Patients with refractory heart failure due to chronic progressive cardiac myopathy (CM) may require mechanical circulatory support as a bridge to transplantation. A few patients can be weaned from support devices if recovery can be achieved. The identification of these patients is of great importance as recovery may be missed if the heart is unloaded by the ventricular assist device (VAD). Testing the load-bearing capacity of the supported left ventricle (LV) by temporarily and gradually reducing mechanical support during cardiac exercise can help identify responders and potentially aid the recovery process. An exercise training protocol was used in 3 patients  with histological CM findings and myocarditis. They were monitored regularly using clinical information and functional imaging with VAD support. Echocardiographic examination included both conventional real-time 3D echocardiography (RT3DE) and speckle tracking (ST). A daily temporary reduction in pump rate (phase A) was followed by a permanent reduction in rate (phase B). Finally, pump stops of up to 30 min were performed once a week (phase C). The final decision on explantation was based on at least three pump stops. Two patients were weaned and successfully removed from the VAD. One of them was diagnosed with acute viral myocarditis. The other had chronic myocarditis with dilated myopathy and mild interstitial fibrosis. The noninvasive assessment of cardiac output and strain under different loading conditions during VAD therapy is feasible and helps identify candidates for weaning despite severe histological findings. The presented protocol, which incorporates new echocardiographic techniques for determining volume and deformation, can be of great help in positively guiding the process of individual recovery, which may be essential for selecting and increasing the number of patients to be weaned from VAD.  This work is based on the hypothesis that in some carefully selected cases, the myocardium can be trained by gradually offering more volume and reloading the left ventricle. Using a new weaning protocol, a consistent progressive reloading of the ventricle was performed and adapted to the patient’s needs. This means that the time frame of the unloading steps can be changed and adapted to the needs of the patient according to the functional echocardiographic data. The entire procedure can be considered analogous to a hypertrophy-oriented resistance training program. The indication for the implantation of a VAD in the paediatric population is end-stage heart failure despite drug treatment. It usually occurs due to an acute trigger , chronic progressive cardiomyopathy or congenital heart defect . The VAD is used in these cases as a bridge until recovery or transplantation. The Berlin Heart Excor is a pulsatile circulatory support system used for paediatric heart failure. The Excor pump offers different ventricle sizes to meet the cardiac output needs of newborns, infants and children. The ventricles are extracorporeal, allowing inspection to rule out clots, look for membrane defects or simply check the filling status of the chambers. There are institutional differences in terms of venous management, anticoagulation drug therapy and maintenance, resulting in a variety of clinical outcomes ,2,3.Between April 2016 and March 2018, 3 patients  were studied as part of the implementation of this method for weaning from a pulsatile LVAD. The patients were admitted to our department for acute heart failure and a ventricular assist device (VAD) was decided as bridging therapy.The left ventricular support consisted of a pulsatile system, namely a Berlin Heart Excor VAD , with a 15-mL ventricle and, in the case of the older child, a 30-mL ventricle, which was reduced to a 15-mL ventricle shortly after implantation. Endomyocardial biopsy (EMB) samples were taken intraoperatively. The EMB samples were examined at the Institute of Pathology and Neuropathology, Department of General and Molecular Pathology and Pathological Anatomy, University of Tübingen, Germany. Metabolic diseases and coronary anomalies were excluded in all patients. Each patient underwent a standard laboratory procedure on admission. The baseline laboratory tests on admission included blood count; renal  and liver parameters; C-reactive protein; troponin; brain natriuretic peptide (BNP), autoimmune antibodies and extended infectious diagnostics including adenoviruses, echoviruses, enteroviruses, herpes viruses , hepatitis C, varicella, influenza type A, parainfluenza and parvovirus B19, toxoplasma and borellia. Trends in troponin, BNP and end-organ parameters such as creatinine were included in decision making during the weaning process.The cornerstone for the weaning decision was the summation of multiple echocardiographic data. In addition to conventional echocardiographic methods, RT3DE and deformation imaging were used. Patients were studied according to a standard protocol for data collection published elsewhere ,5,6,7,8.The protocol consists of three different phases. In the first phase, the frequency of the VAD was reduced daily by 20–25% up to 4 h per day. If echocardiographic parameters were stable, the next phase was initiated with a definitive reduction in frequency to the minimum allowable pump rate of 50–60 beats per minute (bpm). The third and decisive phase was analogous to the off-pump trials in adult cardiology. Our pump stops lasted up to 30 min once a week, with an additional heparin bolus of 100 IU/kg/dose.During the weaning protocol, we collected clinical, laboratory  and 2D echocardiographic data, as well as speckle tracking (ST), VTI measurements and RT3DE recordings of left ventricular enddiastolic (LVEDV) and endsystolic (LVESV), stroke volume (SV) and ejection fraction (EF). The haemodynamic parameters were confirmed in the catheter laboratory.Patient 1 was weaned over 14 weeks. The program included a daily reduction of the frequency for 2 h in the first phase, then an escalation up to 4 h per day and finally a complete reduction of the basic frequency. In the last phase, a stress test in the form of a pump stop was performed.2/min, followed by a pump stop test.Patient 2 was weaned in the first phase over 19 weeks by reducing the frequency daily to 10% of the baseline frequency. If the results were promising, a fixed frequency reduction was applied in the second phase, as well as a daily frequency reduction of 10% limited to four hours. The last phase was based on a pump output of only 1.8 L/mPatient 3 was implanted with a 30 mL Berlin Heart Ventricle that had to be downsized after only 2 weeks due to rapid recovery and filling problems. An analogous protocol was established for patient 1. After the reduction, a constant frequency reduction was performed followed by a total of five clinical stress tests . For tests B and C, a slightly extended pump stop time of 10 min was used. For the last 2 tests, a 30 min pump stop time was used. The weaning process was carried out over several weeks.A 8-month-old girl presented with massively impaired left ventricular function , aortic VTI 6.5 cm at HR 156/min, <Pc 3, ST: global longitudinal strain [GLS] 4Ch −6.5%, 2Ch −6.4%, 2 to 57 mL/m2 (>97th Pc) at the beginning, but it remained constant at 59 mL/m2 at the end of the 2-week training phase. VTI also remained at the 10th Pc and ejection fraction increased from EF 32% to 36%. In phase C, parameters were obtained during pump stop. Data were collected every 5 min and post-processed. An increase in VTIs and EF was observed, as well as a reasonable adjustment in stroke volume without an increase in left ventricular volume. VTIs were above the 90th percentile. The exercise data showed a slight improvement. A test is shown in the attached The biopsy (EMB) revealed histological diagnosis of chronic myocarditis, DD  of dilated cardiomyopathy with mild fibrosis. Metabolic disease and coronary anomaly were excluded. Neither family history nor genetic testing revealed any evidence of major known cardiomyopathies (testing of about 147 gens). Implantation was performed on the fourth day after admission due to further clinical deterioration and ventricular tachycardia. A 15 mL ventricle was used. Postoperative catecholamine therapy was discontinued within three weeks. A weaning schedule was followed for 14 weeks. The program started with a daily reduction of the Berlin heart rate (BH) for 2 h/day to 50/min for three weeks (phase A), an extension to 4 h/day for a fortnight and a complete reduction to 50/min for nine weeks (phase B). To test myocardial recovery, a 30-min pump stop was performed once a week to assess clinical improvement under additional heparin bolus (phase C). All steps were monitored by echocardiographic measurements. Before explantation, a catheter examination was performed to confirm the echocardiographic data. The initial training phase (phase A) resulted in an improvement in strain scores from −8% (GLS 2Ch) and −10% (GLS 4Ch) to results of −13% and −11%, respectively, at the end of the training phase. VTIs were initially measured between the 3rd and 10th Pc and increased up to the 10th Pc. [2, CVS  60%, LVEDP (left ventricular enddiastolic pressure) 8 mmHg. Pump stopped for 30 min: CI 3.6 L/min/m2, CVS 58%, LVEDP 10 mmHg. The Development of the laboratory parameters during the weaning process is plotted over time  50/min: CI (cardiac index) 4.1 L/min/mver time .The device was successfully removed, and the patient was treated with standard congestion therapy. She visits our outpatient clinic regularly, and left ventricular function has now been stable for over six years, with normal heart function and no medical therapy.2, LVESV 136 mL/m2, EF 30%, SV 23 mL) Despite intensive inotropic support, the rapid progression of heart failure was noted, and the implantation of an LVAD was performed two days after hospital admission. Family genetic testing revealed no abnormalities. The pump ventricles had a volume of 15 mL with an initial rate of 100/min (CI 3 L/min/m2). Molecular pathological diagnosis revealed acute lymphocytic parvovirus B 19 myocarditis. Postoperative catecholamine therapy was discontinued within four weeks. Thereafter, the baseline pump rate was reduced to 85/min (CI 2.5 L/min/m2). At this point, the weaning plan could be implemented. The weaning plan was implemented over 19 weeks. We started in this case with a daily reduction in rate for 4 hrs/day to 70/min for 5 weeks; a reduction in base rate to 75/min daily and a reduction from 4 hrs/day to 60/min for 4 weeks (phase A); complete reduction in base rate to 60 bpm (CI: 1.8 L/min/m2) for further 2 weeks (phase B). To check cardiac improvement, a 30 min pump stop was performed once a week (phase C). All steps were carefully documented echocardiographically.An 18-month-old female patient presented to us with suspected acute myocarditis/DD dilated cardiomyopathy. The family history was negative. She was the third child in the family. She had been ill with hand, foot and mouth disease three weeks previously and had received symptomatic supportive care with no further problems. On admission, the child’s condition was severely compromised. We saw a massively dilated left ventricle , an ESV of 55 mL/m2, an SV of 21 mL and an EF of 47%. During pump stop, there was an increase in VTIs and EF and an adequate adjustment in stroke volume without an increase in LVEDV.The first 5 weeks showed a progressive reduction in LVEDV from 190 mL/m2, LVESV 50 mL/m2, EF 46%, SV 21.3 mL, HR 100/min, CI 4.5 L/min/m2, VTI aortal 16 cm (50th pc)). The patient has been managed in our outpatient clinic for four years since explantation, with normalised cardiac function and no medication.ST data demonstrated a slight improvement after ten weeks of participation in the program. However, deformation was not completely normal; some wall motion abnormalities were still persistent. The explantation of the device was successful; the patient could be weaned off the catecholamines and was treated with standard anticongestive therapy. One month after explantation, echocardiographic examination was excellent (LVEDV 89 mL/m2 (>97Pc), LVESV of 104 mL/m2, SV of 28 mL, EF 20% at a HF of 140/min–CI 3.6 L/min/m2. As shown in 2 to 1.5 mL/min/m2 was performed. Biopsy revealed a diagnosis of mild chronic active/DD in healing HHV6 (human herpesvirus 6) myocarditis with diffuse perivascular fibrosis. Histology of the biopsy did not show unequivocal evidence for the diagnosis of dilated cardiomyopathy. Genetic examination of the patient did not reveal any proven genetic alteration that could explain the clinical picture. The molecular diagnosis showed the persistence of a low copy number of HHV6 variant B. This was not consistent with the serological findings. Probational ganciclovir therapy was discontinued after two weeks because of the patient’s neurological impairment with seizures. Acute myocarditis was ruled out. CT and EEG showed no evidence of major cerebral lesions. The weaning protocol was implemented. It differed from that of the other two patients in that the ventricle was rapidly reduced in size. Practically, it comprised two phases, the first immediately after reduction (still on catecholamine therapy) and the second with a constant reduced rate of 80/min. The start of the second phase was decided within four weeks after implantation, after the cessation of catecholamine therapy. Analogous to the other two patients, the tests were performed with a pump stop under heparin protection. In total there were 5 pump-down tests in 8 weeks. The first test took place one week after ventricular reduction and after the cessation of catecholamine therapy and showed promising results , aortic VTI 13 cm at 130/min, 25–50th Pc). Deformation parameters were pathological: ST GLS 4Ch −5%, 2Ch −5%. RT3DE showed LVEDV of 140 mL/m results . A slighjustment . Even thjustment . The girThis new protocol not only enables the identification of recovery candidates, it could also enable recovery. Long-term survival after weaning seems to be better than after transplantation . TherefoCommon to all three protocols was the progressive loading of the ventricle over a patient-adapted period of time under noninvasive  assessment and modification of support as needed based on changes in the heart. McCarthy et al. showed that ventricular function may well recover after acute fulminant myocarditis . Levin GHowever, there are some echocardiographic measurements that have been shown to be very informative for long-term weaning. ,13,14,15The factors that influenced the decision to leave the patients on the protocol were: a preserved sinus rhythm and the RT3DE LVEDV, SV and EF measurements. The deformation parameters are also important but as a long-term observation rather than an acute decision aid.For rapidly increasing volume, we modified the protocol as needed with a slower reduction in pump rate or reduction interval. Repeated reduction in stroke volume associated with an increase in left ventricular volume was a prognostic negative sign of failed adaptation of the ventricle to the patient’s needs. The nonresponder showed an increase in LVEDV of about 10% and a relevant decrease in stroke volume and EF in the last two tests. Based on this experience, we have introduced a new protocol for ventricular training and weaning for these challenging cases in our centre .Our experience has shown the importance of ruling out major metabolic causes of dilated cardiomyopathy (DCM) or genetic causes. According to a review of the literature, the total annual incidence of cardiomyopathies in childhood is estimated at 1:100,000 . There aHypertrophic cardiomyopathies are the second most common form with an incidence of 25–40%. Many children have a mixed phenotype or undergo transition during the course of the disease. Reported incidence may vary by region, race or ethnicity and diagnostic capabilities ,18,21.Children in post-myocarditis status are expected to have a better chance of recovery of function . Acute mA multicentre prospective registry on myocarditis in paediatric patients aims to gain insights into its manifestation, diagnosis and optimal therapy .The currently published data from the registry confirm based on histopathological analysis an inflammatory process in 73% of the included patients. Viral detection (PCR in myocardium or blood sample) may depend on the time of diagnosis. The possibility of the regression of fibrosis and reduction of inflammation are prognostically important .Myocarditis may progress to dilated cardiomyopathy. Many publications describe dilated cardiomyopathy as the most common cause of heart transplantation ,26. The The EMB was obtained intraoperatively in all three of our patients at the time of implantation of the Berlin heart (BH) left ventricular assist device (LVAD). Patient 1 was diagnosed with dilated cardiomyopathy with chronic myocarditis. No. 2 tested positive for parvovirus B19, a clear case of acute viral myocarditis. In patient 3, the EMB result was inconclusive. The primary echocardiographic diagnosis and macroscopic surgical suspicion in patient 3 was that of possible decompensated dilated noncompaction cardiomyopathy. In the literature, we were able to find a number of case reports on the histopathological changes in noncompaction cardiomyopathy . All pubGenetic predisposition is an important aspect that scientists are looking at intensively today. In a 1994 publication, Caforio showed organ-specific cardiac antibodies in 342 relatives of DCM patients as a sign that the immune system is a very important regulator of the way cells respond to injury ,30. In aThe predictive factors for successful weaning are not very well known, let alone well defined. A larger number of patients is needed to identify the risk factors and define the weaning potential. In addition to initial volume offloading, decreased fibrosis development and inflammation and a favourable genetic constellation are prognostically important for the onset of progressive reloading and exercise. Patients 2 and 3 had genetic modifications of unknown significance. These modifications may nevertheless have a phenotypic expression that affects outcome and therapeutic decision-making. Knowledge about the phenotypic expression of certain genetic modifications is still limited. The heterogeneity of patients is certainly also a limitation. The weaning process represents an idea that must be tailored to the individual needs of the patient and continuously adapted to the new clinical data and haemodynamic changes.Retraining a weakened heart may be a viable option for patients with heart failure on VAD therapy. To achieve the best prognosis, early support is essential to avoid prolonged periods of low cardiac output, end-organ dysfunction or cardiac arrest ,32. Once


Post-ischemic left ventricular (LV) remodeling is a biologically complex process involving myocardial structure, LV shape, and function, beginning early after myocardial infarction (MI) and lasting until 1 year. Adverse remodeling is a post-MI maladaptive process that has been associated with long-term poor clinical outcomes. Cardiac Magnetic Resonance (CMR) is the best tool to define adverse remodeling because of its ability to accurately measure LV end-diastolic and end-systolic volumes and their variation over time and to characterize the underlying myocardial changes. Therefore, CMR is the gold standard method to assess in vivo myocardial infarction extension and to detect the presence of microvascular obstruction and intramyocardial hemorrhage, both associated with adverse remodeling. In recent times, new CMR quantitative biomarkers emerged as predictive of post-ischemic adverse remodeling, such as T1 mapping, myocardial strain, and 4D flow. Additionally, CMR T1 mapping imaging may depict infarcted tissue and assess diffuse myocardial fibrosis by using surrogate markers such as extracellular volume fraction, which may predict functional recovery or risk stratification of remodeling. Finally, there is emerging evidence supporting the utility of intracavitary blood flow kinetic energy and hemodynamic features assessed by the 4D flow CMR technique as early predictors of remodeling. Left ventricular (LV) remodeling after myocardial infarction (MI) is the process clinically manifesting as a change in LV architecture, size, and function, regulated by hemodynamic load, neuro-hormonal activation, and genetic factors, which begins within the first hours after MI and lasts up to 1 year . HistoloLV remodeling can be distinguished into two types: the first, physiological and adaptive during development, and the second, maladaptive, as a result of several pathophysiological mechanisms  ,6. The pDespite early reperfusion strategies, nearly 30% of ST-elevation myocardial infarction (STEMI) patients present a higher risk of developing LV adverse remodeling at mid-term FU, which is associated with a higher incidence of long-term poor outcomes such as cardiovascular death, MI, stroke, hospitalization for HF, and resuscitated cardiac arrest . HoweverAdverse LV remodeling in post-ischemic patients has been defined firstly by echocardiography as Δ20% increase in LVEDV 6 months after STEMI, on the basis of the upper limit of the 95% confidence interval of intraobserver variability for change (%Δ) in LVEDV .Echocardiography remains an essential tool to characterize adverse remodeling by using two-dimensional (2D) and three-dimensional (3D) analysis and to predict functional recovery by speckle tracking (2D-STE), whereas contrast echocardiography improves the detection of thrombi in the left ventricle. However, cardiac multimodality imaging allows for the definition of different structural and functional aspects of remodeling, especially for the assessment of LV volumes and geometry . In thisThe importance of defining post-MI LV remodeling comes from several CMR studies that demonstrated its association with worse cardiovascular outcomes  and, conMyocardial strain consists of the deformation of the ventricular wall due to longitudinal and circumferential shortening, radial thickening, and torsion . Myocardp = 0.04). Cha et al. . Th. Th93]. LV blood flow kinetic energy (KE) assessment by 4D flow CMR has demonstrated clinical utility in LV diastolic assessment, prediction of thrombus formation, and adverse LV remodeling after MI . The KE Due to the mutual interaction between myocardial wall mechanics and intracardiac fluid dynamics, 4D flow-derived biomarkers could deepen knowledge of LV physiology and elucidate the mechanisms of cardiac remodeling associated with specific patterns of LV dysfunction. Specifically, hemodynamic forces (HDFs) are exploited to quantify the load exerted by the intracavitary blood on the myocardial wall due to blood pressure gradients generated by the cyclical contraction and relaxation of the LV myocardium . As a tiIn previous studies, heterogeneous cohorts of patients with HF and LV mechanical dyssynchrony exhibited significantly altered HDFs compared to normal subjects . In a grThe HDFs, as well as other 4D flow-based markers, may complement CMR-based assessment of LV global function, such as LV volumes, ejection fraction, and regional myocardial strain . HoweverLV remodeling in chronic MI is related to an increase in the EDV due to the presence of scar tissue, which progressively increases the risk of cardiac mortality, leading to cardiac transplantation in some cases . A surgi2. Conversely, an inadequate volume reduction of 15% results in 100% mortality at 8 years if the ESVi is >90 mL/m2 [CMR imaging has already proven to be a highly reliable, non-invasive imaging technique for the evaluation of SVR candidates . The eva90 mL/m2 .The scar extension estimation by the LGE technique allows discrimination of healthy tissue from infarcted or nonviable myocardial tissue. This is important in SVR planning because when the viable myocardium cannot be directly sutured, a patch is positioned and the scar is sutured over the patch. The excluded wall is closed over viable myocardium or the patch to reinforce the suture . As a reA recent study by Solowjowa et al.  on 205 pCMR imaging, then, is an adequate technique to evaluate patients before and after surgical ventricle restoration, providing a comprehensive assessment of anatomy and giving anatomical, functional, and tissue viability information .LV adverse remodeling is a complex biological process beginning early after MI and increasing the risk of long-term poor cardiovascular outcomes. Additionally, CMR imaging is a valuable tool in estimating adverse remodeling by accurately assessing LV volumes and myocardial deformation and by exploring myocardial tissue features . Further


Among them, we retrospectively studied 165 consecutive hypertensive patients with preserved LV ejection fraction who had echocardiography performed on the same day as a cardio-ankle vascular index (CAVI) in our hospital. The phasic function of both atria was evaluated by two-dimensional speckle-tracking echocardiography. CAVI was measured using Vasela 1500 (Fukuda Denshi®). In the univariate analysis, CAVI was significantly correlated with LA and RA conduit function . A multivariate regression analysis revealed that LA and RA conduit function was independently associated with CAVI . CAVI showed a possibility that the association between heart and vessels are contained from not only LA phasic function but also RA phasic function in hypertensive patients.Hypertension increases arterial stiffness, leading to dysfunction and structural changes in the left atrium (LA) and left ventricle (LV). However, the effects of hypertension on the right atrium (RA) and the right ventricle are still not fully understood. The purpose of this study was to clarify whether there is an interaction not only in the left ventricular system but also in the right ventricular system in hypertensive patients with preserved LV ejection fraction. The current retrospective observational study included patients ( Hypertension is one of the risk factors for cardiovascular disease and can also be a cause of atherosclerosis . InadequRecent technological advancements, such as two-dimensional speckle-tracking echocardiography (2DSTE), have enabled direct measurements of myocardial deformation indices. This technology, which can be used to detect the early stage of atrial and ventricular dysfunction before remodeling, was applied to elucidate the interaction of the left atrium (LA) and left ventricle (LV) caused by hypertension ,7. We haThe clinical characteristics of the study population are summarized in n = 29; group A = 19, B = 10, p = 0.204), concentric remodeling , and concentric hypertrophy . We performed the post hoc power analysis using G*Power software between group A and B. The detection power was 89%  in this study.The mean age was 66.5 ± 11.7 years, and 72% were men. The mean CAVI was 8.9 ± 1.2. In our study, 80 participants (48.5%) were in group B. The patients in group B were of older age, had a higher percentage of diabetes, and had higher levels of serum BNP compared to those of group A. p = 0.0001; p = 0.0001; p = 0.046; p = 0.005; As shown in p = 0.0001; p = 0.0001; p = 0.003; To clarify the correlation between CAVI and 2DSTE, simple regression analyses were performed, with CAVI as a dependent variable . CAVI wap = 0.009, and the RVFWS and CAVI was r = 0.142, p = 0.068. The RVGLS and RVFWS values were similar as follows: The RVGLS for group A was −18.9 ± 5.3 (%) and the RVFWS for group A was −18.7 ± 5.8 (%). The RVGLS for group B was −17.8 ± 4.7 (%) and the RVFWS for group A was −17.6 ± 5.3 (%). The correlation between the RVGLS and CAVI was r = 0.203, p = 0.0001), SBP , and LVGLS  were all identified as independent variables (p = 0.0001), CAVI , and E/e’  were identified as independent variables  with some risk of metabolic abnormalities  who had visited the department of cardiology division of Toho University Sakura Medical Center  and undergone echocardiography between 2015 and 2018. Among them, we retrospectively studied 165 consecutive hypertensive patients with preserved LVEF who had echocardiography performed on the same day as their CAVI. The exclusion criteria were as follows: LVEF <50%, acute myocardial infarction, old myocardial infarction, cardiomyopathy, open-heart surgery, non-sinus rhythm, atherosclerosis obliterans , pulmonary hypertensive disease, moderate or severe valvular disease, and strain analysis not available  ≥140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg or were taking antihypertensive agents. SBP and DBP were measured simultaneously during CAVI measurements using Vasela 1500. We used SBP and DBP values determined from measurements at the right side in this study. According to the American College of Cardiology/American Heart Association, the detail of hypertension was classified as follows and the results are shown in The presence of the following concomitant diseases was recorded: diabetes mellitus  or requiring antidiabetic treatment) and dyslipidemia .Patients were examined in a quiet room with a constant temperature; all the CAVI values were determined from measurements obtained using a vascular screening system  and a previously described method ,9. BriefPs and Pd are systolic and diastolic blood pressure, respectively; PWV is pulse-wave velocity from the origin of the aorta to the tibial artery-femoral artery junction; ΔP is the difference between systolic and diastolic blood pressure ; p is blood density; and a and b are constants. The CAVI value was adjusted for blood pressure based on the stiffness parameter β. We used CAVI values determined from measurements obtained from the right side in this study. The CAVI value was determined with the following equation, derived from the Bramwell–Hill equation:The CAVI values were categorized into two groups according to the current recommendation for the CAVI optimal cut-off value for predicting cardiovascular disease: <9 for normal and ≥9 for abnormal ,40. We dAll echocardiographic examinations were carried out using a commercially available system  according to the American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines . The Simr and LASr), and RA and LA pump function (RASp and LASp) corresponds to RA and LA strain at the onset of the P wave; RA and LA conduit function (RASc and LASc) is the difference between the two  . The software detects borders semi-automatically and tracks the LA and RA borders throughout the entire cardiac cycle. Cases of inaccurate endocardial detection were corrected manually. LA strain was determined as the average of values obtained for six LA segments in the apical 4-chamber and 2-chamber views, whereas RA strain was determined as the average of values obtained from apical 4-chamber views. The reference for zero strain was set at LV end-diastole (R-R triggering), in accordance with current recommendations . Strain  − LASp) A,B r and LAS − LASp) D 42,43]r and LASp < 0.05. We performed the post hoc power analysis using G*Power 3 software (Germany) between group A and B [For continuous variables, the two-tailed unpaired t-test or the Mann–Whitney U test was used; the data are presented as mean ± standard deviation or median (lower and upper limits of interquartile range), as appropriate. For categorical variables, the chi-square test or Fisher’s exact test was applied to the data, as appropriate. We analyzed the relationship between CAVI and various clinical parameters using Spearman’s correlation analysis. A multivariate analysis was performed using stepwise regression analysis with backward elimination to identify independent factors associated with CAVI and atrial phasic function. The SPSS software package  was used for all statistical analyses. Statistical significance was set at  A and B .CAVI showed a possibility that the association between heart and vessels are contained from not only LA phasic function but also RA phasic function in hypertensive patients. Hypertensive patients with high CAVI may require more attention to prevent cardiac remodeling.


Heart failure is the final destination of most cardiovascular diseases, and its complex molecular mechanisms remain largely uncertain. This study aimed to systematically investigate the underlying molecular mechanisms and diagnostic and therapeutic targets of heart failure using bioinformatics. We obtained 8 healthy samples and 8 heart failure samples from GSE8331 and GSE76701. After removing the batch effect, we performed a differential analysis on it and obtained 185 differentially expressed ID. The results of enrichment analysis showed that the molecular mechanisms of heart failure were mostly related to immune, inflammation, and metabolism-related pathways. Immune cell infiltration analysis showed that the degree of infiltration of Tgd cells and Neurons was significantly enriched in heart failure samples, whereas pDCs and NKTs were in healthy tissue samples. We obtained Hub genes including EGR1, EGR2, FOS and FOSB by PPI network analysis. We established a 4-gene diagnostic model with Hub gene, and validated it in GSE21610 and GSE57338, and evaluated the discriminative ability of Hub gene by ROC curve. The 4-gene diagnostic model has an AUC value of 0.775 in GSE21610 and 0.877 in GSE57338. In conclusion, we explored the underlying molecular mechanisms of heart failure and the immune cell infiltration environment of failing myocardium by performing bioinformatic analysis of the GEO dataset. In addition, we identified EGR1, EGR2, FOS and FOSB as potential diagnostic biomarkers and therapeutic targets for heart failure. More importantly, a diagnostic model of heart failure based on these 4 genes was developed, which leads to a new understanding of the pathogenesis of heart failure and may be an interesting target for future in-depth research. An estimated 64.3 million people worldwide have heart failure2. According to the observation data from Europe, the one-year all-cause mortality rate of heart failure exceeds 20%, which brings a heavy economic and social burden to the family and society3. Even with guideline-guided drug therapy, the prognosis for heart failure remains poor. Advanced patients often require frequent hospitalizations and lifelong medical management4. Therefore, early diagnosis of heart failure is of great significance for prognosis.Cardiovascular disease is one of the leading causes of death in humans and includes high blood pressure, arrhythmia, coronary heart disease, heart failure and other heart-related diseases. Heart failure is the ultimate outcome of most cardiovascular diseases, mostly due to structural changes in the heart or functional disorders that impair ventricular filling or ejection function5. Therefore, exploring immune responses in the progression of heart failure could also help develop new diagnostic and therapeutic approaches.The pathological hallmark of heart failure is ventricular remodeling. As far as the information that can be collected from peripheral blood is concerned, although it has the advantages of simplicity and convenience in the early diagnosis of heart failure, it is difficult to detect structural changes in the heart. Imaging tests often do not detect ventricular remodeling until after it has occurred.Therefore, exploring the changes of myocardial gene expression in patients with heart failure is helpful for the early diagnosis of ventricular remodeling in heart failure, and the underlying molecular mechanism behind it also has the value of intervening in the treatment of heart failure. In addition, immune response also plays an important role in the development of heart failure. Infiltrating immune cells release cytokines such as TGF-β1 and TNF-α, which promote heart remodeling6. In addition, even for the same disease, different data sets and different analysis methods may produce different analysis results. For example, the Vijayakrishna Kolur team concluded that HF is related to the adaptive immune system and neutrophil degranulation by analyzing GSE141910, and obtained 10 characteristic genes7. Yang et al.8 analyzed GSE21610 and believed that HF is related to G protein-coupled receptor binding, peroxisome and cAMP signaling pathways, and obtained 5 characteristic genes. Therefore, our work can complement theirs to gain a more comprehensive understanding of the molecular mechanisms of heart failure.With the rapid development of high-throughput technologies and bioinformatics, an increasing number of biomarkers show potential in the diagnosis and prognosis of heart failure, such as middle regional preatrial natriuretic peptide (MR-proANP), middle regional adrenomedullin (MR-proADM), highly sensitive troponin, soluble ST2 (sST2), growth differentiation factor (GDF)-15, Galectin-3, copeptin, Cystatin C (Cys-C) and Sirtuin (SIRT), however, more clinical evidence is needed before these markers can be used in clinicIn this study, we analyzed 2 datasets from GEO databases. Through systematic bioinformatics analysis, we obtained differentially expressed genes (DEGs) between heart failure myocardial samples and healthy heart samples, and explored the underlying pathological mechanisms of heart failure through functional enrichment analysis and PPI network analysis. We analyzed immune infiltration in failing myocardium to help us understand the role of immunity in the development of heart failure. We also constructed a four-gene diagnostic model by logistic regression analysis and validated the diagnostic model's validity in two other datasets.This study explores the underlying pathogenesis of heart failure and hopes to provide potential targets for the diagnosis and treatment of heart failure in the future.www.ncbi.nlm.nih.gov/geo/). The initial search used the keywords "Heart failure", "Homo sapiens", and "expression profiling by array". We choose GSE8331 and GSE76701 datasets of GPL570 platform as model sets. The validation set selects the same platform datasets, GSE21610 (from GPL570 platform), and other platforms datasets, GSE5733812. GSE8331 contains 4 normal human heart samples and 4 failed heart samples with reduced ejection fraction. GSE76701 also contains 4 normal hearts and 4 failing hearts. GSE21610 contains 8 samples of normal hearts, 30 samples of failing hearts before ventricular assist devices (VAD) support and 30 samples of hearts after VAD support. We select 8 normal heart samples and 30 failing heart samples before VAD support as the validation set. GSE57338 is a dataset of 313 samples consisting of normal samples, ischemic left ventricle samples, and idiopathic dilated CMP left ventricle samples. We select 85 healthy samples and 72 failed heart samples among them as the validation set.The expression dataset of cardiac RNAs was collected from the online GEO database |≥ 1 as differential genes. Use the ggplot2 package and the pheatmap package to complete the drawing of the picture16.We used R software (R version 4.2.0) for data preprocessing. Download GSE8331 and GSE76701 from the GEO database via the GEOquery package. Remove probes that correspond to multiple molecules for one probe. For multiple probes corresponding to the same molecule, only the probe with the largest signal value is retained. The filtered data will use the ComBat function of the sva package to remove batch differences. Check the standardization through the box plot, and check the clustering between the sample groups through the PCA plot and the UMAP plot. We used the limma package for differential analysis of heart failure samples and normal samples, and selected genes with 20. Use the GOplot package to combine the log2(FC) of the differential genes to calculate the Z-score value corresponding to each entry21. To avoid ignoring genes that are not significantly different but have important functions, we performed Gene Set Enrichment Analysis (GSEA) on all genes22.To further analyze the function of myocardial expression profiles, we performed Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genes (KEGG) enrichment analysis of DEGs using the clusterProfiler package23. Differences in cell distribution between the heart failure group and the normal group were compared by t-test, and the cut-off value was set at p < 0.1. In addition, we used Spearman's correlation coefficient to evaluate the strength of correlation between cells. The visualization part is done using the ggplot2 package.We used the xCell package  to assess the content of immune and stromal cells in cardiac samples to delineate the cellular heterogeneity landscape of cardiac expression profiles24. Subsequently, we imported the results into Cytoscape 3.6.1 for visualization and subsequent analysis25. In Cytoscape, we use the MCODE plugin to identify highly interconnected clusters with cutoff parameters set as follows: degree cutoff = 3, node score cutoff = 0. 2, k-Core = 2, Max. Depth = 100. The Hub gene was further screened with MCODE score > 4 as the standard26.We uploaded the list of DEGs to the STRING database (string-db.org) to detect protein interactions with the following settings: Network type: full STRING network, meaning of network edges: evidence, minimum required interaction score: medium confidence (0.400)We validated the Hub genes screened in the PPI network in GSE21610  and GSE57338 . We used the pROC package to build diagnostic models of single genes and combined genes, and evaluated the discriminative ability of key genes and diagnostic models by ROC curves.p-value < 0.05 and |log2(FC)|≥ 1, including 136 mRNAs, 46 LncRNAs and 3 unclassified genes. Figure We combined the expression profiles of healthy heart samples and failing heart samples from GSE8331 and GSE76701 datasets of the GPL570 platform into a merged dataset containing 8 healthy samples and 8 disease samples. As shown in Fig. To evaluate the function of DEGs, we combined the log2(FC) of DEGs to perform GO and KEGG enrichment analysis, and the results are shown in Table p-value < 0.05, including Extracellular matrix organization, Genes encoding secreted soluble factors, Ensemble of genes encoding core extracellular matrix including ECM glycoproteins, collagens and proteoglycans, Cytokine-cytokine receptor interaction, and Diseases of metabolism. The visualization results are shown in Fig. To assess the contribution of genes in the dataset in phenotypes, we performed GSEA enrichment analysis on them. The data set is C2.Cp, the random number seed is 2020, and the calculation is performed 1000 times. Each gene set contains between 10 and 500 genes. We visualized the top five datasets that met the criteria of FDR < 0.25 and xCell was used to assess cellular composition heterogeneity between heart failure samples and healthy samples. As shown in Fig. We entered the DEGs into the STRING database for PPI network construction, and finally identified 64 nodes and 73 interactions. In addition, we identified a Hub gene module with 4 nodes and 6 edges by MCODE, and the results are shown in Fig. We identified the composition of the Hub gene module as EGR1, EGR2, FOS and FOSB in the PPI network, all of which were up-regulated genes. We established ROC curve analysis to validate the diagnostic value of selected biomarkers. In the diagnostic model of a single gene, only EGR1 has high diagnostic value, and the AUC of other genes is not high. However, the combined genome has a high diagnostic value for heart failure. We constructed diagnostic models of Hub genes in different datasets by logistic regression and visualized them with ROC curves. The results are shown in Fig. HF is a major public health challenge. The use of drugs such as ARNI and dapagliflozin has also greatly improved the prognosis of heart failure. However, if the occurrence of heart failure can be detected earlier and the treatment can be intervened as soon as possible, the benefit of patients will be greater. In recent years, bioinformatics research has made great progress in the field of heart failure, and breakthroughs have been made in both the diagnosis of heart failure and the underlying molecular mechanisms. Integrating more biomarkers can comprehensively intervene in the diagnosis and treatment of heart failure. In addition, exploring related processes such as immune cells and pathways in the physiological and pathological processes of heart failure can also provide potential diagnostic and therapeutic targets to a certain extent.In this study, we integrated 16 samples from 2 datasets and analyzed the data using bioinformatics.In the GO enrichment analysis results, the main ones involved in heart failure were response to lipopolysaccharide, phosphatidylserine binding, and protein tyrosine kinase activator activity.28. Lipopolysaccharide is a cell wall component of Gram-negative bacteria and has a strong pro-inflammatory effect. Some researchers concluded that even a small concentration of lipopolysaccharide can effectively induce the release of TNFα in an in vitro whole blood model of heart failure patients29. Their study also demonstrated that response to lipopolysaccharide predicts survival in patients with chronic heart failure30. This suggests that maintaining the function of immune cells and the immune system is essential in the treatment of heart failure.The cytokine hypothesis states that the progression of heart failure is attributable to sustained proinflammatory cytokine signaling. TNFα has been shown to induce cardiomyocyte dysfunction, cardiomyocyte fibrosis, and negative inotropic effects, and its elevation is associated with cardiac fibrosis, ventricular dilatation, and mortality31. Cardiomyocyte apoptosis is a key regulator in the development of heart failure32. Therefore, phosphatidylserine can be employed as an early diagnostic indicator of heart failure. It may be also given potential therapeutic value in heart failure by modulating phosphatidylserine binding.Phosphatidylserine is located on the cytoplasmic lobe of the plasma membrane bilayer. Energy loss during cellular injury or apoptosis results in disruption of plasma membrane asymmetry, resulting in surface exposure of phosphatidylserine. Subsequently, macrophages recognize damaged cells and complete the elimination of apoptotic cells. Modulation of membrane fluidity or phosphatidylserine binding can affect this process33. Therefore, maintaining the activity of protein tyrosine kinase activators may reduce the cardiotoxicity of antitumor drugs.Tyrosine kinases are enzymes that catalyze the transfer of phosphate from ATP to tyrosine residues in polypeptides. The small molecule tyrosine kinase inhibitor imatinib is a targeted drug for the treatment of chronic myeloid leukemia, but its cardiotoxicity can cause heart failure. In cardiomyocytes, ABL functions to maintain endoplasmic reticulum homeostasis. Imatinib induces endoplasmic reticulum stress, activates the PERK signaling pathway, and produces mitochondrial dysfunction34. Glutathione metabolism is also involved in endoplasmic reticulum stress and oxidative stress, and 5-oxoproline, the final product of Chac1 enzyme involved in metabolism, is also an important factor leading to heart failure35.In addition, in recent years, studies have found that ferroptosis is also associated with the occurrence of heart failure, which is related to the excessive production of ROS and the inhibition of glutathione synthesis by GPX436. The primary physiological importance of cytochrome P450 enzymes lies in their ability to metabolize arachidonic acid to epoxyeicosatrienoic acid and hydroxyeicosatetraenoic acid metabolites, which play a role in maintaining cardiac homeostasis38. In short, in the KEGG enrichment results, DEGs mainly interfere with heart failure by affecting metabolism-related pathways.In the KEGG pathway enrichment analysis results, Glutathione metabolism and Drug metabolism—cytochrome P450 are mainly involved in heart failure. Abnormal intracellular glutathione metabolism is related to increased free radical production in chronic heart failure. Therefore, glutathione can be used as a marker for evaluating lipid peroxidation in heart failure39. Therefore, the extracellular matrix can not only be used as an indicator to evaluate cardiac homeostasis, but also can be used to design more effective anti-fibrotic cardiac regeneration strategies40. From the results of enrichment analysis, the molecular mechanism of heart failure is closely related to inflammation, metabolism, oxidative stress and immunity.Among the GSEA enrichment results, extracellular matrix organization and Diseases of metabolism were mainly involved in heart failure. The cardiac extracellular matrix contains a dynamic molecular network that provides structural support to cardiac tissue. Its renewal is an important process of cardiac remodeling. Excessive activation of pro-inflammatory cytokines such as TNFα promotes this process41. By regulating the IL-17A/Tgd cells axis, it can effectively regulate the level of inflammation and slow down the process of myocardial fibrosis43. The enrichment of Neurons in heart failure samples may be related to the increase of cardiac sympathetic nerve activity and the enhancement of N-type Ca2 + currents44. pDC and NKT are higher in healthy sample tissues, which is slightly different from previous studies47, and the specific mechanism behind it remains to be further studied.Immune cell infiltration analysis showed that the degree of infiltration of Tgd cells and Neurons was significantly enriched in heart failure samples, whereas pDCs and NKTs were in healthy tissue samples. Cytotoxicity is the main biological effect of Tgd cells. Studies have shown that IL-17A secreted by Tgd cells can induce cardiomyocyte apoptosis48. Studies have shown that inhibiting the expression of EGR1 can slow myocardial fibrosis and thus treat heart failure49. EGR2, which belongs to the EGR family, has pro-inflammatory and pro-apoptotic effects. EGR2 can directly activate the expression of pro-apoptotic proteins such as BCL2 family and BINP3L, and can also upregulate inflammatory proteins such as IFNG and IL650. Studies have shown that inhibition of EGR2 expression via lncRNA and miRNA can alleviate cardiac apoptosis and protect the heart from ischemic injury52. FOS and FOSB belong to the FOS gene family and are regulators of cell proliferation, differentiation, and transformation. In the early stage of cardiac remodeling, c-fos and c-jun were up-regulated, and the two dimerized to form the transcription factor complex AP-1, followed by the up-regulation of inflammatory factors NF-kappa B and NFAT. In late stage, genes involved in cardiac hypertrophic response such as ANP and BNP are up-regulated54. Therefore, the FOS family can be used as an early diagnostic marker of cardiac remodeling and a target for early intervention in the treatment of heart failure.According to PPI network analysis, we obtained Hub genes, including EGR1, EGR2, FOS and FOSB. EGR1 is widely present in human cells and has the ability to express rapidly, playing an important role in cell growth, differentiation, proliferation, and inflammatory responsesThe novelties of our study are as follows. First, we analyzed the molecular mechanisms of heart failure related to immunity, inflammation, and metabolism through bioinformatics. Second, we identified EGR1, EGR2, FOS and FOSB as potential diagnostic biomarkers and therapeutic targets for heart failure. The diagnostic model based on these 4 genes provides a new idea for our future research on the molecular mechanism of heart failure. Nevertheless, this study still has some shortcomings. First, we were unable to determine whether there was a causal relationship between differences in gene expression and the physiopathological mechanisms of heart failure. Secondly, myocardial tissue sampling is often ranked after peripheral blood examination and imaging examination in clinical practice, and the sampling cost is high and the clinical value is limited. Finally, the lack of medication and prognostic data in the GEO database limited further analysis of differential genes. Although our results were validated in two datasets, further clinical trials are needed to confirm our findings.In summary, we explored the underlying molecular mechanisms of heart failure from the enrichment analysis and immune cell infiltration environment by bioinformatics analysis of the GEO dataset, which provided new ideas for the pathogenesis and treatment of heart failure. Through PPI network and logistic regression, we identified EGR1, EGR2, FOS and FOSB as potential diagnostic biomarkers and therapeutic targets for heart failure. More importantly, a diagnostic model of heart failure based on these 4 genes was developed, which leads to a new understanding of the pathogenesis of heart failure and may be an interesting target for future in-depth research.


Cardiac complications are important causes of morbidity in patients with thalassemia intermedia (TI). We aimed to assess left ventricular (LV) function, using new tissue Doppler imaging (TDI) indices, in order to diagnose early ventricular impairment in asymptomatic children and adolescence with the TI.We investigated possible differences in echocardiographic systolic and diastolic parameters between a population of 28 asymptomatic patients  and 35 age-matched healthy control members. All of them underwent 2-D, pulsed Doppler, and tissue Doppler echocardiographic studies for the assessment of the LV mass, Trans-mitral velocities, mitral annular systolic and diastolic velocities, myocardial performance index (MPI), and myocardial acceleration during isovolumic contraction (IVA). The cardiac iron load was estimated by magnetic resonance imaging T2*.p < 0.05). Choosing a TDI-derived MPI > 0.33 as a cutoff point, the global LV dysfunction was detected with a sensitivity of 78% and a specificity of 80%. The patients with LVH significantly exhibited higher values of TDI-MPI and lower values of s′ velocity and IVA when compared against the subjects with normal LV mass.Left ventricular hypertrophy (LVH) was found in 13 (46.4%) patients. We found significantly reduced TDI-derived peak systolic myocardial velocity (s′) in patients, whereas no significant difference was identified between the patients and control group members when the IVA was compared. The ratio of peak mitral inflow velocity to annular early diastolic velocity (E/e′) of the mitral valve as an index of the diastolic function was significantly higher in patients (9 ± 1 vs. 6 ± 1, Subtle LV systolic and diastolic dysfunction develops early in young patients with the TI who have normal cardiac iron concentration. Moreover, LV remodeling as a main cardiac adaptive response plays a principal role in developing myocardial impairment. Thalassemia disorders are the most common inherited hemoglobinopathies with high prevalence in certain regions of the world. Even though individual patients with thalassemia intermedia (TI) have less severe hemolytic anemia than the thalassemia major, they have a heterogeneous clinical presentation –4.Cardiac involvement is one of the most common age-related causes of morbidity in these patients , 5, 6. DCardiac involvement has been mainly characterized by pulmonary hypertension followed by right heart failure in middle-aged patients with TI; however, recent reports have revealed subtle left ventricular (LV) impairment and remodeling in young patients who have no clinical sign of cardiac failure –12. In tMost of the previously published echocardiographic studies revealed conflicting information on the LV function, mainly because of the strong influence of high output states on the echocardiographic indices and the unique pattern of left ventricular geometry , 15, 16.Although latent LV abnormalities have been studied in the adult with TI, there is less research on LV function in children and adolescence , 11.Thus, the aim of our research was to evaluate the LV function and also LV remodeling, using new pulsed Doppler (PWD) and tissue Doppler echocardiographic indices in young TI subjects with normal cardiac iron concentration to identify the latent myocardial involvement. Also, we assessed the utility of a new tissue Doppler parameter, the myocardial acceleration during isovolumic contraction (IVA), as a marker of ventricular contractility among the patients –21.To the best of our knowledge, there is no previous report on the utility of these new echocardiographic indices for the diagnosis of subclinical LV dysfunction in children and adolescents with TI.We enrolled 28 consecutive patients with TI , who were referred for their routine cardiac follow-up. Data from all the patients were retrieved for clinical and hematological evaluation. None of the patients had received a regular transfusion or chelating agents. The inclusion criteria were as follows: (1) age 7–21 years, (2) asymptomatic for heart failure , (3) normal renal and thyroid function, and (4) the absence of congenital or acquired heart disease. The mean serum ferritin value and mean hemoglobin level have been derived from the mean of the three values obtained over the last 3 years. The cardiac iron load was measured by magnetic resonance imaging T2*(MRI T2*). Cardiac iron overload was described as cardiac T2* < 20 ms. A total of 35 age-matched healthy children were selected as controls from cases referred to our department for investigation of a heart murmur.The cardiac investigation was performed during the periodic follow-up of the patients. An echocardiographic study was performed within 6 months of cardiac MRI evaluation. It is worth mentioning that the protocol was approved by our institutional review board.Complete M-mode, two-dimensional, Pulsed Doppler (PWD), and tissue Doppler echocardiographic examinations were performed by a physician who was unaware of the status of the cases.Measurements were performed as stated in the guidelines of the American Society of Echocardiography . All of All of the study subjects were in sinus rhythm. All of the echocardiographic findings were compared between the TI cases and control subjects.2.7  using two-dimensionally directed M-mode echocardiography. The LVM was calculated using the formula as previously described . The LV 2.7 , 24. TheThe LV ejection fraction (LVEF), stroke volume, and cardiac index were obtained using the biplane Simpson’s methods . ReducedLeft ventricular systolic and diastolic functions were also evaluated by using the PWD trace of the mitral valve and pulsed tissue Doppler at the basal septal and basal lateral segments of the mitral annulus.Standard PWD parameters including the peak of early (E) and late (A) diastolic flow velocities were recorded at the tips of the mitral valve leaflets. Pulsed wave tissue Doppler was used to record the velocity profile of the mitral annulus from the apical 4-chambered view. The mean values of longitudinal myocardial velocities including peak early diastolic (e′), late diastolic (a′), and also peak systolic (s′) velocity were measured from the basal septal and basal lateral segments of the mitral annulus.Then, we calculated the ratio of the peak diastolic flow velocity of mitral inflow (E) to peak e’ velocity (E/e′ ratio) as the best non-invasive marker of the LV filling pressure. According to the average of E/e′ ratio in the lateral and septal wall of the mitral valve, patients were categorized into three groups as follows: patients with E/e′ ≥ 14 (diastolic dysfunction and elevated filling pressure), patients with 8 < E/e‘ < 14 (suspected diastolic dysfunction), and those with E/e′ ≤ 8  .The LV-IVA, as an index of the contractile state of the myocardium, was also measured by TDI at the basal lateral side of the mitral annulus. It was defined as the first positive deflection in the tissue Doppler profile at the end of the a′ wave. A line was drawn from the onset of the wave to its peak, and then a slop was measured ; 26.Moreover, the myocardial performance index (MPI), a marker of global ventricular function, was also determined by both PWD and TDI. To obtain PWD-MPI of the left ventricle, Doppler time intervals were recorded as proposed by Tei et al. TDI-MPI was calculated from the tissue Doppler spectra of the septal mitral annulus ; 27–29.t-test or Mann–Whitney U-test, based on whether the variables followed a normal distribution or not. Pearson and linear regression analyses were utilized to evaluate potential relationships between variables. The appropriate cutoff values for variables were identified based on previous reports or using receiver-operator characteristic (ROC) curves. Then, a t-test was used to compare continuous variables  between two categorical groups based on the identified cutoff values. The prediction of the global LV function was carried out through an analysis of the ROC curves for MPI. To assess intra-observer variability, the observer performed repeated measurements of all echocardiographic variables in 8 patients. Then, intraclass correlation coefficients were calculated using SPSS statistical package version 26 . A p-value less than 0.05 was considered significant.Continuous data were checked for normality using the Kolmogorov-Smirnov test and expressed as mean ± SD or median as appropriate. Mean values were compared with each other in the study groups using the Student’s The demographic data and hematological profile of the study population are summarized in History of the previous transfusion was observed in 11 patients (once in seven patients and three times in four patients). All of the subjects were normotensive. The heart rate in TI cases was not significantly different from that of the control group, and the body surface area did not differ between the two groups as well. Splenectomy was performed in 11 patients (39.2%). None of the patients revealed evidence of cardiac iron overload .r = 0.61, p < 0.05). However, no association was found between LVMI and age and also between the mean hemoglobin level and mean serum ferritin concentration.Ventricular diameters, LVMI, stroke volume, and cardiac index were all significantly greater in patients . LVH wasp < 0.05), but myocardial diastolic velocities did not differ between patients with TI and control subjects . Regarding the LV longitudinal systolic function, the myocardial systolic velocity (s′) was significantly different between the patients and control group . According to data from the literature, we considered an s′ wave value less than 7.9 cm/s as a cut point for impaired LV longitudinal contractility. Accordingly, a reduced peak systolic velocity was observed in nine patients (32.1%). Mean age and LVMI were significantly higher in patients with s′ < 7.9 cm/s in comparison with those with s′ > 8 cm/s . Our finding is in favor of the essential effect of progressive LV remodeling on impaired longitudinal myocardial contractility. Association was observed neither between the s′ velocity and mean hemoglobin, nor between the serum ferritin level and s′ velocity. When we assessed the LV contractility state by the measurement of IVA, no significantly different values were found between the patients and control group . However, the IVA value was observed to have a negative relationship with the existence of LVH in patients .Moreover, an inverse relationship was observed between the s′ wave velocity and LVMI (p < 0.05). Furthermore, we found a higher E/e′ ratio in patients with TI in comparison with control subjects, which is in favor of the abnormal LV diastolic function . The peak systolic myocardial values (s′) were lower in the patients with E/e′ > 8 in comparison with the patients with a normal E/e′ ratio, but the difference was not significant . No significant correlation was found between the serum ferritin level and E/e′ ratio either.Evaluation of the LV diastolic function at mitral inflow displayed an increased peak with early and late filling velocities that were compatible with the high cardiac output state; however, only the peak E-value was significantly higher in patients compared to controls . Considering the ROC curve analysis, the TDI -MPI produced an area under the curve of 0.84 to discriminate the patients with and without latent LV dysfunction. Choosing a TDI-MPI > 0.33 as a cutoff value, the LV dysfunction was found with a sensitivity of 78% and a specificity of 80%. The obtained values for PWD-MPI were also higher than the values in normal subjects . The PWD-MPI cutoff value of >0.35 indicated subclinical LV dysfunction with a sensitivity and specificity of 64 and 91%, respectively  and increased the LV end-systolic volume diameter . These findings highlight the essential role of chronic volume overload in the pathogenesis of the LV dysfunction.The MPI, as an indicator of the global LV function obtained by the tissue Doppler method, was significantly higher in patients than in the control group , and moderate for e’ velocity (0.72).The left ventricular function has not been widely investigated in children or adolescence with TI, a disease that has been usually characterized by late-onset pulmonary hypertension followed by right heart failure. In this study, using more sensitive echocardiographic methods, abnormal LV geometry and slight impairment in the LV function were identified in young patients with TI who had no evidence of cardiac iron overload.Individuals with TI often have a high cardiac output state and increased LV dimensions secondary to chronic hemolytic anemia , 30. Difr = 0.56) and with greater LV mass as well (r = 0.54) that were compatible with a high cardiac output state secondary to chronic anemia. These findings are in concordance with previously reported data on more increased LV volumes and mass in patients with TI than in those with the thalassemia major. These studies also emphasized the essential role of the chronic high cardiac output state in the pathogenesis of LV remodeling . Our observation was in line with previous studies and supported the primary role of the high cardiac output state and its compensatory reactions for developing cardiac complications in patients with TI without iron overload  by the TDI, which is relatively independent of volume load, may give early and reliable information to identify subclinical myocardial dysfunction in comparison with conventional methods –52. In aAlthough the TDI-derived systolic myocardial velocity is accepted as a reliable parameter for detecting subclinical LV dysfunction, the measurement of the IVA may provide further information on myocardial contractility in patients with abnormal geometry , 53. The2, p < 0.05), suggesting the primary role of the LV remodeling on impaired myocardial longitudinal contractility. However, no correlation was found between the IVA and LVEF in patients with and without the LVH. Our findings regarding the diagnostic value of the IVA in detecting subtle myocardial contraction abnormalities were in concordance with findings of other researchers in patients with congenital heart disease or hypertensive cardiomyopathy (Despite the increasing use of the IVA as an index of the myocardial systolic function, the IVA values which may predict LV systolic dysfunction in children have not yet been fully established , 56. Altmyopathy , 58. HowPrevious studies describing the LV diastolic function have shown more conflicting data in patients with TI. Some studies demonstrated that both the LV volume loading and high cardiac output level influenced the echocardiographic measurements of the LV diastolic function, mimicking a restrictive pattern of mitral inflow when assessed by conventional methods , 38. RecThe relatively small population of the study subjects is a limitation of our research that precludes a more perfect evaluation of echocardiographic indices of the LV function; however, the population size satisfies the minimum requirements of the statistical tests conducted.Although the E/e′ ratio was shown as the sensitive Doppler measurement to estimate the LV filling pressures in patients with the preserved systolic function, the presence of a single index, which does not fall within the normal range, does not necessarily indicate the abnormal diastolic function. Consequently, the lack of further characterization of the group with the intermediate E/e′, due to small population of patients, is the main limitation of this study. In contrast, because of the lack of diastolic function parameters validated for younger patients, we have to rely on recent guidelines derived from adult studies. Moreover, previous studies have shown a wide range of normal values in children which adversely affect the interpretation of the diastolic function.The use of the apical echocardiographic views to assess the mitral annulus velocities is an attempt to focus on the long-axis motion of the left ventricular myofibrils. However, the motion of the mitral annulus is not entirely due to longitudinal contraction but rather is the sum of longitudinal, spiral, and circumferential contraction. The effects of each of these may vary from a patient with normal geometry to those with the LV remodeling. Although other studies have demonstrated the impact of the IVA for assessing ventricles with abnormal geometry, the greatest limitation of the IVA is reproducibility.We presented substantial LV remodeling, and subtle systolic and diastolic abnormalities in asymptomatic young patients with TI with normal cardiac iron concentration. Our findings suggest that the LV remodeling, which is a primary and basic adaptation response to high cardiac output state, might be the first stage in developing the LV failure.Both myocardial systolic velocity and the MPI obtained by the TDI appear to be sensitive parameters for detecting asymptomatic thalassemic myocardial dysfunction. The increased value of the E/e′ ratio in the majority of the patients may be considered an early indicator of latent diastolic impairment. The prognostic significance of these findings for the identification of patients at risk of progressive heart failure and also the diagnostic impact of the above-mentioned parameters to modify the routine approach for follow-up of these patients are yet to be confirmed by further studies.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The ethics committee approved the study of the Iran University of Medical Sciences with the code number: IR.IUMS.REC 90-02-30-13156, and all patients signed an informed written consent form prior to entering the study. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.RI and KA contributed to the conception and design of the study. RI and FS wrote the sections of the manuscript. RI performed the statistical analysis. KA and MR collected the patient’s information. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.