Levator ani defect (LAD) closely correlates with pelvic floor disorders (PFD). In general, LAD was graded by three-dimensional ultrasonography (3D-US) and MRI, which could be used hardly in some developing area. Our objective was to determine whether two-dimensional ultrasonography (2D-US), a method that is almost universally accessible, could be used to diagnose the LAD. 129 Chinese women with PFD were recruited for the LAD grading by 2D-US and 3D-US and MRI. LAD was classified into intact, partial and complete avulsions. The puborectalis attachment width (PAW) was measured by 2D-US and with the software on the three-dimensional MRI-based LAD models. The results were compared and analyzed using the weighted kappa and the Pearson’s coefficient. Of the 119 patients, 64 were diagnosed with LAD by 2D-US, 70 were identified by 3D-US while 68 were confirmed by MRI. The LAD grading of 2D-US showed good agreement with MRI  and 3D-US . In regard to the consensus of partial or complete avulsions, 2D-US showed excellent good agreement with MRI , superior than 3D-US with MRI . Additionally, iliococcygeus avulsions detected by MRI (n = 7) were accompanied by complete puborectalis avulsions. The averaged PAW was 10.42 ± 5.57 mm measured by 2D-US, which correlated well with the results measured by MRI (Pearson’s coefficient = 0.90). 2D-US, 3D-US and MRI showed the good agreement on LAD diagnosis. Compared with MRI and 3D-US, 2D-US was comparable in grading LAD, especially complete avulsions. The LAM complex has three major components, puborectalis, iliococcygeus, and pubococcygeus2. Delivery-related traumas are the most important causes of levator ani defects (LAD)3. Vaginal deliveries lead to the enlargement of the levator hiatus and the substantial stretch of the LAM, which may cause the LAD1.Levator ani muscle (LAM), a broad muscular sheet covering the outlet of the pelvis, plays a vital role in maintaining the pelvic functions and supporting pelvic organs5. Moreover, the size of the defect has a direct correlation with prolapse symptoms6. It is significant to grade the LAD for the better treatment, the prediction of related symptoms and the further investigations of PFD mechanism.It has been published that LAD closely correlate with pelvic floor disorders, especially pelvic organ prolapses (POP) and stress urinary incontinence (SUI). The LAD appears to double the risk of anterior and central compartment prolapse8, though there is no gold standard. However, MRI has not been widely adopted in urogynecological practice due to its cost and availability. 3D-US has been emerged as a more cost-efficient tool to diagnose LAD9. Neither MRI nor 3D-US is universally available as opposed to 2D-US. For 2D-US, the LAM could be observed by an oblique parasagittal translabial approach10. Most previous studies used 2-dimensional (2D) planes of 3D-US and MRI to describe the morphology of LAM, which was not sufficient for the description of LAM, a three-dimensional structure. Within the specific postprocessing software, 3-dimensional magnetic resonance models (3D-MR-model) can be reconstructed for 3-dimensional overview and valid parameters of LAM.The LAD can be graded by magnetic resonance imaging (MRI), two-dimensional ultrasonography (2D-US) and three-dimensional ultrasonography (3D-US). MRI is considered as the most reliable reference due to its intense soft tissue contrast and discriminatory capacitySo far, no prior studies have compared 2D-US, 3D-US and MRI on the grading of LAD and evaluated the value of 2D-US on the diagnosis of LAD. Our objective was to determine whether 2D-US, an effective imaging method that is universally accessible, could be used to grade the size of the LAD compared with MRI and 3D-US.From November 2019 to September 2021, 129 patients were recruited in this research. Ten patients were excluded due to the exclusive conditions. The LAD grading of 119 patients were assessed, equal to 238 attachments assessed. The general demographic characteristics of patients were presented in Table In the case of avulsions on 3D-US, the hypoechoic insertions appeared at the attachments of the puborectalis muscle at the pubic ramus. 49 patients had no visible avulsions. 48 patients had unilateral avulsions Fig. D, while In the case of avulsions on 2D-US, the attachments of puborectalis to the pelvis were replaced by the hypoechoic zones. 55 patients had no visible defects. 44 patients had unilateral avulsions. Meanwhile, 20 had bilateral avulsions. 55 attachments presented partial avulsions and 29 showed complete avulsions.On MRI, 51 patients were diagnosed with no damage, while 41 had unilateral avulsions   and the diagnosis of avulsion or not . However, these two methods presented moderate agreement in the diagnosis of partial or complete avulsions .The puborectalis attachment width (PAW) of the intact attachments reached 10.42 ± 5.57 mm on 2D-US, while 11.01 ± 5.95 mm on 3D models. The agreement on the measurement of PAW showed excellent agreement with the Pearson’s coefficient of 0.90 (95% CI 0.83–0.97).The kappa for the interobserver agreement of the LAD grading by the MRI was 0.83 (95% CI 0.76–0.89), which was defined as excellent agreement. The interobserver agreement between the two observers in LAD grading by 3D-US and 2D-US had the kappa of 0.79 (95% CI 0.73–0.85) and 0.77 (95% 0.71–0.83), respectively, which were defined as good agreement.11. It was also found that the size of LAD was associated with the severity of POP6. It is significant to grade the defect size for the better treatment and further researches of the PFD mechanism. The LAD has been usually detected and graded by 3D-US and MRI. This study was aimed to determine whether 2D-US, a more universally accessible method in hospital environments, could be used to grade the size of LAD compared with MRI and 3D-US.It has been proved that LAD closely correlates with PFD, especially anterior or central compartment prolapse12. However, 3D-US need the ultrasound diagnostic system equipped with volume transducer. MRI is recognized as the most reliable method for LAD grading due to its superior competence of soft tissue contrast7. However, MRI has not been widely adopted in clinical practice, the main reason being cost and availability. A majority of ultrasound diagnostic systems were equipped with abdominal curved array transducer. 2D-US could be much more widely clinically and economically used, even in some developing countries, if its repeatability and advantages in the LAD diagnosis has been authenticated.3D-US is a non-invasive and widely clinically used method for LAD. It has remarkable advantages in real-time observation, easy-operation and efficiency2. 2D-US, 3D-US and MRI used the different criteria to grade the size of LAD due to the different imaging principles and post-processing modes. In order to grade the extent of LAD, 3D-US used the number of the defect slices, MRI used the ratio of defect to no-defect slices, while 2D-US detected the discontinuity between the hyperechogenic muscle fiber and pelvic wall14. Previous studies had been proved that these different grading criteria on LAD was statistically objective, reliable and repeatable15. This study used the similar method as the previous studies18.According to the anatomy, the size of the levator avulsion was classified into no, partial and complete avulsions18. However, their further analysis showed that the difference between the 3D-US and MRI was mainly in diagnosis of the partial or complete avulsions, which was in line with our findings. So far, no researches have compared 2D-US, 3D-US and MRI on LAD grading. This study compared these three imaging methods to prove the value of 2D-US. It was demonstrated that 3D-US was better in diagnosis of avulsions or not than 2D-US. Whereas 2D-US was better in diagnosing complete avulsions than 3D-US. On the grading of LAD , regarding MRI results as the standards, the diagnostic specificity was 75.0% and the diagnostic sensitivity of 3D-US reached 85.7%. If we used 3D-US to diagnose avulsions and then used 2D-US to confirm partial or complete avulsions, the diagnostic specificity promoted to 98.3% and the diagnostic sensitivity promoted to 92.3%. Therefore, 3D-US combined with 2D-US could better assess the grading of LAD. However, the iliococcygeus  was not invisible by translabial ultrasonography due to the poor resolution beyond 6 cm from perineum. The iliococcygeus avulsions could only be diagnosed by MRI. Moreover, this study also found that the iliococcygeus avulsions accompanied with the complete puborectalis avulsions at the same side, which has not been reported before.Several studies had compared MRI and 3D-US findings on LAD. Zhuang et al. and Notten et al. demonstrated that MRI and 3D-US correlated well in the grading of LAD18. So far, the reasons for the difference were remained unclear. This study proved that the three central slices on TUI (width of 7.5 mm) obtained by 3D-US could not cover the whole attachment with the width of 11.01 ± 5.95 mm, which resulted in the difference. In addition, the length of PAW measured by 2D-US agreed well with the measurement from 3D-MR-models, which illustrated that 2D-US could cover the whole attachment. Therefore, 2D-US had superior performance in grading partial or complete avulsions than 3D-US. Moreover, 2D-US could also observe the contraction and distention of the puborectalis attachments dynamically, which would contribute to the assessment and investigations of LAM contractility.Previous studies found that the difference between MRI and 3D-US mainly in diagnosing partial or complete avulsionsThis study had several limits. First, the subject was not contained nulliparous women with intact LAM for comparison, which would be supplemented in the future works. Second, the PAW in contraction and distention was not recorded in this study, which contributed to assessing the functions of puborectalis.In conclusion, compared with 3D-US and MRI, 2D-US is comparable in grading LAD, especially complete avulsions. In addition, 3D-US combined with 2D-US can more accurately assess the size of LAD.This study was conducted in Fujian Provincial Hospital from November 2019 to September 2021. Written informed consent was obtained from all participants.19. They also underwent the prolapse assessment using the prolapse grading system of the International Continence Society20. Pelvic organ prolapse grading included five stages. Stage 0 assigned if no prolapse, stage I if greater than 1 cm above the hymen, stage II if 1 cm or less proximal or distal to the plane of the hymen, stage III if greater than 1 cm below the plane of the hymen, but protruding no farther than 2 cm less than the total vaginal length and stage IV if eversion of the lower genital tract was complete20. The exclusion criteria were: (1) history of metal implantation; (2) claustrophobia; (3) history of abdominal or pelvic surgery; (4) inability to understand the instructions in Mandarin. MRI was carried out after 1 to 5 days after ultrasound examinations. The grading of LAD was carried out on left or right ends of LAM separately.This comparative research was undertaken in patients included from gynecological department, who were to undergo treatment for prolapse. 129 patients were interviewed about the symptoms of urinary or fecal incontinence using a standardized questionnaire9. The plane of minimal axial dimension was identified by this line. During the pelvic floor maximum contraction, tomographic ultrasound imaging (TUI) was then used to acquire the slices at 2.5 mm intervals, from 5 below to 12.5 mm above the plane of minimal dimension . Complete avulsions were identified if all three central slices (Slice 0 to Slice 2) showed hypoechoic insertions  with a RAB 4–8 MHz volume transducer. On 3D-US, the puborectalis muscle originated from the pubic internal surface and then formed a V-shaped sling bypassing the anorectal junction. On the basis of Dietz’s scoring criteria, the minimal distance in the axial plane between the posterior pubic symphysis border (hypoechogenic area) and the central anterior aspect of puborectalis loop (hyperechogenic muscles) was identified10. The levator ani defects on 2D-US were classified into the intact, partial avulsion and complete avulsions. The intact levator ani muscle showed the hyperechogenic fibers attached to the pelvis without the discontinuity (hypoechogenic insertions)  with a 5–8 MHz convex array transducer. According to the anatomy, the puborectalis muscle attached to the pubis ramus  was measured as the length of origins from the pubic internal surface. We chose the most anterior section of puborectalis (0.5-1 cm) as the measuring range, as close as possible to the pubic internal surface Fig. B. The PATwo different observers (N. Lin and ZH. Fan) performed and assessed the 3D-US and 2D-US scans independently. They were blinded against patients’ demographics and previous examination findings. They were blinded to the measurements made by the other observer. At the start of the research, two observers had approximately 5 years of experience in performing and assessing the ultrasound scans (1000–1500) regarding pelvic floor. Furthermore, two observers confirmed the diagnostic standards before the study and participated in consensus meetings in which 22 3D-US images and 27 2D-US images were discussed.14  equipped with a 35 cm field of view. The standard imaging parameters were: T2-weighted turbo and fast spin echo sequence . According to Delancey’s scoring system, LAD was diagnosed if there was a discontinuity between the puborectalis and the pubic ramus Each MRI scan was assessed offline by two researchers (YL. Xu and XJ. Gao) independently. They were blinded against patients’ demographics and previous examination findings. At the start of the study, two researchers had approximately 4 years of experience in assessing lower abdominal and pelvic floor magnetic resonance images (500–800). In addition, two researchers confirmed the diagnostic criteria before the study and participated in consensus meetings in which 25 magnetic resonance images were discussed.22. The advanced imaging processing tools were applied, such as smoothing and wrapping22 . On the basis of the anatomy, puborectalis, iliococcygeus and pubic ramus were delineated on consecutive axial scans, which could be reconstructed in 3-dimensional renderingThe statistical analysis was undertaken by SPSS 17.0 for Windows . The agreement between the methods and observers was assessed by Cohen’s kappa. The value of kappa less than 0.20 indicates poor, 0.21–0.40 fair, 0.41–0.60 moderate, 0.61–0.80 good, and 0.81–1.00 excellent agreement. The parameters were shown as the mean positive and negative standard deviation (X ± s). The agreement between measuring methods was evaluated by Pearson’s correlation. The Pearson’s coefficient less than 0.20 indicates poor, 0.21–0.40 fair, 0.41–0.60 moderate, 0.61–0.80 good, and 0.81–1.00 excellent agreement. A value of P < 0.05 was considered statistically.This study was approved by the Ethics Committee affiliated with Fujian Provincial Hospital. All procedures performed in the study involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments. All participants signed the informed consent.


Free-wall or mid-wall LGE was associated with an increased risk of MACE after adjustment . The risk of MACE in LVNC significantly increased when the LGE extent was greater than 7.5% and ring-like, multiple segments, and free-wall LGE were associated with MACE. These results suggest the value of LGE risk stratification in patients with LVNC.Current diagnostic criteria for left ventricular noncompaction (LVNC) may be poorly related to adverse prognosis. Late gadolinium enhancement (LGE) is a predictor of major adverse cardiovascular events (MACE), but risk stratification of LGE in patients with LVNC remains unclear. We retrospectively analyzed the clinical and cardiovascular magnetic resonance (CMR) data of 75 patients from three institutes and examined the correlation between different LGE types and MACE based on the extent, pattern (including a specific ring-like pattern), and locations of LGE in LVNC. A total of 51 patients (68%) presented LGE. A specific ring-like pattern was observed in 9 (12%). MACE occurred in 29 (38.7%) at 4.3 years of follow-up (interquartile range: 2.1–5.7 years). The adjusted hazard ratio (HR) for patients with ring-like LGE were 6.10 (95% CI, 1.39–26.75,  Left ventricular noncompaction (LVNC), an uncommon cardiomyopathy characterized by a thickened endocardial layer with prominent trabeculae and a thinned, compacted epicardial layer , can occWe searched the clinical and cardiovascular magnetic resonance (CMR) databases at three institutions for patients’ diagnosis descripted as LVNC or hypertrabeculation between January 2013 and December 2018, and the total number is 85. The CMR images of these patients were measured again according to Petersen’s criteria by two radiologists with at least two years of experience. The inclusion criteria followed Petersen et al.’s CMR criteria: (1) CMR images with a distinct two-layered appearance of trabeculated and compacted myocardium; (2) There are prominent myocardial trabeculations in the noncompacted myocardium and deep intertrabecular recesses communicating with the LV; and (3) Subjects with increased LV trabeculation as measured by a noncompaction/compacted (NC/C) ratio ≥ 1.0 anywhere in the myocardial segments on the CMR images. Current diagnosis is mainly based on this criterion . Both LVStandard gadolinium-enhanced CMR scanning was performed by a 3.0-T whole-body scanner  with a two-element cardiac phased-array coil and ECG-triggering device. After acquiring localization images, 8–12 continuous short-axis cine images that covered the whole left ventricle were obtained by steady-state free-precession sequence. All cine images were acquired at end-expiration. Gadobenate dimeglumine  was injected intravenously at a dose of 0.1–0.2 mL/kg body weight and a flow rate of 2.5–3.0 mL/s after a 20–25 mL saline flush at a rate of 3.0 mL/s. LGE images were obtained using the inversion recovery TrueFISP sequence 10–15 min after contrast injection.All CMR data were analyzed using the commercially available software cvi42 . Image analysis was performed to evaluate conventional cardiac function. For the cine imaging analysis, left ventricular structure and function parameters were measured on the short and long axis at end-diastole and end-systole, respectively. The left ventricular geometric parameters included the ratio of non-compacted to compacted myocardium, the end-diastolic volume (EDV), and end-systolic volume (ESV) mass. Cardiac function measurements, including the LV EDV, LV ESV, LV ejection fraction (EF), LV stroke volume, and LV mass, were analyzed by manually tracing the endocardial and epicardial contours. When delineated, the papillary muscles were excluded from the compacted myocardium. The end-diastolic and end-systolic phases were defined as those with maximum and minimum visual areas, respectively. The endocardial and epicardial boundaries of all images were manually delineated by a radiologist with at least two years of experience who was blinded to the clinical information. In addition, the ratio of NC/C was calculated in end-diastole. In each of three diastolic long-axis views , the segment with the most pronounced trabeculations was chosen for measurement of the thickness of the non-compacted and the compacted myocardium perpendicular to the compacted myocardium, and only the maximal ratio was then used for analysis. The presence and extent of LGE were assessed and quantified on short-axis images, and LGE was deemed present if myocardial enhancement was confirmed on short-axis areas by using a signal intensity threshold of 5 standard deviations (SD) ,22 aboveAll patients were followed up on the telephone by using the standard questionnaire interview and the clinical medical records, which was performed by experienced physicians blinded to the clinical and CMR data. The clinical endpoint of this study was MACEs, defined as HF hospitalizations, thromboembolic events, appropriate ICD therapy, heart transplant, and sudden cardiac death. The duration of follow-up was calculated from the date of first CMR examination to the first occurrence of an endpoint. The median follow-up was 4.3 years (interquartile range: 2.1–5.7 years).p-value < 0.05 was significant. The proportional hazard models were adjusted for LVEF, sex, and age, which may confound the association between LGE and results.Statistical analysis was performed with SPSS software . Continuous variables are expressed as means ± SD and categorical data as percentages. Baseline characteristics were compared using the Kruskal–Wallis rank test for continuous data and the Fisher exact test for categorical data. The Kaplan–Meier method was used to evaluate survival, and multivariate Cox regression analyses were performed to compute the hazard ratio (HR) and 95% confidence interval (CI). A p = 0.023), lower LVEF (p = 0.005), greater LVEDV (p = 0.001) and LVESV (p < 0.001), larger left ventricular systolic mass (p = 0.001), and diastolic mass (p = 0.001). NYHA class ≥ III  were common in all participants, and patients with LGE tended to have a poor NYHA functional (p = 0.01). Baseline characteristics are presented in The final cohort comprised 75 patients; a total of 52 (69.3%) were men, the median LVEF was 29.1% (IQ range: 17.5–37.7%), and LGE was present in 51 (68%). Patients with and without LGE had similar baseline ages. Patients with LGE had higher diastolic blood pressures  patients displayed a ring-like pattern and 42 (56%) a non-ring-like scar pattern. LGE was present only in the septum in 27 (36%) patients, only in the LV free wall in 16 (21.3%), and in both locations in 8 (10.7%). LGE was present only in a single segment in 37 (49.3%) patients, and in multiple segments in 14 (18.7%). LGE was categorized as mid-wall in 43 (57.3%) patients, and non-mid-wall in 8 (10.7%). Additionally, the LGE extent was categorized as three groups .p = 0.007). After adjustment of LVEF, age, and sex, LGE was associated with a higher risk of MACEs , two patients were lost. Of the 73 patients who completed follow-up, MACEs occurred in 29 (38.7%) patients. A total of 9 (31.0%) had HF hospitalizations, 8 (27.6%) underwent primary prevention ICD implantation, 2 (6.9%) had cardiac transplantation, and 10 (34.5%) had sudden cardiac death. MACEs occurred in 25 (50%) patients with LGE and in 4 (17.4%) without LGE , 7.42 , and 9.02 , respectively, compared to the patients without LGE  and 3.59  compared to those patients without LGE. Patients with LGE only in single segment and in multiple segments had adjusted HRs for the MACEs of 2.96  and 8.35  compared to those patients without LGE , 4.92 , and 10.29 , respectively, compared to the patients without LGE. Patients with free-wall LGE had an estimated adjusted HR of 2.85  compared to those without free-wall LGE. Patients with mid-wall LGE and other myocardial locations had adjusted HRs for the MACEs of 4.35  and 1.86 , respectively, compared to those without LGE  (NC/C ratio. The NC/C ratio was categorized as hypertrabeculation (NC/C ratio ≥1 and <2.3) and non-compaction (NC/C ratio ≥ 2.3); the risk between the two groups did not reach statistical significance  .(1)The >7.5% LGE extent may be associated with a significantly poor long-term prognosis in hypertrabeculation and LVNC patients.(2)Ring-like LGE and multiple segments LGE were associated with a particularly high risk of MACEs, which deserves extra clinical attention.(3)The NC/C ratio poorly correlates with clinical outcomes, LGE should be considered in diagnoses as a risk predictor, and our study provided useful risk stratification.The major clinical messages arising from our study were as follows:Myocardial fibrosis can significantly affect patients’ prognoses. LGE is of great significance in identifying high-risk patients. This finding has been widely confirmed in heart diseases ,25. HowePatients with LGE were placed in three groups according to the extent of enhancement. After being adjusted for LVEF, sex, and age, the absence of LGE was still associated with a lower risk of MACE. The risks increased significantly when the LGE extent was greater than 7.5%; HRs were 7.42 and 9.02 in the 7.5–15% and >15% groups, respectively. In a prior study, a ≥15% LGE extent was considered a potentially clinically relevant threshold in HCM ; howeverp < 0.01) compared to the absence of LGE [p = 0.016). This finding indicates that ring-like LGE is also a predictor of adverse events in patients with LVNC or hypertrabeculation. In particular, ring-like LGE also presented even the extent of LGE was low (<7.5%). The worse prognosis may relate to insults of the conduction system. In this regard, qualitative indicators are more convenient for radiologists to diagnose than quantitative analyses by CVi.A recent study points out that a specific ring-like LGE pattern is associated with a particularly high risk of malignant arrhythmic events, which are significant and independent of the total LGE burden and the presence of other additional risk factors; the HR of a ring-like pattern in this study was 68.98 (95% CI, 14.67–324.39; e of LGE . In our e of LGE . The resAnalogously, it is more intuitive to determine whether LGE is present in multiple segments of the left ventricle. We showed that patients with multiple LGE segments were at higher risk of MACEs. In contrast, those with single-segment LGE were at similar risk to those without LGE. In patients with multiple LGE segments, LGE is not only present in consecutive segments at the same short-axis level but also scattered in a total of 17 segments.Mahrholdt et al. showed that in a setting of HHV6 and combined PVB19/HHV6 myocarditis, LGE is predominantly located in the anteroseptal region . Aquaro Current criteria for the diagnosis of LVNC lead to high disease prevalence in patients referred for CMR, and the NC/C ratio > 2.3 is common in a large population-based cohort, indicating that the NC/C ratio alone for LVNC or hypertrabeculation diagnosis may have low specificity ,30. SomeStudy limitation. This study has some limitations. Although this is a multicenter study, the low number of patients limited statistical power. Secondly, all the three centers are large referral hospitals. Some patients who came to our hospitals were referred by multiple primary hospitals with more severe symptoms, therefore, they had a lower LVEF overall, and there may be some selection bias. However, this study also provides more prognostic information for patients with relatively severe symptoms.In LVNC or hypertrabeculation, the risk of MACE increases significantly when the LGE extent is greater than 7.5% or presence as ring-like LGE. Moreover, multiple segments and free-wall LGE are associated with MACE. The detailed study and risk stratification of LGE in LVNC or hypertrabeculation patients will help improve the diagnostic criteria and make this criterion more closely to clinical prognosis. This study provided useful models based on the extent, pattern, and location of LGE, which provide a much-needed approach to quantify risk.


Focal myocardial fibrosis in the systemic right ventricle (RV) is related to ventricular dysfunction and adverse outcome in patients with d-transposition of the great arteries (dTGA) post atrial redirection and those with congenitally corrected TGA (ccTGA). The role of diffuse fibrotic lesions in these conditions remains poorly understood. Our study aimed to investigate diffuse myocardial fibrosis by measuring extracellular volume (ECV) with cardiovascular magnetic resonance (CMR) and to explore correlations between ECV and clinical as well as functional markers of heart failure in patients with TGA and systemic RV.We prospectively included dTGA and ccTGA patients aged ≥14 years and compared them to healthy controls. Standardized CMR included modified Look-Locker Inversion recovery T1 mapping to quantify diffuse myocardial fibrosis in the systemic RV and the subpulmonary left ventricle (LV). The centerline of RV and LV myocardium was marked with a line of interest tool to determine native and post-contrast T1 for quantification of ECV.n  =  8, ccTGA: n = 5) with a median age of 30.3 years were enrolled. LV ECV was higher in patients than in controls , with values increased above the upper limit of normal in 10/13 patients (77%). RV ECV tended to be higher in patients than in controls, albeit without statistical significance . Patients with elevated LV ECV had lower LV ejection fraction than those with normal ECV . Correlations with clinical parameters were not observed. LV ECV was significantly higher than RV ECV (p = 0.016) in the patient group.In total, 13 patients (dTGA: In this study, LV ECV was significantly increased in TGA patients compared to controls, and was associated with LV dysfunction. Our data suggest that ECV may serve as a non-invasive tissue marker of heart failure in TGA with systemic RV. Further research is necessary to evaluate the prognostic implications and the potential role of ECV in monitoring disease progression and guiding therapy, aiming to maintain LV function or train the LV for subaortic location in TGA patients from infancy to adulthood. Given the advances in care for patients with congenital heart disease (CHD), the majority of children born with CHD reach adulthood , 2. HoweMyocardial fibrosis contributes to the development of heart failure in CHD , 6. CardWith the present study, we aimed to determine biventricular extracellular volume (ECV) as a non-invasive measure of diffuse myocardial fibrosis by applying CMR T1 mapping and to evaluate the correlation of ECV with clinical and functional markers of heart failure in patients with TGA and systemic RV.We prospectively enrolled patients of ages ≥14 years with a diagnosis of dTGA post atrial redirection or ccTGA who were referred for clinically indicated CMR. Exclusion criteria were arrhythmias, cardiac decompensation, cardiomyopathies, chronic or acute infection up to four weeks prior to CMR, chronic systemic diseases, significant renal impairment, devices non-compatible with CMR, and claustrophobia. Patients further underwent blood sampling for hematocrit and N-terminal pro brain natriuretic peptide (NT-proBNP) immediately before CMR, and cardiopulmonary exercise testing (CPET).Healthy subjects with normal 12-lead electrocardiogram (ECG), blood pressure, and renal function, and no history or symptoms of cardiovascular disease or contraindications for CMR were included as controls.All participants received standardized CMR at 1.5 T . Blood samples for hematocrit and NT-proBNP were collected immediately before CMR. Cine images were acquired with a steady-state free precision sequence in short axis (SAX) and long axis planes as well as in axial orientation covering the entire ventricles. LGE imaging in SAX was conducted using a T1-weighted inversion-recovery three-dimensional spoiled gradient echo sequence 5 min after intravenous bolus application of gadolinium-DOTA  at a dose of 0.1 mmol/kg. An individually adapted prepulse delay Look-Locker sequence was applied to determine inversion times for nulling myocardium.For T1 mapping, an ECG-gated single-shot modified Look-Locker inversion-recovery (MOLLI) sequence was used  with seqA commercially available workstation  was used to analyze LV and RV volumes  and ejection fraction (EF) from cine image stacks in axial orientation. Volumetric parameters were indexed to body surface area (BSA). In TGA patients, the ventricle in the subpulmonary position was defined as the LV, and the ventricle in the subaortic position as the (systemic) RV.T1 maps were generated with the open-source image reconstruction tool MRmap after manual correction for body motion , stored Medical records of TGA patients were reviewed for adverse events since the date of CMR, including supraventricular and ventricular arrhythmias, implantation of a pacemaker or implantable cardioverter defibrillator (ICD), heart failure-related hospitalization, heart transplantation (HTx), and cardiovascular death.p-values <0.05 to be statistically significant. Data between groups were compared with the Mann–Whitney U test, and within groups using Wilcoxon signed rank test with Bonferroni correction, respectively. For comparisons between categorical variables, Fisher’s exact test was applied. Spearman's correlation coefficient was used to analyze associations between continuous variables. Results are presented as median (range), mean ± SD, or numbers (n) and percentages (%), as appropriate.Statistical analyses were carried out with SPSS version 25.0 , considering n = 7, Mustard procedure: n = 1), and five had ccTGA. A summary of patient characteristics is given in n = 15; female: n = 7) had a median age of 24.4 (23.8–29.0) years and were younger than the patient group (p = 0.004). Differences in gender distribution were not seen.In total, 13 patients with a systemic RV and a median age of 30.3 (25.2–37.9) years were enrolled. Of those, eight patients had dTGA post atrial redirection , and was located at the insertion points (n = 5), the inferior (n = 2) or anterior RV wall (n = 1), and the septum (n = 1). Transmural LGE was not observed.Mild LGE was visible in 75% of the patients  was detected in four patients (31%). LV ECV was significantly higher than RV ECV (p = 0.016) in the patient group. There were no differences in LV ECV and RV ECV between dTGA and ccTGA patients.LV ECV was higher in patients than in controls [34% (30%–41%) vs. 26% (23%–27%), LV ECV and RV ECV of patients did not correlate with clinical characteristics including age at CMR, BSA, systolic or diastolic blood pressure, NT-proBNP, maximum oxygen consumption from CPET, and gender distribution.p = 0.007; p = 0.371, respectively). LV ECV and RV ECV did not differ between patients with and those without LGE . Among patients with positive LGE in the systemic RV, 67% (n = 6) had elevated LV ECV (p = 0.509). There were no differences in the presence of LGE between those with elevated RV ECV and those without (p = 0.509).Patients with elevated LV ECV had significantly lower LVEF than those with values within the normal range  years. One patient was lost to follow-up. Adverse events were observed in 6/12 patients (50%). Of those, four patients (67%) had elevated LV ECV, with additionally elevated RV ECV in two patients. Among those with dTGA post Senning and elevated LV ECV, one patient had isolated non-sustained ventricular tachycardia documented during Holter-ECG. The two patients with elevated LV ECV and RV ECV developed severe dysfunction of the systemic RV and underwent ICD implantation, in one followed by recurrent atrial and ventricular arrhythmias and progressing heart failure, hospitalization, and cardiovascular death 4.0 years after CMR. One patient with ccTGA and elevated LV ECV developed severe heart failure leading to hospitalization and HTx. In those with normal LV ECV, adverse events included hospitalization due to cardiac decompensation in one patient with dTGA post Senning, and complete heart block requiring pacemaker implantation in one patient with ccTGA.In our study, increased LV ECV in TGA patients as compared to controls indicates the presence of diffuse myocardial fibrosis in the subpulmonary LV in the setting of a systemic RV. LV ECV was elevated above the upper limit of normal in the majority of TGA patients and was associated with a reduction in LV function. LV ECV was higher than RV ECV in this cohort.It has been shown that focal myocardial fibrosis visualized with LGE imaging in the systemic RV correlates with ventricular dysfunction, cardiac arrhythmias, exercise intolerance, and clinical deterioration in patients with dTGA post atrial redirection –10 and cCheung et al. in addition to elevated LV ECV also detected higher RV ECV values in the TGA cohort, although with greater involvement of the subpulmonary LV . In our Interestingly, we saw both LV ECV and RV ECV to be elevated in the two dTGA patients requiring ICD implantation due to a severe decline in RV function during follow-up, followed by cardiovascular death in one patient. This points to the importance of interventricular interactions also on the extracellular matrix level, and in turn underlines the potential value of both systemic and subpulmonary myocardial ECV as non-invasive markers for prognosis, risk stratification, and monitoring of disease and therapy in TGA. Moreover, we suspect that the mild, but frequently present LGE in 75% of the TGA patients reflects fibrosis burden that may contribute to the RV dysfunction seen in our cohort. Among patients with positive LGE in the systemic RV, 67% had elevated LV ECV, again pointing to interactions between systemic and subpulmonary ventricles on the tissue level. However, our data in relation to LGE were not statistically significant, which may be explained by the limited number of patients included and the consequent lack of power. Therefore, further research to support our results and their prognostic implications is warranted. The importance of ventriculo-ventricular-interactions and the role of the subpulmonary LV not only as a contributor to morbidity and mortality but also as a potential therapeutic target in right-sided CHD has been well recognized . FurtherOur study is limited by the small sample size. Due to the lack of clinical indication for regular CMR examinations with contrast enhancement, longitudinal ECV data were unfortunately not available. Future long-term studies on larger cohorts to confirm our findings are required, and may potentially elucidate further differences between groups and associations between ECV and markers of heart failure. Healthy controls were younger compared to the patient group. However, an age-related increase in ECV is seen in individuals significantly older than the patients included in our study  and, thuIn this study, LV ECV was significantly higher in TGA patients than in controls and was associated with LV dysfunction. Our data suggest that ECV measurements may serve as an imaging marker of heart failure in the setting of TGA with a systemic RV. Further research is necessary to evaluate the prognostic implications and the potential role of ECV in non-invasively monitoring disease progression and guiding therapy, aiming to maintain LV function or train the LV for subaortic location in TGA patients from infancy to adulthood.


Dispersion of repolarization and mechanical dispersion remained unchanged. Corresponding electrophysiological and mechanical relationships were present at comparable paced heart rates. After rewarming, the increased electromechanical window was reversed in the presence of both spontaneous and paced heart rates. Moderate hypothermia increased electromechanical window positivity, while dispersion of repolarization and mechanical dispersion remained unchanged. This impact of hypothermia may be clinically relevant for selected groups of patients after cardiac arrest.Moderate hypothermia has been used to improve outcomes in comatose out‐of‐hospital cardiac arrest survivors during the past two decades, although the effects remain controversial. We have recently shown in an experimental study that myocardial electrophysiological and mechanical relationships were altered during moderate hypothermia. Electromechanical window positivity increased, and electrical dispersion of repolarization decreased, both of which are changes associated with decreased arrhythmogenicity in clinical conditions. Mechanical dispersion, a parameter also linked to arrhythmic risk, remained unaltered. Whether corresponding electrophysiological and mechanical changes occur in humans during moderate hypothermia, has not been previously explored. Twenty patients with normal left ventricular function were included. Measurements were obtained at 36 and 32°C prior to ascending aortic repair while on partial cardiopulmonary bypass and at 36°C after repair. Registrations were performed in the presence of both spontaneous and comparable paced heart rate during standardized loading conditions. The following electrical and mechanical parameters were explored: (1) Electromechanical window, measured as time difference between mechanical and electrical systole, (2) dispersion of repolarization from ECG T‐wave, and (3) mechanical dispersion, measured as segmental variation in time to peak echocardiographic strain. At moderate hypothermia, mechanical systolic prolongation (425 ± 43–588 ± 67 ms,  Moderate hypothermia stabilizes electromechanical relationships associated with arrhythmic susceptibility in clinical conditions. Anaesthesia was induced by intravenous (i.v.) fentanyl (3.5–7.5 μg/kg), midazolam (0.05–0.15 mg/kg), thiopental (2.5–7.0 mg/kg), and cisatracurium (0.15 mg/kg) and maintained with sevoflurane‐inhalation (1.0–2.5%) and repeated doses of iv. fentanyl (1–2 μg/kg). The patients were monitored according to standard clinical practice at our institution, in addition to the monitoring defined by the study protocol. Three‐lead electrocardiogram (ECG) was obtained by surface leads. Blood pressure was registered from a radial artery line. Central venous catheter , and pulmonary artery catheter  were inserted to obtain central venous pressure (CVP), and temperature and hemodynamic registrations, respectively. After induction of anesthesia, the patients underwent sternotomy and pericardiotomy, before atrial pacemaker leads  were sutured on the right atrium. The patients were cannulated and connected to cardiopulmonary bypass (CPB), . During CPB, ventilation was discontinued, and sedation was provided with propofol infusion (3.5 mg/kg/h). All patients received thiopental (1 g) and methylprednisolone (2 g) prior to graft procedure. While the distal anastomosis was performed, the patients were cooled to deep hypothermia (<28°C). 18/20 patients underwent brief circulatory arrest in this phase. Myocardial preservation with ice cold cardioplegia inducing cold ischemia, was performed in all patients before suturing of the proximal anastomosis. After completing aortic repair and cardiac reperfusion, the patients were rewarmed and weaned off CPB.2.2All measurements were made while the patients were on cardiopulmonary bypass (CPB) to achieve optimal and uniform conditions. The measurements were made at three time points Figure : T1 at 3The surgical setting, with use of CPB‐machine with a heat‐exchanger, enabled standardization with accurate control of body temperature and loading conditions. To obtain comparable and near‐normal cardiac working conditions, CPB flow was carefully reduced to 20% of the estimated maximum flow, hence ventilation was intermittently re‐continued. Loading conditions were made comparable by clamping venous drainage adjusted to mean arterial pressure (MAP) >50 mmHg and central venous pressure (CVP) ±10% of the baseline value. All measurements were performed during a stable phase, with no change in anesthesia or hemodynamic support. Surgical manipulation was paused during the measurements and between T1 and T2. Low dose norepinephrine (0.01 μg/kg/min) was used in two patients during T1 and T2, and low dose nitroprusside infusion (0.25–0.5 μg/kg/min) was continued in five patients at T3. These exceptions were controlled for and had no influence on statistical significance; thus data from all the 20 patients included are presented.2.3A Vivid E95 scanner (GE Vingmed Ultrasound) was used for echocardiographic 2D and Pulsed Wave (PW) Doppler recordings with a 5 MHz transesophageal echocardiographic probe . The recordings were obtained from mid‐oesophageal two‐ and four‐chamber and long‐axis views, and transgastric short‐axis view at mid‐papillary level. All recordings were analyzed offline by designated software . Measurements were made from three consecutive heart cycles and averaged. Four isolated measurements from segment 2 were foreshortened at T2 in three different patients at spontaneous heart rate; hence these measurements were excluded from the calculation of mechanical dispersion. Data were de‐identified, and the investigator was blinded to patient identification and situation.2.4The standardized electrocardiogram (ECG) lead II, was used for electrical measurements and was synchronized with the echocardiographic scanner. QRS complex duration (QRS) was measured from onset of the Q wave to end of the S wave. Electrical systole was represented by QT interval and measured from ECG onset of QRS complex to end of T‐wave (Te), and this was also HR corrected  to aortic valve closing (AVC). QAVC was measured from onset of the QRS to AVC. Isovolumic contraction time (IVCT) and isovolumic relaxation time (IVRT) were measured from mitral valve closing (MVC) to AVO and AVC to mitral valve opening (MVO), respectively. Diastolic filling time was measured from MVO to MVC. Mechanical systole was defined as QAVC. Electromechanical window was calculated as the difference between mechanical and electrical systole measured in the same beat (QAVC–QT).2.6Speckle tracking echocardiography was used to obtain longitudinal strain in four‐chamber, two‐chamber, and long‐axis views  with a two‐sided alpha level of 0.05. Statistical analyses were calculated in SPSS v.26 software (SPSS Inc.). Data are presented as mean ± standard deviation. One‐way analysis of variance (ANOVA) for repeated measures was used to determine whether there were any significant differences between the three time points with spontaneous HR, and between the time points with paced HR. Comparisons between time points T2 and T1, and T3 and T1, were performed by paired Student's 3p < 0.001. Rewarming reversed these changes .Twenty patients were included Table . Recordi3.1At baseline T1; 36°C), electrical systole ended just before the end of mechanical systole, giving a positive electromechanical window. During moderate hypothermia T2; 32°C) duration of the electrical and mechanical systole both increased , both electrical and mechanical systole were still prolonged, compared to baseline at T1. However, the electromechanical window was not significantly different compared with the baseline value (Figure 4This prospective clinical study is the first to explore the isolated effects of moderate hypothermia on electrophysiological and mechanical relationships in patients, by use of a study protocol approximating an experimental design. Electromechanical window positivity increased at 32°C compared to 36°C, while dispersion of repolarization and mechanical dispersion remained unchanged. The increased electromechanical window positivity was reversed to baseline values after rewarming.The electromechanical window is a novel clinical parameter and has not previously been described during moderate hypothermia. In the present study, we found that the QT interval was extended beyond the normal range at moderate hypothermia Viskin, . InteresAfter rewarming, we found that both electrical and mechanical systole remained prolonged at spontaneous HR. The non‐significant trend toward decreased HR after rewarming may have influenced these measurements. Yet, prolonged electrical and mechanical systole were also present at comparable paced HR. These findings may represent a consequence of myocardial stunning due to deep hypothermia and cold ischemia during graft surgery. Importantly, the electromechanical interrelations were restored, and the electromechanical window returned to baseline values, indicating a rapid reversibility of the isolated effects of moderate hypothermia on these parameters.in vitro models have demonstrated a profound increase in dispersions of repolarization at temperatures <30°C, but a remarkable shift at temperatures ≥32°C with reduced dispersion compared to lower temperatures, and an arrhythmogenicity similar to 36°C (Hsieh et al., We found no increase in dispersion of repolarization during moderate hypothermia, either at spontaneous or comparable HR. Dispersion of repolarization measured by TpTe has frequently been applied as a surrogate marker for heterogeneity in repolarization, although this has been controversial (Opthof et al., In patients with coronary artery disease, and after myocardial infarction, mechanical dispersion is frequently enhanced due to heterogeneity between healthy and dyskinetic myocardial tissue, with further increased arrhythmogenicity (Haugaa et al., The isolated impact of moderate hypothermia on electrophysiological and mechanical relationships in our study was increased electromechanical window positivity. Despite the different physiological stimulus compared to long QT syndrome and patients with cardiac disease, we carefully suggest that this finding may have clinical relevance. Measuring the electromechanical window in clinical practice can provide valuable information when treating patients with temperature control, and when deciding the optimal individual protocol in comatose cardiac arrest survivors, according to the recently revised guidelines.4.1The study has some confounders. The open thorax and the surgical setting with changes in autonomic tone and catecholamine levels, may influence electrical changes and mechanical performance (Boudoulas et al., 5In patients with normal left ventricular function, electrical and mechanical systole were prolonged during moderate hypothermia without exaggerating electrical and mechanical dispersion. Electromechanical window positivity increased which is associated with decreased arrhythmic susceptibility in other clinical conditions. This temperature‐related impact may be clinically relevant in selected groups of patients after cardiac arrest.The authors declare that there is no conflict of interest and no financial disclosure.All authors have contributed substantially in conducting the underlying research and drafting this manuscript. All authors read and approved the final manuscript.Ethics approval and consent to participate: yes; consent for publication: yes.


Coronary artery-left ventricular multiple micro-fistulas (CA-LVMMFs) is a rare congenital vascular anomaly that may present with no obvious clinical symptoms or a typical angina attack. CA-LVMMFs is usually found unexpectedly during coronary angiography (CAG).We report a case of a 65-year-old man admitted to the hospital with acute coronary syndrome. CA-LVMMFs was found during coronary angiography. Echocardiography showed apical hypertrophy and blood flow signals were seen in the apical myocardium, connected with the left ventricle. We searched the MEDLINE database and found 39 relevant reports. We made statistics on the clinical characteristics of these patients and found half involved hypertrophy or perfusion defects in the ventricular septum or apex.As a rare congenital anomaly, the effect of CA-LVMMFs on patients is unclear. By reporting a case and summarizing literature reports, we found that CA-LVMMFs may be associated with myocardial hypertrophy, especially ventricular septal and apical hypertrophy.The online version contains supplementary material available at 10.1186/s12872-022-02926-w. Coronary artery fistula (CAF) is a congenital vascular anomaly that occurs in 0.13%-0.22% of adults undergoing coronary angiography (CAG) [2; aortic regurgitation area 4.7 cm2). He then received a CAG examination, which showed that during the left coronary angiography, the contrast agent entered from the diagonal branch, and rapidly flowed into the left ventricle via a diffuse plexus of multiple intramyocardial fistulas, and completely turbidized the left ventricle. Subsequently, the contrast agent was discharged from the left ventricle during systole  and 26 were female (66.7%). Twenty-five patients (64.1%) had fistulas from three coronary arteries, and 35 patients (89.7%) showed fistula communication with the left ventricle. Thirteen patients (33.3%) had a clear history of hypertension, 19 (48.7%) showed definite evidence of myocardial hypertrophy (including any position of the myocardium), 17 (43.6%) showed evidence of myocardial perfusion defects (including any location of the myocardium), 19 (48.7%) showed evidence of myocardial hypertrophy or myocardial perfusion defect (involving the ventricular septum or apex of the heart), and five had a definite diagnosis of hypertrophic cardiomyopathy (12.8%). The diagnostic criteria of the left ventricular wall or ventricular septal thickness of echocardiography were for hypertrophic cardiomyopathy ≥15mm and myocardial hypertrophy ≥12mm. Based on the above data, CA-LVMMFs cases included a high proportion of myocardial hypertrophy or myocardial perfusion defects, and the proportion of patients showing involvement of the ventricular septum or apex position was high. To exclude the interference of secondary myocardial hypertrophy caused by hypertension, we obtained the data for 26 patients without a history of hypertension and identified 11 patients with myocardial hypertrophy or perfusion defects, indicating that their myocardial hypertrophy and perfusion defects were unrelated to hypertension. To exclude the interference of myocardial perfusion defects caused by coronary artery stenosis, we obtained the data for 35 patients without coronary artery stenosis and 17 patients who showed evidence of myocardial perfusion defects (including any location of the myocardium), indicating that their myocardial perfusion defects were unrelated to coronary artery stenosis. We conclude that there may be an unrecognized association between CA-LVMMFs and myocardial hypertrophy and perfusion defects, especially in the ventricular septum and the apex of the heart.Few reports have described the relationship between CA-LVMMFs and myocardial hypertrophy. We have two hypotheses: the first is that CA-LVMMFs initially develops abnormally in the coronary arteries, with increased blood flow directly into the left ventricle leading to increased volume loading and thus myocardial hypertrophy. The other is that the myocardial hypertrophy mediated by genetic mutations appears first and interferes with the development of coronary arteries in the embryo, which affects the microenvironment of vascular dedifferentiation and leads to the formation of CA-LVMMFs.Hypertrophic cardiomyopathy (HCM) is defined by a wall thickness ≥ 15 mm in one or more LV myocardial segments measured by any imaging technique. In up to 60% of adolescents and adults with HCM, the disease is an autosomal dominant disorder caused by mutations in the cardiac sarcomeric protein genes. Mayo Clinic offers a simple clinically applicable phenotype-derived score that is a good predictor of a positive HCM genetic test result. The scoring system includes echocardiographic reverse morphological subtypes, age at diagnosis less than 45 years, maximum left ventricular wall thickness 20 mm or greater, and son on. The Toronto scoring system based on clinical characteristics and echocardiographic variables, including age, female gender, arterial hypertension, and so on， is also a good predictor of the probability of a positive genotype. In the early stage of HCM, patients are usually asymptomatic, and conventional noninvasive cardiac function indicators are within the normal range. As the disease progresses, LV diastolic and systolic function declines, and severe LV diastolic dysfunction develops. In patients with symptomatic left ventricular outflow tract obstruction, symptoms can be improved with medication, surgery, or alcohol ablation. Patients refractory to medical therapy may be candidates for heart transplantation .The literature  shows thThere is no consensus regarding the treatment of CA-LVMMFs. Due to the diffuse characteristics of abnormal microvascular fistulas, scholars have proposed conservative treatment and considered the need to prevent infective endocarditis. Both beta-blockers  and calcIn conclusion, as a rare congenital anomaly, the effect of CA-LVMMFs on patients is unclear. By reporting a case and summarizing literature reports, we found that CA-LVMMFs may be associated with myocardial hypertrophy, especially ventricular septal and apical hypertrophy.Additional file 1: Video 1 Left coronary angiography in right anterior oblique 30° + cranial 20°2. Video 2 Left coronary angiography in right anterior oblique 30° + caudal 20°.Additional file 2: Table1


Here, we report a case of a 54-year-old man who presented with complications of a left ventricle apical aneurysm, which was the result of a myocardial infarction (MI). Interestingly, he sustained the MI following a cardiac contusion whilst playing rugby 32 years ago. He had another MI 10 years later, despite the presence of normal coronary angiography following the initial event, and presented with two episodes of sustained ventricular tachycardia over six months. The patient proceeded to surgical resection of the aneurysm and went on to make a good recovery. A true left ventricular aneurysm (LVA) is a dyskinetic bulging of the LV wall and is usually filled with thrombus. LVAs are lined with a thin wall of scar tissue, which replaces the muscle that undergoes necrosis following an index ischaemic event. In contrast, a false aneurysm appears following the contained rupture of the ventricle . An LVA The patient was a 54-year-old man with a past history of anterior MI following a cardiac contusion whilst playing rugby 32 years prior. This was treated at the time with tissue plasminogen activator (tPA) thrombolysis and his predischarge tests  were satisfactory. A subsequent coronary angiogram was entirely normal. The patient then re-presented with a raised troponin and non-ST-elevation myocardial infarction (NSTEMI) 10 years later. His coronary angiogram was again normal and an echocardiogram showed preserved left ventricular (LV) systolic function, but with a hypokinetic basal septum and apex, and a thinned wall. Meanwhile, MRI demonstrated mild LV impairment and a thinned akinetic filling defect at the apex of the left ventricle consistent with old resolving apical thrombus  requiring emergency direct current (DC) cardioversion for VT at an Accident and Emergency department. A repeat MRI at this stage confirmed normal systolic function, no valvular pathology and again an apical dyskinetic regional wall motion abnormality, with a non-enhancing filling defect. The patient, therefore, underwent ventricular aneurysmectomy via a standard median sternotomy, with complete excision of the LV apical aneurysm. A Cooley repair technique was performed, whereby the normal LV muscular edges were re-approximated using a running linear 4-0 Prolene suture in two layers with two reinforcing strips of Teflon felt Figure . The opeA post-operative trans-oesophageal echocardiogram (TOE) confirmed a good size residual LV cavity. The patient’s post-operative recovery was uneventful and he was discharged home on Day 6. He continued to make an excellent recovery, and an electrophysiology study three months later did not show a predisposition to any ventricular tachycardia.Although LV apical aneurysms are not rare following MI, in this case, the patient had an unusual presentation in that he suffered complications of MI following a direct chest trauma despite the fact that his coronary angiogram was entirely normal on two occasions. We considered the first MI to be a result of the chest trauma and the second NSTEMI was likely a thromboembolic event from his LV aneurysm. The subsequent presentations 20 years later with episodes of ventricular tachycardia were a complication of the LV aneurysm. Ventricular arrhythmias associated with LVAs are believed to originate from an apical rim of scar tissue that acts as a zone of slow conduction . AlthougSurgical treatment is indicated after the diagnosis of LV aneurysm to prevent future complications such as heart failure symptoms, risk of rupture, thromboembolic events or arrhythmias. Given this context, clinical suspicion should be raised by patients with a history of cardiac trauma and MI presenting with recurrent arrhythmias, and specialist referral considered if a thinned dyskinetic LV wall on echocardiogram or filling defect on MRI is visualised.


The Watchman™, Nanostim™, and Micra™ experiences have taught us that intracardiac implantation requires new skills, tools, and techniques. Special training is required, and there is a learning curve for achieving the best outcomes. We also know that a small portion of implants are complicated by significant cardiac perforations that require emergency treatment.A major technology inflexion point has arrived with the introduction of implantable intracardiac electrophysiology devices. Currently, these include left atrial appendage closure devices and leadless right ventricular pacemakers.The implantation of leadless multichamber pacing systems and defibrillators will be more challenging and require more precision than single chamber ventricular devices. Advanced multi-modal imaging will be required to facilitate pre-procedure planning and to provide precise intra-procedure navigation so that IPGs do not injure cardiovascular structures or interfere with valve function or other intracardiac devices. Some patients will undergo concomitant mapping and ablation, or have their left atrial appendages closed. The procedures and devices will require post-implant follow-up and long-term surveillance.These new technologies have placed interventional electrophysiology at a crossroads. The question is what direction will it take? One path is to passively observe novel devices evolve on their own, as they have during the past decade, directed primarily by industry. The analysis and communication of pre-market clinical trial and post-approval registry results will be controlled solely by manufacturers whose only obligation is to report adverse clinical events to the US Food and Drug Administration (FDA). The alternative and more demanding track is for the professional cardiac electrophysiology organizations to become fully engaged at every stage of device development and to actively provide guidance and oversight. This means that the international electrophysiology community will work with industry and the appropriate regulatory authorities to achieve the safest and most satisfactory outcomes for patients.The watch-and-wait pathway in the USA and many other countries will allow almost any licensed physician with hospital or clinic privileges to implant approved intracardiac devices upon successful completion of training programs provided and administered by manufacturers. The FDA does not have the authority to limit or dictate who performs device implants beyond that specified in the product’s labeling. Moreover, current regulations allow almost any hospital to implant intracardiac devices even though it may not have the skilled medical or surgical capabilities to effectively manage complications. Such an approach is not in the best interest of patients, and especially those at highest risk for adverse events.3 for the optimal care of patients with VHD recommends the formation of multi-disciplinary Heart Valve Teams, and it describes two types of heart valve centers: level 1 is a comprehensive center that performs all interventional and surgical valve procedures, while a level 2 primary center performs the most common and least complex procedures. The centers are differentiated by their offerings and expertise, including advanced imaging, and their institution’s infrastructure and facilities. Importantly, the document emphasizes performance and outcome standards for all providers and centers.Interventional electrophysiologists can benefit from the experience of their valvular heart disease (VHD) colleagues who were challenged by the increasing burden of VHD and rapidly evolving transcatheter and surgical therapies. The 2019 the Expert Consensus of Care DocumentA similar approach should be taken for the treatment of heart rhythm disorders by interventional techniques. Centers should be distinguished by their methods for care delivery, procedural experience (volume and complexity), institutional competencies, and participation in clinical studies and registries. Already some electrophysiology programs have integrated multi-disciplinary teams that evaluate patients and make treatment recommendations based on clinical evidence and the patient’s wishes. The proposed multi-disciplinary Heart Rhythm Team Fig.  should bElectrophysiologists will be confronted with difficult choices as more leadless implantable devices from multiple manufacturers enter the marketplace. Which make or model is best for a given application? What are the tradeoffs? Is one product more reliable or longer-lived than another? Are there device-to-device interactions? The answers to these questions require data, and presently electrophysiologists have no practical source other than manufacturers’ periodic product performance reports. Independent open-access registries are needed to track device performance, compare outcomes, and detect safety signals before large patient populations are needlessly exposed to the risk of preventable device-related adverse events. These online registries should be international in scope, freely accessible to participants, and led by the professional societies. We suggest the American College of Cardiology, Heart Rhythm Society, and European Society of Cardiology collaborate to create a Registry to monitor the safety and real-world outcomes of marketed leadless intracardiac devices and to publish the results regularly and when a significant safety signal is identified.As our understanding of arrhythmias improved, so too did the technologies used to treat them. Fifty years ago, practitioners had short-lived single chamber pacemakers and mostly ineffective antiarrhythmic drugs with serious side effects. Today we employ a variety of well-studied and reliable therapies to prevent sudden cardiac death and manage almost any heart rhythm disturbance. Advances have been driven by new knowledge and technologic sophistication. However, to be safe and effective, these therapies often require multi-disciplinary expertise and a supportive infrastructure. Such attributes will be even more important in the decade ahead as new intracardiac devices and ablation techniques become widely available. Our professional organizations should collaborate to advance the practice of interventional electrophysiology so that these innovative treatments can be delivered successfully at the lowest possible risk.


We evaluated the feasibility of a simultaneous low-dose dual-isotope 123I-metaiodobenzylguanidine (MIBG)/99mTc-sestamibi gated CZT-SPECT cardiac imaging. Perfusion and innervation total defect sizes and perfusion/innervation mismatch size (defined by 123I-MIBG defect size minus 99mTc-sestamibi defect size) were expressed as percentages of the total left ventricular (LV) surface area. LV ejection fraction (EF) significantly correlated with perfusion defect size (P < .005), innervation defect size (P < .005), and early (P < .05) and late (P < .01) 123I-MIBG heart-to-mediastinum (H/M) ratio. In addition, late H/M ratio was independently associated with reduced LVEF (P < .05). Although there was a significant relationship (P < .001) between perfusion and innervation defect size, innervation defect size was larger than perfusion defect size (P < .001). At multivariable linear regression analysis, 123I-MIBG washout rate (WR) correlated with perfusion/innervation mismatch (P < .05).Thirty-six patients with HF underwent simultaneous low-dose 123I/99mTc-acquisition protocol is feasible and could have important clinical implications.In patients with HF, a simultaneous low-dose dual-isotope The online version contains supplementary material available at 10.1007/s12350-022-02951-4. Thus, when using a low-dose of 123I-MIBG and 99mTc-labeled tracers, it is possible to considerably reduce radiation exposure.The introduction of novel dedicated SPECT cameras with semiconductor cadmium–zinc–telluride (CZT) detectors has enabled significant improvements in spatial, temporal and energy resolution in the acquisition protocols by comparison to conventional Anger cameras.9 in a phantom study assessing perfusion (99mTc) and innervation (123I) using two commercially available CZT-SPECT cameras demonstrated that a simultaneous dual-isotope (SDI) acquisition is feasible and provides perfectly registered functional images with a reduced imaging time. Prior studies have demonstrated correlation between the impairment of innervation, rest perfusion and mechanical dyssynchrony or diastolic function using sequential perfusion and innervation imaging.11 However, no studies are available on the quantitative evaluation of perfusion and adrenergic innervation in patients with HF using a simultaneous acquisition protocol by CZT-SPECT. The aim of our study was firstly to evaluate the feasibility of a simultaneous low-dose dual-isotope 123I/99mTc-acquisition protocol using a CZT-SPECT camera. We also assessed the relationship between myocardial perfusion, adrenergic innervation and left ventricular (LV) function in patients with HF undergoing this protocol.Recently Blaire et al123I-MIBG imaging to evaluate cardiac adrenergic innervation, underwent low-dose SDI imaging acquisition. Heart failure was defined as the presence of typical symptoms  and/or evidence of structural and/or functional cardiac abnormality, with preserved (≥ 50%), mid-range (40%-49%) or reduced (< 40%) LV ejection fraction (EF).12 The exclusion criteria were atrial fibrillation, implanted pacemaker or prosthetic valve, iodine allergy, severe loss of renal function, symptomatic asthma and pregnancy. For each patient, demographic data and clinical characteristics were noted. Hypertension was defined as a blood pressure > 140/90 mmHg or the use of anti-hypertensive medication. Dyslipidemia was defined as total cholesterol level > 6.2 mmol/L or treatment with cholesterol lowering medication. Patients were classified as having diabetes if they were receiving treatment with oral hypoglycemic drugs or insulin. A patient was considered to have known coronary artery disease based on a history of myocardial infarction or coronary revascularization. Nineteen subjects undergoing 123I-MIBG scintigraphy to rule out disease of the adrenal medulla served as the control group. None of these subjects had a history of neurological or cardiac diseases. The study was approved by the local ethical committee (Protocol Number 110/17) and conformed to the Declaration of Helsinki on human research. Written informed consent was obtained from every patient after complete explanation of the protocol, its aim and potential risks.Thirty-six consecutive patients with HF referred to 123I-MIBG/99mTc-sestamibi imaging protocol . Similarly, 3 hours and 50 minutes after 123I-MIBG administration, a 10 minutes list mode SDI scan (late image) was performed.All patients underwent a low-dose SDI 99mTc and 123I energy windows. The energy windows were approximately 8.5 % asymmetrical (− 7.5 to +4.5 keV) centered on 159 keV for 123I and 10 % asymmetrical (− 7 to +9 keV) centered on 140.5 keV for 99mTc. Summed and gated projections were reconstructed with an iterative maximum likelihood expectation maximization algorithm using 7 and 4 iterations, respectively. No attenuation or scatter correction was performed.Data were acquired by nine mobile CZT detector columns mounted vertically in 90° geometry . List mode acquisition permits the retrospective selection of 99mTc-sestamibi images, a region of interest (ROI) was manually drawn on the left ventricle while size of the mediastinum ROI was determined automatically on the x and y dimensions and positioned manually, as previously reported.6 ROI were automatically copied from the 99mTc-sestamibi images to the 123I-MIBG images using the software provided by the manufacturer. Once ROI were drawn, H/M ratios were calculated by the same nuclear cardiologists from early and delayed planar 123I-MIBG images, as previously reported.13123I-MIBG WR was also calculated using the following formula: [(early heart counts/pixel − early mediastinum counts/pixel) − (late heart counts/pixel decay-corrected − late mediastinum counts/pixel decay-corrected)]/(early heart counts/pixel − early mediastinum counts/pixel).Using the D-SPECT camera, the planar equivalent image (planogram) was obtained by projecting and summing all the elementary 2-D images that shared the same angle onto one large field of view virtual plane. On the 99mTc-sestamibi images using a commercially available software . The myocardial perfusion and innervation images obtained at rest were scored using a 17-segment model of the left ventricle.14 Perfusion and innervation total defect sizes were expressed as the percentage of the total left ventricle surface area using as reference an internal normal database. Perfusion/innervation mismatch size was defined by 123I-MIBG defect size minus 99mTc-sestamibi defect size, again expressed as a percentage of left ventricle surface area.LV volumes, EF and perfusion and innervation defect scores were automatically calculated from gated t test and by one-way ANOVA followed by post hoc multiple comparisons with the Bonferroni correction. Evaluation of relationships between variables was performed using Spearman’s rank correlation analysis. Logistic regression analysis was performed to identify the predictors of reduced LVEF. Moreover, linear regression analysis was performed to identify the predictors of perfusion/innervation mismatch. For the multivariable analysis we only considered variables resulting statistically significant at univariable analysis. Statistical analysis was performed with Stata 15.1 software . A P value < .05 (two-sided) was considered statistically significant.Continuous variables were expressed as mean ± standard deviation (SD) and categorical data as frequencies or percentage. Comparison of continuous data between groups was performed using the two-sided Student’s 123I-MIBG uptake in controls and patients is reported in Table P < .05). In patients, both apex and inferior walls showed a lower 123I-MIBG uptake compared to the other regions (P < .01). To rule out that the 123I-MIBG uptake reduction in the inferior region in patients may reflect normal physiology more than pathological patterns, we compared individual uptake and found that in 26 (72%) patients tracer activity was lower than 2 SD of the mean values in control group  and lower values of early (P < .05) and late H/M ratio (P < .01). Conversely, the extent of perfusion/innervation mismatch was not different (P = .80) between patients with preserved or mid-range and reduced LVEF.Of the 36 patients enrolled, 13 (36%) had a preserved or mid-range 48% ± 2%) LVEF and 23 (64%) a reduced (30% ± 6%) LVEF. The clinical and demographic characteristics of the patient population according to LVEF are described in Table % LVEF anr = 0.48, P < .005) and innervation  defect sizes correlated with LVEF  and late  H/M ratio with LVEF was also found , innervation defect size was larger than perfusion defect size , both in the presence of reduced  or mid-range  LVEF. Linear regression analyses, considering perfusion/innervation mismatch as dependent variable, are reported in Table In the overall patient population, although perfusion defect size was significantly correlated with innervation defect size .13 Hence, WR correlates with the more extensive involvement of neuronal retention system in the mismatch area characterized by a higher amount of adrenergic denervation compared to perfusion impairment. As demonstrated in previous studies, 123I-MIBG WR and late H/M ratio have a prognostic role in patients with HF.25 In particular, a high WR represents an independent predictor for subsequent cardiac events, although lack of correlation to LV function.26 The measurement of perfusion/innervation mismatch, as index of regions with impaired sympathetic innervation and preserved viability and frequently localized at the border of infarcted areas, is a key step in prognosis assessment, as it has been demonstrated that these mismatch areas are triggers of ventricular arrythmias and may be used as potential therapeutic targets.27 Therefore, markers of cardiac sympathetic impairment obtained by CTZ-SPECT could be used to evaluate the clinical and prognostic role of denervated but viable myocardium, improving the risk stratification of high-risk patients. Resting myocardial perfusion imaging is an imaging tool to detect viable myocardium in patients with LV dysfunction with prognostic information incremental to that of clinical data and LV function.30Moreover, using a low-dose SDI protocol, we were able to confirm a relationship between myocardial innervation, perfusion parameters and LV systolic function. Patients with reduced LVEF showed higher values of perfusion and innervation defect sizes and WR, and lower values of early and late 123I-MIBG and 185 MBq of 99mTc-sestamibi) leading to a radiation dose reduction of 31% compared to a standard protocol  without losing in accuracy. This is particularly relevant considering that reduction in radiopharmaceutical dosage enables more cost effective nuclear myocardial perfusion imaging, a very welcome trend against the background of continually increasing use of nuclear cardiology in an increasingly challenging fiscal environment with ever-rising healthcare costs.31 Potential cost reduction in conjunction with the lower exposure could also lead to a marked improvement for dual-isotope acquisition imaging in the evaluation of patient with heart failure.One of the strengths of the present study is represented by the use of a simultaneous protocol with very low dose injected activities Supplementary file2 (PDF 332 KB)Supplementary file3 (MP3 7143 KB)Below is the link to the electronic supplementary material.


Implementation of national systems for patients' physical activity (PA) assessment and counselling is a cost-effective strategy recommended in the WHO Global Action Plan for PA 2018-2030. Although Primary Health Care (PHC) professionals are recognized as key agents for PA promotion, challenges remain on how to develop feasible and scalable tools to support them in promoting patients' PA. The Portuguese model could help other countries improve PA assessment and brief counselling in PHC settings. This study aims to describe the tools' development and usage.The Portuguese Directorate-General of Health developed two evidence-based digital tools to support PA promotion by healthcare professionals: a) PA brief assessment tool; and b) brief counselling tool. The assessment tool was incorporated within the electronic medical health record software ?SClínico? in September 2017. It includes three questions: 1) how many days per week the patient performs any kind of PA ; 2) how much time per day; and 3) how many hours per day the patient spends in sedentary behaviours. The PA brief counselling tool is available through the electronic medical prescription software ?PEM? since December 2017 and consists of five inter-related self-explanatory guides that can be delivered to patients (printed or by email), according to their motivation and PA levels. They facilitate person-centered and autonomy-supportive PA counselling, targeting specific behaviour change mediators, and using validated techniques.From September 2017 to December 2021, 159,179 patients had their PA assessed  and, from these, 16133 received PA brief counselling guides , with a six-fold and three-fold increases, respectively, between 2018 and 2019 (previous to the COVID-19 pandemic). Future actions will address cost-effectiveness of this policy.The brief assessment and brief counselling tools were well-accepted and are increasingly being used, with potential for generalized adoption within the Portuguese Health Care System.Portugal has taken a decisive action to promote PA using PHC as a priority setting. PA tools usage is increasing considerably, highlighting the importance of making available easy-to-use PA promotion tools.


Reductive ring annuloplasty of the tricuspid annulus represents the contemporary surgical approach to functional tricuspid regurgitation (FTR). We set out to investigate the influence of moderate reductive tricuspid ring annuloplasty on tricuspid regurgitation and right ventricular (RV) size, geometry and strain in an ovine model of chronic FTR.Eight healthy Dorsett male sheep (62.8 + 2kg) underwent a left thoracotomy for placement and tightening of pulmonary artery band to at least double proximal pulmonary artery blood pressure. After 8 weeks of recovery, animals underwent sternotomy, epicardial echocardiography and sonomicrometry crystal implantation. Six crystals were placed around tricuspid annulus and 13 on RV free wall epicardium along 3 parallels defining 3 wall regions  and 1 on the RV apex. All animals underwent beating heart implantation of 26 mm MC3 annuloplasty ring during a second cardiopulmonary bypass run after baseline data acquisition. Simultaneous haemodynamic, sonomicrometry and echocardiography data were acquired at Baseline and after reductive tricuspid ring annuloplasty.2, P = 0.0002) and significantly decreased RV end-diastolic volume . Tricuspid ring annuloplasty effectively reduced FTR grade  and had little influence on RV function, cross-sectional area, radius of curvature or free wall regional strains.Implantation of reductive ring annuloplasty resulted in 47 ± 7% annular area reduction  is commonly observed in patients with left-sided valve disease [1], and until recently, it was believed that correction of left valvular pathology would lead to resolution of tricuspid insufficiency. Functional tricuspid regurgitation (FTR) is commonly observed in patients with left-sided valve disease , and untAll animals received humane care in compliance with the Principles of Laboratory Animal Care formulated by the National Society for Medical Research and the Guide for Care and Use of Laboratory Animals prepared by the National Academy of Science and published by the National Institutes of Health. The study was approved by the West Michigan Regional Lab Institutional Animal Care and Use Committee. The approval number for the study was 2020-035.Eight healthy Dorsett castrated male sheep (62 ± 2) had external left jugular intravenous catheters placed under local anaesthesia using 1% lidocaine. Animals were then anaesthetized with propofol (2–5 mg/kg intravenously), intubated and mechanically ventilated. General anaesthesia was maintained with inhalational isoflurane (1–2.5%). Fentanyl (5–20 mg/kg/min) was infused as additional maintenance of anaesthesia. Using sterile technique, the heart was exposed via limited 10 cm left thoracotomy between 4 and 5 intercostal space. Arterial 18G catheter was introduced to left internal thoracic artery for continuous arterial blood pressure measurement. Baseline epicardial echocardiography was performed to assess biventricular function and tricuspid valve competence. An umbilical tape band was placed around the distal main pulmonary trunk and progressively tightened with clips just until brink of continued haemodynamic stability as previously described  to at le® or similar crystalloid solution prior to CPB. After activated clotting time exceeded 480 s, CPB was initiated. The procedure was conducted on the beating heart. After snaring both cava, the right atrium was opened and sonomicrometry crystals  were implanted with 5-0 polypropylene suture. Six crystals were placed around the tricuspid annulus. Thirteen crystals were placed on the on the RV free wall along 3 parallels defining 3 wall regions  and 1 at the RV apex as shown schematically in Fig. After 8 weeks, the sheep were brought back to the operating room and anaesthesia was induced as described above. Using clean technique, the heart was exposed via median sternotomy and baseline epicardial echocardiographic examination was performed to assess biventricular volume, function and FTR. The animal was then fully heparinized (300 µg/kg intravenous bolus) and the right carotid artery and right internal jugular vein were cannulated for cardiopulmonary bypass (CPB). Arterial 18G catheter was introduced to left internal thoracic artery for continuous arterial blood pressure measurement. The heart-lung machine was primed with Plasma-LyteSonomicrometry data were acquired using a Sonometrics Digital Ultrasonic Measurement System DS3  as previously described . Data frEpicardial echocardiography was used to assess RV function and size and TR. Images were acquired with a 1.5- to 4.5-MHz transducer and Vivid S6 ultrasound machine . After image acquisition, the degree of valvular insufficiency was assessed using American Society of Echocardiography criteria. The grading included comprehensive evaluation of colour flow and continuous-wave Doppler. Tricuspid regurgitation was graded accordingly and categorized by an experienced Echocardiographer as none or trace (0), mild (1), moderate (2), moderate to severe (3) and severe (4).t-test for dependent observations with a P-value of <0.05 considered significant. Normality was assessed by using Shapiro–Wilk test, normal distribution was confirmed, additionally, Wilcoxon test was implied for repeated measures to confirm data, with P-value of <0.05 considered as significant. Data analysis was performed using Statistical Package of Social Science (SPSS) version 26.0 for MacOS.All data are presented as mean ± standard deviation. Comparisons of parameters between Baseline and TRA were performed using Student’s P = 0.0001) while mean pulmonary artery pressure increased from 13.1 ± 5.2 to 33.8 ± 13.5 mmHg (P = 0.00001). After 8 weeks of pulmonary banding, systolic pulmonary artery pressure decreased to 41.9 ± 6.4 mmHg while the mean pressure decreased to 27.5 ± 3.1 mmHg indicative of progressive RV failure. Echocardiographic parameters acquired before application of the pulmonary artery band and after 8 weeks of banding are summarized in Table Placement of the pulmonary band was associated with acute increase in systolic pulmonary artery pressure from 19.2 ± 7.5 to 57.4 ± 23.1 mmHg  for their contribution to the peer review process of this article.


The area under the receiver operating characteristic curve of Model 1, wherein the GLS was added to the LVEF, was 0.832 . The C-statistics for Model 2, which included the infarct-related regional parameters was 0.917 . Model 2 was statistically superior to Model 1 in predicting LVR . (4) Conclusions: Both the global and regional CMR parameters were valuable in predicting LVR in patients with AAMI following the PPCI. The local parameters of the infarct zones were superior to those of the global ones.Background: Heart failure is a serious complication resulting from left ventricular remodeling (LVR), especially in patients experiencing acute anterior myocardial infarction (AAMI). It is crucial to explore the predictive parameters for LVR following primary percutaneous coronary intervention (PPCI) in patients with AAMI. Methods: A total of 128 AAMI patients who were reperfused successfully by PPCI were enrolled sequentially from June 2018 to December 2019. Cardiovascular magnetic resonance (CMR) was performed at the early stage (<7 days) and after the 6-month follow-up. The patients were divided into LVR and non-LVR groups according to the increase of left ventricular end diastolic volume (LVEDV) measured by the second cardiac magnetic resonance examination ≥20% from baseline. (3) Results: The left ventricular ejection fraction (LVEF), the global longitudinal strain (GLS), the peak circumferential strain in infarcted segments, and the infarct size (IS) remained significantly different in the multivariate logistic regression analysis (all  Acute myocardial infarction (AMI) can lead to irreversible myocardial necrosis. Al-though the mortality at the acute stage has been notably reduced by primary percutaneous coronary intervention (PPCI), the instances of long-term adverse events, especially chronic heart dysfunction, remain high . NecrotiThe previous risk stratification of AMI, such as Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores ,4, which2; (7) claustrophobia or magnetic resonance imaging contraindications . This prospective study was performed between June 2018 and December 2019 at the cardiology center of the Shanghai Sixth People’s Hospital. The enrolled patients were diagnosed with AAMI and treated with PPCI. The study inclusion criteria were as follows: (1) AMI which was diagnosed according to the AMI diagnostic criteria   and after the six-month follow-up visit. Demographic data and medical history were collected from the patients in the study. The collected data included information on laboratory examinations, coronary vascular disease risk factors, concomitant diseases, and medicines. Ethical approval for this study was obtained from Shanghai Jiao Tong University which is affiliated to the Shanghai Sixth People’s Hospital (2017-KY-003 (K)). All of the patients provided written informed consent. The definition of LVR was an increase in left ventricular end-diastolic volume (LVEDV) at ≥20% over approximately six months of follow-ups (ΔLVEDV% ≥ 20%) .3, field of view 350 × 350 mm; 30 phases in each cardiac cycle). The gadolinium enhancement sequences were acquired 10 min after the contrast injection .The ECG-gated CMR examinations were performed using a 3-T system  within seven days of the onset and at the six-month follow-up visit. The CMR protocol included a localizer, T2-weighted, cine, first-pass perfusion, and delay-enhancement sequences. Each long-axis slice was subjected to balanced, steady-state free precision (bSSFP) cines ). A total of 10–12 continuous slices of short-axis cines were obtained after the injection of the contrast agent , covering the entire LV region from the ring of the mitral valve to the apex , LV end-diastolic volume (LVEDV), and LV end-systolic volume (LVESV) were analyzed using standardized protocols. The LVM was derived by subtracting the papillary muscles at the end diastole . CVI42 . The quaThe angiographic analysis was performed following standard protocols, including those that have been delineated for TIMI . All of The data from 10 LVR patients and 10 non-LVR subjects were sampled to evaluate the inter- and intra-observer variability. The CMR analyses were performed independently by two cardiologists (Dr. MA and Dr. GAO) who were blinded to each other’s recordings. The inter-observer variability was tested using the data from different acquisitions. The observers reanalyzed their own recordings to check for intra-observer variability; these evaluations were conducted at 2 weeks apart.t-tests were used for inter-group comparisons of the normally distributed continuous variables. Fisher’s exact tests or chi-square tests were used to compare the categorical variables. The results are displayed as numbers and percentages. Moreover, univariate and multivariate logistic regression analyses were conducted to identify the prognostic predictors of LVR. A receiver operating characteristic (ROC) curve analysis was used to identify the parameters that were best suited for checking the LVR model. The optimal cut-off values were determined according to the maximum Youden index. The Delong test was used to compare the areas under the ROC curves (AUCs). We also calculated integrated discrimination improvement (IDI) by comparing global and regional parameters in order to find the strongest predictors of LVR following AAMI. The model calibration was assessed using the Hosmer–Lemeshow goodness-of-fit test, and the inter- and intra-observer reproducibility were determined using intraclass correlation coefficients. Standard statistical software , R version 4.2.0 , and GraphPad Prism 9 ) were used to perform all of the calculations. A two-sided p-value of <0.05 was considered to be the threshold for statistical significance.For the continuous variables, the means ± SD or medians and interquartile ranges  are reported, and the variable distributions were evaluated using the Kolmogorov–Smirnov test. Wilcoxon rank-sum tests was used for inter-group comparisons of the non-normally distributed variables, whereas the n = 39) and a non-LVR group (n = 77). The average age was 58.22 ± 12.30 years, and 86.20% of the included patients were male. The patients in the LVR group had a higher serum level of peak hypersensitive cardiac troponin I (hs-cTnI). There were no statistically significant differences in the sex, age, heart rate, body mass index, pain to balloon time, coronary heart disease risk factors, Killip classification at the point of admission, peak pro-brain natriuretic peptide (pro-BNP) levels, TIMI flow pre-PPCI, TIMI flow after PPCI, and medication use between the study groups . The demographic and clinical characteristics of the included patients with AAMI are shown in Of the 128 included study participants, five of them were excluded due to them having a poor CMR image quality, and seven patients did not complete the follow-up. Consequently, 116 patients with AAMI were included in the final analysis; these patients were divided into an LVR group (p < 0.001). There were no differences in the peak circumferential strain in remote non-infarcted segments  after the AAMI onset, and the follow-up CMR tests were conducted at an average of 10 months (IQR: 8–12 months) after the AAMI onset. Compared with the non-LVR group, the patients who developed LVR presented with a lower LVEF and a more extensive IS. The GLS and the GCS of LV were statistically significantly decreased in the LVR group, while there was no difference in LVEDV, LVESV, and GRS. Using a segment strain analysis, the peak radial strain in infarcted segments (p < 0.001). The peak p = 0.006; r = 0.805, p < 0.001). Therefore, the multivariable models included the following parameters: LVEF, GLS, peak p < 0.05).The results of univariate and multivariate logistic regression analyses  are presented in p > 0.05).To predict LVR in the early stages of AAMI, four independent influencing factors of CMR were allocated between the models in order to construct two predictive models. Model 1, which included LVEF and GLS, evaluated the global change in functionality following AAMI, while Model 2, consisting of peak 8–0.907) a. In Mod0–0.965) b. Each mp < 0.05). Moreover, Model 2 demonstrated statistically improved discrimination and reclassification, with an IDI of 0.190 (p = 0.002).We found good intra- and inter-observer variabilities for the evaluated CMR measurements. This study focused on the prediction of adverse LVR with CMR parameters. LVR is a major cause of heart failure following AMI. Strain imaging can detect early or subtle changes in LV function and can effectively predict the AMI prognosis. This study revealed that the analysis of both the regional and global parameters in regard to myocardial strain is valuable for predicting LVR in patients with AAMI who are undergoing PPCI. By investigating two predictive models further, which were composed of the CMR parameters, we found that Model 2, which combined peak To evaluate LVR following AMI, we investigated AAMI that was caused by LAD occlusion in order to avoid confusing different myocardial injuries that are perfused by different coronary arteries. LVR resulting from AAMI impairs the heart function more severely than the remodeling of non-AAMI, and even the level of myocardial necrosis biomarkers serum troponin I are the same . All of p = 0.002). The evidence demonstrated that the myocardial biomechanical changes that follow MI were initially limited to the MI region, but they gradually extended to the neighboring border zones and the remote myocardium over the 28 days post-MI [This study assessed both the global and segmental strain using the feature tracking module of CVI42, and we have identified GLS as a more accurate indicator of LVR than LVEF is. However, the factors describing the circumferential motion of the infarct zones seemed to predict LVR more effectively than GLS did in the present study. GCS is well recognized as a determinant of AMI prognosis based on the findings of two other studies. More specifically, Mangion’s team found that the circumferential strain was an independent prognostic factor in patients with ST-segment elevation myocardial infarction , and Bus post-MI . This mit+IS did ; the forIt is vital to explore the predictors of LVR in regard to the clinical adverse outcomes in patients with AMI. This information would be extremely helpful for patients in the high-risk group, who could receive further novel therapies in addition to routine post-AMI medications, as well as more aggressive up-titration of prognostic medicines  and more in-depth follow-ups in order to identify an adverse LVR. For example, this information could aid the prescription of primary prevention implantable cardioverter-defibrillators which aim to reduce the major clinical events that are associated with AMI.We acknowledge several limitations of the present research. Firstly, this was a single-center study, and therefore, the generalizability of our findings is unclear. Moreover, only 128 patients were diagnosed with AAMI and treated with PPCI. Hence, the enrolled sample size was small, which might have affected the accuracy of the cutoff values that were obtained in the multivariate analysis. The sample size should be expanded to obtain more reliable clinical conclusions, and the follow-up time should be extended. New parameter such as the sphericity index of LV will be explored in future studies.The current study demonstrated that both the global  and regional parameters (peak