Echocardiography is a well-established tool for risk stratification in patients with acute coronary syndrome (ACS). ACS has significant impact on LV dyssynchrony, and detrimental effects on systolic function and long term outcome. The aims of this study were to determine whether LV dyssynchrony carries any predictive information in an unselected ACS population and to evaluate if it has any incremental value to the information given from conventional echocardiographic measurements.The study included 227 consecutive ACS patients. Primary endpoint was the composite of death, new MI, or rehospitalisation due to heart failure. Dyssynchrony was measured as intersegmental variation of time to peak strain, the post systolic index (PSI) and myocardial performance index (MPI) with the standard deviation and difference between lowest and highest value (delta) expressing the amount of dyssynchrony. Septal-lateral delay was also tested. All dyssynchrony parameters were compared with Ejection fraction (EF).The median follow up time was 53 months. 85 patients reached the combined endpoint. Patients with and without a subsequent combined endpoint differed significantly regarding calculated SD: s and delta-value for PSI, time to peak 2D-strain and MPI but not regarding septal-lateral delay. In ROC-analysis none of the dyssynchrony parameters had larger AUC than EF. When adjusting for traditional risk factors none of the dyssynchrony parameters remained associated with outcome, whereas EF still did.LV dyssynchrony seem to have significant prognostic information in patient with acute coronary syndrome but in comparison to conventional parameters such as EF there is no incremental value of this information. Echocardiography is a well-established tool for risk stratification and therapy guidance in patients having acute coronary syndrome (ACS), and echocardiographic measurements such as ejection fraction (EF), wall motion score index (WMSI), the ratio of early mitral inflow over myocardial velocity (E/é), myocardial strain and strain-rate reflecting left ventricular (LV) systolic function and contractility are associated with long-term outcome -6.Regardless of QRS width , ACS hasIntraventricular dyssynchrony of the LV, i.e. difference in timing of myocardial contraction between the different segments of the LV, can be derived from both tissue Doppler imaging (TDI) and speckle tracking from 2D-images using a wide range of different measures.The aims of this study were to determine whether LV dyssynchrony carries any predictive information in an unselected ACS population and to evaluate if this prognostic information has any incremental value to the information given from conventional and established echocardiographic measurements.The study included 227 patients admitted to the coronary care unit at Karolinska University Hospital, Huddinge, between August 2006 and January 2008, with a clinical diagnosis of ACS. The patients were consecutively included except for temporary interruptions of the study due to high work load at the coronary care unit. All patients underwent clinical assessment including clinical history, physical examination, standard 12-lead ECG, ECG-monitoring and serial measurement of biochemical cardiac markers up to 9–12 hours after admission. All other examinations as well as specific treatments of the patients were left to the discretion of the individual cardiologist. Clinical data were prospectively collected and entered into a database. An acute MI was defined according to current guidelines [The primary endpoint was the composite of death from any cause, new MI, or rehospitalisation due to heart failure. Secondary endpoints were death from any cause, new MI and rehospitalisation due to heart failure as separate endpoints and the composite endpoint of death from any cause or rehospitalisation due to heart failure. All in-hospital events were registered in the study database. Only new MIs occurring more than 24 hours after admission were considered as events. Out of hospital, information about death and need for readmission because of MI or heart failure was obtained by merging the database with the Swedish population registry, which includes information of the vital status of all Swedish citizens, and the National Patient Registry, which includes diagnoses on all patients hospitalized in Sweden.Before entering the study, all patients gave their written, informed consent. The study was conducted according to the principles of the Declaration of Helsinki and was approved by the local ethics committee.All echocardiography data were collected at a (median(25th-75th percentile) time of 3(2–4)) days from admission according to the local standard clinical protocol at that time on Karolinska University Hospital by the cardiologist or sonographer on duty that day. The images, including 2D, TDI and spectral Doppler, were collected using a GE Vingmed vivid7 ultrasound machine with standard installed software.The images were analyzed using a dedicated workstation  by a well-trained cardiologist (CW) blinded to baseline data and subsequent outcome.speckle tracking technique using reflector based identification of the individual reflection pattern of specific bright spots (speckles) in the myocardium and tracking these speckles from frame to frame [Myocardial deformation can be calculated from the 2D images from the to frame . With thto frame . This pato frame  which maThe degree of post systolic strain using post systolic index (PSI) also called post systolic shortening (PSS) has been shown to be highly correlated to both chronic and acute ischemia  and alsoFor both PSI and time to peak 2D-strain the intersegmental variation, standard deviation (SD) and the difference between the maximum and minimum (Delta) were used as measurements of LV dyssynchrony.septal-lateral delay, is both robust and feasible, and one of the most established methods [myocardial performance index (MPI) can be calculated, this index is similar to the Tei index, but the latter is not derived from TDI. MPI has shown to predict left ventricular dilatation and death after MI [Measuring the time difference in peak systolic velocity in septum and lateral wall from TDI, often referred to as the  methods . Also deafter MI  and alsoafter MI . MPI hasafter MI , in patiafter MI  and alsoafter MI . TDI is Both Septal to lateral delay and MPI are acquired in post processing recorded color-coded TDI images using the Q-analysis software in the EchoPAC. Septal-lateral delay is recorded from the four chamber projection as the time difference between peak systolic velocity in the basal segments of the septal and lateral myocardial walls. From the velocity curves and all three apical projections the regional time of the phases of the cardiac cycle where measured and the MPI was calculated, as showed in Figure Ejection fraction was measured according to current EACV/ASE recommendations  using thWall motion score index (WMSI) was derived by a visual assessment of the function of all 18 segments of the left ventricle where normokinetic segments got the value 1, hypokinetic segments 2, akinetic 3 and dyskinetic 4. Wall motion score index was calculated by dividing the sum by 18.Continuous data are presented as medians with interquartile range (IQR) and categorical data are presented with frequencies and percentages. When analyzing differences between groups the Mann Whitney-test was used for continuous variables and Chi2-test for categorical variables. To compare the prognostic value regardless of chosen cut off-value, receiver operating characteristics (ROC) analyses expressing prognostic value as area under curve (AUC) with 95% confidence interval (CI)were used and the significance of this measurements are evaluated according to Hanley and McNeil . We alsoTo examine whether measurements of dyssynchrony were independently associated with outcome, Cox-regression analyses were used in two models. In model 1 the analysis was made univariate and the parameters were entered one by one without adjustment for other variables. In model 2, adjustment was made for baseline characteristics well known to be associated with outcome  and in this model, just as in model 1 the echocardiographic parameters was inserted one by one.A total of 227 patients were included in the study. The median follow up time was 53 (range 48–58) months. During this period 85 (37%) patients reached the combined endpoint, among them 42 19%) died, 48 (21%) had a MI and 52 (23%) were readmitted because of an episode of heart failure. The baseline characteristics in all patients and in those with and without a subsequent combined endpoint are presented in Table 9% died, Patients with and without a subsequent combined endpoint differed significantly regarding both calculated SD: s and delta-value for PSI and for time to peak 2D-strain and MPI but not for septal-lateral delay Tables . The patWhen the associations between tested parameters and outcome were evaluated with ROC-analyses, dyssynchrony parameters based on PSI and time to peak 2D-strain were more associated with the composite endpoint than both MPI and septal-lateral delay but none of the dyssynchrony parameters had a larger AUC than EF according to Simpson regardless of endpoint Table . None ofIn a Cox regression analysis when adjusting for traditional risk factors  none of the dyssynchrony parameters remained independently associated with outcome, whereas EF according to Simpson still did Table .The main findings of this study are that the dyssynchrony parameters do carry prognostic information regarding long term outcome after ACS in an unselected population. However, the clinical value of this information is limited since the dyssynchrony parameters seem to have only a moderate predictive prognostic value and no incremental value to well known risk factors such as age, gender, diabetes, hypertension, previous heart failure, creatinine clearance and troponin levels and no incremental value to EF, the most established and commonly used method for assessment of systolic LV function. Given the previous data of the importance of LV dyssynchrony in various clinical patients groups, the seemingly relatively weak prognostic value of LV dyssynchrony in this setting of unselected ACS patients is both somewhat surprising and not easily understandable.One possible explanation might be that these parameters, which have consistently been shown to be very sensitive to detect ischemia in previous studies ,9-11,25,Furthermore there is a lack of detailed knowledge about the time course of the different timing disturbances after ACS. It might therefore be possible that myocardial contractility in a reverse remodeling context actually recover earlier than LV dyssynchrony and if this is true, dyssynchrony measured in the early phase in the recovering myocardium might give a false measure of risk. The result might in fact have been different if the images had been acquired earlier or later after the ACS episode, for example within the first hours of admission or 3–4 weeks.Another possibility is following from the fact that dyssynchrony parameters reflect the relative intersegmental differences. We need to keep in mind that a very large myocardial infarct will affect a larger number of LV segments, which over a certain level could lead to a seemingly paradoxically lower intersegmental variation, Thus, a large myocardial infarction does not necessarily result in a high degree of dyssynchrony.Post systolic contraction, measured with PSI, is known to be highly correlated to ischemia  and seemThe fact that some echocardiographic parameters in this study can predict all the endpoints, both isolated and combined, and with or without new MI indicates that there are unknown confounding factors behind both severity of coronary disease and disturbance of LV function of clinical relevance even though, intuitively, it is hard to see the direct correlation between a plaque rupture and LV dysfunction.One interesting finding, however, is the fact that the predictive value of these parameters seem to be better using death as endpoint compared to the other endpoints. The small number of events and the lack of significant results in this study allow for nothing more than speculations. But nevertheless, one possible explanation might be that death in this group to some extent is due to ventricular arrhythmias and that the dyssynchrony parameters actually predict that more than heart failure and new ischemic events. This is to some extent supported in earlier studies, even though not in an ACS population .A major limitation of this study is that we did not have a standardized time between the coronary angiography and the echocardiographic examination in relation to time of admission. If all echocardiographic examinations would have been performed within the first 24 hours after diagnose and prior to angiography the result might have been different. The result might also have been different if we had included a 3–6 months follow up echocardiographic examination to assess the amount of reverse remodeling and actual persisting damage.Another fact that could be considered as a limitation is the image quality. All the images used in this study were stored from everyday clinical examinations and not by a highly specialized research lab and it is reasonable to believe that the image quality is more essential for timing parameters compared to conventional parameters, which might have affected the results. On the other hand this is also one of the strengths of this study, pointing out the limitation of using the dyssynchrony parameters with the technique and resources we have at hand today in the clinical daily routine.Mechanical LV dyssynchrony seem to carry some significant prognostic information in patient with acute coronary syndrome but in comparison to well-known risk factors and conventional parameters such as EF there is little or no incremental value of this information.The authors declare that they have no competing interests.All authors have contributed to the manuscript and approved the final version.


Lineage-specific regulatory elements underlie adaptation of species and play a role in disease susceptibility. We compared functionally conserved and lineage-specific enhancers by cross-mapping 5042 human and 6564 mouse heart enhancers. Of these, 79 per cent are lineage-specific, lacking a functional orthologue. Heart enhancers tend to cluster and, commonly, there are multiple heart enhancers in a heart locus providing a regulatory stability to the locus. We observed little cross-clustering, however, between lineage-specific and functionally conserved heart enhancers suggesting regulatory function acquisition and development in loci previously lacking heart activity. We also identified 862 human-specific heart enhancers: 417 featuring sequence conservation with mouse (class II) and 445 with neither sequence nor function conservation (class III). Ninety-eight per cent of class III enhancers were deleted from the mouse genome, and we estimated a similar-sized enhancer gain in the human lineage. Human-specific enhancers display no detectable decrease in the negative selection pressure and are strongly associated with genes partaking in the heart regulatory programmes. The loss of a heart enhancer could be compensated by activity of a redundant heart enhancer; however, we observed redundancy in only 15 per cent of class II and III enhancer loci indicating a large-scale reprogramming of the heart regulatory programme in mammals. In t2.(a)et al. [We compared the expression profiles of different mouse heart developmental stages with the expression profile of fetal human heart t-test p-value = 1.3 × 10–18) and populate shorter loci  when compared with lineage-specific heart enhancers. In addition, shared heart enhancers feature higher GC-content  and are more often located in CpG islands .To study the evolutionary trends of the heart regulatory programme, we classified human P300 heart enhancers into shared between humans and mice (dubbed simply shared for the rest of the manuscript) and lineage-specific a; Fisher's exact test p-value = 1.8 × 10–9). More lineage-specific heart enhancers are clustered with lineage-specific heart enhancers (24%) than shared heart enhancers (16%) as well . This suggests the importance of regulatory redundancy in loci of genes expressed in the heart. Also, the reduced clustering of shared and lineage-specific enhancers indicates the separation of ancestral and novel regulatory programmes with recent regulatory structures targeting and building up within loci that previously lacked heart expression.Next, we performed a stochastic simulation (with 1000 replicates) to analyse the clustering between shared and lineage-specific heart enhancers. In the simulation, we randomly selected 500 shared and 500 lineage-specific heart enhancers and computed the percentage of clustered heart enhancers (more than two heart enhancers located in the same locus). Almost twice as many shared heart enhancers are clustered with shared heart enhancers (36%) than with lineage-specific heart enhancers To study how loss or gain of heart enhancers affects the expression of flanking genes and their function in the heart, we further partitioned lineage-specific human heart enhancers into three classes based on evolutionary sequence conservation and the strength of ChIP-Seq signal in their mouse sequence orthologues. In particular, we were concerned with possible false positive lineage-specific elements associated with strict ChIP-Seq cut-offs used to call a region an enhancer. To avoid a potential negative impact of experimental uncertainties, we defined class I representing equivocal lineage-specific enhancers (3114 regions) whose sequences were conserved in the mouse genome and whose mouse homologous regions did not overlap ChIP-Seq peaks, but featured ChIP-Seq read count exceeding the genome-wide background level (see §4 for details). By definition, class I enhancers represent a mix of true human-specific heart enhancers and enhancers potentially shared in humans and mice that were not assigned to the shared class due simply to the low signal in mouse experiment. Therefore, all conclusions stemming from the analysis of the class I data should be taken with a grain of salt. The remaining true lineage-specific human heart enhancers  were split into the class II (417 regions) featuring sequence conserved with mouse and class III (445 regions) featuring no sequence homology in the mouse genome. To prevent indiscriminative results, class I enhancers, which could represent weak heart enhancers in mouse and, thus, be reclassified as shared enhancers, were mainly excluded from the following functional studies.(e)a for raw counts), this enhancer loss should have been compensated by enhancer gain. Class II  enhancers can possibly shed the light on the enhancer gain path. Novel human heart enhancers should have been formed by heart enhancer function acquisition without sequence loss in mouse (class II) or gradual function gain with or without sequence divergence (class I).There are two evolutionary possibilities for giving rise to a human-specific enhancer with no sequence homology in the mouse genome (class III): either a sequence insertion in the human lineage or sequence deletion in the mouse lineage. To delineate between these two scenarios, we used sequence alignments between human and seven distant species forming an out-group , to study the evolutionary history of the genomic regions in question. Ninety-eight per cent (436/445) of these enhancer sequences are present in at least one of the seven distant species. This points to the ancestral nature of class III enhancers and supports a model of enhancer sequence deletion in the mouse lineage for the majority of enhancers forming this class. This, in turn, indicates that the reshaping of the regulatory genome is largely a result on enhancer sequence loss. As there are no fewer mouse heart enhancers than human heart enhancers (see §2(f)p-value = 0.045 and 1.9 × 10–5, respectively) or random expectation . This suggests elevated levels of negative selection acting on heart enhancers located proximally to genes highly expressed in the heart, both from the sequence and function selection viewpoint. In addition, more conserved human-specific heart enhancers (class II) are located in the loci of highly expressed heart genes than human-specific heart enhancers lacking sequence similarity with mouse . As class III corresponds to sequences that have been predominantly lost in the mouse lineage (see §2e), these results demonstrate that the decreased strength of selection acting on the class III elements and allowing their loss in the mouse lineage was probably the result of the reduced importance of the class III elements in the developmental heart programme, as depicted through their genomic location away from genes highly expressed in the heart.To study how different heart enhancers affect the expression of flanking genes, we identified 1000 highly expressed heart genes (see §4 for details) and calculated the percentage of heart enhancers located in the loci of these highly expressed heart genes . Signifi(g)p-value = 2.1 × 10–17 and 1.2 × 10–7, respectively), with shared enhancers demonstrating significantly stronger association with H3K9ac. As H3K9ac is known to be characteristic of strong, distant enhancers [trans-acting factors in the genomic regions they occupy Pseudogenes.org database [p-value = 6.8 × 10–52, 3.1 × 10–51 and 7.4 × 10–29, respectively), suggesting all classes of human heart enhancers are under negative selection pressure.We used two methods—derived allele frequency (DAF) and McDonald–Kreitman test (MK test)—to investigate selective constraints, under which heart enhancers evolve. We downloaded human variation data generated by the 1000 Genomes Project  and useddatabase  as the nP; variation within species) were contrasted to the non-polymorphic human sites different from their chimpanzee (Pan troglodytes) counterparts . P and D enhancer counts  were compared with the corresponding neutral reference counts Pn and Dn calculated using pseudogenes. Neutrality index defined as (Pe/De)/(Pn/Dn) was determined for each type of heart enhancers. All of three types of heart enhancers were subject to negative selection p-value = 9.4 × 10–10), again alluding to the important function this category of heart enhancers plays in heart development. Notably, the least-fold enrichment was observed for the class II elements indicating that the gain of regulatory function takes place in loci previously not strongly involved into the heart regulatory programme. At the same time, the class III fold enrichment almost reaches the level of shared enhancers suggesting that the loss of the class III enhancer counterparts in the mouse genome had a direct impact on the mouse heart regulatory programme.We performed a gene ontology (GO) analysis to quantify the association of heart enhancers with the biological function of flanking genes. We selected all cardiac GO terms containing ‘heart’, ‘cardiac’ or ‘cardio’ in their names for the analysis. Totally, 398 cardiac GO terms and 346 genes annotated to these categories were obtained. All categories of heart enhancers display enrichment in cardiac GO terms confirming the heart function of genes flanking these enhancers . When di(j)There are no functional orthologues of class II and class III human-specific heart enhancers in the mouse genome, which allows us to directly quantify the effects of an enhancer loss on the level of gene expression between human and mouse. To analyse whether the lack of heart enhancer function in the corresponding loci of the mouse genome had a footprint on the expression of flanking genes, we investigated whether the loss of a heart enhancer in the mouse genome (or an enhancer gain in the human genome) was balanced by a gain of a new heart enhancer in the same mouse locus and/or the effects of the enhancer loss/gain were mitigated by other redundant/shadow enhancers in that locus. We centred our analysis on the human loci that have orthologous counterparts in the mouse genome. Within the mouse locus counterparts, 3814 mouse heart enhancers were mapped and 2748 of them were mouse-specific . In addition, because human-specific heart enhancers can reside in the same locus with shared heart enhancers that are sufficient to maintain the heart regulatory activity in the locus , we useda). As the class III almost exclusively corresponds to the loss of enhancers in mouse genome (as opposed to an enhancer gain in the primate lineage), these results suggest that a loss of a heart enhancer in mouse is not balanced by an independent heart enhancer gain in the host mouse locus. As singleton heart enhancers represent only a minority of all heart enhancers, the observed heart regulatory activity eradication in many loci with redundant enhancers can be compensated by activity of other heart enhancers in case of a single enhancer loss. However, these results identify single enhancer loci open to regulatory reprogramming, and indicate that the heart activity has been lost or gained in many of them. In addition, even though the mouse orthologous loci of 15 per cent of class II heart enhancers feature additional mouse-specific heart enhancers, the average distance between the mouse-specific heart enhancer and the mouse orthologue of the human-specific heart enhancers is over 200 kb and is fourfold larger than the distance between the mouse orthologues of shared human heart enhancers and their neighbouring mouse-specific heart enhancers (b). As class II represents the primary set for heart enhancers that have been gained in the human lineage, this suggests that this is a case of convergent evolution with independent heart enhancer acquisition in human and mouse genomes might still differ in the regulatory mechanisms associated with the acquired heart regulatory activity.In contrast to the 60 per cent shared heart enhancers that contain at least one other mouse-specific heart enhancer in the orthologous mouse locus, only 15 per cent of class II and 26 per cent of class III enhancers feature the same trend a. As thenhancers b. As clap-value = 0.03) and class III  human enhancers when compared with mouse orthologues of shared enhancers (c). The presence of another mouse enhancer in the locus (clustered) mitigates the impact on the gene expression level upon a loss of a heart enhancer (c), but the qualitative observations did not reach statistical significance in our analysis owing to the low fraction of class II and class III mouse counterparts featuring another mouse heart enhancer in the locus (a). These results demonstrate that the loss and gain of singleton heart enhancers in the locus has a pronounced impact on the regulatory activity of the corresponding genes.The ultimate impact of the regulatory change following the loss and gain of heart enhancers is the change in the heart expression levels of genes flanking the affected enhancers. In particular, we were interested in learning if (i) the loss of a human enhancer in the mouse lineage leads to a decreased level of heart expression and (ii) the presence of another mouse-specific enhancer in proximity to the site of loss could mitigate the impact on the expression level. To validate this observation, we studied the expression level of genes flanking these singleton human-specific heart enhancers in the mouse genome. Indeed, we observed a significant decrease in the fraction of highly expressed mouse heart genes flanking non-clustered  mouse counterparts of class II http://www.ncbi.nlm.nih.gov/homologene) and R2-value was calculated for each expression profile of different mouse heart developmental stage to study the correlation of the expression profiles between foetal human heart and three different mouse heart developmental stages.Expression profiles of three different mouse heart developmental stages, i.e. foetal , postnatal  and adult , were compared with the expression profile of fetal human heart (GSE1789). Expression profile of human genes were mapped into the mouse genome using Homologene ((b)et al. [P300 ChIP-Seq human heart enhancers  and mouse heart enhancers  were downloaded from May et al. . Mouse het al.  and resu(c)Locus length for intergenic/intronic heart enhancers was determined separately . For an (d)All lineage-specific human heart enhancers were mapped into the mouse genome using liftover  and resu(e)http://www.affymetrix.com) and average expression levels for these 10 human non-heart tissues were calculated. For both of these two expression datasets, a small arbitrary number (16) was added to each expression value to avoid misleading readings for low expression values. Log-transformation was performed for the expression level of each gene, and ratio of expression level in the heart tissue to that in the non-heart tissue was calculated. The top 1000 genes with the highest ratio were selected as the highly expressed human heart genes.Gene expression data in foetal human heart were downloaded from the GEO database (GSE1789), and average expression levels across five normal foetal heart samples were calculated. In addition, gene expression data for 10 human non-heart tissues in the HG-U133_Plus_2.tissue-mixture-data-set were downloaded from Affymetrix , and average gene expression levels across five samples were calculated. Besides, gene expression data for 90 mouse non-heart tissues were downloaded from the GEO database (GSE10246). Normalization similar to the human genome was performed to get the top 1000 highly expressed mouse heart genes.(f)SNP data generated by the 1000 Genomes Project  were useP), i.e. variation within species and fixed difference (D), i.e. variation between species but not within species, and studies the fixed rate of variants. Polymorphism (P) was estimated by the sites of SNP across heart enhancers and fixed difference (D) was determined by the difference between the number of nucleotide differences between human and chimpanzee (d) and the heterozygous sites across heart enhancers (π), i.e. D = d−π. The ratio between polymorphism and fixed difference was calculated for each class of heart enhancers (Pe/De) and was compared with the ratio of the neutral reference (nP/nD). The Neutrality index is defined as (Pe/De)/(Pn/Dn) and if the neutrality index is greater than 1 The MK test was also used to estimate selective constrains over human heart enhancers. The MK test compares the difference between polymorphism ((g)T), and all genes near all heart enhancers were treated as the background dataset (B). Fisher's exact test was performed to calculate the p-value for each GO term and the Bonferroni multiple-testing correction was used to determine whether a GO term is significantly enriched in the test dataset. In addition, to determine whether distinct classes of heart enhancers are enriched in different heart genes and are associated with different heart function, only GO terms containing ‘heart’, ‘cardiac’ or ‘cardio’ in their names and genes associated with these GO terms were used in our analysis. Totally, 398 GO terms and 346 genes were used.To determine whether distinct classes of heart enhancers are overrepresented near some particular classes of heart genes, the closest genes for each class of heart enhancers were used as the test dataset ((h)To study whether human-specific heart enhancers are balanced by mouse-specific heart enhancers so that even though human-specific heart enhancers were lost in the mouse genome their flanking genes are still activated by the compensated mouse-specific heart enhancers, first, we identified singleton human heart enhancers, which were not clustered with any other human heart enhancers in the same loci, for each class of human heart enhancers. In total, 220 shared heart enhancers, 101 conserved human-specific heart enhancers (class II) and 119 non-conserved human-specific heart enhancers (class III) were singleton human heart enhancers. After that, all human-specific heart enhancers were mapped into the mouse genome using liftOver [


Assessing left ventricular (LV) dysfunction by echocardiography in ICU patients is common. The aim of this study was to investigate mitral annular plane systolic excursion (MAPSE) in critically ill patients with shock and its relation to LV systolic and diastolic function, myocardial injury and to outcome.In a prospective, observational, cohort study we enrolled 50 patients with SIRS and shock despite fluid resuscitation. Transthoracic echocardiography (TTE) measuring LV function was performed within 12 hours after admission and daily for a 7-day observation period. TTE and laboratory measurements were related to 28-day mortality.MAPSE on day 1 correlated significantly with LV ejection fraction (LVEF), tissue Doppler indices of LV diastolic function  and high-sensitive troponin T (hsTNT)  whereas LVEF did not correlate significantly with any marker of LV diastolic function or myocardial injury. Compared to survivors, non-survivors had a significantly lower MAPSE . Other univariate predictors were age (p=0.033), hsTNT (p=0.014) and Sequential Organ Failure Assessment (SOFA) scores (p=0.007). By multivariate analysis MAPSE (OR 0.6 (95% CI 0.5- 0.9), p= 0.015) and SOFA score (OR 1.6 (95% CI 1.1- 2.3), p= 0.018) were identified as independent predictors of mortality. Daily measurements showed that MAPSE, as sole echocardiographic marker, was significantly lower in most days in non-survivors .MAPSE seemed to reflect LV systolic and diastolic function as well as myocardial injury in critically ill patients with shock. The combination of MAPSE and SOFA added to the predictive value for 28-day mortality. In intensive care patients a frequently applied method for estimating LV systolic function is left ventricular ejection fraction (LVEF) . LV systMitral annular plane systolic excursion (MAPSE) also known as left atrioventricular plane displacement (AVPD), mitral annulus excursion (MAE) or mitral ring displacement is an M-mode derived echocardiographic marker of LV longitudinal function -8. MAPSEThe aim of this study was to investigate if MAPSE is of prognostic significance in critically ill patients with shock. Further, we wanted to examine if MAPSE correlates with other markers of LV function and myocardial injury.The study was approved by the Regional Ethics Review Board, Lund, Sweden (Dnr.187/2005). Informed consent was sought from the patient or, if not possible, from the next of kin. The study design was a prospective observational cohort study. Patients >18 years old admitted to the mixed-bed ICU of Skåne University Hospital, Malmö, Sweden, were screened for eligibility. We included 55 consecutive patients with Systemic Inflammatory Response Syndrome (SIRS) and concurrent shock, where shock was defined as failure to maintain mean arterial pressure ≥ 70 mmHg, despite adequate fluid resuscitation according to the surviving sepsis campaign algorithm . ExclusiTransthoracic echochardiography (TTE) was performed within 12 hours after admission and daily for a 7-day observation period or until discharge from ICU by one of four experienced echocardiographers . Images were acquired using a Hewlett- Packard Sonos 5500  scanner and a 3 MHz transducer. Two-dimensional (2D) imaging examinations were performed in the standard apical four- and two- chamber views (2C- and 4C views). Tissue harmonic imaging was used to enhance 2D image quality. LV ejection fraction (LVEF) was assessed by visual estimation of EF, based on “eyeball” ejection fraction. M-mode images were obtained at the LV septal, lateral, anterior, and posterior borders of the mitral ring  in the aData are presented as median (lower quartile: upper quartile), percentages or absolute values. For not normally distributed variables we used non-parametric test exclusively. For correlation between two variables, Spearman’s rank correlation was used and for differences between two groups we used Mann-Whitney’s U-test. Categorical data were analyzed with Fisher’s exact test. HsTNT and BNP were log transformed with natural logarithm due to skewed distribution. Discrimination analysis was performed using receiver operating characteristics (ROC) curve under the area using multiple logistic regression predictions. Our aim was to investigate how 28-day mortality can be predicted by more than one explanatory variable measured early during ICU stay. Since we did not have any censored data during this period and odds ratio was the outcome of interest, logistic regression was chosen to be the most suitable method  to test The original study included 55 consecutive patients. Two patients were excluded due to lack of written consent. In two patients TTE examinations were not recorded (death before possible TTE and morbid obesity respectively) and one patient was incorrectly registered in the echocardiography database. These five patients were excluded resulting in a total of 50 analyzed patients. Of 350 expected echocardiographic examinations, 96 were missing because of death or discharge from the ICU before Day 7. Another 23 examinations were lost during the installation of a new offline storing and analysis system. Thus, in total, 231 examinations were available for analysis. An additional file shows this in more detail see  than in survivors (median 11 [IQR 8.9-13] mm) of 28-day mortality (p= 0.028). No other echocardiograohic parameter showed any significant difference , SOFA score (p= 0.007), age p= 0.033) and hsTNT p= 0.014) were identified as univariate predictors of 28-day mortality (Table 3 and hsT4 were idResults at day 1 showed that hsTNT was significantly higher in non-survivors (152 [IQR 80–501] ng/L) than in survivors (77.5 [IQR 18.6-125.3] ng/L) (p= 0.014) whereas there was no difference in BNP   and MAPSE, but none with LVEF. Of note, in our previous study we showed a significant correlation between MAPSE and the systolic marker of tissue Doppler imaging (TDIs)  .Notably, MAPSE and TDI are not interchangeable. The two parameters describe different vector components of longitudinal systolic motion. Although TDIs has been described to correlate well with MAPSE in studies with healthy individuals ,41, theyFinally, we sought to investigate if there was a relationship between cardiac biomarkers (hsTNT and BNP) and MAPSE and found that hsTNT but not BNP was significantly higher in non-survivors and correlated significantly with MAPSE but not LVEF. This is in line with a recent study in septic neonates were hsTNT was significantly higher in non-survivors and correlated with longitudinal LV systolic function measured by TDI but not with fractional shortening . LandesbFirstly, we used eyeballing to measure LVEF. Simpson’s biplane method is the currently accepted standard. We and others have previously shown that eyeball EF was as good as the Simpson’s method ,45, and In this study we showed that MAPSE but not LVEF correlated with other markers of LV function and myocardial injury and could be identified as an independent predictor of 28-day mortality. Its predictive value increased when added to SOFA score. A reduced MAPSE persisted in non-survivors throughout the ICU stay. Future prospective studies should evaluate the advantages and weaknesses of MAPSE in critically ill patients with shock where vasoactive drugs and positive pressure ventilation are commonly used, all influencing echocardiographic measurements.The authors declare that they have no competing interests.LB, RW, MC, PG have made substantial contributions to conception and design of the study. LB, MC and HO participated in interpretation of data, helped to draft the manuscript. PG and LB made substantial contributions in acquisition and analysis of data. All authors have made substantial intellectual contributions to the manuscript and have given final approval of the version to be published.Flow diagram showing number of patients, echocardiographic examinations and hsTNT measurements.Click here for file


In patients presenting with ST-elevation myocardial infarction (STEMI), we investigated the relation of left atrial (LA) deformational parameters evaluated by two-dimensional speckle tracking imaging (2D-STI) with conventional echocardiographic diastolic dysfunction parameters and B-type natriuretic peptide (BNP) level.Ninety STEMI patients who were treated with primary percutaneous coronary intervention (PCI) and 22 healthy control subjects were enrolled. STEMI patients had echocardiographic examination 48 hours after the PCI procedure and venous blood samples were drawn simultaneously. In addition to conventional echocardiographic parameters, LA strain curves were obtained for each patient. Average peak LA strain values during left ventricular (LV) systole (LAs-strain) were measured.BNP values were higher in MI patients compared to controls. Mean LAs-strain in control group was higher than MI group . LAs-strain had significant correlation with LVEF , also significant inverse correlations between LAs-strain and BNP level , E/Em , LA maximal volume , LA minimal volume  and LV end systolic volume  were detected. The cut off value of LAs-strain to predict BNP > 100 pg/ml was determined as 19.9% with 55.3% sensitivity and 77.2% specificity (p < 0.05 AUC:0.7).Our study showed that LAs-strain values decreased consistently with deteriorating systolic and diastolic function in STEMI patients treated with primary PCI. LA-s strain measurements may be helpful as a complimentary method to evaluate diastolic function in this patient population. Acute myocardial infarction (MI) results in left ventricular (LV) both systolic and diastolic dysfunction in survivors. During the early phases of MI 38% of patients have impaired relaxation and 24% of patients have restrictive LV filling pattern . The impDiastolic function can be evaluated with several non-invasive and invasive techniques . Tissue Left atrial (LA) function and morphology is affected by increased LV filling pressures. Assessment of LA strain using two dimensional speckle tracking imaging (2D- STI) is a recently introduced and accurate method for evaluating LA functions. Recent studies have shown clinical importance of LA strain in atrial fibrillation and cardiomyopathy ,11. MoreIn the setting of ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), we aimed to investigate the effects of diastolic dysfunction detected by echocardiography and BNP on LA deformational parameters evaluated with 2D-STI. We also measured phasic LA volumes and assessed their relation to diastolic dysfunction and LA strain.Study population consisted of 90  consecutive STEMI patients who were treated with primary PCI in our institution and 22 healthy subjects  as a control group. To constitute the study population 150 consecutive STEMI patients were examined and 90 of them fulfilled the inclusion criteria for the MI group which were; single vessel disease, patients with no known history of previous cardiovascular disease, definite diagnosis of STEMI, successful treatment with primary PCI with restoration of TIMI flow grade 2 or 3 and absence of cardiogenic shock. Patients with atrial fibrillation, moderate-to-severe valvular stenosis or regurgitation, as well as patients whose LA had an insufficient imaging quality, were also excluded from the study. The study was approved by the local ethical committee . Oral and written informed consent was obtained from the patients.Arterial hypertension was defined as a reported blood pressure of >140/90 mm Hg or in patients receiving anti-hypertensive therapy. Diabetes mellitus was defined according to the World Health Organization definition as a fasting blood glucose concentration of >126 or >200 mg/dL 2 h after an oral glucose tolerance test or in patients receiving permanent medical anti-diabetic therapy. Hyperlipidemia was defined as blood total cholesterol concentrations of >180 mg/dL or low density lipoprotein of >130 mg/dL or when patients were receiving permanent treatment with lipid-lowering agents.All patients underwent an echocardiographic examination in the left lateral position, using the GE Vivid 7 system  with a 3.5 MHz transducer. Blood pressure and heart rate were continuously monitored during the transthoracic examination. All data were transferred to a workstation for further offline analysis . STEMI group patients had echocardiographic examination 48 hours after the PCI procedure. Transmitral early (E) and atrial contraction (A) flow velocities were obtained by pulsed-wave Doppler in the apical four-chamber view. The ratio of E/A velocity and E-wave deceleration time were measured. For TDI, the same echocardiography machine was used to acquire TDI data at high frame rates. The Nyquist limit was set at 15–20 cm/s, and minimal optimal gain was used. The myocardial systolic (Sm), early diastolic (Em), and late diastolic (Am) velocities were obtained at the septal and lateral mitral annulus by placing a tissue Doppler sample volume. The E/Em for septal and lateral annulus, additionally E/A ratios were subsequently calculated. LA dimensions and LV end-systolic (LVESD) and end-diastolic diameters (LVEDD) were measured. LV ejection fraction (LVEF) was estimated by Simpson's biplane method using apical 4-chamber and 2-chamber views.The following LA volumes were measured from apical 4 and 2 chamber views by using biplane modified Simpson’s method and indexed to body surface area (BSA):max): measured during LV contraction just before mitral valve openingMaximum LA volume (LAVmin): measured at the QRS onset on electrocardiographyMinimum LA volume (LAVres): LAVmax − LAVminLA reservoir volume (LAVmax] − [LAVmin]/[LAVmax]LA ejection fraction (LAEF): [LAVTwo-dimensional echocardiography images for the LA were obtained from the apical four-chamber view. All images were obtained while the patients held their breath at end expiration and the images were stored in a cine-loop format from three consecutive beats. The frame rate for images was set between 60 and 90 frames/s. After defining the endocardial border manually, tracings were developed by the software system automatically for each frame. If the automatically obtained tracking segments were adequate for analysis, the software system was allowed to read the data, whereas analytically inadequate tracking segments were either corrected manually or excluded from the analysis. Image tracking algorithm divided the LA wall into 6 segments automatically. The most frequently excluded segments were the ones containing pulmonary vein entrances and LA apex. The typical LA strain curves were obtained for each patient. Average peak LA strain values during LV systole (LAs-strain) for 6 segments were measured Figure .Venous blood samples were drawn simultaneously with echocardiographic examination both in STEMI patients and control subjects. The samples were immediately centrifuged at 1500 rpm for five minutes and plasma was stored at -80C° until the time of measurement. The quantitative determination of BNP in plasma was done by immune fluorescence method using the ADVIA Centaur System .Intra- and inter-observer reproducibility for the LAs-strain was assessed. For intra-observer assessment, images from randomly selected 25 patients were re-analyzed after a week. The Bland–Altman analysis and the intra-class correlation coefficient (ICC) showed good inter- and intra-observer agreement; for inter-observer agreement for LAs-strain, the mean difference was 1.8  and ICC 0.87; and for intra-observer agreement, the mean difference was 1.3  and ICC 0.91.2 test was used. Correlations between variables were tested by using the Pearson or Spearman’s correlation tests. Receiver-operating characteristic (ROC) curves were plotted to determine the optimal cut-off values for LA strain of STEMI patients in order to predict increased BNP. Statistical analyses were performed mainly using SPSS, version 15.0 for Windows; and Medcalc software for Windows was also used when necessary.Continuous variables were expressed as mean (SD) or median (interquartile range) as appropriate. The level of significance was 0.05. To compare parametric continuous variables, the independent Student t-test or the Mann–Whitney U-test was used. For categorical variables, the xThere was a male dominancy in both MI (%89) and control (%83) patients; the mean age of subjects were 52.4 ± 8.7 years in MI group and 50.1 ± 4.7 years in control group. Demographic characteristics of STEMI patients are shown in Table BNP values were significantly higher in MI patients compared to control subjects . The differences between the measurements of transmitral flow velocities  and E/Em, E/A ratios of the groups were also significant , LAVmin , LAEF (r = 0.38 p = 0.001) and LVESV  , also there was a significant inverse correlation between LAs-strain and BNP level , E/Em , LAV) Figure .When the ROC curves were plotted for LA strain to predict increased BNP in STEMI patients; the cut off value of LA strain during LV systole was 19.9% for the MI patients whose BNP values were higher than 100 pg/ml with 55.3% sensitivity and 77.2% specificity  (Figure In our study we demonstrated that LAs-strain was significantly reduced after STEMI compared to controls, additionally it was closely related with LVEF and BNP level. E/Em ratio, LA volumes and BNP were also significantly increased in STEMI patients reflecting increased diastoling filling pressures and diastolic dysfunction. Moreover, LAs-strain value of ≤ 19.9% predicted MI patients whose BNP values were higher than 100 pg/ml with 55.3% sensitivity and 77.2% specificity.Patients who have elevated LV filling pressures after acute MI are more likely to suffer from chronic heart failure and have an increased mortality. Using the E/Em ratio, a close approximation of LV filling pressures can be obtained in a wide spectrum of patients ,15. The When indexed to BSA, LA volume is independently associated with increased cardiovascular risk and disease burden  and is aTwo-dimensional speckle tracking imaging was shown in many studies to be useful in quantification of atrial deformation ,25. The In addition to the LAs-strain being an index of the reservoir function, it is also closely related to LV systolic function as mentioned previously . Cameli max, LAV min and LV end systolic volume. Additionally, when the cut off value of LA strain during LV systole was accepted to be ≤ 19.9%, MI patients with BNP values ≥100 pg/ml were predicted with 55.3% sensitivity and 77.2% specificity.Biomarkers such as BNP may also be used to estimate elevated LV filling pressures . Levels The current study has several limitations. Strain rate and strain have been shown to be influenced by preload change and evaluation of LA function by 2D-STI is relatively difficult and time-consuming, besides; to obtain appropriate LA images for strain analysis in patients with insufficient echocardiographic images is difficult and sometimes impossible. The major limitation of our study was that instead of measuring LVEDP invasively, it was estimated using BNP and echocardiographic parameters. The patients were not followed prospectively to assess the prognostic impact of decreased LAs-strain after MI.In conclusion, we observed that LAs-strain values decreased consistently with deteriorating systolic and diastolic function and decreased LAs-strain values also predicted BNP > 100 pg/ml in STEMI patients treated with primary PCI. With this study we suggest that, LA-s strain measurements may be helpful as a complimentary method to evaluate diastolic function when inconclusive results are obtained by conventional echocardiographic parameters.The authors declare that they have no conflicts of interest.CK,NO and CD constituted the study design; CD, OC, MYE, RBB, BD and MOO performed the echocardiographic examinations and collected the patient data, SH and CD carried out statistical analysis and drafted the manuscript. All authors read and approved the manuscript.


The low-molecular-weight isoform (Lo) of fibroblast growth factor 2 (FGF2) has distinct functions from the high-molecular-weight isoforms (Hi) of FGF2 in the adult stressed heart. However, the specific roles of these isoforms in the unstressed heart were not examined. We investigated whether the FGF2 isoforms modulate cardiac development and physiology in isoform- and sex-specific manners. Young adult male and female mice that were deficient in either Hi FGF2 (Hi KO) or Lo FGF2 (Lo KO) underwent echocardiographic analysis and were compared to their wild-type (WT) counterparts. By comparison to WT cohorts, female Lo KO hearts display a 33% larger left ventricular (LV) volume and smaller LV mass and wall thickness. Mitral valve flow measurements from these hearts reveal that the early wave to atrial wave ratio (E/A) is higher, the deceleration time is 30% shorter and the mitral valve E-A velocity–time integral is reduced by 20% which is consistent with a restrictive filling pattern. The female Hi KO hearts do not demonstrate any significant abnormality. In male Hi KO mice the cardiac output from the LV is 33% greater and the fractional shortening is 29% greater, indicating enhanced systolic function, while in male Lo KO hearts we observe a smaller E/A ratio and a prolonged isovolumic relaxation time, consistent with an impaired relaxation filling pattern. We conclude that the developmental and physiological functions of FGF2 isoforms in the unstressed heart are isoform specific and nonredundant and that these roles are modulated by sex. In the context of the heart, growth factors are critical for modulating cellular proliferation, differentiation and growth, extracellular matrix (ECM) deposition and composition, adhesion, migration, motility, apoptosis and responses to physiological and pathophysiological stimuli (Schneider and Parker Fibroblast growth factor 2 (FGF2), a prototypic member of the FGF family, is encoded by a single gene but expressed in several isoforms due to alternative initiation of translation  of the The first indication that Hi and Lo FGF2 must have differential functions was that their protein expression levels relative to each other are tissue specific and independent of the genomic location of their transgenes   is a reliable method of discerning changes in cardiac geometry and systolic and diastolic function in mice , and Hi KO (Fgf2m3Doe/J) FGF2 mice were used for this study. These mice were generated as described previously  in the University of Arizona's Arizona Research Laboratory (ARL). Five to 10 (Tables Wild-type (WT), Lo KO Fgftm2Doe/J,Echo was performed on a Vevo 770 , using the specially adapted 707B scan head. Before imaging, the mice were anesthetized with 3% isoflurane mixed with 100% oxygen, and anesthesia was thereafter maintained with 1.5% isoflurane. The mice were depilated as required for imaging and placed on a 37°C heated platform throughout the imaging procedure. Echo measurements were taken from at least three different cardiac cycles for each mouse.M-mode imaging from the short axis (midventricular plane) of the left ventricle (LV), using the papillary muscles for reference Fig. A, was us3; LV volume in diastole  = ) × LVID;d3; LV Mass = 1.053 × 3 – LVID;d3), the LV mass was then normalized to body mass; endocardial volume in diastole = (4π/3))2; endocardial volume in systole = (4π/3))2; stroke volume (SV) = Endocardial Volume in diastole − Endocardial Volume in systole; cardiac output (CO) = HR × Endocardial SV/2; LV Fractional Shortening (FS)% = 100 × /LVID;d); mitral valve E to A ratio = E/A; mitral valve peak pressure Gradient  = 2)/106. The velocity–time Integral (VTI) for any PW-Doppler velocity measurements was calculated by integrating over the time interval.Based on the direct Echo measurements we used the Vevo 770 software (v3.0.0) to calculate dependent Echo parameters of the heart. The following calculations were used: LV volume in systole  = ) × LVID;st-test with unequal variance was used to evaluate the data. A difference was considered significant when P < 0.05. In the panels of barographs the height of the bar represents the mean while the error bar represents the standard error of the mean.Two-sided student Echo LV mass is a parameter for determination of LV mass that was extrapolated from systematic analysis of the relationship between the antemortem LV Echo and postmortem anatomic LV Mass . LA dimension can be indicative of aortic stenosis and left atrial enlargement , we obtained CO and SV. M-mode imaging Fig. A was useIn sex comparisons the higher CO, SV, and FS exhibited by male Hi KO hearts are also significantly higher than the female cohorts Fig. B–D. ThisUsing PW-Doppler Fig. A we measThus, the observation that Hi KO male hearts have enhanced systolic function is also supported by the systolic PW-Doppler data that show a higher velocity of pulmonary artery flow  Fig. E which wWhen comparing across sex we find that the E/A ratio is significantly higher in female Lo KO hearts than their male cohorts; this sex difference is absent from both the WT and Hi KO groups Fig. B. On theThis study provides novel evidence on the interaction of sex and endogenous FGF2 isoforms as modulators of cardiac development and physiology. Lo FGF2 signaling is necessary in the female heart only for normal myocardial growth while in both male and female hearts Lo FGF2 signaling is required for normal diastolic function. On the other hand, Hi FGF2 is necessary only in male hearts for modulating systolic function and does not display a physiological role in female hearts. Hence, we demonstrate that Lo FGF2 and Hi FGF2 have nonredundant roles in cardiac development and physiology which are sex specific.Sex differences in cardiac phenotype are well documented in both humans and animal models. With some exceptions, estrogen is associated with a cardioprotective effect while male hormones are considered to be detrimental Du . To dateFGF2 is expressed early in the developing embryonic heart. This expression is spatially and temporally regulated (Liao et al. The female Lo KO heart is interesting in that it has a smaller mass at baseline while the cardiomyocyte cross-sectional area is normal. This is reminiscent of the smaller heart that results from IGF-I receptor deficiency (Holzenberger et al. Lo KO and Hi KO mice were previously used in I/R studies to reveal differential pathophysiological functions of FGF2 isoforms in the heart (Montero et al. Although endogenous FGF2 clearly acts locally in heart tissue (Pellieux et al. Hi FGF2 is essential for normal systolic function in male but not in female hearts. The increased SV and FS in male Hi KO hearts Fig. . Clinica2+ from troponin-C through sarcoplasmic reticulum uptake and subsequent detachment of actin–myosin cross-bridges (Yellin et al. 2+ dysregulation is a possible cause for the impaired relaxation observed in the male Lo KO hearts. Diastolic flow data from the female Lo KO hearts indicates a stiff LV. Clinically, stiffness is a part of diastolic dysfunction and is usually the consequence of pathological changes in either the ECM or the cardiomyocytes. Increased collagen synthesis, decreased degradation or increased cross-linking all can contribute to LV stiffness (Ahmed et al. 2+ uptake (Neagoe et al. Doppler interrogation of diastolic flow further elucidated a sex- and isoform-specific phenotype where male KO hearts display an impaired relaxation pattern. At the cardiomyocyte level, relaxation involves the removal of CaIn light of the results of this study, a model of the role of FGF2 isoforms in cardiac diastolic physiology emerges Fig. . In the The results of this study demonstrate that Lo KO and Hi KO mice are useful tools for studying diastolic dysfunction. The importance of understanding diastolic dysfunction stems from the prognosis of diastolic heart failure that accompanies it. Almost half of patients diagnosed with heart failure are classified under the diastolic heart failure category (Zile and Brutsaert Previous studies were inconclusive on whether FGF2 modulates cardiac growth and development. Our laboratory showed that all KO mice develop normally and have normal cardiac structure and mass (Zhou et al. Even though we reveal a sex-specific role of FGF2 isoforms in cardiac physiology and development, the pathways through which the isoforms signal to modulate cardiac physiology and development are not fully understood. Of special note is the lack of a detailed description of Hi FGF2 signaling and its interaction Lo FGF2 or with its effectors downstream. The interaction of estrogens and androgens with FGF2 isoforms to produce the sex-specific phenotypes observed here also remains to be investigated. In the context of the heart alone, how the isoforms modulate physiological hypertrophy or myocardial pathological remodeling, including ECM composition and cross-talk between the cellular constituents of the myocardium, are questions with possible clinical significance. With our Lo and Hi KO mice we can begin to address these and other questions.


We challenge the hypothesis of enhanced myocardial reperfusion after implanting a left ventricular assist device together with bone marrow mononuclear stem cells in patients with end-stage ischemic cardiomyopathy. Irreversible myocardial loss observed in ischemic cardiomyopathy leads to progressive cardiac remodelling and dysfunction through a complex neurohormonal cascade. New generation assist devices promote myocardial recovery only in patients with dilated or peripartum cardiomyopathy. In the setting of diffuse myocardial ischemia not amenable to revascularization, native myocardial recovery has not been observed after implantation of an assist device as destination therapy. The hybrid approach of implanting autologous bone marrow stem cells during assist device implantation may eventually improve native cardiac function, which may be associated with a better prognosis eventually ameliorating the need for subsequent heart transplantation. The aforementioned hypothesis has to be tested with well-designed prospective multicentre studies. Left ventricular assist devices (LVADs) are increasingly used as "bridge to transplantation" in patients with end-stage heart failure (HF) or more recently as destination therapy in non-transplant candidates. Encouraging results with LVADs as a "bridge to recovery" have been reported from the Berlin group in patients with idiopathic dilated cardiomyopathy (IDCM)  and by SHibernation plays a key role in patients with coronary artery disease (CAD). Rahimtoola first described the condition of chronic sustained abnormal contraction in patients who have CAD which is reversible with revascularization and it is attributable to chronic underperfusion as myocardial hibernation . AlteratIt is estimated that 6-10% of people over the age of 65 suffer from symptomatic HF in developed countries. In the USA and UK there are about 25,000 and 12,000 patients, respectively, aged less than 65 years, with severely symptomatic New York Heart Association (NYHA) class IV heart failure . A meta-The prognosis for patients with chronic ischemic left ventricular (LV) dysfunction is poor, despite advances in pharmacological management. With only 2000 donor hearts available annually in the USA and 150 in the UK, LVADs provide an "off-the-shelf" solution for patients with end-stage ICM ineligible for transplant or for those wishing to avoid immunosuppression . Use of Induction of molecular and cellular changes in the failing myocardium has been observed with the use of LVADs . In an a+), haematopoietic stem cells (CD34+), and mesenchymal stem cells (CD105+) was administered at pre-defined myocardial territories designated as hibernating myocardium on preoperative radionuclide scintigraphy segmental mapping . They were both considered ineligible for heart transplantation due to severe co-morbidities. Autologous BMSCs were collected from bilateral anterior iliac crests during the same anaesthetic for device implantation and treated as previously described. A Jarvik 2000 axial-flow pump with skull pedestal power delivery was implanted for long-term mechanical circulatory support Figure . A stem Ischemic heart disease remains a major health care challenge, and progenitor cell-based therapy holds potential for treating the spectrum of myocardial ischemia. Current therapy for HF is based on the traditional belief that the heart is unable to generate new cardiomyocytes to replace failing or dying ones, but instead adapts to new stresses by myocyte hypertrophy and cardiac remodelling. Replacement of scared tissue and regeneration of viable myocardium remains a challenging target of cell transplantation therapy. However, myocardial regeneration in human has not yet been identified. Even though Orlic D, et al. reported that the injected bone marrow (BM) stem cells differentiated in a mouse myocardial infarction model into cardiomyocytes that reduced infarct size and improved myocardial function , Murry CHuman heart possesses a CSC pool which is reduced in heart failure due to apoptosis, resulting in a reduced number of functionally competent cells . TherefoWhilst originally intended to supply new functional cardiomyocytes, it is now clear that implanted cells respond to their environment by secreting cytokines and growth factors which act both in an autocrine fashion on the donor cells and exert paracrine effects on the host cells . This prAttempts to improve cardiac performance in chronic ischemic HF patients using cell transplantation and mechanical assistance have been reported using autologous skeletal myoblasts and BMSCs ,23. CellIn order to test the hypothesis of myocardial reperfusion with this hybrid approach, detailed myocardial segmental viability studies as well as LV contraction analysis are essential to establish the efficacy of the method. Since the net "healing" capacity of BMSCs is difficult to determine, imaging of transplanted stem cells is crucial in order to investigate the attitude of the engrafted stem cells to the hosting myocardium . The numAlthough cellular recovery and improvement in ventricular function are evident during LVAD support in non-ischemic cardiomyopathy, the degree of cardiac recovery is limited in patients with ICM. Implantation of stem cells to promote myocardial perfusion during mechanical support in end-stage ICM may eventually provide a realistic alternative to cardiac transplantation allowing scarce donor hearts to be used for more complex cardiac defects. This hypothesis has to be tested through further well-designed randomized controlled studies.The authors declare that they have no competing interests.KA Conception and design, provision of patients, data analysis and interpretation, manuscript writing. PA Conception and design, data analysis and interpretation, manuscript writing. HA Data analysis and interpretation. GK Collection and assembly of data. AD Collection and assembly of data. AK Data analysis and interpretation, collection and assembly of data. CP Conception and design, data analysis and interpretation. SW Conception and design, data analysis and interpretation, manuscript writing. All authors read and approved the final manuscript.


Objective. The aim of the study was to describe echocardiographic abnormalities in patients with rheumatoid arthritis, concurrent systemic comorbidities, rheumatologic clinical activity, serologic markers of rheumatoid arthritis, and inflammatory activity. Methods. In an observational, cross-sectional study, rheumatoid arthritis outpatients were included (n = 105). Conventional transthoracic echocardiographic variables were compared between patients with arthritis and non-RA controls (n = 41). For rheumatoid arthritis patients, articular activity and rheumatologic and inflammatory markers were obtained. Results. Ventricular dysfunction was found in 54.3% of the population: systolic (18.1%), diastolic (32.4%), and/or right (24.8%), with lower ejection fraction (P < 0.0001). Pulmonary hypertension was found in 46.9%. Other echocardiographic findings included increased left atrial diameter (P = 0.01), aortic diameter (P = 0.01), ventricular septum (P = 0.01), left ventricular posterior wall (P = 0.013), and right ventricular (P = 0.01) and atrial diameters compared to control subjects. Rheumatoid factor and anti-CCP antibodies levels were significantly elevated in cases with ventricular dysfunction. Angina and myocardial infarction, diabetes, and dyslipidemia were the main risk factors for ventricular dysfunction. Conclusions. Ventricular dysfunction is common in rheumatoid arthritis and associated with longer disease duration and increased serologic markers of rheumatoid arthritis. Screening for cardiac abnormalities should be considered in this kind of patients. Rheumatoid arthritis (RA) is a chronic inflammatory disease –4, and eMultiple studies have shown that accelerated and increased atherosclerosis in autoimmune diseases leads to ischemic coronary artery disease. The proposed mechanisms for this are a major systemic inflammatory state involving T cell lymphocytes, tumor necrosis factor alpha , high density lipoprotein dysfunction, and treatment related hyperhomocysteinemia. All of these factors lead to thickening of arterial intima, myocardial dysfunction, and in some cases myocardial infarction and are responsible for up to 50% of deaths in this population .RA has been linked to several structural heart abnormalities, including increased right ventricular filling pressure, left ventricular hypertrophy, pulmonary artery hypertension, and as much as twice the prevalence of heart failure , 8, 10. Cardiovascular risk and RA disease activity assessment through clinical judgment and appropriate questionnaires in addition to inflammatory markers may provide adequate screening tools to predict heart disease in RA patients, even in asymptomatic stages, which eventually will lead to early, cost effective studies and treatment.We performed an observational cross-sectional study among outpatients of the Internal Medicine and Cardiology Departments of the Instituto Nacional de Ciencias Médicas y Nutrición SZ. Subjects were included if they were at least 18 years old with a previous diagnosis of rheumatoid arthritis. Patients with suspected heart failure, cardiomyopathy, endocarditis or myocarditis, amyloidosis, chronic obstructive pulmonary disease, pulmonary hypertension, secondary Sjögren's disease, infiltrative diseases, severe anemia hematologic disorders, and severe kidney and/or hepatic disease were excluded. Control subjects were outpatients of the Internal Medicine Department with an echocardiogram study and without diagnosis of rheumatoid arthritis who were matched for age and sex with rheumatoid arthritis.Selected patients completed a clinical history and physical examination, emphasizing current and former medications, cardiovascular diseases and other comorbidities, and symptoms and signs of RA activity within the last 7 days. If articular activity was found, an analog visual scale for pain and DAS28 questionnaire were applied to establish RA activity at the time.All patients had transthoracic echocardiograms performed by a cardiologist blinded to the clinical evaluation and treatment received. Wide angle, two-dimensional echoes were videotaped on a 3/4 inch videocassette recorder with patients in left lateral recumbent position, using an HP Sonos ultrasound 5000 imaging system. Apical four chambers and apical two chambers views were selected for left ventricular long axis at end-diastole and at end-systole to calculate ejection fraction and stroke volume. Total peripheral resistances were estimated using standard formulas according to the recommendations of the American Society of Echocardiography.Ventricular dysfunction was diagnosed following the echocardiography criteria of the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Diastolic dysfunction was considered to be present when the ejection fraction was more than 45% and the shortening fraction ≥28%, without severe segmental dyskinesia of the left ventricle and left atrial enlargement or increased thickness of the posterior wall, ventricular septum, and cardiac mass index.The study was approved by the Institutional Ethics Committee of Biomedical Research in Humans of the INCMNSZ, and all participants gave written informed consent.t-test for independent samples or chi-square according to the type of variable. Echocardiographic findings of patients with RA were compared to those of a control group without RA. A P value <0.05 was considered statistically significant. All analyses were performed with commercially available software .Data are presented as mean ± standard deviation for continuous variables with similar distribution to the normal curve. In the case of categorical variables, data are presented as absolute and relative frequencies. Study population was classified in two groups: patients with RA and ventricular dysfunction and patients with RA without ventricular dysfunction. The groups were compared with a Student's In the present study 105 patients with RA were included; the female gender (79%) was predominant. Hypertension (51.4%), coronary artery disease (27.6%), and diabetes (17%) were the most frequent cardiovascular risk factors.Fatigue (42.9%), shortness of breath (49.5%), and edema (39%) were the main symptoms reported potentially associated with heart failure. From the rheumatologic perspective, most patients were in functional categories 1 or 2, with no significant limitations of daily activities. According to the DAS questionnaire, most patients had high or intermediate disease activity at the time of evaluation, 30.5% high and 42.9% intermediate activity. Glucocorticoids, folic acid antagonist (methotrexate), and other disease modifying antirheumatic drugs (DMARD) were used in 26.7% of the patients.Among the echocardiographic findings, patients with RA had lower ejection fractions, greater left atrial and aortic diameters, ventricular septum and left ventricular posterior wall thickness, and right ventricular and atrial diameters. Pulmonary systolic arterial pressure (PSAP) was also increased in comparison to control subjects .Echocardiographic abnormalities indicating ventricular dysfunction were found in 54.3% of the population, including left systolic (18.1%), diastolic (32.4%), and/or right (24.8%) ventricular dysfunction. It was also frequent to observe pulmonary hypertension (46.9%).When patients with RA without ventricular dysfunction were compared to RA patients with ventricular dysfunction, the latter were older, but there were no differences between the groups with respect to the duration of rheumatologic disease. Angina and myocardial infarction, diabetes, and dyslipidemia were frequently found in the patients with ventricular dysfunction. However, serum cholesterol concentrations were lower in patients with ventricular dysfunction, although, LDL cholesterol was slightly higher. HDL concentrations were similar in both groups .With respect to rheumatoid factor and anti-CCP antibodies levels, these were also significantly elevated in cases with ventricular dysfunction, despite similar erythrocyte sedimentation rates in the two groups .P < 0.05).The use of glucocorticoids, folic acid antagonist (methotrexate), or other DMARDs was not different across RA groups, while treatment with beta blockers, diuretics, digitalis, and nitrates was significantly more prevalent in those patients with echocardiographic anomalies . Whether these drugs were capable of maintaining patients asymptomatic is not known.Another interesting finding was that treatment with DMARDS, folic acid antagonists, glucocorticoids, and folic acid supplements was not significantly different between RA patients with asymptomatic ventricular dysfunction and those without. To be sure, treatment with beta blockers, diuretics, digitalis, and nitrates was significantly more prevalent in those patients with echocardiographic anomalies , nor DMARDs were different between the groups in the present study, but diabetes and coronary artery disease traditional risk factors were independently associated with ventricular dysfunction. These findings are different from those reported by other authors that mention that the risk of developing CHF in RA is twice the risk of developing CHF in persons without RA and is not explained by traditional cardiovascular risk factors and/or clinical ischemic heart disease .We consider that RA patients with the clinical and serologic characteristics previously mentioned should be screened for ventricular dysfunction and pulmonary hypertension. Even in clinically asymptomatic patients these entities must be ruled out, since early intervention may prevent the development of clinically symptomatic heart failure and severe pulmonary hypertension, and in later stages interventions will not provide as good a prognosis.The present study illustrates that some rheumatoid arthritis patients present structural heart abnormalities that will probably progress to heart failure. These abnormalities appear to be more common in patients with a history of coronary artery disease and diabetes, longer disease duration, and increased serologic markers of rheumatoid arthritis. Focused assessment directed toward heart failure screening based on clinical judgment and echocardiography in a population with the former characteristics offers an opportunity for appropriate and early management of heart disease.


Recent studies suggest the significance of right ventricular (RV) function in the outcome in patients with left ventricular dysfunction (LVSD); however, global assessment of RV remains to be determined by echocardiogram because of its complex geometry. This study aimed to validate RV outflow tract fractional shortening (RVOT-FS) in the evaluation of RV function and its prognostic value in patients with LVSD.This study included eighty-one patients  with reduced LV ejection fraction (LVEF) (≤40%). Two-dimensional echocardiogram of the parasternal short axis view was obtained at the level of the aortic root, and RVOT-FS was calculated as the ratio of end-diastole minus end-systole dimension to end-diastole dimension.RVOT-FS ranged from 0.04 to 0.8 , and correlated with LVEF , RV fractional area change  and brain natriuretic peptide level . In Cox multivariate regression analysis, RVOT-FS ; p = 0.008] and New York Heart Association functional class III-IV ; p = 0.037] were independent factors to predict the events. During a median follow-up period of 319 days (1 to 1862 days), patients with RVOT-FS ≥ 0.2 showed a higher event-free rate than those < 0.2 by Kaplan-Meier analysis .Our data suggest that RVOT-FS is a simple parameter reflecting the severity of both ventricular function in patients with LVSD. In addition, RVOT-FS might be useful to predict adverse outcomes in such a patient population. Left ventricular ejection fraction is well recognized in the adverse clinical outcomes of patients with chronic heart failure ; however<40%) but not on clinical symptoms, and excluded if they had LVSD due to acute myocarditis and tachycardia-induced cardiomyopathy. Patients underwent coronary angiography, 201Tallium-/ 123I-β-methyl iodophenyl pentadecanoic acid scintigraphy, 18fluoro-deoxyglucose by positron emission tomography imaging, magnetic resonance imaging and endmyocardial biopsy to aid in the definition of the etiology of LVSD, such as ischemic heart disease, hypertensive heart disease, valvular heart disease and secondary cardiomyopathies (ex. sarcoidosis or other infiltrative cardiomyopathies). We notified the patients in writing and on the homepage, or gave written informed consent. This study was approved by the Human Investigation Review Committee of the University of Miyazaki (No.979) and conformed with the principles outlined in the Declaration of Helsinki .This study included 81 patients hospitalized at Miyazaki University Hospital between March 2007 and November 2011. Patients were selected based on the impaired LV systolic function (LV ejection fraction (EF) Echocardiography was performed using an ATL Philips IE33 Ultrasound machine  with the determination of standard and Doppler parameters. Echocardiographic data on admission and at the out-patient clinic were stored (DICOM format), and reviewed digitally off-line on a desktop computer with ProSolv software  by two experienced cardiologists. Size of the left atrium (LA), LV at end-diastole (LVDd) and end-systole (LVDs), and wall thickness of the intraventricular septum (IVSTd) and posterior wall (LVPWTd) at diastole were determined from the two-dimensional parasternal long-axis view on electrocardiogram. LVEF was calculated by the modified Simpson’s method in apical four- and two-chamber views. For evaluating the RV fractional area change (RVFAC), endocardial borders were outlined at end-diastole and end-systole, using an apical four-chamber view , and RVFWe validated the RVOT-FS assessed by echocardiogram with 1.5-Tesla MRI system . Nine subjects were in the supine position with breath holding in expiration and with a vector-cardiographic method for electrocardiographic gating. Transaxial slices using the rephrased gradient echo technique was planned to cover the heart from a level just below of diaphragm to bronchial bifurcation, with repetition time of 2.7-2.9 msec, echo time of 0.8-1.0 msec, a flip angle of 40 degree, and a slice thickness of 10 mm. The diameters of RVOT at end-diastole and end-systole were measured on still frames with manual tracing by means of a track-ball cursor.Plasma brain natriuretic peptide (BNP) concentration was measured by chemiluminescent immunoassay . C-reactive protein in the serum was determined by the latex agglutination test with a measurement range of 0.01 to 32 mg/dL. Estimated glomerular filtration rate (eGFR) was calculated using the equation for the Modification of Diet in Renal Disease .Follow-up was performed by direct examination of medical records or by contact with cardiologists. All patients were followed up until October 2012 unless a major end point terminated the follow-up. In the present study, outcomes were included such as death from cardiovascular diseases , requirement of cardiac transplantation, and unexpected hospitalization due to the worsening of heart failure .t-test or Mann-Whitney test for two continuous parametric or nonparametric variables, and the Fisher’s exact test for qualitative data such as numbers and percentages. Unadjusted and adjusted associations of RVOT-FS with other clinical parameters were evaluated by Spearman rank-correlation coefficient and multivariate linear regression. There were close relationships between the following two variables [LVDd and LVDs ] and [IVSTd and LVPWTd ], and we removed LVDs and LVPWTd as variables in the analysis. A Cox proportional hazards model was used to determine any variables as significant factors to predict cardiovascular events in the study subjects. The covariates included in this model were age, sex, use of β-blocker, angiotensin converting enzyme inhibitor (ACE-I) /angiotensin II type 1 receptor antagonist (ARB), calcium channel blocker, diuretic and aldosterone antagonist, rhythm in electrocardiogram, echocardiographic parameters , BNP, eGFR, hemoglobin, total bilirubin, uric acid, C-reactive protein and New York Heart Association (NYHA) functional class. Results are presented as relative risk with 95% confident interval (CI). Kaplan-Meier analysis was constructed by receiver operating characteristics (ROC) analysis. In addition, Bland-Altman plots were used to compare the agreement of the two methods (echocardiography vs. cine MRI). The plot was displayed as the average of the two values and the difference between the two measurements. Results are shown as absolute numbers (%) or the mean ± standard deviation (SD). Statistical significance was accepted when p < 0.05.Data analyses were performed using GraphPad Software Prism 5  for Bland-Altman plot and SPSS version 11.0  for the rest of the analyses. We used Student’s Table RVOT diameter was 3.1 cm at end-diastole  and 2.1 cm at end-systole , and the mean value of RVOT-FS was 0.3 . Table During a median follow-up period of 319 days (1 to 1862 days), all-cause events occurred in 38 patients . Table > 0.2 or < 0.2. As shown in Figure > 0.2 had a higher prevalence of event-free periods, compared with < 0.2 (log-rank test p = 0.0016).Table Reproducibility of the RVOT-FS measurement was evaluated by calculating the intra- and inter-observer variability in 20 patients. The intra- and inter-observer coefficient variables were 2.5 and 14.7, respectively. We also carried out cine MRI for nine subjects to examine the validity of RVOT-FS assessed by echocardiogram. The Bland-Altman plots demonstrated no evidence of substantial fixed or proportional bias in the two methods (Figure Assessment of RV function is important to understand the pathophysiology of heart failure; however, it is still challenging to find a simple and comprehensive parameter by echocardiogram. In this study, we demonstrated that RVOT-FS reflects the severity of both left- and right-sided ventricular function. In addition, our data suggested that RVOT-FS might be a useful parameter to predict cardiovascular events in patients with LVSD.RV originates from a different embryological source to LV . RVOT isThis is a retrospective observation study with a small number of heterogeneous pathologies in patients with LVSD. We did not assess the other RV systolic parameters, such as peak systolic tricuspid annular velocity, integral of the systolic wave, and tricuspid annular plane systolic excursion . In addiThe present study suggests that RVOT-FS is a parameter to assess the severity of both ventricular functions in LVSD patients. In addition, our findings implicate a measurement of RVOT-FS might provide a predictive value in such a patient population.RVOT: Right ventricular outflow tract; LVSD: Left ventricular systolic dysfunction; FS: Fractional shortening; EF: Ejection fraction; LA: Left atrium; LVDd: LV dimension at end-diastole; LVDs: LV dimension at end-systole; IVSTd: Wall thickness of the intraventricular septum; LVPWTd: Wall thickness of the posterior wall; TR-PG: Tricuspid regurgitation-pressure gradient; RVFAC: RV fractional area change; MRI: Magnetic resonance imaging; BNP: Brain natriuretic peptide; eGFR: Estimated glomerular filtration rate; ACE-I: Angiotensin converting enzyme inhibitor; ARB: Angiotensin II type 1 receptor antagonist; NYHA: New York Heart Association; ROC: Receiver operating characteristics; SD: Standard deviation.The authors have no competing interest.MY, TT and KK designed the study, investigated all patients and analyzed the data. MY and TT wrote the manuscript. MY, TT and KF performed echocardiogram and acquired the measurement. YW and MT performed cine MRI and analyzed the data. HO, T. Ideguchi, J. Kawagoe, and T. Ishikawa have interpreted the data and have been involved in drafting the manuscript. J. Kato performed the statistical analysis and made critical review of the manuscript. All authors have read and given final approval of the manuscript.


Tako-tsubo cardiomyopathy (TTC) accounts for 1% of admissions for chest pain in Japan and up to 1 in 30 cases referred for acute primary angioplasty in Western cohorts. The absence of myocardial late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) has been recommended in the literature to distinguish TTC from either acute myocardial infarction or myocarditis.Data were retrospectively reviewed from 27 consecutive patients with confirmed Mayo Clinic criteria for TTC  presenting to our institution over a 2 year period. A CMR (GE 1.5T Twinspeed) protocol of steady state free precession, triple inversion recovery, and myocardial LGE imaging was performed in the acute phase. LGE was quantified using standardized software (ReportCard V4.0), with both 2 and 5 standard deviations thresholds (SD) above normal remote myocardium, normalized to LV mass.All patients had raised serum troponin I . Mean ejection fraction by CMR was 43% ±8.5% (range 25-51%), mean door-to-CMR time 59 hours. All patients had significantly abnormal wall motion; apical ballooning in 18 and midwall variant in 9 cases. Eleven patients (41%) had diffuse LGE localized to the area of abnormal wall motion, representing 34.5 ±9% LV mass. In 9 of these 11 patients, LGE signal intensity was >5 SD above normal myocardium, representing 16.5 ±12% LV mass. This has not been previously described. Those with >5SD LGE had raised LV volumes and reduced EF (p=0.047). Mean troponin trended to higher levels in LGE positive patients . The pattern of LGE differed to that seen in both ischemia and myocarditis. Improvement in segmental function was confirmed by follow-up CMR or echocardiography in all patients. Figure 1In this single-center series, LGE was present in 41% of cases of TTC, occurring in a diffuse pattern through the areas of myocardial stunning, 82% of which were >5SD above normal myocardium. This likely represents diffuse myocyte damage. Absence of LGE should not, therefore, be used as a diagnostic criterion for TTC. LGE does occur in the tako-tsubo cardiomyopathy, and presence of intense (>5SD) LGE appears associated with worse myocardial injury.