Development of a cardiomyopathy in diabetes mellitus is independent of traditional risk factors, with no clinical trials targeting specific therapeutic interventions. Myocardial fibrosis is one of the key mechanisms and aldosterone is a key mediator of myocardial fibrosis. We propose that aldosterone antagonism will improve cardiac function. We aim to evaluate the efficacy of selective aldosterone receptor antagonism with eplerenone added to optimal medical treatment in improving cardiac structure and function in diabetic cardiomyopathy. We will randomize 130 patients with type 2 diabetes mellitus, stable metabolic control and impaired left ventricular (LV) systolic or diastolic function, to either eplerenone (target dose 50mg) or matching placebo, in addition to optimal medical therapy for 12 months. The primary endpoints are changes in LV systolic and diastolic function, measured by echocardiographic 2-dimensional speckle tracking strain and strain rate and tissue Doppler imaging. The secondary endpoints include changes in echocardiographic markers and plasma biomarkers of collagen turnover; left atrial dimensions and function, incidence of atrial fibrillation and changes in exercise capacity and dyspnea score. The present study will assess whether specific aldosterone antagonism with eplerenone in addition to standard therapy will prevent progression or reverse cardiac dysfunction in diabetic cardiomyopathy using sensitive, robust and quantifiable echocardiographic measures that allow early detection of change. The study may offer a new direction in the management of this condition.ACTRN12610001063000 The incidence of obesity and type 2 diabetes mellitus (T2DM) are increasing towards epidemic levels in both developing and industrialized countries. Patients with T2DM are at increased risk of heart failure from diabetic cardiomyopathy , with thMyocardial fibrosis has been suggested as one of the key mechanisms underlying myocardial dysfunction in T2DM . CardiacOveractivation of the renin angiotensin-II aldosterone system (RAAS) occurs in diabetic cardiomyopathy resulting in cardiac insulin resistance and a cascade of abnormalities mediated by angiotensin II and aldosterone Figure . AldosteThere is paucity of data on the specific use of aldosterone antagonists in T2DM and this is a particular group who are prone to hyporeninemic hypoaldosteronism . As a coCirculating biomarkers of collagen synthesis and degradation provide a means of monitoring ECM turnover and the balance between collagen synthesis and degradation -22. LeveCardiac imaging modalities such as echocardiography and cardiac magnetic resonance imaging can be used to quantify myocardial interstitial fibrosis. Histologically quantified collagen accumulation has been shown to be linearly related to the magnitude of ultrasound backscatter, a marker of myocardial reflectivity, in experimental ,24 as weThe aim of the current study is to investigate whether treatment with eplerenone, a specific aldosterone antagonist, for 12 months, in addition to ACEI or ARB, would improve myocardial structural and functional abnormalities in patients with diabetic cardiomyopathy without advanced heart failure or severe LV systolic dysfunction.This study was designed as a prospective, investigator-initiated, multi-centre, randomized, double blind, placebo controlled study to evaluate the impact of treatment with eplerenone for 12 months on myocardial structure and function in patients with T2DM and LV diastolic or systolic dysfunction, in the absence of class III-IV symptoms with severe LV systolic dysfunction. The study was conducted in accordance with the NHMRC guidelines and was approved by Sydney Southwest Area Health Service Human Research Ethics committee. Figure Eligible subjects include male and female adults that meet the following criteria: 1) An established diagnosis of T2DM of any duration and severity. 2) Presence of LV diastolic or systolic dysfunction. 3) Stable metabolic control , blood glucose levels (HbA1c ≤ 8.0%)) such that minimal or no dose changes of other medications, such as ACEI, ARB, lipid lowering and blood glucose lowering medications are anticipated during the course of the study. 4) NYHA functional class I or II. 5) Treatment with optimal target or maximal tolerated dose of ACEI or ARB and ß-blocker, unless contraindicated. 6) Serum potassium ≤5.0 mmol/L within 1 week prior to randomization.2. 7) Estimated glomerular filtration rate (eGFR) > 30 ml/min/1.73m 8) Subjects who received previous treatment with aldosterone antagonists for more than 7 consecutive days must meet the following additional criteria:a. No history of clinically significant hyperkalemia or renal impairment during previous aldosterone antagonist treatment.a. Aldosterone antagonist treatment has been discontinued for at least 3 months prior to randomization.Subjects are not eligible for enrolment if they present any of the following criteria: 1) Non-sinus rhythm. 2) Pregnancy. 3) Severe heart failure . 4) Significant CAD (patients who have not undergone recent coronary angiography will have significant CAD excluded by stress echocardiography).Further exclusion criteria pertain specifically to the use of aldosterone antagonists, and include: 1) Serum potassium >5.0 mmol/L.2. 2) eGFR < 30 ml/min/1.73m 3) Concomitant potassium sparing diuretic. 4) Combination of ACEI with ARB. 5) Addison’s disease. 6) Acute renal insufficiency. 7) Severe hepatic insufficiency.Preliminary screening for trial eligibility is based on review of medical records by clinical trials staff at or before the baseline visit. After written informed consent, eligible subjects are randomly assigned by the clinical trial pharmacist to treatment with eplerenone or matching placebo. Randomization is by permuted blocks and is conducted via an electronic data management system.All patients will undergo resting echocardiography with strain and strain rate imaging for evaluation of LV and left atrial (LA) function. Myocardial calibrated IB will be performed on grey scale 2-dimensional (2D) images to assess the presence and extent of myocardial fibrosis.All transthoracic echocardiograms will be performed with Vivid E9 . All standard echo and Doppler parameters of LV systolic and diastolic function including tissue Doppler (TDI) will be measured. Maximum, pre-P, and minimum LA volumes will be measured using Simpson’s biplane method of discs.Longitudinal strain and strain rates of the left ventricle Figure  will be Left atrial longitudinal strain and strain rate will be similarly obtained in 2 annular and 2 mid segments of the apical 4- and 2-chamber views using velocity vector imaging   and short axis  views.The IB curves Figure  will be Biomarker levels will be taken prior to commencement of the study medication, as well as after 12 months treatment. Peripheral venous blood will be obtained between 8am and 9am after 15 minutes of supine rest. Serum P1NP and P3NP will be measured by radioimmunoassay ; serum P1CP will be measured by enzyme-linked immunoadsorbent assay ; plasma MMP-1 and MMP-9 will be measured by immunoassay ; plasma TIMP-1 levels will be measured by enzyme-linked immunoadsorbent assay ; serum TGF-ß1 will be measured using an enzyme-linked immunoadsorbent assay ; and serum direct renin and aldosterone levels will be quantified by radioimmunoassay . For quality control and validation purposes, all assays will be performed twice.A 6-minute walk test will be performed and Medical Research Council (MRC) dyspnea score recorded at randomization and after 12 months of therapy.Eplerenone and placebo tablets and packaging are identical in appearance and are manufactured as 25mg tablets by Pfizer . Subjects are commenced on 25mg eplerenone or matching placebo (1 × 25mg tablet) orally once daily, and may have their dose up-titrated to 50mg (2 × 25mg tablet) after 4 weeks in the absence of worsening renal function or hyperkalemia. In accordance with guidelines for management of heart failure ,30, seruThe primary endpoints are changes in global mean peak LV systolic strain and strain rate, peak early diastolic myocardial tissue Doppler velocities at the basal septal LV wall (e’), the ratio of mitral inflow early diastolic velocity to peak early diastolic mitral annular velocity (E/e’), LV calibrated IB, LV mass index and LA strain and strain rate at ventricular systole and early and late ventricular diastole, and LA phasic volumes. Secondary endpoints include changes in collagen turnover measured as changes in serum levels of procollagen type I aminoterminal peptide (PINP), PIIINP, PICP, matrix metalloproteinases 1 and 9 , tissue inhibitor of metalloproteinase-1 (TIMP-1), renin, and aldosterone levels). Other secondary endpoint measurements include MRC dyspnea score, exercise tolerance, as measured by 6-minute walk test distance and incidence of atrial fibrillation.Serious adverse events (SAE) including life-threatening hyperkalemia (>7mmol/L), acute renal failure, hypotension and death will be monitored. 1. Aldosterone antagonism with eplerenone in diabetic cardiomyopathy leads to an improvement in LV systolic and diastolic function, measured by 2D speckle tracking strain and strain rate imaging. 2. Myocardial fibrosis, as measured by echocardiographic calibrated IB and serum collagen biomarkers is reduced by eplerenone. 3. Eplerenone improves LA function and phasic volumes. 4. Changes in LV and LA function with eplerenone are correlated with changes in the degree of myocardial fibrosis.At the time of study design and commencement, there were no studies that examined the impact of aldosterone antagonism with eplerenone on cardiac function as measured by strain and strain rate imaging and cardiac fibrosis in patients with diabetic cardiomyopathy. Therefore, sample size calculation was based on previous studies that examined the effects of spironolactone on strain and strain rate in patients with diastolic heart failure from dilated and hypertensive cardiomyopathies, changes in myocardial calibrated IB in these patients, as well as differences in IB between patients with early diabetic cardiomyopathy and normal controls ,13,28,31Since commencement of this study, Kosmala and colleagues  examinedThese sample size calculations are based on a two-sample t-test and are therefore conservative. As analysis of covariance (ANCOVA) adjusted for the baseline measurement will be the method of analysis, the power will be higher or the minimal detectable effect smaller for the same power target. The gain in efficiency is linked to the correlation (r) between the baseline and on-treatment measurements which is currently unknown for the endpoints involved, but expected to be high .A data safety and monitoring board (DSMB) comprising of personnel with sufficient cardiological, endocrinological and statistical experience will be formed to review the interim results and oversee the conduct of the trial. The DSMB and ethics committee will review all unblinded data on clinical endpoint events and determine whether events meet pre-specified criteria. The DSMB will monitor safety and efficacy of the trial and periodically assess whether the trial should continue.Interim analyses for safety and efficacy are incorporated into this trial. The Haybittle-Peto rule with two interim efficacy analyses detailed in a statistical analysis plan are planned after approximately 30% and 60% of the patients have been followed up at 12 months. Early termination for the study will be recommended for evidence of overwhelming benefit (2-sided p < 0.003 favouring eplerenone) or substantive harm (2-sided p < 0.01 against eplerenone).The intention-to-treat principle will be applied to the analysis. Baseline and demographic characteristics will also be summarized by treatment group. All changes from baseline, including the primary and secondary end-points will be analysed by means of ANCOVA, adjusted for the baseline measurement.2-test or Fisher’s exact test if the number of events is small. All hypotheses are two-sided. A p-value of <0.05 is considered statistically significant.Descriptive statistics will be provided for safety data. The number of patients reporting any SAE, the occurrence of specific SAEs and discontinuation due to SAEs will be tabulated. The effect of treatment on the number of patients experiencing at least one SAE will be tested using a χThere are features of this trial design that deserve particular emphasis:● Patients of all symptomatology and degrees of myocardial abnormalities ranging from grade 1–3 diastolic dysfunction to mild to moderate systolic dysfunction are enrolled. Including patients with more severe grades of baseline diastolic or systolic dysfunction may allow greater improvement on eplerenone. Furthermore, patients with milder degrees of systolic/diastolic dysfunction randomized to placebo may experience disease progression during the course of the study.● Blood pressure independent effects of eplerenone will be examined by recruiting those with stable blood pressure control at baseline, and blood pressure will be continually monitored to ensure stability throughout the study. Furthermore, the dose of eplerenone will not exceed 50mg daily, minimizing the antihypertensive effects.● The impact of aldosterone antagonism on myocardial fibrosis will be measured both by cardiac imaging and serum levels of biomarkers. Furthermore, attempts will be made to correlate the changes in myocardial function with changes in the degree of myocardial fibrosis both on imaging as well as changes in biomarker levels.● In comparison to previous studies examining biomarkers of fibrosis, it is assumed that the beneficial effects of aldosterone antagonism come from more effective suppression of aldosterone, yet few have definitively shown that this beneficial effect is present despite a persistently elevated renin and aldosterone level after treatment. We will measure both renin and aldosterone level before and after treatment in our study.Diabetic cardiomyopathy is an increasingly prevalent disorder for which there is currently no specific therapeutic intervention. This trial, when successfully completed, will advance our understanding of diabetic cardiomyopathy and the underlying mechanisms. This may provide a new direction in the management of diabetes; the early treatment by eplerenone may prevent and reverse the progression of atrial and ventricular dysfunction and myocardial fibrosis to irreversible structural and symptomatic cardiac disease. Thus, the proposed research will have a favourable impact in turning the focus of treatment of this disease from secondary prevention and heart failure symptom management into an interventional approach at the preclinical stage. This may result in a reduction in morbidity and mortality for patients with T2DM, with improved outcomes and consequent substantial health cost savings for the community.2D: 2-dimensional; ACEI: Angiotensin converting enzyme inhibitors; AMI: Acute myocardial infarction; ARB: Angiotensin receptor blockers; CAD: Coronary artery disease; IB: Integrated backscatter; DSMB: Data safety and monitoring board; e’: Peak early diastolic velocity; E/e’: Ratio of mitral inflow early diastolic velocity to peak early diastolic mitral annular velocity; HbA1c: Glycosylated hemoglobin A1c; LA: Left atrial; LV: Left ventricular; MMPs: Matrix metalloproteinases; MMP-1: Matrix metalloproteinase 1; MMP-9: Matrix metalloproteinase 9; NYHA: New York Heart Association functional class; PICP: Procollagen type I carboxy-terminal propeptide; PIIINP: Procollagen type III amino-terminal propeptide; PINP: Procollagen type I aminoterminal peptide; RAAS: Renin angiotension-II aldosterone system; TGF-β: Transforming growth factor-β; TIMP-1: Tissue inhibitor of metalloproteinase 1; T2DM: Type 2 diabetes mellitus.Pfizer Inc. provided eplerenone and placebo tablets for this trial. However, Pfizer has no role in study design, data collection, analysis, interpretation of data, or manuscript preparation. ML has previously received a CardioVascular Lipid research grant support from the sponsor for an unrelated study but has no other financial conflicts.ML jointly conceived the study with DL, performed literature review, designed and implemented the trial, obtained ethics approval, have been involved in the recruitment of subjects, review of trial patients, data collection, and preparation of the manuscript. ML and SH conducted statistical trial planning, SH generated the random allocation sequence and concealment mechanism, reviewed and edited the manuscript, VW contributed towards recruitment and review of subjects, reviewed and edited the manuscript, AM reviewed and edited the manuscript. All authors read and approved the final manuscript.


Little is known about the effect of cardiac resynchronization therapy (CRT) on endo- and epicardial ventricular activation. Noninvasive imaging of cardiac electrophysiology (NICE) is a novel imaging tool for visualization of both epi- and endocardial ventricular electrical activation.NICE was performed in ten patients with congestive heart failure (CHF) undergoing CRT and in ten patients without structural heart disease (control group). NICE is a fusion of data from high-resolution ECG mapping with a model of the patient's individual cardiothoracic anatomy created from magnetic resonance imaging. Beat-to-beat endocardial and epicardial ventricular activation sequences were computed during native rhythm as well as during ventricular pacing using a bidomain theory-based heart model to solve the related inverse problem. During right ventricular (RV) pacing control patients showed a deterioration of the ventricular activation sequence similar to the intrinsic activation pattern of CHF patients. Left ventricular propagation velocities were significantly decreased in CHF patients as compared to the control group . CHF patients showed right-to-left septal activation with the latest activation epicardially in the lateral wall of the left ventricle. Biventricular pacing resulted in a resynchronization of the ventricular activation sequence and in a marked decrease of total LV activation duration as compared to intrinsic conduction and RV pacing .Endocardial and epicardial ventricular activation can be visualized noninvasively by NICE. Identification of individual ventricular activation properties may help identify responders to CRT and to further improve response to CRT by facilitating a patient-specific lead placement and device programming. Cardiac resynchronization therapy (CRT) has evolved as an established treatment in patients with severe heart failure refractory to optimized neurohumoral therapy. Large clinical trials showed a significant benefit on mortality and on morbidity in patients with wide QRS complex in NYHA class III and severely impaired left ventricular ejection fraction (LVEF) There are many studies about electrophysiologic and mechanical mechanisms of CRT. Despite the fact that during CRT the right ventricular lead is placed endocardially and left ventricular pacing is performed using an epicardial lead placed within the coronary veins, little is known about endocardial and epicardial activation in these patients. Invasive catheter based mapping of ventricular activation reflects only right- and left ventricular endocardial sites. Information on epicardial activation is limited to a small area of the left ventricle accessible via mapping in the coronary sinus. Most of these data were obtained by conventional fluoroscopy guided electrophysiological mapping as well as by electromagnetic three-dimensional non-fluoroscopic electroanatomic contact mapping This study was conducted to characterize biventricular endocardial and epicardial activation in heart failure patients undergoing CRT compared to a healthy control group using a novel noninvasive cardiac mapping tool –Noninvasive Imaging of Cardiac Electrophysiology (NICE).Prior to CRT-device implantation or electrophysiologic study, patient-specific anatomic data were obtained by magnetic resonance imaging (MRI) using a Magnetom Vision Plus 1.5 Tesla scanner . MRI was performed during the morning clinical routine, whereas the procedures respectively the measurements were performed in the afternoon with a mean delay of about 2.5 hours. Ventricular end-diastolic geometry and torso geometry were assessed in ECG-gated cine mode during breath-hold as described previously A high-resolution 65-lead electrode array was applied in the catheter laboratory before the ablation procedure. Radiotranslucent carbon electrodes were used to facilitate simultaneous fluoroscopy. ECG recordings were performed using the Mark-8 recording system  at a sampling rate of 2048 Hz (0.3 Hz to 400 Hz band pass filter) and an AC resolution of 500 nV/bit . The Mark-8 recording system is a battery-powered (6 Volts) high-precision ECG amplifier. It was fixed at bedside to keep wire connections as short as possible. Data were transferred to the recording PC via an optic fiber.TM, Polhemus Inc., Colchester, VT, USA). The electrode positions were transformed by a rigid body transformation (rotation matrix and displacement vector) minimizing the root-mean-square (RMS) distance of the seven Polhemus marker positions to the MRI marker positions. The posterior electrodes were placed at the location of the posterior markers.As anatomical data were recorded in the MRI frame, all other geometric data also had to be transformed in this frame. For this purpose seven anterior and lateral MRI markers and the anterior and lateral electrode positions were measured with a magnetic digitizer (FastrakNICE requires assessment of the patient's anatomy (MRI) in order to construct a patient-specific computer model and a high-resolution ECG map providing functional information on target beats. For each patient an individual computer model including compartments of different conductivity  was constructed. For this purpose, a commercial software package  was adapted for contour detection and segmentation as previously described Movie S1A bidomain model based boundary element formulation (linear triangular elements) was applied to relate step-like local activation  at the endocardial and epicardial source points to the simulated potentials at the electrode locations For inverse computation of the ventricular activation sequence the target beats were selected using an automated signal processing algorithm as previously described In the CHF patients NICE was performed during native sinus rhythm (no pacing), right ventricular (RV) and biventricular pacing (biV). In the control patients NICE was performed during intrinsic rhythm as well as during RV pacing via a quadripolar mapping catheter in an apical position. In all patients right and left ventricular total activation duration, earliest septal, endocardial and epicardial breakthroughs, endocardial/epicardial activation sequences were analyzed during native rhythm as well as during the different pacing modes. Atrial synchronous pacing was perfomed in all patients and the AV-interval was optimized either by impedance cardiography or echocardiographically according to Ritter et al t-test  was used to evaluate the results, and a p value <0.05 was considered statistically significant.Results are shown as mean ± SD and are expressed as absolute values. Statistical analysis of the data was performed with SPSS 10.1 for Windows . A two-sided Students The study was approved by the ethics committee of the Medical University Innsbruck (UN3742 281/4.2), and written, informed consent was obtained from all patients.Ten patients  with congestive heart failure (ischemic n = 2) and left bundle branch block (LBBB) undergoing CRT and ten patients  without structural heart disease and normal atrioventricular conduction undergoing an EP study (control) were studied Table 1., During native sinus rhythm earliest ventricular activation was observed endocardially in the right ventricular free wall with the earliest septal breakthrough site located in the mid-septal area of the left ventricle in 8 out of 10 patients. In 2 patients the site of the earliest septal breakthrough was located in an apical-septal position. No patient showed a septal breakthrough at a basal-septal position in the left ventricle. Left septal activation was followed by left ventricular endocardial and right ventricular mid-septal activation. Epicardial activation was observed in both ventricles immediately after endocardial activation . During RV pacing right ventricular septal activation was preceded  and the breakthrough site shifted from a mid-septal to an apical-septal position. Also the septal breakthrough site of the left ventricle was markedly delayed  as compared to native rhythm. In 2 patients the LV septal breakthrough sites changed form mid-septal during intrinsic conduction to an apical-septal site during RV pacing . Left septal endocardial breakthroughs were located in a mid-septal position. One patient showed the earliest LV septal breakthrough in an apical position and in another patient the breakthrough site was located in a basal position. In all CHF patients the left ventricular activation wavefront showed a similar pattern. It turned around the apex and spread radially across the inferior/anterior wall towards the lateral wall of the left ventricle. Although the site of latest ventricular activation was located epicardially in the lateral wall of the left ventricle in all patients, individual differences in the orientation of the area of latest activation  were obvious  whereas left ventricular septal breakthroughs were delayed in LBBB patients . The site of the latest right ventricular activation was located in both groups in the majority of patients in the basal portion of the right ventricle. Moreover, during native sinus rhythm the septum was activated from left to right in control patients whereas this sequence was reversed in CHF patients . In both groups left ventricular endocardial activation started in the septum. Due to LBBB RMS QRS duration was increased in CHF patients as compared to control patients . Also LV total activation duration was increased as compared to control patients . There was no significant difference in right ventricular total activation duration between CHF and control patients Table 3.This is the first study which simultaneously evaluated endocardial as well as epicardial (bi)ventricular activation during native sinus rhythm as well as during different ventricular pacing modes by using a novel noninvasive electroanatomical imaging method (NICE). Due to limitations of current mapping techniques, there are only limited data available about the effects of different pacing modes on biventricular endocardial and epicardial activation in humans In our study control patients showed a deterioration of the ventricular activation sequence during RV pacing comparable to the activation sequence of CHF patients with complete LBBB during native sinus rhythm. During RV pacing the septal, as well as the endocardial and epicardial activation times of the left ventricle were markedly delayed as compared to native sinus rhythm. The septal activation sequence changed from left-to-right during native conduction to a right-to-left septal activation pattern which is in accordance to previous data In CHF patients the delay between right and left ventricular endocardial and epicardial activation was significantly prolonged due to complete LBBB as compared to control patients. In CHF patients biventricular pacing did not affect the direction of transseptal activation respectively the timing of the LV septal breakthrough although the RV septal breakthrough was delayed as compared to native sinus rhythm. This indicates that the major effect of CRT is achieved by preceding the left ventricle by stimulation close to the site of latest left ventricular activation rather than affecting propagation via the intrinsic conduction system. Therefore, optimal placement of the left ventricular lead is crucial and stimulation as close as possible to the site of latest left ventricular activation (during native rhythm) should be aimed at. Epicardial pacing at the left lateral wall and simultaneous endocardial pacing at the right ventricular apex during CRT resulted in a significant decrease of LV total activation duration. Interestingely, total activation duration of the right ventricle was not changed during CRT. This study revealed also differences in propagation velocities of the ventricular activation between the CHF and control group. Left ventricular propagation velocities were significantly decreased in CHF patients as compared to control patients. This is in accordance with the results by Rodriguez et al. Despite the increase of both right and left ventricular total activation duration during RV pacing in control as well as in CHF patients, the absolute increase of left ventricular total activation duration was much more pronounced in CHF patients. In addition, the transseptal activation times were significantly prolonged in CHF patients as compared to control patients. This may cause additional dyssynchrony of papillary muscle contraction and thus, increase the mitral regurgitation in these already compromised patients. In accordance to a previous study by Aurricchio et al. However, in CHF patients deterioration of ventricular activation due to complete LBBB can be reversed by stimulation close to the site of latest left ventricular activation. Most of the time this can be achieved using an epicardial lead which is positioned in a posterolateral branch of the coronary veins. NICE facilitates the identification of target sites for optimal lead placement and may also be helpful in determining responders to CRT. Current guidelines for selection of patients for CRT are based on QRS duration and NICE may have the potential to help to refine this process as it enables visualization of ventricular electroanatomic activation noninvasively. Nevertheless, simultaneous endocardial RV and epicardial LV pacing during CRT results in a different activation pattern as compared to native activation via the intrinsic conduction system. There are some controversial data about potential proarhythmogenic effects of CRT due to the reversal of epicardial and endocardial activation Noninvasive imaging of (bi)ventricular endocardial and epicardial acivation is feasible by using NICE. NICE is effective in characterization of individual LV activation properties and may therefore help to further improve the identification of responders to CRT. Moreover, NICE has the potential to improve the response to CRT by facilitating an individual patient-specific pacemaker therapy.Movie S1Movie clip shows the NICE workflow in a healthy subject. A patient-specific heart volume conductor model of the thorax is build by MRI data. Data derived from high-resolution body surface ECG allows inverse calculation of electroanatomic activation of the heart. At the beginning of each file the red color illustrates earliest activation, blue color illustrates the area of late ventricular activation. Head icon indicates point of view.(WMV)Click here for additional data file.Movie S2NICE activation maps during native rhythm in a control patient with a view on the left septum.(MPG)Click here for additional data file.Movie S3NICE activation maps during native rhythm in a control patient with a view on the right septum.(MPG)Click here for additional data file.Movie S4NICE activation maps of both ventricles in a control patient during RV pacing with a view on the left septum. At the beginning of each file an isochronal activation map is shown where red color illustrates earliest activation, blue color illustrates areas of late ventricular activation. Head icon indicates point of view. “T  = ” shows the activation time in milliseconds.(MPG)Click here for additional data file.Movie S5NICE activation maps of both ventricles in a control patient during RV pacing with a view on the right septum. At the beginning of each file an isochronal activation map is shown where red color illustrates earliest activation, blue color illustrates areas of late ventricular activation. Head icon indicates point of view. “T  = ” shows the activation time in milliseconds.(MPG)Click here for additional data file.Movie S6NICE activation maps during native rhythm in a CHF patient with a view on the left septum.(MPG)Click here for additional data file.Movie S7NICE activation maps during native rhythm in a CHF patient with a view on the right septum.(MPG)Click here for additional data file.Movie S8NICE activation maps of both ventricles in a CHF patient during RV pacing with a view on the left septum.(MPG)Click here for additional data file.Movie S9NICE activation maps of both ventricles in a CHF patient during RV pacing with a view on the right septum.(MPG)Click here for additional data file.Movie S10NICE activation maps in a CHF patient during biV pacing with a view on the left septum. At the beginning of each file an isochronal activation map is shown where red color illustrates earliest activation, blue color illustrates areas of late ventricular activation. Head icon indicates point of view. “T  = ” shows the activation time in milliseconds.(MPG)Click here for additional data file.Movie S11NICE activation maps in a CHF patient during biV pacing with a view on the right septum. At the beginning of each file an isochronal activation map is shown where red color illustrates earliest activation, blue color illustrates areas of late ventricular activation. Head icon indicates point of view. “T  = ” shows the activation time in milliseconds.(MPG)Click here for additional data file.


During systole, the base and apex of the left ventricle (LV) rotate along the longitudinal axis of the LV in opposite directions. When viewed from an apical reference point, systolic rotation at the apex is anticlockwise while the base rotates in an overall clockwise direction. This counter-directional rotation results in a wringing motion of the heart, known as LV torsion (LVT) or twist. The terms ‘torsion’ and ‘twist’ refer to the same phenomenon and define the base-to-apex gradient in rotation. In addition to the systolic phenomenon of LVT, subsequent recoil and untwisting during early diastole is an important component of LV filling. This is commonly measured as peak early diastolic untwisting rate (UTR). The term ‘LV twist mechanics’ encompasses both systolic LVT and diastolic UTR and is an important contributor to overall LV function. Despite recent advances in the understanding of LV twist mechanics, determinants of the magnitude of LVT and UTR remain incompletely characterized.versus subepicardium), and failure to account for potentially important differences in LV geometry . Physiological determinants of LVT include but are not limited to cardiac loading conditions, myocardial contractility, structural heart disease, heart rate, age and exercise training. Previous animal work has investigated the role of several of these factors, and our group . This is in contrast to the majority of previous studies evaluating LVT before and after a haemodynamic perturbation, in which differences in LVT were driven by changes in apical rotation . The authors of the present study speculate that the associated reduction in preload occurring with heat stress may limit changes in LV apical rotation. Although this observation deserves further study, previous work has demonstrated that apical rotation is highly preload dependent  decreased in the exercise heat stress group (and not in the rest heat stress group) is offered as a potential explanation for the different LV twist mechanics responses. This observed decline in mean arterial pressure during hyperthermic isotonic exercise indicates a significant change in cardiac loading conditions. The interplay between loading conditions and LV twist mechanics, which contributes to the findings of the present study, is not completely understood. Additionally, the finding of a lack of further increase in LV twist mechanics with high levels of heat stress and exercise may suggest that there is a physiological limit to LVT/UTR augmentation.Third, the principal finding of this paper is the differential response of LV twist mechanics during rest Novel studies, such as the present investigation by


Tetralogy of Fallot (TOF) is a congenital heart disease frequently treated by surgical repair to relieve symptoms and improve survival. However, despite the performing of an optimal surgical repair, TOF patients are at times characterized by a poor long-term survival rate, likely due to cardiac causes such as ventricular arrhythmias, with subsequent sudden death. In the 80s it was irrefutably demonstrated that QRS prolongation ≥180 msec at basal electrocardiogram is a strong predictor for refining risk stratification for ventricular tachycardia in these patients. The aim of this research was to undertake a review of all studies conducted to assess the impact of QRS duration on the development of life-threatening ventricular arrhythmias in repaired TOF subjects. Tetralogy of Fallot (TOF) is a congenital heart disease characterized by a large ventricular septal defect, an aorta that overrides the left and right ventricles, obstruction of the right ventricular outflow tract, and right ventricle hypertrophy. Surgical repair of this pathology is recommended to relieve symptoms and to improve survival. However, despite the performing of an optimal surgical repair, TOF patients may feature a poor long-term survival rate, likely due to cardiac causes such as ventricular arrhythmias. The pathogenesis of this kind of tachycardia, thought to account for the majority of cases of sudden unexpected death in operated TOF patients, remains to be fully elucidated –3. ConseA Pubmed/Medline search was conducted using the MeSH terms: Fallot, QRS, mechanoelectrical interaction, ventricular tachycardia, arrhythmia, sudden death, pulmonary insufficiency, and combinations of the terms. Articles identified in this manner were retrieved and reference lists searched for additional relevant articles. The search was limited to English-language publications, and no other restrictions were applied. The Pubmed/Medline database was searched from its inception to November 2012.P = 0.037) and measured manually or by computerized means (P = 0.019). The width of QRS did not influence measurements, as the largest intraobserver variation (50 msec) was observed for relatively wide complex  and the largest interobserver (60 msec) for narrow complex . QRS morphology appeared to influence the measurements, as the intra- and inter-observer variations were more consistent in the presence of notching, slurring, and terminal slow vectors. The results obtained underline the difficulty of obtaining QRS measurement both for the operator and in view of the influence produced by the presence of conduction abnormalities, thus reducing the accuracy and reproducibility of the findings [A total of approximately one hundred and fifty studies focusing on this important issue were obtained, the most important of which are reported in this paper . Since t P = 0.01. The widAn association has been reported between ventricular enlargement secondary to pulmonary regurgitation in repaired TOF patients and a prolonged QRS duration at surface ECG . HoweverHowever, the major determinant of QRS prolongation in TOF patients remains right ventricular dilatation, which is influenced by the severity of pulmonary valve regurgitation . It is aP = 0.01) and decreased function . In addition, prolonged QRS duration has been associated with heterogeneous ventricular mechanical activation and reduced strain in the lateral and septal left ventricle walls [Several other concomitant mechanical factors have been indicated in potentially contributing towards QRS complex duration; these include not only increased right ventricular volume, but also increases in left ventricular volume and in right and left ventricular wall mass . Indeed,le walls . P < 0.001) and more symptomatic . In addition, these patients featured increased clinical ventricular arrhythmias . Nonapical left ventricular fibrosis also correlated with ventricular arrhythmias. Again, in a multivariate model, right ventricular fibrosis remained a predictor of ventricular arrhythmias. TOF patients with more diffuse ventricular fibrosis were those with QRS prolongation >180 msec [Even following successful pulmonary valve replacement, severe QRS prolongation and the absence of a reduction in QRS duration are major determinants of an adverse outcome during long-term followup of patients with TOF . Several180 msec . Postoperative factors that may lead to prolongation of the QRS in this setting include valve deterioration with stenosis other than regurgitation . PreviouμV, and root mean square amplitude of the terminal 40 msec. Cardiac catheterization was performed on 19 of the patients studied. Eighteen healthy volunteers were enrolled as controls. Ventricular arrhythmias were found in 13 patients; right ventricular systolic hypertension was found in 1 patient. No significant residual ventricular septal defects were detected. Eight patients had ventricular late potentials, whilst right ventricular systolic pressure did not differ significantly between patients with or without late potentials. Significant differences were detected between patients with ventricular arrhythmias and healthy volunteers; filtered QRS duration was significantly longer in patients with ventricular arrhythmias. Accordingly, signal-averaged electrocardiograms may prove beneficial in determining ventricular arrhythmia risk in TOF patients postoperatively [Early detection of ventricular arrhythmias following TOF surgery is fundamental in contributing towards decreasing morbidity and mortality. The frequency range of the standard electrocardiogram signal is between 0.05 and 100 Hertz, although higher frequencies may at times be detected. Using high-resolution technology, the peak amplitudes of these high-frequency components within the QRS complex can be recorded and analyzed. To this regard, the relationship between ventricular late potentials, ventricular arrhythmias, and right ventricular systolic pressure was studied in 22 patients who had undergone TOF repair (mean followup 40.1 +/−33.5 months). Holter ECG monitoring and signal-averaged electrocardiograms were performed. The studied parameters of this technique included duration of filtered QRS, duration of terminal QRS below 40 ratively . Specifiratively . The findings of this study may provide guidance for use in risk stratification and therapeutic interventions in repaired TOF patients . A studyμV, P < 0.001). The values obtained were correlated with the presence of severe pulmonary regurgitation (P = 0.006). Ten patients (9.9%) experienced late ventricular arrhythmic events and tended to have higher microvolt T wave alternans values than those lacking ventricular arrhythmias . Although microvolt T wave alternans per se was not superior to QRS duration alone in predicting late arrhythmia, positive and negative predictive values increased slightly after adding the microvolt T wave alternans to QRS duration.Microvolt T-wave alternans, another possible indicator of repolarization heterogeneity, has recently been investigated to assess its potential as a predictor of late ventricular arrhythmia in adults with TOF. A total of 101 repaired TOF patients  were studied in comparison with a control group of 103 age- and sex-matched subjects with normal hearts. Age at followup was 20.0 ± 10.6 years. Total surgical TOF repair (60.4% received a transannular right ventricular outflow patch) was performed at a mean age of 4.8 ± 5.8 years. After having excluded 11 patients with indeterminate data, the microvolt T-wave alternans values in 90 TOF patients revealed higher values than those of controls . Significant differences were revealed in all measured parameters between groups 1 and 3, and more importantly between groups 1 and 2. QRS dispersion in group 1 also correlated with QRS duration, but not with JT dispersion [Furthermore, increased QT and JT dispersions, combined with a QRS ≥ 180 ms, refine risk stratification for ventricular tachycardia in these patients, thus suggesting that both depolarization and repolarization abnormalities are associated with ventricular tachycardia after repaired TOF. To this concern, in a previous study QRS duration and QT/QRS/JT dispersion were measured manually from standard ECGs in 10 syncopal repaired TOF patients with QRS ≥ 180 ms and with documented ventricular tachycardia (group 1). They were compared with 9 repaired TOF patients with QRS ≥ 180 ms and no ventricular arrhythmias (group 2), with 40 repaired TOF patients having QRS < 180 ms and no clinical arrhythmias (group 3), and with 40 healthy subjects enrolled as controls (comprising 20 with right bundle branch block (group 4) and 20 with normal ECG patterns (group 5)). Mean QT dispersion in the TOF patients was greater than in the control group . Therefore, in patients who have undergone surgical correction of TOF, all ECG predictors for ventricular arrhythmias are influenced by a series of mechanical factors which involve the two ventricles and which may occur simultaneously [However, even the latter ECG parameters may be influenced not only by right ventricular enlargement, but also by left ventricular volume and biventricular wall mass. Indeed, when assessing left and right ventricular size in repaired TOF patients by magnetic resonance imaging, and the amount of pulmonary regurgitation by velocity mapping magnetic resonance imaging, both biventricular volumes and right ventricular wall mass were seen to be increased. When QT, QRS, JT duration, and interlead dispersion markers were derived from a standard 12 lead ECG, significant differences were registered. In fact, mean QRS duration was significantly prolonged in TOF, as well as dispersion of QRS, QT interval, and JT interval. QRS duration correlated best with right ventricular mass (aneously .The above stated electrocardiographic signs (QRS enlargement combined with QTc and JTc) continue to confirm their efficiency in predicting increased risk for ventricular arrhythmia even during physical exercise. In a study aimed at assessing proarrhythmogenic electrocardiographic changes during maximal physical exercise in patients operated for TOF, R-R duration; QRS, QT, and JT duration, and dispersions were assessed. ECG data were analyzed at rest, at 60% of peak exercise and at peak exercise.2 max. Exercise ECG data from healthy controls were used as reference.Changes in ECG parameters during exercise were calculated and correlated to right ventricle volume, right ventricle ejection fraction, right ventricle wall mass, PR percentage, and VOP < 0.001), but not in controls. At peak exercise, JTc dispersion was larger in TOF patients than in healthy controls (P < 0.01). QTc was not modified with exercise in TOF patients (P = ns) and decreased in controls (P < 0.05). At all levels of exercise mean QTc, QRS duration, and QRS dispersion were larger in TOF patients . Significant associations were found for (1) a greater increase of JTc dispersion with a higher PR percentage, a larger right ventricle volume, a larger right ventricle wall-mass and (2) greater QTc increase with a larger right ventricular volume and reduced right ventricle ejection fraction. In conclusion, during physical exercise inhomogeneity of repolarisation, known to predispose to reentry ventricular arrhythmia, increased in repaired TOF. A greater inhomogeneity was found in the presence of more severe pulmonary regurgitation [On exercise, mean QTc and JTc dispersions increased in TOF patients  was measured at rest, at maximal exercise , and at peak oxygen consumption . Stroke volume was calculated from cardiac output, obtained by CO2 rebreathing. The study findings showed that in patients with QRS shortening, peak VO2 and exercise-induced increase in stroke volume were significantly higher than in patients with QRS prolongation. This study indicated that QRS shortening during exercise in TOF patients was related to a better exercise performance [Furthermore in adult patients with repaired TOF, QRS duration at rest seems to be a predictor of maximal exercise capacity, and changes in QRS duration are likewise associated with the latter. Thus, in a group of TOF patients, QRS duration in Vformance . Anotherformance .Electrophysiological studies have shown that prolonged QRS duration at electrocardiogram is predictive not only of spontaneous adverse arrhythmic events, but even inducible ventricular tachycardia. To investigate this interesting issue, 135 survivors of TOF surgery were studied from 1984 to 1995. Age at surgery ranged from 34 days to 37 years  and age at electrophysiological study was 1.4 to 43 years . QRS duration was 80 to 240 msec (137 ± 29 msec). Sustained ventricular tachycardia was induced in 22 patients (monomorphic in seventeen). Induced sustained monomorphic tachycardia was related to QRS duration, right ventricular dimension, H-V interval, and presence of symptoms at univariate analysis. QRS duration was also related to induced sustained monomorphic ventricular tachycardia at multivariate analysis. QRS duration > or =180 msec was 35% sensitive and 97% specific for induced sustained monomorphic ventricular tachycardia at electrophysiological study. This relationship persisted even when analyzing solely asymptomatic patients. QRS duration > or =180 msec was 100% sensitive and 96% specific for detecting clinical ventricular tachycardia. In the opinion of the authors of the reported paper, the finding of prolonged QRS duration should suggest the need for further testing to determine the risk of adverse arrhythmic events in patients after repair of TOF, even when asymptomatic . The staThe use of antiarrhythmic drugs , widely prescribed in the past, is now limited to the following conditions: (1) patients with high grade ectopic ventricular activity and poor haemodynamic conditions who are not candidates for corrective surgery and do not have sufficiently severe symptoms to justify defibrillator implantation; (2) patients with a defibrillator and frequent episodes of ventricular tachycardia, in order to lower the number of shocks; (3) patients with well-tolerated ventricular tachycardia and good haemodynamic conditions, who are unwilling to undergo ablation or in whom ablation has been unsuccessful and the efficacy of medications has been documented by an electrophysiological study .Implantable cardioverter defibrillators are an important adjunct in the management of repaired TOF with QRS > 180 msec. Nevertheless, as malignant arrhythmias may even be manifested in patients with no residual lesions, QRS prolongation, and ventricular dysfunction, the identification of subjects who would benefit from implantable cardioverter defibrillators remains a clinical challenge . AnotherUnequivocal findings have demonstrated that in TOF patients a QRS prolongation ≥180 msec is a predictor for late sudden death. These results further underline the involvement of depolarization abnormalities in arrhythmogenesis in postrepair Fallot patients . This is


Diastolic dysfunction in heart failure with preserved ejection fraction (HFpEF) may result in pulmonary congestion and lung remodeling. We evaluated the usefulness of major diastolic echocardiographic parameters and of the deceleration rate of early transmitral diastolic velocity (E/DT) in predicting lung remodeling in a rat model of HFpEF.Rats underwent aortic banding (AoB) to induce pressure overload (PO). Left ventricular hypertrophy fully developed 2 weeks after AoB. At 4 and 6 weeks, the lung weight-to-body weight ratio (LW/BW), a sensitive marker for pulmonary congestion and remodeling, dramatically increased despite preserved fractional shortening, indicating the presence of HFpEF. The time course of LW/BW was well reflected by E/DT, by the ratio of early to late transmitral diastolic velocity (E/A) and the deceleration time of E (DT), but not by the ratio of transmitral to mitral annular early diastolic velocity (E/e'). In agreement, the best correlation with LW/BW was found for E/DT , followed by E/A , DT  and finally E/e' . Furthermore, analysis of receiver-operating characteristic curves for the prediction of increased LW/BW revealed excellent area under the curve values for E/DT (AUC = 0.98) and DT (AUC = 0.95), which are significantly higher than that of E/e' (AUC = 0.82). In a second approach, we also found that the new parameter E/DT correlated well with right ventricular weight index and echocardiographic measures of right ventricular systolic function.The novel parameter E/DT outperforms the tissue Doppler index E/e' in detecting and monitoring lung remodeling induced by pressure overload. The results may provide a handy tool to point towards secondary lung disease in HFpEF and warrant further clinical investigations. Based on recent epidemiological studies, up to half of all heart failure patients present an ejection fraction (EF) greater than 40% Chronic backward failure in HFpEF causes pulmonary congestion and consequently lung remodeling. In experimental models of HFpEF, this is characterized by increased lung weight in the absence of pulmonary water retention Diastolic function can be assessed non-invasively by echocardiography using Doppler and tissue Doppler techniques. While the application of diastolic parameters has been suggested to diagnose heart failure-induced lung disease in the latest guidelines In the present study, we evaluated for the first time the diagnostic value of main echocardiographic diastolic parameters in predicting lung remodeling using a well established rat model of HFpEF. Furthermore, we aimed to test our hypothesis that the deceleration rate of early transmitral diastolic velocity (E/DT) can be used to assess heart failure-induced lung remodeling  and fed a standard laboratory chow and water ad libitum at 21°C with a light cycle of 12 h.All animals received humane care in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health . The experimental protocols were approved by the local Institutional Animal Care and Use Committee .Rats were subjected to chronic pressure overload by aortic arch banding (AoB). At 2, 4 and 6 weeks after AoB, we conducted echocardiography and determined the heart weight-to-body weight ratio (HW/BW) and the lung weight-to-body weight ratio (LW/BW) as ex vivo markers for cardiac hypertrophy and heart failure-induced lung remodeling, respectively, in AoB and their age-matched control groups. The LW/BW index was used due to its high sensitivity despite simple measurability Our surgical protocol for the induction of hypertrophy and heart failure in rats has been described in detail earlier Rats were anesthetized by intramuscular injection of a combination of midazolam hydrochloride, medetomidin hydrochloride and fentanyl . Subsequently, the left anterior chest was shaved and rats were placed in a supine position on an examination pad with embedded ECG leads allowing for simultaneous monitoring of ECG, heart rate and respiration throughout an imaging session. Echocardiography was performed using a Vevo 770 rodent ultrasound system , equipped with high-resolution mechanical transducers. We used a 25 MHz-scanhead (RMV710B) for small rats (2 weeks after AoB) and a 17 MHz-scanhead (RMV716) for larger rats (4 and 6 weeks after AoB). Left ventricular size and systolic function were assessed using 2D-guided M-mode from the parasternal long-axis according to the recommendations of the American Society of Echocardiography For the correlation of echocardiographic parameters with LW/BW (at 4 and 6 weeks), rats were euthanized immediately after the echocardiogram. The heart and the lung were carefully isolated from surrounding tissues, washed in saline and weighed. Subsequently, the lung was minced and dried in an incubator at 50°C for 24 hours to determine dry weight. The whole heart and the ventricles were separately weighed after the remaining blood was removed. In addition, the postmortal position of the clip was inspected to verify the induction of pressure overload.Masson's trichrome stain was conducted to visualize collagen fibers using a commercially available kit (Sigma-Aldrich) according to the manufacturer's protocol. This approach was sensitive enough to detect LV myocardial fibrosis induced by pressure overload . Lung tiImages were analyzed off-line by a single observer blinded to necropsy results using VisualSonics Cardiac Measurements (Version 17). For each parameter, measurements were performed from three to six different cardiac cycles and the values were averaged.M-mode measurements from the parasternal long-axis view included anterior wall thickness in diastole and systole (AWd and AWs), left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic dimension (LVESD), posterior wall thickness in diastole and systole (PWd and PWs). It is noteworthy that in contrast to human echocardiogram, the interventricular septum in rats is normally not visible in the long-axis view.Endocardial fractional shortening (eFS) was used to evaluate systolic function and was calculated by: Left ventricular mass index (LVMI) was calculated from M-mode measurements and body weight (BW) using the following formula: Regression analysis revealed that calculated values of LVMI correlated well with necropsy results of the hypertrophy index HW/BW .Mitral inflow Doppler measurements included early (E) and late (A) diastolic peak velocities, deceleration time of E (DT) and isovolumic relaxation time (IVRT). DT was defined as the time between peak E and the intersection of the upper deceleration slope and the zero baseline. Derived parameters of mitral inflow Doppler involved the ratios E/A and E/DT.In tissue Doppler mode, we measured the early (e′) and late (a′) diastolic peak velocities as well as the systolic (s′) peak velocity of the septal mitral annulus. ECG was applied to identify the waves. Derived parameters of tissue Doppler assessments included the ratios E/e' and e'/a'.The functional characterization of the right ventricle involved measurements of tricuspid annular plane systolic excursion (TAPSE) and peak systolic velocity of the tricuspid lateral annulus (Ts'). We did not assess RV fractional area change due to incomplete visibility of the RV apex.The intra- and interobserver variability of the assessed echo parameters were calculated and presented as Bland-Altman plots using Sigma Plot 12.0. We used One Way ANOVA to compare the parameters among AoB and control groups at different time points, One Way Repeated Measures ANOVA to analyze the serial echo results of the follow-up group, and the Holm-Sidak method for pairwise multiple comparisons. Pearson correlation and ROC curve analysis were used to evaluate the diagnostic potential of the investigated echo parameters. Data are expressed as mean ±SEM. All statistical tests were performed using SigmaStat 3.5. Statistical significance was assumed if p<0.05.The intra- and interobserver variability of the assessed echo parameters were low in general (<10%). See Bland-Altman plots in In a separate group of pressure overloaded rats, we performed serial echocardiography to assess the usability of these echo parameters in follow-up examination. E/DT, E/A and DT clearly described a worsening trend from 2 to 6 weeks , which iWe used 34 pressure overloaded rats at 4 and 6 weeks and 7 control rats at 6 weeks for correlation analysis. We assessed the correlation at 4 and 6 weeks because LW/BW was most likely to increase at these two time points . A-wave To evaluate the diagnostic potential of E/DT, E/A, DT and E/e', we applied receiver operating characteristic (ROC) curves generated from the same data used for correlation analyses. Based on LW/BW values of control objects at 4 and 6 weeks , the pre2, for example, E/DT could predict lung remodeling with a sensitivity of 97% and a specificity of 91%. In contrast, the AUC of E/e' was acceptable (0.82), but significantly smaller than that of E/DT or DT, as analyzed by the Delong and Clarke-Pearson method For the detection of lung remodeling in HFpEF, defined as LW/BW >6 mg/g and eFS >30%, a similar constellation was found . The diaTo test if E/DT may predict histological characteristics of lung remodeling, we assessed lung tissue density, interstitial and periarteriolar relative collagen content. We found no changes in interstitial or periarteriolar collagen content at all three assessment time points . HoweverLung remodeling may result in pulmonary hypertension and subsequently RV disease. To assess if E/DT may also predict RV changes, we measure the right ventricular weight-to-body weight ratio (RVW/BW) and systolic parameters of the RV. As presented in The present study addressed for the first time the reliability of echocardiography in evaluating heart failure-induced lung remodeling. By using a well-established model of pressure overload, we found that the novel parameter E/DT best detected and monitored the development of lung remodeling in HFpEF. Following E/DT, the conventional mitral inflow parameters E/A and DT also presented satisfying reliability. In contrast, the tissue Doppler-derived index E/e' correlated only modestly with LW/BW and had lower diagnostic potential compared to mitral inflow parameters in predicting lung remodeling.The tissue Doppler index E/e' has been suggested as a powerful parameter of diastolic function which can even be used to estimate pulmonary capillary wedge pressure (PCWP) While our findings might be surprising, they are consistent with some recent reports in patients questioning the reliability of E/e' in estimating LV filling pressure. For example, Mullens et al. found no association between E/e' and PCWP in a large population of patients with advanced systolic heart failure It is worth noting that our findings do not disprove the role of the E/e' index as an important diastolic parameter. Clearly, E/e' may be useful in certain contexts. For example, as shown in Our study also investigated for the first time the role of the deceleration rate E/DT in assessing heart failure-related lung remodeling. By using a homogeneous animal model, we were able to compare among the echo parameters and found that E/DT is most reliable in detecting and monitoring lung remodeling in pressure overload-induced HFpEF. Furthermore, we also found that E/DT correlated well with RV changes, in particular the RV hypertrophy index. Thus, E/DT may also be useful in predicting RV involvement in HFpEF.We intensively searched for clinical data on E/DT and found only two studies measuring this parameter. Pozzoli et al. reported a strong correlation of E/DT with PCWP in heart failure patients with or without mitral regurgitation In our pressure overloaded rats, we did not observe the flow patterns of the impaired-relaxation or the pseudonormal stage. The E/A ratio was always greater than 1 and DT was decreased at all three time points of assessment. We assume that these two intermediate stages might be present at some time point earlier than 2 weeks, provided that this clinical classification also applies to rats with pressure overload.1 in 2 in Although we showed an excellent diagnostic potential of E/DT in pressure overload, further studies are required to test its role in other models of heart failure. For the clinical use of E/DT, caution should be taken in patients with impaired-relaxation pattern. In this stage, active relaxation of the ventricle is attenuated resulting in reduced atrioventricular pressure gradient dP1 in  and thusBecause we used the LW/BW ratio to validate diastolic parameters, no conclusions can be made about the reliability of these parameters in estimating ventricular filling pressure. The use of a necropsy marker in spite of intracardiac pressure measurements differs from most studies in this field. However, it is important to note that we focused on the characterization of lung remodeling while previous studies have aimed at estimating ventricular filling pressure. For this purpose, the use of the LW/BW ratio is an advantage because it serves as a direct long-term marker for chronic pulmonary congestion. In contrast, pressure measurements would rather be an indirect approach. From another aspect, they would provide snapshot values, which may be influenced by short-term changes in loading conditions or by anesthetics.In pressure overload-induced HFpEF, the mitral Doppler parameter E/DT reliably predicts the presence of lung remodeling and can also be used to monitor its progression. In contrast, the tissue-Doppler index E/e' which has been considered a powerful measure of diastolic function showed a low diagnostic reliability. The results are relevant for the detection and characterization of secondary lung disease associated with heart failure. In addition, they suggest more critical use of E/e' and call for advanced validation of the new and simple parameter E/DT in other models of heart failure and in humans.Figure S1Left ventricular myocardial fibrosis. Masson's trichrome stain of the left ventricle at 6 weeks after AoB reveals marked myocardial fibrosis, which may result in ventricular stiffening and therefore contribute to diastolic dysfunction. Scale bar: 100 µm.(TIF)Click here for additional data file.Figure S2Macroscopic appearance of lung remodeling. Lung of a control or pressure overloaded rat at 6 weeks. Lung remodeling involves an increase in lung size and weight. Scale bar: 1 cm.(TIF)Click here for additional data file.Figure S3Increased tissue density in the remodeled lung. Masson's trichrome stain. Scale bar: 100 µm.(TIF)Click here for additional data file.Figure S4Lung remodeling is characterized by cellular infiltration. Masson's trichrome stain shows massive cellular infiltration without increased lung fibrosis at 6 weeks. Scale bar: 50 µm.(TIF)Click here for additional data file.Appendix S1The rationale why E/DT may characterize pressure overload-induced lung remodeling.(DOC)Click here for additional data file.


Regular training, in particular endurance exercise, induces structural myocardial adaptation, so-called "athlete's heart". In addition to the 2D standard echo parameters, assessment of myocardial function is currently possible by deformation parameters . Aim of study is to assess the role of rotation and twist parameters for better characterize the heart performance in trained elite young athletes from different kind of sports. Eventually, verify early on any possible impact due to the regular sport activity not revealed by the standard parameters.50 young athletes  regularly trained at least three times a week for at least 9 months a year and 10 young controls (mean age 18.5 ± 0.5 years) were evaluated either by to 2D echocardiography or by a Speckle Tracking (ST) multi-layer approach to calculate Left Ventricle (LV) endocardial and epicardial rotation, twist, circumferential strain (CS) and longitudinal strain (LS). Data were compared by ANOVA test.2), epi-CS, epi-LS, epicardial apex rotation and the Endo/Epi twist were significantly higher only in cyclists. In all the groups, a physiological difference of the Endo/Epi basal circumferential strain and twist values have been found. A weak but not significant relationship between the Endo and twist values and LVDD  and CMi was also reported in cyclists.All the found values were within the normal range. Left Ventricle Diastolic Diameter (LVDD 51.7 ± 2.6 mm), Cardiac Mass index (CMi 114.5 ± 18.5 g/mProgressive increase of apical LV twist may represent an important component of myocardial remodelling. This aspect is particularly evident in the young cyclists group where the CMi and the LVDD are higher. ST multilayer approach completes the LV performance evaluation in young trained athletes showing values similar to adults. Regular sport activity normally induces myocardial structural and functional modifications -3. WallsIt can typify different morphological heart features in consequence to various (pressure and/or volume overload) kinds of practiced sports . These cCardiac functional parameters based on myocardial "deformation", are currently used to investigate the heart's function with high sensibility and specificity -8.Investigations in elite athlete's heart have recently provided relevant information on the apex myocardial "reserve" of the left ventricle (LV) -13. HoweAim of the study is to assess the myocardial structure and function in three different regularly trained groups of young elite athletes , by ST multi-layer approach.A group of 50 male young competitive athletes  and 15 male young controls (mean age 18.5 ± 0.5 yrs) were enrolled. The study was approved by local Ethics Committee and an oral informed consent was obtained before the participation to the protocol. For subjects under 18 yrs of age, parental consent was also necessary. Exclusion criteria included evidence of cardiovascular and metabolic disease whose presence had been confirmed by the clinical history. Although it is not a mandatory exam in order to obtain the elegibility, all subjects underwent to echocardiographic exam at rest, including the evaluation of the 2D and deformation parameters. Additional images were recorded in order to permit the post processing analysis by dedicated software.All the athletes were enrolled during the routine evaluation for agonistic sport elegibility. They were regularly trained: soccer and basketball players for 5 ± 1.2 hours/week for 6.7 ± 2.5 years vs. 4.5 ± 0.5 hours/week for 5.9 ± 2.3 years respectively, cyclists for 20.5 ± 0.5 hours/week for 7.4 ± 0.5 years. Controls were sex and age-matched. Although they trained for less than 100 minutes per week and they do not therefore practiced any kind of regular exercise for at least six months, if compared to athletes, controls were similar in anthropometric characteristics.All the echocardiographic exams were performed by two experienced board-certified cardiologists. The two cardiologists had worked together for more than 5 years, and no formal reliability of the studies (inter- or intra-tester) was done. However, in order to verify the substantial overlapping of the measurement performed, 5 subjects among the cases studied were randomly selected and blindly re-analyzed for the main 2D and deformation parameters considered.2 (CMI) was obtained from Devereux procedure [From the long axis view, and following the AHA echo- guidelines , the starocedure , and therocedure .Images were obtained in the left lateral decubitus position, after a 15 minute rest using the Echocardiograph My Lab 50  equipped with a 2.5 MHz probe. The two-dimensional grey scale images were obtained at a frame rate between 60 and 70 Hz. The images were acquired in a cine loops triggered to the QRS complex, in a resting condition and at a heart rate (HR) of approximately 70 bps to avoid the effects of a large HR variability on the rotation and the twist. High quality images were acquired with excellent visualization of the endocardial and epicardial borders. Acquisitions of the apical and basal segments were stored digitally for subsequent off-line analysis with dedicated ST software included in the echocardiograph as shown in the Figure Speckle tracking is a novel and under scrutiny method for the assessment of myocardial deformation -18. It ip value ≤ 0.05 was considered statistically significant.All the data were reported as mean ± SD. Statistical analysis was possible by SPSS 17.0 software. Two-way ANOVA with post-hoc analysis by LSD to compare the groups was used. Multivariate correlations among Endo/Epi twist and indexed cardiac mass (CMi), ejection fraction (EF), heart rate (HR), left ventricle diastolic diameter (LVDD) left ventricle systolic diameter (LVSD) and age were performed. A All the general data were reported in Table 2; p = .01) and controls . At the same time a significantly lower CMi and LV diameters were found in controls and not in the athletes. The wall ratio thickness (WRT) resulted to be similar among the groups. Concerning diastolic function, IVRT was significantly higher in controls than other groups, while DT was homogenous among the athletes. E and A waves were in general significantly lower in cyclist compared to other groups.The CMi was significantly increased more in cyclists in comparison to basket players .In basket players a similar behavior was found in the same region of the LV chamber The epicardial longitudinal strain value, resulted to be significantly lower only at LV septal level in basketball players  and at the LV lateral wall medium-apical segments of the soccer players . On the contrary, no difference in cyclists was found. In controls, none significant variation of LV apical segments has been appreciated, while a higher deformation of basal LV segments was present.2 = 0.44, p = 0.005 ) and LVSD and Endo/twist  has been also found.No correlations among Endo/Epi twist values and HR, EF and age respectively were found among the groups. However a weak positive correlation among CMi and Endo/Epi twist only in cyclists, with an higher CMi than others, has been shown Figure . A positAccording the 'Morganroth hypothesis', "the term 'athletes heart' is used to describe the characteristic enlargement (hypertrophy) of the myocardium in response to repeated exercise stimuli. Associated with this is the widely held concept that different exercise training modalities produce divergent patterns of cardiac hypertrophy in athletes . AthleteFurthermore, some sports involve heterogeneity with respect to static and dynamic cardiovascular demands in either different athletic disciplines - such as parallel bars and floor exercises in gymnastics or positions such as lineman and running back in football, or goalkeeper and mid-fielder in soccer.However, several studies suggest that LV wall thickness is increased more in endurance than strength-trained athletes and have reported no morphological changes in resistance-trained athletes. Therefore individuals with athlete's heart could exhibit further cardiac adaptation in response to both different training and kind of practiced sport ,23. AlthFor this reasons, three groups of young athletes from different kinds of sport  and at different level of dynamic and static components, have been enrolled in the present investigation. According the sports classification , cyclistLV diameter and CMi were significantly higher in cyclists compared to other groups. Although no significant differences have been found, soccer players also showed high CMi values compared to controls and basket players. Despite this, deformation parameters  assessed by Speckle Tracking (ST) multi-layer approach, highlighted how some differences play a relevant role distinguishing myocardial structural function.Previous studies have shown that several physiological and hemodynamic components  are involved during the exercise. They can also be modified by age and gender ,24. In tConcerning functional aspects, a recent study investigated the effect of endurance exercise on LV torsion, showing as an increase of this parameter and also of untwisting rate playing a relevant role as components of the exercise-induced cardiac remodelling in young athletes .Epicardial longitudinal strain was significantly lower in cyclists (-11.70 ± 2%) than soccer  and basket players , despite of mean Endocardial longitudinal strain value didn't show any evident difference among the groups. A trend to correlation was found in cyclists, where the CMi resulted higher either at endocardial  or epicardial level , while no correlation between Endo/Epi longitudinal strain and CMi was found in soccer and basketball players.In the present transversal investigation, evaluation by Multilayer approach of the Endocardial contribution in respect to the Endocardial one, has shown some further relevant differences. The mean 2 = 0.42, p < .01) and epicardial (r2 = 0.27 with p = .04) apical rotation or CMi as showed in cyclists.According to previous studies, a significant increase of epicardial apical rotation was found, but only in the cyclists (5.00 ± 1.7°) compared to basketball players . This behaviour, previously demonstrated in adults  is reinfNo evident correlation between these parameters, on the contrary, has been observed among the others groups of athletes.All the results found suggests that there is a strong relationship in young athletes, between the myocardial remodeling and the degree of LV apical rotation, especially at epicardial level. This aspect is in accordance with previous studies regarding the longitudinal strain parameter.The myocardial contractile function also seems to have a functional reserve in the young athletic population. Therefore the results emphasize the importance of a strain parameter and in particular the role of twist to assess regional myocardium specificities in a young trained athlete's heart.In particular the ST method, in a multi-layer approach, can be considered a helpful tool to distinguish the Endo/Epi rotation and twist measure. This would permit a further investigation of both the subepicardium and subendocardium role of these segments in global myocardial contractility ,26. The The young athlete's heart is characterized by specific, progressive adaptations to regular sport activity and training. However, in some cases (such as in cyclists) LV hypertrophy cannot be fully classified as concentric or eccentric, but represent a mixture of both types. The present results found and the increase of epicardial parameters of mechanical deformation that could be an adaptation to hard training in order to increase LV performance. The use of a speckle tracking method in a multylayer approach allows a more complete assessment of the LV chamber in adolescent agonistic athletes, representing a non-invasive method to investigate the LV performance by Endo/Epi rotation in presence of physiological myocardial hypertrophy. Considering our results and the large heterogeneity of echocardiographic pattern generally found in adolescent subjects, several possible clinical applications of this peculiar deformation parameters approach can be advised.The authors declare that they have no competing interests.ADL and LS have made substantial contributions to study conception and design, acquisition of data, analysis and interpretation of data. GP and GG have been involved in revising study critically and have given final approval of the version to be published. SP has been involved in revising the technical aspects of the used tools and given final approval of the version to be published. All authors read and approved the final manuscript.


Obesity predisposes to heart failure, particularly in sedentary subjects. Among others, alterations in myocardial substrate metabolism, myocardial triglyceride (MTG) accumulation and lipotoxicity may be involved. MTG is excessive in overt diabetes and related to diastolic dysfunction. In men, exercise training improves MTG, cardiac performance, physical fitness and insulin sensitivity. Given the gender difference in metabolic response to obesity these results cannot be simply extrapolated to women. Thus, it was the objective to explore the relation between cardiorespiratory fitness, cardiac function, and MTG in obese women.2; 45±10 yrs). Insulin sensitivity given as composite insulin sensitivity index (c-ISI) was determined by oral glucose tolerance testing and maximum whole-body oxygen uptake as a measure of cardiopulmonary fitness by spiroergometry. Cardiac function was measured by temporal high resolution CMR cine imaging  on a 1.5T clinical MR scanner and diastolic function was derived from volume-time curves as ratio of peak filling rates in early and atrial phase (PFRE/PFRA). MTG was determined by dually gated 1H single voxel spectroscopy (SVS) from a 6-8x20x25 mm3 voxel in the interventricular septum  were equal in both groups.MTG content was negatively correlated with cardiopulmonary fitness r=-0.28, p=0.02) in bivariate correlation analysis , but correlated negatively with insulin sensitivity .In overweight and obese women, reduced cardiopulmonary fitness is associated with increased myocardial triglyceride content. Prediabetic glucose tolerance in obese females is associated with higher MTG and reduced diastolic function. Exercise-based life-style interventions could have a beneficial effect on cardiac function through myocardial triglyceride mobilization.