Sympathetic hyperactivity may be related to left ventricular (LV) dysfunction and baro- and chemoreflex impairment in hypertension. However, cardiac function, regarding the association of hypertension and baroreflex dysfunction, has not been previously evaluated by transesophageal echocardiography (TEE) using intracardiac echocardiographic catheter.We evaluated exercise tests, baroreflex sensitivity and cardiovascular autonomic control, cardiac function, and biventricular invasive pressures in rats 10 weeks after sinoaortic denervation (SAD). The rats (n = 32) were divided into 4 groups: 16 Wistar (W) with (n = 8) or without SAD (n = 8) and 16 spontaneously hypertensive rats (SHR) with (n = 8) or without SAD (SHRSAD) (n = 8). Blood pressure (BP) and heart rate (HR) did not change between the groups with or without SAD; however, compared to W, SHR groups had higher BP levels and BP variability was increased. Exercise testing showed that SHR had better functional capacity compared to SAD and SHRSAD. Echocardiography showed left ventricular (LV) concentric hypertrophy; segmental systolic and diastolic biventricular dysfunction; indirect signals of pulmonary arterial hypertension, mostly evident in SHRSAD. The end-diastolic right ventricular (RV) pressure increased in all groups compared to W, and the end-diastolic LV pressure increased in SHR and SHRSAD groups compared to W, and in SHRSAD compared to SAD.Our results suggest that baroreflex dysfunction impairs cardiac function, and increases pulmonary artery pressure, supporting a role for baroreflex dysfunction in the pathogenesis of hypertensive cardiac disease. Moreover, TEE is a useful and feasible noninvasive technique that allows the assessment of cardiac function, particularly RV indices in this model of cardiac disease. The arterial baroreflex (ABR) system is one of the most powerful and rapidly acting mechanisms for controlling blood pressure (BP) and heart rate (HR). Also, it has a prognostic value in many cardiovascular diseases. In arterial hypertension, sympathetic hyperactivity seems to be related to baro- and chemoreflex impairment and left ventricular (LV) dysfunction. One method of studying ABR dysfunction is the interruption of ABR by sinoaortic denervation (SAD) In the case of spontaneously hypertensive rats (SHR), which is a genetic model of hypertension, this disease has been accompanied by moderate BPV and severe LV hypertrophy. However, a relevant issue not previously shown in SHR that have undergone SAD is the noninvasive determination of detailed cardiac function, particularly RV function, the use of tissue Doppler indices, and the indirect estimation of pulmonary artery pressure.Transesophageal echocardiography (TEE) can be performed in animals by using an intracardiac echocardiographic catheter (ICE) and may be useful for a comprehensive cardiac evaluation in small animal echocardiography Experiments were performed in 2 month of age adult male Wistar (W) and spontaneously hypertensive rats (SHR) obtained from the Animal House of the University of São Paulo, São Paulo, Brazil. The rats (n = 32) were divided into 4 groups: 16 Wistar (W) with (n = 8) or without SAD (n = 8) and 16 SHR with (n = 8) or without SAD (SHRSAD) (n = 8). Ten weeks after SAD, cardiac function was evaluated by exercise testing (ET) at day 1, TEE and transthoracic , femoral artery and vein catheters were inserted for direct measurements of BP, HR, and drug administration at day 3, hemodynamic and autonomic measurements were performed at day 4 and 5, invasive evaluation of biventricular pressures were obtained at day 6, animal sacrifice and the heart was removed at day 7. Rats were housed in standard cages and fed with standard laboratory chow and water ad libitum. The animals were housed in collective polycarbonate cages in a temperature-controlled room (22°C) with a 12-hour dark-light cycle (light 07∶00–19∶00 h). The experimental protocol was approved by the institutional Animal Care and Ethics Committee of the University of São Paulo Medical School, and this investigation was conducted in accordance with the previously described ethical principles in animal research adopted by the Brazilian College of Animal Experimentation (COBEA) and the principles of the Declaration of Helsinki.SAD was performed with the rats anesthetized with Ketamine  and Xylazine . A 3-cm midline incision was made, and the sternocleidomastoid muscles were reflected laterally, exposing the neurovascular sheath Maximal exercise test was performed on a treadmill  using a protocol as previously described The animals were anesthetized with Ketamine  and Xylazine , had their chest shaved, were intubated and placed on small-animal ventilator model 683 . Heart rate was evaluated by simultaneous electrocardiographic monitoring. After lubrication, a monoplane ICE  with 10 F and multiple frequency of 5.5–10 MHz was inserted into the esophagus, posterior to the left atrium. This catheter has a transducer at its tips and generates M-mode, 2-dimensional, spectral Doppler and color Doppler images Transthoracic echocardiography was performed in all the animals after TEE, with a Sequoia 512 machine  equipped with a 10–13 MHz multifrequency linear transducer, as previously described RWT = 2×PWd/LVd, was calculated.LV fractional shortening (FS), was calculated as:Acceleration time (AcT) and TT of the RV outflow and its ratio were obtained at parasternal short-axis view at the level of aorta/left atrium.Ten weeks after SAD, animals were anesthetized with Ketamine  and Xylazine ; femoral artery and vein catheters (PE-lO) filled with 0.06 mL saline solution were inserted for direct measurements of BP, HR, and drug administration. The rats were conscious and allowed to move freely in the cage during the experiments. Twenty-four hours after catheterization, the arterial catheter was connected to a transducer , and BP signals were recorded in conscious, freely moving rats, over a 30-minute period by a microcomputer equipped with an analog-to-digital converter board . The recorded data were analyzed on a beat-to-beat basis to quantify changes in mean BP and HR. Both HR variability (HRV) and BPV were analyzed in time  and frequency domains  8 over 16 384 points with a Hanning window (512) and 50% overlapping. Spectral power for very low frequency , low frequency , and high frequency  bands were calculated by power spectrum density integration within each frequency bandwidth using a customized routine  For baroreflex assessment, increasing doses of phenylephrine (0.25 to 32 ug/kg) and sodium nitroprusside (0.05 to 1.6 ug/kg) were given as sequential bolus injections (0.1 mL) to induce either an increase or decrease in BP, ranging from 5 to 40 mm Hg, and subsequent bradycardic or tachycardic responses to these BP changes Left ventricular and RV functions were measured invasively in anesthetized rats . A polyethylene P50 catheter was inserted in the jugular vein to the RV, and signs of end-systolic (ESP) and end-diastolic pressures (EDP) of the RV were recorded for 5 minutes on a microcomputer equipped with a data acquisition system, at a sampling frequency of 2000 Hz per channel  All data are expressed as mean ± SD. Comparisons of normally distributed continuous variables were performed with 2-way analysis of variance (ANOVA) then followed by Student-Newman-Keuls and Kruskal-Wallis tests for multiple comparisons. The Pearson or Spearman correlation coefficient was used to analyze the relation between noninvasive and invasive indices. Normality was determined by the Shapiro-Wilks test. P<0.05 was considered statistically significant. Statistical analysis was performed with SPSS v 17 .2; *SAD: 49 mmHg2; *SHR: 60 mmHg2; *SHRSAD: 137 mmHg2, *p<0.05 vs. W, Blood pressure and HR did not change between the groups with and without SAD, although SHR had higher BP levels compared with W. BP variability was increased in SHR groups compared to W. After SAD, BP variability increased in all groups compared to W  was increased compared to that in SAD (0.9±0.2 km/h). Similarly, SHRSAD (1.0±0.3 km/h) compared to SHR had decreased maximal velocity .The W group had values intermediate between the other groups, did not have low values as the SAD and SHRSAD, nor high values as SHR, but did not differ between groups (1.16±0.11 km/h).RV maximal volume increased in SHR compared to W and SAD, and RV minimal volume increased in SHR and SHRSAD compared to W . Right vLV diastolic function showed that SHR and SHRSAD increased IVRT compared to W. Also, SAD presented increased AFF compared to W . RV diasTissue Doppler imaging showed that S’ of the septum was reduced in SHRSAD compared to SAD and SHR. At the lateral mitral annulus, SHRSAD presented decreased S’ compared to W. At the tricuspid annulus, SHRSAD showed diminished S’ compared to W and SAD . Also, tMyocardial performance index increased in SHR compared to SAD. Also, MPI TDI of the lateral region of the mitral annulus increased in SHRSAD compared to SHR .All groups had a reduction of AcT compared to W and SHR, reflecting a possible increase in pulmonary artery pressure in all groups .The amount of data gathered from M-mode echocardiography suggests concentric hypertrophy in SHR and SHRSAD compared to the other groups . Left atDifferent from TEE, TTE showed that all groups had both reduced TAc and AcT/TT compared to W .Biventricular EDP was increased in all groups compared to W . Also, eThere was a negative correlation between AcT of RV outflow velocity and RV EDP , a positive correlation between RV maximal volume and LV mass/weight , and a positive correlation between AcT of RV outflow by TTE and TEE .We performed the relation between invasive and echocardiographic indices .In the present study, we found that 10 weeks after SAD, baroreflex sensitivity impairment significantly changed the morphological, functional, and hemodynamic cardiac variables in W and SHR. Also, denervated animals did not have altered BP and HR, but did have increased BP variability and decreased functional capacity. Also, baroreflex dysfunction participated in RV impairment, first demonstrated noninvasively here, by transesophageal echocardiography.Krieger first described SAD in rats in 1964, and this technique has been useful to assess the baroreflex role in both physiological and pathological situations In our study, SHR with/without SAD had increased LV mass, relative wall thickness, indicating concentric LV hypertrophy LV diastolic function showed that only IVRT was different between groups, which was greater in SHR with/without denervation compared to W, reflecting LV diastolic dysfunction in hypertension. This parameter was reduced in SHRSAD compared to SHR. This finding could indicate advanced diastolic dysfunction, as LA size was increased in SHRSAD, but not in SAD. A previous study from our group showed that diastolic function was worse in denervated normotensive animals, independent of BP variability Left ventricular global myocardial function by pulsed-wave MPI was increased in SHR compared to W, as expected. However, the same index analyzed by LV TDI was increased in SHRSAD compared to SHR, suggesting that baroreflex dysfunction could induce an additional impairment in this index. The importance of our findings is that the MPI has prognostic value in many cardiopathies, including pulmonary artery hypertension Different from our previous study, we did not find LV morphological alterations in SAD in the present study. This finding could be related to the denervation process, which is not always homogeneous in all animals, as some afferent fibers have a different path to the central nervous system, via the vagal nerve, for instance.et al found an increase in RV mass of 22% and a decrease in 6% in body weight (unpublished data).Considering the high BPV variability in hypertension, in SAD and the association of both, RV hypertrophy has been described RV assessed by TEE showed increased maximum and minimum volumes in hypertensive animals, denervated or not, suggesting that hypertension associated or not with LV dysfunction may be related to RV dysfunction. Although previous guidelines have suggested that the RV area, and not volume, be measured, here we studied the volumes that could also reflect RV alterations, as they were obtained by 2-dimensional echocardiography End-diastolic RV pressure was greater in experimental groups compared to W, indicated that SAD with/without hypertension was related to right ventricular diastolic dysfunction.Possibly, the decrease in acceleration time of RV outflow in SAD, SHR, and SHRSAD indicates increased pulmonary artery pressure and its consequent RV hypertrophy, especially because the denervation included the resection of the afferent chemoreceptors. Moreover, we agree with Van Vliet We found that baroreflex dysfunction impairs biventricular and LA functions, and increases pulmonary artery pressure, particularly in hypertensive rats, supporting a role for baroreflex dysfunction in the pathogenesis of hypertensive cardiac disease. Also, TEE is a useful and feasible noninvasive technique allowing the assessment of cardiac function, particularly RV indices in this model of cardiac disease. Our data was supported by concomitant invasive measurements.It was necessary to perform orotracheal intubation to perform TEE, because respiratory depression occurred by the manipulation of the TEE transducer in the esophagus. In humans, the assessment of RV volumetric quantification and the EF measurements have many limitations, because the complex RV shape limits performance of the required assessments


In conditions requiring repeated blood transfusion or where iron metabolism is abnormal, heart failure may result from accumulation of iron in the heart (cardiac siderosis). Death due to heart failure from cardiac iron overload has accounted for considerable early mortality in β-thalassemia major. The ability to detect iron loading in the heart by cardiovascular magnetic resonance using T2* sequences has created an opportunity to intervene in the natural history of such conditions. However, effective and well tolerated therapy is required to remove iron from the heart. There are currently three approved commercially available iron chelators: deferoxamine, deferiprone and deferasirox. We review the high quality randomized controlled trials in this area for iron chelation therapy in the management of cardiac siderosis. In conditions of iron overload, either due to recurrent blood transfusion or abnormal iron metabolism, iron accumulation within organs can have fatal consequences. Beta-thalassemia major (TM) is a condition of abnormal hemoglobin resulting in profound anemia that requires lifelong regular blood transfusion, typically from the age of 2 years. As a consequence of the repeated transfusions and the body’s inability to clear excess iron, iron can build up within tissues. The accumulation of iron within the heart (cardiac siderosis) can result in heart failure and this has been the commonest cause of death in TM. The development of iron chelators offered a solution to this problem, but long-term experience showed persistently high and premature cardiac mortality. This has been related in large part to conventional measures of iron loading such as serum ferritin and liver iron concentration being poor surrogates of iron loading in the heart. It is possible to have high levels of iron loading in the liver without significant cardiac loading and vice versa. Consequently cardiac siderosis may not be identified until late, when it presents with heart failure that is associated with a very poor prognosis.∗ as a measure of myocardial iron concentration has been particularly important as it remains the only technique available for this purpose  signal has lead to the development of targeted MR sequences to assess the tissue iron concentrations in the liver and the heart. The use of cardiovascular magnetic resonance (CMR) to quantify the parameter T2 purpose . T2∗ assalidated, is well alidated,. In addi∗ MR as an endpoint, because it remains the only validated technique to measure myocardial iron. Myocardial T2∗ is considered “normal” when >20 ms. Cardiac iron loading is considered “present” with T2∗ <20 ms, and is considered severe with T2∗ <10 ms because the rate of heart failure increases dramatically below this threshold  of iron chelation for cardiac siderosis. In addition to the paucity of data, the robustness of the presented data is variable. We describe and review the published trials, relating them to the recent guidelines for the management of β-thalassemia major by the American Heart Association AHA; . The effhreshold .Currently, there are three commercially available products with FDA and EU approval for iron chelation in the clinical setting. As well as varying in the mode of administration, there are significant differences between the three chelators with regard to efficacy, tolerability, and patient compliance.The first iron chelator approved for clinical use was deferoxamine. The greatest drawback with this agent is that due to poor gut uptake, it needs to be given parenterally . The short half life results in typical administration for 8–12 h per day for at least 5 days of the week. This has a profound impact on patient compliance and considerable work has been done to provide devices for subcutaneous drug delivery. Once severe cardiac iron loading is present, months to years of careful therapy is needed to clear the iron. Even when used as a continuous intravenous infusion, deferoxamine only clears myocardial iron at 5% per month . Side efDeferiprone was licensed around 30 years later than deferoxamine. Deferiprone is rapidly absorbed from the gastrointestinal tract and is therefore taken orally, usually three times a day. The oral formulation has significant compliance advantages over deferoxamine. Significant side effects include agranulocytosis, gastrointestinal disturbance and arthropathy. Given the risk of neutropenia, weekly monitoring of the neutrophil count is advised. Deferiprone is commonly used in combination with deferoxamine for enhanced iron clearance.The most recent of the chelators is deferasirox. This is taken orally with rapid absorption and can be taken once daily. Adverse events are typically gastro-intestinal upset, rash and raised creatinine. More serious adverse events include Fanconi syndrome, and eye and ear toxicity. Monitoring of renal and hepatic function are recommended for deferasirox.∗ CMR as an endpoint. The first RCT compared oral deferiprone monotherapy against subcutaneous deferoxamine . Left ventricular (LV) ejection fraction (EF) increased significantly more in the deferiprone treated group . This RCT established that deferiprone was superior to deferoxamine over 1 year for the removal of cardiac iron, and the improvement of LV EF in patients with asymptomatic myocardial siderosis. A further report from this trial also showed that right ventricular EF also improved more in the deferiprone patients, than with deferoxamine . The combined group also showed significantly great improvement in absolute LV EF , and absolute endothelial function . A further report from this trial showed that right ventricular EF also improved more in the combined group, than with deferoxamine alone  and no signs of cardiac dysfunction. The geometric mean of the myocardial T2∗ improved with deferasirox from 11.2 ms to 12.6 ms at 1 year (+12%) and with deferoxamine from 11.6 ms to 12.3 ms (+7%). The between-arm ratio of the geometric means was 1.056 with the 95% confidence intervals of 0.998 and 1.133). The lower boundary was greater than the pre-specified margin of 0.9, establishing non-inferiority of deferasirox vs. deferoxamine (P = 0.057 for superiority of deferasirox). Mean LVEF remained stable and within the normal range after 1 year of treatment with deferasirox (66.9–66.3%) and deferoxamine (66.4–66.4%). The change in mean LVEF after 1 year was not different between the two treatments (P = 0.54).The third RCT  compared oral deferasirox against subcutaneous deferoxamine . This wa∗ assessment technology and also non-randomized trials  and consultant to Siemens. He is also a consultant to ApoPharma, Novartis, Shire and Bayer.


Multi-modality interrogation of myocardial health and disease using fused Positron Emission Tomography (PET) and magnetic resonance (MR) data has been limited by the need for separate scans, and complex and potentially imprecise co-registration of the individually-acquired PET and MR images. We sought to explore the potential of hybrid simultaneous PET/MR (hs-PET/MR) imaging to precisely localize changes in cardiac metabolism in areas of acute myocardial infarction (MI) and the area-at-risk (AAR) in acute ST-segment elevation myocardial infarction (STEMI) patients reperfused by primary percutaneous coronary intervention (PPCI).18F-fluorodeoxyglucose (FDG) PET metabolic imaging was acquired, following patient preparation . Matched short-axis slices of each modality: LGE, T2 maps, FDG, covering the entire left ventricle were analysed by 2 blinded investigators using 3 segmentation methods : manual; Otsu; 2 standard deviation (2SD) thresholding. 2 further investigators analysed respective coronary angiograms to derive BARI and APPROACH angiography jeopardy scores, both CMR-independent estimates of AAR size.Hs-PET/MR  cardiac imaging was performed in 21 STEMI patients within 10 days of PPCI. A standard CMR protocol, included: localisers, functional cine imaging, with T2 mapping  and late gadolinium enhancement to delineate the AAR, and area of infarction respectively. Simultaneously, The AAR delineated by T2-mapping correlated significantly with both the BARI  and APPROACH  scores, thereby independently validating this technique at 3T. In all patients myocardial FDG uptake was reduced in areas of MI (LGE). The total volume of myocardium with reduced FDG uptake was larger than the measured MI size , and was similar in size to the AAR measured by T2-mapping , the Rosetrees Trust, and was also supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. SKW is supported by British Heart Foundation Clinical Research Training Fellowship (grant number FS/10/72/28568).


Solitary papillary muscle (PM) hypertrophy is an unique type of hypertrophic cardiomyopathy (HCM), which is characterized by predominant papillary muscle hypertrophy sparing the rest of other left ventricular segments. It has recently drawn our attention about the mechanism of left ventricular mid-cavity obstruction and the influence of pressure gradient in the left ventricular outflow tract (LVOT), thus carries clinical importance.We reported a symptomatic, 83-year-old woman who presented with dynamic, high resting left ventricle (LV) mid-wall gradient without obvious septal hypertrophy or systolic anterior motion (SAM). Subsequent real-time (RT) three-dimensional echocardiography (3DE) and cardiac magnetic resonance imaging (MRI) demonstrated large, hypertrophic accessory papillary muscles squeezing mid-cavity of left ventricle producing dynamic pressure gradient during systole in the absence of left ventricular wall anomalies.We proposed that combined use of echocardiography particularly RT-3DE and cardiac magnetic resonance imaging (MRI) can accurately identify this specific type of hypertrophic cardiomyopathy without remarkable traditional features. Hypertrophic obstructive cardiomyopathy (HOCM) refers to those subjects with significant dynamic left ventricular outflow tract (LVOT) obstruction due to mechanical causes, with most presents with asymmetrical septal hypertrophy resulting in dynamic systolic anterior motion (SAM) of mitral leaflets .Solitary papillary muscle (PM) hypertrophy, a peculiar form of HCM manifested as predominant PM hypertrophy sparing the rest of other LV segments, has recently gained much attention owing to its mechanical consequences on left ventricular outflow tract (LVOT) pressure gradient formation ,3.A 83-year-old woman with history of hypertension and hyperlipidemia. The blood pressure and hyperlipidemia were well-controlled with medication. She was admitted to our hospital with chest pain on effort and exertional shortness of breath. Her vital sign was stable with blood pressure 131/70 mmHg and heart rate 67 beats per minute at initial presentation. A mid-systolic ejection murmur was heard along the left sternal border with chest X-ray showed minor pulmonary congestion. Incidental high resting LV mid-wall pressure gradient  though significantly hypertrophied PMs . Beta-blockade was then prescribed and the symptoms improved drastically during the subsequent follow up.Repeated 2D transthoracic echocardiogram during hospitalization revealed no more pressure gradient (plummeted to 5 mmHg) after holding diuretics Figure B. MeanwhSo far, left ventricular hypertrophy remained the predominant and major phenotypic component of hypertrophied cardiomyopathy . Few casWhile HCM subjects with concomitant morphological papillary muscle anomalies may present with higher degree of resting LVOT gradient , it is nCurrent guidelines for LV mass calculation do not take papillary muscle mass into account, while our relevant findings may suggest include papillary muscles in LV mass assessment, especially for these morphologically abnormal papillary muscle subjects.Solitary papillary muscle hypertrophy as an uncommon variant form of HCM with coexisted additional, accessory papillary muscle may develop abnormally high resting LV mid-wall pressure gradient without SAM or significant regional LV wall hypertrophy. Cardiac MRI and RT-3DE may have their peculiar roles in uncovering these cardiac morphological/structural anomalies aiming for a more comprehensive analysis on their spatial relationships.In conclusion, we recommended that for subjects with unusually high LV mid-wall or LVOT pressure gradient with unrevealing regional LV segment anomalies, RT-3DE and MRI should be considered as a screening tool to disclose these under-diagnosed, specific HCM subjects in daily routine.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.LV: Left ventricle; RT: Real time; 3DE: three-dimensional echocardiography; MRI: magnetic resonance imaging; PM: Papillary muscle; HCM: Hypertrophic cardiomyopathy; HOCM: Hypertrophic obstructive cardiomyopathy; LVOT: Left ventricular outflow tract; SAM: Systolic anterior motion; DHE: Delayed hyperenhancement.The authors declare that they have no competing interests.KTS was the primary author of the text. CHY assisted in image acquisition and retouching. CLH conceived of the report, provided the images, and modified the manuscript. JYH provided additional supervision. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/14/34/prepubReal time 3D Echocardiography, four chamber view.Click here for fileReal time 3D Echocardiography, short axis view.Click here for fileReal time 3D echocardiography sequences in short axis view, divided the left ventricle into 9 slices during end-diastolic phase.Click here for file


Learning Objective. The MRI T2* weighted images including those with Gd contrast medium enhancement effect may be useful for evaluating the risk of perioperative intracranial hemorrhage in IE.A 59-year-old woman visited a local hospital for fever and was diagnosed as having infective endocarditis (IE) on the basis of blood cultures and transthoracic echocardiography. Based on clinical episodes of subarachnoid hemorrhage after admission, it was judged that she was not a good candidate for urgent open heart surgery, and it was decided to treat her with conservative medical therapy for the acute phase. We explored the optimum timing for surgery by employing gadolinium (Gd) contrast medium-enhanced magnetic resonance imaging (MRI) T2* weighted image (black dots) due to her high risk of perioperative cerebral hemorrhage. After the disappearance of the contrast media enhancement effect around the black dots, open heart surgery was performed successfully on the 103rd hospitalization day. The patient was discharged 22 days after the surgery with no clinical complications. This case suggests that disappearance of the contrast media enhancement effect around the black dots may be a useful marker for optimal timing of surgery to minimize the risk of perioperative cerebral hemorrhage in patients with IE.  Infective endocarditis (IE) is a serious disease characterized by refractory heart failure combined with sepsis. Intracranial bleeding is an important potential complication which can be influenced by the timing of open heart surgery . Here weStreptococcus viridans was detected by blood culture. Transthoracic echocardiography (TTE) revealed the presence of vegetations on the aortic and mitral valves with regurgitation. On the basis of the Duke criteria, she was diagnosed with definite infective endocarditis (IE), and intravenous antibiotic treatment (penicillin G 18 × 106 units/day + gentamicin 80 mg/day) was started. She was admitted to our hospital on December 6, 2012.A 59-year-old woman had an intermittent fever from the end of October to the end of November 2012 when she consulted a local hospital and 2 (room air) 96%, and heart sound systolic murmur (Levine IV). Blood test data were as follows: WBC 6.17 × 103/μL, C-reactive protein 1.7 mg/dL, aspartyl aminotransferase 29 IU/L, alanine aminotransferase 17 IU/L, lactate dehydrogenase 276 IU/L, blood urea nitrogen 3.9 mg/dL, and serum creatinine (CRE) 1.18 mg/dL. Chest X-ray showed a cardiothoracic ratio of 60% with lung congestion and pleural fluid. TTE and transesophageal echocardiography revealed a left ventricular dimension (diastole/systole) of 5.0/2.7 cm, ejection fraction of 73%, and an estimated systolic right ventricular pressure of 75 mmHg. The vegetation on the anterior mitral leaflet and noncoronary cusp of the aortic valves was found with regurgitation due to ruptured chordae tendineae. The vegetation size was 8–10 mm.On presentation, her clinical characteristics were height 155 cm, weight 50.9 kg, blood pressure 141/76 mmHg, heart rate 93 beats per minute regular, body temperature 36.4°C, SpOBrain MRI T2* weighted images revealed black dots on the right frontal lobe, both sides of the parietal lobe and the right occipital lobe, and a localized subarachnoid hemorrhage in the right postcentral gyrus. An enhancement effect with gadolinium (Gd) contrast media was seen in the dot on the right occipital lobe. According to recent reports, this type of MRI imaging may indicate fragility of the arterial wall of a brain mycotic aneurysm . As a coTherefore, conservative medical treatment was started with carperitide, furosemide, and antibiotic for the acute phase. The acute phase passed without worsening of the heart failure, but subarachnoid hemorrhage developed again on the 26th day after admission . A 4 mm Small valvular vegetations were detected on the leaflet edges of the aortic tricuspid valves and were resected. A vegetation was detected on the ruptured chordae tendineae of the middle scallop of the posterior leaflet (P2) of the mitral valve. In addition, we resected another vegetation and thickening of the posterior leaflet (P3) and the anterior leaflet. The procedure was completed by mitral annuloplasty only because valve function was preserved. The cardiopulmonary bypass and aortic cross-clamp time was 134 minutes.The mitral valve posterior leaflet was infiltrated by lymphocytes and consisted of irregular fibrotic tissues. Inflammatory fibrous connective tissue with calcification was observed in the aortic valve left coronary cusp. Granular tissue with calcification and multinucleated giant cells were observed in the noncoronary aortic valve cusp.The outcome of IE is occasionally poor due to septic complications and refractory heart failure resulting from valvular destruction. Several reports have demonstrated that early open heart surgery may be desirable in patients with IE . HoweverThe “black dot”  on the MRI T2* weighted image suggests the presence of hemosiderin due to microbleeding from a cerebral artery –8. The fThe MRI T2* weighted images including those with Gd contrast medium enhancement effect may be useful for evaluating the risk of perioperative intracranial hemorrhage in IE. On the basis of the present case, the disappearance of the contrast medium enhancement effect around the black dots may be a useful marker for optimizing the timing of surgery so as to minimize the risk of perioperative cerebral hemorrhagic complication in patients with IE.


Both high-sensitivity cardiac troponin T and B-type natriuretic peptide are useful in detecting myocardial fibrosis, as determined by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR), in patients with non-obstructive hypertrophic cardiomyopathy. However, their values to predict myocardial fibrosis in hypertrophic obstructive cardiomyopathy (HOCM) remain unclear. We investigated the role of N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) and cardiac troponin I (cTnI) to identify LGE-CMR in patients with HOCM.Peripheral concentrations of NT-proBNP and cTnI were determined in patients with HOCM . Contrast-enhanced CMR was performed to identify and quantify myocardial fibrosis.LGE was detected in 120 of 163 patients (73.6%). Patients with LGE had significantly higher levels of NT-proBNP and cTnI than those without LGE . The extent of LGE was positively correlated with log cTnI  and log NT-proBNP . On multivariable analysis, both log cTnI and maximum wall thickness (MWT) were independent predictors of the presence of LGE , whereas log NT-proBNP was not. According to the ROC curve analysis, combined measurements of MWT ≥21 mm and/or cTnI ≥0.025ng/ml indicated good diagnostic performance for the presence of LGE, with specificity of 95% or sensitivity of 88%.Serum cTnI is an independent predictor useful for identifying myocardial fibrosis, while plasma NT-proBNP is only associated with myocardial fibrosis on univariate analysis. Combined measurements of serum cTnI with MWT further improve its value in detecting myocardial fibrosis in patients with HOCM. Hypertrophic cardiomyopathy (HCM) is a common inheritable cardiac disease with a prevalence of 1 in 500 of the general population . AsymmetMyocardial fibrosis, as a hallmark of HCM, can be identified noninvasively by contrast-enhanced cardiovascular magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE), which has been demonstrated to be associated with SCD and other adverse outcomes –7.Circulating N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) levels are elevated in patients with HCM, and correlate positively with symptoms of heart failure, hypertrophy severity, left ventricular diastolic dysfunction and LVOT gradient, and predict death and heart failure-related events –10. CardKawasaki et al reported that combined measurements of high-sensitivity cardiac troponin T (hs-cTnT) and B-Type Natriuretic Peptide (BNP) were useful for detecting myocardial fibrosis in patients with non-obstructive HCM . Plasma 2), concomitant neoplasm, infection, or connective tissue disease were excluded. Subjects who had a history of alcohol septal ablation, septal myectomy or permanent mechanical device implantation were also excluded from the present study. Hypertension was defined as a systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg, or receiving antihypertensive drugs.We retrospectively included consecutive patients with HOCM who underwent a comprehensive cardiac evaluation in Fuwai Hospital  between November 2008 and August 2013, by reviewing their de-identified medical records. The diagnosis of HCM was based on a maximum left ventricular wall thickness ≥15 mm , as measured by echocardiography or CMR, in the absence of any other accountable cardiac or systemic disease . The preThe present study was performed in accordance with the Declaration of Helsinki. All procedures included in this study were undertaken as part of routine clinical practice, and the data which could identify subjects were removed. Informed consent was exempted because of the retrospective nature of the current study.All subjects underwent a comprehensive cardiac evaluation, including complete medical history, physical examination, 12-lead electrocardiography (ECG), 24-hour ambulatory ECG monitoring, transthoracic echocardiography (TTE), blood examination, CMR, and coronary angiography. Eventually, 163 patients were enrolled in the present study. TTE was performed using the Phillips iE33 Color Doppler Ultrasound System . M-mode, 2-dimensional, and pulsed and continuous-wave Doppler study were used in the standard evaluation in accordance with recommendations of the American Society of Echocardiography . The sev2, slice thickness 6 mm, inter-slice gap 2 mm, at least 20 phases, repetition time (TR) 2.7 ms, echo time (TE) 1.2 ms, temporal resolution 40 ms, image matrix 192×162, and flip angle 70°. Images of LGE were acquired 10–15 minutes after bolus injection of 0.2 mmol/kg gadolinium-diethylenetriamine pentaacetic acid , using a segmented phase-sensitive inversion recovery (PSIR) Turbo Fast Low Angle Shot (FLASH) sequence in the same views as used in cine imaging. The optimal inversion time was adjusted to null normal myocardium typically between 250 and 350 ms. Typical imaging parameters were: FOV 380×320 mm2, slice thickness 6 mm, inter-slice gap 2 mm, TR 8.6 ms, TE 3.36 ms, image matrix 256×162, flip angle 25°, pixel size 2×1.5 mm2, and parallel acquisition technique (PAT) factor of 2.All CMR studies were performed with a 1.5-Tesla scanner , under breath control and electrocardiographic gating. The CMR imaging protocol was reported previously . A true All CMR images were transferred to workstation . The dedicated software  was used for image analysis off-line.Endocardial and epicardial contours of the LV myocardium (excluding papillary muscles) were manually traced at end diastole and end systole on each LV short-axis cine image. LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction (LVEF), stroke volume (SV), cardiac output (CO), and LV mass (LVM) were then calculated in a standard fashion. LV mass was derived by multiplying LV myocardial volume measured at end diastole with the specific gravity of myocardium (1.05 g/ml). Furthermore, all of those parameters were indexed to body surface area (BAS), except LVEF. The maximal septal and LV wall thickness were traced and measured from the short-axis views at end diastole. The left atrial diameter was determined as the distance from the center of the mitral annulus to the posterior atrial wall on vertical and horizontal long-axis cine images.LGE was estimated both qualitatively as a binomial variable (positive/negative) and quantitatively. The presence of any higher signal intensity area compared to the nulled normal myocardium was determined as LGE positive, otherwise LGE negative, by reviewing all short and long axis contrast-enhanced artefact-free images. The quantification of LGE was performed using the previously described visual scoring method based on the standard 17-segment model of the left ventricle , 22. TheFrom short axis planes, the location of LGE in the LV were recorded as: (1) right ventricular insertion points (the anterior and inferior attachment points of the right ventricle to the interventricular septum); (2) septum ; (3) apical (confined to the LV apex); and (4) all other LV locations .Venous blood samples were drawn under resting conditions within 2 days of TTE and 7 days of CMR examination. All of the following biomarkers were measured within 4 hours of blood collection as routine sample analysis.Plasma levels of NT-proBNP were measured using an electrochemiluminescent immunoassay  on a Cobas 6000 analyzer (Roche Diagnostics), with a lower detection limit of 0.6 pmol/L. The inter-assay coefficient of variation was ≤4.6% and the intra-assay coefficient of variation was ≤4.2%.For measurement of serum cTnI, an immunochemiluminometric assay  was performed on a Beckman Coulter Access 2 analyzer. According to the manufacturer, the lower limit of detection is 0.01ng/ml. The upper limit of normal  was 0.04ng/ml. The inter-assay and intra-assay coefficients of variation were less than 6.07% and 4.42%, respectively.Circulating endothelin (ET) has a very short half-life, while its precursor (big ET-1) has a longer half-life and is easier to be detected. Plasma big ET-1 was measured using a commercial enzyme immunoassay  on a Cobas 6000 analyzer (Roche Diagnostics), with a detection limit of 0.02 pmol/L. Cross-reactivity with ET-1, ET-2, and ET-3 was less than 1%. The inter-assay and intra-assay coefficients of variation were less than 4% and 5%, respectively.Serum hs-CRP was measured using the Particle Enhanced Immunoturbidimetric Assay  on an Olympus AU-5400 analyzer (Olympus Diagnostics), with a lower detection limit of 0.25 mg/L. The inter-assay coefficient of variation was ≤11.9% and the intra-assay coefficient of variation was ≤6.6%.Serum CK-MB was determined by an immunoinhibition assay  on an Olympus AU-5400 analyzer (Olympus Diagnostics), with a lower detection limit of 3 U/L. The inter-assay and intra-assay coefficients of variation were less than 6%.2 test or Fisher’s exact test (as appropriate). Correlation between two continuous variables was examined using Pearson’s correlation test or Spearman’s correlation test (as appropriate). As the values of NT-proBNP, cTnI, and big-ET follow lognormal distribution, they were subjected to logarithmic transformations for t tests, scatterplots, correlations and regression analysis.Statistical analysis was performed with the statistical package SPSS 21.0 . A 2-tailed P value of <0.05 was considered to be statistically significant. Continuous variables are expressed as mean ± standard deviation (SD), or median (interquartile range [IQR]), and were compared with the independent-samples t-test or the Mann–Whitney U-test (as appropriate). The comparison of categorical variables, which were expressed as frequencies (percentages), was performed using χMultivariate binary logistic regression analysis using backward elimination was performed to identify potential predictors of the presence of LGE. The predicting variables were pre-specified on the basis of univariate p values of <0.10 and previously published literature. The included variables were as follows: age, hypertension, duration from initial diagnosis, family history of HCM, New York Heart Association (NYHA) functional class, calcium channel antagonists, resting LVOT gradient, LVEF, left ventricular end-diastolic volume index (LVEDVI), left ventricular mass index (LVMI), maximum wall thickness (MWT), log NT-proBNP, log cTnI, and hs-CRP. The optimal cut-off values for cTnI and MWT to predict LGE were determined by receiver-operating characteristic (ROC) curve analysis. Sensitivity, specificity and positive and negative predictive values were calculated for selected cTnI and MWT cut-off points.One hundred and sixty three patients with HOCM were included in this study . Baseline characteristics are presented in LGE was identified in 120 of 163 patients (73.6%). Patients with LGE were younger , and were more likely to have a family history of HCM , than those without LGE. The median duration from initial diagnosis of HOCM to study entry was longer in patients with LGE compared to patients without LGE . There was a trend towards more NYHA functional class II and less NYHA functional class IV in patients with LGE (P = 0.05). Medications taken did not differ significantly between the two groups, except that patients with LGE were less likely to take calcium antagonists . No other significant differences were observed between LGE-positive group and LGE-negative group, concerning family history of sudden death, history of syncope, non-sustained ventricular tachycardia or atrial fibrillation.2, P <0.001), and also higher proportion of maximum wall thickness ≥30mm , as compared to those without LGE. LVEDVI and left ventricular end-systolic volume index (LVESVI) were larger in LGE-positive patients than in LGE-negative patients . In contrast, left ventricular ejection fraction (LVEF) was lower in patients with LGE than in those without LGE , although all patients had normal systolic function (LVEF ≥50%).Patients with LGE had greater maximum wall thickness  and LVMI  involved 31.6 ± 14.5% of left ventricular myocardium ranging from 2.9% to 73.5%. The most frequently observed locations for LGE were the RV insertion points identified in 109 of 120 patients (90.8%), followed by other septal locations in 60 (50.0%), other LV locations in 34 (28.3%) and the LV apex in 22 (18.3%) patients.Among the overall studied population, the extent of LGE was positively correlated with maximum wall thickness , LVESVI , and LVMI ; in contrast, it was inversely correlated with age , resting LVOT gradient , peak LVOT gradient , and LVEF  . In patiThe median levels of NT-proBNP and cTnI were significantly higher in patients with LGE than in those without LGE .LGE% was positively correlated with log cTnI  and log NT-proBNP  in the overall patients with HOCM . In patiLog NT-proBNP was significantly associated with log cTnI in the overall patients with HOCM  and in patients with LGE , but not in patients without LGE  . In addiMultivariable binary logistic regression analysis was performed to identify potential predictors of the presence of LGE. Variables included in the multivariate analysis were described previously in statistical methods. As shown in Receiver operating characteristic (ROC) curve analysis was performed to evaluate the utility of MWT and cTnI as predictors for the presence of LGE . AccordiTo the best of our knowledge, this is the first study to investigate the association between circulating biomarkers and myocardial fibrosis determined by LGE-CMR in patients with HOCM. We found that peripheral concentrations of NT-proBNP and cTnI were significantly associated with the presence and severity of LGE in our HOCM cohort, on univariate analysis. After adjusting for other relevant variables in multivariate logistic regression analysis, serum cTnI together with MWT were independent predictors of the presence of LGE, whereas NT-proBNP was not. Furthermore, on ROC curve analysis, combined measurements of MWT ≥21 mm and/or cTnI ≥0.025 ng/ml showed good predictive values for the presence of LGE, with specificity of 95% or sensitivity of 88%. In addition, not taking calcium antagonists, decreased systolic function and reduced resting LVOT gradient also played a role in detecting myocardial fibrosis in these patients. Notably, the rates of LGE 74%) in the present study were high when compared to the literature 56% to 66%) [% to 66% 4% in theMultiple studies have been performed to determine serological markers of collagen metabolism in patients with HCM, however, their results are inconsistent , 24, 25.BNP is produced and released by ventricular and atrial cardiocytes, through multiple mechanisms –28. NumeThe underlying mechanisms of correlations between elevated natriuretic peptides and cardiac fibrosis in HCM remain unclear. Possible explanations are as follows. First, the observed correlation between natriuretic peptides and fibrosis could be the consequence of their simultaneous positive relationships with the extent of left ventricular hypertrophy , 7. In tCardiac troponins, as specific and sensitive markers of myocardial damage, are well established diagnostic and prognostic biomarkers in patients with acute coronary syndrome . Those eThe potential explanations for correlations between myocardial fibrosis and cardiac troponins in HCM remain unresolved. Myocardial perfusion reserve was reduced in proportion to the magnitude of hypertrophy and fibrosis in patients with HCM . MoreoveIn line with prior investigations in patients with HCM , 23, 40,Consistent with previous reports , 42, thiIn this study, compared to patients without LGE, those with LGE was less likely to take calcium antagonists. Patients taking calcium antagonists showed less severe LGE . Additionally, usage of calcium antagonists predicted less probable presence of LGE on multivariate regression analysis. The inverse relationship between calcium antagonists and the presence and extent of myocardial fibrosis in patients with HOCM haven’t been reported previously, further studies are needed to validate this phenomenon.Similar to prior studies , 43, patThe present study had several limitations. First, this is a cross-sectional and single-center study conducted in a tertiary referral hospital, for which some inherent biases were unavoidable. Second, LGE was evaluated visually and indicated semi-quantitatively. However, this method was used frequently, and has been demonstrated to be feasible and reliable compared to the quantitative planimetry method , 22. ThiAs established biomarkers for cardiac overload and myocardial injury respectively, NT-proBNP is not, but serum cTnI is useful in identifying myocardial fibrosis, and combined measurements of serum cTnI and MWT further improve its value for predicting myocardial fibrosis in patients with HOCM and normal systolic function. If replicated, routine measurements of serum cTnI and MWT in daily clinical practice may become preferred substitute for LGE-CMR to assess myocardial fibrosis in HOCM, in consideration of their better accessibility and cost-effectiveness than LGE-CMR. Furthermore, gadolinium is not benign, particuS1 Table(XLSX)Click here for additional data file.S2 Table(DOC)Click here for additional data file.S1 Text(DOC)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.


Late Gadolinium enhancement represents a widely employed method for detecting myocardial scarring e.g. after myocardial infarction or for myocardial Inflammation. A frequent finding is slight basal septal enhancement as well as intramyocardial enhancement, mostly referred as myocardial fibrosis. Less is known about the impact on myocardial conduction and a possible correlation to ECG findings such as atrioventricular node conduction delay and bundle branch blockations.For 81 consecutive patients  referred for magnetic resonance cardiac (MRI) including a late gadolinium enhancement study scans were anonymized and correlated to an ECG performed within one week before or after the MRI. A 1.5T Siemens Sonata with TIM upgrade was used. Scanning protocol comprised short- and long axis cine mode and a perfusion study with Gd-DOTA and/or T1 and T2 TSE as well as 2d and 3d IR short axis sequences for late enhancement. The latter was analysed visually for the study by two experienced operators and subdived as (1) normal, (2) intramyocardial fibrosis, (3) subendocardial or transmural ischemic scar and (4) bright acute inflammation or postmyocardial subepicardial enhancement pattern. The ECGs had been re-evaluated by an experienced cardiologist.The baseline data between the 4 groups was similar :group 1 : 30 patients (37%), LVEF 62% (17-79%), EDVI 73ml (40-222ml), ventricular septum thickness (IVS) 11mm, age 57yrs;group 2 (fibrosis): 30 patients (37%), LVEF 58% (20-76%), EDVI 72ml (45-142ml), IVS 13mm, age 68yrs;group 3 (ischemic scar): 15 patients (19%), LVEF 51% (30-76%), EDVI 82ml (36-152ml), IVS 11mm, age 69yrs;group 4 (myocarditis): 6 patients (7%), LVEF 55% (42-71%), EDVI 82ml (57-122ml), IVS 10mm, age 44yrs.Atrial fibrillation was present in 10%, 20%, 27%, and 0% respectively.ECG findings are presented in Table Abnormal ECG findings such as AV conduction delay and bundle branch blockation are significantly correlated to myocardial scarring or fibrosis in late enhancment studies.None.


Currently, standard segmented cardiac cine and delayed enhancement images are acquired with independent sequences requiring multiple breath-holds (BH), ideal inversion time (TI) setting, and individual image analysis. We describe our initial experience with the use of a multi-contrast real-time cine (multi-TI cine) prototype sequence .2; slice thickness: 7 mm; temporal resol.: 40 ms; 7 heart beats (HB)/slice), modified Look-Locker inversion recovery post-contrast T1 mapping , and segmented spoiled gradient-echo late gadolinium enhancement (LGE) images . Followed by multi-TI real-time cine performed in the same cardiac planes . The multi-TI cine prototype has been described in detail elsewhere1, but briefly it consists of an inversion recovery highly accelerated SSFP 2D real-time cine sequence, featuring sparse sampling and k-t regularization. Using an offline reconstruction algorithm based on a registration and motion-propagation strategy, a full-length cine can be reconstructed for each acquired TI  that included short- and long-axis steady-state free-precession (SSFP) segmented cine measurements  were included. All sequences were successfully performed and reconstructed, rendering good-quality images on subjective analysis. In all patients, a multi-TI cine, with ideal myocardial nulling, could be produced for simultaneous cardiac function and LGE analysis. Figure Despite currently having inferior spatial and temporal resolution as compared to standard cine and LGE sequences, multi-TI cine seems to be able to detect myocardial tissue and functional abnormalities, with the advantage of shorter acquisition times, ideal myocardial nulling and combined functional and LGE assessment. Future developments and studies will be needed to adequately determine its accuracy and validate its clinical application.Internal.


In addition, the six segmental MADs of the mitral annulus were significantly negatively correlated with the six segmental strains of the left ventricle . MADglobal was significantly negatively correlated with LSglobal . The tissue motion annular displacement (TMAD) at the midpoint was significantly negatively correlated with LSglobal . The 2D TMAD technique of measuring MAD was feasible and practically approachable for rapidly evaluating the left ventricular longitudinal global and segmental systolic functions of patients with HCM.The early detection of abnormal left ventricular systolic functions in patients with hypertrophic cardiomyopathy (HCM) remains a challenge. The aim of this study was to identify a novel method for the assessment of left ventricular systolic function in patients with HCM. A total of 65 patients with HCM were included in this study. The patients were divided into obstructive HCM  and non-obstructive HCM  groups. The healthy control group comprised 48 participants. Two-dimensional (2D) speckle-tracking technology was used to measure the left ventricular global and segmental longitudinal strains and mitral annular displacement (MADs). Compared with healthy control group, the six segmental strains and the global strain of the left ventricle (LS Modern molecular biological studies have confirmed that hypertrophic cardiomyopathy (HCM) is an autosomal dominant genetic disease caused by the genetic mutation of the myocardial sarcomere gene –4, and iA number of novel ultrasound technologies, including tissue Doppler imaging (TDI), TDI-derived strain imaging and two-dimensional (2D) speckle tracking, are used to detect the reductions in left ventricular longitudinal systolic functions in patients with HCM. However, these techniques significantly depend on image quality and are time-consuming. The tissue motion annular displacement (TMAD) technique is a novel technology developed in accordance with speckle-tracking technology. This technique is able to assess the left ventricular longitudinal systolic functions by tracking the positions of the mitral annulus in the left ventricular systolic phase. TMAD quickly evaluates the left ventricular longitudinal systolic functions and does not require high image quality . In the A total of 65 patients with HCM were selected. The inclusion criteria  were as The iE33 xMatrix UCG system  with external QLAB quantitative analysis software, version 8.1  was used. The left ventricular end-diastolic diameter, interventricular septum and posterior left ventricular wall thickness were measured along the left ventricular long-axis view. The septum/posterior wall ratio was calculated. The pulsed wave (PW) sampling volumes were placed under the mitral valves of the apical four-, two- and three-chamber views. The early and late mitral inflow velocities  were measured, and E/A was calculated. In the TDI mode, PW sampling volumes were placed in the interventricular septum, lateral wall, anterior wall, inferior wall, anterior septum, and the ring side of the posterior-wall mitral valve. Early and late myocardial diastolic velocities (Em and Am) were measured, and the mean values were obtained for the calculation of Em/Am and E/Em. When the PW sampling volume was placed on the aortic valve of the aortic long-axis view, the PGlvot was measured. The measurements of the aforementioned ultrasound data were based on the American Society of Echocardiography guidelines and requirements .seg) of the ventricular wall. When more than two segments of the wall were not effectively tracked, the track was considered ineffective.All subjects were imaged in the left lateral position, with synchronous ECG display. The 2D images of three consecutive cardiac cycles of the apical four-, two- and three-chamber views were collected. The depth and fan size were adjusted to reach the maximum frame frequency (>50 frames/sec). Data were stored in a removable hard disk for offline analysis. QLAB software, version 8.1 was used to perform the following: Importation of the 2D grey-scale images; selection of the cardiac motion quantification (CMQ) module; sketching of the endocardium and epicardium in the region of interest (ROI) interface; and adjustment of the ROI width to match the myocardial thickness. After completely outlining the endocardium and epicardium, the software was run to automatically track the ROI cardiac echo spots and provide all myocardial segmental longitudinal strain curves and peaks . The lefseg). The average value of the six wall segments was considered to represent the global displacement of the mitral ring . The ratio of the midpoint MAD of the apical four-, two- and three-chamber views to the left ventricular long-axis was recorded as normalized midpoint displacement of the mitral ring [TMAD midpt (%)].TMAD data were measured in the apical four-, two- and three-chamber views. The 2D grey-scale images were imported into QLAB software, version 8.1. Subsequently, the CMQ module was selected to outline three points in the ROI. Two points were placed in each of the interventricular septum and lateral wall side of the mitral ring of the apical four-chamber heart, the anterior interventricular septum, and the posterior wall side of the apical three-chamber heart, and anterior wall side and inferior wall side of the apical two-chamber heart. The third point was fixed on the surface of the apical endocardium . The sofFive healthy subjects and five patients with HCM were randomly selected, in which the TMAD of a total of 60 segments was measured. The MAD values of all segments were measured by doctors A and B. The difference reflected the interobserver error. Doctor B repeated the measurement of the same index of the above points two weeks later. From this measurement, the difference was used to reflect the intraobserver error. The degree of variation of these differences was then calculated. The error percentage of each measured value was used as the variability index, that is, (x1−x2)/[(x1+x2)/2] × 100, where ×1 is the result of the first measurement and ×2 is the result of the second measurement.2 test was used to compare the intergroup countable data. P<0.05 was considered to indicate a statistically significant difference.All data were analysed using SPSS statistical analysis software, version 16.0 . The normally distributed measurement data were expressed as mean ± standard deviation. The quantitative parameters of the three groups were compared using analysis of variance. The least significant difference method was used for pairwise comparison. Pearson’s correlation was used to analyse the intergroup relationship and the χNo statistical differences were identified in the gender ratio, age, height, weight, body surface area, heart rate or blood pressure among the three groups P>0.05; .The interventricular septal thickness (IVST), left ventricular posterior wall thickness (LVPWT), septum/posterior wall ratio and left atrial volume (LAV) of the HOCM and NOHCM groups were increased compared with those of the healthy control group. Additionally, the left ventricular end-diastolic volume (LVEDV), early peak mitral inflow velocity (MV E), Em and peak myocardial systolic velocity (Sm) of the HOCM and NOHCM groups decreased, and the late peak mitral inflow velocity (MV A) and E/Em ratio of the HOCM and NOHCM groups increased compared with those of the healthy control group, whereas Am decreased. No significant differences were identified in the ejection fraction (EF), left ventricular end-systolic volume (LVESV) and left ventricular internal diameter at end diastole (LVIDd) among the three groups .seg and LSglobal of the HOCM and NOHCM groups significantly increased compared with the healthy control group (P<0.01). No statistically significant difference was identified in the left ventricular segmental strains and LSglobal between the HOCM and NOHCM groups . No statistically significant differences were identified in the MADglobal and segmental MAD values of the HOCM and NOHCM groups . The TMAD midpt (%) was also significantly negatively correlated with LSglobal  between the intra- (5.24±2.60 vs. 5.83±2.51) and interobserver variabilities (6.99±3.32 vs. 6.47±2.80) (P>0.05).global and TMAD midpt values were significantly negatively correlated with the LSglobal values. Therefore, we considered that it is possible to use TMAD to quickly and accurately assess the left ventricular longitudinal global and segmental functions of patients with HCM. Additionally, MAD may be more sensitive than LVEF in terms of identifying the left ventricular global and segmental systolic dysfunction.TMAD technology was used in the present study to evaluate the left ventricular longitudinal systolic functions of patients with HCM. Through a comparison conducted using 2D-STI, the LVEF in the HCM group was found to be non-significantly reduced compared with that in healthy controls. However, the left ventricular global and segmental longitudinal systolic functions of the patients with HCM were observed to be significantly reduced. In addition, the MADs were significantly negatively correlated with the left ventricular segmental strains. Furthermore, MADThe main pathological changes associated with HCM are myocardial hypertrophy, muscle cell disorder, contractile protein dysfunction and interstitial fibrosis . Of thesThe mitral annulus is part of the fibrous skeleton of the heart. This structure has a large number of muscle fibres attached to the skeleton, which are arranged longitudinally throughout the space between the apex and base . The conet al . However, the representative index of left ventricular global systolic function, namely, MADglobal and the left ventricular segmental strains had a good correlation with the TMAD detection of the MADglobal and MADseg. Therefore, TMAD was able to accurately assess the left ventricular longitudinal global and segmental systolic functions. TMAD is advantageous due to its low-quality image requirements and rapid measurement (The 2D-STI method is able to track 2D ultrasound myocardial spot positions through a frame-by-frame process and determine the myocardial strain through the spot position-change rate to reflect the left ventricular contractile function ; it oversurement .In conclusion, TMAD was able to accurately and quickly evaluate the left ventricular longitudinal global and segmental systolic functions with low-quality image requirements and good reproducibility. In addition, TMAD may be used for the evaluation of left ventricular longitudinal systolic functions in patients with HCM. The proposed technique exhibits possible potential prognostic value in the early diagnosis, disease progression monitoring, efficacy assessment and prognosis evaluation of HCM.This study included a small number of cases. Therefore, it was not possible to determine the MAD normal reference values. Furthermore, the impact factors affecting MAD remain unclear. MAD was simply the reflection of the ventricular wall segmental overall function at the mitral annular attachment point, and was not able to reveal the systolic functions of the corresponding basal, middle and apical segments. Therefore, the information regarding left ventricular motion in the patients with HCM provided by the TMAD data was less than that provided by the strain data. All limitations of this study necessitate further study.


CMR is an established method for the diagnosis and assessment of myocardial infarction in routine exams. In addition, there has been a growing interest in using infarct size as a surrogate endpoint for clinical trials assessing the efficacy of acute MI reperfusion treatments and MI size is reported to be a stronger predictor of outcome than LVEF and LV volumes.Various Contour segmentation was implemented using a fast automated segmentation framework (B-spline Explicit Active Surfaces) that coWhen evaluated on the phantom study, accuracy of all algorithms reached 100% when CNR>7. For low CNR values, whereas xSD and FWHM appeared more robust, GMM illustrated its intrinsically higher sensitivity to the noise level. Figure CMRSegTools brings in a user friendly interface integrated as a plugin in the widely available advanced open-source OsiriX dicom workstation, a toolbox allowing to calculate, display and interactively analyze myocardial lesions and especially myocardial infarct lesions. CMRSegTools offers a fast, real-time and integrated process and advanced published algorithms for quantification purposes in CMR through an ergonomic interface. It can be proposed for newly available methods, as a plateform for algorithm performance comparison and validation.


Percutaneous edge-to-edge repair with MitraClip has been recommended as an alternative to conventional mitral valve repair in symptomatic severe mitral regurgitation at very high surgical risk. Data on the impact of MitraClip on left ventricular volumes are scarce. Therefore we aimed to assess left ventricular remodeling following MitraClip.Consecutive patients scheduled for MitraClip were prospectively studied. Patients with pacemaker or ICD were excluded. Transthoracic echocardiography and CMR at 1.5 Tesla were performed before and 6 months after MitraClip procedure. Left ventricular volumes were measured using transthoracic echocardiography (biplane Simpson's method) and short-axis SSFP CMR images covering the left ventricle. Mitral insufficiency was graded using color Doppler flow mapping (grade 1-4).CMR was performed in 16 patients with symptomatic severe (grade 3 or 4) functional mitral regurgitation (median 73 years (range 45-87 years), M/F: 7/9, left ventricular ejection fraction (EF), 31% (20-73%), logistic EuroSCORE 23% (10-35%)). MitraClip reduced mitral regurgitation , but failed in 2 patients . MitraClip caused intracavitary metallic artefacts at the base of the heart, but did not impede endocardial border definition. No change in left ventricular volumes was measured following successful MitraClip implantation (enddiastolic volume before MitraClip: 221 ml (102-334 ml) versus following MitraClip: 215 ml  NS; endsystolic volume: 154 ml (31-248 ml) versus 145 ml (40-240 ml) NS and ejection fraction: 31% (20-73%) versus 32% (16-61%) NS). Negative remodeling occurred in both patients with MitraClip failure . There was a high correlation between biplane Simpson's method and CMR assessed left ventricular enddiastolic  and endsystolic  volumes.CMR allowed precise assessment of left ventricular volumes. Despite reduction of mitral regurgitation, no change of left ventricular volumes was measured at 6 months follow-up.N/A.


Balaenoptera physalus) song consists of down-swept pulses arranged into stereotypic sequences that can be characterized according to the interval between successive pulses. As in blue (B. musculus) and humpback whales (Megaptera novaeangliae), these song sequences may be geographically distinct and may correlate with population boundaries in some regions. We measured inter-pulse intervals of fin whale songs within year-round acoustic datasets collected between 2000 and 2006 in three regions of the eastern North Pacific: Southern California, the Bering Sea, and Hawaii. A distinctive song type that was recorded in all three regions is characterized by singlet and doublet inter-pulse intervals that increase seasonally, then annually reset to the same shorter intervals at the beginning of each season. This song type was recorded in the Bering Sea and off Southern California from September through May and off Hawaii from December through April, with the song interval generally synchronized across all monitoring locations. The broad geographic and seasonal occurrence of this particular fin whale song type may represent a single population broadly distributed throughout the eastern Pacific with no clear seasonal migratory pattern. Previous studies attempting to infer population structure of fin whales in the North Pacific using synchronous individual song samples have been unsuccessful, likely because they did not account for the seasonal lengthening in song intervals observed here.Fin whale ( Megaptera novaeangliae) songs evolve during the breeding season, but also change from one year to the next, with neighboring populations sharing some song components Balenoptera musculus) songs remains relatively constant B. physalus) in all ocean basins Song can be described as a regular and repeated sequence of sounds, organized into a hierarchical structure Fin whale songs consist of stereotypic sequences of down-swept pulses organized into regularly repeated patterns Several baleen whale species exhibit geographic differences in vocalizations that may correspond to population boundaries. Minke and Bryde's whale call types vary across ocean basins Two types of autonomous, seafloor-mounted passive acoustic recorders were deployed at sites off Southern California, in the Bering Sea, and near Hawaii between 2000 and 2003 and 2005–2006 . RecordeBeginning in 2005, upgrades to the acoustic system allowed for high-frequency recording by High-Frequency Acoustic Recording Packages TritonTriton. All pulses within an individual song sequence were marked and only song sequences of at least 2 minutes duration were used for analysis. Occasionally more than one whale could be heard singing at once, identifiable as overlapping sequences of regularly repeated pulse patterns. In this case pulses from each individual were marked in series, with all song pulses from one sequence marked, followed by all song pulses from the overlapping sequence. If it became difficult to distinguish individual sequences from each other, no additional pulses were marked. It is probable that song segments were measured from more than one whale per day given the occurrence of overlapping songs or long  breaks in song on a given day. Pulses that were not clearly part of song sequences were not marked or enumerated during this analysis. Because more than one analyst contributed to song IPI measurements over the whole dataset, inter-analyst variability was examined by assigning each of the three contributing analysts to mark the same sequence of song pulses over 4 separate one-hour periods selected from the entire song dataset. Differences in measured IPIs between analyst pairs were compared and found to have an overall average absolute difference in IPI of less than 0.1 s with standard deviation 0.33 s.Acoustic data were analyzed using custom-written software Inter-pulse intervals were calculated using the start time of each pulse within an individual song sequence . No atteth percentile of the distribution. The 25% and 75% quartiles of daily IPIs were also calculated to evaluate variability within song.Monthly variation in fin whale song was assessed by first calculating monthly median short and long IPIs. Variability within song IPIs within each month and site was compared using Median Average Deviation (MAD). The MAD is the median of the absolute deviations from the data's median and is a robust measure of statistical dispersion, more resilient to outliers in a dataset than the standard deviation Following inspection of monthly IPIs and identification of gradual change between October and February across all three sites, a median IPI was calculated for October, December, and February at each site for each year with data in those months. We define the start of the song year to be July 1, as there is typically a break in the occurrence of fin whale song during the summer at all sites. These monthly measures represent median IPI lengths for early, middle, and late season song, providing quantitative measures of IPI length at different times during the year and facilitating comparison with future studies of fin whale song that may have access to shorter periods of data. The average monthly change in median IPIs was calculated from October to February, or from the first to last month with song within that period, to compare seasonal rate of change across monitoring locations.When we found substantial variability around the median IPIs in some months (assessed as first or third quartiles greater than 1), we further assessed the data to determine whether this variability could be attributed to plasticity in IPIs of the same song type or if the variability could represent occurrence of more than one song type. The distribution of song IPIs was evaluated for each month with high variability using histograms to examine whether IPIs clustered into a single short and long IPI peak or might be separated into multiple song peaks.No protected species were invasively sampled during the study.Fin whale song pulses were marked for three years of acoustic data recorded off Southern California and in the Bering Sea, and two years of data recorded near Hawaii, resulting in over 25,600 marked song pulses . The aveDoublet song was first recorded in August or September and continued through April or May in the Bering Sea and off Southern California. Similar doublet song intervals were present in all three regions from November or December to March or April of each year . At all When fin whale songs were recorded during the same season at two or more sites- 2000-01 at all three regions, 2001-02 off Southern California and in the Bering Sea, and 2005-06 off Hawaii and in the Bering Sea- IPIs were similar across sites, though some inter-annual and geographic variability was evident , Table 2While variability within each marked day was generally low  IPI  present September through January to singlet “long” (15.1 s) IPIs present March through May Although variability in the IPI was generally low within months at individual sites, as well as across sites and years, there were a few exceptions. Variability was particularly high in December of each year, roughly the mid-point of the singing season. In those months, it appeared that not all fin whale songs sampled on a given day consisted of the same IPIs , we cannot account for the variation due to the number of callers sampled in each day, or the duration of singing by an individual. This limitation could be important if a single animal is more likely to maintain a consistently timed song, and variation in aggregate IPIs was directly related to the number of measured singers. An additional limitation of the presented analysis is also the use of human analysts to manually mark the start time of individual song pulses. We attempted to minimize variation in the ability to accurately identify the start of individual calls within the spectrogram by standardizing viewing window parameters  and the analysis parameters , and also looked for differences in measured IPIs of the same song sequences across analysts. Although some variation within and among analysts is present, the median difference in a subset of song IPIs measured by all analysts indicates they were marking song pulses in a consistent manner with high precision , the seasonal and annual patterns observed here cannot be attributed to error by the human analysts. Further, the level of variation observed within each day is fairly low (0.3–1.3 MAD) in most cases and does not obscure the overall patterns of individual songs, nor the seasonal change in song IPIs. While use of energy-based peak detectors may result in more accurate selection of pulse start times, analyst consistency was high and any variation due to the accuracy of analyst picks is overwhelmed by the overall song patterns. Finally, because songs were marked on only two days per month, overall variation in fin whale calling at each site is likely underestimated, with some song variants potentially missed. The additional variation may be significant when more singing whales are in or passing through the region at the peak of the singing season.Despite some of these uncertainties, the occurrence of consistent annual change in fin whale song IPIs within and across monitoring sites over six years raise the question- why is there a strong circannual rhythm in fin whale song patterns? Circannual rhythms are common in mammals and birds Male signaling during the reproductive season can serve a range of purposes: to guard territory or for resource advertisement, to facilitate female choice, or in male-male interaction An alternative driver of this behavior, rather than attraction of females, could be male-male interactions, either antagonistic, such as mate guarding or direct competition, or social communication. The decline in the call rate during peak conception (November to March) observed in this study is not consistent with the mate guarding hypothesis, which predicts peak call rates during peak conception Passive acoustic data concurrently collected during four years at three different locations across the eastern North Pacific have revealed synchronous seasonal change in fin whale song across this broad region. The song IPIs reset annually to a relatively short singlet or doublet in the late summer and fall and progress to longer IPIs by the spring in the Bering Sea, near Hawaii, and off southern California. Such changes are difficult to interpret given the paucity of information on fin whale social structure and mating systems, but do suggest connectivity of fin whales across the eastern North Pacific. Additional study will be required to determine how wide-spread these seasonally changing IPIs occur, whether they truly represent a single population, and whether and how well broad sampling can be used to infer population movements, connectivity, and ecology over the long-term.


We report a case of a 53-year-old female presenting with a new-onset heart failure that was contributed secondary to noncompaction cardiomyopathy. The diagnosis was made by echocardiogram and confirmed by cardiac MRI. Noncompaction cardiomyopathy  is a newly discovered disease. It is considered to be congenital (genetic) cardiomyopathy. It is usually associated with genetic disorders and that could explain the genetic pathogenesis of the non-compaction cardiomyopathy. Our case had a history of Charcot-Marie-Tooth disease. There is a high incidence of arrhythmia and embolic complications. The treatment usually consists of the medical management, defibrillator placement, and lifelong anticoagulation. Heart transplantation will be the last resort. By auscultation, there was a holosystolic murmur grade 2/6 in the lower left sternal border. There were no rales, rhonchi, or wheezes on auscultation at the time of presentation to us. The patient was then referred by her primary physician to the cardiologist office. EKG was done and showed sinus bradycardia with heart rate of 54/minute. There were nonspecific ST-T wave changes. Patient had an echocardiogram  was 30.5 sec, serum creatinine was 61.83 µmol/L, blood urea nitrogen was 7.84 mmol urea /L, serum sodium [Na+] was 143 mmol/L, and serum potassium [K+] was 4.3 mmol/L. Cardiac enzymes: troponin I baseline was 0.02 μg/L. B-natriuretic peptide was 194 pg/mL.Ejection fraction was 25%. There was severe hypokinesis of the anteroseptal region with mild hypokinesia of the inferolateral wall. Right ventricle systolic function was moderately to severely reduced. There were severe mitral regurgitation, tricuspid regurgitation, dilated inferior vena cava, and increased right atrial pressure. Patient did a nuclear stress test showing abnormal myocardial perfusion of the left ventricle, left ventricular dilation, and area of thickening of the anterolateral portion of the left ventricle. It also showed severe global hypokinesia of the anterior wall and interventricular septum. The clinical, EKG, and hemodynamic response was normal. Patient was started by the cardiologist on carvedilol, lisinopril, vitamin D2, and warfarin for anticoagulation in addition to the furosemide. Laboratory work included the following. Hemoglobin was 109 g/L, WBC was 8.8 × 10Patient was scheduled for elective cardiac catheterization. The catheterization showed the following. Hemodynamic assessment demonstrated mild systemic hypertension, moderately to severely elevated left ventricular end-diastolic pressure, severely depressed cardiac output, markedly elevated pulmonary capillary wedge pressure, mildly to moderately elevated systemic vascular resistance, and moderately elevated pulmonary vascular resistance. There were severe left sided failure and moderate to severe right sided failure. There was moderate pulmonary hypertension. There was no angiographic evidence for occlusive coronary artery disease. Global left ventricular function was severely depressed. EF calculated by contrast ventriculography was 22%, EF by echo was 25%, and EF by radionuclide angiography was 29%. The left ventricle was moderately dilated. There was no mural thrombus. The mitral valve exhibited severe regurgitation. Impression: the coronary anatomy is normal. Left ventricular function is markedly abnormal (noncompaction cardiomyopathy (NCC)). The patient had a Holter monitor showing infrequent premature ventricular contractions.Cine MRI, morphology, phase-contrast, and contrast cardiac MRI were performed .Left ventricle: LVED volume is 262 mL, LVES volume is 208 mL, and LVEF is 20%. There were severe LV dilatation with normal LV wall thickness, severe diffuse LV hypokinesis, no regional akinesis or dyskinesis, severe LV dilatation with normal LV wall thickness, and severe diffuse left ventricular hypokinesis. No regional akinesis or dyskinesis was found. Contrast late enhancement study showed no evidence of segmental or significant patchy late contrast enhancement of myocardial wall, no evidence of infarction or infiltration, and no evidence of large area of myocardial edema or myocarditis. Cardiac MRI findings showed Severe MR  secondary to left ventricular dilatation, mitral annular dilatation, and left ventricular dysfunction. These findings were most consistent with dilated cardiomyopathy. After the revision with the cardiologist and given the previous echocardiographic results, it was found that the apex of LV is almost circumferentially heavily trabeculated with a ratio of trabeculated endocardial layer  to myocardial layer  of >3 though there is no involvement of apical septum; in the midlevel of LV the lateral wall and some part of inferior wall and anterolateral wall are heavily trabeculated with a ratio of noncompact (14 mm) to compact layer (6.5 mm) of >2; the basal segment of LV is mostly spared from trabeculation except lateral wall which is minimally/mildly trabeculated. The papillary muscles appear sponge-like with smaller muscle bundles. Left ventricle noncompaction is suspected with prominent lateral wall and most apical noncompact layer as well as sponge-like papillary muscle appearance. Left ventricle end-diastolic volume is 262 mL and left ventricle end-systolic volume is 208 mL.The patient had a Medtronic single chamber AICD (automated implanted cardioverter defibrillator).Noncompaction cardiomyopathy (NCC), also called spongiform cardiomyopathy, is a rare congenital cardiomyopathy that affects both children and adults [d adults . It resud adults . During d adults . The nord adults . NVM  and Charcot-Marie-Tooth disease in the present patient remains to be established. Indications for a causal relation are as follows . Having Noncompaction cardiomyopathy  is a rare form of cardiomyopathy that is usually diagnosed by echocardiogram or cardiac MRI. Misdiagnosis and underreporting of the disease make it difficult to fully understand and study that disease, especially that it is a newly discovered and described entity of the cardiomyopathy. Correlation has been reported with other genetic diseases like Charcot-Marie-Tooth disease in our case.


Non-invasive survey of left ventricular end-diastolic pressure (LVEDP) by transmitral Doppler echocardiography and tissue Doppler imaging carries important information about left ventricular diastolic function in chosen subsets of patients. This study is planned to assess whether mitral annular velocities  as assessed by tissue Doppler imaging and transmitral Doppler echocardiography are associated with invasive measures of left ventricular end diastolic pressure and also the estimation of sensitivity and specificity of these methods.One hundred ten consecutive patients admitted to cardiac catheterization underwent simultaneous Doppler interrogation measurements of left ventricular pressure were obtained with fluid-filled pressure. The E/Ea ratio associated well with LVEDP (P<0.005 r=0.4) and the correlation more marked in the patients with reduced contractile function. This correlation was independent of gender.The E/Ea ration of <8 best discriminated elevated (LVEDP>12) from normal LVEDP with a sensitivity of 73.5% and specificity 57.8%, PPV and NPV were 75.75% and 55% respectively. Our study results also showed that quantitative estimation of LVEDP could be suggested by the equation of LVEDP=1.2 E/Ea+6.67± 8 mmHg P<0.005 B=0.4.Male-LVEDP=0.9 E/Ea + 7.78±7.67 mmHg (r=0.4 Pa<0.005)EF>_50% -+LVEDP=1.48 E/Ea + 9.05±5.23 (r=0.4 P<0.05)EF<50% -+LVEDP=0.76 E/Ea + 8.4±2.3 (r=0.5 P<0.005) Heart failure is a major problem of all types of heart disease. Heart failure is a relatively common disease and it is estimated that 4/6 million people in America are undergoing treatment and in a year, 55 thousand new cases are added. The prevalence of heart failure increases significantly with age, and about 1 to 2 percent of people aged 59-50 years and over 75 to 10% are common. The final diagnosis at discharge in patients with heart failure in the United States is over 65 years. Despite a steady decline in the incidence of coronary heart disease and stroke, the incidence and prevalence of heart failure is increasing. From 1985 to 1995 the number of admissions to hospital for heart failure increased by 51% and 870 thousand hospital discharge occurred in 1996 due to heart failure . In AmerApproximately one third of patients with CHF whose diastolic failure is prevail that as pulmonary or systemic congestion and complications caused by the presence of normal or near-normal systolic function, another one third, have combined systolic and diastolic dysfunction. Others one third have only systolic dysfunction. In the Framingham study population, patients who have CHF 51% of them had EF about 50% or higher-65% of those who had EF of more than or equal 50% were women, but 75% of patients who had EF less than 50% were men- mortality in patients who had EF of more than or equal 50% was 8.7%, compared to patients with EF below 50%  is low but is about 4 times higher than the control group that in terms of age are match. In the study of Olmstand County/Minnesota similarly poor prognosis of diastolic and systolic dysfunction has been reported. Diastolic dysfunction often happens in the absence of systolic dysfunction. This disorder can be caused by increased myocardial stiffness or impaired relaxation that the latter leads to a decrease in end-diastolic dilation. When this happens, the pressure of the dilated left ventricle rises to achieve the same end-diastolic volume that result in increased venous pressure and pulmonary congestion takes place . Intra-c1-Does not require dye or radio Nuclides.2-Will not be exposed to x-rays.3-It is more secure and safe.4-Repeated measurements are possible.5-Does not need for special place equipment.6-Does not cause hemodynamic changes.7-Relatively easy.8-It is reliable.9-Gives immediate information.10-Show common changes of the heart .Doppler echocardiography can cause problems that include: 1-Good video quality was not possible in some patients 2-Techniques related to the performer 3 – With changing of the location the sample is changed. Therefore, echocardiography should be performed by trained personnel carefully and diligently . This stDiastolic function indices can be classified into three groups.1-Isovolemic Relaxation criteria.2-Indices of left ventricular diastolic pressure that is obtained from the pressure-volume relation.3-The form of ventricular diastolic filling is obtained by Doppler echocardiography, radionuclide angiography.Note that since a similar study has not been done and the aforementioned study has been done in subjects with different ages and in different sample volumes without sex comparison and sometimes uncertain results of PCWP associated with calculations of non-invasive or trans-mitral Doppler echocardiography and tissue Doppler is obtained. We are to do research in the field of coronary risk factors, presence or absence of coronary failure in patients with different ages and type of left ventricular end-diastolic pressure estimation with non-invasive methods and compare this calculation in patients with normal and abnormal cardiac systolic function.In this study that is an observational study  110 patients are examined with non-random and consecutive sampling method. People who were candidates for coronary angiography and mild cardiac valve disease were enrolled after obtaining informed consent from them. After the selection of samples and informed consent by patients, patients were transferred to lab coat and end-diastolic left ventricular pressure by fluid-filled catheter connected to a transducer method was measured by digital catheter in the left ventricle. Transducer zero parallel to the mid-axillary line was set before the angiography catheter and route of the catheters to transducer was checked in terms of the absence of air bubbles. Left ventricular end-diastolic pressure curve in 5 end-breath cycles were recorded. Left ventricular pressure curve record had done under the trained technician (collaborator), then left ventricular end-diastolic pressure by collaborator in c-point by line drawing of the R-wave in EKG simultaneously, was calculated by collaborator and form 1 was completed. A day after angiography (at least 12 hours passed from angiography) the patient was referred to the center of angiography and echocardiography were performed by collaborator with vigmed system 5. First the left ventricular function was calculated by Simpson’s method in Vivian 4C and then trans-mitral flow measured with beam position transducer at the tip of the mitral leaflets with a maximum angle of 20 from the flow path with pulse Doppler amount of E-5 end-expiratory cycles in terms of m/sec was calculated and then system was regulated to investigate tissue Doppler and lateral mitral annulus motion in sample size 1.5-2mm with the proper sweep and speed of 50-25, the amount of Ea. In terms of m/sec was calculated and at the end form 2 has been completed. Note that the person performing echocardiography during echocardiography was not informed of angiography result and the amount of specified pressure in lab coat, then the raw tables were completed and the ratio of E/Ea and its relation to left ventricular end-diastolic pressure was measured. Also exclusion criteria are as follows:1-Moderate to severe valve disease2- Lack of patient corporation3- Hemodynamic instability of patient for referral to echocardiography.At the end SPSS software was used to data analysis of the study .Of 110 patients, 38 (34.55%) were female and 72 (65.45%) were male and the age range was (78-35 years) that 76 (69.1%) were under 65 years and 34 (30.90%) were equal to or greater than 65 years. According to coronary risk factors and extent of coronary artery disease patients in two groups with increased left ventricular end-diastolic pressure (patients with diastolic heart failure) and those with normal end-diastolic pressure LVEDP ≤ 12mHg are shown in Tables Unless atrial mechicaI failure is present.AR=pulmonary venous peak atrial contraction reversed velocity DT=early left venlricular filling deceleration time; E/A=earl*to* atrial left ventricular filling ratio; EA=peak early diastolic annular myocardial velocity; IVRT=isovolumic relaxation lime: S/D=systolic-to-diastolic pulmonaryVenous flow ratio; Vp=color M-mode flow propagation vekcity.From Garciamj et al. New Doppler echocardiographic applicatoins for the study of diastolicfunction .As is evident from The statistical tests used for quantitative variables from central indexes (median-mode-mean) and dispersion index of SD and for comparison of E/Ea or end-diastolic pressure Pearson’s correlation coefficient logistic regression was used. The statistical analysis was performed using SPSS, then curve was drawn and then with drawing a regression curve ventricular end-diastolic pressure was calculated with the formula:LVEDP=1.2E/Ea +6.67 ± 8mHg P <0.005 r=0.4Left ventricular end-diastolic pressure is accessed in terms of sex using the following formula:a+6.06±8.07mHg r=0.4 p<0.005Male→LVEDP=1.38E/Ea+7.78±7.67mHg r=0.4 P<0.005Female →LVEDP=0.9E/ERegression curve based on left ventricular function with two groups of normal systolic function of the heart (preserved) using the following formula to diagnose their diastolic function.a+9.05±5.23mHg LVEDP=1.48E/EPeople with impaired diastolic and systolic function in combinationa+8.4±2.3mHg LVEDP=0.76E/EAs would be expected in patients with abnormal systolic function, measurement of left ventricular end-diastolic pressure with echocardiography was more accurate than those with normal systolic function. Cut of point ratio E/Ea according to regression curves were calculated by the number 8. The proportion of patients with E/Ea less than 8 are non-diastolic dysfunction and in those with E/Ea equal to or greater than 8, are with diastolic heart failure. According to Table 5, echocardiography was performed by Doppler trans-mitral and tissue Doppler method with determining the ratio of E/Ea ¬ to calculate the left ventricular end-diastolic pressure, have sensitivity equal to 73.5% and specificity equal to 57.8% and PPV and NPV was calculated 75.75% and 55%, respectively. Limitations of this study include translational and rotational motions of the mitral annulus, which can have influence on the interpretation of diastolic dysfunction, it is noteworthy that in similar studies the amount of it has considered slight and with careful and correct determination of the sampling location by the person performing it and use of annulus lateral instead of septal the error is minimal. The effect of WMA on the motion of mitral annulus in similar studies had no significant impact. But it needs to be investigated further in future studies. Differentiation of different forms of heart failure especially normal diastolic function of the type of pseudo-normalization in trans-Doppler this technique (TDI) may help. This study was estimation of left ventricular end-diastolic pressure with non-invasive method independent of sex, and in both sexes calculation of the LVEDP was statistically significant and not different. As the calculation of the LVEDP in cases with systolic heart failure was more accurate, but the correlation between E/Ea and LVEDP in both groups of cases with systolic heart failure and cases with preserved systolic function was statistically significant. Given that previous studies on the assessing of left ventricular filling pressures by Doppler trans-mitral only in those with systolic dysfunction of heart was not statistically significant, raise the clinical value of this study. According to sensitivity and acceptable PPV this method and results of previous studies (sensitivity 73.5% vs. 81%)  Echocard