There is a known link between myocardial fibrosis as defined by late gadolinium enhancement (LGE), severity of left ventricular remodeling and ventricular arrhythmias in hypertrophic cardiomyopathy (HCM). Noninvasive quantification of fibrosis may offer the possibility for risk stratification. Due to their often diffuse and blurred character these lesions remain difficult to differentiate from healthy myocardium in several cases.Recent studies showed the superiority of Gadobenate dimeglumine (Gd-BOPTA) compared with Gadopentetate dimeglumine (Gd-DTPA) in distinguishing infarcted from viable myocardium which can be explained by the higher relaxivity of Gd-BOPTA. Therefore we hypothesized that Gd-BOPTA may have advantages over Gd-DTPA for depiction of non-ischemic fibrosis.We prospectively enrolled eight Patients with clinically established HCM and positive LGE during clinical routine scan with 0.2 mmol/kg Gd-DTPA (0.5 molar). They underwent a second scan at least 72 hours apart from the first CMR exam with 0.2 mmol/kg Gd-BOPTA (0.5 molar) using the same CMR protocol and sequence parameters. None of the patients had renal failure, coronary artery disease or general contraindications for CMR.LGE was assessed in a short axis stack acquired 15 minutes after contrast administration by using state of the art inversion recovery gradient echo sequence  with a TI adjusted to null signal from normal myocardium. Positive LGE was judged positive if signal intensity was above mean + 2 standard deviations of remote myocardium.Signal intensities of injured myocardium, healthy myocardium, LV cavity and air were measured in identical locations by using anatomical landmarks in dedicated software . Signal to noise ratio (SNR) and contrast to noise ratio (CNR) were calculated.We observed no complications relating to contrast administration. Both the SNR of injured myocardium  and the CNR between healthy and injured myocardium  were significantly higher with Gd-BOPTA. SNR of LV cavity was significantly higher  with Gd-BOPTA resulting in a poorer contrast between injured myocardium and blood which did not affect the diagnosis since LGE was exclusively non-subendocardial.Gd-BOPTA improves the visualization of non-ischemic fibrosis in HCM. This may offer the potential for a more accurate quantification of focal myocardial fibrosis in this setting.


While the role of early mobilization in the immediate postinfarction period has been well demonstrated, little is known in present about the link between early mobilization and reduction of systemic inflammation. At the same time, the impact of early mobilization on regression of left ventricular remodeling has not been elucidated so far.Here we present the study protocol of the REHAB trial, a clinical descriptive, prospective study, conducted in a single-center, with the purpose to analyze the impact of early mobilization in reducing left ventricular remodeling, the complication rates and mortality in patients who had suffered a recent acute myocardial infarction (AMI). At the same time, the study aims to demonstrate the contribution of early mobilization to reduction of systemic inflammation, thus reducing the inflammation-mediated ventricular remodeling. 100 patients with AMI in the last 12 hours, and successful revascularization of the culprit artery within the first 12 hours after the onset of symptoms in ST-segment elevation acute myocardial infarction or within first 48 hours in non ST-segment elevation AMI will be enrolled in the study. Based on the moment of mobilization after AMI patients will be distributed in 2 groups: group 1 – patients with early mobilization (<2 days after the onset of symptoms) and; group 2 – subjects with delayed mobilization after AMI (>2 days after the onset of symptoms). Study outcomes will consist in the impact of early mobilization after AMI on the ventricular remodeling in the post-infarction period, as assessed by cardiac magnetic resonance imaging, the rate of in-hospital mortality, the rate of repeated revascularization or MACE and the effect of early mobilization on systemic inflammation in the immediate postinfarction phase.In conclusion, REHAB will be the first trial that will elucidate the impact of early mobilization in the first period after AMI, as a first step of a complex cardiac rehabilitation program, to reduce systemic inflammation and prevent deleterious ventricular remodeling in patients who suffered a recent AMI. As a consequence, rehabilitation of AMI survivors has become a real public health issue and a major challenge to be solved.,4 In this context, both health care systems and general population have started to become aware of the fact that the current approach, mainly involving interventional and pharmacological treatments, is neither effective nor sufficient.,6 As patients with recent AMI deserve special attention, structured multifaced and multidisciplinary interventions for assessment and management of cardiovascular (CV) risk factors, guidance on physical activity and psychosocial sustenance,8 were developed and implemented as case-management models of cardiac rehabilitation (CR) programs.–11As a severe form of coronary heart disease, acute myocardial infarction (AMI) involves a significant burden in terms of disability, especially in the increasing population of elderly patients. Along with patient physical reintegration, CR programs involve preventive strategies for subsequent CV events, death or hospitalization from cardiac causes. While the objectives are identical, settings differ according to local or national protocols and experiences, including residential, ambulatory community, or home-based strategies.Divided in 3 phases: inpatient, outpatient, and long-term interventions, CR aims to improve functional capacity and recovery, prevent disability and restore the quality of life.–18 A large variety of biomarkers have proven their prognostic role in LV remodeling, being well associated with inflammation and microcirculatory dysfunction .One of the most important predictors of long-term evolution after an AMI is represented by the left ventricular (LV) remodeling. Postinfarction LV represents a maladaptive and dynamic process resulting from the complex interaction between the size of the infarcted area, genetic predisposition and inflammation, in which systemic inflammation plays a crucial role. This phenomenon is associated with mechanical and biochemical changes, leading to arrhythmia, ventricular dysfunction and heart failure on the long term.–23Among inflammatory biomarkers whose maintenance at a high serum level has been proved to be prognostic for ventricular remodeling, interleukin-6 (IL-6), tumor necrosis factor-α, and interleukin-1β are the most widely studied, and may serve as prognostic markers for the development of postinfarction heart failure. At the same time, it has been hypothesized that specific CD11/CD18 integrin receptors, complement cascade activators, complement component 1, complement component 5 or P-selectin can be used to form antibodies that would block the inflammation, however the results of such studies are still un-conclusive. The success of regular exercise in reducing the risk of coronary disease development and complications was strongly associated with the reduction of C-reactive protein (CRP) and fibrinogen levels. Moreover, Church et al found an inverse correlation between cardiorespiratory exercise and systemic level of CRP, an inflammation-related biomarker validated as a significant predictor for the development of an AMI.,26In a series of non-pharmacological therapeutic strategies concerning the inflammatory component of atherosclerotic disease, exercise training proved to be the most outstanding.,27 While the role of early mobilization in the immediate postinfarction period has been well demonstrated, little is known in present about the link between early mobilization and reduction of systemic inflammation. At the same time, the impact of early mobilization on regression of LV remodeling has not been elucidated so far.According to current ESC and ACC/AHA guidelines for the management of patients with ST-segment elevation acute myocardial infarction (STEMI), mobilization should be performed in the first 12 and 24 hours following an uncomplicated acute AMI (level of evidence C).1.2primary objective of the study is to evaluate the impact of early mobilization after AMI on the ventricular remodeling in the post-infarction period, as assessed by cardiac magnetic resonance (CMR) imaging.The secondary objectives includeThe (1)to investigate the effect of early mobilization on systemic inflammation in the immediate postinfarction phase(2)to investigate the impact of early mobilization on in-hospital mortality and the role of early mobilization in reducing in-hospital complications in patients suffering an AMI.22.1This is a prospective, non-randomized, cohort study, carried out in a single-center, which aims to assess the link between early mobilization after AMI, systemic inflammation, and LV remodeling in patients with recent STEMI.2.2The clinical study has the approval of the local Ethics Committee for Scientific Research of the University of Medicine and Pharmacy of Tirgu-Mures  and the Ethics Committee for Scientific Research of the Cardio Med Medical Center . All study procedures will be conducted according to the Declaration of Helsinki and each subject will provide signed written informed consent before randomization process.2.3The study will be a single-center, observational, non-randomized study including 100 patients with AMI, presenting with either STEMI or non ST-segment elevation AMI (NSTEMI).Inclusion criteria:Patients with AMI in the last 12 hours.Successful revascularization of the culprit artery within the first 12 hours after the onset of symptoms in STEMI or within first 48 hours in NSTEMI (according to the risk class).Signed written informed consent.Exclusion criteria:Patient refusal;Any condition that would contraindicate CMR examination;Women during pregnancy or lactation period;Women able to procreate without any contraceptive usage;2) or acute renal injury that requires hemodialysis;Chronic kidney disease .2.5This study will enroll 100 patients with AMI meeting the inclusion criteria, who will be distributed in two groups: group 1 – patients with early mobilization (<2 days after the onset of symptoms) and; group 2 – subjects with delayed mobilization after AMI (>2 days after the onset of symptoms).2.6Medical records, physical exam, laboratory analysis ;ElectrocardiographyTransthoracic echocardiography for assessment of LV systolic and diastolic performance, speckle tracking echocardiography, Dobutamine viability testLate gadolinium enhancement CMR for evaluation of ventricular function and remodeling, extent of myocardial scar and transmurality index.2.6.1Routine biochemistry and CBC analysis will be performed at the main laboratory of the Emergency Clinical County Hospital of Tirgu-Mures, immediately after randomization, during the acute phase of infarction. Inflammatory status (hs-CRP levels) will be evaluated at 7 days after the acute cardiac event via immunoturbidimetric assay. Serum levels of matrix metalloproteinase 9 and IL-6 will be evaluated with enzyme linked immunosorbent assay. Serum inflammatory biomarkers will be analyzed in Advanced Medical and Pharmaceutical Research Center of the University of Medicine and Pharmacy Tirgu-Mures. Serum levels of NT-proBNP will be determined at randomization, at the main laboratory of the Emergency Clinical County Hospital of Tirgu-Mures by electrogenerated chemiluminescence.2.6.2Transthoracic echocardiographic assessment will be performed at first visit in all patients, in the first days during the hospitalization for the acute coronary event. Speckle tracking technology will be used for evaluation of ventricular volumes and wall motion analysis, using a Vivid E9 ultrasound system .2.6.3All CMR images will be acquired with the use of a 1.5T Siemens Magnetom Aera equipment. The LGE-CMR will be used to quantify the infarct size, the extent of myocardial necrosis and the transmurality index, 10 minutes after gadolinium intravenous injection. Imaging data post-processing will be conducted with the use of Medis Q Mass 8.1 software , which involves manually tracing of the epicardial and endocardial borders, while setting the threshold for hyper-enhancement in the acquired image sequence.2.7REHAB study will be conducted from October 2019 to October 2020.2.8primary outcome of the study will consist in the impact of early mobilization after AMI on the ventricular remodeling in the post-infarction period, as assessed by CMR imaging.The Secondary outcomes of the study will be represented by rate of in-hospital mortality and the rate of repeated revascularization or MACE (including CV death or stroke) in patients with early mobilization as compared to those with delayed mobilization, and the effect of early mobilization on systemic inflammation in the immediate postinfarction phase.2.9Baseline (day 0):Achieve written informed consent form all patients.Check all inclusion/exclusion criteria.Record demographic information, medical records, CV risk factorsPerform and record physical examination and 12-lead electrocardiography (ECG).Laboratory analysis .Transthoracic echocardiography / speckle tracking.Visit 1 :hs-CRP assessment.Visit 2 (month 1):LGE-CMR .Visit 3,4,5 Record results of physical exam, medical records, ECG.Transthoracic echocardiography / speckle tracking.Final study visit (month 12)Record results of physical exam, medical records, ECG.Transthoracic echocardiography / speckle tracking.End-point assessment.2.10The study will enroll 100 patients with AMI who presented within the first 12 hours after the onset of symptoms and underwent successful revascularization of the culprit artery within the recommended timeframe, with TIMI 3 flow. Patients will be divided into 2 groups on the basis of the time interval from admission to mobilization: early (<2 days) mobilization group, versus delayed (>2 days) mobilization group. The sample size was calculated using Stat Mate 2.0 software, which indicated that a sample size of 50 subjects per group has a 90% power to detect an increase in major adverse CV events rates proportion of 3.28, with a significance level  of 0.05 (2-tailed).3This manuscript presents the protocol of a clinical descriptive, study, conducted in a single-center, with the purpose to analyze the impact of early mobilization in reducing LV remodeling, the complication rates and mortality in patients who had suffered a recent AMI. At the same time, the study aims to demonstrate the contribution of early mobilization to reduction of systemic inflammation, thus reducing the inflammation-mediated ventricular remodeling.3.1,29 Published results have documented that CR improves patient outcomes, on a magnitude similar to the reduction in mortality and morbidity rates obtained by aspirin therapy or percutaneous coronary intervention implementation, and probably with similar cost-to-benefit ratios.After 50 years from the first implementation of a post AMI CR program, the clinical benefits and cost-effectiveness of CR are now unequivocally demonstrated by clinical evidence, CR becoming an indispensable component of patient-oriented care. at this moment CR after AMI is a Class I recommendation from both European and American guidelines. Unfortunately, despite the body of professional recommendations indicating CR as the most important evidence-based intervention for secondary prevention after AMI, CR programs integration into daily practice proves to be a challenge. In despite of the availability of suitable CR programs, many studies demonstrate currently that only 25% of suitable patients are referred or finally take up any form of CR, with <10% participation in elderly subjects. Moreover, even when implemented, most of CR programs rely only on short-term strategies, with 30% to 40% of patients discontinued CR after first 6 months, and up to 50% dropping out after 1 year. A series of research indicates the barriers that hold responsibility for the underuse of CR are generally centered around patient, healthcare provider, health system and community levels. Patient involvement seems to be particularly challenging, therefore implementation of novel strategies is urgently needed to address this problem, as this approach can minimize the probability of subsequent coronary events while maximizing functional capacity. Home-based programs, community-based group strategies or internet-based programs may represent alternative approaches to structured supervised CR providing risk modification, education and guidance.–40Supported by systematic reviews and meta-analyses documenting a reduced mortality,3.2,18,41,42Progression of the LV remodeling leads to alterations in cardiac geometry, function and structure of the myocardium. This affects the ventricular contraction that becomes asymmetric. Therefore, LV dilates, the cardiac volumes increases and the stroke volume decreases.,42,43 Studies proved that initiation of the LV remodeling process does not correlate only with the infarcted size. LV remodeling depends also on inflammatory response that involves local chemokine production, necrotic tissues removal and extracellular matrix formation.,18,41–44 Several recent studies have proved that miRNAs play also an important role in LV remodeling. The reduced expression of miRNA after AMI correlates with a proliferation of cytokines to the fibroblast line, thus with cardiac fibrosis and consequently the reduction of myocardial vascularization favoring LV remodeling.One of the most important determinants of the LV remodeling is the infarct size. However, in some situations, although the infarcted area has been enlarged, myocardial reparative response can prevent the development of LV remodeling.3.3–46 After AMI, the sudden death of cardiomyocytes occurs, leading to the emergence of a pro-inflammatory response necessary for the necrotic cell clearance cells from the infarcted area. Paradoxically, myocardial reperfusion therapy leads to the aggravation of this inflammatory process. Thus, overexpression of proteases – matrix metalloprotease MMP2 and MMP9 and an impairment of autophagosome clearance occurs, leading to activation of the RISK pathways. The most frequent outcomes are associated with cardiac dilatation, infarct area expansion and cardiac fibrosis.–50The inflammatory response after AMI plays an important role in cardiac repair especially in preventing the occurrence of adverse LV remodeling and the onset of heart failure.,46,51 Endothelial cells are one of the major sources of pro-inflammatory chemokines responsible for molecular adhesion to the endothelial surface. With an important role in the recruitment of neutrophils, monocytes and lymphocytes in the infarcted area, endothelial cells increase reactive oxygen species production by activating various signaling pathways, which involve additional secretion of chemokines and cytokines.,46,47A large multiple cytoplasmic complex is formed that mediates activation of pro-inflammatory cells  with critical role in amplifying the pro-inflammatory response. Thus, the activation of natural killer cells and inflammasomes represents the second stage of the cytokine response to AMI. Inflammasomes are cytoplasmatic complexes that typically contain one of the nod-like receptor family proteins capable to recognize and induce the inflammatory response after AMI.,53 On the other hand, an insufficient repair response may be responsible for cardiac rupture or LV aneurysm. In conclusion, mechanical properties of scar tissue are the determinants of AMI-related outcomes.In the first minutes after AMI, blood cytokines invade the infarcted area through the CCL2 / C-C chemokine receptor type 2 signal pathway. Early reperfusion of the myocardial tissue reduces the number of cytokines accumulated in the infarcted area by stimulating the immune reaction and thus is necessary for a favorable cardiac response after AMI.3.4,55,56In the acute phase of AMI, maintenance of the pro-inflammatory - anti-inflammatory balance is dependent on the multifactorial interaction between cellular elements  and immunological mechanisms mediated by lymphocytes, fibroblasts, dendritic cells.–59The cytokines released by the inflammatory cells have various actions on the myocardium as follows: activation of proteinases, acceleration of myocyte apoptosis with reduced contractility, increase of intercellular matrix, activation of fibroblasts. This effects lead to hypertrophy of non-infarcted myocardial segments, thinning of the necrosis area, myocardium pathological remodeling profile, which is aggravated by the persistence of the proinflammatory status.–62The complexity of the chronic inflammatory phenomenon after AMI requires a multifactorial approach against both cell dynamics, humoral mechanisms and chemical cellular reactions of mitochondrial destructive type, oxidative stress and calcium loading, which is why the therapeutic approach must be anti-inflammatory, mitochondrial and endothelial protective.3.5,64 However, in certain circumstances excessive inflammatory response may cause further myocardial impairment and excessive fibrosis, leading to heart failure.,66 A three-month program of CR reported a favorable effect of early CR on serum levels of hsCRP, independent of statin therapy and weight reduction. In this study CR produced similar reduction in hsCRP levels as therapy with statins, a 50% reduction of hsCRP levels being obtained in patients treated with statins coupled with CR and exercise training. Moreover, similar reduction in hsCRP levels were observed regardless of variation in weight, suggesting that exercise training play a prominent role in inflammation reduction. The positive impact of exercise training on the reduction of IL-6 and tumor necrosis factor α soluble receptor 1 levels was demonstrated in a group of patients with moderately severe and severe chronic heart failure and known ischemic heart disease. The anti-inflammatory cytokine IL-10 primarily inhibits the release of tumor necrosis factor-α. Exercise induces a cascade of cytokine inhibitors, but also the protective role of IL-10. However, the impact of early rehabilitation programs after AMI is not elucidated yet, while most of the studies concern the effects of physical rehabilitation on inflammatory status in chronic stable disease. In a three-week CR study conducted in early post-AMI period, while passive recovery with optimal medical treatment led to a slow inflammatory regression, physical training of moderate intensity proved an additional anti-inflammatory effect. Beside the impact on inflammatory markers, CR involved a significant improvement in terms of metabolic risk profile. Changes in hsCRP levels were correlated with exercise training and the degree of BMI. Since adipose tissue consist the source of IL-6, a precursor of CRP, it could be presumed that CR could directly influence the fatty cell metabolism, causing suppression of the inflammatory pathway. These results suggest that overweight and obese patients, presenting a high-risk group in secondary CV prevention due to their inclination towards the metabolic syndrome, could particularly benefit from early CR after AMI. Even if effects of CR on IL-10 levels are poorly investigated, Smith et al reported a 36% increase of Il-10 levels in patients performing a 6-months CR. IL-8 is considered one of the leading promoters of atherosclerosis in diabetic and obese subjects,71 and presents significantly decreased plasma concentrations in patients who followed a CR program as compared with a control group. Beside its benefits in terms of inflammatory status, at this moment growing clinical consensus indicate CR beneficial impact on course of post-AMI cardiac remodeling process.,74 In AMI survivors presenting left ventricle (LV) systolic disfunction CR has been recommended to the medical therapy in order to prevent the progression of LV systolic impairment,,76 as physical exercise increase myocardial perfusion independent of coronary lesions, a fact that may induce a consistent recovery of regional and global LV contractility. Moreover, compelling evidence showed that CR implementation in post-AMI patients induce a favorable course of LV remodeling process, presenting pro-angiogenic effects, as inadequate angiogenesis represents a critical cornerstone process in the development of maladaptive remodeling, promoting the transition from cardiac hypertrophy to dilatation and dysfunction.–83 Although majority of research results proved a positive influence of CR in post-AMI patients, improving adverse remodeling process and cardiac function, the proper CR intensity, duration and time to start are yet to be optimized.The severe tissue damage caused by AMI involves a generalized inflammatory reaction in the early period, orchestrating healing and recovery of the heart.In conclusion, the primary contribution of the REHAB trial will be to elucidate the impact of early mobilization in the first period after AMI, as a first step of a complex CR program, to reduce systemic inflammation and prevent deleterious ventricular remodeling in patients who suffered a recent AMI.All authors have been involved in all stages of the study design and have participated in writing the protocol. Submission to ethical committee was done by Ghircau Susca Mihaela.Ghircau Susca Mihaela, Opincariu Diana, and Theodora Benedek will be involved in trial statistical analysis and interpretation. All the authors approved the final manuscript.


Restoration of normal epicardial coronary flow in acute ST segment elevation myocardial infarction does not ensure adequate perfusion at the myocardial tissue level. In the era of primary PCI, patients with acute myocardial infarction treated successfully with PCI are discharged mostly within first week. There are no studies available regarding blood flow at the tissue level in these patients during effort.Assessment of stess and rest perfusion defects early after STEMI successfully treated with pPCI.61 patients with first anterior STEMI (57 ± 10 yrs. 52 M) who underwent successful pPCI have been included into the study. CMR was performed on 1.5 T scanner between 5 and 10 days after pPCI. Myocardial perfusion was assessed at rest and in stress condition during infusion of adenosine  during first-pass perfusion imaging. Microvascular obstruction regions (MVO) were assessed on early enhancement images acquired 1–2-minutes after stress perfusion. Delayed enhancement (DE) images were acquiered 15 minutes after Gd-DTPA. Transmurality of myocardial perfusion defecits at rest and in stress condition, MVO were evaluated using 5 point scale in 16 segments. DE was also evaluated in segment 17. The sum of scores were calculated for each variable. Scar size and MVO were additionally quantitatively analyzed using MASS software. The results were given in ml and in % of LV volume.Only in 2 patients there was no evidence of at least subendocardial stress perfusion deficit. Stress perfusion sum of scores discriminated patients with normal EF (mean 59 ± 1%) and LV dysfunction . Median stress perfusion sum of scores was 15 points (ranged 0 to 37). Median rest perfusion scores was significantly lower . Median MVO and DE sum of scores were 3 points (ranged 0–33) and 25 (3–42) respectively. DE measured as a % of LV volume has discriminated patients with severe  vs moderate LV dysfunction  with a cut of point 40%. Regression model revealed that only DE and stress perfusion sum of scores have significantly contributed to the LV EF model at discharge.Despite TIMI 3 flow in coronary artery myocardial perfusion defects at the tissue level are very frequent. Only in patients with preserved LV function pharmacological stress have not induced or intensed perfusion deficits. All patients with STEMI anterior successfully treated with pPCI, even with mild LV dysfunction should avoid effort which could induce ischemia. The pathogenesis remains unknown. Further studies are needed.


Isolated cleft of the anterior mitral leaflet (ICAML) in dogs without a septal defect is a rare pathological condition. Until now, only one paper has contributed to the detailed understanding of canine ICAML. Reports have confirmed that 3-dimensional echocardiography (3-DE) is a simple and fast imaging technique that is useful for the diagnosis of ICAML and morphological evaluation of the mitral valve in humans. However, to our knowledge, no studies have provided details about the effectiveness of 3-DE in ICAML diagnosis in dogs. Thus, we aimed to determine the usefulness of a diagnostic technique using 3-DE in a 2-year-old Cavalier King Charles Spaniel with ICAML that exhibited mild mitral valve regurgitation. ICAML was initially assessed by transthoracic two-dimensional echocardiography. A diagnosis of congenital mitral regurgitation due to ICAML and understanding of the morphological structure of the valve was established based on the 3-DE findings. Isolated cleft of the anterior mitral leaflet  is a very rare cause of congenital mitral regurgitation (MR) in humans –3. Only The patient was a 2-year-old castrated male Cavalier King Charles Spaniel that weighed 8.2 kg. The patient had a left ventricular systolic murmur confirmed at another hospital at 4 months of age. MR was confirmed using color-flow Doppler instead of two-dimensional echocardiography (2-DE). The patient was diagnosed with MR due to mitral valve dysplasia. The patient had been receiving temocapril hydrochloride (0.12 mg/kg/SID) and pimobendan (0.3 mg/kg/BID) from the age of 10 months. The patient came to our hospital for cardiac scrutiny.On presentation to the hospital, the animal showed a heart rate of 147 beats per minute, a blood pressure of 117/80 mmHg, and oxygen saturation of 96%. A grade IV/VI left apical systolic murmur was heard on auscultation. There were no symptoms such as coughing or exercise intolerance, and no abnormal findings were found in blood cell counts or biochemical tests. Normal levels of cardiac biomarkers, namely, N-terminal probrain natriuretic peptide , atrial natriuretic peptide , and cardiac troponin I , were observed.Thoracic radiography revealed a vertebral heart scale of 10.1 v  with no cardiac enlargement. No abnormal findings were found in the lung parenchyma or chest cavity, and there was no pulmonary vascular shadow. Electrocardiography revealed a sinus rhythm, and the electrical axis was 58°. Real-time 2-DE was performed using the ultrasound diagnostic equipment of Vivid E 95 . MR was observed on a left parasternal long-axis view using color-flow Doppler echocardiography . A cleftThe blood flow velocity wave was measured by the continuous-wave Doppler method, which showed a maximum speed of 5.01 m/s and a maximum pressure difference of 100 mmHg in the mitral valve regurgitant flow velocity waveform. In the left ventricular inflow velocity waveform, the E wave and A wave were 0.63 and 0.37 m/s, respectively. Morphological evaluation was performed using the left parasternal short-axis view. This revealed a left atrium-to-aorta ratio of 1.56 at the aortic valve level , a left ventricular end-diastolic diameter of 33.0 mm at the papillary muscle level, and the normalized left ventricular internal dimension in diastole . On the basis of these findings, we judged that the severity of the MR was mild.The examinations led to a diagnosis of congenital MR due to ICAML. Although organic cardiac abnormality was observed, there was no heart enlargement . Following discussion with the owner, treatment with oral temocapril hydrochloride and pimobendan, as prescribed from other hospitals, was continued. The symptoms related to the cardiac condition remained unchanged and did not worsen without treatment until the dog died of lymphocytic leukemia.Although anterior MVC can be encountered within the spectrum of atrioventricular septal defects (AVSD), it is rare for them to be diagnosed as an isolated finding in dogs. ICAML is assumed to be a partial defect of the endocardial bed –3. In huThe occurrence of ICAML in canines is rare and has only been reported once . Thus, t


A 68-year-old male with a witnessed out-of-hospital cardiac arrest while jogging who was managed with extracorporeal cardiopulmonary resuscitation (ECPR) is presented. The patient was found to be in refractory ventricular fibrillation by emergency medical service personnel and underwent advanced cardiac life support (ACLS) protocol with placement of an automated chest compression device. He was emergently transported to the cardiac catheterization laboratory. Due to refractory ventricular fibrillation, he was placed on venoarterial extracorporeal membranous oxygenation (VA-ECMO). Coronary angiography at that time showed nonobstructive coronary artery disease. Management with VA-ECMO and other supportive measures were continued for 5 days, after which a cardiac magnetic resonance imaging was performed with findings consistent with acute myocarditis. His condition substantially improved, and he was discharged from the hospital with good neurologic and functional status. Fulminant myocarditis is often fatal, but aggressive supportive measures with novel ECPR protocols may result in recovery, as it happened in this case. Myocarditis, an inflammation of the myocardial tissue, is not uncommon. Over two million cases are reported annually worldwide resulting in approximately 350,000 deaths , 2. The A 68-year-old man had a witnessed cardiac arrest while jogging. Bystander cardiopulmonary resuscitation (CPR) was immediately initiated followed by advanced cardiac life support (ACLS) upon arrival of emergency medical service (EMS) personnel. The patient was noted to be in persistent ventricular fibrillation despite multiple defibrillations. A LUCAS chest compression system  was applied and the patient was transported directly to the Ross Heart Hospital at The Ohio State University for ECPR. Upon arrival to the cardiac catheterization laboratory, the patient was still in ventricular fibrillation. He was placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) via the femoral artery and vein, as an adjunct to CPR, per our institution's ECPR protocol. A coronary angiography was then performed that demonstrated mild coronary artery disease . After i2 and 72 mL/m2, respectively)  showed sinus tachycardia with left intraventricular conduction defect. Laboratory testing results were notable for an initial lactate of 7.8 mmol/L and a peak troponin of 40 ng/mL. Transthoracic echocardiogram demonstrated severe left ventricle (LV) systolic dysfunction with an ejection fraction of 20% and a dilated LV (LV end diastolic and systolic volume indexes were 92 mL/mctively) . VasopreCardiac magnetic resonance imaging was obtained on hospital day 10 and demonstrated severe LV systolic dysfunction with an ejection fraction of 25%; there was also extensive epicardial late gadolinium enhancement and elevated T2 signal consistent with acute myocarditis . Prior t2 and 32 mL/m2, respectively; these findings were improved compared to the initial echocardiogram.At 30-day follow-up in heart failure clinic, the patient was doing well. He had no recollection of events immediately prior to his hospitalization or several days into the hospital course. He had no signs or symptoms of heart failure. The patient was walking one mile daily without symptoms. ECG findings demonstrated sinus rhythm with persistent left intraventricular conduction defect. Renal function that was impaired during the hospitalization was normal at this time, and therapy with losartan 25 mg twice daily was started. In addition, the medications that were initiated at hospital discharge were continued without dose adjustment. At 60 days after the patient's hospitalization, a repeat transthoracic echocardiogram was obtained that demonstrated a LV ejection fraction of 30% and LV end diastolic and systolic volume indexes of 77 mL/mVA-ECMO is an extracorporeal  technique that provides both cardiac and respiratory support sustaining life . Using VIn a study by Pozzi et al., 68 patients 43 ± 11 years) that underwent ECPR for refractory out-of-hospital cardiac arrest were included  years th. Based oA crucial component to an ECPR program is providing effective chest compressions in order to adequately perfuse the vital organs. Automated CPR devices have shown to improve cerebral blood flow compared to manual CPR and are critical to have in the field; automated CPR devices also play an important role during ambulance transport maintaining adequate compressions and for the safety of EMS personnel , 15.Out-of-hospital cardiac arrest has exceedingly high mortality in all patients, as well as in patients with fulminant myocarditis. Long-term mortality outcomes in fulminant myocarditis are usually good if patients survive the initial hospitalization . As mostImplementation of an ECPR program in patients with fulminant myocarditis and cardiac arrest can prove to be life-saving, as was the case with the patient presented here. Due to limited experience on the topic, a national or international registry would be useful to further define the role of ECPR in the care of these patients.


Biomaterial injection is a novel therapy to treat ischemic heart failure (HF) that has shown to reduce remodeling and restore cardiac function in recent preclinical studies. While the effect of biomaterial injection in reducing mechanical wall stress has been recently demonstrated, the influence of biomaterials on the electrical behavior of treated hearts has not been elucidated. In this work, we developed computational models of swine hearts to study the electrophysiological vulnerability associated with biomaterial injection therapy. The propagation of action potentials on realistic biventricular geometries was simulated by numerically solving the monodomain electrophysiology equations on anatomically-detailed models of normal, HF untreated, and HF treated hearts. Heart geometries were constructed from high-resolution magnetic resonance images (MRI) where the healthy, peri-infarcted, infarcted and gel regions were identified, and the orientation of cardiac fibers was informed from diffusion-tensor MRI. Regional restitution properties in each case were evaluated by constructing a probability density function of the action potential duration (APD) at different cycle lengths. A comparative analysis of the ventricular fibrillation (VF) dynamics for every heart was carried out by measuring the number of filaments formed after wave braking. Our results suggest that biomaterial injection therapy does not affect the regional dispersion of repolarization when comparing untreated and treated failing hearts. Further, we found that the treated failing heart is more prone to sustain VF than the normal heart, and is at least as susceptible to sustained VF as the untreated failing heart. Moreover, we show that the main features of VF dynamics in a treated failing heart are not affected by the level of electrical conductivity of the biogel injectates. This work represents a novel proof-of-concept study demonstrating the feasibility of computer simulations of the heart in understanding the arrhythmic behavior in novel therapies for HF. For some patients with severe, progressive HF, transplant is the only viable option. Recent development of alternative treatments to the prevent of HF after myocardial infarction (MI) include the injection of biomaterials to restore cardiac function3. Pre-clinical trials suggested that injection of passive biopolymers can reduce remodeling in post-MI hearts and, at the same time, improve the left ventricular (LV) function. Algisyl-LVR is a commercial alginate hydrogel implant that has shown to improve function of the heart restoring a physiological LV anatomy4, while being feasible and safe in patients with critical HF at the time of surgery. Algisyl-LVR is injected into the mid-wall of the left ventricle, creating a solid rounded inclusion after consolidation5. Recent studies have shown that Algisyl-LVR injections stimulate the genesis of a fibrotic encapsulation that restrains the adjacent cardiomyocytes around the surface of the implanted biogel6. The constraint effect results in the prevention of left-ventricular dilation, which in turn reduces the cardiac wall stress7, which has shown to improve cardiac function and reduce maladative cardiac remodeling in swine models of MI8.Heart failure (HF) is a severe, chronic and progressive condition whose prevalence is expected to increase worldwide in the next decades. The total cost of HF in the United States alone is projected to be 69.7 billion dollars by 2030, representing approximately 244 dollars for every US adult. Even though survival after diagnosis of HF has improved over time with better treatments and dedicated devices, 50% of people die within five years after diagnosis9. The primary source of such abnormalities is related to irregular spatiotemporal dispersion on the electrical properties at the cellular and tissue levels, such as the major ionic currents, action potential duration (APD) and action potential restitution11. The associated structural and electrophysiological changes occurring after MI act as a substrate for arrhythmia12. Because patients eligible for biomaterial injection therapy are already exposed to the development of cardiac arrhythmia, it is decisive that the treatment does not increase their susceptibility to the formation of an anomalous electrical propagation within the myocardium.Patients with severe HF are at increased risk of ventricular tachycardia (VT), that can quickly evolve in ventricular fibrillation (VF), leading to sudden cardiac death. VT and VF are related to abnormal impulse propagation within the heart, namely spiral (in 2D) and scroll waves (in 3D)13. Three-dimensional finite element analyses informed by echocardiography data from sheep hearts were carried out to compare different material properties of infarcted and healthy regions, showing that the presence of tissue filler significantly reduces myofiber stresses14. Idealized ellipsoidal LV models have also been used to measure the mechanical effects of different biomaterials, identifying the optimal distribution of injectates in terms of mechanical power15. High-resolution ex-vivo data was used to show that biopolymer injections act as an LV mid-wall constraint mechanism that prevents adverse remodeling in the heart without secondary effects on the cardiac function7. While these studies helped to elucidate the promising outcomes of biomaterial injections from a mechanical point of view, their role in cardiac electrical behavior remains poorly investigated. Few recent animal studies have done so. In one study, conductive biomaterials aimed at restoring impulse propagation in rat hearts reduced the QRS interval, suggesting improved electric conduction after MI16. Hydrogel injections, with a high degree of intra-myocardial spread, did not cause significant electrical abnormalities in rat hearts17. The knowledge acquired from experimental approaches is still limited because of the complex nature of these treatments and the strong constraints in measuring electrical propagation in vivo.Recently, the mechanical response of infarcted hearts to biomaterial injections was quantified using predictive computational modeling19. For instance, through MRI-based canine ventricular geometries, the arrangement and size of the peri-infarct (border) zone (BZ) were shown to be related to electrical excitation wavebreaks and onset of subsequent arrhythmias20. Detailed electrophysiological models of human ventricles were used to study the morphology of VF, confirming that VF dynamics mainly depend on APD restitution properties21. In-silico studies of histologically-based rabbit heart models with infarction were used to develop indices for measuring vulnerability to VT, which were previously validated in clinical applications and optical mapping22. Prediction of electrophysiological behavior of cell-based heart repair was addressed using 3D whole-heart modeling to explore the sustainability of VF of these treatments, demonstrating the promising outcomes of computational modeling for evaluating alternative therapies for HF23. More specifically, patient-specific in-silico studies have allowed the quantification of scroll-wave filaments arising during VF27, and their association to the effectiveness of defibrillation therapies30. This knowledge takes high relevance in the clinical management of failing hearts, as current clinical guidelines recommend implantable defibrillators as therapy for primary prevention of sudden cardiac death after MI32. The capabilities of using computational models to study the electrical behavior of infarcted hearts have been demonstrated, but have not been used to assess the potential role of biomaterial-injection treatments in the arrhythmic behavior of treated subjects.The vast literature about computational models in cardiac electrophysiology has made it possible to simulate most of the complex mechanisms leading to cardiac arrhythmogenesis, particularly when using highly-detailed anatomical models of the heartIn this work, we investigated the electrical behavior and arrhythmic potential of swine hearts treated with biomaterial injections by means of computational modeling. To this end, we used high-resolution DT-MRI images of swine hearts treated with Algisyl-LVR to create a computational model that represent the biventricular cardiac anatomy as well as the myocardial fiber orientations. We modeled and parameterized the transition zone from infarcted tissue towards the healthy tissue and modeled local tissue heterogeneities from MRI, accounting for injectate volumes. To account for transmural dispersion of repolarization, we divided the heart walls into three layers with endocardial, mid-myocardial, and epicardial cells, and modeled their distinctive behavior using a biophysical cellular model with specific properties for each layer. By performing an extensive computational campaign, we quantitatively characterized the electrical restitution properties of treated and untreated heart models and their performance during VF conditions. To do this, we developed a numerical method to compute important parameters such as activation time (AT) distributions, diastolic interval (DI) distributions and filament counting during simulations. Moreover, to assess the regional dispersion we constructed probability density functions of the APD restitution curve in different regions of the heart. Finally, we examined how the passive electrical properties of the injections influenced the long-term dynamics of VF for the treated heart models. By using computational modeling, this research assesses for the first time the potential of biomaterial injections to become a substrate for arrhythmia and their influence in the dynamics of VF.A restitution protocol simulation was performed in three different computational heart models: a normal control heart (NC), a heart control with ischemic heart failure without biomaterial treatment (HFC), and a heart with ischemic HF and biomaterial injections (HFI). Figure Given the heterogeneous distribution of the APD within the myocardium, the relation between the APD and the cycle length (CL) was computed for the surface of the epicardium (EPI), the left-ventricle endocardium (LV), right-ventricle endocardium (RV) and left-ventricle mid-myocardium (LVMM). Figure mentclass2pt{minimmentclass2pt{minimWe studied VF sustainability in all hearts via an S1–S2 stimulation protocol for induction of VF. Figure c is defined as the ratio between the gel conductivity and the normal tissue conductivity. Figure To understand the potential impact of the electrical properties of gel injectates in VF sustainability, we performed a sensitivity analysis where the number of filaments during VF was studied for different levels of gel conductivity. We considered four levels of gel conductivity by setting in silico pilot study of the influence of biomaterial injection therapy on the arrhythmic behavior of failing hearts. We successfully developed a robust and computationally-efficient method that allows high-resolution subject-specific MRI and DT-MRI data to be used to evaluate the regional distribution of the APD restitution curve and the number of filaments formed during VF of control and treated hearts. We note that our study represents a proof-of-concept study with only one subject per group, and therefore is not sufficiently powered to make inter-group conclusions. Despite this limitation, it represents a unique effort to understand how the dispersion of repolarization and VF dynamics behavior change in failing hearts treated with alginate hydrogel injections, as no electrophysiological studies for this treatment have been reported to date.In this work, we present a novel 34. Figure 37. For instance, experimental studies in human hearts with ischemic HF in the LV have shown that altered dynamics of the restitution curve at high pacing frequencies lead to electrical instabilities38.Simulations of standard restitution protocols suggest that there are important differences in the spatial distribution of AT and APD between the normal heart and both hearts with ischemic HF, treated and untreated. Spatial heterogeneity in the APD was observed in all three hearts, with a marked transmural gradient that can be explained by the use of different ionic cellular models for the endocardium, mid-myocardium and epicardium regions in the heart, see Figs. 39. Since the HFI resulted in a larger number of filaments than the HFC heart, higher defibrillation-energy levels may be required in treated hearts29. Since ischemic HF biomaterial-treated hearts are already at high risk of developing arrhythmias, these results provide crucial knowledge to be considered in the experimental design of defibrillation treatment of hearts with gel injectates.We have studied the VF dynamics in normal, untreated HF and treated HF subjects. In all three cases, we reached conditions for inducing and sustaining fibrillation by varying the location and duration of the excitation. We note that the injected current needed to induce VF in the NC case was considerably higher than in the HFC and HFI cases, which is consistent with experimental and clinical observations. During the sustained fibrillation regime, the average number of filaments in the HFC and HFI hearts stabilized around 34 and 40, respectively Fig. . The NC 6. These features induce a higher dispersion of repolarization, materialized in our case in critical changes in the distribution of APD in the RV and LV regions. Bimodality of the LV provides a wider substrate for discordant alternans and wavebreaks because of the larger volume of conductive mass available in the LV that can accommodate a large number of spiral waves40. We remark that such an information is not directly inferrable from classical restitution curves, usually quantified only at specific locations, but it is crucial to connect the analysis of APD restitution distributions with an intrinsic spatial feature (electrotonic and memory effects) given by the spiral core filament in our analysis41.A mechanistic explanation of the higher sustainability of VF observed in treated and untreated hearts can be supported by the changes in dispersion of repolarization resulting from remodeling. Post-MI HF results in marked alterations in key structural features of the heart such as cardiomyocyte principal orientation as well as changes in the cardiac volume42.In the first set of simulations, we treated biomaterial injections as non-conductive regions within the myocardium, which may not be the case for a biocompatible material. To assess the validity of this assumption, we developed a sensitivity analysis study where injections within the myocardium were varied to understand the effect of gel conductivity in our results. We found that gel conductivity does not alter VF dynamics, as shown in Fig. 8. These alterations may resemble the situation of border zones located near the boundary of the IZ, where strong cardiac remodelling is observed. These border zones reportedly play a meaningful role in the propagation of action potentials, since they may promote the formation of abnormalities such as action potential alternans10 and arrhythmias43. While recent multiscale models of cardiac tissue have been able to theoretically link the remodelling of gap-junction conductivity with reduced conduction velocity in cardiac tissue44, further studies should quantify in biophysical terms the level of remodelling found at the gel-intact tissue interface, in order to incorporate additional nonlinearities in the emerging cardiac behavior48. Another limitation is the absence of electromechanical coupling in our simulations. Because Algisyl-LVR injection treatments are specifically developed to deliver passive mechanical support to the ventricle, the electromechanical coupling plays a decisive role to examine the overall performance of treated hearts. Computational models that incorporate electromechanical coupling have become increasingly relevant given the role of deformation in the local electrical behavior and spatial propagation of electrical impulses, particularly in VF dynamics53. Therefore, future efforts should include electromechanical coupling in order to better characterize the behaviour of biomaterial-treated hearts, at the expense of increasing the computational costs.This work has limitations that should be addressed in future extensions. An important limitation is that only one subject per group was considered, which is largely justified by the high computational burden, both in wall-clock time and in required infrastructure, that each simulation demands. While each group necessitates a larger population in order for the results to be statistically meaningful, we remark that the aim of this work is to present a proof-of-concept study that demonstrates the feasibility of performing pre-clinical studies of biomaterial injection in-silico. In particular, our results can be used as preliminary data in the design of future computational studies. In such an effort, the electrophysiological cellular model will require dedicated measurement and fine-tuning of the restitution parameters to set the spatiotemporal dynamics within a patient-specific framework. Further, it is worth noting that the behavior of interfaces between healthy myocardial tissue and gel biomaterials necessarily imply alterations in the local reaction dynamics and conduction properties, which currently remains an open topic from the experimental and theoretical perspectives54. Another avenue of research is to extend the current simulations to include electrophysiological models that could take into account the multiscale nature of the myocardial tissue, and muscle contraction.Future work may help to elucidate how biomaterial injection treatments can be enhanced such that the overall function of HF hearts could be improved without affecting their electrical performance. For instance, future efforts could focus on understanding how the distribution of injections can affect the electrophysiological behavior of treated hearts. Recent studies show that the volume and location of biomaterial injections correlate with the reduction of pathological conditions within the heart6. The three selected subjects included natural geometrical differences due to biological variance and remodeling to ischemia. This has been quantified in previous studies which showed local wall thinning and fiber reorientation due to ischemia, but that the global structure and morphology of the hearts were not significantly different6. The injection protocol for the hydrogel delivers a total of 12–14 intra-myocardial injections (0.3 mL each) in a circumferential pattern into the LV free wall during an open chest procedure. These are administered in roughly 1.5 cm apart and in two rows: one above and one below the mid-ventricular plane between the base and the apex. The hydrogel, which accounts for roughly 3% of the total LV wall volume, does not disrupt fiber orientation, but rather conforms to the native structure it is injected into, forming ellipsoidal shapes orientated with the local fiber structure6. The solidified injections mitigate the effects of adverse remodeling by anchoring and supporting the surrounding tissue in the nearby vicinity of the circumferential pattern. A deeper analysis of therapy efficacy and the mechanism of action in mechanical terms was recently provided in a recent study7.This study considered one normal control heart (NC), one heart control with ischemic heart failure without biomaterial treatment (HFC), and one heart with ischemic HF and biomaterial injections (HFI). These subjects were selected as representative of larger cohorts considered in a previous morphological study of the effects of fiber remodeling under biogel treatmentex vivo segmentation of high-resolution MRI and DT-MRI of swine hearts. The experimental protocol, image acquisition, segmentation process and reconstruction methodology have been described previously55. In brief, myocardial infarction was induced by occluding the obtuse marginal branches of the left circumflex artery. Eight weeks after MI, animals underwent Algisyl-LVR injection, and hearts were excised eight weeks later. Anatomical MRI and DT-MRI were acquired using a readout-segmented diffusion-weighted spin-echo sequence with 55, local properties for the infarcted and healthy tissues are modulated by the volume fraction of healthy tissue. This volume fraction is represented by the space-dependent scalar function 43. A gray zone ratio (GZR) could also be computed from this function to characterize the differences in GZ distribution between each heart under study. Myocardial fiber orientation, based on DT-MRI, was assigned to the mesh nodes and interpolated inside each finite element, delivering a continuous spatial vector field representation of the cardiac fiber orientation 55. To account for transmural dispersion of repolarization, we used a Laplace’s interpolation method56 to divide the heart wall into epicardial, mid-myocardial, and endocardial layers using a thickness ratio of 2:3:3, respectively. Figure Subject-specific accurate geometric representations of heart bi-ventricular structure, infarcted tissue, and biomaterial injections are used as the computational domain for the numerical simulations Figs.  and 8. Ions Fig. . FollowiT] was modeled using the monodomain electrophysiology equation derived from current balance57, which takes the form 58 by assuming that both intracellular and extracellular spaces have equal anisotropy ratios. In an averaged macroscopic sense, the conduction velocity is faster along the fiber direction and slower in a direction transverse to it. In particular, the conductivity tensor 59. We selected a conductivity ratio of 4, establishing the longitudinal conductivity as Given the cardiac domain 11 for ventricular human cells. This model is fitted to reproduce APD restitution curves measured in humans, and have an extensive description of the intracellular calcium dynamics. It has been broadly used for the study of reentrant arrhythmia and electrical instability at cellular and tissue levels. In this model the ionic current density, defined as the sum of all transmembrane current densities, is given by60, see Fig. 11. For the simulation of VF, the parameter values reported in21 were employed, which are included in Table The transmembrane ionic current is modeled according to the model proposed by ten Tusscher and Panfilov (TP06)entclass1pt{minima61, where linear tetrahedral elements are employed to approximate the transmembrane potential field. Time integration was performed using an operator splitting method58. All numerical implementations were developed in Python, using the FENICS Project software and the Cbcbeat software collection in an in-house parallel computing platform. Given the well-known dependency of the conduction velocity to the mesh size, conduction velocity convergence was carried out for linear tetrahedral elements  and repolarization times (RT), during numerical simulations with a time step esh Fig. . The nodTo compute the APD restitution distribution, the three heart models were paced at the apex location  with the condition 63. This method allows one to group elements that are closely packed together forming a specific filament. Each group (filament) formed is classified, updated and counted every An S1–S2 protocol was implemented to induce VF in each heart model. The S1 stimulation site was the septum LV endocardium, while the S2 stimulus was delivered at the posterior zone of the epicardium, near the tail of the S1 wave. The timing between S1 and S2 was fine-tuned to obtain excitation wave-break, formation of a scroll-wave and evolution into VF. A vulnerable window was measured as the elapsed time between the S1 and S2 pulses for which a sustained VF was achieved (c is a conductivity ratio that modulates the conductivity of the gel based on the value used for transversely-isotropic propagation in normal cardiac tissue. Accordingly, for values of the conductivity ratio 6465. ECG signals were analyzed using Fourier Transform, from which power spectra were constructed, and the fundamental frequency was identified.The electrical properties of alginate hydrogel implants have not been reported to date, thus in the previous experiments we have assumed that its conductivity is zero. To assess the effect of gel conductivity on VF sustainability in the treated heart, we performed a sensitivity analysis where the biogel is assumed to behave as a passive conductor. VF simulations were performed assuming an isotropic conductivity in the gel of the formSupplementary Information.


The aim was to investigate the predictive values of heart rate variability, deceleration, and acceleration capacity of heart rate in sudden cardiac death in postinfarction patients with left ventricular ejection fraction (LVEF) ≥ 35%.We enrolled 138 acute myocardial infarction patients (MI) randomly in sinus rhythm with LVEF ≥ 35% after myocardial infarction. Data on heart rate variability, deceleration runs, deceleration, and acceleration capacity were obtained from 24h‐dynamic electrocardiogram recordings. Clinical characteristics, medications, and echocardiography data were noted. The endpoints were sudden cardiac arrhythmias (SCA), including malignant arrhythmias in the hospital and viewed sudden death out of the hospital. Relationships between autonomic parameters and endpoints were evaluated.p = .018), TP (p = .007), VLF (p < .001), DC (p < .001), and low‐risk DRs (p < .001) than those without SCA. A low SDNN level , low VLF level , low DC level , and higher risk DRs  were identified as independent risk factors of SCA for postinfarction patients with LVEF ≥ 35%. The area under the ROC curve (AUC) of SDNN, VLF, and DC for identification of SCA were, respectively, 0.724 (p = .019), 0.807 (p < .001), and 0.804 (p = .002). SDNN, VLF, and DC combined assessment area under the ROC curve were 0.828 (p < .001).During follow‐up for over 24 months in MI patients, 10 patients occurred sudden cardiac arrhythmias. Subjects with SCA showed lower levels of SDNN (Decreased SDNN, VLF, DC, and abnormal DRs are independently associated with increased risks of sudden cardiac arrhythmias in post‐MI patients with LVEF ≥ 35%. Combined SDNN, VLF, and DC may help identify a high‐risk group of malignant arrhythmias in postinfarction patients. It is a major clinical question in the USA  admitted into the hospital for emergency treatment were enrolled in the prospective study. Myocardial infarction was diagnosed clinically as commonly described before  patients received 24 h ambulatory electrocardiogram (Holter) via DMS300‐3A after PCI before discharge. Normal daily living activities were allowed during the ECG recordings. Holter was analyzed by experienced cardiologists. Artefactual beat labels were manually eliminated via DM Software CardioScan II (version 12.5.0078a). The time and frequency domain of HR variability (HRV), deceleration and acceleration capacity and DRs were automatically computed and recorded. Relative counts of deceleration runs of 1–10 RR intervals were divided into low‐, intermediate‐, and high‐risk groups as has been noted , statin drugs, positive inotropic, and hemodynamic support if necessary in hospital. The usage of β‐blockers, ACEI/ARB, spironolactone, and necessary drugs was traced during follow‐up.Postinfarction patients were checked at least 24 months. Patients were followed up by home‐visit, call consultations to patients or family members, outpatient records, and electronic medical records system, etc. Drug usage of ACEI/ARB, aspirin, and spironolactone was recorded during the follow‐up period. The main end point of this study was the combined end point of sudden cardiac arrhythmias (SCA) including ventricular fibrillation, sustained ventricular tachycardia with hemodynamic deterioration detected by ECG monitoring or ECG, and viewed sudden cardiac death out of hospital, verified from the hospital and from either the physicians or those who had witnessed the death. Sudden cardiac death was defined taking the following items as references: (a) witnessed death occurring within 60 min from the onset of new symptoms, unless other noncardiac causes were obvious; (b) unwitnessed death (<24 h) without preexisting, advanced circulatory diseases, or other causes of death; or (c) unsuccessful resuscitation.We also recorded the information of a combined end point of major cardiovascular events (MACE) consisting of myocardial reinfarction, hospitalizations for heart failure, progressive coronary artery lesions indicating another stent implantation, or other cardiovascular death at the earliest time after discharge. The initial time of follow‐up was set as the day after percutaneous transluminal coronary intervention, and the end point of follow‐up was the first onset of SCA events, MACE events, or the end date of follow‐up (August 2019). The follow‐up time was calculated in months.2.42 tests and Mann–Whitney U test were used for multivariate comparisons of continuous and categorical variables, respectively. The receiver operating characteristic curve (ROC) was performed to determine the diagnostic values of variables in identifying SCA. Because patients might die before developing SCA, we used the competing‐risks regression to determine risk factors and to evaluate survival curves and hazard ratios for arrhythmias. For all analyses, values of P < 0.05 were considered statistically significant.The data were analyzed by the software of SPSS23.0 and Stata/SE 14.0. Continuous variables are expressed as a median and inter‐quartile range. Qualitative data are presented as absolute numbers and percentages. Pearson's χ3p = .013) and had a higher Grace score (p = .035). Other variables such as the Gensini score, echocardiography data, and medications showed no difference between SCA and non‐SCA  cases lost contact during follow‐up. 138 consecutive acute myocardial infarction (MI) was finally included. During follow‐up in MI patients, 10 (7.2%) occurred sudden cardiac arrhythmias, and MACE occurred in 29 patients, with 18 (13.0%) cases of hospitalizations for heart failure, 3 (2.2%) cases of myocardial reinfarction, 1 (0.7%) cases of death for cardiac shock, 7 (5.1%) cases of progressive coronary lesions. Clinical characteristics, blood tests, echocardiography data, and medications were shown in Table p = .018), TP (p = .007), VLF (p < .001), DC (p < .001) and the proportion of low‐risk DRs (p < .001) showed statistical difference between the two groups, whereas other time and frequency domain indexes of HRV and AC lost significance , 0.807 (p < .001), 0.804 (p = .002), respectively. SDNN, VLF, and DC combined assessment area under ROC curve were 0.828 (p < .001) , sex, age, diabetes, and LVEF. Split SDNN, VLF, and DC were evaluated separately. On multivariate competing‐risks regression, lower levels of SDNN, VLF, and DC remained significant predictors of SCA Table , even af4Our analysis from myocardial infarction patients with preserved or moderately reduced LVEF came to several findings. First, decreased SDNN, VLF, DC, and abnormal DRs were shown to be independently associated with increased risks of sudden cardiac arrhythmias in post‐MI patients with LVEF ≥ 35%, whereas other variables by time and frequency domain analysis of HRV did not have any prognostic values. Second, combined SDNN, VLF, and DC might help identify a high‐risk group of SCA.Cardiac autonomic modulation dysfunction is involved in triggering of sudden cardiac death (La Rovere et al., It should be noted that when comparing SCA and non‐SCA patients, SDNN, TP, VLF, DRs, and DC displayed remarkably statistical differences, whereas other autonomic data we selected lost significance. SDNN was one of the earliest and most widely used parameters for SCD prediction, and it was said to be independently associated with mortality and cardiac arrhythmias after myocardial infarction (Bigger et al., Another novel founding of our study was the great prognostic value of DRs than other conventional autonomic parameters. DRs, short for heart rate deceleration runs, constructed one part of the heart rate asymmetry and were a method based on monotonic runs of heart rate decelerations. Separated from complex patterns of continuous RR interval time series, DRs quantifies the heart rate deceleration based on simple counts of gradually prolonging RR intervals (Guzik et al., The study conducted by us has certain limitations. First, what we must recognize is that the conclusions we have are based on a limited simple size with a large time span and a low number of endpoints. It is probably more appropriate to interpret the findings of our study as hypotheses. It still remains unknown how external conditions such as introduced new drugs in recent years correlate with the long‐term arrhythmia and our results. The hypothesis‐generating results we came to need further verification in a larger study in the future. Second, we did not take heart rate turbulence into consideration for the limitation of a lower simple size. Furthermore, subjects enrolled were the elderly with a median age 65 years old. Thus, it is uncertain whether the conclusions can be used in younger ones. However, despite these limitations, the results of our study can provide ideas and methods for risk prediction for sudden cardiac death in postinfarction patients with LVEF ≥ 35%.


Patients with myocardial inflammation were more often smokers  and had higher C-reactive protein (CRP) levels . In logistic regression models CRP ≥ 8.15 mg/dl  and Troponin I (TnI) ≥ 136.5 pg/ml  were independently associated with myocardial inflammation, whereas no association was found for elevated brain natriuretic peptide . In prognostic performance calculation the highest positive predictive value (90%) was detected for the combination of Global longitudinal strain (GLS) ≥ -13.95% and TnI ≥ 136.5 pg/ml (0.90 (0.74–0.96)). Elevated CRP, TnI and GLS in combination with TnI can be useful to detect myocardial inflammation. Smoking seems to predispose for myocardial inflammation.Inflammatory cardiomyopathy diagnosed by endomyocardial biopsy (EMB) is common in non-ischemic heart failure (HF) and might be associated with adverse outcome. We aimed to identify markers predicting myocardial inflammation in HF. We screened 517 patients with symptomatic non-ischemic HF who underwent EMB; 397 patients  were included in this study. 230 patients were diagnosed with myocardial inflammation, defined as ≥ 7.0 CD3 According to data from the Framingham Heart Study, the lifetime risk of developing HF is estimated to be 20% for the ages between 40 and 80 years2. It is caused by structural, but also functional cardiac abnormalities, which result in loss of myocardial function3. However, in the absence of coronary artery disease, which is the leading cause of HF6, inflammatory cardiomyopathy is common, particularly in HF with reduced ejection fraction (HFrEF). Thereby, according to the report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the Definition and Classification of Cardiomyopathies, inflammatory cardiomyopathy is defined as cardiac dysfunction in co-prevalence with inflammatory disease of the myocardium established by immunological, histological and immunohistochemical criteria7. The exact incidence of inflammatory cardiomyopathy underlying HF is not known. However, according to postmortem analysis, inflammatory cardiomyopathy or myocarditis seems to account for approximately 40% of the sudden cardiac deaths in the young8. Regarding endomyocardial biopsy (EMB) studies myocardial inflammation can be diagnosed in 9 to 23% of the patients with non-ischemic cardiomyopathy10. According to the above mentioned definitions, inflammatory cardiomyopathy can only be diagnosed on basis of EMB results12. Although the results of studies addressing the immunosuppressive therapy of inflammatory cardiomyopathy remain controversial15, results of the TIMIC trial suggest that immunosuppressive therapy in patients with virus negative inflammatory cardiomyopathy may be an effective and safe option for recovery of cardiac function in addition to optimal medical therapy16. Inflammatory cardiomyopathy can progress rapidly and may require immediate immunosuppressive therapy to prevent adverse outcomes. Thus, we aimed to identify predictors of myocardial inflammation in HF patients in order to improve diagnostic and therapeutic management.Heart failure (HF) is a global health problem which affects approximately over 37 million people world wide17. Ischemic HF, valvular HF and systemic disease with known cardiac involvement were ruled out prior to EMB. The analysis of the patients’ medical records involved the following data: personal medical history, clinical presentation, laboratory values, echocardiography and the finding of the EMB, including viral activity. The exclusion criteria are presented in Fig. Patients presenting with symptoms of HF at the Heart Failure Outpatient clinic, the emergency department or chest pain unit of the University Medical Centre Mainz between 14/10/2012 and 18/12/2018, who underwent EMB were enrolled in this retrospective monocentric analysis. Decision to obtain EMB of the patients was based on guidelines published of the AHA, the ACC and the ESC in 20073. Global longitudinal strain (GLS) was measured offline utilizing QLab 13.0  automatic speckle-tracking software. The tracking result was visually controlled and manually readjusted if necessary. In case of persistent poor tracking quality, datasets were excluded from analysis. GLS was automatically calculated by average of GLS in apical four, three and two chamber view.Transthoracic echocardiography was performed in our echocardiography lab by trained and certified specialists of our department using iE33 Philips, a General Electrics E9 or Siemens Acuson s2000 machines. All examinations were performed with the patient in the standard left lateral position while apnea or quiet breathing. Routinely 2–4 cardiac cycles were obtained at frame rates of 50–100 fps and digitally transferred into a picture archiving and communication system (Xcelera) for offline analysis. Left ventricular (LV) ejection fraction (LVEF) was assessed by biplane Simpson’s method in the apical four and two chamber view. For the assessment of cardiac structure, LV internal diameters were measured. LVEF was categorized into classes LVEF ≥ 50% (HF with preserved LVEF = HFpEF), LVEF 40–49% (HF with mid-range reduced LVEF = HFmrEF) and LVEF < 40% (HFrEF)18. In case of right heart biopsy, the femoral vein was used. Immediately after sampling the biopsy, the specimens were stabilized in a solution to preserve ribonucleic acid (RNA) integrity  and were sent for further examination to a specialized laboratory approved by Food and Drug Administration . For immunohistological evaluation, heart muscle tissue probes fixated in RNAlater were embedded in Tissue Tec  and immediately snap‐frozen in methyl butane which had been cooled in liquid nitrogen, and then stored at – 80 °C until processing. Embedded specimens were cut serially into cryosections of 5 mm thickness and placed on 10% poly‐l‐lysine‐pre‐coated slides. As part of a routinely performed work up in case of unclear heart failure histological and immunohistochemical examination as well as virus detection was conducted. Using specific antibodies inflammatory processes were detected by identifying immune cell infiltration and expression of cell adhesion molecules. The specimens of the patients in this study were tested for CD3-positive lymphocytes , CD11a+/LFA-1+ lymphocytes , macrophages Mac-1 macrophages , Perforin positive (cytotoxic T Cells)  and the expression of adhesion molecules HLA-1  and ICAM-1 . Myocardial inflammation was defined as ≥ 7.0 CD3+ lymphocytes/mm2 and/or ≥ 35.0 Mac1 macrophages/mm2 in accordance with previous published studies19. Diagnosis of relevant myocardial virus activity was performed by polymerase chain reaction (PCR) detecting the genomic sequences of viruses that most commonly cause myocarditis. This included: enterovirus, adenovirus, human cytomegalovirus, herpes simplex virus, Epstein–Barr virus, human herpesvirus 6, parvovirus B19 and influenza A and B viruses. Virus load was calculated via quantitative PCR methods. In case of relevant myocardial virus activity patients were excluded from analysis.EMB was performed using a biopsy forceps  by taking up to eight biopsies either from the right ventricular septum or from the lateral wall of the LV. In case of LV biopsy the procedure was carried out via the right or left femoral artery or via trans-radial cardiac catheterization as reported before2 and/or ≥ 35.0 Mac1 macrophages/mm2) are provided as median and interquartile range (IQR) or absolute numbers and corresponding percentages. We tested the continuous variables of the groups (inflammation vs. no inflammation) using the Mann–Whitney-U test and categorical variables with the Fisher’s exact or the chi2 test, as appropriate.Descriptive statistics for relevant baseline comparisons of symptomatic non-valvular, non-ischemic heart failure patients, who underwent EMB, stratified according inflammation  were considered to be statistically significant.Receiver operating characteristics (ROC) curves were calculated for TnI, BNP, CRP and GLS with regard to myocardial inflammation and the area under the curve (AUC) is presented with the corresponding 95% CI. Additionally, patient cohort-optimised cut-off values of these mentioned laboratory markers with regard to myocardial inflammation were calculated based on ROC analyses using Youden index quantification. The software SPSS  was used for computerized analysis. Univariate and multivariate logistic regression models were analyzed to investigate predictors of myocardial inflammation in heart failure patients, thereby using patient-optimised cut-off values derived from the ROC analyses. Results are presented as odds ratio (OR) and 95%CI. The multivariate regression models were adjusted for (1) age and sex, obesity and (2) cardiovascular risk factors (CVRF) including history of smoking, arterial hypertension, diabetes mellitus and hyperlipoproteinaemia.+ and Mac1 were 6.470/mm2 [IQR 2.0/16.085] and 33.6/mm2 [16.9/58.1), respectively, defining a cut-off of ≥ 7.0 CD3+ lymphocytes/mm2 and/or 35.0 Mac1 macrophages/mm2.Overall, 517 patients with symptomatic non-valvular, non-ischemic HF who underwent EMB between 2012 and 2018 were screened. Results from EMB with CD3+ and/or Mac1 cell count were available in 447 cases. 50 cases were excluded due to relevant virus activity  was more prevalent in HF patients with myocardial inflammation. While the groups did not differ regarding mean values of LVEF, GLS (Table p = 0.003) were higher and median hemoglobin levels  were lower in patients with myocardial inflammation (Table In 230 patients (57.9%), myocardial inflammation was diagnosed. Patients with and without inflammatory cardiomyopathy were of comparable age and revealed no differences regarding presented symptoms at admission. History of smoking  as well as elevated CRP values (≥ 8.15 mg/l)  were independently associated with myocardial inflammation. No association was detected for elevated BNP (≥ 1030.5 pg/ml) values . Regarding echocardiographic parameters, LVEF categories and reduced GLS (≥ − 13.95%) were not associated with myocardial inflammation (Table p = 0.004). Additionally, but to a smaller extent, the combination of TnI and CRP was also independently associated with myocardial inflammation   , but this association showed only a trend towards significance in the fully adjusted model   Table , Fig. 4.The key findings of the present study are that (I) elevated CRP and TnI levels are associated with inflammatory cardiomyopathy in patients with non-ischemic, non valvular heart failure; (II) TnI levels ≥ 136.5 pg/ml and CRP levels ≥ 8.15 mg/l are potential predictors of myocardial inflammation; (III) common heart failure biomarkers such as BNP and reduced LVEF were not predictive for myocardial inflammation and; (IV) GLS might add a benefit to predict myocardial inflammation when combined with TnI.20, since immunosuppressive therapy can significantly improve the prognosis of HF patients with presence of myocardial inflammation16. Thus, readily available markers like the ones identified in our study might help to select patients for EMB and for shorter control follow-up examinations. Although cardiac MRI diagnostics has become increasingly important in the diagnosis of myocardial inflammation22, sensitivity and specificity of MRI findings are not unequivocal. Since EMB can be performed easily as part of coronary catheter examination18 and should be carried out as early as possible if there is clinical or laboratory suspicion of inflammatory myocardial disease, our study results might help to accelerate the diagnostic work-up of HF.A growing body of evidence indicates that myocardial inflammation may lead to severe cardiac damage, deteriorate into dilated cardiomyopathy and be accompanied by poor prognosis. This implies that early diagnosis using predictive markers may avert poor outcome23. Because cardiac troponins are detectable in the blood for approximately one week24 and have a half-life of 2h25, elevated troponins are suitable to indicate permanent myocardial cell injury27, which can be explained by inflammatory infiltration with consecutive cell damage documented in the EMB. Contrary to our results, Sramko et al. demonstrated that troponin was not able to distinguish between patients with idiopathic dilated cardiomyopathy or inflammatory dilated cardiomyopathy arguing that troponin indicates myocardial injury without indicating weather its due to myocardial inflammation or simply caused by myocardial wallstress related to heart failure28. However, the study sample size was small, and EMB was only performed on the right ventricle making a sampling error more likely.The association of elevated CRP and TnI with myocardial inflammation was independent of age and sex, supporting earlier findings by Lauer et al., who reported that patients with elevated troponin T values were more likely to have EMB-proven myocarditis29. However, it has to be pointed out that the sensitivity for highly sensitive CRP in detecting myocarditis was only 50.1% whereas the specificity was 80.7%. Since CRP is also increased in acute myocardial infarction30 or in rheumatic valve disease31. CRP should not be interpreted alone, but in conjunction with cardiac troponin. Moreover, as the present study indicates, cut-off values for TnI and CRP seem to be higher with regard to myocardial inflammation compared to cut-off values used for diagnosis of acute coronary syndrom. Further studies are needed to prove those cut-off values in patients with myocardial inflammation.Similar to positive troponin values, positive CRP values were associated with detection of inflammation in EMB. These results go in line with observation by Liu et al., who demonstrated that highly sensitive CRP levels were higher in patients with EMB-confirmed myocarditis than in patients without myocarditis32. However in contrast to our study GLS values were compared when LVEF had already been improved. Eventhough it has been shown that GLS is a superior predictor of adverse cardiac events compared with LVEF34, studies demonstrate that in general and irrespectively of outcome prediction, GLS correlates well with LVEF in heart failure patients35. Therefore the results of our study suggest that GLS alone is not able to identify patients with myocardial inflammation in the presence of reduced LVEF. Nevertheless, the combined evaluation of GLS and Troponin values were the second strongest predictor of myocardial inflammation in multivariate regression analysis. Additionally, the best prognostic performance was found for the combination of GLS and Troponin. In particular, the high positive prognostic value of 90% to predict myocardial inflammation is promising. Thus, the combination of GLS and Troponin may help to identify patients with myocardial inflammation in the future and could add a benefit in the diagnosis and follow up treatment of those patients.Interestingly GLS was not able to distinguish between EMB proven myocardial inflammation and no inflammation. Escher et al. demonstrated before, that patients with acute myocarditis had reduced GLS values. After a follow-up period of 6.2 months patients with persistent inflammation had worse GLS values than patients without inflammation36. Recently, Detorakis et al. reported a significant correlation of smoking habits with late gadolinium enhancement extent in cardiac MRI in patients with clinically suspected myocarditis37. Prolonged exposure to tobacco smoke may cause cardiovascular cell damage, suggesting that increased myocardial cell necrosis and cell death would make myocardial inflammatory infiltration more likely38.Interestingly, smoking was associated with myocardial inflammation in our study. In a very small study sample, it was shown, that in patients hospitalized for acute myocarditis smoking was the most prevalent cardiovascular risk factor39 and even low grade inflammation is associated with lower hemoglobin levels40. As experimental models have demonstrated that low cardiac iron levels promote heart failure42 the link between the observed lower hemoglobin levels could be an effect of possibly local iron distribution disorders due to myocardial inflammation. Since hemoglobin levels in the present study were generally not significantly decreased, more data are needed to support this observation.Another finding of the present study was that patients with myocardial inflammation had lower hemoglobin levels. It is well known that anemia of inflammation or anemia of chronic disease is primarily a disorder of iron distribution43, arterial hypertension44, muscle hypertrophy45 or increased pulmonary arterial pressure46. We expected that inflammation would also cause elevated BNP levels as reported earlier47, particularly in patients with myocarditis and dilated cardiomyopathy50. Increase of BNP has also been detected in systemic inflammation regardless of systolic function51. In the present study, no differences in BNP levels and LVEF were found in patients with and without myocardial inflammation, reflecting a rather compensated disease state of our study population with low rates of hydropic decompensation. Myocarditis and inflammatory cardiomyopathy are a dynamic processes; after inflammation has subsided, a reduced LVEF is due to secondary post-inflammatory fibrosis and myocardial cell death and scars52. As conditions with and without inflammation lead to changes of LVEF and BNP, the present study demonstrates that increase of BNP and the decrease of LVEF do not specifically reflect the presence of inflammation, but rather reflect a general loss of myocardial tissue with consecutive changes in hemodynamic conditions regardless weather inflammation can be detected or not.The primary stimulus for natriuretic peptide synthesis by myocardial cells is related to increased LV wall stress induced for example by acute myocardial infarction53. The authors conclude that only positive results of EMB can be considered diagnostic. However, the cited study included a very small sample of only 36 patients.There are certain limitations of our study which need to be mentioned: Firstly, our study was conducted as a monocentric retrospective data analysis. Therefore, it has to be emphasized that the results of this study can only serve in terms of a hypothesis generating research and the results of the present study should be verified by prospective trials. Secondly, there is no generally applicable definition of myocardial inflammation. Thus, it might be difficult to adopt the results to other endomyocardial biopsy studies, but generating more information about inflammation process was one of the main aims of our study. Finally, a potential limitation regarding EMB interpretation might be the sampling error. Regarding this point, Hauck et al. demonstrated that sampling error was prevalent 45% in Ieft and up to 37% in right EMBElevations of readily available markers like cardiac TnI and CRP as well as the combination of GLS and TnI may predict inflammatory cardiomyopathy and might be useful to select patients for EMB and for shorter control follow-up examinations. In the diagnostic approach to detect suspected myocardial inflammation, higher cut-off values concerning cardiac and inflammatory biomarkers may have to be applied. Smoking is associated with inflammatory cardiomyopathy in non-ischemic, non valvular HF patients and may indicate individuals at risk to develop inflammatory cardiomyopathy.All data were obtained from individuals enrolled between 2013 and 2018 in the retrospective monocentric Mainz Endomyocardial Biopsy in Heart Failure Study , which was approved by the Ethics Committee of Rhineland Palatinate to be in accordance with the legal regulations and the declaration of Helsinki.Supplementary Information.