Early Detection of Myocardial Damage: A Multimodality Approach.

Cardiovascular diseases are possible complications of antineoplastic treatment and may lead to premature morbidity and mortality among cancer survivors. A symptom-based follow-up is ineffective, and there are growing evidences that early detection of myocardial damage in patients treated with antineoplastic drugs is the key point to prevent the occurrence of damage and improve the prognosis of these patients. Different techniques have been proposed to monitor cardiac function in oncologic patients such as cardiac imaging (echocardiography, nuclear imaging, and cardiac magnetic resonance) and biomarkers (troponin and natriuretic peptides). The European Association of Cardiovascular Imaging/American Society of Echocardiography consensus document encourages an integrated approach to early detect cardiotoxicity.

Update on the Organizational Aspects of Echocardiography in Italy (From Operator Training to the Report: 2007-2019): A Consensus Document by the "Società Italiana di Ecocardiografia e CardioVascular Imaging" Accreditation Area and Board 2017-2019.

In 2007, Società Italiana di Ecocardiografia e CardioVascular Imaging (SIECVI) already SIEC, published the document on the organization of echocardiography in Italy. In the years following the technological evolution, cultural and health factors have changed "the way, we do echo" as a tool for the different clinical pathways. The SIECVI Accreditation Area and Board 2017-2019 considered necessary to review and update the document in the light of innovation in the application of ultrasound for the heart disease assessment. In the document, we have considered the role of SIECVI in multimodal imaging, the need of training and certification of operators, the quality of echo machines, the accreditation of laboratories, the compilation of the report and its responsibility, and the presence of the sonographers in the EchoLab.

Bicuspid Aortic Valve Registry of the Italian Society of Echocardiography and Cardiovascular Imaging (REgistro della valvola aortica bicuspide della società italiana di ECocardiografia e CArdiovascular imaging): Rationale and Study Design.

BACKGROUND: Bicuspid aortic valve (BAV) is the most common congenital heart disease, affecting 0.5%-2% of the general population. It is associated not only with notable valvular risk (aortic stenosis and/or regurgitation, endocarditis) but also with aortopathy with a wide spectrum of unpredictable clinical presentations, including aneurysmal dilation of the aortic root and/or ascending thoracic aorta, isthmic coarctation, aortic dissection, or wall rupture. METHODS: The REgistro della Valvola Aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging is a retrospective (from January 1, 2010)/prospective, multicenter, observational registry, expected to enroll 3000 patients with definitive diagnosis of BAV made by transthoracic and/or transesophageal echocardiography, computed tomography, cardiovascular magnetic resonance, or at surgery. Inclusion criteria were definitive diagnosis of BAV. Patients will be enrolled regardless of the presence and severity of aortic valve dysfunction or aortic vessel disease and the coexistence of other congenital cardiovascular malformations. Exclusion criteria were uncertain BAV diagnosis, impossibility of obtaining informed consent, inability to carry out the follow-up. Anamnestic, demographic, clinical, and instrumental data collected both at first evaluation and during follow-up will be integrated into dedicated software. The aim is to derive a data set of unselected BAV patients with the main purpose of assessing the current clinical presentation, management, and outcomes of BAV. CONCLUSIONS: A multicenter registry covering a large population of BAV patients could have a profound impact on the understanding of the natural history of this disease and could influence its management.

Virtual Dissection by Ultrasound: Probe Handling in the First Year of Medical Education.

OBJECTIVES: The aim of the present study was to assess the educational plan of first-year students of medicine by analyzing their scores in ultrasound body scanning. METHODS: Since 2009, the San Paolo Medical School (Milan, Italy) has vertically integrated the study of anatomy with ultrasound-assisted virtual body dissection. Three modules were supplied: musculoskeletal system, heart and abdomen pelvis. 653 first-year students were trained. The students alternated as mutual model and operator. A skillfulness score was assigned to each student. The scores were consequently listed. Nonparametric exact multiple contrast tests were employed to determine relative group effects. RESULTS: Statistical analysis showed that: no gender-related differences were found (0:49; p=0.769); peer learners performed less well than peer tutors (0.677; p=0); between modules, scores in the musculoskeletal system (pMS=0.726) tend to be higher (p<0.001) than those obtained in the heart and abdomen pelvis (pH=0.398; pAP=0.375 p=0.270); significant differences were found compared to the beginning of the project's academic year. CONCLUSION: The students considered this didactic course an engaging and exciting approach. Acceptance of peer teaching was extraordinarily high. Autonomous exercitation allowed the students to improve self-criticism and enhance their own skills. The level of expertise obtained by peer tutors and by peer learners can be considered satisfactory. The main objective of training future physicians on personal stethoechoscope with the necessary competence seems to have been successfully started.

[Postural effect in patients with patent foramen ovale: evaluation of right-to-left shunt with transcranial Doppler and transthoracic echocardiography and correlation with arterial oxygen saturation]. / L'effetto della postura nei pazienti con forame ovale pervio: valutazione dello shunt destro-sinistro con Doppler transcranico ed ecocardiografia transtoracica e correlazione con la saturazione arteriosa di ossigeno.

BACKGROUND: Transcranial Doppler echocardiography and transthoracic echocardiography may detect with high accuracy right-to-left shunt (RLS) due to patent foramen ovale (PFO). However, a standardized diagnostic protocol has never been established. It has been suggested that standing or sitting positions may improve sensitivity of transcranial Doppler due to increased LRS in such positions. We aimed to test efficacy of the sitting position in addition to the supine position in the grading of RLS in patients with PFO. We have also evaluated whether an increase in RLS is associated with a fall in oxygen saturation (SaO2). METHODS: From September 2015 to February 2016, 70 consecutive patients with suspected PFO underwent transcranial Doppler echocardiography and transthoracic echocardiography with microbubble count and evaluation of SaO2. RESULTS: RLS due to PFO was diagnosed in 58 patients (82.9%). An increase in RLS grade in the sitting position was observed in 28 out of 58 patients (48.3%) (group 1), whereas no increase was detected in 30 patients (51.7%) (group 2). Among the clinical and echocardiographic variables considered, group 1 and group 2 differed only in the prevalence of atrial septal aneurysm (35.7 vs 3.3%, p=0.002). Postural changes were not associated with a fall in SaO2. CONCLUSIONS: RLS increases in about half of patients with PFO in the sitting position compared with the supine position, whereas no changes occur in SaO2.

[Information and Communication Technology in medicine in Italy: problems and perspectives. A document by the "e-cardio" area of the Italian Association of Hospital Cardiologists (ANMCO)]. / Il problema della corretta implementazione dell'Information and Communication Technology in medicina nel nostro Paese: documento dell'Area "e-cardio" dell'Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO).

In Italy, health protection is an individual right protected by the article 32 of the Constitution, granted to everyone since 1978 by the foundation of the National Health Service. However, regionalization of the healthcare system has caused noticeable discrepancies among the different areas of the country. The use of the Information and Communication Technology (ICT) may be useful to solve them. The purpose of this document is to analyze the implementation of ICT in Italy, on the basis of the suggestions given by the Italian Association of Hospital Cardiologists (ANMCO). In 2010, the Italian government introduced the electronic health record (EHR), which includes a minimum core of essential documents that should be created and updated by general practitioners. The obvious limitations of this methodology become clear in the urgency-emergency clinical setting, where the availability of particular clinical data may influence both patient prognosis and cost reduction. Also the privacy rules, currently very restrictive, cause a drawback in reliability of the data reported in the EHR, thus arising the need for a balance shift from privacy to health rights at the level of both the individual and the community. A minimum core of mandatory clinical data to be included in the EHR should be defined. No formal indications for filling out the medical records are available and most few experiences concern "bureaucratic documents" on the diagnostic and therapeutic process. Conversely, we believe that medical records should become a diagnostic and therapeutic tool that makes health rights uniform across the country. Each medical record form should include the following features: a simple interface, a mandatory association of clinical findings and reports, data portability and accessibility, and adherence of the information to a minimal dataset. Additionally, medical records data should merge into a modified EHR available at any time and place through network access points with adequate connection speed. In this respect, inhomogeneous availability of broadband in Italy is at present a major challenging issue. Finally, current training programs in medicine do not allow for widespread application of ICT among young physicians. Some essential topics should be covered by university formative credits. It is crucial to address different needs: the patient needs, making data on "biological heritage" always available; the physician needs, providing them with professional tools able to improve their daily quality of work; the managers' and public decision makers' needs, helping to optimize costs of the healthcare system.

C-reactive protein but not atrial dysfunction predicts recurrences of atrial fibrillation after cardioversion in patients with preserved left ventricular function.

OBJECTIVES: Maintenance of sinus rhythm after cardioversion of atrial fibrillation is a major clinical challenge also in patients with preserved left ventricular function. Subclinical inflammation and atrial strain have been recognized as important contributors to atrial fibrillation onset and perpetuation. Aim of the study was to compare the predictive role of C-reactive protein (CRP) and indices of atrial dysfunction in relation to subacute arrhythmic recurrence rate in patients with persistent atrial fibrillation and normal left ventricular ejection fraction (LVEF). METHODS: We studied 53 patients with a mean LVEF of 58.7 +/- 6%. Left atrial diameter and area, left atrial auricle emptying velocity, N-terminal pro-b-type natriuretic peptide (NT-proBNP) and CRP levels were determined few hours before electrical cardioversion. NT-proBNP and CRP levels were also measured 1 h and 3 weeks after cardioversion. RESULTS: Subacute atrial fibrillation recurrences were documented in 18 (33.9%) patients. Whereas none of the parameters reflecting atrial dysfunction predicted arrhythmic outcome, higher CRP levels (>3.0 mg/l) were significantly associated with atrial fibrillation recurrences [odds ratio (OR): 1.6; 95% confidence interval (CI): 1.4-2.5; P = 0.031]. No changes in CRP levels were evident after cardioversion independently of underlying rhythm. On the contrary, NT-proBNP levels, which were correlated with left atrial auricle emptying velocity, significantly decreased only in patients who maintained sinus rhythm (from 638 +/- 329 to 295 +/- 261 pg/ml; P < 0.001). CONCLUSION: The present study demonstrates that in patients with persistent atrial fibrillation and preserved LVEF, CRP level is an independent predictor of atrial fibrillation subacute recurrence rate, whereas none of the indices of atrial dysfunction is associated with arrhythmic outcome. NT-proBNP levels reflect, instead, the hemodynamic alterations secondary to arrhythmia presence.

[The "Appropriatezza ECO Milano" project. Assessment of appropriateness of indications, prescriptions and clinical utility of two-dimensional Doppler echocardiography among inpatients and outpatients of Milan, Italy]. / Progetto "Appropriatezza ECO Milano". Valutazione basale dell'appropriatezza delle indicazioni, della modalità delle prescrizioni e dell'utilità clinica dell'esame ecocardiografico bidimensionale color Doppler all'interno delle aziende ospedaliere e sul territorio.

BACKGROUND: The value of echocardiography in the diagnosis and follow-up of most cardiovascular diseases is well established, even though the ever-increasing demand for the use of this technique is not always justifiable. The "Appropriatezza ECO Milano" project was developed among hospitals in Milan (Italy) to foster a rational use of echocardiography. The aim of this study was to evaluate and improve appropriateness of requests for two-dimensional color Doppler echocardiography, considering indications, prescription behaviors and clinical utility in both the outpatient and inpatient settings. METHODS: Following several meetings, a consensus was reached whereby a multicenter, observational study would be undertaken. We assessed the value of each request in agreement with the 2003 American College of Cardiology/American Heart Association/American Society of Echocardiography guidelines. An ad hoc Microsoft Access database was developed to collect study data, which refer to May 2007. Eleven hospitals participated in the study. RESULTS: 4130 echocardiographic examinations were considered (2300 performed in men and 1830 performed in women; mean age 64 +/- 16 years); 1701 examinations were performed in hospitalized patients and 2429 in outpatients. The incidence of pathological findings was higher in hospitalized patients (73%) than in outpatients (53%) (Pearson chi2 = 29, p<0.001). A higher additional clinical value was found in hospitalized vs non-hospitalized patients (48 vs. 35%, Pearson chi2 = 99; p <0.001). In both settings, the majority of echocardiographic examinations were requested by cardiologists (inpatients 36%, outpatients 54%). The most appropriate examinations were performed more frequently in class I or class IIA hospitalized patients (73%) than in outpatients (52%) (Pearson chi2 = 277, p<0.001). Furthermore, the least accurate the indication, the less the clinical utility found in examinations requested from hospitals and outpatient clinics (64 vs 61% in class I patients, Pearson chi2 = 413, p<0.001; 5 vs 11% in class III patients, Pearson chi2 = 584, p<0.001). Conclusions. Our data confirm an inadequate level of appropriateness of requests for two-dimensional color Doppler examinations in either inpatients or outpatients. After over 10 years of passively observing and recording this trend, a timely resolution of these issues is topical in order to improve the implementation of criteria and to guarantee cost-effective and high-quality cardiovascular care.

High-grade video compression of echocardiographic studies: a multicenter validation study of selected motion pictures expert groups (MPEG)-4 algorithms.

BACKGROUND: Large files produced by standard compression algorithms slow down spread of digital and tele-echocardiography. We validated echocardiographic video high-grade compression with the new Motion Pictures Expert Groups (MPEG)-4 algorithms with a multicenter study. METHODS: Seven expert cardiologists blindly scored (5-point scale) 165 uncompressed and compressed 2-dimensional and color Doppler video clips, based on combined diagnostic content and image quality (uncompressed files as references). One digital video and 3 MPEG-4 algorithms (WM9, MV2, and DivX) were used, the latter at 3 compression levels (0%, 35%, and 60%). RESULTS: Compressed file sizes decreased from 12 to 83 MB to 0.03 to 2.3 MB (1:1051-1:26 reduction ratios). Mean SD of differences was 0.81 for intraobserver variability (uncompressed and digital video files). Compared with uncompressed files, only the DivX mean score at 35% (P = .04) and 60% (P = .001) compression was significantly reduced. At subcategory analysis, these differences were still significant for gray-scale and fundamental imaging but not for color or second harmonic tissue imaging. Original image quality, session sequence, compression grade, and bitrate were all independent determinants of mean score. CONCLUSIONS: Our study supports use of MPEG-4 algorithms to greatly reduce echocardiographic file sizes, thus facilitating archiving and transmission. Quality evaluation studies should account for the many independent variables that affect image quality grading.

[Teleconsulting in echocardiography using a standard cable on HDSL]. / Teleconsulto in ecocardiografia con cavo telefonico standard in HDSL.

BACKGROUND: Teleconsultation in echocardiography is complex owing to the heavy images and video files to be exchanged; moreover standards for data acquisition still need to be defined. The aim of this experience was to verify the feasibility to connect two laboratories for teleconsulting using a standard HDSL telephone cable. METHODS: Hardware included one echocardiograph, one PC, video aquisition board and network board, USB webcam, Network router and an HDSL line for data communication. Software includes MS Windows XP and Netmeeting. The live interactivity between the labs was granted by a video streaming in MPEG4 format, directly delivered by the PC communication software. Standard DICOM was used for formal aspects. The platform has been verified during a demo at "National Congress of Cardiovascular Echography" in 2005. RESULTS: The experiment survey collected at the Teleconference gave a consistently good result. Twenty-one subjects filled in the questionnaire: 12 of them (57%) reported a difference between the video streaming and DICOM; whereas 7 of them (33%) did not point out it. Overall findings have been positive, even though 15 members (71%) reported feasibility with some difficulties; 18 members (86%) reported the possibility of really using this technology in the future. The total cost was 145000 euro. CONCLUSIONS: In our opinion, overall cost is more than acceptable especially considering how often to send data is more convenient than moving sick people or consultants.

Doppler echocardiographic assessment of the effects of inhaled long-acting beta2-agonists on pulmonary artery pressure in COPD patients.

Increase in pulmonary artery pressure (PAP), which is common in severe chronic obstructive pulmonary disease (COPD), is a predictor of mortality independent of airflow limitation. beta-agonists might slightly attenuate this increase because they exert a vasodilating effect on pulmonary circulation when systematically administered. We have investigated the acute effects of salmeterol and formoterol on echocardiographic systolic pulmonary artery pressure (sPAP) in 20 patients with COPD and a sPAP greater than 20mmHg at rest. Acute haemodynamic responses to inhaled formoterol or salmeterol were assessed in all patients, in a randomized, double-blind double-dummy fashion. On two consecutive days, patients received, in a randomized order, formoterol 12microg via Turbuhaler plus placebo via Diskus or salmeterol 50microg via Diskus plus placebo via Turbuhaler. Transthoracic Doppler echocardiography measurements of sPAP were made before and 15, 30, 60 and 180min after bronchodilator inhalation. Lung function, pulse oximetry and heart rate were also monitored at the same times. Mean sPAP significantly (p<0.05) decreased in comparison with baseline at 15, 30, and 60min post inhalation but returned towards control levels at 180min after both salmeterol and formoterol. There was no correlation between the maximum increase in FEV(1) and maximum decrease in sPAP either after inhalation of salmeterol (r(2)=0.071) or after that of formoterol (r(2)=0.0006). The increases in FEV(1) in comparison with baseline were always significant (p<0.05) from 15 to 180min post inhalation after either salmeterol or formoterol. Neither pulse oximetry nor heart rate changed in a significant manner (p>0.05). This study demonstrated that salmeterol and formoterol were equally beneficial for pulmonary haemodynamics in patients with COPD. A direct vasodilatation due to the activation of beta-adrenoceptors that are present in pulmonary vessels is a likely mechanism of their action in inducing the decrease in sPAP.

[Echocardiographic features in a case of tuberculous lymphadenitis]. / L'ecocardiogramma in un caso di linfoadenite tubercolare.

Tuberculosis can secondarily affect the heart, mainly the pericardium and less frequently the endocardium and coronary vessels. Tuberculous myocarditis usually is a post-mortem diagnosis, and affects the right atrium and left ventricle presenting as miliary granulomas with or without caseating necrosis, or as diffuse cellular infiltration. We report the case of a 65-year-old man, affected by tuberculous lymphadenitis, with a history of hyperkinetic atrial and ventricular arrhythmias. Magnetic resonance, transthoracic and transesophageal echocardiography showed a peculiar cardiac involvement, characterized by right ventricular and left atrial infiltration. As the patient refused myocardial biopsy, the diagnosis of tuberculous myocarditis was stated ex-adjuvantibus, after specific multidrug chemotherapy with complete remission of all echocardiographic abnormalities. Echocardiography represents a useful diagnostic tool in patients presenting with clinical and electrocardiographic features, that even not specific could be suggestive of tuberculous myocarditis, whose incidence could be greater than reported in the literature.

[Transesophageal and transthoracic echocardiography in the monitoring of a new endovascular left ventricle assist device]. / L'ecocardiografia transesofagea e transtoracica nel monitoraggio di un nuovo sistema endovascolare di assistenza ventricolare sinistra.

We report our experience with echocardiography to guide the placement of a new left ventricular assist device, the Impella Recover 100, and to monitor its functioning. We monitored the introduction of 4 Impella Recover 100 devices in 2 patients by means of the transesophageal approach in the operating room, and thereafter we monitored the functioning of the devices by means of the multisection transthoracic approach in the intensive coronary care unit. The first Impella placement was performed in a patient as a "bridge" to heart transplantation, whereas the other three placements were performed in a patient as "recovery" for acute myocarditis. In all patients transesophageal echocardiography turned out to be a valuable tool to monitor the introduction and the perioperative hemodynamic management of the Impella device. In the early postoperative phase, transthoracic echocardiography allowed us to assess any pump displacement, and optimize biventricular function and adequate inotropic support. In conclusion, transthoracic and transesophageal echocardiography resulted in a valuable method for monitoring the correct placement and functioning of the left ventricular assist device Impella Recover 100.

Myocardial Doppler at rest for the identification of myocardial viability.

BACKGROUND: Echocardiography may permit the detection of a nonviable myocardium. The aim of this study was to test if resting pulsed wave-tissue Doppler imaging (PW-TDI) might yield additional markers. METHODS: Fifty patients (38 males, 12 females, mean age 63 +/- 6 years) with left ventricular dysfunction (ejection fraction 35 +/- 10%) underwent echocardiography. The posterior septum, anterior septum, lateral, inferior, anterior and posterior walls were sampled on the basal segments in the apical views at PW-TDI. The following variables and cardiac phases were tested: 1) the isovolumic contraction phase velocity, polarity or detectability, 2) the ejection phase velocity, a detectable interval between the ejection phase and aortic valve closure, or ejection phase shape, and 3) the isovolumic relaxation phase velocity or ejection velocity/post-systolic shortening ratio. From the tested PW-TDI variables, viable and nonviable patterns were assembled, taking rest-redistribution 201thallium single-photon emission computed tomography as the independent reference for myocardial viability. Patients with significant loading alterations, mitral or aortic valve disease, and arrhythmias were excluded. RESULTS: Out of 219 dyssynergic segments, viability as identified according to conventional rest echocardiographic criteria appeared in 94 (47%), as identified at PW-TDI in 116 (53%), and as identified at nuclear imaging in 105 (48%). The resting PW-TDI variables consistent with absent myocardial viability were as follows: 1) an isovolumic contraction phase velocity equal to the ejection phase velocity +/- 1 cm/s, or absent, 2) an ejection phase velocity < or = 4 cm/s, usually with a gap between the ejection phase and aortic valve closure, or any shape of ejection but the typical single phase, and 3) an isovolumic relaxation phase velocity < 5 cm/s with an ejection phase velocity/isovolumic relaxation phase velocity ratio < 0.8. The accuracy for the identification of myocardial viability was: agreement 73%, kappa 0.44 for echocardiography, and agreement 75%, kappa 0.47 for PW-TDI. CONCLUSIONS: PW-TDI nonviable patterns may be a helpful additional tool for the identification of patients without residual myocardial viability.