Background: The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand better how different echocardiographic modalities are used and accessed in Italy. Methods: We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved via an electronic survey based on a structured questionnaire, uploaded on the SIECVI website. Results: Data were obtained from 228 echocardiographic laboratories: 112 centers (49%) in the northern, 43 centers (19%) in the central, and 73 (32%) in the southern regions. During the month of observation, we collected 101,050 transthoracic echocardiography (TTE) examinations performed in all centers. As concern other modalities there were performed 5497 transesophageal echocardiography (TEE) examinations in 161/228 centers (71%); 4057 stress echocardiography (SE) examinations in 179/228 centers (79%); and examinations with ultrasound contrast agents (UCAs) in 151/228 centers (66%). We did not find significant regional variations between the different modalities. The usage of picture archiving and communication system (PACS) was significantly higher in the northern (84%) versus central (49%) and southern (45%) centers (P < 0.001). Lung ultrasound (LUS) was performed in 154 centers (66%), without difference between cardiology and noncardiology centers. The evaluation of left ventricular (LV) ejection fraction was evaluated mainly using the qualitative method in 223 centers (94%), occasionally with the Simpson method in 193 centers (85%), and with selective use of the three-dimensional (3D) method in only 23 centers (10%). 3D TTE was present in 137 centers (70%), and 3D TEE in all centers where TEE was done (71%). The assessment of LV diastolic function was done routinely in 80% of the centers. Right ventricular function was evaluated using tricuspid annular plane systolic excursion in all centers, using tricuspid valve annular systolic velocity by tissue Doppler imaging in 53% of the centers, and using fractional area change in 33% of the centers. When we divided into cardiology (179, 78%) and noncardiology (49, 22%) centers, we found significant differences in the SE (93% vs. 26%, P < 0.001), TEE (85% vs. 18%), UCA (67% vs. 43%, P < 0001), and STE (87% vs. 20%, P < 0.001). The incidence of LUS evaluation was similar between the cardiology and noncardiology centers (69% vs. 61%, P = NS). Conclusions: This nationwide survey demonstrated that digital infrastructures and advanced echocardiography modalities, such as 3D and STE, are widely available in Italy with a notable diffuse uptake of LUS in the core TTE examination, a suboptimal diffusion of PACS recording, and conservative use of UCA, 3D, and strain. There are significant differences between northern and central-southern regions and echocardiographic laboratories that pertain to the cardiac unit. This inhomogeneous distribution of technology represents one of the main issues that must be solved to standardize the practice of echocardiography.

Venous thromboembolism (VTE) represents a major health problem, especially in cancer patients, who experience a significantly higher incidence of both deep vein thrombosis and pulmonary embolism compared to the general population. Indeed, patients with cancer have a prothrombotic state resulting in both increased expression of procoagulants and suppression of fibrinolytic activity. In addition, VTE increases the morbidity and mortality of these patients. For all these reasons, the prevention and treatment of VTE in cancer setting represent major challenges in daily practice. In general, low-molecular-weight heparin monotherapy is the standard of care for the management of cancer-associated VTE, as Vitamin K antagonists are less effective in this setting. Direct oral anticoagulants offer a potentially promising treatment option for cancer patients with VTE, since recent studies demonstrated their efficacy and safety also in this peculiar setting.

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.

In 2007, Societa 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.

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.

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.

ABSTRACT An association between atrial myxoma and left ventricular failure is rarely described, is not completely understood, and may have multiple etiologies. We present a 49-year-old man with no history of cardiovascular disease who was admitted to our hospital with pulmonary edema. He was in atrial fibrillation with rapid ventricular response. Echocardiography showed a 10.5-cm left atrial myxoma, which had been asymptomatic until the onset of congestive heart failure in the presence of severe left ventricular systolic dysfunction. Left ventricular inflow obstruction associated with the giant atrial mass could not be the only cause for acute heart failure.

Background: We prospectively assessed the incremental value of a pocket-sized echocardiography (PSE) device during cardiology consultations, in addition to physical examination, ECG reading, and chest x-ray. Methods: A total of 443 consecutive patients (53% men), referred for bedside consultations, underwent physical examination, ECG, and CXR, followed by PSE examination. The physician completed a detailed questionnaire (clinical and echocardiographic data, scanning time, abnormal results). Receiver operating characteristic (ROC) curve analysis was generated to test the predictive discrimination value of the different methods. The incremental value of PSE examination compared to clinical visit alone or combined with ECG results was expressed as a global chi-square value. Results: The PSE examination did not influence the definitive diagnosis in only 23.5% of cases, while 25.3% of the diagnoses were confirmed and verified by PSE. The clinical diagnosis was enriched by PSE in 21.9% of cases, and the diagnosis was changed in 26.2%. The area under curve (AUC) of physical examination + ECG results (sensitivity: 80%; specificity: 67%) was significantly higher than physical examination alone (sensitivity: 75%; specificity: 62%) (P < 0.0002), and the AUC of PSE results (sensitivity: 88%; specificity: 86%) was significantly higher than physical examination + ECG results (P < 0.0001). The PSE results, combined with clinical and ECG results, had a significant incremental diagnostic value during cardiology consultation when compared to the clinical visit alone or with ECG results (P < 0.0001). Conclusions: PSE had an incremental diagnostic value during bedside cardiology consultation, increasing the number of appropriate diagnoses and reducing the routine use of echocardiography.

Aims While patient history taking and physical examination remain the cornerstones of patient evaluation in clinical practice, there has been a decline in the accuracy of the latter. Hand-held echocardiographic devices have recently been introduced and could potentially improve the diagnostic accuracy of clinical examination. The aim of this study was to assess the usefulness of a new miniaturized echocardiographic system to perform bedside echocardiography in initial outpatient cardiology consultations, in addition to physical examination. Methods and results: One hundred fifty-one patients, referred for initial cardiology outpatient consultations, were studied in 6 Cardiologic Centres in Italy. Each patient was submitted to physical examination followed by VScan (GE Healthcare) assessment. Scanning time, the number of examinations with abnormal results after physical examination and the VScan, and the information obtained by physical examination alone and followed by the VScan (in terms of its importance in reaching a diagnosis, in the necessity of performing routine echocardiography, and in the decision to release the patient from the outpatient clinic) were assessed. The main consultation motives were: dyspnea (28%), chest pain (24%), arrhythmias (19%), shock (5%), syncope (5%), before surgery cardiologic evaluation (25%). The scanning time with the VScan was184±83 seconds. Its use after physical examination led to diagnosis in 106 patients (70%) and to an additional 25 patients (16%) being released from the outpatient clinic. After physical examination followed by VScan assessment, only 37 patients (24%) were sent to the echocardiography lab for further examination. The VScan modified the decision of whether to send a patient to the echocardiography lab, with referral determined by the VScan in 18 patients (11%) and no referral determined by the VScan in 58 patients (29%). The main diagnoses made with VScan were: increase of left and or right ventricular chambers, atrial dilation, left ventricular hypertrophic or dilative remodeling, previous myocardial infarction, low Left Ventricular ejection fraction, mitral or aortic valvular insufficiency or stenosis, pericardial effusion. Conclusions: The VScan utilization caused a negligible increase in the duration of consultations. It showed incremental value over physical examination, increasing the number of diagnoses, reducing the use of unnecessary routine echocardiography, increasing the number of adequate echocardiographic studies, and determining a large number of releases from the outpatient clinic.

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.

Nel nostro Paese la tutela della salute è un diritto dell’individuo sancito dall’articolo 32 della Costituzione e garantito a tutti nel 1978 con l’istituzione del Servizio Sanitario Nazionale. La regionalizzazione del Servizio Sanitario Nazionale ha però determinato evidenti discrepanze nelle diverse aree del nostro Paese che l’impiego dell’Information and Communication Technology (ICT) potrebbe contribuire a risolvere. Scopo di questo documento è di analizzarne l’implementazione nel nostro Paese, sottolineando le proposte avanzate dall’Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO). Nel 2010 è stato introdotto il fascicolo sanitario elettronico (FSE), contenitore di un nucleo minimo di documenti, che deve essere compilato dal medico di medicina generale. I limiti di questa metodologia diventano vistosi in urgenza-emergenza quando avere specifici dati specialistici condiziona la prognosi del paziente e la riduzione dei costi. Anche le norme della privacy sono di ostacolo all’attendibilità dei dati inseriti nel FSE. È necessario spostare l’equilibrio dal diritto della privacy a quello della salute, sia del singolo che della collettività, individuando un nucleo minimo di informazioni ineliminabili dal documento. Sulla cartella clinica non esistono indicazioni formali e le poche esperienze l’hanno costruita come un “documento burocratico”. Per riuscire a garantire in modo omogeneo il diritto alla salute andrebbe trasformata in uno “strumento” di diagnosi e cura con le seguenti caratteristiche: un’interfaccia semplice, l’unione inscindibile di reperto e referto, la portabilità ed accessibilità dei dati, il rispetto del minimal dataset. I dati delle cartelle dovrebbero poi confluire in un FSE modificato disponibile in qualsiasi momento, da qualsiasi punto di accesso alla rete e ad una velocità minima garantita. Purtroppo la disomogenea diffusione della banda larga è un ostacolo al momento insormontabile. Anche l’attuale impianto formativo dei futuri medici non aiuta la diffusione della cultura dell’ICT. Andrebbero inseriti nei crediti formativi universitari alcuni argomenti irrinunciabili. È indispensabile mettere ordine tra esigenze confluenti: quelle dei pazienti di avere realmente sempre disponibili i dati sul proprio “patrimonio biologico”, quelle dei medici di utilizzare strumenti che siano di reale ausilio per migliorare la qualità della loro professione, quelle dei manager e della politica di ottimizzare i costi della sanità.

B-type natriuretic peptide (BNP) is increased in post-cardiac surgery patients, however the mechanisms underlying BNP release are still unclear. In the current study, we aimed to assess the relationship between postoperative BNP levels and left ventricular filling pressures in post-cardiac surgery patients.

Background Serum C-reactive protein (CRP) is involved in the acute phase reaction after surgery, even though its clinical significance remains a matter of debate. We evaluated CRP levels in cardiac surgery patients without clinical or laboratory signs of infection.Methods We screened 737 consecutive patients referred to our center 8 5 days after cardiac surgery. Patients with fever (> 3720C), elevated white blood cell count (> 11 000/ml), neutrophilia (> 70%), or any inflammatory, infective or malignant disease were excluded. CRP levels were measured on admission and at discharge and the values were related to the following variables: age, sex, diabetes mellitus, renal failure, type of surgery, postoperative atrial fibrillation, pericardial or pleural effusion, and length of hospital stay. Follow-up (mean: 23 8.5 months) was available for 175 patients (94%).Results In the 187 patients enrolled in the study, the CRP values were significantly elevated (median: 4.23mg/dI, interquartiles range: 2.68-6.64) independent of any variable analyzed. At discharge, CRP levels were significantly reduced compared with values on admission (median: 1.55 mg/dl, interquartiles range: 0.84-2.37, P< 0.001). At follow-up, 19 events (10.8%) occurred (two noncardiac deaths, 17 hospital readmissions for cardiac reasons); nonetheless, no correlation was found with CRP values either on admission or at discharge.Conclusion Early after cardiac surgery, in patients without clinical or laboratory signs of acute infection, CRP levels are significantly elevated, do not correlate with clinical variables, and decrease at discharge. These findings suggest a systemic inflammatory response to surgery-related stress, which carries a favorable prognosis at follow-up. Eur J Cardiovasc Prev Rehabil 15:482-487 (c) 2008 The European Society of Cardiology

Il prolasso valvolare mitralico (PVM) ancora oggi rappresenta un problema cardiologico complesso in alcuni suoi aspetti, che traggono generalmente origine da inquadramenti clinici non chiari. Vengono esaminati i principali aspetti di questa patologia, a partire dalle sue dimensioni epidemiologiche e dall’incidenza di complicanze cardiovascolari e aritmiche, molto diversa nelle varie casistiche perché condizionata da importanti “bias” nella selezione dei pazienti e nell’interpretazione dei dati. La definizione stessa di prolasso mitralico ha avuto a lungo contrapposte due accezioni prevalenti, quella “cardiochirurgica” e quella “cardiologica”.Quest’ultima, attualmente più diffusa nella comunità medica, identifica il PVM come la protrusione di tutto o parte dei lembi mitralici in atrio sinistro in relazione all’anello, indipendentemente dal fatto che sia mantenuta la coaptazione dei lembi. Pertanto l’insufficienza mitralica viene considerata una delle possibili complicanze, insieme a quelle aritmiche sia sopraventricolari che ventricolari. Si tratta per lo più di aritmie non minacciose, la cui incidenza aumenta se il PVM si associa ad insufficienza mitralica e se la valvola presenta fenomeni degenerativi mixoidi. L’inquadramento diagnostico del PVM si basa oggi unicamente sull’esame ecocardiografico, che può fornire dettagli anatomo-funzionali della valvola malformata utili sia per una corretta diagnosi, sia per la più appropriata correzione chirurgica. Dopo un iniziale riepilogo delle principali caratteristiche anatomiche della valvola mitrale normale, si esaminano i piani di scansione transtoracici e transesofagei per lo studio della mitrale in generale e quelli più idonei alla diagnosi di PVM. Vengono quindi descritti i criteri ecocardiografici diagnostici e considerato anche il contributo aggiuntivo della ricostruzione tridimensionale della valvola, soprattutto in termini di localizzazione morfologica delle alterazioni. La scelta del “timing” chirurgico della correzione scaturisce dall’integrazione dei dati noti della storia naturale della patologia, dalla clinica, dal grado di insufficienza valvolare e dalle alterazioni cardiovascolari secondarie al vizio valvolare. Nel contesto dell’atto chirurgico riparativo valvolare, si inserisce l’importante contributo dell’ecocardiografia transesofagea che, nelle fasi pre- e postoperatorie, fornisce al chirurgo dettagli anatomici, riscontri in tempo reale dell’efficacia delle correzioni effettuate e le eventuali complicanze dell’intervento stesso.

Cardiac ultrasound plays a pivotal role in assessing pulmonary artery pressures. Estimation of right atrial pressure can be derived from the dimensions and respiratory variation of the inferior vena cava and Doppler modalities provide an accurate and comprehensive evaluation of right ventricular and pulmonary artery pressures. Peak pulmonary artery pressure can be calculated from continuous wave Doppler sampling of the tricuspid regurgitant jet, while pulsed wave Doppler sampling of the pulmonary regurgitant jet allows evaluation of mean and diastolic pulmonary artery pressures. In patients with tricuspid regurgitation that is either absent or not adequately detectable by Doppler method, Doppler right ventricular outflow tract investigation can be helpful. Recent data indicate that analysis of right ventricular function using myocardial Doppler echocardiography may also provide new insights for the non-invasive estimation of pulmonary artery pressures. In particular, right ventricular isovolumic relaxation time measured by myocardial Doppler echocardiography at the tricuspid annulus may provide an alternative method for estimating pulmonary artery pressure, especially in patients with tricuspid regurgitation not detectable or spectral Doppler not properly interpretable.

Mitral valve prolapse (MVP) is still a clinical challenging problem. In this report, we review the main characteristics of this entity. Epidemiology of MVP, which relies on the diagnostic criteria adopted, and the incidence of complications, both arrhythmic and structural, are influenced by the characteristics of the population studied, which may lead to bias in data interpretation. Even the definition of MVP may differ according to the cardiologist's or cardiac surgeon's point of view. Usually, cardiologists define MVP as the protrusion of all or part of the mitral leaflets into the left atrium, independent of maintenance of coaptation. Therefore, using this definition, mitral regurgitation is considered as a complication rather than a diagnostic criterion. Arrhythmias, either supraventricular or ventricular, are other possible complications, mostly not life-threatening and associated with myxomatous degeneration of the valve.Diagnosis of MVP is based on echocardiography, which provides detailed anatomic and functional evaluation of the affected valve. Leaflet thickness and motion as well as presence and severity of mitral regurgitation can be assessed, with important diagnostic and prognostic implications. Echocardiographic evaluation of the mitral valve requires a systematic approach in order to define the leaflet/scallop involved and the mechanisms of mitral regurgitation. To this aim, three-dimensional reconstruction may add further insights into objective rendering of mitral valve pathology.Finally, surgical timing in mitral regurgitation due to MVP is an evolving issue and the likelihood of surgical repair is a crucial factor in the optimal timing of surgical intervention, especially in asymptomatic patients with severe mitral regurgitation.

OBJECTIVESThe aim of this study was to assess the potential value of hand-carried ultrasound (HCU) devices in the diagnosis and follow-up of patients with pleural effusion (PE) after cardiac surgery.METHODSSeventy consecutive patients were evaluated at bedside early after cardiac surgery, in the upright sitting position, using an HCU device on hospital admission and every 3 days until hospital discharge. The posterior chest wall was scanned along the paravertebral, scapular, and posterior axillary lines. For each hemithorax, an effusion index was derived as the sum of the intercostal spaces between the lower and upper limits of the PE along the lines of scanning, divided by 3. A standard chest radiograph was performed in all patients on hospital admission and at hospital discharge, and was qualitatively scored (0, absent; 1, small; 2, large PE). The findings of the HCU device and radiograph were compared using kappa statistics and the Kruskal-Wallis test.RESULTSA chest ultrasound was feasible in all patients (mean [+/- SD] time, 5 +/- 2 min). Compared with the chest ultrasound, a physical examination showed a sensitivity of 69% and a specificity of 77%. On hospital admission, the HCU device detected a PE in 72 of 140 hemithoraxes. Agreement with the finding of the radiograph was 76% (kappa = 0.52). In 15 hemithoraxes, the HCU device revealed a PE that had not been diagnosed using the radiograph. Conversely, in 18 hemithoraxes a PE that had been diagnosed with a radiograph was not confirmed by the HCU device. The correlation between ultrasound and radiographic scores was statistically significant (p < 0.001). At hospital discharge, a PE was present in 31 of 140 hemithoraxes according to the findings of the HCU device, and in 38 of 140 hemithoraxes according to the findings of the radiograph (agreement, 78%; kappa = 0.44).CONCLUSIONSIn patients early after cardiac surgery, HCU devices allow rapid PE detection and improve the clinical diagnosis. Compared to a radiograph, this method offers the unique advantage of the bedside evaluation of patients without the need for radiation exposure.