Background: Left ventricular global longitudinal strain (GLS) measured by speckle-tracking echocardiography (STE) has become a key marker of myocardial systolic function, yet normal reference values remain heterogeneous, and the magnitude of physiological sex differences is not fully defined. We performed a systematic review and meta-analysis to establish pooled GLS reference estimates in healthy individuals, quantify sex-related differences, and contextualize deformation findings relative to conventional systolic function. Methods: A systematic search of PubMed, Scopus, and EMBASE identified observational studies reporting GLS in healthy adults assessed by two-dimensional or three-dimensional STE. Random-effects meta-analysis using standardized mean differences (SMD) compared GLS between women and men. Descriptive pooled reference values were derived using weighted median and interquartile range (IQR) reconstruction from study-level distributions. Meta-regression analyses explored demographic, clinical, and methodological sources of heterogeneity. A complementary analysis evaluated sex-related differences in left ventricular ejection fraction (LVEF) within the same populations. Results: Thirty-two studies, including 19,157 healthy individuals, were analyzed. The pooled population had a weighted median age of 47.5 years and 53% female participants. Overall, GLS demonstrated a weighted median of 20.3% (IQR 17.8-22.5). Women showed higher GLS values than men (20.8% [18.4-23.1] vs. 19.4% [17.0-21.6]). Meta-analysis of 28 studies confirmed significantly greater GLS in females (SMD 0.487, 95% CI 0.409-0.565; p < 0.001), with consistent findings across imaging modalities and no subgroup interaction. Between-study heterogeneity was substantial (I2 = 82.7%), although effect direction was uniform. Meta-regression analyses identified no significant moderators, and sensitivity analyses confirmed stable estimates without publication bias. Segmental analysis demonstrated a physiological base-to-apex strain gradient. In contrast, LVEF was largely comparable between sexes, with no clinically meaningful difference (SMD 0.257, 95% CI 0.186-0.327; p < 0.001), indicating preserved global systolic performance despite differences in myocardial deformation. Conclusions: GLS demonstrates a consistent physiological range in healthy populations, with women exhibiting higher longitudinal deformation than men, independent of the imaging modality. These findings support the adoption of sex-specific GLS reference values and highlight the complementary roles of deformation and volumetric indices in improving the interpretation of myocardial function and reducing misclassification in clinical practice.

BACKGROUND:Bundle branch conduction abnormalities are associated with ventricular dyssynchrony, impaired myocardial mechanics, and progressive systolic dysfunction. Advanced deformation imaging techniques, including speckle-tracking echocardiography (STE) and cardiac magnetic resonance feature tracking (CMR-FT), may identify subclinical ventricular dysfunction beyond conventional left ventricular ejection fraction (LVEF). We performed a systematic review and meta-analysis to evaluate conventional systolic function and myocardial deformation abnormalities associated with left bundle branch block (LBBB) and right bundle branch block (RBBB). METHODS:PubMed, Scopus, and EMBASE databases were systematically searched for observational studies evaluating ventricular systolic function and myocardial deformation parameters in patients with LBBB and/or RBBB using STE and/or CMR-FT. Comparative meta-analyses were performed using standardized mean differences (SMDs) with 95% confidence intervals (CIs). Separate analyses were conducted for LVEF and left ventricular global longitudinal strain (LV-GLS). RESULTS:Sixteen studies were included in the systematic review, whereas eight were eligible for quantitative meta-analysis. Compared with healthy controls, patients with LBBB demonstrated significantly reduced LVEF (SMD -0.404, 95% CI -0.553 to -0.255; p < 0.001) and impaired LV-GLS (SMD -0.345, 95% CI -0.535 to -0.156; p < 0.001). In contrast, isolated RBBB was not associated with significant overall differences in either LVEF (SMD 0.051, 95% CI -0.146 to 0.247; p = 0.613) or LV-GLS (SMD 0.064, 95% CI -0.134 to 0.262; p = 0.527). Direct comparisons demonstrated significantly greater impairment of both LVEF (SMD -0.361, 95% CI -0.519 to -0.202; p < 0.001) and LV-GLS (SMD -0.436, 95% CI -0.595 to -0.276; p < 0.001) in LBBB than in RBBB. STE-based studies generally demonstrated larger effect sizes and greater heterogeneity than CMR-FT investigations. CONCLUSIONS:Bundle branch conduction abnormalities, particularly LBBB, are closely associated with impaired left ventricular systolic performance and myocardial mechanics. LV-GLS abnormalities appeared consistently more pronounced than LVEF abnormalities across several comparisons, suggesting that myocardial deformation imaging may be more sensitive to the mechanical consequences of conduction abnormalities at a population level. Given the observational nature of the included studies, the substantial clinical and methodological heterogeneity across populations, the limited evidence available for RBBB, and the potential influence of residual confounding factors such as age and underlying structural heart disease, these findings should be considered hypothesis-generating and warrant confirmation in larger prospective studies.

Background: Epicardial adipose tissue (EAT) is a metabolically active visceral fat depot increasingly associated with the development and progression of coronary artery disease (CAD). Transthoracic echocardiography is the most widely used modality for EAT assessment; however, substantial heterogeneity exists regarding the timing of measurement within the cardiac cycle, with EAT thickness variably assessed during systole or diastole. Whether these measurements provide equivalent information for identifying obstructive CAD remains unclear. This systematic review and meta-analysis evaluated the association between echocardiographically measured EAT thickness and angiographically confirmed obstructive CAD, with specific focus on systolic versus diastolic assessments. Methods: PubMed, Scopus, and EMBASE were systematically searched through December 2025 for observational studies comparing EAT thickness in patients with and without obstructive CAD confirmed by invasive coronary angiography. Random-effects models were used to pool standardized mean differences (SMDs) for systolic and diastolic EAT thickness. Heterogeneity was assessed using the I2 statistic, publication bias by funnel plots and Egger's regression test, and robustness by meta-regression and leave-one-out sensitivity analyses. Results: Twenty-two studies including more than 6500 patients were analyzed. Both systolic and diastolic EAT thickness were significantly greater in patients with obstructive CAD than in non-CAD controls. Systolic EAT showed a large, pooled effect size (SMD 1.27; 95% CI 0.96-1.59; p < 0.001), while diastolic EAT demonstrated a similarly strong association (SMD 1.59; 95% CI 1.10-2.07; p < 0.001). Heterogeneity was substantial (I2 > 90%), but the direction of effect was consistent across all studies. Meta-regression analyses indicated that demographic, clinical, metabolic, geographic, and methodological characteristics, including ultrasound software/vendor category and timing of EAT measurement, did not significantly moderate the association between EAT thickness and obstructive CAD. No significant publication bias was detected, and sensitivity analyses confirmed the robustness of the results. Conclusions: Echocardiographically measured EAT thickness is strongly and consistently associated with obstructive CAD, irrespective of whether measurements are obtained during systole or diastole. Although both approaches show robust discriminatory capacity at the population level, differences in effect magnitude suggest that they may not be fully interchangeable. Moreover, in the absence of standardized and broadly applicable cut-off values, the interpretation and clinical management of EAT measurements as individual risk predictors require further investigation.

Thoracic morphology is increasingly recognized as an important determinant of cardiopulmonary phenotype, influencing cardiovascular mechanics, respiratory physiology, and the interpretation of diagnostic imaging findings. Although the radiological Haller Index (HI) remains the reference standard for quantifying pectus excavatum severity, its dependence on computed tomography and ionizing radiation limits widespread clinical implementation, particularly in settings requiring serial evaluations. To overcome these limitations, the Modified Haller Index (MHI) was developed as a simple, non-invasive, radiation-free alternative that combines external thoracic anthropometry with echocardiographic assessment. Since its introduction, the MHI has undergone clinical validation and has progressively expanded beyond the assessment of chest wall deformities, demonstrating that thoracic conformation is not merely an anatomical characteristic but a clinically relevant determinant of cardiovascular and respiratory physiology. Growing evidence indicates that thoracic morphology influences cardiac chamber geometry, ventricular filling, stroke volume, myocardial deformation, ventricular–arterial coupling, exercise stress echocardiography findings, pulmonary function, and symptom perception across a broad spectrum of cardiovascular and respiratory diseases. Elevated MHI values identify individuals with a reduced antero-posterior thoracic diameter and a distinctive cardiopulmonary phenotype characterized by external cardiac compression, smaller cardiac chambers, restrictive ventilatory physiology, and apparent alterations in myocardial mechanics despite the absence of intrinsic myocardial disease. Building upon the clinical validation of the MHI, a novel patented anatomical measurement device was engineered to standardize thoracic morphometric assessment by enabling direct acquisition of both latero-lateral and antero-posterior thoracic diameters within a single measurement procedure. The device integrates dedicated anatomical reference elements, an innovative adjustable sternal pointer, movable measurement components, and a standardized acquisition workflow into a portable, low-cost, and radiation-free platform, thereby improving measurement reproducibility while simplifying bedside MHI determination. This narrative review summarizes the historical evolution of thoracic morphometry, the development and clinical validation of the MHI, the engineering rationale, structural architecture, and measurement workflow of the patented device, and the growing evidence supporting the clinical significance of thoracic conformation across cardiovascular and respiratory medicine. Together, the MHI and the proposed anatomical measurement device establish a practical platform for standardized, radiation-free thoracic morphometry that may facilitate routine bedside phenotyping. Future integration with digital technologies, artificial intelligence, and advanced imaging systems may further enable next-generation digital thoracic phenotyping for personalized cardiovascular and respiratory characterization, risk stratification, and precision medicine.

Background: Risk stratification in aortic stenosis (AS) remains challenging, particularly in patients with preserved left ventricular ejection fraction or inconclusive symptom status, as conventional parameters primarily reflect valvular obstruction and may underestimate the extent of cardiac dysfunction. Left atrial reservoir strain (LASr) has emerged as a promising and potentially more comprehensive marker of atrial function and diastolic burden, with potential prognostic implications. Methods: A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Scopus, and EMBASE were searched from inception to April 2026. Studies including adult patients with moderate or severe AS and evaluating LASr using different imaging modalities (speckle-tracking echocardiography, cardiac computed tomography, or cardiac magnetic resonance) were considered eligible if clinical outcomes were reported. Data were qualitatively synthesized, and continuous variables were summarized as weighted medians with interquartile ranges. Results: Twenty-one studies were included, encompassing a large and clinically heterogeneous population. During follow-up, a substantial proportion of patients experienced adverse events, including mortality, heart failure hospitalization, arrhythmic events, and composite cardiovascular outcomes. Across studies, reduced LASr consistently emerged as a significant predictor of adverse outcomes. This association was observed both when LASr was analyzed as a continuous variable and when defined using study-specific cut-off values, which generally clustered within a relatively narrow range. Importantly, LASr demonstrated incremental prognostic value beyond conventional echocardiographic parameters, including left atrial size, left ventricular ejection fraction, global longitudinal strain, and indices of diastolic dysfunction. The prognostic relevance of LASr was consistent across different imaging modalities, including both echocardiography and cardiac computed tomography (with no eligible studies using cardiac magnetic resonance). Conclusions: LASr is a robust and reproducible marker of adverse prognosis in patients with AS, reflecting the cumulative burden of left-sided pressure overload and atrial remodeling. Its integration into multiparametric assessment may enhance risk stratification and support more individualized clinical decision-making. Further prospective studies are warranted to standardize measurement techniques and define clinically actionable thresholds.

Background: Prognostic heterogeneity in heart failure (HF) is substantial and not fully captured by conventional left-sided echocardiographic parameters. Growing evidence highlights the importance of right ventricular-pulmonary arterial (RV-PA) interaction in HF pathophysiology and outcomes. The echocardiographic tricuspid annular plane systolic excursion-to-systolic pulmonary artery pressure (TAPSE/sPAP) ratio has been proposed as a simple noninvasive surrogate of RV-PA coupling, yet its prognostic value across the HF spectrum remains incompletely defined. Methods: This systematic review followed PRISMA guidelines and was registered in INPLASY. PubMed, Scopus, and EMBASE were searched from inception through January 2026 for observational studies evaluating the prognostic value of TAPSE/sPAP in adult patients with HF. Study selection, data extraction, and risk-of-bias assessment were performed independently by two reviewers. Owing to substantial heterogeneity, a qualitative synthesis with weighted pooled descriptive statistics was performed. Results: Fifteen observational studies including 5389 patients were analyzed, with a median follow-up of approximately 1.9 years, ranging from in-hospital outcomes to long-term follow-up of up to 15 years. Study populations encompassed a wide range of HF phenotypes and clinical settings, including acute and chronic HF, preserved and reduced ejection fraction, valvular heart disease, infiltrative cardiomyopathies, and advanced HF. Across studies, reduced TAPSE/sPAP was generally associated with adverse outcomes, including all-cause mortality and HF-related events, with reported hazard ratios ranging from approximately two- to five-fold. Prognostically relevant TAPSE/sPAP cut-off values tended to cluster within a relatively narrow range, with most thresholds between 0.36 and 0.40 and a weighted median of approximately 0.36. When reported, TAPSE/sPAP showed favorable discriminative performance for adverse outcomes. Overall methodological quality was predominantly fair. Conclusions: Across heterogeneous HF populations, impaired TAPSE/sPAP appears to be a consistent marker of adverse prognosis. These findings support TAPSE/sPAP as a practical, noninvasive indicator of RV-PA uncoupling that may contribute to risk stratification and phenotyping in heart failure. Prospective studies focusing on specific HF phenotypes are needed to clarify its role in longitudinal monitoring and therapeutic decision-making.

Background: Risk stratification of patients with mitral regurgitation (MR), including both primary (degenerative) and secondary (functional) forms, remains challenging, particularly in asymptomatic or minimally symptomatic stages, as clinical assessment and resting echocardiography may underestimate disease severity and functional impairment. Exercise stress echocardiography (ESE) enables dynamic evaluation of regurgitation severity, ventricular performance, and cardiopulmonary response, potentially improving prognostic assessment. Methods: A systematic review was conducted according to PRISMA guidelines. PubMed, Scopus, and EMBASE were searched from inception to March 2026. Studies including adult patients with primary or secondary MR undergoing exercise-based stress echocardiography and reporting clinical outcomes were selected. Studies using exclusively pharmacological stress were excluded. Data were qualitatively synthesized, and continuous variables were summarized as weighted medians and interquartile ranges. In addition, emerging and non-conventional prognostic markers, including anatomical indices such as the modified Haller index (MHI), were explored to provide a more comprehensive risk stratification framework. Results: Nineteen studies were included, encompassing a heterogeneous population in terms of MR etiology, severity, and clinical presentation. During follow-up, a substantial proportion of patients experienced adverse events, including heart failure, mitral valve intervention, or death. Exercise-derived parameters consistently showed strong prognostic value. In particular, exercise-induced worsening of MR severity (increase in effective regurgitant orifice area and regurgitant volume), absence of contractile reserve, elevated filling pressures (E/e'), and exercise-induced pulmonary hypertension were associated with worse outcomes. Reduced functional capacity and impaired right ventricular-pulmonary arterial coupling provided additional prognostic information. Emerging markers, including chest wall configuration assessed by MHI, appeared to further refine risk stratification in selected patient subsets. In contrast, resting parameters were less consistently predictive. Conclusions: ESE provides incremental prognostic information in patients with MR by identifying dynamic abnormalities not evident at rest. Its integration into clinical evaluation, together with novel anatomical and functional markers, may improve risk stratification and support earlier identification of high-risk patients who could benefit from timely intervention. Further studies are needed to standardize methodologies and define clinically relevant thresholds.

Background: Over the last 15 years, few echocardiographic studies have examined the biventricular mechanics by speckle tracking echocardiography (STE) in patients affected by chronic obstructive pulmonary disease (COPD) without advanced lung disease. We aimed to summarize the main findings of these studies and quantify the overall effect of COPD on biventricular mechanics in patients without severe airflow obstruction. Methods: Eligible studies assessing cardiac function by conventional transthoracic echocardiography (TTE), implemented with a STE analysis of left ventricular (LV)-global longitudinal strain (GLS) and/or right ventricular (RV)-GLS in COPD patients without severe airflow obstruction vs. healthy controls, were selected from the PubMed, Embase and Scopus databases. The primary endpoint was to quantify the effect of COPD on LV-GLS and RV-GLS in individuals without advanced lung disease. Continuous data [LV-GLS, RV-GLS, left ventricular ejection fraction (LVEF) and tricuspid annular plane systolic excursion (TAPSE)] were pooled as the standardized mean difference (SMD) comparing COPD cohorts with healthy controls. Results: Ten studies were included, totaling 682 COPD patients and 316 healthy controls. Overall, COPD showed a large effect on LV-GLS (SMD −1.296; 95%CI −2.010, −0.582, p < 0.001) and RV-GLS (SMD −1.474; 95% CI −2.142, −0.805, p < 0.001), a medium-to-large effect on TAPSE (SMD −0.783, 95% CI −0.949, −0.618, p < 0.001) and a small effect on LVEF (SMD −0.366, 95% CI −0.659, −0.074, p = 0.014). The I2 statistic value for the LV-GLS (91.1%), RV-GLS (88.2%) and LVEF (76.7%) studies suggested a high between-study heterogeneity, while that for the TAPSE (38.1%) studies was compatible with a low-to-moderate between-study heterogeneity. Egger’s test yielded a p-value of 0.16, 0.48, 0.58 and 0.50 for LV-GLS, RV-GLS, LVEF and TAPSE studies, respectively, indicating an absence of publication bias. Meta-regression analyses excluded that the effect of COPD on biventricular mechanics might be influenced by potential confounders (all p > 0.05). Sensitivity analysis confirmed the robustness of the LV-GLS, RV-GLS and TAPSE studies’ results. Conclusions: COPD appears to be independently associated with a mild attenuation of biventricular mechanics in patients with moderate airflow limitations, despite a preserved LVEF and TAPSE on conventional TTE. STE analysis may allow clinicians to identify COPD patients with subclinical myocardial dysfunction and an increased risk of heart failure and cardiovascular complications early.

Primary mitral regurgitation (PMR) is the most common mitral valve disorder in clinical practice. Although several prognostic indicators derived from resting transthoracic echocardiography (TTE) and exercise stress echocardiography (ESE) are available, patient outcomes remain highly variable, with substantial differences in complication rates and mortality. Identifying individuals at lower cardiovascular risk is therefore clinically relevant, as they represent a large proportion of cases. Current guidelines recommend an integrative approach-combining qualitative, semi-quantitative, and quantitative indices-to determine the timing of intervention, but they do not specifically address risk stratification in low-risk PMR populations. Recent studies have highlighted the potential prognostic value of chest wall configuration, assessed noninvasively using the Modified Haller Index (MHI). Defined as the ratio of latero-lateral thoracic diameter to the antero-posterior (A-P) sternum-spine distance, MHI appears to influence myocardial deformation indices obtained by speckle-tracking echocardiography (STE). Patients with PMR due to mitral valve prolapse (MVP) often show a reduced A-P thoracic diameter caused by sternal depression. Among these, those with an MHI > 2.5 or A-P diameter ≤ 13.5 cm display greater impairment in global and basal strain, particularly in longitudinal and circumferential directions. These abnormalities likely reflect extrinsic geometric constraints and cardiac displacement leading to apparent dyssynchrony rather than intrinsic myocardial dysfunction. A reduced A-P diameter was also independently associated with mitral annular disjunction (MAD) in MVP and emerged as a determinant of impaired strain in this subgroup. In a retrospective cohort of 424 symptomatic MVP patients with moderate MR undergoing ESE, positive tests and exercise-induced severe MR were uncommon. Importantly, an MHI > 2.5 or an A-P diameter ≤ 13.5 cm was associated with a favorable medium-term prognosis, with few adverse cardiovascular events. This narrative, non-systematic review, based on a structured but non-PRISMA literature search, summarizes current evidence on conventional and novel echocardiographic prognostic markers and their implications for risk stratification in PMR. As such, it carries inherent limitations, including potential selection bias, incomplete retrieval of unpublished or negative studies, and reliance on single-center observational data. The findings should therefore be interpreted cautiously and validated through larger, independent, multicenter investigations.

Background: Left ventricular (LV) mechanics assessed by speckle-tracking echocardiography provides sensitive markers of cardiac adaptation to exercise. Different training modalities-endurance, high-intensity interval training (HIIT), and acute exercise tests-impose distinct hemodynamic loads, yet their comparative effects on LV deformation remain unclear. Importantly, acute and chronic endurance exposures may elicit divergent myocardial responses that must be interpreted separately. Methods: A systematic search of PubMed, Scopus, and EMBASE (through September 2025) identified studies evaluating LV mechanics in response to endurance, HIIT, or acute exercise among healthy or recreationally active individuals. Echocardiographic parameters of strain and torsion were extracted, and methodological quality was appraised using the NIH Quality Assessment Tool. Results: Twenty-three studies (859 participants) met inclusion criteria. Acute prolonged endurance exercise-particularly marathon and ultra-endurance events-was associated with transient, fully reversible reductions in global longitudinal, circumferential, and radial strain and torsion, despite preserved ejection fraction, reflecting short-term myocardial fatigue rather than maladaptive remodeling. In contrast, chronic endurance training maintained or improved LV mechanics without evidence of dysfunction, while HIIT interventions consistently enhanced LV systolic strain and rotational indices across diverse age groups and sexes, reflecting improved contractile efficiency and physiological remodeling. Acute exercise produced heterogeneous, load-dependent strain responses, with isometric stress increasing regional strain and maximal exertion inducing temporary global reductions. Between-study heterogeneity was moderate, methodological quality generally good, and small-study effects varied by modality, being most evident in endurance studies, borderline for HIIT, and limited for acute tests due to sample size. Conclusions: Acute endurance exercise produces transient, reversible LV deformation changes, whereas chronic endurance training preserves mechanical efficiency. HIIT reliably enhances systolic strain and torsional mechanics, and acute exercise elicits variable but physiologically meaningful responses. These findings clarify that transient post-race strain reductions reflect physiological fatigue, not chronic maladaptation, and underscore the modality-specific nature of myocardial adaptation to exercise.

Background: Pregnancy induces substantial cardiovascular remodeling, yet whether maternal cardiac adaptation differs across ethnic groups remains unclear. Body size, ventricular geometry, and thoracoabdominal configuration may modulate key functional indices such as left ventricular ejection fraction (LVEF) and global longitudinal strain (LV-GLS). This systematic review compared echocardiographic characteristics between Asian and Western healthy pregnant women in late gestation and explored physiological mechanisms underlying observed differences. Methods: A comprehensive search of PubMed, Scopus, and EMBASE identified studies reporting transthoracic echocardiography in healthy singleton third-trimester pregnancies across Asian and Western populations. Extracted variables included anthropometry, ventricular dimensions and volumes, LVEF, and LV-GLS. Pooled estimates were calculated using inverse-variance weighting, with heterogeneity quantified using the I2 statistic. Study quality was assessed with the NIH Case-Control Quality Assessment Tool. Comparative forest plots visualized population differences. Results: Twenty studies involving 1431 participants (578 Asian and 853 Western women) met inclusion criteria. Asian women consistently exhibited smaller ventricular chambers, higher LVEF, and more favorable LV-GLS. Importantly, these differences persisted after indexing LV-GLS to BSA, indicating that body-size normalization attenuates-but does not eliminate-population differences in myocardial deformation. Western women demonstrated slightly attenuated GLS despite preserved LVEF, plausibly attributable to larger cardiac size, higher wall stress, greater diaphragmatic elevation, and increased extrinsic thoracic compression. Between-study heterogeneity was substantial (I2 > 95%) due to variation in imaging platforms, strain software, and population characteristics. Methodological quality was fair, with frequent lack of sample-size justification and incomplete confounder adjustment. Conclusions: Healthy Asian pregnant women display a hyperdynamic systolic phenotype, whereas Western women show a physiologically appropriate, load-related attenuation of LV-GLS with preserved LVEF. These findings highlight the need for ethnicity-associated and anatomy-aware echocardiographic reference values and support incorporating thoracic geometric indices, such as the modified Haller Index, into strain interpretation during pregnancy.

Background: Takotsubo syndrome (TTS) often mimics anterior ST-elevation myocardial infarction (STEMI) caused by left anterior descending (LAD) occlusion, yet the two entities differ fundamentally in pathophysiology and mechanical behavior. Two-dimensional speckle-tracking echocardiography (2D-STE) enables detailed assessment of left ventricular (LV) deformation beyond conventional ejection fraction (LVEF). This meta-analysis compared global and regional LV strain patterns in TTS versus LAD-related anterior STEMI during the acute phase. Methods: A systematic search of PubMed, Embase, and Scopus through October 2025 identified observational case-control studies directly comparing TTS and angiographically confirmed anterior STEMI, with LV mechanics assessed by 2D-STE. Random-effects models were used to pool standardized mean differences (SMDs) for LVEF; global longitudinal strain (GLS); apical, mid-ventricular, and basal longitudinal strain (ALS, MLS, BLS); and global radial strain (GRS). Heterogeneity (I2), publication bias (funnel plots, Egger's test), meta-regression, and leave-one-out sensitivity analyses were performed. Results: Six studies comprising 221 TTS and 290 anterior STEMI patients met the inclusion criteria. TTS patients were older, predominantly female, and had fewer metabolic risk factors, while LV size was comparable. LVEF was significantly lower in TTS (SMD -1.149; 95% CI -2.20 to -0.10; p = 0.032), with stable findings across sensitivity analyses and no evidence of publication bias. GLS, ALS, MLS, and BLS showed only a non-significant trend toward greater impairment in TTS, and these comparisons were limited by marked inter-study heterogeneity. In contrast, GRS was significantly and consistently more reduced in TTS (SMD -1.284; 95% CI -1.59 to -0.98; p < 0.001), indicating more profound global radial dysfunction. Meta-regression showed no significant influence of demographic factors or vendor-specific software on LVEF or GLS differences. Conclusions: Compared with LAD-related anterior STEMI, TTS is associated with more severely depressed LVEF and markedly impaired radial strain, while longitudinal strain differences remain inconclusive and suggest only a potential trend toward greater dysfunction, reflecting the limited and heterogeneous evidence. These findings are consistent with diffuse, stress-induced myocardial stunning in TTS and suggest that 2D-STE may aid differentiation between stress cardiomyopathy and ischemic infarction in the acute setting, although longitudinal strain parameters should be interpreted cautiously and regarded as hypothesis-generating.

Dyspnea is a cardinal clinical feature of post-cardiac surgery patients, resulting from the most important post-surgical complications, whether they are cardiac or pulmonary related. Cardiac rehabilitation is the setting of a multidisciplinary approach where post-operative transthoracic echocardiogram (TTE) and cardiopulmonary exercise test (CPET) can be used to allow early identification of the dyspnea causes including cardiovascular and respiratory. In this paper we examined the case of 52-years-old woman, affected by mitral valve prolapse with severe regurgitation associated with mild-to-moderate tricuspid regurgitation and mild increase in pulmonary artery pressure, treated surgical with mitral and tricuspid valvuloplasty (Guiraudon approach). In the post-surgery phase, the patient complained a persistent dyspnoea during minimal effort with evidence of mild hypoxemia at rest and of significant drop in oxygen saturation during effort. At TTE, a large ostium secundum type atrial septal defect was detected with a significant bi-directional shunt, confirmed by transesophageal approach. The patient underwent to a repeat cardiac surgery during which a large opening of the interatrial septum correction due to the rupture of the suture thread was corrected. The post-operative phase was regular. The TTE showed a good outcome of mitro-tricuspid valve repair and a stable closure of the atrial septum and the CPET data demonstrated significant improvement of functional capacity without oxygen desaturation. In conclusion, this clinical case demonstrated the need of a multiparametric approach and the crucial role of experts-performed and surgery-technique-guided instrumental insights in the common challenge of dyspnea and oxygen desaturation at rest and during exercise after cardiac surgery.

Background: Mitral valve prolapse (MVP) is the most common valvular abnormality in the general population and has been linked to mitral regurgitation, arrhythmias, and sudden cardiac death. Its prevalence and prognostic significance in athletes remain uncertain, raising important questions for pre-participation screening, eligibility for competition, and long-term follow-up. Methods: We systematically searched PubMed, Scopus, and EMBASE databases from inception through August 2025 for original studies reporting MVP prevalence in athletes, diagnosed by echocardiography or pathological assessment. Data on study characteristics, diagnostic definitions, prevalence, arrhythmias, and outcomes were independently extracted by three reviewers. Methodological quality was appraised using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: Twelve studies published between 1987 and 2024 met inclusion criteria, enrolling 19,463 athletes from diverse sports and competitive levels. A total of 407 MVP cases were identified, corresponding to a crude pooled prevalence of 2.4%. Prevalence estimates varied substantially (0.2–20%), reflecting heterogeneity in study populations and diagnostic definitions. When all studies were pooled using a random-effects model, the overall prevalence was 2.0% (95% CI 1.2–2.8%). A sensitivity analysis restricted to contemporary, unselected athletic cohorts yielded a prevalence of 1.1% (95% CI 0.4–1.9%), closely aligning with population-based estimates. Ventricular arrhythmias were more frequent than supraventricular arrhythmias, particularly in association with bileaflet prolapse, leaflet thickening, or significant mitral regurgitation. Most athletes were asymptomatic, and only one prospective study provided long-term follow-up, confirming a generally benign prognosis, though rare adverse events (atrial fibrillation, valve surgery) were documented. Conclusions: MVP is relatively uncommon in athletes and occurs at rates similar to the general population. In most cases, prognosis is favorable and should not preclude sports participation. Nonetheless, recognition of high-risk phenotypes with arrhythmogenic potential highlights the need for individualized evaluation and tailored surveillance strategies in sports cardiology practice.

Background: Since the 1990s, numerous investigations have assessed the diagnostic effectiveness—specifically sensitivity, specificity, and accuracy—of exercise stress testing (EST), stress echocardiography (SE), stress myocardial single-photon emission computed tomography (SPECT), and stress cardiac magnetic resonance imaging (CMR). However, the outcomes of these studies have often been inconsistent and inconclusive. To provide a clearer comparison, we conducted systematic reviews and meta-analyses aimed at quantitatively evaluating and comparing the aggregated diagnostic performance of these four commonly used techniques for detecting coronary artery disease (CAD). Methods: A comprehensive search of PubMed, Scopus, Embase, Cochrane Library, and Web of Science was conducted to identify cohort studies evaluating the diagnostic accuracy of EST, SE, stress myocardial SPECT, and stress CMR in symptomatic patients with suspected or confirmed CAD. The main goal was to compare their diagnostic value by pooling sensitivity and specificity results. Each study’s data were extracted in terms of true positives, false positives, true negatives, and false negatives. Results: A total of 104 studies, comprising 16,824 symptomatic individuals with either suspected or known CAD, met the inclusion criteria. The pooled sensitivities for CAD detection were 0.66 (95% CI: 0.59–0.72, p < 0.001) for EST, 0.81 (95% CI: 0.79–0.83, p < 0.001) for SE, 0.82 (95% CI: 0.78–0.85, p < 0.001) for stress myocardial SPECT, and 0.83 (95% CI: 0.81–0.85, p < 0.001) for stress CMR. Corresponding specificities were 0.61 (95% CI: 0.55–0.67, p < 0.001), 0.85 (95% CI: 0.82–0.87, p < 0.001), 0.74 (95% CI: 0.70–0.78, p < 0.001), and 0.89 (95% CI: 0.86–0.92, p < 0.001), respectively. Considerable heterogeneity was observed across the studies, as reflected by I2 values ranging from 82.5% to 92.5%. Egger’s generalized test revealed statistically significant publication bias (p < 0.05 for all methods), likely due to the influence of smaller studies reporting more favorable results. Despite this, sensitivity analyses supported the overall robustness and reliability of the pooled findings. Conclusions: Among the diagnostic tools assessed, EST demonstrated the lowest accuracy for detecting obstructive CAD, whereas stress CMR exhibited the highest. Although stress myocardial SPECT showed strong sensitivity, its specificity was comparatively limited. SE emerged as the most balanced option, offering good diagnostic accuracy combined with advantages such as broad availability, cost-effectiveness, and the absence of ionizing radiation.

The battle against COVID-19 has entered a new phase with Rehabilitation Centres being among the major players, because the medical outcome of COVID-19 patients does not end with the control of pulmonary inflammation marked by a negative virology test, as many patients continue to suffer from long-COVID-19 syndrome. Exercise training is known to be highly valuable in patients with cardiac or lung disease, and it exerts beneficial effects on the immune system and inflammation. We therefore reviewed past and recent papers about exercise training, considering the multifactorial features characterizing post-COVID-19 patients' clinical conditions. Consequently, we conceived a proposal for a post-COVID-19 patient exercise protocol as a combination of multiple recommended exercise training regimens. Specifically, we built pre-evaluation and exercise training for post-COVID-19 patients taking advantage of the various programs of exercise already validated for diseases that may share pathophysiological and clinical characteristics with long-COVID-19.

Objectives and Background: Hemodynamic changes at rest and during exercise in heart failure (HF) after cardiac resynchronization therapy (CRT) are still undefined. Methods: In 93 HF patients, before and 8 ± 3 months after CRT, we assessed clinical conditions, ECG and standard echocardiography and we performed a maximal cardiopulmonary exercise test with non-invasive measurement of cardiac output (CO) by inert gas rebreathing method. Results: At rest, CRT shortened QRS and improved NYHA class and left ventricular ejection fraction (LVEF), but not CO and stroke volume (SV). On average, at peak exercise, a significant improvement of oxygen uptake (VO2) (from 13.8 ± 3.8 ml/min/kg to 14.9 ± 4.6, p<0.0025), CO (from 6.19 ± 1.82 L/min to 6.97 ± 2.21, p<0.0001), and SV (from 62 ± 18 mL to 71 ± 19, p<0.0001) were detected. Regardless of HF severity, after CRT, patients showed a significant peak SV and CO increase, but a significant peak VO2 increase was observed only in patients with the lowest pre-CRT peak VO2 (5.9-11.3 ml/kg/min). Conclusions: Our data showed that: a) SV at rest was not affected by CRT, regardless of LVEF improvement; b) post-CRT peak VO2 improvement was limited to HF patients with low pre-CRT peak VO2; c) post-CRT, a similar peak CO increase was observed regardless of pre-CRT peak VO2. Consequently, the assessment of peak CO is preferable to analyze CRT effects on exercise.

Exercise training is a well-established therapy for heart failure (HF) patients recommended in the European Society of Cardiology (ESC) HF guidelines [ [1] Ponikowki P. Voors A.A. Anker S.D. et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016; 37: 2129-2200 PubMed Google Scholar ]. The last Cochrane Library Review about “Exercise-based cardiac rehabilitation for adults with heart failure” underlined the important benefits of exercise-based rehabilitation that include a reduction in the risk of overall hospital admissions in the short term, as well as a potential improvement of all-cause mortality in the long term (>12 months follow up) [ [2] Long L. Mordi I.R. Bridges C. Sagar V.A. Davies E.J. Coats A.J.S. Dalal H. Rees K. Singh S.J. Taylor R.S. Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst. Rev. 2019; 1 (Art. No.: CD003331) PubMed Google Scholar ].