Increased left atrial volume and reduced atrial emptying are predictors of adverse cardiac events in adults. The atrium in single ventricle hearts contributes to ventricular filling to a greater degree than in normal hearts. Standardized methods of determining atrial function in single ventricles are lacking. We aimed to assess the feasibility and reproducibility of quantifying atrial volumes and function in hypoplastic left heart (HLH) prior to the Glenn operation.Fourteen patients with HLH prior to Glenn surgery 4.2 ± 1.2 months) underwent CMR cine imaging in 2 chamber (2CH) plane, 4 chamber (4CH) plane and 3D-atrial short-axial oblique (3D-SAO) stack (Figure .2 monthsMonoplane 4CH and biplane methods showed high correlations for aEDV and aESV as well as small mean differences compared to 3D-SAO Table . DespiteCMR atrial volume assessment is feasible in HLH prior to Glenn operation. The monoplane 4CH and biplane methods show the best correlate of atrial volumes and function. Increased RV mass may be associated with reduced atrial function.None.


To assess the outcome of surgery of functional mitral regurgitation (FMR) in idiopathic dilated cardiomyopathy (IDCM).We retrospectively investigated 146 patients  with severe functional mitral valve (MV) insufficiency due to dilated cardiomyopathy that were operated on between 2004 till 2012. 35 pts were in New York Heart Association class IV and 102 were in class III. Most of pts had severe enlarged LV  with depressed systolic function . Concomitant procedures were tricuspid repair (139 pts) and atrial fibrillation ablation (32 pts). In 35 pts (24%) epicardial LV lead was fixed with subsequent CRT implantation during the same hospitalization. Mitral valve annuloplasty with different types of undersized ring were performed in 101 patients, and 45 had mitral valve replacement .There were no perioperative deaths, in 2 pts BiVAD were started due to inability to wean from CPB. 4 patients (2.7%) died within 30 days postoperatively. Overall freedom from MR ≥ 2+ was 96.1%. Both LV end-diastolic and end-systolic volumes indexed significantly decreased (both p=0.0001). After MV repair ejection fraction increased from 25.2±7,5% to 29,2±9,4% . The mean follow-up was 47.6±4.1 months. 1-years survival was 78±0.04%, 5-years - 39±0.08%. The fact of mitral valve replacement versus repair did not influence survival . The type of ring used for annuloplasty not influenced survival (long-rank p=0.37). Statistical analysis identified preoperative NYHA class as predictor of long-term survival (hazard ratio (HR) 4.53, 95% CI 2.7–13.5, p=0.004).Despite high operative risk in patients with IDCM, mitral valve surgery can be performed successfully with acceptably low hospital mortality, clinical improvement and a moderate recovery of LV function.


Assessing the reproducibility of new quantitative magnetic resonance imaging (MRI) biomarkers is an important part of validation -3. FouriAfter obtaining informed consent, healthy volunteers (N=10) were examined on Day-1 and Day-8. On Day-1 MRI tagging was used to collect two measurements of LV twist for intra-exam comparisons. LV twist was measured again on Day-8 for inter-exam assessment. The following imaging parameters were used to acquire short-axis images at the base and apex: 280-330 x 280-330 mm field-of-view, 6mm slice thickness, 192x192 acquisition matrix, 395 Hz/pixel receiver bandwidth, TE/TR =2.33-2.39/4.71-4.83 ms, 8 VPS, 12° imaging flip angle, 8 mm tag spacing, i-pat acceleration factor 2 with 24 central lines, and 14-27 cardiac phases. The breath hold duration was 15 heart beats (12.5 ± 1.9 seconds) depending upon heart rate. LV short-axis tagged images were acquired on a 3T scanner in order to ensure detectability of tags during systole to mid-diastole. The collection order of horizontal and vertical tags at the apex and base of the LV was randomized for each exam. FAST was used to automatically estimate LV systolic and diastolic twist parameters subsequent to ~3 minutes of user interaction. Peak LV twist was reported as mean±SD. Reproducibility was assessed using the concordance correlation coefficient (CCC) and the repeatability coefficient (RC= 95%-CI range).Mean peak twist measurements were 13.4±4.3° , 13.6±3.7° , and 13.0±2.7°(Day-8). Bland-Altman analysis resulted in intra- and inter-exam bias and 95%-CI of -0.6°  and 1.4° , respectively. Paired t-tests showed no significant differences in peak LV twist for intra- and inter-exam values . The Bland-Altman RC for peak LV twist was 2.6° and 4.0° for intra- and inter-exam respectively. The CCC was 0.9 and 0.6 for peak LV twist for intra- and inter-exam respectively indicating excellent and moderate agreement respectively.FAST is a semi-automated method that provides a quick and quantitative assessment of LV systolic and diastolic twist that demonstrates excellent intra-exam and moderate inter-exam reproducibility in preliminary studies. FAST estimates of LV twist may serve as a useful biomarker of LV dysfunction in longitudinal studies.Funding from AHA and UCLA to MLR and NIH to DBE.


Treatment options in patients with amyloidotic transthyretin (ATTR) cardiomyopathy are limited. Epigallocatechin-3-gallate (EGCG), the most abundant catechin in green tea (GT), inhibits fibril formation from several amyloidogenic proteins in vitro. Thus, it might also halt progression of TTR amyloidosis. This is a single-center observational report on the effects of GT consumption in patients with ATTR cardiomopathy.n = 9) before and after consumption of GT and/or green tea extracts (GTE) for 12 months.19 patients with ATTR cardiomyopathy were evaluated by standard blood tests, echocardiography, and cardiac MRI (n = 2), discontinuation of GT/GTE consumption (n = 2), and heart transplantation (n = 1). After 12 months no increase of left ventricular (LV) wall thickness and LV myocardial mass was observed by echocardiography. In the subgroup of patients evaluated by cardiac MRI a mean decrease of LV myocardial mass (−12.5 %) was detected in all patients. This was accompanied by an increase of mean mitral annular systolic velocity of 9 % in all 14 patients. Total cholesterol  and LDL cholesterol  decreased significantly during the observational period. No serious adverse effects were reported by any of the participants.Five patients were not followed up for reasons of death (Our observation suggests an inhibitory effect of GT and/or GTE on the progression of cardiac amyloidosis. We propose a randomized placebo-controlled investigation to confirm our observation.The online version of this article (doi:10.1007/s00392-012-0463-z) contains supplementary material, which is available to authorized users. Cardiac ATTR amyloidosis is observed as the predominant manifestation associated with distinct mutations in the TTR gene also known as familial amyloid cardiomyopathy (FAC)  and reprWithout treatment both hereditary and non-hereditary forms of cardiac ATTR amyloidosis are progressing and fatal after several years. Patient’s prognosis mostly depends on the extent of cardiac involvement. Despite that therapeutic options for patients with light-chain amyloidosis have been ameliorated during the past years , treatmehttp://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/002294/human_med_001498.jsp&mid=WC0b01ac058001d124).Assuming a prevalence of 0.5 % for clinically relevant cardiac ATTR amyloidosis in the growing elderly population (>60 years) there is a high need for novel effective preventive and therapeutic measures against this otherwise fatal disease. Experimental studies evaluated the suppression of hepatic synthesis of TTR by antisense oligonucleotids . SeveralLaboratory studies have shown that human TTR is rather stable at physiological pH 7.4 but tends to denature at pH 6.5–7, levels observed under inflammatory or ischemic conditions, indicating that prevention of such conditions could help to reduce the risk for TTR to denature and become converted into amyloid . Recent n = 10, 53 %) or non-hereditary SSA  cardiac ATTR amyloidosis and compensated heart failure. Patients were observed over a period of 12 months while consuming GT and/or GTE. Routine medication was continued during this period. The observation was approved by the institutional Ethics Committee of the University of Heidelberg and complied with the Declaration of Helsinki .The protocol followed that of Hunstein . All pat2PO4 buffer containing 20 % ascorbic acid and 0.1 % EDTA (pH 3.6)] and stored at −20 °C until analysis. The EGCG levels were measured via LC-MSMS (liquid chromatography equipped with a triple quadruple mass spectrometer). In short, 100 μL of the stabilized plasma was acidified with 20 μL 5 N HCl and extracted twice with ethyl acetate. The organic phase was evaporated and resolved in 300 μL of a solution containing two volumes of a 20-mM ammonium acetate buffer pH 3.6 and 1 volume methanol. The separation was performed on a C18 Reversed-Phase Column with a gradient of 20 mM ammonium acetate against methanol. The transitions monitored in the mass selective detector under negative modus were 457 (precursor Ion) to 125 product Ion, 457 (precursor Ion) to 169 product Ion , and as internal standard 319 (precursor Ion) to 191 product Ion.Blood samples were collected in EDTA-containing tubes. As EGCG rapidly changes its structure above pH 7, binds to proteins, and becomes oxidized, the blood samples were immediately transferred to an ice bath and the plasma was separated from the cellular fraction by centrifugation at 4 °C. One ml of each plasma sample was mixed with 50 μL of an ascorbate-EDTA solution  ×  serum albumin [g/L] ; IVS intBelow is the link to the electronic supplementary material.


We recently reported that mitochondrial dysfunction, characterized by increased mitochondrial permeability transition (MPT), was present in a translational swine model of heart failure with preserved ejection fraction (HFpEF). Cyclophilin D is a key component of the MPT pore, therefore, the purpose of this study was to test the efficacy of a novel cyclosporine (CsA) dosing scheme as a therapeutic alternative for HFpEF. Computed tomography (CT), two‐dimensional speckle tracking two‐dimensional speckle tracking (2DST), and invasive hemodynamics were used to evaluate cardiac function. CT imaging showed 14 weeks of CsA treatment caused eccentric myocardial remodeling  and elevated systemic pressures. 2DST detected left ventricular (LV) mechanics associated with systolic and diastolic dysfunction prior to the onset of significantly increased LV end diastolic pressure including: (1) decreased systolic apical rotation rate, longitudinal displacement, and longitudinal/radial/circumferential strain; (2) decreased early diastolic untwisting and longitudinal strain rate; and (3) increased late diastolic radial/circumferential mitral strain rate. LV mechanics associated with systolic and diastolic impairment was enhanced to a greater extent than seen in untreated HF animals following CsA treatment. In conclusion, CsA treatment accelerated the development of heart failure, including dilatory LV remodeling and impaired systolic and diastolic mechanics. Although our findings do not support CsA as a viable therapy for HFpEF, 2DST was effective in differentiating between progressive gradations of developing HF and detecting diastolic impairment prior to the development of overt diastolic dysfunction. We recently reported that mitochondrial dysfunction, characterized by increased mitochondrial permeability transition (MPT), was present in a translational swine model of heart failure with preserved ejection fraction (HFpEF). Cyclophilin D is a key component of the MPT pore, therefore, the purpose of this study was to test the efficacy of a novel cyclosporine (CsA) dosing scheme as a therapeutic alternative for HFpEF. CsA treatment accelerated the development of heart failure, including dilatory LV remodeling and impaired systolic and diastolic mechanics. Although our findings do not support CsA as a viable therapy for HFpEF, 2DST was effective in differentiating between progressive gradations of developing HF and detecting diastolic impairment prior to the development of overt diastolic dysfunction. Although heart failure with preserved ejection fraction (HFpEF) has been clinically recognized for over three decades, it remains somewhat of an enigma. It is known HFpEF patients are a heterogeneous group displaying multiple pathological mechanisms and comorbidities such as hypertension, obesity, diabetes, chronic kidney disease, and aging , banded HF sedentary , and banded HF CsA treated . Heart failure was induced by aortic banding for a period of 20 weeks using methods previously published by our laboratory  was achieved while maintaining a distal peripheral vascular mean arterial pressure (MAP) of ~90 mm Hg  under anesthesia using phenylephrine (I.V. 1–3 μg kg−1 min−1) at a heart rate of 100 beats/min . Following the development of left ventricular (LV) hypertrophy, treatment with CsA  or placebo began 6 weeks post aortic banding and continued daily for 14 weeks. Animals were fed a standard diet averaging 15–20 g/kg once daily, and water was provided ad libitum. Dissection of vital tissues occurred at the time of death. All animal protocols were in accordance with the “Principles for the Utilization and Care of Vertebrate Animals Used in Testing Research and Training” and approved by the University of Missouri Animal Care and Use Committee.Before aortic banding, intact male Yucatan miniature swine  were matched for body mass and cardiac function then assigned into three groups: nonsham sedentary control . Heparin was given with an initial loading dose of 300 U/kg i. v., followed by maintenance of 100 U/kg each hour. A median sternotomy was performed and the pericardium opened at the apex for insertion of catheters. Great care was taken to leave the pericardium as intact as possible. A custom fluid‐filled angiocatheter was inserted into the apex of the heart for measurement of LV pressure, advanced into the aorta for measurement of peripheral systemic MAP in the aorta , and data were recorded using LabChart . Animals were allowed to stabilize for 10 min after LV catheter placement until a stable pressure and heart rate pattern were observed. This state of homeostasis was labeled “Resting”. Catheter placement was visualized and confirmed using angiography .Central and peripheral hemodynamic measures were collected 20 weeks post aortic banding as described previously  in the supine/right lateral position 2 and 14 weeks after beginning treatment with CsA using a GE Vivid I Ultrasound system as previously described by our lab  or SigmaStat version 3.5. Group comparisons were made using either one‐way or repeated measures analysis of variance (ANOVA). Group differences revealed by ANOVA were found using Student Newman‐Keuls post hoc analysis. Within group comparisons were made using paired samples P < 0.05, 5.5 ± 0.3 and 6.7 ± 0.4 mm for baseline preaortic banding and 1 month post banding, respectively; paired‐samples t‐test) but not CON animals  and was significantly different between groups 2 months post aortic banding  similar to previous findings from our lab . In total, these results indicate concentric LV hypertrophy (an observation commonly associated with LV pressure overload) was present prior to the onset of CsA treatment. No differences in echocardiographic measures of morphology existed between HF and HF‐CsA groups at this time, therefore, data from both aortic‐banded groups were combined prior to the start of CsA treatment. CT assessment of LV morphology  was reduced in HF‐CsA animals after 14 weeks of treatment Fig. , and thiIn this study, we provide a thorough examination of myocardial function following a novel drug intervention using a comprehensive combination of techniques including CT, 2D speckle tracking, and invasive hemodynamics in a translational large animal model of HFpEF. In the presence of existing hypertrophy and developing heart failure, our results indicate: (1) our novel CsA dosing scheme accelerated the development of early evidence for heart failure, including dilatory LV remodeling and impaired systolic and diastolic mechanics; (2) 2D speckle tracking was effective in differentiating between progressive gradations of developing heart failure; and (3) 2D speckle tracking is able to detect impaired diastolic LV mechanics early in the disease process prior to the development of overt diastolic dysfunction.−1 day−1) was shown to inhibit the MPT pore and beneficially influence cardiac remodeling in mice  used for immunosuppression in the pig (Okumi et al. It is well established that conventional therapies proven effective in HFrEF have failed to improve the prognosis of HFpEF patients over the past three decades, leading to an unacceptably high rate of mortality and illustrating the need for the development of novel therapeutic strategies (Maeder and Kaye In contrast to this objective, the most interesting finding of the study was that chronic treatment with low doses of CsA induced LV dilation and exacerbated systolic and diastolic dysfunction during developing heart failure, refuting our initial hypothesis. Although our results indicate the novel CsA dosing scheme administered in this study does not appear to be an effective therapeutic alternative for HFpEF, the accelerated development of heart failure in treated animals provided a unique opportunity to evaluate 2D speckle tracking as an effective means of identifying distinct stages of LV function along a spectrum of developing heart failure. CsA‐dependent dilatory remodeling of the LV was associated with altered LV mechanics associated with reduced systolic emptying, impaired early diastolic filling, and enhanced atrial systole that extended beyond that observed in HF animals. These mechanical measures were associated with impaired hemodynamics and cardiac function. Specifically, reductions in cardiac torsion Fig. A and B, Augmenting atrial systole is another common compensatory mechanism of preserving diastolic filling in heart failure patients, and evidence of this is present in both the HF and HF‐CsA groups and reflected as an increase in late diastolic longitudinal Fig. A and radInterestingly, LV mechanics associated with systolic dysfunction was also observed in the HF group. These findings appear counterintuitive, as HFpEF patients typically demonstrate preserved systolic function at rest. Preservation of resting systolic function is a common feature of HFpEF, although decreased cardiac functional reserve is well established in this patient population (Tan et al. Recently, 2D speckle tracking echocardiography has received increasing attention as a clinically relevant diagnostic tool for assessing myocardial function in HFpEF patients (Kosmala et al. Finally, we addressed the possibility that data generated in the current and previous studies by our lab were unique to the animal model. Systolic longitudinal strain and strain rate values in CON animals were similar to recently reported norms reported for healthy adults (Lotfi‐Tokaldany et al. Although outside the hemodynamic and imaging focus of this study, we are currently examining multiple molecular mechanisms regarding the detrimental cardiac outcomes observed following our CsA dosing regimen. Regarding systemic hemodynamic mechanisms, it is well known that CsA can cause hypertension (Hoorn et al. This study used a comprehensive combination of techniques including CT, 2D speckle tracking, and invasive hemodynamics difficult to duplicate clinically, however, there are limitations. A recent editorial addressed the topic of variability in strain measures regarding why 2D speckle tracking has not become standard for clinical diagnosis of heart disease Marwick . A growiIn conclusion, our results indicate chronic low‐dose CsA treatment accelerates the development of heart failure. Although our findings do not support the use of low‐dose CsA as a viable therapeutic alternative for HFpEF, our results demonstrate 2D speckle tracking is effective in differentiating between progressive gradations of developing heart failure. Furthermore, we were able to detect impaired diastolic LV mechanics prior to the development of overt diastolic dysfunction. Our findings add to the growing body of evidence suggesting 2D speckle tracking holds significant potential as a clinically relevant diagnostic tool for assessing myocardial function in heart failure patients.The authors thank Melissa Cobb, Jan Ivey, and Kurt Marshall for their considerable technical contributions, which were essential to the successful completion of the study.None declared.


Quantitative noninvasive imaging of myocardial mechanics in mice enables studies of the roles of individual genes in cardiac function. We sought to develop comprehensive three-dimensional methods for imaging myocardial mechanics in mice.k-space trajectory for efficient data acquisition. A semi-automatic 2D method was adapted for 3D image segmentation, and automated 3D methods to calculate strain, twist, and torsion were employed. A scan protocol that covered the majority of the left ventricle in a scan time of less than 25 minutes was developed, and seven healthy C57Bl/6 mice were studied.A 3D cine DENSE pulse sequence was implemented on a 7T small-bore scanner. The sequence used three-point phase cycling for artifact suppression and a stack-of-spirals rrE, ccE, and llE, respectively. Peak end-systolic values for the shear strains were 0.00 ± 0.08, 0.04 ± 0.12, and 0.03 ± 0.07 for rcE, rlE, and clE, respectively. The peak end-systolic normalized torsion was 5.6 ± 0.9°.Using these methods, multiphase normal and shear strains were measured, as were myocardial twist and torsion. Peak end-systolic values for the normal strains at the mid-ventricular level were 0.29 ± 0.17, -0.13 ± 0.03, and -0.18 ± 0.14 for Using a 3D cine DENSE sequence tailored for cardiac imaging in mice at 7 T, a comprehensive assessment of 3D myocardial mechanics can be achieved with a scan time of less than 25 minutes and an image analysis time of approximately 1 hour. The application of noninvasive cardiac imaging to genetically-engineered mice is widely used to evaluate the roles of individual genes in cardiac function. These methods have been used to elucidate the roles of genes in normal function and the effects of genes and therapies in cardiac dysfunction -5, with A number of different CMR tissue tracking methods may be used to assess cardiac mechanics, including myocardial tagging ,11, harmk-space. A spiral trajectory was chosen to achieve a short echo time (TE) and a time-efficient sampling of k-space :where V0 was an n × N matrix containing the distance vectors where f, the deformed distance vectors were denoted as f Vin Equation [4]:At any certain cardiac phase V0 and f Vcan be expressed byAssuming uniform and isotropic strain within the space specified by the VOI and its neighbors, the relationship between f Fis the 3D deformation gradient tensor, an n × n matrix. In order to obtain a robust solution in the ill-conditioned case, singular value decomposition (SVD) was used to solve fF. Specifically, SVD was performed on S and unitary matrices U and V as shown in Equation [6]:where S0 was calculated as:Then another intermediate matrix f Fwas calculated as:Finally, the deformation gradient tensor f Ewas calculated asand the 3D Lagrangian finite strain tensor I is the identity matrix. The strain tensor, fE, was decomposed into the local radial, circumferential and longitudinal (RCL) coordinate system, defined with respect to the LV contours at the first cardiac phase [rrE, ccE, and llE, and the shear strains rcE, rlE, and cl E[where ac phase , to obta and Ecl . The defθ between the radial lines connecting the center of the slice to the center of the voxel of interest at end diastole  and at each cardiac phase . Mouse body temperature was maintained at 36.4 ± 0.3°C during imaging using circulating thermostated water, and anesthesia was maintained using 1.25% isoflurane in O2 inhaled through a nose cone. Each complete CMR study took approximately 1 hour, including animal preparation, localizer scanning, and functional imaging.Seven wild type (WT) C57BL/6 mice  were studied under protocols that conformed to the Guide for the Care and Use of Laboratory Animals  and were approved by the Animal Care and Use Committee at the University of Virginia. All imaging was performed on a 7T ClinScan CMR system  equipped with a gradient system that has a maximum strength of 650 mT/m and a maximum slew rate of 6666.7 mT·m3, TR = 7 ms, TE = 0.69 ms, flip angle = 15°, number of cardiac phases = 14, number of averages = 3, number of spiral interleaves = 27, number of spiral interleaves per cardiac phase per heartbeat = 1, and displacement encoding frequency = 1.1 cycles/mm. To achieve a balance of minimal off-resonance-induced blurring and data acquisition efficiency, the spiral readout duration was limited to 3 ms. The specific value of 3 ms was chosen based on the range of off-resonance frequencies that was recently measured in the mouse heart at a field strength of 7T [3, which covered the entire mouse LV, as the longitudinal dimension of the mouse LV is approximately 6 mm and the average radius of the mouse LV is approximately 2 mm. The scan time was approximately 23 minutes, depending on heart and respiratory rates. The imaging volume was oriented such that the 3D partition direction was aligned with the long axis of the LV. Fourteen 3D partitions were acquired symmetrically about the k-space origin, and zero-padding to 28 partitions was performed during reconstruction. After Fourier Transform in the partition direction, 3 partitions at each end of the volume were discarded to avoid aliasing. The resulting 3D image matrix size was 128 × 128 × 22.For 3D cine DENSE CMR, pulse sequence parameters included voxel size = 0.25 × 0.25 × 0.4 mmth of 7T . Specifith of 7T , which ith of 7T . Since ath of 7T , we reasrrE, ccE, and ll Eare shown in Figure Image quality was routinely very good in the mid-ventricular region where off-resonance effects are usually minimal. An example demonstrating this image quality is shown in Figure rrE, ccE, and llE, are plotted. These results demonstrate the measurement of normal radial thickening, circumferential shortening, and longitudinal shortening in healthy mice. The high spatial resolution of strain provided by cine DENSE is evident in these measurements, as statistically significant transmural differences in cc Eare resolved using this technique, where the thickness of the LV wall is approximately 1 mm.Using 3D cine DENSE, in addition to extensive spatial coverage, myocardial mechanics are measured as a function of cardiac phase across the cardiac cycle. For example, data summarizing the time-varying normal strains at the mid-ventricular level for all seven mice are shown in Figure rcE, rlE, and clE, as shown for the mid-ventricular region in Figure Using 3D cine DENSE, we were also able to measure the shear strains Lastly, using displacements that were measured in basal, mid-ventricular, and apical slices, we calculated myocardial twist and torsion as a function of cardiac phase. These results are displayed in Figure cc Eand by the measurement of shear strains.The major contribution of this study is that a 3D cine DENSE method is described that enables a comprehensive evaluation of mouse heart mechanics with a scan time of less than 25 minutes and a data analysis time of approximately one hour. These times are significantly shorter than prior scan times of approximately one hour and prior image analysis times of several hours. The 3D cine DENSE method also provides relatively high spatial resolution, evidenced by the resolution of transmural differences in k-space trajectory to achieve efficient data sampling. To avoid excessive blurring due to off-resonance effects at 7T, we limited the spiral readout duration to 3 ms. We also used 3D field maps and previously described deblurring methods [We used a 3D stack-of-spirals  methods . Using trr Evalues of 0.29 ± 0.17, cc Evalues of -0.13 ± 0.03 and ll Evalues of -0.18 ± 0.14. These values are in close agreement with prior 2D and 3D myocardial tagging studies [We measured peak normal end-systolic mid-ventricular strains in the mouse heart and found  studies ,22-24, 2 studies ,26, and  studies -33. As s studies . Also, t studies ,45,46. F studies -24.A limitation of this study is that another independent technique such as myocardial tagging was not used in the same mice to validate 3D cine DENSE measurements. However, the literature contains 3D strain and torsion data for the mouse heart, and our results are similar to the literature values. Also, 3D cine DENSE was directly validated vs. 2D methods for human imaging , and thi-/-) [CMR of myocardial mechanics in mice enables the investigation of the roles of individual genes and experimental therapies in cardiac function. For example, Gilson et al and Vandsburger et al have used myocardial tagging in mice to elucidate the roles of genes that encode for nitric oxide synthases in myocardial mechanics ,48. HARP-/-) . In a re-/-) . CompareUsing a 3D cine DENSE sequence tailored for cardiac imaging in mice at 7T, a comprehensive assessment of 3D myocardial mechanics can be achieved with a scan time of less than 25 minutes and an image analysis time of approximately 1 hour.XZ is an employee of Siemens Medical Solutions USA, Inc. FHE received research funding from Siemens Medical Solutions.XZ and FHE participated in the design and development of the pulse sequence and post-processing software, study design, manuscript drafting and figure preparation. LBG performed data acquisition and analysis, and participated in figure preparation. BSS participated in the development of post-processing software. ADG participated in the development of post-processing software and figure preparation. CHM contributed to pulse sequence development, providing expertise in spiral imaging. BAF contributed expertise in cardiac physiology and participated in manuscript preparation. All authors read and approved the final manuscript.


Diabetes mellitus (DM) patients surviving myocardial infarction (MI) exhibit a substantially higher incidence of subsequent heart failure (HF). Neuregulin (NRG)-1 and erythroblastic leukemia viral oncogene homolog (ErbB) receptors have been shown to play a critical role in maintenance of cardiac function. However, whether myocardial NRG-1/ErbB is altered during post-MI HF associated with DM remains unknown. The aim of this study was to determine the impact of type 1 DM on the myocardial NRG-1/ErbB system following MI in relation to residual left ventricular (LV) function.in vivo LV function was assessed via echocardiography. Myocardial protein expression of NRG-1β, ErbB2 and ErbB4 receptors, and MDM2  was assessed in the remaining, viable LV myocardium by Western blotting. Changes in ErbB receptor localization in the surviving LV myocardium of diabetic and non-diabetic post-MI rats was determined using immunohistochemistry techniques.Type 1 DM was induced in rats via administration of streptozotocin . Control rats were injected with citrate buffer (vehicle) only. Two weeks after induction of type 1 DM, MI was produced in DM and non-DM rats by ligation of the left coronary artery. Sham MI rats underwent the same surgical procedure with the exception that the left coronary artery was not ligated. At 4 weeks after surgery, residual P < 0.05), indicating an increased functional severity of HF among the DM + MI rats. Up-regulation of NRG-1β and ErbB2 protein expression in the MI group was abrogated in the DM + MI group concurrent with degradation of MDM2, a downstream negative regulator of p53. ErbB2 and ErbB4 receptors re-localized to cardiac myocyte nuclei in failing type 1 diabetic post-MI hearts.At 4 weeks post-MI, echocardiography revealed that LV fractional shortening (FS) and LV ejection fraction (EF) were significantly lower in the DM + MI group compared to the MI group (LVFS: 17.9 ± 0.7 vs. 25.2 ± 2.2; LVEF: 35.5 ± 1.4 vs. 47.5 ± 3.5, respectively; Type 1 DM prevents compensatory up-regulation of myocardial NRG-1/ErbB after MI coincident with an increased severity of HF. Diabetes mellitus (DM) patients surviving myocardial infarction (MI) have substantially higher cardiovascular morbidity and mortality than those without DM . The pooIn vivo, endothelium-selective deletion of NRG-1 has been demonstrated to worsen post-ischemic contractile recovery after coronary artery ligation [Neuregulin (NRG)-1, along with the erythroblastic leukemia viral oncogene homolog (ErbB) 2, 3, and 4 receptor tyrosine kinases through which NRG-1 ligands signal, have been shown to play an essential role in cardiac development  and mainligation .Recently, changes in the NRG-1/ErbB system have been documented to occur in the setting of type 1 DM. In rats with type 1 diabetic cardiomyopathy, mRNA expression and phosphorylation of the ErbB2 and ErbB4 receptors as well as NRG-1 protein expression were observed to be markedly decreased . AdminisAccordingly, the aim of the present study was to determine whether DM adversely affects myocardial NRG-1/ErbB after MI and thereby enhances the development of HF. Using a rat model of HF due to MI by coronary ligation in the presence of STZ-induced DM, a type 1 model, we assessed the protein expression profiles of NRG-1β, ErbB2 and ErbB4 receptors, MDM2 , as well as changes in ErbB receptor localization in the surviving LV myocardium of diabetic post-MI rats in relation to residual LV function. We chose to utilize a type 1 DM model even though the vast majority of acute myocardial infarct patients are type 2 diabetics for several reasons. First, the risk of mortality from ischemic heart disease is exceptionally high in patients with type 1 DM . Second,Guide for the Care and Use of Laboratory Animals published by the US National Institutes of Health.Sprague–Dawley rats were obtained from Harlan . Experiments were performed according to a protocol approved by the Institutional Animal Care and Use Committee at Vanderbilt University Medical Center (Protocol ID#: M/09/322). The investigation conforms to the Type 1 DM was induced in male Sprague–Dawley rats (200–224 g body weight) by administering a single intraperitoneal injection of STZ (65 mg/kg body wt) prepared daily in citrate buffer pH 4.5 for maximal stability. The control vehicle (CV) group was injected with an equal volume of the vehicle. Development of DM was confirmed 48 hours later by the presence of glycosuria (>2000 mg/dl) along with polyuria as described previously . Two weeRats were anaesthetized intraperitoneally with Nembutal (40 mg/kg). Rats were then rapidly intubated and mechanically ventilated by a constant volume small animal ventilator . A left thoracotomy was performed at the fourth intercostal space and the LAD was ligated at the level immediately below the bottom of the left atrium by irreversible tightening of a 6–0 suture loop. The bottom of the left atrium was used as a demarcation point to ensure consistent placement of the ligature and resultant reproducibility of similar infarct sizes among the groups of animals. This demarcation point was also used to avoid ligation of the LAD too proximally to its origin which would lead to fatal cardiac arrhythmias. MI was confirmed by regional cyanosis of the myocardial surface distal to the suture, accompanied by S-T segment elevation on the electrocardiogram (ECG). Sham MI (SMI) animals underwent the same surgical procedure with the exception that the LAD was not ligated. Rats were allowed to recover and then used at 4 weeks post-MI for different studies.Transthoracic echocardiographic images of hearts from all groups of rats were obtained at 4 weeks post-MI using an ultra high-resolution ultrasound scanner  under nembutal anesthesia. For M-mode recordings, the parasternal short-axis view was used to image the heart in two dimensions at the level of the papillary muscles. LV fractional shortening (FS) and ejection fraction (EF) were recorded along with LV cavity dimensions (end-diastolic and end-systolic).Following echocardiographic assessment, hearts from all groups of rats were rapidly excised and perfused with ice-cold physiological saline and weighed. The atria and ventricles were dissected and the infarcted (scar) and non-infarcted regions of the LV was separated, weighed, and frozen in liquid nitrogen. The non-infarcted LV tissue was used for all molecular analyses.Pieces of tissues from the lungs and liver were removed and weighed. For the determination of dry weight, these were placed in an oven at 65°C until a constant weight was reached. Ratios of wet to dry weight were calculated for both lungs and liver.LV tissue was homogenized in 1X RIPA lysis buffer (Millipore), supplemented with protease inhibitor cocktail (Roche). 50 μg of protein was loaded onto a PAGE using precasted gradient gel 4-12% NuPage gels (Invitrogen). After electrophoresis, proteins were transferred to an Immun-Blot PVDF membrane using a Semi-Dry transfer apparatus. Membranes were blocked using PBST-5% BSA and then incubated overnight at 4°C with antibodies directed against ErbB2, ErbB4 and murine double minute 2 (MDM2)  (Santa Cruz). NRG-1β and α-tubulin (Santa Cruz) were also analyzed by western blot. Secondary horseradish peroxidase-conjugated antibody  was applied for 1 h at room temperature. Blots were visualized using the SuperSignal West Pico chemiluminiscent substrate (Thermo Scientific) and analyzed with NIH Image J densitometry software.LV specimens were embedded in O.C.T. medium (Tissue-Tek), and 5–10 μM sections were prepared with a cryotome. Nonspecific binding was blocked with 0.1% Bovine serum albumin in PBS for 30 min, and coverslips were incubated overnight with anti-ErbB2 and anti-ErbB4 (Santa Cruz) and antibody against N-Cadherin (Sigma). A secondary antibody conjugated with FITC and TXRD-conjugated phalloidin (Molecular Probes) was added for 1 h. Coverslips were mounted using Vectashield (Vector laboratories). DAPI (Vector laboratories) was used according to manufacturer instructions for nuclear staining. Images were generated with LSM710 confocal microscope .Prior to MI surgery and at the time of sacrifice, blood samples were collected from the tail vein for the determination of blood glucose levels using Accutrend Plus test strips and meter (Roche).t-test. Values of P < 0.05 were considered statistically significant.Protein concentrations of LV tissue samples were determined using the Modified Lowry Protein Assay Reagent Kit (Pierce). Data were expressed as the mean ± S.E.M. Group means were compared by one-way analysis of variance (ANOVA), and ANOVA followed by Bonferroni’s test was used to identify differences between multiple groups. Comparisons between two groups were performed by Student’s Mortality following induction of MI was higher among the DM + MI group compared to the MI group (47% vs. 33%). Blood glucose levels were significantly elevated in the DM and DM + MI groups of rats compared with the non-diabetic animal groups Table . AnimalsEchocardiographic studies revealed differences in residual LV function between MI and DM + MI groups of rats. Representative echocardiograms obtained from a sham MI, MI and DM + MI rat are shown in Figure As shown in Table Myocardial NRG-1β protein expression showed differences between the MI and DM + MI groups of rats Figure . A 96% aMyocardial ErbB2 and ErbB4 receptor protein expression was analyzed in all groups of rats Figure . CompareMyocardial MDM2 protein expression was analyzed in all groups of rats Figure . CardiacWe examined the cellular localization of ErbB2 and ErbB4 in heart tissue by immunostaining. In the control vehicle heart, ErbB2 and ErbB4 were localized primarily in the cellular membrane of myocytes including the intercalated disk Figure E which bLittle is known about perturbations in biological processes that take place in the diabetic heart following MI. The major novel findings of the present study are: (1) up-regulation of myocardial NRG-1β protein expression following MI is abrogated by the concomitant presence of type 1 DM; (2) up-regulation of myocardial ErbB2 protein expression following MI is abrogated by the concomitant presence of type 1 DM; (3) degradation and decreased protein expression of MDM2 occurs in type 1 diabetic post-MI hearts; (4) ErbB2 and ErbB4 re-localize to the nucleus from the intercalated disk in cardiac myocytes of failing type 1 diabetic post-MI hearts; and (5) these alterations in the myocardial NRG-1β/ErbB pathway in the type 1 diabetic post-infarction heart are associated with an increased functional severity of HF. These findings shed new light on the underlying mechanisms that contribute to the impaired response to infarction in diabetic hearts. Furthermore, our data support the concept that augmentation of myocardial NRG-1β/ErbB is an important cardioprotective adaptation to MI that is lost in the presence of type 1 DM.Numerous studies have demonstrated the cardioprotective role of the NRG-1/ErbB signaling pathway. Ischemia-reperfusion injury is associated with activation of NRG-1β/ErbB4 signaling that mediates recovery . NRG-1/Eper se as the adverse factor and suggest that the suppression of the NRG-1β/ErbB pathway induced by STZ-diabetes precludes harnessing this system as a compensatory mechanism to help in recovery of myocardial function after superimposition of cardiac injury involving MI. One question that arises from these findings is: How does DM down-regulate myocardial NRG-1/ErbB expression? In this regard, NRG-1 mRNA and protein expression are known to be down-regulated by angiotensin II [In the present study, we found that STZ-diabetic rats without MI exhibited reduced myocardial expression of the 115 kDa fragment of NRG-1β and ErbB2 receptor. This is consistent with a recent report showing down-regulation of ErbB receptor mRNA expression and NRG-1 protein expression in LV myocardium of STZ-diabetic rats [ensin II . In lighensin II . Increasensin II  and hencHaving found that ErbB2 and ErbB4 protein expression was down-regulated in type 1 diabetic hearts with advanced post-MI HF, we also looked at their localization in cardiomyocytes. Our results demonstrate that ErbB2 localizes to the peri-nuclear area and ErbB4 localizes to the nucleus in cardiac myocytes of failing type 1 diabetic post-MI hearts, thereby confirming our Western blot analysis. Previous studies have demonstrated that the increased localization of ErbB4 to the nucleus in adult rat ventricular myocytes may be an indicator of cell stress response , a findiIn vivo, cardiac expressions of p53 have been observed to be markedly increased in STZ-diabetic animals [MDM2 is activated by ErbB2 signaling and under normal circumstances is the principal negative regulator of p53 via ubiquitination and subsequent degradation  Figure A. Since  animals ,28 resulIn vitro, it is interesting that treatment of neonatal rat cardiac myocytes with the saturated fatty acid palmitate disrupts NRG-1β activation of the PI3-kinase/Akt pathway leading to an increase in p53 expression concurrent with degradation of MDM2 [Derangements in fatty acid metabolism inherent to DM may be responsible for and linked to diabetes-induced changes in myocardial NRG-1/ErbB signaling. Fatty acid accumulation increases cardiac p53 expression in association with cardiac dysfunction in DM . Marked  of MDM2 . The pho of MDM2 ,31. TakeThe significantly lower HR observed in the STZ-diabetic groups of rats is consistent with our previous observations ,32 as weThe tendency of clinical trials to focus on cardiovascular disease in type 2 DM (as opposed to type 1 DM) in spite of the fact that the age-adjusted relative risk for cardiovascular disease in type 1 DM far exceeds that of type 2 DM has resulted in an under-appreciated link between type 1 DM and cardiac disease . As suchFirst, our data do not provide direct proof of a cause-and-effect relationship between the impairment of myocardial NRG-1β/ErbB up-regulation after MI and the exacerbation of LV failure by type 1 DM. However, in a recent study, administration of recombinant human NRG-1 (rhNRG-1) to STZ-induced diabetic cardiomyopathy rats rescued the depressed cardiac function  suggestiOur results suggest that loss of compensatory up-regulation of myocardial NRG-1β/ErbB coupled with disruption of ErbB receptor localization may be responsible, at least in part, for the greater incidence and severity of HF in post-MI patients with co-existing DM. In addition, our finding of degradation and decreased expression of MDM2 in failing type 1 diabetic infarcted hearts implicates this downstream ErbB2 receptor-associated pathway as part of the molecular pathophysiology of aggravated HF in the type 1 diabetic post-infarction heart. Taken together, these observations provide innovative and valuable mechanistic insights into the diabetes-related deficit in response to MI. Approaches aimed at restoring the myocardial NRG-1/ErbB pathway in the diabetic post-MI heart may prove to be beneficial in preventing and/or ameliorating the subsequent development of HF.DM: Diabetes mellitus; ECG: Electrocardiogram; ErbB: Erythroblastic leukemia viral oncogene homolog; HF: Heart failure; HR: Heart rate; LV: Left ventricular; LVFS: Left ventricular fractional shortening; LVEF: Left ventricular ejection fraction; LVIDd: Left ventricular internal dimension, diastolic; LVIDs: Left ventricular internal dimension, systolic; MDM2: Murine double minute 2; MI: Myocardial infarction; NRG-1: Neuregulin-1; SEM: Standard error of mean; STZ: Streptozotocin.The authors declare that they have no competing interests.OO contributed to the conception and design of the study, acquisition and analysis of data, and drafted the article. EAK contributed to acquisition and analysis of immunohistochemistry data and revising the article critically for important intellectual content. DBS contributed to analysis and interpretation of data and revising the article critically for important intellectual content. MFH contributed to the conception and design of the study, analysis and interpretation of data, and revising the article critically for important intellectual content. All authors read and approved the final manuscript.


T2* mapping has the potential to image myocardial hemorrhage and fibrosis by virtue of its short T2*. We aimed to quantify T2* in acute and chronic myocardial ischemia/reperfusion (I/R) injury in mice.Imaging of myocardial infarct composition is essential to assess efficacy of emerging therapeutics. n = 9). Sham-operated mice (n = 8) served as controls. MRI was performed at baseline, and 1, 7 and 28 days after surgery. MRI at 9.4 T consisted of Cine, T2* mapping and late-gadolinium-enhancement (LGE). Mice (n = 6) were histologically assessed for hemorrhage and collagen in the fibrotic scar.I/R-injury was induced in C57BL/6 mice  and remote myocardium (13.9 ± 0.8 ms) was lower than at baseline. On days 7 and 28, LGE was heterogeneous. T2* in the infarct decreased to 7.9 ± 0.7 and 6.4 ± 0.7 ms, whereas T2* values in the remote myocardium were 14.2 ± 1.1 and 15.6 ± 1.0 ms. Histology revealed deposition of iron and collagen in parallel with decreased T2*.Baseline T2* values are dynamic during infarct development and decrease significantly during scar maturation. In the acute phase, T2* values in infarcted myocardium differ significantly from those in the chronic phase. T2* mapping was able to confirm the presence of a chronic infarction in cases where LGE was inconclusive. Hence, T2* may be used to discriminate between acute and chronic infarctions. Despite recent advances in therapeutics and diagnostics, morbidity and mortality after myocardial infarction (MI) remains a great socio-economic burden in Western societies. Early identification of patients with sub-optimal cardiac recovery is of great importance to improve clinical management. For this reason, both functional and structural characterization of the infarcted myocardium is important for risk stratification of patients after MI.T1-and T2-weighted imaging [Technological advances in cardiovascular magnetic resonance (CMR) have demonstrated different ways to track and characterize MI at different time points –6. CMR h imaging , 16–18. T1-weighted imaging is performed some time after injecting a gadolinium-based contrast agent to delineate injured myocardium in a late gadolinium enhancement (LGE) scan [Typically, GE) scan . The enhGE) scan . In the T2 relaxation time to myocardial water content has led to the application of T2-weighted CMR protocols to image myocardial edema as an indicator of inflammation and necrosis in acute MI [T2* contrast has been explored as a tool to diagnose the presence of hemorrhage and myocardial iron [T2* has the potential to image fibrosis in the infarct zone using an ultra-short echo time (UTE) technique [In view of the above limitations, several alternative contrast mechanisms are explored to study the pathophysiological changes in the injured myocardium. The sensitivity of the acute MI , 21–24. ial iron , 25–28. echnique .T2* values in the infarcted myocardium. To investigate this, we quantified T2* using a T2*-mapping protocol longitudinally in acute and chronic ischemia/reperfusion (I/R) infarcts in mice. We explored the utility of T2* mapping as a complementary tool to LGE to characterize the infarcted myocardium.In this paper, we hypothesize that the structural and pathological changes in acute and chronic MI, such as the presence and development of myocardial hemorrhage and fibrotic tissue progressively influence n = 23, body weight = 20–25 g) were used in this study. CMR measurements were performed at baseline (BL), 1 day (acute infarct), 7 and 28 days (chronic infarct) after induction of MI by 30 min transient ligation of the left coronary artery (LCA) (n = 9). A sham-operated group (n = 8) served as control. The CMR protocol for the infarct group consisted of a multi-gradient-echo quantitative T2*-mapping sequence, traditional LGE to assess the location and size of the infarct, and gradient-echo Cine imaging to determine cardiac function. The sham-operated (control) group underwent gradient-echo Cine imaging only to evaluate cardiac function. In the first group of nine mice with MI, one mouse died at day 28 during the CMR scan. Another three mice of this group presented a small infarct on LGE images at day 1, but no chronic myocardial infarct at day 7 and 28  were killed either at day 1 (n = 2), 7 (n = 2), or 28 (n = 2) for the histopathological characterization of myocardial tissues. All animal experiments were performed in accordance with the national guidelines on animal care and with prior approval by the Animal Experimentation Committee of Utrecht University.C57Bl6/J mice . Mice were anesthetized with 1.5–3 vol% isoflurane in a 2:1 mixture of air (0.3 l/min) and oxygen (0.15 l/min). The mice were put on a custom-built cradle and positioned inside a 3-cm-diameter quadrature volume coil. During the CMR examination anesthesia was maintained at 1.5–2.5 vol% isoflurane to keep the respiratory rate at 50–60 bpm. We did not use ECG leads for cardiac triggering but derived both cardiac and respiratory motion signals from a pressure pad placed under the chest of the mouse.2. Because of the slight difference of hearts size between mice and the dilation of each heart after infarction, seven to nine short-axis slices with inter-slice distance of 1 mm and no slice gap were measured to cover the heart from apex to base. Based on the Cine short-axis images, a mid axial slice was selected that included an area of remote viable tissue as well as a substantial infarct area. T2* mapping was performed in this slice using a cardiac-triggered multi-gradient-echo sequence with the following parameters: TR = R–R interval, TE = 1.22, 3.45, 5.68, 7.91, 10.14, and 12.37 ms, slice thickness = 1 mm, matrix = 128 × 128, field-of-view = 3 × 3 cm2. The trigger delay was chosen in the mid-diastolic rest period of the heart cycle observed in the Cine series. The acquisition window of less than 13 ms resulted in images, which were sufficiently co-registered for the different echo times to allow for a pixel-wise T2* determination  was optimized to null the signal from remote myocardium [The CMR protocol consisted of the following steps. After global shimming and RF pulse calibration, 2- and 4-chamber view scout scans were made to plan a single mid-cavity short-axis slice. Cine imaging was performed with a retrospectively-triggered (self-gated) gradient-echo sequence , with thocardium , 34. Gadocardium . The conT2* maps were generated in Mathematica 7  by pixel-wise fittings of the multi-gradient-echo signal intensities to the equation T2* values are reported as group average and standard deviation of the mean T2* in the ROIs. Cine images were analyzed with Qmass digital imaging software . Semi-automatic segmentation was used to determine end-diastolic volume (EDV), end-systolic volume (ESV), wall thickness (WT) and systolic wall thickening (SWT). Ejection fraction (EF) was calculated as 100%(EDV − ESV)/EDV.For histological evaluation a 1.5-mm-thick slice containing infarcted myocardium was fixed in 4% formalin and paraffin-embedded. Hereafter, 5-μm-thick sections were mounted on glass slides and stained with Picrosirius red staining for collagen, Prussian blue staining for iron, and Hematoxylin-Eosin (HE) for cellular structures. The stained sections were photographed with a digital image microscopy using white or polarized light.t test and the Mann–Whitney exact two-tailed U test were performed to compare mean values in subjects for each time point post MI versus baseline. Results were considered statistically significant for a p value of less than 0.05. The correlation analysis of T2* values against WT was performed using linear regression.All statistical analysis was evaluated using . Results were expressed as mean ± standard deviation for each group of animals. An independent two-tailed sample T2* map as shown in Fig. T2* values were homogeneous throughout the LV myocardial wall and consistent between mice, with a mean T2* value of 17.1 ± 2.0 ms in the free wall.An image series of a mid-axial slice with varying TE for a representative mouse at baseline is shown in Fig. T2* maps, and Cine images at diastole, for a representative mouse at day 1, 7 and 28 after induction of the MI. On day 1, LGE resulted in a homogeneous enhancement of the infarct in the mid-anterior and mid-anterolateral wall, whereas on days 7 and 28 enhanced area was smaller, heterogeneous, and difficult to detect. Corresponding T2* maps revealed a different picture. At day 1, a significant change in T2* could be detected in the LGE-based infarct area. Further, at days 7 and 28, T2* dramatically decreased, particularly in the mid-anterolateral region indicating the existence of a significant infarct. The presence of an infarct was further corroborated by the Cine images, which showed increased WT in the mid-anterior and mid-anterolateral wall at day 1, followed by progressive thinning below baseline levels at days 7 and 28, respectively.Figure T2* maps of one of three mice with a small infarct in the mid-anterolateral wall, as indicated by a small area of LGE at day 1. Gadolinium enhancement could not be detected anymore at days 7 and 28. In the first group of n = 9 mice with MI, n = 3 mice displayed this atypical behavior. Presumably, LGE at day 1 revealed a small area at risk that could not be detected in the chronic phase. Importantly, T2* values in the mid-anterolateral wall also remained unaffected throughout infarct healing and did not deviate from baseline values.Figure T2* values  from baseline (17.1 ± 2.0 ms) to day 1 (12.0 ± 1.1 ms) followed by a further decrease (p < 0.005) both at day 7 (7.9 ± 1.0 ms) and day 28 (6.4 ± 0.7 ms). In addition, the mid-septal (remote) area showed a significant (p < 0.05) decrease of T2* values from baseline (18.2 ± 2.0 ms) to day 1 (13.9 ± 0.8 ms), then slightly recovered at day 7 (14.2 ± 1.1 ms) and day 28 (15.6 ± 1.0 ms).Quantitative n = 5) infarct sizes from LGE analysis of a mid-ventricular slice as function of days after surgery are presented in Fig. p < 0.05, compared to day 1) of the LV area at days 7 and 28, respectively, which could be related to infarct resorption over time [Global cardiac function of both infarct and sham-operated groups was assessed by Cine imaging Fig. a–c. The ver time .Fig. 5Lep < 0.005) transient increase day 1 after MI, followed by progressive thinning  showed a significant  was confirmed by akinesia of that area and locally suppressed systolic thickening (SWT) in Cine imaging. Figure T2* in the infarct region was preserved during follow-up, indicating that for this mouse the initial area at risk recovered at later time points, as confirmed by healthy LV function. Thus, T2* is able to provide additional information, complementary to LGE, about the myocardial viability after infarction. Taken together, these findings suggest that T2* can be used as a surrogate marker for myocardial recovery during follow-up after MI.Comparing Figs. T2* as a diagnostic marker for myocardial injury is contamination of intrinsic T2* values by the presence of macroscopic susceptibility differences, mainly present at the air-lung interfaces [T2* values at the lung-heart interface (see for example Fig. T2* reduction were therefore inaccurate. Also the orientation of the heart with respect to the magnetic field could alter absolute T2* values. Improvements in local shimming techniques might alleviate some of these susceptibility contaminations. Still, use of T2* mapping as a stand-alone technique without the complementary information from LGE is undesired.A limitation to the use of terfaces , 27. OccT2*-mapping technique in a mouse model of myocardial I/R injury provides useful and complementary information to LGE and Cine imaging. The changes of the T2* were associated with the infarct age, reversibility of the injury, and gave an indication of the structural variation in the myocardium throughout infarct maturation. T2* decrease in the infarcts was associated with iron and collagen depositions. In cases where LGE was inconclusive, T2* mapping was able to confirm the presence of a chronic myocardial scar in mice. Taken together, T2* mapping may provide important additional information on myocardial viability in the acute and chronic phase and scar maturation after acute MI.Imaging of the myocardium with a


Little is known about the state of left ventricular (LV) mechanics long-term after repair of coarctation of the aorta (COA). We sought to determine whether LV myocardial deformation indices measured by cardiac magnetic resonance-based feature tracking (CMR-FT) were abnormal in repaired COA with normal LV ejection fraction (EF), relative to healthy adult controls, and whether such alteration was related to LV hypertrophy.We retrospectively identified 81 patients after COA repair  with inclusion criteria at follow-up CMR of: age ≥13years, time post-repair ≥10 years, no aortic valve disease, LV-EF>50%). CMR-FT was performed in four-chamber and short-axis steady-state free-precession cine sequences to derive global and segmental LV deformation indices and indexed  end-diastolic/end-systolic volumes, mass, and LV-EF. LV deformation and volumetric indices were compared firstly between COA patients and normal controls , and secondly between COA patients with (mass >97th percentile for gender and BSA) versus without LV hypertrophy.In COA patients versus healthy controls, LV-EF was 62 ±7.2 % (mean±SD) versus 58±3.0% (p=0.01), and LV mass 66±16.8 g/m2 versus 57.7±6.0 g/m2 (p=0.0001). The LV global longitudinal strain (GLS) was decreased to -17.0±4.7% in COA versus -20±5% in controls (p=0.02) and the global radial strain (GRS) was reduced to 40±15% versus 50±12.4% in controls (p=0.003). In contrast, the global circumferential strain (GCS) was preserved in COA patients at -23±4.7% versus -24.6±2.4% in controls (p=0.14). Regionally, decrease in LS was particularly marked in the basal segments . In COA with LV hypertrophy  versus COA without LV hypertrophy , GLS was more markedly decreased to -15.7±4.8% versus -18.5±4.2%, p= 0.016). In contrast, both GRS and GCS were similar between both COA subgroups(p=0.49 and 0.27).In patients late after COA repair with normal LV-EF, GLS and GRS are reduced whilst GCS is preserved, compared with controls. GLS is even more reduced in the presence of LV hypertrophy. Longitudinal strain is particularly reduced in basal LV segments. GLS may qualify as indicator of early LV dysfunction if confirmed in prospective outcome studies.None.


MicroRNA-208a (mir-208a) is essential for cardiac hypertrophy and fibrosis. Endoglin, a co-receptor of transforming growth factor-β is also essential for cardiac fibrosis. Endoglin has been shown to be a target of mir-208a in the in vitro mechanical stress model. Volume overload can lead to heart failure and cardiac fibrosis. The role of mir-208a and endoglin in volume overload heart failure is well known. We sought to investigate the mechanism of regulation of mir-208a and endoglin in volume overload-induced heart failure. Aorta-caval (AV) shunt was performed in adult Sprague-Dawley rats to induce volume overload. Heart weight and heart weight/body weight ratio significantly increased in AV shunt animals. AV shunt significantly increased left ventricular end-diastolic dimension as compared to sham group. Mir-208a was significantly induced by AV shunt from 3 to 14 days. Endoglin, myosin heavy chain-β and brain natriuretic peptide were significantly induced by AV shunt from 3 to 14 days. Overexpression of mir-208a in the sham group without AV shunt significantly increased endoglin expression similar to the AV shunt group. Antagomir-208a attenuated the endoglin expression induced by AV shunt. Pretreatment with atorvastatin also attenuated the endoglin expression induced by AV shunt. AV shunt significantly increased myocardial fibrosis as compared to sham group. Overexpression of mir-208a in the sham group significantly increased myocardial fibrosis. Antagomir-208a and atorvastatin significantly attenuated the myocardial fibrosis induced by AV shunt. In conclusion, mir-208a increased endoglin expression to induce myocardial fibrosis in volume overloaded heart failure. Treatment with atorvastatin can attenuate the myocardial fibrosis induced by volume overload through inhibition of endoglin expression. Cardiac fibrosis is closely associated with heart failure because cardiac fibrosis may cause the loss of normal cardiac function A microRNA (mir) is small, 22-nucleotide non-protein-coding RNA that inhibits transcription or translation by interacting with the 3′untranslated regions of target mRNA and promoting target mRNA degradation (gene silencing) AV shunt was performed on rats to induce volume overload. On the day of surgery, the Sprague-Dawley rats weighing 280 to 330 g were anesthetized with 2% isoflurane and the vena cava and aorta were exposed via abdominal midline incision after confirming a fully anaesthetized state (.e.g. no response to toe pinching). The aorta-caval shunt was produced as previously described Hemodynamic monitor of rats was performed with polyethylene catheters to measure through a Grass model tachogragh preamplifier as previously described Cardiac function of rats was evaluated noninvasively by echocardiography performed with an Acuson Sequoia 512 machine using a 15-MHz probe at the day of sacrifice, 7 and 14 days (AV shunt) after the surgery as previously described CAACAGAAGTGCTTGGAAG and reverse primer, GGCTGATCGACGGTAGCT. The 165 bp amplified product was digested with EcoRI and BamHI restriction enzymes and ligated into pmR-ZsGreen1 plasmid vector  digested with the same enzymes. The constructed plasmid (co-expression mir-208 and green fluorescent protein) was transfected into left ventricular myocardium using a low pressure-accelerated gene gun  essentially following the protocol from the manufacturer. In brief, 2 mg of plasmid DNA was suspended in 5 ml of PBS and then 100 µl was added to the loading hole near the nozzle. Pushing the trigger of the low pressure gene gun released the DNA-containing solution, which was directly propelled by helium at a pressure of 15 psi into left ventricular myocardium of the rat. The distribution of fluorescent image in treated rat was visualized by a dissecting fluorescence microscope with high resolution CCD . After 3 days, the rat chest was re-open and the fluorescent image on left ventricular myocardium was detected. If the fluorescent image was able to visualize, it was regarded as a successful transfection. The efficiency of using this method is around 30%.A 71 bp rat-mir-208a precursor construct was generated as follows. Genomic DNA was amplified with forward primer, Western blot was performed as previously described ‘TaqMan® MicroRNA real-time quantitative assays were used to quantitate mir as previously described The left ventricle was harvested and fixed in 10% formaldehyde and sliced into 5 µm paraffin sections. For immunohistochemical stain, the slides were postfixed in 4% paraformaldehyde for 20 min, treated in 3% hydrogen peroxide/PBS for 25 min, blocked in 5% normal rabbit serum for 20 min, blocked with biotin/avidin for 15 min each, and incubated with fluorescent isothiocyanate (FITC)-conjugated rat monoclonal anti-endoglin antibody, polyclonal myosin heavy chain antibody (Santa Cruz Biotechnology). For 2 hours at room temperature, biotinylated rabbit-anti mouse IgG at 1∶400 for 30 min, and Vector Elite ABC biotin-avidin-peroxidase complex for 30 min. Sections were then developed with diaminobenzidine and diaminobenzidine enhancer (Vector), counterstained with hematoxylin. Images were examined with a fluorescent microscope.CTTTTTGCTCGTCTTAT, Exiqon, Vedbaek, Denmark) and tissues were incubated for 90 minutes at the hybridization temperature and washed twice for 10 minutes in sodium chloride/sodium citrate buffer.Five-micrometer-thick tissue sections of left ventricular myocardium were mounted on positively charged barrier frame slides, dewaxed in xylenes, and rehydrated through an ethanol dilution series (100% to 25%). Tissue sections were digested with 5 µg/mL of proteinase K for 20 minutes at 37°C to facilitate probe penetration and exposure of miRNA species. To minimize nonspecific binding based on charge interactions, tissues were subjected to a brief acetylation reaction . Then, tissue sections were prehybridized at the hybridization temperature for 30 minutes in prehybridization solution which consisted of 50% deionized formamide, 5× sodium chloride/sodium citrate buffer, 1× Denhardt's solution, 500 µg/mL of yeast tRNA, and 0.01% Tween. The prehybridization solution was replaced with 200 µl of hybridization solution containing 10 pmol of the FAM-labeled LNA miR-208a probe . The Dunnett's test was used to compare multiple groups to a single control group. Tukey-Kramer comparison test was used for pairwise comparisons between multiple groups after the ANOVA. A value of P<0.05 was considered to denote statistical significance.The heart weight and heart weight/body weight ratio significantly increased after AV shunt for 7 and 14 days . The heaAs shown in As shown in To investigate the effect of mir-208a on myocardial endoglin expression, over-expression of antogomir208a and mutant type mir-208a (mut-208a) in the left ventricle was performed. AV shunt at 7 days significantly increased myocardial endoglin and βMHC protein expression and over-expression of antagomir208a significantly inhibited the increase of myocardial endoglin and βMHC protein expression induced by AV shunt. Over-expression of mutant mir-208a (mut-208a) did not have the effect on myocardial endoglin and βMHC expression induced by AV shunt. Over-expression of mir-208a in the sham group without AV shunt significantly increased myocardial endoglin and βMHC protein expression while over-expression of mut-208a in the sham group did not induce myocardial endoglin and βMHC protein expression . PretreaAV shunt and over-expression of mir-208a in the sham group significantly increased myocardial fibrosis area as compared to sham group . Over-exEndoglin expression is increased in human hearts with severe left ventricular failure and in heart failure induced by transaortic constriction, a pressure overload in mice Mirs are reported to be aberrantly expressed in hypertrophic heart Patients with congenital heart disease may have myocardial fibrosis similar to patients with acquired heart failure Statin, a 3-hydroxy 3-methyl glutaryl-CoA reductase (HMG-CoA reductase) inhibitor, improves survival in patients with ischemic and non-ischemic heart failure In conclusion, we demonstrate for the first time that mir-208a increases endoglin expression to induce myocardial fibrosis in volume overloaded heart failure. Treatment with atorvastatin can attenuate myocardial fibrosis induced by volume overload through inhibition of endoglin expression.Figure S1Immunohistochemnical staining of left ventricular myocardium after induction of aorta-caval shunt with or without atorvastatin treatment. There are significantly increased immunoreactive signals for endoglin and MHCβ after AV shunt for 7 days. Pretreatment with atorvastatin significantly decreased the immunoreactive signal induced by AV shunt. Rare endoglin signals were seen in the sham group.(TIF)Click here for additional data file.Figure S2Transfection of mir-208a into myocardium was monitored by a dissecting fluorescence microscope as shown in green color.(TIF)Click here for additional data file.


We report a 71-year-old woman with takotsubo-like myocardial dysfunction accompanied with cerebellar hemorrhage. On admission time, although she was unconscious by cerebellar hemorrhage, no obvious heart failure and serological disorder were observed. Three days later, operation for extraventricular drainage was performed. However, conscious level did not change. Four days after admission, the change of electrocardiogram wave pattern and the decrement of heart wall motion were detected. These findings revealed takotsubo-like myocardial dysfunction had occurred. Physical stresses by cerebellar hemorrhage and cranial operation might cause cardiac disorder. This is a remarkable case of takotsubo-like myocardial dysfunction, which is brought about cerebellar hemorrhage against subarachnoid hemorrhage. Transient left ventricular apical ballooning (TLVAB) characterizes takotsubo cardiomyopathy. It has been named after the shape of the heart that resembles Japanese octopus catcher pot with short narrow neck and round bottom –4. This 2O. The discharge amount was about 150 mL per day. Although drainage was continued, no remarkable improvement of conscious level was observed. Four days after admission, electrocardiography showed negative T wave in leads V4, V5, and V6. Further, ST elevation was observed in leads V1, V2, and V3 . Twenty-two days after admission, systolic blood pressure became lower and reached 60 mmHg, rapidly. Oxygen saturation level in blood fell to 93%. In addition, heart rate gradually decreased. The patient died on that day  by cardiac dysfunction. A 71-year-old woman was admitted to Kanazawa Medical University Himi Municipal hospital due to loss of consciousness after sudden severe headaches and dizziness on June 4, 2011. The level of consciousness was that eye opening was nil (E1), best motor response was extended (M2), and best verbal response was nil (V1) in Glasgow Coma Scale. Hypertension (228/126 mmHg on admission time) was observed. Direct and indirect light reflexes were lost and both pupils were miotic (2 mm/2 mm). However, doll's eye sign was not observed. Brain-computed tomography (CT) showed midcerebellar hemorrhage with intraventricular bleeding . Followi, and V3 . EchocarWe diagnosed a 71-year-old woman with cerebellar hemorrhage accompanied with takotsubo-like myocardial dysfunction. The causes of such myocardial dysfunction are characterized by progression of catecholamine production and disturbance of autonomic nerve regulation –29. HighCerebellar hemorrhage in vermis and intraventricular bleeding with hydrocephalus might cause physical stress to the patient. Further, operative treatment for extraventricular drainage also accumulated additional stress on her. These stresses might bring the autonomic imbalance, which is caused out of catecholamine regulation. Several stresses triggered takotsubo-like myocardial dysfunction. This myocardial dysfunction is usually associated with brain stroke . Especiaα2 receptors on myocardium [Cardiac beat is regulated by autonomic nerve control . Sympathocardium . In thisIn conclusion, not only subarachnoid but aslo cerebellar hemorrhage can cause to takotsubo-like myocardial dysfunction. The evaluation of cardiac function by ECG and echocardiogram is important to assess the onset of cardiomyopathy in patients with cerebellar hemorrhage.


Myocardial hemorrhage can be assessed implementing T2 and T2* mapping techniques, however robust myocardial T2 and T2* mapping is challenging at 3T. The goal of this study was to test T2 and T2* myocardial mapping techniques at 3T, with potential improvement in image quality on a system employing B1 shimming, with two methods of for B0 shimming.Hemorrhage in the core of acute myocardial infarction (AMI) and area at risk appear to be markers of prognosis, enabling targeted therapy and potentially changing outcome. Myocardial T2 and T2* mapping have been used to detect such tissue changes at 1.5T. Such investigation at 3T is challenging due to additional susceptibility variation .We studied T2 and T2* myocardial mapping techniques at 3T on a system employing B1 shimming, with two methods of B0 shimming.Fifteen volunteers and three STEMI patients were scanned on a 3T Philips Achieva TX system with a 32-channel cardiac coil. Triggered, single breath-hold, multi-echo sequences were employed from which T2* and T2 maps were calculated. For the T2 map, the shot of 24 refocused spin echoes was subdivided into six groups, with a linear k-space order within each group contributing to a separate k-space. This strategy allows data acquisition within a breath hold. The echoes used for the centre of k-space for each image/group had consistent parity.Conventional first-order volume B0 shimming  was compared with image based (IB) B0 shimming, for which first- and second-order field adjustments are calculated from B0 maps, to maximise B0 map homogeneity over an arbitrarily-shaped volume prescribed by the user which can be drawn around the heart .In all cases, septal, anterior and posterior ROIs were manually drawn to obtain average T2 or T2* values.Figure In 9 of the total of 15 volunteers, IB shimming reduced T2* map heterogeneity, particularly in the inferolateral wall. In the remaining 6 volunteers, conventional volume shim and IB shimming performed equally. For the T2 mapping, no difference in artefact power between conventional volume shim and IB B0 shimming was detected, although homogeneity improved away from susceptibility artefact.The patient data reflected a similar pattern with additional increase in T2 and T2* values in the affected MI territory.T2 mapping is robust on a B1-shimmed 3T system, with the modified k-space filling strategy employed here. Septal T2* mapping was robust; outside the septum IB B0 shimming can improve T2* maps but inferolateral susceptibility effects remain problematic. Some caution in interpreting T2* values outside the septum has to be taken. At 3T, T2 mapping may prove more useful, particularly outside of the septum.S.P and J.P.G received an unrestricted educational research grant from Philips Healthcare.


Editorial comment on ‘Preventing LVAD implantation by early short-term mechanical support and prolonged inodilator therapy: a case series with acute refractory cardiogenic shock treated with veno-arterial ECMO and optimised medical strategy’J.J. Brugts, O. Manintveld, A. Constantinescu, D. Donker, R. van Thiel, K. Nieman, L. Jewbali, F. Zijlstra, K. CaliskanIn this issue of the Netherlands Heart Journal, Brugts et al. describe a series of cases with acute severe refractory cardiogenic shock . All thrThe authors conclude that the combination of extracorporeal membrane oxygenation (ECMO) and early introduction of heart failure medication under the umbrella of phosphodiesterase inhibition provided momentum to survive and prevent LVAD implantation.The introduction of extracorporal life support in the 1970s has defined the standard of care in so-called ‘crash and burn’ (INTERMACS 1) patients . The cliThe rise of durable LVADs has significantly improved survival in end-stage heart failure and has provided a successful bridge to transplantation . HoweverAnalysis on survival after implantation of a durable LVAD in different INTERMACS categories revealed dramatically high mortality rates in INTERMACS profiles 1 and 2, compared with less critically ill patients . This fiTo promote reversal of heart failure, different combinations of pharmacological strategies have been investigated. For example, sustained recovery was seen in the majority of a small group of patients with acute and severe non-ischaemic cardiomyopathy without active myocarditis treated with a strict pharmacological treatment consisting of the β2-agonist clenbuterol . From thA recent retrospective study on early heart failure pharmacotherapy in ongoing cardiogenic shock compared patients who did and did not receive heart failure therapy within 24 h of admission. In comparison with no therapy, administration of β-blocker was significantly associated with an increased 30-day mortality and longer median duration of shock .Rather than preventing the pathway of long-term LVAD support, the reported cases elegantly describe recovery of heart failure with state of the art treatment with ECLS in potentially reversible causes of cardiogenic shock. The additive value of the pharmacological regimen cannot be concluded from this series without a control group. Controlled studies are necessary to examine the value (or harm) of early introduction of heart failure medication.


Previous studies evaluating cardiac effects of chemotherapy have focussed on the left ventricle (LV) and largely been retrospective. Although right ventricle (RV) systolic dysfunction is an adverse prognostic marker in cardiomyopathy states, the RV effects of chemotherapy are not well defined.Thirty six breast cancer patients undergoing chemotherapy  underwent serial CMR imaging (for LV and RV volumes/ejection fraction) and echocardiography for tricuspid annular systolic plane excursion (TAPSE) at baseline, 1, 3 and 12 months. RV impairment following chemotherapy was defined as an reduction of CMR RVEF below normal range (defined as 50%)1 and/or an absolute reduction of RVEF of at least 5% from baseline.Significant changes in CMR volumes and systolic function were observed in both the ventricles (table). Although LV function decreased, EF remained above the lower limit of normal (defined as 57%1) in all patients. RV function changes were of greater magnitude. 23% of patients had significant RV impairment at 3 months and 81% had RV impairment evident at 12 months (as defined above). TAPSE decreased from 23±3 to 21.1±3; p<0.001 at 3 months. Patients that received anthracyclines were more likely to have significant RV impairment at 12 months, p value <0.005.RV functional changes can be detected both early and late following current chemotherapy regimes using CMR and modern echocardiographic techniques. Although anthracyclines likely causes biventricular dysfunction, in our study they were more likely to cause persistent RV impairment at 12 months. These findings support routine surveillance of RV function in contemporary breast cancer chemotherapy.nil


Central artery dilation and remodeling are associated with higher heart failure and cardiovascular risks. However, data regarding carotid artery diameter from hypertension to heart failure have remained elusive. We sought to investigate this issue by examining the association between carotid artery diameter and surrogates of ventricular dysfunction.P<0.001) and correlated with serum brain natriuretic peptide level . Multivariable models showed that CCAD was associated with increased LV mass, LV mass‐to‐volume ratio , reduced LV longitudinal and radial strain , and twist . CCAD set at 8.07 mm as a cut‐off had a 77.6% sensitivity, 82.3% specificity, and area under the receiver operating characteristic curves (AUROC) of 0.86 (95% CI 0.80 to 0.92) in discriminating HFpEF. In addition, CCAD superimposed on myocardial deformation significantly expanded AUROC  in heart failure discrimination models.Two hundred thirteen consecutive patients including 49 with heart failure and preserved ejection fraction (HFpEF), 116 with hypertension, and an additional 48 healthy participants underwent comprehensive echocardiography and tissue Doppler imaging. Ultrasonography of the common carotid arteries was performed for measurement of intima‐media thickness and diameter (CCAD). Cardiac mechanics, including LV twist, were assessed by novel speckle‐tracking software. A substantial graded enlargement of CCAD was observed across all 3 groups (6.8±0.6, 7.7±0.73, and 8.7±0.95 mm for normal, hypertension, and HFpEF groups, respectively; ANOVA Increased carotid artery diameter is associated with worse LV geometry, higher brain natriuretic peptide level, and reduced contractile mechanics in individuals with HFpEF. It is associated with high rates of clinical events similar to systolic heart failure and is linked to the growth of an aging population.16 and enlarged arterial diameter4 in response to chronic increase in load status have been associated with vascular wall thickening—an adaptive response to wall tension increases according to the law of Laplace.17 However, data supporting central arterial remodeling in the transition from HTN to heart failure have not been extensively examined.Reduced aortic wall elasticity18 In addition, such imaging techniques can provide a more comprehensive understanding of cardiac mechanics and the adaptive response in patients with various cardiovascular risks.19Recent advances in echocardiography techniques such as speckle‐tracking–based myocardial deformation imaging facilitate the quantitative assessment of subclinical myocardial dysfunction.The goal of this study was to investigate vascular remodeling and associated hemodynamics changes as exhibited in the carotid arteries, in relation to cardiac geometry, cardiac mechanics, or left ventricular (LV) twist and plasma brain natriuretic peptide (BNP) level, in subjects with HTN and HFpEF.From January 2008 to December 31, 2009, we consecutively studied 213 patients retrospectively from the cardiovascular outpatient clinic at a tertiary care hospital in North Taiwan: 116 had HTN and 49 had HFpEF. The setting was based on a routine health check‐up program with noninvasive imaging study performed. The initial object was to characterize myocardial function and some associated clinical features of high cardiovascular risk subjects. Cases of HFpEF were identified on the basis of the discharge diagnosis record adjudicated by experienced cardiologists and should have documented pulmonary edema on chest radiography at the time of their index hospitalization with LV ejection fraction >50% by echocardiographic measures. An additional 48 asymptomatic, healthy participants without previous diagnosis of any systemic disease were recruited at the time of their routine annual health check‐up. Exclusion criteria were significant valvular heart (moderate to severe) diseases, a history of pacemaker implantation, valvular surgery, ongoing atrioventricular block or episodes of frequent cardiac arrhythmias that make recording difficult, acute or overt renal dysfunction (serum creatinine ≥2.5 mg/dL), severe obstructive pulmonary disease, and a history of acute coronary syndrome in the preceding 12 months. Thorough review of the data, including baseline characteristics, medical histories, smoking and physical activity, as well as detailed physical examination results, was obtained using structured questionnaires. The imaging acquirement and quantification were carried out by the same experienced technician with no changes regarding the procedures, raters, technology, or standard of care affecting the measurements over the entire 2‐year study period. Categorization into the HTN group was confirmed by detailed chart review and defined by previous HTN diagnosis (systolic blood pressure >140 mm Hg or diastolic blood pressure >90 mm Hg by sphygmomanometer) with regular medication control yet without clinical heart failure signs or symptoms. The presence of coronary artery disease (CAD) was defined as a history of a previous myocardial infarction, history of angioplasty, or >50% luminal narrowing by coronary angiography. Biochemical values including fasting glucose level, lipid profiles, blood urea nitrogen, and creatinine, were obtained with an Hitachi 7170 Automatic Analyzer  from venous blood samples, with BNP was measured by the Abbott AxSYM  method. The data preparation and study design were retrospective and had passed the institutional board review. We did not obtain oral informed consent from all of the subjects. The local ethics committee approved the design of this study in accordance with the Declaration of Helsinki (11MMHIS143).21 The aortic root diameter was defined as the largest end‐diastolic diameter from the parasternal long‐axis view  equipped with a 2‐ to 4‐MHz transducer (M4S). Parameters including left atrial diameter, LV internal diameter, derived LV mass, and LV mass index were determined from M‐mode measurements using American Society of Echocardiography criteria.xis view A, middleLV end‐diastolic and end‐systolic volumes were further quantified using the biplane Simpson method with ratio of LV mass to volume calculated using LV mass divided by LV end‐diastolic volume. Assessment of LV diastolic function was determined by pulsed‐wave Doppler of transmitral inflow velocities measured at the tip of the mitral leaflets with E/A ratio assessed from early (E) and late diastolic (A) filling velocities. Tissue Doppler imaging was used to determine the lateral mitral annular velocities, measuring both the peak systolic (S′) and early diastolic (E′) values. Left‐sided ventricular filling pressures (E/E′) were estimated using the ratio of the early (E) transmitral hemodynamic Doppler velocity divided by the tissue Doppler imaging–derived early diastolic (E′) lateral mitral annular velocity.The extracranial common carotid arteries (CCAs) were sequentially assessed using a high‐resolution 5‐ to 10‐MHz linear‐array ultrasound transducer (GE‐VingMed) by an experienced technician. All subjects had their carotid intima‐media thickness (IMT) measured at the far wall of the distal 1 cm of each CCA A, left. P<0.001). Bland–Altman analysis of these 2 methods showed a high degree of agreement (limits of agreement: −0.217 to 4.146).Thirty subjects in the study cohort  had computed tomography (CT) scans A, right.22Baseline 2‐dimensional images  for longitudinal strain and 3 short‐axis views  were analyzed by offline endocardial border manual tracing, using novel offline proprietary software  based on automated speckle‐tracking algorithms. The global longitudinal strain was averaged from all 3 apical views  and displayed as a bull's‐eye map B, left w23 Coupled ventriculoarterial function was thus evaluated by arterial elastance index/end‐systolic elastance. The pulse pressure (PP) was determined using the brachial systolic blood pressure minus the diastolic blood pressure. The central PP was estimated by a regression equation used for the brachial PP determined by carotid applanation tonometry.14 Central artery compliance was estimated by calculating the ratio of stroke volume to PP:End‐systolic pressure was estimated as systolic blood pressure×0.90 with stroke volume measured as the product of the cross‐sectional area of the LV outflow tract  and the velocity‐time integral (using pulsed‐wave Doppler assessment of flow across the LV outflow tract) measured on the apical 5‐chamber view. The effective arterial elastance index was estimated as end‐systolic pressure/stroke volume with LV end‐systolic elastance calculated using the modified single‐beat measure.24The wall tensile stress of the carotid artery (carotid tensile stress), during the end‐diastole phase, was estimated by the product of the mean blood pressure and one‐half of the ratio of the lumen diameter (carotid radius) to the IMT ([pressure×radius]/IMT).2 or Fisher exact test, as appropriate. One‐way ANOVA was performed to test the differences in the continuous data among the 3 groups with the post‐hoc Bonferroni correction for paired comparisons. Because the carotid IMT and remodeling depend largely on age and other cardiovascular risk factors, an ANCOVA was also used to adjust for relevant covariates in the comparison of mean values among the 3 groups. The minimum required samples needed to detect significant difference between the HFpEF and HTN groups by longitudinal myocardial deformation (strain), a sensitive and powerful clinical marker for such purpose,25 was calculated. A reported mean of −14.9 and SD of 2.9 in the HFpEF25 group and mean of −16.9 and SD of 4.1 in the HTN26 group resulted in an effect size (Cohen's d) of 0.563. Given that the subjects with HFpEF had a smaller amount with a potentially wide range of longitudinal strain value compared with subjects with HTN (from −15.9% to −18.8%),26 the authors prespecified the ratio as a 2:1 allocation ratio, leading to a sample size of nearly 100:50 for HTN and HFpEF, respectively, with an power of 90% and an α rate of 5%. The sample size calculation was performed by using G*Power 3.1.5 . Additionally, a normal control group was included to contrast the difference from the HTN and HFpEF groups.Continuous data are reported as the mean±SD and compared using a nonparametric trend test (Wilcoxon rank sum test) across ordered age groups with categorical or proportional incidence data expressed as a proportion and compared with use of the χP value provided for statistical significance (P of ΔAUROC). To avoid overspecification, calibration with 5‐fold cross‐validation was performed. A multivariable regression model was used to determine the significance of the covariate‐adjusted relation between myocardial deformation data and clinical variables, biochemical profiles and echo‐derived measurements of the aortic root, and carotid artery diameters with individual odds ratios, and P values and 95% CIs.The diagnostic and incremental values of the CCAD superimposed on diastolic parameters and myocardial deformation data were assessed using receiver operating characteristic (ROC) curves with the optimal cut‐off chosen for maximum sensitivity and specificity for the clinical diagnosis of HFpEF. The incremental value between models was assessed by changes of area under ROC (ΔAUROC), with P value was set for 2‐tailed probability with a P value <0.05 considered statistically significant.All data were analyzed with use of the STATA 9.0 software package (StataCorp). The P<0.05). Both the HTN and HFpEF groups had higher systolic and diastolic blood pressure . Moreover, both the HTN and HFpEF groups had higher blood sugar levels, worse renal function, lower serum HDL and Hb, and higher serum high‐sensitivity C‐reactive protein and BNP levels than the control group .The baseline demographic data for the 213 participants enrolled in this study are presented in P<0.05). Both vascular elastance  and LV end‐systolic elastance reflecting vascular and ventricular stiffness were worse in the HFpEF group (P<0.05), whereas ventriculoarterial coupling  remained similar across 3 groups. Furthermore, the patients with HFpEF also had a significantly higher aortic root and left atrial diameter; greater wall thickness, LV mass index, relative wall thickness, and mass‐to‐volume ratio; and reduced stress‐corrected mid‐wall function . In addition, both the HTN and HFpEF groups had higher estimated central pulse pressures compared with the healthy group (both P<0.05). A significantly higher left‐sided ventricular filling pressure, by E/E′, was also observed in the HFpEF group (P<0.05).P<0.05). In addition, LV twist behavior was significantly lower in the HFpEF group (P<0.05).Myocardial deformation, from both longitudinal and radial measures, was significantly lower in both the HTN and HFpEF groups compared with the normal controls , and a graded substantial enlargement of CCAD from the healthy, HTN, to HFpEF groups  even when adjusted for age, body mass index, and blood pressure. A significantly decreased carotid artery IMT‐to‐diameter ratio (carotid artery remodeling) was also observed in HFpEF compared with the HTN group (ANOVA P<0.001). r=0.42, P<0.001) and elevated carotid artery tensile stress ; however, there was no direct relationship between the arterial compliance and CCAD .P<0.05). In addition, there was an association between larger aortic diameter and a reduction in longitudinal and radial strain  or twist , although these associations were less pronounced in the multivariable models (P<0.05) in the univariable model. In the multivariable models, larger CCAD remained significantly independent of reduced longitudinal, radial strain, and degree of LV twist .The association among ventricular geometry, aortic diameter, and parameters of carotid arteries was shown in e models . In addiR2=0.31, P<0.001). As assessed with the ROC analysis, the AUROC for the diagnosis of HFpEF by using carotid artery IMT, remodeling, and CCAD was 0.61 (95% CI 0.53 to 0.69), 0.6 (95% CI 0.51 to 0.68), and 0.86 (95% CI 0.80 to 0.92), respectively. The optimal cut‐off value for carotid artery diameter, in the diagnosis of HFpEF, was 8.07 mm, which yields a sensitivity of 77.6% and a specificity of 82.3%. When CCAD was superimposed on the E/E′, the AUROC increased from 0.84 to 0.88  in response to chronic, elevated arterial pressure was shown to contribute to rupture of the load‐bearing elastin fibers in response to mechanical fatigue resulting from higher tensile wall stress.30 However, such effects were less likely in the more peripheral muscular arteries.35 Similarly, owing to the large amount of circular and longitudinal muscular layers encircling the media layer of the aorta,35 its adaptive behavior in response to increased load may be different from that of the medium‐sized CCAs, where elastic fibers predominate.36 However, to what extent such carotid artery may remodel in the transition from HTN to HFpEF remains largely unexplored. We therefore speculated that when vascular remodeling fails to overcome the chronic, elevated mechanical stress due to pulsatile stretch and reaches a point of “no‐return,” the consequence will include the manifested dilatation of the carotid arterial lumen that may accompany the development of HF .nt of HF . Further40 Because aging and HTN can play a major role in carotid artery dilatation and remodeling,28 it is worth emphasizing that such observed large artery remodeling in terms of either wall thickening through proteoglycan/collage matrix deposition or increased internal diameter per se may share a similar pathophysiology with ventricular remodeling and worsened myocardial deformation, a putative precursor in the development of heart failure.41 Indeed, we demonstrated that both remodeling patterns were in line with ventricular geometric alterations and worse ventricular contractile function in terms of lower deformation values, with larger artery diameter being more consistent even after adjusting for blood pressure and clinical variables. Unlike the triggered released of BNP42 as a more linear function reflecting the degree of myocardial damage from HTN to HF development, the clinical interpretation by using simply judging LV morphology for such purpose may be complicated by its phenotype diversity and the lack of consensus. Therefore, we proposed that enlarged carotid artery diameter, which tracks with increased ventriculoarterial stiffness, elevated serum BNP level, and reduction of myocardial deformation indices, could be a useful clinical marker in early identifying ventricular functional decline.Impaired endocardial longitudinal function has been shown to be a sensitive marker for identifying early‐stage diseased myocardium, particularly in patients with hypertrophy and ischemia, which may be exacerbated by elevated mechanical stress, which could be readily identified by deformation imaging.The limitations of this study include the following. First, the findings in this study are from a cross‐sectional study design and are based on a relatively small sample size with no longitudinal follow‐up data. The subjects in this study with HFpEF were older, with a higher percentage of men in the healthy group. However, there was considerable overlap with the patients with HTN of similar age, and this would not be expected to influence the results. Also, the data on the central pulse pressure were obtained from regression equations and not through invasive procedures. Furthermore, the effect of interventions on the arterial remodeling and diameter was not tested in this study, and the potential benefit of intervention in clinical practice was not investigated and should require further study.The results of this study demonstrated that larger carotid artery diameter, worse LV geometry, and impaired ventricular systolic function may progress in parallel, indicating that both large arteries and ventricles in subjects with HFpEF are prone to mechanical failure from increased load and elevated tensile stress. Therefore, enlarged carotid artery diameter may serve as useful clinical marker for identifying subjects at risk for HF.