Bio-Humoral and Non-Invasive Haemodynamic Correlates of Renal Venous Flow Patterns across the Heart Failure Spectrum.

Background: We evaluated the bio-humoral and non-invasive haemodynamic correlates of renal congestion evaluated by Doppler renal venous flow (RVF) across the heart failure (HF) spectrum, from asymptomatic subjects with cardiovascular risk factors (Stage A) and structural heart disease (Stage B) to patients with clinically overt HF (Stage C). Methods: Ultrasound evaluation, including echocardiography, lung ultrasound and RVF, along with blood and urine sampling, was performed in 304 patients. Results: Continuous RVF was observed in 230 patients (76%), while discontinuous RVF (dRVF) was observed in 74 (24%): 39 patients had pulsatile RVF, 18 had biphasic RVF and 17 had monophasic RVF. Stage C HF was significantly more common among patients with dRVF. Monophasic RVF was associated with worse renal function and a higher urinary albumin-to-creatinine ratio (uACR). After adjusting for hypertension, diabetes mellitus, the presence of Stage C HF and serum creatinine levels, worsening RVF patterns were associated with higher NT-proBNP levels, worse right ventricular-arterial coupling, larger inferior vena cava and higher echo-derived pulmonary artery wedge pressure. This trend was confirmed when only patients with HF Stage C were analysed after adjusting for the left ventricle ejection fraction (LVEF). Conclusion: Abnormal RVF is common across the HF spectrum. Worsening RVF patterns are independently associated with increased congestion, worse non-invasive haemodynamics and impaired RV-arterial coupling. RVF evaluation could refine prognostic stratification across the HF spectrum, irrespective of LVEF.

Deep phenotype characterization of hypertensive response to exercise: implications on functional capacity and prognosis across the heart failure spectrum.

AIMS: Limited evidence is available regarding the role of hypertensive response to exercise (HRE) in heart failure (HF). We evaluated the systolic blood pressure (SBP) to workload slope during exercise across the HF spectrum, investigating haemodynamic and prognostic correlates of HRE. METHODS AND RESULTS: We prospectively enrolled 369 patients with HF Stage C (143 had preserved [HFpEF], and 226 reduced [HFrEF] ejection fraction), 201 subjects at risk of developing HF (HF Stages A-B), and 58 healthy controls. We performed a combined cardiopulmonary exercise stress echocardiography testing. We defined HRE as the highest sex-specific SBP/workload slope tertile in each HF stage. Median SBP/workload slope was 0.53 mmHg/W (interquartile range 0.36-0.72); the slope was 39% steeper in women than men (p < 0.0001). After adjusting for age and sex, SBP/workload slope in HFrEF (0.47, 0.30-0.63) was similar to controls (0.43, 0.35-0.57) but significantly lower than Stages A-B (0.61, 0.47-0.75) and HFpEF (0.63, 0.42-0.86). Patients with HRE showed significantly lower peak oxygen consumption and peripheral oxygen extraction. After a median follow-up of 16 months, HRE was independently associated with adverse outcomes (all-cause mortality and hospitalization for cardiovascular reasons: hazard ratio 2.05, 95% confidence interval 1.81-5.18), while rest and peak SBP were not. Kaplan-Meier analysis confirmed a worse survival probability in Stages A-B (p = 0.005) and HFpEF (p < 0.001), but not HFrEF. CONCLUSION: A steeper SBP/workload slope is associated with impaired functional capacity across the HF spectrum and could be a more sensitive predictor of adverse events than absolute SBP values, mainly in patients in Stages A-B and HFpEF.

Speckle-tracking echocardiography: a new technique for assessing myocardial function.

Speckle-tracking echocardiography has recently emerged as a quantitative ultrasound technique for accurately evaluating myocardial function by analyzing the motion of speckles identified on routine 2-dimensional sonograms. It provides non-Doppler, angle-independent, and objective quantification of myocardial deformation and left ventricular systolic and diastolic dynamics. By tracking the displacement of the speckles during the cardiac cycle, strain and the strain rate can be rapidly measured offline after adequate image acquisition. Data regarding the feasibility, accuracy, and clinical applications of speckle-tracking echocardiography are rapidly accumulating. This review describes the fundamental concepts of speckle-tracking echocardiography, illustrates how to obtain strain measurements using this technique, and discusses their recognized and developing clinical applications.

Echocardiography in patients with hypertrophic cardiomyopathy: usefulness of old and new techniques in the diagnosis and pathophysiological assessment.

Hypertrophic cardiomyopathy (HCM) is one of the most common inherited cardiomyopathy. The identification of patients with HCM is sometimes still a challenge. Moreover, the pathophysiology of the disease is complex because of left ventricular hyper-contractile state, diastolic dysfunction, ischemia and obstruction which can be coexistent in the same patient. In this review, we discuss the current and emerging echocardiographic methodology that can help physicians in the correct diagnostic and pathophysiological assessment of patients with HCM.

Arterial-ventricular coupling and parameters of vascular stiffness in hypertensive patients: Role of gender.

OBJECTIVE: Non-invasive estimation of arterial-ventricular coupling has been extensively used for the evaluation of cardiovascular performance, however, a relative small amount of data is available regarding arterial-ventricular coupling and its components in hypertension. The present study was designed to investigate the relationship between left ventricular elastance, arterial elastance, parameters of vascular stiffness and the influence of gender in a population of hypertensive individuals. METHODS: In 102 patients, trans-thoracic cardiac ultrasound, parameters of aortic stiffness (carotid-femoral pulse wave velocity) and wave reflection (augmentation index) were recorded. Ultrasound images of common carotid arteries were acquired for the assessment of intima-media thickness as well as carotid compliance and distensibility coefficient. RESULTS: Mean age was 61 years, 32% diabetes, 56% dyslipidemia, 9% previous cardiovascular events; women (n = 32) and men were superimposable for cardiovascular risk factors prevalence. In the population, ventricular elastance was significantly correlated with arterial elastance (r = 0.887), age (r = 0.334), gender (r = -0.494), BMI (r = -0.313), augmentation index (r = 0.479) (all p < 0.001); and with carotid compliance and distensibility coefficient (r = 0.229 and r = - 0.250, respectively, both p < 0.05); however, only arterial elastance and gender were independently associated with ventricular elastance in multiple regression models adjusted for confounding factors. Gender-specific analysis revealed that arterial elastance and augmentation index remained statistically significant associated with ventricular elastance in men (r = 0.275, p = 0.04); instead augmentation index was no longer significant (r = 0.052, p = 0.77) in the female sex. CONCLUSIONS: In hypertensive patients, main determinants of ventricular elastance are arterial elastance, as an integrated index of arterial vascular load, and gender; however, pressure augmentation might play an additional role in men.

Carotid and aortic stiffness in essential hypertension and their relation with target organ damage: the CATOD study.

OBJECTIVE: The objective of the study is to investigate in the hypertensive population the possible differential association between increased aortic and/or carotid stiffness and organ damage in multiple districts, such as the kidney, the vessels, and the heart. METHODS: In 314 essential hypertensive patients, carotid-femoral pulse wave velocity (cfPWV, by applanation tonometry) and carotid stiffness (from ultrasound images analysis), together with left ventricular hypertrophy, carotid intima-media thickness, urinary albumin-creatinin ratio, and glomerular filtration rate were measured. Increased cfPWV and carotid stiffness were defined according to either international reference values or the 90th percentile of a local control group (110 age and sex-matched healthy individuals). RESULTS: When considering the 90th percentile of a local control group, increased cfPWV was associated with reduced glomerular filtration rate, either when carotid stiffness was increased [odds ratio (OR) 13.27 (confidence limits (CL) 95% 3.86-45.58)] or not [OR 7.39 (CL95% 2.25-24.28)], whereas increased carotid stiffness was associated with left ventricular hypertrophy, either when cfPWV was increased [OR 2.86 (CL95% 1.15-7.09)] or not [OR 2.81 (CL95% 1.13-6.97)]. No association between increased cfPWV or carotid stiffness and target organ damage was found when cutoffs obtained by international reference values were used. The concomitance of both increased cfPWV and carotid stiffness did not have an additive effect on organ damage. CONCLUSION: Aortic and carotid stiffness are differentially associated with target organ damage in hypertensive patients. Regional arterial stiffness as assessed by cfPWV is associated with renal organ damage and local carotid stiffness with cardiac organ damage.

Incremental prognostic value of a complex left ventricular remodeling classification in asymptomatic for heart failure hypertensive patients.

We evaluated the prognostic impact of a complex remodeling classification (CRC) in asymptomatic patients with arterial hypertension (AH). We retrospectively included 749 hypertensive patients (female 325, 43.4% age 62 ± 11.3 years) in Stages A and B of heart failure. CRC was evaluated including indexed left ventricular mass, end-diastolic volume, and relative wall thickness. After 45-month follow-up, we considered a composite endpoint: total mortality, myocardial infarction, myocardial revascularization, cerebrovascular events, and acute pulmonary edema. Blood pressure was controlled in 265 patients (35.4%), 317 (42.3%) were in Grade 1 of AH, 123 (16.4%) in Grade 2, and 44 (5.9%) in Grade 3. Considering CRC, 292 patients (38%) presented normal/physiological hypertrophy, 102 (13.6%) concentric remodeling, 29 (3.9%) eccentric remodeling, 157 (21%) concentric hypertrophy, 11 (1.5%) mixed hypertrophy, 52 (6.9%) dilated hypertrophy, and 36 (4.8%) eccentric hypertrophy. We observed a total of 73 events (9.7%). Kaplan-Meier method demonstrated a significant different survival in CRC-derived classes (P < .001). Cox regression demonstrated CRC as independent predictor (P = .01), after adjusting for age, gender, diabetes mellitus, grade of hypertension, antihypertensive therapy, stable ischemic heart disease, obesity, systolic and diastolic dysfunction, and classic remodeling classification. In asymptomatic patients with AH, CRC is an independent predictor of poor outcome.

Ventricular repolarization is prolonged in nondipper hypertensive patients: role of left ventricular hypertrophy and autonomic dysfunction.

OBJECTIVE: The aim of this study was to investigate the influence of circadian behavior of blood pressure, left ventricular hypertrophy, and autonomic function on QTc interval duration in untreated hypertensive patients. DESIGN: Hypertensive patients underwent simultaneous blood pressure and ECG 24-h ambulatory monitoring. Patients were classified into two groups on the basis of a lack of nocturnal fall in blood pressure, as dippers and nondippers. A group of normotensive healthy subjects was studied as controls. METHODS: QT and QTc intervals were automatically computed and spectral analysis was applied to RR interval time series from the same electrocardiogram (ECG) recordings. Left ventricular mass index (LVMI) was computed by echocardiogram. RESULTS: No difference among the three groups was found concerning mean values and circadian pattern of heart rate; by contrast, QTc was significantly longer in nondippers compared to dippers or to normotensive subjects, particularly at night-time, whereas all groups exhibited similar circadian variations in heart rate. Compared to dippers, nondippers showed significantly higher LVMI, which positively correlated with QTc, and parasympathetic withdrawal, which negatively correlated with QTc. CONCLUSIONS: Nondippers show a prolonged ventricular repolarization throughout the 24-h period, absent either in dippers or normotensives. The association of left ventricular hypertrophy and vagal deactivation may lead to prolongation of QTc, potentially facilitating ventricular arrhythmias in nondipper hypertensive patients.

Endothelial function in hypertension: role of gender.

Endothelium plays an important role in the modulation of vascular tone and structure mainly through the production of nitric oxide (NO), which causes local vasodilation and counteracts processes leading to atherothrombosis. A dysfunctioning endothelium, characterized by reduced NO availability owing to impairment of the L-arginine-NO pathway and, above all, to production of oxygen free radicals, can impair local vasomotion and promote the development of atherosclerosis and of atherothrombotic vascular events. Aging is associated with endothelial dysfunction both in normotensive subjects and in hypertensive patients, and hypertension seems to induce earlier onset of those mechanisms (i.e. impairment of the L-arginine-NO pathway and oxidative stress) that cause age-related endothelial dysfunction. Premenopausal normotensive women are protected against the deleterious effect of aging on endothelial function, and age-related impairment of endothelial function is attenuated in premenopausal hypertensive women. This protective effect on endothelial function seems to be mediated by endogenous estrogen, which preserves NO availability by activating the L-arginine-NO pathway in normotensive women and, again, by activating this pathway but above all by inhibiting oxidative stress in hypertensive women. Thus, the protective effect of endogenous estrogen on endothelial function could be a plausible mechanism contributing to the lower cardiovascular risk of premenopausal women. Finally, whether endogenous androgen can impair endothelial function is still an unsolved issue since data concerning the effect of testosterone on endothelial function are scanty and contradictory.

Abnormal left ventricular longitudinal function assessed by echocardiographic and tissue Doppler imaging is a powerful predictor of diastolic dysfunction in hypertensive patients: the SPHERE study.

BACKGROUND: Through integrated use of echo-Doppler and tissue Doppler imaging (TDI), it is possible to obtain a comprehensive evaluation of both left ventricular (LV) diastolic and longitudinal functions. In this study, we sought to assess the prevalence of LV diastolic dysfunction (LVDD) and its relation with indices of long-axis function in asymptomatic patients with arterial hypertension. METHODS AND RESULTS: A perspective echo-Doppler study was performed in 1556 consecutive asymptomatic patients with grade 2-to-3 arterial hypertension aged 40-80 years enrolled in the SPHERE (multicenter proSPective study of ecHocardiography in hypERtEnsion) study. All patients had a LV ejection fraction (EF)≥50% and no history of heart failure or coronary artery disease. Advanced LVDD was identified by an average mitral-to-peak early diastolic annular ratio (E/e')≥13. Less than advanced LVDD was identified by: 8

Plasma metalloproteinase-9 and restrictive filling pattern as major predictors of outcome in patients with ischemic cardiomyopathy.

OBJECTIVE: Assessment of plasma matrix metalloproteinase-9 (MMP-9) and Doppler markers of increased left ventricular (LV) filling pressure may be added to risk stratify patients with ischemic cardiomyopathy (IC). Therefore, we aimed at investigating the value of plasma MMP-9 and restrictive filling pattern (RFP) in IC patients. METHODS: Eighty-eight consecutive patients hospitalized for heart failure (LV ejection fraction ≤ 40%) due to IC were enrolled. A complete M-mode and two-dimensional echo-Doppler examination were performed. Patients were defined as having RFP if they had a mitral E wave deceleration time<150 ms. Plasma MMP-9 and N-terminal protype-B natriuretic peptide levels were assessed at the time of the index echocardiogram. The end point was all-cause mortality or hospitalization for worsening HF. Follow-up period was 25 ± 17 months. RESULTS: Median value of MMP-9 was 714 ng/ml. On univariate analysis, a number of measurements predicted the composite end point: NYHA class>2, RFP, MMP-9>60.5 ng/ml, LV ejection fraction<27%, anemia, pulmonary pressure ≥ 35 mm Hg, N-terminal protype-B natriuretic peptide>1742 pg/ml, and glomerular filtration rate<60 ml/min/1.73 m(2). Independent variables of outcome were anemia (HR=1.9, p=0.031), and the combination of plasma MMP-9 and RFP (HR=3.2, p=0.004). On Kaplan-Meier survival curves, patients with elevated MMP-9 levels and RFP had the lowest event-free survival rate (log-rank: 29.0, p<0.0001). The net reclassification improvement showed a significant increase in the prediction model when elevated MMP-9 and RFP were added to the base model that included clinical, biochemical and echocardiographic parameters (p<0.0001). CONCLUSION: MMP-9 levels and RFP have an incremental predictive value to risk classify IC patients.

Developments in imaging technologies related to hypertensive cardiovascular diseases.

This article reviews the current imaging techniques and the methodologies used to derive quantitative markers of hypertension in the cardiovascular system. Firstly, simple but effective methods to assess regional and global function of large arteries are discussed. After, the role of echocardiography and high-resolution magnetic resonance imaging to assess geometric and mechanical indices of hypertension related cardiac diseases are summarized. In particular, quantitative indices of deformation and strain are derived from quantitative analysis of doppler tissue and tagged magnetic resonance images. Finally, the importance of high field magnetic resonance imaging to assess myocardial microcirculation is described.

Plasma matrix metalloproteinase-9 better predicts outcome than N-terminal protype-B natriuretic peptide in patients with systolic heart failure and a high prevalence of coronary artery disease.

Metalloproteinases have been proposed as biochemical markers of left ventricular (LV) remodeling in systolic heart failure (HF). However, their role in the prognostic stratification of these patients remains controversial. In the present study, we aimed at investigating the value of plasma metalloproteinases-3 and -9 in comparison with N-terminal protype-B natriuretic peptide in patients with systolic HF. One hundred and 27 consecutive patients hospitalized for systolic HF (LV ejection fraction < 45%) were enrolled. Coronary artery disease (CAD) was the aetiology in 67% of the study patients. Plasma metalloproteinases-3 and -9 and N-terminal protype-B natriuretic peptide levels were assessed. A complete echocardiographic and Doppler examination was also performed. Follow-up period was 24-15 months. On univariate analysis, a number of measurements predicted cardiac events in the following order of power: NYHA class >2, LV ejection fraction < 25%, metalloproteinases-9 > 238 ng/ml, mitral E wave deceleration time < 150 ms, N-terminal protype-B natriuretic peptide > 1586 pg/ml and metalloproteinases-3 > 15 ng/ml. However, on multivariate analysis the only independent variables of cardiac events were NYHA class (OR=2.26, p=0.059) and plasma metalloproteinases-9 (OR=2.00, p=0.029). On Kaplan-Meier survival analysis, patients with elevated levels of metalloproteinases-9 exhibited a significantly worse event free-survival at 45 months than those without (21% vs. 54%, log-rank: 13.93, p=0.0002). A worse survival was also observed in patients with elevated N-terminal protype-B natriuretic peptide levels with respect to those without (18% vs. 46%, log-rank: 9.11, p=0.025). Our results demonstrated the value of plasma metalloproteinases-9 levels for prognostication of patients with systolic HF and a high prevalence of CAD.

Circulating matrix metalloproteinase-3 and metalloproteinase-9 and tissue Doppler measures of diastolic dysfunction to risk stratify patients with systolic heart failure.

Abnormal matrix metalloproteinase (MMP) activity and diastolic dysfunction may affect left ventricular (LV) remodeling and prognosis, but it is not known whether the combined evaluation of MMP-3 and MMP-9 and variables of diastolic dysfunction are useful for the risk stratification of patients with systolic heart failure (HF). Therefore, this study was designed to assess the value of combining circulating levels of MMPs and tissue Doppler measures of LV diastolic dysfunction to risk-stratify patients with systolic HF. Consecutive patients with systolic HF due to either ischemic or nonischemic cardiomyopathy (n = 134) and LV ejection fractions <45% were submitted to complete echocardiographic and Doppler examinations. The ratio of mitral E peak velocity and averaged e' velocity (E/e') was calculated. Plasma levels of MMP-3 and MMP-9 were measured at the time of index echocardiography. All-cause mortality was defined as the end point. The mean LV ejection fraction was 28 +/- 9%. There was a total of 32 deaths during follow-up (24 +/- 14 months). Several clinical, biochemical, Doppler, and echocardiographic parameters were associated with the outcome on univariate Cox regression analysis. After statistical adjustment for the potentially confounding factors by multivariate analysis, E/e' (hazard ratio 1.11, p = 0.0028), ejection fraction (hazard ratio 0.92, p = 0.017), and MMP-9 (hazard ratio 1.01, p = 0.027) remained significant independent predictors of the end point. Kaplan-Meier curves showed that survival was worse in patients with E/e' ratios >/=13 and MMP-9 levels >89.9 ng/mL (p <0.0001). In conclusion, the assessment of circulating MMP levels and tissue Doppler measures of LV diastolic dysfunction may improve the prognostic stratification of patients with systolic HF.

[Real-time multiplane echocardiography. Current applications, limits and perspectives]. / Ecocardiografia multiplanare in tempo reale. Applicazioni attuali, limiti e prospettive.

Echocardiography is the most commonly used imaging technique in current clinical cardiology practice and is usually performed using a monoplane approach. In recent years new matrix-array transducers have become available that allow the real-time simultaneous display of two or more echocardiographic scanning planes from the same acoustic window. This multiplane approach is particularly interesting as it may reduce, during the examination, the number of probe movements and consequently facilitate image acquisition. In some clinical applications, moreover, the multiplane approach improves both accuracy and reproducibility of echocardiography. This review evaluates the state of the art of multiplane echocardiography and discusses possible clinical applications, advantages and limitations of this technique.

[Transthoracic real-time three-dimensional echocardiography: clinical role, value and limitations in assessing heart valves]. / Ecocardiografia tridimensionale transtoracica in tempo reale. Applicazioni, vantaggi e limiti per lo studio delle valvulopatie.

The introduction of three-dimensional echocardiography and its evolution from time-consuming and cumbersome off-line reconstruction to real-time volumetric technique (real-time three-dimensional echocardiography) are one of the most significant advances in ultrasound imaging of the heart of the past decade. This imaging modality currently provides realistic views of cardiac valves capable of demonstrating the anatomy of various heart valve diseases in a unique, noninvasive manner. In addition, real-time three-dimensional echocardiography offers completely new views of the valves and surrounding structures, and allows accurate quantification of severity of valve disease. This article reviews the advantages of real-time three-dimensional echocardiography in assessing heart valves and shows also technological limitations in order to provide the scientific basis for its clinical use.

Coronary flow reserve in idiopathic dilated cardiomyopathy: relation with left ventricular wall stress, natriuretic peptides, and endothelial dysfunction.

Studies have demonstrated impaired coronary blood flow reserve (CBFR) in idiopathic dilated cardiomyopathy (IDCM). It was the aim of this study to examine the potential underlying mechanisms for CBFR reduction in patients with IDCM by Doppler ultrasound techniques. Forty-eight clinically stable patients with heart failure caused by IDCM (New York Heart Association classes 1-3) were evaluated by echocardiographic and Doppler techniques with the assessments of CBFR and brachial artery flow-mediated dilation (FMD). CBFR was estimated as the hyperemic (dipyridamole: 0.84 mg/kg in 10 minutes, intravenously) to resting coronary diastolic peak velocities ratio. N-terminal pro-brain natriuretic peptide (Nt-pro-BNP) plasma levels were measured at the time of the index echocardiogram. Left ventricular (LV) ejection fraction was 30% +/- 8%, and wall motion score index was 2.0 +/- 0.25. The best correlation with CBFR was found with LV wall thickness-to-cavity radius (r = 0.77, P < .0001). A strong correlation of log-transformed Nt-pro-BNP levels was observed with CBFR (r = -0.64; P < .0001). No significant correlation was documented between CBFR and FMD. The stepwise regression model showed that LV wall thickness-to-cavity radius was the strongest independent predictor of CBFR followed by New York Heart Association class and log-transformed Nt-pro-BNP leading to a cumulative R value of 0.82 (P < .0001). The results of the study indicate that by measuring variables related to LV end-diastolic wall stress, such as LV wall thickness-to-cavity radius and plasma Nt-proBNP, it is possible to have information about CBFR in patients with heart failure secondary to IDCM.

N-terminal protype-B natriuretic peptide and Doppler diastolic variables are incremental for risk stratification of patients with NYHA class I-II systolic heart failure.

BACKGROUND: In systolic heart failure (HF), preventing the development of severe symptoms, before patients are in advanced NYHA functional classes, is a worthwhile target of therapy. Early recognition of left ventricular (LV) diastolic dysfunction and neuroendocrine activation may have an important impact on patient's outcome. AIM: To investigate whether N-terminal proBNP (NT-proBNP) and mitral flow and tissue Doppler (TD) diastolic parameters are incremental for risk stratification of systolic HF patients in NYHA class I and II. METHODS: The study consisted of 232 consecutive outpatients with systolic HF (ejection fraction [EF] 544 pg/ml (hazards ratio [HR]: 2.66; p=0.012), EF <37% (HR: 2.45; p=0.006), E

[Real-time three-dimensional echocardiography: current applications, advantages and limits for the evaluation of the left ventricle]. / Ecocardiografia tridimensionale in tempo reale. Attuali applicazioni, vantaggi e limiti per lo studio del ventricolo sinistro.

In the last decades the introduction and development of echocardiography allowed a significant improvement in the diagnosis as well as in the morphological and functional evaluation of several heart diseases, and today many therapeutic decisions are taken based on the results of the echocardiographic examination. One of the most important development in the field of echocardiography is three-dimensional imaging, which has evolved from the slow and labor-intense off-line reconstruction techniques to the faster and simpler real-time volumetric imaging, which has the potential to be integrated in routine clinical practice. One of the major proven advantages of real-time three-dimensional echocardiography is the evaluation of left ventricular volume, mass and function, which is achieved by eliminating the need for geometric modeling and the errors caused by foreshortened views. In this review we discuss the state-of-the-art and anticipate future developments of real-time three-dimensional echocardiography that are relevant to its application to the left ventricle.

[Echocardiographic evaluation of the athlete's heart: from morphological adaptations to myocardial function]. / Lo studio ecocardiografico del cuore d'atleta: dagli adattamenti morfologici alla funzione miocardica.

The definition of the athlete's heart includes the mechanisms of cardiac adaptation to training, characterized by the increase of internal chamber dimensions, ventricular wall thickness, and atrial chambers. The morphology of the athlete's heart is intermediate between concentric and eccentric left ventricular hypertrophy (LVH), in relation to the large prevalence of mixed sports activities and training protocols (including both aerobic and anaerobic exercise). Echocardiography is the tool of choice for the assessment of the athlete's heart and also for the differentiation of physiologic and pathologic LVH (hypertrophic cardiomyopathy and LVH due to arterial hypertension). The initial echocardiographic approach includes the quantitative analysis of the left ventricle, in order to calculate left ventricular mass, left ventricular mass index and relative wall thickness for diagnosing concentric or eccentric LVH. Tissue Doppler (pulsed or color modality) and strain rate imaging (Doppler or two-dimensional modality) may give additional information to the standard indices of systolic function. Diastolic function can be evaluated not only by standard Doppler transmitral inflow measurements but also using pulsed tissue Doppler, which may allow to distinguish the athlete's LVH from diastolic impairment of hypertensive patients or hypertrophic cardiomyopathy by the simple determination of myocardial early diastolic velocity. Also the morphological and functional features of the left atrium and of the right ventricle can be assessed in the athlete's heart by combining standard echocardiography with new echocardiographic technologies.