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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Morphological Study of Left Ventricular False Tendons in Human Cadaveric Heart Specimens
Correspondence Address :
Shalom Elsy Philip,
Senior Resident, Department of Anatomy, All India Institute of Medical Sciences, Rajkot, Gujarat, India.
E-mail: tfcshalom@gmail.com
Introduction: Left Ventricular False Tendons (LVFT) are normal and common anatomical variants of the left ventricle. They may be associated with findings of cardiac pathology or they may be an isolated finding from 2D echocardiogram. These structures may mimic pathologic structures, such as intraventricular chorda rupture, vegetation or thrombus, but considered as false tendon.
Aim: To study the morphology, age and gender specific proportions of false tendons in cadaveric heart specimens.
Materials and Methods: A descriptive cross-sectional study was conducted in Mysore Medical College and Research Institute, Mysuru, Karnataka, India, from October 2015 to March 2017. A total of 100 human cadaveric heart specimens of both males (n=50) and females (n=50) aged 18-76 years were collected from Department of Anatomy and postmortem specimens from Department of Forensic Medicine. The morphology of tendons was studied regarding its location, gross appearance and parameters such as its length and width. The statistical analysis was done using Chi-square test and Analysis of Variance (ANOVA) test appropriately using the software Statistical Package for Social Service (SPSS), version 20.0 for windows.
Results: False tendons were seen in 49 of heart specimens. Total 40 of the specimens showed one LVFT and nine showed two LVFT. Out of total 44 (58.67%) specimens aged 50 years or less had false tendons, while in older specimens, only 5 (20%) were found to have false tendon (p-value <0.05). The common location of false tendons was Posteromedial Papillary Muscle (PMPM) to mid interventricular septum 11 (18.9%), followed by PMPM to free wall 9 (15.5%). The tendons were fibrous in 53 (91.4%), fibromuscular in 4 (6.9%) and 1 (1.7%) was muscular in nature. Out of 50 female and 50 male heart specimens, 24 and 25 had LVFT, respectively (p-value=0.891).
Conclusion: Sound knowledge of heart morphology can avoid false diagnosis in patients with false tendon, as it can simulate other pathological murmurs and structural heart disease in echocardiography.
Interventricular septum, Posteromedial papillary muscle, Pseudotendons
The Left Ventricular False Tendons (LVFT) commonly defined as false tendon which is discrete, thin, cord like fibromuscular structures that connect two walls, the Papillary Muscle (PM), or PM to a wall, usually the ventricular septum, it also often crosses subaortic outflow and left ventricular cavity (1). They are normal and common anatomical variants of the left ventricle occurring in 50% of hearts and may get calcified with age. They are frequently observed in men but their incidence does not appear to be age related (2). They may be single or multiple and sometimes branched. The LVFT, also referred to as pseudo-tendons, aberrant fibrous bands, false tendons, intracardiac strings, anomalous left ventricular bands, musculi-transversi, and ventricular cords. The term anomalous, false, aberrant is given due to the variation from the normal insertion of chordae tendineae that is not attached to mitral leaflets. It was first reported by British anatomist and surgeon Sir William Turner in 1893 as filaments of tissue crossing the cavity of left ventricle (3). But variety of chordal anomalies has been described including congenital absence, abnormal length, and anomalous insertion (4).
The development of echocardiography has allowed the demonstration of LVFTs in-vivo and the subsequent association of these structures with numerous clinical phenomena (5). Since about a century ago, false tendons in the left ventricular cavity have been noted as anatomic variants at autopsy. Recently, cardiologists are concerned about their possible association with innocent heart murmurs and its possible role in ventricular arrhythmias due to the presence of conduction tissue (6). The present study was taken up since few literatures are available on cadaveric studies (7),(8),(9),(10),(11),(12) for determining the incidence of false tendons, various types and insertion with their significance in the field of cardiology especially in adult population.
A descriptive cross-sectional study was conducted in Mysore Medical College and Research Institute, Mysuru, Karnataka, India, from October 2015 to March 2017. The study was conducted after approval from Institutional Ethics Committee, (letter dated 07-11-2015: ECR/134/Inst/KA). The study was done on 100 human heart specimens of both male and female cadavers aged 18 to 76 years of age.
Sample size calculation: Sample size was estimated statistically by ‘estimation technique for proportion’ with level of significance (α)=5%, admissible error=10% with proportion of tendons=0.55. Thus, sample size of heart specimens was 99 (which were rounded off into 100).
Inclusion and Exclusion criteria: Any filamentous, fibrous or muscular linear structures crossing LV cavity from the PM or from the anterior or posterior free wall of the LV, attaching to the interventricular septum and probe must pass through either side of the tendon to delineate the trabecular work (7), were included in study. Any gross evidence of injured, lacerated, anomalies, surgeries, and decomposed heart specimens, trabecular structures, or linear structure adherent to the wall, or anomalous chordae tendineae attaching elsewhere other than mitral valve apparatus, or ridge or subaortic membrane were excluded from the study.
Procedure
Specimens were collected from Department of Anatomy and postmortem specimens from Department of Forensic Medicine. After exploring the pericardial cavity, the heart was detached from the major venous channels (superior vena cava and inferior vena cava) and aorta was cut 3 cm above the coronary sinus and then the heart was extracted with intact epicardium and coronary vessels. The specimens were tagged, stored in 10% formalin solution and were dissected. The heart was held in anatomical position. After identifying all the chambers, an incision was put at the right border of heart exposing the right atrium and ventricle cavity and interventricular septum. Now an incision was made on the interventricular septum from the level of aortic valves till its base of septum exposing the entire left ventricle cavity as whole with PMs, and chordae tendineae, so to prevent damage to any left ventricular tendons running across the cavity (13).
Parameters such as incidence, age, gender specific proportions of false tendons, its location such as free wall to free wall, free wall to septum, posteromedial and Anterolateral Papillary Muscle (ALPM) to septum and between PMs were studied. Measurements such as length and width were taken with help of vernier calipers. Classification of tendons to fibrous (1.4 mm), fibromuscular (1.5-2.4 mm) and muscular (>2.5 mm) were done based on the width of the tendons (7).
Statistical Analysis
The data were summarised using descriptive statistics like mean, standard deviation and inferential statistics using Chi-square test and Analysis of Variance (ANOVA) test appropriately. All the statistical calculations were performed using the software Statistical Package for the Social Sciences (SPSS) version 20.0 for windows.
In the present study, the incidence of LVFTs in heart specimens was 49%. Total 40 of the specimens showed one LVFT and nine showed two LVFT, hence total number of tendons being 58. The age of the specimens ranged between 18-76 years with median age being 42 years. Association between age range and distribution of LVFT is shown in (Table/Fig 1) and the difference was statistically significant (χ2=11.22, df=1, p-value <0.05). Association of LVFT with gender is shown in (Table/Fig 2). Pearson Chi-square test found no statistically significant difference between gender and the distribution of LVFT. (χ2=0.231, df=2, p-value=0.891). The common location of LVFT was PMPM to mid interventricular septum (N=11, 18.9%), followed by PMPM to free wall (N=9, 15.5%) (Table/Fig 3), (Table/Fig 4). The mean length and width of the LVFT is shown in (Table/Fig 5). The types of tendons are fibrous, fibromuscular, muscular, which were of 53 (91.4%), 4 (6.9%), 1 (1.7%), respectively. Association of types of tendons and width is shown in (Table/Fig 6). There is statistically significant difference in the width of the fibrous, fibromuscular and muscular LVFTs (f-value=91.6, p-value=0.001, df=57).
In the present study, the incidence of LVFTs in heart specimens was 49%. Total 40 of the specimens showed one LVFT and nine showed two LVFT, hence total number of tendons being 58. The age of the specimens ranged between 18-76 years with median age being 42 years. Association between age range and distribution of LVFT is shown in (Table/Fig 1) and the difference was statistically significant (χ2=11.22, df=1, p-value <0.05). Association of LVFT with gender is shown in (Table/Fig 2). Pearson Chi-square test found no statistically significant difference between gender and the distribution of LVFT. (χ2=0.231, df=2, p-value=0.891). The common location of LVFT was PMPM to mid interventricular septum (N=11, 18.9%), followed by PMPM to free wall (N=9, 15.5%) (Table/Fig 3), (Table/Fig 4). The mean length and width of the LVFT is shown in (Table/Fig 5). The types of tendons are fibrous, fibromuscular, muscular, which were of 53 (91.4%), 4 (6.9%), 1 (1.7%), respectively. Association of types of tendons and width is shown in (Table/Fig 6). There is statistically significant difference in the width of the fibrous, fibromuscular and muscular LVFTs (f-value=91.6, p-value=0.001, df=57).
The LVFTs have little clinical significance per se, but these anatomical variants are important because of their potential to be mistaken for more important pathologic entities. These tendons are not the chordae tendineae connecting the PM to the mitral valve leaflet. Therefore, “false tendon” has become more popular (14). Advent of echocardiography has rekindled the interest in this field and helped the demonstration of LVFT in vivo and its association with clinical conditions. LVFT may cause precordial murmurs, which is functional, so-called innocent murmur (7),(8) and tendon attaching to the base of the interventricular septum or the sub aortic region may cause gradient or plays a role in pathogenesis of discrete subaortic stenosis (15). It also causes premature ventricular contractions (16). False tendons may give rise to reentry mechanism producing more severe arrhythmias such as ventricular tachycardia and fibrillation (7),(17). Left ventricular tendons may cause obstruction while navigating devices in the left ventricle (18). Studies have shown that, left ventricular tendons can be falsely associated with left ventricular aneurysm (19). LVFT can simulate mural thrombus by producing intracavitary echoes in echocardiography. So, false positive diagnosis can be minimised by identifying and distinguishing this structure (20). Echocardiogram (Echo) studies have documented false tendons as potential for erroneous diagnosis of thrombi, tumors, subaortic membrane, flail mitral leaflet (9),(21). LVFT could be contributory factor of dysrhythmias during LV catheterisation studies (22).
The LVFT are normal anatomical variants seen in left ventricle with a frequency between 0.5% and 77.9% with echocardiography (7),(23),(24). In congenital heart specimens alone 61.8% were noted (7). Potential genetic inheritance of false tendons has been reported (25). As autopsy was not performed on many cases, giving less opportunity for anatomic confirmation of these bands. In the present study 49% of tendons were observed. Nine (18%) of the 49 specimens were observed with more than one tendon. There is no statistically significant difference between the number of tendons present in a single heart with the gender and age. The literature shows that there is no significant difference in incidence of left ventricular tendons in acquired or congenital heart diseases or normal patients (26). In the present study, the disease status was unknown. LVFT are more commonly seen in males than females (2). In the present study, tendons were seen in 50% in males and 48% in females, more or less equal and statistically insignificant which was similar to the study of Abdullah NM et al., (27).
The LVFT gets calcified with age, and their incidence does not appear to be age related (2). However, studies of Cocchieri M and Bardelli G, Philip S et al., Gerlis LM et al., Brenner JI et al., Perry LW et al., showed that incidence of LVFT is more likely to be seen in younger age group like neonates, infants, children (6),(7),(11),(24), (28). Philip S et al., reported a maximum of 77.9% in <18 years as they were easily identifiable in this age group because of better delineation of images by echocardiography (7), moreover that many trabeculations could be over diagnosed and chance of resorption is very high in children, can partially explored why incidence is less in the cadaveric specimens when compared to echocardiographic results. Although many have studied about these structures with echocardiography (Table/Fig 7), very little literature is available using cadaveric specimens by dissection method (Table/Fig 7) (6),(7),(8),(9),(10),(11),(12),(24),(26),(27),(28),(29),(30),(31),(32),(33),(34).
The location of the tendons varies from free wall to free wall, free wall to septum, posteromedial and ALPM to septum and between PM (9). Most commonly observed location was posteromedial PM to mid interventricular septum (n=11, 18.9%), followed by PMPM to free wall (n=9, 15.5%). Luetmer PH et al., observed false tendons (12%) between two PMs second in frequency and location of tendons had no association with gender and age (9). Although Grzybek M et al., reported to have observed the tendons connecting the interventricular septum to the anterolateral or posteromedial PM more in newborn, infant, adult hearts and rarely in foetal hearts (12).
The characteristics of the tendon such as length and thickness of tendon varied in each specimen. Grzybek M et al., reported that tendons individual parts of anterior or posterior PM were generally thin and short, tendons connecting ALPM to PMPM were narrow and of medium thickness, tendons connecting interventricular septum to PM were generally long (12). Also, the false tendons were found to be thicker in foetal, newborn and infant hearts than in adult hearts. Luetmer PH et al., observed that length of the tendons ranged from 7 mm to 35 mm and longest were seen in tendons connecting septum to PM (9). Luetmer PH et al., and Abdulla AK et al., reported the thickness of the tendon variable ranging from 1 mm to 3 mm (9),(26). In the present study, the thickness ranged between 0.03 mm to 3.7 mm. The longest length of tendon was seen in tendons connecting septum to PM and was supported by study of Luetmer PH et al., (9). Embryologically, inner muscle layer of the primitive heart may give rise to false tendons (28). Left ventricular tendons were further classified by Philip S et al., according to the width and histopathology of tendon studied, as fibrous (1.4 mm, 44.4%), fibromuscular (1.5-2.4 mm, 50.7%), and muscular type (>2.5 mm, 5.3%) (7). In the present study, fibrous, fibromuscular, muscular were of 53%, 4%, 1%, respectively and histopathology was not done. This difference in paediatric and adult age group could be partially explained as a process elongation of tendon as the heart enlarges and some amount of resorption could take place as the age progresses.
Limitation(s)
Heart specimens of less than 18 years of age were not obtained in the present study period and corresponding clinical echocardiographic data on LV tendon was not available for correlation study.
Association of left ventricular tendons with various clinical conditions and in otherwise normal patients, emphasises the necessity for an awareness of these anatomic variants when evaluating patients for left ventricular pathology. It is relatively benign in nature but may confuse with clinical conditions having similar echocardiographic appearance, but it may cause functional murmur. Recognition of this entity by cadaveric exposition is important to know the morphology for clinical correlation and also to avoid false diagnosis. Keeping in mind the ever evolving and yet unexplored facts of this subject, the present study was undertaken to shed more light on this topic of left ventricular tendons.
DOI: 10.7860/JCDR/2022/52729.15925
Date of Submission: Oct 06, 2021
Date of Peer Review: Oct 21, 2021
Date of Acceptance: Dec 02, 2021
Date of Publishing: Feb 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA
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