Diastolic Flow Research Articles

Coronary Endothelial Dysfunction and Vasomotor Dysregulation in Myocardial Bridging

Myocardial bridging (MB), a congenital variant where a coronary artery segment is tunneled within the myocardium, is increasingly recognized as a contributor to coronary endothelial and vasomotor dysfunction. Beyond the hallmark systolic compression observed on angiography, MB disrupts endothelial integrity, impairs the release of vasoactive substances, and induces vasomotor abnormalities. These effects exacerbate ischemic symptoms and predispose to atherosclerosis in the proximal segment, particularly in conditions such as ischemia/myocardial infarction with nonobstructive coronary arteries. Recent studies underscore MB’s association with coronary vasospasm, microvascular endothelial dysfunction, and adverse cardiovascular outcomes, including sudden cardiac death. These findings highlight the interplay between MB’s structural anomalies and functional impairments, with factors such as the bridge’s length, depth, and orientation influencing its hemodynamic significance. Advances in imaging and coronary physiology assessment, including acetylcholine testing and stress diastolic fractional flow reserve/iFR/RFR, have enhanced diagnostic precision. This review explores the multifaceted impact of MB on coronary physiology, emphasizing its role in endothelial dysfunction and vasomotor regulation. Recognizing MB’s contribution to cardiovascular disease is essential for accurate diagnosis and tailored management strategies aimed at mitigating ischemic risk and improving patient outcomes.

Defining the predictors for post renal transplant left ventricular dysfunction in end-stage renal disease patients.

Reduced left ventricular (LV) function predicts poor outcomes in end-stage renal disease (ESRD). This study aimed to identify the pre-renal transplantation echocardiographic parameters that can predict post-renal transplantation LV failure. This prospective longitudinal study was conducted on patients with ESRD who underwent renal transplantation during 1 year. All patients underwent echocardiography, including ejection fraction (EF), global longitudinal strain (GLS), left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic volume (LVEDV), left ventricular end-diastolic diameter (LVEDD), interventricular septal (IVS) thickness, peak velocity of early diastolic transmitral flow (E), peak velocity of late transmitral flow (A), early diastolic myocardial relaxation (Em), E/A, E/Em, Left atrial volume (LAV) index, tricuspid regurgitation peak gradient (TRPG), systolic pulmonary artery pressure (SPAP), tricuspid annular plane systolic excursion (TAPSE), 1 week before and 1 month after renal transplantation. Fifty patients participated in the current study. All echocardiographic parameters improved after transplantation. Post-renal transplantation LV dysfunction was observed in 21 (42%) patients. Pre-renal transplantation echocardiographic parameters (LVEDV, LVESD, LVEDD, IVS, E/Em, TRPG, SPAP, and LAV index) could predict post-transplantation LV failure with high accuracy (AUC: 0.978).

Clinical significance of right ventricular - pulmonary arterial uncoupling in hypertrophic cardiomyopathy

Abstract Background Right ventricular (RV) – pulmonary arterial (PA) coupling represents the relationship between RV function and the afterload in the pulmonary vascular system. It is a non-invasive surrogate on how the RV is adapted to an increased afterload in the pulmonary circulation. In cases of exhaustion of compensatory RV remodeling, the ratio decreases and there is RV-PA uncoupling. Several studies reported the usefulness of this parameter in patients with heart failure, including in preserved ejection fraction. There is no evidence regarding the association between RV-PA coupling and hypertrophic cardiomyopathy (HCM). We aimed to evaluate this parameter in patients with HCM. Methods This prospective cohort study enrolled patients with HCM without obstructive epicardial coronary artery disease, that underwent a comprehensive evaluation. Echocardiography was used to assess RV-PA coupling as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP). In addition, coronary flow reserve in the left anterior descending artery (CFR_LAD) was also evaluated: diastolic coronary flow velocity was measured in basal conditions and in hyperemia and CFR was calculated as the ratio of hyperemic and basal peak diastolic flow velocities. This was used as a surrogate marker of coronary microvascular dysfunction. Functional capacity was evaluated by cardiopulmonary exercise testing (CPET). Cardiac magnetic resonance (CMR) was also performed to evaluate RV function (volumes and ejection fraction), and the extent of late gadolinium enhancement (LGE) in the left ventricle (LV). Results We enrolled 62 patients, with a mean age of 55 (15) years, 64% males. In 64% it was an asymmetrical septal hypertrophy phenotype, in 31% an apical hypertrophy, and in 27%, it was an obstructive HCM. Mean TAPSE/PASP was 0.556 (0.23) and median was 0.50. All patients had a normal LV ejection fraction. TAPSE/PASP showed a modest predictive accuracy for peak VO2 < 20 ml/Kg/min, a marker of decreased functional capacity (AUC 0.671, 95% CI 0.535 – 0.807, p=0.022), with the best cut-off set at 0.60 (sensitivity 85% and specificity 47%). By univariable linear regression analysis, peakVO2 was correlated with age, male gender, E/E’, indexed left atrial volume, indexed right ventricle end-systolic and end-diastolic volumes, CFR_LAD and TAPSE / PASP. The HCM phenotype or the presence of obstruction were not associated with peakVO2. Multivariable stepwise linear regression analysis showed that the independent predictors of peakVO2 were male gender (b-estimate: 0.305, p=0.002), age (b-estimate: - 0.323, p=0.002), RV indexed end-diastolic volume (b-estimate: 0.200, p=0.043) and TAPSE/PASP (b-estimate: 0.275, p=0.005). Conclusion In patients with HCM, RV-PA uncoupling is associated with a reduction in functional capacity. Therefore, it is a marker of disease severity.

Microvascular dysfunction contributes to atrial fibrillation in hypertrophic cardiomyopathy, a multimodality study

Abstract Background Microvascular dysfunction (MVD) constitutes one of the most important pathophysiological features in hypertrophic cardiomyopathy (HCM). Chronic and recurrent myocardial ischemia potentially contributes to arrhythmic risk, namely to atrial fibrillation (AF). Purpose To analyze the impact of MVD in the occurrence of AF in HCM patients (P), assessed by coronary flow velocity reserve (CFVR) on echocardiography (echo) and ischemia on cardiovascular magnetic resonance (CMR). Methods Prospective study, which enrolled HCM P without obstructive epicardial coronary artery disease, who underwent stress echo and stress CMR. By echo, the evaluation of CFVR in the left anterior descending (LAD) artery was performed in apical three chambers view. Diastolic coronary flow velocity was measured in basal conditions and in hyperemia, induced by adenosine perfusion (0.14 mg/kg/min intravenously, during 2 minutes). CFVR was calculated as the ratio of hyperemic to basal peak diastolic flow velocities. On CMR, perfusion imaging was acquired during regadenoson-induced hyperemia. To quantify the ischemic burden, the myocardium was divided into 32 subsegments (16 AHA segments subdivided into an endocardial and epicardial layer, excluding segment 17) and the ischemic burden was calculated as the number of involved subsegments, assigning 3% of myocardium to each subsegment. Late gadolinium enhancement (LGE) was quantified used the 6 standard deviation method. Kaplan Meyer curves were performed to evaluate the impact of CFVR, ischemia, left atrial volume and LGE in the occurrence of atrial fibrillation during the follow up. Results 73P were enrolled, 47 (64%) males, mean age 54.3(14.8) years. 19 P (26%) had obstructive HCM, mean maximal wall thickness (MWT) was 20.1(4.6)mm, left ventricular (LV) mass 96.9(30.6)g/m2, LV ejection fraction 71.6(8.4)%, left atrial volume (LAV) 47.0(16.8)ml/m2, CFVR LAD 1.8(0.4), ischemic burden 22.5(17.1)% of LV. During the follow up of 54.6(7.8) months (minimum 42months, maximum 80months), P with more severe microvascular dysfunction (CFVR LAD<2.0 and ischemia ≥18% of LV) had significant higher incidence of atrial fibrillation (figure 1). P with CFVR LAD≥2.0 and LAV≤34ml/m2 had significantly less AF comparing to P with CFVR LAD<2.0 and LAV>34ml/m2. Interestingly, P with only one of this risk factors had similar incidence of AF, pointing toward a similar impact of microvascular dysfunction and LA dilatation. Although LGE is a well-known surrogate marker of disease severity, extension of the ischemia seemed to play a more important role in AF development, as patients with ischemia ≥ 18% of LV and LGE < 15% had more AF than P with ischemia < 18% of LV and LGE ≥ 15%. Conclusion Microvascular dysfunction and consequent ischemic burden were linked to AF, which likely reflects advanced disease, involving atrial myocardium beyond LV myocardium, contributing for atrial dysfunction and arrhythmogenicity. Figure 1

Impact of mitraclip on diastolic inflow dynamics and energy loss in severe mitral regurgitation: a topological flow data analysis

Abstract Background The MitraClip is a transcatheter edge-to-edge repair device whose efficacy in treating mitral regurgitation (MR) has been increasingly established in recent years. A unique aspect of this procedure is that, during diastole, the mitral valve orifice can be divided into two or more openings, a feature not seen in traditional surgical mitral valve repair. However, the impact of this division on diastolic inflow dynamics and left ventricular workload remains unclear. Methods We performed topological flow data analysis based on echocardiography vector flow mapping (iTEcho, Cardio Flow Design Inc.) to compare left ventricular flow vortex, streamlines, and energy loss in patients with severe MR before and after MitraClip. The patients examined in this study had severe atrial functional MR due to long-standing atrial fibrillation and underwent MitraClip with the placement of one clip at the A2-P2 leaflets of the mitral valve. Post-procedure, the severity of MR improved to a mild degree. Additionally, these parameters were compared with data from healthy individuals. Results In a healthy patient, during the diastolic filling phase, a unidirectional vortex is observed beneath the anterior leaflet, accompanied by a straightforward flow stream (Figure 1-A). Conversely, in severe MR, vortices form beneath both the anterior and posterior mitral leaflets, resulting in highly distorted, curved trans-mitral flows (Figure 1-B). Post-MitraClip intervention, unlike in healthy patients, a twin vortex structure with oppositely directed swirling flows is seen beneath the anterior leaflet. However, compared to the pre-MitraClip state, a straightforward trans-mitral flow is restored (Figure 1-C). Analysis of energy loss reveals that the maximum energy loss before MitraClip treatment was 18.4 mW/m², which was associated with the distorted, curved blood flow in mid-diastole (Figure 2-B). In contrast, post-MitraClip treatment, the energy loss significantly improved to 5.9 mW/m², which was attributed to the improvement in diastolic inflow blood flow (Figure 2-C). Conclusion Although the vortex structure in diastole after the clip is different from that in healthy cases, successfully reduced energy loss with straight streamlines is obtained, indicating feasible inflow dynamics despite the double orifice.

Unfavorable systemic and coronary hemodynamic profile of left ventricular hypercontractile phenotype in hypertrophic cardiomyopathy

Abstract Background The left ventricular (LV) hypercontractile phenotype (HP) plays a critical role in hypertrophic cardiomyopathy (HCM) and is usually identified with the left ventricular outflow tract gradient (LVOTG). Purpose To assess the systemic and coronary hemodynamic profile associated with HP identified with increased LV elastance (also known as force) at rest in patients with HCM. Methods We enrolled 1248 HCM patients (age 50 ± 15 years, 798 males, 64%) with ejection fraction (EF) ≥50%, referred for rest transthoracic echocardiography (TTE) in 14 quality-controlled sites from 7 countries TTE assessment included LVOTG, EF, and LV force (systolic blood pressure + LVOTG/LV end-systolic volume, mmHg/mL). Volumetric echocardiography with Simpson’s method was used to measure EF from end-diastolic volume (EDV) and end-systolic volume (ESV), stroke volume (SV), arterial elastance (AE) and ventricular-arterial coupling (VAC). We also assessed resting peak diastolic coronary flow velocity (D-CFV) in the mid-distal left anterior descending artery in a subset of 275 patients. Results EF equaled 68 ± 7%, force = 6.8 ± 5.3 mmHg/ml and LVOTG = 22 ± 28 mmHg. HP was identified as the highest quartile of force (> 7.85 mmHg/ml, mean value= 13.3 ± 7.0). HP showed the lowest SV (46 ± 18 ml) and EDV (61 ± 20 ml), with the highest AE (3.19 ± 1.35 mmHg/ml) and VAC (3.46 ± 1.59) compared to other quartiles (p<0.001) ( see Picture) . D-CFV was not higher in patients with HP (n = 65) compared to those (n = 210) without HP (41± 11 vs 38 ± 14 cm/s, p=ns, but higher in comparison to joint first and second Force quartile (n=122) vs 37 ±14 p =0.0472). Table displays the demografic, clinical and TTE parameters related to HP (Table). In multivariate logistic analysis 4 independent predictors of HP were identified: SBP >130 mmHg with OR 2.5, female sex with OR 5.4, LV EF >70% with OR 6.1 and LVOTG >30 mmHg with the highest OR = 6.3. Conclusion: HCM patients with HP exhibit a distinctive systemic hemodynamic and coronary physiology profile, characterized by low SV, high VAC, and supranormal baseline D-CFV compared to non-HP patients. These findings suggest reduced cardiovascular efficiency and increased myocardial oxygen demand, possibly detrimental over time.

Severe secondary tricuspid regurgitation is associated with nonfatal heart failure hospitalization but not with mortality in patients with chronic heart failure aged 80 years or older

Abstract Background Previous studies have shown that tricuspid regurgitation secondary to heart failure (HF) is common with considerable effect on their outcomes. However, impact of secondary tricuspid regurgitation (sTR) on survival and hospitalization in patients with ultra-elderly HF are uncertain. Purpose To investigate impact of severe sTR in ultra-elderly HF. Methods We retrospectively enrolled 163 patients (median age, 87 years, 72 male) with HF aged ≥ 80 years-old admitted to our hospital for the treatment of decompensated HF. Clinical characteristics including echocardiographic data were obtained before discharge. In the present study, severe sTR was defined as vena contracta width ≥ 7mm based on the current guidelines. The date of discharge was considered the entry time-point of observation. Primary outcomes were defined as all-cause death, cardiac death or nonfatal HF hospitalization. Results Severe sTR was present in 35 patients (21.5%). During a median follow-up period of 500 (interquartile range, 255-1268) days, 60 all-cause deaths, 41 cardiac deaths and 51 nonfatal HF hospitalizations were occurred. In univariate Cox proportional hazards analysis, age, body mass index, albumin, hemoglobin, B-type natriuretic peptide (BNP), estimated glomerular filtration rate and the ratio of peak early diastolic trans-mitral flow velocity to annular velocity (E/e’) were associated with all-cause death. In multivariate Cox proportional hazards analysis, hemoglobin [hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.59-0.90, p = 0.0037] and BNP levels (HR 1.003, 95%CI 1.001-1.004, p = 0.0008) were independently associated with all-cause death. Similarly, age, body mass index, presence of ischemic heart disease, albumin, hemoglobin, BNP and E/e' were associated with cardiac death in univariate analysis, and multivariate analysis showed that hemoglobin (HR 0.74, 95%CI 0.58-0.93, p = 0.013) and BNP (HR 1.003, 95%CI 1.001-1.004, p = 0.0034) were independently associated with cardiac death. Severe sTR was not associated with mortality even in univariate analysis. On the other hand, univariate analysis showed that age, albumin, hemoglobin and severe sTR were associated with nonfatal HF hospitalization, and multivariate analysis revealed that severe sTR (HR 1.91, 95%CI 1.02-3.42, p = 0.044) was the only factor independently associated with nonfatal HF hospitalization. Conclusion In ultra-elderly patients with chronic HF aged ≥ 80 years, severe sTR was associated with nonfatal HF hospitalizations but not with both cardiac and all-cause deaths. This result may indicate that percutaneous therapies should focus on the optimal timing of intervention in patients with severe sTR with respect to overall survival and quality of life.

Inflammatory and imaging predictors of development of ischemic mitral regurgitation following ST-elevation myocardial infarction

Abstract Background Development of ischemic mitral regurgitation (MR) after ST-elevation acute myocardial infarction (STEMI) is a complex process that is less understood mechanistically, challenging to assess by standard echocardiography and associated with worse cardiovascular outcomes. Purpose To identify predictors of post-STEMI MR through serial assessment of biomarkers of inflammation and myocardial injury, and cardiac remodeling by echocardiography and cardiac magnetic resonance (CMR). Methods In the Registry for Post-myocardial Infarction Left Ventricular Remodeling and Heart Failure Prevention (REDEFINE-HF), 94 patients with STEMI (60±10 years, 76% men) were investigated in the acute infarction phase and at 6-month follow-up by both bio- and imaging markers. Left ventricular (LV) end-diastolic (EDV) and end-systolic (ESV) volumes were assessed by both echocardiography and CMR. MR ẃas graded by a multiparametric echo-approach as by current guidelines. LV filling pressures were estimated from the mitral peak early diastolic flow to annulus velocity ratio (E/e´). Additionally, the extent of microvascular obstruction and intramyocardial hemorrhage (an index of reperfusion injury) were assessed by CMR at baseline. The primary outcome was a composite of death, heart failure hospitalizations, and acute myocardial infarction during follow-up. Results In acute STEMI phase, 57% of patients had mild and 13% moderate MR, with an increase in prevalence to 79% mild and 15% moderate MR at 6-month follow-up (p<0.001). Patients with both acute-phase and 6-month follow-up MR had higher baseline troponin T and interleukin-6, higher concomitant LV filling pressures and echo-ESV, and larger infarction size by CMR (all p<0.05). In logistic regression analysis, mild-moderate acute-phase MR was associated with higher LV CMR-ESV after adjustment for clinical, biochemical and imaging confounders (p<0.05, R2=0.42). In Cox regression analysis, mild-moderate 6-month post-STEMI MR was predicted by higher baseline interleukin-6 (HR 1.01 [1.00-1.03] and more extensive acute-phase intramyocardial hemorrhage (HR 1.20 [1.03-1.40]) and microvascular obstruction by CMR (HR 1.14 [1.03-1.23]) (all p<0.05), but not by comorbidities, daily medication, total ischemic time, culprit vessel or extent of coronary artery disease. During 19±8months follow-up, 17 events occurred, all in patients with ischemic MR at follow-up (bootstrap p<0.001). Higher age and larger LV CMR-ESV were independent predictors of the composite outcome (-2Log likelihood 50, both p<0.05). Conclusion Ischemic mild-moderate MR occurs through complex interactions between inflammatory, microvascular and tissue remodeling pathways. A multimodality approach combining bio- and imaging markers helps identify individuals at risk for this clinical condition pertaining negative prognostic implications.

Post-craniotomy intracranial pressure monitoring: a novel approach combining optic nerve sheath diameter ultrasonography and cervical-cerebral arterial ultrasound.

Elevated intracranial pressure (ICP), a common complication in traumatic brain injuries (TBI), can lead to optic nerve sheath diameter (ONSD) enlargement and flow spectrum changes from the internal carotid artery (ICA) to middle cerebral artery (MCA). This study will investigate the use of Cervical-Cerebral Arterial Ultrasound (CCAU) for non-invasive ICP assessment and evaluating the related indices' clinical utility in TBI patients with decompressive craniotomy (DC). ONSD and flow spectrum changes were measured within 24 h after DC in 106 patients via ultrasonic ONSD measurement and CCAU, simultaneously. Intracranial pressures were invasively monitored, using a microsensor or ventricular catheter as the gold standard. Patients were classified into two groups, namely the normal group and the elevated group, based on distinct intracranial pressure thresholds of 15 mmHg, 20 mmHg and 22 mmHg. Subsequently, Bland Altman plot used for evaluating agreement between estimate for ICP (ICPe) and invasive ICP (ICPi). Then, the correlation between ONSD, MCAPI (pulsatility index of MCA), PI-ratio (MCAPI/ICAPI), and ICPe was examined through linear regression analysis. Finally, receiver operator characteristic curves (ROC) were also analyzed for different indexes and their combinations (using logistic model). Significant differences were observed between the normal and elevated ICP groups with respect to ONSD, PI-ratio, MCAPI and MCAFVd (diastolic flow velocity of MCA) (p < 0.05). The correlation coefficients for the relationships between ONSD, PI ratio, FVdMCA, and PI with ICPi were 0.62, 0.33, 0.32 and 0.21, respectively, each demonstrating statistical significance (p < 0.05). Analysis of the ROC curves demonstrated that the area under the curve (AUC) for predicting elevated ICPi at thresholds of 15 mmHg, 20 mmHg, and 22 mmHg via combined ultrasonographic measurements of the PI ratio and ONSD was the largest, specifically 0.74 (95% CI: 0.65-0.82), 0.77 (95% CI: 0.69-0.85), and 0.79 (95% CI: 0.70-0.86), respectively. Ultrasonographic measurements of ONSD, PI-ratio, MCAPI and MCAFVd demonstrate a moderate to low weak correlation with ICPi measurements. ICPe is not considered sufficiently precise for noninvasive accurate ICP assessment. The concurrent utilization of CCAU and ONSD measurements may offer superior accuracy for elevated ICP in TBI patients with DC, especially in specificity. Further research is imperative to validate these findings within a more extensive patient population.

Association between cerebral oxygenation and usual parameters of cerebral perfusion in critically ill patients with acute brain injury.

In patients with acute brain injury (ABI), optimizing cerebral perfusion parameters relies on multimodal monitoring. This include data from systemic monitoring-mean arterial pressure (MAP), arterial carbon dioxide tension (PaCO2), arterial oxygen saturation (SaO2), hemoglobin levels (Hb), and temperature-as well as neurological monitoring-intracranial pressure (ICP), cerebral perfusion pressure (CPP), and transcranial Doppler (TCD) velocities. We hypothesized that these parameters alone were not sufficient to assess the risk of cerebral ischemia. We conducted a retrospective, single-center study of patients admitted in our ICU between 2015 and 2021. Patients with ABI and multimodal neuromonitoring were included. ABI included traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracranial hemorrhage and ischemic stroke. The relationship between jugular venous oxygen saturation (SjvO2) and cerebral perfusion parameters was analyzed. Patients were categorized into two groups based on SjvO2, with a threshold of 60% used to define cerebral ischemia. We compared the parameters used to optimize cerebral perfusion between groups and their diagnosis accuracy for cerebral ischemia was evaluated. Univariable and multivariable analyses were performed to assess the association between the guideline-recommended therapeutic targets and the risk of cerebral ischemia. 601 evaluations from 96 patients with simultaneous ICP, SjvO2 and TCD were analyzed. Poor relationships were found between SjvO2 and the parameters of cerebral perfusion. TCD flow velocities and PaCO2 were lower in the cerebral ischemia group while MAP, ICP and CPP were not different between groups. Most ischemic episodes occurred despite ICP < 22 mmHg and CPP ≥ 60 mmHg. For the diagnosis of cerebral ischemia, only TCD parameters and PaCO2 were associated with an area under the curve (AUC) > 0.5 but with a low accuracy. In multivariable analysis, the only guideline-recommended therapeutic target associated with a reduction of cerebral ischemia was a diastolic flow velocity (FV) > 20 cm.s-1.

Three-dimensional aortic arch geometry and blood flow in neonates after surgical repair for aortic coarctation.

Recurrent coarctation of the aorta (re-CoA) is a well-known although not fully understood complication after surgical repair, typically occurring in 10%-20% of cases within months after discharge. To (1) characterize geometry of the aortic arch and blood flow from pre-discharge magnetic resonance imaging (MRI) in neonates after CoA repair; and (2) compare these measures between patients that developed re-CoA within 12 months after repair and patients who did not. Neonates needing CoA repair, without associated major congenital heart defects, were included. Transthoracic echocardiography (echo) and 4D phase-contrast MRI were performed prior to discharge after CoA repair to assess 3D arch geometry, flow velocity and flow pattern in the distal aortic arch corresponding to the area at risk for re-CoA. Arch geometry was assessed by measuring angles of the aortic arch and its branches using 3D patient-specific geometries segmented from MRI. Continuous data are presented as median and interquartile range. The median age at CoA surgery was 9 days. Four out of the included 28 patients (14%) developed re-CoA within the first 12 months after surgery. Re-CoA was associated with repair technique (lateral thoracotomy 100% vs. 33%, p = 0.02), higher postoperative isthmic flow velocity by echocardiography (1.9 [0. 9] m/s vs. 1.25 [0.5] m/s, p = 0.04) and postoperative crenel aortic arch (100% vs. 21%, p = 0.007) with a larger distance between the first and last branching points (12.6 [3.1] mm vs. 7.3 [7.0] mm; p = 0.01). A smaller angle between the ascending aorta and the brachiocephalic artery (89 [58]° vs. 122 [37]°, p = 0.05) and between the proximal aortic arch and the left carotid artery (75° vs. 97 [37]°, p = 0.04), with a more pronounced caliber change between the ascending aorta and the proximal (1.85 vs. 0.86 [0.76]; p = 0.03) and distal aortic arch (2.19 [2.42] vs. 1.01 [0.94]; p = 0.03) were observed in re-CoA patients. Patients who developed re-CoA had more left-handed helical flow in systole (p = 0.045), more right-handed helical flow in diastole (p = 0.02), and less vortical flow (p = 0.05). Subtle changes in aortic arch geometry and flow pattern early after neonatal CoA repair may contribute to the risk of re-CoA.

Impact of kidney transplantation vs. dialysis waiting for deceased donor on left ventricular diastolic dysfunction.

Left ventricular (LV) diastolic dysfunction is frequently observed in patients with end-stage kidney disease (ESKD) and a significant risk factor for the development of cardiovascular events in those patients. We hypothesized that the ratio of early diastolic peak mitral flow velocity to early mitral annulus velocity (E/e' ratio), the widely used non-invasive LV diastolic dysfunction index, would show improvements following kidney transplantation (KT). A total of 192 KT recipients who underwent echocardiography before KT and 2 years after KT were included this analysis. Moreover, 137 patients with ESKD on dialysis, waiting for deceased donor were included as a control group. Multiple linear regression analysis was used to identify the factors related to changes in the E/e' ratio. The median duration between conducting the two echocardiographies was 809 days for the KT recipients and 798 days for the controls. The mean E/e' ratio showed a significant decrease in KT recipients (10.9 vs. 9.8, respectively; p=0.002), but not in the controls (11.7 vs. 11.9, respectively; p=0.605). In multiple linear regression, KT (standardized β (SB) = -0.156; p=0.009) and administration of β blocker (BB) at enrollment (SB = -0.130; p==0.034) and at 2 years (SB=0.206, p=0.001) were significant predictors of the change in the E/e' ratio. LV diastolic dysfunction showed a noticeable improvement in the patients after KT compared to those on the waiting list and undergoing dialysis. Further studies, including patients with volume status and major cardiovascular events, may be helpful for validating these findings.

Accuracy of Intraoperative Transesophageal Echocardiographic Doppler Parameters in Assessing the Right Ventricular Diastolic Function After Repair of Tetralogy of Fallot in Pediatric Patients.

This study aimed to assess the accuracy of tricuspid spectral Doppler (E/A) and tissue Doppler parameters (E/E') to diagnose right ventricular diastolic dysfunction (RVDD) in comparison to American Society of Echocardiography (ASE criteria) in pediatric tetralogy of Fallot (TOF) patients after surgical repair. This prospective, observational study was done at a tertiary care hospital involving 40 pediatric TOF patients aged less than 2 years who underwent complete intracardiac repair with cardiopulmonary bypass (CPB). Echocardiographic observations were made using a pediatric transesophageal echocardiography probe after surgical repair in the post-CPB period. The ASE-described parameters (late diastolic forward flow in the main pulmonary artery, right atrial dilatation, inferior vena cava dilatation, and hepatic venous flow reversal) were acquired to diagnose the RVDD. The tricuspid Doppler parameters (E/A and E/E') were measured, and its predictive ability to diagnose RVDD was analyzed and compared with the ASE criteria. Based on the ASE criteria, 13 patients (32.5%) were diagnosed to have RVDD. We found that an E/E' ratio of ≥ 6.26 and an E/A ratio of >1.34 can be taken as the cutoff for diagnosing the RVDD. Based on the tricuspid Doppler parameters (E/A > 1.34 and E/E' >6.26), 17 patients (42.5%) were diagnosed to have RVDD, which was comparable to that of the diagnosis by ASE criteria (P > 0.05). The results suggested that the use of tricuspid Doppler parameters can be equally accurate and reproducible to the current ASE-described echocardiographic parameters for diagnosing RVDD after surgical repair of TOF.

Case report of familial hypercholesterolemia with internal carotid neck swelling

ABSTRACT Familial hypercholesterolemia is a multi-gene disorder affecting 1 in 200-500 individual which is characterized by increased level of total cholesterol and low density lipoprotein (LDL) which deposit cholesterol reach protein leading to xanthomas, corneal arcus and prone to develop risk for atherosclerosis and coronary heart disease. 11 year female, born of consanguineous marriage attended with yellowish patches (Xanthelasma) bilaterally present over upper eyelid, buttock since 5-6 years. In family history younger girl along with both parents has Xanthelasma. In investigations, routine blood, urine and ECG&amp; ECHO was normal except lipid profile of patient and sibling was abnormal. Child was treated with atorvastatin and dietary advice. In follow up after 3 month, child had complained of neck pain and swelling to left side. Then USG neck and Color Doppler showed reduced diastolic flow of left ICA and type two plaques and type 111 plaque in Rt common carotid artery. Anti-platelets was added and referred to cardiologist for coronary angiography which showed LAD – proximal mid distal diffuse plaque, LCX- proximal eccentric plaque. This case highlights the significance of conscious and proactive genetic screening for familial hypercholesterolemia especially in consanguineous marriage, to diagnose, treat and prevent mortality with premature coronary artery disease.

Doppler Characterization of Left Anterior Descending Coronary Artery Diastolic Flow Profiles in Hypertrophic Cardiomyopathy

Doppler Characterization of Left Anterior Descending Coronary Artery Diastolic Flow Profiles in Hypertrophic Cardiomyopathy

Autosomal recessive renal tubular dysgenesis: antenatal ultrasound scanning and molecular investigations.

This study aimed to elucidate the fetal ultrasound characteristics, pathology, and molecular genetic etiology of autosomal recessive tubular dysplasia. This retrospective study examined four fetuses with autosomal recessive tubular dysplasia (ARRTD) from two pregnancies, utilizing ultrasound evaluations and fetal renal pathology. Whole-exome sequencing-copy number variation analysis was employed to identify gene mutations. We present for the first time renal vascular resistance in fetuses with ARRTD, characterized by increased renal blood flow resistance and reversed diastolic blood flow, indicating fetal renal insufficiency. This is the first report of a nonsense mutation (C.571C>T) found in the angiotensinogen gene. ARRTD disease should be strongly suspected when ultrasound examinations reveal increased renal blood flow resistance, oligohydramnios, and inadequate bladder filling, regardless of the presence of renal abnormalities.

The Correlation Between Uric Acid, Urinary Protein and Umbilical Artery Blood Flow Related Parameters and Maternal and Infant Prognosis in Patients with Gestational Hypertension.

To investigate the correlation between uric acid (UA), urinary protein (UP) and umbilical artery blood flow related parameters and maternal and infant prognosis in patients with hypertensive disorder complicating pregnancy (HDP). A total of 110hDP patients who underwent prenatal examination and delivered in our hospital from June 2018 to May 2023 were selected as the HDP group. According to the prognosis of mother and infant, they were divided into normal prognosis group (n=80) and poor prognosis group (n=30). In addition, 110healthy pregnant women who received prenatal examination in the same hospital during the same period were randomly selected as healthy control group. The maternal and infant outcomes, UA, 24-h-UP level, umbilical artery blood flow pulsation index (PI), resistance index (RI) and systolic and diastolic blood flow velocity ratio (S/D) were compared between the two groups. Logistic regression analysis was used to analyze the factors related to the above probability and maternal and infant prognosis. The total incidence of adverse maternal and infants outcome in the HDP group was higher than that of HC (37.5% VS16.65%) (P <0.05). The HDP group UA, 24-h-UP and PI, RI, and S / D higher than HC (P <0.05). Logistic regression analysis shows that the age of pregnant women and 24-h-UP, PI, RI, S / D are related factors that affect the prognosis of adverse maternal and infants outcome (P <0.05). The UA and UP levels and umbilical artery blood flow-related parameters in HDP patients were significantly increased. Maternal age and 24-h-UP, RI, and S/D are all relevant factors that affect the adverse maternal and fetal prognosis of HDP patients.

Association of pulsatility of lenticulostriate arteries with cognitive decline in elderly adults: a 7T dual‐VENC PC‐MRI study

AbstractBackgroundCerebral small vessel disease (cSVD) is a major cause of vascular dementia. Mounting evidence suggests that cSVD pathology is closely linked to vascular dysfunction of lenticulostriate arteries (LSAs). Arterial pulsatility, quantified by pulsatility index (PI), has been used as an indicator of vascular dysfunction. With the advent of ultra‐high field 7T, the velocity and pulsatility of LSAs can be reliably measured. Directly assessing pulsatility of LSAs may offer valuable insight into pathophysiology of cSVD and cognitive impairment. This study aims to investigate relationship between LSA pulsatility and cognitive performance within an aged cohort.MethodTwenty‐five elderly participants (13 female: 71 ± 9.2 years) were enrolled in the study with written informed consent. Cognitive assessments were conducted including 19 participants undergoing the Mini‐Mental State Exam (MMSE) and 23 taking Montreal Cognitive Assessment (MoCA). High‐resolution phase‐contrast MRI (PC‐MRI) with dual‐VENC (Venc=20cm/s and 40cm/s) was performed on a Siemens 7T MRI scanner to image velocities of LSAs. PI was calculated by the difference between the peak systolic flow velocity and minimum diastolic flow velocity divided by the mean velocity throughout a cardiac cycle. Pearson correlation was used to evaluate the associations between LSA PI and age, education level, and cognitive measurements. A linear mixed‐effects model was used to test the association between LSA PI and cognitive measurements while correcting for the effects of age, gender, and education.ResultFlow velocity curves and PI values of LSAs were successfully extracted and calculated from all 25 participants. Figure 1 shows an example of LSA imaging using PC‐MRI and the acquired velocity curve of LSAs. LSA PI significantly increased with age and lower education levels (p=0.002, 0.03, respectively) (Figure 2). Increased PI was strongly associated with lower MMSE scores with and without corrections for age, gender, and educational level (p=0.048, 0.028) (Figure 3). A similar trend was observed between PI and MOCA scores, although there was no significance (p=0.31).ConclusionThis study has demonstrated that LSA pulsatility assessed by 7T high‐resolution PC‐MRI is strongly associated with aging, education, and cognitive performance. These findings suggest the dysfunction of LSA could contribute to the cSVD pathology and result in cognitive impairment.

EVALUATION OF THE RELATIONSHIP BETWEEN IRON LOAD, AGE, AND CARDIAC FUNCTION IN CHILDREN AND YOUNG ADULTS WITH THALASSEMIA MAJOR: A PULSED-WAVE DOPPLER AND TISSUE DOPPLER IMAGING STUDY

Objective: To determine the structural and functional cardiac differences in children and young adults with thalassemia major (TM) compared to healthy subjects using pulsed-wave Doppler and tissue Doppler imaging methods and determine the relationship between iron overload and these differences. Materials and Methods: We analyzed the data of pediatric and young adult TM patients (n = 44) aged 4–22 years and an age- and gender-matched control group (n = 40) in our hospital data system between Oct.01.2023 and Oct.01.2024. Height, weight, body mass index (BMI), systolic–diastolic blood pressure measurements, complete blood count, ferritin, cardiac T2* magnetic resonance imaging (MRI) values, and echocardiography results were recorded. In addition to comparisons between the two groups, correlation analysis was performed between ferritin–cardiac T2* MRI results and echocardiographic parameters and age in TM patients. Results: Our study showed growth retardation (low height standard deviation score (SDS), low weight SDS and low BMI SDS), dilatation of the left cavities (high left ventricular internal diameter end diastole (LVIDd)), increased left ventricular muscle mass (high left ventricular mass index (LVMI)), cardiac distinctive diastolic (restrictive pattern: left ventricular (LV) peak early diastolic flow (E)/peak late diastolic flow (A) and E/early diastolic myocardial peak flow (E') high), and subclinical systolic (LV peak systolic flow low and LV Tei index high) dysfunction. In addition, iron load (ferritin and cardiac T2* MRI) was correlated with LVMI, and cardiac diastolic and systolic function indicators. As age increased, ferritin value did not change, but cardiac T2* MRI value decreased and diastolic–systolic parameters worsened. Conclusion: Periodic cardiac T2* MRI and Doppler echocardiography examinations of patients with TM may detect subclinical myocardial dysfunction at an early stage, thus providing a window of opportunity for intervention.

Involvement of Melatonin, Oxidative Stress, and Inflammation in the Protective Mechanism of the Carotid Artery over the Torpor-Arousal Cycle of Ground Squirrels.

Hibernating mammals experience severe hemodynamic changes over the torpor-arousal cycle, with oxygen consumption reaching peaks during the early stage of torpor to re-enter arousal. Melatonin (MT) can improve mitochondrial function and reduce oxidative stress and inflammation. However, the regulatory mechanisms of MT action on the vascular protective function of hibernators are still unclear. Morphology, hemodynamic, mitochondrial oxidative stress, and inflammatory factors of the carotid artery were assessed in ground squirrels who were sampled during summer active (SA), late torpor (LT), and interbout arousal (IBA) conditions. Changes were assessed by methods including hematoxylin and eosin staining, color Doppler ultrasound, ELISA, Western blots, and qPCR. Changes in arterial blood and serum melatonin were also measured by blood gas analyzer and ELISA, whereas mitochondrial oxidative stress and inflammation factors of primary vascular smooth muscle cells (VSMCs) were assessed by qPCR. (1) Intima-media carotid thickness, peak systolic velocity (PSV), end diastolic blood flow velocity (EDV), maximal blood flow rate (Vmax) and pulsatility index (PI) were significantly decreased in the LT group as compared with the SA group, whereas there were no difference between the SA and IBA groups. (2) PO2, oxygen saturation, hematocrit and PCO2 in the arterial blood were significantly increased, and pH was significantly decreased in the LT group as compared with the SA and IBA groups. (3) The serum melatonin concentration was significantly increased in the LT group as compared with the SA and IBA groups. (4) MT treatment significantly reduced the elevated levels of LONP1, NF-κB, NLRP3 and IL-6 mRNA expression of VSMCs under hypoxic conditions. (5) Protein expression of HSP60 and LONP1 in the carotid artery were significantly reduced in the LT and IBA groups as compared with the SA group. (6) The proinflammatory factors IL-1β, IL-6, and TNF-α were reduced in the carotid artery of the LT group as compared with the SA and IBA groups. The carotid artery experiences no oxidative stress or inflammatory response during the torpor-arousal cycle. In addition, melatonin accumulates during torpor and alleviates oxidative stress and inflammatory responses caused by hypoxia in vitro in VSMCs from ground squirrels.