PDF-ECG in clinical practice: A model for long-term preservation of digital 12-lead ECG data.

BACKGROUND: In clinical practice, data archiving of resting 12-lead electrocardiograms (ECGs) is mainly achieved by storing a PDF report in the hospital electronic health record (EHR). When available, digital ECG source data (raw samples) are only retained within the ECG management system. OBJECTIVE: The widespread availability of the ECG source data would undoubtedly permit successive analysis and facilitate longitudinal studies, with both scientific and diagnostic benefits. METHODS & RESULTS: PDF-ECG is a hybrid archival format which allows to store in the same file both the standard graphical report of an ECG together with its source ECG data (waveforms). Using PDF-ECG as a model to address the challenge of ECG data portability, long-term archiving and documentation, a real-world proof-of-concept test was conducted in a northern Italy hospital. A set of volunteers undertook a basic ECG using routine hospital equipment and the source data captured. Using dedicated web services, PDF-ECG documents were then generated and seamlessly uploaded in the hospital EHR, replacing the standard PDF reports automatically generated at the time of acquisition. Finally, the PDF-ECG files could be successfully retrieved and re-analyzed. CONCLUSION: Adding PDF-ECG to an existing EHR had a minimal impact on the hospital's workflow, while preserving the ECG digital data.

A multidisciplinary consensus document on follow-up strategies for patients treated with percutaneous coronary intervention.

The number of percutaneous coronary interventions (PCI) is increasing worldwide. Follow-up strategies after PCI are extremely heterogeneous and can greatly affect the cost of medical care. Of note, clinical evaluations and non-invasive exams are often performed to low risk patients. In the present consensus document, practical advises are provided with respect to a tailored follow-up strategy on the basis of patients' risk profile. Three strategies follow-up have been defined and types and timing of clinical and instrumental evaluations are reported. Clinical and interventional cardiologists, cardiac rehabilitators, and general practitioners, who are in charge to manage post-PCI patients, equally contributed to the creation of the present document.

Comprehensive diagnostic workup in patients with suspected heart failure and preserved ejection fraction.

Diagnosis of heart failure with preserved ejection fraction (HFpEF) can be challenging and it could require different tests, some of which are affected by limited availability. Nowadays, considering that new therapies are available for HFpEF and related conditions, a prompt and correct diagnosis is relevant. However, the diagnostic role of biomarker level, imaging tools, score-based algorithms and invasive evaluation, should be based on the strengths and weaknesses of each test. The aim of this review is to help the clinician in diagnosing HFpEF, overcoming the diagnostic uncertainty and disentangling among the different underlying causes, in order to properly treat this kind of patient.

Current use of echocardiography in cardio-oncology: nationwide real-world data from an ANMCO/SIECVI joint survey.

Aims: The need for cardio-oncology competencies is constantly growing, and with the establishment of cardio-oncology services, cardiovascular imaging, particularly transthoracic echocardiography (TTE), has become pivotal in patients' management. However, care pathways for oncologic patients largely depend on local health structures' resources. This survey from Associazione Italiana Medici Cardiologi Ospedalieri and the Italian Society of Echocardiography and Cardiovascular Imaging aimed at investigating the use of echocardiography in cardio-oncology services and knowledge levels on cancer patients' care. Methods and results: Data were obtained via an electronic survey based on a structured questionnaire uploaded to the promoting societies' websites. Responses came from 159 centres with echocardiography. According to one-third of participating centres, workload related to cancer patients represented >30% of the total requests. The most common TTE indication (85%) was left ventricular ejection fraction (LVEF) evaluation. Many centres (55%) still assessed LVEF solely by bidimensional method or visual estimation in case of inadequate acoustic windows. At the same time, almost 40% of centres reported routinely using global longitudinal strain when feasible. We further performed a sub-analysis according to the presence (33%) or absence (77%) of dedicated cardio-oncologists, revealing significant differences in cardiovascular surveillance strategies and cardiotoxicity management. Conclusion: This survey on echocardiography practice for cancer patients reveals a significant gap between actual clinical practice and standards proposed by recommendations, underlying the need for stronger partnerships between cardiologists and oncologists and dedicated, well-structured cardio-oncology services.

[Paradoxical low flow-low gradient aortic stenosis: lights and shadows]. / Stenosi aortica "paradoxical low flow-low gradient": luci ed ombre.

Paradoxical low flow-low gradient aortic valve stenosis (AVS) is an increasing phenotype in the general population, particularly after the seventh decade of life. It is an AVS in which, despite the preserved ejection fraction, the mean transvalvular gradient is not suggestive of severe AVS (<40 mmHg). The pathophysiology is often intertwined with conditions resulting in heart failure with preserved ejection fraction, such as arterial hypertension and cardiac amyloidosis. Its management is rather controversial about the diagnosis and therapeutic management. The aims of this focus are: to clarify the role and reliability of the main available diagnostic methods, the efficacy of surgical and percutaneous treatments, and to develop a diagnostic-therapeutic algorithm for managing this condition in clinical practice. This algorithm will involve a multi-parametric evaluation, integrating standard echocardiographic assessment with three-dimensional planimetric valve area calculation, determination of the energy loss index), and calcium score calculation by computed tomography scan. This approach aims to ascertain the severity of the stenosis and determine the appropriate therapeutic management.

[Atrial cardiomyopathy as a link between atrial fibrillation and stroke. Clinical implications and future diagnostic-therapeutic implications]. / La cardiomiopatia atriale come legame tra fibrillazione atriale e ictus. Implicazioni cliniche e implicazioni diagnostico-terapeutiche future.

Atrial myopathy is characterized by atrial fibrotic remodeling, together with electrical, mechanic and autonomic remodeling. Methods to identify atrial myopathy include atrial electrograms, tissue biopsy, cardiac imaging, and serum biomarkers. Accumulating data show that individuals with markers of atrial myopathy have an increased risk of developing both atrial fibrillation and strokes. The aim of the present review is to present atrial myopathy as a pathophysiologic and clinical entity, to describe methods for its detection and the possible implications on management and therapy in selected group of patients.

Unveiling the Hidden Chamber: Exploring the Importance of Left Atrial Function and Filling Pressure in Cardiovascular Health.

The left atrium (LA) is a vital component of the cardiovascular system, playing a crucial role in cardiac function. It acts as a reservoir, conduit, and contractile chamber, contributing to optimal left ventricle (LV) filling and cardiac output. Abnormalities in LA function have been associated with various cardiovascular conditions, including heart failure, atrial fibrillation, valvular heart disease, and hypertension. Elevated left ventricular filling pressures resulting from impaired LA function can lead to diastolic dysfunction and increase the risk of adverse cardiovascular events. Understanding the relationship between LA function and LV filling pressures is crucial for comprehending the pathophysiology of cardiovascular diseases and guiding clinical management strategies. This article provides an overview of the anatomy and physiology of the LA, discusses the role of LA mechanics in maintaining normal cardiac function, highlights the clinical implications of elevated filling pressures, and explores diagnostic methods for assessing LA function and filling pressures. Furthermore, it discusses the prognostic implications and potential therapeutic approaches for managing patients with abnormal LA function and elevated filling pressure. Continued research and clinical focus on left atrial function are necessary to improve diagnostic accuracy, prognostic assessment, and treatment strategies in cardiovascular diseases. It will explore the importance of assessing LA function as a marker of cardiac performance and evaluate its implications for clinical practice. In accordance with rigorous scientific methodology, our search encompassed PubMed database. We selected articles deemed pertinent to our subject matter. Subsequently, we extracted and synthesized the salient contents, capturing the essence of each selected article.

Spontaneous coronary artery dissection: the emerging role of coronary computed tomography.

Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome and myocardial infarction, more frequent among young women. Invasive coronary angiography (ICA) is the gold standard for the diagnosis of SCAD, although the risk of propagating dissection flap is considerable. Therefore, coronary computed tomography angiography (CCTA) is an emerging alternative modality to diagnose SCAD with the advantage of being a non-invasive technique. Clinicians should be aware of the predisposing conditions and pathophysiology to raise the pre-test probability of SCAD and select the most appropriate diagnostic tools. In recent times, improvements in spatial and temporal resolution and the use of semi-automated software providing quantitative assessment make CCTA a valid alternative to ICA also for the follow-up. Moreover, CCTA may be helpful to screen and evaluate extra-coronary arteriopathies closely related to SCAD. In this review, we illustrate the current and the potential role of CCTA in the diagnosis of SCAD, highlighting advantages and disadvantages of this imaging modality compared to ICA.

[Ten questions on cardiac magnetic resonance in patients with heart failure: from etiological diagnosis to prognostic stratification]. / Dieci quesiti in tema di risonanza magnetica cardiaca nel paziente con scompenso cardiaco: dalla diagnosi eziologica alla stratificazione prognostica.

Cardiac magnetic resonance (CMR) imaging has progressively become part of the imaging methods recommended in patients with heart failure. CMR represents the gold standard for assessing volumes, function, biventricular kinetics and providing tissue characterization through scans with and without contrast medium. In patients with heart failure with reduced ejection fraction (HFrEF) and ischemic dilated cardiomyopathy, CMR allows to search for viability, accurately estimate volumes and ejection fraction. It can assess scar extent for predicting response to cardiac resynchronization therapy and for establishing an indication for implanting a defibrillator in borderline cases. In patients with HFrEF and non-ischemic dilated cardiomyopathy, CMR helps to identify specific etiological subgroups and to estimate the arrhythmic risk beyond ejection fraction. In patients with heart failure with preserved ejection fraction, CMR offers the possibility of diagnosing specific phenotypes, including sarcomeric hypertrophic cardiomyopathy, amyloidosis or Fabry disease, and adds prognostic information. Both clinical and scientific interest in this imaging method is constantly expanding; the clinicians dealing with heart failure cannot fail to know the technique, the indications and all the potential that CMR can offer.

Catheter ablation of atrial fibrillation in heart failure: clinical, prognostic, and echocardiographic outcome.

PURPOSE: Catheter ablation (CA) for atrial fibrillation (AF) in heart failure (HF) patients is associated with a lower rate of cardiac events compared with medical therapy. This study deals with the clinical, echocardiographic, and prognostic outcomes in these patients. Prognostic scores, as MAGGIC (Meta-analysis Global Group in Chronic Heart Failure) score, may help to predict the outcomes. METHODS: From a single center, 47 patients with AF, HF, and left ventricular ejection fraction (LVEF) < 50% underwent CA. The primary endpoints were NYHA functional class, LVEF, and MAGGIC score. RESULTS: The median age of patients was 59 years; 49% had paroxysmal AF. At 12 months, a significant improvement of NYHA class (median before II [interquartile range (IQR) II-III] vs median after I [IQR I-II]) and of LVEF (median before 44% [IQR 37-47] vs median after 55% [IQR49-57]) was observed (p value < 0.001). The MAGGIC 1-year and 3-year probability of death was estimated before (mean score 13 [IQR 11-17]) and at 12-month (mean score 11 [IQR 8-13]), showing a significant decrease in the probability of death (p value <0.001). At 12-month, a lower LVEF was associated with more HF hospitalizations (p value 0.035). Coronary artery disease (CAD) (HR 5, p value 0.035) and MAGGIC score (HR 1.2, p value 0.030) were predictors of HF hospitalization. CONCLUSIONS: CA for AF in HF patients was associated with a significant improvement of NYHA functional class and LVEF and a higher life expectation. CAD history, LVEF < 40%, and MAGGIC score before ablation were predictors of HF hospitalization.

[Role of nuclear cardiology in clinical practice: state of art]. / Ruolo della cardiologia nucleare nella pratica clinica: stato dell'arte.

Nuclear imaging plays a pivotal role not only in in the evaluation of myocardial ischemia, but also in the evaluation of cardiac infectious, inflammatory, infiltrative and innervation disorders. Myocardial ischemia and viability, cardiac amyloidosis, sarcoidosis, large vessel vasculitis, infective endocarditis, infected cardiac implantable electronic devices, vascular graft infection, and myocardial innervation dysfunction are the main indications for the use of nuclear medicine procedures in both diagnosis and response assessment. With this summarized paper we share a comprehensive review of the role and the use of nuclear cardiology in different cardiac diseases.

[Lung ultrasonography: what the cardiologist should know]. / Ecografia del polmone: quello che il cardiologo dovrebbe conoscere.

In recent years, lung ultrasonography has acquired an important role as a valuable diagnostic tool in clinical practice. The lung is usually poorly explorable, but it provides more acoustic information in pathological conditions that modify the relationship between air, water and tissues. The different acoustic impedance of all these components makes the chest wall a powerful ultrasound reflector: this is responsible for the creation of several artifacts providing valuable information about lung pathophysiology. Lung ultrasonography helps in the diagnostic process of parenchymal and pleural pathologies, in the differential diagnosis of dyspnea and in the clinical and prognostic evaluation of the SARS-CoV-2 infection.

[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.

[An unusual presentation of cardiac involvement during the COVID-19 pandemic]. / COVID-19 e coinvolgimento cardiaco: una presentazione inusuale.

Severe acute respiratory syndrome coronavirus 2 may affect the cardiovascular system and cause acute cardiac injury. Other authors described cases of myocarditis with reduced systolic function and/or a life-threatening presentation. We describe the clinical course of an unusual presentation with isolated reversible high degree atrioventricular block in a patient with COVID-19. In this case, a "wait and see approach" avoided an unnecessary permanent pacemaker implantation.

Takotsubo Syndrome Associated with COVID-19.

OBJECTIVE: The availability of public health information for optimised supportive care is critical during the COVID-19 pandemic. We describe the first case of COVID-19 complicated by Takotsubo cardiomyopathy. MATERIALS AND METHODS: We report the clinical, laboratory and radiological findings of a patient with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). RESULTS: The nasopharyngeal swab was positive for SARS-CoV-2 and x-ray images demonstrated pathognomonic pneumonia. The patient developed tachycardia and the echocardiogram confirmed the diagnosis of Takotsubo cardiomyopathy. CONCLUSIONS: Doctors should be aware of the need to thoroughly study this new infection in order to understand its underlying mechanisms and related complications. LEARNING POINTS: We report the first case of Takotsubo cardiomyopathy associated with COVID-19.We discuss a rare presentation in the current pandemic.COVID-19 can be associated with cardiac complications, even after the onset of pneumonia, and so strict monitoring of these patients is essential.

[Non-ischemic ventricular dysfunction in COVID-19 patients: characteristics and implications for cardiac imaging on the basis of current evidence]. / La disfunzione ventricolare non ischemica nei pazienti con COVID-19: caratteristiche e implicazioni per l'imaging cardiaco in base alle attuali evidenze scientifiche.

Coronavirus 2019 disease (COVID-19), caused by SARS-CoV-2, can lead to cardiac impairment with various types of clinical manifestations, including heart failure and cardiogenic shock. A possible expression of cardiac impairment is non-ischemic ventricular dysfunction, which can be related to different pathological conditions, such as myocarditis, stress and cytokine-related ventricular dysfunction. The diagnosis of these pathological conditions can be challenging during COVID-19; furthermore, their prevalence and prognostic significance have not been elucidated yet. The purpose of this review is to take stock of the various aspects of non-ischemic ventricular dysfunction that may occur during COVID-19 and of the diagnostic implications related to the use of cardiac imaging techniques.

[Grey zones in cardiovascular adaptations to physical exercise: how to navigate in the echocardiographic evaluation of the athlete's heart]. / Le "zone grigie" degli adattamenti cardiovascolari all'esercizio fisico: come orientarsi nella valutazione ecocardiografica del cuore d'atleta.

"Athlete's heart" represents a series of mechanisms through which cardiac chambers can adapt to physical activity. Echocardiography has a major role in sports cardiology and it can help physicians to investigate the so-called "grey zones", defined as diagnostic overlaps between athlete's heart and several cardiac diseases: wall thickness and left ventricular size in hypertrophic and dilated cardiomyopathy, ventricular trabeculations in left ventricular non-compaction cardiomyopathy, left atrial size and atrial fibrillation, right ventricular systolic dysfunction in arrhythmogenic right ventricular cardiomyopathy. The use of advanced ultrasound methods such as tissue Doppler and two-dimensional strain can be added to the classic echocardiographic assessment to complete a multi-parametric evaluation, guiding the sports physician and cardiologist in the correct framing of these patients.

[Imaging in acute aortic syndrome: not just dissection]. / L'imaging nella sindrome aortica acuta: non solo dissezione.

Acute aortic syndrome includes three main pathological conditions: aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU). These are life-threatening conditions, therefore early diagnosis and interventional/surgical treatment are fundamental for the survival of affected individuals. While anatomical findings of classical AD provided by imaging techniques are known to all cardiologists, imaging findings of IMH and PAU are less known, as are their prognostic implications and consequences on management and treatment strategies. This review aims to describe and discuss findings and role of imaging techniques in patients with IMH and PAU.

[Functional tricuspid regurgitation: imaging, surgical indications, reparative techniques and results]. / L'insufficienza tricuspidale funzionale: imaging, indicazioni chirurgiche, tecniche riparative e risultati.

Although the indications for surgical management of severe functional tricuspid regurgitation (TR) are now generally accepted, controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, particularly in patients with annular dilation. Echocardiographic imaging is the gold standard to identify functional TR and distinguish it from a primitive or degenerative form. Currently, surgery remains the best approach for the interventional treatment of TR. Ring annuloplasty seems to provide better results than suture annuloplasty (De Vega technique) and rigid rings appear to be more reliable in the long term, in comparison with flexible bands. Tricuspid valve repair is more beneficial compared with replacement, except in highly selected cases of long-standing TR with multifactorial mechanism.

[The role of multimodality imaging in COVID-19 patients: from diagnosis to clinical monitoring and prognosis]. / L'imaging integrato nel percorso del paziente con COVID-19: dalla diagnosi, al monitoraggio clinico, alla prognosi.

The integrated clinical, laboratory and ultrasound approach is essential for the diagnosis, monitoring and evaluation of the patient's therapy in COVID-19 pneumonia. The ideal imaging strategy in this setting is not yet well defined. Bedside pulmonary ultrasound presents an undeniable series of advantages in patients at high risk of infection, and can provide incremental data in the respiratory intensive care for the serial control of the individual patient, as well as for home delivery of stabilized patients. Chest X-ray is characterized by low sensitivity in identifying earlier lung changes. 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 imaging findings may not change the therapeutic approach. Echocardiography should be limited to patients with hemodynamic instability.