## 4 Discussion
strated that the DMD patients exhibited noticeably lower GCS and GLS than the controls: GCS: \(-14.7\)\(\pm\)\(4.7\)% vs. \(-23.1\)\(\pm\)\(2.9\)%, GLS: \(-13.6\)\(\pm\)\(5\)% vs. \(-18.8\)\(\pm\)\(3\)%, respectively (all \(p\)-values < 0.001). Eighteen (56%) DMD patients presented LGE, while fourteen (44%) DMD patients presented no evidence of LGE and the DMD LGE - group showed decreased segmental values only in inferolateral and anterolateral segments compared to the healthy controls. A recent research study by [PERSON] et al. [26] employed a novel 4D CMR regional strain analysis to assess 40 pediatric Duchenne patients across three consecutive annual visits. The results revealed that peak systolic strain served as early marker of cardiomyopathy progression. This method shows great potential for early detection and ongoing monitoring, which could enhance patient outcomes by enabling timely interventions and more effective disease management. In the current study, segmental LGE distribution was most frequent in the inferolateral region, then in the anterolateral region. [PERSON] et al. [27] reported that LGE was mostly basal inferolateral (90%) and basal anterolateral (60%). The research study of [PERSON] et al. [28] showed that the most frequently involved segments, at basal and middle levels, were inferolateral and anterolateral. CMR imaging provides enhanced imaging clarity in DMD, particularly in male patients. Moreover, CMR enables the evaluation of myocardial strain through harmonic phase imaging (HARP) and CMR-FT. While HARP imaging necessitates additional tagged images, limiting its clinical feasibility, CMR-FT imaging can be feasible using clinically obtained SSFP images, thus enhancing its practicality in clinical settings. Consequently, CMR-FT strain imaging may provide more clinically applicable strain measurements. CMR-FT revealed myocardial strain alterations among DMD patients not identified by STE [24]. The results of the current study align with those in the literature and proved several hypotheses, confirming CMR as the gold standard for detecting and assessing the severity of cardiomyopathy in DMD patients. It is the technique of choice for myocardial tissue characterization by detecting fibrosis and precisely estimating cardiac volumes and functions in DMD patients. It also highlights that CMR-FT can detect alterations in the myocardium of individuals with DMD, even in the absence of late gadolinium enhancement. In addition, this study demonstrated that the myocardial global strain parameters correlated well with LV geometry. This correlation suggests that alterations in the LV geometry, such as changes in wall thickness or thickening, are closely associated with changes in myocardial strain. Consequently, assessing these strain parameters can provide valuable insights into the structural and functional state of the heart, particularly in the context of various cardiac conditions [29; 30]. The current study has several limitations. Initially, the study was limited to a single center, leading to potentially biased case selection. Moreover, DMD is a rare disease that posed challenges to the study, notably in recruiting enough participants from a single center due to its rarity. This limitation may have impacted the prediction accuracy of our findings. Despite these limitations, the notable results and robustness of the present research prompt one to consider expanding the used dataset and exploring the application of artificial intelligence and machine learning in future research projects. In future research, leveraging deep learning algorithms holds great promise for aiding in the early detection of cardiac dysfunction in DMD patients and assessing progression rates to aid in therapy assessment.