In a prospective study with 720 HF patients and 300 healthy referents, TMAO levels were higher in HF patients, as well as associated with higher mortality and BNP levels compared to those with normal heart function.110 In another study with 112 HF patients, TMAO was also associated with left ventricular diastolic dysfunction.111 Using a pressure-overload model of HF, choline and TMAO increased cardiac fibrosis, hypertrophy and reduced left ventricular ejection fraction relative to the control diet.112. This evidence concerns the gene NPPB and hydrops fetalis.