We furthermore aimed to identify nuclear imaging biomarkers that could be used to quantify and monitor response to tafamidis therapy.Tafamidis treatment positively affects left ventricular (LV) structure and function and improves outcomes in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). We aimed to investigate the relationship between treatment response and cardiac amyloid burden identified by serial quantitative 99mTc-DPD scintigraphy and SPECT/CT imaging at baseline and after treatment with tafamidis 61 mg once daily  were divided into two cohorts based on the median (−32.3%) of the longitudinal percent change in standardized uptake value (SUV) retention index. ATTR-CM patients with a reduction greater than or equal to the median (n = 20) had a significant decrease in SUV retention index (P < 0.001) at follow-up, which translated into significant benefits in serum N-terminal prohormone of brain natriuretic peptide levels (P = 0.006), left atrial volume index (P = 0.038), as well as LV  and right ventricular (RV)  functions compared with patients with a decrease less than the median (n = 20).Forty wild-type ATTR-CM patients who underwent 99mTc-DPD SPECT/CT imaging with SUV may be a valid tool to quantify and monitor response to tafamidis treatment in affected patients.Treatment with tafamidis in ATTR-CM patients results in a significant reduction in SUV retention index, associated with significant benefits for LV and RV function and cardiac biomarkers. Serial quantitative 99mTc-DPD SPECT/CT imaging with determination of SUV retention index as part of a routine annual examination can provide evidence of treatment response in ATTR-CM patients receiving disease-modifying therapy. Further long-term studies with 99mTc-DPD SPECT/CT imaging may help to evaluate the relationship between tafamidis-induced reduction in SUV retention index and outcome in patients with ATTR-CM and will demonstrate whether highly disease-specific 99mTc-DPD SPECT/CT imaging is more sensitive than routine diagnostic monitoring.  In particular, nuclear imaging, such as bone scintigraphy with radiolabelled phosphonates like 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD), allows visualization of amyloid deposits by planar imaging and has become the non-invasive gold standard for the diagnosis of ATTR-CM.3 Novel nuclear imaging techniques, such as single-photon emission computed tomography/computed tomography (SPECT/CT), provide a 3D visualization of radioactivity in the body and determination of a standardized uptake value (SUV) indicating the concentration of the radiopharmaceutical in each tissue5 and may render additional support in understanding the relationship between treatment and response to disease-modifying therapies like tafamidis,6 which positively affects left ventricular (LV) structure and function and improves outcomes in ATTR-CM patients.8The potentially life-threatening diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CM) is pathophysiologically characterized by disintegrated liver-derived transthyretin (TTR) that accumulates as amyloid fibrils in the myocardium, leading to progressive heart failure (HF) with fatal prognosis, especially if left untreated.99mTc-DPD SPECT/CT imaging with SUV to identify nuclear imaging biomarkers that could be used to quantify and monitor response to tafamidis treatment. Therefore, serial 99mTc-DPD scintigraphy and SPECT/CT imaging were performed in ATTR-CM patients prior to and after treatment with tafamidis, divided into two cohorts based on longitudinal changes in SUV parameters, and compared for clinical and imaging outcomes.Hence, the present study aimed to investigate the relationship between tafamidis treatment and response in ATTR-CM patients using quantitative The study was conducted as part of a prospective HF registry at the Department of Internal Medicine II, Division of Cardiology at the Medical University of Vienna, Austria, which includes a dedicated amyloidosis outpatient clinic. The study was approved by the local ethics committee (#796/2010) in accordance with the Declaration of Helsinki, and all participants provided written informed consent prior to registry inclusion for baseline and follow-up assessments.99mTc-DPD scintigraphy and SPECT/CT imaging at baseline and follow-up; (ii) presence of mutation in the TTR gene (ATTR variant); this patient population is very heterogeneous and has an individual, mutation-dependent and highly variable disease course compared with wild-type ATTR; and (iii) treatment with tafamidis prior to baseline assessment.Consecutive registry patients diagnosed with ATTR-CM between June 2019 and April 2021 were screened for study eligibility; eligible study participants underwent baseline and follow-up assessments at our dedicated amyloidosis outpatient clinic as part of a prospective investigative imaging study. ATTR-CM patients were excluded if the following criteria were met: (i) inability to undergo et al.,3 bone scintigraphy was performed in patients with clinical suspicion of cardiac amyloidosis. The diagnosis of ATTR-CM was confirmed when patients had significant myocardial tracer uptake (Perugini grade ≥ 2) on bone scintigraphy and no paraprotein or monoclonal protein was detected by serum and urine immunofixation and serum free light chain assay.9 Patients with ATTR-CM were offered sequencing of the TTR gene, which was accepted by all patients.In accordance with the non-invasive diagnostic algorithm published in 2016 by Gillmore 10) was administered once daily (QD), either under Pfizer’s early access program following publication of the ATTR-ACT trial8 or after approval by health insurance reimbursement.Tafamidis 61 mg ] and troponin T, as well as haemoglobin and serum creatinine levels.Clinical status was defined by New York Heart Association (NYHA) functional class. Submaximal functional capacity was assessed by the 6 min walk test according to the American Thoracic Society guidelines.99mTc radiolabelled DPD (mean activity: 725.4 MBq ±25.7) using a hybrid SPECT/CT system  equipped with a low-energy, high-resolution collimator [mean dose length product (DLP): 86.3 mGy*cm ±30.7]. There were no differences between baseline and follow-up in the timing of 99mTc-DPD scintigraphy and SPECT/CT imaging after tracer application, 99mTc-DPD activity , and DLP . Images were acquired in 180° configuration, 64 views, 20 s per view, 256 × 256 matrix, and an energy window of 15% around the 99mTc photopeak of 141 keV. Subsequent to the SPECT acquisition, a low-dose CT scan was acquired for attenuation correction . Image acquisition and reconstruction were performed using xSPECT/CT QUANT (xQUANT) technology , which uses a 3% National Institute of Standards and Technology (NIST) traceable precision source for standardization of uptake values across different cameras, dose calibrators, and facilities.13Nuclear imaging was performed at the Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine at the Medical University of Vienna. Planar whole-body images were obtained 2.5 h and SPECT/CT imaging of the thorax 3.0 h after intravenous injection of r = 0.9998, P = 0.010).6For the automatic contouring of the 3D volume of interest (VOI) of the myocardium, a threshold for maximal activity was developed in phantom experiments at which 39% of maximal activity resulted in a VOI of ∼155 mL, which was in good agreement with the cardiac insert volume of 155 mL and yielded a clear linear relationship between the applied and measured activity concentrations, as confirmed by linear regression analysis . The myocardial VOIs were reviewed by the operator and corrected if sternal or rib uptake was evident. From these VOIs, an SUV was determined, indicating the concentration of the radiopharmaceutical in the respective tissue, with SUV peak representing the highest average SUV within a 1 cm3 volume. Bone uptake  was calculated by placing a cubic 2.92 mL VOI in an intact vertebral body of a thoracic spine  in an area without degenerative changes to minimize distortion from high degenerative tracer accumulation. For determination of SUV peak paraspinal muscle, a cubic 1.19 mL VOI was placed in the left paraspinal muscle, attempting to match the same position at baseline and follow-up. Confounders caused by competing tracer uptake between respective tissues can be overcome by a composite SUV retention index that balances uptake between the heart, bone, and soft tissue compartments and thus may provide a means of monitoring response to therapy.14 It was calculated according to the following formula:Myocardial uptake on SPECT/CT images was determined using dedicated software . Three-dimensional myocardial VOIs were automatically generated using a threshold-based method, as previously described, allowing clear separation of myocardial uptake from blood pool activity  and evaluated by two independent, experienced observers blinded to patients’ baseline values. Dedicated software and SUV calculation methods were not changed between baseline and follow-up.Planar whole-body images were evaluated independently by two experienced physicians and visually graded according to Perugini 17 Image analyses were performed after image acquisition on a modern offline clinical workstation equipped with dedicated software  by certified cardiologists who were blinded to patients’ baseline values. Dedicated software and calculation methods were not changed during measurements over time.Transthoracic echocardiography (TTE) was performed by certified and experienced operators using modern equipment  according to current recommendations.2, or implanted cardiac device] underwent cardiac magnetic resonance (CMR) imaging on a 1.5 T scanner  according to standard protocols,20 which included late gadolinium enhancement  and T1 mapping. All CMR imaging parameters were analysed with dedicated software  by certified radiologists and cardiologists who were blinded to patients’ baseline values. Dedicated software, T1 mapping, and extracellular volume (ECV) calculation methods were not changed between baseline and follow-up.Patients without contraindications  were deemed eligible; detailed reasons for study exclusion or discontinuation are shown in Figure  All study participants (n = 40) underwent TTE at baseline and follow-up ; in addition, 25 ATTR-CM patients without contraindications were subjected to baseline and follow-up CMR imaging . ATTR-CM patients were divided into two cohorts based on the median (−32.3%) of the longitudinal percent change in SUV retention index. Twenty ATTR-CM patients treated with tafamidis had a longitudinal percent decrease in SUV retention index greater than or equal to the median and were assigned to Cohort A, whereas the remaining 20 patients treated with tafamidis had either a percent decrease less than the median or even a percent increase from baseline and were assigned to Cohort B .A total of 45 treatment-naïve ATTR-CM patients were evaluated for study eligibility, of whom 40 wild-type ATTR-CM patients who underwent Table  On average, ATTR-CM patients were 78.6 years (SD: 6.6) old and predominately male (82.5%). Median serum NT-proBNP levels were markedly elevated with 2181 pg/mL (IQR: 1248–3164) and comparable between the groups . Nuclear imaging with 99mTc-DPD scintigraphy of the total ATTR-CM cohort classified 47.5% patients with Perugini grade 2% and 52.5% with grade 3, without significant between-group differences . Quantitative 99mTc-DPD SPECT/CT imaging at baseline revealed a mean cardiac SUV peak of 14.64 g/mL (SD: 4.54) and a mean SUV retention index of 4.96 g/mL (SD: 2.46), which did not differ between patients in distinct cohorts . Echocardiographic imaging of ATTR-CM patients showed LA enlargement [left atrial volume index (LAVI): 41.2 mL/m2 ± 15.1], which was comparable between groups . Analysis of longitudinal function by 2D speckle-tracking echocardiography (STE) revealed impairments in LV global longitudinal strain (LV-GLS: −12.88% ± 3.14) and right ventricular (RV) longitudinal strain (RV-LS: −15.39% ± 5.37) that did not vary between cohorts . ATTR-CM patients who underwent CMR  had mildly reduced LV function  and RV function , which did not differ between cohorts  .Detailed baseline characteristics for the entire study population and for individual cohorts are depicted in Table 2. 99mTc-DPD scintigraphy and SPECT/CT follow-up were performed after a median of 9.0 months (IQR: 7.0–10.0). Using serial quantitative 99mTc-DPD SPECT/CT imaging, we found a significant reduction in cardiac SUV peak  in the overall ATTR-CM cohort under tafamidis treatment, which is also evident when considering the individual cohorts . Adjustment with the SUV retention index revealed a significant decrease in the overall cohort  and Cohort A  at follow-up, while there was no improvement in Cohort B . Echocardiographically, we observed a significant decrease in LAVI  in patients in Cohort A, but evidence of increase in LAVI  in patients in Cohort B. Using 2D-STE, we found evidence of stabilization of LV-GLS  and RV-LS  in Cohort A, but significant impairments in LV  and RV  longitudinal functions in Cohort B. Analysis of cardiac function by CMR showed significant improvements in LV  and RV  functions in ATTR-CM patients in Cohort A.Detailed follow-up characteristics for the overall cohort and individual cohorts are shown in Cohort A showed a statistically significant decrease in SUV retention index  at the end of the observation period, which translated into significant benefits in serum NT-proBNP levels , LAVI , as well as LV function  and RV function  compared with patients in Cohort B.ATTR-CM patients in 8 Novel nuclear imaging techniques such as quantitative SPECT/CT imaging may contribute to a better understanding of the relationship between tafamidis treatment and response and may therefore be suitable for monitoring disease-specific therapies.6 Using serial quantitative 99mTC-DPD SPECT/CT imaging with SUV, we were able to demonstrate that (i) treatment with tafamidis 61 mg QD in ATTR-CM patients resulted in a significant decrease in cardiac SUV peak and SUV retention index from baseline; (ii) ATTR-CM patients in whom the percent decrease in SUV retention index was greater than or equal to the median had significant benefits in serum NT-proBNP levels, LAVI, as well as LV and RV function; (iii) serial quantitative 99mTC-DPD-SPECT/CT imaging with SUV may be a valid tool for quantifying and monitoring disease-specific therapy in affected patients.Treatment with tafamidis positively affects LV structure and function and improves outcomes in ATTR-CM patients.n = 40) treated with tafamidis 61 mg QD for a median of 9.0 (IQR 7.0–10.0) months showed a significant decrease in cardiac SUV peak (P < 0.001) and SUV retention index (P < 0.001) compared with baseline, which is consistent with previous findings.22 Moreover, ATTR-CM patients in whom the percent decrease in SUV retention index was greater than or equal to the median  had a significant reduction in SUV retention index (P < 0.001) at the end of the observation period, while patients in whom the percent decrease was less than the median  showed no significant improvement at follow-up (P = 0.116), resulting in significant differences in cohort comparison .In the present study, ATTR-CM patients (Cohort A (P = 0.002) as opposed to Cohort B . These findings suggest that the reduction in SUV retention index induced by tafamidis is associated with clinical benefits and may be reflected in clinical outcomes.When comparing the two cohorts on a clinical level, we observed a significant improvement in serum NT-proBNP levels in patients in Cohort A had a significant improvement in LVEF (P = 0.047) and evidence of LV-GLS stabilization (P = 0.520), while patients in Cohort B showed no beneficial effect on LVEF  and experienced a significant worsening of LV longitudinal function at follow-up . These results are consistent with recently published echocardiographic data describing less deterioration of LV-GLS with tafamidis treatment.24 In addition, we observed significant benefits in LVCI in patients of Cohort A compared with patients in Cohort B , which is further supported by the results of our CMR imaging study, in which a beneficial effect of tafamidis treatment on LV function was observed.7Further evidence that the tafamidis-induced decrease in SUV retention index is associated with beneficial effects was provided by imaging of the LV. ATTR-CM patients in Cohort A (P = 0.580), while patients in Cohort B experienced a significant deterioration of RV longitudinal function (P = 0.030). This is also evident in the assessment of RV function by CMR, which showed significant benefits in patients in Cohort A compared with Cohort B . Interestingly, beneficial effects of tafamidis on RV function have not yet been reported in the literature. However, in ATTR-CM, amyloid fibrils can also be expected to be deposited in the RV,25 as shown by the tracer accumulation in Figure 3, demonstrating improvements in the LV and RV in Cohort A at follow-up. Therefore, tafamidis-induced reduction in cardiac SUV peak and SUV retention index in Cohort A may affect both LV and RV, as reflected by significant improvements in LVEF (P = 0.057) and RVEF (P = 0.036) in the CMR cohort.When focusing on the RV, we found evidence of stabilization of RV-LS in ATTR-CM patients in Cohort A and Cohort B. Further long-term studies to evaluate the association between tafamidis-induced reduction in SUV retention index and outcome are warranted and will demonstrate whether highly disease-specific 99mTc-DPD SPECT/CT imaging is more sensitive than routine diagnostic monitoring.Nevertheless, there is still uncertainty about the mechanisms underlying the beneficial response to tafamidis treatment and whether there are differences in outcomes between patients in 99mTC-DPD SPECT/CT follow-up, as well as differences between timing of baseline TTE, CMR, and 99mTC-DPD SPECT/CT imaging and follow-up may have affected the results. However, this is the first study to systematically perform serial quantitative 99mTC-DPD SPECT/CT imaging with clinical and imaging outcomes in ATTR-CM patients treated with tafamidis. Third, the significant beneficial effects on LVEF observed with CMR in Cohort A were not reflected in TTE, indicating a small observed effect. However, CMR is the established gold standard for quantification of EF.26 Fourth, although there is evidence that cardiac SUV peak correlates with ECV14 and thus with amyloid burden in the myocardium,27 this has not yet been histologically validated. However, the study’s main findings are consistent with previously published data. Finally, the observation period was too short to assess differences in outcome between cohorts.Several limitations are inherent to the present study. First, the present study is limited by its sample size due to the single-centre design, and centre-specific bias cannot be excluded. However, limiting data collection to one centre has the advantages of constant quality of work-up, adherence to a constant clinical routine, and constant follow-up. Second, individual differences in the duration of tafamidis treatment depending on the timing of 99mTc-DPD SPECT/CT imaging with SUV, we demonstrated that treatment with tafamidis 61 mg QD in ATTR-CM patients results in a significant reduction in SUV retention index, associated with significant benefits for LV and RV function and cardiac biomarkers. Our data suggest that serial quantitative 99mTc-DPD SPECT/CT imaging with SUV may be a valid tool to quantify and monitor response to tafamidis treatment in affected patients.Using serial quantitative European Heart Journal - Cardiovascular Imaging online.jead030_Supplementary_DataClick here for additional data file.


The cluster of atrial fibrillation (AF) with heart failure (HF) may be associated with a poorer prognosis. Its epidemiology and impact on clinical outcomes and quality of life among HF subjects in Africa have not yet been fully described. This study aimed at describing the epidemiology of AF among HF subjects, its impact on quality of life, clinical characteristics, and associations.140 HF subjects were recruited by stratified random sampling method, and 12-lead electrocardiography was done to diagnose AF. Statistical analysis was done with SPSS 21.0. Informed consent was obtained from all participants.The frequency occurrence of AF was 28 (20.0%) of the HF subjects and were similar in age, systolic blood pressure, diastolic blood pressure, right ventricular internal dimension, packed cell volume, and gender distribution with those in sinus rhythm. The mean (S.D) six minutes walk test distance was significantly lower among HF subjects with AF compared to those without AF . Pulmonary hypertension, intracardiac clots, and kidney dysfunction were more frequent among HF subjects with AF than among those without AF. HF subjects with AF had a higher frequency of clusters of comorbidities than those without AF. AF was most prevalent and left atrial dimension was highest among subjects who had HF with reduced ejection fraction, compared to other HF phenotypes.AF is common in HF among Nigerians and is associated with poor quality of life and poorer functional status compared to those with sinus rhythm. Atrial fibrillation (AF) and heart failure (HF) frequently coexist together or in clusters with other comorbidities . AF is tThe epidemiology of AF and its impact on clinical outcomes and quality of life among HF subjects is not yet fully described among Africans. AF among Africans is more likely to be valvular AF due to a high burden of rheumatic and infective valvular heart diseases –10. SomeThere is a complex interplay between HF and AF. HF can precipitate AF, and AF can also lead to HF ,11,13–16This study was conducted in the cardiology clinics of two teaching hospitals in Ogbomoso, southwest Nigeria—Ladoke Akintola University of Technology Teaching Hospital, Ogbomoso, and Bowen University Teaching Hospital. One hundred and forty chronic HF subjects who were being seen at the study centers and had been on follow-up for at least six months were recruited through a stratified random sampling method. The diagnosis of HF was made using the Framingham criteria . The patAll participants were thoroughly examined clinically. Weight was measured with a standardized weighing scale to the nearest 0.5 kg. Height was measured with a stadiometer to the nearest cm. Body mass index was determined and categorized as normal, overweight, mild obesity, moderate obesity, and severe obesity. Various investigations were done, which include full blood count, blood film appearance, full iron parameters , urinalysis, and electrolytes, urea and creatinine. Echocardiography was done according to the American Society of Echocardiography guidelines, with the patient in the left lateral position. Anaemia was defined as Hb <12g/dl in women and <13g/dl in men according to the World Health Organisation (WHO) criteria. Atrial natriuretic peptides (ANP) assay was done using the Elabscience enzyme-linked immunosorbent assay (ELISA) kit method . The normal range of ANP was defined as 86–111 pg/ml according to the manufacturer's manual. Pulmonary hypertension was defined as estimated pulmonary arterial systolic pressure greater than 35mmHg. The Pulmonary arterial systolic pressure was evaluated with the addition of tricuspid regurgitant velocity gradient to the estimated right atrium diastolic end-diastolic pressure. Iron deficiency was defined as Transferrin saturation (TSAT) <20% because TSAT is a better marker of iron status than ferritin during inflammation as ferritin overestimates iron store in inflammatory conditions.a standardized protocol. The interpretation was done by the two researchers who are senior cardiology fellows, and they were blinded to the clinical data during electrocardiogram interpretation. The parameters measured include heart rate, mean QRS axis, PR interval, P wave duration, and amplitude, QRS wave duration and morphology, QTc intervals, ST segment for changes in depression or elevation, T wave abnormalities, and Electrocardiography (ECG) heart chamber enlargement. AF was defined as the absence of a P wave on routine 12-lead ECG with or without irregular R-R interval. AF is a type of supraventricular tachyarrhythmia and it is the commonest type. Long rhythm strips were used often in making the diagnosis. Intracardiac clot(s) refer to suspected clots in at least one chamber of the heart that was found on standard transthoracic echocardiography. Further imaging could not be done to confirm the presence of intracardiac clots due to the non-availability of cardiac magnetic resonance (CMR), contrast echocardiography, or transesophageal echocardiography. Anticoagulation in these patients was estimated to be poor as most of them were on very low doses of warfarin at study entry with no serial monitoring of the international normalized ratio due to financial constraints.Transferrin saturation (TSAT) was determined as 100 x serum iron/TIBC. A 12-lead electrocardiogram was done for all participants according to Ethical approval was obtained from the Research Ethics Committee of LAUTECH Teaching Hospital, Ogbomoso, Nigeria. All participants gave their written informed consent. Statistical analysis was done with the Statistical Package for Social Sciences version 21.0 . Qualitative variables were summarized as frequencies (percentages), while quantitative variables were summarized as means (standard deviation). Student's t-test, analysis of variance, or Chi-square test were used as appropriate, to determine the statistical significance of the difference between the two groups. P <0.05 was taken as statistically significant.Ethical Approval: Ethical approval was obtained from the Research Ethics Committee of Ladoke Akintola University of Technology Teaching Hospital, Ogbomoso, Nigeria . Informed written consent was obtained from all participants.The mean age of study participants was 62.96 ± 16.3 years. Mean (S.D) systolic and diastolic blood pressures were 125.1 ± 22.5 mmHg and 78.23 ± 14.0 mmHg respectively. The mean (S.D) heart rate was 90.2 ± 18.8 beats per minute, while the mean body mass index (S.D) was 24.7 ± 6.5 kg/m2. There were more females among the study participants , and 87.1% of all study participants were previously diagnosed to have hypertension. Mean (S.D) serum urea and creatinine were 17.2 ± 22.7 µmol/l and 126.7 ± 117.4 mmol/l respectively as shown in 2, p <0.05) were significantly higher among HF subjects with AF than those with sinus rhythm. Ejection fraction was significantly lower among HF subjects with AF compared with subjects with sinus rhythm .The clinical, demographic, and functional characteristics of HF subjects with a diagnosis of AF compared to those with normal sinus rhythm are also shown in The mean six minutes walk test distance was significantly lower among HF subjects with AF compared to those with sinus rhythm  as stated in AF was more prevalent in patients with heart failure with reduced ejection fraction (HFrEF) compared to heart failure with preserved ejection fraction (HFpEF) and heart failure with mid-range ejection fraction (HFmrEF) as shown in The clustering of AF and HF portends serious functional, clinical, and prognostic challenges. Identifying the relationship and bidirectional impact between the two clinical syndromes is important to ascertain the risk and mitigate the additional risk of morbidity and mortality from cardiovascular disease. This study revealed that AF is found in at least one-fifth of HF patients. It is most likely that the frequency would have been more than this if long-term (Holter) Electrocardiography (ECG) had been done. This is in contrast with the earlier assertion that cardiac arrhythmias such as AF may be very rare among Africans,8–10. ThThe mortality rate among Africans with HF has been reported to be at least twice the world average and about four times that of South America. A potential reason for this, among others, is the additionally worse comorbidity profile, which AF contributes to –26. The Other authors have also suggested that AF is more prevalent among men than women . This stThe prognostic implication and clinical correlation of clustering of AF with HF: This study showed several interesting findings when AF coexisted with HF. Subjects with AF and HF had poorer conventional indices of functional status, mortality, and prognosis when compared to age- and gender-corrected HF cohorts with sinus rhythm. Subjects with coexisting AF and HF had significantly reduced ejection fraction and a higher proportion of kidney impairment, pulmonary hypertension, intracardiac clots, and associated comorbidities than those without AF. The left atrial dimension was also significantly higher among those with AF. The six minutes walk test was significantly lower among HF subjects with AF than those with sinus rhythm. This revealed that the presence of AF in HF patients is associated with poorer prognosis and functional status compared to when patients have sinus rhythm. Many of these factors are conventional markers of prognosis in HF and have been shown, in large populations, to be highly predictive of morbidity and mortality (ortality –37. It iortality ,9,21,27.ortality ,39.HF subjects who had AF in this study had poorer functional profiles than those with sinus rhythm and are most likely at greater risk of mortality than those with sinus rhythm ,5,9. Oth. The mechanisms by which HF can lead to an arrhythmogenic atrial substrate, including fibrillation, are elevated left-sided filling pressures, mitral regurgitation, atrial enlargement, interstitial fibrosis, and electromechanical remodeling (There is a lot of interest in the pathophysiology of AF in HF in recent times. The factors responsible for the initiation and propagation of AF in HF are multiple, complex, and interrelated. AF and HF also share common aetiologic factors. Therefore, their interaction can be related to the additional and multiplicative impact of these predisposing factors on the quality of life, symptomatology, and clinical outcomes of AF patients. The association of left atrial dilatation and AF is well described in the literature. Left atrial dilatation is both a cause and an effect of AF . The thimodeling ,14. Othemodeling . On the modeling . The assmodeling .This study has some limitations. First is the fact that long-term ECG such as Holter ECG was not done to identify patients with paroxysmal and persistent AF. Evaluating this would have increased the observed prevalence of AF among HF subjects: the single ECG done would most likely have underestimated the burden of AF among HF subjects, and this is a major limitation of this study. There is also the need for a longitudinal prospective study to document the prognostic association and differences in outcome and quality of life in HF subjects with AF compared to those without AF. We could not evaluate these associations and differences due to the design of the study. The relatively small sample size also limits the generalizability of this cross-sectional review: this was a hospital-based study, and its findings may therefore not be completely representative of the general population.Conclusively, this study showed that AF is commonly associated with heart failure, especially HFrEF, in Nigerians. It may be associated with poor quality of life, poorer function and temporal profile, and increased risk of cardiac thromboembolism as evidenced by the higher prevalence of intracardiac clots found in this study. It is associated with advanced HF and may be closely related to left atrial dilatation and more with HFrEF among HF phenotypes among Africans with HF.


To predict whether the left pulmonary artery (LPA) to the main pulmonary artery (MPA) ratio measured by echocardiography in left congenital diaphragmatic hernia (CDH) was related to death or need for extracorporeal membrane oxygenation (ECMO).This retrospective study analyzed neonates with left CDH born between 2018 and 2022 in a single tertiary medical institution. Echocardiography was performed immediately after birth. The diameter of the LPA was measured at the bifurcation, and the diameter of the MPA was measured at the maximal dimension during the systolic phase. The Nakata index, McGoon ratio, and ejection fraction (EF) were analyzed and compared with the LPA: MPA ratio as predictive values.Seventy-two neonates with left CDH were included, 19 (26.4%) died or needed ECMO, and 53 (73.6%) survived without ECMO. The lower observed/expected lung-to-head ratio, lower EF, lower LPA: MPA ratio, lower RPA: MPA ratio, lower Nakata index, and lower McGoon ratio were associated with death or need for ECMO. By multivariate analysis, lower LPA: MPA ratio, RPA: MPA ratio, and Nakata index were independent postnatal risk factors for death or need for ECMO. Among the measurements, the LPA: MPA ratio had the highest area under the curve (0.957) with a sensitivity of 84.2% and specificity of 96.3% at a cut-off value of 31.2%.In patients with left CDH, the LPA: MPA ratio measured by echocardiography could be used as an independent postnatal predictor of death or need for ECMO. Congenital diaphragmatic hernia (CDH) is one of the life-threatening congenital anomalies, occurring in 1 every 4000 live births . In newbThe diameters of branch pulmonary arteries (PAs) are correlated with lung hypoplasia in patients with CDH , 8. A smThis retrospective study analyzed a convenience sample of neonates with left CDH born between 2018 and 2022 in the neonatal intensive care unit (NICU) of Asan Medical Center, Seoul, South Korea. Right-sided CDH, preterm neonates aged < 34 gestational weeks, outborn neonates, neonates with major congenital anomalies, those with chromosomal abnormalities, and those who did not undergo echocardiography within 6 h of birth were excluded. Demographic, clinical, and echocardiographic data were collected by medical records review. Demographic data included gestational age, birthweight, sex, and small for gestational age. Clinical data included observed-to-expected lung-to-head ratio (o/e LHR) measured using the tracing method during the prenatal period, liver herniation, need for patch repair, need for ECMO, and death. For those neonates with multiple prenatal measurements of o/e LHR, the lowest value was used for analysis. The primary outcome was death or need for ECMO.This study was approved by the Institutional Review Board (IRB) of Asan Medical Center (IRB No. 2023-0096), and the requirement for informed patient consent was waived.A single pediatric cardiologist (M.J.K) performed echocardiography on all neonates included in the study within 6 h of birth. The results were confirmed by a second pediatric cardiologist. Echocardiography was performed using a Philips EPIQ 7 system  with 12 MHz transducers. The echocardiographic data were collected by review of electronic medical records. In the absence of medical records, two-dimensional analysis was conducted using a TomTec®  on the echocardiograms. The diameters of the PAs were measured at the parasternal short-axis view  > 40 for > 6 h; (2) hypercapnic respiratory failure: PaCO2 > 70 mm Hg with pH < 7.15 with peak inspiratory pressure > 30 cm H2O or frequency < 7 Hz, and amplitude > 40; and (3) systemic hypotension  caused by PH nonresponsive to fluid and inotropic therapy. Surgical repair was performed after the stabilization of pulmonary hypertension and ventilation, or ECMO decannulation.All patients were treated with a standardized CDH treatment protocol at our center. All patients were intubated immediately after birth in the delivery room, and an orogastric tube was inserted to decompress the bowel. After admission to the NICU, patients were managed by the conventional ventilator mode with permissive hypercapnia and limitation of peak inspiration pressure. High-frequency oscillatory ventilation was used in the case of refractory hypercapnia or high peak inspiratory pressures. PH was managed with inotropics including milrinone and norepinephrine. NO inhalation was employed if the left ventricular (LV) function was preserved. The criteria for administration of ECMO were as follows: (1) hypoxic respiratory failure: preductal oxygen saturation < 70% with mean airway pressure > 15 cm HP < 0.05 was considered statistically significant. Univariate logistic regression analysis was performed, and statistically significant variables were examined by multivariate analysis. By receiver-operating characteristic curve analysis (ROC), the area under the curve (AUC) and cut-off values of variables to predict death or need for ECMO were calculated. Youden’s index was used as the cut-off value. The sensitivity, specificity, positive predictive value, and negative predictive value of the cut-off value were calculated. Based on the cut-off value, statistically significant variables were dichotomized, and the odds ratio (OR) and its corresponding 95% confidence interval (CI) for the outcome were calculated. Missing data were filled with multiple imputations by the Markov chain Monte Carlo method. Statistical analysis was conducted using IBM SPSS version 27 .The primary outcome was mortality or need for ECMO. Data were described as the mean ± standard deviation and absolute number with percentages, as appropriate. The χ2 test was used to evaluate categorical variables, and the Mann–Whitney U-test was used to compare continuous variables between groups. A total of 115 neonates were admitted between 2018 and 2022, and 13 patients were excluded because of major congenital or chromosomal anomalies. Twenty-four patients were excluded for having a right-sided hernia and two for preterm birth. Three patients were not enrolled because of the missing echocardiographic report immediately after birth, and one outborn patient was excluded. In total, 72 neonates were included, and 53 (73.6%) survived without ECMO . The highest AUC was observed for the LPA: MPA ratio at 0.957 , followed by the RPA: MPA at 0.830 , and the Nakata index, at 0.915 . The cut-off values of the variables were 49.9%, 31.2%, 40.1%, and 90, respectively  dysfunction , 22. In This study used EF as a indicator of LV dysfunction, but EF has several limitations for this use in patients with CDH. First, EF is measured with a two-dimentional method that assumes the LV is cylinder shaped , but in This study had several limitations. First, this is a retrospective, single-center study that analyzed a relatively small sample size. However, data were collected through a short-period cohort with a consistent strategy; thus, the outcome was highly reliable. Second, a review of echocardiography results was not blinded; however, due to the study’s retrospective nature, the measurement of PA diameters could be unbiased. Third, although the technique of measuring diameters could be different between observers, echocardiography was performed by one pediatric cardiologist and double-checked by another pediatric cardiologist. Fourth, some data were missing, and this was minimized by filling with multiple imputations. All PAs diameters were available, and only a few data of the EF and McGoon ratio were missed. Therefore, this might not affect our main result of the LPA: MPA ratio as a predictor of left CDH outcomes.In conclusion, the LPA: MPA ratio was found to be the best early echocardiography index among the PA diameter variables for predicting mortality and the need for ECMO in newborn infants with CDH. Our study suggests that measuring PA diameters immediately after birth is a simple and useful means of management preparation in CDH, particularly for patients who are not prenatally diagnosed.


The Nellix endovascular sealing system (EVAS) was a unique concept with regard to its sealing concept that failed, related to high migration rates. We investigated the changes in aortoiliac morphology during the cardiac cycle before and after EVAS using electrocardiography (ECG)-gated CT.  Eight patients scheduled for EVAS were prospectively enrolled. ECG-gated CT scans were made pre- and postoperatively. Measurements were performed in the mid-systolic and mid-diastolic phases. Endpoints were changes in infrarenal aortoiliac morphology postoperatively compared to preoperatively and their changes in the cardiac cycle. p < 0.001). EVAS increased the luminal AAA volume (p < 0.001), with a decrease in thrombus volume (p < 0.001) in both phases and an increase in total volume (p < 0.001) in the systolic phase. During follow-up, one patient presented with >5 mm migration. There were no differences in the movements of this patient compared to the remaining patients.  Both pre- and postoperatively, there were no changes during the cardiac cycle. EVAS caused an increase in neck diameter and surface in both phases ( The cardiac cycle had a very limited effect on the aortoiliac dynamics before and after EVAS and, therefore, there is probably not a role for ECG-gated CT in enhanced surveillance programs. EVAS itself has a significant impact on anatomy, particularly the neck diameter, length, and volumes of the AAA. After its commercial introduction in 2013, the Nellix endovascular sealing system (EVAS) was rapidly adopted in the vascular community, but late complications such as proximal endoleaks and proximal migration were observed. This first led to a refined IFU which significantly reduced the applicability of the technique [Excessive motion of the aorta, in both the longitudinal and lateral directions, has been suggested as a risk factor for endograft migration after conventional EVAR . This coA previous study has examined the translation and aortic curvature of EVAS during the cardiac cycle, but no quantitative anatomical parameters have been examined previously . This stth WMA General Assembly, Fortaleza, Brazil, 2013) and in accordance with the applicable guidelines, regulations, and acts. For this prospective study, approval by an independent institutional review board was obtained, and each patient had given written informed consent before inclusion in this study. Patient scan information and data were stored anonymously. The study was registered on clinicaltrials.gov with ID: NCT02438605.This was a single-center prospective observational study. Eight patients who were scheduled for EVAS were prospectively enrolled in this study. Each patient underwent an ECG-gated CT preoperatively and six weeks after EVAS. The preoperative CT was used for procedural planning. Patient demographics as well as procedural data were collected and all pre-and postoperative imaging was studied. The study was conducted according to the principles of the Declaration of Helsinki (64An (electrocardiography) ECG-gated CT provides images at various stages of the cardiac cycle. By analyzing these images, it is possible to measure the movements of the stent graft and the arteries during the diastole and systole cycles of the heart. A Phillips Brilliance iCT 256-slice scanner was used to perform the ECG-gated CT scans in all cases, with dose modulation (automatic), using a standardized protocol, and during a single breath hold. Radiation exposure was tube voltage 120 kV, reference mAs 400 mAs, and pitch 0.34. The scan was made at 10 time points during the cardiac cycle and at the highest atrial pressure (20%) and lowest atrial pressure (78%), which were the chosen phases for further assessment. The studied slice thickness was 0.9 mm, and Xenetix 300  was used as iodine contrast medium and adapted according to the patient's weight. The scan was started using bolus triggering at the height of the aortic arch at a threshold of 150 HU over baseline.All images were analyzed using 3Mensio . Measurements were performed based on anatomical landmarks, after creating a central lumen line (CLL) with the workflow assistant in 3Mensio. The measurement protocol was partially based on reporting standards and previous studies regarding CTA-imaging after EVAR . In ordeα-angle was defined as the angle between the suprarenal aorta and the neck of the aneurysm. The β-angle was defined as the angle between the neck and the aneurysm sac.Measurements on morphology were divided into three areas, including the infrarenal neck, the AAA sac, and the common iliac arteries. The start of the neck was defined as the lowest point of the inferior renal artery. The level with 15% increase in neck diameter compared to the diameter at the level of the lowest renal artery was defined as the end of the neck. The start of the aneurysm sac was defined as the end of the neck, and the end was defined as the first slice cranial to the apex of the aortic bifurcation. The All measurements were performed by two independent researchers (L.H. and T.L.) and tested for interobserver variability. Outliers and differences were remeasured for accuracy and corrected if necessary.p < 0.01 were considered statistically significant. All measurement data are presented using medians and interquartile ranges .Data collection and analysis were performed using IBM SPSS Statistics version 21.0 . All data were checked for outliers and reevaluated for correctness. The Wilcoxon signed rank test was used to test for differences in anatomy both preoperatively and postoperatively as well as during the cardiac cycle. The values Interobserver variability was measured using the intraclass correlation coefficient (ICC). The two‐way random effects model on absolute agreement was used. Using the Landis and Koch interpretation for the kappa value, agreement was scored as poor (<0.20), fair (0.21–0.40), moderate (0.41–0.60), good (0.61–0.80), and perfect (0.81–1.00).Patient demographics are presented in The study included 8 patients suitable for elective AAA repair using the Nellix endovascular sealing system , of which 6 (75%) were male, with a median age of 75.5 (Q25–Q75: 62.2–83.1) years. The maximum AAA diameter was 58.5 mm (range 42.0–75.1 mm). A median volume of 83 mL (range 50–135 mL) of the polymer was used to reach a mean fill pressure of 185 mmHg (range 166–220 mmHg). During implantation, one patient that had a type Ia endoleak caused by underfilling of the endobags had a secondary fill, resolving the issue. In another patient, concomitant angioplasty and stenting of the left superficial femoral artery were performed using a self-expanding nitinol stent  because of a flow-limiting stenosis.The median procedure time was 75 minutes (range 49–101 min), and patients were admitted for a median of 2 days (range 2–4 days). One patient underwent a successful reintervention for a common femoral artery occlusion one day after surgery. Using intra-arterial thrombolysis, the occlusion was dissolved, and the patient was discharged four days after surgery and had a further uneventful follow-up. One patient developed an occlusion of the left popliteal artery seven days after the operation which was successfully treated with thrombolysis. All other patients underwent an uneventful recovery, and no major adverse events were seen at discharge and after 6 weeks of follow-up. The median follow-up was 25 months (range 6–36 months). Within this period no patients died, and there was one patient that presented with a distal migration of ≥5 mm without clear signs of a type Ia endoleak.The median ICC for continuous variables to assess interobserver variability was 0.68 (range 0.50–0.78) and was therefore classified as good according to Landis and Koch interpretation of ICC.The changes in neck anatomy are displayed in There were no significant changes observed in the infrarenal neck area during the cardiac cycle in both the pre- and postoperative CT scans. Almost all variables were higher in the diastolic heart phase except for neck length and the lumen volume. With regard to neck angulation, there are some slight changes in both alpha and beta angles and the angulation of the renal arteries during the cardiac cycle, without statistical significance, and with a wide variability in both the pre- and postoperative scans.p=0.674).When comparing the pre- and postoperative CT scans, a significant increase in neck diameter and surface was observed after EVAS in both the diastolic and systolic phases. In addition, the neck length significantly decreased after EVAS between both phases. The sealing length, defined as the start of the endobag to the start of the aneurysm, was 23.0 mm (range 4.8–34.1 mm) at the peak diastolic phase and 18.6 mm (range 6.3–36.3 mm) at the peak systolic phase . In a recent meta-analysis including 703 patients from seven studies with a mean follow-up of more than two years (range 24–72 months), the pooled estimated incidence of type 1 endoleak, migration, and re-intervention were 25%, 22%, and 27%, respectively . AlthougThe data presented in this study suggest that the EVAS reconstruction was stable during the cardiac cycle in these patients, as we found in general no significant changes during the cardiac cycle in both the pre- as well as the postoperative state. These results, however, were measured in the postoperative period and, as a consequence do not ensure the longitudinal stability of the reconstruction. It is known that in patients, particularly when treated outside the IFU, stent migration may occur, leading to a proximal endoleak . Root caThe Nellix device itself caused significant changes in the aortic anatomy, particularly with regard to an increased neck diameter, surface, and length, and to the aortic volumes, including the luminal and thrombus volumes. Previous studies which have examined the post-EVAS changes of the anatomy confirm these findings . It has All of these changes are likely to be caused by the polymer-filled endobags. The pressurization of these endobags may squeeze the thrombus, declining its volume and increasing the flow volume, and could exert a pressure on the arterial wall, leading to an increase in neck size and AAA volume. These observations emphasize the difference of the EVAS technique when compared to standard EVAR. The implications of these observations, however, are yet unknown. As an unexpected observation, Berg et al. described a lower incidence of the postimplant syndrome after EVAS when compared to EVAR . WhetherThe current study has limitations. First, the sample size was relatively small. Second, we used only two series of the ECG-gated CT scan. The scans were performed with a total of ten phases during the cardiac cycle. An analysis of all ten phases might have provided more data. However, to attain for the anatomy in its' maximum range, the diastolic and systolic pressures are chosen as the best phases for analysis as they are the phases with both the minimal and maximum changes during the heart cycle. Moreover, CT scans were only available in the early postoperative phase. This would have been relevant, for example, to see if the decrease in neck length after EVAS would be stable in time or would be progressive. The interobserver variability of this study was small, as little to no changes had to be made after secondary measurement of all variables. Software automatization of the CLL is mostly to credit for the accuracy, as measurement can be reproduced in a consistent way.This study shows that the cardiac cycle has little to no effect on the morphology of the arteries both before and shortly after EVAS, and therefore there is probably not a role for ECG-gated CTA in enhanced surveillance programs. EVAS itself has a significant impact on anatomy, particularly the neck diameter, length, and volumes of the AAA.


The aim of this study was to perform a retrospective analysis of patients with acute anterior wall ST-segment elevation myocardial infarction (AAW-STEMI) whose left anterior descending (LAD) artery was completely occluded and reperfused by primary percutaneous coronary intervention (PPCI) and to determine the influencing factors and prognostic value of left ventricular systolic dysfunction (LVSD) in the acute phase of acute myocardial infarction (AMI).A total of 304 patients with AAW-STEMI were selected. The selected patients were divided into two groups: the preserved left ventricular ejection fraction (pLVEF) group  and the reduced left ventricular ejection fraction (rLVEF) group . The influencing factors of LVSD and their predictive value for LVSD were analyzed. Patients were followed up by examining outpatient records and via telephone. The predictive value of LVSD for the cardiovascular mortality of patients with AAW-STEMI was analyzed.P < 0.05). The receiver operating characteristic (ROC) analysis showed that the peak CK had the strongest predictive value for LVSD, with an area under the curve (AUC) of 0.742  as the outcome. At a median follow-up of 47 months , the Kaplan‒Meier survival curves up to 6-year follow-up revealed a total of 8 patients succumbed to cardiovascular disease, with 7 (6.54%) in the rLVEF group and 1 (0.56%) in the pLVEF group, respectively . Univariate and multivariate Cox proportional hazards regression analysis demonstrated that rLVEF was an independent risk predictor of cardiovascular death in patients with AAW-STEMI discharged after PPCI (P < 0.01).Age, heart rate (HR) at admission, number of ST-segment elevation leads (STELs), peak creatine kinase (CK) and symptom to wire-crossing (STW) time were independent risk factors for LVSD  in a timely manner and initiate early standard therapy for incident LVSD in the acute phase of AAW-STEMI reperfused by PPCI. A trend toward increased cardiovascular mortality at follow-up was significantly linked to LVSD. New-onset heart dysfunction is a common complication of acute myocardial infarction (AMI). Acute anterior wall ST-segment elevation myocardial infarction (AAW-STEMI) leads to more pronounced left ventricular systolic dysfunction (LVSD) and more adverse left ventricular (LV) remodeling than STEMI in other areas . GuideliLVSD can be represented by left ventricular ejection fraction (LVEF), and it is defined as LVEF < 50% , 7. ImprAdopting a retrospective cohort research method, a total of 547 patients with AAW-STEMI reperfused by PPCI were selected in the Tianjin First Central Hospital from January 2016 to September 2021. All selected patients fulfilled the diagnostic criteria of AAW-STEMI in the “2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation “ . PPCI waThe inclusion criteria were as follows. (1) The symptom to admission time was within 12 h. (2) The cardiac function classification at admission was Killip I. (3) Emergency angiography confirmed complete occlusion of the LAD artery without other coronary occlusions. (4) The postprocedural thrombolysis in myocardial infarction (TIMI) grade was TIMI grade 3 flow.2). (7) Patients who died during hospitalization. (8) Abandon treatment and discharge automatically.The exclusion criteria were as follows. (1) Coronary angiography showing incomplete occlusion of the LAD artery. (2) Patients whose cardiac function was Killip grade 2 or above upon admission. (3) Coronary angiography showing occlusion of the left main artery. (4) The postprocedural TIMI grade was less than TIMI grade 3 flow. (5) History of old myocardial infarction or chronic heart failure. (6) Complicated with liver failure (CLIF Consortium Acute on Chronic Liver Failure score > 64) or renal failure  group (LVEF ≥ 50%) and rLVEF group (LVEF < 50%), see Fig. P value of < 0.05 was considered significant.Continuous variables with a normal distribution are reported as the mean ± standard deviation (P < 0.05).The mean age of the selected patients was 58.63 ± 11.81 years old (range 27–84 years), and 254 (83.55%) were male. Differences in the baseline and clinical outcomes between the pLVEF group and the rLVEF group are summarized in Table On multivariate analysis, LVSD was used as the dependent variable, and the significantly different indicators on univariate analysis in Table P < 0.05). Peak CK was positively correlated with the number of STELs. Opening or proximal occlusion of LAD artery generated a significant increase in CK than middle or distal occlusion (P < 0.05). Peak CK was higher in younger AAW-STEMI patients whose age were less than 50 years . The STW time was approximately 30 min longer in the ≥ 60 years group than in the < 60 years group (P < 0.05). The average first medical contact to wire-crossing (FTW) time was 77.11 min, the fastest time was 19 min, the longest time was 237 min, the proportion of patients with less than 90 min was 75.24%, and 37.79% achieved the currently advocated FTW of < 60 min.In subgroup analysis, patients with HR ≥ 80 bpm at admission were more likely to develop LVSD than patients with HR < 70 bpm (P = 0.02]). The total number of exposed persons was 821, and the cardiovascular mortality rate was 0.97 per 100 person-years. Univariate Cox regression analysis was performed for each suspected confounding factor. Prior ischemic stroke, GRACE score and rLVEF were adverse predictors for cardiovascular death in patients with AAW-STEMI reperfused by PPCI (P < 0.05). These three indicators from univariate analysis were included in multivariate Cox regression analysis, demonstrating that rLVEF was an independent predictor of cardiovascular death, see Table There were 15 patients lost to follow up, the rate was 4.93%. Except for 2 patients with non-cardiovascular death, a total of 8 patients dead of cardiovascular disease after a median follow-up of 47 months (interquartile range: 27 to 64 months): 7 (6.54%) patients in the rLVEF group and 1 (0.56%) patient in the pLVEF group, respectively  . LVEF isThe number of individuals who develop HF after AMI undergoing PCI increases with age . In an oAccelerated HR is an important external manifestation of sympathetic nerve excitement, which is one of the primary internal mechanisms for the occurrence and development of HF after AMI. In the early stage of AMI, increased HR further promotes myocardial oxygen consumption and shortens myocardial perfusion time, which can directly cause the expansion of the infarction size. As the stroke volume decreases and coronary perfusion decreases, HR increases in an attempt to regain cardiac output and maintain sufficient perfusion of the heart . The forElectrocardiography has several advantages including simplicity, non-invasive and low cost. It not only has the ability to estimate the location and range of a myocardial ischemic area, but also can be used to predict possible adverse events and complications, playing a central role in the diagnosis of STEMI in an emergency setting. Blood is supplied by LAD artery to the left anterior wall, the anterior lateral wall, and the front two-thirds of the ventricular septum. When LAD artery is blocked, those area will be damaged or even necrosis, and the corresponding anterior wall leads will show typical “damage type” changes, namely ST segment elevation. Anterior myocardial infarctions lead to more pronounced LVSD and more adverse LV remodeling compared with myocardial infarction in other areas .When occCK has certain value for the early diagnosis and severity of AMI patients. CK mainly exists in skeletal muscle and myocardium, and also exists in brain tissue. It plays an important role in catalyzing cell energy conversion and regulating cell electrophysiological activities. When MI occurs, myocardial cells rupture and necrosis, and then CK will be released into the blood. CK will increase within 6 h, and reach peak at about 24 h, and then return to normal, generally lasting for 3–4 days. A large infarct size is associated with progressive LV remodeling. Patients with higher peak CK are more likely to experience left ventricular remodeling after STEMI and present more often with a lower LVEF , 33. PatLarger infarct size is associated with greater LV dysfunction, adverse cardiac remodeling, and HF over time. Shortening the STW time is very important to reduce the risk of HF in patients, especially those with AAW-STEMI . STW timSTEMI is associated with cardiomyocyte loss, fibrosis, and cardiac remodeling, which together represent the main pathophysiological mechanisms that comprise the clinical picture of HF. Timely reperfusion therapy can save the ischemic myocardium and reduce the loss of viable mass. Medication following reperfusion therapy is also critical to improving prognosis. In this study, early application of ACEIs/ARBs or ARNIs and β-blockers failed to improve the LVEF level in the acute phase. However, it has been confirmed that the early application of ACEIs/ARBs or ARNIs and β-blockers can inhibit myocardial remodeling and improve long-term prognosis . ImproveSeveral limitations should be acknowledged. First, the present study was a single-center, retrospective, observational study, and unexpected and unmeasured confounders may have affected the outcomes. Second, we studied patients whose cardiac function was Killip grade 1 because we observed that this population accounted for the majority of patients who presented within 12 hours of the onset of AAW-STEMI. In contrast to the conventional treatment for Killip class 1 cardiac function, treatment for HF was initiated for patients with Killip grade 2 or above upon admission. And we selected patients who had improved after hospitalization and were discharged from the hospital, excluding those who died during hospitalization. Therefore, this patient subgroup was not entirely representative of the overall cohort. Third, in multivariable Cox regression analysis, there were only 8 events of cardiovascular death. Although the number of events was small, the difference in cardiovascular mortality between pLVEF group and rLVEF group was extremely significant. Fourth, LVEF calculated by transthoracic echocardiography was a crude estimation of the true performance. Ideally, cardiac MRI would better define the extent of cardiac damage. Fifth, due to the lack of dynamic measurements of LVEF, we did not analyze and discuss the effect of changes in LVEF on prognosis during follow-up. Sixth, the rate of prescribing optimal drug therapy after STEMI was lower than expected in our cohort. Last, the sample size of the present study might be relatively small, and the proportion of very elderly patients in this study was lower.Our findings suggested that age, HR at admission, number of STELs, peak CK, and STW time were independent risk factors for LVSD in the acute phase in patients with AAW-STEMI whose LAD artery was completely occluded and underwent PPCI. HR at admission and STW time are factors that we can intervene in. All these predictors may be used to identify timely the risk of LVSD and initiate early standard therapy in these patients to decrease the occurrence of HF as much as possible. Incident LVSD in the acute phase after AAW-STEMI was significantly associated with long-term adverse outcomes. For patients with LVSD, closer follow-up is recommended to help these patients benefit from early optimization.


The objectives of this study were to assess the changes in the left myocardial function after chemotherapy for childhood lymphoma and observe the predictive or monitor value for cancer treatment-related cardiac dysfunction (CTRCD) by speckle-tracking echocardiography.A total of 23 children with histopathological diagnoses of lymphoma were included, with age-matched normal controls. Comparative analysis of clinical serological tests and left heart strain parameters in children with lymphoma, including left ventricular global longitudinal strain (LVGLS); global myocardial work (GMW) indices, which include global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency; and the LS of subendocardial, middle, and subepicardial layer myocardium during left ventricular systole were measured: left atrial strain of reservoir phase (LASr), left atrial strain of conduit phase (LAScd), and left atrial strain of contraction phase (LASct).p < 0.05), and the degree of decrease also showed a regular pattern of epicardial layer < middle layer < subendocardial layer while the difference was not significant (p > 0.05). After chemotherapy, maximum flow rate in early mitral relaxation/left atrial systolic maximum flow rate (E/A) and left atrial volume index of each group were in the normal range, and the values of LASr, LAScd, and LASct slightly increased in the second cycle and decreased significantly in the fourth cycle after chemotherapy, reaching the lowest level; LASr and LAScd were positively correlated with GLS.One-way ANOVA showed that GLS, GWI, GCW, LASr, and LAScd were closely associated with CTRCD and multivariate logistic regression analysis showed that GLS was the most sensitive predictor for detecting patients at lofty risk of anthracycline-related cardiotoxicity. Both before and after chemotherapy, GLS in the left ventricle showed a pattern of basal segment < middle segment < apical segment and subepicardial < middle < subendocardial layer (LVGLS is a more sensitive and earlier indicator to predict CTRCD compared with conventional echocardiography-related parameters and serological markers, and GLS of each myocardial layer showed a certain regularity. Left atrial strain can be used for early monitoring of cardiotoxicity in children with lymphoma after chemotherapy. Anthracyclines (ANTs) are first-line drugs for lymphoma chemotherapy, and antitumor mechanisms primarily include the inhibition of DNA and RNA synthesis in cells and inhibition of topoisomerase II activity, which are toxic to cardiomyocytes while inhibiting tumor cell growth and being progressive, irreversible, and dose-dependent . ChemothWe quantitatively evaluated the functional changes of LV and LA after ANT chemotherapy in children with lymphoma and explored the clinical application value of conventional echocardiography, serological makers, and ultrasound strain parameters to early detect the chemotherapy-induced cardiac dysfunction and to provide a new rationale for the clinical monitoring of the cardiotoxicity of ANTs.From January 2019 to March 2020, 28 children with lymphoma-confirmed histopathological diagnosis were first selected at Children's Hospital of Chongqing Medical University, who completed at least two courses of chemotherapy with normal LVEF (>53%) and sinus rhythm. The exclusion criteria included congenital heart disease, myocarditis, severe arrhythmia, cardiac function impairment due to anemia and nephrotic syndrome, and poor image quality due to excessive obesity and severe pneumonia. Therefore, we excluded 5 patients , and a total of 23 subjects were included in the final analysis; the flowchart of this cohort shown in The age, height, weight, blood pressure, heart rate, and chemotherapy regimen of every child were recorded, and the child's body surface area and the cumulative amount of Adriamycin after every two courses of treatment were measured. Venous blood samples were taken from each kid before chemotherapy and within 24 h after every two chemotherapies to measure the serum levels of creatine kinase isoenzymes MB (CK-MB) and troponin I ultra (TnI-Ultra) before and after chemotherapy.The same physician performed echocardiograms before chemotherapy and within 24 h after every two courses of chemotherapy using a GE system  and M5S transducer (3.5 MHz) as per current guidelines , 15. PosThe images were obtained in DICOM format, and the left atrial myocardial motion was depicted in the apical four-chamber view and apical two-chamber view with the matching software EchoPAC 204 to calculate the left atrial end-diastolic dimension (LAEDd), left atrial end-diastolic volume (LAEDV), left atrial end-systolic volume (LAESV), and the biplane left atrial ejection fraction (LAEF) and left atrial volume index (LAVI); in the mode of Auto-EF, the apical two-chamber and four-chamber end-systolic left ventricular intimal surfaces were depicted, and LVEF was calculated by the biplane Simpson method; the crest mitral valve orifice blood flow rate was measured by spectral Doppler in the apical four-chamber view to calculate E/A.In auto function imaging (AFI), the corresponding standard view of three-chamber, four-chamber, and two-chamber heart  was selected. The software can automatically track the LV membrane surface to form a range of interest through the electrocardiogram; manually depict or finetune if necessary; calculate the GLS of LV in APLAX, 4CH, and 2CH; and the software automatically calculates the average value GLPSAvg (LVGLS) . At the The left atrial global strain was automatically tracked at a finishing time of diastole , left atrial strain of reservoir phase (LASr), left atrial strain of conduit phase (LAScd), left atrial strain of contraction phase (LASct) at 4CH and 2CH were calculated and record it respectively, and their mean values BiSr, BiScd, and BiSct, recorded as LASr, LAScd, LASct . All part test, Single factor variance analysis, and repeated measures analysis of variance (ANOVA); non-normally distributed data are expressed as the median ± interquartile range and between groups were analyzed with the Wilcoxon signed rank test. Correlation analysis was performed using Pearson correlation analysis, and diagnostic efficacy was assessed using binary logistic regression analysis and receiver operating characteristic (ROC) curve. p < 0.05 was considered statistically significant.Statistical analysis was performed using SPSS 25.0 software. LVGLS, LAScd, and Sct were negative values, and absolute values were taken for a description in this paper; normally distributed data and approximately normally distributed data are expressed as the mean ± standard deviation (SD); differences between groups were analyzed with independent-sample n = 23) consisted of 20 males and 3 females with a mean age of 9.34 ± 3.59 years (range 5–15 years). They all completed at least two chemotherapy courses (cumulative ANT dose 50 mg/m2): 19 patients completed four chemotherapy courses (cumulative ANT dose 100 mg/m2), 12 patients completed six chemotherapy courses (cumulative ANT dose 150 mg/m2), and 8 patients completed eight chemotherapy courses (cumulative ANT dose 230 mg/m2). Twenty-three children developed varying degrees of nausea, vomiting, and myelosuppression after chemotherapy only within different chemotherapy cycles, which resolved spontaneously after the end of chemotherapy without other discomforts such as palpitations or dizziness and had no significant abnormalities in myocardial markers or electrocardiograms. In addition, only 1 of the 23 patients died of severe infection within 1 year after the end of chemotherapy. The control group consisted of 23 patients, 20 males and 3 females, with an average age of 9.42 ± 3.15 years . There were no obvious differences in age, weight, height, and gender distribution between the control and study groups (p > 0.05). The diastolic blood pressure (DBP) was significantly lower than healthy controls (p < 0.05). There was no statistical significance in body surface area (SA), heart rate (HR), and systolic blood pressure (SBP) between 23 children with lymphoma before chemotherapy and 2, 4, and 6–8 times after chemotherapy and the control group (p > 0.05) (The study population ( > 0.05) . During  > 0.05) .p > 0.05). After chemotherapy, the data of LVEF determined by the Simpson method decreased in the normal range compared with that before chemotherapy (p > 0.05); LAVI before chemotherapy in children with lymphoma were lower when compared with the normal group   .p < 0.05), while GCW, LASr, LAScd, and LASct were not significantly different between the two groups (p > 0.05). Compared with that before chemotherapy, the mean values of GLS in children with lymphoma after chemotherapy at cycles 2, 4, 6, and 8 showed a decreasing trend at cycles 2 and 4 . However, they fluctuated at cycles 6 and 8 (p > 0.05) (p > 0.05).LVGLS, GWI, GWW, and GWE were significantly lower than healthy controls ( > 0.05) . There wp < 0.05) whether before chemotherapy or after chemotherapy; and the degree of decreased also showed revealed a regular pattern of epicardial layer < middle layer < subendocardial layer while the difference was not significant (p > 0.05)  .p > 0.05). Correlation analysis showed that LASr was weak positively correlated with LAVI, LVEF, GLS, and LASct ; LAScd was weak positively correlated with E/A, LAEF, and LAVI , moderate positively correlated with LVEF and GLS , and strong positively correlation with LASr ; LASct was weak positively correlated with LAVI , moderate positively correlated with LASr, and there was no significant association with E/A, LAEF, LVEF, GLS, and LAScd (r = −0.138 to 0.229)  had LASr lower than 35%. LASr, LAScd, and LASct were slightly increased after the second cycle of chemotherapy but decreased after the fourth cycle of chemotherapy, and the overall mean value was below that of the healthy control group, and slightly increased again in the sixth and eighth cycles after chemotherapy. The overall mean value exceeded that before chemotherapy but was lower than that in the second cycle of chemotherapy ; at the o 0.229) .B = −0.965, Exp (B) = 0.381, p < 0.05]. When the absolute value of LVGLS was < 17.67, the sensitivity for predicting CTRCD was 0.765, the specificity was 0.917, and the area under the curve (AUC) = 0.857 , but the minimum age of this study was 50 years, which was different from our study subjects in age. Unfortunately, we lacked the criteria for the diagnosis of LAVI abnormalities in children, so the predictive value of LAVI in children may be underestimated.The left atrial changes are asymmetric and difficult to measure quantitatively, and the left atrial size is influenced by many factors, which leads to unreliable results such as LAESV. We discovered that LAVI before chemotherapy in lymphoma children was clearly lower than those in the control group, LAVI predicts diastolic dysfunction by reflecting the magnitude of LV filling pressure, and monitors LV diastolic function more accurately than E/A and LAD . Followi2 in breast cancer patients, and serum Hs-cTnT concentrations after anthracycline chemotherapy showed a gradually increasing trend over four chemotherapy stages, while only one of our children had anthracycline concentrations reaching 350 mg/m2, mostly less than 100 mg/m2. This could also explain why serum indicators in our investigation did not indicate any changes  and the European Association of Cardiovascular Imaging (EACVI) recommended LVEF criteria were not met, but a GLS decrease of >15% from baseline can be considered subclinical CTRCD , 46, 47.LVGLS is a more sensitive and earlier indicator to predict CTRCD compared with conventional echocardiography-related parameters and serological markers. GLS of each myocardial layer showed a certain regularity. Left atrial strain can be used for early monitoring of cardiotoxicity in children with lymphoma after chemotherapy.


Cardiac resynchronization therapy (CRT) is typically achieved by pacing both ventricles. However, left ventricular–only pacing has been shown to be noninferior to biventricular pacing in patients with left bundle branch block and normal atrioventricular conduction. However, there is no evidence in favour of CRT with single-site pacing for patients with single-ventricle physiology. In this case, we performed CRT with single-site pacing in a patient with tricuspid atresia and left bundle branch block, enabling successful Fontan completion. A 12-month-old girl (5.6 kg) with tricuspid atresia (TA) and left bundle branch block (LBBB) underwent successful permanent epicardial resynchronization using single-site pacing. She was diagnosed with type 2c TA , coarctation of the aorta, and patent left superior vena cava. She underwent aortic arch repair and pulmonary artery banding 7 days after birth, followed by bilateral bidirectional Glenn operation with Damus-Kaye-Stansel anastomosis at the age of 5 months. LBBB occurred after the surgery, posing a risk for adverse effects on the patient’s circulatory status. However, circulatory disruption did not occur, and the patient was discharged from the hospital 3 weeks after operation. After discharge from the hospital, congestive heart failure gradually developed. Unfortunately, this condition could not be controlled despite the administration of diuretics and angiotensin-converting enzyme inhibitors.At the age of 8 months, the patient required hospitalization and intravenous inotropic support. Coil embolization of the aortopulmonary collaterals was performed, but it failed to control the heart failure. The serum levels of the N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) ranged 5885-23,720 pg/mL. Ventriculography and echocardiography revealed that the left ventricular (LV) contraction was delayed compared with that of the right ventricle (RV). Electrocardiography revealed LBBB C, which One month later, a permanent epicardial dual-chamber pacemaker was implanted. Permanent atrial pacing leads were placed on the right atrium. The cathode of a permanent ventricular lead was sutured on the posterior wall of the left ventricle, whereas the anode was placed on the anterior wall of the RV. The leads were connected to a pacemaker device . After the initiation of LV pacing, her blood pressure was increased by 20 mm Hg. The device was implanted in the posterior sheath of the rectus abdominis muscle in the upper abdomen. In addition, we placed another ventricular lead, which was not connected to the pacemaker device, on the anterior wall of the RV for an upgrade to biventricular pacing. We prepared to upgrade to biventricular pacing using anodal pacing or a CRT lead in case of ineffective LV-only pacing .Figure 2The atrioventricular (AV) interval in children exhibits large variability. Therefore, we turned on the negative AV hysteresis function and set the AV delay to be 10 milliseconds shorter when the V lead sensed a self-pulse. The clinical condition improved after pacemaker implantation, whereas the NT-proBNP levels were decreased to 2899 pg/mL. Echocardiography revealed major improvement of interventricular synchrony. Speckle tracking analysis showed that the RV-to-LV delay was almost zero, although the RV-to-LV delay had been 260 milliseconds before resynchronization , A and BCRT is a well-established treatment for adult patients with LV systolic dysfunction without congenital heart disease. CRT for patients with single-ventricle (SV) physiology is becoming increasingly common.Currently, there is no evidence in favour of CRT with single-site pacing for patients with SV physiology. However, LV-only pacing has been shown to be noninferior and even superior to biventricular pacing in adult heart failure patients with preserved AV conduction or LBBB.There are other advantages in selecting SV pacing in small children. In paediatric patients with little subcutaneous tissue, there is an advantage in choosing a smaller device in terms of pocket complications associated with generator implantation. In addition, in paediatric patients who will require frequent lead replacement in the future, consideration should be given to reducing the number of leads used.The risks associated with selecting SV pacing for children are as follows. In children with large variability in heart rate, it is expected that the variability of AV intervals will also be large.We could not determine the reason for LBBB. The patient did not have LBBB before the first surgery. However, she experienced a transient LBBB at the time of her first surgery. The LBBB resolved during the recovery period and did not recur until the second surgery. At the time of the second surgery, persistent LBBB occurred and did not resolve. We could not identify the reasons for the development of LBBB after cardiac surgery, which did not require ventricular resection. Nevertheless, these surgeries are performed under cardiac arrest. Damage of the intraventricular conduction system is a possible complication in this setting.Although the LBBB occurred immediately after surgery, the patient did not present symptoms of heart failure until discharge. Presumably, the heart failure developed as the patient became more active after discharge from the hospital. It was suspected that LBBB was not the only cause of congestive heart failure. Other undetectable causes, such as cardiomyopathy, may have contributed to the development of LBBB. However, LBBB-induced interventricular dyssynchrony was one of the major causes of the poor circulatory status observed in this patient. Fortunately, we were able to correct the LBBB-induced interventricular dyssynchrony with CRT using single-site ventricular pacing and improve the patient’s circulatory status.•Cardiac resynchronization therapy using single-site ventricular pacing may be a good therapeutic option for single-ventricle physiology patients with bundle branch block and otherwise normal atrioventricular conduction.To the best of our knowledge, this is the first reported case of successful CRT using single-site ventricular pacing in an SV physiology patient with BBB and otherwise normal AV conduction.


Chronic mitral regurgitation promotes left atrial (LA) remodeling. However, the significance of LA dysfunction in the setting of ventricular functional mitral regurgitation (FMR) has not been fully investigated. Our aim was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in patients with FMR and reduced left ventricular ejection fraction (LVEF).Patients with at least mild ventricular FMR and LVEF < 50% under optimized medical therapy who underwent transthoracic echocardiography at a single center were retrospectively identified in the laboratory database. PALS was assessed by 2D speckle tracking in the apical 4-chamber view and the study population was divided in two groups according to the best cut-off value of PALS, using receiver operating characteristics (ROC) curve analysis. The primary endpoint-point was all-cause mortality.2 (IQR: 9 – 22mm2). According to current European guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 – 6.6), 148 patients died. The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS. On multivariable analysis, PALS remained independently associated with all-cause mortality , even after adjustment for several (n = 14) clinical and echocardiographic confounders.A total of 307 patients  were included. Median LVEF was 35% (IQR: 27 – 40%) and median effective regurgitant orifice area (EROA) was 15mmPALS is independently associated with all-cause mortality in patients with reduced LVEF and ventricular FMR.The online version contains supplementary material available at 10.1186/s12947-023-00307-7. Functional mitral regurgitation (FMR) is a complex and heterogeneous condition, most frequently secondary to left ventricular (LV) remodeling and dysfunction , 2. It iWhile many studies focused primarily on LV function and geometry, the interest in the left atrium (LA) has been resurging over the recent years . Both pr2-D speckle tracking echocardiography (2D STE) is an angle-independent method for the quantification of myocardial deformation, and its feasibility for the study of LA function has been validated in previous studies –13. It hAlbeit standardized reference values are still lacking, peak atrial longitudinal strain (PALS), or LA longitudinal strain during the reservoir phase, has been consistently reported as a reproducible measurement and with encouraging results . It provThe aim of this study was to assess the prognostic significance LA function, as assessed by PALS, in patients with LV systolic dysfunction and ventricular functional mitral regurgitation.Patients with at least mild ventricular FMR and reduced left ventricle ejection fraction (LVEF), defined as LVEF < 50%, who underwent transthoracic echocardiography between 2010 and 2018 were retrospectively identified at a single center laboratory database. Optimal guideline directed medical therapy (GDMT) for at least 3 months  was a prerequisite for inclusion [The first available echocardiographic study after optimal GDMT with the patient in a hemodynamically stable state served as the index time point for time-to-event analyses. Medical history and current medication were collected at the time of the index echocardiographic exam. The study protocol was reviewed and approved by the local ethics' committee, which waived the need for informed consent.Transthoracic echocardiography (TTE) was performed with commercially available equipment . Two-dimensional (2D), M-mode and Doppler data were retrospectively retrieved from the echocardiographic database for offline analysis . LV volumes (end-systolic and end-diastolic) were measured in the apical 2- and 4-chamber views and LVEF was calculated according to Simpson’s biplane method and indexed for body surface area . LateralMitral regurgitation (MR) quantification was performed with the proximal isovelocity surface area (PISA) method including the effective regurgitant orifice area (EROA) and the regurgitant volume (RegVol) . A 4-chaLA speckle-tracking strain was measured using a dedicated LA-tracking software  on the apical four-chamber view at a frame rate > 50fps (mean 55fps), according to current European Association of Cardiovascular Imaging (EACVI) recommendations . The onsPatients were assessed at least once a year and vital status was documented at the institutional electronic medical records, which is updated using the Portuguese National Patient Registry. During follow-up, titration of medical therapy, indications for cardiac devices and any kind of mitral intervention or heart transplant/left ventricular assist device were left at the discretion of the Heart Failure Team. The primary endpoint was all-cause mortality. Vital status was available for all patients.2) test, Mann–Whitney U and independent samples t-test were applied for comparison where appropriate.Categorical values are presented as absolute numbers (and percentage) and continuous variables as mean ± standard deviation  or as median and interquartile range . Pearson’s Chi-squared (χP < 0.001).The inter-observer variability of PALS measurement was assessed by calculating the intraclass correlation coefficient analysis on a random sample of 30 echocardiograms, by comparing a repeated analysis performed one week later by a second blinded independent operator. It showed very good reproducibility inter-observer variability with an intraclass correlation coefficient of 0.98  curve was used to determine the discriminative ability of PALS for all-cause mortality and the maximum Youden’s index was employed to identify the best cut-off of PALS. In a subsequent analysis, the population was divided into four groups according to the determined PALS cut-off and the presence of severe LA dilatation, based on current recommendations . AdditioP-value < 0.05 were included in the multivariable model. Multicollinearity was excluded using variance inflation factor. The proportional hazards assumption using Schoenfeld residuals was tested and satisfied.Kaplan–Meier survival curves were plotted to compare groups, and the log-rank test was used to assess for significant differences in time to endpoint between groups. Patients were right-censured if mitral intervention  or heart transplant/left ventricular assist device (LVAD) were performed. Cox proportional hazards regression was applied for univariable and multivariable analysis to investigate the association between clinical and echocardiographic parameters with all-cause mortality. Variables with a P-value < 0.05 (two-sided). All analyses were performed using SPSS v26.0  and STATA v13.0 .Statistical significance was set at 2 (9-22mm2). According to the new ESC 2021 guidelines for the management of valvular heart disease, 32 patients (10.4%) had severe FMR. A total of 307 patients  were included. Baseline clinical and echocardiographic characteristics are shown in Tables –77; 77% During a median follow-up of 3.5 years (IQR 1.4–5.6), 148 patients (48.2%) died. Of note, during the study period 9 patients performed transcatheter edge-to-edge repair (TEER), 2 underwent surgical mitral valve repair or replacement and 5 patients received heart transplant/LVAD; these patients were right censured at the time of intervention.p < 0.001). The best cut-off of PALS for predicting all-cause mortality was 15% , and it was employed to dichotomize the population , larger end-systolic LV volumes (P < 0.001), higher estimated LV filling pressures , poorer LV and RV function (both P < 0.001), and higher EROA and SPAP values .PALS showed a reasonable discriminative power for all-cause mortality . Additionally, Kaplan–Meier survival curves were also performed when dividing the population into four groups according to both PALS and LAVI, PALS and history of AF, and PALS and EROA . Age , creatinine , LVEF , and EROA  were the other independent predictors of all-cause mortality. PALS remained independently associated with all-cause mortality after excluding patients with milder degrees of FMR  Impaired PALS is associated with poorer LV function and more severe FMR; and (2) In patients with reduced LVEF and FMR, PALS is independently associated with all-cause mortality and holds additional information over conventional LA and LV measurements.Ventricular FMR is a frequent finding in HF patients and is associated with worse prognosis, in part related to the additional volume overload and increased LV end-diastolic wall stress and remodeling . However2 was associated with worse prognosis independently of PALS. Beyond modulating ventricular FMR prognosis, progressively lower PALS were also found to have a linear relationship with worse outcomes in patients with HF with reduced LVEF, with excess risk occurring for a PALS value inferior to the previously identified threshold [A study reporting a very similar PALS cut-off to the one we have found (14% vs. 15%) has demonstrated the interplay between FMR and LA function . Not onlhreshold .Globally, patients with HF and FMR have an extremely poor prognosis with reported mortality rates of up to 47% at 5 years of follow-up, although it can vary significantly according to individual clinical variables . IdentifThese present data show that PALS can be a promising index, as it holds independent prognostic significance across the whole spectrum of ventricular FMR, including mild regurgitation. In fact, the paradigm in the management of valvular heart disease is shifting towards the use of more advanced imaging measurements such as speckle tracking echocardiography  and tissue characterization with late gadolinium enhancement cardiac magnetic resonance (CMR) . These ep < 0.001) (Supplementary Fig.Some limitations of this study should be acknowledged. Because of the retrospective nature of the study, a significant proportion of patients initially screened was excluded due to suboptimal frame rate or inadequate acoustic window quality, which is known to increase the risk of bias (Supplementary Fig. In a cohort of patients with reduced LVEF and FMR, impaired PALS was independently associated with an increased risk for all-cause mortality. PALS assessment may be an easy and emerging method for prognostic purposes and therapeutic guidance in this population.Additional file 1.