In patients of advanced age, the feasibility of myocardial ischemia testing might be limited by age-related comorbidities and falling compliance abilities. Therefore, we aimed to test the accuracy of 3D cardiac magnetic resonance (CMR) stress perfusion in the elderly population as compared to reference standard fractional flow reserve (FFR).Fifty-six patients at age 75 years or older  underwent 3D CMR perfusion imaging and invasive coronary angiography with FFR in 5 centers using the same study protocol. The diagnostic accuracy of CMR was compared to a control group of 360 patients aged below 75 years . The percentage of myocardial ischemic burden (MIB) relative to myocardial scar burden was further analyzed using semi-automated software.p > 0.05 all). While MIB was larger in the elderly patients (15% ± 17% vs. 9% ± 13%), the diagnostic accuracy of 3D CMR perfusion was high in both elderly and non-elderly populations to predict pathological FFR (AUC: 0.906 and 0.866).Sensitivity, specificity, and positive and negative predictive values of 3D perfusion CMR deemed similar for both age groups in the detection of hemodynamically relevant (FFR < 0.8) stenosis (≥ 75 years: 86%, 83%, 92%, and 75%; < 75 years: 87%, 80%, 82%, and 85%; 3D CMR perfusion has excellent diagnostic accuracy for the detection of hemodynamically relevant coronary stenosis, independent of patient age.• The increasing prevalence of coronary artery disease in elderly populations is accompanied with a larger ischemic burden of the myocardium as compared to younger individuals.• 3D cardiac magnetic resonance perfusion imaging predicts pathological fractional flow reserve in elderly patients aged ≥ 75 years with high diagnostic accuracy.• Ischemia testing with 3D CMR perfusion imaging has similarly high accuracy in the elderly as in younger patients and it might be particularly useful when other non-invasive techniques are limited by aging-related comorbidities and falling compliance abilities.The online version contains supplementary material available at 10.1007/s00330-022-09040-7. The worldwide population aged ≥ 65 years is projected to nearly double within the next three decades, while the number of people aged 80 years and older is expected to triple until 2050 . The prevalence of coronary artery disease (CAD) also increases with age and the pre-test probability of CAD is highest among individuals older than 70 years with angina pectoris or angina equivalent symptoms . TherefoCardiac magnetic resonance (CMR) myocardial perfusion imaging allows for ruling out myocardial ischemia with a high degree of accuracy and is supported by the latest guideline of the European Society of Cardiology (ESC) for this indication . ConventGiven this background, we investigated the performance of 3D cardiac magnetic resonance perfusion in patients aged ≥ 75 years for the detection of coronary artery disease as compared to the current reference standard invasive coronary angiography using fractional flow reserve (FFR). We hypothesized that 3D cardiac magnetic resonance perfusion is as accurate in elderly patients as in younger individuals.All patients included in the current study were retrospectively enrolled from a research database of a previously published multi-center trial, who underwent 3D perfusion CMR study and invasive coronary angiography with fractional flow reserve (FFR) due to known or suspected CAD –9. Imagi3 voxel size reconstructed to 2.0 × 2.0 × 5.0 mm3, TR/TE 1.9/0.8 ms, flip angle of 15o, saturation delay of 150 ms and partial Fourier acquisition. A volume of 16 slices was acquired pro heartbeat using 10 × undersampling resulting in a net acceleration of 7 ×. The acceleration technique used for 3D cardiac perfusion imaging was published previously [Subject to availability at the participating sites, 1.5-T or 3.0-T magnetic resonance scanner systems were used from a single vendor (Philips). Cardiac synchronization was provided using vector ECG and signal reception was ensured using either 5-, 6-, 28-, or 32-channel torso coil arrays. Cine images at standard axes and whole-heart 3D first-pass perfusion at stress and rest in short-axis (SA) orientation covering the complete left ventricle from base to apex were acquired. A saturation-recovery gradient-echo pulse sequence was used for the perfusion study with the following parameters: 350 × 350 mm FOV, 2.3 × 2.3 × 10.0 mmeviously . FinallyAnalysis of CMR perfusion exams was performed as part of the original multi-center studies in a core laboratory using dedicated software . Readers were blinded to both clinical and angiographic data. The number of acquired SA slices during the perfusion study was adapted for the individuals’ heart size (ranging between 9 and 16 slices). Thereafter, acquired slices with > 75% circumferential LV myocardium and clear delineated LV cavity during first-pass perfusion imaging were further analyzed, while each slice was divided into 6 segments. Segmental myocardial ischemia was assessed visually, defined as a perfusion deficit during first-pass stress perfusion with at least 25% transmurality and persistent for ≥ 3 consecutive dynamics, without corresponding defects on rest perfusion or enhancement on LGE. Moreover, the transmurality of each myocardial segment positive for ischemia was further grated using a 4-point scale  and converted into a perfusion score, which was normalized to the heart size with an average of 12 myocardial slices in correspondence with the 17-segment model of the American Heart Association [Myocardial ischemic burden (MIB), defined as the percentage of hypoenhanced myocardium relative to total myocardial volume, was further quantified using a semi-automated method . For this purpose, LV endo- and epicardial borders were contoured manually on the dynamic frame of stress perfusion study with the maximal myocardial hypoenhancement extent throughout peak signal intensity of remote myocardium and ischemic myocardial area was quantified with a threshold-based method using > 2 standard deviation beneath remote myocardium signal intensity, expressed as ischemic burden (IB). A disk summation method was used to calculate total myocardial volumes. Myocardial scar burden (SB) defined as hyperintense tissue on the LGE scans in comparison to remote myocardium was quantified similarly using the same software, and in case of overlap, the myocardial scar was subtracted from the myocardial hypoattenuation and was normalized to LV volume. MIB equals IB – SB.X-ray coronary angiography was performed according to standard techniques and routine protocol at each site. At least two orthogonal views of every major coronary artery and their side branches were obtained. Quantitative coronary angiography (QCA) was assessed offline  in a core laboratory blinded to CMR and clinical data. Significant stenosis was defined as a luminal narrowing ≥ 50% of the coronary artery. FFR was assessed with a 0.014-in. coronary pressure sensor-tip wire in all vessels present with diameter stenosis between ≥ 50 and ≤ 80% in two orthogonal views and a luminal diameter of at least 2 mm. A functional relevant stenosis was defined as exhibiting an FFR value of < 0.8. A luminal stenosis > 80% or total occlusion was considered hemodynamically relevant and no FFR was performed. No routine-controlled pull-back procedure was performed.p value < 0.05 was considered statistically significant. Diagnostic accuracy was determined with receiver–operator–characteristics (ROC) curve analysis . Statistical analysis was performed using SPSS software (SPSS version 23).The Shapiro-Wilk-test was used to assess the normality of continuous variables. Continuous variables are reported as mean ± standard deviation. Categorical variables are expressed as numbers and percentages. Student’s t-test was used for comparison of normally distributed continuous variables between stress and rest. Non-normally distributed continuous data was compared using the Mann-Whitney U test. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated on a patient level with correspondent 95% confidence intervals (95% CI). Chi-squared test was used to compare categorical data. All tests were two-tailed and a The study cohort consisted of 56 patients at the age of 75 years or older  and 360 patients aged below 75 years . Patient characteristics and clinical data are summarized in Table The prevalence of relevant coronary artery stenosis, defined as ≥ 50% luminal narrowing, was 70% (39/56 patients) among the elderly and 54% (195/360 patients) in the group aged below 75 years. Hemodynamically relevant stenosis, specified with FFR using 0.8 as a cut-off value, was 68% (38/56 patients) and 52% (186/360 patients) in the population aged 75 years or older and in the population aged below, respectively.. No significant differences were seen in octogenarians (≥ 80 years) compared with patients < 80 years of age  as compared with FFR. The correspondent sensitivity and specificity of dynamic 3D CMR to detect ischemia using FFR as a reference were 87% 95% CI: 72–96) and 83% (95% CI: 59–96) in the population aged ≥ 75 years and 87% (82–92) and 80% (73–86) among patients aged < 75 years, respectively. There was no significant difference in the diagnostic performance of 3D CMR perfusion between the different age groups, as summarized in Table –96 and 8 age see . Examplep = 0.055). The AUC to predict pathological FFR for MIB in the elderly population was 0.906 (95% CI: 0.822-0.991) versus 0.866 (95% CI: 0.824-0.907) in those < 75 years. Diagnostic findings are summarized in Table MIB was larger among patients ≥ 75 years old than patients aged < 75 years, although the difference did not reach the level of statistical significance  using 3D CMR perfusion. We compared our findings with the reference standard invasive coronary angiography using FFR. 3D CMR perfusion showed excellent diagnostic accuracy for the detection of hemodynamically significant lesions , independent of patient age. Furthermore, we demonstrated that quantitative ischemia analysis with 3D CMR perfusion is a precise technique for the prediction of hemodynamically relevant coronary artery lesions, as compared with FFR. Importantly, our findings remained consistent in the subgroup analysis of octogenarian patients (aged ≥ 80 years).Recently, a substantial decrease from 45 to 15%) in the prevalence of obstructive CAD was recognized among patients with angina-like symptoms 5 to 15% , while tThere is a paucity of data specifically evaluating CMR stress perfusion in elderly patients aged 75 years or above. An early study performed on 309 individuals ≥ 70 years confirmed the safe applicability of dobutamine and adenosine stress CMR; however, the diagnostic accuracy of stress perfusion with CMR was not established . PatientIn the present study, we demonstrated that the high sensitivity and specificity values of 3D stress perfusion CMR to detect ischemia remain consistent in the elderly population (87% and 83%), as compared to younger individuals (87% and 80%). Our results are comparable with a recent meta-analysis where the pooled sensitivity and specificity values of perfusion stress CMR to identify functionally significant CAD were 89% (95%CI: 85–92%), 87% (95%CI: 83–91%), respectively, whereas the mean age of the included cohort was 63 ± 3 years .p = 0.162). The markedly high PPV might however justify the benefit of this ischemic test in the elderly population, where the prevalence of 50–90% luminal coronary stenosis with potential therapeutic implications is most prevalent. This finding was further supported by our quantitative analysis, where a larger MIB was found in the older population, although this result did not reach statistical significance . Our findings need to be validated in larger clinical trials. Importantly, ≥ 10% reversible myocardial ischemia of the entire LV myocardium is associated with an elevated (> 3%) annual risk for myocardial infarction, or cardiovascular death, as compared with a normal test (≤ 1%) [Notably, we observed a trend towards a higher positive predictive value (PPV) of 3D stress CMR in individuals 75 years and older, than in younger patients, as compared to FFR, which however was not statistically significant  , 24, whit (≤ 1%) . ImportaThere are several limitations of our study. First, patient selection bias might influence study results, as individuals already scheduled for invasive coronary angiography were included in the original multicenter study. Likewise, the inclusion of patients from a predefined study group resulted in a skewed distribution of patients under 75 years old and above. Second, CMR stress perfusion was accomplished using a fixed standard dosage of adenosine adopted for patients’ weight, and no higher doses were administered. Thus, CMR might be false negative in some patients and MIB might be underestimated, especially as adequate stress response was not individually monitored . However, a mean change in heart rate ≥ 10 bpm from rest to stress (67 ± 11 vs. 84 ± 15) is a good marker of an adequate pharmacological stress reaction. Third, quantitative myocardial blood flow during stress CMR could not be measured, while MIB reflects the percentage of ischemia to myocardial volume in a selected time-point during first-pass myocardial perfusion. Fourth, CMR examinations were both performed at 1.5 T and 3.0 T and therefore the different signal-to-noise ratios might influence study results; however, a previous sub-study of the same trial did not find significant differences between the strength fields . Fifth, In conclusion, myocardial ischemia testing is feasible in the elderly population with a high degree of accuracy using 3D CMR perfusion. Quantitative analysis of myocardial ischemia burden on 3D CMR perfusion is an excellent predictor of hemodynamically significant coronary lesions in patients with advanced age.ESM 1(PDF 168 kb)


To elucidate underlying disease mechanisms, we compared transition of gadolinium-based contrast agent bolus in cardiac chambers in magnetic resonance imaging between young patents with cryptogenic ischemic stroke and stroke-free controls. We included 30 patients aged 18–50 years with cryptogenic ischemic stroke from the prospective Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers and Outcome (NCT01934725) study and 30 age- and gender-matched stroke-free controls. Dynamic contrast-enhanced T1-weighted first-pass perfusion images were acquired at 1.5 T and analyzed for transit time variables, area under curves, relative blood flow, and maximum and minimum enhancement rates in left atrial appendage, left atrium, and left ventricle. These data were compared with previously published left ventricular non-compaction data of the same study population. Arrival time of contrast agent bolus in superior vena cava was similar in patients and controls . Arrival and peak times showed comparable characteristics in patients and controls (P > 0.535). The minimum enhancement rate of the left ventricle was lower in patients than in controls (− 28 ± 11 vs. − 36 ± 13 1/(cardiac cycle), P = 0.012). Area under curves, relative blood flow, and other enhancement rates showed no significant differences between patients and controls (P > 0.107). Relative blood flow of cardiac chambers correlated with non-compacted left ventricular volume ratio (P < 0.011). Our results indicate slower washout of contrast agent and blood flow stagnation in the left ventricle of young patients with cryptogenic ischemic stroke. The washout was associated with left ventricular non-compaction, suggesting conditions favoring formation of intraventricular thrombosis. Up to 50% of ischemic strokes in adults younger than 50 years are cryptogenic by nature, that is, without evident etiology based on routine diagnostic evaluation . CryptogContrast agent characteristics, such as transit times in different compartments of the body, have been commonly derived in diagnostic nuclear medicine using time-activity curves . AnalogoHere, we aimed to compare first-pass circulation characteristics of the cardiac chambers between young patients with cryptogenic ischemic stroke and stroke-free controls. Specifically, we sought to determine whether circulation was prolonged in the left atrial appendage (LAA), left atrium (LA), and left ventricle (LV), as well as to link first-pass characteristics to LVNC.This is a substudy of the prospective multicenter Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers and Outcome  study. SECRETO is an international prospective multicenter case–control study of young adults. In this substudy, we included 30 patients with cryptogenic ischemic stroke aged 18–50 years and 30 age- and gender-matched stroke-free controls from Helsinki University Hospital. The SECRETO study has been approved by the Ethics Committee of the Helsinki and Uusimaa Hospital District, and each participant provided written informed consent. Details of the study protocol have been published previously , 16. Brifit MR scanner . The main image acquisition protocol has been published previously [All subjects in the substudy underwent cardiac MRI using a 1.5 T MAGNETOM Avantoeviously . The proContrast agent administration was performed in two phases to shorten the initial bolus duration and to visualize the washout (in addition to the wash in) of contrast agent. The bolus injection was started at the same time as the perfusion sequence, with 1/2 of the bolus injected. The final 1/2 of the bolus was injected after the perfusion sequence was acquired. Our experience with one-phase bolus injections has shown that no clear washout of the contrast agent occurs during first pass, leaving the MRI signal intensity at a high level compared with baseline; this is suboptimal for semi-quantitative circulation analysis of the washout phase, and the calculation of such parameters as full width at half maximum (FWHM) or full width at tenth maximum (FWTM) is not possible. The use of two-phase bolus injection provided a clear washout phase. A second signal increase in the time-intensity curves is caused by recirculation, and only the first peak in the curves was used for analysis  by an experienced medical physicist (LL) blinded to patient-control status of each participant. Time (cardiac cycles)-intensity (arbitrary units) curves for SVC, LA, and LV were obtained by placing circular regions of interest (ROIs) of at least 150 mmThe time-intensity curves were used to calculate several semi-quantitative circulation parameters: arrival time , time-to-peak , FWHM, and FWTM for SVC, LAA, LA, and LV. An example of the analyzed time parameters is given in Fig. Finally, we sought correlations between the circulation parameters of this study and previously published LVNC related data in the same study population . The LVNt-test if data were normally distributed or otherwise with Mann–Whitney U test. Correlations were calculated using Pearson correlation coefficient if data were normally distributed or otherwise using Spearman’s rank correlation coefficient. P-values < 0.05 were considered significant.Statistical analysis was performed with IBM SPSS Statistics for Windows, version 27 . Normality of the analyzed continuous variables was assessed using the Kolmogorov–Smirnov test. Continuous variables are presented as either mean ± standard deviation or median (interquartile range), depending on data normality. Differences between patients and controls were evaluated using Student’s Demographic data, LV volumetric data, and LVNC data of the study population are presented in Table Results for the time variables in the first-pass circulation analysis are displayed in Table The calculated AUCs, rBFs, and enhancement rates showed mostly similarities between patients and controls Table . HoweverSignificant correlations emerged between the relative blood flow of several cardiac chambers, and maximum and minimum enhancement rate of LA and LV, and LVNC variables in the entire study population (N = 60) Table . The nonWe utilized MRI-derived gadolinium first-pass analysis to study circulation in the hearts of young patients with cryptogenic ischemic stroke and stroke-free controls. We were able to detect a significant difference in the contrast agent washout in the left ventricles of our study population. The washout, together with relative blood flow, was significantly associated with the left ventricular non-compacted LV volume ratio, linking prolonged circulation to LVNC in cryptogenic ischemic stroke.We used a two-phase contrast agent bolus injection to visualize contrast agent washout in addition to wash in and sampled the LAA twice per cardiac cycle to increase the temporal resolution. We still could not explicitly prove our first hypothesis that circulation is prolonged in LAA or LA in our patients with cryptogenic ischemic stroke relative to stroke-free controls. However, there was a significant difference in the minimum enhancement rate of the LV, which describes contrast agent washout. The differences in AT, TTP, FWHM, FWTM, AUC, and rBF in the LV of patients and controls were all non-significant, indicating similar circulation behavior. None of these parameters directly depict the rate of contrast agent wash in and washout, however. Importantly, patients and controls had no significant differences in left ventricular end-systolic or end-diastolic volumes, ejection fractions, or valvular insufficiencies that could explain the slower washout of contrast from the LV. Therefore, the observed difference in contrast agent washout is probably a true sign on LVNC being the cause of blood flow stagnation. Whether the patients with slight LVNC finding but not fulfilling the criteria of non-compaction cardiomyopathy have actual myocardial pathology, or merely a normal variation with increased risk of thrombosis, cannot be concluded from this imaging-only study.To further assess possible pathology explaining the difference in contrast washout between patients and controls, we assessed its correlation with previously found LVNC in the study population . In the Since none of our patients fulfilled the criteria on non-compaction cardiomyopathy, the higher tendency for LVNC among the patients, compared to controls, merely reflects the continuous nature of risk. LVNC is a probably a risk factor for thromboembolism due to a larger area of endocardium, as well as increased amount of myocardial indentations and crypts, and in addition to this, we also found that LVNC causes stagnation of blood flow, hence making another contribution to the formation of thrombosis. However, due to the nature of our study, we cannot draw conclusions on whether any differences in secondary prevention can be of use in cryptogenic stroke patients with LVNC not fulfilling the criteria of non-compaction cardiomyopathy. However, the finding can be of use in further studies, and there might be a degree of LVNC below the limit of non-compaction cardiomyopathy criteria, causing a significant risk of intracardiac thrombosis.The main strengths of our study are: All patients underwent a standardized and thorough clinical diagnostic work-up before they were labeled as having cryptogenic ischemic stroke. Our cardiac MRI protocol was rigorous to enable detection of subtle differences between patients and controls. The study also has limitations. Our sample size is relatively small, reflecting the high demands placed on all study participants. The MRI protocol is limited to the semi-quantitative analysis of the time-intensity circulation curves. No information on the native pre-contrast T1 values was available, which is a requirement for the quantitative contrast agent concentration calculation , 17. DueContrast-enhanced cardiac MRI can be used to study circulation in different cardiac chambers. We observed a tendency for stagnation of blood flow in the left ventricle of young patients with cryptogenic ischemic stroke, with a link to LVNC pathology, suggesting conditions favoring formation of intraventricular thrombosis.


Ventilation times were longer in the retrograde VTI group. The postoperative vs. baseline delta VTI ratio of the hepatic vein correlated with positive fluid balance, maximum central venous pressure, and ejection fraction.  Conclusion: The increase of the retrograde hepatic flow during the first 24 h following cardiac surgery was associated with positive fluid balance and the decrease of the right ventricular function. Measurement of venous congestion or venous abdominal insufficiency seems to be a useful tool in guiding fluid therapy and hemodynamic management.Introduction: Hepatic venous flow patterns reflect pressure changes in the right ventricle and are also markers of systemic venous congestion. Fluid management is crucial in patients undergoing cardiac surgery. Methods: Our goal was to determine which factors are associated with the increased congestion of the liver as measured by Doppler ultrasound in patients undergoing cardiac surgery. This prospective, observational study included 41 patients without preexisting liver disease who underwent cardiac surgery between 1 January 2021 and 30 September 2021 at a tertiary heart center. In addition to routine echocardiographic examination, we recorded the maximal velocity and velocity time integral (VTI) of the standard four waves seen in the common hepatic vein (flow profile) using Doppler ultrasound preoperatively and at the 20–24th hour of the postoperative period. The ratios of the retrograde and anterograde hepatic venous waves were calculated, and the waveforms were compared to the baseline value and expressed as a delta ratio. Demographic data, pre- and postoperative echocardiographic parameters, intraoperative variables , postoperative factors  and perioperative laboratory parameters  were used in the analysis. Results: Of the 41 patients, 20 (48.7%) were males, and the median age of the patients was 65.9 years (IQR: 59.8–69.9 years). Retrograde VTI growth showed a correlation with positive fluid balance (0.89 (95% CI 0.785–0.995) c-index. After comparing the postoperative echocardiographic parameters of the two subgroups, right ventricular and atrial diameters were significantly greater in the “retrograde VTI growth” group. The ejection fraction and decrement in ejection fraction to preoperative parameters were significantly different between the two groups. ( Objective assessment of hemodynamic conditions is fundamental to guide the clinical management of the cardiac surgery patient during the postoperative period ,2,3. MetMany physicians performing point of care ultrasound assessment (POCUS) usually use inferior vena cava (IVC) measurements to predict fluid status. However, there are more venous structures that clinicians could evaluate. Using solely IVC measurements can lead to inaccurate results because they do not accurately represent the patient’s preload conditions of the left ventricle. The IVC can also be dilated in conditions such as tricuspid or mitral insufficiency, pulmonary hypertension, or in athletes. Many recent protocols, such as the venous excess ultrasound examination (VExUS) use several hepatic, portal, and renal structures for Doppler ultrasound analysis ,13. The However, the influence of postoperative interventions, such as fluid therapy and the use of vasoactive drugs, or the probably significant effect of positive pressure ventilation, has not been analyzed in relation to venous return.The aim of our study was to investigate the postoperative factors that might be associated with increased hepatic venous congestion during the postoperative period in patients undergoing cardiac surgery. The investigation focused on the changes and relationships among hepatic waveforms and echocardiographic parameters, ventilator settings, fluid and vasoactive medications, and laboratory parameters of renal and liver functions during the first 24 h. Our goal in our prospective observational study was to determine which factors are associated with the increased congestion of the liver as measured by Doppler ultrasound in patients undergoing cardiac surgery.2), hepatic cirrhosis, and portal vein thrombosis.  were collected. Postoperative factors  were also used in the analysis. Laboratory results were collected during the preoperative period and on the first, second, and third postoperative days. In addition, information on the predictors of the European System for Cardiac Operative Risk Evaluation II score (EuroSCORE II) was used and  the VasoThe ultrasound examinations were performed by board-certified cardiologists  and were recorded on the same machine and analyzed by the same person after completion of the study (CE). Standard 2D parameters recorded were ejection fraction, tricuspid annular plane systolic excursion, atrial and ventricular diameters, and the occurrence of any valvular pathology. The physicians managing the patients during the postoperative period were blinded to the results of the study-specific measurements.Blood flow was measured in the common hepatic vein right before draining into the inferior vena cava using pulse-waved Doppler ultrasound. The normal hepatic vein waveform has four components: a retrograde A, an anterograde S, a transitional V , and an anterograde D wave ,19. Fig We recorWe investigated the correlations between echocardiographic parameters and the changes in hepatic venous flow parameters. Changes of serum creatinine, bilirubin, and transaminase levels from their baseline values were also correlated with changes of the VTI ratios. Fluid overload and the amount of vasoactive support were analyzed both as continuous parameters and comparison between groups who had growth in the VTI ratio compared to those without growth.p > 0.05). Multivariable models were tested for multicollinearity. To test the diagnostic ability of the binary (hepatic venous congestion and non-VTI growth) classifier system, receiver operating characteristic curves were generated. Statistical tests were two-sided, and p < 0.05 was considered statistically significant. Statistical analyses were performed with SPSS software, Version 27.0 .Normality was assessed using the Kolmogorov–Smirnov test. Normally distributed values were described as means and standard deviations (SD) and skewed distributions as medians and interquartile ranges (interquartile range 25–75) and were compared using the Mann–Whitney U test. Continuous variables were first expanded with restricted cubic splines and were only used in linear form if the deviation from linearity was not significant, as indicated by the global F test  were male. The median age of the patients was 65.9 years (IQR: 59.8–69.9 years). The baseline demographic and clinical characteristics of the study population are shown in  V waves .p = 0.001 and 0.009).After comparing the echocardiographic parameters between the two subgroups, the postoperative right ventricular and atrial diameters were significantly greater in the “retrograde VTI growth” group . The ejeWe analyzed the vasoactive and inotropic scores, respiratory parameters, central venous pressures (CVP), and fluid balance.Ten patients needed inotropic support on the first postoperative day. Among the standard laboratory parameters, postoperative GFR values were lower, and blood urea nitrogen and bilirubin levels were higher in the “VTI ratio increased” subgroup. .p = 0.003)  and needed higher positive end-expiratory pressures (= 0.003) .Retrograde VTI growth showed a 0.89 (95% CI 0.785–0.995) C-index relationship with positive fluid balance.In the univariable linear regression model, the postoperative/baseline delta VTI ratio of the hepatic vein correlated with fluid balance, maximum central venous pressure, and delta ejection fraction . There wWe found that higher preoperative retrograde VTI ratios were associated with higher postoperative retrograde VTI ratios. In the first 24 h, the increase of the retrograde flow in the hepatic veins was associated with worse ejection fraction, higher positive fluid balance, increased right atrial and ventricular diameters, and higher central venous maximum filling pressures.The link between congestive heart failure, right ventricular failure, and liver dysfunction has been highlighted in the past decades ,22,23. RMeasuring venous flow patterns with ultrasound is an easy and noninvasive method that can help guide fluid management. These new diagnostic concepts, such as the inspection of the venous flow patterns in the renal and hepatic veins, can help in the early detection of fluid overload. It can be different from and nonparallel with right-sided cardiac dysfunction, and it cannot be predicted by the volume or cardiac output changes on the arterial side . In our Fast track management after cardiac surgery can be beneficial, as early return of spontaneous breathing and extubation will promote negative thoracic pressure, increasing the venous return, preloading, and helping to maintain cardiac output . ProlongIn the postoperative period, preload optimization can lead to fluid overload, particularly in low cardiac output states, preexisting or newly developed right-sided heart failure, and pulmonary hypertension. In other words, monitoring the hepatic venous waveform can help in the early detection of abdominal congestion states and fluid overload.Measurement of venous congestion or venous abdominal insufficiency seems to be an important tool in guiding fluid management and vasoactive therapy . Volume


Degenerative mitral regurgitation (DMR) due to mitral valve prolapse (MVP) is a common valve disease associated with significant morbidity and mortality. Timing for surgery is debated for asymptomatic patients without Class I indication, prompting the search for novel parameters of early left ventricular (LV) systolic dysfunction.To evaluate the prognostic impact of preoperative forward flow indices on the occurrence of post-operative LV systolic dysfunction.TVI, forward stroke volume index, and forward LVEF were assessed as potential risk factors for LVEF <50% at 6 months post-operatively.We retrospectively included all consecutive patients with severe DMR due to MVP who underwent mitral valve repair between 2014 and 2019. LVOTTVI was the strongest independent predictor of post-operative LV dysfunction after adjustment for age, sex, symptoms, LVEF, LV end systolic diameter, atrial fibrillation and left atrial volume index . The best sensitivity (81%) and specificity (63%) was obtained with LVOTTVI ≤15 cm based on ROC curve analysis.A total of 198 patients were included: 154 patients (78%) were asymptomatic, and 46 patients (23%) had hypertension. The mean preoperative LVEF was 69 ± 9%. 35 patients (18%) had LVEF ≤ 60%, and 61 patients (31%) had LVESD ≥40 mm. The mean post-operative LVEF was 59 ± 9%, and 21 patients (11%) had post-operative LVEF<50%. Based on multivariable analysis, LVOTTVI represents an independent marker of myocardial performance impairment in the presence of severe DMR. LVOTTVI could be an earlier marker than traditional echo parameters and aids in the optimization of the timing of surgery.LVOT TVI) and stroke volume index (SVi), could represent simple and reproducible indicators of early LV systolic dysfunction, helping risk stratification and decision-making.Mitral valve prolapse (MVP) is a common valvular heart disease with a prevalence that approaches that of bicuspid aortic valve and is estimated to occur in between 0.6 and 2.4% of the population , 2. MVP We conducted an observational retrospective single-center study that included all consecutive patients with severe primary degenerative MR (DMR) due to MVP who underwent MV repair between 2014 and 2019, whose forward SVi was available and whose post-operative follow-up (FU) was ≥6 months. Exclusion criteria were outside echocardiographic diagnosis without institutional full evaluation, secondary MR, mitral stenosis, significant aortic valve disease, previous valvular surgery, congenital heart disease and patients with incomplete or unavailable clinical or echo data. Coronary artery disease was not considered an exclusion criterion if it did not generate secondary MR. Patients who denied authorization for anonymous publication of their clinical data for research purposes were also excluded. The study was conducted in accordance with institutional guidelines, national legal requirements and the revised Declaration of Helsinki. All included patients provided written consent for research and publication of their study data .TVI was recorded as recommended (TVI and was indexed to body surface area (BSA) and referred to as SVi. A threshold of <35 ml/m2 was considered as a priori abnormal by reference to aortic stenosis  performed in our institution by experienced cardiologists within 3 months prior to surgery and at 6 months FU were available in all patients. Transthoracic echocardiograms were performed within routine clinical practice using standard methods , 22. LV stenosis . Forwardstenosis .2 test if valid (Fisher's exact test otherwise) for the qualitative variables and using Student's t-test if valid (Mann–Whitney test otherwise) for the quantitative variables. For echocardiographic parameters, a univariate logistic regression model was used to estimate crude odds ratios with their 95% CIs quantifying the excess risk of post-operative LV dysfunction. Multivariate analyses were then performed to assess the independent effect of echocardiographic parameters while taking into account potential prognostic factors selected beforehand according to the literature data and to the results of univariate analysis. Adjusted odds ratios were estimated with their 95% CIs. Firth's correction was applied by performing Firth's penalized-likelihood logistic regression to take into account the small number of post-operative LV dysfunction.The endpoint was the occurrence of post-operative LV systolic dysfunction defined by an LVEF <50% at ≥6 months after MV repair . QuantitReceiver operating characteristic (ROC) curves were established to determine the optimal cutoff value of echocardiographic parameters to predict post-operative LV dysfunction. Echocardiographic parameters were then dichotomized according to the identified cutoff values. Univariate and multivariate Firth's penalized-likelihood logistic regression models were built to estimate crude and adjusted odds ratios with their 95% CIs related to these dichotomized parameters for predicting post-operative LV dysfunction.p-values<0.05 were considered significant. We used R version 4.0.5 for all statistical analyses.All tests were two-sided. All 2). The middle portion of the posterior leaflet (P2) was the most frequently involved segment either isolated or in combination with other locations. The mean preoperative LVEF was normal, but 35 (18%) patients had a preoperative LVEF ≤60%, and 2 (1%) had an LVEF<50%. The mean LVESD was 35 ± 7 mm, and 61 (31%) patients had LVESD ≥40 mm. The mean LA volume index (LAVI) was 72 ± 24 ml/m2, and 131 (66%) patients had an LAVI ≥60 ml/m2. The mean systolic pulmonary artery pressure (sPAP) was 40 ± 15 mmHg, and 36 (18%) patients had sPAP>50 mmHg. The mean LVOTTVI was 16 ± 3 cm. The forward SVi was 37 ± 8 ml/m2, and 88 (44%) patients had a forward SVi <35 ml/m2. The mean forward LVEF was 38 ± 13%, and 167 (84%) patients had forward LVEF<50% , and 45 (23%) had a history of atrial fibrillation (AF), which was permanent in 22 (11%). The majority of patients were in NYHA class I-II (78%) at the time of surgery. The mean BNP level was 126 ± 133 pg/ml, and the Euroscore was low . All patLVEF<50% .Surgery was indicated by symptoms or LVEF ≤60% or LVESD ≥40 mm (class I indications) in 102 (51.5%) patients and by AF or sPAP ≥50 mmHg while asymptomatic with no overt LV dysfunction (Class IIa indications) in 23 (11.5%). In addition, 73 (37%) patients had “early” class IIa indications (asymptomatic and sinus rhythm and sPAP <50 mmHg and LVEF >60% and LVESD < 40 mm).All patients underwent MV repair, including 150 patients (76%) with neo-chordae and 48 patients (24%) with leaflet resection. An annuloplasty ring was implanted in all patients. The mean duration of cross-clamping time was 55 ± 18 min. Operative trans-TEE showed no residual MR in 99 (50%) patients, mild MR in 95 (48%) patients and moderate MR in 4 (2%) patients. The LVEF was 55 ± 9% at discharge. No operative deaths or post-operative strokes were noted.TTE performed at 6 months after FU in all 198 patients showed a mean LVEF of 59 ± 9% with 21 (11%) patients displaying post-operative LV dysfunction. The vast majority of patients had no or trivial MR, 21 (11%) had mild MR, and none had moderate or severe MR.Univariate risk factors for post-operative LV systolic dysfunction are listed in Multivariate analysis  revealed the following results:TVI  and mean forward SVi  were independently associated with post-operative LV systolic dysfunction, whereas forward LVEF exhibited borderline significance . The impact of all classic predictors confirmed in univariate analysis disappeared when simultaneously combined with either LVOTTVI or forward SVi with the exception of LVESD, which remained significant. However, the OR was lower than that of LVOTTVI  and forward SVi  were independently associated with post-operative LV systolic dysfunction, whereas forward LVEF was not . The impact of all classic predictors confirmed in univariate analysis disappeared when simultaneously combined with either LVOTTVI or forward SVi with the exception of LVESD and LAVI, which remained significant. However, the OR were lower than that of LVOTTVI  and forward SVi , whereas forward LVEF remained nonsignificantly associated with post-operative LV dysfunction .▪ Adjustment to LV end-diastolic volume (LVESV) instead of LVESD did not change the independent impact of LVOTTVI (Se = 81% and Sp = 63%), 31 ml/m2 for forward SVI (Se = 67% and Sp = 79%) and 30% for forward LVEF (Se = 62% and Sp = 79%) as the most accurate in predicting post-operative LV dysfunction (ROC curves identified thresholds of 15 cm for LVOTfunction .p < 0.01), forward SVI ≤31 mL/m2  and forward LVEF ≤30%  were strongly and independently associated with post-operative LV systolic dysfunction. The impact of LVESD and LAVI was weaker in all models, as attested by the lower OR  had an LVOTTVI ≤15 cm. The forward SVi was 32.8 ± 4.5 ml/m2. The two patients (40%) had a forward SVi ≤31 ml/m2. The mean forward LVEF was 30 ± 3.1% and four patients (80%) had a forward LVEF ≤30%. All of these five patients had at least one of these markers.Among 95 asymptomatic patients with preoperative LVEF >60% and LVESD <40 mm, 5 patients (5%) developed “unexpected” LV systolic dysfunction. Among these five patients, the mean LVOTTVI and forward SVI were identified as independent risk factors for post-operative LV dysfunction and appeared to be stronger predictors than classic clinical and echocardiographic markers, particularly LVEF; and (3) thresholds of 15 cm for LVOTTVI and 31 ml/m2 for forward SVI could be early indicators of latent LV dysfunction, helping risk stratification and decision-making.Our study including 198 patients with MV repair for severe DMR due to MVP showed that (1) post-operative LV systolic dysfunction occurred in 11% of all patients and in 5% of asymptomatic patients despite normal preoperative classic echocardiographic LV parameters; (2) LVOTIn the absence of randomized trials, DMR due to MVP has nourished a passionate controversy around the optimal timing of surgical indication in asymptomatic patients without signs of overt LV dysfunction for more than two decades. In this debate, supporters of early strategies , 28–31 a2+ATPase2, which is also referred to as SERCA 2, and an increase in the secretion of matrix metalloproteinases that initiates matrix proteolytic activity, cell apoptosis and ultimately impaired myocardial contractility  that is easy to obtain in routine practice with low skill requirements in contrast to forward SVI and forward LVEF. Both of these parameters indeed require the tricky measurement of LV outflow tract diameter, the squared value of which magnifies any inaccuracy in its recording. In addition, forward LVEF requires LV tracing and perfect apical views. Despite reflecting the same physiologic concept, the increased robustness of LVOTTVI observed in our study population could be the consequence of such methodological matters.Consequently, efforts have been focused on defining new surgical signals with the common objective of preserving LV function, but none have been fully validated to date. Myocardial deformation has been investigated , and pat markers . Forward markers . Forward markers . This paTVI reported in this study in DMR is consistent with its known impact in the risk stratification of several cardiac diseases, including congestive heart failure (Given the retrospective design and relatively small study population employed in this study, these findings require validation in future large-scale prospective studies. Hypertension was present in 23% of patients, and high blood pressure values at the time of echo could have artificially decreased forward flow indices independent of LV function. However, the consistency of their predictive value in all multivariable models and their incremental values over classic signals, particularly in detecting unexpected LV dysfunction, does not favor this hypothesis. In addition, the predictive value of LVOT failure , stable  failure . LVEF foTVI appears to be the most robust and could be used as an easy recording tool in routine practice for risk stratification, thereby refining surgical indications in patients with no Class I or IIa indications.In patients with severe DMR, forward flow parameters could represent pertinent indicators of intrinsic LV performance, and alterations in these parameters could serve as earlier markers of latent LV dysfunction compared with conventional echocardiographic indices. Among these parameters, LVOTThe original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by APHM Assistance publique des Hopitaux de Marseille, RGPD: 2019-48 (please see All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


We lack data on the effect of single premature ventricular contractions (PVCs) on the clinical and echocardiographic response after cardiac resynchronization therapy (CRT) device implantation. We aimed to assess the predictive value of PVCs at early, 1 month-follow up on echocardiographic response and all-cause mortality.In our prospective, single-center study, 125 heart failure patients underwent CRT implantation based on the current guidelines. Echocardiographic reverse remodeling was defined as a ≥ 15% improvement in left ventricular ejection fraction (LVEF), end-systolic volume (LVESV), or left atrial volume (LAV) measured 6 months after CRT implantation. All-cause mortality was investigated by Wilcoxon analysis.P = 0.04). However, when patients were followed up to 9 years, its significance diminished .The median number of PVCs was 11,401 in those 67 patients who attended the 1-month follow-up. Regarding echocardiographic endpoints, patients with less PVCs develop significantly larger LAV reverse remodeling compared to those with high number of PVCs. During the mean follow-up time of 2.1 years, 26 (21%) patients died. Patients with a higher number of PVCs than our median cut-off value showed a higher risk of early all-cause mortality (HR 0.97; 95% CI 0.38–2.48; In patients undergoing CRT implantation, lower number of PVCs predicted atrial remodeling and showed a trend for a better mortality outcome. Our results suggest the importance of the early assessment of PVCs in cardiac resynchronization therapy and warrant further investigations.The online version contains supplementary material available at 10.1186/s12872-022-02725-3. Cardiac resynchronization therapy (CRT) improves cardiac function, reduces the number of hospitalizations and all-cause mortality in patients with mild to severe heart failure and a prolonged QRS –3. HowevThe most frequent factors that can diminish effective biventricular pacing are arrhythmic events, including atrial fibrillation, premature atrial or ventricular complexes, or single beats . In ordeIn patients with a biventricular pacing rate over 98%, approximately a 44% reduction can be observed in the composite endpoint of all-cause mortality and heart failure events . AlthougA subgroup analysis of the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) trial also showed the importance of premature ventricular and atrial complexes . A relatAccordingly, we aimed to determine the association between the early detection of single ventricular premature contractions and echocardiographic changes and all-cause mortality in patients undergoing CRT implantation.In our prospective, observational cohort study, a total of n = 125 patients on optimal pharmacological treatment with severe chronic systolic heart failure [left ventricular ejection fraction (LVEF) ≤ 35%], wide QRS (≥ 130 ms), and ongoing symptoms [New York Heart Association (NYHA) class II-IVa] were enrolled and underwent CRT implantation  days after the implantation procedures, respectively.Detailed laboratory tests, echocardiographic examination, NYHA functional class assessment, physical examination including a six-minute walk test (6MWT) and pacemaker interrogation were performed at baseline and 6-months after CRT implantation.All-cause mortality was assessed by the National Health Fund Death Registry index and by the regular follow-ups.CRT implantation was performed according to the current guidelines. We used the subclavian transvenous approach and performed an angiogram in order to choose the ideal coronary sinus branch. Optimal lead positions were assessed by chest X-rays by using the right and left anterior oblique views. Left ventricular leads were implanted, preferably into the lateral or posterior side branch, while the right ventricular lead was recommended to be implanted in a septal position. After lead positioning, electrical parameters were measured. In patients with intraoperative phrenic nerve stimulation, repositioning was performed.During regular follow-up visits, pacemaker interrogation was performed, and printouts were collected. The electronic database was compiled by the same physician. Ventricular, atrial and total arrhythmic events were collected from the 1- and 6-months follow-ups, and only those interrogation data were analyzed that reported the total number of single PVCs. If patients were not able to attend the 1-month follow-up visit (n = 25), the 6-month data was divided by 6.Out of the total patient population, n = 67 patients had the complete pacemaker interrogation data and therefore were included in the final analysis Fig. .Echocardiography was performed according to current standards in a left lateral position by using the Philips iE33 echocardiography system equipped with an S5-1 transducer . Image acquisition was performed according to the current recommendations . MeasureThe primary endpoint was all-cause mortality during the follow-up period, which was evaluated in n = 67 patients.Secondary endpoints included three echocardiographic response criteria defined as at least a 15% relative improvement in LVEF, or at least a 15% decrease in LVESV, or at least a 15% decrease in LAV 6 months after CRT implantation. A total of thirty-eight patients had baseline and 6-month echocardiographic data and were analyzed for echocardiographic response  and Graphpad Prism 6.03  software.A two-sided The normality of the data was checked via the Shapiro–Wilk test. Continuous variables were presented as mean ± standard deviation (SD), or as median with interquartile range , as appropriate. Categorical data were described with frequency and percentage. Baseline clinical characteristics were compared by unpaired t-test, or Mann–Whitney U-test, as relevant. The Fisher’s exact test was used for comparison of categorical data.For the later analyses, we chose a cut-off point  with 95% confidence intervals (CI) were calculated for all-cause mortality via logistic regression analyses as a forward stepwise way.The mean age of the patients (n = 67) was 66.2 ± 10.2 years, 52% had ischemic etiology of heart failure, and the mean LVEF was 29.0 ± 6.0%. The electrocardiogram (ECG) showed typical left bundle branch block (LBBB) morphology in 73% of the cases  and blood urea nitrogen levels were similar in the two groups . Serum potassium levels that might influence arrhythmic events or the number of premature beats were also similar in the two groups .There were no statistically significant differences between the two groups as regards to baseline clinical parameters, medical history or echocardiographic parameters Table . There wBiventricular pacing rate did not differ significantly in patients with “low PVCs” and “high PVCs” at the 1-month follow up  indicating that the amount of PVCs in this range did not influence the biventricular pacing rate.P = 0.04) .During the mean follow-up time of 2.1 years, 19 (28%) patients died. In the “low PVCs” group n = 7 patients passed away, while in the “high PVCs” group n = 12 patients reached the primary endpoint  .We analyzed echocardiographic changes 6 months after CRT implantation in thirty-eight patients in “low” versus “high PVCs” groups. Left ventricular parameters were similar in the 2 groups   Table .Table 3CWe found that the number of PVCs 1 month after CRT implantation has impact on the echocardiographic left atrial reverse remodeling, while has moderate—if any—influence on mortality in our patient cohort.CRT is an effective therapy in symptomatic patients with chronic systolic heart failure, low ejection fraction, and wide QRS, but the beneficial response is multifactorial; it strongly depends on optimal patient selection, electrical parameters at implantation, and the biventricular pacing rate –3. BasedRuwald et al. also found similar results: patients with a relatively low burden of ectopic beats (as low as 1 in 1.000) are more likely to have a worse echocardiographic response and clinical outcome . In the above-mentioned MADIT-CRT substudy, ectopic beats  with an occurrence as low was 0.1% were linked to poorer reverse remodeling and increased heart failure events . In our While further studies also raised the question whether the origin of PVCs might have an impact and influence on the subsequent echocardiographic reponse. Wojdyła-Hordyńska et al. described after investigating 110 consecutive patients underwent monomorphic PVC ablation from an outflow tract origin or from the left ventricle, only outflow tract PVC elimination predicted left ventricular improvement in 6 months .P = 0.21) These patients have intermediate outcomes in both echocardiographic, and long-term mortality and HF hospitalizations, supposedly due to an improved left ventricular diastolic filling [The effect of CRT on left ventricular and atrial reverse remodeling has been studied previously. Left atrial reverse remodeling may be due to the synchronous contraction leading to a better left ventricular filling, an increased cardiac output and decreased mitral regurgitation , 14. Bot filling .In a MADIT-CRT subanalysis by Mathias et al., 22% of the patients underwent CRT implantation had discordant left sided reverse remodeling (either LAV or LVESV reduction). Those with complete left sided reverse remodeling had a significantly lower rate of HF and death compared to the discordant and lesser reverse remodeling patient group. But, the discordantly reverse remodeled patients had better outcomes compared to those in the lesser reverse remodeling group. Predictive factors of complete reverse remodeling were sex , non-ischemic etiology, and a lower percent of unfavorbale clinical parameters  . In our Considering the above-mentioned results, we do not know whether, in such a relatively low prevalence of PVCs, is it a cause or symptom of e.g. a more activated sympathetic nervous system? Could it be relevant to decrease the number of PVCs and if so, what would be the proper method (ablation or drugs)?While PVCs can facilitate heart failure progression in patients with CRT due to the loss of effective biventricular pacing, their hemodynamic effect can also be relevant considering the impaired systolic and diastolic function. Even though the cause and consequences of PVCs, and most relevantly their clinical implications are ambiguous, but the early identification of patients with a higher number of PVCs, as well as their close follow-up and maximized medical treatment might be beneficial.The early assessment of single premature ventricular contractions 1 month after CRT implantation shows association with 6-month left atrial reverse remodeling and presumably of a better outcome.Our study is limited by the relatively small sample size and the low number of endpoints. Nonetheless, our results are in line with other large, multicenter, randomized trials. Second of all, when pacemaker interrogation files of the 1-month follow-up were not available (n = 25), the 6-month data was divided by six. The implanted CRT devices varied in brand and type, thus present a limitation due to their different PVC detection modes. Moreover it should be noted that PVC burden may be altered by atrial fibrillation episodes, fused beats, and supraventricular contractions with aberration. This analysis is mainly hypothesis-generating, and the results should be regarded, therefore as preliminary. More extensive studies are needed to confirm the results and the clinical impact of PVCs in patients undergoing CRT implantation.Additional file 1: Figure S1. PVC distribution of enrolled patients at 1-month, 6-month and total PVC number. Figure S2. Difference in LAV changes after 6 months in patients with low vs. high PVCs, with 15000 beats as cut-off value. (low PVC group (mean ± SD): − 18.4 ± 26.6 ml vs. high PVC group (mean ± SD): − 0.56 ± 20.6 ml; p = 0.029). Table 1. Baseline clinical variables, medical history, echocardiographic measurements, medical therapy and laboratory parameters of patients dichotomized by 15000 beats as cut-off value value


A 12-year-old boy known to have Duchenne muscular dystrophy presented to our Emergency Department with acute onset central chest pain.A 12-lead electrocardiogram (ECG) was performed showing ST-segment elevation with reciprocal changes. An echocardiogram showed reduced left ventricular systolic function with an ejection fraction of 45%. Initial cardiac biomarkers were significantly elevated, with troponin-T result recorded at 7,065 ng/L (reference range: 0-14 ng/L). The patient was admitted to the pediatric intensive care unit with a differential diagnosis of acute myocardial infarction or acute myocardial injury related to cardiomyopathy and commenced on an ACE (angiotensin-converting enzyme) inhibitor. Computed tomography (CT) of the coronary arteries was performed, which showed normal coronary arteries and cardiac anatomy.The patient was discharged on day 5 and continues to follow up in the pediatric cardiology clinic. He was commenced on a beta blocker at one-month follow-up when he was asymptomatic. Duchenne muscular dystrophy (DMD) is an X-linked disease that usually results from a dystrophin gene abnormality. Absence of dystrophin protein in skeletal and cardiac tissue results in contractile protein degradation, fibrosis, and apoptosis . It affeAdvancements in respiratory care have improved life expectancy to the late 20s, with cardiomyopathy emerging as the most prevalent cause of death -4.Elevated liver transaminases and creatine kinase often trigger a referral to neurologists, and current standards advise performing genetic testing for the DMD gene first before muscle biopsy ,5.Children usually present with progressive neurological deficit characterized by gait disturbances, speech problems, and proximal muscle weakness. Weakness starts in the proximal lower limbs and trunk, later involving the upper limbs and distal muscles . The majWe present a case of a 12-year-old boy who presented to our Emergency Department (ED) with no previous records of baseline investigations at our hospital and a chief complaint of central crushing chest pain and electrocardiogram (ECG) changes suggestive of myocardial ischemia.A 12-year-old boy presented to our ED complaining of crushing central chest pain, which started 12 hours prior, radiating to his back and jaw. A 12-lead ECG at first medical contact showed inferolateral ST-segment elevation with reciprocal changes . His vital signs were normal except a resting tachycardia of 103 beats per minute. The case was discussed with the interventional cardiologist as well as the pediatric cardiologist, the latter based in a network hospital in the same city. Initial cardiac biomarkers were significantly elevated, with troponin-T result recorded at 7,065 ng/L (reference range: 0-14 ng/L) using the Elecsys® troponin T-high sensitive assay . The patient was admitted to the pediatric intensive care unit with a differential diagnosis of acute myocardial infarction or acute myocardial injury related to cardiomyopathy. Inflammatory markers and an infection screen were also performed, which were negative for any extrinsic infectious etiology for this presentation.Based on the presentation to ED with crushing chest pain, the ECG changes noted, and the elevated cardiac biomarkers, an initial working diagnosis of acute myocardial infarction was made.Another differential diagnosis was cardiomyopathy-related acute myocardial injury. Cardiomyopathy is more commonly described in DMD. In this case, the cardiomyopathy may have been largely asymptomatic prior to presentation. On attendance in ER, the clinical features were not consistent with heart failure, and a structurally normal heart was seen on echocardiography; however, it should be noted the absence of typical symptoms of heart failure such as dyspnea on exertion and limited exercise tolerance are common in DMD. Furthermore, in early stages, due to restricted left ventricular (LV) enlargement, the echocardiogram may appear normal .A 12-lead ECG in the ED showed a sinus rhythm and ST-segment elevation in the inferior and lateral leads of more than 2 mm with corresponding reciprocal changes. Signs of right ventricular hypertrophy (RVH), i.e., right axis deviation, dominant R wave lead V1, and dominant S waves in leads V5 and V6  of 45%, mild insufficiency of the aortic valve, and no structural anomalies. Cardiac CT angiography of the coronaries was performed the next day, which demonstrated normal cardiac anatomy and normal coronary arteries. Unfortunately, our patient did not undergo cardiac magnetic resonance imaging (CMR) on admission.Serial troponins were collected on a daily basis, which showed a decreasing trend with a troponin level of 1,271 ng/L recorded on the day of discharge. A repeat echocardiogram was performed before discharge, which showed an improved EF of 58% and normal ventricular systolic function.At eight-week follow-up, a repeat echocardiogram was reported showing mildly depressed LV systolic function with an EF of 49% and mild insufficiency of the aortic valve. Troponin-T assay was now recorded at a level of 74.8 ng/L. The patient was commenced on bisoprolol and continues to follow up in the clinic.Cardiac disease in DMD has been described preclinically as young as in toddlers. By the age of 18, the vast majority of DMD patients have cardiac disease, with the commonest being cardiomyopathy. Dilated cardiomyopathy is more common followed by hypertrophic cardiomyopathy. Symptoms are often absent due to restricted physical activity [Arrhythmias such as atrial tachycardias, ventricular tachycardia, and ventricular fibrillation have been reported in advanced cardiomyopathy. Sinus tachycardia is the most common arrhythmia observed ,9. HeartAbnormal ECG findings are found in 70% of cases, including sinus tachycardia, short PR interval, dominant R wave in lead V1, deep Q waves in the inferolateral leads, RVH, aberrant conduction, and a prolonged QT interval .Cardiac biomarkers can be chronically elevated due to their skeletal muscle origin, with cardiac troponin I (cTnI) being more specific than cardiac troponin T (cTnT) possibly because it is not expressed in human skeletal muscle and is strongly associated with cardiovascular disease ,12. FurtEchocardiography has been used for the assessment of cardiac wall motion and EF due to it is availability and low cost. It has limitations in being operator-dependent. CT coronary angiography might be a useful tool for assessment if CMR is not readily available. CMR is recommended for screening of disease progression showing hallmark changes in the posterobasal and basal inferiolateral areas of the left ventricle . LGE in Hor et al. reported eight DMD pediatric cases who presented with chest complaints, ST-segment elevation, and elevated troponin levels. In all eight patients, normal coronary perfusion was confirmed by CT angiography or cardiac catheterization, whereas on CMR, abnormal systolic function was demonstrated . They atThe principle of pharmacological treatment in DMD is to delay onset of heart failure. Early steroid therapy has a beneficial impact on lung function, LV function, and skeletal muscle. Similarly, use of angiotensin-converting enzyme (ACE) inhibitors has been proven to delay the onset and progression of LV dysfunction .Once LV dysfunction is established, corticosteroids remain beneficial and are shown to delay establishment of myocardial fibrosis on CMR . ACE inhBeta blockers have also been shown to be beneficial in DMD as an anti-arhythmic, improve EF, and reduce detrimental ventricular remodelling . AldosteSome anti-arrhythmic drugs can increase skeletal muscle weakness, otherwise their use in DMD patients is similar to non-DMD patients .In patients with end-stage heart failure, use of mechanical cardiac support devices is also a feasible option. Similarly, non-invasive ventilation is a treatment option for restrictive ventilatory defects resulting from progressive respiratory muscle weakness .DMD patients can attend ED with many acute problems, with respiratory complaints perhaps being the commonest. Dyspnea is often mild compared to the severity of disease. Undifferentiated chest pain from cardiac and non-cardiac causes are both likely. Esophagitis and musculoskeletal chest pain, with the latter from coughing, have been reported. Constipation is also common but look for other high-risk conditions first such as steroid-related ulcer disease. Renal colic is another differential diagnosis when presenting with abdominal pain. They are also prone to back pain from osteoporotic vertebral fractures. Fatigue is also reported possibly attributed to nocturnal hypoventilation, mood disturbances, and advanced cardiomyopathy. Have a low threshold to discuss the care of DMD patients with their parent team, often the neurologists .It is worth noting that 5% of all myocardial infarctions do not have obstructed coronary arteries, a condition termed “myocardial infarction with normal coronary arteries” (MINOCA). In these cases, sepsis, pulmonary embolism, substance misuse, myocarditis, or oxygen supply-demand mismatch resulting in type 2 myocardial infarction (e.g. from anemia or thyrotoxicosis) should be excluded ,29. In cIn conclusion, our patient with chest pain and ECG changes suggestive of myocardial ischemia was objectively evaluated for coronary artery disease. It is plausible our patient had episodic myocardial injury due to myocardial disease progression, with the latter being a common cause of morbidity and mortality in DMD patients.DMD patients can present to ED with a variety of complaints that are often respiratory or cardiac in nature. It is also worth remembering that vertebral compression fractures and other fragility fractures are common in children with DMD due to osteoporosis and steroid use. Progressive muscle weakness eventually leads to complete loss of mobility. Respiratory muscle weakness may result in mucus plugging, atelectasis, pneumonia, and respiratory failure.Frontline healthcare practitioners should be aware of the high prevalence of cardiomyopathy in these patients, which increases with age. Such patients should have an ECG performed, which should be compared to a baseline ECG if possible. As a rule, be vigilant and discuss these cases early on with their parent team. Cardiac biomarkers can be chronically elevated in DMD. However, a high level of suspicion coupled with an echocardiogram can assist in the diagnosis of acute myocardial injury in these cases. Where available, CMR assists in the evaluation of patients with cardiomyopathy-related myocardial injury, with characteristic LGE seen.


Purpose: There is a paucity of data on physiological heart adaptation in elite-level judo female athletes. This study aimed to assess left ventricular morphology and function in highly trained elite female judokas.Methods: The study prospectively included 18 females aged 23.5 ± 2.25 years, nine elite level judokas, and nine healthy non-athlete volunteers. All participants underwent a medical examination, electrocardiogram, and transthoracic 2D echocardiogram. Left ventricular diastolic and systolic diameters and volumes were determined, and parameters of left heart geometry and function (systolic and diastolic) were measured, calculated, and compared between groups.Results: When groups were compared, judokas had significantly increased left ventricular cavity dimensions p < 0.01, left ventricular wall thickness p < 0.01, and volumes p < 0.01. Elite female judokas exhibited left ventricular dilatation demonstrated as high prevalence increased end-diastolic volume/index, and increased end-systolic volume/index in 88.9% of judokas vs. 0% in controls, p < 0.01. Left ventricle mass/index was significantly increased in judokas, p < 0.01), with a 43.3% difference between groups. The majority (77.7%) of judokas had normal left ventricular geometry, although eccentric hypertrophy was revealed in 2 (22.2%) of judokas.Conclusion: Elite, highly trained female judokas exhibit significant changes in left heart morphology as a result of vigorous training compared to non-athletes. These findings suggest that female judokas athletes’ heart follows a pattern toward chamber dilatation rather than left ventricular wall hypertrophy. Judo is a popular combat sport worldwide. As reports from International Judo Federation (IJF) claim, there are 1,181 female judokas competing on an elite level, spread across all weight categories. Despite many proven positive physiological benefits of practicing judo, it inevitably leads to the exhibition of various adaptations of the cardiovascular system . Combat Over time these complex adaptive changes usually lead to the development of the “athlete’s heart” . Early rUnderstanding the specific features of the athlete’s heart in specific populations is of great importance in order to know what to expect of a specific athlete’s sports discipline and gender. Initial and follow-up examinations help us to differentiate physiological exercise that induces cardiac remodeling from pathological conditions. Differentiating exercise-induced cardiac remodeling of abnormal cardiovascular pathology is important in screening and diagnosing potentially life-threatening conditions. Essentially, there is limited data regarding female athletes’ heart response to long-term elite-level judo participation and training stimulus . To our This study aimed to assess left ventricular morphology and function in highly trained elite female judokas.The study prospectively included 18 females aged 23.5 ± 2.25 years. The Judo group consisted of nine elite-level judo athletes  and nine healthy non-athlete female student volunteers previously not involved in regular exercise training for the last 5 years in the control group. All judokas were a part of the national team, participating in both national and international contests. Subjects started with judo practicing between six and 8 years old, the average duration of the judo training experience was 16.55 ± 3.16 years, with twenty to twenty-five (20-25) hours of training volume per week. Judokas spent 1,5-2 h of training in the weight room two to three times a week. The participants competed for the Serbia senior national team in international competitions and scored for the IJF rank, and they achieved the minimum of one ranking. Two competitors were category up to 48 kg, two −52, one −57, two −63, one −78, and one +78 kg. They are all still competing. Four of them achieved the Olympics norm , and two were close to the Olympics norm and the 25th place. Three of them participated in the Olympics, one didn’t because two were in the same category −48 kg, but only one could participate.All participants underwent a medical examination, electrocardiogram (ECG), and transthoracic 2D echocardiogram at the Institute for Cardiovascular Diseases of Vojvodina, Serbia. All participants underwent a standard resting 12-lead surface ECG record at a paper speed of 25 mm/s and gain of 10 mm/mV. One cardiologist interpreted each ECG to exclude potential abnormalities. Exclusion criteria were: A previous history of arterial hypertension, diabetes mellitus, heart, kidney, hepatic, infectious, psychiatric, malignant, disorders, taking drugs that can influence ECG intervals, and electrolyte imbalance. The study was performed corresponding to the Helsinki Declaration with ethical approval obtained from the local ethics committee of the University of Novi Sad, Serbia (Ref. No. 46-06-02/2020-1). Measurements were done in the early morning hours before any water or food intake. For the judo group at least 24 h after the last training. Body height (BH) measurement was performed in a standing position with heels together, toes apart, and hands close to the body with an anthropometer, according to Martin , with an accuracy of 0.1 cm. Body mass (BM) was determined using an Omron weight scale BF511  with an accuracy of 0.1 kg. Body surface area (BSA) and body mass index (BMI) were calculated using the following formulas:.All subjects underwent two-dimensional transthoracic echocardiography (ECHO) using Vivid E9  machine that is equipped with an M5S-D, 1.5–4.6 MHz transducer with continuous ECG monitoring during the examination. Subjects were instructed to take a left lateral decubital position for examination. One investigator, blinded to the clinical characteristics of the participants, without blinding was evaluating echocardiographic parameters . All measurements and calculations were performed by previously described methods according to standardized procedures by the European Association of Cardiovascular Imaging  and the t)–(5/6A2L), where A1 is epicardial area at end-diastole (cm2), A2 endocardial area at end-diastole (cm2), L-ventricular length at end-diastole (cm), t = average wall thickness (cm), 1, 05-specific gravity of the muscle (g/ml). To obtain the indexed value (LVMi) the LVM was divided by BSA. Calculation of left ventricular hypertrophy level (LVHL) was calculated by adding intraventricular septum diameter (IVSDd) and posterior wall thickness (PLWd) and dividing the sum by two (LVHL= (IVSDd + PLWd)/2).Parasternal long-axis view (2D) was used to measure LV end-diastolic (LVEDd) and systolic (LVEDs) diameter, the diastolic thickness of the inter-ventricular septum (IVS), posterolateral wall (PLW), aortic root, ascending aorta dimension and cusp separation. Volumes of the left atrium (LA) were measured by the Simpson method using apical 4-chamber and 2-chamber views at end-systole in maximum LA size (LAVs) and then normalized for body surface area (BSA) as LAVs index (LAVsI). Using the biplane method of disks, left ventricular end-diastolic (EDV) and end-systolic volumes (ESV) were measured, and EF was calculated. Left ventricular mass (LVM) was calculated by the software automatically via area–length method, according to measures obtained from parasternal short-axis view in which mid-ventricular systolic and diastolic epicardial and endocardial surfaces were traced (with the exclusion of papillary muscles), including measuring the systolic and diastolic mitral-to-apical distance in apical 4-chamber view. LVM = 1, 05 (5/6A2 (L + According to left ventricular mass index (LVMI) and relative wall thickness (RWT), left ventricular morphology is classified into one of four structural groups: 1) normal geometry, characterized by normal LVMI ≤95 g/m2 and RWT ≤42 mm; 2) concentric remodeling, LVMI ≤95 g/m2 and RWT >42 mm; 3) Concentric hypertrophy, LVMI>95 g/m2 and RWT>42 mm; and 4) Eccentric hypertrophy LVMI>95 g/m2 and RWT ≤42 mm (8).In the apical 4-chamber view, using transmitral pulsed-wave (PW) Doppler at the tips of mitral leaflets peak early wave (E), atrial late (A) diastolic filling velocities were measured, and E/A ratio was calculated. Tissue Doppler on the mitral annulus was obtained at the septal and lateral positions, where peak early (e′) velocities were measured and averaged. E/e' ratio was calculated from E velocity and averaged e' velocities obtained from septal and lateral positions of the mitral annulus.t-test or Chi-square test where appropriate. A t-test was used to compare continuous variables with normal distribution, and a chi-square test was used to compare categorical variables. A p-value < 0.05 was considered statistically significant. All calculations and interpretations were made using Statistical Package for Social Sciences–SPSS Version 20.0 .The analysis included descriptive statistics. To test the normal distribution, the Kolmogorov-Smirnov test was used. Continuous variables data are presented as mean ± standard deviation. Categorical variables are expressed as absolute numbers and percentages. The data were compared using the Students p = 0.84, BW 63.92 ± 13.87 vs. 62.67 ± 9.35 kg, p = 0.83, BMI 22.82 ± 6.64 vs. 22.31 ± 3.04 (kg/m2) p = 0.83, and BSA 1.70 ± 0.19 m2 vs. 1.71 ± 0.18 m2, p = 0.93. The mean age of judo athletes was 24.67 ± 3.84 years, while the mean age of the control group was 23.44 ± 0.88 years, p = 0.38.There was no statistically significant difference between judo and control group for: BH 166.56 ± 7.29 vs. 167.44 ± 10.78 cm, p < 0.01, LVEDd/BSA 29.05 ± 2.34 vs. 25.45 ± 2.56 mm/m2, p < 0.01, with 22.46% difference, LVEDs 33.11 ± 2.32 vs. 27.00 ± 2.55 mm, p < 0.01, and LVEDs/BSA 19.63 ± 2.04 vs. 16.03 ± 2.58 mm/m2, p < 0.01, with 14.14% difference), LV wall thickness  and volumes EDVI 70.07 ± 7.75 vs. 49.12 ± 6.32ml/m2, p < 0.01, ESVI 28.39 ± 3.14 vs. 17.15 ± 2.40 ml/m2, p < 0.01, (p < 0.01 in controls and increased ESV (>42 ml) and ESVI (>24 ml/m2) in 88.9% vs. 0% of controls, p < 0.01.When groups were compared judokas had significantly increased left ventricular cavity dimensions  exhibited normal left ventricular geometry. Eccentric hypertrophy was found in two judokas (who had an Olympic norm) 22.2% vs. 0%, p = 0.14.Majority of judokas , left ventricular wall thickness didn’t exceed 11mm, but 10.3% exhibited left ventricular internal diameter above 50 mm, and 4.2% above 55 mm . In our Our results confirm that athlete training is associated with enhanced systolic and diastolic function, probably mediated by a combination of enhanced early relaxation and increased LV compliance. The diastolic function shows evidence of enhancement in lower late atrial A wave, higher e' waves, and lower filing velocities E/e.’ Greater stroke volumes and SVI reflect improvement in systolic function. In a large meta-analysis, when groups of endurance-, resistance- and mixed-training athletes and healthy controls were compared, the E/A ratio was either normal or slightly, but not significantly, enhanced in athletes compared to controls . In 1991Whyte et al., in a meta-analysis of 13 studies , including 38 (16.7%) judokas (classified into the strength and sprint group) suggested that female athletes follow a similar pattern of cardiac adaptation as men . As therp < 0.001)  , these f< 0.001) , 3–4 min< 0.001) . We hypo< 0.001)  prior to< 0.001) . Echocar< 0.001) . These rThese findings confirm that an athlete’s physiological cardiac adaptation pattern is much more complicated than first thought and that it can’t be generalized to a sports discipline. It probably depends on numerous individual parameters like individual sport type, duration of practicing, weekly training volume, the athlete’s weight category, and other variables that influence the physiology of heart adaptation. Further longitudinal studies could help us piece the puzzle together and see the whole picture.n = 18 subjects. However, our sample consisted of nine elite-level judokas competing at an international level, where four of our subjects met entry norms for the Olympic games in 2020. Therefore, recruiting a larger number of athletes at this level is constricted. The measurements were only performed once by only one echocardiographist, and parameters are only indexed to BSA, which may not represent the most precise method.Admittedly, the first weakness of this study is the small sample size of only These findings suggest that elite, highly trained female judokas exhibit significant changes in left heart morphology. Furthermore, athletes’ heart follows a pattern toward chamber dilatation rather than left ventricular wall hypertrophy. The study deals with the population of judo elite-female athletes that have not been exclusively previously investigated, furthermore gives us a different insight into the cardiac remodeling in this specific population. These results indicate that cardiac remodeling is complex and depends on undouble different factors. The findings might assist us in perceiving physiological training-induced adaptations from pathological conditions which may predispose adverse cardiovascular events among athletes. Results may encourage us for further research to strengthen our knowledge related to specific heart structure and function adaptations that play a crucial role in heart remodeling classification and the distinction between pathophysiology and individual sport-specific adaptations.


This review centers on the usefulness of echo-Doppler studies in the diagnosis of ostium secundum atrial septal defects (ASDs) and in their management, both in children and adults. Transthoracic echocardiography can easily identify the secundum ASDs and also differentiate secundum ASDs from other kinds of ASDs, such as ostium primum ASD, sinus venosus ASD and coronary sinus ASD, as well as patent foramen ovale. Preliminary selection of patients for device occlusion can be made by transthoracic echocardiograms while final selection is based on transesophageal (TEE) or intracardiac (ICE) echocardiographic studies with optional balloon sizing of ASDs. TEE and ICE are extremely valuable in guiding device implantation and in evaluating the position of the device following its implantation. Echo-Doppler evaluation during follow-up is also useful in documenting improvements in ventricular size and function, in assessing the device position, in detecting residual shunts, and in identifying rare device-related complications. Examples of echo images under each section are presented. The reasons why echo-Doppler is very valuable in diagnosing and managing ASDs are extensively discussed. Several varieties of atrial septal defects (ASDs) exist and these are ostium secundum, ostium primum, sinus venosus, and coronary sinus ASDs. In this review, only ostium secundum ASDs, hereafter referred to as ASDs, will be discussed. The prevalence of these defects is 9 to 13% of all congenital cardiac defects ,3,4. TheTransthoracic echocardiographic (TTE) examination is very useful in making the diagnosis of ASD in babies and children, as well as teenagers and adult subjects with thin build. In adolescents and adults with poor precordial and subcostal echo windows, transesophageal or intracardiac echocardiography is necessary to demonstrate all features of ASD. The pathophysiologic features of ASDs, namely dilatation of the RA, RV, and PAs , along wThe ASD can be clearly visualized by two-dimensional (2D) echocardiograms A. In norAs mentioned above, some patients have fenestrated atrial septal defects; such fenestrated defects can also be demonstrated by transthoracic echocardiographic studies .A composite of images from subcostal views of an atrial defect with left-to-right shunting is illustrated in Two-dimensional and color flow imaging in several views should also be carried out to identify the entrance of each pulmonary vein into the left atrium (LA) and to exclude partial anomalous pulmonary venous return. Peak Doppler velocity of tricuspid insufficiency jet and end-diastolic velocity of pulmonary insufficiency jet are useful in calculating the pressures in the PA with the usage of a modified Bernoulli equation: PA, pulmonary artery; V, Doppler flow velocity.Determination of PA pressures is important, particularly because the closure of ASD is not indicated in subjects with pulmonary hypertension, specifically in patients with pulmonary vascular obstructive disease.Natural reduction in the diameter of the ASD or complete closure is well documented in the literature ,9, and tTTE studies are also useful in distinguishing ostium secundum ASD  from ost® device , Amplatzer Cribriform device , and GORE® CARDIOFORM-ASD-Occluder (W.L. Gore).Surgical closure was the conventional and favored treatment for ASDs ,11,12,13The current guidelines for ASD closure were reviewed by respective Committees of the American College of Cardiology, American Heart Association, and European Society of Cardiology ,24. OnceWe have, in the past, attempted to develop objective echocardiographic features that might forecast the successful device closure of an ASD . In thisAt the present time, the ultimate decision to insert the device is made after detailed TEE or ICE evaluation of the diameter and shape of the ASD and rims of the ASD and balloon sizing of the ASD (as will be detailed in the subsequent sections) in the Cardiac Catheterization Laboratory.Three-dimensional (3D) echocardiographic studies were initially developed in the early 1990s ,29, as rThe standard practice at this time is to perform either TEE ,40 or ICAfter securing information on the diameter of the ASD and excluding any anomalous connections of the pulmonary veins, a thorough assessment of the rims of the atrial septum is undertaken during TEE or ICE. The rims of the ASD are named either on the basis of the location of the septal rim relative to the ASD, such as superior–posterior, superior–anterior, inferior–posterior, or inferior–anterior , or the The technique of balloon sizing the atrial defects was developed by King and his associates in the late 1970s . They wip < 0.001) with balloon-sized atrial defect diameter than with Qp:Qs and angiographic diameter [p > 0.1) from the actual measurement of balloon-sized atrial defect diameter (15.3 ± 4.0 mm). The relationship between the calculated and measured balloon-sized atrial defect diameters was excellent  , we attempted to estimate balloon size by other techniques of appraisal of the diameter of the ASD, namely, transthoracic echo diameter of the ASD, pulmonary-to-systemic flow ratio (Qp:Qs), and angiographic dimension of the ASD, to evaluate if the balloon-sized diameter of the atrial defect can be forecasted . The stadiameter . Based odiameter , we pros< 0.001) . The disSubsequently, static balloon sizing of the atrial defects, utilizing either AGA Amplatzer  or NuMED PTS  sizing balloons, was developed and most cardiologists started routinely using this method. After positioning the balloon catheter through the ASD, the balloon is expanded by injecting diluted contrast material till there is no shunting by color Doppler or waisting of the balloon was demonstrated ; over-inSome studies have indicated that balloon sizing may unintentionally enlarge the ASD size. Because of this reason and the ability to estimate balloon-stretched ASD diameter by TTE size ,47, as dIn summary, the author believes that there is no necessity to regularly balloon size the ASDs prior to device occlusion. Estimation of the stretched diameter of ASD by the formula (1.05 × trans-thoracic echo diameter + 5.49 mm) alluded to above ,47 and mWhen the author began performing transcatheter ASD occlusion in the mid-late 1980s, TEE had not yet become a standard method of diagnosis of ASD, nor was it a monitoring tool for ASD occlusion. Fluoroscopy supplemented with transthoracic echo  was usedSubsequent to the advent of TEE ,40 and IA suitable-sized device delivery sheath (depending upon the size of the selected ASO) is positioned in the upper-left pulmonary vein. The chosen ASO is fastened onto the delivery wire and the ASO is unscrewed by one rotation , and pulled into a loader sheath while immersed in saline. The ASO is inserted into the device delivery sheath while infusing the loader sheath constantly with saline, thus, avoiding unintentional air bubble entry into the delivery sheath. The ASO is pushed forward within the delivery sheath till it arrives at the end of the device delivery sheath, monitored by intermittent fluoroscopy. The delivery sheath is withdrawn from the pulmonary vein so that its tip is in the free LA and the ASO is pushed forward, thus, effecting the release of the left atrial disc. The whole system is slowly pulled back, such that the LA disc is apposed to the left atrial aspect of the atrial septum, closing the ASD; this is performed with continuous echocardiographic A and intFollowing verification of the position of the device by fluoroscopy and TEE B, color ® device is largely comparable to that detailed in the ASO section, explained in detail previously [The general protocol for transcatheter occlusion with the Gore HELEXeviously , and wilThe ACD is useful for occluding fenestrated ASDs . The met® device described above and is detailed elsewhere [® device. Once the left atrial disk is formed, it is retracted slowly to oppose the LA side of the ASD, while scrutinizing both with fluoroscopy and TEE. At this juncture, the delivery catheter is withdrawn into the lower part of the RA and the RA disc is delivered on the RA side of the ASD, another time by a simple “push out” method. After the location of the device is confirmed by TEE    and rema < 0.01) .p = 0.004}) and LV MPI (0.37 ± 0.12 vs. 0.31 ± 0.11 {p = 0.04}) improved at follow-up  in practice during follow-up. Nevertheless, such thrombi may be detected by the currently used echocardiographic studies.Device migration along with aortic wall perforation by the Amplatzer device has been reported ,70,71,72In over 300 Amplatzer Device implantations at my hospital during the past eighteen years, no patient developed fistulae between the aorta and the atria, in spite of careful and systematic follow-up echo-Doppler studies (unpublished observations). We have to presume that this is likely to be connected to avoiding over sizing the device at our hospital. However, relatively low incidence of these complications  could also be a factor for not seeing such complication in our 300 patients. Yet, it is important to perform careful echo-Doppler studies periodically during follow-up to detect the aforementioned complications.ASDs are frequent congenital heart defects, both in children and adults. Echocardiography is useful in diagnosing the ASDs, quantifying their size, and defining if indications for ASD occlusion (RV volume overload) are present. Echo studies also are valuable in distinguishing secundum ASDs from other types of atrial defects. An initial selection of patients for closure of ASDs by transcatheter methodology can be made by transthoracic echocardiograms, although the final selection is made by the findings of TEE or ICE and possibly the balloon sizing of ASDs. The procedure of device implantation is largely guided by TEE or ICE along with fluoroscopy. TEE and ICE are specifically useful for assessment of the position of the devices subsequent to their deployment in the catheterization laboratory. Follow-up evaluation with TTE studies is performed to appraise the device position, to identify residual shunts, and to detect rare complications. Based on this review, it may be concluded that the non-invasive transthoracic and invasive transesophageal and intracardiac echocardiographic studies are of immense value, both in the diagnosis of ASDs and in their management. Three-dimensional echo may help with a more accurate definition of complex ASDs.