Texture analysis (TA) is a newly arisen field that can detect the invisible MRI signal changes among image pixels. Myocardial infarction (MI) is cardiomyocyte necrosis caused by myocardial ischemia and hypoxia, becoming the primary cause of death and disability worldwide. In recent years, various TA studies have been performed in patients with MI and show a good clinical application prospect. This review briefly presents the main pathogenesis and pathophysiology of MI, introduces the overview and workflow of TA, and summarizes multiple magnetic resonance TA (MRTA) clinical applications in MI. We also discuss the facing challenges currently for clinical utilization and propose the prospect. Myocardial infarction (MI) is myocardial necrosis caused by ischemia and hypoxia of cardiomyocytes, an imbalance between oxygen offering and myocardial requirement. It belongs to a part of the clinical manifestation of the acute coronary syndrome (ACS) . MI is aThe European Society of Cardiology (ESC) has conducted the fourth universal definition of MI from cardiac troponin values (cTn) and clinical myocardial ischemia evidence that is ranging from symptoms of myocardial ischemia, ECG abnormalities, and new imaging evidence . HoweverAs the imaging techniques evolve, it plays a more and more important role in MI. Cardiac magnetic resonance (CMR) has advantages, such as non-Radiative, multiparameters and sequences, multiplanar reconstruction capabilities, and high tissue resolution, which composes the “gold standard” tool for evaluating the cardiac structure and function non-invasively and becomes the best available imaging technique for detection of MI , 8. MeanThis article concentrates on the role of MRTA in MI. In this study, we review the major pathogenesis and pathophysiology of MI, the basic concepts and types of MRTA, the clinical applications of MRTA in MI, current challenges, and potential prospects.Myocardial infarction is most commonly owing to coronary thrombosis from the rupture of an atherosclerotic plaque . When thIn MI, once the onset of myocardial ischemia, there is a subsequent decrease in myocardial perfusion, bringing about the reduction of tissue oxygenation, which transforms the hypoxia cardiomyocytes from aerobic to anaerobic metabolism, bringing about edema of cardiomyocyte and ultimately tissue necrosis .The myocardial necrosis process resembles a “wavefront” phenomenon that is ranging from the endocardium to the epicardium  Figure . Within Texture analysis (TA) is a part of radiomics. Through image post-Processing technology, the distribution and relationship of pixel or voxel gray are analyzed to extract many quantitative texture features that are not visible by the naked eyes in medical images . The imaWith high gray and spatial resolution, MRI images possess extensive and similar image information. Therefore, the statistical method becomes the most commonly used method in MRTA. For statistical-based TA, various properties control the distribution and relations of gray-scale values in images to represent texture . First-oStructural-based TA catches intensity changes between the central and adjacent voxels. Local binary patterns (LBP) are a non-Parametric algorithm and also the most frequently used method that depicts the local features of gray-scale connection between image pixels and neighboring pixels .Model-based TA explicates texture in an image with sophisticated mathematical models, for example, stochastic or fractal models. The model parameters are estimated and applied to image analysis. Due to a lack of direction selectivity, this method is unsuited for depicting local image structures .Transform-based TA enables the spatial information of images to convert into spatial frequencies. It contains Gabor, Fourier, and Wavelet transform. As the most widespread method, Wavelet transform can analyze the frequency content of images in different spatial frequency resolutions .Artificial intelligence (AI) is rapidly gaining importance in the medical imaging field and is likely to gradually turn into clinical practice in the next few years , 27. AccMagnetic resonance texture analysis clinical applications in MI emerge as a promising research domain, and many findings have presented encouraging results. The series of studies can be divided into three broad categories: establishing the diagnosis, determining the age of infarct, stratifying risk .Despite the relative importance of various MRI technologies vary, MRI plays a significant role in establishing a diagnosis for both AMI and CMI . The rapApart from being a useful diagnostic tool, MRI can also be applied for differentiation between acute and chronic infarction, which is especially helpful when the patient has multi-infarct in different vascular areas or when an infarct occurs with no clinical symptoms. Distinguishing AMI from CMI has vital clinical significance for treatment and follow-up, especially in patients with pre-Existing CMI, and the probability of locating acute lesions by ECG or coronary angiography is limited. The management of two types of infarcts differs. It is crucial to determine the infarct age, especially when both infarction entities coexist, complicating that will complicate the therapeutic plan and follow-up after treatment. Several imaging features involving the identification of AMI and CMI in previous studies, such as wall thickening and thinning , microvaCompared with those current technologies that rely on image visual evaluation, the quantitative character of TA is a unique advantage. Edema of AMI and fibrosis of CMI hold the most essential characteristics of cardiac pathological changes correspondingly and affect the internal structure of tissues, which indicates there may be some inherent texture discrepancy in the images of tissues influenced by AMI and CMI. Larroza et al.  performeIn recent years, MRTA plays a new role in identifying multiple prognostic indicators that guide risk stratification and prognosis prediction in patients with MI. The applications mainly involve five sub-aspects: (1) differentiation of reversible from irreversible myocardial injury; (2) evaluation of transmurality; (3) detection of MVO; (4) assessment of scar size combined with segmentation; and (5) identification of scar heterogeneity.Differentiating reversible from irreversible myocardial damage is valuable for prognosis prediction. The salvaged myocardium is an independent predictor of prognosis and is associated with mortality, representing the risk area but can be rescued or rescued through revascularization . The myoOne promising result about the differentiation of reversible from irreversible myocardial injury based on MRTA was reported by Bing-Hua Chen et al. . They exThe transmurality of infarction possesses an independent prognostic value in measuring the recovery of contractile function after treatment, and a greater transmural extent is related to poorer recovery , 51.Magnetic resonance texture analysis shows several promising results in the evaluation of transmurality. Ma et al.  combinedMicrovascular obstruction appears in severe microcirculation damage caused by myocyte death, overflow of intracellular substances, severe stasis, and occlusion of end arteries and capillaries . MoreoveMa et al.  applied The extent of infarct can predict left ventricular adverse remodeling (LVAR) and correlates negatively with prognosis –55. BesiMagnetic resonance texture analysis-combined segmentation can better provide the signal intensity features of the scar, then to help better segment the scar and assess scar size. Kotu et al.  segmenteAfter MI, the necrotic tissue is gradually replaced by granulation and fibrous tissue and finally, develops into scar tissue. The myocardium presents heterogeneous nature owing to scarring, and the scar tissue is complex on a histopathological level. In addition, numerous studies have shown that the degree of scar heterogeneity correlates directly with the risk of arrhythmia events, thereby, better guide the implantation of an implantable cardioverter defibrillator (ICD) , 65. In The scar can be described as two areas: (1) the core area, which consists of fibrous tissue and the myocardial fibers which are in a state of complete death, does not respond to the electrical signals transmitted by the myocardium to tell the heart to contract; (2) the border area, also known as peri-infarct area or gray zone area, contains heterogeneous tissue composed of necrotic tissue mix with bundles of viable cardiomyocytes; the electrical signals in these areas will be disturbed, which may lead to reentry and sometimes arrhythmias , 39, 57.Some studies reveal that MRTA helps to identify arrhythmias events for patients with previous MI. Engan et al.  performeDespite these superiorities, extensive clinical application of MRTA in MI remains challenging. First, most of the studies are small sample pilot exploration in a single center, and almost all of them are retrospective studies. The conclusions obtained lack extensive verification support, and the clinical evidence is not sufficient. Therefore, prospective, multicenter, and large sample studies are needed. Second, at present, medical imaging equipment lacks the same image acquisition and imaging algorithm standard, and different acquisition times of the same MR machine and acquisition of different MR machines can affect the stability of radiomics features, and the reproducibility is low. Consequently, strict protocols and standardized methodologies should be followed to maximize the validity of future research. Third, there are many feature parameters in TA, and the prediction accuracy is affected by feature parameters, feature selection methods, and classifiers. In addition, MRTA software is manifold, and there is no evidence to show which software is superior at present. However, 3D TA includes more spatial information and is superior to 2D TA but applies less due to increased complexity. Thus, more accurate and widely applicable feature selection and pattern recognition methods will become the development direction of MRTA.In the era of big data, TA has become a research hotspot in the field of precision medicine and AI . CompareAlthough multiple MRTA clinical applications in MI have shown encouraging results, some aspects are not or rarely referred to and may become future developments.In traditional imaging, the following factors are also related to risk stratification and prognosis in patients with MI that may be helpful for MRTA clinical application, for instance, (1) hemorrhage in the core of infarct has been demonstrated as an adverse prognostic indicator that is relevant to LVAR, large infarct size, and increased LV end-systolic volume ; (2) iscIn addition to the above future developments that MRTA has potential in risk stratification and prognosis prediction in MI, the combined application with MRTA also has a certain prospect. First, except for the cine, mapping, and LGE, applying MRTA to other CMR quantitative techniques, such as strain, diffusion tensor imaging (DTI), perfusion-weighted imaging (PWI), and intravoxel incoherent motion (IVIM), can enrich the clinical research methods of MI. Second, MRTA combined with other imaging techniques, such as ECG, echocardiography, and myocardial radionuclide tomographic imaging may improve early MI diagnosis and prognosis. Third, cTn is the most diagnostic biochemical marker for MI, the combination of MRTA and cTn will increase the understanding of the connection between texture change and progression of MI. Fourth, the combination of radiomics characteristics and genomic data is described as radiogenomics . Gene reAt present, the inferential diagnosis of MI is based on the combination of biochemical markers, ischemic symptoms, or ECG changes. We are entering an era of combined imaging and clinical assessment in disease detection and diagnosis. MRTA can detect the invisible signal changes, thus, provides an additional non-Invasive method to establish the diagnosis, determine the age of infarct, and stratify risk and predict prognosis in MI. Although its current application for MI imaging faces some challenges, MRTA shows good clinical application prospects in MI.FP conducted the reference analysis and wrote the manuscript. LGG and HZ contributed to the topic conception, manuscript revision, and decision to submit for publication and are the co-corresponding authors. The remaining authors contributed to the reference collection and helped in the revision of the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by the National Natural Science Foundation of China (Grand No. 81860316).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In this report, we present a case of a 51-year-old male patient with a left ventricular (LV) pseudoaneurysm and a ruptured lateral wall due to a previous myocardial infarction. This patient was referred to the Coronary Care Unit with a past history of acute coronary syndrome of two months. He presented with palpitations and acute pulmonary edema upon admission. Color Doppler detected a ruptured lateral ventricular wall, and an echocardiogram confirmed the presence of a lateral ventricular wall pseudoaneurysm. Emergency LV aneurysmal rupture repair surgery was performed on this patient, and the postoperative findings were stable till discharge. A left ventricular (LV) pseudoaneurysm is formed when a free myocardial wall rupture is contained by the surrounding pericardium and scar tissue . A pseudA 51-year-old patient with a previous medical history of diabetes mellitus and hypertension was referred to our tertiary hospital and admitted with acute pulmonary edema and palpitations. He was an active smoker, and was diagnosed with acute coronary syndrome and put on aspirin two months prior to his visit. Lab investigations showed that the troponin level was elevated at 0.169 ng/mL  [A life-threatening complication of MI is rupture of the LV free wall, occurring in roughly 4% of patients with infarcts and around 23% of those suffering fatal infarcts. Free wall rupture is rarely contained by the overlying, adherent pericardium, resulting in a pseudoaneurysm or false aneurysm of the left ventricle [LV pseudoaneurysms have been found to mostly occur in the posteroinferior wall and in basal segments rather than in apical segments. The paucity of anterior LV pseudoaneurysms could be explained by the fact that an anterior rupture is more likely to cause a hemopericardium and death than a posterior rupture. Moreover, because most hospitalized patients remain in a recumbent position, an inflammatory reaction of the posterior pericardium might cause pericardial adhesions and the establishment of a posterior LV pseudoaneurysm .The majority of LV pseudoaneurysms develop after MI or cardiothoracic surgery. In a systematic literature review of 290 patients, MI (55%), surgery (33%), and trauma 7%) were the top three associations. LV pseudoaneurysms pose a significant risk of rupture, which is far higher than that of a true aneurysm. Congestive heart failure, chest pain, and dyspnea were the most commonly reported symptoms in patients with LV pseudoaneurysm, according to one systematic literature review. In addition, the clinical presentation of patients with LV pseudoaneurysms is varied. According to the systematic literature evaluation, more than 10% of patients (n = 290) were asymptomatic % were th.Noninvasive imaging modalities, including echocardiography, CTA, and cardiac magnetic resonance imaging (MRI), are the investigations of choice for diagnosing LV pseudoaneurysm . Color fLV pseudoaneurysm has a strong indication for surgery since untreated pseudoaneurysms have a 30%-45% chance of rupturing . Unless LV pseudoaneurysms are very rare and often present with dyspnea, chest pain, and congestive heart failure. MIs are the most common cause of LV pseudoaneurysm followed by cardiothoracic surgery. Multiple diagnostic tools are available, such as echocardiography, CTA, and cardiac MRI. LV pseudoaneurysms are strong indications for surgery. New techniques need to be developed to treat LV pseudoaneurysm as current surgeries carry a reasonable risk.


Danon disease is an X-linked multisystemic disorder characterized by skeletal myopathy, cardiomyopathy, and intellectual disability.Herein, we describe two patients affected by Danon disease from the same family, a father (Patient 1) and his daughter (Patient 2). In Patient 1, a short PR interval with pre-excitation was evident. In Patient 2, over a 24-h period 2369 atrial premature beats and rare isolated ventricular ectopics were detected. Both patients exhibited left ventricular hypertrophy with non-compaction myocardium, and the left ventricular ejection fraction was impaired in Patient 1 and normal in Patient 2. In Patient 2, the total left ventricular strain value was reduced, and layer-specific strain revealed that subepicardial strain impaired more than in other layers. Late gadolinium enhancement was detected both in left and right ventricles in Patient 2, and cardiac fibrosis was more apparent in the subepicardium of left ventricular free wall. Four-dimensional (4D) echocardiography revealed that left atrial reservoir strain and left ventricular total longitudinal strain were induced.Novel 4D echocardiography and left ventricular systolic strain may play important role in diagnosis and myocardial functional evaluation in Danon disease. Learning pointsNon-compaction cardiomyopathy may be one of the two-dimensional (2D) echocardiographic characteristics present in Danon disease.Left ventricular strain measured via 2D speckling-tracking, especially for layer-specific strain, can be a more sensitive method for diagnosis and ventricular function evaluation in Danon disease.Four-dimensional volume and strain echocardiography may play important roles in the diagnosis and prognostic evaluation of Danon disease.Danon disease is an X-linked multisystemic disorder that predominantly involves the mental retardation, skeletal myopathy, and hypertrophic cardiomyopathy.Figure 1A). Echocardiography revealed a hypertrophic dilated left ventricle with poor systolic function [left ventricular ejection fraction (LVEF) 24%] and signs suggestive of non-compaction myocardium . Doppler parameters indicated reduced e′ velocity at the mitral valve annulus and increased tricuspid regurgitation velocity. A restrictive filling pattern was evident via pulse Doppler of the mitral valve. According to the American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines and references,A 31-year-old man categorized as New York Heart Association Class IV was admitted to the hospital after suffering from anorexia for 2 weeks and dyspnoea for 1 week in August 2001. He had previously undergone surgery for appendicitis and had on other past medical history. He exhibited mild intellectual disability, and electrocardiography (ECG) depicted a short PR interval with pre-excitation and negative T waves . She evidently had no learning difficulties. On physical examination, she appeared well developed and had normal skeletal muscle strength and muscle tone. Laboratory parameters included elevated aspartate aminotransferase (64 IU/L), creatine kinase-myocardial isoenzyme (7.5 ng/mL), lactate dehydrogenase (510 U/L), TnTI (0.09 ng/mL), N-terminal pro-brain natriuretic peptide (543.4 pg/mL), and lipoprotein(a) (0.93 g/L). Alanine aminotransferase (18 IU/L) and creatine kinase (108 U/L) were in normal ranges.Patient 1’s daughter (Patient 2) was admitted to hospital in February 2019 at the age of 19 years with dyspnoea and palpitation while sleeping for 6 months. She had no past medical history. Approximately 10 years prior, echocardiography and ECG had been performed and were normal . In 24-h Holter monitoring, there were 2369 atrial premature beats (2.6% burden) and rare isolated ventricular ectopics. Coronary computed tomography angiography was normal. Echocardiography revealed left ventricular hypertrophy, and no significant left ventricular outflow tract obstruction was evident in resting echocardiography or dobutamine stress echocardiography (5–20 µg/kg/min). Blood was sent for genotyping and a heterozygous nonsense mutation in the LAMP2 gene (LAMP2: p.Gln240Ter het) was identified. She was diagnosed with Danon disease and started on an oral β-blocker followed by diltiazem administration. Her father (Patient 1) had died 17 years prior because of heart failure in the context of hypertrophic cardiomyopathy. A pedigree chart is shown in Figure 3. Three generations involving five family members were assessed, but no relevant mutations were detected in other family members.Twelve-lead ECG indicated left ventricular hypertrophy with deep negative T waves, and the QRS duration was 120 ms . The affected segments had a two-layer structure that consisted of a compact epicardial layer and an endocardial layer, and the endocardial layer that exhibited prominent trabecular meshwork and deep intertrabecular spaces. The ratio of non-compacted to compacted myocardial layers at the site of maximal wall thickness (22 mm) was 2.1. The LVEF measured via the biplane method was 65%, and the left atrial volume index was 22.1 mL/m2. Doppler parameters included septal e′ velocity 4 cm/s and lateral e′ velocity 6 cm/s, and E/e′ was 15.8, E wave velocity was 0.82 m/s, and E/A was 1.5, suggesting Grade 1 impaired diastolic dysfunction. The structure, function, and strain of the right ventricle were normal.In December 2020, echocardiography was performed again for Patient 2, including 4D echocardiography and two-dimensional (2D) left ventricular systolic strain. The 2D echocardiographic parameters were similar to the echocardiography performed 1 year ago, which revealed normal ventricular volumes and ejection fractions but demonstrated concentric left ventricular hypertrophy. Non-compaction myocardium characterized by prominent trabeculations and deep intertrabecular recesses was detected at the basal to apex ventricular segment of the left ventricular inferior, lateral, and anterior walls  indicated global longitudinal strain decreased to −9.5%, which was less than it had been 1 year prior (−12.7%). Layer-specific strain indicated that the myocardial longitudinal peak strain of the epicardial layer reduced more than other layers, and the endocardial layer strain in the left ventricle apex was normal.Left ventricular strain  and left ventricular longitudinal strain was decreased (–6%).Figure 7), and more LGE was evident in the epicardium of the free wall of the left ventricle. At the last follow-up (September 2021), she was clinically stable.Cardiac imaging depicted increased thickness of left ventricular wall, and late gadolinium enhancement (LGE) distributed in both right and left ventricular myocardium . The LGE results were consistent with the layer-specific strain, which suggested that the epicardial layer of the left ventricle was affected more than other layers.Speckle-tracking echocardiography has recently enabled the measurement of myocardial strain and strain rate, which are evidently useful for the evaluation of cardiac function in Danon disease.Figure 7).Four-dimensional volume–strain echocardiography is a recently developed technique that can facilitate the acquisition of higher temporal resolution and spatial resolution with a higher frame rate, and it is less prone to artefacts than other methods. In Patient 2 in the present case series, 4D volume and strain echocardiography enable the evaluation of cardiac function and myocardial tissue characterization precisely and non-invasively in the current case series (In conclusion, non-compaction myocardium was detected in both cases of the current case series, it may be one of 2D echocardiographic characteristics in Danon disease. Left ventricular strain evaluated left ventricular function more sensitively than LVEF. Layer-specific strain shows more significant impairment in the epicardium, which tallies nicely with the location and degree of LGE in the subepicardium. Novel 4D echocardiography and left ventricular systolic strain may play an important role in diagnosis and myocardial functional evaluation in Danon disease.Zhou Bingyuan is a PHD of cardiovascular medicine.European Heart Journal—Case Reports online.Slide sets: A fully edited slide set detailing these cases and suitable for local presentation is available online as Consent: The authors confirm that written consent for submission and publication of this case report including the images and associated text it contains has been obtained from patient in accordance with COPE guidelines.Conflict of interest: None declared.Funding: None declared.ytab443_Supplementary_DataClick here for additional data file.


A rare case of congenital mitral insufficiency characterized by a fenestration in the anterior leaflet of mitral valve is reported. At operation, the mitral valve was successfully repaired by closure of unusual valvular tissue orifice with bovine pericardium and suture of the free edge between A1 and A2 without a ring annuloplasty. The patient was born and then sent home the day after a standard cesarean delivery. He had his first regular pediatrician visit at 30 days of age and presented symptoms of shortness of breath. Due to quickly worsening symptoms, he returned to the emergency room when he was 2 months old, with severe dyspnea, hypotension, and had a cardiac arrest. After resuscitation maneuvers were successful, an emergency echocardiographic study revealed severe coarctation of the aorta, small patent ductus arteriosus (PDA), enlarged left atrium and ventricle, bicuspid aortic valve, and moderate mitral regurgitation (MR) (prolapsed anterior leaflet).The prostaglandin was initiated, and the patient was brought to the operating room. The repair was done via left thoracotomy and, in addition to the coarctation and PDA, we also found an undiagnosed aberrant right subclavian artery originating in the descending aorta. Both were repaired. Against the odds, the MR persisted, even with almost absent aortic gradient and normal left ventricular function. Since the postoperative echocardiography failed to show an easily repairable lesion , he was sent home with full treatment of diuretics, vasodilators, and digoxin.In the follow-up, when he was 5 months old, he had persistent cardiac failure symptoms and was readmitted with New York Heart Association class IV. Marked cardiomegaly with the left atrium as the predominant chamber was seen on the chest radiograph associated with signs of pulmonary congestion. Electrocardiography showed sinus rhythm, right-axis deviation, and left atrium hypertrophy. The new cross-sectional echocardiography revealed a perforation in the anterior leaflet of the mitral valve (MV)  and the Surgery was performed via a median sternotomy, using cardiopulmonary bypass, with moderate hypothermia (28°C) and cold potassium cardioplegia, and we could see a very enlarged left atrium. The MV was exposed directly via the left atrium and a 0.4-mm diameter gap like a hole on the anterior mitral leaflet was identified. The cordae were thick and an area of scar corresponding to the regurgitation jet was clearly visible . The def[1]. The most common lesion in congenital MV disturbance is an abnormality of the papillary muscles, followed by the involvement of leaflets, commissures, and chordae tendineae. This condition is often associated with anomalies involving the left side of the heart , or as part of a syndrome.Mitral incompetence is a rare congenital malformation. It was first described by Semans and Taussig (1938). Primary congenital MV abnormalities are identified according to the four anatomic components of the valve [2].The etiology of congenital mitral insufficiency accompanying coarctation of the aorta is not clear. An embryologic association between the two lesions is difficult to explain, but it is possible for the same insult to cause unrelated congenital defects Despite advances in the treatment of complex congenital heart defects in very small infants, congenital mitral incompetence sufficiently severe to require an operation during the first year of life is still a therapeutic challenge. In view of its poor results, surgical treatment for congenital MV disease is always delayed until severe symptoms develop with medical treatment.Contrary to the preoperative expectation, correction of the coarctation of the aorta and associated PDA before MV surgery did not result in improvement of cardiac failure. Removal of the aortic obstruction did not reduce the volume of blood regurgitating into the left atrium as we expected if the diagnostic of prolapsed leaflet was correct. Had the correct diagnosis been made, MR could have been corrected earlier, therefore avoiding the left atrium enlargement and all the complications in between the two operations.[3]. An understanding of the pathologic anatomy of congenital MR is absolutely relevant to its optimal surgical management. If one recognizes that regurgitation is due to a leaflet perforation, it may well be possible to patch the perforation, thereby avoiding MV replacement.In reviewing the literature, we have found very few descriptions of patients treated surgically with congenital mitral incompetence and coarctation of the aorta. It is even more difficult to find an MR caused by a deficient tissue growth like a fenestration in the anterior leaflet, like this case


None of the regular PAs predicted convergent thinking , nor were they associated with the acute aerobic exercise intervention effects on divergent and convergent thinking. These findings suggest that engaging in regular vigorous-intensity PA and walking may be useful strategies to enhance different aspects of divergent thinking in daily life.The beneficial effects of regular physical activity (PA) on cognitive functions have received much attention. Recent research suggests that regular PA may also enhance creative thinking, an indispensable cognitive factor for invention and innovation. However, at what intensity regular PA brings the most benefits to creative thinking remains uninvestigated. Furthermore, whether the levels of regular PA affect the acute PA effects on creative thinking is also unclear. In the present study, using a previous dataset that investigated the effects of an acute bout of aerobic exercise on creative thinking in healthy Japanese young adults (22.98 ± 1.95 years old) in the year 2020, we tested the association between different intensities of regular PA  and creative thinking with the cross-sectional baseline data using multiple linear regression. We also investigated whether regular PA levels were associated with the acute aerobic exercise intervention effects on creative thinking. The results showed that cross-sectionally, the regular PAs were differentially associated with divergent but not convergent thinking. Specifically, whereas the amount of vigorous-intensity PA was positively associated with fluency and flexibility, the amount of walking was positively associated with novelty on the alternate uses test (AUT) measuring divergent thinking. Importantly, the explained variances of fluency, flexibility, and novelty were 20.3% ( The World Health Organization (WHO) recommends that adults aged 18–61 years should conduct at least 150 min of moderate-intensity physical activity (PA), 75 min of vigorous-intensity PA, or an equivalent combination of both moderate- and vigorous-intensity PA ,3,4,5). Creative thinking is generally believed to comprise two fundamental cognitive processes: divergent and convergent thinking ,7,8. DivWe have recently conducted a systematic review of studies on acute PA and creative thinking and concluded that acute PA has the potential to enhance divergent and convergent thinking  ). For inHowever, to the best of our knowledge, the effects of regular or chronic PA on creative thinking has not been systematically reviewed so far. Whereas the effects of acute PA are transient, those of regular PA are long lasting and may be more valuable for long-term enhancement of creative thinking. We, therefore, searched (1) interventional studies that investigated the effects of multiple sessions of PA interventions on creative thinking and (2) observational studies that investigated the association between the levels of regular PA and creative thinking  on one or several measures of divergent thinking, such as fluency  on AUT and figural fluency on TTCT ,20,21,22Although the results of our systematic review indicate beneficial effects of regular PA on creative thinking , the influence of PA intensity or, in other words, at what intensity regular PA brings the most benefits remains unclear. None of the identified interventional studies specified the intensity of their PA programs. Two of the cross-sectional studies did differentiate the intensity of regular PA, but the results were inconclusive. Rominger et al. (2020)  reportedFurthermore, none of the studies we reviewed have examined the interaction effect between regular and acute PA on creative thinking. In the field of PA and mood, studies have reported that subjects with high levels of regular PA may show more enhanced mood in response to a new, acute bout of PA ,29. HoweTherefore, in the present study, we conducted a secondary analysis of a previously published study  that invThe study was approved by the Institutional Review Board of Yamaguchi University Hospital and preregistered on the University hospital Medical Information Network Clinical Trial Registry . The study was carried out following the latest version of the Declaration of Helsinki, and all subjects agreed to participate in the study and provided written informed consent. The characteristics of the participants and procedure of the intervention have been described in . In brieAs shown in The international physical activity questionnaire long-form  was empDivergent thinking was measured with the AUT . In thisConvergent thinking was evaluated with the matchstick arithmetic problems developed by Knoblich et al. . At pre-For the acute aerobic exercise intervention, we used an automated physical test program built in an exercise bike . The program lasted 15 min and consisted of 10 min of physical test and 5 min of cooldown. This was essentially a graded exercise program designed for convenient physical testing. Under this program, subjects sat quietly on the bike during the first minute to measure their resting pulse, after which they started pedaling at a pace of 50 rpm. The workload increased at 4 and 7 min after the start of the program according to the pulse rate of the subjects at the moment. This program was chosen as the exercise intervention because its workload was predicted to fall between normal cycling at moderate intensity and intense cycling with maximal effort, two intensities tested by Colzato et al. (2013) . Exercisn = 40). The normality of the data was checked using the Shapiro–Wilk test. Due to non-normal distribution of total PA, Spearman correlation analysis was used to examine the association between total PA and creative thinking at baseline as well as the acute aerobic exercise intervention effects. Confidence intervals (CI) for the Spearman correlation coefficients were calculated based on [p < 0.05 was used.The statistical analysis was conducted with IBM SPSS Statistics 26.0. To investigate the association between regular PA and creative thinking at baseline, we combined subjects from the exercise and control groups together (based on . Multiplp = 0.067) and flexibility  but not novelty  on AUT of divergent thinking (p = 0.575).Spearman correlation analysis indicated that total PA was marginally associated with fluency  and flexibility (p = 0.032), walking positively predicted novelty (p = 0.016) on AUT measure of divergent thinking. Notably, the models explained 18.8–20.3% variances of the AUT measures. A partial regression plot of the associations is shown in p = 0.976).To investigate the independent effects of different intensities of regular PA on creative thinking at baseline, we incorporated all three intensities of regular PA as independent variables to predict creative thinking using multiple linear regression models . The resp > 0.09) or control  group.Spearman correlation analysis indicated that total PA was not associated with any of the acute intervention effects on divergent or convergent thinking in either the exercise . However, in the control group, the amount of moderate-intensity PA positively predicted the matchstick retest measure of convergent thinking in response to the control intervention  are considered small in magnitude . More imVigorous-intensity PA refers to activities that require hard physical effort and cause large increases in breathing, for instance, heavy lifting, fast bicycling, and intense aerobics. We have previously proposed that higher intensities of PA may bring more benefits to the brain because they generally cause more extensive, enhanced, and long-lasting neurobiological changes . For insThe WHO Guidelines on Physical Activity and Sedentary Behavior has recommended vigorous-intensity and moderate-intensity PA as the primary PA for people of all age groups, including children, adolescents, adults, and older adults . HoweverMeanwhile, we found that regular PA was not associated with the acute aerobic exercise intervention effects. The interaction effect of regular and acute PA on mood has been reported and debated e.g., ,30,32). ,32. 30,3Several limitations of the present study have to be noted. Firstly, our subjects were undergraduate students, which prohibits us from generating our findings to other populations. Secondly, our sample size was relatively small, in particular for the analysis on the interaction between regular and acute PA effects. Thirdly, given our small sample size, we did not probe the potential sex difference in the associations between regular PA and creative thinking. Fourthly, we used only a self-report scale  to measure PA. Although the validity of the scale has been established , there rIn a sample of young adults, we found that regular vigorous-intensity PA was positively associated with fluency and flexibility, while regular walking was positively associated with novelty of divergent thinking. None of the different intensities of regular PA were associated with convergent thinking or the acute aerobic exercise intervention effects on divergent and convergent thinking. These findings suggest that engaging in regular vigorous-intensity PA and walking may be employed as useful strategies to enhance different aspects of divergent thinking in daily life. Whereas the WHO recommends vigorous-intensity and moderate-intensity PA as the primary PA for people of all age groups, the current study indicates that in the case of creative thinking, walking may be more valuable than vigorous- and moderate-intensity PA, since only walking is associated with novelty of divergent thinking. If these findings are replicated by more robust studies, they will have great implications for cognitive and performance enhancement.


The functional assessment of the fetal heart has been incorporated into cardiac ultrasound screening as a routine procedure, encompassing fetuses with and without structural heart diseases. It has long been known that various cardiac and extracardiac conditions, such as fetal growth restriction, fetal tumors, twin-to-twin transfusion syndrome, fetal anemia, diaphragmatic hernia, arteriovenous fistula with high cardiac output, and congenital heart diseases , can alter hemodynamic status and fetal cardiac function. Several ultrasound and Doppler echocardiographic parameters of fetal cardiovascular disease have been shown to correlate with perinatal mortality. However, it is still difficult to identify the signs of fetal heart failure and to determine their relationship with prognosis. The aim of this study was to review the main two-dimensional Doppler ultrasound parameters that can be used in the evaluation of fetal cardiac function, with a focus on how to perform that evaluation and on its clinical applicability. The atria receive venous blood, whereas the ventricles eject blood into the systemic circulation. Once the intraventricular pressure falls below the atrial pressure, the atrioventricular (AV) valves open and blood flows into the ventricles as a result of depolarization and atrial contraction. The terms active filling and passive filling are used in reference to the macroscopic appearance, given that both processes are molecularly active .As the heart rate increases, the atria increase their contribution to cardiac output by shortening the passive ventricular filling time. In situations in which the heart rate increases, to counter the reduction in the passive filling time of the ventricles, the sympathetic nervous system, which is responsible for the positive inotropic effect, also increases the ventricular relaxation time by decreasing the duration of the action potential of myocardial muscle fibers. From a cardiac function point of view, systolic changes alter the ICT, whereas diastolic changes affect the IRT.As the ventricles undergo depolarization and contraction, there is a progressive increase in intraventricular pressure and closure of the AV valves, after which isovolumetric contraction begins. The isovolumetric contraction time (ICT) is the time between the closure of AV valves and the opening of aortic and pulmonary valves, which results in blood being pumped into the pulmonary and systemic circulation. The semilunar valves open when the intraventricular pressure exceeds the pressure within those valves. As the ventricular contractility decreases, the intraventricular pressure decreases and the semilunar valves close. The time between the closure of the semilunar valves and the opening of the AV valves is known as isovolumetric relaxation time (IRT). During ventricular systole, the atria fill continuously, causing the atrial pressure to increase until it exceeds the ventricular pressure, the AV valve to open, and a new cycle to begin.Systolic volume and the amount of blood pumped by the heart during a single heartbeat depend mainly on three factors: preload, afterload, and contractility. Preload is the ventricular end-diastolic pressure. It is the main determinant of ventricular volume and, consequently, of the distention capacity of the ventricular muscle fiber. According to the Frank-Starling law, a normal heart increases its contractility when the distention of myocardial muscle fibers increases. Therefore, an increase in ventricular end-diastolic volume causes an increase in systolic volume. Afterload is the pressure that the heart muscle fibers must overcome to allow the pumping of blood. Therefore, an increase in afterload decreases ventricular contractility, thus reducing systolic volume. Systemic blood pressure is the main contributor to increased afterload. Finally, contractility is the ability to shorten muscle fiber and depends on the action of the sympathetic nervous system. The release of norepinephrine increases the contractility of the heart and, consequently, systolic volume: stroke volume, cardiac output, ejection fraction, relaxation fraction, myocardial contractility, and myocardial performance index (MPI). Various parameters have been developed for the assessment of cardiac function. They were initially developed for use in adults and later adapted for the evaluation of fetal hearts. Some parameters use Doppler flow mapping, whereas others use cardiac biometrics, cardiac cycle time, or a combination of the two. The main parameters are as follows evaluated stroke volume and cardiac output in 222 fetuses from 13 weeks of gestation to term. The authors demonstrated that stroke volume and cardiac output increased exponentially with advancing gestational age. The median cardiac output in both ventricles ranged from 40 mL/min at 15 weeks to 1,470 mL/min at 40 weeks gestation. The median fetal weight-corrected cardiac output was 425 mL × min−1 × kg−1, and the median cardiac output ratio between the RV and LV was approximately 1.4, remaining stable during pregnancy, the RV being dominant.Mielke et al.. Due to the greater technical difficulty in the use of conventional markers of cardiac function, there has been increasing interest in the study of alternative methods, such as determination of the AV blood flow  and the MPI, as well as spectral tissue Doppler, all of which allow evaluation of the contractility and degree of deformity of the fetal heart musculature.In the past, fetal cardiac function was assessed by measuring the ejection fraction and ventricular shortening fraction through the use of M-mode and two-dimensional (2D) ultrasound. However, the use of those techniques before birth had some limitations because of the small dimensions of the fetal heart, movement artifacts, inappropriate fetal position, and the geometric complexity of the fetal RV; its first component is the E wave, which represents the passive filling phase, whereas its second component (the A wave) represents the active filling phase.The E/A ratio represents the relationship between the early and late peak flow velocity through the AV  valves during diastole. Determining the E/A ratio with spectral Doppler allows evaluation of the ventricular diastolic component of the cardiac cycle. To calculate the E/A ratio, it is necessary to place the spectral Doppler sample volume just below the AV valves. As shown in . In healthy fetuses, the peak velocity of the A wave is generally higher than is that of E wave. As gestational age advances, the E and A wave velocities increase, the increase in E wave velocity being more pronounced because of the greater capacity of the fetal heart for compliance and relaxation,7. This pattern of blood flow through the AV valves manifests as progressive elevation of the E/A ratio through pregnancy. A reduction in the E/A ratio indicates that the ventricular filling process depends more on the atrial contraction than on the negative pressure exerted during the relaxation phase and may therefore also indicate impaired diastolic ventricular function.The biphasic form of blood flow through the AV valves can be identified as of 9 weeks of gestation.The E/A ratio should be evaluated in the four-chamber view of the heart, in the absence of fetal body and respiratory movements. The sample volume should be 2-3 mm and should be positioned distal to the AV valves, preferably with an insonation angle < 20°. The pulse repetition frequency must be adjusted so that the velocity wave occupies at least 75% of the scale and that 3-5 symmetrical waves are visibleThe MPI is calculated, by spectral Doppler, with the following formula:ET is the ejection time. The MPI is capable of assessing overall cardiac function because it comprises the systolic and diastolic components of the cardiac cycle and can be used in order to assess the two ventricles separately. The MPI values for the fetal LV remain relatively stable and vary slightly during gestation, the mean being 0.36, with a standard deviation of 0.28-0.44. The ICT represents the time between ventricular contraction and the opening of the aortic and pulmonary valves. During the ICT, there is increased intraventricular pressure without changes in the volume of the RV or LV. The IRT begins with diastole after closure of the aortic and pulmonary valves. At that moment, there is ventricular isovolumetric relaxation but no entry or exit of blood; therefore, the intraventricular pressure gradually declines. The ET starts when the intraventricular pressure is sufficient to promote the opening of the aortic and pulmonary valves, causing myocardial deformation and blood to gain systemic circulation.where . The IRT is the main parameter that changes during the early phase of myocardial dysfunction, the change being due to the suppression of calcium reuptake by cardiomyocytes, which prolongs the time required for complete myocardial relaxation,12.Myocardial dysfunction increases the MPI values through prolongation of the IRT and reduction of the ET were the first to use MPI to assess overall fetal cardiac function by analyzing two waves during the same cardiac cycle. One subsequent study showed that there is great variability when this measurement technique is employed. Friedman et al. proposed a method for assessing MPI by positioning the spectral Doppler sample volume near the mitral influx and aortic outlet. Thus, it would be possible to evaluate the isovolumetric and ejection periods simultaneously during the same cardiac cycle.Tsutsumi et al. used mitral and aortic valve opening clicks as references to improve the estimation of the time intervals for MPI calculation. Hernandez-Andrade et al. described the use of a modified MPI, which was used as a reference to identify different time points: the beginning of the opening clicks and the beginning of the closing clicks  or in the opposite direction (closing clicks). Small echoes know as "reflected" clicks can be identified in the opposite direction from the original clicks. Original and reflected clicks share the same peak point . Raboissg clicks . That te, pregestational diabetes mellitus, twin-to-twin transfusion syndrome, pre-eclampsia, and congenital heart diseases. It is a reliable parameter for identifying early cardiac dysfunction and early changes related to fetal cardiac adaptation to various perinatal insults. Increased MPI is rarely transient, and the MPI remains high in complicated cases.The MPI has been used in order to assess fetal cardiac dysfunction in a number of conditions, including fetal growth restriction. In the literature, there is no consensus on the exact caliper positioning at the moment of MPI measurement. That inconsistency in the methodology contributes to the wide variation between normal values and consequent difficulty in comparing the results across studies. Although the protocol for the most widely used technique for measuring the MPI states that the calipers should be positioned at the beginning of the opening click and at the beginning of the closing click, there is still no consensus on the literature. In one study, the calipers were positioned to span the space between the end of one click and the beginning of the next, the authors arguing that this form of measurement would be the most physiological, given that it does not include the period of valve movement in the calculation of ICT and IRT. In another study, the calipers were positioned at the peak of the click. The use of peak clicks improved the reproducibility of MPI measurement by establishing a clearer reference point for measuring ICT, IRT, and ET, thus avoiding variations due to differences in the width of the valve clicks.During evaluation of the MPI, manual positioning of calipers on the Doppler velocity wave is used in order to evaluate the time intervals between the various clicks. Minor variations in caliper position can lead to millisecond variations in time intervals and, consequently, significant changes in the MPI values.  conducted a prospective cohort study of 62 fetuses between 28 and 36 weeks of gestation in women with low-risk pregnancies. The authors showed that sweep speed and the filter setting were the parameters that had the greatest influence on the MPI value. Reduced scanning speed resulted in less reproducibility, because it reduced the accuracy of the determination of the time intervals . Lowering the filter worsened reproducibility of the MPI, which improved when the filter was raised. When the filter was too low, artifacts appeared near the baseline, making it difficult to identify the beginning of the valve opening and closing clicks. In contrast, raising the filter allowed better click identification and eliminated the blurred area near the baseline. The authors found that modifying the gain had little effect on MPI variability. In fact, they showed that the gain adjustment, which largely depended on maternal body mass index and fetal position, could be individually adjusted to make the sonographer feel more confident in identifying valve clicks. The authors also stated that the best device settings to ensure the highest reproducibility seemed to be a sweep speed of 8 cm/s, a gain of 60 dB, and a 281-Hz filter for the Siemens Antares system, compared with a sweep speed of 5 cm/s, a gain of −10 dB, and a 210-Hz filter for the GE Voluson 730 Expert system.Another technical detail that also contributes to the variation in the mean MPI values for the LV is the differences between the settings and ultrasound device brands. It enables simultaneous evaluation of the systolic and diastolic components of the cardiac cycle and provides a good approximation of ventricular contractility by analyzing the motility of the AV valve annulus.Tissue Doppler is a reproducible technique that allows analysis of myocardial motility by assessing the peak velocities of contraction and expansion of a myocardial segment by positioning the spectral Doppler sample volume in the mitral and tricuspid annuli were the first to establish the reference values for fetal cardiac function, as well as to describe changes in RV myocardial velocity waves, LV septum, and interventricular septum in the fetal heart. Under normal conditions, the A′ wave has a peak velocity greater than that of the E′ wave. As gestational age advances, there is a decrease in the E′/A′ ratio due to changes in ventricular compliance that can be identified from the AV valve velocity pattern. In addition to the annular peak velocities, it is possible to calculate the tissue MPI′ through spectral tissue Doppler by analyzing the time periods of the velocity spectrum . In addition, position the Doppler sample volume (2-4 mm) should be positioned at the basal segment of the RV or LV . The insonation angle between the ultrasound beam and ventricular wall or interventricular septum should be < 30°, and no correction angle should be used. The filter and gain should be set low to avoid high-frequency signals. It is also necessary to obtain at least three speed waves in order to perform a proper analysis of the results-31. The main limitation of spectral tissue Doppler is that it evaluates the velocity of only a small portion of the myocardium and does not analyze the capacity or rate of myocardial deformation. The advantage of spectral tissue Doppler is that it allows a more accurate assessment of cardiac contractility by analyzing a segment of the myocardium rather than changes in cardiac chamber dimensions.The limitations for performing spectral tissue Doppler in fetal cardiology include improper fetal positioning, inappropriate angle of insonation, small size of the fetus, high fetal heart rate, and the low resolution capacity of some ultrasound devices. Despite those limitations, several recent studies have shown that spectral tissue Doppler is a reliable, reproducible method,34. In the grayscale 2D image, that acoustic point changes position as myocardial deformity occurs during the cardiac cycle.One echocardiographic imaging technique is 2D speckle tracking (2DST), which analyzes the motion of tissues in the heart on the basis of the speckle pattern in the myocardium. That speckle pattern is a mixture of interference patterns and natural acoustic reflections. It can be described as tracking a speckle (acoustic point) in a 2D image. The movement of the point creates vectors with different orientations. This technique is independent of the insonation angle,35, because, unlike tissue Doppler, it does not require a Doppler signal in order to study the displacement of the acoustic points.In 2DST, the acoustic point is tracked through the acquisition of 2D cine images of the cardiac cycle, which are analyzed frame by frame throughout the cycleFor proper acquisition of a 2D cine images of the cardiac cycle film, it a frame rate of approximately 40-80 fps should be used. Using lower frame rates can result in a loss of acoustic point tracking quality. Caution must be taken when maximizing cardiac imaging using the depth and zoom tools, because the myocardial borders may be lost.−1. The path taken by the point can be analyzed in orthogonal and tangential planes. The first orthogonal plane described here evaluates the longitudinal strain rate. In the longitudinal plane, there is shortening of the cardiac cavities and deformity of the myocardium in the basal-apical direction. The cavity is smaller during systole than during diastole, so the deformation in the longitudinal plane is negative,35. In the radial plane, we evaluated the wall thickness on the short axis of the ventricles, which is called radial strain. Because the systolic thickness is greater than the diastolic thickness, the deformation in the radial plane is positive,36. The circumferential plane is also assessed on the short axis of the ventricles. The circumferential dimension of the cavities is known as circumferential strain. The circumference is smaller in systole than in diastole, so the deformation in the circumferential plane is also negative,36. In tangential planes, the displacement of acoustic points is evaluated in the epicardium and endocardium, in order to demonstrate the slip between the layers of the ventricle, although that technique is still in the validation phase,35.Displacement of the acoustic point is called myocardial deformity or strain and is expressed as a percentage. It may be negative or positive depending on whether the myocardial fibers are shortening or lengthening, respectively. The speed with which this displacement occurs can also be measured (in cm/s). The movement of each acoustic point can be plotted on a curve as a function of time, known as strain rate, expressed in 1/s or s. The method has great potential for the evaluation of diseases that impair myocardial contractility and can detect early changes in cardiac function prior to the age at which cardiovascular diseases would typically be diagnosed. It is a technique that may improve the understanding of what occurs in myocardial fibers during the cardiac cycle in fetuses. Multiple studies have been conducted to establish normal values that serve as a starting point to analyze cardiac function using this technique and thus allow such diseases to be identified in the prenatal period.In the literature about the evaluation of fetal cardiac function, 2DST figures prominently assessed global longitudinal cardiac strain and strain rate in 33 healthy fetuses and 15 fetuses with heart disease. The authors found that segmental measurements were not significantly different from global measurements; therefore, global measurements may be a useful tool to evaluate fetal cardiac function. Peng et al. evaluated 151 normal fetuses and found that strain and strain rate can be measured easily and in a reproducible manner. However, they reported that the values for RV and LV global longitudinal strain decreased throughout gestation. It is of note that, throughout pregnancy, strain values are higher in the LV than in the RV. In contrast, strain rates seem to remain stable and similar in both ventricles throughout gestation.To date, there are limited data on the strain and strain rate in healthy fetuses, as well as on the evolution of those measures throughout pregnancy. Using velocity vector imaging, Barker et al.A variety of cardiac ultrasound/echocardiographic parameters can be used in order to identify fetal heart failure and predict the risk of adverse perinatal outcomes. The shortening fraction enables the evaluation of ventricular global systolic function . However, the shortening fraction is altered in the late stages of myocardial dysfunction and its determination is impaired by technical limitations in myocardial asymmetry, such as fetal growth restriction and fetuses in women with pregestational diabetes. The MPI is used in order to assess systolic and diastolic cardiac function and can be calculated by analyzing the time periods in the cardiac cycle, as determined with spectral or tissue Doppler. Despite the clinical applicability of the MPI, there is variability among reference values in the literature. Consequently, it is important to minimize variations among ultrasound systems for the measurement of MPI by using the proper presets established by the sonographer and echocardiographer for each system. Spectral and tissue Doppler imaging of AV valve flow can be used for the assessment of diastolic cardiac function, in which the E/A and E′/A′ ratios reflect the ventricular compliance. In such assessments, tissue Doppler is more accurate than is spectral Doppler and enables the segmental analysis of diastolic myocardial function. Given that the diastolic ventricular inflow can be transmitted to the atrium, Doppler imaging of the pulmonary veins and inferior vena cava can be also used in this analysis. Other advanced techniques, such as 2DST and strain imaging, may be used in the assessment of the degree of deformity of the myocardium. Therefore, the evaluation of fetal cardiac function should encompass a variety of Doppler ultrasound/echocardiographic parameters that can be selected on the basis of specific fetal conditions.


Short‐term electrocardiography is one of the most suitable tools to study the electrical activity of the heart, but the use of a tool such as a Holter‐monitor with the ability to assess the long‐term of the heart electrical activity, can provide more accurate information about these activities by comparing the results. It is possible to understand the superiority of each over the other and the resulting differences. Therefore, 60 female Holstein cows in 10 age groups, including 1 day, 1, 3, 6 months, 1, 2, 3, 4, 6 and 8 years were included in the study (6 heads in each age group). Electrocardiography (for 5 min) and Holter‐monitoring (for 24 hr) were performed from the entire study population. The Q, R and T amplitudes in electrocardiography were significantly higher than those in Holter‐monitoring. The P, R and T durations and P‐R, R‐R, Q‐T and S‐T intervals at all ages were significantly longer in the Holter‐monitoring than in the electrocardiographic method. The heart rate of animals was significantly lower in the 24‐hr Holter‐monitoring than in the short‐term electrocardiography. The trend of changes of all parameters was significant during ageing. Cardiac arrhythmias included sinus arrhythmia and sino‐atrial block, which were the most common cardiac arrhythmias in the 24‐hr Holter‐monitoring. It appears that long‐term Holter‐monitoring is a more reliable method than short‐term electrocardiography to assess cardiac arrhythmias. Additionally, the indicators of electrical activity of the heart (waves) in the Holter‐monitoring method are significantly different from short‐term electrocardiography, which is probably due to the collection of information over a long period and in non‐stressful situations. Furthermore, it appears that the use of the 24‐hr Holter‐monitoring method is preferable to the short‐term electrocardiography method to evaluate the electrical activity of the heart of cows at all ages. Short‐term electrocardiography is one of the most suitable tools to study the electrical activity of the heart, but the use of a tool such as a Holter‐monitor with the ability to assess the long‐term of the heart electrical activity, can provide more accurate information about these activities by comparing the results. It is possible to understand the superiority of each over the other and the resulting differences. Cardiac activities include electrical and mechanical functions, and the proper functioning of the heart's mechanical activity depends on the accuracy of its electrical performance  and software (to review and process the recorded information) , in October 2020, 60 Holstein cows in 10 equal age groups, including 1 day, 1, 3 and 6 months, 1, 2, 3, 4, 6 and 8 years, were selected. Animals were kept in an open‐shed system with free access to water and shade, and balanced rations based on the NRC requirements were provided. All animals were clinically evaluated before the start of the study, and their clinical health was confirmed, especially from the perspective of cardiovascular health. In addition, the animals had no history of severe debilitating diseases. At the beginning of the study, at 09:00 a.m., ECG was taken from the entire study population for 5 min as described below, and then by installing Holter‐monitor, their heart electrical activities were continuously evaluated for 24 hr.2.2Initially, electrocardiograms were taken for 5 min from all of the studied animals with a base‐apex lead system . Before attaching the electrodes to the skin, the sites were prepared with alcohol and an electrocardiogram jelly. In all animals, the positive electrode (left arm) was attached to the apex of the heart between the fifth or sixth intercostal space along the left olecranon, the negative electrode (right arm) on the jugular furrow at the top of the heart base, and the neutral electrode was placed along the spine at a location far from the heart  were attached for a continuous 24‐hr recording period . A positive electrode was attached to the apex of the heart between the fifth and sixth intercostal space near the left olecranon, another positive electrode was attached to the jugular furrow at the top of the heart base, the negative electrode was attached to the left side of the chest near the spine, and the earth electrode was placed in the lower left half of the chest, aligned with the negative electrode . Comparison of the mean of similar parameters recorded by the two different techniques at each age group was performed by two independent samples t‐test. The trend changes of each parameter by recorded electrocardiogram (within 5 min) and Holter‐monitor (during 24 hr) were evaluated by the Repeated Measures ANOVA. All statistical analyses were conducted by the SPSS software, version 22, and the level of significance was considered at p < .05.The normality of the data was evaluated based on the results of the Kolmogorov–Smirnov test. The results of this test indicated that all data were normally distributed. The data were presented as the mean ± standard error of mean (3p < .05; Table p < .05; Table p < .05; Table p < .05; Table p < .05; Table Table 4There are several methods to assess the cardiovascular system in cattle such as peripheral pulse, mucous membrane colour, capillary refill time, apex beat palpation, jugular pulses, auscultation of heart sounds, cardiac percussion, ultrasonography, radiography, pericardiocentesis, microbial blood cultures, complete blood counts, circulating electrolytes and cardiovascular biomarkers, ECG, and Holter‐monitoring (Constable et al., Evaluation of cardiac electrical activity is clinically necessary to confirm the health of the animal, and the use of an effective, efficient and accurate method is required. ECG is one of the methods defined for this purpose, but in some cases, some heart disorders may not occur in the short time that the device is attached to the animal, and therefore the heart electrical activity should be monitored for a longer period of time. Accordingly, this study evaluated the heart electrical activity of Holstein cows by the standard short‐term ECG and 24‐hr Holter‐monitoring, and then compared the information obtained from these two techniques to determine which method was more effective and efficient in assessing the electrical activity of the heart.Based on the data obtained from this study, most of the parameters recorded by 24‐hr Holter‐monitoring were significantly different from the short‐term ECG Table . It may Cardiac rhythm evaluation in the studied cows indicated that the distribution and variability of heart rhythm were different in both techniques. In some of the studied cows by other researchers, the atrio‐ventricular block was identified only by Holter‐monitoring, which may be due to increased tonicity of the vagus nerve at rest (Guccione et al., In the current research, the frequency of cardiac arrhythmias was higher in Holter‐monitoring than in ECG, which is probably due to the increased vagus nerve tonicity during rest and non‐stress times. Pessoa et al.  examinedVery limited researches have been conducted on the long‐term evaluation of the electrical activity of cows' hearts using Holter‐monitoring, and none of them had a comprehensive comparison between short‐term ECG and 24‐hr Holter‐monitoring during ageing. Scheer et al.  have sugin utero. With the expected fall in the pulmonary artery pressure during the neonatal period, the right ventricular wall stress and thickness decrease until the right ventricular pressure leads to approximate adult amounts (Bansal & Bansal, Figures In the current study, amplitudes were higher in younger animals than in adult ones Figure . It may p < .05; Table Our study indicated that the values of durations Figure  and inte5In conclusion, cardiac electrical activities of cows were altered during ageing, and theses alterations were related to the physiological changes of heart. Furthermore, recorded indices of cardiac electrical functions by the short‐term ECG were significantly different from those recorded by the 24‐hr Holter‐monitoring. It may be suggested that these differences may be associated with stress‐free recording by Holter‐monitor during a long period. Finally, it can be stated that long‐term Holter‐monitoring is a more reliable technique to assess the heart electrical activities and cardiac arrhythmias of cows at different ages.Aliasghar Chalmeh: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing‐original draft; Writing‐review & editing. Sanaz Karamifar: Investigation; Project administration; Writing‐original draft; Writing‐review & editing.https://publons.com/publon/10.1002/vms3.448.The peer review history for this article is available at


Over one-half of patients with multiple myeloma (MM) die of heart failure or arrhythmia. Left ventricular ejection fraction (LVEF) is used to describe left ventricular systolic function. However, depressed LVEF means advanced stage of left ventricular dysfunction in patients with MM. Left ventricular pressure-strain-derived myocardial work (LVMW) is a novel and noninvasive method for evaluating LV function related to LV dynamic pressure load. MW is assessed by LV MW index (LVMWI), constructive work, wasted work, and LV MW efficiency (LVMWE). In this study, we aimed to investigate the value of LVMW in cardiac function assessment and clinical prognosis of MM patients with preserved LVEF.A total of 72 subjects, including 40 untreated MM patients with preserved EF  and 32 non-MM patients, were enrolled in this study. Laboratory data and clinical history of all the patients were collected. All the patients underwent comprehensive echocardiographic examinations and then LVMWI and LVMWE were calculated. Moreover, cardiac adverse events (CAEs) were observed in MM patients treated with bortezomib-based therapy after 6 months and the prognostic value of MW was assessed.p < 0.05); (3) GWE, LgdFLC, and arrhythmia were independent risk factors of CAEs. The AUC of GWE for predicting CAEs in MM patients treated with bortezomib-based therapy for 6 months follow-up was 0.896 .(1) LV myocardial global work index (GWI), myocardial global work efficiency (GWE), and global longitudinal strain (GLS) were lower in the thick wall group of patients with MM compared with the normal wall group and controls. Cardiac segmental analysis of LVMWI in patients with MM showed an apical sparing pattern; (2) The area under the curve (AUC) of GWE for judging the disease severity based on the Revised International Staging System (R-ISS) was 0.835 (95% CI: 0.684–0.933, MM Patients with preserved EF had subclinical LV systolic dysfunction, which was worse in the thick wall group. LVMWI was presented as “apical sparing” in patients with MM. A lower LVGWE may have a predictive value for CAEs in patients with MM after 6 months of follow-up. Multiple myeloma (MM) is a multiple-system disease with the overproduction of monoclonal immunoglobulins and clonal proliferation of neoplastic plasma cells in the elderly . MeanwhiLeft ventricular global longitudinal strain (LVGLS) has proven to be reliable for both the diagnosis and risk stratification in patients with cardiac dysfunction , especiaIn this study, we aimed to investigate the value of left ventricular pressure-strain-derived myocardial work (LVMW) in cardiac function and clinical prognosis in MM patients with preserved LVEF. This may assist clinicians in the early detection of myocardial injury.E/A ratio >2 or average E/e′ ratio > 14), coronary heart disease, cardiomyopathy, renal failure, or other significant alterations. In total, 40 eligible patients with MM were divided into the two groups according to the thickness of the LV wall : the normal wall group (n = 20) and the thick wall group (n = 20). In total, 32 non-MM patients who had normal echocardiography and matched with age, gender, and blood pressure were selected as the control group. Clinical history and laboratory examination of patients with MM were collected. All the patients with MM were stratified based on the R-ISS  protein was detected by serum immunoelectrophoresis with an automatic electrophoresis analyzer and its supporting reagent . A serum-free light chain (FLC) kit  was used to determine the serum-FLC level. Referring to the type of involved monoclonal FLC, which was kappa or lambda FLC, the difference between the involved FLC and uninvolved FLC was defined as dFLC. The serum β2M level was detected using a scattering immune turbidimetry automatic protein analyzer .The ultrasound system  with a 1.7–3.3 MHz phased-array transducer (M5S) was used.Standard echocardiography, including two-dimensional (2D), M-mode, and Doppler echocardiography, was performed according to the guidelines of the American Society of Echocardiography . LV end-Myocardial work was calculated using a PSL curve integrated with LV deformation and pressure. Deformation was measured as LS by the speckle-tracking technique. Peak systolic LV pressure was assumed to be equal to the peak arterial pressure, which was measured immediately before the echocardiographic study using an arm-type mercury sphygmomanometer. Then, a noninvasive LV pressure curve adjusted according to the duration of isovolumic and ejection phases defined by valvular timing events was constructed.Image acquisition: Dynamic images were collected in three planes: apical four-, two-, and three-chamber planes for more than 3 cardiac cycles. Then, the data were analyzed offline by EchoPAC 203 workstation . Initially, the myocardial automatic functional imaging analysis mode was selected. The system could automatically recognize the above three dynamic images and select the cardiac cycle with the best image quality for myocardial tracking of the motion trajectory. If there is a deviation in the tracking, the position and size of the area of interest can be manually adjusted. Initial tracking was conducted at the apical three-chamber to confirm the closing time of the aortic valve and other planes have completed the analysis in turn. Then, the system generated a 17-segment bull's-eye automatically, which is obtained according to the weighted average of the peak LS of each segment during systole. The overall global longitudinal strain (GLS) was expressed in absolute values. Finally, the MW analysis mode was selected to analyze and obtain LV-PSL.Characteristics of MW in patients with MM are shown in (1) Global WI (GWI): Total work within the area of the LV-PSL calculated from mitral valve opening and closure.(2) Constructive myocardial work: Work contributing to LV ejection during systole.constructive MW = The area of constructive MW = The area of (3) Wasted myocardial work: Work performed by the LV that does not contribute to LV ejection.Wasted myocardial work = The area of (4) Myocardial work efficiency: The ratio of work contributing to LV ejection and total work.Myocardial work efficiency = Constructive myocardial work / All the patients were followed up after 6 months for their survival and cardiac adverse events (CAEs). All the patients received bortezomib-based therapy. CAEs were defined following the recommendations in the common terminology criteria for adverse events version 4.0 . Cardiact-test and one-way ANOVA were adopted for comparison of two and three independent groups of normally distributed variables, respectively. The Wilcoxon signed-rank test was used for nonnormal distribution. The chi-squared test and Fisher's exact test were used to compare binary variables. The Spearman and Pearson correlation coefficients were calculated for dFLC and other MM-related parameters and N-terminal probrain natriuretic peptide (NT-proBNP). The multivariable logistic regression models were used to further assess the risk factors of CAEs. The univariate regression analysis of variables, positive variables, and important clinically significant indicators were included in the multivariate regression analysis model. The receiver operating characteristic (ROC) curve analysis was performed adjusting for NT-proBNP and echocardiographic indices. Value of p < 0.05 was considered statistically significant. IBM SPSS for Windows version 17.0  was used for all the analyses.Continuous variables were presented as mean ± SD for normally distributed data or median (25th percentile and 75th percentile) for nonnormally distributed data. Categorical variables were presented as frequencies. The The clinical characteristics of 40 patients with MM and 32 control subjects are shown in E/e′ ratio, an index of LV diastolic function, was higher in the thick wall group of patients with MM than in the normal wall group and controls. Moreover, the left ventricular mass index (LVMI) was higher in the thick wall group compared with the normal wall group and controls (p < 0.05). However, in a tricuspid regurgitation shown in 25 patients with MM, there was no statistical difference between the thick wall and normal wall groups.Conventional 2D and Doppler echocardiographic characteristics are shown in p < 0.05). Nevertheless, there was no statistical difference in GWI and GLS between the normal wall group of MM patients and controls. GWE was lower in the normal wall group than in controls. For segmental changes, we found that WI-basal was lower in the thick wall group than in the normal wall group and controls. WI-mid was higher in the normal wall group compared with the thick wall group and controls, while there was no difference in WI-mid between the thick wall group and controls. However, there was no significant difference in WI-apical among the three groups, which showed an apical sparing pattern.As shown in p < 0.05) and LV GWE (p < 0.05), but LV GWI (p > 0.05). NT-proBNP was negatively correlated with LV GLS, LV GWI, and LV GWE (p < 0.05) (Troponin T showed negative correlations with LV GLS ( < 0.05) .p < 0.05), NT-proBNP (p < 0.05), and LVMI (p < 0.05), but negatively correlated with GLS (p < 0.05), GWI (p < 0.05), and GWE (p < 0.05). β2M, another indicator of MM disease severity, was positively correlated with NT-proBNP (p < 0.05) and negatively correlated with GLS (p < 0.05), GWI (p < 0.05), and GWE (p < 0.05).As shown in p = 0.016) and GWE , while there was no difference in GLS . The diagnostic value of GWI and GWE in the R-ISS is shown in p < 0.05). However, GWI had no diagnostic value for the R-ISS (p > 0.05).Furthermore, we analyzed the diagnostic value of MW in the MM stage. Patients were divided into <III stages and ≥III stages according to the R-ISS. Significant differences were found between the R-ISS < III stages and the R-ISS ≥ III stages group in GWI . The multivariable model showed that arrhythmia, LgdFLC, and GWE were independent risk factors for CAEs.Cardiac adverse events were followed-up after 6 months in patients with MM treated with bortezomib-based therapy. One of these patients had lower extremity edema, one patient had syncope and prolonged RR interval, one patient had new-onset atrial fibrillation, one patient had a decreased LVEF, and three patients had significantly elevated TnT and NT-proBNP levels. Then, patients were divided into the two groups: with or without CAEs. The univariable and multivariable logistic regression models were used to analyze the risk factors of CAEs in patients with MM and the results are shown in p = 0.001). The AUC of GWE was 0.896 , demonstrating its potential predictive value for CAEs in patients with MM  and even superior specificity  compared with regional strain to identify acute coronary artery occlusion in patients with non-ST-segment elevation myocardial infarction . Further prospective studies with a larger size sample are needed.MM patients with preserved EF had subclinical left ventricular systolic dysfunction, which was worse in the thick wall group. GWI presented an “apical sparing” pattern in patients with MM. A lower LV GWE may have a diagnostic and predictive value for disease severity and CAEs in patients with MM treated with bortezomib-based therapy for 6 months.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Biomedical Research Ethics Committee of West China Hospital, Sichuan University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.ZL designed the study and wrote the manuscript. LZ, YX, ZT, QLi, and SL collected the data and generated the database. FW, QLu, and ML analyzed and interpreted the data. HH and TN supervised the study. All authors critically revised the manuscript for important intellectual content.HH is funded by Key Research and Development Programs of the Science and Technology Department of Sichuan Province (Grant no. 2019YFS0414).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Cor triatriatum is a congenital atrial abnormality, which comprises a membrane that divides the atrium into two chambers. Symptoms can arise either due to the obstructive nature of this membrane or related to other associated anomalies, such as atrial septal defects or abnormal pulmonary venous return.The authors report the case of an adult male, in whom an incidental finding of cor triatriatum sinistrum was documented in association with mitral valve prolapse. However, both the late diagnosis and the association with mitral valve disease are uncommon.Multimodality imaging evaluation can prove very helpful in these cases to better define the anatomy of the left atrium and appropriately plan for intervention when indicated. Cor triatriatum is a congenital abnormality where a septum divides the atrium into two cavities, giving rise to a heart with three atrial chambers. This rare anomaly  can be found either on the left (sinistrum) or the right (dextrum) atrium, but cor triatriatum sinistrum is more frequent [Most cases are diagnosed during childhood, mainly when this membrane causes obstruction to the blood flow, from the upper chamber, where the venous drainage takes place, to the lower chamber, in relation with the atrioventricular valve. The presence of symptoms is also related to other associated congenital abnormalities, such as atrial septal defects, abnormal pulmonary or systemic venous return, or more complex lesions, with single ventricle physiology . SurgicaThe authors present the case of an adult with mitral valve prolapse and an incidental finding of cor triatriatum sinistrum.A 67-year-old male with a history of uncontrolled dyslipidemia and a former smoker was referred to Cardiology after detecting an irregular pulse and a heart murmur. He had no relevant family history and complained only of infrequent palpitations. However, upon examination, a holosystolic murmur was audible in the apex. Also, an arrhythmic pulse was present in relation to frequent ventricular ectopic beats, evident on ECG, with no other relevant changes. The transthoracic ECG showed a severe mitral regurgitation, in the context of an anterior mitral leaflet prolapse, as well as bi-atrial dilation, mild left ventricle dilation , with preserved ejection fraction (65% Simpson biplane) and low pulmonary hypertension probability. Also, a membrane was noted in the left atrium, dividing this chamber into two, suggestive of cor triatriatum sinistrum Figure . Holter monitoring revealed very frequent ventricular ectopic beats (12336) and two short runs of non-sustained monomorphic ventricular tachycardia, with symptomatic improvement for which anti-arrhythmic medication was prescribed.Routine blood workup did not find relevant changes, aside from elevated N-terminal prohormone of brain natriuretic peptide (NTproBNP) levels .Given the presence of cardiovascular risk factors and significant ventricular arrhythmia, a cardiac magnetic resonance with perfusion imaging was performed. It did not show inducible ischemia or late gadolinium enhancement and confirmed the transthoracic echocardiography's previous findings Figure .The patient was referred for transesophageal echocardiography to further characterize the mitral valve anatomy. The mitral valve prolapse, involving A2 and A3 scallops, accounted for the eccentric mitral regurgitation Figure ; other pHe was diagnosed with atrial flutter and started on oral anticoagulation during follow-up. However, he remained asymptomatic, with good functional capacity on exercise testing. Valve intervention was discussed, and a conservative approach with close follow-up was decided.Triatrial heart or cor triatriatum is the name of the condition where septation divides one of the atria into two chambers, thus forming a heart with three atria.In the case of the cor triatriatum sinistrum, the upper chamber contains the pulmonary veins, and the lower chamber connects with the left atrial appendage and the mitral valve. The embryological explanation for the presence of the septum is not yet fully understood. However, the most widely accepted explanation is the "malincorporation" theory, which advocates that there is abnormal incorporation of the common pulmonary vein in the left atrium . No riskThe septum is usually a fibro-muscular membrane that can assume different shapes  and can either be intact or have one opening or multiple fenestrations. The proposed classifications, such as Loeffler's and Lucas' classification, take into account the anatomy and physiology of the membrane, the communication with the lower chamber, the pulmonary venous drainage, and the presence of other associated abnormalities ,4.These same aspects also determine the presence of symptoms, mainly when the membrane itself has a small, restrictive opening or other associated congenital lesions. In the first case, cor triatriatum sinistrum mimics the presentation of mitral stenosis, with dyspnea, orthopnea, or hemoptysis and accounting for evidence of pulmonary congestion, but in the absence of an opening snap or a loud S1. The clinical presentation can be particularly severe in children with recurrent respiratory distress, wheezing, and failure to thrive . Other sAs previously mentioned, the diagnosis is rare in adults, but the isolated form or classical type, with a single wide opening, is the most frequent in this age group. Nevertheless, with progressive thickening and calcification, it can become clinically relevant. Also, atrial arrhythmias and embolic events can appear due to the enlargement of the atrium, mainly in relation to atrial fibrillation .Echocardiography, particularly with three-dimensional imaging, plays a significant role in diagnosis since it can provide comprehensive anatomical evaluation and functional assessment, and screening of associated abnormalities. In addition, cardiac CT and MRI can offer relevant additional information, mainly when there are multiple defects or a history of previous interventions, with cardiac catheterization being of little additional value nowadays . Surgical correction is advised in the presence of symptoms, either related to the defect itself or the associated abnormalities. In a few selected cases, with favorable anatomy, balloon dilation can be considered .Our case illustrates the classical type, where cor triatriatum sinistrum was an incidental, late diagnosis associated with mitral valve disease. However, given that the patient had no functional limitation, with preserved ejection fraction and only mild left ventricle dilation, a decision for clinical surveillance was made. Nevertheless, the diagnosis of cor triatriatum sinistrum may prove relevant since it will ensure better surgical planning when a mitral valve repair is advised. Multimodality imaging evaluation is key in complex cases of congenital heart disease. In our case, this strategy proved helpful and warranted full characterization of both the congenital heart defect and valve disease.Cor triatriatum sinistrum is a rare congenital abnormality uncommon in adults. The presentation in adulthood depends on anatomical and functional aspects and associated congenital abnormalities. Although also infrequent, its association with mitral valve disease can occur.Multimodality imaging should be the preferred strategy to assess complex congenital heart disease cases, mainly when intervention is considered.


Cardiomyopathies are diseases of heart muscle that may originate from genetic defects, cardiac myocyte injury or infiltration of myocardial tissues. Dilated cardiomyopathy is the most common phenotype and is often a final common pathway of numerous cardiac insults. Mostly it remains unknown in the absence of echocardiography, histopathology and genetic evaluation. Though common it is underdiagnosed with not much of data available in our setup.st of February to 31st July 2018 for the period of six months in Shree Birendra Hospital, a tertiary care military hospital at Chhauni, Kathmandu. Pediatric age group patients and those who refused to give consent were excluded. Data obtained were entered in Microsoft Excel 2010 and analyzed by IBM SPSS 21.This study was analytical cross-sectional study of hospital data on Echocardiographic findings in 65 patients of DCM visiting cardiology unit for Echocardiographic evaluation from 1Among 65 patients enrolled 40 (61%) were male and 25 (39%) female with male to female ratio of 1.6:1. Elderly people (61-75 years) with an average age of 65 were commonly involved and they presented mostly with congestive heart failure, 32 (49%). Echocardiographic evaluation showed 36 (55%) with mildly dilated Left Ventricle (5.6-6.0cm). Majority had reduced Left ventricular systolic function with an average Ejection fraction (EF) of 39.6%. No significant difference between male and female with the average EF% (P=0.990) and there was no significant relation between age and average EF% (P=0.091).Dilated Cardiomyopathy is the commonest cardiomyopathy phenotype mostly presenting with congestive heart failure. It is often underdiagnosed in our part of the world, however echocardiography will easily detect the condition. Various etiologies such as genetic defects, cardiac myocyte injury and infiltration of myocardial tissues leads to CM. Dilated cardiomyopathy (DCM) is the most common type with enlargement of one or both of the ventricles resulting in systolic dysfunction with reduced ejection fraction (EF%).7 DCM approximately accounts for 25% of the Congestive heart failure (CHF) cases and remaining 75% are due to ischemic, hypertensive or non-systolic heart failure.9 Genetic and specific studies in highly specialized centers can identify causes in about 50% cases and remaining are the diagnosis of exclusion, termed idiopathic variants.12The annual mortality rate has a wide range between 10% and 50%.The aim of this study is to determine incidence, and evaluate Echocardiographic findings in patients of DCM.st of February to 31stJuly 2018 for the period of six months in Shree Birendra Hospital (SBH), a tertiary care military hospital at Chhauni, Kathmandu. Diagnosis of DCM was done on the basis of history, clinical features (symptoms & signs) and Echocardiographic evaluation. Data from register book were retrieved after ethical approval from institutional review committee. Standardized questionnaire developed by the researcher was used to obtain clinical and socio-demographic characteristics of the patients after informed consent. Pediatric age group patients and those who refused to participate were excluded.An analytical cross-sectional study was done utilizing hospital data on Echocardiographic findings in 65 patients of DCM visiting cardiology unit for Echocardiographic evaluation from 1Maximum internal diameter of left ventricle (LV) during diastole less than or equal to 5.5cm considered normal. M-mode measurement of LV during systole and diastole used for calculating Ejection fraction (EF) where EF% less than 50% considered reduced. Left ventricular diastolic dysfunction (LVDD) grade one defined by E/A ratio less than one and grade two as E/A ratio more than one  with some structural LV filling defect .Echocardiography was performed by Cardiologists to see cardiac structural and functional abnormalities. Machine used was SIEMENS Model: ACUSON SC2000 having the facility of two dimensional view, M-mode and color flow Doppler imaging. Data obtained were entered in Microsoft Excel 2010 and analyzed by software IBM SPSS 21. Statistical significance between male and female with EF was calculated by means t-test whereas relationship between age and EF by ANOVA . P<0.05 was considered significant.Among 65 patients enrolled 40 (61%) were male and 25 (39%) female with male to female ratio of 1.6:1. Most of the cases have unknown etiology 53 (81%). On Echocardiography, 36 (55%) had mildly dilated Left Ventricle (5.6-6.0cm) . AdditioFunctional Mitral regurgitation in 48 (74%) with Grade I Left ventricular diastolic dysfunction in 56 (86%). Majority had reduced Left ventricular systolic function with Ejection fraction between 21% and 30%, an average of 39.6% .Elderly age group (61-75 years) with an average age of 65, were encountered frequently 34 (52%) and the most common clinical presentation was congestive heart failure 32 (49%) .Besides, mild pericardial effusion found in 2 (3%) and none of our cases had any intra-cavitary thrombus or vegetation.On applying two sample means ‘t-test’ there was no statistical significant difference between average EF% of both male and female (P = 0.990) .Similarly, by ANOVA  there was no relationship of age and average EF% (P = 0.091) .13 53% were male and 47% female, similar to our study with males outnumbering females. Most of our patients presented with congestive heart failure (49%) supported by Animasahun BA et al.14 where it was 54.5%. Similar result was evident in the study by Towbin JA et al.12DCM was more common in male than female (61% vs 39%) and frequent on the elderly with the mean age of 65 years in our study population. In the study done by Suha MA et al.2 In our study association of RV dilation was 18%.Dilated Left ventricle (LV) is mandatory for the diagnosis of DCM, however Right ventricle (RV) may similarly be affected, Mathew T et al.3 Meese RB et al,15 Ballester M et al,16 Chandraratna PA et al.17 and its presence predicts poor outcome, Donal E et al.18Incidence of functional Mitral Regurgitation (MR) in our study was 48%. Functional MR, which occurs as a consequence of regional or global LV dysfunction despite a structurally normal mitral valve, is a common complication in patients with DCM, Jun K et al,19 Lavine SJ et al,20 Appleton CP et al.21 and Pinamonti B et al.22Some degree of Left ventricular diastolic dysfunction (LVDD) is inevitable in DCM ranging from grade one to four. We had 86% cases with LVDD grade one. Assessment of diastolic function in DCM also correlated by studies Nishimura RA et al,23 Also evidenced byFolland ED et al.24 and Stamm RB et al.25LV systolic dysfunction quantified by measuring Ejection fraction (EF) in percentage and the estimated EF% assumes uniform or global left ventricular function, Shah PM.26 and Gottdiener JS et al.27 The limitations of our study being the data of a single center and lack of etiologic evidence.None of our cases had intra-cavitary thrombus, however it is a common complication in patients with DCM, Asinger RW et al.Patients commonly present with symptoms and signs of congestive heart failure and a simple Echocardiography will easily detect the condition. However, etiologic diagnosis is not possible mostly in a resource limited settings. More research works to be done to understand this common heart failure condition and our aim should be to diagnose preclinical DCM cases and thereby reduce significant mortality and morbidity.