Evaluation of handgrip strength in children with pulmonary hypertension.

BACKGROUND: Handgrip strength is a crucial indicator of upper extremity muscular strength and is vital for monitoring disorders like cardiac diseases that restrict a patient's physical activity and result in muscle atrophy. The aim of our study was to evaluate whether muscle strength loss is present in patients with pulmonary hypertension and whether this test can be an alternative to 6-minute walk test. MATERIALS AND METHODS: The study included 39 healthy children who were admitted to the outpatient clinic and 16 children with a diagnosis of pulmonary hypertension who were being followed in our centre. We assessed the differences in upper extremity handgrip strength using the Jamar Hydraulic Hand Dynamometer device among both healthy children and those diagnosed with pulmonary hypertension. Moreover, we compared the handgrip strength of pulmonary hypertension patients with significant prognostic indicators such as NYHA class, 6-minute walk test, and pro-brain natriuretic peptide. RESULTS: The mean dominant handgrip strength was 20.8 ± 12 kg in the patient group and 21.6 ± 12.4 kg in the control group (p = 0.970). Handgrip strength was shown to be negatively connected with pro-brain natriuretic peptide (r = -0.565, p = 0.023) and positively correlated with 6-minute walk test (r = 0.586, p = 0.022) during the patient group evaluation. CONCLUSION: Six-minute walk test needs a customised physical area (30 m of a straight hallway) and trained personnel for applying the test. The handgrip strength test, a different muscle strength indicator, can be used to more clearly and simply indicate the decline in patients' ability for effort. Additionally, it was found in our study that handgrip strength decreased as pro-brain natriuretic peptide levels rose, a crucial measure in the monitoring of pulmonary hypertension.

Comparison of echocardiographic aortic stiffness index measurements and pulse wave velocity measurements in obese and overweight children.

BACKGROUND: Aortic/arterial stiffness is a reliable, independent predictor and a risk factor for cardiovascular mortality. Arterial stiffness is assessed by pulse wave velocity and echocardiography. The purpose of this study is to analyse aortic/arterial stiffness in patients using echocardiographic and pulse wave velocity techniques. MATERIALS AND METHODS: The participants of this study consisted of 62 patients who presented to the Gazi University Pediatric Endocrinology and Pediatric Cardiology outpatient clinics, including 21 obese, 20 overweight, and 21 normal-weight patients. Echocardiography was performed on all patients, and echocardiographic measurements were compared to pulse wave velocity measurements. RESULTS: The mean (min-max) arterial strain measurements were 0.146 ± 0.0 (0.06-0.3) in the obese group and 0.106 ± 0.0 (0.05-0.18) in the overweight group. In comparison to the overweight group, the obese group had greater arterial strain measurements. The pulse wave velocity measurements in the obese and overweight groups were greater than those in the normal weight group (p > 0.05). Elastic modulus and aortic stiffness ß index values were shown to be positively correlated with pulse wave velocity measurements in the obese group (r = 0.56, r = 0.53, respectively; p = 0.008, p = 0.01, respectively). Systolic and diastolic blood pressure measurements were correlated with pulse wave velocity measurements in the obese group (r = 0.98, p = 0.0001, respectively). CONCLUSION: In our study, echocardiographic aortic measurements showing the vessel wall were correlated with pulse wave velocity measurements. Echocardiographic evaluation should be included in the routine follow-up of patients because pulse wave velocity measurement devices are not available in all centres, echocardiography is available in many centres, it is easily applicable, and it facilitates the follow-up of patients.

Evaluation of quality of life and parental attitudes in patients who underwent atrial septal defect closure in childhood.

OBJECTIVE: In this study, we aimed to evaluate quality of life and parental attitudes in children who underwent an atrial septal defect closure procedure with a transcatheter or surgical method in childhood and whether they continued their lives with similar activities to their healthy peers by comparing the two groups. METHODS: Patient forms to define sociodemographic and clinical features, the Questionnaire for Measuring Health-Related Quality of Life in Children and Adolescents (KINDL) to measure the quality of life of children, and the Parent-Child Relationship Test (Parental Attitude Research Instrument) to measure parental attitudes were used. RESULTS: The groups were similar in terms of age and sex. The mean quality of life scale scores were high in all groups, and there was no statistically significant difference between the scores. Parents of the patients who underwent closure received higher scores from the demographic attitudes and recognition of quality subdimension compared to the parents of the healthy group. CONCLUSIONS: The quality of life of children with atrial septal defect closure was found to be similar to their healthy peers. Additionally, the effects of surgical or percutaneous closure of atrial septal defect on quality of life are similar. Children with atrial septal defect closure perceive their health status as well as their healthy peers, and this perception does not cause any difference in the attitudes and behaviours of families.

Early Echocardiographic Findings of Pulmonary Hypertension-specific Therapy in Children.

Objective: Echocardiography is a very useful tool for the diagnosis and evaluation of pulmonary hypertension (PH). This study was planned to investigate whether echocardiographic (ECHO) data of patients with PH are effective in the follow-up and course of treatment. Methods: A retrospective analysis of the data from 26 PH patients was performed. Analyses were performed on the data of the patients, including their demographics and ECHO findings. The ECHO measurements of the patients were labeled as 0 (beginning of the PH specific therapy), 1 (on the 15th day of the therapy), 2 (one month after the previous echocardiogram). Results: The left ventricle ejection fraction (EF) (p=0.05) and fractional shortening (FS) (p=0.038) values in ECHO2 were significantly higher than those in ECHO1. Aortic velocity-time integral1 (VTI1) was significantly higher than aortic VTI0 (p=0.001; p<0.01), and tricuspid annular plane systolic excursion2 (TAPSE2) was significantly higher than TAPSE0 (p=0.046). Moreover, right ventricular ejection time1 (RVET1) was significantly higher than RVET0 (p=0.034), and left ventricular ejection time1 (LVET1) was significantly higher than LVET0 (p=0.003). Conclusions: This study provides information on ECHO parameters that improve during the initial stages of therapy. Based on the results of our study, even at the beginning of treatment, there were increases in right and left ventricular filling, EF, and FS. Clinical deterioration of PH can be detected early/before the clinical status of the patient worsens with detailed examinations using echocardiography.

Successful treatment of two cases of acute myocarditis with colchicine.

Colchicine is an FDA-approved medicine that has been used for many years to prevent and treat gout flares as well as familial mediterranean fever. It is also used off-label to treat pericarditis, calcium pyrophosphate illness, and Behçet's syndrome. There are additional studies on the use of colchicine, which is accepted as the standard treatment for pericarditis in adults, post-pericardiotomy syndrome, post-operative and post-ablation atrial fibrillation, coronary artery disorders, prior to percutaneous coronary procedures, and myocarditis. Colchicine appears to be a promising oral cardiovascular treatment targeting the inflammatory axis, owing to its low cost and moderate side-effect profile. Our aim is to emphasise that colchicine treatment, which has a strong and effective anti-inflammatory effect profile, should be kept in mind in addition to conventional treatment in childhood myocarditis.

Subcutaneous use of treprostinil in pediatric pulmonary hypertension patients: A report of three cases.

Treprostinil was approved by the United States Food and Drug Administration for use in the treatment of pulmonary arterial hypertension in 2002. Intravenous or subcutaneous treprostinil is used in pulmonary arterial hypertension patients in the functional classes of II-IV to alleviate exercise-related symptoms, or in cases where epoprostenol treatment should be reduced due to side effects. In this article, we describe three pediatric cases of pulmonary arterial hypertension in whom subcutaneous treprostinil was used.

Coexistence of transposition of the great arteries, coarctation of the aorta, and bilateral pulmonary artery hypoplasia.

Transposition of the great arteries is the most common cyanotic CHD in newborns. This CHD, in which the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, is often accompanied by one or several defects such as atrial septal defect or patent foramen ovale, ventricular septal defect and patent ductus arteriosus, which allow the transition between both parallel circulations. Rarely, the disease may be accompanied by left ventricular outflow tract obstruction (subpulmonary obstruction) and coarctation of the aorta.We present a highly complicated and unusual transposition of the great arteries patient with critical aortic coarctation and hypoplastic pulmonary arteries with abnormal outflow and course.

Effect of vitamin D on myocardial remodeling and inflammatory status in children with congenital heart disease.

BACKGROUND: Vitamin D insufficiency is a common public health problem that is often unrecognized in children with congenital heart disease, and is not generally evaluated at congenital heart disease (CHD) follow-up. Recent studies have suggested that inadequate vitamin D status may have an adverse effect on cardiovascular health. This study investigates the relationship between vitamin D levels and hemodynamic parameters in children with CHD. METHODS: Included in the study 40 patients (25 females, 15 males) with CHD, who were evaluated for Ross heart failure score, vitamin D, parathyroid hormone (PTH), calcium, phosphorus, alkaline phosphatase (ALP), whole blood count (WBC) and echocardiographic measurements, and all measurements were repeated in the third month of the therapy. RESULTS: The mean vitamin D level was 16.4 ± 6.6 ug/L before and 27.5 ± 9.9 µg/L in the third month of therapy, while the mean PTH level was 53.3 ± 34.9 pg/mL before and 43.8 ± 21.4 pg/mL in the third month of therapy. The mean WBC was 8084 ± 2324/µL before and 7378±1893/µL in the third month of the therapy, and the mean platelet (PLT) count was 280,897 ± 80,119/µL before and 307,179 ± 60,202/µL in the third month of the therapy. The mean ejection fraction (EF) was 64% ± 7.2% before and 66.7% ± 6.2% in the third month of therapy, while the right ventricle (RV) myocardial performance index (MPI) was 32.1% ± 6.7% before and 28.9% ± 6.5% in the third month of the therapy. IL10 level was increased in four patients in the third month of therapy. A statistically significant decrease in PTH level and WBC, and an increase in PLT number and IL-10 level were detected by the therapy. Furthermore, echocardiographic findings revealed a statistically significant increase in EF and a decrease in RVMPI attributable to the therapy. DISCUSSION: The decreased levels of PTH, which is a proinflammatory marker, the increases in IL-10, which is an antiinflammatory cytokine, and the decreases in the number of WBC resulting from vitamin D treatment demonstrate the antiinflammatory effects of vitamin D. An improvement in EF means improvement in left ventricular contractility, while a decrease in RV MPI has been shown to improve the systolic and diastolic function of the right ventricle. These results suggest that vitamin D therapy has a positive effect on the heart, and so vitamin D levels should be evaluated during the routine follow-up of congenital heart disease.

High take-off right coronary artery in a patient with tetralogy of Fallot.

High take-off coronary artery anomaly is a quite rare anomaly which is usually seen in isolated form and diagnosed incidentally. Association with tetralogy of Fallot is also rare and it is not one of the well-known coronary anomalies seen in this disease. Here, we describe high take-off right coronary artery in a 10-month-old female patient with tetralogy of Fallot which was diagnosed during catheter angiography. It is very important to show this anomaly sometimes with additional imaging techniques as it alters all the surgical approach including aortic cannulation.

Insulin resistance in children with familial hyperlipidemia.

Background The aim of the study was to investigate whether there is insulin resistance in children with familial hyperlipidemia (FHL) and to determine the factors affecting insulin resistance. Methods Hyperlipidemic children aged between 4 and 18 years and followed up with an FHL diagnosis were included in the study. The children of adults followed up with an FHL diagnosis were also recruited after the screening period. The scanned children were divided into two groups as hyperlipidemic and normolipidemic. A total of 77 patients of whom 52 were hyperlipidemic and 25 were normolipidemic were assessed in the study. Insulin resistance was evaluated (homeostatic model assessment of insulin resistance [HOMA-IR]) by performing the oral glucose tolerance test (OGTT). Results Of the patients, 36 were male and 41 were female; the average age was 11.6±3.9 years, and the body mass index (BMI) was established to be 20.3±4.4. In hyperlipidemic and normolipidemic patients, the following were determined: fasting insulin: 10.6 (±0.89) µU/mL, 4.9 (±0.45) µU/mL (p=0.000); 2-h insulin: 28.7 (±12.7) µU/mL, 18.9 (±10.5) µU/mL (p=0.000); and HOMA-IR: 1.9 (±0.17), 0.86 (±0.7) (p=0.000). No relationship was identified between lipid profiles and insulin resistance. Nevertheless, there was a positive correlation between insulin resistance and apolipoprotein B (Apo B) levels (0.52), and a negative correlation was determined in carnitine levels (-0.64). Conclusions Insulin resistance was established to be higher in children with FHL compared to normolipidemic children. Insulin resistance was not related to lipid phenotypes, but to Apo B levels and carnitine levels. Insulin resistance should be a routine method of evaluation in the follow-up of children with FHL.

A rare reason in a child with feeding intolerance: Intravaginal struvite stone.

Tokgöz Y, Erdem AO, Özbey BC, Terlemez S. A rare reason in a child with feeding intolerance: Intravaginal struvite stone. Turk J Pediatr 2018; 60: 86-88. Vaginal stones are rarely seen in childhood; they are categorized as primary and secondary whether they are a foreign object focus (nidus) or not. Urethrovaginal fistula is the most common etiological cause; other etiologies are considerably rarely reported. Primary vaginal stones are formed as a result of urinary salt accumulate. A 14-year-old girl, suffering from an unidentified neurodegenerative disease, was admitted with complaints of cough, poor feeding and vomiting. Abdominal X-ray showed a large calcific mass; further evaluation revealed a vaginal struvite stone, and it was removed surgically. No anatomical reason was determined for the formation of stone and it was accepted as primary vaginal stone.

Fat soluble vitamin levels in children with newly diagnosed celiac disease, a case control study.

BACKGROUND: In children diagnosed with celiac disease, fat soluble vitamin levels were aimed to be evaluated and it was intended to determine whether fat soluble vitamin levels were needed to be assessed routinely in these patients during diagnosis. METHODS: Between May 2015-May 2016, diagnosis symptoms of celiac patients (CD) in newly diagnosed pediatric group were questioned, fat soluble vitamin levels simultaneous with intestinal biopsies were evaluated. Vitamin levels were compared with those of healthy control group. RESULTS: A total of 52 patients involving 27 female (51.9%), 25 male (48.1%); and a total of 50 healthy control group including 25 female (50%), 25 male (50%) were evaluated. The average age of patients was 9 ± 4.3 years, and their average weight was determined as 16.2 ± 6.3 kg. Growth retardation was the most frequent symptom in our patients (61.5%). Abdominal pain (51.9%) and diarrhea (11.5%) are among the other most commonly seen symptoms. In the histological examination of patients, Marsh 3B n = 23 (45.1%) was mostly established. Vitamin A and vitamin D levels of patients were determined significantly lower compared to those of control group. Vitamin A and vitamin D deficiencies were identified significantly higher compared to those of healthy control group. Vitamin D insufficiency was observed in 48 patients (92.3%) and vitamin D deficiency was determined in 32 (61.5%) out of 48. Vitamin A deficiency was established in 17 (32.7%) patients. Vitamin E and vitamin K1 deficiency were determined in no patients. In the healthy control group, vitamin D deficiency was seen in 2 (4%) patients, vitamin D insufficiency was determined in 9 (18%) patients. Other vitamin levels were identified at normal levels in the healthy group. CONCLUSIONS: In newly diagnosed children with CD, a significant lowness was established in vitamin D and A. The evaluation of vitamin A and D levels will be helpful in the course of diagnosis in these patients.

Investigation of antiviral resistance and escape mutations in children with naive chronic hepatitis B patients and their parents.

Tokgöz Y, Terlemez S, Sayan M, Kirdar S. Investigation of antiviral resistance and escape mutations in children with naive chronic hepatitis B patients and their parents. Turk J Pediatr 2018; 60: 514-519. In this study, it was aimed to scan the resistance to nucleoside analogs in naive pediatric patients with chronic hepatitis B treatment and their parents and the rate of accompanying possible escape mutations. A total of 34 children who did not receive any treatment regarding chronic hepatitis B and 19 parents who caused vertical transmission or acquired transmission from father were involved in the study. Serological tests concerning hepatitis B virus and transaminases in conjunction with viral load were studied. HBV genotypes, subgenotypes were determined by surface gene sequencings. The gene mutations coding polymerase (pol) for resistance against nucleoside analogs and escape mutations in the genes coding surface (S) proteins were analyzed with PCR method. All cases were genotype D. Only one pediatric patient was D2; the rest of all pediatric patients and their parents were genotype D1. Resistance was not identified against nucleoside analogs in any children or their parents. HBsAg escape mutations determined in the chronic hepatitis B patients were 18.8% (10 case). It can be speculated with this results that the resistance may not be considered as a problem in the preference of nucleoside analogs in treatment of naive children. Nevertheless, escape mutations were seen as high in both children and parents as well. Since it interests public health on a large scale, advanced studies and evaluation of vaccination escape mutations` rate in broad case series and their follow up are of great importance in the determination of health policies with regard to hepatitis B infection control.

A Rare Complication of Patent Ductus Arteriosus Ligation: Inadvertent Ligation of the Left Pulmonary Artery.

BACKGROUND: The inadvertent ligation of the left pulmonary artery (LPA) is a rarely seen surgical complication that has been presented in the literature in a limited number of cases after patent ductus arteriosus (PDA) ligation surgery. Case Report: A PDA closure operation was performed on our patient, a 28-week-old preterm. In the postoperative follow-up, we identified on echocardiography taken on the same postoperative day that the ductus space was still present. On CT angiography, we determined that not only was the ductus space still continuing, but, in addition, ligation of the LPA had been performed inadvertently. An LPA reconstruction operation was performed on the patient 46 days after the first operation. However, owing to severe tissue damage in LPA, LPA reperfusion did not occur in the postoperative period. Conclusion: Although inadvertent ligation of the left pulmonary artery during PDA ligation surgery is rarely seen in patients who have undergone closure surgery, this complication should be kept in mind in the postoperative follow-up period. Patient findings such as physical examination, lung angiography and postoperative echocardiography should be assessed with this in mind.

A Systemic-Onset Juvenile Idiopathic Arthritis Patient with Reduced Anakinra Treatment Admitted with an Attack.

Interleukin-1 plays an important role in the pathogenesis of systemic-onset juvenile idiopathic arthritis (SoJIA), and the use of anti-interleukin-1 therapy has been increasing. We report a case of a 14-year-old male patient with SoJIA. He was in remission with anakinra treatment for almost 2 years. When we extended the therapeutic range and decreased the dose (1 mg/kg twice a week), he developed symptoms mimicking pulmonary embolism and cardiac ischemia. Increased cardiac enzyme levels and echocardiographic findings were interpreted as myopericarditis. Pulmonary computed tomography angiography revealed no thrombus. An SoJIA attack was considered because of high level of acute-phase reactants and clinical findings. Intensive immunosuppressive therapy with 2 mg/kg/day anakinra was reinitiated. Clinical and laboratory parameters began to improve on the fifth day of treatment. Thus, anti-interleukin-1 therapy is very important in patients with SoJIA. Although the treatment dose was gradually reduced and the therapeutic range was extended, it is noteworthy that the case progressed to a severe clinical condition. Broad prospective studies regarding whether, how long, and for what reasons the dosages of these drugs should be reduced in patients with SoJIA with no genetic disorders are required.

The effects of iron treatment on viscosity in children with cyanotic congenital heart disease.

OBJECTIVE: This study was planned to determine the effects of iron treatment in children with cyanotic congenital heart disease. METHOD AND MATERIALS: A total of 39 patients with cyanotic congenital heart disease including 20 (51%) females, 19 (49%) males and whose mean age was 9.9 ± 6.2 years, average weight was 33 ± 18.4 kg were evaluated. Patients were categorized into two groups as having iron deficiency and no iron deficiency with respect to their ferritin levels. 4 mg/kg/day iron treatment with two valences was applied to the groups with iron deficiency for 3 months. Clinical and laboratory findings of both groups were assessed at the outset and 3 months later and viscosity measurements were carried out. RESULTS: Iron deficiency was identified in 21 (53.8%) out of 39 patients. Average Hb and Hct values following 3-month iron treatment increased from 14.8 ± 2.4 g/dl to 16.0 ± 2.0 (P = 0.003) and from %45.8 ± 7.5 to %47.6 ± 7.2 (P = 0.052), respectively. Average viscosity value, however, was 5.6 ± 1.0 cP, it reduced to 5.5 ± 1.0 cP value by demonstrating very little reduction (P = 0.741). Nevertheless, O2 sat value increased from 71.7 to 75% and complaints such as headache, visual blurriness, having frequent sinusitis decreased. CONCLUSIONS: It was observed that iron treatment increased Hb and Hct levels in patients with cyanotic congenital heart disease without raising viscosity and it ensured improvement in clinical symptoms.

Evaluation of arterial stiffness in children with type 1 diabetes using the oscillometric method.

AIMS: Pulse wave velocity (PWV) is an accepted evaluation method to assess vascular changes and determine cardiovascular disease risk in type 1 diabetes (T1D) patients. The aim of this study was to identify atherosclerosis risk by using oscillometric device in pediatric patients who had T1D but no end organ impairment and no cardiovascular disease findings. MATERIALS AND METHODS: Pediatric patients with T1D and no determined end organ impairment and cardiovascular disease were involved in the study. RESULTS: A total of 72 patients with T1D containing 32 males and 40 females were included in the study. A total of 77 patients including 39 males and 38 females were evaluated as healthy control group. The average age of patients with T1D was 12.8±3.7years, their average weight was established as 43.8±16.7kg. The average age of control group was 12.3±1.6years and average weight was determined as 46.8±12.8kg. When the results obtained by pulse wave method were compared; PWV and Alx_75 values in T1D patients (respectively, 4.63±0.40 and 22.9±6.7) were determined significantly higher than those of control group (respectively, 4.42±0.34 and 16.6±6.6). A positive correlation was identified between diabetes duration and HbA1c (instant and mean) levels in patients with T1D with respect to PWV and Alx_75 values. CONCLUSIONS: Arterial stiffness was impaired in children with T1D with no end organ impairment using oscillometric method. This impairment was related to high HbA1c levels and diabetes duration.

Evaluation of Neurodevelopment and Factors Affecting it in Children With Acyanotic Congenital Cardiac Disease.

BACKGROUND: The rate of congenital heart disease is 0.8% in all live births. The majority of this, however, is acyanotic congenital heart disease. The survival rate of children with cardiac disease has increased with the developments provided in recent years and their lifetime is extended. OBJECTIVES: This study aims to evaluate neurodevelopment of children with uncomplicated acyanotic congenital heart disease in preschool period and determine the factors affecting their neurodevelopmental process. PATIENTS AND METHODS: 132 children with acyanotic congenital heart disease aged 6 - 72 months were involved in the study. Mental development and intelligence levels of patients under 2 years old were assessed by using Bayley Development Scale-III, and Stanford Binet Intelligence test was employed for patients over 2 years old. Denver Developmental Screening Test II was applied to all patients for their personal-social, fine motor, gross motor and language development. RESULTS: The average age of patients (67 girls, 65 boys) included in the study was 35.2 ± 19.6 months. It was determined that there were subnormal mental level in 13 (10%) patients and at least one specific developmental disorder in 33 (25%) patients. Bayley Mental Development Scale score of patients who had received incubator care in perinatal period was found significantly low (88 ± 4.2) compared to those with no incubator care (93.17 ± 8.5) (P = 0.028). Low educational level of father was established to be linked with low mental development scores at the age of 2 and following that age (P < 0.05). Iron deficiency anemia was discovered to be related to low psychometric test scores at every age (P < 0.05). CONCLUSIONS: Neurodevelopmental problems in children with acyanotic congenital heart disease were found higher compared to those in society. Mental development and intelligence levels of patients were determined to be closely associated with receiving incubator care, father's educational level and iron deficiency anemia.

Effect of plasma NOx values on cardiac function in obese hypertensive and normotensive pediatric patients.

BACKGROUND: Hypertension (HT) is a major comorbidity of obesity that is associated with an increased risk of cardiovascular disease and higher mortality. The aim of our study was to evaluate cardiac function in obese hypertensive (OHT) and obese normotensive (ONT) pediatric patients and determine the effects of plasma nitric oxide (NOx) values on cardiac function, while demonstrating the role of plasma NOx in HT in obese pediatric patients. METHODS: The study population consisted of 62 patients (27 boys, 35 girls), aged 13-18 years and 21 age-matched healthy controls. All subjects enrolled in the study underwent echocardiography (Echo) evaluation and ambulatory blood pressure monitoring for HT. Plasma NOx and biochemical values were studied in both patient groups separately. RESULTS: Plasma NOx levels were found to be lower in the OHT group than in the ONT and control groups (p < 0.001) and to be negatively correlated with left ventricular mass index values (p < 0.05). Both the OHT and ONT groups had concentric hypertrophy of the heart. CONCLUSIONS: Plasma NOx plays an essential role in obesity-induced HT. Concentric hypertrophy of the left ventricle was found in both the OHT and ONT groups, indicating structural deformation of the heart.