Phosphatidylserines are known to sustain skeletal muscle activity during intense activity or hypoxic conditions, as well as preserve neurocognitive function in older patients. Our previous studies pointed out a potential cardioprotective role of phosphatidylserine in heart ischemia. Therefore, we investigated the effects of phosphatidylserine oral supplementation in a mouse model of acute myocardial infarction (AMI). We found out that phosphatidylserine increases, significantly, the cardiomyocyte survival by 50% in an acute model of myocardial ischemia-reperfusion. Similar, phosphatidylserine reduced significantly the infarcted size by 30% and improved heart function by 25% in a chronic model of AMI. The main responsible mechanism seems to be up-regulation of protein kinase C epsilon (PKC-ε), the main player of cardio-protection during pre-conditioning. Interestingly, if the phosphatidylserine supplementation is started before induction of AMI, but not after, it selectively inhibits neutrophil’s activation, such as Interleukin 1 beta (IL-1β) expression, without affecting the healing and fibrosis. Thus, phosphatidylserine supplementation may represent a simple way to activate a pre-conditioning mechanism and may be a promising novel strategy to reduce infarct size following AMI and to prevent myocardial injury during myocardial infarction or cardiac surgery. Due to the minimal adverse effects, further investigation in large animals or in human are soon possible to establish the exact role of phosphatidylserine in cardiac diseases. Long term prognosis for patients with acute myocardial infarction (AMI) depends on residual heart function. Despite the significant development in treatment for ischemic heart diseases in the last decade, cardiac mortality remains the number one cause of death in developed countries. New treatments are needed to reduce myocardial infarct size and post-infarct adverse left ventricle (LV) remodeling in order to prevent heart failure and improve clinical outcomes in patients presenting with acute AMI. Infarct size and resultant cardiac function are the major determinants of post-infarct heart failure ,2, a conAlthough it is possible to protect the heart against AMI using endogenous cardioprotective interventions by applying brief cycles of ischemia-reperfusion to the heart, termed ‘ischemic conditioning’ , the traIn this regard, we have previously found changed phosphatidylserine fraction in the heart of Cxcr4 heterozygotes mice as a possible adaptation to chronical ischemia . Howeverp = 0.0437), as showed by Evans-blue and tetrazolium staining , as well as in the group that received phosphatidylserine only after AMI , when compared to those of control group  after phosphatidylserine treatment pre- and post-AMI . We have found that phosphatidylserine-treatment resulted in a dose-dependent upregulation of cardioprotective mediators, such as PKC-ε , but not in the group that received phosphatidylserine only after AMI (0.71 ± 0.46 relative expression), when compared to those of control group , but not in the group that received phosphatidylserine only after AMI (127.64 ± 46.65 TGF-β1 positive cells/power field), when compared to those of control group  . NeverthTaken together, phosphatidylserine supplementation might be a promising therapeutic strategy to reduce infarct size and prevent the progression of heart failure. As a pre-treatment it may be beneficial in patients undergoing cardiac surgery or cardiac catheterization, where it may limit the commonly occurring peri-operative, inflammatory response, and ischemia-reperfusion injury. Therefore, phosphatidylserine supplementation might represent a promising therapeutic strategy to be tested for improving clinical outcomes following AMI.Despite good results and limited side-effects, we consider that there are more extended investigations which should be performed before clinical application. A human pilot study for finding the proper and most effective dose would be needed to establish the value for the clinical significance. Further, we need more studies to investigate (1) how efficient is the preventive phosphatidylserine supplementation in patients presenting cardiac disease and increased risk for an AMI and (2) why is the phosphatidylserine supplementation less protective if given after the onset of AMI. Moreover, detecting the eventual side-effects depending on different pathologies, for example kidney insufficiency or diabetes, as well as the interaction with the current clinical medication is required.All animal experiments were performed in accordance with European legislation and approved by local German authorities . All mice were housed under standardized conditions in the Animal Facility of the University Hospital Aachen .C57Bl/6 wild-type male 10–12 weeks old mice  were subjected to AMI, as previously described ,66. A moIn brief, mice were anesthetized using 100 mg/kg ketamine and 10 mg/kg xylazine i.p., and were intubated and ventilated with oxygen using a mouse respirator . C57Bl/6 wild-type male 10–12 weeks old mice  were subjected to acute myocardial ischemia-reperfusion by inducing left anterior descending coronary artery occlusion for 60 min and reperfusion for 24 h. The ribs, muscle layer, and skin incision were closed, and buprenorphine (0.1 mg/kg) was administered until full recovery. The mice were randomly assigned to 2 treatment groups: (1) control group: saline vehicle control by oral gavage once daily for one week prior to AMI and until end point; (2) PS group: phosphatidylserine (5 µg/g body weight) dissolved in saline per gavage with treatment given both one week prior and until end point 24 h post-AMI. All mice were included in the analysis, unless they died during the experiment.In separate experiments, AMI was induced after left thoracotomy by permanent ligation of the left anterior descending coronary artery with 0/7 silk. The ribs, muscle layer, and skin incision were closed, and buprenorphine (0.1 mg/kg) was administered until full recovery. Treatment was started one week prior to AMI induction (PS group) or directly following AMI (PS after group) and continued until the end point, four weeks after AMI. The mice were randomly assigned to 3 treatment groups: (1) control group: saline vehicle control by oral gavage once daily for one week prior to AMI and four weeks following AMI; (2) PS group: phosphatidylserine (5 µg/g BW) dissolved in saline applied per oral gavage with treatment given both one week prior and four weeks post-AMI; and (3) PS post group: PS only given for four weeks following AMI to simulate the clinical situation for treatment of patients diagnosed with AMI at the time of hospital presentation. At the end of the experiment the mice were euthanized using isoflurane overdose and the hearts were excised for further experiments.The left ventricular heart function was determined by echocardiography performed on a small-animal ultrasound imager  before and four weeks after AMI. Measurements of short and long cardiac axis were taken in B-Mode  and M-Mode using a 40 MHz transducer. During the procedure, mice were anesthetized with 1–2% isoflurane. The ejection fraction (EF %), fractional shortening (FS %), cardiac output (CO L/min), heart rate (HR bpm) and left ventricular diameters (mm) were recorded and analyzed with VevoLab Software. The measurements were performed by two different investigators. Since the data was similar from both investigators, only one data set is shown in the manuscript.Since infarction was induced by an open-chest surgery, usual markers for detection of cardiac injury, such as troponin and creatinine kinase, could not be used. For the re-perfused AMI model, area at risk (AAR) and infarction size were measured 24 h after ischemia-reperfusion injury, according to guidelines for cardio-protection analysis in experimental models . The hea2.Infarct size was evaluated at 4 weeks after permanent left anterior descending coronary artery ligation. Mice were anesthetized  and hearts were excised, fixed in formalin and embedded in paraffin. Serial sections  were stained with Gomori’s 1-step trichrome stain . The infarcted area was determined for all sections using Diskus software  and expressed as a percentage of total left ventricular volume. The 3D reconstructions were performed using MATLAB Software. Blue-stained collagen content was analyzed with Cell P Software  and expressed as a percentage of the infarct area [2 for 10 days until 80% confluency. One hour before hypoxia, phosphatidylserine  was added to the medium in different concentrations . Afterwards, the cardiomyocytes were incubated for 5 h in hypoxia . Finally, total mRNA was extracted either as described below or AlamarBlue® assay  was performed. 10% AlamarBlue® was added to each well and incubated for 4 h to assess cell viability. The reduction in AlamarBlue® was measured with a photometer at the wavelength 540/630 nm.Neonatal cardiomyocytes were isolated from 3 days old mice, as previously described . In summTotal mRNA was extracted from cultured neonatal cardiomyocytes and infarcted mouse heart tissues  and transcribed  as recommended in the suppliers protocol. Quantitative real-time PCR was performed using PowerUp SYBR Green Master Mix  and ViiA™ 7 Real-Time PCR System , targeting the specific genes of Bax, PKCε, Bcl2, HMOX1, HIF1α, IL-1ß, IL-6, TNF-α, and β-actin .n = 6), as previously described [+ and F4/8− neutrophils were gated and CCR3 expression was evaluated via BD CellQuest software. CCR3 expression is shown as relative difference to the unstimulated control.Neutrophils were isolated from bone marrow of 10–12 weeks old male C57Bl/6 wild-type mice . The means of two groups were compared with unpaired Student’s-t test, using Welch’s correction by significant variance. More than two groups were analyzed using 1-way ANOVA followed by Newman–Keuls or Tukey’s multiple comparison Test or 2-way ANOVA followed by Bonferroni’s multiple comparison Test, for more than two variable parameters, as indicated. Phosphatidylserines mediate cardio-protection by reducing the infarction size and improving heart function following acute myocardial infarction.Phosphatidylserines have an anti-inflammatory effect by reducing the activation of neutrophils.Phosphatidylserines supplementation is a promising potential therapeutic approach for myocardial infarction and ischemia-reperfusion injury during percutaneous coronary intervention or cardiac surgery.Phosphatidylserine supplementation represents a viable low-cost strategy to increase cardiac cell survival and to reduce the inflammatory response following acute myocardial infarction. Thus, phosphatidylserine supplementation might be a promising therapeutic strategy to reduce myocardial infarction size and prevent heart failure in patients suffering a myocardial infarction and its complications. Moreover, used as a pre-treatment in patients undergoing cardiac catheterization or cardiac surgery it may limit peri-interventional and operative myocardial injury. Therefore, phosphatidylserine supplementation might represent a novel and simple therapeutic strategy for improving clinical outcomes following myocardial infarction.


Since they are prone to pitfalls, this pilot study aimed to explore the diagnostic practicality of the 3-h visual grading scale relative to the upper segment of sternum (VGSs) approach for interpreting 99mTc-PYP planar images. Methods: A total of 42 patients were enrolled in this retrospective study. SPECT/CT approach and planar approaches including H/CL ratio, VGSr, and VGSs were utilized to interpret the 99mTc-PYP images obtained at both 1 and 3 h. The classification criteria of the latest expert consensus recommendations were considered as the gold standard. The concordance between the interpretation of each approach and the gold standard was investigated. Results: In addition to 1- and 3-h SPECT/CT approaches, the interpretation of planar images using the 3-h VGSs approach was also applicable, which turns identical to the gold standard . Conclusions: For the interpretation of 99mTc-PYP planar images, the 3-h VGSs approach should be the optimal method, particularly in the case without available or feasible tomography imaging. Only one imaging session (planar and SPECT/CT) at 3 h would be sufficient for the detection of ATTR-CA, and favorable for patient satisfaction.Background: Two different approaches, 1-h heart-to-contralateral (H/CL) ratio and 3-h visual grading scale relative to ribs (VGSr), have been established to interpret  Cardiac amyloidosis (CA) is a sort of infiltrative/restrictive cardiomyopathy, leading to significant mortality . The mos99mTc-pyrophosphate (99mTc-PYP) myocardial uptake is confirmed in the absence of immunoglobulin light chain abnormality ) values as appropriate, while categorical variables were as frequency (percentage). Group differences were tested using the two-sample Forty-two patients  were finally included in this pilot study. Among them, 5 patients (11.9%) were classified as “strongly suggestive of ATTR-CA”, while the other 37 patients (88.1%) as “non-suggestive of ATTR-CA”, based on the classification criteria of expert consensus recommendations [99mTc-PYP compared with the surrounding blood pool. Though 8 patients had a history of rib fracture, all these lesions were not located at the precordial region. The thickness of both interventricular septum and LV posterior wall of the subjects with “strongly suggestive of ATTR-CA”, were significantly greater than those with “non-suggestive of ATTR-CA” . Besides, patients with “strongly suggestive of ATTR-CA” showed a significantly greater estimated glomerular filtration rate (eGFR) and a higher level of Troponin I . The H/CL ratio, VGSr and VGSs at both 1 h  and 3 h (p < 0.001 in each comparison), were significantly higher in patients with “strongly suggestive of ATTR-CA”, when compared to those with “non-suggestive of ATTR-CA”.The demographic and clinical characteristics of the subjects were summarized in p < 0.001; κ = 0.151, p = 0.092; κ = 0.463, p = 0.002 and κ = 1.000, p < 0.001; respectively) and 3 h , compared to the classification criteria of expert consensus recommendations, were presented in a contingency table  planar images [99mTc-PYP and 99mTc-DPD has been reported, the uptake degree of different radiotracers in the myocardium is indeed different [99mTc-PYP (62.4%) compared to those in centers using 99mTc-DPD (10.7%). In our present study, 6 patients with Grade ≥2 referring to 3-h VGSr did not present myocardial tracer uptake, but radiotracer activity in LV cavity on SPECT/CT images. Meanwhile, the 3-h VGSs approach, as well as 1- and 3-h SPECT/CT approaches, reclassified these “false positive” cases as being “negative”. Likewise, when excessive activity in the LV cavity was noticed on planar images, the consequent “false positive” interpretation of typical cases displayed in numerous studies  could provide identical diagnostic information for the detection of ATTR-CA.The newly proposed 3-h VGSs approach should be superior to canonical 1-h H/CL ratio or 3-h VGSr approaches for the interpretation of


Myocardial infarction (MI) rapidly impairs cardiac contractile function and instigates maladaptive remodeling leading to heart failure. Patient-specific models are a maturing technology for developing and determining therapeutic modalities for MI that require accurate descriptions of myocardial mechanics. While substantial tissue volume reductions of 15–20% during systole have been reported, myocardium is commonly modeled as incompressible. We developed a myocardial model to simulate experimentally-observed systolic volume reductions in an ovine model of MI. Sheep-specific simulations of the cardiac cycle were performed using both incompressible and compressible tissue material models, and with synchronous or measurement-guided contraction. The compressible tissue model with measurement-guided contraction gave best agreement with experimentally measured reductions in tissue volume at peak systole, ventricular kinematics, and wall thickness changes. The incompressible model predicted myofiber peak contractile stresses approximately double the compressible model . Compensatory changes in remaining normal myocardium with MI present required less increase of contractile stress in the compressible model than the incompressible model . The compressible model therefore provided more accurate representation of ventricular kinematics and potentially more realistic computed active contraction levels in the simulated infarcted heart. Our findings suggest that myocardial compressibility should be incorporated into future cardiac models for improved accuracy. MI induces myocardial fibrosis, which includes significant compositional, structural, and functional changes during the transition from infarcted myocardium to scar tissue2. This maladaptive remodeling process is typically severe and irreversible, leading to dilatation of the left ventricle (LV), wall thinning, papillary muscle displacement, mitral valve leaflet tethering and regurgitation, and mitral annular dilatation3. These profound pathophysiological changes collectively induce progressive heart failure (HF)4. Current treatment strategies for MI-induced remodeling and HF continue to rely primarily on empirical clinical experience and there is an urgent need for novel therapeutic modalities, studies of treatment duration and dosing, and design of mechanical supports that can be personalized for each patient.Myocardial infarction (MI) causes irreversible damage to cardiac muscle due to cessation of local blood flow following coronary artery occlusion. Approximately 1.5 million people suffer MI annually in the United States, with more than 15.9 million cases occurring globally. MI impairs cardiac contractile function within 1 min, and the subsequent post-ischemic event cascade is triggered almost immediately without rapid intervention5, and great progress has been made in organ-level cardiac modeling to describe the diverse aspects of heart biomechanical function, electrophysiology, heart disease, and treatment8. Current application areas include the etiology and pathophysiology of myocardium remodeling, its impact on tissue-level properties and organ-level cardiac function, and improvement of virtual surgery technologies and medical device development. In silico modeling can also provide quantitative risk stratification tools for these interventions9. A patient-specific computational platforms that can accurately predict the effects of MI on cardiac function, both acutely and chronically, would therefore be extremely valuable for developing and determining treatment strategies. However, simulation approaches must rest on a firm understanding of the function of myocardial tissue function in health and disease, which remains an active area of research10.In silico modeling is becoming a major tool for improving our fundamental understanding of HF and developing patient specific therapies15. In particular, through the use of full 3D kinematics, triaxial structural-mechanical measurements, and finite element modeling, complex 3D coupling behavior between myofibers and collagen fibers in the extracellular matrix has been revealed. In contrast, only a single multi-axial study has been performed on active contraction16. Specific passive and active mechanics were found to be different, i.e., passive properties are more compliant and markedly nonlinear, whereas the activated properties are substantially stiffer and more linear. Clearly, the development of computational models of myocardial behaviour remains a challenging area, as several fundamental phenomena remain incompletely understood.Given the thick-walled structure of the heart, a fully three-dimensional approach to modeling myocardium mechanical behavior is clearly necessary. Recent studies have explored the passive state in cuboidal specimens17. Thus, volumetric changes are strongly correlated with the anisotropic myofiber fiber architecture and the microvessels aligned with these fibers rather than the larger transverse transmural vessels. If increases in perfusion pressures modulate myocardial volume, then intuitively, actively contracting myocardium should also be able to drive blood in and out of the coronary vasculature. Despite their functional importance, the exact effects of contractile forces on blood flow in the coronary vessels, microcirculation, and venous collection systems over the cardiac cycle remain unclear, as does their relation to myocardial volume changes during systole. The passive response of myocardium is commonly modeled either as a single-phase, nonlinear anisotropic incompressible hyperelastic solid, or one with embedded cylindrical vessels of known distensibility and varying diameter as function of the perfusion pressure18. The well-established “garden hose” effect, i.e., altered coronary perfusion changes the apparent stiffness of the tissue, is described by this later class of models. More formal modeling frameworks employ the theory of poroelasticity, which treats the myocardium as a mixture, with the goal of capturing the interactions between the solid and fluid phases. For myocardium, poroelasticity has been employed to describe observed viscoelastic behavior due to fluid filtration in the extracellular space and blood vessels19, to employ muscle contraction as the driving force for blood flow20, and to describe stiffening with increase in fluid pressure21.One such area is the interrelationship between myocardial deformation and perfusion pressure. Studies of ex vivo perfusion pressure in isolated and arrested hearts have demonstrated that: (i) myocardial deformation is not isochoric (i.e. not volume-preserving), and perfusion pressurization produces substantial radial thickening and increase in myocardial tissue volume  associated with an increase in intramyocardial capacitance; and (ii) there is decrease of myocardial compliance (or stiffening) in the longitudinal and radial directions22. Results demonstrated a progressive reduction in myocardial volume from end-diastole (ED) to end-systole (ES), with a normalized volume To provide additional insight into the nature of local myocardial compressibility, we recently conducted a novel experimental study to quantify local , but compressible in systole to allow for volume reductions while actively contracting22. Compressibility was incorporated through a specialized material model that utilized a penalty term allowing for only reductions in volume modulated by active contraction. That is, the bulk modulus was not a material constant, but instead, a material function that decreased with the current amount of local active fiber stress.The mechanical behavior of passive myocardium was described using a transversely isotropic Fung-based hyperelastic model for the deviatoric component, with four parameters. Parameter values were then fitted to the Klotz end-diastolic pressure–volume curve24. Because the end-diastolic configuration employed to generate the heart geometry was pressurized  state, myocardium can be considered functionally incompressible. Thus, passive material parameters were calibrated such that the organ-level model reproduced a general end-diastolic pressure–volume relationship (EDPVR)f are then multiplied by the global stress due to contraction t when the measured pressure at time t is applied to the endocardial surface.The temporal and spatial heterogeneity of calcium transients estimated from epicardial MAPs drives active contraction in the asynchronous simulations . Wall thickness derived from the simulations for incompressible case was approximately 1.133, whereas the compressible case was 1.094, a value very close to the experimentally measured case of 1.0933  thickness and LV height), and a 22. The resulting accurate accounting of myocardial compressiblity at the In the current study, we sought to model the myocardium strictly at the organ level, considering a local volume scale of mentclass2pt{minimincreased from 0.84 in the pre-MI state to 0.95 at 60 min post-snare. This clearly demonstrated the effects of reduced perfusion on the local myocardial volume during systole. In addition, decreased from 0.86 in the pre-MI state to about 0.825 in the same 90 min post-MI period. These experimentally measured features were both significant and experimentally verified in the computational results  during systole for both material models  was defined as the time of 60% decay of the MAP and whose width was related to the re-polarization time, based on experimental recordings70. Although this simplification is a limitation of our study, this methodology increases realism compared to mechanical models employing synchronous contraction patterns71. A further limitation is that the unloaded heart is not completely stress-free due to the presence of residual stresses73. Residual stress is an active area of research and its inclusion is planned for subsequent versions of our modeling effort.The relationship between the action potential and contraction force is complexrelative changes in predicted active contraction forces between the pre- and post-MI states. While not directly verifiable, our findings suggest that use of a compressible material model improves our ability to predict more realistic relative changes in contractile forces in the remaining normal myocardium post-MI. Accurate force generation is important as it is a key determinant of borderzone growth and remodeling in the post-MI heart. The compressible tissue modeling approach presented in this work therefore contributes to a more complete representation of the physiological function of heart in heath and disease.In conclusion, this study has demonstrated that utilization of myocardial compressibility can improve organ-level simulation accuracy of the deformation patterns of LV. More importantly, use of the compressible myocardial material model revealed profound effects on the All data collection for the development of the in silico heart model was performed at the Visible Heart Laboratory , in three steps: (i) in vivo, (ii) ex situ, and (iii) ex vivo. Anteroapical MI was in a total of ten adult Dorset sheep (weight around 40–50 kg) by ligation of the left anterior descending (LAD) and D2 coronary arteries following surgical protocols Fig. a. All exP was measured with a balloon pressure catheter placed through the left carotid and aortic valve. Distance segments were generated using sonomicrometry crystals placed on the LV base, LV apex, and LV anterior and posterior midwall. Measurements were taken at 500 Hz. Approximations of LV volume were computed using a half-elliptical volume V, with the LV apex-to-base distance as the long axis a and the anterior-to-posterior LV wall distance as the short axis diameter b, with HR) was obtained from the temporal lag in between two QRS complexes measured with standard echocardiography, and time was non-dimensionalized to EDV and ESV, respectively) and yielded standard cardiac function metrics, such as stroke volume In the one animal used for construction of our sheep-specific model, LV pressure For validation of the biventricular model, echocardiographic images were acquired with corresponding electrocardiogram (ECG) data. We chose representative end-diastole (ED) and end-systole (ES) frames at the maximum volume and at the minimum volume, respectively. Frames were collected at long axis, short axis, and four-chamber long axis views. We measured, averaged, and recorded key features in all frame such as LV height. These measurements were taken in units of pixels within ImageJ software, using irregular area and straight-line selection tools. We normalized each measurement with respect its value in the ED frame. After the heart was excised, it was cleaned and then perfusion fixed in 10% buffered formalin under end-diastolic pressure (around 15 mmHg) with valves coapted. MRI was subsequently performed to obtain the anatomy of heart at end-diastole. Following MRI, the samples were kept at 4 22. The sonocrystal array spanned the entire LV free wall and was composed by 27 sonocrystals placed in the endocardium, epicardium, and mid-wall  around the apex were too close to epicardium, large variations appeared and so only six endocardial sonocrystals (4–9) were used to represent wall thickness change. The validation data for wall thickness change was generated by averaging values over 10 ovine heart for groups. The same technique was applied to wall thickness calculation for the in-silico heart models. We tracked a total of 845 nodes on finite element mesh on endocardium over one cardiac cycle and wall thickness changes were averaged based on these values.K is the bulk modulus  modelK dependent on the amount of active contraction, i.e.,To account for the distinctive type of compressible material behavior  were taken in scattered locations throughout the LV and RV epicardium. We used measured electrical data to spatially and temporally modulate the heterogeneity of active contraction. When modeling MI, contraction was shut down in the infarcted area with no mechanical property changes in the myocardium.The pressure–volume (PV) loop, measured in vivo through catheterization and sonomicrometry from the infarcted heart, was used to fit the modulation of active contraction in all cases to allow direct comparison of results Fig. . The meaThe finite element mesh were created in Trelis (Csimsoft Inc.) using 10-node tretrahedral elements and it was treated as input file into Abaqus . The constitutive model of myocardium was written in UMAT which contains passive behavior following Fung’s orthotropic model, active contraction fitted by MAP waveforms and volumetric response in Eq. . The kin23 parameters and Klotz et al.24. Starting from the ED ventricular geometry, the FE heart model was unloaded to a stress-free configuration and then inflated to ED pressure. This step was performed iteratively to match the FE model curve with the EDPVR curve. The fitted passive model matched the general EDPVR with a difference of 0.53 mL in end-diastolic volume ; however, a functional form for bulk modulus was modeled as a function that is dependent on the current and local magnitude of active contraction, such that the material becomes compressible during active systole and reductions in volume can occur. Because we were interested in modeling changes from end-diastole to peak-systole, a linearly decreasing function from the very high bulk modulus of nearly-incompressible passive myocardium with increasing active contraction magnitude was sufficient to obtain the reductions in volume observed from end-diastole to peak-systole in our sonocrystal studies.All in-vivo data that was utilized in this work was followed the ARRIVE guidelines.Supplementary Information 1.Supplementary Information 2.


Congestion related to cardiac pressure and/or volume overload plays a central role in the pathophysiology, presentation, and prognosis of heart failure (HF). Most HF exacerbations are related to a progressive rise in cardiac filling pressures that precipitate pulmonary congestion and symptomatic decompensation. Furthermore, persistent symptoms and signs of congestion at discharge or among outpatients are strong predictors of an adverse outcome. Pulmonary congestion is also one of the most important diagnostic and therapeutic targets in chronic heart failure. The aim of this review is to analyze the importance of clinical, instrumental, and biochemical evaluation of congestion in HF by describing old and new tools. Lung ultrasonography (LUS) is an emerging method to assess pulmonary congestion. Accordingly, we describe the additive prognostic role of chest ultrasound with respect to traditional clinical and X-ray assessment in acute and chronic HF setting. Congestion occurrence is the primary cause of acute HF (AHF) decompensation, and it is considered the main cause of hospitalization . The cliPhysical examination is the first step for the detection of congestion and severity. The search for signs and symptoms, such as jugular vein distention, pulmonary crackles, hepatomegaly, dyspnea at rest, presence of peripheral edema, and additional cardiac sound can reveal the presence of central and systemic congestion. Clinical evaluation is important in the identification of pulmonary congestion, but the specificity and sometimes the sensitivity of the signs and symptoms of pulmonary congestion are often scarce . DyspneaChest radiography (CRx) is a fast and inexpensive method performed especially in the Emergency Department (ED) as a first-line diagnostic imaging modality in patients with acute dyspnea ,12,13. HB-type natriuretic peptide (BNP) was initially described by Japanese researchers in 1988. An early study, published in 1994, showed that this biomarker could help distinguish between cardiac and non-cardiac causes of dyspnea. Since the initial studies showing the usefulness of NPs for HF diagnosis, a vast number of other clinical applications for these neurohormones have emerged. NPs are now being used in outpatient heart failure clinics, for screening programs, and for risk-prediction algorithms in various settings. Over last 10 years, NPs measurement significantly increased diagnostic sensitivity, and it reduced the diagnostic time process in patients with dyspnea . For theThese hormones have a very high negative predictive value that allows dyspnea of cardiogenic origin to be ruled out when values are in the normal range. In particular, their contribution is important in the assessment of new-onset heart failure . NPs areNPs elevations are closely related to high cardiac filling pressure values, parietal stress, and distension, which are the most important triggers for hormone release. Throughton et al.  evaluateAlthough these blood tests have a very high sensitivity, their specificity remains relatively low. In fact, several features may influence baseline levels: chronic kidney disease, atrial fibrillation, and ischemic heart disease tend to increase the value, whereas other conditions such as obesity and HFpEF showed lower levels. In patients with acute renal failure, NPs levels may be increased independently of the presence of cardiac dysfunction; therefore, diagnosing CHF in this population should rely on more standard criteria. Despite these findings, NT-proBNP has recently been demonstrated to be useful both in diagnosing and excluding CHF across a wide spectrum of renal function, but higher cutoff points may be applied .Lung ultrasonography (LUS) is a quantitative, simple, economic, and rapid method to assess pulmonary congestion . This diAfter critical analysis of previous studies, we can discern between two different methods quantifying B-lines: a score approach and a count-based method. The former method considers a minimum number of B-lines for each space as a “positive” zone  and then adds up the number of positive zones ,35. The The subdivisions of the chest into 8 zones and 28 sub-zones permits the best quantification of B-line count. The eight zones of interest are the anterior and lateral hemi-thoraxes, scanning along the parasternal, midclavicular, anterior axillary, and medium axillary line from the second to the fifth intercostal space on the right hemithorax, and from the second to the fourth intercostal space on the left hemithorax. Each of the mentioned areas are in turn subdivided into four further zones. The subspaces belonging to the fifth left intercostal space are excluded from the count . Nevertheless, the role of congestion in diagnosis of HF has been emerging over last 10 years. Different approaches in different populations and settings and the analysis of patients with various clinical characteristics and different congestion status has led to diversity in terms of cutoffs and scan procedures. The first pioneering study analyzing the additive diagnostic role of chest ultrasound in ambulatory outpatients reported a significant correlation among B-line congestion scores and NPs levels. Therefore, a B-line cutoff >15 was described as a reliable threshold for pulmonary congestion. That report was the first to demonstrate that LUS assessment was a simple and relatively accurate method to assess decompensation . Other sSince the diagnostic role and exact threshold in outpatients is debated, LUS assessment in acute care settings is probably much more accurate. Indeed, Coiro et al. describe sixty consecutive acute care patients who underwent clinical echocardiographic and LUS examinations, in which B-lines >30 was associated with improved diagnostic accuracy and predicted a combined end point during 3-month follow-up .In a direct comparison between AHF with either reduced or with preserved ejection fraction, we found a similar number of B-lines in both HF subtypes; although it was slightly higher in those with reduced ejection fraction, the correlation with the other echo parameters of congestion remained similar. Therefore, a cutoff value >32 was predictive of poor outcome. Pellicori et al. showed that a cutoff value of ≥3 B-lines in at least two zones per hemithorax  had substantial sensitivity (94–97%) and specificity (96–97%) in patients with AHF—higher than in physical examination, CRx, and NT-proBNP)  . FinallyThe role of B-lines in guiding therapy is another interesting field because in theory the serial LUS examination during hospitalization could help in treatment tailoring and congestion grading before discharge. The simple difference between B-line counts at admission and before discharge could guide physicians in therapy optimization. Similarly, in a study conducted by Cortellaro et al., LUS analysis was applied for assessing the effective determination of pulmonary congestion and diuretic response after diuretic therapy during the first 24 h after admission. Significant B-line differences between admission and ongoing treatment was associated with good diuretic response and relevant decongestion . As repoA high number of B-lines at the time of discharge from a hospitalization for AHF or in ambulatory patients with CHF identifies those at high risk of subsequent HF readmissions or death in observational studies .Over the years, several studies have been conducted in order to establish the effectiveness of B-lines in the prognostic evaluation of patients with HF. Gustafsson et al., found that a high number of B-lines assessed by a five-zone method adjusted for age, systolic function, and NT-proBNP identified an increased the risk of death or hospitalization after 6-month follow-up .Gargani et al.  showed tIn our previous study , we idenB-LINES IN PRIMARY CARE—Early diagnosis of HF can reduce the number of hospitalizations with related consequences on quality of life and risk. An early diagnosis could be performed in the setting’s general population by a specific diagnostic screening, including clinical assessment and rapid ultrasound chest and abdominal scan. Indeed, in primary care (PC), HF diagnosis by simple check-up is difficult because of the symptoms’ non-specificity and the late onset of clinical signs of congestion. For this reason, LUS can be an additive, easy, and rapid method for ruling-in patients with a new diagnosis of HF. A recent study evaluating LUS in primary care showed that the evaluation of B-lines in anterior, lateral, and posterior areas demonstrated a positive predictive value (92%) to accurately rule-in HF patients . AssociaB-LINES IN CHF OUTPATIENTS—Since almost 90% of HF recurrence is related to congestion, the presence of pulmonary congestion may identify patients with high risk of HF hospitalization and death . For thiB-LINES AS GUIDE FOR TREATMENT—Treatment with diuretics—in particular, loop diuretics—in patients with HF plays an important role in reducing pulmonary congestion. Because LUS reflects the dynamic variation in pulmonary water content, a serial and repetitive screening could be of relevance in both acute HF and chronic HF patients prone to multiple rehospitalization (Frequent Flyers). Assessment and quantification of pulmonary congestion may help to guide treatment in patients with HF and help to improve their prognosis . Rivas-LDespite the elevated sensitivity of B-line findings in pulmonary congestion assessment, B-line number could change when patients assume different positions: the traditional position for LUS acquisition is a semi-supine standing that allows both the posterior and anterior chest zones to be viewed. This is not always possible in patients with acute dyspnea who cannot assume such a forced position. Another weakness is related to the exam specificity: B-line occurrences are not only proper for use in HF, but they are relevant for use in several pulmonary disease, such as pulmonary fibrosis and COPD, acute respiratory distress syndrome (ARDS) and interstitial pneumonia . A recenCurrent weakness may be bypassed using an integrated approach that includes different imaging tools. As reported in a recent study, B-line analysis together with BNP and cava vein distention lead to a more accurate diagnosis and better risk stratification . CurrentAlthough this diagnostic algorithm may reduce misdiagnosis and the number of false positives, it is only partially applicable in the emergency setting and in ambulatory patients because it requires a specific experience and cardiology competence.Clinical congestion plays a central role in HF exacerbation and in its detection during early-phase avoidance of recurrent hospitalization and functional deterioration. Thus, congestion detection before HF-related symptom occurrence remains a goal for clinical management. Typically, clinical assessment mainly reveals peripheral water retention and increased central venous signs, but it is less specific in the detection of pulmonary congestion. Similarly, the traditional CRx has good accuracy in AHF and in more advanced stages, but it is less accurate in chronic settings. In this framework, LUS demonstrated optimal diagnostic power and good prognostic relevance. Some gaps remain with regard to the different methods and applications as well as to the diagnostic cutoff capable of ruling-in an HF diagnosis. The contemporary assessment of some echocardiographic findings of congestion with B-line assessment may facilitate HF diagnosis and monitoring. The future challenge is to recognize the best available imaging variables of congestion and to apply a standardized algorithm in clinical practice.


ABSTRACT IMPACT: Advanced cardiac magnetic resonance imaging techniques can help to protect cancer patients from cardiotoxicity from immunotherapy with a more sensitive assessment of cardiac function with strain imaging for detection of abnormal cardiac function in the setting of normal left ventricular ejection fraction. OBJECTIVES/GOALS: Immune checkpoint inhibitors (ICI) are associated with fatal cardiotoxicity. Cardiac magnetic resonance (CMR) imaging can assess ICI-associated cardiotoxicity, but the utility of CMR strain imaging is unknown. We present a study of patients with ICI-associated cardiotoxicity evaluated with fast strain-encoded (fast-SENC) CMR. METHODS/STUDY POPULATION: This prospective study was approved by the institutional IRB and informed consent was obtained from 15 patients  between August 2018 and January 2020. All patients with ICI-associated cardiotoxicity had abnormal troponin values and evidence of cardiotoxicity on T2-weighted and/or delayed enhancement CMR images. All patients underwent standard CMR assessment with steady state free precession cine images, T2-weighted imaging, and delayed gadolinium enhancement imaging. Additionally, free-breathing SENC images were obtained and then processed by a team of blinded cardiovascular imaging specialists using Myostrain software . RESULTS/ANTICIPATED RESULTS: Left ventricular ejection fraction (LVEF) was normal in both groups . Global longitudinal LV strain was significantly depressed in the ICI cardiotoxicity group versus controls . The average global circumferential LV strain was mildly abnormal (defined as strain > -17) in the ICI cardiotoxicity group and trended towards a higher value compared with controls . The average number of dysfunctional segments (defined as strain > -10) was significantly higher in the ICI cardiotoxicity group . The proportion of abnormal myocardium was higher in the ICI cardiotoxicity group , as well as the proportion of myocardium found to be dysfunctional . DISCUSSION/SIGNIFICANCE OF FINDINGS: Despite having preserved LVEF, patients who met criteria for ICI-associated cardiotoxicity had both global and regional abnormal LV strain. Fast-SENC imaging may provide a sensitive tool for detection of early cardiotoxicity in this population. This study is limited by its small cohort and a larger prospective study would be of value.


Fibroblast activation protein (FAP) as a specific marker of activated fibroblasts can be visualized by positron emission tomography (PET) using Ga-68-FAP inhibitors (FAPI). Gallium-68-labeled FAPI is increasingly used in the staging of various cancers. In addition, the first cases of theranostic approaches have been reported. In this work, we describe the phenomenon of myocardial FAPI uptake in patients who received a Ga-68 FAPI PET for tumor staging.Ga-68 FAPI PET examinations for cancer staging were retrospectively analyzed with respect to cardiac tracer uptake. Standardized uptake values (SUV) were correlated to clinical covariates in a univariate regression model.max 2.2 ± .6 vs 1.5 ± .4, P < .05 and SUVmean 1.6 ± .4 vs 1.2 ± .3, P < .05, respectively). Univariate regression demonstrated a significant correlation of coronary artery disease (CAD), age and left ventricular ejection fraction (LVEF) with remote SUVmean uptake, the latter with a very strong correlation with remote uptake .From 09/2018 to 11/2019 N = 32 patients underwent FAPI PET at our institution. Six out of 32 patients (18.8%) demonstrated increased localized myocardial tracer accumulation, with remote FAPI uptake being significantly higher in patients with vs without localized focal myocardial uptake  contains supplementary material, which is available to authorized users. Activation of fibroblasts is mandatory for repair and regeneration after myocardial injury including myocardial infarction (MI), progressive heart failure, or chemotherapy-induced injury, with the main mechanism of extracellular matrix remodeling.Aim of this study was to descriptively assess patterns of cardiac Ga-68 FAPI uptake in consecutive patients having undergone this imaging technique for staging after cancer treatment. Furthermore, we aimed to link this tracer uptake to clinical characteristics with respect to a cardiac disease history of the study cohort.We retrospectively analyzed patients having undergone FAPI PET imaging for cancer staging at the University Hospital Essen, Germany. According to the local standard, patients receiving anti-cancer treatment undergo cardiac diagnostic work-up before chemotherapy as well as half-annually after initiation of therapy to identify potential complications at an early stage. This standardized diagnostic work-up includes assessment of medical records, assessment of NYHA state and medical history by direct questioning as well as transthoracic echocardiography. Baseline characteristics comprised age at FAPI scan, sex, history of atrial fibrillation, coronary artery disease (CAD) including a history of MI, left ventricular ejection fraction (LVEF), cardiovascular risk factors, chronic kidney disease, and cancer entity including applied specific chemo- and immunotherapy. Anti-cancer treatment included alkylating agents, antibodies, anthracycline and platin derivatives, topoisomerase inhibitors, antimetabolites, and taxanes. Radiation therapy plans were used to calculate the heart dose in patients who received radiation during the course of cancer therapy. All relevant information were collected in a self-designed encrypted database, with all patients having signed informed consent before FAPI scan. All procedures performed were in accordance with the ethical standards of the institutional review board (IRB) of the Medical Faculty of the University Duisburg-Essen and with the principles of the 1964 Declaration of Helsinki and its later amendments.PET was performed 12 ± 7 minutes after injection of 140 ± 24 MBq Ga-68 FAPI-04 as previously described.3 VOI in the lateral wall of the left ventricle or the right atrium. From these VOIs, the maximum standardized uptake value (SUVmax) and the mean SUV (average uptake in a spheric VOI of 1 cm3 surrounding the hottest voxel) were measured. In the case of focal tracer accumulation in the lateral wall, cardiac remote uptake has been measured by placing this spherical VOI in the septum . All data were analyzed using dedicated medical imaging software .In the case of focal tracer uptake in the left ventricular myocardium, a volume of interest (VOI) was defined comprising the entire focal tracer accumulation. Uptake of remote myocardium and blood pool was assessed by placing a spherical 1 cmU test and an unpaired t test, respectively, Chi-square test was applied to compare dichotomized variables. SUVmean and SUVmax were used for further assessment of variables associated with remote FAPI uptake in a univariate linear regression model. To compare matched continuous variables, the 2-tailed paired Student t test was applied. A P value of less than .05 was considered statistically significant. Statistical analyses were performed using SPSS for Windows .Continuous variables are expressed as mean ± standard deviation unless otherwise annotated. A Kolmogorov–Smirnov test was conducted to test for normality where indicated. Non-parametric and parametric variables were compared using the Mann–Whitney From 09/2018 to 11/2019 N = 32 patients underwent PET imaging for staging after systemic anti-cancer treatment for different kinds of cancers. The majority of patients was female , with an overall mean age of 58.7 ± 15.0 years at time of PET scan. Left ventricular EF was preserved in the majority of patients, with an overall mean LVEF of 57.5 ± 7.3 %. The most frequent tumor entities were pancreatic cancer (18/32 (56.3%)), melanoma (2/32 (6.3%)), and osteosarcoma (2/32 (6.3%)).max 7.1 ± 4.8 vs 2.2 ± .6, P < .05, SUVmean 5.2 ± 4.0 vs 1.6 ± .4, P < .05) and significantly higher than the corresponding remote myocardial uptake in patients without focal myocardial uptake .Six out of 32 patients (18.8%) demonstrated focal myocardial FAPI tracer accumulation clearly above background. Quantitative assessment of this focal myocardial uptake in those six patients was significantly higher compared to remote myocardium . Blood pool was not different between patients with vs without focal myocardial tracer uptake .Also, FAPI uptake in remote myocardium was higher in patients with vs without focal myocardial tracer uptake (SUVTable P = .03), with a lower LVEF  and a higher percentage of significant CAD  compared to non-uptake patients. The exact location of visually detectable tracer uptake in the 6 patients is reported in Table P < .01 and P = .03 for CAD and MI, respectively). Figures Our data suggest that patients with focal FAPI uptake were older , whereas LVEF was strongly correlated with remote uptake   tracer uptake  were older, with a higher prevalence of CAD/MI and lower LVEF. In patients with CAD, the visual tracer uptake seemed to correlate with the area of primarily diseased myocardium. In patients with increased uptake in certain myocardial areas, an increased uptake was also found in the remote myocardium, while no difference in blood pool activity was detected. Remote myocardial uptake was correlated to CAD, age, and LVEF, the latter showing a highly significant correlation.Fibroblast activation protein is not expressed in normal cardiac fibroblastsWe demonstrate that fibroblast activation in the remote myocardium is also significantly increased in patients with focally increased uptake of certain myocardial areas. This points at left ventricular remodeling processes in those patients besides the localized uptake areas. At the moment we cannot draw a final conclusion on the mechanisms behind higher fibroblast activation in remote areas as the patient number in the present study was low. We speculate that potentially a generalized myocardial injury, as it is the case in microvascular dysfunction present in CAD, could be causative for this phenomenon. This cannot be finally proven at the moment as there are not conclusive histopathological studies validating cardiac FAPI uptake with fibroblast activation as it is the case for FAPI uptake in malignancy.This is a retrospective study of FAPI PET in a heterogeneous population of patients. Therefore, the data must be treated with caution and do not allow to draw general conclusions. Some limitations have to be mentioned. First, despite preclinical work showing highly specific binding to FAP,This is the first report to assess cardiac FAPI uptake in cancer patients. Higher age, a history of CAD/MI as well as impaired LVEF seem to be associated with increased localized uptake. These results point towards the potential role of FAPI imaging to assess myocardial localized as well as generalized injury. Further research efforts are needed to clearly link myocardial FAPI uptake to myocardial fibroblast activation. Finally, studies are warranted to assess if FAPI uptake might be used to risk-stratify patients with respect to a progression of CAD or left ventricular remodeling.This pilot study demonstrates that cardiac fibroblast activity can be assessed by Ga-68 FAPI PET imaging. Fibroblast activity correlated with CAD, MI, age, and especially LVEF, pointing at the potential of this technique to significantly improve the understanding of structural/fibrotic remodeling processes in cardiac pathophysiology.Electronic supplementary material 1 (DOCX 159 kb)Electronic supplementary material 2 (M4A 4056 kb)Electronic supplementary material 3 (PPTX 560 kb)Below is the link to the electronic supplementary material.


Fibrillin-1 gene. Given the presence of fibrillin-1 microfibers in the myocardium, myocardial dysfunction and associated arrhythmia are conceivable and have been shown to contribute to morbidity and mortality in patients with Marfan syndrome. In this review, we will discuss data on myocardial disease from human studies as well as insights obtained from the study of mouse models of Marfan syndrome. We will elaborate on the various phenotypic presentations in childhood and in adults and on the topic of arrhythmia. We will also briefly discuss the limited data available on other genetic forms of aortic disease.Genetic aortic diseases are a group of illnesses characterized by aortic aneurysms or dissection in the presence of an underlying genetic defect. They are part of the broader spectrum of heritable thoracic aortic disease, which also includes those cases of aortic aneurysm or dissection with a positive family history but in whom no genetic cause is identified. Aortic disease in these conditions is a major cause of mortality, justifying clinical and scientific emphasis on the aorta. Aortic valve disease and atrioventricular valve abnormalities are known as important additional manifestations that require careful follow-up and management. The archetype of genetic aortic disease is Marfan syndrome, caused by pathogenic variants in the  FBN1, COL3A1, LOX); (II.) components involved in the TGFβ pathway ; and (III.) components of the vascular smooth muscle cell apparatus  (Heritable Thoracic Aortic Diseases (HTAD) encompasses a spectrum of genetic conditions in which aortic disease (aneurysms and dissections) has an underlying genetic trigger or familial occurrence. HTAD is classified as syndromic and non-syndromic. The genetic causes fall into several distinct groups of genes coding for (I.) components of the extracellular matrix (ECM) (FBN1), which codes for the ECM protein fibrillin-1. The condition was first described in 1895 by the French pediatrician Antoine Bernard Marfan who described a constellation of skeletal abnormalities characterized by joint contractures and conspicuously long fingers (arachnodactyly) in a young girl (The paradigm syndromic HTAD entity is Marfan syndrome (MFS). MFS is an inherited connective tissue disease caused by pathogenic variants in the Fibrillin-1 gene  Heart failure in very young children with MFS (neonates and infants) (2) CMP in classical MFS. We will discuss both entities separately in the next sections.st month of life  is a term usually reserved for very early clinical presentations of MFS even though some patients may present after the 1 of life . The exa of life . Childre of life . Some ch of life  20–22).–22.st mo failure , 24.Children with the infantile form of MFS usually present a less severe course . These cFor obvious reasons, cardiovascular research and management recommendations for classic MFS have heavily focused on aortic disease. Interest in studying myocardial involvement was raised in the nineties with a study from Savolainen and colleagues, indicating abnormal diastolic function in children with MFS, assessed by cardiac magnetic resonance (CMR) .Moreover, several  series on survival in MFS have listed heart failure as one of the leading causes of death. Estimates vary between 5 and 30% , 28 puttFBN1 variant plays a role in defining the risk for developing CMP is still unclear. Two independent studies observed a higher incidence of left ventricular dilation and decreased left ventricular function in patients carrying non-missense variants (In addition to these extrinsic (secondary) causes of heart failure, several reports from independent researchers have shown intrinsic myocardial dysfunction in MFS. The reported prevalence of what is now known as Marfan CMP ranges from 3%  to 68%  across dvariants , 49, whivariants .Next to impaired function, arrhythmia may be considered as another manifestation of myocardial disease in MFS . Most ofn = 274) underwent 24h ambulatory monitoring. Ventricular ectopy was present in 7% of these children, but (NS)VT was not observed. The prevalence of ventricular arrhythmia in these two studies is clearly different but probably reflects clinical variability among the cohorts. On the contrary, these studies show that ventricular arrhythmia, although uncommon, can present at an early age. Physicians taking care of children with MFS should also be vigilant for these complications.One of the first studies of arrhythmia in children with MFS took place in the early 80s . In thisThe mechanisms underlying severe ventricular arrhythmia in MFS are not clear yet. Judging from the numbers above, it seems that age might play an important factor, although this has not been clearly shown . So far,Lately, mitral annular disjunction (MAD), defined as the separation between the posterior mitral valve leaflet hinge point and the left ventricular myocardium, has gained interest in patients with MFS. A recent study shows that 46% of patients have MAD and that presence of MAD is associated with a worse aortic and mitral outcome . In non-Besides an abnormal substrate, triggering factors might also play a role in developing arrhythmia in MFS. Subtle ECG changes have been identified in patients with MFS independent of aortic root diameter, mitral and/or tricuspid valve prolapse or chamber dimension and function. Patients with MFS display slightly prolonged PQ- and QTc-intervals compared to healthy controls , 54.Atrial arrhythmia in MFS has been given less attention. Atrial fibrillation seems to be more common in MFS than in the general population and seems to occur at a younger age , 64. Othfbn1mgR/mgR Marfan mouse model. A decrease in passive filling properties of the left ventricle in this model suggests an impaired elastic recoil of the left ventricle  pseudoaneurysms. In WT mice, fibrillin-1 fibers cross the entire right ventricle free wall from lumen to pericardium. In the setting of MFS, reduced amounts of fibrillin-1 fibers may result in the formation of a gap crossing the entire right ventricle free wall. To our knowledge, there is no confirmation of such findings in human Marfan disease, but this definitely deserves further research.In addition to the evidence for functional impairment of the myocardium in mouse models for MFS, some interesting morphological alterations are also worth mentioning. In the sections . As mentn humans , 73. NexMyocardial disease is an upcoming problem in MFS, especially in adults. As indicated above, a subgroup of children is also at risk. Careful monitoring of myocardial function and potential complications such as arrhythmia in patients with MFS is warranted. Yearly echocardiographic evaluation and follow-up should include assessment of biventricular systolic and diastolic function. Whether CMR will aid in risk stratification in patients with MFS still needs to be elucidated. Patients with enlarged left ventricular diameter, patients with MAD and patients with palpitations, (pre)syncope, or chest pain can benefit from an ambulatory electrocardiogram. As in general recommendations NT-pro-BNP levels are useful to monitor heart failure and may be useful for risk stratification for arrhythmia in Marfan syndrome , 55, 56.There is currently no evidence that treatment of arrhythmia and heart failure in patients with MFS should differ from the guidelines for other non-MFS patients. If congestive heart failure is present as a result of valvular dysfunction, afterload-reducing agents can improve cardiovascular function. Whether losartan (or other angiotensin receptor blockers), drugs known for their beneficial effect in heart failure should be considered a first line choice in these patients is not known. In a small study with losartan in patients with MFS, we did not observe a significant effect on LV dimensions- and function . IndicatEnd-stage heart failure is uncommon in patients with MFS but heart transplantation may be considered. Although early results with this procedure in MFS were not good , subsequThe role of β-blocker therapy for the treatment of arrhythmia or prevention of SCD in MFS is not clear yet. In one study, two of the three patients presenting SCD were under treatment with β-blocker . In our There is very scarce literature on myocardial disease and arrhythmia in HTADs and evidence of myocardial dysfunction in this group of diseases, mainly comes from case reports and casual description from registries.TGFBR1 with heart failure necessitating heart transplant was published (TGFB2, TGFBR2 and SMAD3 (SMAD3 was already reported in one of the first case series characterizing patients with pathogenic variants this gene (TGFBR2 has been published (LDS was first described in 2005 as a connective tissue disorder with important vascular involvement . Shortlyublished . Severalnd SMAD3 –84. Myochis gene . Only onublished . In thisFindings based on human studies and from mouse models provide increasing evidence for the clinical relevance of CMP in genetic aortic disease, but more data are required for further confirmation and delineation.Careful monitoring of myocardial function and potential consequences such as arrhythmia in patients with MFS and other HTAD is warranted. Further study to understand the underlying pathophysiology of myocardial disease is necessary to identify better treatment targets and improve patient's outcome.JDB and LM-M wrote and reviewed this paper. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer SM declared a past co-authorship with one of the authors JDB.


To validate the feasibility of free-breathing, non-gated, high-pitch heart-to-brain computed tomography arteriography (CTA) in acute ischemic stroke and the capability of non-gated heart-to-brain CTA in showing cardiac anatomy.The study protocol was approved by the institutional medical ethics review board. Free-breathing, non-gated, high-pitch heart-to-brain CTA was performed on patients with acute ischemic stroke referred for multimodal CT using a third-generation dual-source CT. Patients scheduled for ECG-triggered heart-to-brain CTA served as controls. Quantitative and/or qualitative image quality of the four cardiac chambers, left atrial appendage, interventricular and interatrial septa, carotid arteries, and coronary arteries were evaluated and compared between the two groups.Free-breathing, non-gated, high-pitch heart-to-brain CTA was performed on 30 patients with acute ischemic stroke, whereas the control group included 31 cases. There is no significant difference in the image quality of CTAs between the two groups at cardiac chambers and carotid arteries. The image quality of coronary arteries also showed no significant difference between the two groups. The mean dose length products of CTA in the two groups were 129.1 ± 30.5 mGy cm and 121.6 ± 30.3 mGy cm, respectively. Cardiac abnormality can be shown in patients with acute ischemic stroke.It is feasible to use free-breathing, non-gated, high-pitch heart-to-brain CTA with dual-source CT in acute ischemic stroke for cardiac etiology screening. Ischemic stroke has various etiologies, including large-artery atherosclerosis, cardiogenic emboli, small-vessel occlusion, and other determined or undetermined etiology . BecauseComputed tomography perfusion (CTP) combining computed tomography arteriography (CTA) of cerebral and carotid arteries has been used as the second-line imaging to non-enhanced brain CT for patients with ischemic stroke, mainly for large vessel diseases , 8. ReceThe study protocol was approved by the institutional medical ethics review board. Patients with acute ischemic stroke who were referred for multimodal CT from March 2018 to December 2018 were recruited consecutively, and informed consent was obtained from each patient or his/her representative. Another group of patients with ischemic stroke who were scheduled for heart-to-brain CTA in this period were used as controls. Standard exclusion criteria for contrast-enhanced CTA included: previous allergic reaction to iodinated contrast, renal disease with serum creatinine level higher than 1.5 mg/ml, and detected cerebral hemorrhage by a non-enhanced scan.The CT scans were performed with a third-generation dual-source CT scanner .Combined CTP and non-gated high-pitch heart-to-brain CTA protocol consisted of four steps. (1) Anteroposterior and lateral localizing topogram, (2) Non-contrast brain CT, (3) Perfusion CT. The acquisition parameters were as follows: 2 × 96 × 0.6 mm collimation, 80 kV, 50 mA, 0.25 s gantry rotation time, 114 mm coverage, and 5 mm slice. The dual-phase contrast injection protocol consists of 40 ml of iodinated contrast (Ultravist 370 mgI/ml) injected through the right or left (preferably the right) antecubital vein and followed by saline flush of 40 ml. The injection rate was 5 ml/s for both the contrast and saline. (4) Free-breathing, non-gated, and high-pitch heart-to-brain CTA. The acquisition parameters were as follows: collimation 2 × 96 × 0.6 mm, 90 kV tube voltage, reference tube current-time product 90 mA, 4D dose modulation , and a pitch of 3.2. The rotation time was 0.25 s. The acquisitions were obtained in the caudocranial direction from the diaphragm to the vertex without breath-holding, and no ECG wire was connected. The injection protocol consisted of 60 ml of iodinated contrast, followed by 40 ml of saline. The injection rate was 5 ml/s for both the contrast and the saline. Scan timing was achieved with bolus-tracking technique with a monitoring region of interest (ROI) placed in the ascending aorta at the level of the left main coronary artery (threshold 100 HU). The CTA data acquisition was initiated with a delay of 6 s.The scheduled heart-to-brain CTA protocol consisted of topogram, non-contrast heart-to-brain CT, and ECG-triggered high-pitch heart-to-rain CTA under breath-holding after inspiration. For patients with a heart rate under 70 bpm, the trigger phase was set at a 60% RR interval and for those with a heart rate higher than 70 bpm, the trigger phase was set at a 20% RR interval , 11. TheImages of 0.6-mm slice thickness were reconstructed from raw data using Advanced Modeled Iterative Reconstruction  and transferred to the workstation . A medium-smooth tissue convolution kernel (Bv36) was used. Curved planar reformation (CPR), maximum intensity projection (MIP), and multiplanar reformation (MPR) were used for further evaluation of the carotid, cerebrovascular, coronary arteries, and cardiac chambers.Qualitative and/or quantitative evaluation of image quality was performed for carotid CTA, coronary CTA, and cardiac morphology. Parameters for quantitative image quality evaluation included absolute contrast enhancement and contrast-to-noise ratio.2 for aorta and 2–3 mm2 for the other locations) within each contrast-enhanced lumen. ROIs were also placed in the connective tissue surrounding each vessel lumen.The mean attenuation of vessels was measured by placing a spherical ROI /Image Noise.Quantitative measurements were performed at the following locations: bilateral internal carotid artery (ICA) (3 cm above carotid bifurcation), bilateral common carotid artery (CCA) (3 cm below carotid bifurcation), bilateral vertebral artery, ascending aorta, descending aorta, superior vena cava, and bilateral internal jugular veins. The measurements of superior vena cava, ascending aorta, and descending aorta were performed at the level of the right pulmonary artery. ROIs in the internal jugular veins were placed at the level of the superior margin of the hyoid bone .2 in the lumen avoiding calcifications and plaques. Background attenuation was measured by placing an ROI of 2–3 mm2 in the adjacent tissue. Then CNR of each segment was calculated.Objective evaluation of coronary arteries was performed on the 15 segments according to the standards of the American Heart Association (AHA) . All theSubjective evaluation was performed by two independent radiologists with more than 5 years of experience in cardiovascular imaging, without knowledge of the scan protocol.All the images were transferred to the workstation and evaluated in random order. Patient information and scan protocol were concealed. Discrepancies in image assessment by the two radiologists, if any, were discussed and resolved by consensus. A 15-segment classification criterion from AHA was used to analyze the coronary artery segment by segment. The image quality was analyzed with a 4-point method as follows: 1 point, severe image artifacts with a poor demonstration of the coronary artery, and the boundary of the blood vessel is vague; 2 points, mid-level artifacts in images with relatively good contrast between the coronary artery and surrounding tissues; 3 points, light level of image artifacts, good contrast between the coronary artery and surrounding tissues with a clear demonstration of the blood vessel; and 4 points, good demonstration of coronary artery, clear and sharp edge is also shown.2 in the lumens. ROIs of about 10 mm2 were placed in the septa to measure the background attenuation. CNRs were then calculated by using the equation mentioned above.An objective evaluation was performed on each cardiac chamber and left atrial appendage (LAA) by placing an ROI of up to 100 mmThe image quality at LAA and septum was also evaluated subjectively with a 3-point scale: 1 point, poor contrast or severe motion artifact that could not be used to analyze; 2 points, mid-level artifacts and relatively good contrast; and 3 points, good contrast and without motion artifacts.VOL) and dose-length product (DLP) of the CTAs were recorded.Volume CT dose index . Continuous variables were expressed as mean ± SD and evaluated with an independent sample p > 0.05). Among the 30 patients with acute ischemic stroke, two cases of LA/LAA thrombi, one case of patent foramen ovale, and one case of hemostasis in LAA were found . About 31 patients  were recruited in the control group. There was no statistically significant difference between the two groups in age, BMI, and heart rate , and there was no significant difference between the two groups in the mean attenuation and the mean CNR values .In the non-gated group, the mean attenuation values of cardiac chambers were as follows: LA 429.07 ± 96.4, LV 444.1 ± 87.4, RA 174.2 ± 67.0, RV 188.3 ± 70.4, and LAA 463.4 ± 127.0. In the ECG-gated group, the mean attenuation values were as follows: LA 425.8 ± 112.1, LV 483.4 ± 80.4, RA 129.3 ± 31.2, RV 131.7 ± 39.3, and LAA 490.8 ± 84.2. There was no significant difference between the two groups in the mean attenuation, LA and LAA, whereas there was a statistical difference at RV and RA .There was no significant difference between the two groups in qualitative evaluation of motion artifact at LAA and interatrial septum .vol and DLP of CTA scan in the non-gated group were 2.6 ± 0.6 and 129.1 ± 30.5 mGy cm, respectively. The mean CTDIvol and DLP of CTA scan in the ECG-gated group were 2.4 ± 0.6 and 121.6 ± 30.3 mGy cm, respectively. There was no significant difference .The mean CTDIBecause of the elevated incidence of cardiogenic stroke, the need for evaluation of possible etiology of cardiogenic emboli has increased. Therefore, TEE has been increasingly used for stroke patient evaluation . HoweverStudies have also suggested that a dual-source CT can be used to speed up CTA scans with specific protocols. Sun et al. introduced an ECG-triggered high-pitch spiral scan CTA to cover the range from the heart to the brain using the second-generation dual-source CT scanner and proved the feasibility and image quality in non-emergent patients . HoweverAnother concern for increased scan range would be the radiation dose. Former studies have proved that the radiation dose of high-pitch heart-to-brain CTA is pretty low . In compMany studies have proved that a large proportion of cardiogenic and cryptogenic strokes may be related to the underlying abnormality of the left atrium, especially the LAA and interatrial septum. These abnormalities include thrombus in the LAA, hemostasis in the LAA, patent foramen ovale, interatrial septal aneurysm, etc. The detection of these abnormalities depends on adequate illustration of cardiac chambers and the septa, especially the structures related to the left atrium. As the in-plane temporal resolution of the high-pitch scan is very high (66 ms) for the third-generation dual-source CT scanner, although the image quality of coronary arteries might be affected, the image quality of larger structures as cardiac chambers might be sustained. In our study, the image quality of LA, LAA, and interatrial septum is acceptable, with no difference between ECG-triggered and not-gated scans. In addition, even the study was not designed specifically for suspected cardiogenic stroke, and abnormalities of cardiac chambers were detected in some cases .Besides the cardiac chambers, the image quality of carotid vessels was also adequate. This proved that no deterioration of the evaluation of carotid and cerebral vessels occurred when incorporating the cardiac scan into the existing CTA protocol. Interestingly, the image quality of coronary arteries was also comparable to the ECG-triggered high-pitch CTA. Based on the theoretical basis of the high-pitch scan, although non-gated scans were purely randomly timed, it has a good chance to meet at least part of the relative static phase. The high in-plane temporal resolution of the high-pitch scan may be another reason.As the first study to evaluate the feasibility to incorporate a high-pitch heart-to-brain CTA scan into the multimodal CT protocol for acute ischemic stroke, limitations may still exist. As the sample size is small and not dedicated to suspected cardiogenic stroke, only 4 cases with positive findings were found. The profit of this protocol needs to be further evaluated. Second, as the CTA scan was just a single cardiac phase and single contrast phase scan, cardiac function data which may be valuable for therapeutic strategy and prognosis prediction cannot be obtained, and the differentiation between LAA thrombus and hemostasis may be difficult. Third, at present, the high-pitch protocol is only available on the second-and third-generation dual-source CT scanner, the possibility of heart-to-brain CTA in the emergent department needs to be verified while these scanners are not on site.In summary, we introduced a free-breathing, non-gated, and high-pitch heart-to-brain CTA protocol incorporated in the multimodal CT of acute ischemic stroke and validated the feasibility and image quality, without an increase of radiation dose. Prolonged CTA range can provide more information and be profitable for patients with acute ischemic stroke, especially for those suspected of cardiogenic stroke or embolic stroke of undetermined source.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/The studies involving human participants were reviewed and approved by the Institutional Medical Ethics Review Board, Xuanwu Hospital. The patients/participants provided their written informed consent to participate in this study.XDu, KLi, and JLu: conceived and designed the experiments. JLiu, XZhu, and XDuan: performed the experiments. JLiu, CW, JW, and QLi: analyzed the data. JLiu: wrote the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by the grant from the Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding (ZYLX201609), the Beijing Municipal Science and Technology Commission (Z161100000516087), and the Beijing Municipal Administration of Hospitals' Ascent Plan (DFL20180802).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


After correcting for multiple comparisons, the results had a tendency toward statistical significance (adjusted-p < 0.10). There was significant difference in the mean values of pGLS  between the studied groups. The results of ROC analysis showed that a cut-off value of −16.60% for pGLS provided an estimated sensitivity of 92.31%  and 71.43% specificity  for the diagnosis of CoA in neonates . pGLS can be regarded as a feasible and reproducible parameter reflecting LV dysfunction in newborns with CoA when compared to newborns with a false-positive diagnosis.Our objectives are to compare speckle-tracking peak global longitudinal (pGLS) and regional strain values in neonates with coarctation of aorta (CoA) and control groups. Echocardiographic parameters measured by speckle-tracking were studied in a retrospective single-center study. A comparison of pGLS and segmental deformation between neonates with CoA and control group was performed using a three-way mixed ANOVA model. There was a significant difference in the means of segmental strain values between CoA and control group at the apical ( Neonatal aortic coarctation (CoA), defined as narrowing of the isthmic region of the aorta, is one of the ductal-dependent cardiac malformations commonly encountered in pediatric pathology, with an incidence of 5–8% . ObstrucCoA in the newborn has significantly contributed to neonatal mortality and morbidity. Despite clinical protocols based on saturation determination and echocardiographic examination, a significant number of newborns with this pathology are diagnosed only a few days after discharge from the maternity ward with signs of critical heart failure and cardiogenic shock, due to the narrowing of the arterial duct .Prenatal diagnosis has made important contributions in improving the postnatal diagnosis rate for newborns with CoA, despite the fact that due to fetal circulation this pathology does not manifest before birth . VentricIn light of the above mentioned, we aimed to establish the usefulness of the speckle-tracking method in newborns with intrauterine suspicion of CoA and we outlined the following objectives: (i) to compare the speckle-tracking peak global longitudinal and regional strain in neonates with CoA and control groups, (ii) to assess the diagnostic performance of echocardiographic parameters for which differences were obtained between groups, and (iii) to evaluate the reproducibility of speckle-tracking echocardiographic measurements.This is a retrospective single-center study conducted at the Children’s Cardiology Clinic, from the Institute of Cardiovascular Diseases and Transplantation, Târgu-Mureș, for a period of 3 years, from January 2018 until December 2020. All newborns, in which the suspicion of aortic coarctation had arisen in the last trimester of pregnancy, were included in this study. All patients were examined echocardiographically within the first 24 h postnatal period, then they were kept under clinical surveillance, and echocardiographic reevaluations were made daily until confirmation or exclusion of the diagnosis. The exclusion of the diagnosis could not be made in either of the cases within the first 24 h.The inclusion criteria were the following: newborns examined echocardiographically in the first 24 h at the Children’s Cardiology Clinic who had intrauterine suspicion of CoA diagnosis based on ventricular disproportion, particularly anatomy of the aortic arch, with suboptimal dimensions and wide arterial duct; existence in the database of the first echocardiographic evaluation containing a 2D four-chamber view, recorded with a minimum frequency of 60 Hz.The exclusion criteria were as follows: a gestational age of less than 36 weeks, low birth weight for gestational age, other associated heart malformations , and systolic dysfunction with ejection fraction under 50%, maternal pathology .All echocardiographies were performed with an Epiq echocardiograph. The images of the newborns included in the study  were revThe control group was represented by newborns in whom aortic coarctation was not confirmed.The selected 2D images were analyzed offline using a PhilipsQlab 13 software with autostrain left ventricle (LV) and autostrain right ventricle (RV) functions .The cardiac cycle was defined in M mode by the movement  of the mitral valve generated automatically by the software, so that the analysis could be made on an entire cardiac cycle. Three points were marked at the level of the endocardium . The edge of the endocardium was drawn automatically, then verified and corrected manually. The peak global longitudinal strain (pGLS) and segmental deformation were measured, the interventricular septum and the walls being divided into 3 segments . The intThe study was approved by the ethics committees of the Institute of Cardiovascular Diseases and Transplantation and George Emil Palade University of Medicine and Pharmacy Targu-Mures 1276/25.02.2021.1, Q3) for quantitative variables, or as absolute (relative frequency) for qualitative variables. Comparison between neonates with CoA and control group concerning speckle-tracking global longitudinal and regional strain was performed after the evaluation of univariate and multivariate (where appropriate) normality by univariate statistics, QQplots, univariate and multivariate Shapiro tests. The comparison between two groups concerning demographic characteristics was performed using Student’s t-test, Mann–Whitney test, or Chi-square tests. Because we were interested in comparing CoA and control groups concerning regional strain values measured by speckle-tracking echocardiography, we performed a three-way mixed ANOVA. In the mixed ANOVA design, regional strain as an outcome variable was modeled as a function of the cardiac wall  and cardiac segment . We also tested the 3-way and 2-way interaction between the 3 independent factors . In the case of significant interaction term, the analysis was followed up by pairwise analysis using Student’s t-test with a post hoc adjustment of p-values by the Benjamini–Hochberg procedure.Demographic and echocardiographic data were described as arithmetic mean ± SD (standard deviation) or median with interquartile interval . The LV pGLS measured on the LV, longitudinal strain measured on the free wall of right ventricle, and longitudinal strain on the RV in 4-chamber view were considered as three correlated, dependent variables. Because of the presence of multicollinearity between RV free walland RV4C, the former was excluded from MANOVA analysis. After ascertainment of the multivariate normality and sphericity condition (by Box’s M-test for Homogeneity of Covariance Matrices), we performed a MANOVA analysis. In order to identify the source of differences inmeans of longitudinal strain values between groups, a one-way ANOVA was done as post hoc analysis with a post hoc adjustment of Diagnostic performance of significant echocardiographic parameters was evaluated by the area under receiver operating characteristic (AUC) and associated 95% confidence interval.Interrater reliability analysis was performed using intraclass correlation coefficients (ICC) and 95% confidence interval. A two-way mixed-effects model was used to determine consistency of cardiac speckle-tracking measurements between the 2 raters. The level of reliability was interpreted using the confidence interval for ICC: poor reliability , moderate reliability , good reliability , and excellent reliability  .diff, Upper limit = mean difference + 1.96 SEdiff, where SEdiff was the standard error of differences between the two raters regarding the evaluated cardiac parameters). If the 95% confidence interval of the bias contained the value 0, there was no statistical evidence for systematic bias between the measurements of the 2 raters. The 95% limits of agreement (lower LoA and upper LoA) were also calculated in order to quantify the total bias, the lower LoA = bias − 1.96 SDdiff and upper LoA = bias + 1.96 SDdiff where SDdiff was the standard deviation of differences between the measurements of the2 raters. The paired Student’s t-test was also used to test if the mean differences differed significantly from zero for each studied cardiac parameter.Absolute Agreement between 2 assays of speckle-tracking echocardiography parameters was evaluated by Bland–Altman analysis. The mean differences (bias) were determined as a measure of accuracy, while 95% CI for bias was estimated as a measure of precision  chosen at 0.05.All statistical analyses were performed using the R software version 4.04 .During the above-mentioned period, there were 44 newborns with the suspicion of CoA, but only 41 were eligible for inclusion in the study: 13 newborns in whom the diagnosis of CoA was confirmed postnatally and required surgery in the first 14 days of life and 28 newborns, respectively, for whom the suspicion of the diagnosis was not confirmed and were discharged from the neonatal ward as healthy newborns. All patients from the latter group went on to be reevaluated clinically and by echocardiography at 1, and 3 months, with none of them developing coarctation of the aorta.p = 0.362). Similar results were obtained concerning sex distribution  and gestational age , but there was a significant difference in mean weight between the two groups .The baseline characteristics of 13 neonates with CoA (CoA group) and a group of 28 healthy neonates (Control group) were described in p = 0.541) or RV asynchronism .There was no significant difference in frequencies of LV The frame rate for the echocardiographic exam was kept between 61–101 Hz, with a median frame rate of 90 Hz and no significant differences between neonates with CoA and controls  = 0.39, p = 0.661]. There was a tendency toward statistical significance for main effect of segment on strain values . There was no significant 3-way interaction between group, wall, and segment (p = 0.377), but the group-by-wall and wall-by-segment were significant interaction terms on strain values (p = 0.017). The results of pairwise tests showed the that mean strain value was significantly different in the CoA group when compared to thecontrol at the apical and basal segments of inter-ventricular septum, respectively, at the apical segment of LV (p < 0.10).We performed a 3-way mixed ANOVA on the strain values (%) with Groups (CoA versus Control) as between factor, wall  and segment  as within factors. There was no statistically significant main effect of group  between CoA and control group (mean ± SD: −13.72 ± 3.88 versus −17.29 ± 3.83 for CoA and control group). There was no statistical evidence for significant difference in the mean value of RV4C between CoA and control groups .A one-way MANOVA was performed to determine if the LV pGLS values measured on LV and longitudinal strain values measured on the RV4C were significantly different between the studied groups. There was a statistically significant difference between the CoA and control groups on the combined dependent variables (LV pGLS and RV4C), F = 5.98, The LV pGLS with a cut-off value of −16.60% provided a value of 92.31%, 95% CI:  sensitivity and 71.43% specificity, 95% CI:  for the diagnosis of CoA in neonates .Biventricular as well as segmental strain values were measured by two raters. The level of reliability was moderate-to-good for basal and apical segments of the LV lateral wall, for medial and apical segments of the interventricular septum, and for LV pGLS measurements, while for apical, basal, medial segments of RV, and longitudinal measurements on the free wall of RV and RV4C, we found a good to excellent reliability . The medThe Bland–Altman analysis  showed tThe present study aimed to evaluate the postnatal ventricular parameters in neonates with CoA and control groups and to quantify the performance of echocardiographic parameters in the diagnosis of CoA. It is a comparative study that followed the differences in global and segmental ventricular deformation in newborns with CoA. To our knowledge, this is the first study from Romania and within the first few published in the international literature, performed on a group of newborns with intrauterine suspicion of aortic CoA, which aimed to compare the cases in which CoA was confirmed to the ones where it was not. All newborns included in the study showed significant ventricular disproportion and suboptimal size of the aortic arch or disproportion of the large vessels at the intrauterine evaluation. However, the diagnosis of aortic coarctation was confirmed in only 13 newborns. It is known that ventricular disproportion has moderate sensitivity and low specificity in the diagnosis of aortic coarctation, making other echocardiographic parameters necessary in order to reduce the false-positive diagnostic rates. It should also be mentioned that among fetuses with the suspicion of aortic coarctation, the percentage of false-positive cases is higher in the last trimester, when compared to fetuses in whom the suspicion arises at a younger gestational age .The feasibility of the method of evaluating myocardial deformation by speckle-tracking in newborns is documented in several previous studies ,11,12,13The LV has a smooth ventricular cavity and myocardium formed by longitudinal and circumferential fibers, the deformation during systole being formed by longitudinal and circumferential shortening and radial thickening ,15. A stIn the neonatal period, the shape and kinetics of the interventricular septum are indicators of the hemodynamic and pressure changes characteristic of this period ,18. In tThe RV can be characterized by thin walls and a cavity with a more complex geometry and architecture in comparison to the LV. The contraction of the longitudinal fibers (located in the depth) determine the dominant deformation, which significantly contributes to the beating flow ,15. The We also studied the synchronism in the contraction of the ventricular segments, both for the left ventricle and for the right ventricle, without obtaining statistically significant changes between the two groups.CoA is a widely debated topic in the scientific literature from the recent years, being a clinical entity with a significant impact on neonatal mortality and morbidity. Prenatal diagnosis of CoA is of major importance in reducing neonatal mortality . HighligThe usefulness of quantification of myocardial deformation by the speckle-tracking method in assessing ventricular function was demonstrated not only in healthy fetuses , but in The study published by Miranda demonstrates the usefulness of the speckle-tracking method for analyzing myocardial function in fetuses with CoA. In the mentioned study the variability of results between observers is possibly due to the analysis of images with suboptimal frame rates. Fetuses with CoA have low LV pGLS and strain rates in comparison to the control group, and there are also regional differences at the level of the LV free wall, respectively, however, with no significant differences in the free wall of the RV . In our DeVore proposes several 2D echocardiographic parameters that evaluate the ventricular size, shape and function, and the global and segmental speckle-tracking analysis, respectively. The use of logistic regression analysis demonstrates the possibility of making the diagnosis between fetuses with CoA, when compared to fetuses with false-positive diagnosis . As in tThe main limitation of this study is the retrospective nature of the data and the lack of a group of healthy newborns, examined on their first day of life in order to establish the optimal cut-off value likely to discriminate between healthy neonates and those with CoA. Another limitation is related to the small sample size, although the prevalence of CoA is known to be low. Although strain rates would have been more sensitive, they were not computed due to software limitation and the failure to do so represents a limitation of our study. Because of retrospective design of the study only A4C view images were available for evaluation. Given their small ages, obtaining transverse images to compute circumferential strain would be difficult in neonates. In addition, although we highlighted the potential utility of the LV pGLS to discriminate neonates with CoA from newborns with false-positive diagnosis in the presence of a persistent arterial duct, more prospective studies with a larger number of neonates with CoA would be needed to establish if LV pGLS can be considered useful in the diagnosis of ductal-dependent aortic coarctation or to characterize the myocardial function and predict the CoA risk in neonates as an independent factor adjusting for other potential covariates.The speckle-tracking analysis is a feasible and reproducible method able to discriminate neonates with CoA from newborns with false-positive diagnosis in the presence of a persistent arterial duct. The speckle-tracking peak global longitudinal strain (LV pGLS) can be considered useful in the diagnosis of ductal-dependent aortic coarctation in neonates with suspected prenatal CoA. The study of the deformation of segments of the interventricular septum could represent an area of interest for a prospective study, as parameters seem to have diagnostic value.