Left ventricular ejection fraction (LVEF) results from the combined action of longitudinal and circumferential contraction, radial thickening, and basal and apical rotation. The study of these parameters together may lead to an accurate assessment of the cardiac function.Ninety healthy volunteers, categorized by gender and age (≤ 55 and >  55 years), were evaluated using two-dimensional speckle tracking echocardiography. Transversal views of the left ventricle (LV) were obtained to calculate circumferential strain and left ventricular twist, while three apical views were obtained to determine longitudinal strain (LS) and mitral annular plane systolic excursion (MAPSE). We established the integral myocardial function of the LV according to: 1. The Combined Deformation Parameter (CDP), which includes Deformation Product (DP) - Twist x LS (° x %) - and Deformation Index (DefI) -Twist / LS (° / %)-; and 2. the Torsion Index (TorI): Twist / MAPSE (° / cm).p = 0.003), but did not vary with gender.The mean age of our patients was 50.3 ± 11.1 years. CDP did not vary with gender or age. The average DP was − 432 ± 172 ° x %, and the average DefI was − 0.96 ± 0.36 ° / %. DP provides information about myocardial function , and the DefI quotient indicates which component (s) is/are affected in cases of abnormality. TorI was higher in volunteers over 55 years (16.5 ± 15.2 vs 13.1 ± 5.0 °/cm, The proposed parameters integrate values of twisting and longitudinal shortening. They allow a complete physiological assessment of cardiac systolic function, and could be used for the early detection and characterization of its alteration. Assessment of LV systolic function is the cornerstone of an echocardiographic examination. Many parameters can be used for clinical and research purposes, but LVEF is the most commonly employed. LVEF results from the combined action of longitudinal and circumferential contraction, radial thickening, and basal and apical rotation. However, LVEF has many limitations as a parameter, some of them related to imaging techniques and others to the definition itself , 2.The particular double helical structure of myocardial fibers results in systolic rotation of the base and apex of the LV in opposite directions round its longitudinal axis, and the algebraic subtraction of this rotation causes twisting of the heart muscle. Due to this muscular movement, the base of the LV moves towards the apex, producing a longitudinal shortening of the LV . TherefoSpeckle tracking echocardiography  (STE) isr = 0.93) [Initially, rotational mechanics of the LV were measured using invasive approaches , 12. How = 0.93) , 16.It has been suggested that, in the future, a combined approach in which both changes in LV rotational mechanics and longitudinal shortening are evaluated and interpreted in an integrated way will be necessary to establish normal reference values –20. The We present values of strain and rotational mechanics obtained with STE in a healthy population. Based on these values, new parameters are proposed for the study of cardiac function, implying a more integral evaluation of the components involved in the mechanism of contraction.This is an observational, prospective study in which 104 healthy volunteers were initially enrolled after being randomly selected among hospital staff. Inclusion criteria were: age > 18 years, absence of cardiovascular disease and/or risk factor, and normal physical and electrocardiographic examinations. Exclusion criteria were sports training and pregnancy.The hospital’s Clinical Research and Ethics Committee approved the study. The written informed consent of the participants was obtained.Two ultrasound systems  equipped with 2.5 MHz transducer were used. Two-dimensional views of the apex  were obtained to calculate longitudinal strain (LS). From the parasternal short axis perspective, transverse projections of the mitral valve, papillary muscles and apex facilitated calculation of radial strain, circumferential strain and rotational parameters. All images were obtained at a frequency of between 50 and 80 frames/second. The moment of aortic valvular closure was determined in the long axis apical projection. All images were transferred to a workstation for computer analysis .The LV endocardial border was traced manually slightly within the myocardium to calculate myocardial strain. Then, with the help of the software, a second larger concentric circle was automatically generated near the epicardium to include the full thickness of the myocardial wall. The program automatically divided each projection into six equal segments and performed frame-by-frame speckle tracking, providing automated tracking confirmation (verified by the operator) and generating strain values, expressed as percentages.Rotation is an angular displacement of a myocardial segment in a transverse projection around the longitudinal axis of the LV. Apical systolic rotation occurs in a counter-clockwise direction and is expressed in degrees with positive values when viewed from the vertex. Conversely, basal rotation is produced in a clockwise direction, with negative values. The twist that occurs as a consequence is the net difference, in degrees, between apical and basal rotation.Care was taken to ensure that all ultrasound adjustments, including image depth and frame rate, were maintained for each individual’s data collection. Images of four and two chambers were recorded for analysis of end-diastolic and end-systolic volumes, and LVEF was calculated using Simpson’s biplane method.In addition to LS, longitudinal shortening of the LV was estimated from the systolic excursion of the mitral annular plane (MAPSE) in the four-chamber projection by placing the M-mode cursor at the septal and lateral level of the ring and averaging both values. The base-apex distance (B-A) was determined in the four-chamber view, at the end-diastole and at the beginning of the QRS.Classic Torsion (CTor): Twist/B-A distance (degrees/cm)Torsion Index (TorI): Twist/MAPSE (degrees/cm)Deformation Product (DP): Twist x LS (degrees x %), andDeformation Index (DefI): Twist / LS (degrees / %).Combined Deformation Parameter (CDP):We evaluated the various parameters that contribute to LV myocardial function Fig. :Classic p value of < 0.05 was considered statistically significant. The intraclass correlation coefficient was used to evaluate intraobserver and interobserver reproducibility of continuous variables, according to a random sample of 10 cases, with masking and measurements performed at different moments.Continuous variables are expressed as mean and standard deviation, and proportions as percentages. We compared strain values according to gender and age (≤ 55 years and >  55 years) using a Student’s t test. Normality of distribution of the studied parameters was confirmed. A Statistical analyses were performed using the IBM SPSS Statistics v.19.0.0329 software package.Our study population was eventually composed of 90 healthy subjects after 14 of the original 104 were excluded due to a deficient ultrasonic window that made it impossible to obtain adequate measurements in all segments of the LV. Mean age was 50.3 ± 11.1 years, women 43.3%.Table The mean values of LS, radial strain and circumferential strain are presented in Table p = 0.05, and 16.5 ± 15.2 vs 13.1 ± 5.0, p = 0.003, respectively), while no age differences were observed with respect to DefI  in humans [The arrival of STE has revived interest in LV torsion, and research shows a very close correlation with cardiac resonance  is usually defined by dividing the twist by the B-A distance during the final phase of the diastole, expressed in degrees/cm . AccordiThe parameters proposed in this work for the evaluation of ventricular torsion, such as TorI and DefI, provide a more reliable representation of the components of cardiac systole. They involve quantification of longitudinal shortening and twist, as an expression of dynamic systolic events that occur simultaneously in an elastic organ such as the ventricular myocardium.It is important to underline the difference between the meanings of the commonly used definition classic torsion (CTor)  and the The torsion generated as a result of this interaction, and which depends on the helical shape of the myocardial fibers, contributes to the thickening of the myocardium towards the ventricular centroid and the consequent ejection of the corresponding systolic volume. Therefore, with the proposed indices (TorI and DefI), we intend to provide a measure of intrinsic muscular torsion that is independent of cardiac size. CTor normalizes twist with respect to a static dimension such as the diastolic size of the LV. Thus, the extent of the torsion may be reduced according to its classical definition  (CTor) and increased when calculated by TorI and DefI, as can be appreciated in Table However, MAPSE is not always feasible; namely, in patients with mitral prosthesis or calcification of the mitral annulus. As a result of this limitation, together with the fact that the LS and twist can be visualized with the same speckle tracking technology base, it is preferable to use DefI. In addition, MAPSE and LS do not always occur in parallel, and the latter has already demonstrated itself to be easily measured and to have prognostic capacity when considered in isolation –38.We propose the “Combined Deformation Parameter” (CDP) for the estimation of myocardial function throughout the evaluation of the two fundamental components of contractile mechanics: twist and LS. The CDP consists of two aspects: first of all, the state of myocardial function, evaluated as the “Deformation Product” (Twist x LS), which quantifies the longitudinal deformation and the twist, both of which increase contractility. Secondly, the extent of the involvement of each component in ventricular function is assessed by the DefI quotient (Twist/LS). The different possible combinations are shown in Table The CDP may be useful for monitoring cardiopathies characterized by ventricular volume overload, in which LS may not represent the earliest alteration nor be the only alteration. Similarly, just as the study of cardiotoxicity in oncology is mainly based on the evaluation of EF and LS, the CDP may be an asset in the evaluation of transmural myocardial conditions that are not limited to LS.In this sense, heart failure has also recently been classified according to alterations in the mechanical function of the LV . After hCardiac structural and functional changes during the early stages of heart failure can act as compensatory mechanisms. However, as the disease progresses, these mechanisms are often insufficient. When evaluated in isolation, LS has proven its prognostic capacity , 43 as tThere is a consensus that future practice needs to adopt a combined approach in which changes in LV rotational mechanics and longitudinal shortening are considered and interpreted together, and normal values will need to be established if this to be possible , 19. We The proposed parameters integrate values of twisting and longitudinal shortening. In the present work, we provide reference values obtained in a population of healthy subjects. These parameters allow a complete physiological assessment of cardiac systolic function, and could be used for the early detection and characterization of its alteration.Despite the great advantages offered by 2D-STE, it does have several limitations. It depends on the quality of the image, produces inaccuracies due to planar movement, the quality of the tracking is usually lower at the distal level compared to nearby fields, and frames that are too high or too low are associated with poor tracking. Some limitations are overcome with 3D-STE , but a lThe sample size is limited so that the new parameters deserve more extensive validation. Maybe a future, multicentre study could provide a definite answer regarding the usefulness of the proposed parameters. Likewise, the value of the new parameters should be validated against other methodologies, such as magnetic resonance imaging.


To study ventricular‐arterial coupling(VAC) in uremic patients by application of two‐dimensional speckle tracing imaging (2DSTI).BA), papillary muscle (LSPM), and apex values (LSAP) were calculated.One hundred uremic patients were divided into two groups based on left ventricular ejection fraction (LVEF): group 1 with LVEF ≥ 5%, and group 2 with LVEF < 55%. Forty healthy subjects were recruited as a control group. Conventional echocardiography was performed; VAC components and myocardial performance index were calculated. Longitudinal strain (LS) of 17 segments was measured using 2DSTI. Mean base (LSP < 0.05). EF, fractional shortening (FS), end‐systolic elastance (Ees) were significantly higher in group 2 (P < 0.05). SLBA, SLPM, and SLAP differed significantly among the groups . SLBA, SLPM, and SLAP correlated positively with Ees, EF, and FS  but negatively with arterial elastance (Ea), VAC, systemic vascular resistance index (SVRI), and rate‐pressure product (RPP) . Multiple regression analysis revealed that relative wall thickness (RWT), LVMI, LSAP, and stroke works (SW) were independent predictors of VAC .Compared to subjects in the control group and group 1, subjects in group 2 exhibited decreased LV end‐diastolic volume (EDV), end‐systolic volume (ESV), LV mass index (LVMI), and VAC (AP was an independent predictor for VAC.In patients with uremia, LV myocardial LS gradually decreased as LV systolic dysfunction decreased. VAC correlated negatively with left ventricular LS, and LS This modality may be used to objectively assess myocardial deformation and quantitatively analyze regional wall motion abnormalities. 2DSTI is also preferable for evaluation of apical segment movement because the approach used avoids the angle dependence of Doppler technology.The aim of this paper was to assess the utility of 2DSTI for evaluation of cardiovascular stiffness and VAC in patients with uremia.22.1This study enrolled 100 patients  with uremia seen at the Urology Department of our hospital during the period from January 2015 to December 2017. Subjects were divided into 2 groups: group 1 included subjects with normal LV systolic function; group 2 included patients with LV systolic dysfunction. Systolic dysfunction was defined as LV ejection fraction (LVEF) <55%. Patients were excluded if they had valvular disease, coronary heart disease, hypertrophic cardiomyopathy, congenital heart disease, or peripheral arterial disease. All uremic patients were on hemodialysis for 4 hours a day, 3 times a week. Patients without standardized treatment were excluded. Each patient underwent assessment by 2DSTI before hemodialysis.Forty healthy volunteers  who had no history of renal or cardiovascular disease were included as controls. All subjects included as controls had normal physical examination, echocardiographic, and electrocardiographic results. The study was approved by the Ethics Committee at Gaozhou People's Hospital, and each patient who participated in the study provided written informed consent.2.2Two‐dimensional echocardiography was performed with a commercial ultrasound machine  equipped with an S5‐1 transducer (1–5 MHz). Conventional echocardiography was performed with the patient in the left lateral decubitus position. LV end‐diastolic diameter (EDD), LV end‐systolic diameter (ESD), LV posterior wall thickness (PWT), and interventricular septum thickness (IVST) were measured according to the criteria provided by the American Society of Echocardiography . These parameters were used to calculate LV mass index (LVMI)2.3Arterial elastance (Ea) was estimated as end‐systolic pressure (ESP)/stroke volume (SV), with ESP estimated as systolic pressure × 0.9.V0 is LV volume when LV pressure = 0.LV end‐systolic elastance (Ees) was calculated as follows:Accordingly, VAC was calculated as Ea/Ees.Stroke works (SW) was obtained as ESP × SV;2.4BA), papillary muscle (LSPM), and apex (LSAP) were calculated.Offline strain measurements were performed with Qlab 8.0 software. Apical four‐, two‐, and three‐chamber views were obtained with frame rates >60 frame/sec. The regional four‐chamber view of the left ventricular apex was analyzed first. Three points were selected for analysis. The software program automatically provided an outline of the endocardium to produce a region of interest (ROI). ROI width was adjusted manually to reflect myocardial thickness.2.5P < 0.05 was considered statistically significant.Statistical analyses were performed using SPSS 20.0 software . All data are expressed as mean values ± SD. Analysis of variance for multiple comparisons was used to assess between‐group differences. Pearson's correlation coefficients were applied to evaluate correlations between variables of interest. Multiple linear regression analysis was performed to explore the determinants of VAC. 33.1P < 0.05) (Table Descriptive characteristics of the patient population are presented in Table 5) Table .3.2P < 0.05). LSBA, LSPM, and LSAP were lower in group 1 (P < 0.05), compared with the control group. LVEDV, LVESV, and LVMI were significantly higher in group 2, compared with the control group and group 1 (P < 0.05). EF, FS, LSBA, LSPM, and LSAP were significantly lower in group 2 than in the control group and group 1 (P < 0.05). RWT was slightly higher in group 2 than in the control group, but this trend was not statistically significant. There were no differences across groups in SV, CO, or CI  and negatively correlated with Ea, VAC, SVRI, and RPP . No significant correlation with SW and RWT was observed. Multiple linear regression analysis showed that RWT, LVMI, LSAP, and SW were independent predictors of VAC. Standard regression coefficient b′ was −0.443, 0.537, −0.470, and −0.491, respectively   was significantly decreased, especially in patients with LV systolic dysfunction (group 2). Correlation analysis revealed a moderate negative correlation between VAC and LSBA, LSPM, and LSAP . Ees was positively correlated with LSBA, LSPM, LSAP; Ea was negatively correlated with LSBA, LSPM, and LSAP.2DSTI technology is a noninvasive tool that has recently garnered increasing interest among clinicians. This modality provides a quantitative analysis of segmental contractility and an objective evaluation of myocardial function.BA nor LSPM shows changes in response to hypertensive stimuli, LV contractility is affected mainly by LSAP rather than LSBA or LSPM, suggesting that LSAP may contribute to VAC only partially.AP are a major determinant of VAC, whereas changes in LSBA and LSPM may have only minor effects on VAC.Previous studies have investigated the determinants of VAC in hypertension and diastolic dysfunction.5This study had some limitations. Firstly, the duration of uremia should be an important parameter when analyzing the effects of uremia on cardiac function and VAC. However, this study failed to analyze the duration of illness in uremic patients, as some patients did not know how long they had been suffering from uremia. Secondly, during dialysis treatment, blood biochemical parameters associated with uremia changed dynamically. This study did not include laboratory analysis. It is expected that in future studies, changes in cardiac function and VAC during this dynamic process will be analyzed. Finally, future studies should investigate global LS in uremic patients.6AP was an independent predictor for VAC.In conclusion, LV myocardial LS decreased gradually as LV systolic dysfunction decreased in patients with uremia. VAC was normal in uremic patients with normal LV systolic function but abnormal in patients with LV systolic dysfunction. VAC correlated negatively with left ventricular LS, and LS


Dr. Derek J. Hausenloy is a Professor at Duke-National University of Singapore and University College London.He is Honorary Consultant Cardiologist at the National Heart Centre Singapore and the Barts Heart Centre.Professor Hausenloy graduated from Manchester University, UK, and performed a PhD in Cardiovascular Medicine at the University College London, UK, investigating the role of mitochondria as targets for cardioprotection. He performed his clinical Cardiology training in London and subspecialized in cardiac MRI. His main research interests include cardioprotection  and small animal and clinical cardiac magnetic resonance imaging, publishing numerous findings on the subject.He is also a Fellow of the European Society of Cardiology (FESC) and American College of Cardiology (FACC).1. By understanding the pathophysiology underlying the effect of ischemia/reperfusion injury on the heart, we hope to identify new treatments for protecting the heart, thereby preserving cardiac contractile function and improving clinical outcomes in patients with ischemic heart disease.Ischemic heart disease is the leading cause of death and disability worldwide. One major clinical manifestation of ischemic heart disease is an acute myocardial infarction. For patients presenting with an acute myocardial infarction, a blockage within the coronary artery deprives oxygen and nutrients to the myocardium resulting in damage to the heart muscle (termed ischemic injury). In these patients, the treatment of choice is to remove the blockage using coronary angioplasty to restore blood flow to the heart muscle - paradoxically, this can in itself cause further damage to the heart (termed reperfusion injury)1,2. Crucially, although treatments are in place to limit ischemic injury, there is currently no effective therapy for preventing reperfusion injury, and so new treatments are required to target and prevent this form of myocardial injury.Initial research in this field focused on the detrimental effects of ischemia on the myocardium, but over the time, it has become apparent that, although reperfusion is essential to salvage viable heart muscle following an acute myocardial infarction, restoring blood flow can in itself damage the heart muscle – termed myocardial reperfusion injury3.Although a vast number of new treatments for protecting the heart against ischemia/reperfusion injury have been discovered in the research laboratory, the translation of this knowledge into the clinical setting has been challenging. The reasons for this are many and include the use of animal ischemia/reperfusion models, which do not accurately represent the patient presenting with an acute myocardial infarction, and the inadequate design of the clinical studies4. This treatment strategy has been shown to be effective at preventing ischemia/reperfusion injury in patients presenting with an acute myocardial infarction 5 and in patients undergoing cardiac bypass surgery 6.By subjecting the heart to brief non-lethal episodes of ischemia and reperfusion it is possible to upregulate endogenous mechanisms of protection within the heart and render the myocardium resistant to the detrimental effects of ischemia/reperfusion injury – a phenomenon which has been termed ‘ischemic conditioning’. The most promising approach to translating ischemic conditioning into the clinical setting is to apply the protective stimulus to the arm by simply inflating and deflating a blood pressure cuff placed on the upper arm – a phenomenon termed ‘remote ischemic conditioning’In 5-10 years, I would hope that we will have discovered a new treatment for protecting the heart against ischemia/reperfusion injury which is capable of improving clinical outcomes in acute myocardial infarction patients, in terms of improved patient survival and less heart failure.Given the challenges of pursuing a career in research, it is essential that the young scientist be passionate for research and have a good mentor looking out for them.


MFR is a predictor of adverse cardiac events in patients with non-ischemic systolic heart failure and previous studies using different methods have found association between myocardial blood flow and left ventricular dilatation. The aim of this study was to investigate whether there is an association between increasing end-systolic- and end-diastolic volumes (ESV and EDV) and MFR in these patients measured with Rubidium-82 positron emission tomography computed tomography (82Rb-PET/CT at rest and adenosine-induced stress to obtain MFR and volumes. To account for differences in body surface area (BSA), we used indexed ESV (ESVI): ESV/BSA (ml/m2) and EDV (EDVI). We identified factors associated with MFR using multiple regression analyses.We scanned 151 patients with non-ischemic heart failure with initial left ventricular ejection fraction ≤35% with 2; 95% confidence interval [CI] -5.6 to − 1.8; P < 0.001) and increasing EDVI . Results remained significant after multivariable adjustment. Additionally, coronary vascular resistance during stress increased significantly with increasing ESVI (estimate: 3.1 mmHg/(ml/g/min) per (10 ml/m2); 95% CI 2.0 to 4.3; r = 0.41; P < 0.0001) and increasing EDVI (estimate: 2.7 mmHg/(ml/g/min) per (10 ml/m2); 95% CI 1.6 to 3.8; r = 0.37; P < 0.0001).Median age was 62 years (55–69 years) and 31% were women. Mean MFR was 2.38 (2.24–2.52). MFR decreased significantly with both increasing ESVI , ClinicalTrials.gov Identifier: The online version of this article (10.1186/s12872-019-1047-x) contains supplementary material, which is available to authorized users. Myocardial flow reserve  is a strong marker of myocardial vasomotor function and quantification of MFR may identify microvascular dysfunction –3. MFR i82Rb-PET/CT with adenosine stress is a robust and validated method  0.76 to 1.09) and median global stress MBF was 2.18 ml/g/min (IQR 1.69–2.76). Table 2); 95% CI 0.3 to 2.9; r = 0.21; P = 0.02), ; 95% CI 0.2 to 2.6; r = 0.17; P = 0.047), . The statistical correlations between CVR during stress and ESVI and EDVI, respectively were strong in univariable analyses: ESVI estimate: 3.1 mmHg/(ml/g/min) per (10 ml/m2); 95% CI 2.0 to 4.3; r = 0.41; P < 0.0001 ; 95% CI 1.6 to 3.8; r = 0.37; P < 0.0001), ; 95% CI 1.3 to 5.0; P < 0.001 and EDVI estimate: 2.2 mmHg/(ml/g/min) per (10 ml/m2); 95% CI 0.6 to 3.8; P < 0.01).Coronary vascular resistance values at rest and during stress are also shown in Table 2; 95% CI -6.0 to − 1.1; r = 0.29; P < 0.01) and with increasing EDVI . At stress, CVR was significantly associated with both ESVI (estimate: 3.2 mmHg/(ml/g/min) per (10 ml/m2); 95% CI 1.7 to 4.6; r = 0.42; P < 0.0001) and EDVI (estimate: 2.8 mmHg/(ml/g/min) per (10 ml/m2); 95% CI 1.3 to 4.2; r = 0.38; P < 0.001). The associations remained significant after multivariable adjustment. At rest, no significant associations were found between CVR and ESV and EDV, respectively.When investigating only the 118 patients with idiopathic cardiomyopathy, we found similar results for both MFR and CVR. MFR decreased with increasing ESVI (estimate − 3.5% /10 ml/m2), 95% CI 0.7 to 1.3, P < 0.0001 and SRS: estimate 0.9 per (10 ml/m2), 95% CI 0.7 to 1.1, P < 0.001) and multivariable (SSS: estimate 0.9 per (10 ml/m2), 95% CI 0.3 to 1.4, P < 0.01 and SRS: estimate 0.8 per (10 ml/m2), 95% CI 0.3 to 1.2, P < 0.001). No significant association was found between ESVI and SDS either in a univariable or a multivariable analysis. Results were similar for EDVI. Association with SSS and SRS were significant univariable (SSS: estimate 0.9 per (10 ml/m2), 95% CI 0.6 to 1.2, P < 0.0001 and SRS: estimate 0.8 per (10 ml/m2), 95% CI 0.6 to 1.0, P < 0.001), whereas there were no significant relation between SDS and EDVI (SDS: estimate 0.1 per (10 ml/m2), 95% CI -0.04 to 0.3, P = 0.14). In multivariable analyses the association between EDVI and SSS as well as SRS remained significant (SSS: estimate 0.6 per (10 ml/m2), 95% CI 0.1 to 1.1, P = 0.02 and SRS: estimate 0.6 per (10 ml/m2), 95% CI 0.2 to 1.0, P < 0.01). Results for SSS and SRS remained significant associated with both ESVI and EDVI in the univariable analyses, when only including the 88 patients with more than 5% abnormal perfusion (SSS ≥4).Summed rest-, stress- and difference scores  were assessed in all patients Table . We foun82Rb-PET/CT in patients with non-ischemic systolic heart failure showed that MFR decreased linearly with increases in ESVI and EDVI. These findings remained significant when adjusting for relevant covariates. Further, we found a positive association between stress CVR and ESVI as well as stress CVR and EDVI. Of our patients 64% or 46% had resting ESV higher than 59 ml or 78 ml and 72% or 66% had resting EDV higher than 108 ml or 115 ml. These values corresponded to one standard deviation above the mean normal values in the background literature.This study of MFR assessed by 82Rb-PET/CT, as gold standard quantitative measurement of myocardial perfusion, and ESVI and EDVI in patients with varying types of non-ischemic systolic heart failure. In these patients, we found a linear association between increasing ESVI and EDVI and decreasing MFR. These findings have, to our knowledge, not previously been explored in patients with non-ischemic systolic heart failure using 82Rb-PET/CT. Previous studies have investigated patients with dilated cardiomyopathy using either echocardiography with coronary Doppler catheter to measure coronary flow reserve [99mTc-MIBI) washout rate as a surrogate measure [Our results concur with previous findings of decreased MFR in patients with non-ischemic systolic heart failure –6, 24, a reserve , 13 or S measure  which arThe linear relationship between increasing ESVI and EDVI and the decreasing MFR may suggest an association between degree of dilatation and microvascular disease progression. Studies on dilated cardiomyopathy have not found any correlation between myocardial perfusion abnormalities and extent of myocardial fibrosis , 26 indiSeveral experimental observations about myocardial perfusion have previously been made. Tsagalou et al. found that in patients with dilated cardiomyopathy, decreased MFR obtained by thermodilution was associated with decreased myocardial capillary density measured in endomyocardial biopsies. These results support that angiogenic therapies with intramyocardial delivery of different kinds of vascular endothelial growth factors could be considered for future treatment of heart failure . In contIn the current study we found a significant positive association between CVR during stress and ESVI and EDVI that remained significant in a multivariable analysis. One explanation could be that the lower MFR is simply due to a higher CVR at stress in these patients, perhaps caused by higher myocardial tissue pressure in diastole . Median It is well known that impaired MFR is associated with increased CACS both in patients with intermediate risk of coronary artery disease and in asymptomatic adults , 31. AlsIt remains uncertain whether impaired myocardial perfusion causes dilatation or dilatation leads to impaired perfusion. If the first scenario is true, treatment focused on the impaired perfusion may prevent further dilatation. To investigate the second scenario further, it would be interesting to measure MFR before patients initiate treatment for heart failure and when they are fully up titrated to observe if MFR improves with reversibility in dilatation.82Rb-PET/CT scan. We adjusted for various potential risk factors in the multivariable adjustment and the association between MFR and ESVI as well as between MFR and EDVI stayed significant. We chose not to include LV mass in the multivariable adjustment, because of a very strong correlation between ESVI and LV mass (r = 0.92) and EDVI and LV mass (r = 0.90), respectively. However, if LV mass was included in the model, the association between both MFR and ESVI and MFR and EDVI remained significant, while LV mass was not independently correlated with MFR. Patients could be included in our study with some extent of coronary arteriosclerosis. However, this was not the cause of their heart failure and CACS did not explain the association between MFR and ESVI and EDVI, respectively. Additionally, at the time of 82Rb-PET/CT, no patients complained of angina, none had received interventional treatment and only 2.6% of patients received calcium antagonists and 2.0% received long lasting nitrates.This study was conducted in a group of patients with non-ischemic systolic heart failure from a larger randomized clinical trial . The pat82Rb-PET/CT with a quantitative measure of myocardial perfusion to show a linear association between myocardial perfusion and end-systolic- and end-diastolic volumes in patients with non-ischemic systolic heart failure. Whether microvascular dysfunction plays a role in heart failure development remains uncertain. Our results imply that myocardial perfusion measured as MFR may be a useful tool to elucidate this. Clinical trials investigating changes in MFR and its relation to treatment responses may clarify the clinical use of MFR in patients with non-ischemic systolic heart failure.In patients with non-ischemic systolic heart failure, impaired MFR was significantly associated with increased left ventricular ESV and EDV. This is the first study using Additional file 1:Table S1. Multivariable analysis with myocardial flow reserve as the dependent variable including end-diastolic volume index, sex, age, hypertension, diabetes, NT-pro-BNP, LV bundle branch block, LV ejection fraction, atrial fibrillation during scan, increases in heart rate from rest to stress and coronary calcium score as possible explanatory variables. (DOCX 19 kb)


Heart failure (HF), is a major public health issue globally. Echocardiography is cost–effective in the diagnosis in expert hands. This study was conducted to estimate the usefulness of Aortic Root Systolic Excursion (ARSE) as a simple and accurate measure to estimate Left Ventricular (LV) function.This was a cross-sectional echocardiographic study among adults aged ≥ 18 years, with or without heart failure, in sinus rhythm, and with no LV out–let obstruction. We studied the correlations of ARSE with some selected indices of LV Systolic Functions. We determined optimal cut–offs of ARSE in detecting LV dysfunction. We generated a simple regression equation to best estimate LV ejection fraction according to the modified Simpson method.Overall 213 echocardiograms were included from 106 males (49.8%), with mean age of the participants being 52.4 (SD: 18.3) years. The rate of LV systolic dysfunction was highest with Teicholz method (17.4%) and lowest with MAPSE method (5.2%). ARSE correlated with the LV functions. This was highest for the Simpson method , and lowest for the ITV method . Optimal cut-offs to detect LV systolic dysfunction was ≈ 6.6 mm. For an LV ejection fraction < 55%, the sensitivity was 82.9%, and the specificity was 97.2%, with an AUROC of 91.6%.The logarithmic regression equation was best in predicting LV ejection fraction (AUC: 60.2%), followed by the power model (AUC: 56.7%), and the linear model (AUC: 53.6%).ARSE correlated well with LV systolic function. The cut–off ≤ 6.5 mm suggest LV systolic dysfunction. LV Ejection Fraction was best estimated with the generic equation: LVEF (%) = 29 x In [ARSE]. Ünlüer et al , where ARSE is in millimeters (mm). An ARSE ≤ 6.5 mm suggests an LVEF < 55% measured using the Simpson method.Ünlüer et al [Ünlüer et al [Ünlüer et al [Ünlüer et al [Ünlüer et al. 20 + 40 x ARSE (cm). This linear model explained 53.6% of the data. The best model we are proposing is the simplified Logarithmic model 29 x In ARSE (mm) which explained 60.2% of the data. However, the model by Ünlüer et al can be computed off-hand, while our model needs a calculator.The idea of studying movements of parts of the heart such as the aorta as a surrogate of heart function should probably be age long, as M-mode was the first modality to be described . Few stuer et al  and Burger et al . Howeverer et al , where der et al . Also, ter et al  on our ger et al  in termsAnother surrogate of LV systolic function that is easy to measure by the less skilled and busy physician is the E-point septal separation (EPSS) ,17. HoweARSE in low-income settings like ours has some clinical utilities. There are about 64 cardiologists in Cameroon, for a total population of about 23 million inhabitants. Most of them are concentrated in two major neighboring cities. Thus, most patients with cardiovascular disorders are cared for by general practitioners (GPs) who lack specialized skills in cardiac ultrasound. There is also an increasing number of low-technology echographs in our setting that lack the sophisticated cardiac algorithms. There is clearly the need for some task shifting to GPs, including basic cardiac ultrasound techniques with ARSE evaluation. Monitoring and guidance of GPs in distant areas by cardiologists can be carried out through telecommunication which is widely available in our setting. In low-income settings, GPs can be trained to assess ARSE, and abnormal ARSE (≤6.5mm) will warrant referral to the nearest cardiologist for a formal echocardiography. However, the reproducibility of ARSE measurements by GPs is not known. There is a need for a well-designed study to assess the reproducibility of ARSE measurements as well as other LV systolic function indices by GPs. Even in busy cardiac ultrasound laboratories in low income, ARSE can be used to give an idea of the expected LV ejection fraction. Further studies are needed to see if ARSE gives information beyond the LV ejection fraction–such as the aortic root rigidity.Despite this improvement, we encountered some difficulties in measuring ARSE in certain participants. Some participants presented with increased or multiple layer echogenicity of the posterior or far aortic wall, making precise measurements of ARSE difficult. Such cases occurred with breathing. These were considered technically difficult and the measurements uncertain. Such data were not included in the analysis. Also, some participants appeared to have asymmetry in the movements of the aortic wall, with the anterior or near wall having a higher amplitude of movements than the posterior portion despite perpendicular sectioning in M-mode. All measurements were performed on the posterior wall of the aortic root, so as not to violate the protocol. The effect of sampling ARSE from the anterior wall in such conditions remains uncertain.Our findings should be considered in the light of some limitations. No intra-observer or inter-observer variability testing was carried-out. In order to ensure measurements as per protocol, the measurements were carried out in the presence of the principal investigator (AMJ) who worked with the cardiologist (BH). At least three measurements per parameter were obtained when the first two measurements were markedly different. More precise echocardiographic measurements of LV volumes aiding with contrast (SonoVue) were not used. 3D echocardiographic measurements of LV volume that correlate well with MRI measurements were also not used. This technique cannot be generalized to all patients as we excluded patients < 18 years, patients with significant LV outlet obstruction, large pericardial effusion, and markedly enlarged left atrium. However, about ¾ of cases of heart failure in low-income settings are accounted for by hypertensive heart disease, rheumatic heart disease, and the dilated cardiomyopathies . DespiteAortic Root Systolic Excursion (ARSE) is an acceptable surrogate of LV systolic functions at set threshold of < 6.6 mm (approximately ≤ 6.5 mm) in predicting an LVEF < 55% according to the Simpson method. In this prospectively conducted cross-sectional study on the correlations of Left Ventricular (LV) functions with ARSE, we have confirmed that ARSE correlates moderately with LV systolic functions with a good sensitivity, specificity, accuracy, predictive values, and likelihood ratios. We have also established that LV systolic function assessed by the modified Simpson method can best be estimated from ARSE using the modified generic equation: LVEF (%) = 29 x In [ARSE), where ARSE is in millimeters (mm). Despite the improvements shown in our study, we recommend further research on Aortic Root Systolic Excursion (ARSE) so as to validate our findings. In practice, GPs in low income settings can be trained to measure ARSE, and an abnormal ARSE will warrant referral to a cardiologist for formal echocardiography.S1 Dataset(XLS)Click here for additional data file.S1 FigARSE is measured at the far wall of the aortic root using the TM mode. ARSE is measure between the yellow lines (red arrow).(TIF)Click here for additional data file.


Brugada syndrome is characterized by typical electrocardiogram changes and a high risk for sudden cardiac death . In addition to the well known electrical substrate, morphological and functional alterations appeared to be present in a subset of the Brugada syndrome patients . Echocardiographic speckle tracking enables us to detect subtle contraction alterations . We performed transthoracic echocardiography with speckle tracking analysis in 82 healthy controls and 175 Brugada syndrome patients. Main findings are presented and discussed in the article “Contraction alterations in Brugada syndrome; association with life-threatening ventricular arrhythmias” . This related Data article contains segmental longitudinal strain values for RV and LV, and the comparison of echocardiographic parameters between Brugada syndrome patients with spontaneous and drug-induced type 1 pattern and between patients with and without ventricular arrhythmia inducibility during electrophysiological study. First, we compared patients who presented a spontaneous type 1 electrocardiogram pattern with patients who were diagnosed based on a drug-induced type 1 pattern .Table 2DSecondly, we compared patients in whom a sustained ventricular arrhythmia could be induced during electrophysiological study compared to patients in whom no ventricular arrhythmia could be induced . A total22.11–V2) positioned in the second, third, or fourth intercostal space Brugada syndrome patients were recruited from the database of the University Hospital of Brussels. All had been diagnosed with Brugada syndrome based either on a spontaneous or drug induced ST segment elevation with a type 1 morphology of ≥2 mm in 1 or more leads among the right precordial leads , equipped with a 2D broad-band M3S transducer (2.5 MHz). In each patient standard parasternal long- and short-axis images, apical 4-, 2- and 3-chamber views and a RV focused 4-chamber view were acquired The LV end-diastolic volume (LVEDV) and LV end-systolic volume (LVESV) were measured and the ejection fraction (EF) was calculated by modified Simpson's biplane method. Tricuspid annular plane systolic excursion (TAPSE) was obtained by M-mode through the tricuspid annulus on the 4-chamber view. RV outflow tract (RVOT) proximal and distal diameters were measured from the parasternal short-axis view. End-diastolic and end-systolic RV area (RVA) were obtained from the RV focused 4-chamber view and fractional area change (FAC) was calculated Speckle tracking analysis was performed on the 3 apical views for the LV and on the RV focused 4-chamber view for the RV 2.3appeared in ≥1 right precordial leads. The drug infusion was discontinued if QRS prolongation exceeded 30%, frequent premature ventricular beats or type 1 Brugada ECG occurred or development of high-degree atrio-ventricular block.Ajmaline (1 mg/kg) was administered intravenously over a 5-min period to unmask the diagnostic type 1 electrocardiogram pattern in case of non-diagnostic baseline electrocardiogram. The test was considered positive if type 1 ECG 2.4Electrophysiological study protocol consisted of a single site of stimulation at the right ventricular apex, three basic pacing cycles , and introduction of up to 3 ventricular premature beats down to a minimum of 200 ms. A patient was considered inducible if a sustained (≥30 seconds) ventricular fibrillation or ventricular tachycardia was induced.2.5Continuous data was presented as mean ± standard deviation or median with interquartile range (IQR). Categorical data was presented as number (%). Comparisons were performed using T-test, Mann-Whitney U test, χ2 or Fischer's exact test as appropriate.Statistical analysis was performed using SPSS version 24.0 .


To determine whether the semi-automated two-dimensional echocardiography (2DE) layer strain software, compared to cardiac magnetic resonance (CMR), is reliable for left ventricular (LV) volume quantification.We retrospectively selected 84 patients who underwent CMR and 2DE on the same day. Novel 2DE layer strain software automatically provides LV contour in 3 myocardial layers and performs layer specific speckle tracking analysis, which calculates LV volumes, ejection fraction (LVEF), and global longitudinal strain (GLS) in each layer. These values were compared with reference values from CMR disk-area summation and feature tracking methods. Coverage probability (CP) was determined using predefined cut-off values and absolute differences in LV volumes of 30 mL, those in LVEF of 10%, and those in GLS of 4%. The software did not work in 3 patients (feasibility: 96%). Different layers resulted in different degrees of under- or over-estimation of LV volumes. Epicardial tracking significantly overestimated the LV volumes and significantly underestimated LVEF and GLS. Mid-myocardial tracking had less underestimation of LV volumes and equivalent CP values of LVEF (0.77 vs. 0.75 using the disk-area summation method and 0.90 vs. 0.94 using the feature tracking method) and GLS (0.95 vs. 0.92) compared with endocardial tracking. The new software showed excellent reproducibility, especially endocardial and mid-myocardial tracking.Mid-myocardial tracking with the novel 2DE strain software provided less bias of LV volumes with high CP values of LVEF and GLS, which suggests that mid-myocardial layer speckle tracking analysis approximates CMR derived LV functional parameters. Global and regional strain analysis with echocardiography using the speckle tracking software is gaining popularity for the investigation of cardiac chamber mechanics . AlthougApplication of fully automated software is one potential solution for this limitation. The automated contour trace (ACT) method is a semi-automated approach to perform left ventricular (LV) layer speckle tracking analysis after clicking three anatomical landmarks on the apical long axis-views. A recently developed prototype software has a potential to further reduce observer variability of LV border determination, resulting in the reduction of measurement variabilities.Accordingly, the aim of this study was to investigate the reliability and accuracy of the novel 2DE semi-automated layer strain software, compared to those of cardiac magnetic resonance (CMR), for the quantification of LV mechanics.We retrospectively selected patients who had undergone clinically indicated CMR and who were also willing to undergo 2DE examination on the same day from June 2017 to May 2018 at the University of Occupational and Environmental Health Hospital. Because patients were selected solely based on the clinical indication of CMR, we did not exclude any patients due to poor 2DE image quality. This study was approved by the ethics committee in the University of Occupational and Environmental Health. Approval number is H30-033. As this was a retrospective study, the Institutional Review Board waived the requirement for informed consent.Apical 4-chamber, 2-chamber, and long-axis views with three consecutive cardiac cycle were acquired using the Aplio 300 ultrasound system equipped with a PST-30BT transducer  before the CMR examination. The receiving frequency was set at 3.0 MHz in the tissue harmonic imaging mode. Imaging data were stored on the hard-disk for off-line analysis. The image quality was assessed from the three apical views and classified into 3 grades  in the LV 18-segment model according to a previous study .The CMR examination was performed using a 3T scanner  with a phased-array cardiovascular coil. In each patient, retrospective electrocardiography-gated localizing spin-echo sequences were used to identify the long axis of the heart. Steady state free precession (SSFP) dynamic gradient-echo cine loops were acquired using retrospective electrocardiographic gating and parallel imaging techniques at 10–15 seconds breath-holds, with the following general parameters: 8-mm imaging plane slice thickness, 40×40 cm field of view, 200×160 scan matrix, 50° flip angle, 3.8/1.7 ms repetition/echo times, 20 views per segment, and 20 reconstructed cardiac phases. For each patient, 8–16 short-axis slices from the base of the heart to the apex and 3 standard LV long-axis views were recorded. Short-axis SSFP images were used for disk-area summation analysis. Three LV long-axis SSFP images  were used for the feature tracking analysis.We used the vendor-dependent prototype software that has an advanced ACT method. First, the examiner identified three specific anatomical landmarks on both sides of the mitral annulus and the apical endocardium at the end-diastolic frame on the apical 4- and 2-chamber views. On the apical long-axis view, the examiner identified the posterior part of the mitral annulus, upper part of the anterior interventricular septum, and the apex . SubsequWe used the same width of ROI in all 3 apical views in each patient, and the width of ROI was adjusted according to the LV wall thickness and usually ranged from 5.1 mm to 6.2 mm. Finally, the software performed speckle tracking analysis on a frame-by-frame basis on the three layers in the ROI  Movies aThe LV volumes were measured from multiple short-axis SSFP images using the disk-area summation method with an analytical software . LVEF was calculated by LVEDV–LVESV / LVEDV (%).The LV volumes, LVEF, and GLS measurements on CMR images were performed using the CMR feature tracking software , which is a vector-based analysis tool based on a hierarchical algorithm. For each of the three apical long-axis SSFP images, the LV endocardial border at the end-systolic frame was semi-automatically determined by a 3-point click . The software then automatically propagated the contour and followed its features throughout the cardiac cycle to generate LV volume curves from which LVEDV, LVESV, and LVEF were determined. The software also provided segmental peak LS values on the bull’s eye map as well as the GLS.Intra-observer variabilities of LVEDV, LVESV, LEEF, and GLS were assessed by having the examiner repeat the measurements using the 2DE layer strain analysis, at 2-week interval, in randomly selected 30 patients, and inter-observer variabilities were determined by having a second examiner perform these measurements in the same 30 patients. The intra- and inter-observer variability values were calculated as the absolute differences between the corresponding two measurements in percentages of their mean and intraclass correlation (ICC).th percentile to the 75th percentile) according to data distribution. Categorical data are expressed as numbers or percentages. Repeated measurements of one-way analysis of variance or Friedman’s analysis with post-hoc comparison was performed to compare more than two groups. A linear correlation and Bland-Altman analysis were performed to determine the r value, bias, and 95% confidence interval (CI). Coverage probability (CP) was the probability of the absolute differences falling within the acceptable difference [Continuous data are presented as mean ± standard deviation or median and interquartile interval   . CP was GLS using CMR feature tracking was 10.4 ± 4.1, and the corresponding values using 2DE endocardial, mid-myocardial, and epicardial tracking were 10.8 ± 3.7, 9.9 ± 3.4, and 9.0 ± 3.1, respectively. Post-hoc analysis revealed significant differences between CMR feature tracking and 2DE epicardial tracking (p<0.001). However, no significant differences were noted between CMR feature tracking and 2DE endocardial tracking (p = 0.680) as well as between CMR feature tracking and 2DE mid-myocardial tracking (p = 0.270). Good correlations were noted between CMR feature tracking and 2DE layer speckle tracking . CP was Intra and inter-observer variabilities of LV volumes, LVEF, and GLS are presented in The main results of this study can be summarized as follows: (1) Compared to CMR, 2DE endocardial speckle tracking significantly underestimated LV volumes; (2) In contrast, 2DE epicardial tracking significantly overestimated LV volumes and significantly underestimated LVEF; (3) 2DE mid-myocardial tracking provided the lowest bias of LV volumes with high CP values of LVEDV, LVESV, and LVEF; (4) No significant differences in GLS were observed between CMR feature tracking and endocardial tracking as well as between CMR feature tracking and mid-myocardial tracking; (5) Intra- and inter-observer variabilities for LV volumes, LVEF, and GLS were quite low, especially when results from endocardial or mid-myocardial tracking were used.There is general agreement that 2DE often underestimates LV volumes because of the foreshortening of the acquired image and geometric assumption. Some previous validation studies on the accuracy of 3DE for LV quantification also described the results from direct comparison of LV volumes and LVEF between 2DE and CMR. All but one study consistently showed 2DE had a larger bias of LV volumes against CMR than 3DE –20. AlthACT analysis was initially established between the late 1990s and early 2000s for the measurement of LV volumes and LVEF . After sLV volume determination using endocardial speckle tracking still showed volume underestimation of 30–55 mL. Although there were no differences in LVEF between endocardial speckle tracking and the standard CMR method, a 3% overestimation of LVEF was observed compared with CMR feature tracking. Although CP values for LVEDV and LVESV were low, CP of LVEF was 0.77 using the standard CMR method or 0.90 using CMR feature tracking, indicating that the bias of LVEF between the two methods was <10% in approximately 80–90% of cases, even though one-fourth of patients had poor image quality. When results from mid-myocardial tracking were used, there was still some underestimation of LVEDV. However, the observed bias (< 20 mL) reached a similar range of bias reported using 3DE with fully automated left chamber quantification software , 23. ComThe layer strain analysis revealed transverse gradient of GLS, which was in agreement with previous studies , 25. HowRegarding observer variabilities, the ICC was higher and the coefficient of variation was similar to or lower than those reported in the previous layer specific strain studies , 26–28, Quantification always faces two challenges: accuracy and reliability. If a measurement is highly reliable with some limitation regarding accuracy, most clinicians consider it useful. It achieves consistent measurement values on individual images, which is quite useful when conducting a longitudinal study. The excellent reliability of this software suggests that it can detect clinically subtle, but statistically significant changes in LV function during a serial follow-up in observational and interventional studies in a smaller number of subjects compared with manual tracing methods.This study has several limitations that should be acknowledged. First, we employed a relatively narrow width of ROI to enhance the tracking quality of the epicardial layer. Thus, our results from epicardial tracking were not solely a reflection of those from the epicardium. Second, after the manual clicking of 3 points in each apical long-axis view, we did not perform manual editing in any case. Although additional manual correction could reduce measurement bias, it may increase observer variabilities. Third, we measured GLS using CMR feature tracking and did not use myocardial tagging. However, CMR feature tracking is increasingly used to quantify heart chamber mechanics .Using a novel semi-automated 2DE layer specific speckle tracking software, mid-myocardial tracking provided less bias of LV volumes with high CP values of LVEF and GLS against CMR as a reference. Lower observer variability also supports mid-myocardial speckle tracking to quantify LV volumes and function.S1 Movie(MP4)Click here for additional data file.S2 Movie(MP4)Click here for additional data file.S3 Movie(MP4)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.


Illicit drugs are an uncommon etiology of acute myocarditis but should be evocated in young population. This association may result in further complications, mainly ventricular arrhythmia and therefore increases sudden cardiac deaths among young abusers. Withholding drug intoxication to prevent recurrent events is a major key of management. Toxicomania is a worldwide health and social problem. In 2015, World Health Organization estimates that 255 millions of people are drug users and more than 10% of them have health disorders A 38‐year‐old man was admitted in our cardiology department for palpitations and dizziness. He was a 27 pack‐years smoker and a multidrug abuser since 10 years. In fact, he was consuming twice a week cocaine and four joints a day of cannabis. An electrocardiogram (ECG) was rapidly performed. It showed a regular wide QRS tachycardia at 220 beats/min with a negative concordance pattern in all precordial leads and an extreme axis deviation  and a daily three joints of cannabis abuser for 3 years. He is also a monthly cocaine consumer for <1 year. He presented to emergency department for new‐onset palpitations. An immediate ECG demonstrated a regular wide QRS tachycardia at 170 beats/min with left bundle branch block pattern and left QRS axis Fig. , Panel AAccording to Lake Louise consensus criteria, CMR findings suggestive of myocarditis are as follows: (1) Regional or global myocardial signaling intensity increase in T2‐weighted images suggestive of edema; (2) Increased global myocardial early gadolinium enhancement ratio between myocardium and skeletal muscle in gadolinium‐enhanced T1‐weighted images suggestive of hyperemia and capillary leakage; 3) At least one focal lesion with nonischemic regional distribution in inversion recovery prepared gadolinium‐enhanced T1‐weighted images (late gadolinium enhancement) suggestive of necrosis and fibrosis. In the setting of clinically suspected myocarditis, CMR findings are consistent with myocardial inflammation, if at least two of the above‐cited criteria are present  At leastIn a series of 40 autopsies performed in the context of cocaine‐associated deaths, it was demonstrated that myocarditis with mononuclear infiltrate was responsible of 20% of deaths and was nearly 10 times more common than acute thrombotic coronary occlusion.This finding showed that drug abuse induced myocarditis could be responsible of sudden cardiac death likely via ventricular arrhythmia, which was the relevant complication in our two patients.The evocated mechanism of VT, in this case, is scar‐related macroreentry due to the development of necrosis and fibrosis as shown by CMR In our both cases, the VT morphology on ECG have suggested an apical VT exit; however, myocardial scars on CMR were specially located in the subepicardial layers of lateral wall of the left ventricle.In the first case, cocaine seems to be the etiology of the myocardial damage owing to the more established association between cocaine and myocarditis and also the existence of ECG signs of cocaine intoxication revealed after the reduction of VT. In fact, complete right bundle branch block, shown in our case, was described to be the consequence of sodium channel blockade, the main mechanism of action of cocaine In both cases, the diagnosis of drug‐induced myocarditis was a diagnosis of exclusion. Autoimmune and viral myocarditis should be mentioned. Nonetheless, given the history of the two patients and the electrocardiographic pattern in the first case, in relation with cocaine and or Marijuana should raise suspicion for a causal association. Performing an endomyocardial biopsy could help the etiological diagnosis, since in drug abuse myocarditis, contraction band necrosis could be demonstrated and could confirm the causal association In our patients, we preferred not to prescribe beta blockers as it is contraindicated in case of cocaine intoxication because of the risk of coronary vasospasm and myocardial infarction Ventricular tachycardia is a challenging finding, in which CMR plays a key role for the diagnosis of potential reversible causes mainly acute myocarditis. This complicated situation can be induced by illicit drug abuse. Such an uncommon association should notably be evocated in young population and must lead to definitively stop abusing the culprit drug.SO, OG: conceived of this case report. All authors read and approved the final manuscript.None declared.


Ten-year survival in the combined vs. single therapy group for the anterior heart walls was 100 vs. 72.2% (p = 0.027). For the lateral and posterior heart walls were 73.7 vs. 73.3% (p = 0.97) and 84.2 vs. 72% (p = 0.27), respectively. Kaplan-Meier survival analysis showed benefit only for the anterior heart wall . Single therapy procedures on all heart walls  or on the anterior heart wall only  were found to be predictors of 10-year late mortality. Combined therapy (TMLR + CABG) provides benefit for perioperative mortality and long-term survival only when provided on the anterior heart wall. For patients with disseminated coronary atherosclerosis, cardiac mortality was found to be increased when followed up 6 years later, regardless of the therapy applied.Coronary artery disease involving heavily calcified lesions has been associated with worse short- and long-term outcomes including increased mortality. This paper aims to evaluate long-term survival benefit when CABG + transmyocardial laser revascularization (TMLR) are performed on the hearts of patients with disseminated coronary atherosclerosis (DCA). This novel retrospective study was conducted between 1997 and 2002 and followed 86 patients with ischemic heart disease and severe DCA who underwent TMLR using a Holmium:YAG laser and/or CABG. There were 46 patients who had CABG plus TMLR on at least one heart wall (“combined therapy group”) and 40 patients who had CABG or TMLR separately on at least one heart wall (“single therapy group”). For the whole group, actuarial survival at 10 years was 78.3% in the combined group compared to 72.5% in the single therapy group ( Coronary artery bypass grafting and percutaneous coronary interventions are effective methods of myocardial revascularization for patients with coronary artery disease. The population of patients eligible for revascularization has changed in recent years, in regard to significantly increased patient age, number of associated diseases, and number of patients with diabetes. These factors have been reported to exacerbate the development of atherosclerosis . As a reCoronary artery disease involving heavily calcified lesions has been associated with worse short- and long-term outcomes after percutaneous coronary intervention , 4. The Severely calcified lesions make it difficult to complete the distal anastomosis of the graft to the target coronary artery. As a result, there has been an increase in number of patients in whom it is not possible to perform a complete revascularization. Relative to incomplete revascularization, complete revascularization has been associated with lower long-term mortality (risk ratio [RR] 0.71), decreased rates of myocardial infarction (RR 0.78), and repeat coronary revascularization (RR 0.74) [Transmyocardial laser revascularization (TMLR) is an approved surgical procedure that involves the creation of transmural laser channels within regions of ischemic myocardium. TMLR is performed with a low powered Holmium:YAG laser that delivers precise laser energy directly to the target area of the heart muscle. During TMLR, the surgeon uses one of the CardioGenesis flexible, fiber optic handpieces to deliver precise bursts of Holmium:YAG laser energy directly to the area of the heart muscle that is suffering from ischemic heart disease. It takes approximately 6–10 pulses to transverse the myocardium and creates channels 1 mm in diameter. More than 50,000 TMLR procedures have been performed in more than 38 countries. Over the past two decades, results from prospective and retrospective studies on TMLR have provided data supporting the safety and effectiveness of TMLR when performed as sole therapy, as well as combination therapy with CABG in patients not amenable to traditional methods of surgical or percutaneous revascularization [In consideration of the reported favorable outcomes of short-term CABG plus TMLR therapy, it was hypothesized that TMLR in combination with CABG can improve late survival when compared to TMLR or CABG alone group.The aim of this study was to evaluate the actuarial 10-year survival rate when patients with severe disseminated coronary atherosclerosis were treated with CABG and TMLR.Between 1997 and 2002, 86 patients with three-vessel ischemic heart disease and (diffuse) CAD with severe (coronary) lesion calcification underwent TMLR and/or coronary artery bypass grafting at our institution. Coronary calcifications were stratified visually into severe, moderate, and none to mild using readily apparent densities noted within the vascular wall at the stenosis level. Moderate lesion calcification was defined as radiopaque densities noted during the cardiac cycle involving only one side of the vascular wall, whereas severe lesion calcification was defined as radiopaque densities noted without cardiac motion before contrast injection generally involving both sides of the arterial wall .Diffuse CAD was defined as follows: length of significant stenosis ≥ 20 mm, multiple significant stenosis (≥ 70% narrowing) in the same artery separated by segments of apparently normal (but probably diseased) vessel, and significant narrowing involving the whole length of the coronary artery .n = 86) were scheduled to undergo CABG based upon a previous diagnosis of disseminated coronary atherosclerosis and presence of severe angina symptoms. CABG was performed when possible to create anastomosis . The gold standard in coronary artery bypass grafting was performed by grafting the left internal thoracic artery to the left anterior descending arteries and the remaining anastomosis using venous material. TMLR was performed using a Holmium:YAG laser with an average of 13.8 channels per heart wall. TMLR was performed with a low powered Holmium:YAG laser that delivers precise laser energy directly to the target area(s) of the heart muscle. During TMLR, the surgeon used a CardioGenesis fiber optic handpiece to deliver precise bursts of Holmium:YAG laser energy directly to an area of heart muscle that was suffering from ischemic heart disease. Approximately 6–10 pulses were required to transverse the myocardium and create channels one-millimeter in diameter. Patients received only TMLR in the event where CABG could not be performed due to technical difficulties associated with the graft.All patients , while 64 patients had interventions on the lateral wall , and 69 patients underwent interventions on the posterior heart wall .In this series, 46 patients underwent combined CABG plus TMLR on at least one heart wall (“combined therapy group”), while 40 did not receive combined treatment on any heart wall (“single therapy group”). Patients may have undergone concomitant TMLR + CABG with the CABG and TMLR procedures performed on separate heart walls. Results were further analyzed according to procedure type  performed on each of the three heart walls . There were 80 out of the 86 total patients who underwent procedures on the anterior heart wall  on the anterior heart wall, while the second involved the same parameters, but with single therapy (CABG or TMLR only).Baseline patient demographics for anterior wall intervention are presented in Table The study is a retrospective evaluation of a long-term follow-up of patients who underwent the appropriate procedure which was agreed at the time of intervention. All patients were operated in our center and remained under our supervision and voluntarily showed for follow-up appointments at our outpatient clinic. All patients were consented by writing to include their case into the analysis. The study was approved by the Bioethics Committee (L.dz.OIL/KBL/OIL/11/216).p < 0.05 were considered to be statistically significant and all p values are two-sided.Statistical analyses were performed using STATISTICA 10. Categorical data were compared by the chi-square test or Fisher exact test if the expected number of observations in any cell was < 5. Continuous data are presented as mean ± SD or median interquartile range and were compared using the analysis of variance or Kruskal-Wallis test. The long-term survival was estimated using Kaplan-Meier time-to-event methodology and was compared using the F Cox test. Multivariable regression analysis using Cox proportional hazard models to assess for independent predictors for probability of survival and for the association between probability of survival and type of procedure was performed during surgery for the whole group and for the anterior heart wall group. Values of The overall mortality rate for all patients was 31%. Median survival for both groups (averaged) was 137 months. The median survival times of 129 and 138 months were for the single therapy and combined groups, respectively  = 138 months).p = 0.535 and p = 0.739, respectively)  of the heart. For any heart wall, the cumulative 10-year survival and freedom from cardiac death valued 72.5 and 77.5% in the single therapy group, compared to 78.3 and 80.4% in the combined therapy group (p = 0.976), and 84.2 vs. 72% (p = 0.277), respectively. However, when survival rates were compared for the anterior wall combined vs. single therapy groups, the anterior wall combined group significantly improved survival and freedom from cardiac death with rates of 100 vs. 72.2% and 100 vs. 76.4% (p = 0.027 and p = 0.044), respectively . The same results were observed for freedom from cardiac death     performed on anterior heart wall. Kaplan-Meier survival analysis showed a trend towards the long-term survival and freedom from cardiac death benefit for combined procedure on anterior heart wall  Figs. .Fig. 3KaMoreover, all Kaplan-Meier analysis showed an increased mortality in the early postoperative period. When freedom from all-cause death and cardiac death was observed in all investigated subgroups after 5 to 6 years, survival rates decreased. This deterioration in time was also noted in the subgroup of combined therapy. Thus, a high perioperative mortality was observed following a period of high freedom from cardiac death rate and moderate increase in cardiac mortality after 5 to 6 years of follow-up.p = 0.279) and lack of combined procedures on any heart wall  were found to be independent predictors of late mortality.Lack of combined procedures on the anterior wall , and embolic phenomenon associated with coronary calcifications and may lead to increased rate of ischemic outcomes. Severely calcified vessels may result in difficulty performing vascular anastomoses, resulting in prolonged procedural time, suboptimal results, or even failure to achieve a functional graft. In addition, severely calcified coronaries can limit the capacity to achieve complete revascularization, which has been shown to be associated with poor long-term outcome , 13, 14.p < 0.001). In multivariate Cox regression analysis, severe lesion calcification was also found to be an independent predictor of increased all-cause mortality  [The Syntax Trial, which reported on the implications of severe coronary calcification in patients undergoing coronary artery bypass surgery trial, found that patients with calcified coronaries, had an increased mortality at 5-year follow-up  . Severe p = 0.02) and improved 1-year actuarial survival  for patients that underwent TMLR+CABG, compared to CABG alone [P < 0.0001) [Only two randomized controlled trials have been performed assessing CABG plus adjunctive TMLR vs. CABG alone , 16. Out 0.0001) . This stThe results of this 10 year follow-up showed a vast improvement in survival in patients undergoing surgery at anterior wall with combined TMLR plus CABG, compared to other groups of patients. The anterior wall was an important element responsible for left ventricular systolic function. Left ventricular function impacted overall patient survival, signifying the importance of the intervention performed on the anterior heart wall of patients with severe coronary calcification.In general, implementation of additional laser revascularization decreased mortality and resulted in a reduction in the severity of myocardial symptoms. The exact mechanism responsible for providing angina relief is still debated. Denervation of the sympathetic nerve fibers innervating the heart is one of proposed mechanism of relief of angina following TMLR. Another proposed mechanism, angiogenesis, or formation of new blood vessels, has shown the strongest experimental and clinical evidence for being the primary basis of angina relief after TMLR. Additionally, upregulation of pro-angiogenic factors, such as vascular endothelial growth factor, fibroblast growth factor 2, and platelet-derived endothelial cell growth factor, was demonstrated in myocardial tissue following TMLR –20.Moreover, in all patients groups, a high perioperative mortality was observed followed by a period of high freedom from cardiac death rate and moderate increase in cardiac mortality after 5 to 6 years of follow-up. Therefore, this study suggests that individuals who undergo incomplete revascularization are in need of close monitoring not only within the early postoperative period, but also in the years post-surgery. This observation presumably arises from the fact that patients who survive perioperative period present with moderate improvement in the left ventricular function, in spite of ongoing ischemic heart failure that exacerbates after few years and results in the late increase of cardiac mortality. Thus, the benefits of applying a combined therapy on any of the heart walls, especially on the anterior heart wall, are observed after 6 years of follow-up. The postoperative improvement in left ventricular function is presumably present after both therapeutic strategies, but in case of a combined therapy applied on any heart wall, the late increase in mortality is less relevant and occurs relatively later post-surgery.Presented results show that perioperative period is associated with high risk of mortality, both cardiac and non-cardiac. Moreover, as it concludes from the Kaplan-Meier estimate, performing a combined procedure on the anterior heart wall results in lower in-hospital mortality. This observed benefit presumably results from a better protection from the anterior heart wall ischemia when a combined therapy is applied. As the patients who were qualified for this procedure represented an increasing number of individuals with advanced ischemic heart disease and many comorbidities, high perioperative risk was noted prior to the surgery. However, the presented result may improve the strategy to diminish in-hospital mortality in this challenging demography of patients.P = .02) and perfusion .More details about myocardial angiogenesis and hemodynamic myocardial function were published by Atluri et al. . In thisIn regard to myocardial contractility, echocardiography showed significant improvement in LV contractility in the ischemic lateral wall post-TMR. Moreover, global wall motion score index showed significant improvements in global myocardial function. These results suggest that myocardial angiogenesis may be important in improvements in patients with anterior wall lesions.In year 2017, Ahn et al. published meta-analysis of three large studies: SYNTAX, PRECOMBAT, and BEST trials (3280 patients: 1520 patients undergoing CABG and 1692 patients undergoing PCI) . The ratThis is a single-center, non-randomized study. Data were analyzed retrospectively. No perfusion studies were performed before/after procedures.The presence of diffuse atherosclerosis and massive calcification was a proven risk factor for occurrence of MACE in the postoperative period and during follow-up. The combination of TMLR and CABG on the same wall of the heart was beneficial for patients with diffuse atherosclerosis, since the advanced atherosclerotic process prohibited adequate blood supply to the area even when the graft was working properly.It is hypothesized that TMLR provides additional support to CABG grafts through angiogenesis or the formation of a new network of fine vessels. These neovessels are thought to deliver blood flow to areas of the heart that would not be reached by CABG grafts alone due to the presence of severe atherosclerosis. It is hypothesized that this combination treatment increased the perfusion to grafted areas and was found to be superior to CABG alone, although it was not investigated directly in the presented study.Combined therapy (TMLR + CABG) provided benefit in perioperative mortality and long-term survival only when provided on the anterior heart wall.Previous diagnostic methods have been unable to provide clear evidence regarding the mechanism responsible for the effectiveness of TMLR. As a result, TMLR is not a widely accepted treatment for ischemic heart disease. Based on the observations from this novel study, combined TMLR and CABG performed on the anterior heart wall provided good outcomes with improved long-term survival in patients with severe coronary calcification.For patients with DCA, cardiac mortality increases after 6 years follow-up, regardless of the therapy applied. This increase occurs later in groups of patients who received combined therapy, regardless which heart wall it was.


Persistent left ventricular (LV) systolic dysfunction in patients with acute lymphocytic myocarditis (LM) is widely unexplored.To assess the frequency and predictors of persistent LV dysfunction in patients with LM and reduced LVEF at admission.We retrospectively evaluated 89 consecutive patients with histologically-proven acute myocarditis enrolled at three Italian referral hospitals. A subgroup of 48 patients with LM, baseline systolic impairment and an available echocardiographic assessment at 12 months (6–18) from discharge constituted the study population. The primary study end-point was persistent LV dysfunction, defined as LVEF <50% at 1-year, and was observed in 27/48 patients (56.3%). Higher LV end-diastolic diameter at admission , non-fulminant presentation  and presence of a poor lymphocytic infiltrate  emerged as independent predictors of persistent LV dysfunction at multivariate analysis . Pre-discharge LVEF was lower in patients with persistent LV dysfunction compared to the others , and this single variable showed the best accuracy in predicting the study end-point .More than half of patients presenting with acute LM and LVEF <50% who survive the acute phase show persistent LV dysfunction after 1-year from hospital discharge. Features of subacute inflammatory process and of established myocardial damage at initial hospitalization emerged as predictors of this end-point. Acute lymphocytic myocarditis (LM) presenting with left ventricular (LV) systolic dysfunction represents a challenge in terms of diagnosis, management and prognostication –5. PreviWe retrospectively analyzed all the patients with histologically proven acute myocarditis consecutively admitted at 3 Italian referral Centers for cardiomyopathies  from 2000 to 2016. For the purpose of this study, the following inclusion criteria were applied: 1) duration of heart failure (HF) symptoms ≤30 days; 2) impaired LV function  histology and immunohistochemistry findings consistent with LM at endomyocardial biopsy, according to international criteria ; 4) avaiThe study was approved by the Ethic Committees of Trieste, Milan and Pavia Hospitals. The study complied with the declaration of Helsinki.All the patients underwent a thorough invasive and non-invasive assessment at index hospitalization. In all the patients surviving the acute phase, clinical follow-up within 12 (6–18) months from index hospitalization was scheduled, including clinical evaluation, laboratory testing, and echocardiographic assessment.Endomyocardial biopsy (EMB) was performed from either the left or the right ventricle according to the Center experience or single case evaluation. The mean number of histological samples per patient was 4 (range 1–6) , 11. SamWhen clinical condition was sufficiently stable, patients received recommended HF medical treatment as indicated by current guidelines. Patients with fulminant forms, defined by the need for inotropes or vasopressors and/or mechanical circulatory support during the acute phase , 8, wereEchocardiographic assessment consisted in comprehensive M-mode, 2-dimensional and Doppler studies. Systolic and diastolic ventricular function and valve regurgitations were defined according to international guidelines . In partThe primary study end-point was the persistence of a LVEF <50% at follow-up . SecondaFollow-up information were obtained through phone calls with patients, their relatives, or general practitioner or by consulting the office of national statistics. The end of follow-up was considered as June 30, 2017  or the date of death or HTx.Summary statistics of clinical and laboratory variables were expressed as mean and standard deviation, median and interquartile range or counts and percentage, as appropriate . Comparisons between groups were made by the ANOVA test on continuous variables, using the Brown-Forsythe statistic when the assumption of equal variances did not hold, or the non-parametric Mann-Whitney test when necessary. The Chi-square or Fisher’s exact test were calculated for discrete variables. Uni- and multi-variable logistic regression analyses were estimated to determine the most predictive combination of independent factors associated with the primary end-point, by means of a full-model strategy applied each time starting from a different subset of at most three parameters, due to the low event rate. For each combination of parameters, the predictive accuracy of the corresponding vector of estimated probabilities of event was evaluated by means of a receiver operating characteristic (ROC) curve. Since the limited number of events, the De Long test between areas under the curves (AUCs) had a limited power, and for this reason the model with the absolute highest accuracy was retained. This final model was internally validated with a bootstrap-based procedure, in order to account for the optimism in the AUC estimate . To explLinear association between variables was analysed using Pearson’s correlation coefficient for normally distributed variables and Spearman’s correlation coefficient for not normally distributed variables and significance of both coefficients was reported. The IBM-SPSS version 19 and the R statistical software version 3.4.0, libraries “survival” and “rms” were used for statistical analyses.Baseline characteristics of the studied cohort (n = 48) are summarized in nd and 3rd columns; After 10 months  of follow up, 27 patients (56%) showed a persistent LV systolic dysfunction. One of these patients underwent HTx for refractory HF at 7 months from the diagnosis . At baseline, signs and symptoms of HF were less severe  in patients with persistent LV systolic dysfunction at follow up compared to the others. Moreover, patients with persistent LV dysfunction had a longer median duration of symptoms at admission  and, consistently, presented with a larger LV size, showed more frequently a poor (rather than plentiful) lymphocytic infiltrate at EMB, and a lower LVEF at discharge in comparison with patients without persistent LV dysfunction. Finally, they were younger and more frequently presented signs of acute inflammation . At discharge, LVEF was already > 50% in the majority of the patients that showed normal LV systolic function at 1-year follow-up . On the contrary, only one out of the 27 patients with persistent LV dysfunction at 1 year (3.7%) exhibited a normal LVEF of 55% at discharge, which deteriorated to 35% at 12 months.LVEF measured at pre-discharge had a similar accuracy in predicting persistent LV dysfunction at follow up compared to the admission model (AUC 0.946 95% CI 0.882–1.00).Twenty-three (48%) patients of our population had fulminant acute myocarditis survived after the acute phase. They were treated with intravenous inotropes, plus mechanical support in 13 (57%) of the cases. Among them, 83% had at least a moderate lymphocytic infiltrate and the majority of them (78%) received immunosuppressive treatment. Six out of the 23 fulminant forms (26%) showed persistent LV dysfunction at follow up. Compared with patients with fulminant presentation who recovered, they had similar baseline LVEF  but a less frequent plentiful infiltrate at EMB  and a lower rate of normalized LVEF at pre-discharge . .During a median follow-up of 48 (interquartile range 16–94) months, patients with persistent LV dysfunction at follow-up showed a trend for higher rates of cardiac death or HTx compared with patients showing normalized LVEF  and LV dysfunction (mean LVEF at admission 26%). To the best of our knowledge, this study is the first report on persistent LV systolic dysfunction in histologically proven lymphocytic myocarditis, and provides some important insights: 1) more than half of the patients surviving the index hospitalization exhibited persistent LV systolic dysfunction, at discharge and during follow-up; 2) fulminant forms were characterized by a poor outcome during hospitalization confirming recent studies  3) increAlthough LV systolic dysfunction is not very common in patients presenting with acute LM, this setting constitutes a diagnostic and management challenge.  These paFulminant forms comprised almost half of our cohort. It must be noted that more than 80% of fulminant cases who survived presented at least moderate inflammatory infiltration and most of them were treated with steroids. More than 75% of patients with fulminant myocarditis who survived after the acute phase showed a normal LV systolic function already at the discharge. This could explain the apparently paradoxical low percentage of beta-blockers in the group of patients with LVEF recovery at follow-up evaluation. However, 26% of survived fulminant myocarditis were characterized by persistent LV systolic dysfunction at 1 year. Notably, they were characterized by a poor inflammation at EMB performed at index hospitalization. These finding underscores the need of individualized long-term follow-up and therapy [This study considers one of the largest cohorts of biopsy-proven acute LM patients with LV systolic dysfunction at presentation, and some clinical implications for patient management and further studies may be derived: 1) early endomyocardial biopsy is highly recommended in patients with clinically suspected myocarditis and newly diagnosed significant LV dysfunction: these patients should be promptly referred to experienced centers for both diagnosis and treatment, that may include advanced circulatory support and transplantation; 2) time course of LV dysfunction must be followed and characterized during index hospitalization, since significant improvement of LVEF may occur, and pre-discharge LVEF predicts long-term LV function; 3) fulminant myocarditis portends a high risk for early death or need for HTX, but full recovery is possible, often persistent over time. This observation, together with the high rate of persistent LV dysfunction and its association with dilated LV and smoldering inflammation at EMB at admission -which may reflect delayed diagnosis- and some recent evidences , suggestThis study suffers from the intrinsic methodological limitations of all observational retrospective studies. Moreover, the study population derives from tertiary referral centers and this constitutes a selection bias. Our study considered a small number of patients and events and this explain wide confidence intervals of the estimates, even if the boostrap-based internal validation of the regression model gave satisfactory results.Troponin essays used in the enrolling Centers were different. As a consequence, it was not possible to use the troponin values at diagnosis as included variable, despite it was generally increased in the study patients.and troponin were available in a minority of our patients and therefore were not considered. This limitation is due to the long enrollment period with patients enrolled more than 10 years ago, when especially CMR use was not as widespread as today. The relevance of late gadolinium enhancement detected at CMR can provide further hints to identify patients at risk to maintain LV dysfunction at follow up evaluation as suggested by recent studies [Data derived from cardiac magnetic resonance (CMR) or laboratory data such as natriuretic peptides  studies .Given the retrospective and observational nature of the study and the differences in timing of initiation, drug combination and doses, and duration of immunosuppressive therapy, no inferences can be derived about the role of immunosuppression in acute myocarditis with LV dysfunction.Patients with acute lymphocytic myocarditis presenting with LV systolic dysfunction exhibit a persistent LV impairment at 1-year in more than 50% of the cases.Features suggestive of a poor inflammatory process associated with cardiac enlargement, and lack of early recovery, emerged as potential useful tools for predicting persistent LV systolic dysfunction during follow-up.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.