Acute Modifications of Left Ventricular Torsional Mechanics Induced by Cardiac Resynchronization Therapy Affect Short-Term Reverse Remodeling.

BACKGROUND: Left ventricular (LV) torsion is an important aspect of cardiac mechanics and is altered in heart failure patients. Cardiac resynchronization therapy (CRT) has a positive effect on LV function, but the exact mechanisms through which it works are not completely depicted. Our aim was to investigate (1) the acute CRT effect on LV torsional mechanics in heart failure patients using 3D speckle tracking echocardiography (3DSTE) and (2) its effect on short-term LV remodeling. Methods and Results: We considered 48 patients (age 72±11 years, 35 men) who received CRT. They underwent 3DSTE during CRT-on (biventricular stimulation) vs. CRT-off (intrinsic conduction/right atrial/ventricular stimulation alone), in a random fashion. Patients were classified as CRT responders based on LV systolic volume reduction ≥15% at 6 months (final population: 31 responders, 17 non-responders). Acute CRT positively affected responders in terms of LV torsion (from 0.32±0.06°/cm CRT-off to 0.41±0.06°/cm CRT-on), but adversely affected non-responders (from 0.54±0.08°/cm CRT-off to 0.28±0.08°/cm CRT-on, interaction P=0.02). A similar trend was confirmed for apical (interaction P<0.04), but not for basal torsion (interaction P=0.351). CONCLUSIONS: CRT has a positive role in acute recovery of LV torsion (particularly in its apical component) in responders, likely modulating the improvement in LV remodeling at early follow-up.

One-Year Clinical Outcomes of Forty-Eight Millimeter Everolimus-Eluting Stent Implanted in Very Long Lesions: A Propensity-Matched Comparison (The FREIUS Study).

BACKGROUND: Long coronary lesions still remain a challenge, with poor immediate results and suboptimal outcomes when compared to class A/B1 lesions. The presence of overlapped segments of metal struts and polymer might trigger an abnormal inflammatory reaction, resulting in a higher restenosis rate. The aim of our study was to evaluate the safety, feasibility, and cost effectiveness of a 48 mm everolimus-eluting stent (EES) during treatment of very long coronary lesions. METHODS AND RESULTS: The FREIUS study is a prospective data collection of consecutive patients undergoing 48 mm EES implantation in six high-volume European centers. Each patient was matched through a propensity score to a comparable patient treated with two or more second-generation overlapped drug-eluting stents. The primary endpoint was the combined incidence of cardiac death, target-vessel myocardial infarction, and target-lesion revascularization (device-oriented composite endpoint [DOCE]). The secondary endpoints were all-cause death, each individual component of the primary endpoint, and definite/probable stent thrombosis. From January 2014 to April 2015, a total of 218 patients were treated with at least one 48 mm EES and were compared with 218 matched controls. Overall, 9% of patients reached the primary endpoint. Cumulative survival free from DOCE incidence did not differ between the two groups (7% in the cases vs 10.5% in the controls; P=.10). After multivariable analysis, only clinical presentation with myocardial infarction (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.5-2.1; P=.01) and stent number (HR, 1.4; 95% CI, 1.1-1.8; P=.02) emerged as independent predictors of DOCE. CONCLUSION: The use of 48 mm EES offers a safe and effective strategy for the treatment of very long coronary lesions.

Optical coherence tomography guidance during bioresorbable vascular scaffold implantation.

Bioresorbable vascular scaffold (BRS) represent a revolutionary concept in interventional cardiology. After initial enthusiasm, recent real world registries, including patients with increasing lesion complexity, reported not trivial rates of scaffold thrombosis (ScT). The importance of correct patients selection as well as technical aspects during BRS implantation procedures has been highlighted in several studies suggesting that the high rate of ScT might be related to uncorrected patients/lesions selection together with underutilization of intracoronary imaging guidance leading to suboptimal BRS implantation. The high-resolution power together with the lack of shadowing observed beyond polymer struts makes optical coherence tomography (OCT) the optimal imaging technique to guide BRS implantation and identifies eventually scaffolds failures.

Incremental value of right atrial strain for early diagnosis of hemodynamic deterioration in pulmonary hypertension: a new noninvasive tool for a more comprehensive diagnostic paradigma.

AIMS: Increased right atrial size is related to adverse prognosis in pulmonary hypertension. The potential incremental value of right atrial function assessment is still unclear. We tested the relationship between right atrial two-dimensional speckle-tracking echocardiography impairment and hemodynamic, functional and clinical deterioration in patients with pulmonary hypertension. METHODS: We prospectively evaluated 36 patients (27 female, 9 male; mean age 68 ±â€Š13 years) with suspected pulmonary hypertension undergoing right heart catheterization and 16 matched controls. All patients underwent baseline evaluation by New York Heart Association functional class, 6-min walking test, brain natriuretic peptide (BNP), and standard two-dimensional echocardiography in less than 48 h of right heart catheterization. Right atrial two-dimensional speckle-tracking echocardiography was assessed by averaging all segments in standard four-chamber apical view. RESULTS: Right atrial global integral strain was significantly lower in patients compared with controls (11.40 ±â€Š5.22% vs. 25.72 ±â€Š5.95 P < 0.001). Moreover, right atrial global strain, but not right atrial area or volume, was correlated with invasively measured cardiac index (CI) (r = 0.72; P < 0.0001) and pulmonary vascular resistances in all patients, even though stronger in subjects with precapillary pulmonary hypertension (r = -0.42, P = 0.018; r = -0.54, P = 0.007 respectively; P = 0.007). It was also correlated with New York Heart Association (P = 0.027), BNP (P = 0.002), and 6-min walking test (P = 0.006). After multivariate analysis including right atrial volume, tricuspid annular plane systolic excursion, left atrial strain, and BNP, right atrial global strain showed the strongest correlation with CI. Area under the curve optimal cutoff for predicting CI at least 2.4 l/min/m was 17% (area under the curve: 0.83, sensitivity: 90%, specificity: 54%). CONCLUSION: Right atrial global strain can identify right atrial functional impairment before structural changes and may be implemented in a comprehensive, noninvasive right heart assessment for diagnosis and follow-up of pulmonary hypertension patients.

Non-invasively estimated left atrial stiffness is associated with short-term recurrence of atrial fibrillation after electrical cardioversion.

BACKGROUND: As atrial stiffness (Kla) is an important determinant of cardiac pump function, better mechanical characterization of left atrial (LA) cavity would be clinically relevant. Pulmonary venous ablation is an option for atrial fibrillation (AF) treatment that offers a powerful context for improving our understanding of LA mechanical function. We hypothesized that a relation could be detected between invasive estimation of Kla and new non-invasive deformation parameters and traditional LA and left ventricular (LV) function descriptors, so that Kla can be estimated non-invasively. We also hypothesized that a non-invasive surrogate of Kla would be useful in predicting AF recurrence after cardioversion. METHODS: In 20 patients undergoing AF ablation, LA pressure-volume curves were derived from invasive pressure and echocardiographic images; Kla was calculated during ascending limb of V-loop as ΔLA pressure/ΔLA volume. 2D-speckle-tracking echocardiographic LA and LV longitudinal strains and volumes, ejection fraction (EF) and ventricular stiffness (Klv), as obtained from mitral deceleration time, were tested as non-invasive Kla predictors. In 128 sinus rhythm patients 1 month after electrical cardioversion for persistent AF, non-invasively estimated Kla (computed-Kla) was tested as predictor of recurrence at 6 months. RESULTS: Tertiles of mean LA pressure correlated with increasing Kla (trend, p=0.06) and decreasing LA peak strain, LVEF, and LV longitudinal strain (p=0.029, p=0.019, and p=0.024). There were no differences in LA and LV volumes and Klv across groups. Multiple regression analysis identified LV longitudinal strain as the only independent predictor of Kla (p=0.014). Patients in highest quartile of computed-Kla (estimated as [log]=0.735+0.051×LV strain) tended to have highest AF recurrence rate (25%) as compared with remaining 3 quartiles (9%, 9%, 3%, p=0.09). CONCLUSION: Kla can be assessed invasively in patients undergoing AF ablation and it can be estimated non-invasively using LV strain. AF recurrence after cardioversion tends to be highest in highest quartile of computed-Kla.

Time-related changes in neointimal tissue coverage of a novel Sirolimus eluting stent: Serial observations with optical coherence tomography.

BACKGROUND: DES has reduced rates of restenosis compared with BMS but it has been associated with delayed healing and increase of stent thrombosis. The aim of our study was to evaluate the vascular time-related changes following implantation of a new SES coated with an amorphous silicon carbide that allows faster re-endothelisation (Orsiro-Biotronik). METHODS: This prospective registry enrolled STEMI-patients with multi-vessel disease, thus candidates for a two-step procedure. PCI of the culprit lesion was performed with at least one Orsiro stent that was OCT-analysed during the second-step procedure (deferred to 30,90 and 180-days). RESULTS: 16 of the 95 patients with MVD underwent an OCT evaluation of the study device implanted in the culprit lesion during the second-step staged procedure and were enrolled in the present Registry. A total of 3060-struts were analysed. The percentage of uncovered struts was 19.6% at30-days, 1.3% at90-days and 1.8% at180-days (p<0.001). The percentage of cross section with ≥1 uncovered struts were 51.3% at30-days, 6.5% at90-days and 5.7% at180-days (p<0.001). The percentage of cross sections containing thrombus was 6.2% at30-days while no thrombus was detected both at90 and 180-days. CONCLUSIONS: Our data shows that the new Orsiro stent promotes early and persistent strut coverage with low peri-strut thrombus. This pilot OCT evaluation might suggest a low incidence of late adverse events and anticipate safe outcome after early withdrawal of dual antiplatelet therapy.

Acute contractile recovery extent during biventricular pacing is not associated with follow-up in patients undergoing resynchronization.

BACKGROUND: It has been reported that contractility, as assessed using dobutamine infusion, is independently associated with reverse remodeling after CRT. Controversy, however, exists about the capacity of this approach to predict a long-term clinical response. This study's purpose was to assess whether long-term CRT clinical effects can be predicted according to acute inotropic response induced by biventricular stimulation (CRT on), as compared with AAI-VVI right stimulation pacing mode (CRT off), quantified at the time of implantation. METHODS: In 98 patients (ejection fraction 29 ± 10%), acute changes in left ventricular (LV) elastance (Ees), arterial elastance (Ea), and Ees/Ea, as assessed from slope changes of the force-frequency relation obtained when the heart rate increased, and also assessed while measuring triplane LV volumes and continuous noninvasive blood pressure, were related to death or rehospitalization during a 3-year follow-up. Other covariances tested were age, gender, disease etiology, QRS duration, amount of mitral regurgitation, LV diastolic volume, ejection fraction, and the degree of asynchrony and longitudinal strain at baseline. RESULTS: There was a marked increment in the Ees slope with CRT (interaction P = 0.004), no Ea change, and modest Ees/Ea increase (interaction P < 0.05). In Cox analysis, however, neither slope changes nor baseline values of Ees, Ea, and Ees/Ea were associated with long-term follow-up. Only ventricular diastolic volume (direct relation P = 0.002) and QRS duration (inverse relation P = 0.009) predicted death/rehospitalization. CONCLUSIONS: Acute contractile recovery in CRT patients is not associated with 3 years prognosis. Instead, death or rehospitalization can be predicted from QRS duration and LV diastolic volume at baseline.

Very high-pressure dilatation for undilatable coronary lesions: indications and results with a new dedicated balloon.

AIMS: Calcific coronary lesions impose a rigid obstacle to optimal balloon and stent expansion and the 20 to 30 atm limit that non-compliant (NC) balloons reach can be insufficient. The aim of our study was to evaluate the safety and efficacy of a new dedicated super high-pressure NC balloon (OPN NC®; SIS Medical AG, Winterthur, Switzerland). METHODS AND RESULTS: We retrospectively evaluated a consecutive series of 91 lesions in which conventional NC balloons at maximal pressure failed to achieve an adequate post-dilatation luminal gain and were therefore treated with an OPN NC balloon up to 40 atm. Angiographic success was defined as residual angiographic diameter stenosis <30%. MLD and %DS were measured at baseline, after NC balloon, OPN NC balloon and stent implantation. Angiographic success was achieved in 84 lesions (92.3%). All of the remaining lesions received rotational atherectomy with the exception of two cases in which rotational atherectomy was not attempted because of small vessel size and excessive tortuosity. MLD and acute gain were significantly greater and %DS was significantly lower post OPN NC balloon compared with conventional NC balloon inflation (p<0.001). No coronary perforations occurred. No acute or 30-day follow-up MACE was reported. CONCLUSIONS: When conventional NC balloons fail, the new OPN NC dedicated high-pressure balloon provides an effective and safe alternative strategy for the dilatation of resistant coronary lesions.

Indications and immediate and long-term results of a novel pericardium covered stent graft: Consecutive 5 year single center experience.

BACKGROUND: The use of covered stent grafts during percutaneous coronary intervention (PCI) is a life saving solution to seal acute iatrogenic vessel rupture. However, the presence of an impenetrable mechanical barrier is also appealing during treatment of friable coronary plaques but the synthetic PTFE-membrane that might trigger excessive neointimal proliferation has limited its elective-use. Pericardium tissue may offer an appealing "natural" alternative. Aim of our study is to report the consecutive 5-year single center experience with the use of pericardium-covered stents (PCS) (ITGI-Medical, Israel) in a variety of emergency and elective applications. METHODS: Nineteen consecutive patients undergoing implantation of PCS at the Royal Brompton in the last 5-years. Reasons for PCS implantation included treatment of degenerated vein grafts, large coronary aneurysms, and acute iatrogenic vessel rupture. RESULTS: Angiographic success, defined as the ability of the device to be deployed in the indexed lesion with no contrast extravasation with residual angiographic stenosis <30% and a final thrombolysis in myocardial infarction (TIMI)-3 flow was achieved in all cases. Procedural success, defined as the achievement of angiographic success without any major adverse cardiovascular event (MACE) was achieved in 94.7% of patients. In-stent restenosis (ISR) was observed in 26.3% and all patients underwent successful target vessel revascularization with DES (mean time to restenosis 9.0 ± 4.0 months). At a mean follow-up of 32.5 ± 23.3 months no acute or late stent thrombosis was observed. CONCLUSION: PCSs were effective in the treatment of friable embolization-prone coronary plaques, sealing of acute iatrogenic vessel rupture and exclusion of large aneurysms with no thrombosis but high target lesion revascularization.

[An unusual case of postinfarction ventricular septal rupture in a patient with angiographically normal coronary arteries]. / Un caso inusuale di rottura di setto interventricolare postinfartuale in coronarie indenni da lesioni.

Ventricular septal defect is a rare but potentially fatal complication of acute myocardial infarction. It usually occurs during the first episode of myocardial infarction, most often in patients with single vessel coronary artery disease and total occlusion of the culprit vessel, in the absence of an adequate collateral circulation. However, this complication is observed in patients with myocardial infarction with normal coronary arteries and its pathogenesis may be attributed to different mechanisms such as inflammation, hypercoagulable state or coronary vasospasm. We report the case of a 59-year-old female patient with anteroseptal myocardial infarction developed 4 days after admission, complicated by ventricular septal defect with signs of congestive heart failure and angiographically normal coronary arteries.

Systolic heart failure and cardiac resynchronization therapy: a focus on diastole.

Conflicting data exist about the effects of cardiac resynchronization therapy (CRT) on diastolic function (DF). Aim of the study was to assess if and how CRT affects DF in systolic heart failure patients. We also investigated potential relations between CRT-induced left ventricular changes and the composite clinical endpoint of progressive heart failure and cardiac death over 3 years follow-up. 119 CRT patients underwent clinical evaluation and echocardiography before CRT and 4 months later. DF was quantified by transmitral velocities [E/A waves, deceleration time (DT), E/DT], early diastolic mitral annulus velocity (E'), E/E' ratio and 2-D speckle tracking strain rate during isovolumetric relaxation (IVR, SRivr). End-diastolic pressure-volume relationship (EDPVR) was also assessed noninvasively using a single-beat method. Overall stiffness was quantified by ventricular stiffness (Klv) normalized to end-diastolic volume (EDV). New York Heart Association class improved at 4 months (from 2.7 ± 0.7 to 1.9 ± 0.6, p < 0.001) as did ventricular filling (E/DT from 0.48 ± 0.29 to 0.39 ± 0.31 cm/s(2), p = 0.01). In contrast, relaxation (E', SRivr) and filling pressures (E/E', E/SRivr) did not change. Slope of EDPVR did not change with CRT. Such finding, together with an unmodified Klv/EDV and a 7 ± 18 % reduction in EDV (p = 0.001), suggested reverse remodelling towards a smaller equilibrium volume. Finally, end-systolic LV volume decreased from 147 ± 59 to 125 ± 52 ml and ejection fraction increased from 0.26 ± 0.07 to 0.32 ± 0.09 (both p < 0.001). Using a Cox regression model we found that only changes (Δ) in diastolic, but not systolic indexes, correlated with the composite clinical endpoint, with increments in ΔEDV20 and ΔE/DT, single or combined, greatly increasing risk of heart failure and/or cardiac death (p = 0.003). Ventricular reverse remodelling, together with improvement in ventricular filling, rather than improvements of systolic function, predict clinical prognosis long-term post-CRT.

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

P2Y12 inhibitors: pharmacologic mechanism and clinical relevance.

Platelets play a critical role in the pathogenesis of atherothrombotic processes and inhibition of platelet aggregation by antiplatelet therapy is essential and really important in the acute coronary syndromes or in the setting of percutaneous coronary intervention. The first family of adenosine diphosphate P2Y12 receptors inhibiting drug is represented by thienopyridines and among these ticlopidine was the first approved by Food and Drug Administration; actually its use is discouraged because of its potential side effects (neutropenia, anemia, gastrointestinal distress and thrombotic thrombocytopenic purpura). The second generation of thienopyridines is represented by clopidogrel that has replaced ticlopidine in the clinical practice; clopidogrel has the largest clinical experience. Prasugrel represents the third generation. It inhibits platelet aggregation by irreversibly blocking the adenosine diphosphate P2Y12 receptor. Ticagrelor, Cangrelor and Enilogrel represent the last generation of thienopyridines. This review is focused on the effects of adenosine diphosphate P2Y12 inhibitors.

Stable ventricular fibrillation in a heterotopic heart transplant recipient.

We present an unusual case of ventricular fibrillation in a conscious patient symptomatic for chest pain and shortness of breath. Almost 20 years ago he underwent heterotopic cardiac transplantation for the treatment of severe idiopathic cardiomyopathy. In the precyclosporine era, this technique was extremely useful because of the high rate of graft rejection in which the maintenance of the native heart could prevent patient death. To date, with the improvements in immunosuppressive therapy, it is generally reserved to a specific subset of conditions. A coronary angiography and a cardiac MRI confirmed the diagnosis. Six months follow-up ECG was unchanged suggesting the persistence of a double heart rhythm in the same body.

The relationship between early left ventricular myocardial alterations and reduced coronary flow reserve in non-insulin-dependent diabetic patients with microvascular angina.

AIMS: To evaluate left ventricular (LV) systolic and diastolic myocardial function, and their relation to coronary flow reserve in patients with non-insulin-dependent diabetes mellitus (DM) and microvascular angina. METHODS AND RESULTS: We selected a population of 45 normotensive patients with DM (56.3 ± 8.2 years; 25 males) with LV ejection fraction >50% and microvascular angina (anginal pain, positive imaging stress test and normal coronary angiography). Thirty-five age- and sex-matched healthy controls were also enrolled. All the patients underwent standard echocardiography, Tissue Doppler (TDI), two-dimensional strain (2DSE) imaging, and coronary flow reserve (CFR) measurement. LV myocardial early diastolic peak velocities (E(m)) and peak systolic 2DSE were reduced in both interventricular septum (IVS) and LV lateral wall (p<0.01) in DM, as well as CFR (1.89 ± 0.7 vs 2.55 ± 0.56, p<0.0001) compared with controls. By multivariate analysis, the independent determinants of E(m) were glycated haemoglobin (ß coefficient=-0.36; p<0.01) and age (ß=-0.46, p<0.001), while global longitudinal strain was predicted by glycated haemoglobin (ß=0.48, P<0.001) and by the duration of the disease (ß=0.38, P<0.005). An independent association between LV global longitudinal strain and CFR (ß coefficient=-0.47, p<0.001) in DM patients was also evidenced. CONCLUSIONS: TDI, 2DSE and CFR are valuable non-invasive and easy-repeatable tools for detecting LV myocardial and coronary function in DM patients with microvascular angina.

Methodological approach for the assessment of ultrasound reproducibility of cardiac structure and function: a proposal of the study group of Echocardiography of the Italian Society of Cardiology (Ultra Cardia SIC) part I.

When applying echo-Doppler imaging for either clinical or research purposes it is very important to select the most adequate modality/technology and choose the most reliable and reproducible measurements. Quality control is a mainstay to reduce variability among institutions and operators and must be obtained by using appropriate procedures for data acquisition, storage and interpretation of echo-Doppler data. This goal can be achieved by employing an echo core laboratory (ECL), with the responsibility for standardizing image acquisition processes (performed at the peripheral echo-labs) and analysis (by monitoring and optimizing the internal intra- and inter-reader variability of measurements). Accordingly, the Working Group of Echocardiography of the Italian Society of Cardiology decided to design standardized procedures for imaging acquisition in peripheral laboratories and reading procedures and to propose a methodological approach to assess the reproducibility of echo-Doppler parameters of cardiac structure and function by using both standard and advanced technologies. A number of cardiologists experienced in cardiac ultrasound was involved to set up an ECL available for future studies involving complex imaging or including echo-Doppler measures as primary or secondary efficacy or safety end-points. The present manuscript describes the methodology of the procedures (imaging acquisition and measurement reading) and provides the documentation of the work done so far to test the reproducibility of the different echo-Doppler modalities (standard and advanced). These procedures can be suggested for utilization also in non referall echocardiographic laboratories as an "inside" quality check, with the aim at optimizing clinical consistency of echo-Doppler data.

Apical-sparing Tako-tsubo: a case report.

We present a case of "apical-sparing Tako-Tsubo" syndrome in a postmenopausal woman with normal coronary arteries. Atypical variants of Tako-Tsubo like syndrome have been recently reported. Our patient showed a suggestive noncoronary-distributed dyskinetic area, in a clinical setting of typical chest pain, recent stressful events, troponin elevation and normal coronary angiogram; wall motion normalized within two days.

[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.

[The non-invasive catheterization laboratory]. / Il laboratorio di emodinamica non invasiva.

The objective of this review was to explore the clinical relevance of Doppler echocardiographic techniques in the evaluation of right and left ventricular function. It is well known that echocardiographic and Doppler analysis are able to provide information about several hemodynamic parameters, such as cardiac output, diastolic filling pressure, vascular resistances and pulmonary arterial pressures. This integrated approach, completely reliable and non-invasive, could allow to obtain useful information not only from a diagnostic and prognostic point of view but also for a potential therapeutic management, either pharmacological or surgical. This review summarizes the current knowledge and the emerging applications of echocardiographic and Doppler techniques focusing on the close correlation between Doppler-derived data and those coming from invasive techniques. On the basis of these evidences, the importance, even in daily clinical practice, of a non-invasive catheterization laboratory is clear and able to supply key information about ventricular function and, at the same time, to avoid expensive and unpleasant invasive procedures for patients.