Elevated galectin-3 concentration in patients with HFrEF might indicate concomitant RV dysfunction and exercise intolerance.Galectin-3 is a biomarker of fibrosis, inflammation and oxidative stress, and its role in heart remodelling and exercise intolerance has not been conclusively proven in heart failure (HF) patients with reduced ejection fraction (rEF). We prospectively assessed 67 consecutive patients with symptomatic HF and left ventricular (LV) EF ≤ 35% during optimal medical therapy, with a mean serum galectin-3 concentration of 15.3 ± 6.4 and a median of 13.5 ng/mL. The group with galectin-3 concentrations greater than or equal to the median had significantly worse right ventricular (RV) systolic function parameters , higher pulmonary artery systolic pressure, more advanced tricuspid regurgitation and lower RV-to-pulmonary circulation coupling index, while no significant differences were found in LV parameters. Moreover, this group achieved significantly lower parameters in cardiopulmonary exercise testing. Significant negative correlations were found between galectin-3 concentration and RV parameters and exercise capacity parameters and have persisted after adjustment for glomerular filtration rate, but not all of them have persisted after adjustment for NT-proBNP. Multivariate regression analysis revealed that TAPSE (β coefficient: − 0.605;  Heart failure (HF) remains one of the most prevalent and complex clinical syndromes with various stages and presentations. Despite improvements in medical therapy, outcomes remain poor, especially in symptomatic patients with severely reduced ejection fraction (rEF).1. In the failing heart, Gal-3 is released by activated cardiac macrophages and cardiac fibroblasts2. Galectin-3 is involved in numerous physiological and pathological processes, including inflammation, fibrosis, immunity and oxidative stress, which appears to stimulate pathological remodelling and fibrogenesis, particularly by inducing fibroblast proliferation and collagen deposition6. Therefore, Gal-3 is a “culprit” biomarker in HF and not simply a “bystander” like N-terminal pro B-type natriuretic peptide (NT-pro BNP) or C reactive protein. Although an increased Gal-3 concentration was found to be an independent predictor of mortality and HF hospitalization in chronic HF, the role of Gal-3 in remodelling has not been conclusively demonstrated in patients with heart failure with reduced ejection fraction (HFrEF)8.There is extensive research on biomarkers in HF, and galectin-3  has recently gained interest. Galectin-3, a soluble β-galactoside-binding lectin, is an important member of the lectin family. It is expressed in various cell types, including fibroblasts, endothelial cells and inflammatory cells10. This finding was also confirmed in patients with hypoxia-induced pulmonary artery hypertension, those with congenital heart diseases and young patients with obesity. Few small studies have revealed a role of Gal-3 in RV remodelling and dysfunction induced by pulmonary arterial hypertension12, and there are no published data in patients with HFrEF addressing this issue.Comprehensive echocardiography allows precise heart remodelling and functional assessment. Current guidelines for the diagnosis and treatment of acute and chronic HF emphasize that, along with left ventricular (LV) assessment, assessment of right ventricular (RV) structure and function, including the estimation of pulmonary arterial pressure, is an obligatory element of echocardiographic examination. Recently, in experimental data, an association between Gal-3 and pulmonary artery hypertension was observed13. In addition, data on the relationship between Gal-3 and exercise capacity (EC) in HF patients are scarce and ambiguous17. Therefore, the aim of this study was to investigate the relationship of Gal-3 concentration with echocardiographic parameters of LV and RV geometry and function with regard to EC expressed by cardiopulmonary exercise testing (CPX) parameters in patients with chronic HFrEF.Diminished exercise capacity is a key symptom in HF. Previous studies have demonstrated that RV dysfunction is associated with exercise intolerance in HF patientsThe study group consisted of 67 patients , and seventy-five percent of patients had ischaemic cardiomyopathy. All patients were symptomatic, in NYHA class II or III, despite optimal medical therapy. The mean Gal-3 concentration was 15.3 ± 6.4, with a median of 13.5 ng/mL. Table Patients with higher Gal-3 were more frequently treated with oral anticoagulants.All patients presented severe LV systolic dysfunction with a mean LV EF of 26 ± 6% and a mean LV global longitudinal strain (GLS) of − 7 ± 3%. Diastolic dysfunction was present in 59 (88%) patients. Echocardiographic parameters are shown in Table p < 0.001)  and right atrial pressure (RAP). Additionally, the tricuspid annular plane systolic excursion (TAPSE)/PASP ratio, a non-invasive index of RV-to-pulmonary circulation coupling, was significantly lower; these data are presented in Table 1) Table .Table 4B2) and at the anaerobic threshold were significantly lower in patients with a Gal-3 concentration at or above the median. Exercise duration was shorter, and peak systolic blood pressure was lower in this group than in the group with Gal-3 concentrations lower than the median. Additionally, the percentage of predicted maximal heart rate (HR) achieved at peak exercise was lower in patients with higher Gal-3 concentrations. The investigated groups did not differ either in respiratory exchange ratio at peak exercise or in ventilatory response to exercise assessed in minute ventilation-carbon versus carbon dioxide production (VE/VCO2) slope. Furthermore, no pulmonary limitations of exercise were noted in any patients. Breath reserve at peak exercise was preserved in both groups. Significant but weak negative correlations were found between Gal-3 concentration and exercise duration, HR at peak exercise, percentage of predicted maximal HR, and peak VO2 (Table p = 0.009)  Table .Table 5CThe major finding of this study is that in symptomatic patients with chronic HFrEF, elevated Gal-3 concentration is related to worsened RV function but not LV function. To our knowledge, this is the first study on this group of patients demonstrating an impairment in RV long-axis function, higher PASP and increased RAP and therefore a lower index of RV-to-pulmonary circulation coupling (TAPSE/ PASP ratio), which is one of the most important non-invasive indexes in terms of RV failure assessment. In the group with higher Gal-3 concentrations, we observed a decline in EC expressed as lower oxygen uptake at peak exercise and at the anaerobic threshold in CPX. Negative associations of Gal-3 with TAPSE and HR at peak exercise were found in backward multivariate linear regression analysis.18. A possible explanation is that all patients from our study group were in chronic but stable condition, during carefully controlled optimal medical therapy. All of them were treated with diuretics.Although there are data on the association between galectin-3 and renal function, in our study all found correlations persist after adjustment for GFR20. In HFrEF, the development of RV HF is observed due to pressure overload resulting from an increase in pulmonary hypertension, which leads to a gradual increase in RV afterload and volume overload, mainly due to tricuspid regurgitation. Right ventricular dilation and a decline in longitudinal function are the main steps in RV failure development21. All the elements of the abovementioned pathology were observed in our study group with higher Gal-3 concentrations. Several potential mechanisms underlying the relationship between Gal-3 and RV function have been postulated and vigorously investigated. Right ventricle remodelling and fibrosis may lead to RV dysfunction. Crnkovic et al.22 assessed the expression of fibrotic markers in the right ventricle of patients with pulmonary hypertension and in experimental animal models. Established fibrosis was found to be characterized by marked expression of Gal-3 and enhanced numbers of proliferating RV fibroblasts22. In an animal model, Hao et al.9 demonstrated that Gal-3 inhibition ameliorated hypoxia-induced pulmonary artery hypertension and reduced the inflammatory response, and they showed the genetic and molecular pathways involved. In congenital heart disease patients and mouse models, Shen et al.10 identified facilitating roles of Gal-3 in pulmonary artery remodelling and the progression of pulmonary artery hypertension. Moreover, in a study on patients with pulmonary artery hypertension and in an animal model, He et al.11 found that Gal-3-mediated pulmonary artery hypertension induced RV remodelling by interacting with NADPH oxidase 4 and NADPH oxidase 4-derived oxidative stress. Although patients with primary pulmonary hypertension were not represented in our study group, higher systolic pulmonary artery pressure and higher right atrial pressure were found among patients with Gal-3 concentration at or above the median. Pulmonary hypertension is a powerful predictor of mortality in patients with symptomatic HF23, and it also leads to RV dysfunction because the right ventricle tolerates volume better than pressure overload due to RV anatomy. In our study, significantly lower TAPSE/PASP ratios were found in patients with Gal-3 concentrations greater than or equal to the median, suggesting uncoupling of the right ventricle-pulmonary artery. The TAPSE/PASP ratio was significantly correlated with the Gal-3 concentration. A similar correlation was found by Gopal et al.12 in young obese patients with metabolic heart disease.RV function has proven to be a prognostic factor in HF with preserved and reduced EF24.In our study some found correlations between Gal-3 and RV function parameters have not persisted after adjustment for NT-proBNP. Natriuretic peptides and NT-proBNP among them play a crucial role in the diagnosis of HF, especially acutely decompensated. Nevertheless, there are some difficult points in their interpretation. RV dysfunction and pulmonary hypertension are listed as the clinical conditions when NT-proBNP level might be higher than expected. On the other hand, lower NT-proBNP level than expected is associated with end-stage cardiomyopathy25 . In our group none of the liver function parameters or scores was significant.Advanced heart failure is a complex clinical syndrome, and a condition of other target organs, like liver, must be taken into account, especially in patients with coexisting RV dysfunction. Therefore, we have included liver function parameters into the backward multivariate linear regression analysis model: total bilirubin, ALT, FIB-4 and MELD-XI. We have chosen MELD-XI score because it is relevant concerning oral anticoagulant therapy and its prognostic utility in patients with end-stage heart failure was shown13.Additionally, the role of the RV in determining EC has gained much interest. In our previous study on symptomatic patients with chronic HFrEF, we demonstrated that the presence of RV systolic dysfunction was independently related to reduced EC2 at peak exercise, and exercise time. In multivariate regression analysis, HR at peak exercise was independently negatively related to Gal-3 concentration. HR response during exercise is an important factor determining EC, especially in patients with HFrEF and severe LV contractile dysfunction27. Patients with higher Gal-3 concentrations may have worse HR responses during exercise than those with lower Gal-3 concentrations and therefore worse EC.In the current study, we found a weak but significant negative correlation between Gal-3 concentration and HR at peak exercise, percentage of predicted maximal HR, VO2 slope between groups 30. It could be due to described stronger correlations between ventilatory efficiency and RV function during exercise which were not analyzed in our study 30.Although there are some data that ventilatory efficiency relates to elevated pulmonary pressure and correlates with RV dysfunction, in our study, there were no differences in VE/VCO32 . It is a likely explanation why most of the weak correlations between Gal-3 and exercise capacity parameters have not persisted after adjustment for NT-proBNP.NT-pro BNP correlates strongly with exercise tolerance and can predict low EC measured by CPX in patients with impaired LV function 14 found a significant but weak negative correlation between Gal-3 levels and oxygen uptake at peak exercise . In contrast, Atabakhshian et al.16 reported no significant correlation between Gal-3 levels and functional capacity in 76 patients with compensated HF in NYHA classes I–IV with LV EF < 45% (p = 0.420). In this study, functional capacity was assessed as patient ability to perform activities according to NYHA classes16. Fernandes-Silva et al.17 investigated EC and the response to exercise training programmes according to inflammatory biomarker plasma concentrations in 44 HF patients with LV EF < 40%. The authors found that peak VO2 was significantly improved only in patients with low levels of inflammatory biomarkers. Similarly, cardiac rehabilitation improved peak VO2 compared with the control condition in patients with a Gal-3 concentration lower than the median  but not among those with a Gal-3 concentration higher than the median 17. In another study, Billebeau et al.15, in a group of 107 chronic HF patients with LVEF ≤ 45%, showed that improvement of EC after cardiac rehabilitation correlated with a reduction in Gal-3 and other cardiac biomarkers, suggesting an overall improvement of the neuro-hormonal profile. The authors suggested that cardiac rehabilitation could be a therapeutic intervention accompanied by a decrease in Gal-3 concentration15.Exercise intolerance in patients with chronic HF is a strong predictor of survival and HF progression. The relations between inflammatory biomarkers and exercise capacity in HF patients are ambiguous. In a group of 895 HF patients included in the HF-ACTION Study, Felker et al.18 showed that Gal-3 concentration was elevated in patients with both stable and acutely decompensated HFrEF compared to controls. However, there is no consensus in the literature on Gal-3 relevance in LV remodelling and prognostic value in patients with HF. Lisowska et al.33 demonstrated no correlation between the LV EF value and Gal-3 concentration in patients with myocardial infarction and stable coronary artery disease. In the study consisting of 240 HFrEF patients with predominant ischaemic aetiology, Lok et al.34 found a significant correlation between Gal-3 levels and changes in LV end diastolic volume, but no correlation between Gal-3 levels and LV end diastolic volume value. Elevation of Gal-3 levels and LV remodelling were more prominent in patients with modest LV enlargement than in patients with larger ventricles at baseline, who developed reverse remodelling more frequently. This observation suggests that Gal-3, a marker of inflammation and fibrosis, is especially elevated in HF patients with LV remodelling compared to patients without LV remodelling. Moreover, increased Gal-3 levels were found to be more pronounced in acute HF than in chronic HF, suggesting a moderate inflammatory response in chronic HF compared to that in acute HF35. Other studies demonstrated that higher concentrations of Gal-3 were correlated with an increased risk for new HF in healthy people and LV remodelling in acute MI patients with preserved LVEF, suggesting that Gal-3 could play a more important role in early fibrosis at the early stage of HF36. In contrast, our study group consisted of patients with chronic HF with severe systolic dysfunction and rather enlarged LV volumes. Our findings are in accordance with the observation that Gal-3 is not associated with outcomes in older patients with advanced chronic HF of ischaemic aetiology and therefore may have limited prognostic value in such a group of patients37.In our study, Gal-3 concentration did not correlate with the echocardiographic parameters of LV geometry and function. Several processes involved in HF, such as fibrogenesis, myofibroblast proliferation and inflammation, are linked with Gal-3. Gopal et al.14. The data on values of Gal-3 in healthy subjects are relatively scarce, mainly due to difficulty of gathering truly healthy population, carefully characterizing and representing various age ranges. Results are also sometimes contradictory, with regard to age and sex. Agnello L et al. recruited 706 blood donors and found that median Gal-3 concentration was 14.3 (Interquartile range 11.9–16.7) ng/mL with 97.5th percentile URL 26.1 ng/mL and it was related to age38. Mueller T et al. also examined blood donors concluded that 97.5th percentile URL for Gal-3 was 16 ng/mL in males and 17 ng/mL in females39 .The question of values of Gal-3 concentration, normal and abnormal, remains open. It mainly depends on the tested population. In our study, the mean Gal-3 concentration was 15.3 ± 6.4, with a median of 13.5 ng/mL (interquartile range 11.1–18.1). It is in concordance with HF-Action Study, in which a cohort of 895 subjects with chronic HF with systolic dysfunction, EF < 35% were analyzed. The median Gal-3 concentration in this cohort study was 14 ng/mL (interquartile range 11.0–18.6)Certain limitations of this study should be considered. First, this is a single centre study with a relatively small number of patients. Although our study group was rather homogeneous, as we enrolled candidates for cardiac resynchronization therapy implantation, we must appreciate the complexity of HFrEF pathophysiology. Second, only a single Gal-3 concentration measurement was performed per patient; however, the timing was carefully selected within 24 h with echocardiographic examination and CPX.In symptomatic patients with chronic HFrEF, Gal-3 concentration was related to worsened RV, but not LV, function and was accompanied by a lower index of RV-to-pulmonary circulation coupling. Further, Gal-3 concentration negatively correlated with EC, however most of the correlations have not persisted after adjustment for NT-proBNP. Multivariate regression analysis revealed that Gal-3 concentration was negatively related to TAPSE and HR at peak exercise.Elevated Gal-3 concentrations in patients with HFrEF might indicate concomitant RV dysfunction and exercise intolerance. The clinical relevance of this finding needs to be confirmed in further studies.13. Routine laboratory tests, including measurements of serum NT-proBNP concentrations, were performed immediately, and the remaining serum was frozen for further biochemical analyses. To assess liver function we calculated indexes of cirrhosis and fibrosis using well-defined formulas of the following scores:Consecutive patients with symptomatic HF in New York Heart Association (NYHA) classes II-III and severe LV systolic dysfunction (LV EF ≤ 35%) referred to our Cardiology Department between January 2013 and December 2015 for consideration of cardiac resynchronization therapy were evaluated with echocardiography and CPX within 24-h intervals as we previously described and published42.13. The exclusion criteria were haemodynamic instability, severe organic valvular disease, chronic lung diseases, inability to perform an exercise treadmill test13. All 67 patients enrolled in this observational study were prospectively assessed. A detailed description of the methods and results was published earlier13. The Gal-3 concentrations of the previously frozen serum samples were measured, and analyses of the association of Gal-3 concentration with echocardiographic parameters, namely, LV and RV geometry and function and EC, were performed.All patients remained on optimal medical therapy with no further options for myocardial revascularization or other aetiological HF treatmentThis study was performed in accordance with the requirements of the Declaration of Helsinki. The study and all its protocols were approved by the Bioethical Committee of the Centre of Postgraduate Medical Education. All the participants provided written informed consent prior to the inclusion to the study.44. Detailed assessment of LV geometry, systolic and diastolic function derived from 2D echocardiography, Doppler examination, tissue Doppler imaging and 2D speckle tracking echocardiography was performed. LV EF was calculated according to the modified Simpson’s rule. Other assessed parameters included dP/dt, LV diastolic dysfunction grade, E/eʹ ratio, left atrial maximum volume index (LAVi), mitral regurgitation grade, peak systolic myocardial velocity (LV s′), and LV GLS.Echocardiographic examinations were performed with a Vivid E9 ultrasound machine . All measurements were performed by an experienced cardiologist according to the recommendations of the American Society of Echocardiography, the European Association of Cardiovascular Imaging and the guidelines for echocardiographic assessment of the right heartRV geometry and function assessment was based on M-mode, 2D echocardiography, Doppler examination, tissue Doppler imaging and 2D strain assessment. Measurements including fractional area change (FAC) in the RV, TAPSE, peak systolic myocardial velocity (sʹ) and peak early (e′) and late diastolic velocities at the RV, RV systolic longitudinal 2D strain, RV free wall 2D strain and assessment of RV wall motion abnormalities were carried out. Systolic pulmonary artery pressure (PASP) was estimated. The TAPSE/PASP ratio was used as a non-invasive index of RV-to-pulmonary circulation coupling.2 slope, exercise duration, HR at peak exercise, percent of maximum predicted HR at peak exercise, and blood pressure at peak exercise. VE/VCO2 slope (VE plotted versus VCO2 slope) was calculated by linear regression from rest to peak exercise. All CPX was performed according to the American Thoracic Society/American College of Chest Physicians Guidelines45.A symptom-limited treadmill CPX with a Schiller Cardiovit CS-200  and an Ergo Spiro adapter  was performed at the same time of the day (between 11 am and 1 pm). The Naughton or modified Bruce protocol was used, depending on the patient’s functional status. Oxygen uptake at peak exercise in mL/kg/min was used as EC parameter. Other analysed exercise parameters were oxygen uptake at the anaerobic threshold, minute ventilation, ventilatory reserve at peak exercise, VE/VCO47. The assay principle combines a one-step immunoassay sandwich method with final fluorescence detection (ELFA—enzyme-linked fluorescence assay). Assay calibration was performed according to the manufacturer’s recommendations, and values were normalized to the standard curve47. This assay has a measurement range of 3.3 to 100 ng/mL, high repeatability (CV approximately 1%) and reproducibility (CV approximately 5%). The intra-assay and inter-assay variances for Gal-3 were 1.25% and 5.5%, respectively47.Serum Gal-3 concentration was measured using reagents and an instrument in the VIDAS family p-value < 0.05 was considered statistically significant. Spearman's correlation coefficients were calculated to assess the relationship between continuous variables. Partial correlations between galectin-3 and examined variables after adjustment for GFR and NT-proBNP were assessed. Backward multivariate linear regression analysis was performed to explore the relationships between Gal-3 concentration and clinical characteristics, RV echocardiographic parameters and EC parameters. The following parameters were included in the model: plasma NT-proBNP, GFR, ALT, total bilirubin, MELD-XI, FIB-4, RV outflow diameter, TAPSE, RV s′, PASP, TAPSE/PASP, peak VO2, HR at peak exercise, VO2 pulse and VE/VCO2 slope. The analyses were carried out using STATA 14.1 .Categorical variables are presented as numbers and percentages. Continuous variables are presented as the mean ± standard deviation (SD) or as the median when appropriate. Continuous variables were compared using Student’s t-test or the Mann–Whitney U test for non-parametric data. A


The activity of t-PA is controlled by plasminogen activator inhibitor-1. t-PA has crucial functions during spermatogenesis. One polymorphism was reported for Alu polymorphism in the t-PA gene and male infertility. The current work aimed at studying the association between Alu element insertion in t-PA gene was amplified. In addition, total t-PA concentration, plasminogen activator inhibitor-1 /t-PA complex concentration, and t-PA activity in seminal plasma were measured by enzyme-linked immunosorbent assay.Using polymerase chain reaction on genomic DNA isolated from the blood of 79 participants, a region polymorphic for t-PAAlu insertion (Alu), heterozygous Alu or homozygous for t-PAAlu deletion (Alu) did not change significantly  when compared with the control participants (n = 29). On the other hand, a significant decrease (p = 0.0001) of t-PA total concentration in seminal plasma was observed in the infertile group in comparison with the control group. However, the results indicate that there is no association between the t-PAAlu different genotypes and the total t-PA seminal concentration in the infertile group when compared to the control group (p = 0.63).The results indicate that the percentage of infertile participants (n = 50) who were homozygous for t-PA Alu polymorphism and t-PA seminal concentration or male infertility.Data obtained from the current study does not support an association between  The male reproductive system consists of several organs that work together to produce sperm and other components of the semen (1). The seminiferous tubules are lined with epithelial cells that contain spermatogonial stem cells, which develop into healthy sperm, and Sertoli cells (2). In addition, the testes contain Leydig cells that secrete testosterone (3).The primary hormones involved in the male reproductive system are testosterone, luteinizing hormone, and follicle-stimulating hormone. Testosterone is responsible for the development of male characteristics and regulates the gene expression or activates signaling pathways in Sertoli cells that are required to maintain spermatogenesis. Luteinizing hormone stimulates the production of testosterone by Leydig cells, and follicle-stimulating hormone is necessary to induce Sertoli cells to secrete androgen binding-protein (4-8).Infertility is defined as the inability of couples in reproductive age to achieve pregnancy after one year of unprotected intercourse. Worldwide, approximately 10-15% of couples are considered infertile. According to the World Health Organization (WHO), male factors are diagnosed in almost 50% of infertility cases, either solely (20%) or in combination with female factor (30-40%) (9-12).Sertoli cells play critical roles during spermatogenesis by providing optimal environment for germ cell development as well phagocytosing residual bodies shed by developing germ cells (13).In addition, Sertoli cells are responsible for secreting tissue plasminogen activator (t-PA) (14-15). t-PA is a protein involved in the fibrinolytic system that converts plasminogen, an inactive proenzyme, into the active protease plasmin that dissolves fibrin clot. The extracellular proteolysis mediated by plasminogen activators (PA) is associated with many important biological processes such as tissue remodeling, tissue destruction, and cell migration, in addition to some reproductive events such as ovulation, luteolysis, and embryo implantation. The activity of t-PA is controlled by plasminogen activator inhibitor-1 (PAI-1), which regulates t-PA activity by binding to t-PA's active site, preventing the formation of plasmin (16-18).t-PA is located at chromosome 8p12-p11.2 (19). Many studies on human population have indicated a 300-bp Alu repeat sequence insertion within intron 8 of the t-PA gene (20-23). One polymorphism was reported for this Alu repeat; either the presence of this repeat . It was reported that there is an association between Alu polymorphism in the t-PA gene and t-PA plasma levels (23). However, the plasma level of t-PA is not only dependent on the secretion of t-PA but also on its rate and degree of complex-formation with PAI-1 (23). During spermatogenesis, t-PA has a role in the transport of preleptotene primary spermatocytes, through the blood-testis barrier, from the basal to the adluminal compartments of the seminiferous tubules. In addition, t-PA is involved during spermiation . However, and as far as our knowledge is concerned, the association between t-PAAlu polymorphism and spermatogenesis has not been established. Thus, the current study aimed at studying the association between Alu polymorphism in the t-PA gene and male infertility.In the human genome, The current study was a case-control study conducted between May and December 2018. A total of 79 Jordanian males consulting gynecologists at different assisted reproduction centers in Amman, Jordan were recruited to participate in the current study. Patients were identified from patient's registry at the centers. All included participants signed a consent form.Blood samples were collected in EDTA blood collection tubes and seminal fluid samples were collected in sterile cups and were handled according to the WHO guidelines (27). Seminal fluid analysis (SFA) was performed according to the WHO guidelines (27).Genomic DNA was extracted from blood samples of control and infertile men using a commercial genomic DNA purification kit .DNA amplification by polymerase chain reaction (PCR) in a thermal cycler  was performed following these conditions: initial denaturation for 2 min at 96°C, followed by 35 cycles of denaturation for 30 sec at 96°C, annealing for 30 sec at 65°C and elongation for 30 sec at 96°C. The total volume of each reaction was 30 µl containing 1 µl of each forward (GTAACCATTTAGTCCTCAGCTGTTCTCCT) and reverse (CCATGTAAGAGTAGAAGGAGACTCAG- TCA) primers (28), 8 µl of nuclease-free water, 15 µl of the master mix , and 5 µl of DNA sample.t-PA Alu inserts are designated Alu, heterozygotes as Alu, and homozygotes for the absence of the insert as Alu.PCR products were separated on 2% agarose gel electrophoresis containing 0.5 µg/ml ethidium bromide. Homozygote individuals carrying the Seminal total t-PA concentration was measured using the Human Total t-PA ELISA Kit . The absorbance on a microplate reader  at a 450 nm was read immediately. On the other hand, seminal PAI-1/t-PA concentration was measured using the Human PAI-1/t-PA ELISA Kit . The activity of seminal t-PA was assayed using the Human t-PA Chromogenic Activity Kit . The absorbance was read at 405 nm for a zero-minute background reading and then was read every 1 hr on a microplate reader  for 6 hr.The study was approved by the Institutional Review Board (IRB) of the Hashemite University, which conforms to the World Medical Association Declaration of Helsinki (code: KTB/16/11/1800801).t test was performed, while the difference between the two proportions was calculated using the two-proportion test. Factorial ANOVA for higher orders (2-way or 3-way) was used to test for interactive effects for multiple categorical independent variables. Statistical analysis was performed using the Statistica software, StatSoft Inc., Tulsa, OK, USA (version 10). P-value All genotypes and frequencies for the insertion or deletion of the recruited individuals were calculated according to the counting method. The observed genotypes and alleles frequencies were compared with those expected in order to verify the Hardy-Weinberg equilibrium. To determine the differences between the two means, the Student's Seminal fluid was collected from the 79 participants and analyzed. Twenty-nine samples were normal . Alu genotypes and allelic frequency of Alu insertion/deletion of the t-PA gene in control and infertile participation are shown in Table II. The results indicated that the percentage of infertile participants who were homozygotes for Aluwas slightly decreased (66%) compared to the control group (75.9%); however, this decrease was insignificant (p = 0.43). On the other hand, the percentage of both Aluhomozygotes and heterozygotes Alu were insignificantly increased in the infertile group  when compared to the control group  . The allelic frequency of the AluThe Total t-PA concentration, PAI-1/t-PA complex concentration, and t-PA activity in seminal plasma were assessed by ELISA assay for the control and infertile groups (Table III). The results show that the total seminal t-PA (free and complexed with PAI-1) was significantly lower in the infertile group in comparison to the control group . On the other hand, the concentration of seminal t-PA complexed with PAI-1 in the infertile group was higher than the control group; however, this increase was insignificant (p = 0.19). The decrease in concentration of total seminal t-PA and the increase in t-PA/PAI-1 reflected in reduced activity of t-PA in the infertile group, though this reduction was insignificant .Alu polymorphism in the t-PA gene and the total t-PA concentration in seminal plasma, multifactorial ANOVA test was performed. The results shown in Table IV indicate that the total t-PA concentration in the three t-PAAlu genotypes of the infertile group was lower than those of the control group. However, the statistical analysis of the results indicate that there was no association between the different t-PAAlu genotypes and the total t-PA seminal concentration in the infertile group when compared to the control group .In order to assess if there was an association between In the current study, total t-PA concentration, PAI-1/t-PA complex concentration, and t-PA activity in seminal plasma for control and infertile groups were determined (Table III). The results show that the total seminal t-PA (free and complexed with PAI-1) was significantly lower in the infertile group in comparison with the control group . On the other hand, the concentration of seminal t-PA complexed with PAI-1 in the infertile group was higher than the control group; however, this increase was statistically insignificant (p = 0.19). The decrease in the concentration of the total seminal t-PA and the increase in the t-PA/PAI-1 were reflected in reduced activity of t-PA in the infertile group, although this reduction was insignificant .t-PA is a protein involved in the fibrinolytic system that converts the proenzyme plasminogen into the active protease plasmin that dissolves fibrin clot . In addition, the extracellular proteolysis mediated by t-PA is associated with many important biological processes, such as tissue remodeling, tissue destruction, and cell migration. The activity of t-PA is controlled by PAI-1 .t-PA has been implicated in many diseases such as thrombotic disorders including strokes and myocardial infarction (29). In addition, it was found to be involved in the process of angiogenesis in cancer cells (30). Its concentration was reported to be increased in breast cancer and myocardial infarction patients. Furthermore, it has also been associated with polycystic ovary syndrome (PCOS) (29). Moreover, it was postulated that it has a role during spermatogenesis. Sertoli cells-secreted t-PA plays a role in the transport of preleptotene primary spermatocytes, through the blood-testis barrier, from the basal to the adluminal compartments of the seminiferous tubules. In addition, t-PA was also shown to play a role in the process of spermiation at stages IX-XII .It was reported that the limiting factor of how much active t-PA is available in an organ is the capacity of the organ endothelium to increase its secretion of t-PA when required, that is, the major physiological regulator of local (organ level) fibrinolytic capacity is the secretion rate of t-PA .A single study reported the relation of t-PA concentration with male infertility. A higher concentration of t-PA was found in normal male compared with oligo/azoospermia patients. In addition, a higher number of immotile spermatozoa in the semen was associated with higher t-PA activities (31). The results presented in the current study is in accordance with their results in terms of concentration, but not activity (Table III). A possible explanation for the lower t-PA concentration could be due to the malfunction of the Sertoli cells, which it is the source of t-PA in the testis . However, testing this hypothesis is beyond the scope of this work.Alu DNA fragment is a major driving force for evolution. The Alu element affects genes either negatively via inactivation of genes or positively by altering their function (32). The Alu (I/D) t-PA polymorphism occurs in intron 8 of the t-PA gene and consists of the presence  or absence  of Alu fragment. The three t-PAAlu genotypes are Alu, Alu and the heterozygote genotype Alu (21). A genetic polymorphism may affect the primary structure of a protein, but may also affect its synthetic rate or its plasma level if the protein involved is a secretory protein. However, several studies reported that Alu (I/D) polymorphism in t-PA locus gene does not affect the synthesis rate of t-PA . Nevertheless, one study reported that homozygous carriers of Alu (I/I) t-PA polymorphism have an increased “in vivo” release rate of t-PA from vascular endothelial cells, even though this polymorphism is located in a non-coding area of the t-PA gene (22).t-PA Alu genotypes in the normal and infertile participants was determined. The results indicate that there was no association between the different t-PAAlu genotypes and the total t-PA seminal concentration in the infertile group when compared to the control group . The small sample size of the current study could be the reason behind this insignificant association.In the current study, the association between the total t-PA concentration and t-PA Alu polymorphism and t-PA seminal concentration or male infertility.In conclusion, data obtained from the current study does not support the presence of an association between The authors declare that there is no conflict of interest.


We aim to describe the trend of dσ*/dtmax in differing severity of aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) and the association of dσ*/dtmax with clinical outcomes in moderate AS and severe AS. We retrospectively studied a total of 1738 patients with AS  and preserved LVEF ≥ 50% diagnosed from 1st January 2001 to 31st December 2015. dσ*/dtmax worsened with increasing severity of AS despite preserved LVEF . Low dσ*/dtmax < 2.8 s−1 was independently associated with a higher composite outcome of aortic valve replacement, congestive cardiac failure admissions and all-cause mortality . In conclusion, dσ*/dtmax declined with worsening AS despite preserved LVEF. Low dσ*/dtmax < 2.8 s−1 was independently associated with adverse clinical outcomes in moderate AS and severe AS with preserved LVEF.The global left ventricular (LV) contractility index,  Aortic valve replacement (AVR) is a class I indication for symptomatic severe AS or asymptomatic severe AS with reduced left ventricular ejection fraction (LVEF) < 50%3. Recent studies have demonstratedthe benefit of early surgical interventionin AS when LVEF remains preserved8. However, measurement of LVEF is dependent on alteration in left ventricle (LV) loading condition and may not necessarily reflect the intrinsic contractile state of the LV11. A novel echocardiographic-derived global LV contractility index, dσ*/dtmax represents an integrated assessment of LV contractility, as it is primarily dependent on the outflow rate and wall volume of the LV chamber. dσ*/dtmax is a validated index that measures the maximal rate of change in pressure-normalized LV wall stress16. As compared to normal controls, dσ*/dtmax was found to be lower in heart failure patients with preserved LVEF15. To date, dσ*/dtmax has not been studied in pressure overload states. We aim to describe the trend of dσ*/dtmax in different severity categories of AS with preserved LVEF, and the association of dσ*/dtmax with clinical outcomes in moderate AS and severe AS with preserved LVEF.Aortic stenosis (AS) is the most common native valvular heart disease amongst the elderly populationst January 2001 to 31st December 2015 from a single-centre were retrospectively examined. Patients with other significant valvular lesions (of at least moderate severity) or any prior valvular interventions were excluded. They were divided into differing severity categories of AS based on the aortic valve area calculated by continuity equation: mild AS , moderate AS  and severe AS . Baseline demographics and echocardiographic parameters were documented. Global LV contractility index, dσ*/dtmax were calculated for all patients using non-invasive echocardiographic measurements. In patients with moderate AS and severe AS, clinical outcomes were obtained by review of medical records and outpatient attendance extracted up to 30th November 2018 for analysis. Composite events were defined as a combination of AVR, congestive cardiac failure (CCF) admissions and all-cause mortality. The association of global LV contractility index, dσ*/dtmax with the composite outcome and its individual components were studied. Receiver operating characteristic curves were used to identify the optimal cut off value for dσ*/dtmax for composite clinical events. Ethics approval was obtained from the National Healthcare Group Domain Specific Review Board (DSRB) prior to the conduct of the study. This study complied with all DSRB requirements based on Declaration of Helsinki and the ethical principles in the Belmont Report. The DSRB requirements were also compliant with the guidelines stipulated by the Bioethics Advisory Committee. No patient identifiers were obtained during the study, and no tissue samples were collected. A waiver for the need for patient consent was obtained from DSRB.Consecutive patients with isolated AS and preserved LVEF ≥ 50% diagnosed on index echocardiography from 117. We classify severity of AS based the European Association of Cardiovascular Imaging and the American Society of Echocardiography recommendations on echocardiographic assessment of aortic valve stenosis18. Aortic valve area was calculated using continuity equation. The transaortic peak velocity and transaortic mean pressure gradient were obtained using continuous wave Doppler from multiple windows to obtain the maximum velocity. Left ventricular outflow tract (LVOT) diameter was measured on parasternal long axis view. LVOT peak velocity and velocity time integral were performed using pulse wave Doppler from apical 3-chamber view, 5 mm away from the aortic valve in the LVOT18. Assessment of diastolic function to derive mitral E velocity, mitral E/A ratio, mitral E wave deceleration time and septal E/e’ ratio were done based on current recommendations for LV diastolic function19. Septale’ velocity was obtained using pulse wave tissue doppler imaging at apical four chamber view with the sample volume at the basal septal region. During LV contraction, myocardial sarcomere activation generates myocardial wall stress that induces intracavity pressure during LV contraction, which can be measured by maximal dP/dt. Myocardial wall stress occurred prior to the rise of LV intracavitary pressure and can be potentially used as a measurement of ventricular performance. By using biomechanical model, LV wall stress is expressed as: σ = P(3V/2Vm + 1/2), where σ is wall stress, P and V are LV intracavitary pressure and volume, Vm is myocardial volume. Rearranging the equation, we get: σ* = σ/P = (3V/2Vm + 1/2). Analogous to dP/dtmax, we defined dσ*/dtmax as:  dσ*/dtmax = 3(dV/dt)max/2Vm, where σ* is σ/P or pressure-normalized wall stress, and dV/dtmax is the maximal flow rate. The latter is calculated from standard echocardiography : dV/dtmax = Vpeak x πD2/4, where D is the LVOT diameter measured in the 2-dimensional parasternal long axis. Myocardial volume (Vm) is calculated from the quotient of LV mass (obtained from standard M-mode echocardiography) and myocardial density (assumed to be 1.05 g/ml)16.Transthoracic echocardiography was performed by cardiac sonographers with standard echocardiography imaging system and analysed by qualified cardiologists. Blood pressures and heart rates were obtained at the start of the studies. Chamber dimensions, LV wall thickness, chamber volume, LV mass and biplane modified Simpson’s LVEF were measured using standard recommendations for LV chamber quantificationsdσ*/dtmax in predicting composite clinical outcomes  on subsequent follow-up. Youden’s index (J) was tabulated to determine the optimised cut off for this outcome. dσ*/dtmax was defined as low when it was below the cut-off value identified by the receiver operating characteristic analysis. Clinical outcomes were compared by the construction of Kaplan–Meier curves. To adjust for differences in baseline characteristics between groups, a multivariable Cox proportional hazards regression model was constructed to obtain the risk-adjusted association between dσ*/dtmax and composite clinical outcomes. Covariates that potentially may have had confounding effect on contractility index in predicting poor clinical outcomes  were incorporated into the model. A two-tailed value of p ≤ 0.05 was used to reject the null hypothesis. Statistical analysis was done using SPSS 21.0 .Categorical data were expressed as frequency and percentages. Continuous variables were summarized as mean (±standard deviation). Chi-squared tests, Student’s t-tests and one-way analysis of variance (ANOVA) with post-hoc Bonferroni analyses were used to compare variables between groups. A receiver operating characteristic curve was constructed for dσ*/dtmax with increasing severity of AS . dσ*/dtmax was significantly different between the different categories of AS severity on post-hoc pairwise Bonferroni analysis.A total of 1738 patients with isolated AS  were included in this study. Table −1 for dσ*/dtmax to be associated with occurrence of composite outcome with an area under the curve of 0.61, 95% CI: 0.58–0.64, p < 0.001, sensitivity of 59% and specificity of 59%. A total of 601 (50.6%) patients had dσ*/dtmax < 2.8 s−1 and 587 (49.4%) had dσ*/dtmax ≥ 2.8 s−1. Patients with low contractility index (dσ*/dtmax < 2.8 s−1) were similar in terms of age and clinical profile, except for a higher incidence of chronic kidney disease (21.6% vs 13.1%) and ischemic heart disease (36.6% vs 29.6%). The LVEF was similar in spite of a lower contractility index . Patients with lower contractility index (< 2.8 s−1) also had smaller aortic valve area, higher transaortic mean pressure gradients and peak velocity and lower LVOT velocity. The LV end diastolic volume index and stroke volume index were both significantly higher in patients with lower contractility index (Table During a median follow up of 3.58 years (interquartile range: 1.11–6.06 years) in patients with moderate AS and severe AS (n = 1188), composite outcomes occurred in 625 (52.6%) patients . The cumulative mortality rates for moderate AS and severe AS were 34.6% and 40.9%, respectively. By using receiver operating characteristic analysis, we identified an optimized cut-off of < 2.8 sdσ*/dtmax < 2.8 s−1 as compared to 254 (43.3%) patients with dσ*/dtmax ≥ 2.8 s−1 . On Kaplan-Meier survival time-to-event analysis, patients with dσ*/dtmax < 2.8 s−1 had significantly higher occurrence of composite events  and its individual components of AVR , CCF admissions  and all-cause mortality  as compared to dσ*/dtmax ≥ 2.8 s−1.  (Table Composite outcomes occurred in 371 (61.7%) patients with dσ*/dtmax with worsening severity of AS (from mild AS to severe AS) despite having preserved LVEF ≥ 50%. (ii) Low dσ*/dtmax < 2.8 s−1 was associated with higher composite clinical outcomes of AVR, CCF admissions and all-cause mortality. (iii) After adjusting for age, cardiovascular risk factors, and echocardiographic markers of AS severity , low contractility index (< 2.8 s−1) remained independently associated with poor clinical outcomes on multivariable Cox regression.The main findings of this study were as follows: (i) There was a declining trend of the global LV contractility index, dσ*/dtmax was conceived de novo using basic mechanical engineering principles and geometrical assumptions of the LV. It estimated the maximum rate of development of LV wall stress in relation to LV pressure . As LV wall stress is generated intrinsically by sarcomere contraction that in turn transmits to extrinsic LV pressure, the index is based on the hypothesis that the capacity of the LV to develop intramyocardial stress to eject blood volume constitutes LV contractility12. dσ*/dtmax is dependent on the maximal outflow rate from the ventricle at ejection phase, normalized to myocardial volume21. To date, there is no technique to measure LV wall stress directly. dσ*/dtmax takes into account the combination of LV wall stress  and wall material properties. In experimental studies, it was found to be insensitive to preload and afterload changes within physiological limits and may potentially reflect intrinsic LV contractility13. Conveniently, we were able to calculate dσ*/dtmax non-invasively using routine echocardiographic measurements  without the need for specialized acquisition, software or intensive analysis. Zhong L. et al. studied dσ*/dtmax in heart failure patients and found that heart failure patients with preserved LVEF had lower dσ*/dtmax at 2.57 s−1 as compared to 4.30 s−1 in normal controls14.The global LV contractility index, 3. Due to its load-dependent nature, LVEF may not be a sensitive marker of global LV systolic function22. In chronic AS, LV hypertrophy and increased LV mass developed as adaptive responses to normalize increased wall stress (from pressure overload)23. These LV geometric changes allow for preservation of LVEF despite depressed myocardial shortening24. As the disease progresses, LV remodelling leads to sub-endocardial ischemia and myocardial fibrosis that reduces global LV systolic function28. Therefore, we need to detect subtle impairment in LV performance before the deterioration of LVEF. For better quantification of LV systolic function, studies had looked at newer indices such as LV systolic longitudinal function, mitral annulus systolic displacement, myocardial systolic velocity s from tissue Doppler imaging and myocardial deformation parameters 33. Longitudinal strain had been commonly used to evaluate LV mechanics in AS and found to be abnormal in AS patients despite preserved LVEF36. Our data were accrued over a long period and most images are no longer amendable to global longitudinal strain (GLS) analysis. Indeed, the measurement of GLS has been demonstrated to be useful in assessing subclinical LV dysfunction, and subsequent decline in the preserved LVEF. However, measurement of GLS may be time-consuming, and requires either off-line analysis or specialised software systems that may only be installed on machines with higher specifications. It is operator dependent with high inter-observer variability. These factors may limit its use in certain centres. By contrast, the novel contractility index we studied was based on physiological principles and can be easily derived from readily available echocardiographic parameters. In our study, dσ*/dtmax was lowest in severe AS at 2.58 s−1, as compared to 3.17 s−1 in moderate AS and 3.69 s−1 in mild AS, indicating the presence of sub-clinical myocardial dysfunction with increasing pressure overload leading to LV remodelling. Severe AS has the lowest dσ*/dtmax despite having a lower prevalence of hypertension and ischemic heart disease as compared with mild AS and moderate AS.Proper assessment of LV function in AS is essential in clinical decision making. The current guideline recommends AVR for symptomatic patients or asymptomatic patients when LVEF is ≤ 50%6. Traditionally, symptom status, aortic valve area, aortic jet velocity, transaortic mean pressure gradient were important predictors of adverse outcome in AS. More recently, Cioffi G. et al. showed that asymptomatic severe AS with inappropriate LV hypertrophy had a 4.5-fold higher risk of death, AVR or hospital admissions; while Lancelloti P. et. al. found an integrated measurement of peak aortic jet ≥ 4.4 m/s, LV longitudinal myocardial impedance ≤ 15.9%, valvuloarterial impedence ≥ 4.9 mmHg/ml/m2 and indexed left atrial area ≥ 12.2cm2/m2 improved risk stratification in AS38. Non-echocardiographic tools such as computed tomographic aortic valve calcium scoring and magnetic resonance imaging focal mid-wall fibrosis were predictive of mortality in AS40. Our study found that reduced global LV contractility index, dσ*/dtmax < 2.8 s−1 in patients with moderate and severe AS was associated with higher risk of AVR, CCF admissions and death despite preserved LVEF. These observations were likely due to the presence of myocardial fibrosis and poorer contractile reserve in patients with lower baseline dσ*/dtmax that accounted for the worse clinical outcomes. Current evidence demonstrated that the assessment of LV function solely by LVEF measurement is not adequate. Hence, dσ*/dtmax may be useful as an additional tool in risk stratification of AS and help to pre-select patients who may benefit from early intervention.Risk stratification for proper timing of AVR in AS is complex and challenging41. There has been a growing interest in risk stratification and outcome prediction strategies for TAVR candidates beyond the Society of Thoracic Surgeon’s risk score and EUROscore42. By the time these patients develop LV dysfunction, they may have poorer outcome post AVR28. Our study cohort spanned 15 years (2001 to 2015) and our TAVR program was started in 2010. Out of 1188 patients with moderate and severe AS at baseline, 171 subsequently underwent surgical AVR while only 30  underwent TAVR. While we have observed with this cohort that dσ*/dtmax was sensitive for early LV dysfunction and carried prognostic implications, we had not used it to plan for TAVR. It will require a prospective strategy trial to validate its utility in this setting.Transcatheter aortic valve replacement (TAVR) has been shown to reduce mortality and morbidity and evolved as a treatment option for patients at intermediate surgical risket al., AS was characterized in 122,809 male patients (mean age 61 ± 17 years) and 118,494 female patients (mean age 62 ± 19 years), and 16,129 (6.7%), 3,315 (1.4%), and 6,383 (2.6%) patients had mild, moderate, and severe AS, respectively43. 5-year mortality rates for patients with mild AS, moderate AS and severe AS were 43%, 56%, and 67%, respectively. 1-year mortality rates for patients with mild AS, moderate AS and severe AS were 15%, 21%, and 29%, respectively; implying death events were front-loaded. Our population is older, and cumulative mortality rates at median 3.6 years follow-up for mild AS, moderate AS and severe AS were 29.3%, 34.6% and 40.9%, respectively. Specifically, the mortality rate among mild AS in our cohort is mid-way between the 1- and 5-year mortality rates in Strange et al. This underscores the adverse prognosis for mortality events even in mild AS. Patients with mild AS and moderate AS may die while at this stage of the disease due to other co-morbidities that may not be related to AS itself. In addition, those in moderate AS may progress to severe AS with high risk of death during the follow up period. After adjusting for co-morbidities such as diabetes, ischemic heart disease and traditional prognostic markers of AS such as aortic valve area and transaortic peak velocity, dσ*/dtmax remained significant associated with poor composite clinical outcomes in moderate AS and severe AS.Our study observed high mortality rates that commensurate with prior large registry of AS. In a recently published paper by Strange dσ*/dtmax in pressure overload state. However, it has the inherent limitations of an observational study. Patients with mild AS or moderate AS may have other co-morbidities contributing to mortality beyond the aortic valve disease. We also did not assess patients’ symptoms status at the point of the index echocardiographic study, or if they developed symptoms on subsequent follow-up. In addition, we did not compare dσ*/dtmax with other more advanced imaging techniques like strain. However, unlike strain, dσ*/dtmax can be easily derived from conventional echocardiographic parameters without the need for specialized software. Future larger prospective studies can focus on comparing dσ*/dtmax with advanced imaging such as speckle-tracking analyses.This was the first study to look at the novel global LV contractility index, dσ*/dtmax declined with worsening AS severity despite preserved LVEF ≥ 50%. Low dσ*/dtmax < 2.8 s−1 was independently associated with higher composite outcomes of AVR, CCF admissions and all-cause mortality in moderate AS and severe AS.Global LV contractility index,


The patient was admitted to the intensive care unit due to multiple VT episodes with a suspected inferolateral and apical origin . VT episodes were resistant to antiarrhythmic drugs and to antitachycardia pacing, so a decision was made to perform VT ablation.Left ventricular (LV) assist devices (LVADs) are a treatment option in patients with advanced heart disease. Ventricular tachycardias (VTs) are common in patients with continuous-flow LVADs and have been associated with increased mortality rates.3. The Advisor™ HD Grid catheter is characterized by significant tip flexibility and adaptability to the cavity surface, which allow the operator to conduct very detailed anatomical mapping of the LV and high-definition reconstructions of the area surrounding the inflow cannula that projects into the LV cavity .After a single transseptal puncture, a steerable sheath (Agilis®) was placed in the LV and a multipolar mapping catheter  was advanced until the zone of interest was reached. Special attention was needed to avoid contact between the catheter tip and the inflow cannula of the LVAD, which was placed in the apex and 5. Programmed ventricular stimulation induced three different VTs, including two corresponding with clinical ones; unfortunately, all induced VTs were nonsustained and complete activation mapping was not feasible. Nevertheless, multipoint rapid acquisition and high-definition mapping with the Advisor™ HD Grid catheter allowed us to localize areas of putative critical isthmus. These areas, located in the inferior–apical–septal aspect of the inflow cannula border zone, showed very slow conduction and mid-diastolic electrograms during nonsustained VTs . Ablation was performed with the irrigated TactiCath™ SE catheter, targeting areas of previously annotated late potentials and mid-diastolic electrograms, especially in the surrounding of the inflow cannula. The postablation programmed ventricular stimulation did not induce any VT. Final remapping showed complete abolition of all late potentials .Voltage and activation mapping were performed, showing late and highly fractionated potentials all around the cannula, especially in the inferoapical–septal aspect


Background: Mitral valve prolapse (MVP) is characterized by an abnormal movement of the valvular apparatus which may affect the papillary muscles (PMs) function and structure. Aim of the study was to investigate abnormal PM signal in MVP by using cardiac magnetic resonance imaging (MRI). Methods and Results: We enrolled 47 consecutive patients with MVP evaluated by cardiac MRI. Additional groups included healthy volunteers, patients with moderate-to-severe mitral regurgitation (not caused by MVP) and patients with hypertrophic cardiomyopathy. Visual assessment of the PM signals was carried out and the signal intensity (SI) of both the antero-lateral and postero-medial PMs was normalized by that of the left ventricular (LV) parietal myocardium. Our results show that in the MVP group only, the PM signal intensity was significantly lower compared to the one of the LV parietal myocardium. This sign did not correlate with either LV late gadolinium enhancement or positive anamnesis for significant arrhythmias. Conclusions: In MVP patients only, PM signal is significantly reduced compared to LV parietal myocardium (“darker appearance”). The described findings are not clearly related to evidence of myocardial fibrosis, as assessed by MRI, and to previous occurrence of complex ventricular arrhythmias. MVP) is the most common valvular disease, with an estimated prevalence of 1% to 3% in the general population1. It is characterized by a significant displacement of one or both leaflets into the left atrium, with structural alterations in all components of the valvular leaflets2. In patients with MVP, the subvalvular apparatus is also affected and abnormal traction of the papillary muscles (PMs) and chordae has been described3.Mitral valve prolapse  and electrophysiological stability of the PMs and the left ventricular (LV) parietal myocardium, may favour the development of a pro-arrhythmic phenotype8.Clinical expression of MVP is extremely variable, but the compendium of potential adverse sequelae is dominated by the occurrence of significant mitral regurgitationMRI) has proven to be an excellent tool for the characterization of MVP9. Cine MRI allows adequate study of the mitral valvular apparatus, while late gadolinium enhancement (LGE) imaging is useful for the detection of areas of PM and LV fibrosis10.Cardiac magnetic resonance imaging (SI) of the PMs is typically lower compared to that of LV parietal myocardium as measured on cine images. Furthermore, we looked into a possible association of abnormal PM signal with demonstration of myocardial LGE and occurrence of complex ventricular arrhythmias in MVP patients.We hypothesized that in MVP patients, even before fibrosis can be eventually detected with LGE imaging, PMs have an altered signal on cine MRI. In particular, we sought to demonstrate that in MVP the signal intensity . Diagnosis of MVP was based on demonstration by cardiac MRI of >2-mm systolic displacement of any mitral valve leaflet into the left atrium, as measured on a LV long-axis view9. In this group of patients, any previous evidence of complex ventricular arrhythmias (defined as repetitive ventricular ectopic beats ≥3 beats in a row) on ECG holter-monitoring, electrophysiological study report or other clinical reports was recorded at the time of the cardiac MRI scan. Patients with history of coronary artery disease, cardiomyopathy, congenital heart defects or cardiac surgery were excluded from the study. Separate cohorts comprised patients with significant (moderate-to-severe) mitral regurgitation from mechanism other than MVP , performing a clinical cardiac MRI in order to assess the MR severity or cardiac remodelling, and patients with hypertrophic cardiomyopathy , whose typical indication for cardiac MRI was the quantification of LV hypertrophy  and LV myocardial fibrosis. Finally, a cohort of healthy volunteers  with no known risk factors or history of cardiac disease was recruited for this cardiac MRI study. This study was approved by the Ethics Committee of the “Azienda Sanitaria Locale of Naples, Campania Centro” , and all subjects  gave written informed consent. The study was carried out in accordance with relevant guideline and ethical regulations.We enrolled a group of consecutive MVP patients who presented to perform a cardiac MRI in order to better characterize the valvular morphology and structure as well as to search for LV myocardial fibrosis  and a multi-channel phased-array coil system. The cardiac imaging protocol included breath-hold, ECG-gated steady state free precession (SSFP) cine images acquired in standard 4-chamber, 2-chamber and 3-chamber views as well as a short-axis stack, covering the entire LV from the atrioventricular ring to the apex. Typical acquisition parameters were: slice thickness 8 mm (with 2-mm gap); flip angle 60°; temporal resolution 35–50 ms; repetition time and echo time 4.0/2.0 ms; typical in-plane spatial resolution 1.8 × 1.8 mm. To assess LGE as expression of replacement myocardial fibrosis, post-contrast T1-weighted inversion recovery images were acquired in the same LV short-axis and long-axis planes 10 minutes after 0.1 mmol/kg intravenous administration of gadobutrol  using an ECG-gated breath-hold 3D sequence  and then repeated at 20 minutes applying a 2D magnitude and phase sensitive segmented inversion-recovery sequence . For both 2D and 3D LGE scans, appropriate inversion times were selected to null LV myocardium.42, Circle Cardiovascular Imaging Inc., Calgary, Canada). LV volumes were calculated by tracing endocardial contours at end-diastole and end-systole on the LV short-axis stack. Epicardial contours were defined manually at end-systole in each short-axis slice. The LV mass was estimated by multiplying the total myocardial volume for the specific gravity of myocardium as previously described12. All the values were indexed for the body surface area. The potential presence of LGE areas involving the LV myocardium (including PMs) was visually examined and described.All MRI studies were analysed off-line using a commercially available software (CViROI) and trying to avoid the inclusion of LV cavity signal. Using the same short-axis slice, a different ROI was drawn into the interventricular septum to assess LV parietal SI  ratio and posterior papillary signal (PPS) ratio.For the measurement of PM signal, a mid-ventricular short-axis cine SSFP image in end-systolic phase was selected as it allowed for a better visualization of the PMs. Cine long-axis images were not considered for this analysis as the PMs were not consistently visualized in those images. Initially, the PM signal was visually categorized using a binary score, with “0” being equal to the myocardium SI and “1” representing visually darker PM  independently measured APS ratio and PPS ratio without prior knowledge of the clinical data. For intraobserver variability, one reader (A.S.) independently repeated APS ratio and PPS ratio measurements in an identical fashion on two occasions (3 months apart), while blinded to previous results.t test or one-way ANOVA was used as appropriate. A χ2 test was used to compare categorical variables expressed as proportions. All p values are 2 sided and considered statistically significant when <0.05. When required, we provided p values after Bonferroni correction13. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), cut-off values and area under the curve for APS ratio and PPS ratio in identifying MVP patients were derived using receiver-operating characteristics curve (ROC) analysis. Cohen’s kappa (κ) was used to explore the level of agreement between the visual assessment and the SI measurements. Interobserver and intraobserver reproducibility were assessed by means of intraclass correlation coefficient (ICC). All the statistical analyses were performed using IBM SPSS statistics 20.0 software .Continuous data are summarized as mean ± SD. For data comparison, a paired Baseline characteristics of the included study groups are shown in Table p < 0.001 vs. MVP; Fig. p < 0.001 vs. MVP; Fig. The APS ratio values were significantly lower in MVP patients (0.70 ± 0.17) than in HV (1.06 ± 0.14), MR patients  and HCM patients .ROC curve analysis was used to test the diagnostic performance of APS ratio and PPS ratio to identify MVP patients Fig. . A best p = 0.4). Clear areas of LGE involving the PMs could be identified in 15% (7/47) of the MVP patients. In this group, LV LGE involving the infero-lateral wall was noted (with a non-ischemic pattern) in 1 patient only. Similar values of APS ratio and PPS ratio were measured in the arrhythmic  and non-arrhythmic MVP groups  as well as in MPV patients with or without LGE involving the PMs and/or the LV parietal myocardium .A total of 10 (20%) patients showed more than mild MR in the MVP group, but no differences were observed in terms of PM signal compared to MVP patients without significant MR ; intraobserver ICCs for PPS ratio = 0,84 ; interobserver ICC for APS ratio = 0,92 ; interobserver PPS ratio for PPS ratio = 0,92 .The main findings of this study are three-fold: (1) on standard cine MRI images obtained in MVP patients, the PM signal is lower compared to LV parietal myocardium  adjacent to the postero-medial PM insertion and reported a clear association with sustained ventricular arrhythmias10. On the opposite, Han et al., by using a highly sensitive MRI sequence, reported LGE involving the PMs in 63% of patients with MVP with no additional LGE areas in the LV parietal myocardium9. Basso et. al demonstrated with both autopsy and cardiac MRI high prevalence of PM and LV fibrosis, but this was obtained in a selected group of MVP patients who either died suddenly or presented with complex ventricular arrhythmias5. Additional autoptic studies suggested that the presence of LV or PM fibrosis seems to be limited to high risk cases with the presence of extensive bileaflet prolapse and dilatation of the annulus (Barlow disease)26. Moreover, when present the fibrosis was typically evident microscopically and not macroscopically and even in cases with MVP-related SCD, a quarter of cases showed histologically normal heart27.previous studies described areas of myocardial fibrosis in patients with MVP, reporting an association with increased risk of arrhythmias or sudden cardiac deathIn our MVP group, LV or PM fibrosis as defined by LGE MRI was detected only in few cases. However, the arrhythmic phenotype in our population of MVP patients was rare, indicating that we may have considered a group of relatively benign cases. Nonetheless, darker PMs were observed to the naked eye in 79% of patients in the MVP group, suggesting that this imaging finding could constitute an early sign of the increased mechanical stress of PMs.Our cohort of MVP patients was consecutively recruited from a single center and, because of the referral pattern, the evidence of complex ventricular arrhythmias was low. There was no significant difference for both APS and PPS ratios in the arrhythmic and non-arrhythmic MVP sub-groups, but studies performed in MVP populations at higher arrhythmogenic risk could provide additional hints.28. Initial reports described an increased diffuse fibrosis involving the LV parietal myocardium in MVP patients as compared to controls, but reliable T1 measurements are difficult to obtain at the level of PMs30.Diffuse interstitial fibrosis involving the LV myocardium can be assessed by native or post-contrast T1 mapping techniquesOur study demonstrates that patients with MVP have a typical abnormal PM signal as compared to LV parietal myocardium on cine cardiac MRI. The finding of a reduced PM signal (“darker appearance”) can accurately differentiate MVP from healthy controls and other conditions potentially involving the mitral sub-valvular apparatus.This novel imaging marker is not clearly related to the presence of LV and/or PM fibrosis as detected by LGE MRI and to previous occurrence of significant ventricular arrhythmias. More studies are needed to test the diagnostic utility of this sign and its potential role for risk stratification of patients with MVP.


On Cox regression, TAPSE/PASP emerged as a prognostic predictor of the primary combined endpoint, together with STS-Score. TAPSE/PASP was a better prognostic predictor than either TAPSE or PASP separately. Conclusions: TAPSE/PASP ratio appears as a novel prognostic predictor in patients undergoing MitraClip implantation that might improve risk stratification and candidate selection.Background: Transcatheter mitral valve repair (TMVR) is an effective therapy for high-risk patients with severe mitral regurgitation (MR) but heart failure (HF) readmissions and death remain substantial on mid-term follow-up. Recently, right ventricular (RV) to pulmonary arterial (PA) coupling has emerged as a relevant prognostic predictor in HF. In this study, we aimed to assess the prognostic value of tricuspid annular plane systolic excursion (TAPSE) to PA systolic pressure (PASP) ratio as a non-invasive measure of RV-to-PA coupling in patients undergoing TMVR with MitraClip . Methods: Multicentre registry including 228 consecutive patients that underwent successful TMVR with MitraClip. The sample was divided in two groups according to TAPSE/PASP median value: 0.35. The primary combined endpoint encompassed HF readmissions and all-cause mortality. Results: Mean age was 72.5 ± 11.5 years and 154 (67.5%) patients were male. HF readmissions and all-cause mortality were more frequent in patients with TAPSE/PASP ≤ 0.35: Log-Rank 8.844,  Over the past decade, transcatheter mitral valve repair (TMVR) with the MitraClip system  has proven a safe and effective treatment alternative for high-risk patients with severe mitral regurgitation (MR) ,2,3,4.Currently, the indication for TMVR with the MitraClip system as an alternative to surgery is set by a dedicated Heart Team, after a thorough evaluation of each individual case, including appropriateness and feasibility of the procedure, risk stratification and benefit prediction ,6. This Patients with severe MR considered for a MitraClip procedure often associate pulmonary hypertension (PH) and right ventricular (RV) dysfunction, which are indicators of a worse outcome ,13,14. IRecently, RV to pulmonary arterial (PA) coupling has emerged as a relevant prognostic indicator in HF and PH ,18,19. RIn this study we aimed to assess the ability of baseline TAPSE/PASP ratio to improve prognostic stratification in patients undergoing successful TMVR with MitraClip.228 consecutive patients undergoing TMVR with MitraClip between June 2012 and June 2018 at 17 Spanish centres were included.Patients’ data were obtained from the Spanish MitraClip observational multicentre Registry, endorsed by the Cardiac Catheterization and Interventional Cardiology Section of the Spanish Society of Cardiology. The sample included patients with primary and secondary MR graded as moderate to severe (3+) or severe (4+) on pre-procedural echocardiography. Only patients that displayed persistent HF symptoms despite optimized guideline directed medical therapy were included. At each of the centres, the corresponding Heart Team established the indication of TMVR with MitraClip as the best treatment alternative, after careful evaluation of each case. Follow-up data were prospectively collected at each participating center by serial clinical, analytical and echocardiographic evaluations. Only patients with a comprehensive baseline echocardiographic examination that underwent successful TMVR with residual MR grade ≤ 2+ were included in the current analysis.The Ethics Committee of each of the participating centres approved the Study Protocol and all patients provided written informed consent prior to their enrolment.MR severity was graded as none, mild (1+), moderate (2+), moderate to severe (3+) and severe (4+) according to regurgitant volume and effective regurgitant orifice area. TAPSE was measured as the peak excursion of the tricuspid annulus from end-diastole to end-systole in the apical 4-chamber view with the M-mode. RV systolic pressure was determined from the peak velocity of the tricuspid regurgitation (TR) jet using the simplified Bernoulli equation. Right atrial pressure was estimated by the diameter and collapsibility of the inferior vena cava and added to the calculated gradient to yield PASP. Echocardiography measurements were recorded and averaged over three consecutive heart cycles in patients in sinus rhythm and over 3–5 heart cycles in patients in atrial fibrillation.Right heart catheterization (RHC) was performed via femoral or brachial vein employing standard methodology in a small subset of the total sample, at the discretion of the patient’s physician and standard hemodynamic measurements were registered.The details of the mitral repair procedure have been previously described . All proThe primary combined endpoint was defined as the composite of HF readmissions and all-cause death during the first-year post-procedure, including in-hospital mortality. Secondary endpoints consisted of the occurrence of each of these events separately. Follow-up for HF hospitalizations began after discharge from index admission.Periprocedural complications and in-hospital and thirty-day outcomes were defined as per Mitral Valve Academic Research Consortium criteria  and encoCategorical variables were expressed as frequencies and percentages and continuous variables as mean±standard deviation. The sample was divided in two groups according to the median value of baseline TAPSE/PAPS ratio.χ2 test, unpaired Student’s t-test and Mann–Whitney U-test, as appropriate.Comparisons between patient’s groups according to TAPSE/PASP ratio or event status were made by p-value ≤ 0.10 on univariate analysis as well as variables expected to influence outcome based on previous publications, after exclusion of colinearity. Discrimination measures by means of Harrell’s C-statistics were calculated for Cox regression model and the proportional hazard assumption for exposure of variables included in the model was verified.Survival curves for baseline TAPSE/PAPS were constructed with the Kaplan–Meier method and compared with the Log-Rank test. A multivariate Cox regression model was performed, including all variables with a Correlation analysis was performed by means of Pearson correlation coefficient to assess for the existence of a linear relationship between baseline TAPSE/PASP ratio and other hemodynamic parameters.p-value < 0.05 was considered statistically significant for all tests. Statistical analyses were performed with SPSS 21.0  for Windows.A A total of 228 consecutive patients were included in our study. Mean age was 72.5 ± 11.5 years and 154 (67.5%) patients were male. The vast majority of patients were highly symptomatic at baseline  and surgical risk was moderately increased . MR was severe in 187 (82.1%) patients and moderate-severe in the remainder 41 (17.9%) cases. The underlying MR aetiology was classified as secondary in 147/225 (65.3%) patients, primary in 50/225 (22.2%) cases, mixed aetiology in 28/225 (12.3%) and was not reported in 3 cases. All patients underwent successful TMVR with the MitraClip device with 1.5 ± 0.6 clips on average. Postprocedural MR was reduced to grade 0–1+ in 147 (64.5%) patients and to grade 2+ in the rest.Median value of TAPSE/PAPS was 0.35, with lower values indicating RV to PA uncoupling, in agreement with cutoff values with prognostic implications reported in prior studies in HF ,20,24,25Next, the correlation between TAPSE/PASP ratio, a non-invasive index of the RV to PA coupling state and RHC derived variables, including RV to PA coupling parameters, were assessed by means of the Pearson correlation coefficient. TAPSE/PASP presented a positive linear relationship with PA compliance and a negative linear relationship with PA pulse pressure, PASP and LA v-wave pressure, p = 0.003), at the expense of 61 (26.8%) HF admissions and 22 (9.6%) all-cause deaths. 12 deaths occurred in patients with a previous hospitalization for HF and 2 during index hospital admission. Cardiovascular mortality accounted for 10 (45.5%) of total deceases.During a median follow-up period of 260 days (IQ range: 115–394), the primary combined endpoint occurred in 71 (31.1%) patients  and NYHA III to IV functional class at baseline . STS-Score was numerically higher in patients that met the primary endpoint, although this association was not statistically significant , , . Moreove 0.059), .p = 0.045) and also among patients that maintained a reduced TAPSE/PASP ≤ 0.35 after successful TMVR . Of note, TAPSE/PASP ratio raised over the 0.35 threshold in almost two thirds of patients with baseline TAPSE/PASP ≤ 0.35 that had this parameter reassessed after TMVR, , alongside with STS-Score , Multivariate Cox regression identified TAPSE/PASP as an independent prognostic marker for the primary combined endpoint , together with STS-Score .Interestingly, TAPSE/PASP ratio maintained its prognostic value regardless of MR aetiology. On Kaplan–Meier survival analysis, a TAPSE/PASP ratio ≤ 0.35 was associated with a higher risk for the primary combined endpoint in patients with primary MR, To the best of our knowledge, this is the first study to assess the prognostic value of TAPSE/PASP ratio in patients undergoing successful TMVR with the MitraClip system. In this sample, TAPSE/PASP emerged as a prognostic predictor for the primary combined endpoint encompassing HF readmissions and all-cause mortality, alongside with STS-Risk Score. Importantly, TAPSE/PASP ratio provided a better prognostic stratification on multivariate Cox regression analysis than either TAPSE or PASP separately.RV to PA coupling has recently been established as a valuable prognostic predictor in HF ,20,21. TOur results are consistent with previous studies that have recently reported the prognostic value of TAPSE/PASP ratio in several HF and PH populations, ,20,21,22In addition, TAPSE/PASP ratio presented a significant negative correlation with baseline LA v-wave pressure. This finding could reflect greater LA stiffness in patients with worse RV to PA coupling as per TAPSE/PASP values, in agreement with prior studies that link loss of LA reservoir function with RV–PA uncoupling  and impaAltogether, identification of readily available, accurate prognostic predictors remains especially relevant in patients undergoing MitraClip implantation to avoid futility, as patients considered for this intervention often present advanced HF and a high load of comorbidities. Prior studies have recognized numerous indicators of worse outcomes in this population, including reduced bi-ventricular function, enlarged left ventricular (LV) volumes, PH, severe TR and advanced functional class, amongst others ,14,15,31Our study adds to aforementioned trials as it identifies a novel parameter, the TAPSE/PASP ratio, which improves prognostic stratification of patients undergoing TMVR adding to already known risk indicators, regardless of MR aetiology. This is finding is important considering the contradictory results on the utility of MitraClip in patients with HF and secondary MR recently reported by the COAPT and MITRA-FR trials ,33. SeveIn addition, STS-Score, which assembles information on multiple variables with known prognostic relevance, also presented independent prognostic value in our sample, although weaker than that provided by TAPSE/PASP ratio. Integration of both STS-Score and TAPSE/PASP ratio may improve the assessment of a patients’ candidacy for TMVR with MitraClip. Of note, other known prognostic predictors in MitraClip candidates such as LVEF and LV volumes did not improve prognostic stratification in our study, but this should be regarded with caution as LVEF was only mildly reduced and LV volumes mild-to moderately enlarged across our sample. Similarly, severe TR, which was present in 11.8% of patients, also lacked prognostic value, possible due to lower LV volumes and higher LVEF values observed in these patients.Notwithstanding, TAPSE/PASP ratio was unable to predict all-cause mortality on a separate basis, which could be due to the relatively low incidence of deaths and their frequent relation to non-cardiovascular causes. Accordingly, further trials with larger samples and follow-up periods that are powered for the detection of hard endpoints, as is mortality, are required to confirm our initial results.p < 0.0001.Our study has several limitations. First, it is an observational study based on a retrospective analysis of a multicentre registry. Limitations inherent to this design as is the potential existence of confounding factors or selection and follow-up bias cannot be discarded. Moreover, we lacked a central core lab to assess imaging and procedural data and event adjudication were not crosschecked. Accordingly, definite conclusions regarding the clinical value of TAPSE/PASP ratio for the prediction of cardiovascular adverse events cannot be established from this single study and further adequately powered trials will be needed to confirm our initial results. Second, RHC was only conducted in a small subset of the total sample, at the discretion of the patient´s physician. This strategy represents real life practice an indeed, a systematic invasive assessment of right chambers pressures via RHC was not performed in the vast majority of studies evaluating prognostic predictors in patients undergoing MitraClip procedure. Thus, a stronger influence of hemodynamic parameters on outcomes cannot be excluded based on our results. Notwithstanding, non-invasive parameters employed in our study such as TAPSE/PASP ratio or echo derived PASP estimation have previously been validated against invasively assessed gold standards ,26,29 anIn this sample of HF patients with significant MR undergoing successful TMVR with MitraClip System, the TAPSE/PASP ratio emerged as a relevant prognostic predictor of the primary combined endpoint encompassing HF readmissions and all-cause mortality, regardless of MR aetiology and TR severity. Importantly, TAPSE/PASP ratio outperformed the prognostic value of each of its components, namely TAPS and PASP, on a separate basis. In agreement with prior investigations, TAPSE/PASP ratio displayed a significant correlation with other parameters evaluating the RV to PA coupling state such as PA compliance and PA pulse pressure, which reinforces its role as a non-invasive indicator of the right-sided cardiopulmonary unit.


Long-term recovery was the least in the HLHS group: EF prior to Fontan 54 ± 2% vs. 56 ± 6% and 60 ± 4%, respectively (p < 0.01). With a median follow-up of 8 years post-BDCPC, six patients had Fontan circulation failure, four died, and three had heart transplantation. EF less than 50% at hospital discharge after BDCPC was strongly correlated to these major cardiac events . Patients with HLHS are at great risk of ventricular dysfunction after BDCPC. This is not a transient phenomenon and contributes to worse prognosis.Decline of single ventricle systolic function after bidirectional cavopulmonary connection (BDCPC) is thought to be a transient phenomenon. We analyzed ventricular function after BDCPC according to ventricular morphology and correlated this evolution to long-term prognosis. A review from Mayo Clinic databases was performed. Visually estimated ejection fraction (EF) was reported from pre-BDCPC to pre-Fontan procedure. The last cardiovascular update was collected to assess long-term prognosis. A freedom from major cardiac event survival curve and a risk factor analysis were performed. 92 patients were included; 52 had left ventricle (LV) morphology and 40 had right ventricle (RV) morphology (28/40 had hypoplastic left heart syndrome (HLHS)). There were no significant differences in groups regarding BDCPC procedure or immediate post-operative outcome. EF showed a significant and relevant decrease from baseline to discharge in the HLHS group: 59 ± 4% to 49 ± 7% or − 9% ( The bidirectional cavopulmonary connection (BDCPC) has been utilized as an intermediate procedure prior to Fontan for patients with functionally single ventricle (SV) hearts since the 1980s –5 or aftThe BDCPC is thought to have the least morbidity and mortality and is generally associated with a short cardiopulmonary bypass time . HoweverThis study aimed to evaluate ventricular function before and after BDCPC according to ventricular morphology using visually estimated ejection fraction. Our hypothesis was that, after BDCPC, ventricular dysfunction was associated with right ventricular (RV) morphology. Our second goal was to evaluate survivorship from major cardiac events after BDCPC and to identify the risk factors for poor long-term prognosis. Our hypothesis was that the post-BDCPC ventricular dysfunction was associated with worse long-term prognosis.We conducted an IRB-approved, retrospective study using chart reviews from the Mayo Clinic SV, HLHS, BDCPC, and Fontan databases. All patients consented for the use of medical records. We included all patients with a functionally SV heart who had a BDCPC at Mayo Clinic  between 1997 and 2017. All patients included in this study had pre- and post-BDCPC imaging data available to assess the ventricular function. We created two groups according to the SV morphology: Left ventricle (LV) morphology (LV group) and RV morphology (RV group). The RV group was then subdivided into HLHS (HLHS group) and non-HLHS (non-HLHS RV group). Demographic data, surgical management data, laboratory studies, and echocardiography measurements were collected to assess differences between groups. Catheterization measurements were reported pre-BDCPC and pre-Fontan. Volumetric EF obtained during catheterization was calculated using the stroke volume method as follow: EF = (end-diastolic volume (EDV) − end-systolic volume (ESV))/EDV.Among the echocardiographic data, atrioventricular valve (AV) regurgitation was visually estimated as: 0 = none or trivial, 1 = mild, 2 = moderate and 3 = severe. Aortic arch obstruction was assessed according to mean systolic Doppler gradient in the descending thoracic aorta as: 0 = none (< 5 mmHg), 1 = mild (5–14 mmHg), 2 = moderate (15–24 mmHg), 3 = severe (≥ 25 mmHg).We used 2D echocardiographic visually estimated ejection fraction (EF) to assess ventricular function. This is a semi-quantitative measurement of systolic ventricle function by an expert sonographer, comparable to biplane auto-EF  and magnTo assess the reliability of our 2D echocardiographic visually estimated EF measurement, one author (MV) performed a second blinded analysis, on a subset of 30 patients randomly selected at each available time-point.We finally compared EF results obtained by 2D echocardiography  and by catheterization (volumetric EF) at pre-BDCPC and pre-Fontan time-points.The most recent cardiovascular clinical update was collected to assess long-term prognosis. Major cardiovascular events included the following: Fontan circulation failure, Fontan or BDCPC takedown, not a candidate for Fontan completion, thromboembolism, protein-losing enteropathy, plastic bronchitis, liver cirrhosis, heart transplantation, or death. A freedom from major cardiac event survival curve was constructed for each group according to ventricle morphology and discharge EF.2. EF < 50% was defined as ventricular dysfunction. The secondary endpoint was defined by the hazard ratio (HR) for major cardiac event in patients with ventricular dysfunction post-BDCPC adjusted to baseline EF.Evaluation of risk factors for a major cardiac event was performed to investigate long-term prognosis based on the previous results. Factors that were studied included ventricular dysfunction pre-BDCPC, ventricular dysfunction post-BDCPC , RV morphology, HLHS anatomy, age at BDCPC < 4 months old, extra cardiac disease, BDCPC bypass time > 65 min, and Nakata index pre-BDCPC < 200 mm/mComparative analysis was conducted between the LV group and the entire RV group.To isolate the effect of HLHS morphology, a subgroup analysis was performed dividing the RV group into HLHS group and non-HLHS RV group and another comparative analysis was conducted among the LV group, the HLHS group, and the non-HLHS RV group.Descriptive statistics included calculations of mean and standard deviations or median and interquartile 1, 3 for continuous variables according to their distribution, counts, and percent for categorical variables. Differences between groups according to descriptive parameters and mean EF changes (primary endpoint) were analyzed using t-test or one-way ANOVA. Repeated-measures analysis using proc mixed in was performed to show differences in mean EF evolution between groups over time.Inter-reader reliability for 2D echo visually estimated EF measurement was evaluated using intra-class correlation coefficients (ICC) . ICC valp value < 0.05 was considered statistically significant.Analyses were performed using GraphPad Prism version 5.04  and SAS software version 9.4 . A Ninety-two patients met the inclusion criteria in this study. 52 had LV morphology and 40 had RV morphology (28/40 had HLHS and 12/40 had non-HLHS RV). Specific cardiac lesions included HLHS (30%), tricuspid atresia (22%), double outlet right ventricle (12%), pulmonary atresia with intact ventricular septum (10%), double inlet left ventricle (9%), and unbalanced atrioventricular canal (9%).p = 0.045). The HLHS group (5.3 ± 1.4 mos.) was the youngest at time of BDCPC. The Nakata index was significantly smaller in the RV group than in the LV group . In the HLHS group, the Nakata index was the lowest (162 ± 84 mm/m2).Table Table p = 0.04). Five of 92 patients (5%), all with HLHS, had > Grade 1 aortic arch obstruction pre-stage II. Four of these 5 patients had aortic arch enlargement at time of BDCPC. None had > grade 1 aortic arch obstruction at time of Fontan.Eleven of 92 patients (16%) had a > Grade 1 AV valve regurgitation pre-BDCPC. Eight of these 11 patients underwent AV valve surgical repair at time of BDCPC. 7 patients still had a > Grade 1 AV valve regurgitation at time of Fontan. In the non-HLHS RV group, AV valve function declined with time: 8% patients had > Grade 1 regurgitation at pre-BDCPC while 27% had > Grade 1 regurgitation prior to Fontan. There was a significant difference between groups in > Grade 1 AV valve regurgitation at pre-Fontan evaluation . At discharge, there was a significant decrease of mean EF in the HLHS group (55% to 49 ± 7% (− 6%), p < 0.01) and RV non-HLHS group (58 ± 3% to 54 ± 6% (− 4%), p = 0.04) while EF remained stable in the LV group (61 ± 5% to 59% (− 2%), p = 0.19). In the HLHS group, EF did not recover pre-Fontan as compared to the non-HLHS RV and LV groups .Table p < 0.01) vs 4% (p = 0.04) and 1% (p = 0.14), respectively.Table p = 0.02).Figure p < 0.0001. We found a linear correlation between those two methods: Y = 0.91 × X + 0.03 (p < 0.0001).2D echo visually estimated EF measurement was associated with good inter-reader reliability: ICC = 0.88; 95% CI [0.75–0.95]. The comparison between EF values obtained by 2D echo and catheterization at pre-BDCPC and pre-Fontan time-points also showed a good reliability with a mean error (bias) of 1.3%; 95% CI [− 5%– + 7%] and a Spearman’s coefficient rho = 0.64, p = 0.36). Thirty-five patients (19 in the LV group and 16 in the RV group) had ≥ 10 years follow-up. Seventy-seven percent of patients underwent Fontan at a median age of 34 months  with an interval between BDCPC and Fontan procedures of 26 months . One patient was lost to follow-up, and therefore included as censured data in the survival analysis.The median follow-up was 8 years  after BDCPC, there was no difference between groups . Most patients with a major cardiac event (62%) experienced ventricular dysfunction post-BDCPC . Major cardiac events were reported as follows:6 patients had Fontan circulation failure or were not Fontan candidates1 patient had BDCPC takedown (detailed above), 1 patient had Fontan takedown (due to pulmonary vein stenosis), 2 patients were not candidates for Fontan procedure because of pulmonary artery hypoplasia, and 2 others were considered as “failing Fontan” . Four of these 6 patients experienced ventricular dysfunction post-BDCPC.4 patients died: 1 after BDCPC (detailed above) and 3 after Fontan . All patients experienced ventricular dysfunction post-BDCPC.3 patients had heart transplantation at 14  years old; 11  years post-Fontan, all were in the RV group and none had ventricular dysfunction post-BDCPC.Thirteen major cardiac events occurred, mainly in the RV group . Patients with post-BDCPC ventricular dysfunction (discharge EF < 50%) had a higher HR  than those with a discharge EF ≥ 50%, with 75% vs. 92% freedom from major cardiac events at 15 years, respectively, (p = 0.04).Figures p < 0.001). The HR for major cardiac event in patients with post-BDCPC ventricular dysfunction  is 3.9 times higher than patients with a discharge EF of ≥ 50% (p = 0.04). Every 5% decrease in EF from baseline to discharge was associated with a 1.63 HR. This result approached statistical significance (p = 0.052). Younger age at BDCPC (< 4 months old) and associated extracardiac disease were also associated with a higher HR of a major cardiac event. Finally, we found no significant association between Nakata index, cardiopulmonary bypass time, or ventricular morphology with major cardiac events (Table The HR for major cardiac events in patients with pre-BDCPC ventricular dysfunction (pre-BDCPC EF < 50%) is 7.8 times higher than for patients with pre-BDCPC EF of ≥ 50%  for major cardiac events including Fontan circulation failure, heart transplantation, or death. Similarly, the risk of a major cardiac event was proportional to the post-BDCPC EF decrease.Retrospective studies of patients with functional SV with long-term follow-up data reported other risk factors that negatively impact prognosis including arrhythmia, atrioventricular valve regurgitation, and prolonged pleural effusion drainage , 34. TwoSeveral studies have correlated SV function to prognosis: qualitative SV dysfunction pre-Norwood , lower lSimilar to other reports , 39, ourHLHS anatomy in our study was strongly associated with post-BDCPC ventricular dysfunction which was related to poor long-term prognosis. Despite improvements in surgical techniques and anesthesia management, medical treatment of RV failure remains ineffective , 42 and Mayo Clinic is a tertiary care referral center for congenital heart disease. This study is limited by the number of patients who had follow-up echocardiograms at our institution.Assessing functionally SV function remains an unresolved issue especially for RV type morphology. Since this was a retrospective study, biplane pyramidal EF, strain analysis, 3D echocardiography, and cardiac MRI were not available for all patients. We also needed imaging data pre- and post-stage II. For now, only standard 2D echocardiography is considered as appropriate imaging for routine surveillance post-stage II ; hence, Major cardiac event survival curves according to SV morphology showed no difference until 10 years post-stage II follow-up and then a separation of the two curves with big steps down for the RV group but without significant difference between groups. Small number of patients with long-term follow-up may be confounding factor and potentially explains why the difference between groups was not statistically significant.A prospective study is critically needed given these limitations.Compared to patients with LV morphology, patients with RV morphology, especially those with HLHS, are at greater risk of post-BDCPC ventricular dysfunction. This dysfunction is associated with long-term major cardiac events. Strategies to maintain ventricular function as normal as possible at BDCPC could be reasonably expected to contribute to improved long-term prognosis, especially for patients with HLHS. These results should be confirmed by a multicenter prospective study to minimize inclusion bias. Preserving ventricular function remains a therapeutic challenge for the care team. New therapeutic approaches are needed in this regard.