scholarly journals Application and Validation of the Tricuspid Annular Plane Systolic Excursion/Systolic Pulmonary Artery Pressure Ratio in Patients with Ischemic and Non-Ischemic Cardiomyopathy

Diagnostics ◽  
2021 ◽  
Vol 11 (12) ◽  
pp. 2188
Author(s):  
Stanislav Keranov ◽  
Saskia Haen ◽  
Julia Vietheer ◽  
Wiebke Rutsatz ◽  
Jan-Sebastian Wolter ◽  
...  
Keyword(s):  
Ischemic Cardiomyopathy ◽  
Validation Cohort ◽  
Pressure Ratio ◽  
Global Longitudinal Strain ◽  
Interventricular Septum ◽  
Systolic Pulmonary Artery Pressure ◽  
Lv Remodeling ◽  
Prognostic Utility ◽  
Echocardiographic Parameters ◽  
Poor Outcomes

The main aim of this study was to assess the prognostic utility of TAPSE/PASP as an echocardiographic parameter of maladaptive RV remodeling in cardiomyopathy patients using cardiac magnetic resonance (CMR) imaging. Furthermore, we sought to compare TAPSE/PASP to TAPSE. The association of the echocardiographic parameters TAPSE/PASP and TAPSE with CMR parameters of RV and LV remodeling was evaluated in 111 patients with ischemic and non-ischemic cardiomyopathy and cut-off values for maladaptive RV remodeling were defined. In a second step, the prognostic value of TAPSE/PASP and its cut-off value were analyzed regarding mortality in a validation cohort consisting of 221 patients with ischemic and non-ischemic cardiomyopathy. A low TAPSE/PASP (<0.38 mm/mmHg) and TAPSE (<16 mm) were associated with a lower RVEF and a long-axis RV global longitudinal strain (GLS) as well as higher RVESVI, RVEDVI and NT-proBNP. A low TAPSE/PASP, but not TAPSE, was associated with a lower LVEF and long-axis LV GLS, and a higher LVESVI, LVEDVI and T1 relaxation time at the interventricular septum and the RV insertion points. Furthermore, in the validation cohort, low TAPSE/PASP was associated with a higher mortality and TAPSE/PASP was an independent predictor of mortality. TAPSE/PASP is a predictor of maladaptive RV and LV remodeling associated with poor outcomes in cardiomyopathy patients.

scholarly journals P747 Echocardiographic evaluation of haemoglobinopathies patients and their correlation with haematologic determinants

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
T Branco Mano ◽  
L Moura Branco ◽  
S Aguiar Rosa ◽  
A Agapito ◽  
A T Timoteo ◽  
...  
Keyword(s):  
Diastolic Dysfunction ◽  
Serum Ferritin ◽  
Transthoracic Echocardiography ◽  
Longitudinal Strain ◽  
Global Longitudinal Strain ◽  
Interventricular Septum ◽  
Left Ventricular ◽  
Cardiac Complications ◽  
Echocardiographic Parameters ◽  
The Mean

Abstract Background Although heart disease in haemoglobinopathy have dramatically reduced with modern therapy, cardiac complications are still a leading cause of morbimortality. It became essential to detect cardiac complications in early stages in order to provide specific therapy and to improve prognosis. Transthoracic echocardiography (TTE) has a paramount role in this field. Purpose To evaluate cardiac function in haemoglobinopathy patients and to correlate echocardiographic parameters with haematological determinants. Methods Retrospective analysis of haemoglobinopathy patients (pts) referred to a tertiary centre for cardiac evaluation and transthoracic echocardiography. Epidemiological, clinical, laboratory and echocardiographic data were analysed. Comparations between echocardiographic data and haemoglobin and serum ferritin levels were performed (independent T test). P value &lt;0.05 was considered statistically significant. Results 55 pts were included: 58% female, mean age 37.9 ± 10.9 years, 85% with sickle cell disease, 13% (N = 7) with previous thromboembolic event and 20% (N = 11) with documented hemosiderosis. 36% (N = 20) were symptomatic (9 pts with palpitations, 6 pts with thoracic pain and 5 pts with exertion dyspnea – New York Heart Association class II). The mean haemoglobin level was 8.96 ± 1.91 g/dL and serum ferritin 1335.5 ± 2452 ng/mL. All patients had preserved left and right ventricular systolic function (TAPSE 27.1 ± 4.9mm) The mean left ventricular (LV) end-diastolic diameter indexed to body surface area (female 32.2 ± 4.7mm/m2; male: 31.2 ± 4.0mm/m2) and LV mass index (female 105.6 ± 31.4g/m2; male: 134.7 ± 97.3g/m2) were increased in both genders, although interventricular septum thickness was in the superior normal range (mean 9.3 ± 1.6mm). Left atrium enlargement was also present (29.9 ± 8.4mm/m2). The mean global ratio between early mitral inflow velocity and mean (septal and lateral) mitral annular early diastolic velocity (E/e") was 7.5 ±2.3, and 12 pts (21.8%) had impairment of LV diastolic function. Global longitudinal strain (GLS) was assessed in 35 pts, with a mean value of 19.6 ± 2.9%. 40% (14 pts) had GLS &gt; -18%, being the septal wall the most frequently affected. Pulmonary hypertension was rare (3 pts), with mean arterial pulmonary pressure of 27.7 ± 7.0mmHg. An agreement was found between serum ferritin levels and GLS impairment defined as GLS &gt; -18% (2649ng/ml vs 549ng/ml, p = 0.04). Pts with diastolic dysfunction had a trend to higher serum ferritin levels (2753ng/ml vs 1001ng/ml, p = 0.06). The haemoglobin levels did not correlate with echocardiographic parameters. Conclusion In the study population of haemoglobinopathy pts, mainly constituted by cardiac asymptomatic individuals, LV diastolic dysfunction and LV global longitudinal strain were impaired in 22% and 40%, respectively. These echocardiographic parameters revealed to be related to serum ferritin levels.

scholarly journals Echocardiographic diagnosis of atrial cardiomyopathy allows outcome prediction following pulmonary vein isolation

2021 ◽  
Author(s):  
Martin Eichenlaub ◽  
Bjoern Mueller-Edenborn ◽  
Jan Minners ◽  
Martin Allgeier ◽  
Heiko Lehrmann ◽  
...  
Keyword(s):  
Sinus Rhythm ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Validation Cohort ◽  
Low Voltage ◽  
Predictive Values ◽  
Contact Mapping ◽  
Non Invasive ◽  
Increased Risk ◽  
Echocardiographic Parameters

Abstract Background Relevant atrial cardiomyopathy (ACM), defined as a left atrial (LA) low-voltage area ≥ 2 cm2 at 0.5 mV threshold on endocardial contact mapping, is associated with new-onset atrial fibrillation (AF), higher arrhythmia recurrence rates after pulmonary vein isolation (PVI), and an increased risk of stroke. The current study aimed to assess two non-invasive echocardiographic parameters, LA emptying fraction (EF) and LA longitudinal strain (LAS, during reservoir (LASr), conduit (LAScd) and contraction phase (LASct)) for the diagnosis of ACM and prediction of arrhythmia outcome after PVI. Methods We prospectively enrolled 60 consecutive, ablation-naive patients (age 66 ± 9 years, 80% males) with persistent AF. In 30 patients (derivation cohort), LA-EF and LAS cut-off values for the presence of relevant ACM (high-density endocardial contact mapping in sinus rhythm prior to PVI at 3000 ± 1249 sites) were established in sinus rhythm and tested in a validation cohort (n = 30). Arrhythmia recurrence within 12 months was documented using 72-h Holter electrocardiograms. Results An LA-EF of < 34% predicted ACM with an area under the curve (AUC) of 0.846 (sensitivity 69.2%, specificity 76.5%) similar to a LASr < 23.5% (AUC 0.878, sensitivity 92.3%, specificity 82.4%). In the validation cohort, these cut-offs established the correct diagnosis of ACM in 76% of patients (positive predictive values 87%/93% and negative predictive values 73%/75%, respectively). Arrhythmia recurrence in the entire cohort was significantly more frequent in patients with LA-EF < 34% and LASr < 23.5% (56% vs. 29% and 55% vs. 26%, both p < 0.05). Conclusion The echocardiographic parameters LA-EF and LAS allow accurate, non-invasive diagnosis of ACM and prediction of arrhythmia recurrence after PVI. Graphic abstract

Epicardial fat thickness in infants of diabetic mothers

2021 ◽  
pp. 1-6
Author(s):  
M.M. Vela-Huerta ◽  
N. Amador-Licona ◽  
R. Domínguez-Damiá ◽  
A. Heredia-Ruiz ◽  
H.V. Orozco-Villagomez ◽  
...  
Keyword(s):  
Interventricular Septum ◽  
Left Ventricular ◽  
Epicardial Fat ◽  
Left Ventricular Ejection ◽  
Epicardial Fat Thickness ◽  
Infants Of Diabetic Mothers ◽  
Significant Difference ◽  
Echocardiographic Parameters ◽  
Fat Thickness ◽  
Diabetic Mothers

BACKGROUND: Epicardial fat thickness (EFT) in adults and children has been related to the metabolic syndrome and other cardiovascular risk factors; however, scarce studies have evaluated it in infants of diabetic mothers (IDM) in whom, alterations in the thickness of the interventricular septum have been reported. This study compares the EFT in IDM versus infants of non-diabetic mothers (INDM) and its association with others echocardiographic parameters. METHODS: We performed a cross sectional study in 93 infants (64 IDM and 29 INDM). To evaluate EFT dimensions, an echocardiogram was performed within the first 24h of extrauterine life in both groups. In diabetic mothers, HbA1c was also determined. RESULTS: There was no significant difference in birth weight between the groups although gestational age was lower in IDM. The EFT (3.6 vs. 2.5 mm, p <  0.0001), the interventricular septum thickness (IVST) (6.2 vs. 5.2 mm, p <  0.0001) and the IVST / left ventricle posterior wall (1.3 vs. 1.1, p = 0.001) were higher in the IDM; while the left ventricular expulsion fraction [LVFE] (71.1 vs. 77.8; p <  0.0001) was lower than in the INDM, respectively. We found a positive correlation between EFT with IVST (r = 0.577; p = 0.0001), LVPW (r = 0.262; p = 0.011), IVST/LVPW index (r = 0.353; p = 0.001), and mitral integral early velocity (r = 0.313; p = 0.002), while a negative correlation with LVFE was observed (r = –0.376; p = 0.0001). CONCLUSIONS: The EFT is higher in IDM than in INDM. It was positively related with echocardiographic parameters of left ventricular thickness and negatively with left ventricular ejection function.

scholarly journals Heart in Acromegaly: The Echocardiographic Characteristics of Patients Diagnosed with Acromegaly in Various Stages of the Disease

2018 ◽  
Vol 2018 ◽  
pp. 1-7 ◽  
Author(s):  
Agata Popielarz-Grygalewicz ◽  
Jakub S. Gąsior ◽  
Aleksandra Konwicka ◽  
Paweł Grygalewicz ◽  
Maria Stelmachowska-Banaś ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Healthy Volunteers ◽  
Global Longitudinal Strain ◽  
Interventricular Septum ◽  
Left Ventricular ◽  
Volume Index ◽  
Control Group ◽  
Glucose Metabolism Disorders ◽  
Acromegalic Cardiomyopathy ◽  
The Right

To determine whether the echocardiographic presentation allows for diagnosis of acromegalic cardiomyopathy. 140 patients with acromegaly underwent echocardiography as part of routine diagnostics. The results were compared with the control group comprising of 52 age- and sex-matched healthy volunteers. Patients with acromegaly presented with higher BMI, prevalence of arterial hypertension, and glucose metabolism disorders (i.e., diabetes and/or prediabetes). In patients with acromegaly, the following findings were detected: increased left atrial volume index, increased interventricular septum thickness, increased posterior wall thickness, and increased left ventricular mass index, accompanied by reduced diastolic function measured by the following parameters: E’med., E/E’, and E/A. Additionally, they presented with abnormal right ventricular systolic pressure. All patients had normal systolic function measured by ejection fraction. However, the values of global longitudinal strain were slightly lower in patients than in the control group; the difference was statistically significant. There were no statistically significant differences in the size of the right and left ventricle, thickness of the right ventricular free wall, and indexed diameter of the ascending aorta between patients with acromegaly and healthy volunteers. None of 140 patients presented systolic dysfunction, which is the last phase of the so-called acromegalic cardiomyopathy. Some abnormal echocardiographic parameters found in acromegalic patients may be caused by concomitant diseases and not elevated levels of GH or IGF-1 alone. The potential role of demographic parameters like age, sex, and/or BMI requires further research.

Abstract 12952: Global Longitudinal Strain is Simple, Effective & Sensitive Assessment of Cardiac Chamber Function in Patients With Acute-phase Myocarditis

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Shaun Khanna ◽  
Aditya Bhat ◽  
Henry H Chen ◽  
Kennith Gu ◽  
Gary Gan ◽  
...  
Keyword(s):  
Acute Phase ◽  
Longitudinal Strain ◽  
Myocardial Dysfunction ◽  
Global Longitudinal Strain ◽  
Disease Process ◽  
Left Ventricular ◽  
Lv Function ◽  
Lv Mass ◽  
Echocardiographic Parameters ◽  
Cardiac Therapy

Introduction: Myocarditis is an inflammatory disease process with growing clinical relevance in the current COVID-19 pandemic. Acute-phase myocarditis is known to result in subclinical changes in left ventricular (LV) function despite normal LV ejection fraction (LVEF), as assessed by myocardial deformation indices. The presence of right ventricular (RV) and left atrial (LA) subclinical dysfunction however has not been well described in current literature. Hypothesis: Myocarditis patients have subclinical impairment of LV, RV and LA function as assessed by global longitudinal strain (GLS) on speckle tracking echocardiography. Methods: Consecutive patients with clinical diagnosis of myocarditis admitted to our institution during 2013-2018 were assessed (n=76). Patients who did not meet appropriate diagnostic criteria (n=14), had impaired LVEF or prior cardiac disease (n=8) or poor transthoracic echocardiogram images (n=14) were excluded from analysis. Clinical and echocardiographic parameters were compared to age- , gender- and risk factor- matched controls. GLS was performed by two independent observers using vendor independent software (TomTec Arena, Germany v4.6). Results: The final cohort consisted 40 patients with myocarditis (age 44.3±16.7, 60% male) and 40 matched controls (44.5±16.6, 60% male). No significant differences in baseline clinical characteristics were observed between groups. No differences in LVEF, indexed LV mass, RV fractional area change, indexed LA volume or TR pressure gradient (p>0.05 for all) were demonstrated between the two groups. Patients with myocarditis had a lower mean LV strain (GLS%: -16.4±2.9 vs -19.7±2.7, p=0.0001), a lower mean RV Free Wall Strain (FWS) (GLS%: -22.1±4.1 vs -26.2±6.9, p=0.03) and a lower mean LA reservoir strain (GLS%: 27.5±4.6 vs. 33.7±6.3, p<0.0001) when compared to controls. Conclusions: Our results demonstrate the presence of significant subclinical global myocardial dysfunction despite normal traditional echocardiographic indices, in patients with acute-phase myocarditis. Routine assessment of GLS may identify such patients for early targeted cardiac therapy.

scholarly journals Can myocardial work indices contribute to the exploration of patients with cardiac amyloidosis?

Open Heart ◽  
2020 ◽  
Vol 7 (2) ◽  
pp. e001346
Author(s):  
Aénora Roger-Rollé ◽  
Eve Cariou ◽  
Khailène Rguez ◽  
Pauline Fournier ◽  
Yoan Lavie-Badie ◽  
...  
Keyword(s):  
Cardiac Amyloidosis ◽  
Characteristic Curve ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Peak Oxygen Consumption ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Echocardiographic Parameters ◽  
Global Work ◽  
Better Than

BackgroundCardiac amyloidosis (CA) is a life-threatening restrictive cardiomyopathy. Identifying patients with a poor prognosis is essential to ensure appropriate care. The aim of this study was to compare myocardial work (MW) indices with standard echocardiographic parameters in predicting mortality among patients with CA.MethodsClinical, biological and transthoracic echocardiographic parameters were retrospectively compared among 118 patients with CA. Global work index (GWI) was calculated as the area of left ventricular pressure–strain loop. Global work efficiency (GWE) was defined as percentage ratio of constructive work to sum of constructive and wasted works. Sixty-one (52%) patients performed a cardiopulmonary exercise.ResultsGWI, GWE, global longitudinal strain (GLS), left ventricular ejection fraction (LVEF) and myocardial contraction fraction (MCF) were correlated with N-terminal prohormone brain natriuretic peptide (R=−0.518, R=−0.383, R=−0.553, R=−0.382 and R=−0.336, respectively; p<0.001). GWI and GLS were correlated with peak oxygen consumption (R=0.359 and R=0.313, respectively; p<0.05). Twenty-eight (24%) patients died during a median follow-up of 11 (4–19) months. The best cut-off values to predict all-cause mortality for GWI, GWE, GLS, LVEF and MCF were 937 mm Hg/%, 89%, 10%, 52% and 15%, respectively. The area under the receiver operator characteristic curve of GWE, GLS, GWI, LVEF and MCF were 0.689, 0.631, 0.626, 0.511 and 0.504, respectively.ConclusionIn CA population, MW indices are well correlated with known prognosis markers and are better than LVEF and MCF in predicting mortality. However, MW does not perform better than GLS.

scholarly journals Cardiac mechanics as predictors of left ventricular reverse remodelling in patients with dilated non-ischemic cardiomyopathy

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M Ferrandez ◽  
F Islas ◽  
A Travieso ◽  
J Diz-Diaz ◽  
A Restrepo ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ischemic Cardiomyopathy ◽  
Multimodality Imaging ◽  
Global Longitudinal Strain ◽  
Cardiac Mechanics ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Imaging Parameters ◽  
Reverse Remodelling

Abstract Background and purpose The appearance of left ventricular reverse remodelling (LVRR) is associated with a better prognosis in patients with dilated non-ischemic cardiomyopathy (DCM). Our aim was to identify cardiac imaging parameters, including speckle tracking by transthoracic echocardiography (TTE) and feature tracking by CMR, associated with LVRR in a prospective cohort of patients with DCM. Methods From 2014 to 2021, 182 patients with DCM and left ventricle ejection fraction (LVEF) &lt;40% were prospectively evaluated in our hospital. LVRR was defined as an increase in LVEF ≥10 points or absolute LVEF ≥50%, associated with a reduction in left ventricular end- diastolic diameter ≥10%. Patients underwent multimodality imaging evaluation including CMR with a 1.5 Tesla scanner, and TTE. Cardiac mechanics, including global longitudinal strain (GLS), strain rate (SR) and mechanical dispersion (MD) were measured. Results Median age of our cohort was 62.3 (14.4) years, and 67.7% were male. Most patients (&gt;90%) were treated with beta-blockers or RASS blockers, and 67% with mineralocorticoid receptor antagonists. 30% had cardiac resynchronization therapy (CRT) and 37% had ICD as primary prevention. Mean LVEF was 31.3%. During a mean follow-up period of 35.9 (35.4) months, 38.3% of patients had LVRR. Age and gender distribution were similar in both groups. Regarding cardiovascular risk factors and pharmacological treatment, no differences were found between patients with and without LVRR. Baseline CRT therapy was not associated with LVRR (22.6% vs 34.7%; p=0.249). However, there was a trend towards higher LVRR in those who received CRT during follow-up 18.8% vs 0%; p=0.069). Patients who experienced LVRR had lower basal LVEF (23.4% vs 29%; p&lt;0.008), as well as poorer RV function, including lower RVEF (40.5% vs 51%; p=0.006) and lower TAPSE (16 mm vs 19 mm; p=0.021). Regarding cardiac mechanics, those patients with lower GLS (−9% vs −12%; p=0.001), and higher MD (73 mm vs 55 mm; p=0,050) had LVRR more frequently during follow-up. The presence of a left bundle branch block (LBBB) contraction pattern by strain was associated with higher rate of LVRR (83.3% vs 30.4%; p=0.011). The burden of fibrosis measured by LGE with CMR was not associated with LVRR (14% vs 12%; p=NS). Patients with LVRR had a lower cardiovascular mortality (3.3 vs 14.3%; p=0.117), lower mortality due to heart failure (0% vs 12.2%; p=0.046), less heart failure hospitalizations (20% vs 46.9%; p=0.016), and a lower incidence of ventricular tachyarrhythmias (3.3% vs 18.4%; p=0.051). Conclusions LVRR in patients with DCM receiving optimized medical therapy is associated with a better prognosis. Imaging parameters, including a lower basal LVEF, RVEF, GLS and higher MD, as well as LBBB echo pattern, were associated with a higher frequency of LVRR, and might help to identify patients who could benefit from CRT/and may be helpful to stratify patients's risk. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals Interventricular septal curvature as an additional echocardiographic parameter for evaluating chronic thromboembolic pulmonary hypertension: A single-center retrospective study

2021 ◽  
Author(s):  
Akane Matsumura ◽  
Ayako Shigeta ◽  
Hajime Kasai ◽  
Hajime Yokota ◽  
Jiro Terada ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Pressure Gradient ◽  
Interventricular Septum ◽  
Chronic Thromboembolic Pulmonary Hypertension ◽  
Left Ventricular ◽  
Accurate Estimation ◽  
Heart Catheterization ◽  
Systolic Pulmonary Artery Pressure ◽  
Additional Tool ◽  
Thromboembolic Pulmonary Hypertension

Abstract Background: Noninvasive estimation of the actual systolic pulmonary artery pressure measured via right-sided heart catheterization (sPAPRHC) is important for the management of pulmonary hypertension, including chronic thromboembolic pulmonary hypertension (CTEPH). Evaluation related to the interventricular septum (IVS) is generally performed with only visual assessment and has been rarely assessed quantitatively in the field of echocardiography. Thus, this study aimed to investigate the utility of echocardiographic IVS curvature to estimate sPAPRHC in patients with CTEPH. Methods: Data of 72 patients with CTEPH were studied retrospectively. We estimated sPAPRHC using echocardiographic IVS curvature (esPAPcurv) and left ventricular eccentricity index (esPAPLVEI), and compared their ability to predict sPAPRHC with estimated sPAPRHC using tricuspid regurgitant pressure gradient (esPAPTRPG). Results: IVS curvature and LVEI were significantly correlated with sPAPRHC (r = - 0.52 and r = 0.49, respectively). Moreover, the IVS curvature was effective in estimating the sPAPRHC of patients with trivial tricuspid regurgitation (r = - 0.56) and in determining patients with sPAPRHC ≥70 mmHg with higher sensitivity (77.0%) compared to those with esPAPTRPG and esPAPLVEI. Conclusion: Our results indicate that the echocardiographic IVS curvature could be a useful additional tool for estimating sPAPRHC in CTEPH patients in whom accurate estimation of sPAPRHC using tricuspid regurgitant pressure gradient is difficult.

Signal transduction pathways initiated by catecholamines in takotsubo syndrome: focus on nitrosative stress and energetic impairment

ESC CardioMed ◽  
2018 ◽  
pp. 1283-1286
Author(s):  
John D. Horowitz ◽  
Thanh Ha Nguyen ◽  
Sven Y. Surikow ◽  
Gao Jing Ong ◽  
Cher-Rin Chong ◽  
...  
Keyword(s):  
Signal Transduction ◽  
Longitudinal Strain ◽  
Nitrosative Stress ◽  
Global Longitudinal Strain ◽  
Myocardial Inflammation ◽  
Resonance Spectroscopy ◽  
Takotsubo Syndrome ◽  
Echocardiographic Parameters ◽  
Increased Sensitivity

Takotsubo syndrome reflects an ‘aberrant’ response to acute catecholamine stimulation, largely but not entirely as a manifestation of increased sensitivity to β‎2-adrenoceptor stimulation and signal transduction via Gi proteins, especially in ageing female hearts. It is now apparent that prolonged impairment of quality of life and slow recovery of echocardiographic parameters such as global longitudinal strain after episodes of takotsubo syndrome reflect ongoing myocardial inflammation and associated oedema, together with impairment of cardiac energetics on phosphorus magnetic resonance spectroscopy.

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