Stress Echocardiography in Italian Echocardiographic Laboratories: A Survey of the Italian Society of Echocardiography and Cardiovascular Imaging.

Background: The Italian Society of Echography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand the volumes of activity, modalities and stressors used during stress echocardiography (SE) in Italy. Methods: We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved through an electronic survey based on a structured questionnaire, uploaded on the SIECVI website. Results: Data were obtained from 228 echocardiographic laboratories, and SE examinations were performed in 179 centers (80.6%): 87 centers (47.5%) were in the northern regions of Italy, 33 centers (18.4%) were in the central regions, and 61 (34.1%) in the southern regions. We annotated a total of 4057 SE. We divided the SE centers into three groups, according to the numbers of SE performed: <10 SE (low-volume activity, 40 centers), between 10 and 39 SE (moderate volume activity, 102 centers) and ≥40 SE (high volume activity, 37 centers). Dipyridamole was used in 139 centers (77.6%); exercise in 120 centers (67.0%); dobutamine in 153 centers (85.4%); pacing in 37 centers (21.1%); and adenosine in 7 centers (4.0%). We found a significant difference between the stressors used and volume of activity of the centers, with a progressive increase in the prevalence of number of stressors from low to high volume activity (P = 0.033). The traditional evaluation of regional wall motion of the left ventricle was performed in all centers, with combined assessment of coronary flow velocity reserve (CFVR) in 90 centers (50.3%): there was a significant difference in the centers with different volume of SE activity: the incidence of analysis of CFVR was significantly higher in high volume centers compared to low - moderate - volume (32.5%, 41.0% and 73.0%, respectively, P < 0.001). The lung ultrasound (LUS) was assessed in 67 centers (37.4%). Furthermore for LUS, we found a significant difference in the centers with different volume of SE activity: significantly higher in high volume centers compared to low - moderate - volume (25.0%, 35.3% and 56.8%, respectively, P < 0.001). Conclusions: This nationwide survey demonstrated that SE was significantly widespread and practiced throughout Italy. In addition to the traditional indication to coronary artery disease based on regional wall motion analysis, other indications are emerging with an increase in the use of LUS and CFVR, especially in high-volume centers.

Myocardial metastasis from oesophageal cancer.

Three years after surgical resection of oesophageal tumour, during the regular instrumental oncologic follow-up performed by thoracic computed tomography scan in an otherwise asymptomatic 48-year-old man, a left ventricular mass was detected. It developed during a 6-month-period, and at the time of discovery it measured 63 × 61 mm. The mass was further evaluated with echocardiography and cardiac magnetic resonance imaging, and a histology specimen was obtained by myocardial biopsy, revealing it was a metastasis from the primitive tumour, in the absence of other organ involvement. The diagnostic process and possible therapeutic options for solitary intracardiac metastasis in the absence of involvement of other organs are briefly discussed.

Added value of real time three-dimensional echocardiography in the diagnosis of an apical right ventricular metastasis from malignant melanoma.

In a man presenting to the emergency room with dyspnea and atypical chest pain irradiated among the scapulae, with new-onset diffuse negative T-waves on the ECG, the first clinical and diagnostic hypothesis was pulmonary embolism (PE). However, computed tomography (CT) performed in emergency was negative for PE, showing instead a marked defect in right ventricle (RV) filling. For this reason, echocardiography was performed to better investigate the nature of the space-occupying lesion, and several echocardiographic modalities were used (two-dimensional transthoracic and transesophageal echocardiography and three-dimensional [3D] transthoracic echocardiography). They revealed the presence of a mass attached to the apex of the RV, partially obstructing the inflow and outflow tracts. Cardiac magnetic resonance imaging was also performed, confirming the findings of 3D echocardiography. After that, several other diagnostic imaging techniques were used for disease staging, since the patient had a history of surgical excision of a malignant melanoma of the skin several years before. Whole-body CT, soft tissue echography and positron emission tomography revealed the widespread diffusion of the primary tumor to distant organs. For this reason, we suspected that the RV mass could also be an intracardiac metastasis from malignant melanoma, and did not perform biopsy given the bad clinical conditions and the worse prognosis of the patient. However, he was entered in an experimental therapeutic protocol with Vemurafenib because he showed B-RAF gene mutation at molecular gene analysis.

Persistence of arterial functional abnormalities after successful coronary revascularization.

BACKGROUND: In patients with myocardial ischemia and coronary atherosclerosis, arterial stiffness and endothelial function are impaired. Whether these alterations can be favorably affected by successful coronary revascularization is debated. METHODS: We studied 39 hospitalized patients 59.3 ± 3.2 years old (mean ± SEM). In 21 patients with angiographic evidence of significant coronary artery stenosis, revascularization procedures were performed (stenting n = 11 and bypass surgery n = 10). The remaining patients had no significant stenosis and thus served as controls. Prerevascularization measurements included carotido-femoral pulse wave velocity (PWV), radial artery flow-mediated vasodilatation and a complete echocardiographic examination. The same measurements were performed 6 months later. Pharmacological treatment consisted of different cardiovascular drugs and remained substantially unchanged over the 6-month follow-up period. RESULTS: With the exception of an increased left ventricular mass index (LVMI; 130 ± 5.3 versus 105.8 ± 7.2 g/m(2), P < 0.05) and a lower Em/Am (0.6 ± 0.01 and 0.8 ± 0.01 respectively, P < 0.05) observed in patients with coronary stenosis, all other hemodynamic, cardiac and vascular variables were similar in the two groups. Following the 6-month follow-up period, all variables remained substantially unchanged, with the exception, in revascularized patients, of a significant reduction in LVMI (-12%, P < 0.05) and an improvement in Tissue Doppler Imaging-measured diastolic function (Em/Am + 30%, P < 0.05). This was not associated, however, with any significant change in PWV and in flow-mediated vasodilatation. CONCLUSION: Cardiac revascularization has no effect on arterial function, assessed either as arterial stiffness or as flow-mediated vasodilatation. On the contrary, the improvement in coronary blood flow triggers local cardiac changes, namely, a reduction in LVMI and an improvement in diastolic function.

Unusual localization of a malignant fibrous histiocytoma on the mitral valve.

The present report describes the case of a 55-year-old woman who suffered from cardio-embolic stroke originating from malignant fibrous histiocytoma (MFH) localized on the mitral valve. The patient underwent transthoracic two-/three-dimensional and transoesophageal echocardiography which demonstrated the mass protruding in the outflow tract of the left ventricle. Differential diagnosis had to be made with other masses in the left ventricle, such as thrombi, vegetations, and cardiac tumours. Surgery was performed to remove the tumour and the surgery findings confirmed echocardiographic images. Primary cardiac tumours are a rare entity, and their incidence is approximately 0.0017-0.019%. The majority of them are benign, but in a quarter of cases they are malignant. This case is an example of an MFH which caused embolism to the central nervous system.

Optimizing long-term cardiac management after major vascular surgery: Role of beta-blocker therapy, clinical characteristics, and dobutamine stress echocardiography to optimize long-term cardiac management after major vascular surgery.

BACKGROUND: Survivors of major vascular surgery are at increased risk of late cardiac complications. OBJECTIVE: To examine the cardioprotective effect of beta-blockers. METHODS: A follow-up study was conducted in 1286 patients who survived surgery for at least 30 days. Patients were screened for cardiac risk factors and dobutamine stress echocardiography (DSE) results; 1034 patients (80%) underwent preoperative DSE, and 370 (29%) received beta-blockers. The main outcome measure was late cardiac death or myocardial infarction. RESULTS: Seventy-four patients (5.8%) had late cardiac events. Cardiac event rates in patients with 0, 1 to 2, and 3 or more risk factors were 1.6%, 4.7%, and 19.2%, respectively. In patients without risk factors, beta-blockers were associated with improved event-free survival (2.8% vs 0%), and DSE had no additional prognostic value. In patients with 1 to 2 risk factors, the presence of ischemia during DSE increased cardiac events from 3.9% to 9.8%. However, if patients with ischemia were treated with beta-blockers, the risk decreased to 7.2%. In patients with 3 or more risk factors, DSE and beta-blockers stratified patients into intermediate- and high-risk groups. In patients without ischemia, beta-blockers reduced the cardiac event rate from 15.1% to 9.5%, whereas the cardioprotective effect was limited in patients with 3 or more risk factors and positive DSE findings. CONCLUSIONS: Long-term beta-blocker use is associated with a reduction in the cardiac event rate, except for patients with 3 or more risk factors and positive findings on DSE.

A case of cardiac localization of graft-versus-host disease after allogenic bone marrow transplantation.

A 29-year-old male developed symptoms and signs of heart failure shortly after allogenic bone marrow transplantation for chronic myelogenous leukemia. Echocardiographic evaluation showed left ventricular wall thickening, a left ventricular restrictive filling pattern and pericardial effusion. Cardiac magnetic resonance revealed nodular areas compatible with lymphocyte infiltration. The hypothesis of cardiac graft-versus-host disease was supported by the reversibility of all the abnormalities after specific treatment.

[Echocardiography in patients with acute cerebrovascular syndromes. Rational use and clinical impact]. / L'ecocardiografia nei pazienti con sindromi cerebrovascolari acute. Razionale all'utilizzo ed impatto clinico.

About 30% of acute cerebrovascular attacks have a cardioembolic etiology. It is well known that intracardiac thrombi or tumors are related to acute cerebrovascular attacks. However, the role of other cardiac lesions is not so clear. Echocardiography, in particular with transesophageal echocardiography, has the potentiality to correctly identify the cardiac source. In the clinical scenario, the diagnosis is important but the clinical impact in terms of therapy should also be considered. The aim of this paper was to review the potential role of echocardiography in patients with an acute cerebrovascular attack and to propose an evaluation flow-chart of these patients.