scholarly journals The association between invasive microvascular function and CMR-derived microvascular injury indicators and left ventricular function and infarct size at 1-month after reperfused STEMI

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
A Demirkiran ◽  
N W Hoeven ◽  
H Everaars ◽  
G N Janssens ◽  
H J Berkhof ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Ejection Fraction ◽  
Linear Regression Analysis ◽  
Left Ventricular ◽  
Coronary Microcirculation ◽  
Microvascular Function ◽  
Lv Function ◽  
Microvascular Injury ◽  
Non Invasive ◽  
Lv Ejection Fraction

Abstract Background The restoration of the coronary microcirculation in ST-segment elevation myocardial infarction (STEMI) patients remains hampered in up to 50% of the STEMI patients after successful primary percutaneous coronary intervention (PCI). The association between the coronary microvascular function and injury indicators and functional outcome remains debated. Purpose This study aims to investigate the relation between post-PCI invasive microvascular function and cardiovascular magnetic resonance (CMR)-derived microvascular injury indicators and left ventricular (LV) function and infarct size (IS) at 1-month after STEMI. Methods The study was performed in 110 STEMI patients who underwent angiography for primary PCI and at 1-month follow-up. Invasive assessment of coronary microcirculation physiology in the culprit artery was performed during both procedures and included coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR). Data were available for 101 patients. A ratio of >2 for CFR and a value of <25 U for IMR were considered normal. CMR was performed during the acute phase (2 to 7 days after PCI) and at 1-month and provided assessment of LV function, IS and non-invasive information of microvascular injury in 78 patients by microvascular obstruction (MVO) and intra-myocardial hemorrhage (IMH). Results Over 1-month, CFR, IMR, LV function, and IS all significantly improved (p≤0.001). In univariable linear regression analysis, the post-PCI normal index CFR and IMR (both p=0.04), MVO presence, MVO size, IMH presence, IMH size (all, p<0.001) were significantly associated with LV ejection fraction at 1-month. Additionally, the post-PCI index CFR (p=0.04), MVO presence, MVO size, IMH presence, IMH size (all, p<0.001) were all associated with 1-month IS. In a multivariable linear regression analysis model including invasive and non-invasive coronary microcirculation function and injury indicators, MVO presence was identified as the only independent marker related to both 1-month LV ejection fraction and IS (both p<0.001). Conclusion(s) In STEMI patients, CMR-derived coronary microcirculation injury indicators reveal a closer association with 1-month LV function and IS outcome than invasive microcirculatory measurements. MVO presence is independently associated with 1-month LV ejection fraction and IS. FUNDunding Acknowledgement Type of funding sources: Private company. Main funding source(s): The REDUCE-MVI study was funded by Astra Zeneca to MvL and NvR.

scholarly journals Left ventricular myocardial work in patients with high gradient severe symptomatic aortic stenosis

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
G Sa Mendes ◽  
J Abecasis ◽  
S Maltez ◽  
S Guerreiro ◽  
P Freitas ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Tissue Characterization ◽  
Left Ventricular ◽  
Low Flow ◽  
Lv Function ◽  
High Gradient ◽  
Non Invasive ◽  
Lv Ejection Fraction

Abstract Background Left ventricular myocardial work (LVMW) is a novel method to evaluated left ventricular (LV) function using pressure-strain loops. It might correct global longitudinal strain (GLS) for afterload, being eventually useful to assess whether GLS reduction is due to reduced contractility (reflected as reduced myocardial work) or increased afterload (reflected as increased myocardial work). Aim To describe indices of LVMW in a group of patients with severe symptomatic aortic stenosis (AS). Methods We prospectively studied 104 consecutive patients (age: 71 years [IQR 66.5–75.5] years, 51% men) with severe symptomatic high gradient AS: mean transaortic pressure gradient: 56.5mmHg [IQR 46.8–67.8]; aortic valve area: 0.73cm2 [IQR 0.61–0.88]; indexed stroke volume: 47.7±1.3 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0–61.3]; GLS: −14.5% [IQR −16.1 to −10.6]), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance for LV myocardium tissue characterization. As proposed for AS, LV systolic pressure was corrected adding the mean transaortic pressure gradient to non-invasive systolic blood pressure cuff measurement in the echocardiographic algorithm. Four LVMW indices were collected in 83 patients (patients excluded for atrial fibrillation, left bundle branch block or absence of non-invasive blood pressure registration) and correlated to LV function indexes, LV hypertrophy and remodeling, myocardial tissue characterization, BNP and troponin levels (Pearson or Spearman correlation). These same indexes were compared in patients with LV ejection fraction (EF) below and above 50%, normal and reduced flow and presence of replacement fibrosis. Results Global constructive work (GCW) (2658.6±76.4mmHg%), global myocardial work (GMW) (2218.7±74.9mmHg%) and global wasted work (GWE) (262.0mmHg% [198.8–339.5]) were high above normal with concomitant lower work efficiency (WE) (88.0% [83.2–91.8]. Weak correlations were found between LVMW indexes and parameters describing aortic valve severity, flow and LV function (table). Except for significant differences of LVMI in patients with reduced LV ejection fraction (GCW 2770.3±687.4 vs 2056.0±380.7mmHg%, p=0,014 and GMW 2362.5±657.9 vs 1621.3±319.9, p=0,021 in patients with LV EF>50% vs. LV EF<50%, respectively) work indexes were neither significantly different in low-flow patients nor in those with myocardial late gadolinium enhancement. Conclusions Global constructive and myocardial work are increased in these patients with severe aortic stenosis. This might reflect an increased afterload predominance rather than a LV functional impairment, particularly relevant in this group of patients with exclusive high gradient disease and preserved LVEF. FUNDunding Acknowledgement Type of funding sources: None. Correlations between LVMI – LV function

Myocardial work in Stage 1 and 2 hypertensive patients

2021 ◽  
Author(s):  
Akshar Jaglan ◽  
Sarah Roemer ◽  
Ana Cristina Perez Moreno ◽  
Bijoy K Khandheria
Keyword(s):  
Ejection Fraction ◽  
Longitudinal Strain ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Hypertensive Patients ◽  
Non Invasive ◽  
Significant Difference ◽  
Lv Ejection Fraction ◽  
Global Work ◽  
Stage 1

Abstract Aims Myocardial work (MW) is a novel parameter that can be used in a clinical setting to assess left ventricular (LV) pressures and deformation. We sought to distinguish patterns of global MW index in hypertensive vs. non-hypertensive patients and to look at differences between categories of hypertension. Methods and results Sixty-five hypertensive patients (mean age 65 ± 13 years; 30 male) and 15 controls (mean age 38 ± 12 years; 7 male) underwent transthoracic echocardiography at rest. Hypertensive patients were subdivided into Stage 1 (n = 32) and Stage 2 (n = 33) hypertension based on 2017 American College of Cardiology guidelines. Exclusion criteria were suboptimal image quality for myocardial deformation analysis, reduced ejection fraction, valvular heart disease, intracardiac shunt, and arrhythmia. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency were estimated from LV pressure–strain loops utilizing proprietary software from speckle-tracking echocardiography. LV systolic and diastolic pressures were estimated using non-invasive brachial artery cuff pressure. Global longitudinal strain and LV ejection fraction were preserved between the groups with no statistically significant difference, whereas there was a statically significant difference between the control and two hypertension groups in GWI (P = 0.01), GCW (P < 0.001), and GWW (P < 0.001). Conclusion Non-invasive MW analysis allows better understanding of LV response under conditions of increased afterload. MW is an advanced assessment of LV systolic function in hypertension patients, giving a closer look at the relationship between LV pressure and contractility in settings of increased load dependency than LV ejection fraction and global longitudinal strain.

scholarly journals Non-Invasive Assessment of Left Ventricle Ejection Fraction: Where Do We Stand?

2021 ◽  
Vol 11 (11) ◽  
pp. 1153
Author(s):  
Alessandra Scatteia ◽  
Angelo Silverio ◽  
Roberto Padalino ◽  
Francesco De Stefano ◽  
Raffaella America ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Ejection Fraction ◽  
Systolic Function ◽  
Left Ventricular ◽  
Left Ventricle Ejection Fraction ◽  
Advantages And Disadvantages ◽  
Non Invasive ◽  
Lv Ejection Fraction ◽  
Lv Systolic Function ◽  
Invasive Evaluation

The left ventricular (LV) ejection fraction (EF) is the preferred parameter applied for the non-invasive evaluation of LV systolic function in clinical practice. It has a well-recognized and extensive role in the clinical management of numerous cardiac conditions. Many imaging modalities are currently available for the non-invasive assessment of LVEF. The aim of this review is to describe their relative advantages and disadvantages, proposing a hierarchical application of the different imaging tests available for LVEF evaluation based on the level of accuracy/reproducibility clinically required.

scholarly journals Bone marrow mesenchymal stem cells transfer in patients with ST-segment elevation myocardial infarction: single-blind, randomized controlled muticentre trial

2020 ◽  
Author(s):  
Runfeng Zhang ◽  
Jiang Yu ◽  
Ningkun Zhang ◽  
Wensong Li ◽  
Jisheng Wang ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Ejection Fraction ◽  
General Hospital ◽  
Myocardial Viability ◽  
Left Ventricular ◽  
Control Group ◽  
Lv Function ◽  
St Segment Elevation ◽  
Lv Ejection Fraction

Abstract Objective: Our aimed to evaluate efficacy and safety of intracoronary autologous bone morrow mesenchymal stem cells (BM-MSCs) transplantation in patients with ST-segment elevation myocardial infarction（STEMI）. Methods: In this randomised, single-blind, controlled trial, patients with STEMI (aged 39-76 years) were enrolled at 6 centers in Beijing (the People's Liberation Army Navy General Hospital, Beijing Armed Police General Hospital, Chinese People's Liberation Army General Hospital, Beijing Huaxin Hospital, Beijing Tongren Hospital, Beijing Chaoyang Hospital West Hospital). Patients underwent optimum medical treatment and percutaneous coronary intervention,and were randomly assigned in a 1:1 ratio to BM-MSCs group or control group. The primary endpoint was change of myocardial viability at 6 months' follow-up and left-ventricular (LV) function at 12 months' follow-up.The secondary endpoints were incidence of cardiovascular event, total mortality and adverse event at 12 months' follow-up. The myocardial viability assessed by single- photon emission tomography (SPECT). The left ventricular ejection fraction was used to assess LV function. All patients underwent dynamic ECG and laboratory evaluations. This trial is registered with ClinicalTrails.gov, number NCT04421274. Results: Between March , 2008, and July , 2010, 43 patients were randomly assigned to BM-MSCs group (n=21)or control group(n=22) and followed up for 12 months. LV ejection fraction increased from baseline to 12 months in the BM-MSCs group and control group ( mean baseline-adjusted BM-MSCs treatment differences in LV ejection fraction 4.8% (SD 9.0) and mean baseline-adjusted control group treatment differences in LV ejection fraction 5.8% (SD 6.04) ). After 6 months of follow-up, there was no significant improvement in myocardial metabolic activity in the BM-MSCs group before and after transplantation. however,there was no statistically significant difference between the two groups in the change of LV ejection fraction (p=0.30) and myocardial metabolic activity(p>0.05). We noticed that ,after 12 months of follow-up, except for 1 death and 1 coronary microvascular embolism in the BM-MSCs group, no other events occurred and Alanine transaminase(ALT) and C-reactive protein(CRP) in BM-MSCs group were significantly lower than that in control group. Conclusions: It is unreasonable to speculate that intracoronary transfer of autologous bone marrow MSCs could augment recovery of LV function and myocardial viability after acute myocardial infarction.Trial registration: clinicaltrials,NCT04421274. Registered 06,08,2020- Retrospectively registered, https://register.clinicaltrials.gov/NCT04421274.

scholarly journals Personalised reprogramming to prevent progressive pacemaker-related left ventricular dysfunction: A phase II randomised, controlled clinical trial

PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0259450
Author(s):  
Maria F. Paton ◽  
John Gierula ◽  
Judith E. Lowry ◽  
David A. Cairns ◽  
Kieran Bose Rosling ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Ejection Fraction ◽  
Usual Care ◽  
Phase Ii ◽  
Left Ventricular ◽  
Lv Function ◽  
Controlled Clinical Trial ◽  
Rv Pacing ◽  
Lv Ejection Fraction

Background Pacemakers are widely utilised to treat bradycardia, but right ventricular (RV) pacing is associated with heightened risk of left ventricular (LV) systolic dysfunction and heart failure. We aimed to compare personalised pacemaker reprogramming to avoid RV pacing with usual care on echocardiographic and patient-orientated outcomes. Methods A prospective phase II randomised, double-blind, parallel-group trial in 100 patients with a pacemaker implanted for indications other than third degree heart block for ≥2 years. Personalised pacemaker reprogramming was guided by a published protocol. Primary outcome was change in LV ejection fraction on echocardiography after 6 months. Secondary outcomes included LV remodeling, quality of life, and battery longevity. Results Clinical and pacemaker variables were similar between groups. The mean age (SD) of participants was 76 (+/-9) years and 71% were male. Nine patients withdrew due to concurrent illness, leaving 91 patients in the intention-to-treat analysis. At 6 months, personalised programming compared to usual care, reduced RV pacing (-6.5±1.8% versus -0.21±1.7%; p<0.01), improved LV function (LV ejection fraction +3.09% [95% confidence interval (CI) 0.48 to 5.70%; p = 0.02]) and LV dimensions (LV end systolic volume indexed to body surface area -2.99mL/m2 [95% CI -5.69 to -0.29; p = 0.03]). Intervention also preserved battery longevity by approximately 5 months (+0.38 years [95% CI 0.14 to 0.62; p<0.01)) with no evidence of an effect on quality of life (+0.19, [95% CI -0.25 to 0.62; p = 0.402]). Conclusions Personalised programming in patients with pacemakers for bradycardia can improve LV function and size, extend battery longevity, and is safe and acceptable to patients. Trial registration ClinicalTrials.gov identifier: NCT03627585.

scholarly journals The Acute Effects of Esmolol in Intact and Infarcted Myocardium–Experimental Study

2020 ◽  
pp. 1-7
Author(s):  
Savvas Toumanidis ◽  
John Agrios ◽  
Anna Kaladaridou ◽  
Dimitrios Bramos ◽  
Elias Skaltsiotes ◽  
...  
Keyword(s):  
Ejection Fraction ◽  
Speckle Tracking ◽  
Systolic Pressure ◽  
Left Ventricular ◽  
Lv Function ◽  
Short Axis ◽  
Acute Effects ◽  
Anterior Myocardial Infarction ◽  
Infarcted Myocardium ◽  
Lv Ejection Fraction

Aim: Early intravenous use of b-blockers within the first hours of STEMI is less firmly established. The aim of this study was to evaluate the effect of esmolol on left ventricular (LV) haemodynamic, rotational and strain parameters in intact myocardium and early post an experimental acute anterior myocardial infarction (MI). Methods: In 20 healthy pigs LV torsional and strain parameters were calculated from basal and apical short axis epicardial planes with speckle tracking technique using EchoPAC platform. LV measurements at baseline and during esmolol infusion (0.5 mg/kg for 1 min, then 0.05 mg/kg/min for 5 min) were compared in intact myocardium and repeated without b-blocker and during esmolol infusion 2 hours post LAD ligation. Results: LV function was highly dependent on the esmolol infusion, in the intact and even more in the infarcted myocardium. LV ejection fraction, LV dP/dtmax and LV end-systolic pressure decreased significantly, a deterioration produced by the administration of esmolol. Torsion-twist and untwisting rate also presented significant reduction in correlation with ejection fraction and cardiac output, appearing to affect especially the apex torsional and strain parameters. Conclusion: Esmolol infusion significantly reduces LV haemodynamic, torsional and strain parameters in intact myocardium and early post MI. These results suggest that early intravenous use of esmolol in patients with STEMI is risky and it is prudent to wait for the patient to stabilize before starting esmolol.

Measurement of Left Ventricular Function During Arm Ergometry Using the VESTTM Nuclear Probe

1994 ◽  
Vol 19 (4) ◽  
pp. 462-471
Author(s):  
Len S. Goodman ◽  
Jack M. Goodman ◽  
Linda Yang ◽  
Joanna Sloninko ◽  
Terry Hsia ◽  
...  
Keyword(s):  
Ejection Fraction ◽  
Left Ventricular ◽  
Peak Exercise ◽  
Lv Function ◽  
Trained Subjects ◽  
Arm Exercise ◽  
Systolic Volume ◽  
End Systolic Volume ◽  
Lv Ejection Fraction ◽  
Rest And Exercise

A chest-mounted left ventricular (LV) nuclear probe (VEST™) for use during arm and leg ergometry is presented, with a discussion of the validity and reproducibility of LV function measures at rest and exercise. During both arm and leg ergometry in trained subjects, transient changes in LV function/volumes were observed. LV ejection fraction and relative end-systolic and end-diastolic volumes were 25 to 30% less with the arms versus the legs, agreeing with data from other studies using conventional techniques. At peak exercise with both limbs, LV ejection fraction and relative LV end-systolic volume increased, followed by immediate postexercise normalization. The effect was greatest with the arms and reflects the effect of high intramuscular and arterial pressures generated during arm cranking, leading to increased LV afterloading. The VESTTM permits rapid and noninvasive assessment of LV function during arm exercise, avoiding the limitations of other techniques. Key words: arm exercise, radionuclide, chest-mounted probe

scholarly journals Association Between Left Ventricular Mechanical Deformation and Myocardial Fibrosis in Nonischemic Cardiomyopathy

2020 ◽  
Vol 9 (19) ◽  
Author(s):  
Ibolya Csecs ◽  
Farhad Pashakhanloo ◽  
Amanda Paskavitz ◽  
Jihye Jang ◽  
Talal Al‐Otaibi ◽  
...  
Keyword(s):  
Cardiovascular Magnetic Resonance ◽  
Magnetic Resonance ◽  
Ejection Fraction ◽  
Global Longitudinal Strain ◽  
Mechanical Deformation ◽  
Left Ventricular ◽  
Lv Function ◽  
Nonischemic Cardiomyopathy ◽  
Deformation Parameters ◽  
Lv Ejection Fraction

Background In patients with nonischemic cardiomyopathy, nonischemic fibrosis detected by late gadolinium enhancement (LGE) cardiovascular magnetic resonance is related to adverse cardiovascular outcomes. However, its relationship with left ventricular (LV) mechanical deformation parameters remains unclear. We sought to investigate the association between LV mechanics and the presence, location, and extent of fibrosis in patients with nonischemic cardiomyopathy. Methods and Results We retrospectively identified 239 patients with nonischemic cardiomyopathy (67% male; 55±14 years) referred for a clinical cardiovascular magnetic resonance. LGE was present in 109 patients (46%), most commonly (n=52; 22%) in the septum. LV deformation parameters did not differentiate between LGE‐positive and LGE‐negative groups. Global longitudinal, radial, and circumferential strains, twist and torsion showed no association with extent of fibrosis. Patients with septal fibrosis had a more depressed LV ejection fraction (30±12% versus 35±14%; P =0.032) and more impaired global circumferential strain (−7.9±3.5% versus −9.7±4.4%; P =0.045) and global radial strain (10.7±5.2% versus 13.3±7.7%; P =0.023) than patients without septal LGE. Global longitudinal strain was similar in both groups. While patients with septal‐only LGE (n=28) and free wall–only LGE (n=32) had similar fibrosis burden, the septal‐only LGE group had more impaired LV ejection fraction and global circumferential, longitudinal, and radial strains (all P <0.05). Conclusions There is no association between LV mechanical deformation parameters and presence or extent of fibrosis in patients with nonischemic cardiomyopathy. Septal LGE was associated with poor global LV function, more impaired global circumferential and radial strains, and more impaired global strain rates.

scholarly journals Left Ventricular Deformation in Patients with Connective Tissue Disease: Evaluated by 3.0T Cardiac Magnetic Resonance Tissue Tracking

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Jin Wang ◽  
Ke Shi ◽  
Hua-yan Xu ◽  
Qin Zhao ◽  
Xi Liu ◽  
...  
Keyword(s):  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
Connective Tissue ◽  
Ejection Fraction ◽  
Connective Tissue Disease ◽  
Left Ventricular ◽  
Lv Function ◽  
Peak Strain ◽  
Apical Slice ◽  
Lv Ejection Fraction

AbstractThe aim of this study was to assess left ventricular (LV) myocardial strain in patients with connective tissue disease (CTD) and compare LV deformation between subgroups of idiopathic inflammatory myopathy (IIM) and non-IIM. Ninety-eight patients with CTD, comprising 56 with IIM and 42 with non-IIM, and 30 healthy subjects were enrolled and underwent 3.0T cardiac magnetic resonance imaging (MRI) scanning. The LV function and strain parameters were measured and assessed. Our result revealed that CTD patients had preserved LV ejection fraction (60.85%) and had significantly decreased global and regional peak strain (PS) in radial, circumferential, and longitudinal directions (all p < 0.05). IIM patients showed significantly reduced global longitudinal PS (GLPS) and longitudinal PS at apical slice, whereas all strain parameters decreased in non-IIM patients. Except GLPS and longitudinal PS at apical slice, all strain parameters in non-IIM patients were lower than those in IIM patients. By Pearson’s correlation analysis, the LV global radial and circumferential PS were correlated to N-terminal pro-brain natriuretic peptide level and LV ejection fraction in both IIM and non-IIM patients. This study indicated that CTD patients showed abnormal LV deformation despite with preserved LVEF. The impairment of LV deformation differed between IIM and non-IIM patients.

scholarly journals Does left ventricular function predict cardiac outcome in Anderson–Fabry disease?

2020 ◽  
Author(s):  
Letizia Spinelli ◽  
Giuseppe Giugliano ◽  
Antonio Pisani ◽  
Massimo Imbriaco ◽  
Eleonora Riccio ◽  
...  
Keyword(s):  
Adverse Events ◽  
Ejection Fraction ◽  
Fabry Disease ◽  
Adverse Outcome ◽  
Univariate Analysis ◽  
Left Ventricular ◽  
Lv Function ◽  
Lv Ejection Fraction ◽  
Cardiac Outcome

AbstractIn Anderson–Fabry disease (AFD) the impact of left ventricular (LV) function on cardiac outcome is unknown. Noninvasive LV pressure–strain loop analysis is a new echocardiographic method to estimate myocardial work (MW). We aimed to evaluate whether LV function was associated with outcome and whether MW had a prognostic value in AFD. Ninety-six AFD patients (41.8 ± 14.7 years, 43.7% males) with normal LV ejection fraction were retrospectively evaluated. Inclusion criteria were sinus rhythm and ≥ 2-year follow-up. Standard echocardiography measurements, myocardial mechano-energetic efficiency (MEE) index, global longitudinal strain (GLS) and MW were evaluated. Adverse cardiac events were defined as composite of cardiac death, malignant ventricular tachycardia, atrial fibrillation and severe heart failure development. During a median follow-up of 63 months (interquartile range 37–85), 14 events occurred. Patient age, cardiac biomarkers, LV mass index, left atrium volume, E/Ea ratio, LV ejection fraction, MEE index, GLS and all MW indices were significantly related to adverse outcome at univariate analysis. After adjustment for clinical and echocardiographic parameters, which were significant at univariate analysis, GLS and MW resulted independent predictors of adverse events (p < 0.01). By ROC curve analysis, constructive MW ≤ 1513 mmHg% showed the highest sensitivity and specificity in predicting adverse outcome (92.9% and 86.6%, respectively). MW did not improve the predictive value of a model including clinical data, LV diastolic function and GLS. LV function impairment (both systolic and diastolic) is associated with adverse events in AFD. MW does not provide additive information over clinical features and systolic and diastolic function.

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