EACVI survey on radiation exposure in interventional echocardiography.

AIMS: The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey on radiation exposure in interventional echocardiography. The survey aimed to collect data on local practices for radioprotection in interventional echocardiography and to assess the awareness of echocardiography operators about radiation-related risks. METHODS AND RESULTS: A total of 258 interventional echocardiographers from 52 different countries (48% European) responded to the survey. One hundred twenty-two (47%) participants were women. Two-thirds (76%) of interventional echocardiographers worked in tertiary care/university hospitals. Interventional echocardiography was the main clinical activity for 34% of the survey participants. The median time spent in the cath-lab for the echocardiographic monitoring of structural heart procedures was 10 (5-20) hours/month. Despite this, only 28% of interventional echocardiographers received periodic training and certification in radioprotection and 72% of them did not know their annual radiation dose. The main adopted personal protection devices were lead aprons and thyroid collars (95% and 92% of use, respectively). Dedicated architectural protective shielding was not available for 33% of interventional echocardiographers. Nearly two-thirds of responders thought that the radiation exposure of interventional echocardiographers was higher than that of interventional cardiologists and 72% claimed for an improvement in the radioprotection measures. CONCLUSION: Radioprotection measures for interventional echocardiographers are widely variable across centres. Radioprotection devices are often underused by interventional echocardiographers, portending an increased radiation-related risk. International scientific societies working in the field should collaborate to endorse radioprotection training, promote reliable radiation dose assessment, and support the adoption of radioprotection shielding dedicated to interventional echocardiographers.

Cardiovascular magnetic resonance in autoimmune rheumatic diseases: a clinical consensus document by the European Association of Cardiovascular Imaging.

Autoimmune rheumatic diseases (ARDs) involve multiple organs including the heart and vasculature. Despite novel treatments, patients with ARDs still experience a reduced life expectancy, partly caused by the higher prevalence of cardiovascular disease (CVD). This includes CV inflammation, rhythm disturbances, perfusion abnormalities (ischaemia/infarction), dysregulation of vasoreactivity, myocardial fibrosis, coagulation abnormalities, pulmonary hypertension, valvular disease, and side-effects of immunomodulatory therapy. Currently, the evaluation of CV involvement in patients with ARDs is based on the assessment of cardiac symptoms, coupled with electrocardiography, blood testing, and echocardiography. However, CVD may not become overt until late in the course of the disease, thus potentially limiting the therapeutic window for intervention. More recently, cardiovascular magnetic resonance (CMR) has allowed for the early identification of pathophysiologic structural/functional alterations that take place before the onset of clinically overt CVD. CMR allows for detailed evaluation of biventricular function together with tissue characterization of vessels/myocardium in the same examination, yielding a reliable assessment of disease activity that might not be mirrored by blood biomarkers and other imaging modalities. Therefore, CMR provides diagnostic information that enables timely clinical decision-making and facilitates the tailoring of treatment to individual patients. Here we review the role of CMR in the early and accurate diagnosis of CVD in patients with ARDs compared with other non-invasive imaging modalities. Furthermore, we present a consensus-based decision algorithm for when a CMR study could be considered in patients with ARDs, together with a standardized study protocol. Lastly, we discuss the clinical implications of findings from a CMR examination.

Correction to: A case of intracoronary and endovenous levosimendan as a rescue therapy for refractory cardiac arrest.

After publication of this supplement [1], it was brought to our attention that the author 'L. Vegnuti' has been erroneously omitted from the author list of the following abstract.

Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment.

Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.

Critical finger ischemia and myocardial fibrosis development after sudden interruption of sildenafil treatment in a systemic sclerosis patient.

Systemic sclerosis (SSc) is a connective tissue disease frequently associated with Raynaud's Phenomenon (RP). Among possible pharmacological treatments, phosphodiesterase 5 inhibitors are considered in cases of severe non -responsive RP. We present the case of a male SSc patient wh presented with critical finger ischemia and concomitant appearance of myocardial fibrosis after sudden interruption of sildenafil treatment.

Usefulness of lung ultrasound in a newborn with pulmonary atelectasis.

The use of ultrasound for the evaluation of the lung is relatively recent. We describe the case of a newborn with pulmonary atelectasis and shift of the mediastinum underlining both advantages and limits of lung ultrasound (LUS). The baby, 1 month of age, was admitted to our hospital for tachypnoea, vomiting and poor weight gain. Chest X-ray (CXR) showed displacement of the heart to the right, suggesting the presence of atelectasis of the right lung. LUS confirmed the displacement of the mediastinum to the right and atelectasis of the right lung, clearly visible as a consolidation with the presence of air bronchograms. The computed tomography image showed that the lung parenchyma displayed in the right hemithorax could be attributed to the hyperexpanded left lung. However, once this information was acquired, and compared to the ultrasound picture, we were able to monitor the patient by LUS until normalization, thus avoiding further exposure to ionizing radiation. Our case, in accordance with the recent Literature, indicates that LUS can be adopted as a simple and non-invasive method for evaluating children with lung disease. It is easy to perform at bedside, allows a close follow-up and avoids the use of ionizing radiation.

[Ultrasound lung comets: new echographic sign of lung interstitial fibrosis in systemic sclerosis]. / Le comete ultrasoniche polmonari (ULC): un nuovo segno ecografico di fibrosi polmonare nella sclerodermia.

OBJECTIVE: Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are common complications of systemic sclerosis (SSc). Echocardiography evaluates PAH, and chest sonography detects even mild ILC as ultrasound lung comets (ULC), i.e. multiple comet-tails fanning out from the lung surface and originating from subpleural interlobular septa thickened by fibrosis. AIM: to assess ILaD and PAH by integrated cardiac and chest ultrasound in SSc. METHODS: We enrolled 30 consecutive SSc patients (age= 54+/-13 years, 23 females) in the Rheumatology Clinic of Pisa University. In all, we assessed systolic pulmonary arterial pressure (SPAP), from maximal velocity of tricuspid regurgitation flow, and ULC score with chest sonography (summing the number of ULC from each scanning space of anterior and posterior right and left chest, from second to fifth intercostal space). All patients underwent plasma assay for anti-topoisomerase antibodies (anti-Scl70), and antiicentromere associated with development of pulmonary involvement. Twenty-eight patients also underwent high resolution computed tomography, HRCT (from 0= no fibrosis to 3= honey combing). RESULTS: ULC number - but not SPAP - was correlated to HRCT fibrosis and presence Scl-70 antibodies. ULC number was similar in localized or diffuse forms (16+/-20 vs 21+/-19, p=ns) and was unrelated to SPAP (r=0.216, p=ns). CONCLUSIONS: Chest sonography assessment and ULC allow a complete, simple, radiation-free characterization of interstitial lung involvement in SSc - all in one setting and with the same instrument, same transducer and the same sonographer. In particular, ULC number is associated with HRCT evidence of lung fibrosis and presence of Scl-70 antibodies.

Ultrasound lung comets for the differential diagnosis of acute cardiogenic dyspnoea: a comparison with natriuretic peptides.

BACKGROUND: Acute dyspnoea as a presenting symptom is a frequent diagnostic challenge for physicians. The main differential diagnosis is between dyspnoea of cardiac and non-cardiac origin. Natriuretic peptides have been shown to be useful in this setting. Ultrasound lung comets (ULCs) are a simple, echographic method which can be used to assess pulmonary congestion. AIM: To evaluate the accuracy of ULCs for predicting dyspnoea of cardiac origin compared to natriuretic peptides. METHODS: We evaluated 149 patients admitted with acute dyspnoea. Chest sonography and NT-proBNP assessments were performed a maximum of 4 h apart and independently analyzed. ULCs were evaluated via cardiac probes placed on the anterior and lateral chest. Two independent physicians, blinded to ULCs and NT-proBNP findings, reviewed all the medical records to establish the aetiologic diagnosis of dyspnoea. RESULTS: Cardiogenic dyspnoea was confirmed in 122 patients and ruled-out in 27 patients. The number of ULCs was significantly correlated to NT-proBNP values (r=.69, p<.0001). Receiver operating characteristic analysis, showed an area under the curve of .893 for ULCs and .978 (p=.001) for NT-proBNP, in predicting the cardiac origin of dyspnoea. CONCLUSIONS: In patients admitted with acute dyspnoea, pulmonary congestion, sonographically imaged as ULCs, is significantly correlated to NT-proBNP values. The accuracy of ULCs in predicting the cardiac origin of dyspnoea is high.

Evaluation of ultrasound lung comets by hand-held echocardiography.

BACKGROUND: Ultrasound lung comets (ULCs) are a clinically useful sign of extravascular lung water. They require very limited technology (2 D-echo), and a short learning curve. The aim of the present study is to compare ULCs information obtained by experienced echocardiologists using a full feature echocardiographic platform and by inexperienced sonographers using a hand-held echocardiography system. METHODS: 20 consecutive in-hospital patients underwent, within 15' and in random order, 2 ultrasound examinations for ULCs by 2 observers with different specific expertise and different technology: 1) "high-tech veteran": ULCs assessment with full feature echocardiographic platform (HP Sonos 7500 Philips Medical Systems, Andover, MA, USA) by a trained echocardiologist, with > or =2 years expertise in ULCs assessment and accredited by the European Association of Echocardiography; 2) and a "low-tech beginner": ULCs assessment with hand-held echocardiography (Optigo; Philips, Andover, MA) by an echocardiographer with very limited (30') dedicated training on ULCs assessment. In each patient, ULC score was obtained by summing the number of comets from each of the scanning spaces in the anterior right and left hemithorax, from the second to the fifth intercostal space. RESULTS: There was a significant, tight correlation (r = .958, p < 0.001) between the 2 observations in the same patient by "high-tech veteran" and "low-tech beginner". CONCLUSION: ULCs are equally reliable in the hands of highly experienced echocardiologists using full feature echocardiographic platforms and in the hands of absolute beginners with miniaturized, compact, and battery-equipped echocardiographic systems. From the technological and expertise viewpoint, ULCs are the "kindergarten" of echocardiography, ideally suited for bedside evaluation of patients with both known or suspected heart failure.