool (msec−1) in the two scanners used in the study .


Furthermore, COPD patients had more impaired LA strain (LAS) than non-COPD patients in all cardiac cycle phases (estimated mean differences after adjusting for LVEF and age: during reservoir phase: −7.5% (p < 0.001); conduit phase: 5.5% (p < 0.001); contraction phase: 1.9% (p = 0.034)). There were no correlations between PFT variables and strain values. In conclusion, the presence of COPD was associated with more impaired LV and LA functions after AMI, as detected by strain analysis, which was independent of age, LVEF, and PFT variables.Myocardial strain analysis, which describes myocardial deformation (shortening or lengthening), provides more detailed information about left ventricular (LV) and atrial (LA) functions than conventional echocardiography and delivers prognostic information. To analyze the effects of COPD on left heart function upon acute myocardial infarction (AMI), consecutive AMI patients were retrospectively screened, and patients were included if a post-AMI echocardiography and results of recent pulmonary function tests (PFTs) were available. Strain analysis was performed by a cardiologist who was blinded to clinical information. Overall, 109 AMI patients were included . COPD patients (41%) had significantly more impaired LV “global-longitudinal-strain” (LV-GLS) compared to non-COPD patients (−15 ± 4% vs. −18 ± 4%;  Chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) represent major causes of mortality worldwide, and the combination of both diseases is particularly unfavorable in terms of prognosis ,2. BesidThe protocol for this retrospective study was approved by the local ethics committee , and the study was performed in accordance with the ethical standards laid down in the Declaration of Helsinki in its latest revision. Due to the retrospective study design, the requirement for informed consent to participate has been waived by the local ethics committee.All patients admitted to our institution due to AMI between January 2015 and December 2019 were retrospectively screened for eligibility .Patients were only included if results of current or recent (not older than six months prior to AMI) pulmonary function test (PFTs) and a post-AMI transthoracic echocardiography with an adequate image quality were available. Demographic data, disease history, coexisting medical conditions, smoking, and medication history were retrieved for all patients. Patients’ data were retrieved from the patient data management system .Echocardiography was performed by primary investigators with commercially available ultrasound systems . Standardized echocardiographic measurements were obtained by primary investigators in accordance with the guidelines of the EACVI (European Association of Cardiovascular Imaging) and ASE (American Society of Echocardiography). LVEF was measured in 4 chamber and 2 chamber views by Simpson’s method of discs.Whole-body plethysmography  was performed by primary investigators before and after bronchodilation according to current guidelines and recommendations ,20,21. SAt the time of analysis, patients were stratified into the two following subgroups: the presence of COPD versus no COPD, according to the GOLD criteria . Strain -LASr = strain during reservoir phase, measured as the strain value from the ventricular end-diastole to the mitral valve opening at ventricular end-systole .-LAScd = strain during conduit phase, measured as the strain value from the mitral valve opening to the onset of atrial contraction . In patients with atrial fibrillation, LAScd has the same value as LASr, but with a negative sign.-LASct = strain during contraction phase, measured only in patients in sinus rhythm as the strain value from the onset of atrial contraction to ventricular end-diastole .LAS values were measured as recommended by the “EACVI/ASE/Industry Task Force” in apical 4-and 2-chamber views and were reported separately for the three phases of LA cycle: reservoir, conduit, and contraction phase E,F 24]::24]:-LAShttps://www.R-project.org/ (accessed on 9 February 2022); version 3.5.2).Data were summarized using absolute frequencies, percentages, means, standard deviations, and quartiles within the study sample and for patients with and without COPD. Data entry errors were identified with the help of plotting each variable and identifying outliers. Groups were compared using the Kruskal–Wallis rank sum test and Pearson chi-squared test. Pearson correlation coefficients were calculated to measure the strength of linear associations. Differences in mean strain values between COPD/non-COPD groups were estimated using linear models  with and without adjustment for LVEF, age, and when measurable for maximum tricuspid regurgitation velocity, which was measured as a surrogate for pulmonary artery pressure. Along with the parameter estimates, 95% confidence intervals were calculated. The R software for statistical computing was used for calculations (R Core Team (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL p = 0.05, respectively). Regarding the type of AMI (STEMI vs. NSTEMI), an 11 percentage point difference between patients with and without COPD was not statistically significant . Furthermore, patients with and without COPD did not differ in terms of additional co-morbidities, including atrial fibrillation, whereas—as expected—there were significant differences with respect to PFT variables. Additional demographic data, co-morbidities, and medications at admission are described in A total of 184 AMI patients who had results of current/recent PFTs were screened for eligibility , of whomp = 0.01,). Furthermore, COPD patients had significantly more impaired LV-GLS values compared to patients without COPD , (estimated differences in means between patients with and without COPD for LV-GLS 3.8% (standard error (SE) = 0.9), p < 0.001)  .p = 0.003), after adjusting for LVEF and age    and afte= 0.009) . Among p= 0.009) .p = 0.03; left atrial volume index (LAVI): 32 ± 14 vs. 25 ± 9 mL/m2, p = 0.01; respectively) (p < 0.001); LAScd 7% ; LASct 3% )  , along w 0.002)) .p < 0.001), LAScd 6% , LASct 2% ; estimated differences in means between patients with and without COPD after adjusting for LVEF and age: LASr −7.5% , LAScd 5.5% , LASct 1.9%  (The difference in LAS between patients with and without COPD remained significant even after adjusting for LVEF and age : estimat= 0.034) .By analyzing the relationship between PFT variables and strain values, there were no significant correlations.The present study showed that COPD is associated with more impaired left ventricular and left atrial deformation after AMI as measured by strain analysis. These abnormalities could be missed when LV function is only quantified by LVEF, as the differences in strain values between both groups were significantly different even after adjustment for LVEF and age. Conversely, pulmonary function test variables did not correlate with strain values in either group (COPD and non-COPD). It is possible that COPD-related burdens other than mechanical effects could influence left cardiac function after AMI.The presence of COPD is known to worsen short- and long-term outcomes as well as prognosis after AMI ,25. OutcChanges in intrathoracic volume and pressure could serve as a potential explanation for the association between COPD and left heart dysfunction after AMI. However, in our study, there were no correlations between PFT variables and LV and LA strain values. Neither dynamic nor static lung volumes correlated with strain values, and parameters of hyperinflation also showed no correlations with LV or LA strain values. Overall, the pathophysiologic mechanisms of COPD-related myocardial dysfunction are still unclear and it is likely that multiple mechanisms are involved, including cardiomyocyte dysfunction due to low-grade inflammation or oxidative stress as well as enhanced LV remodeling and fibrosis ,31,32, wOne limitation of our study is the lack of follow-up data. This would be very interesting, and future studies are needed to define risk groups based on cardiac strain analysis in COPD patients after AMI. This might help to optimize the treatment of both CAD and COPD. Another limitation is that 41% of patients were excluded because echocardiograms were not available after AMI or because the echocardiographic image quality was inadequate. However, previous studies have reported that up to 28% of echocardiograms are not suitable for LV-GLS analysis . The higCOPD is associated with more impaired left ventricular and left atrial functions after AMI, as detected by LV global longitudinal strain and LA strain analyses. These abnormalities could not be explained by impaired lung volumes and might be due to other pathophysiologic mechanisms of the systemic disease COPD.


Mortality in infarct-related cardiogenic shock (CS) remains high, reaching 40–50%. In refractory CS, active mechanical circulatory support devices including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are rapidly evolving. However, supporting evidence of VA-ECMO therapy in infarct-related CS is low. The current review aims to give an overview on the basics of VA-ECMO therapy, current evidence, ongoing trials, patient selection and potential complications. Cardiogenic shock (CS) is the leading cause of death in hospitalized patients with acute myocardial infarction (AMI) . Up to 1Next to percutaneous LV assist devices, veno-arterial extracorporeal membrane oxygenation (ECMO), also called extracorporeal life support (ECLS), is the major representative of mechanical circulatory support in CS. Compared to other mechanical circulatory support devices, VA-ECMO is able to give full hemodynamic and respiratory support. With 80% of all cases, CS is the leading entity for VA-ECMO use. Particularly between 2010 and 2015, its use increased exponentially . In addiThe detailed structure of ECMO devices vary between manufacturers. Basically, the VA-ECMO system contains of (1) an inflow cannula transporting blood from a central vein to the pump, (2) a pump with, today almost always, centrifugal flow to keep hemolysis to a minimum, (3) a membrane oxygenator able to fully undertake oxygenation and decarboxylation of the blood, (4) a blood warmer, and (5) an outflow cannula leading to a central artery . The devDespite the steadily increasing use, available evidence of VA-ECMO in AMI-CS is low and guideline recommendations are relatively weak. European heart failure guidelines recommend a short-term percutaneous mechanical circulatory support in selected patients with refractory CS  . Americap = 0.0008) [®, Abiomed, Danvers, MA, USA). These showed no mortality benefit for VA-ECMO .Outcome data on VA-ECMO in AMI-CS are mostly reduced to non-randomized trials. Sattler et al. showed in a very small retrospective single-center study in AMI-CS patients a higher number of survivors with VA-ECMO at short-term follow-up compared to patients without VA-ECMO . In anot 0.0008) . Howeverp = 0.86). Furthermore, there was no difference with respect to secondary endpoints such as all-cause mortality , stroke or bleeding. When comparing only in-hospital survivors, VA-ECMO therapy was associated with a longer intensive care unit stay and duration of mechanical ventilation. However, considering the comparatively low overall mortality and a median LV ejection fraction of 50% after 30 days, the severity of CS in the included patients may have been only modest. Further limitations include a higher number of diseased coronary vessels in the control group, which is known to be an independent predictor of worse outcome in CS [The only available randomized trial on VA-ECMO in AMI-CS available to date included just 42 patients randomized in a 1:1 fashion to VA-ECMO or medical therapy only, in addition to revascularization . The majme in CS ,14.Currently, three large randomized trials (RCT) are evaluating the use of VA-ECMO in AMI-CS . Detailed characterizations of the three trials are displayed in Patients with CS due to mechanical complications of AMI play a special role in VA-ECMO therapy. In these, VA-ECMO might be used as an option for bridging to surgical or interventional therapy, which is often performed after an interval of one week or longer. Again, there is little evidence. In contrast to the European heart failure guidelines, guidelines in acute coronary syndromes recommend short-term mechanical circulatory support with a class of recommendation IIb, level of evidence C for ventricular septal rupture and refractory CS . A recenVA-ECMO therapy is an invasive treatment strategy frequently associated with complications, which can lead to worse outcomes, and is further described in the chapter below. The use of VA-ECMO is by no means a guarantee of favorable outcome. Short-term survival of AMI-CS treated with VA-ECMO reaches 25–45% in registries ,17.Patient selection is therefore of high importance until further evidence is available.Absolute contraindications are rare. In AMI-CS patients with non-corrected aortic dissection, severe aortic regurgitation or uncontrolled bleeding constituting a contraindication for parenteral anticoagulation VA-ECMO should be avoided. VA-ECMO therapy in elderly patients is associated with higher mortality and should therefore be carefully evaluated. A small retrospective analysis of VA-ECMO in AMI-CS showed that mortality reached 80% in patients older than 60 years .In general, VA-ECMO should not be used in cases where acute or chronic conditions make the recovery unlikely, as well as when the therapy cannot lead to a next step in patient care .Different scores were developed to assess CS severity and to support future identification of potentially suitable patients for mechanical circulatory support  ,20. SincNext to general AMI-CS risk models, prediction scores derived from CS cohorts treated with VA-ECMO due to refractory shock were developed ,24. WithThe Society for Cardiovascular Angiography and Intervention (SCAI) introduced an expert consensus classification system not based on a numerical score but on different CS stages mainly depicted by clinical presentation and with a dynamic assessment over time . The posHowever, in the near future, no score will be able to satisfactorily guide clinical decisions. This applies in particular for the prediction of futility, which is gaining increasing importance against the background of ethical and economic considerations.Retrospective analyses recently indicated that the timing of VA-ECMO therapy might influence outcomes. Lee et al. showed in a multicenter registry covering 362 patients with VA-ECMO for refractory CS that all-cause mortality at 30 days was lower in the group of patients with early VA-ECMO initiation compared to those with late VA-ECMO treatment in a weighted Cox model  . Early Vp = 0.045) [Although early revascularization is the central pillar of AMI-CS treatment, a retrospective single-center study by Choi et al. indicated a superiority of VA-ECMO initiation prior to revascularization: In a total of 147 patients, 50 patients received VA-ECMO prior to revascularization as opposed to 97 patients after revascularization. The primary endpoints of in-hospital mortality, LV assist device implantation and heart transplantation occurred significantly less frequently in the group with VA-ECMO before revascularization  .However, the evidence regarding the timing of VA-ECMO is still low considering the retrospective design of the studies and a high risk of bias, especially in the study of Choi et al. Of the ongoing RCTs, VA-ECMO-SHOCK intends VA-ECMO insertion prior to PCI and EURO-SHOCK 30 min after revascularization in cases of ongoing refractory CS.Evidence-based recommendations on intensive care therapy during VA-ECMO treatment are scarce.For optimal hemodynamic assessment and monitoring, the placement of a pulmonary artery catheter (PAC) becomes of reappearing interest after its use in CS has declined to less than 10% . There aHigher levels of pharmacological hemodynamic support were associated with higher mortality in observational studies in CS . TherefoThe large majority of patients on VA-ECMO are mechanically ventilated due to respiratory insufficiency following AMI-CS. Positive end-expiratory pressure reduces right and left ventricular afterload. Hypoxic pulmonary vasoconstriction might be reduced following better oxygenation. However, invasive ventilation, especially using high pressures, is associated with lung injuries and infections. As VA-ECMO is able to assure sufficient gas exchange, mechanical ventilation should be performed as lung protective as possible during VA-ECMO.The need for renal replacement therapy (RRT) is frequent in patients with VA-ECMO, with up to 85% of cases with fluid overload being the common reported indication ,41. Currp = 0.006; Shin et al.: OR for mortality or significant neurologic deficit at discharge, 0.17, 95% CI 0.04–0.68; p = 0.012) in in-hospital cardiac arrest [eCPR has a separate role in VA-ECMO therapy. The primary goal is to establish systemic perfusion in refractory cardiac arrest to diagnose and possibly treat the underlying cause. The most common cause of out-of-hospital cardiac arrest remains acute myocardial infarction . Thus, ac arrest ,45. Howec arrest . Afterwac arrest . The tric arrest . SeveralWhile full biventricular and respiratory support are appealing for bridge to recovery or device/transplant, complications rates of VA-ECMO are still high.-Bleeding-Clotting-Hemolysis-Limb ischemia-Inadequate LV unloading-Harlequin syndrome-InfectionThe most frequent include:Bleeding and thrombotic complications are closely related, and hemostatic balance is a major challenge of VA-ECMO treatment. VA-ECMO therapy requires continuous anticoagulation. There are no specific guidelines on anticoagulation regimens due to a lack of evidence. Usually, unfractionated heparin is used; alternatively, low molecular weight heparins or argatroban. With unfractionated heparin, an activated partial thromboplastin time of 1.5 times above the upper limit is often aimed for. Anticoagulation is necessary to prevent thrombus formation in the oxygenator and subsequent thromboembolic complications to the large foreign surface, which can have disastrous consequences due to the involvement of the central venous and arterial system. Relevant clot formation in the VA-ECMO circuit is described in about 10% of cases, thrombotic stroke less frequently with 4–7% of VA-ECMO cases [p < 0.0001).Anticoagulation, in turn, increases the risk of bleeding, which is already elevated as a consequence of the consumption of clotting factors because of the large synthetic surface, endothelial injury and shear stress in the extracorporeal circuit. The usually necessary administration of transfusion of blood components leads to immunological responses, which can further increase the bleeding tendency . With neHemolysis in ECMO patients is common due to an increased shear stress in the circuit. In most cases, the manifestation is low level, especially since the wide-spread use of centrifugal pumps. However, in cases of risk factors, such as the insufficient flow in the outflow cannula leading to a rise in the negative pump head pressure, necessity of a high blood flow, or development of pump head thrombosis, severe hemolysis can occur and is reported in up to 5% of patients . Lyu et Limb ischemia occurs almost exclusively in patients with peripheral VA-ECMO cannulation in about 3.6% of patients . Therefop < 0.001) [Ventricular unloading under VA-ECMO therapy has come more and more into focus in recent years. Findings suggest that due to the return of blood to the aorta, the afterload of the LV might increase . This ma< 0.001) .Different techniques for venting of the LV have been established. These should be considered in situations outlined in ®, Abiomed, Danvers, MA, USA). The pump is placed through a femoral or axillary artery and provides unloading by pumping blood from the LV into the ascending aorta.The so called ‘ECMELLA’ (or ‘ECPELLA’) strategy describes a situation where VA-ECMO is combined with an LV microaxial flow pump (Impellap = 0.03) despite a higher rate of severe bleeding , hemolysis (33.6% vs. 22.4%), interventions due to access site-related ischemia (21.6% vs. 12.3%), abdominal compartment syndrome (9.4% vs. 3.7%) and the need for renal replacement therapy (58.5% vs. 39.1%) [Retrospective studies showed a survival benefit in patients with this venting strategy compared to patients with VA-ECMO only. The largest propensity-matched study of Schrage et al., analyzed a total of 510 patients from four multinational tertiary care centers and showed an association with lower 30-day mortality of ECMELLA compared to VA-ECMO alone  .p < 0.001), although a higher reduction in mortality for preload targeting venting strategies was displayed [In animal and human in vivo studies, the use of intra-aortic balloon counterpulsation (IABP) showed a significant decreased LV afterload and PCWP . A recenisplayed .Further strategies to enhance LV unloading include a pigtail catheter from the LV to the venous ECMO cannula and surgical cannulation of the LV through the apex or percutaneous balloon atrial septostomy. However, these are rarely used in clinical routine. Recent animal data could confirm the advantage of atrial septostomy on hemodynamics .® venting. EARLY-UNLOAD (NCT04775472) is recruiting 116 patients to compare early left atrial septostomy with selective septostomy.To date, no RCTs of LV unloading in VA-ECMO therapy are available to support a selective or routine use. Currently, two RCTs are being conducted: REVERSE (NCT03431467) aims to randomize a total of 96 patients to either VA-ECMO alone or VA-ECMO with early Impella CPThe Harlequin syndrome describes a condition in which, in the event of severely restricted gas exchange in the lungs, insufficiently oxygenated blood enters the coronaries and the upper half of the body via the first branches of the aorta. It occurs exclusively in cases of retrograde aortic blood return . As a consequence of this watershed phenomenon, the risk of myocardial and cerebral hypoxia is increased, especially when the LV starts recovering. Close clinical monitoring and blood samples from the right radial artery are imperative. In the case of suspected Harlequin syndrome, mechanical ventilation should be optimized and the setting of VA-ECMO cannulation should be adapted in case of ongoing differential hypoxia by the implementation of VAV-ECMO or central aortic cannulation to provide antegrade flow .Once hemodynamic and rhythmic stabilization has been achieved, gradual weaning of VA-ECMO should be considered.Prior to this, euvolemia should be achieved and echocardiography performed to ensure that the patient’s own cardiac output is adequate. In a small retrospective analysis covering a total of 51 patients with different causes of CS, higher arterial systolic and pulse pressures, aortic VTI (≥10 cm), LVEF (<20–25%), and lateral mitral annulus peak systolic velocity  were found to be positively predictive of successful weaning . FurtherLiberation from VA-ECMO can be performed either by a stepwise flow reduction , or, alternatively, a liberation trial can be implemented with flow reduction in three steps . After 30 min of the respective step, predefined hemodynamic, respiratory, catecholamine and lactate targets should be assessed to decide for continuation or discontinuation of the trial .After weaning, decannulation will be performed depending on the initial cannulation strategy: In the case of central cannulation, surgical removal is obligatory. In the case of peripheral cannulation, different options to achieve hemostasis are available. As described above, attention should be paid to the developing dead-space between the arterial cannula and the antegrade sheath during decannulation . The forThe use of VA-ECMO as the only mechanical circulatory support device enabling full biventricular support is steadily evolving. While the concept is appealing in refractory or severe CS, and also as an eCPR strategy, evidence of its use is mainly restricted to relatively small, non-randomized studies, one RCT in CS and two RCT in eCPR. Stronger evidence on patient selection and treatment modalities is urgently needed, especially against the background of a high complication rate.


The average angle of the entrance of the CS into the right atrium was 107.25° ± 9.68°. In the group with an RV impairment, it was 105.91° ± 9.22°, while in the patients with normal values of the RV, it was 108.82° ± 10.04°; p = 0.0682. A multiple regression showed that end systolic volume (p = 0.0017) and stroke volume (p = 0.0144) are important predictors of the CS ostium. Conclusions: Some relationships were found between the CS and the selected parameters that describe the function of the RV. This may suggest a role for the CS as a right ventricular buffer, which could potentially be treated as a marker of an RV impairment.The aim of this study was to assess the influence of the parameters of the coronary sinus (CS) on the parameters that describe the function of the right ventricle (RV), which were calculated using cardiac computed tomography. Methods: A CT scan of the heart was performed on 150 patients due to suspicion of coronary artery disease using a Siemens Somatom Force (2 × 192 × 0.6) and a syngo.via workstation. The “CT coronary” and in some cases the generic presets were used to measure the CS ostium in millimeters (mm). The functional measurements of right heart ventricles were examined using the “CT cardiac function” automatic function on a 256 × 256 matrix. Results: The average diameter of the CS ostium was 16.29 ± 4.37 mm. In the group with RV impairment, it was 16.56 ± 4.76, whereas in the group with normal values of the RV, it was 15.98 ± 3.88 mm,  The coronary venous system consists of several elements, the most important of which is the network of the veins of the heart , from which blood flows into one large vessel that is called the great cardiac vein, which passes into the coronary sinus (CS)—Increased afterload is the major pathophysiological mechanism of right ventricle (RV) failure. Heart disease involving the right heart may primarily reduce RV contractility through decreased cardiac output or reduced RV preload, contributing to RV failure. The causes of right ventricular failure include myocardial ischemia/infarction, myocarditis, and most cardiomyopathies. Furthermore, pericardial disease can alter RV preload and ventricular interrelationship, while arrhythmias can exacerbate RV dysfunction ,11,12. IMost available papers have used only the hemodynamic parameters of the left heart. This may be due to the difficulty in assessing the RV using the available diagnostic methods ,13 causeOne hundred and fifty consecutive patients  were included in this prospective, single center study. The exclusion criteria were typical for a cardiac CT examination, such as severe renal failure (serum creatinine > 200 µmol/L or estimated glomerular filtration rate < 30 mL/min), major allergy to iodinated contrast agent, inability to give informed consent, and pregnant or lactating. CT scans of the heart in all of the patients were performed due to suspicion of coronary artery disease (CAD). The imaging was performed by a Siemens Somatom Force scanner (VB20_SP2) using 192 0.6 mm layers on a 512 × 512 matrix. Sixty ml of high-quality contrast agent was administered . A nitroglycerine dose was given according to the guidelines and, if needed, an intravenous B-blocker (metoprolol) was also administered to selected patients if it was not contraindicated. An automatic dose control program was used to fulfill the ALARA rules of being “as low as is reasonably achievable”.The images were analyzed on the latest version of syngo.via (version VB30A_HF06). The “CT coronary” and, in some cases, the “MM ” presets were used to measure the CS ostium (largest diameter) in millimeters. The angle of the entrance of the CS into the right atrium was always measured between the long axis of the left ventricle in degrees and the half delineated straight through the ostium of the CS. Both calculations were performed on axial scans. The data were evaluated by two researchers experienced in coronary CT examinations (more than 20 years of experience).The functional measurements of right heart ventricles were examined using the “CT cardiac function” automatic function on a 256 × 256 matrix. The scheme of the hemodynamic measurements of both ventricles is presented in Finally, the patients were divided into two subgroups according to their RV ejection fraction (RV EF), which was calculated using cardiac CT: RV EF < 45% (impairment of RV) and RV EF ≥ 45%.The Medical University of Silesia ethics committee approved the study protocol (KNW/0022/KB/216/19). The study protocol complied with the version of the Helsinki Convention that was current at the time the study was designed. Due to the nature of the study, it was not necessary to obtain any additional written consent.t test  or the Mann–Whitney test (otherwise). The normality of the distribution of the variables was determined using the Shapiro–Wilk test. Pearson correlation (r) analysis, which measures the strength of association between two variables, was also performed. Intra- and inter-observer agreement between CS measurements was evaluated in a subset of 30 patients (20%). The reproducibility of the measurements was measured using the Bland–Altman method and by calculating the inter-rater agreement coefficient kappa. A simple linear regression model was used to estimate the relationship between one independent variable and one dependent variable using a straight line. p values below 0.05 were interpreted as indicating significant dependencies. The analysis was conducted using MedCalc  and StatSoft Statistica 13  software.The obtained data were statistically analyzed. The analysis of the quantitative variables was performed by calculating the mean ± standard deviation. The values of the quantitative variables in the two groups were compared using Student’s Average body mass index (BMI) was 28.38 ± 5.16. The most prevalent risk factor was hypercholesterolaimia  and arterial hypertension . It is worth mentioning that diabetes was recognized in 33 out of 150 patients (22%). Thirty-four out of 150 patients ware active smokers or had been in the previous 5 years.The first step of analysis was to evaluate the agreement between the two researchers who made the measurements. The inter-observer error for the CS diameter was 0.01 (95% CI 0.9053–0.9477) and the inter-rater agreement kappa was 0.92; for the angle of the entrance of the CS into the right atrium, the inter-observer error was 0.03 (95% CI 0.7262–0.8553) and the kappa was 0.79. The intra-observer error for the CS diameter was 0.01 (95% CI uth0.8994–0.9431) and the intra-rater agreement kappa was 0.92; for the angle of the entrance of the CS into the right atrium, the intra-observer error was 0.06 (95% CI 0.5917–0.8618) and the kappa was 0.72. The presented results are acceptable when measuring the CS.The functional parameters of the RV, which were determined using a cardiac CT, are presented in p = 0.4199) compared to those patients with a normal-sized RV of 15.98 ± 3.88 mm. The average angle between CS and the right atrium was 107.25° ± 9.68°. In the group with an RV impairment, it was 105.91° ± 9.22°, while in patients with a normal-sized RV, it was 108.82° ± 10.04°; p = 0.0682.The study included 16  patients with heart failure, including nine (6%) who had heart failure due to a reduced ejection fraction and seven (4.67%) who had heart failure with a preserved ejection fraction. The average diameter of the CS ostium was 16.29 ± 4.37 mm. In the group with an RV impairment, it was 16.56 ± 4.76; this was not statistically higher . The cited Turkish authors predicting heart failure patients with an impaired RV function found a cut-off value for the diameter of the CS of 7.35. These authors concluded that the CS diameter can be used as a novel echocardiographic marker for RV impairment in patients with HF. While this is quite an interesting observation, we did not investigate it in the presented research.One of the rare studies that is similar to ours is the paper by Çakıcı et al., the aim of which was to evaluate CS dilatation in patients with heart failure and to demonstrate its relationship to the hemodynamic parameters of the RV . The citThe same group of authors under the supervision of Cetin investigated the relationship between the CS diameter and pulmonary artery systolic pressure in 100 of 155 patients who had been diagnosed with pulmonary hypertension and normal left ventricular systolic function on whom transthoracic echocardiography was performed . An inteIn our opinion, although the results of the Turkish authors are extremely interesting, the quality of echocardiographic imaging for CS is often limited, especially when measuring small structures. This problem is rarely observed in a cardiac CT, the “gold standard” for visualizing anatomy, in which the quality of the venous system is usually very good. Unfortunately, unlike the echo exams, it exposes the patient to radiation and an iodine-based contrast agent to which some patients are allergic. It is difficult to perform a functional examination in CT, which is a strong point of echocardiography. All of the results suggest the necessity to assess the CS using all of the imaging methods, including echocardiography and CT. In 2012, Maffei et al. confirmed that despite its good agreement with magnetic resonance, CT is unlikely to become the preferred imaging investigative tool for the functional assessment of LV and RV because of the exposure to radiation and the need to administer a contrast material . The sitWhat is the clinical usefulness of the presented results? In our opinion, the clinical implications are limited to a few potential situations. When there are available CT raw images of the heart (DICOM) performed earlier for other reasons, we can use these data to evaluate the relations between RV and the CS. Another clinical situation is when there is a need for RV function evaluation in magnetic resonance imaging and the patient is excluded due to metal elements inside the body; in this case, CT is a good alternative. In our CT lab, we implemented an analysis of the cardiac venous system as a potential marker of right ventricular failure. To the best of our knowledge, our publication is the first to analyze the relationship between the RV and the venous system of the heart in CT.The presented regressions, although statistically significant, should be considered weak.Some significant relationships were found between the CS and selected parameters that describe RV function. This may suggest a role of CS diameter as a potential marker of right ventricle impairment.


Background: Left ventricular non-compaction (LVNC) is a rare cardiomyopathy typically involving the left ventricle (LV); however, the right ventricle (RV) can also be affected. This case-control study aimed to assess the morphology and function of LV and RV in children with LVNC. Methods: Sixteen children  with LVNC were compared with 16 sex- and age-matched controls. LV and RV morphology and function were evaluated in cardiovascular magnetic resonance (CMR) studies. Additionally, LV and RV global radial (GRS), circumferential (GCS), and longitudinal strain (GLS) were assessed using tissue-tracking analysis. Results: Patients with LVNC did not differ from the healthy controls in terms of age, height, weight, and body surface area (BSA). In total, 4/16 subjects with LVNC had mid-wall late gadolinium enhancement (LGE). Compared to the control group, patients with LVNC had higher end-diastolic volume (EDV) indexed for body surface area (BSA), lower ejection fraction (EF), and lower LV strain parameters . Children with LVNC also presented with thicker RV apical trabeculation, whereas there were no differences in RV EF and EDV/BSA between the groups. Nevertheless, children with LVNC had impaired RV GRS and GCS (both p < 0.05). Conclusions: LVNC in pediatric patients is associated with LV enlargement and impaired LV systolic function. Additionally, children with LVNC have increased RV trabeculations and subclinical impairment of RV myocardial deformation. Left ventricular non-compaction (LVNC) is a rare, yet gradually more recognized myocardial pathology. It constitutes the third most prevalent primary cardiomyopathy in the pediatric population, after dilated and hypertrophic cardiomyopathies, and accounts for nearly 10% of cardiomyopathy cases in children . LVNC maLVNC typically involves the LV, which has a thin compacted myocardial layer and prominent trabeculations and intertrabecular recesses ,4. NeverCMR is the reference method for the non-invasive evaluation of ventricular mass, volume, and function, as well as for the characterization of the myocardium. Its capacity to provide accurate and reproducible information on cardiac morphology and function renders it the best currently available noninvasive diagnostic method for assessing both ventricles in children with LVNC ,16. SeveThis case-control study aimed to evaluate LV and RV morphology and function in pediatric patients with LVNC and to compare them with age- and sex-matched controls. In addition, we sought to assess the differences between children with LVNC, in whom LGE was detected, and the remaining LVNC patients without LGE.The study cohort consisted of 16 children aged 6–17 years, prospectively recruited among hospitalized patients with LVNC suspected on echocardiography and subsequently confirmed in CMR. LVNC was diagnosed using the Jacquier criteria, i.e., when trabeculated left ventricular mass (LVM) >20% of global LVM . ChildreSixteen sex- and age-matched individuals with normal morphological and functional CMR scans were identified by database search and included as the control group. The indication for the CMR scan in the control group included non-diagnostic echocardiographic examination; suspected structural abnormalities on echocardiography; syncope or chest pain with a low pre-scan probability of being cardiac in origin; and suspected, but excluded in 24-h ambulatory blood pressure monitoring, primary hypertension.CMR imaging was conducted using a 1.5 T whole-body magnetic resonance scanner , with a dedicated cardiac phased-array coil and ECG gating. Based on the scout and reference scans, steady-state free precession (SSFP) cine images of the heart in the standard four-, three-, and two-chamber planes were acquired. The ventricles were also visualized in the short-axis plane view, from the base, parallel, and across the atrioventricular valves, to the apex of the heart using 12 contiguous slices. The imaging was performed at end-expiration using the following parameters: repetition time (TR)/echo time (TE) 42.5/1.2 ms, spatial resolution = 8 × 1.5 × 1.5 mm, flip angle 62°, minimum 25 phases per cardiac cycle. In LVNC patients, late gadolinium-enhanced imaging was performed 10–15 min after contrast agent administration ).The CMR studies were analyzed using CVi42  on a dedicated diagnostic workstation. To determine the left ventricular compacted mass (LVM), left ventricular and right ventricular end-diastolic volume , and ejection fraction , the end-diastolic and end-systolic phases were identified based on the long-axis and the midventricular short-axis scans. LV endocardial and epicardial borders and RV endocardial borders were automatically contoured in those phases and then manually corrected. The interventricular septum and the papillary muscles were included in the compacted LVM . AdditioLV and RV EDV, compacted LVM, and trabeculated LVM were indexed for BSA, determined using the Du Bois formula m)0.725) . To idenm)0.725) . Z-scoreBiventricular myocardial deformation was evaluated using a dedicated CVi42 tissue tracking module. In the end-diastolic phase in all slices that encompassed the ventricles, LV endocardial and epicardial as well as RV endocardial contours were automatically traced by the software and manually corrected, excluding papillary muscles and trabeculations. In the same phase, RV free wall epicardial contours were traced manually. After propagation of the contours through the other phases, they were assessed and corrected if necessary. LV and RV global circumferential and global radial strain (LV/RV GCS and LV/RV GRS) were assessed using the cine short-axis slices. The global longitudinal strain was measured on the two- and four-chamber cine images for the LV (LV GLS) and using the four-chamber view for the RV (RV GLS).The studies were assessed for the presence of late gadolinium enhancement (LGE), with LV divided into segments using the 17-segment cardiac model. Increased signal intensity in the late scans was considered as LGE when it was visible in two different spatial orientations. Besides categorical differentiation between patients with and without features of myocardial fibrosis, the extent of LGE was quantitatively assessed using a dedicated module, with pathological enhancement defined as myocardium with signal intensity >6 SD above the mean in a reference region of interest in an effectively nulled part of the myocardium .t-test if normally distributed or the Wilcoxon signed-rank test if non-normally distributed. Categorical variables are reported as count (percentage) and were compared between the groups using the McNemar test.Statistical analysis was performed using R Studio (NHST statistics) with dabest package version 0.3.1 . Continut-test or the Mann–Whitney depending on the normality of distribution; categorical variables were compared using the chi-square test.The comparison between LVNC patients with LGE and those without LGE was performed using the unpaired Student’s To further explore the data, in addition to the classic null hypothesis significance testing, we used permutation tests, the results of which are presented in separate columns of the tables. The effect size of the difference between patients and healthy controls was analyzed using the paired mean difference with bias-corrected and accelerated 95% confidence intervals obtained with bootstrapping on 5000 resamples.p-values of less than 0.05 were considered statistically significant.PRDM16, RBM20 (in two patients), ACTN2, HCN4, EYA4, KCNQ1, TTN, ACTC1, HCCS. NYHA functional class was assessed as I in 25% of patients (4/16) and as II in the remaining 75% (12/16) of children. In half of the patients (8/16), abnormalities in resting ECG or 24 h monitoring were noted . Most children  were treated pharmacologically and received between one and three medications .The LVNC group consisted of 16 patients aged 6–17 years ). Only 1 patient (6%) declared episodes of chest pain, whereas dyspnea or syncope was not reported. No patients had a history of thromboembolic events. A significant portion of the children with LVNC  had a family history of LVNC or other cardiomyopathies. In a majority of patients , pathologic molecular variants associated with LVNC were identified in the following genes: p = 0.055).The patients were compared with a control group composed of age- and sex-matched children, who presented without any structural or functional cardiac abnormalities detected in CMR. The patients with LVNC did not differ significantly from the controls in terms of height, BMI, or BSA . There wCMR results in the study groups are presented in p < 0.001), trabeculated LVMI  and trabeculated/global LVM ratio  compared to the control group  vs. 0.89 , ol group . Compact2  vs. 76.3 mL/m2 , p = 0.015) (Children with LVNC had higher mean EDV/BSA than the controls (82.1 mL/m= 0.015) a. In the= 0.015) .p = 0.037)  b. Nevertp = 0.033; LV GCS: -15.9 ± 2.2% vs. -18.2 ± 6.8%, p = 0.022; GLS: -15.4 ± 2.8% vs. -17.6 ± 2.5%, p = 0.032)  .p = 0.006)  a. LVNC p= 0.006) b, yet RVp = 0.004 and −10.3 ± 4.6% vs. −12.9 ± 3.3%, p = 0.015, respectively), with no differences in mean RV GLS values.RV EF values were comparable between the study groups c; howevep < 0.001).In the LVNC group, mid-wall left ventricular LGE was observed in 4 of the 16 patients (25%). In this subgroup of children with LVNC, mean LGE percentage of LV mass was 5.6 ± 2.2% and involved between 1 and 4 LV segments. Children with LGE did not differ from the other participants with diagnosed LVNC in terms of age or anthropometric parameters . They ha2 vs. 78.1 ± 9.6 mL/m2, p < 0.001) and compacted LVMI .LV NC/C ratio, LV EF, and LV global strain values did not differ between the two groups. Yet compared to other children with LVNC, patients with LGE had higher LV EDV/BSA  compared to the other patients with LVNC. They also presented with higher RV EDV/BSA . RV EF and RV global strain values did not differ significantly between the two subgroups.Children with LGE had more pronounced RV trabeculations  [In our study, as expected by the definition of the cardiomyopathy, we observed markedly increased LV trabeculations in the LVNC group, which was indicated by higher NC/C ratio, trabecular LVMI, and trabecular to global myocardial mass ratio. Importantly, the LVNC group was characterized by significantly lower, yet still preserved, mean LV EF (60 ± 7%) and substantially higher LV EDV/BSA compared to the control group . Moreove2) . In anot2) . Compare2) ,19. The 2) . Neverth2) ,28.The results of our study also indicate that children with LVNC have impaired LV myocardial deformation . It is aMore studies were conducted in adults, also yielding similar results. In a CMR study, 59 adults with LVNC had impaired LV deformation compared to healthy controls . ImportaCMR permits for a precise RV assessment and the results of our study demonstrate features of subclinical RV involvement in pediatric patients with LVNC, characterized by thicker RV apical trabeculations and impaired RV deformation. Increased RV trabeculations in children with LVNC was rarely reported and mainly in echocardiographic studies. Pignatelli et al. diagnosed RV non-compaction in echocardiography in 8 out of 36 pediatric patients with LVNC . IncreasMore data on RV morphology in LVNC is available from studies with adult participants. In a cohort of 113 LVNC patients, Andreini et al. diagnosed RV noncompaction in 20 adults (18%), a similar percentage as in the pediatric study by Ergul et al. . Two othThe results concerning RV remodeling and systolic dysfunction in LVNC patients are contradictory. Stämpfli et al. did not observe significant differences between the study groups in RV size or systolic function, yet the latter was assessed by calculating fractional area change . SimilarMyocardial fibrosis, as indicated by the presence of LGE, is an important, independent prognostic factor in cardiomyopathies, including LVNC ,43,44. AIn our study, LGE was noted in 25% of patients with LVNC, which is similar to data reported by Cheng et al. and Nucifora et al., who demonstrated the same prevalence of LGE in their cohorts ,20. The In the present study, we observed significant differences between the patients with LGE and the remaining children with LVNC. Similarly to the results of a larger pediatric study by Cheng et al., individuals with LGE had significantly larger LV, indicative of maladaptive remodeling and suggesting an association between myocardial fibrosis and remodeling . FurtherThe main limitation of the study is the small size of the study group, which is related to the low LVNC prevalence in the pediatric population. The use of estimation statistics allowed us to approximate the effect size of the differences between groups and to a degree attenuated the impact of a small sample size. Nevertheless, the results of the study should be considered as hypothesis-generating and should be confirmed by larger, multicenter, prospective studies. Another limitation of this study is the fact that it was performed in a single tertiary center and hence the patients may not be representative of the general population. Thirdly, the study lacks longitudinal assessment of the patients. The evaluation of the clinical course of LVNC in children is much needed and requires further investigation. Future studies could focus on CMR features impacting prognosis and hence permitting better identification of individuals with increased cardiovascular risk.LVNC in children and adolescents is associated with left ventricular enlargement, reduced systolic function, and impaired myocardial deformation. Moreover, pediatric patients with LVNC have increased right ventricular apical trabeculations and subclinical right ventricular myocardial deformation impairment. Left ventricular fibrosis is prevalent in a significant percentage of children with LVNC and is linked to biventricular remodeling.


Left ventricular dimensions and function were assessed with B-mode ultrasound and Doppler. The ratio of left ventricular early diastolic peak filling velocity to peak velocity during atrial contraction (E/A) across the mitral valve and the ratio of E to velocity of the E-wave (E’) across the lateral and septal mitral annulus (E/E’) were used as indexes of left ventricular diastolic function. Intra-ventricular septal wall thickness was greater in throwers compared to sprinters . Left ventricular end diastolic diameter/body surface area was higher in endurance athletes and sprinters vs. throwers . The E/A was higher in endurance athletes and sprinters vs. throwers . The E/E’ was lower in endurance athletes and sprinters vs. throwers . Compared to age-matched historical controls , left ventricular diastolic function was not different in throwers, but superior in endurance athletes and sprinters (p < 0.01). Masters throwers have altered left ventricular dimensions and function vs. other athletes, but a lifetime of heavy resistance training does not appear to alter left ventricular function compared to age-matched controls.There is controversy whether a lifetime of heavy resistance training, providing pressure-overload, is harmful for left ventricular function. We compared left ventricular dimensions and function in elite Masters athletes involved in throwing events (requiring strength;  Aerobic endurance training in middle-age or older adults is able to alter cardiac function and might contribute to enhanced left ventricular diastolic function. Changes in heart morphology include eccentric hypertrophy of the heart, where ventricular dimensions and volumes are increased due to volume overload . On the Throwers involved in track and field events may represent different somatotypes than master resistance-trained athletes (such as powerlifters) previously evaluated. Because throwers would probably be larger individuals where absolute strength, rather than relative strength  is more important, they may exhibit somatotypes that are more similar to those from “Strongmen” competitions. Younger Strongmen competitors  have greater absolute  cardiac dimensions  than controls, but accompanied by reduced diastolic function , indicating that these individuals may be at greater risk for cardiovascular dysfunction .Elite masters-level athletes are ideal to study because they would have been practicing intense training routines for long time periods; therefore, they can provide important information on how effects of aging on cardiac structure and function can be altered with chronic training. Our study represents a novel assessment of high-level track and field athletes drawn from the World Masters Athletic Championships and therefore some of the most highly-trained athletes in the world for their age groups. Previous studies evaluating master-level strength-trained athletes evaluated much smaller groups of athletes who were younger  than athletes in the current study and not trained at a “world-class” level as the athletes in the current study .The purpose of our study was to assess older athletes involved in throwing events at the World Masters Athletics Championships, to evaluate individuals who are older and with greater years of resistance training than those evaluated in earlier studies . We comp1 with study identifier DRKS00015172. The study was approved by the Masters Athletics Organizing Committee, the Ethics Commission of the North Rhine Medical Association, and the University of Saskatchewan Biomedical Research Ethics Review Board. Participants were informed of the experimental risks and signed an informed consent document prior to the investigation.This was a cross-sectional study evaluating cardiac structure and function in athletes who participated in the 23rd World Masters Athletic Championship in Málaga Spain from September 4th to 15th, 2018. This was a sub-study as part of the Masters Athletic Field Study 2018 (MAFS-18) which was registered with the German Registry for Clinical TrialsInclusion criterion for the study was that participants had to be registered for the World Masters Athletic Championship. All data collection occurred onsite at the championships. Exclusion criteria were injuries or illnesses that affected jump tests or contraction of the calf muscle, another main outcome parameter of the MAFS-18. The time of day tested varied as data collection occurred throughout the day . The study included 21 throwers , 65 endurance athletes, which included athletes from long- and middle-distance events  and 68 sprinters . The group of throwers included 15 top-10 finishers (in their respective age group), five podium placements, and two world champions. The endurance group included 26 top-10 finishers, nine podium placements, and five world champions. The sprint group included 24 top-10 finishers, eight podium placements, and three world champions.trans-tricuspid regurgitation jet  . Two-dimtion jet . EjectioTraining characteristics were assessed by questionnaire that asked about hours per week devoted to training during the competitive and off-seasons, hours per week devoted to training to build up muscle bulk (hypertrophy) and the length of the competitive season in months per year. The athletes were also asked (yes or no) whether they regularly included explosive weight training  and plyometrics  as part of their training routine.post hoc analysis was used if there was a significant effect for athletic group or athletic group × sex interaction. The E/A ratio and E/E’ ratio, as indicators of global diastolic function were compared between each athletic group and means from age-matched historical controls  . Comparisons between athletic groups (throwers vs. endurance athletes vs. sprinters) and sexes  were made using a 2-factor (3 × 2) between-groups ANOVA. Least squared difference > 1,000)  using ann = 2).We also assessed differences across athletic groups and age by grouping athletes as ≥60 years  and <60 years  and using an athletic group × age ANOVA. This age cut-off was chosen because it divided the throwing and endurance groups evenly. Sex was not included as a factor in this sub-analysis because the number of younger females in the group of throwers was considered too small (p < 0.01); therefore, we used age as a covariate in this analysis.Within each athletic group we also compared cardiac structure and function variables between the top-ranked finishers  and the rest of the athletes using a rank (top six vs. others) × sex  between-groups ANOVA. The top-ranked sprinters were significantly older than the other sprinters  whether they regularly used explosive weight training or plyometrics as part of their training (this was expressed as a percentage). Significance was accepted at p < 0.001) and sprinters were heavier than endurance athletes (p < 0.01). Throwers were taller than endurance athletes (p < 0.01). Throwers had greater body surface area compared to sprinters and endurance athletes (p < 0.001) and sprinters had greater body surface area compared to endurance athletes (p < 0.001).Participant characteristics are presented in p < 0.01). A significantly greater proportion of throwers and sprinters indicated they regularly performed explosive weight training and plyometrics than endurance athletes (p < 0.001). The endurance athletes had a longer competitive season compared to sprinters (p < 0.05).Training variables for the different athletic groups are presented in p = 0.01; p = 0.054). Endurance athletes (p < 0.001) and sprinters (p < 0.01) had greater left ventricular end diastolic diameter when expressed relative to body surface area compared to throwers, and endurance athletes had greater relative diameter compared to sprinters (p < 0.05) ( < 0.05) .For all three athletic groups, we did not observe overt left ventricular diastolic dysfunction. Left atrial volume indexed to body surface area and maximal velocity of transtricuspid regurgitation, if present, neither differed between groups nor was elevated beyond a clinically relevant threshold .p < 0.01; p < 0.001)  and endurance athletes (p < 0.05). The E/E’ ratio as a surrogate for left ventricular end diastolic pressure was lower in endurance athletes and sprinters compared to throwers  . Althougn = 1) and relevant, yet asymptomatic aortic insufficiency (n = 1). Four subjects had to be excluded because of atrial fibrillation. We did not observe any mitral vitium that might have prohibited diastolic assessment. Athletic groups did not differ for ejection fraction, as a measure of systolic function , left ventricular posterior wall thickness , left ventricular mass , left ventricular mass indexed to body surface area , and E/E’ ratio , and lower E/A ratio .When athletic groups were divided into older (≥60 years) and younger (<60 years) groups, there were 11 older and 10 younger participants in the throwing group, 32 participants each in the older and younger endurance groups, and 28 older and 40 younger participants in the sprint group. There was no significant athletic group × age interactions, indicating that changes with age were similar across athletic groups. The older group had greater septum thickness  compared to the other athletes (n = 49) had greater left ventricular end-diastolic diameter , and left ventricular mass indexed to body surface area . There was a rank × sex interaction for E/E’ ratio, where the top-ranked endurance females (n = 7) compared to the rest of the endurance females (n = 18) had a lower ratio . For sprinters, the top-ranked athletes (n = 14) compared to the rest of the athletes (n = 54) had lower E/E’ ratio , but no differences in cardiac structure.When the top six finishers from each athletic group were compared to the rest of the athletes, there was no difference within the throwers for any measure of cardiac structure and function (data not shown). For endurance athletes, the top-ranked athletes . Higher age was associated with a thicker septum and left ventricular posterior wall and increased left ventricular mass, as well as lower cardiac function as indicated by higher E/E’ and lower E/A ratios, changes which are expected with age . These cWhen comparing athletes who finished in the top six in the world for their age group to the remaining athletes, there were no differences for cardiac structure and function within the group of throwers, indicating that their adaptation to training is quite consistent across elite vs. less elite athletes. In contrast, within the endurance and sprint groups the more successful athletes  had differences in either structure or function compared to their less successful counterparts. Within the endurance group, top six finishers had greater left ventricular end diastolic diameter and left ventricular mass (relative to body surface area) compared to the rest of the athletes, indicating that volume overload was especially experienced by these athletes. These changes in cardiac structure are similar to previous studies of elite master endurance athletes . The top2 for the males in our study); therefore, perhaps their training for absolute strength was of greater intensity. In addition, throwers need to train for power in addition to strength; therefore, training routines may differ. Throwing involves movement with maximal velocity; therefore, there may be some limits on body size for successful performance. Within the throwing group, hammer and javelin throwers are usually smaller than throwers in other events, but when we compared these groups, there were no differences in body mass or body surface area (data not shown). Another factor for differences in diastolic function could be that strongmen competitors are generally not limited in anabolic steroid use  on a final position basis and/or random basis, and/or; (b) at the discretion of the Anti-Doping and Monitoring Committee by any method that it shall choose, including target testing, and/or; (c) any athlete who has broken or equaled a World Masters Athletic Championships World Record.” Chronic anabolic steroid use is associated with reduced diastolic function, as indicated by lower E/A ratio , we had hypothesized that they might have similar heart structure and function as younger “strongmen” competitors. Younger “strongmen” competitors (age 35 years) have similar intra-ventricular septum thickness (∼12 mm) compared to the Masters throwers in our study . Youngerroid use  whereas /A ratio . DespiteResistance-trained athletes of younger age than the throwers in our study  had measures of cardiac structure that were varied compared to the throwers in our study. Our cross-sectional results for Masters throwers and endurance athletes are partially supported by one longitudinal training study in older males (aged 65–75 years). Twelve months of endurance training  increased left ventricular end-diastolic diameter and enhanced E/A ratio, with no changes with resistance training . Unlike n = 13; mean age 47 years) to endurance  athletes . More specifically, throwers had highest intra-ventricular septum thickness; whereas endurance athletes and sprinters had higher relative end-diastolic ventricular diameter. These may result in differences between athletic groups for diastolic function, which was superior in endurance athletes and sprinters, but not impaired in throwers compared to age-matched historical controls. Surprisingly, sprinters had similar left ventricular structure and diastolic function compared to endurance athletes, indicating adaptation to their training programs may be more similar to endurance training than resistance training. The practical application of our study is that although a lifetime of training for strength and power appears to affect cardiac structure , it does not appear to negatively affect left ventricular function.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Commission of the North Rhine Medical Association, and the University of Saskatchewan Biomedical Research Ethics Review Board. The patients/participants provided their written informed consent to participate in this study.PC, CT, and JR: study planning. FH, SM, PC, SW, SS-G, and JR: data collection. PC: manuscript writing. All authors edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.