Coronary microvascular dysfunction affects left ventricular global longitudinal strain response to dipyridamole stress echocardiography: a pilot study.

The aim is to investigate, by means of speckle tracking echocardiography, left ventricular (LV) contractile function at rest and during dipyridamole stress in patients with coronary microvascular dysfunction (CMD). 59 patients (39% women, mean age 65.6 ± 6.1 years) with history of chest pain and without obstructive coronary artery disease (CAD) underwent dipyridamole stress echocardiography. Coronary flow was assessed in the left anterior descending coronary artery. Coronary flow reserve (CFR) was determined as the ratio of hyperaemic to baseline diastolic coronary flow velocity. CMD was defined as CFR < 2. Global longitudinal strain (GLS) was measured at rest and at peak dose. Nineteen patients (32%) among the overall population showed CMD. Baseline GLS was significantly lower in patients with CMD (- 16.8 ± 2.7 vs. - 19.1 ± 3.1, p < 0.01). A different contractile response to dipyridamole infusion was observed between the two groups: GLS significantly increased up to peak dose in patients without CMD (from - 19.1 ± 3.1 to - 20.2 ± 3.1, p < 0.01), and significantly decreased in patients with CMD (from - 16.8 ± 2.7 to - 15.8 ± 2.7, p < 0.01). There was a significant inverse correlation between CFR and ∆GLS (r = - 0.82, p < 0.01). Rest GLS and GLS response to dipyridamole stress are markedly impaired among patients with chest pain syndrome, non-obstructive CAD and CMD, reflecting subclinical LV systolic dysfunction and lack of LV contractile reserve due to underlying myocardial ischemia.

Myocardial Work Efficiency in Physiologic Left Ventricular Hypertrophy of Power Athletes.

Aims: The athlete's heart in power training is characterized by physiologic concentric remodeling. Our aim was to analyze left ventricular (LV) myocardial deformation and contractile reserve (CR) in top-level power athletes (PA) at rest and during exercise and their possible correlations with functional capacity. Methods: Standard echo, lung ultrasound, and LV 2D speckle-tracking strain were performed at rest and during exercise in PA and in age- and sex-comparable healthy controls. Results: 250 PA (male: 62%; 33.6 ± 4.8 years) and 180 age- and sex-comparable healthy controls were enrolled. LV ejection fraction (EF) at baseline was comparable between the two groups, while LV global longitudinal strain (GLS) was reduced in PA (GLS: -17.8 ± 2.4 in PA vs. -21.9 ± 3.8 in controls; P < 0.01). Conversely, myocardial work efficiency (MWE) did not show significant difference between the two groups (94.4 ± 3.2 in PA vs. 95.9 ± 4.6% in controls; P NS). At peak exertion during exercise stress echocardiography (ESE), PA showed better exercise capacity and peak VO2 consumption (51.6 ± 10.2 in EA vs. 39.8 ± 8.2 mL/Kg/min in controls, P < 0.0001), associated with augmented pulmonary artery systolic pressure (PASP). By multivariable analysis, MWE at rest was the most predictive factor of maximal watts (P < 0.0001), peak VO2, (P < 0.0001), PASP (P < 0.001), and number of B-lines (P < 0.001), all measured at peak effort. Conclusions: In power athletes, MWE showed less load dependency than GLS. Normal resting values of MWE in PA suggest a physiological LV remodeling, associated with a better exercise capacity and preserved CR during physical stress.

Biventricular dysfunction and lung congestion in athletes on anabolic androgenic steroids: a speckle tracking and stress lung echocardiography analysis.

AIMS: The real effects of the chronic consumption of anabolic-androgenic steroids (AASs) on cardiovascular structures are subjects of intense debate. The aim of the study was to detect by speckle tracking echocardiography (STE) right ventricular (RV) and left ventricular (LV) dysfunction at rest and during exercise stress echocardiography (ESE) in athletes abusing AAS. METHODS AND RESULTS: One hundred and fifteen top-level competitive bodybuilders were selected (70 males), including 65 athletes misusing AAS for at least 5 years (users), 50 anabolic-free bodybuilders (non-users), compared to 50 age- and sex-matched healthy sedentary controls. Standard Doppler echocardiography, STE analysis, and lung ultrasound at rest and at peak supine-bicycle ESE were performed. Athletes showed increased LV mass index, wall thickness, and RV diameters compared with controls, whereas LV ejection fraction was comparable within the groups. left atrial volume index, LV and RV strain, and LV E/Em were significantly higher in AAS users. Users showed more B-lines during stress (median 4.4 vs. 1.25 in controls and 1.3 in non-users, P < 0.01 vs. users). By multivariable analyses, LV E/Ea (beta coefficient = 0.35, P < 0.01), pulmonary artery systolic pressure (beta = 0.43, P < 0.001) at peak effort and number of weeks of AAS use per year (beta = 0.45, P < 0.001) emerged as the only independent determinants of resting RV lateral wall peak systolic two-dimensional strain. In addition, a close association between resting RV myocardial function and VO2 peak during ESE was evidenced (P < 0.001), with a powerful incremental value with respect to clinical and standard echocardiographic data. CONCLUSIONS: In athletes abusing steroids, STE analysis showed an impaired RV systolic deformation, closely associated with reduced functional capacity during physical effort, and-during exercise-more pulmonary congestion.

[Transcranial color Doppler ultrasonography: methodology and usefulness for the study of patent foramen ovale in cryptogenic stroke]. / Eco-color Doppler transcranico: metodologia e utilità nello studio del forame ovale pervio nell'ictus criptogenetico.

Non-invasive Doppler ultrasonographic study of cerebral arteries (transcranial Doppler, TCD) has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency (≤2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays a valid indication for TCD in the outpatient setting is the research of right-to-left shunting, responsible for the so-called "paradoxical embolism", most often due to patency of foramen ovale, which is responsible for the majority of cryptogenic strokes occurring in patients younger than 55 years. TCD also allows to classify the grade of severity of such shunts using the so-called "microembolic signal grading score". Therefore, TCD is an essential cardiological exam for the detection of patent foramen ovale, assuming an important role as a first-level examination to guide the subsequent diagnostic-therapeutic management. In addition, TCD has found many useful applications in neurocritical care practice. It is useful for the identification of intracranial vascular stenosis and for the assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury and brain stem death. It is also used to evaluate cerebral hemodynamic changes after stroke, to investigate cerebral pressure autoregulation, and for the clinical evaluation of cerebral vasomotor reactivity.

Potential role of an athlete-focused echocardiogram in sports eligibility.

Sudden cardiac death (SCD) of an athlete is a rare but tragic event and sport activity might play a trigger role in athletes with underlying structural or electrical heart diseases. Preparticipation screenings (PPs) have been conceived for the potential to prevent SCD in young athletes by early identification of cardiac diseases. The European Society of Cardiology protocol for PPs includes history collection, physical examination and baseline electrocardiogram, while further examinations are reserved to individuals with abnormalities at first-line evaluation. Nevertheless, transthoracic echocardiography has been hypothesized to have a primary role in the PPs. This review aims to describe how to approach an athlete-focused echocardiogram, highlighting what is crucial to focus on for the different diseases (cardiomyopathies, valvulopathies, congenital heart disease, myocarditis and pericarditis) and when is needed to pay attention to overlap diagnostic zone ("grey zone") with the athlete's heart. Once properly tested, focused echocardiography by sports medicine physicians may become standard practice in larger screening practices, potentially available during first-line evaluation.

Multimodality imaging in COVID-19 patients: A key role from diagnosis to prognosis.

The integrated clinical, laboratory and ultrasound approach is essential for the diagnosis, evaluation and monitoring of the patient's therapy in coronavirus disease 2019 pneumonia. The ideal imaging approach in this context is not yet well defined. Chest X-ray is characterized by low sensitivity in identifying earlier lung changes. The "bedside" pulmonary ultrasound has an undeniable series of advantages in the patient at high infectious risk and can provide incremental data in the respiratory intensive care for the serial control of the individual patient as well as for the home delivery of the stabilized subjects. Pulmonary computed tomography shows high sensitivity but should not be routinely performed in all patients, because in the first 48 h it can be absolutely negative and in the late phase the imaging findings may not change the therapeutic approach. Echocardiography should be limited to patients with hemodynamic instability to assess ventricular function and pulmonary pressures.

The Pharmacological Approach to Oncologic Patients with Acute Coronary Syndrome.

Among acute coronary syndrome (ACS) patients, 15% have concomitant cancer, especially in the first 6 months after their diagnosis, as well as in advanced metastatic stages. Lung, gastric, and pancreatic cancers are the most frequent malignancies associated with ACS. Chemotherapy and radiotherapy exert prothrombotic, vasospastic, and proinflammatory actions. The management of cancer patients with ACS is quite challenging: percutaneous revascularization is often underused, and antiplatelet and anticoagulant pharmacological therapy should be individually tailored to the thrombotic risk and to the bleeding complications. Sometimes oncological patients also show different degrees of thrombocytopenia, which further complicates the pharmacological strategies. The aim of this review is to summarize the current evidence regarding the treatment of ACS in cancer patients and to suggest the optimal management and therapy to reduce the risk of adverse coronary events after ACS in this high-risk population.

Speckle tracking evaluation in endurance athletes: the "optimal" myocardial work.

To analyze left ventricular myocardial deformation and contractile reserve in endurance athletes at rest and during exercise, and their possible correlations with functional capacity. The athlete's heart in endurance training is characterized by physiologic eccentric remodeling, with left ventricle adaptation at rest and echocardiographic parameters at low end of normality. Assessment of left ventricle systolic function and contractile reserve has an important role in the decision-making and in differential diagnosis with cardiomyopathies. Standard echo, lung ultrasound, left ventricle 2D speckle-tracking strain and myocardial work were performed at rest and during exercise in endurance athletes and in age- and sex-comparable healthy controls. 350 endurance athletes (male sex 58.5%; 31.6 ± 4.2 years) and 150 healthy controls were enrolled. Left ventricular ejection fraction at baseline was comparable between the two groups. Resting left ventricular global longitudinal strain was reduced in endurance athletes (- 18.4 ± 2.6% vs. - 22.4 ± 3.3% in controls; p < 0.01). Myocardial work efficiency did not show significative difference between the two groups. At peak exertion during exercise stress echocardiography, endurance athletes showed better exercise capacity and peak VO2 consumption (58.6 ± 10.2 ml/kg/min vs 38.6 ± 3.3 ml/kg/min in controls, p < 0.0001), associated with a preserved contractile reserve and augmented pulmonary artery systolic pressure. By multivariable analysis myocardial work efficiency at rest was closely related to maximal watts (p < 0.0001), peak VO2, (p < 0.0001), left ventricular E/e' (p < 0.001) and number of B-lines (p < 0.001), all measured at peak effort. Myocardial work efficiency shows less load-dependency than global longitudinal strain. Normal resting values of myocardial work efficiency in endurance athletes suggest a physiological remodeling, associated with a better exercise capacity and preserved contractile reserve during physical effort.

Echocardiography in Athletes in Primary Prevention of Sudden Death.

Echocardiography is a noninvasive imaging technique useful to provide clinical data regarding physiological adaptations of athlete's heart. Echocardiographic characteristics may be helpful for the clinicians to identify structural cardiac disease, responsible of sudden death during sport activities. The application of echocardiography in preparticipation screening might be essential: it shows high sensitivity and specificity for identification of structural cardiac disease and it is the first-line imagining technique for primary prevention of SCD in athletes. Moreover, new echocardiographic techniques distinguish extreme sport cardiac remodeling from beginning state of cardiomyopathy, as hypertrophic or dilated cardiomyopathy and arrhythmogenic right ventricle dysplasia. The aim of this paper is to review the scientific literature and the clinical knowledge about athlete's heart and main structural heart disease and to describe the rule of echocardiography in primary prevention of SCD in athletes.

Correction to: Left atrial myocardial dysfunction after chronic abuse of anabolic androgenic steroids: a speckle tracking echocardiography analysis.

In the original publication of the article, the seventh author name "Giampaolo Tocci" has been misspelt. The correct name is given in this.

Left atrial myocardial dysfunction after chronic abuse of anabolic androgenic steroids: a speckle tracking echocardiography analysis.

Anabolic-androgenic steroids (AAS) are used by power athletes to improve performance. However, the real effects of the chronic consumption of AAS on cardiovascular structures are subjects of intense debate. To detect by speckle tracking echocardiography (STE) underlying left atrial (LA) dysfunction in athletes abusing AAS and assess possible correlation between LA myocardial function and exercise capacity during cardiopulmonary stress test. 65 top-level competitive bodybuilders were selected (45 males), including 35 athletes misusing AAS for at least 5 years (users), 30 anabolic-free bodybuilders (non-users), compared to 40 age- and sex-matched healthy sedentary controls. Standard Doppler echocardiography, STE analysis and bicycle ergometric test were performed to assess LA myocardial function and exercise capacity. Athletes showed increased left ventricular (LV) mass index, wall thickness and stroke volume compared with controls, whereas LV ejection fraction, LV end-diastolic diameter and transmitral Doppler indexes were comparable between the three groups. Conversely, LA volume index, LV and LA strain and LV E/Em were significantly increased in AAS users. By multivariate analyses, LV E/Em (beta = - 0.30, p < 0.01), LA volume index (- 0.42, p < 0.001) and number of weeks of AAS use per year (- 0.54, p < 0.001) emerged as the only independent determinants of LA lateral wall peak STE. In addition, a close association between LA myocardial function and VO2 peak during cardiopulmonary exercise testing was evidenced (p < 0.001), showing a powerful incremental value with respect to clinical and standard echocardiographic data. STE represents a promising technique to assess LA myocardial function in athletes abusing steroids. AAS users showed a more impaired LA deformation, associated with reduced functional capacity during physical effort.

Speckle tracking analysis in intensive care unit: A toy or a tool?

The use of conventional echocardiography in the intensive care unit (ICU) is today established to assess left and right ventricular systolic function, for preload determination and procedural guidance. Next step in ICU echocardiography could be the use of novel ultrasound techniques such as strain echocardiography to assist in the management of patients with acute coronary syndrome, heart failure, or pulmonary embolism. This review has gathered the available evidence supporting the incremental value of strain in the diagnostic workup of cardiac diseases treated in ICU.

Mitral Prolapse: An Old Mysterious Entity - The Incremental Role of Multimodality Imaging in Sports Eligibility.

Mitral valve prolapse is generally a benign condition characterized by fibromyxomatous changes of the mitral leaflet with displacement into the left atrium and late-systolic regurgitation. Although it is an old clinical entity, it still arouses perplexity in diagnosis and clinical management. Complications, such as mitral regurgitation (MR), atrial fibrillation, congestive heart failure, endocarditis, ventricular arrhythmias, and sudden cardiac death (SCD), have been reported. A large proportion of the overall causes of SCD in young competitive athletes is explained by mitral valve prolapse. Recent studies have shown the fibrosis of the papillary muscles and inferobasal left ventricular wall in mitral valve prolapse, suggesting a possible origin of ventricular fatal arrhythmias. Athletes with mitral valve prolapse and MR should undergo annual evaluations including physical examination, echocardiogram, and exercise stress testing to evaluate the cardiovascular risks of competitive sports and obtain the eligibility. In this setting, multimodality imaging techniques - echocardiography, cardiac magnetic resonance, and cardiac computed tomography - should provide a broad spectrum of information, from diagnosis to clinical management of the major clinical profiles of the disease.

Left ventricular hypertrophy or storage disease? the incremental value of speckle tracking strain bull's-eye.

Left ventricular hypertrophy (LVH) develops in response to a variety of physical, genetic, and biochemical stimuli and represents the early stage of ventricular remodeling. In patients with LVH, subclinical left ventricular (LV) dysfunction despite normal ejection fraction (EF) may be present before the onset of symptoms, which portends a dismal prognosis. Strain measurement with two-dimensional speckle tracking echocardiography (STE) represents a highly reproducible and accurate alternative to LVEF determination. The present review focuses on current available evidence that supports the incremental value of STE in the diagnostic and prognostic workup of LVH. When assessing the components of LV contraction, STE has an incremental value in differentiating between primary and secondary LVH and in the differential diagnosis with storage diseases. In addition, STE provides unique information for the stratification of patients with LVH, enabling to detect intrinsic myocardial dysfunction before LVEF reduction.

Exercise-Induced Atrial Remodeling: The Forgotten Chamber.

Cardiac changes in athletes involve the left ventricle and atrium. Mild left atrial enlargement is common among competitive athletes, possibly a physiologic adaptation to exercise conditioning. The prevalence of this remodeling and the association with supraventricular arrhythmias has not been systematically addressed. Echocardiography screens for patients with disease involving the left atrium. New techniques like speckle tracking can recognize early atrial dysfunction and assess left atrial myocardial function in patients with either physiologic or pathologic left ventricular hypertrophy. This article reviews echocardiographic techniques in delineating the athlete's morphology and functional properties of the left atrium.

The role of new echocardiographic techniques in athlete's heart.

'Athlete's heart' is a common term for the various adaptive changes induced by intensive exercise. Exercise causes alterations of the heart in hemodynamic response to the increased systemic and pulmonary demand during exercise. The understanding of these adaptations is of high importance, since they may overlap with those caused by pathological conditions. Cardiac imaging assessment of the athlete's heart should begin with a complete echocardiographic examination. In recent years classical echocardiographic surveys have been joined by new developments: tissue Doppler imaging, strain rate echocardiography, and real-time 3-dimensional echocardiography. This review paper focuses on the importance of these new echocardiographic techniques in delineating the morphological characteristics and functional properties of the athlete's heart.

Augmentation or reconstruction of PCL? A quantitative review.

PURPOSE: The purpose of this quantitative review is to document effectiveness and complications of posterior cruciate ligament (PCL) surgery and compare outcomes, advantages and disadvantages of reconstructive and augmentation procedures. METHODS: A systematic literature search was performed in PubMed, Medline, Ovid, Google Scholar and Embase databases using the combined keywords "PCL reconstruction," "PCL augmentation," "clinical outcomes" and "functional outcomes" with no limit for year of publication. Articles were included if they reported data on clinical, functional and imaging outcomes who had undergone reconstruction or augmentation of the PCL for management of PCL injuries. Two authors screened the selected articles for title, abstract and full text in accordance with predefined inclusion and exclusion criteria. The methodological quality of all articles was assessed by two authors according to the Coleman methodology score. The critical appraisal was made using the Physiotherapy Evidence Database (PEDro) scale. RESULTS: A total of 34 studies, 22 retrospective, 9 prospective and 5 were randomized control trials were included by full text. The modified Coleman methodology score averaged 70.8 (SD 6.5), median 73 (range from 60 to 82). At IKDC assessment, the average rate of normal (A) and nearly normal (B) outcomes was 89.8% (SD 4.2) (from 85 to 93%; median 91.4) after PCL augmentation and 80.1% (SD 12.4) after PCL reconstruction (from 57.2 to 100%; median 81.8 %) were rated as normal (A) and nearly normal (B). The average Lysholm Knee Scores after PCL augmentation were 93.1 points (SD 1.9) and ranged from 82.1 to 94.2 (median 90.5) after PCL reconstruction. The KT 1000 difference improved from an average preoperative difference of 8.8 mm (SD 0.9) to an average postoperative of 2.1 mm (SD 0.6) after PCL augmentation (average improvement of 6.7 mm (SD 4.7)) and from 8.2 (SD 3.6) to 2.3 mm (SD 2.0) (average improvement of 5.9 mm SD 4.2) after PCL reconstruction. Postoperatively, the Telos stress radiographic side to side difference averagely improved by 8.6 mm (SD 6.1) after PCL augmentation, from 11.1 mm (SD 1.4) to 2.5 mm (SD 0.4), and by 8.0 mm (SD 5.7) after PCL reconstruction, from 11.5 mm (SD 2.2) to 3.5 mm (SD 1.3). CONCLUSIONS: Augmentation and reconstruction procedures are grossly equivalent, but more data examining the long-term functional status, recovery to preinjury daily and sport activities and occurrence of degenerative changes are needed. LEVEL OF EVIDENCE: IV.