Non-ischemic dilated cardiomyopathy encompasses a wide spectrum of myocardial disorders, characterized by left ventricular dilatation with systolic impairment and increased risk of sudden cardiac death. In spite of all the therapeutic progress that has been made in recent years, dilated cardiomyopathy continues to be an important cause of cardiac transplant, being associated with an enormous cost burden for health care systems worldwide. Predicting the prognosis of patients with dilated cardiomyopathy is essential to individualize treatment. Late gadolinium enhancement-cardiac magnetic resonance imaging, microvolt T-wave alternans, and genetic testing have emerged as powerful tools in predicting sudden cardiac death occurrence and maximizing patient’s selection. Despite all these new diagnostic modalities, additional tests to complement or replace current tools are required for better risk stratification. Therefore, biomarkers are an easy and important tool that can help to detect patients at risk of adverse cardiovascular events. Additionally, identifying potential biomarkers involved in dilated cardiomyopathy can provide us important information regarding the diagnostic, prognostic, risk stratification, and response to treatment for these patients. Many potential biomarkers have been studied in patients with dilated cardiomyopathy, but only a few have been adopted in current practice. Therefore, the aim of our review is to provide the clinicians with an update on the well-known and novel biomarkers that can be useful for risk stratification of patients with non-ischemic dilated cardiomyopathy. PatieIn the last few years, significant advances have been made in emerging techniques that can provide useful risk prediction, such as genetic, imaging, cardiopulmonary exercise testing variables or circulating biomarkers. The measurement of biomarkers is of great importance for risk stratification and to find new therapeutic strategies to improve the prognosis. Although they are not specific to NIDCM, they can be of great importance, and one possible way to make them clinically useful is to make use of a DCM-related biomarker modeling score system.-The measurement of the biomarker can be repeated with cost-efficient methods.-It must bring more information compared to other tests already performed.-It should be clinically useful for decision making.Morrow and de Lemos  establisIt is quite challenging to categorize the biomarkers that can be used for risk stratification of patients with dilated cardiomyopathy. To date, there is no generally accepted classification of these biomarkers, and the often-used classification in all the studies on this issue is the one mentioned by Braunwald . AnotherThis review describes the latest data on serum biomarkers that are correlated with prognosis as well as data on novel potential biomarkers that can aid in risk stratification of patients with non-ischemic dilated cardiomyopathy.C-reactive protein is a nonspecific biomarker of inflammation and a well-known causative factor of endothelial dysfunction . As obseIt is known that inflammation has an important role in the pathophysiology and progression of heart failure, its presence indicating a poorer prognosis . AdditioGalectin-3 is an inflammatory biomarker of which the values are elevated in patients with myocardial inflammation and fibrosis . This prN-terminal pro-B-type natriuretic peptide values above and below the median [Chemerin is a newly discovered adipokine expressed in liver, lung, pancreas and adipose tissues. Several studies have demonstrated that chemerin is associated with inflammation, obesity, metabolic syndrome, coronary artery disease and, recently, with the presence of dilated cardiomyopathy and chronic heart failure ,32,33,34e median .Tumor necrosis factor-α is a pro-inflammatory cytokine produced by activated macrophages and monocytes. Different studies have demonstrated the role of TNF-α in the pathophysiology of atherosclerosis, myocardial infarction and chronic heart failure ,36,37. EB-type natriuretic peptide is a biomarker produced mainly by ventricular cardiomyocytes and its level increases in response to increased wall stretching, such as pressure overload and volume expansion. NT-proBNP is the best biomarker in the family of natriuretic peptides to diagnose and monitor heart failure and it can also be used to screen for asymptomatic left ventricular dysfunction, because it is larger and has a longer half-life than BNP, making its measurement easier ,38. ThusST2 is a member of the interleukin-1 receptor family, a protein secreted by monocytes in response to mechanical strain . ST2 hasCardiac troponin T and I are sensitive and specific markers of myocardial injury. Additionally, this troponin can predict an adverse outcome in patients with dilated cardiomyopathy. However, their clinical use is limited by the low sensitivity of the conventional commercial assay system . TherefoH-FABP is a low molecular weight cytosolic protein that is rapidly released into the circulation when the myocardium is injured. Studies have demonstrated that patients with chronic heart failure have increased serum levels of H-FABP, suggesting the presence of ongoing myocardial damage ,54,55. ACardiac myosin binding protein-C is a sarcomeric protein with important implications in the regulation of cardiac systolic and diastolic function. Considering that DCM manifests as a deterioration of systolic and diastolic function, more and more studies are being done to better understand MyBP-C implications in patients with dilated cardiomyopathy . DiffereMatrix metalloproteinases are enzymes capable of degrading extracellular matrix proteins. They have an important role in tissue remodeling associated with different physiological or pathological processes as morphogenesis, angiogenesis or tissue repair. Patients with dilated cardiomyopathy have an important myocardial tissue remodeling, which is associated with an extensive reorganization of the cardiac extracellular matrix. One of the first studies that evaluated the cardiac extracellular matrix remodeling by analyzing the matrix metalloproteinases in DCM patients, with a focus on their possible prognostic value, was published by Franz et al. They measured the serum levels of matrix metalloproteinase 9, tissue inhibitor of metalloproteinase 1, fetal tenascin-C and fibronectin, markers known to be involved in the reorganization of the extracellular matrix, and demonstrated that an increase of every single of these parameters is significantly related to a lower survival of DCM patients . In anotMyeloperoxidase is a leukocyte-derived enzyme produced by monocytes, neutrophils and endothelial cells ,62. It iSeveral neurohormones, such as norepinephrine, renin, aldosterone, angiotensin 2 and arginine vasopressin, have been described as biomarkers in patients with heart failure . High ciEndothelin-1, a novel endothelium-derived potent vasoconstrictive peptide, has been demonstrated to increase in plasma of patients with dilated cardiomyopathy ,69. More+ cell populations in patients with dilated cardiomyopathy and ischemic cardiomyopathy. They found an increased number of circulating cells with stem cell markers in DCM patients, compared to healthy individuals and ischemic heart disease patients. Furthermore, they observed that myocardial homing factors were significantly overexpressed in ischemic versus non-ischemic hearts. This may be explained by an impaired endogenous myocardial regeneration via circulating CD34+ cell populations, secondary to a lack of upregulation of important myocardial homing factors [Cardiac endothelial changes that occur in patients with dilated cardiomyopathy are associated with disease progression and outcome. Therefore, more and more efforts are made to identify biomarkers that have prognostic value, such as endothelial progenitor cells (EPCs). As a response to defective vascularization that has been reported in DCM patients, there is a peripherally increased number of EPCs that contribute to vascular repairs in vivo ,72,73. T factors . These f factors . There a factors ,76,77.Bisphenol A is a widespread component of polycarbonate plastics and epoxy resins, with implications in several cardiovascular diseases . UnfortuCirculating microRNAs are small non-coding RNAs that influence protein translation and has gained much interest as potential genomic biomarkers. Their evaluation could help with the differentiation of the etiology behind heart failure (ischemic vs. nonischemic) and possibly with the prediction of the future course of the disease ,88. AlthCardiac fibrosis is common in patients with NIDCM, being a progressive process, associated with important implications on prognosis and mortality. Syndecan-1 is a member of transmembrane proteoglycan family, involved in cell–matrix interactions and is believed to regulate cardiac fibrosis. Studies have shown that circulating syndecan-1 levels are correlated with markers of fibrosis and remodeling, patients with elevated levels having poor renal function ,93. AddiPatients with severe heart failure develop different changes in adipokine levels, progressive catabolism and long-term systemic inflammation. T-cadherin is an adiponectin receptor expressed in the heart and blood vessels . ConsideGrowth differentiation factor-15 is a stress-responsive cytokine and is emerging as a biomarker implicated in fibrosis, inflammation and ventricular remodeling. Recent studies evaluated the role of GDF-15 as a biomarker of myocardial fibrosis in patients with NIDCM , its corDespite recent advances, non-ischemic dilated cardiomyopathy still remains a disease with unacceptable morbidity and mortality, possibly due to the complex pathophysiology. Thus, novel biomarkers addressing specific paths of damage are of urgent need for identification of patients at higher risk of pump failure and sudden cardiac death. In the last years, a growing number of biomarkers have been studied and proposed as potentially useful for risk stratification of patients with dilated cardiomyopathy, but none of them resemble the characteristics of an ideal biomarker. However, existing evidence proves biomarker evaluation to be a very promising tool in risk stratification of patients with dilated cardiomyopathy. We consider that the future holds great promise in improving risk stratification by the incorporation of clinical data, genetic data, imaging data, data from wearable and implantable cardiac devices and serum biomarkers in artificial intelligence algorithms for diagnosis, risk stratification, prognosis and therapeutic management purposes.In conclusion, the results presented in this review are of great importance, since it shows that serum biomarkers can be used for risk stratification and for estimating the prognosis of patients with dilated cardiomyopathy. This is essential at the time point of initial clinical presentation because patients with an unfavorable prognosis could be targeted for strict monitoring and more intensive treatment. Assessment of some of these biomarkers might improve arrhythmic risk stratification of patients with NIDCM and appropriate patient selection for prophylactic ICD implantation. The need to find such biomarkers lies in the fact that an optimal heart failure treatment is frequently initiated much too late in patients with non-ischemic dilated cardiomyopathy, despite the use of increasingly advanced diagnostic tools.


Acute myocarditis was recently demonstrated in previously healthy young male patients after receipt of mRNA SARS-CoV-2 vaccines. Herein, we report on a 21-year-old man who presented with acute fatigue, myalgia, and chest pain 2 days after his second SARS-CoV-2 vaccination with BNT162b2. Cardiac magnetic resonance (CMR) showed acute myocarditis, with mildly impaired LV-function and abundant subepicardial late gadolinium enhancement (LGE). Control CMR after 3 months showed full functional recovery and complete disappearance of LGE. The benefits of SARS-CoV-2 vaccination may significantly exceed the very rare and, in this case, fully reversible adverse effects. Baseline cardiac troponin was normal , but ECG showed ST-elevation in precordial leads V2–V5  vaccination with BNT162b2 . No history of cardiac disease, risk factors, or family history of cardiovascular or autoimmune diseases was present. Temperature was normal (36.9°C), whereas leukocytosis (11.1/nl) was present with elevated C-reactive protein of 71 mg/L  imaging was performed using standard balanced steady-state free precession sequences  followed by standard mid-ventricular short axis acquisition for T1 mapping  and T2 mapping . After administration of .1 mmol/Kg Dotarem?-gadoterate meglumine, late gadolinium enhancement (LGE) images were acquired using a segmented phase sensitive inversion recovery sequence .The CMR imaging showed acute myocarditis, and mildly impaired LV-function (EF = 49%) , whereasRecently, a couple of studies demonstrated acute myocarditis in previously healthy young male patients following receipt of mRNA SARS-CoV-2 vaccine –3. The aThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.SG and GK performed the procedure and wrote the manuscript. All 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.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.


Concomitant tricuspid regurgitation (TR) is common in patients with mitral regurgitation (MR). While current guidelines recommend repair of both valves at the time of surgery when feasible, high risk patients are often undertreated, leading to significant morbidity and mortality. With advances in transcatheter edge-to-edge repair (TEER) devices and technique, combined TEER for treating significant MR and TR has emerged as a new tool for heart failure management. Recent evidence has shed light on which patients with severe TR should be targeted for transcatheter intervention either in isolation or in combination with a MV TEER procedure and allows for expanded treatment options in patients who otherwise would be limited to medical management. Technological advancements remain ahead of robust clinical data, and thus randomized clinical studies in patients with severe MR and TR will be instrumental in determining the best approach in treating these patients with transcatheter therapies. Transcatheter edge-to-edge repair (TEER) with the MitraClip  has been demonstrated to be safe and effective in treating severe mitral regurgitation (MR) of both degenerative and functional etiologies , 2. SimiFunctional (secondary) tricuspid regurgitation (TR) is the most frequently encountered etiology for TR and refers to regurgitation not related to primary organic tricuspid valve disease . MultiplSignificant TR may not improve predictably after treatment of the left-sided valve lesion and reduced RV afterload; thus, TR should be managed as part of the index procedure –12. MV rMR is either functional, secondary to annular dilatation and leaflet tethering as seen with ischemic or dilated cardiomyopathies and atrial fibrillation, or primary in the setting of mitral valve apparatus dysfunction in rheumatic heart disease, myxomatous degeneration, infective endocarditis (IE), among other etiologies. Most cases of significant TR are secondary to dilatation of the tricuspid annulus and/or leaflet tethering due to RV remodeling in the setting of pressure or volume overload such as pulmonary hypertension, dilated cardiomyopathies, or atrial fibrillation –21. PrimEchocardiography remains the critical imaging modality in selecting patients for combined MV and TV TEER, which includes complete transthoracic echocardiography (TTE) and transesophageal echocardiographic (TEE) views according to recommendations  for a coThe use of advanced echocardiography features such as multiplanar views and 3-dimensional imaging has significantly improved the accuracy of the diagnosis and invasive management of valvular disease. Using the X-plane mode, two simultaneous orthogonal planes are obtained, allowing visualization of morphological details and precise determination of cardiac valvular lesions . While eInterventional echocardiography is an emerging and growing field and is essential for the guidance of many transcatheter structural heart procedures. Similar to other transcatheter valve interventions, combined MV and TV TEER procedural success relies on adequate visualization of the cardiac structures and skilled intraprocedural guidance, with a focus on device positioning and successful grasping of the MV and TV leaflets. Imaging quality will depend not only on numerous patient characteristics , but also on the device used for repair.For streamlined intraprocedural guidance, the rapid transition between mid-esophageal multiplanar views to transgastric to 3-D imaging of the valve is required. Furthermore, standardizing imaging views of the valves allows for efficient communication between the interventionalist and the interventional echocardiographer, increasing the rate of procedural success while decreasing procedure time. In general, transcatheter TV procedures are more challenging than those on the MV as the TV leaflets are often difficult to simultaneously visualize on 2D echocardiography , thus 3DPostprocedural assessment by TEE in the immediate post-deployment phase of the procedure is crucial in assessing the reduction in regurgitation severity and to rule out procedural complications  or pericardial effusion). Follow up postprocedural TTE targets the assessment of long term success in terms of sustained reduction of regurgitation, ventricular reverse remodeling, reduction in afterload and stability of the device .In the presence of concomitant severe MR and TR, double surgical valve intervention is indicated in patients with acceptable risk . CurrentWhile surgical data suggests that repairing the TV after addressing the predominant MV disease does not pose a significant additional surgical risk, some patients with mild preoperative TR might benefit from isolated MV surgery alone. This is evidenced by a study in 1,900 patients with degenerative MV disease with a structurally normal TV, of which 67 underwent a combined repair procedure. In those with mild preoperative TR, <20% of patients developed 2+ or greater TR at 3 years . In contHistorically, surgical TV repair durability has been inconsistent, with recurrence rates of significant TR in up to 40% of cases depending on the technique performed . Ring an2 diameter on preoperative TTE; >70 mm diameter on direct intraoperative measurement of the inter-commissural distance), degree of RV dysfunction or remodeling, leaflet tethering height, pulmonary artery hypertension, AF, and intra-annular RV pacemaker or implantable cardioverter-defibrillator leads , moderate (39%), and severe (19%) who underwent MitraClip for severe MR revealed several important findings pertaining to patient selection for a combined TEER procedure. First, TR improvement was associated with a lower rate of HF hospitalization at 2 years with a hazard ratio of 0.6. Second, patients with TAD (≥34 mm) at follow up had a higher rate of HF hospitalization. Third, TR was more likely to improve after MitraClip when the TAD decreased on follow up echocardiography. Fourth, that patients with atrial fibrillation were less likely to experience a decrease in TAD (and thus TR) and finally that MR > grade II at discharge was associated with lack of improvement in TR . Thus, wBecoming facile with TEER for treating MR is key to performing TEER for severe TR. Nevertheless, there remains a learning curve that needs to be overcome in order to optimize procedural success and improve patient outcomes. It has been shown that the learning curve when treating MR with MitraClip is steepest from 25 to 50 cases . In a reWhen planning TV TEER procedures, the choice of device can present a challenge given that these devices were developed for the mitral valve, whereas tricuspid valve leaflets are thinner and more fragile and severe TR tends to involve larger leaflet malcoaptation gaps. Some evidence from MV TEER has shown that the XTR clip leads to more SLDA and leaflet tearing , howeverThe MitraClip™ G4 system offers 2 new clip sizes (NTW and XTW) which measure 6 mm in the center, 50% wider than the 4-mm width of the NT/XT clip. The G4's larger grasping capability in addition to the option for independent leaflet grasping would be advantageous for treating TR, as recently reported , 60. FurThere are several advantages in considering a combined TEER procedure. First, a combined approach closely mirrors what is recommended in the guidelines for surgical intervention for TR in the setting of severe MR . Second,Although currently the most common interventional technique, TEER has anatomical limitations for the treatment of every patient with MR and TR. In future, a tailored approach using an expanded toolbox will allow more nuanced device selection based on valve anatomy and disease stage. Combined valve repair  and replacement, or combined valve replacement may become a reality with advances in device development and procedural technique. Furthermore, future studies are needed to identify patients who will benefit the most from this treatment, the optimal anatomic features and standardized procedural success criteria associated with positive clinical outcomes.As residual significant TR after MV TEER is an independent predictor for increased mortality, developing transcatheter therapies and having a more robust understanding of which patients will benefit from a combined TEER procedure is important. Small studies have demonstrated that a combined approach is safe, effective, and has shown promising short-term results, however randomized clinical trials are needed in this realm, especially regarding durability and persistent improvement in outcomes. Recent data has shed additional light on the deleterious effects of residual TR after MV TEER, including the implications of tricuspid annular dimensions and concomitant atrial fibrillation which will help guide patient selection for a combined procedure. There are several advantages to considering a combined procedure, both from clinical and cost perspectives. While there is a learning curve associated with both MV and TV TEER, the recent CE mark of the TriClip G4 and PASCAL systems will facilitate TV TEER in clinical practice. Ultimately, patients with concomitant severe MR and TR who are not ideal surgical candidates should be considered for a combined TEER procedure, using the available data to determine their suitability for this attractive therapeutic approach.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.NF has received speaker honoraria from Abbott Vascular and is a consultant for Edwards Lifesciences. The remaining 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.


ES, EA), and myocardial work indices derived from longitudinal strain analysis before and 1‐h after percutaneous PDA closure. A total of 35 patients were included with mean [±SD] age at intervention of 30.8 ± 9.9 days and median [IQR] weight of 1130  grams. There was a reduction in preload and stroke volume, an increase in EA  and in EES  post‐closure. Myocardial work indices reduced after PDA closure, including global work efficiency . A total of 17 (48.6%) patients developed post‐closure instability which was associated with younger age, lower preload, and higher EA and EES. Percutaneous PDA closure is associated with major short‐term changes in VAC and myocardium energetics, which may provide novel insights on the physiology of PDA closure and on the differential vulnerability to changes in loading conditions.Definitive closure of a patent ductus arteriosus (PDA) causes significant changes in loading conditions of the left ventricle (LV) which can lead to cardiorespiratory instability including hypotension, low cardiac output, oxygenation, and ventilation impairment. Physiological insights of the adaptation of the LV can be gained by looking at ventriculo‐arterial coupling (VAC) and myocardial work‐energetics. We conducted a retrospective cohort study of preterm infants with echocardiographic assessment of VAC parameters, including end‐systolic and arterial elastance (E Definitive closure of patent ductus arteriosus is associated with significant changes in ventriculo‐arterial coupling and myocardial work indices including reduced preload, stroke volume, global longitudinal strain, and ventricular efficiency, with increased arterial elastance. Patients who develop cardiorespiratory instability after the procedure have higher arterial and end‐systolic elastance. These data may provide an enhanced understanding of the physiology of patent ductus arteriosus closure and serve as a guide to optimize care and provide targeted therapies in vulnerable preterm infants. Coupling refers to the influence of the load imposed by the arterial system on ventricular systolic performance  from September 2019 until May 2021. Patients were excluded from analysis if the procedure was unsuccessful (defined as patient leaving the catheterization laboratory without a device placed in the PDA) or if there was another congenital heart defect with the exception of small patent foramen ovale (PFO) and/or atrial septal defect (ASD). Comprehensive targeted neonatal echocardiography (TnECHO) is performed by the Neonatal Hemodynamics team according to a standardized protocol that includes comprehensive imaging of intracardiac anatomy, outflow tract concordance and integrity, aortic arch anatomy, pulmonary vein location/flow, and transitional shunts  was collected by the oscillometric method in the right arm  and in one of the calves  at the end of both TnECHOs (before and 1‐h after closure) with appropriately sized cuffs when the infant was calm. When available, invasive blood pressure  was recorded concomitantly. For the calculations used in this study, including ventriculo‐arterial coupling and myocardial work, the BP obtained from the right arm oscillometric measurement was preferentially used.2.2Evaluations were performed using the Vivid E90 cardiovascular ultrasound system  with a 12‐MHz high frequency phased‐array transducer probe. Standard two‐dimensional, M‐mode, color Doppler, pulse‐wave Doppler, and continuous‐wave Doppler images were obtained. All echocardiography analyses were performed using a dedicated workstation  by a single trained investigator, who was blinded to the clinical information to minimize bias. Three consecutive cardiac cycles were evaluated and averaged for each measurement to be used in the study.2.32 π)] by VTI and heart rate and indexed to weight (kg)  and the heart rate. The annulus of the aortic valve was measured, from the parasternal long axis, between hinge points with the valve open at the end of ejection. LVO (expressed in ml/min/kg) was calculated by multiplying the aortic cross sectional area [calculated as:  + DBP]/3  + (DBP × 0.6) + 1.4]  has been described more often in the literature and therefore was used as the primary outcome in this study. To estimate EA, we used two different methods to estimate stroke volume obtained by echocardiography methods. EA calculations have been previously described using M‐mode measurements  was obtained from the Simpson's biplane method and all formulas of ESP were used as follows: EES1 = ESP1/ESV, EES2 = ESP2/ESV, EES3 = ESP3/ESV  were performed using both methods of SV estimation: VAC1 = ESV/SV by Biplane method; VAC2 = ESV/SV by LVO method  as the primary outcomes.All the VAC parameters were obtained by estimating end‐systolic pressure (ESP) and using ventricular volumes obtained from the TnECHOS. We used different methods to calculate ESP as per the following formulas: ESP1. The graph represents the mean values for EA1, EES1 and the ESP1 volume point (ESP1/ESV). The intercept with the x‐axis represents V0 for the EES1 line and EDV for the EA1 line.Ventriculo‐arterial coupling graphs prior to and after the procedure were drawn by using the volumes estimated from the Simpson's biplane method and the ESP2.5Automated functional imaging (AFI)  using 2D‐STE was performed from the apical four‐, two‐ and three‐chamber views of the LV  or mean airway pressure (MAP) compared to pre‐closure value, for at least 1‐h, in the first 24 h of post‐closure. Ventilation failure was defined as need for rescue high frequency ventilation in patients who were on conventional mechanical ventilation because of inability of conventional settings to maintain adequate ventilation support in the first 24 h of post‐closure. Systolic hypotension was defined as systolic arterial pressure below the 3rd percentile for age for at least 1‐h in the first 24 h of the procedure. Escalation in cardiovascular support was defined as an increase in inotrope score by >20% of the pre‐closure value or need to initiate a new agent (not including milrinone) in response to hypotension, shock and/or LV systolic dysfunction on echocardiography  and nonparametric tests (Mann–Whitney) as appropriate for continuous variables. Categorical variables were presented as frequencies (%) and compared using the Chi‐squared test or Fisher's exact test. Intra‐ and inter‐observer reliability testing were performed for myocardial work analysis. Testing was performed for a single set of defined images  in 10 randomly selected TnECHOs (5 prior and 5 after PDA percutaneous closure). Intra‐observer reliability was assessed by one investigator (A.B.) who performed offline analysis of the same TnECHO studies 4 weeks apart to reduce recall bias, while inter‐observer was assessed by a second investigator (A.S.) who was unaware of the previous results. Agreement between investigators was evaluated using the Bland–Altman method to calculate the bias (mean difference) and the 95% limits of agreement 1.96 SD around the mean difference)..Descriptive statistics were used for demographics and clinical data. The Shapiro–Wilk test was used to test continuous variables for normality. Mean with standard deviation and median with interquartile range were calculated for data with normal and non‐normal distribution, respectively. Pre‐ and post‐procedural variables were compared using paired 32O, median [IQR] FiO2 of 35% , and respiratory severity score ; 1 patient had procedure cancellation as the PDA was considered too small for definitive closure upon arrival to the catheterization laboratory; 1 patient had incomplete clinical and echocardiographic data. Ultimately, a total of 35 neonates  were included in the final cohort whose mean [±SD] birth weight was 729 ± 197 grams and gestational age was 25.07 ± 1.71 weeks. Mean age at intervention was 30.8 ± 9.9 days and median [IQR] weight and postmenstrual age were 1130  grams and 29.1  weeks, respectively. All patients were mechanically ventilated prior to the procedure, of whom 28 (80%) were managed with high frequency jet ventilation and the remainder were supported by conventional mechanical ventilation (pressure‐control synchronized intermittent mandatory ventilation). Baseline respiratory illness severity was a mean [±SD] MAP of 12.1 ± 2.2 cmH3.1A and EES are steeper after PDA closure, with a smaller area under the curve. Decreases in ventricular efficiency were noticed after the procedure as estimated by the VAC formulas as well as by the pressure‐strain loops of myocardial work , −0.65 ± 0.4 vs. −0.89 ± 0.5 ml/kg estimated by LVO (nonsignificant)]. Changes in global longitudinal strain and in myocardial work indices were more pronounced in the infants who developed instability, although these did not reach statistical significance; specifically, GLS decreased by 6.7 ± 3 versus 4.3 ± 3.3% while GWE decreased by 3.5 ± 4.4 versus 2 ± 3.3% in infant with and without instability, respectively.A total of 17 (48.5%) patients developed post‐PDA closure instability which was predominantly due to oxygenation and/or ventilation failure  of the echocardiography studies [80% (28/35) of the pre‐procedural and 88.5% (31/35) of the post‐procedural scans]. The main reason for inability to perform myocardial work analysis was poor tracking of the LV wall, particularly from the LV three‐ and/or two‐chamber views. Intra‐ and inter‐observer reliability testing, including the percentage bias, 95% limits of agreements and intraclass correlation coefficient are summarized in Table 4A.Percutaneous PDA closure is associated with increased arterial elastance, end‐systolic elastance, and changes in ventriculo‐arterial coupling and ventricular efficiency in the short‐term. These changes have a similar trend to what has been reported by Nagata et al. in echocardiograms performed in the first 24 h after PDA surgical ligation  after PDA closure.We also observed a significant decrease in SV and EF, with increases in EES and lower VAC than adults such that the normative data for term infants is close to 0.5  and stiffness  components . In the presence of a significant left‐to‐right PDA shunt, the pre‐ductal circulation (including the right arm) is exposed to a higher SV; therefore, a discordance in BP parameters between upper and lower limbs is possible. Additionally, exposure of the LV to both the systemic and the pulmonary vascular beds with an open PDA is likely to impact the non‐invasive methodology to estimate EA. This represents a limitation in the interpretation of our results and poses questions about the most accurate noninvasive method to estimate arterial elastance in the presence of a significant transductal shunt. These changes are likely to be less relevant in the post‐procedural estimations as both pre‐ and post‐ductal circulations are exposed to the same circulating cardiac output; therefore, either upper or lower limb BP parameters are more equally reflective of the arterial load imposed to the LV.The arterial load imposed on the LV encompasses peripheral vascular resistance, total arterial compliance, characteristic impedance as well as systolic and diastolic time intervals , such that the BP remains relatively unchanged in the face of a decrease in SV. This is particularly important given that clinicians at the bedside may fail to recognize that significant physiological changes in coupling, myocardial work, and LV performance can occur in the face of relative stability of vital signs immediately after PDA closure. These changes are likely to have a profound impact on the risk of developing post‐closure cardiorespiratory instability.Both active and passive cardiac muscle properties determine EP Figure . In pretES both prior to and after intervention , location , and formula  is more reflective of “true” ESP in preterm infants and in those with PDA shunts. Additionally, the reliability of noninvasive arterial elastance estimation when the LV is exposed to both the systemic and the pulmonary vascular bed is not known. Second, neither Simpson's biplane nor stroke volume estimated by pulse‐wave Doppler has been validated in the estimations of arterial and end‐systolic elastance. There are also no studies evaluating the normative data for myocardial work in preterm infants. Third, in the estimation of EES it is appropriate to neglect V0 in patients with near normal loading conditions  into EES = ESP/ESV (Chantler et al., 0 is increased, and therefore neglecting V0 may underestimate EES and overestimate EA/EES. Fourth, we included a population in which most patients received milrinone prophylaxis. It is possible that milrinone, as a phosphodiesterase inhibitor with inotropic, lusitropic, and vasodilator properties (Akita et al., Fifth, our study only includes the TnECHO performed 1‐h after PDA closure with no further longitudinal data. It is possible that sustained changes in loading conditions, as well as the impact of weaning off from anesthesia, may further enhance changes in BP, and hence ESP and VAC estimations. Lastly, we did not assess fluid status in the patients included in this cohort. There were significant differences in pre‐procedural preload and stroke volume between patients with and without cardiorespiratory instability which could be attributed to differential fluid management. We believe that the changes in preload are most likely related to shunt volume given the relative homogeneity in fluid practices at our institution.There are some important caveats to our study, particularly related to the retrospective design and the methods used to estimate VAC. 5Percutaneous PDA closure leads to changes in ventriculo‐arterial coupling and myocardium energetics. An increase in arterial elastance, and hence LV afterload, associated with decreases in preload leads to decreased ventricular efficiency post‐closure. Furthermore, higher end‐systolic elastance may be associated with increased risk for post‐closure cardiorespiratory instability. These data provide novel insights in the physiology of PDA closure. It also enhances the understanding of the vulnerability to changes in loading conditions and may serve as a guide to optimize care and provide targeted therapies. Further studies are needed to validate measures of VAC in preterm infants according to PDA status and investigate the role of myocardial work indices in different physiological states in the neonatal population.The authors have no conflict of interest to disclose.Adrianne R Bischoff participated in the conception, design, acquisition, and analysis of data, drafted the article, and approved the final version. Amy H Stanford participated in acquisition of data, review of the manuscript for important intellectual content, and approved the final version. Patrick J McNamara participated in the conception, design, review of the manuscript for important intellectual content, and approved the final version.Clinical.Patient consent was not required.Fig S1Click here for additional data file.Table S1‐S3Click here for additional data file.


This study is aimed at exploring how soleus H-reflex change in poststroke patients with spasticity influenced by body position.  Twenty-four stroke patients with spastic hemiplegia and twelve age-matched healthy controls were investigated. Maximal Hoffmann-reflex (Hmax) and motor potential (Mmax) were elicited at the popliteal fossa in both prone and standing positions, respectively, and the Hmax/Mmax ratio at each body position was determined. Compare changes in reflex behavior in both spastic and contralateral muscles of stroke survivors in prone and standing positions, and match healthy subjects in the same position. p = 0.000, Hmax/Mmax: p = 0.016). However, Hmax/Mmax ratios were increased in standing position on both sides in poststroke patients with spasticity . The Hmax and Hmax/Mmax ratios were significantly more increased on the affected side than unaffected side irrespective of the position.  In healthy subjects, Hmax and Hmax/Mmax ratios were significantly decreased in the standing position compared to the prone position (Hmax:  The motor neuron excitability of both sides was not suppressed but instead upregulated in the standing position in subjects with spasticity, which may suggest that there was abnormal regulation of the Ia pathway on both sides. Spasticity is defined as velocity-dependent increase in the tonic stretch reflexes (muscle tone) , which iIn clinical practice, spasticity is usually measured at rest, based on the combination of physical signs, including increased muscle tone and tendon hyperreflexia. A previous study conducted by our research group showed that from the supine position to standing or sitting position, Modified Tardieu Scale (MTS) and Triple Spasticity Scale (TSS) scores significantly increased in the evaluated muscles of the hemiplegic upper limb in all poststroke patients . Wang etBurke et al. believed that the loss of homosynaptic inhibition between the Ia afferent pathway and motor neurons changes in reflex circuits affecting motoneuron excitability , and the intrinsic property changes of motor neurons and muscles make up the leading causes of increased muscle tone and tendon hyperexcitability in spastic patients . The effSeveral studies showed that spastic patients exhibited a larger H-reflex amplitude or Hmax/Mmax ratio than the control group or their unaffected side in the prone position , suggestAccordingly, the objectives of this study were as follows: (1) if varying posture could influence H-reflex excitability on both sides in stroke patients with lower limb spasticity and (2) to compare changes in reflex behavior in both spastic and contralateral muscles of stroke survivors and match healthy subjects in a standing position. We hypothesized that posture transformation would affect the H-reflex excitability of spastic patients on both sides. Our theory would thus help us understand that the role modulation of afferent Ia spinal cord pathway plays in a standing position. Also, if the hypothesis proves right, it would enable us to explore further the pathophysiological mechanism(s) of spasticity in a standing position. We also hypothesized that unstable posture might acutely increase spinal cord excitability.ChiCTR-TRC-1800018427).We recruited a total of twenty-four hemiparetic spastic stroke survivors in the rehabilitation inpatient department in Huashan Hosipital and twelve age-matched healthy subjects (patient's caregiver) serving as controls. Inclusion criteria for the stroke subjects were (1) hyperactive ankle jerk with clonus and extensor plantar response (Babinski response), (2) present range of motion (ROM) difference between two speed and the quality of ankle joint plantar flexor muscle reaction elicited on the fast passive stretch ≥ 2 according to the Modified Tardieu Scale (MTS), (3) Brunnstrom recovery stage 3 or 4 in the lower limb, (4) the ability to stand independently, and (5) the presence of soleus H-reflex. Exclusion criteria were (1) with history of Parkinson's disease or other neurological diseases; (2) taking any medication that may affect motor control or nerve function, such as Baclofen; (3) medically unstable or concurrent uncontrolled systemic illnesses; (4) skin ulceration, irritation, and inflammation in bilateral calves which influence placing electrodes; and (5) severe disturbance of emotion, visual, and cognitive impairment. All participants gave informed consent via the study protocol approved by the ethics committee of Huashan Affiliated Hospital, Fudan University  at the fixed time (8 : 00 am-9 : 00 am) before the rehabilitation on the same day. The recruitment curves were carried out in two different body postures: prone position and standing position. In the prone position, the subjects comfortably laid on the treatment bed face down, while a triangular sponge pad was placed under their ankle joint to relax the calf triceps. In standing position, however, participants were asked to stand still, with their head and the upper body in a neutral position, eyes straight ahead, feet apart with the toes facing forward, and the upper limbs hanging on both sides of the torso. The center of gravity of the body is located between the feet and cannot be deflected. The evaluation was as follows: the unaffected side in a prone position, the affected side in a prone position, the unaffected side in a standing position, and the affected side in a standing position. After the tests in a prone position, each participant was given a five minutes break for which the subject's position was then changed. The self-adhesive surface electrodes (2.0 cm Ag-AgCl square electrodes) were attached to the belly of Soleus (active electrode) and the Achilles tendon (reference electrode). A ground electrode (2.0 cm Ag-AgCl square electrode) was attached to the skin between the active electrode and the reference electrode. The tibial nerve was stimulated at the popliteal fossa using a handheld bipolar stimulator (1 ms rectangular pulse), with the cathode was pointing towards the proximal end. Where the stimulator electrodes were to be placed on the skin was marked with an indelible pen to ensure that the same recording site was used in the successive session. The optimal stimulation site of the posterior tibial nerve was identified using the stimulating electrodes.The H-reflex (Hmax) was determined using many stimuli as required at 0.5 mA, precisely around the intensity eliciting the largest amplitude of the H-reflex. The maximum amplitude of the M-wave (Mmax) was determined as the size of the response to a stimulus of supramaximal intensity. Amplitude was measured from baseline to the largest negative peak in each series while determining the Hmax/Mmax ratio. Recording parameters settings are as follows: the sensitivity is 2 mV, the scanning speed is 5 ms/cm, and the stimulation intensity duration is 1 ms. The EMG signal was amplified (1 mV/D) and band-pass filtered .t-test  and using Kruskal-Wallis (nonparametric test) to test if it does not meet the normal distribution.The H-reflex  from each subject were presented as mean ± SD. One-way ANOVA was employed to assess the differences in H-reflex data among the affected side, unaffected side in spasticity patients, and the average value of both sides in healthy subjects. The H-reflex results of the same side in stroke patients with spasticity in different positions were tested using a paired-sample The demographic and clinical characteristics of all participants are summarized in p = 0.0002), but the differences between the affected side and the healthy subjects as well as the unaffected side and the healthy subjects were not statistically significant . Nevertheless, no statistical difference in the Hmax/Mmax ratio was found between the unaffected side and the healthy subjects.In the prone position, post hoc multiple comparisons were used for the H-reflex data of the affected side, the unaffected side, and the healthy group. The mean ± SD of the Hmax for the affected side, the unaffected side, and healthy control groups were 3.75 ± 1.95 mV, 2.96 ± 1.92 mV, and 3.28 ± 1.44 mV, respectively. Significant differences existed between the affected side and the unaffected side (nificant . The Hmap < 0.0001) and the affected side and the unaffected side (p = 0.038). Nevertheless, the differences between the unaffected side and the healthy subjects were not statistically significant. The mean ± SD of the Hmax/Mmax ratio for the affected side, the unaffected side, and healthy control groups were 43.58 ± 19.05%, 32.32 ± 16.23%, and 22.95 ± 9.58%, respectively. The statistical differences for the Hmax/Mmax ratio were found between any two groups in the standing position.In the standing position, the mean ± SD of the Hmax for the affected side, the unaffected side, and healthy control groups were 3.46 ± 1.69 mV, 2.88 ± 1.84 mV, and 2.41 ± 0.97 mV, respectively. Significant differences existed between the affected side and the healthy subjects : p = 0.016). Individual results on the affected side of most stroke patients showed that the data of H-reflex  in prone position were lower than in the standing position (14/24 for the Hmax and 20/24 for the Hmax/Mmax ratio), however, which showed no statistical difference in the mean value of the Hmax ((a): p = 0.284) and the Hmax/Mmax ratio ((b): p = 0.095) from the prone position to the standing position in patients. On the unaffected side, the mean value of the Hmax/Mmax ratio was significantly larger in the standing position than in the prone position ((d): p = 0.006).In healthy controls , the meaThe primary observation in the present study is that a transformed position can significantly alter spinal cord excitability in stroke patients with spasticity. In neurologically intact individuals, a striking decline could be found in Hmax and Hmax/Mmax ratios from the prone to the standing position. Notably, in the participants with lower limb spasticity, the H-reflex was not suppressed on both sides during postural adjustment. Regardless of the prone and the standing position, the affected sides exhibited distinctly increasing in terms of spinal excitability, and the Hmax/Mmax ratio in the unaffected side was significantly higher in the standing position. It suggests that the neural mechanisms responsible for posture adjustment may be different between stroke patients with spasticity and the healthy subjects.The pathophysiological mechanism of spasticity after stroke is complicated and still being explored. It is currently believed that the cause of stretch reflex hyperexcitability in stroke patients with spasticity is primarily due to abnormal remodeling of the descending conduction pathway above the spinal cord level and error processing within the spinal cord level . All theIn the present study , when a Compared to the healthy subjects in standing positions, the H-reflex amplitude of the affected side distinctly increased in the stroke patients with spasticity Figures  and 3. TIn the present study, we found out that the H-reflex excitability was not inhibited on both sides, and the anterior horn cell's excitability of the unaffected side was even enhanced in the standing position in spastic patients. It also indicates that the abnormal Ia reciprocal inhibition in these patients can occur on both sides. The results of the present study are in line with the study by Phadke et al. . On the Besides the intraspinal processing, the reticulospinal tract (RST) might be taken into consideration. The RST is best known for playing an essential role in maintaining joint position, posture against gravity, and locomotion . ReticulIn healthy people, there may be a positive correlation between the depression or downward modulation of the soleus H-reflex and the degree of the postural instability in which the subjects are placed . The depThis study has some limitations. First, we found a clinical phenomenon which might be explained by RST, but we did not verify this hypothesis. Therefore, our further study will focus on exploring the underlying mechanisms in stretch reflex hyperexcitability involving the role of RST using indirect noninvasive measure such as acoustic startle reflex (ASR) to make a further investigation about the spinal or supraspinal mechanism of H-reflex changes in standing position. Secondly, the current study was based on a small sample of participants. Despite it, we still observed the H-reflex difference between the two postures in the same patient.In standing position, the H-reflex excitability of the tibial nerve is partially upregulated in stroke patients with spasticity on both sides. The findings also suggested that the impaired regulation of Ia afferent pathway may be a potential source of postural control defects in poststroke spasticity.


E-vortex circulation correlated directly to e’ (p = 0.003), A-vortex circulation correlated directly to A and a’ (both p < 0.001), and S-vortex circulation correlated directly to s’ (p = 0.032). Despite changes in vortex patterns, energy loss was not significantly different in older individuals. Normal aging is associated with altered intracardiac vortex patterns throughout the cardiac cycle, with the late-diastolic A-vortex becoming physiologically more dominant. Maintained energy efficiency accompanies changes in vortex patterns in aging hearts.Analysis of the cardiac vortex has been used for a deeper understanding of the pathophysiology in heart diseases. However, physiological changes of the cardiac vortex with normal aging are incompletely defined. Vector flow mapping (VFM) is a novel echocardiographic technique based on Doppler and speckle tracking for analysis of the cardiac vortex. Transthoracic echocardiography and VFM analysis were performed in 100 healthy adults . The intracardiac flow was assessed throughout the cardiac cycle. The size  and circulation  of the largest vortices in systole (S-vortex), early diastole (E-vortex), and late diastole (A-vortex) were measured. Peak energy loss (EL) was calculated from information of the velocity vector of intracardiac flow in systole and diastole. With normal aging, the circulation ( Vortices are rotational whirling bodies of fluid. In recent decades, advances in imaging techniques including cardiac magnetic resonance, particle image velocimetry , and vecAging is associated with a reduction in LV suction force and an increase in dependence on atria-driven active LV filling . While eHealthy volunteers were prospectively studied between January 2019 and June 2019. Inclusion criteria were age ≥ 18 years, absence of history of cardiovascular and other chronic diseases, absence of arrhythmia, and normal transthoracic echocardiography. Exclusion criteria were inadequate echocardiographic images or abnormal echocardiographic findings. The ethics committee of our institution approved the study protocol. Written informed consent was obtained from all subjects. This study was registered in the Chinese Clinical Trial Registry (ChiCTR1900022476).Two-dimensional and Doppler transthoracic echocardiography was performed in all subjects using the Lisendo 880 ultrasound machine . The LV end-diastolic (LVEDV) and end-systolic volume (LVESV), and ejection fraction (LVEF) were measured using the biplane Simpson’s method . The earColor Doppler acquisitions were performed in the apical long-axis view to allow VFM analysis, with the Nyquist limit increased to minimize aliasing phenomenon, while maintaining a sufficient region of interest to include the entire LV and a frame rate of ≥20 per second. The data were transferred to a DAS-RS1  workstation for VFM analysis. The LV endocardium in the end-diastolic frame was traced manually. The software then automatically traced the endocardium throughout the cardiac cycle for speckle-tracking detection of LV wall motions, with manual editing if necessary. Automated anti-aliasing was performed with the same software.ω) on an arbitrary plane (S) enclosed by a closed curve:VFM was used to evaluate intracardiac blood flow and viscous EL. Circulation was calculated by using the following equation, equivalent to the integral of normal component of vorticity (The areas and circulations of the largest clockwise vortex during systole (S-vortex), early diastole at the time of E wave (E-vortex), and late diastole at the time of A wave (A-vortex) were recorded.EL was calculated by the following equation:µ is the viscosity coefficient of blood, and ui and uj are the velocity components in the x and y directions [S), early diastole (peak ELE), and late (peak ELA) diastole, as well as the mean EL during systole (mean ELS) and diastole (mean ELD), were measured.By using the continuity equation, the velocity vector of individual pixels was calculated from information of the adjacent boundaries. A weight function was used to integrate the calculated vectors ,16. EL wrections . The peap-values were two-sided, with p < 0.05 considered statistically significant. All statistical analyses were performed using SPSS software version 25.0 .Data were reported as mean ± standard deviation or counts (percentage) when appropriate. The cohort was divided into three groups according to age . Binary variables were compared between age groups using the Chi-square test. The Shapiro–Wilk test was used to test for normality. The Kruskal–Wallis test was used to compare non-parametric continuous variables between the three age groups, while analysis of variance was used to compare parametric continuous variables. Spearman’s correlations evaluated the relationship between VFM profiles and age. All p < 0.0001) and e’/a’ ratio (p < 0.0001), but a higher E/e’ ratio (p < 0.0001).A total of 100 healthy subjects  were included. Demographics, as well as conventional 2D, Doppler, and tissue Doppler echocardiographic findings are summarized in In all subjects regardless of age, two intracardiac vortices form during early diastole at the time of the E wave near the LV base, including a larger clockwise vortex (E-vortex) in front of the anterior mitral valve leaflet and a smaller anti-clockwise one behind the posterior mitral valve leaflet. The two vortices grow and migrate towards mid-LV, then fade at the end of the E wave. At the time of the A wave, two vortices form again near the LV base, with a larger anterior clockwise vortex (A-vortex) and a smaller posterior anti-clockwise vortex. The anterior clockwise vortex persists into systole and migrates to the base of heart near the LV outflow tract, reaching its maximal size in mid-systole (S-vortex). A representative example of a normal intracardiac vortex formation is shown in The normal LV EL is characterized by three distinct peaks in EL in systole, early diastole, and late diastole, corresponding to the formation of respective intracardiac vortices .p = 0.0003) with stronger circulation (p < 0.0001). The mean ELS was significantly lower than the mean ELD  in healthy subjects across all age groups. Older individuals showed a significantly lower peak ELE (p = 0.005) but a higher peak ELA (p < 0.0001); however, the mean ELD was not significantly different between age groups (p = 0.772). There was no intergroup difference in the mean and peak ELS.s) = −0.623, p < 0.0001). Aging also correlated weakly with weaker E-vortex circulation  and stronger S-vortex circulation ; the correlation between the S-vortex area and aging was not statistically significant . Generally, a larger vortex area correlated to stronger circulation, as observed for the S-vortex , E-vortex , and A-vortex .There was a significant correlation between aging and stronger A-vortex circulation , while peak ELA correlated with a higher mitral inflow A velocity . E-vortex circulation correlated directly to e’ , A-vortex circulation correlated directly to A  and a’ , and S-vortex circulation correlated directly to s’ . Additionally, stronger E-vortex circulation correlated to a higher peak ELE , while stronger A-vortex circulation correlated to a higher peak ELA . However, there was no significant correlation between S-vortex circulation and the mean and peak ELS .Peak ELIn this study, we confirmed previous descriptions of the pattern of vortex formation and energy loss in healthy individuals ,18,19,20Muñoz et al. published a detailed account of the behavior, evolution, and transitions of the intracardiac vortex, which included a detailed analysis of the vortex area and circulation . Our stuAge-related decline in myocardial relaxation and, therefore, LV suction cause an increase in reliance on active atrial filling, with a larger and more intense late diastolic vortex. This differs from patterns observed in young healthy hearts, where active late LV filling generates small vortices that persist into systole ,20,21,22S is preserved. On the other hand, ELD not being elevated in older individuals, despite the changes in diastolic vortex patterns, suggests that the increase in A-vortex area and circulation may be seen as a compensatory response to the decline in E-vortex area and circulation.We observed that EL is significantly higher in diastole than in systole, consistent with previous reports ,24. ThisMost previous studies of intracardiac flow have used other techniques, such as cardiac magnetic resonance and particle image velocimetry. Though extensively studied, these techniques each have significant limitations: cardiac magnetic resonance is expensive, requires significant time for processing, which prohibits flow visualization at the time of imaging, and is limited in availability at many centers; meanwhile, particle image velocimetry, though allowing for rapid flow visualization at the time of imaging, requires contrast agent injection, often turning an otherwise non-invasive transthoracic echocardiography into an invasive procedure . These mThe close links between diastolic markers, vortex area, and vortex circulation suggest that vortex patterns and intracardiac EL may be deranged in patients with diastolic dysfunction. Data of vortex patterns and intracardiac energetics are scarce for this group of patients  and furtIntracardiac vortex is a three-dimensional structure that moves in multiple planes. Visualizing a vortex with a two-dimensional imaging technique such as VFM inherently runs the risk of missing smaller vortices due to the plane of imaging, such as the small vortices that result from the disintegration of the PMVL vortex in late diastole . This prIn aging hearts where there is an increased dependence on atria-driven LV filling, the early diastolic E-vortex declines in strength, while the late diastolic A-vortex becomes physiologically dominant with increased size and strength. These inverse changes in the E-vortex and A-vortex were accompanied by maintained energetic efficiency. Further investigations of vortex imaging may yield clinically significant findings in a variety of conditions.


Pulmonary vein (PV) isolation (PVI) is the most important component of catheter ablation of atrial fibrillation (AF) and can be achieved by radiofrequency or cryoballoon ablation (CBA). The CBA system has shown excellent efficacy and safety in a number of clinical trials and is independent of the PV anatomy. However, pneumonectomy can significantly alter the anatomy posing a challenge to CBA. Few cases of PVI accomplished by CBA have been described in patients with lobectomy, but none in the pneumonectomy population. We describe a case of successful CBA for paroxysmal AF in a patient with a left total pneumonectomy. Both the 2012 American College of Cardiology/American Heart Association/Heart Rhythm Society and the 2020 European Society of Cardiology guidelines for the diagnosis and management of AF recommend catheter ablation (class I level of evidence A) for patients with symptomatic paroxysmal AF refractory or intolerant to anti-arrhythmic drugs.A 76-year-old man with a past medical history of hypertension, coronary artery disease , and non-tuberculous mycobacterial left lung infection complicated by chronic severe left bronchiectasis necessitating a left pneumonectomy was referred to our institution for the management of symptomatic persistent AF. He was first diagnosed with persistent AF about a year prior and required cardioversion to normal sinus rhythm. He remained in normal sinus rhythm for about six months, followed by recurrence of AF. At that time, he was started on sotalol therapy, which was discontinued due to excessive fatigue. He was not a candidate for amiodarone or other anti-arrhythmic drugs due to his chronic non-tubercular mycobacterial lung infection and potential drug interactions, notably QT prolongation, with his chronic antibiotic therapy. Therefore, the decision was made to proceed with AF ablation. and demonstrated a left mediastinal shift due to his pneumonectomy . Intracardiac echocardiography (ICE) was also performed to help define the anatomy of the interatrial septum and guide transseptal puncture. Transseptal puncture was more challenging in this patient due to the rotation of the heart, but imaging helped to overcome this challenge. Pre-interventional imaging also helped define the PV anatomy. The patient had a remnant left common PV stump as a result of his history of left pneumonectomy and two widely patent right-sided PVs. The length of the left common PV stump was noted to be around 30 mm. The size of the veins is given in Table 1. Anchoring the CBA catheter in the PV stump can be difficult if the length of the pulmonary stump is short. After carefully reviewing the anatomy, it was concluded that the length of the left common PV remnant was sufficient to attempt CBA.As part of routine pre-procedural planning, the patient underwent contrast computed tomography (CT) imaging of the heart, which excluded an intracardiac thrombus ® mapping catheter  and the CARTO® electroanatomic mapping system . The latter demonstrated electrical activity in the left common PV stump and the two right-sided PVs . We then advanced the Achieve catheter  to the left common PV stump. Thereafter, we were able to successfully occlude the left common PV stump using a 28-mm Arctic Front™/Achieve cryoballoon catheter system (Medtronic) and achieve electrical isolation. Then, we successfully performed CBA of the right-sided veins while monitoring the phrenic nerve function. Each of the PVs was frozen once if isolation was seen by 30 seconds, and, if not seen, the veins were frozen twice. Local temperature, esophageal temperature, time to −30°, and thawing were monitored during each isolation procedure. Post-CBA, voltage mapping of the left atrium demonstrated isolation of all three PVs . He was in normal sinus rhythm after the procedure and was discharged home. Unfortunately, at the one-month follow-up visit, he was found to have recurrence of AF. The patient was unable to tolerate atrioventricular (AV) nodal blocking agents due to hypotension, and anti-arrhythmic drugs were contraindicated due to harmful interactions with chronic antibiotic therapy for non-tubercular mycobacterial infection. After patient-centered discussion, he was treated with an AV node ablation and permanent pacemaker implantation.For the CBA, the patient was placed under general anesthesia and an esophageal temperature probe was inserted for close monitoring. We first performed voltage mapping of the left atrium using the PentaRay6 The landmark FIRE AND ICE trial showed that AF ablation using cryoballoon is as effective as using the contact force-guided RF energy.7 These modalities primarily differ in their side-effect profile. RF ablation is associated with a higher incidence of atrioesophageal fistula, whereas cryoablation is associated with a greater risk of phrenic nerve injury.7PVI is the mainstay of treatment in the catheter ablation of AF. PVI eliminates the electrophysiological triggering activity of muscular sleeves at the conjunctional points between the left atrium and the PVs.8 Radiological studies assessing the prevalence and characterization of PV variants in patients with AF revealed anatomical variants in over 24% of the cases, with a high prevalence of left common trunks and supernumerary right PVs.9 Current ablation approaches mainly target the antral region of PVs, but the use of a newer and larger 28-mm second-generation balloon in CBA has reduced constraints from anatomical variations, including larger PVs, in patients with AF.11 Khoueiry et al. demonstrated that, regardless of the PV anatomy, both RF and CBA had similar efficacy and safety profiles at mid-term follow-up of AF ablation.3 Furthermore, in the FIRE AND ICE trial, cryoablation was comparable to RF in terms of efficacy in patients not selected on the basis of their anatomy.6Pulmonary venous anatomy is more variable than the anatomy of the pulmonary arterial system. Furthermore, developmental anomalies such as a single common left PV are commonly encountered in clinical practice.12 Although case reports of patients with pulmonary lobectomies undergoing successful CBA for paroxysmal AF have been documented, lobectomies usually do not lead to significant anatomical changes in cardiac and other thoracic structures.13 In contrast, a left pneumonectomy can result in cardiac rotation due to mediastinal shifting , and a right pneumonectomy can result in a lateral shift of the heart.5 Cardiac rotation causes difficulties in angiographic visualization of PVs, which is an important step in achieving effective PVI.4 After a pneumonectomy, remnant PV stumps typically have lengths of more than 20 mm, whereas muscular sleeves typically have lengths below 10 mm but can reach up to 25 mm inside the PVs.14 Thus, remnant PV stumps are electrically active and frequently remain the sites of active firing, underlining the importance of PVI of the stumps.15 In a study investigating the challenges of PVI in 19 patients with a prior pulmonary lobectomy or pneumonectomy, Fink et al. achieved complete PV visualization in only three (37.5%) patients with a prior pneumonectomy, resulting in incomplete PVI and consequently high rates of recurrent arrhythmias. Of the four patients in the study who underwent a CBA, only one had a history of a total pneumonectomy. In this patient, the left PV stumps could not be visualized angiographically during the index procedure, hence only the right PVs were isolated. The authors did not employ preoperative imaging due to institutional limitations and concluded with a strong recommendation for pre-interventional imaging techniques such as magnetic resonance imaging in patients with a previous pneumonectomy to achieve complete PVI.4There is limited literature on the impact of pneumonectomy on outcomes with CBA. The previous studies did not include patients with a history of pneumonectomy, which can significantly alter the PV anatomy. Kanmanthareddy et al. demonstrated that PVI of PV stumps in post-lobectomy patients with AF was possible using RF ablation, but the study did not include CBA.16 Our experience with RF showed higher rates of post-ablation atypical flutter compared to CBA. The difference in rates of atypical flutter was not investigated in the FIRE AND ICE trial, and further studies are needed to explore this outcome. We routinely utilize preoperative imaging, including cardiac CT angiography and ICE, to delineate the variable relationship between the left atrium, PVs, and surrounding structures and to exclude a left atrial appendage thrombus. We also routinely use the pre-ablation voltage map prior to AF ablation using cryoballoon or RF in all patients in our institution. In this patient who had previously undergone a left pneumonectomy, the left common PV was clipped and ligated with a residual stump. After reviewing the anatomy of the left common PV remnant based on cardiac CT, ICE, and the fast anatomical map, we determined that the length of the PV stump was sufficient to allow effective anchoring of the cryoballoon using the Achieve catheter, and so a decision was made to proceed with CBA. Hence, we were able to successfully achieve complete PVI in all three PVs using the CBA catheter system , and 4.The modality of choice for patients with a previous pneumonectomy remains unclear and is often institution-dependent. We are a high-volume center that uses CBA as the modality of choice for patients with AF. Our practice is supported by a recent study by Mörtsell et al., who studied the second-generation cryoballoon and the irrigated RF energy with regard to outcomes and safety. The study demonstrated lower re-ablation rates and shorter procedure times with CBA as compared to RF ablation.17 To the best of our knowledge, our case is the first to demonstrate that AF CBA can be successfully performed in patients with prior total pneumonectomy.This case highlights the importance of careful selection of patients for CBA, based upon meticulous review of their pre-interventional cardiac CT and intraprocedural imaging. Preprocedural imaging in such patients is helpful for delineating the PV anatomy; identifying potential technical difficulties; and, most importantly, selection of therapy, ie, RF ablation versus CBA.This report illustrates the successful CBA of persistent AF in a patient with a prior left total pneumonectomy. The choice of modality for AF ablation in patients with a pneumonectomy should be individualized based on their preoperative and intraoperative cardiac imaging. Larger studies are needed to determine the differences in outcomes using RF ablation or CBA in this population.


The right ventricular complication happens when the right ventricle (RV) fails to move sufficient blood through the pulmonary circle to enable enough left ventricular pumping. A significant pulmonary embolism/right-sided myocardial infarction may cause this to develop suddenly in a previously healthy heart, but many of the patients treated in the critical care unit have gradual, compensated RV failure as a result of chronic heart and lung disease. RV failure management aims to decrease afterload and improve right-side filling pressures. Vasoactive medications have a lower effect on lowering vascular obstruction in the pulmonary circulation than in the systemic circle because the vascular tone is lower in the pulmonary circulation. Any factors that induce an elevation in pulmonary vascular tone must be addressed, and selective pulmonary vasodilators must be administered in a prescription that does not result in systemic hypotension or compromise oxygenation. The system-based systolic arterial pressure should be kept near the RV systolic pressure to ensure RV perfusion. When these efforts prove futile, judicious application of inotropic medications for better RV contractility may help ensure cardiac output. After obtaining the finest medical treatment, certain individuals may need the implantation of a mechanical circulatory support device.This meta-analysis is intended to compare the Impella and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) mechanical supports for patients with acute right ventricular failure. This comparison should demonstrate the best mechanical support between the two through thorough analysis.The analysis was begun by data collection from relevant sites; PUBMED and EMBASE were searched in collaboration with Google Scholar. Keywords were searched: Impella for acute right ventricle failure and VA ECMO for acute right ventricle failure. The results that were close to the search titles had their respective articles downloaded for further scrutiny.The search finally brought 1001 related articles that were exposed to further analysis to find more refined and closer articles within the needs of this meta-analysis. After extensive scrutiny, 23 articles were found to be the best for these analyses. The data showed that VA ECMO had better results than Impella for acute RV failure. However, the data were not statistically significant, as either the numbers of the studies were not enough or the null hypothesis was true and there was no true difference between them. More studies will be needed to confirm this. Pathophysiology of acute right ventricular (RV) dysfunctionThe left ventricle (LV) and RV functions are linked together. Even while the LV stroke effort ensures blood flows forward into the stiffer high-pressure channels, the RV makes relatively little change in the low-pressure circulatory vessels that feed the pulmonary arteries . The rigVenoarterial (VA) Extracorporeal Membrane Oxygenation (ECMO)VA ECMO is a kind of cardiopulmonary passage that has been modified to allow patients to move about. It may be used to keep critically sick patients with chronic cardiopulmonary failure alive for many days or even several weeks, depending on their condition. ECMO has been mainly utilized in neonatology for more than 40 years, even though it is available in other areas of medicine. Patients with excess but treatable lung diseases, such as influenza, pneumonia, and adult respiratory distress syndrome, were the primary beneficiaries of venovenous (VV) ECMO when it was initially introduced into clinical practice . Over thIncreasing numbers of adult cardiac ECMO oxygenation procedures are being performed. In the past 10 years, there has been a 1,180 percent rise in the amount of money available. Between 1997 and 2007, there were about 200 runs per year. Each year between 2014 and 2016, there were almost 2,000 runs total. Data from the Extracorporeal Life Support Organization was used to compile the research that was discussed in this article [ImpellaThere has been a considerable rise in the usage of subcutaneous mechanical support (SMS) in the past 10 years. Following recent findings on the dubious usefulness of intra-aortic balloon pumps (IABPs), especially in sensitive post-infarction shock, it is expected that emerging devices that provide better circulatory support would have more therapeutic benefits -9. The TDiscussion on ImpellaImpella Access Site ManagementTo avoid the difficulties associated with bigger sheaths, the Impella support access point should be carefully selected and maintained. When deciding on the site access and implantation method for an elective Impella implantation, consider the patient's anatomy as well as the operator's level of expertise. The Impella 2.5 and CP should be implanted percutaneously via the common femoral artery while Impella 5.0 should be implanted through the axillary artery . An angiography may be used to determine whether or not arterial access is required in a small period. Even though Impella may be treated with closure devices like Perclose  for many days, longer-term implants should not be cured using percutaneous preclosure methods owing to the risk of infection. By removing the peel-away sheath and using the repositioning sheath, the arterial flow interruption caused by the Impella catheter may be prevented . In the Impella Placement and Position During Long-Term SupportProper Impella posture is required at all times while providing long-term support for the Impella product line. The device must be correctly positioned over the aortic valve to prevent complications such as suction episodes, hemolysis, and insufficient hemodynamic support. To begin paying attention to devise placement in the catheterization lab or operating room, the first step is to avoid migration into the left ventricular (LV) chamber . Excess Position and Operation of Impella in RVImpella RP is a percutaneous mechanical circulatory support device that allows for early intervention in medically resistant right ventricular failure (RVF). A prompt introduction of mechanical assistance may act as a bridge to recovery, a heart transplant, or destination treatment in the right RVD given the reversible nature of the disease . Since tOne of the first studies to show that the Impella RP is hemodynamically successful included 30 participants in the RECOVER RIGHT trial . It was Patient SelectionWhen the conditions allow, pre-procedural imaging of the RV to rule out the existence of a thrombus is highly recommended. When an Impella ingests a blood clot in the RV, it is quite probable that the Impella will cease working altogether. Regardless of how careful you are, there is always the risk of inadvertently harming yourself or someone else if you swallow some of the catheter's contents by mistake. Severe aortic regurgitation is another contraindication to this procedure (AR). The installation of a reliable valve to separate the left ventricle from the aorta enables Impella-calculated forward flow to be as efficient as possible . AccordiAcute right ventricular failure without hemodynamic support is shown in blue in the pressure-volume loop; Impella CP (Abiomed) support is depicted in green, and ECMO support is depicted in yellow (red). It is necessary to know the loop area to compute the mechanical effort of the ventricle. Pay close attention to how much space is saved by the Impella device, as well as the distinct oblique vertical lines indicating that the ventricle is continuously drained, even during the "isovolumic" stages of the procedure .High-Risk InterventionPatients who have been denied coronary course sidestep joining  because of an unsuitable danger of inconveniences or passing might have one more revascularization choice as percutaneous coronary intercession (PCI). There are numerous potential clarifications for this. Patients who go through PCI, are again in danger of hemodynamic breakdown, conceivably deadly musicality anomalies, and peri-procedural sequelae. Then again, if circulatory help is started before mediation, it very well might be feasible to do complex PCI without encountering fast circulatory decay during coronary impediment, considering broader reperfusion treatment. The intricacy of coronary course infection, just as clinical co-morbidities, including old age, diabetes, and renal brokenness, just as an earlier technique history, decide whether a patient has a high-hazard clinical show . ConfounManagement of ImpellaAnticoagulationTo give Impella support, two anticoagulant arrangements should be utilized independently and independently: 1. Foundational anticoagulation titrated utilizing ordinary strategies; 2. Anticoagulant infused to the cleanse liquid to forestall blood passage into the engine chamber and pushed out into the plunging aorta and the fundamental UFH might be quit, empowering the ACT to diminish into the 150 s range. Long-term support frequencies are provided. A very low incidence of complications occurs with elective high-risk operations, and this is similar to the incidence seen with IABP. N40 mg/dL hemoglobin free .EchocardiographyTransthoracic (TTE) or transesophageal echocardiography (TEE) bedside echocardiography should be 24 hours available a day, seven days a week (TEE). Images taken with TTE give the finest look in the parasternal long-axis perspective. In this case, it's critical to locate the device's intake, which should be approximately 3.5 cm from the RV cavity's vena cava valve. The best TEE research is typically obtained at the mid-esophageal view with a rotation of 120-130 degrees . If therWeaningAs long as the patient's hemodynamics remain stable, no further pharmacological inotropic assistance is needed. The results of short weaning trials performed under echocardiographic supervision may be used to determine if myocardial healing has occurred. Weaning off Impella is accomplished gradually over the last four to six hours, with support decreasing to about 1-1.5 L/min over the last four to six hours . The useCommon console complicationsThe most frequent complication is bleeding, particularly with extended usage. However, for some people, the advantages exceed the dangers .Discussion on VA ECMOActivation, Cannulation, Management, and Weaning Are All Part of the VA Ecmo Logistical ProcessEach phase of an ECMO patient needs a unique set of abilities to fulfill the logistics. The experts engaged in an ECMO patient's treatment frequently depend on experience . The teaActivationActivation of the ECMO team, unless in an urgent matter, requires an initial interactive discourse between the members of the team to assess the possibility of success based on the clinical setting, place’s capabilities, and perfect cure projections . If mostCannulation2 index. The pressure drop between the venous cannula and the artery side of the circuit should not exceed 100 and 300 mmHg, respectively [3/kg/min is required to keep an adult alive. Each cannula's flow characteristics are indicated by a pressure-flow curve in addition to its length and diameter. The UM number (flow at a pressure drop of 100 mmHg across the cannula) describes the cannula and flow characteristics anywhere from the periphery to the heart [Cannulation cannot be emphasized enough. Percutaneous access is needed for ECPR at the catheterization lab or the patient's bedside. In less urgent cases, surgical amputation may be considered. An anticoagulated patient's large-bore cannula must be carefully placed into an artery to avoid hematoma, bleeding, and vascular damage. Percutaneous insertion is frequently done using ultrasound guidance and micropuncture needles. Experts in the field, such as interventional cardiologists or cardiothoracic and vascular surgeons, should perform calculations. The current literature does not define the size of cannulas required for VA ECMO support. Cannulas are selected to give full support for a patient, resulting in a 2.2 l/min/mectively . A flow he heart . Althoughe heart ). Ambulahe heart .Management of ECMO flowThe aorta is typically filled by retrograde ECMO flow from the arterial cannula, which is usually sufficient for an ECMO flow of 50 to 70 ml/kg/min (4 to 6 l/min). As a consequence, the RV now has additional afterload to cope with. When right ventricular end-diastolic pressure (RVEDP) and pulmonary capillary wedge pressure are both high, pulmonary congestion may occur. To shunt blood from the RA to the left atrium and reduce the elevated right-sided pressures, inotropes  or an inMonitoringEach ECMO patient requires a blood vessel line and a pneumonic vein catheter. Some contemporary siphons  ceaselessly screen blended venous immersion, conceivably hindering the requirement for a pneumonic supply route catheter, which is regularly used to screen blended venous immersion. While using thermodilution to decide heart yield, an obscure measure of the chilly bolus is brought into the ECMO circuit, making it prone to be mistaken. To evaluate aspiratory blood vessel tension as a substitute for left ventricular widening, a Swan-Ganz catheter ought to be set and used. Lactate estimation dependent upon the situation might be valuable .AnticoagulationBlood product interaction with the ECMO circuit's surface is reduced when patients are given systemic anticoagulants. One hour after ECMO is begun, fibrinogen and albumin attach to the biopolymer components of the circuit, triggering platelet aggregation, activation, and consumption . If the Ventilator ManagementIndividuals undergoing ECMO may be able to avoid the need for a ventilator if their condition improves. Because ECMO allows for up to complete the gas exchange, a cognizant patient in cardiogenic shock may breathe spontaneously while on ECMO, regardless of whether or not their respiratory function is functioning. Ventilator support, on the other hand, maybe required for airway protection in patients who need sedation such as those who have had a cardiac arrest. In hospitals, low tidal volume ventilation (3 to 5 ml/kg) is often used to minimize lung damage and improve patient outcomes. One or more of the following protective mechanical ventilation settings: an 8/min rate, a positive end-expiratory pressure of 10 to 15 Torr, an inspired oxygen percentage of 0.40, a low tidal volume . Hemodialysis employs the technique of ECMO. In certain cases, continuous VV hemodialysis may be done utilizing an ECMO circuit, whereas, in others, separate vascular access is required. Hemodialysis using the conventional method is also available as an alternative treatment option.TemperatureA heat exchanger is also included in the membrane oxygenator for further efficiency. As a result, it is possible to adjust the temperature of a patient as needed. This conceals the fact that you are suffering from a "fever" as well as the fact that you are suffering from an infection. It may be beneficial to maintain a patient's temperature below 36 F for up to 24 hours following an anoxic insult if extracorporeal membrane oxygenation is utilized .WeaningIf a patient's condition gets better while on ECMO, weaning becomes the next stage. Withholding ECMO at slower rates, such as 0.5 l every six to 24 hours or even more slowly, down to nil, may be more effective than abruptly discontinuing it . The mosComplication of ECMOBleedingPatients on VA ECMO often need anticoagulation, making them prone to clotting issues and bruising than the general population. Hemoglobin levels of 8 to 10 mg/dl are suggested for achieving optimum blood oxygen saturation. However, if transfusions are needed, there is a risk of desensitization and transfusion-related acute lung damage in a prospective transplant candidate (TRALI). Heparin (or a direct thrombin inhibitor) dose may be reduced or anticoagulation may be stopped to control bleeding. According to some studies, you may be able to safely stop taking your anticoagulant for up to three days without suffering any side effects if you have anticoagulation intolerance . ProtamiInfectionBacteremia and sepsis are the most common infectious VA ECMO consequences, and longer ECMO runs are linked with a greater incidence of infection. Within 14 days of starting ECMO, more than 53% of patients get infected. When there are infectious complications, mortality rates may rise as high as 60% of the population. A sterile approach must be used while doing cannulation, particularly if the operation is urgent or emergency in nature .Throughout the studies, VA ECMO had treated 230 patients, and four have been diagnosed with acute RV failure together with cardiogenic shock -22,24. PMethodsInclusion CriteriaTypes of research: Because there were no publications that compared Impella to VA ECMO in advanced heart failure, this meta-analysis included all randomized controlled trials (RCTs) that separately addressed Impella and Va ECMO for acute heart failure. Cross-over trials, as well as quasi-randomized controlled trials and cluster-randomized trials, were not included.Participants' types: All trials involving humans and animals with acute RV failure, heart failure, or both were included in this analysis. Individuals who underwent surgery for which VA ECMO or Impella was planned as a surgical therapy were excluded from this research.Types of interventions: A comparison was made between ECMO utilizing pumps to drive venovenous and venous-arterial circuits as well as pump-free arteriovenous circuits (e.g. intermittent positive-pressure ventilation). Study results comparing ventricular assist devices to other mechanical cardiac support devices were omitted.Language of the studies: We used English as the primary language for our search. All the articles that were included were in English. Other languages articles were excluded from the studyExclusion CriteriaStudies that failed to satisfy the inclusion criteria were excluded.Search Criteria for Identification of the Articlestrials.com/) and clinical trials  for conferences, meetings, and abstracts.Searched based on electronics, we searched PubMed and EMBASE. Other resources were additional databases of current studies like current controlled trials  and clinical trials  for conference proceedings, meeting abstracts, and current trials. They were able to find three trials that were relevant to their investigation (ongoing studies). Because the 23 publications included in this research offered enough information to meet the analytic requirements, data had to be extracted from each of them.A total of 1001 items were found, with 613 coming from PubMed and 388 from EMBASE. After removing all of the duplicate articles (710), just 291 articles remained for further screening. Following a rigorous initial screening process, four clinical trials and an economic assessment of one of those trials were found to be strong candidates for inclusion in this study. There were 268 publications whose titles or abstracts could not be eliminated, therefore, the whole papers had to be obtained and evaluated. None of them fulfilled the requirements for inclusion (excluded studies). Although LR and RT refreshed the search every day, no new results were found. Researchers searched databases, including current controlled studies  was associated with greater levels of psychological distress, discomfort, and being unable to do the things you normally do every day. Extended time since ECMO had a substantial impact on HRQL improvement. VA ECMO use has the potential to cause developmental and neurologic abnormalities as well as other long-term issues. Low oxygen levels in the brain before ECMO or intracranial bleeding have been linked to neurological disorders.Worth mentioning is that we found two animal studies  ,10, whicIn conclusion, acute right ventricle failure needs mechanical support, such as Impella and VA ECMO, for ultimate treatment, as per the analysis described above. Even though both the mechanical devices provide significant assistant to patients with this kind of heart complication, Impella proved to be relatively effective and capable of handling serious complications as the numbers of survivors were statistically high per event. VA ECMO was first used in the operating room as a cardiopulmonary bypass and has since been adapted for use in the critical care unit and beyond. Extracorporeal life support is useful in restoring circulatory support when other therapies fail in people who are anticipated to recover from the source of their RV failure or as a bridge to surgical treatments such as pulmonary endarterectomy or lung transplantation. According to a growing amount of registry and observational data, the Impella system seems to play a major role in limiting RV failure. Impella's early usage in patients with RV failure is linked with a greater probability of survival, according to new research. An Impella-supported PCI may also help with regular right cardiac catheterizations, which may enhance results. So far, there hasn't been enough RCT research to demonstrate that Impella can be used to treat cardiogenic shock. While there is a lot of evidence that Impella can help with specific high-risk PCI procedures, there haven't been any compelling RCT results to back it up. However, generally, the statistical insignificancy in the data could either mean that the null hypothesis is true and there is no difference between VA ECMO and Impella in the treatment of acute right ventricular failure or could indicate that the data could be inconclusive. Either way, more studies are required.