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Atrial fibrillation (AF) can lead to embolic stroke and in subjects with non-valvular AF most of thrombi are sited in the left atrial appendage (LAA). LAA is a structure located in the free wall of heart with a wide variable and complex anatomy. LAA occlusion (LAAO) could be taken in consideration in subjects with non-valvular AF and who cannot have long-term anticoagulant therapy. It is a complex preventive procedure given the high variability of patients characteristics and several LAAO devices available nowadays. Moreover, the ideal postprocedural antithrombotic strategy is still unclear. In this review we aim to describe clinical features of patients committed for LAA occlusion and the function of multimodality imaging in subjects selection, procedural management and follow up.

Background: Transcatheter aortic valve replacement (TAVR) is an alternative treatment in surgically intermediate- or high-risk patients with classical low-flow, low-gradient (LFLG) aortic stenosis (AS). The objective of this study was to investigate whether two-dimensional (2D) speckle-tracking echocardiography (STE) can predict left ventricular (LV) flow reserve during dobutamine stress echocardiography (DSE) and remodeling after TAVR in patients with LFLG AS.Methods: Seventy-five symptomatic patients with severe LFLG AS were recruited (mean age, 77.6 +/- 8.4 years). Patients underwent a complete clinical evaluation, standard echocardiography, 2D STE, and DSE. Echocardiographic analysis was performed before and 6 months after TAVR using global longitudinal strain (GLS) measured on 2D STE.Results: All patients received self-expanding transcatheter prosthetic valves. Six months after TAVR, LV GLS (12.8 +/- 3.2% vs 16.3 +/- 4.2%, P < .0001) significantly increased. In a multivariate analysis, LV GLS before TAVR (P < .0001) was an independent predictor of LV flow reserve during DSE. By receiver operating characteristic curve analysis, a cutoff value for LV GLS of

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.

Introduction: Coronary microvascular dysfunction (CMD) is a potential cause of myocardial ischemia and may affect myocardial function. CMD can be identified, in patients with non-obstructive coronary artery disease (CAD), by a reduced transthoracic Doppler-derived coronary flow reserve (CFR), which is an index of coronary arterial reactivity. Hypothesis: The aim of this study was to investigate the dipyridamole-induced changes of global longitudinal strain (GLS) in patients with CMD. Methods: fiftythree patients (35M, 18F; mean age 67±8 years) without obstructive CAD, assessed by invasive coronary angiogram, underwent dipyridamole stress echocardiography. CFR were determined as the ratio of hyperaemic to baseline diastolic coronary flow velocity. CMD was defined as CFR < 2. GLS was visualized as a bull’s-eye map in a quick and feasible manner. In each patient, we used a frame rate of 70 frames/sec for adequate 2D strain analysis. We analyzed GLS at each step of stress test and compared peak-dose values with baseline. Results: Sixteen patients (30%) among the overall population showed CMD. There were no significant differences in baseline characteristics between patients with or without CMD. GLS, at baseline, was significantly lower in patients with CMD (-16.7±3.77 vs. -17.9±3.75 - p Conclusions: GLS analysis, performed by comparing dipyridamole peak-dose with baseline values, shows that in patients with CMD there is a different response of left ventricular myocardiim to stress test. It could be assumed that the inverse correlation between CFR and delta GLS reflects a progressive subclinical worsening of left ventricular myocardial function in these patients. Larger studies could confirm our data.

Background Coronary microvascular dysfunction (CMD) is a potential cause of myocardial ischemia and may affect myocardial function at rest and during stress. CMD can be identified, in patients with non-obstructive coronary artery disease (CAD), by a reduced transthoracic Doppler-derived coronary flow reserve (CFR), which is an index of coronary arterial reactivity, and can be impaired in both obstructive CAD and CMD. The aim of this study was to investigate the dipyridamole-induced changes of global longitudinal strain (GLS) in patients with CMD. Methods 43 patients (29M, 14F; mean age 68±7 years) without obstructive CAD, assessed by invasive coronary angiogram, underwent dipyridamole stress echocardiography. Coronary flow was assessed in the left anterior descending coronary artery (LAD) and was identified as the colour signal directed from the base to the apex of the left ventricle, containing the characteristic biphasic pulsed-Doppler flow signals. CFR were determined as the ratio of hyperaemic to baseline diastolic coronary flow velocity. CMD was defined as CFR GLS was measured using automated function imaging, through the positioning of three endocardial markers (two markers at the mitral annulus and one at the apex) in each apical view. Subsequently, the obtained segmental values of GLS were visualized as a bull's-eye map in a quick and feasible manner. We had optimal left ventricular endocardial tracking in the overall population. In each patient, we used a frame rate of 70 frames/sec for adequate 2D strain analysis. We analyzed GLS at each step of stress test and compared peak-dose values with baseline. Results Thirteen patients (30%) among the overall population showed CMD. There were no significant differences in baseline characteristics between patients with or without CMD. GLS, at baseline, was significantly lower in patients with CMD (−16.9±3.78 vs. −17.8±3.77 – p Conclusions GLS analysis, particularly performed by comparing dipyridamole peak-dose with baseline values, shows that in patients with CMD there is a different response of left ventricular myocardiim to stress test. It could be assumed that the inverse correlation between CFR and delta GLS reflects a progressive subclinical worsening of left ventricular myocardial function in these patients. Larger studies could confirm our data. Funding Acknowledgement Type of funding source: None

Coronavirus 2019 (COVID-19) disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to cardiac impairment, with increased troponin levels, left ventricular (LV) dysfunction and myocarditis ([1][1],[2][2]). Information for right ventricular (RV) involvement and

Cardiomyopathies (CM) are a heterogeneous group of muscle heart diseases, divided into 3 main categories (dilated, hypertrophic, and restrictive). In addition to these subgroups, athlete's heart and hypertensive cardiopathy are both the result of heart adaptation to increased loading conditions, making it possible to include them in the CM group. Right heart involvement is clear in some CM as arrhythmogenic CM, carcinoid syndrome, and endomyocardial fibrosis, whereas in others, like hypertrophic or dilated CM, it is known that the right heart has a prognostic impact but less clear is its pathogenic role.

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

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

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

Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied in both outpatient and inpatient settings. Its main use in current clinical practice is the research for "Paradoxical Embolism," due to migration of thromboembolic material from systemic venous circulation to the left cardiac chambers and arterial circulation through cardiopulmonary shunts such as patent foramen ovale which represents an important cause of cryptogenic stroke, especially in patients under 55 years of age. In this review, we shall describe the incremental diagnostic role in cryptogenic stroke for this imaging modality. TCD not only can be used to detect right-left cardiopulmonary shunts but it also allows to classify the grade of severity of such shunts using the so-called "Microembolic Signals grading score."

Transthoracic Doppler echocardiographic examination is commonly performed to define the diastolic ventricular function since it is widely available, noninvasive, and inexpensive with respect to other diagnostic imaging modalities. However, data regarding age- and gender-matched reference values are scanty and sometimes conflicting. This study aims to explore the physiologic variations of left ventricular (LV)From June 2007 to February 2014, 1168 healthy Caucasian adults (mean age 45.1 ± 15.6 years) performed standard echocardiographic examination (transthoracic echocardiogram).In healthy subjects, transmitral

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

Background: Transthoracic Doppler echocardiographic examination is commonly performed to define the diastolic ventricular function since it is widely available, noninvasive, and inexpensive with respect to other diagnostic imaging modalities. However, data regarding age- and gender-matched reference values are scanty and sometimes conflicting. This study aims to explore the physiologic variations of left ventricular (LV) E/e' ratio as assessed in a large cohort of healthy adults and to investigate clinical and echocardiographic correlates. Methods: From June 2007 to February 2014, 1168 healthy Caucasian adults (mean age 45.1 +/- 15.6 years) performed standard echocardiographic examination (transthoracic echocardiogram). Results: E/e' constantly increases across all the age classes (P < 0.0001, analyses of variance both for males and females) with a strong statistically significant linear positive correlation with age. Stepwise multiple linear regression analysis identified age (P < 0.0001), LV mass (P < 0.001), LV end-diastolic volume (P < 0.01), and left atrial volume (P < 0.001) as the only independent determinants of E/e' ratio (model R-2 = 0.54, P < 0.0001). Conclusions: In healthy subjects, transmitral E velocity to e' ratio changes in relation to the age: it increased with a statistically significant correlation in individuals older than 60 years. Hence, differences related to demographic and anthropometric measurements may potentially develop a misclassification of otherwise normal individuals when established on dichotomically suggested normal reference values. Our study can demonstrate that it is indispensable to apply specific cutoff related to the age and gender to properly assess LV diastolic function.

Long-term physical training in elite athletes is characterized by physiological adaptation of cardiovascular structures, with structural, functional, and electrical remodeling, defined as athlete's heart.

Several studies have described the adaptive remodeling of the heart during exercise. In some more practiced endurance athletes, there is a disproportionate load on the right ventricle (RV), at least during exercise, and this might be the basis for a chronic pro-arrhythmic RV remodeling. Especially, in these kinds of athletes the recovery after detraining might be incomplete, in particular for RV changes. The observation of acute myocardial injury based on transient elevation of biomarkers and chronic myocardial scar, not completely reversible changes of the RV and an increased prevalence of some arrhythmias support the existence of an "exercise-induced cardiomyopathy." The aim of this paper is to review current knowledge about changes in the right heart in highly trained athletes and how these change influence cardiac function.

During last decades, most studies have examined the exercise-induced remodeling defined as "athlete's heart". During exercise, there is an increased cardiac output that causes morphological, functional, and electrical modification of the cardiac chambers. The cardiac remodeling depends also on the type of training, age, sex, ethnicity, genetic factors, and body size. The two main categories of exercise, endurance and strength, determine different effects on the cardiac remodeling. Even if most sport comprise both strength and endurance exercise, determining different scenarios of cardiac adaptation to the exercise. The aim of this paper is to assemble the current knowledge about physiologic and pathophysiologic response of both the left and the right heart in highly trained athletes.

Bicuspid aortic valve (BAV) cannot be considered an innocent finding, but it is not necessarily a life-threatening condition. Athletes with BAV should undergo a thorough staging of the valve anatomy, taking into consideration hemodynamic factors, as well as aortic diameters and looking for other associated significant cardiovascular anomalies by use of a multimodality cardiac imaging approach. Furthermore an accurate follow-up is mandatory with serial cardiological controls in those allowed to continue sports.

During last decades, most studies have examined the exercise-induced remodeling defined as “athlete’s heart”. During exercise, there is an increased cardiac output that causes morphological, functional, and electrical modification of the cardiac chambers. The cardiac remodeling depends also on the type of training, age, sex, ethnicity, genetic factors, and body size. The two main categories of exercise, endurance and strength, determine different effects on the cardiac remodeling. Even if most sport comprise both strength and endurance exercise, determining different scenarios of cardiac adaptation to the exercise. The aim of this paper is to assemble the current knowledge about physiologic and pathophysiologic response of both the left and the right heart in highly trained athletes.

Intense exercise may cause heart remodeling to compensate increases in blood pressure or volume by increasing muscle mass. Cardiac changes do not involve only the left ventricle, but all heart chambers. Physiological cardiac modeling in athletes is associated with normal or enhanced cardiac function, but recent studies have documented decrements in left ventricular function during intense exercise and the release of cardiac markers of necrosis in athlete’s blood of uncertain significance. Furthermore, cardiac remodeling may predispose athletes to heart disease and result in electrical remodeling, responsible for arrhythmias. Athlete’s heart is a physiological condition and does not require a specific treatment. In some conditions, it is important to differentiate the physiological adaptations from pathological conditions, such as hypertrophic cardiomyopathy, arrhythmogenic dysplasia of the right ventricle, and non-compaction myocardium, for the greater risk of sudden cardiac death of these conditions. Moreover, some drugs and performance-enhancing drugs can cause structural alterations and arrhythmias, therefore, their use should be excluded.

Background Although transthoracic echocardiography (TTE) is an excellent noninvasive screening test for pulmonary hypertension, the physiologic range of Doppler echocardiography-derived pulmonary pressures remains not completely investigated. The aim of the present study was, therefore, to explore the full spectrum of pulmonary pressures and right ventricular (RV) functional indexes by TTE in healthy subjects and to investigate clinical and echocardiographic correlates. Methods A random sample of 1,480 healthy individuals (mean age, 36.1 ± 15.5 years; range, 20-80 years; 905 men) underwent a comprehensive TTE. Pulmonary artery systolic pressure (PASP), mean pressure, and pulmonary vascular resistance were estimated by standard Doppler echocardiography formulas. In addition, RV diastolic (Doppler transtricuspid inflow measurements) and systolic indexes (RV fractional area change, RV tissue Doppler peak systolic velocity, tricuspid annular plane systolic excursion) were calculated. Results PASP and mean pulmonary artery pressure values were significantly higher in subjects aged > 50 years and in those with a BMI > 30 kg/m 2 . In particular, a PASP > 40 mm Hg was found in 118 subjects (8%) of those aged > 50 years and in 103 (7%) of those with a BMI > 30 kg/m 2 . No differences by age were registered in RV systolic indexes and in pulmonary vascular resistances. On multivariate analysis, in the overall study population, age, BMI, mitral E/e′ ratio, and left ventricular stroke volume were the only independent predictors of PASP. Conclusions This study delineates an estimate of pulmonary hemodynamics in a wide age range cohort of healthy subjects. Pulmonary pressures increased with age and BMI, as expected.

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

Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied on both outpatient and inpatient settings. It involves the use of a low-frequency (≤2 MHz) transducer, placed on the scalp, to insonate the basal cerebral arteries through relatively thin bone windows and to measure the cerebral blood flow velocity and its alteration in many different conditions. In neurointensive care setting, TCD is useful for both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, and brain stem death. It also allows to investigate the cerebrovascular autoregulation in setting of carotid disease and syncope. In this review, we will describe physical principles underlying TCD, flow indices most frequently used in clinical practice and critical care applications in Neurocritical Unit care.

To test whether two-dimensional longitudinal strain (2DSE) performed after revascularization by percutaneous coronary intervention (PCI) could predict left ventricular (LV) remodeling in patients with recent non-ST elevation myocardial infarction (NSTEMI).In 70 patients (62.7 ± 8.7 years) with recent NSTEMI (between 72 hours and 14 days), undergoing coronary angiography for recurrent angina, myocardial deformation parameters were measured by 2DSE before and 24 hours after reperfusion therapy. Strain in all LV segments was averaged to obtain a global value (Global longitudinal Strain--GLS). Infarct size was estimated by clinical parameters and cardiac markers. After 6 months from intervention, LV negative remodeling was defined as lack of improvement of LV function, with increase in LV end-diastolic volume of greater than or equal than 15%.At follow-up, patients were subdivided into remodeled (n=32) and non-remodeled (n = 38) groups. Patients with negative LV remodeling had significantly lower baseline LV ejection fraction (44.8±6.9 vs. 48.7 ± 5.5 %; p0.05), higher peak troponin I (p0.001) and reduced GLS (- 10.6±6.1 vs - 17.6 ± 6.7 % p0.001) than those without LV remodeling. GLS showed a close correlation with peak troponin I after PCI (r = 0.64, P0.0001) and LV WMSI (r = 0.42, p0.01). By multivariable analysis, diabetes mellitus (P0.005), peak of Troponin I after PCI (P0.0005), GLS at baseline (OR: 4.3; p0.0001), and lack of improvement of GLS soon after PCI (OR: 1.45, P0.01) were powerful independent predictors of negative LV remodelling at follow-up. In particular, a GLS ≤ 12 % showed a sensitivity and a specificity respectively of 84.8% and 87.8% to predict negative LV remodelling at follow-up.in patients with recent NSTEMI, longitudinal LV global and regional speckle-tracking strain measurements are powerful independent predictors of LV remodeling after reperfusion therapy.

Riassunto Obiettivi Lo scopo dello studio e stato quello di stabilire se la frazione di eiezione del ventricolo destro stimata all’ecocardiografia tridimensionale real-time (real-time 3D echocardiography, RT3DE) possa individuare i pazienti affetti da cardiomiopatia dilatativa (dilated cardiomyopathy, DCM) con capacita funzionale maggiormente compromessa al test cardiopolmonare. Materiali e metodi 55 pazienti affetti da cardiomiopatia dilatativa in fase di scompenso cardiaco cronico (eta 56,5 ± 9,1 anni; 40 maschi; 30 di eziologia ischemica; Classe NYHA III: 40) e 30 soggetti sani di controllo sono stati sottoposti attraverso RT3DE all’analisi sia del ventricolo sinistro sia del ventricolo destro. Dopo aver acquisito le immagini, il software post processing ha elaborato i dati della RT3DE relativi all’indice di dissincronia sistolica (systolic dyssynchrony index, SDI) dei 16 segmenti del ventricolo sinistro e ha registrato, inoltre, la frazione di eiezione del ventricolo sinistro e del ventricolo destro. La risonanza magnetica cardiaca e stata effettuata in un sottogruppo di 20 pazienti affetti da cardiomiopatia dilatativa per confermare le misurazioni ottenute mediante RT3DE. Tutti i pazienti con cardiomiopatia dilatativa sono stati inoltre sottoposti a test cardiopolmonare, condotto al cicloergometro, per la misurazione di VO2 di picco (espresso come percentuale del valore predetto), soglia anaerobica (VE/VCO2 slope) e circulatory power (CP). Risultati Nei pazienti dilatati la frazione di eiezione media era pari a 29,8 ± 4,6%. Il valore di SDI del ventricolo sinistro valutato alla RT3DE era 8,4 ± 4,2 e la frazione di eiezione del ventricolo destro era 51,3 ± 4,6%. Al test cardiopolmonare il valore medio di VO2 di picco era 15,2 ± 4,4 mL/kg/min, mentre quello di CP era 2,1 ± 0,8. Attraverso l’analisi univariata, la frazione di eiezione del ventricolo destro e risultata direttamente proporzionale al VO2 di picco (%) (r = 0,55; p Conclusioni Nei pazienti affetti da cardiomiopatia dilatativa la riduzione della funzione sistolica del ventricolo destro e associata in maniera indipendente a una peggiore tolleranza all’esercizio fisico aerobico.

BACKGROUND: The aim of the study was to detect if right ventricular (RV) ejection fraction assessed by real-time 3-dimensional echocardiography (RT3DE) could predict patients with dilated cardiomyopathy (DCM) with greater functional impairment in response to cardiopulmonary exercise. METHODS AND RESULTS: Seventy chronic heart failure patients with DCM (55.5 ± 9.1 years; 48 males; 30 ischemic; New York Heart Association Class III: 48) underwent both left ventricular (LV) and RV analysis by RT3DE. Postprocessing software provided data of RT3DE systolic dyssynchrony index of 16 LV segments (systolic dyssynchrony index [SDI]) and of both LV and RV ejection fraction. Cardiac magnetic resonance was performed in a subgroup of 40 DCM patients to confirm RT3DE measurements. All the patients underwent also bicycle cardiopulmonary exercise test with evaluation of oxygen consumption (VO2) peak% (percentage of the predicted value), VE/VCO2 slope, and circulatory power (CP). Mean LV ejection fraction was 29.8 ± 4.6%. RT3DE LV SDI index was 8.4.4 ± 4.2, and RV ejection fraction was 51.3 ± 4.6%. By cardiopulmonary test, mean VO2 peak was 15.2 ± 4.4 mL·kg·min, and mean CP was 2.1 ± 0.8. By univariable analyses, significant correlations were detectable between SDI index and VO2 peak% (r = -0.56; P < .0001) and peak CP (r = -0.48; P < .0005). Also RV ejection fraction directly correlated with VO2 peak% (r = 0.58; P < .0001) and inversely with VE/VCO2 slope (r = -0.44; P < .001). By multivariable analysis, SDI index (β coefficient = -0.46; P < .001) and 3D RV ejection fraction (β coefficient = 0.42; P < .001) emerged as the only independent determinants of VO2 peak% during cardiopulmonary test. CONCLUSIONS: Increased LV electromechanical dyssynchrony and impaired RV function in DCM patients are independently associated with worse ability to perform aerobic exercise.

BACKGROUND: The aim of this study was to define the range of left ventricular (LV) velocities and deformation indexes in highly trained athletes, analyzing potential differences induced by different long-term training protocols. METHODS: Standard echocardiography, pulsed-wave tissue Doppler echocardiography, and two-dimensional strain echocardiography of the interventricular septum and lateral wall were performed in 370 endurance athletes and 280 power athletes. Using pulsed-wave tissue Doppler, the following parameters of myocardial function were assessed: systolic peak velocities (S(m)), early (E(m)) and late (A(m)) diastolic velocities, and the E(m)/A(m) ratio. By two-dimensional strain echocardiography, peaks of regional systolic strain and LV global longitudinal strain were calculated. RESULTS: LV mass index and ejection fraction did not significantly differ between the two groups. However, power athletes showed an increased sum of wall thicknesses (P < .01) and relative wall thickness, while LV stroke volume and LV end-diastolic diameter (P < .001) were greater in endurance athletes. By pulsed-wave tissue Doppler analysis, E(m) and E(m)/A(m) at both the septal and lateral wall levels were higher in endurance athletes. By two-dimensional strain echocardiography, myocardial deformation indexes were comparable between the two groups. E(m)/A(m) ratios ≥ 1 were found in the overall population, while 90 % of athletes had an E(m) ≥ 16 cm/sec, S(m) ≥ 10 cm/sec, and global longitudinal strain ≤ -16%. Multivariate analyses evidenced independent positive association between Em peak velocity and LV end-diastolic volume (P < .001) and an independent correlation of global longitudinal strain with the sum of LV wall thicknesses (P < .005). CONCLUSIONS: This study describes the full spectrum of systolic and diastolic myocardial velocities and deformation indexes in a large population of competitive athletes.

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

Objective: In dilated cardiomyopathy (DCM), right ventricular (RV) dysfunction has been reported and attributed both to altered loading conditions and to RV involvement in the myopathic process. The aim of the study was to detect RV myocardial function in DCM using two-dimensional (2D) strain echocardiography and to assess the effects of cardiac resynchronization therapy (CRT) on RV myocardial strain during a 6-month follow-up. Methods and Results: A total of 110 patients (mean age: 55.4 ± 11.2 years) with either idiopathic (n = 60) or ischemic (n = 50) DCM, without overt clinical signs of RV failure, underwent standard echo and 2D strain analysis of RV longitudinal strain in RV septal and lateral walls. The two groups were comparable for clinical variables (New York Heart Association class III in 81.8%). Left ventricular volumes, ejection fraction, stroke volume, and mitral valve effective regurgitant orifice were similar between the two groups. No significant differences were evidenced in Doppler mitral and tricuspid inflow measurements. RV diameters were mildly increased in patients with idiopathic DCM, while RV tricuspid annulus systolic excursion and Tei-index were comparable between the two groups. RV global longitudinal strain and regional peak myocardial strain were significantly impaired in patients with idiopathic DCM compared with those having ischemic DCM (all P < 0.001). Using left ventricular end-systolic volume as marker for response to CRT, 70 patients (63.3%) were long-term responders. Ischemic DCM patient responders to CRT showed a significant improvement in RV peak systolic strain. Conversely, in patients with idiopathic DCM and in ischemic patients nonresponders to CRT, no improvement in RV function was evidenced. By multivariable analysis, in the overall population, ischemic etiology of DCM (P < 0.0001), positive response to CRT (P < 0.001), and longitudinal intraventricular dyssynchrony (P

Aims In dilated cardiomyopathy (DCM), attenuation of left atrial (LA) booster pump function has been observed, and attributed both to altered LA loading conditions owing to left ventricular (LV) diastolic dysfunction and to LA involvement in the myopathic process. The aim of the present study was to detect LA systolic dysfunction in DCM using speckle-tracking two-dimensional strain echocardiography (2DSE), and to assess the effects of cardiac resynchronization therapy (CRT) on LA myocardial strain during 6 month follow-up. Methods and results A total of 90 patients (aged, 52.4+10.2 years) with either idiopathic (n = 47) or ischaemic (n = 43) DCM underwent standard Doppler echo and 2DSE analysis of atrial longitudinal strain in the basal segments of LA septum and LA lateral wall, and in LA roof. The two groups were comparable for clinical variables (NYHA class: III in 72.2%; IV in 27.8%). LV volumes, ejection fraction, stroke volume, and mitral valve effective regurgitant orifice were similar between the two groups. No significant differences were evidenced in Doppler transmitral inflow measurements. LA diameter and maximal volume were also similar between the two groups. Conversely, LA active emptying volume and fraction were both lower in patients with idiopathic DCM. Peak systolic myocardial atrial strain was significantly compromised in patients with idiopathic DCM compared with ischaemic DCM in all the analysed atrial segments (P , 0.001). At follow-up, 64 patients (71.1%) (37 idiopathic and 27 ischaemic) were responders, and 26 (28.9%) (10 idiopathic; 16 ischaemic) were non-responders to CRT (responder: decrease of LV end-systolic volume .15%). A significant improvement in LA systolic function was obtained only in patients with ischaemic DCM responders to CRT (P , 0.001). By multivariable analysis, in the overall population, it was found that ischaemic aetiology of DCM (b-cofficient = 0.62; P , 0.0001) and positive response to CRT (b-cofficient = 0.42; P , 0.01) were the only independent determinants of LA lateral wall systolic strain. Conclusions Two-dimensional strain represents a promising non-invasive technique to assess LA atrial myocardial function in patients with DCM. LA pump and reservoir function at baseline and after CRT are more depressed in idiopathic compared with ischaemic DCM patients. Future longitudinal studies are warranted to understand further the natural history of LA myocardial function, the extent of reversibility of LA dysfunction with CRT, and the possible prognostic impact of such indexes in patients with congestive heart failure.

Athletes heart is a left ventricular adaptation to long-term, intensive training which includes changes as increased cavity diameter, wall thickness and mass. Even if the standard 2-dimensional echocardiography represents an irreplaceable method in the evaluation of cardiac adaptations to physical exercise, the data currently available suggests the usefulness of Doppler Myocardial Imaging (DMI) in the assessment of the myocardial systolic and diastolic function of the athletes heart. In particular, DMI analysis in the trained subject has demonstrated interesting prospective for : 1) the differential diagnosis from pathological left ventricular hypertrophy due to Hypertrophic Cardiomyopathy (HCM); 2) the prediction of cardiac performance during physical effort; 3) the evaluation of the bi-ventricular interaction; 4) the analysis of the myocardial adaptations to various training protocols; 5) the early identification of specific genotypes associated with cardiomyopathies. Such a combined use of standard 2-D echo and DMI may be taken into account for a valid noninvasive and easy-repeatable evaluation of both physiological and pathological ventricular hypertrophy.

Background Conflicting data have been reported about the nature (physiologic versus pathologic) of left ventricular (LV) hypertrophy in master athletes. Aim of the study To analyze LV and right ventricular (RV) myocardial function in master athletes with LV hypertrophy induced by either endurance or strength training. Methods Standard Doppler echo and colour Doppler Myocardial Imaging (DMI) of LV and of RV basal lateral walls were performed in 40 competitive master (>45years) endurance athletes (ATE), in 20 master strength-trained athletes (ATS) and 25 age-matched healthy sedentary subjects, all males. By use of DMI, the following parameters of myocardial function were assessed: systolic peak velocities, precontraction time, contraction time, early (E m ) and late ( A m ) diastolic peak velocities, E m / A m ratio, relaxation time. Results The two groups were comparable for age, but ATS at rest showed higher heart rate, systolic blood pressure, and body surface area. LV mass index did not significantly differ between the two groups of athletes. However, ATS showed increased wall thickness and relative wall thickness, while LV stroke volume and both LV and RV end-diastolic diameters were greater in ATE. All transmitral and transtricuspid Doppler indexes were higher in ATE. DMI analysis showed in ATE higher E m and E m / A m ratio at the level of both RV and LV lateral walls. In the overall population of athletes, linear regression models evidenced independent positive association of RV peak E m velocity with both LV stroke volume and maximal workload achieved by bicycle ergometer (both p Conclusions RV early diastolic myocardial function is positively influenced by preload increase in master athletes and represents an independent determinant of cardiac performance during physical effort. Therefore, colour DMI may be taken into account to distinguish different cardiac adaptation to either endurance or strength sport training in master athletes.

Aims Transcatheter aortic valve implantation (TAVI) is an alternative treatment in surgically high-risk or inoperable patients with severe aortic stenosis (AS). The objective of this study was to analyze the effects of TAVI on left ventricular (LV) and left atrial (LA) longitudinal function assessed by speckle tracking echocardiography (2DSTE) in patients with AS. Methods In our prospectively conducted study, a total of 55 symptomatic (New York Heart Association class II or higher) patients with severe AS, considered to be at increased risk for undergoing surgical aortic valve replacement, were recruited (age: 78.6 ± 7.4 year). Patients underwent a complete clinical and laboratory evaluation, in addition to standard echocardiography and 2DSTE. Echocardiographic analysis was performed before and 6 months after TAVI. 2DSTE measured segmental and global longitudinal strain (GLS) and radial strain. Results All the patients received the CoreValve self-expanding prosthesis. Six months after TAVI, patients showed a significant reduction in mean transaortic gradient (52.1 ± 15.8 vs. 11.2 ± 3.3 mmHg, P

Although transthoracic echocardiography (TTE) is an excellent noninvasive screening test for pulmonary hypertension, the physiologic range of Doppler echocardiography-derived pulmonary pressures remains not completely investigated. The aim of the present study was, therefore, to explore the full spectrum of pulmonary pressures and right ventricular (RV) functional indexes by TTE in healthy subjects and to investigate clinical and echocardiographic correlates.A random sample of 1,480 healthy individuals (mean age, 36.1 ± 15.5 years; range, 20-80 years; 905 men) underwent a comprehensive TTE. Pulmonary artery systolic pressure (PASP), mean pressure, and pulmonary vascular resistance were estimated by standard Doppler echocardiography formulas. In addition, RV diastolic (Doppler transtricuspid inflow measurements) and systolic indexes (RV fractional area change, RV tissue Doppler peak systolic velocity, tricuspid annular plane systolic excursion) were calculated.PASP and mean pulmonary artery pressure values were significantly higher in subjects agedgt; 50 years and in those with a BMIgt; 30 kg/m2. In particular, a PASPgt; 40 mm Hg was found in 118 subjects (8%) of those agedgt; 50 years and in 103 (7%) of those with a BMIgt; 30 kg/m2. No differences by age were registered in RV systolic indexes and in pulmonary vascular resistances. On multivariate analysis, in the overall study population, age, BMI, mitral E/e' ratio, and left ventricular stroke volume were the only independent predictors of PASP.This study delineates an estimate of pulmonary hemodynamics in a wide age range cohort of healthy subjects. Pulmonary pressures increased with age and BMI, as expected.

BACKGROUND: The right heart is a major determinant of prognosis in cardiac transplant recipient patients. AIM: To investigate right ventricular morphology and function and their relationship with exercise capacity in cardiac transplant recipient patients using standard tranthoracic echocardiography and a new three-dimensional echocardiographic software adapted for right ventricular analysis. METHODS: One hundred fifteen relatively stable cardiac transplant recipient patients (71 men; 58.3 ± 5.8 years; 7.8 ± 4.5 years after transplantation) and 80 healthy age-comparable and sex-comparable controls underwent standard echocardiography, tissue Doppler imaging (TDI), and three-dimensional echocardiography, focused on the right ventricular analysis. Along with left heart parameters, right ventricular measurements included end-diastolic diameters at basal and mid-cavity level; base-to-apex length; tricuspid annulus plane systolic excursion (TAPSE); TDI right ventricular systolic peak velocity (Sm); and three-dimensional ejection fraction. Using the peak systolic tricuspid regurgitation velocity (TRV) and the end-diastolic pulmonary regurgitation velocity, the modified Bernoulli equation was used to calculate the pulmonary artery systolic (PASP) and diastolic pressures. Pulmonary artery vascular conductance (PAVC) was estimated by left ventricular stroke volume/4 × (TRV - pulmonary regurgitation velocity). RESULTS: Left ventricular diameters and ejection fraction did not significantly differ between the two groups, whereas mass index was increased in cardiac transplant recipient patients (P

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 the most widespread indication for TCD in outpatient setting is the research of right to left shunting, responsable of so called “paradoxical embolism”, most often due to patency of foramen ovale which is responsable of the majority of cryptogenic strokes occuring in patients younger than 55 years old. TCD also allows to classify the grade of severity of such shunts using the so called “microembolic signal grading score”. In addition TCD has found many useful applications in neurocritical care practice. It is useful on both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoidal haemorrhage (caused by aneurysm rupture or traumatic injury), traumatic brain injury, brain stem death. It is used also to evaluate cerebral hemodynamic changes after stroke. It also allows to investigate cerebral pressure autoregulation and for the clinical evaluation of cerebral autoregulatory reserve.

Background Our objective was to explore the right ventricular (RV) dimensions and function and the effect of long-term intensive training in a large population of top level athletes using real-time three-dimensional (3D) echocardiography. Methods A total of 430 top-level athletes (220 endurance-trained athletes [ETAs] and 210 strength-trained athletes; 265 men [61.6%]; mean age 27.4 ± 10.1 years, range 18–40) and 250 healthy controls underwent a transthoracic echocardiographic examination. Three-dimensional RV measurements included serial short-axis reconstructions of the RV volumetric data sets, and the RV endocardial contour was traced with cross-reference to the long-axis images for identification of the tricuspid annulus. The end-diastolic and end-systolic RV volumes and ejection fraction were calculated off-line using the method of the summation of discs. Results The strength-trained athletes had a greater heart rate, body surface area, and systolic blood pressure at rest than the ETAs and controls. All RV diameters and 3D volumes and all transmitral and transtricuspid Doppler indexes were greater in the ETAs. Also, the left ventricular stroke volume, cardiac index, and pulmonary artery systolic pressure were greater in the ETAs, and all two-dimensional and 3D RV systolic indexes were comparable. On univariate analysis, the 3D RV end-diastolic volume was significantly associated with advanced age, male gender, duration of training, endurance training, increased left ventricular stroke volume, and pulmonary artery systolic pressure. On multivariate analysis, in the overall study population, the type and duration of training ( P P P Conclusions The results of the present study have delineated the upper limits of the RV dimensions in highly trained athletes as measured by real-time 3D echocardiography. The RV end-diastolic volume was significantly greater in the ETA than in the strength-trained athletes and controls.

Background Although cardiac adaptation to different sports has been extensively described, the potential relationship of training with aortic root (AR) elastic properties and diameters in top-level athletes remains not fully investigated. The aims of this study were to compare AR morphology and stiffness between highly trained athletes and sedentary subjects and to assess the independent determinants of AR stiffness and distensibility in athletes. Methods Four hundred ten elite athletes (220 endurance-trained athletes [ATE] and 190 strength-trained athletes [ATS]; 290 men; mean age, 28.3 ± 13.6 years; age range, 18–40 years) and 240 healthy controls underwent standardized comprehensive transthoracic echocardiography, including Doppler studies. End-diastolic AR diameters were measured at four locations: the aortic annulus, the sinuses of Valsalva, the sinotubular junction, and the maximal diameter of the proximal ascending aorta. The aortic distensibility index was calculated as 2 × (systolic proximal ascending aortic diameter − diastolic proximal ascending aortic diameter)/(diastolic proximal ascending aortic diameter) × (pulse pressure) (cm −2 · dyn −1 · 10 −6 ). AR stiffness index was defined as (systolic blood pressure/diastolic blood pressure)/(systolic proximal ascending aortic diameter − diastolic proximal ascending aortic diameter)/diastolic proximal ascending aortic diameter. Analysis of variance was performed to evaluate differences among groups. Results Left ventricular (LV) mass index did not significantly differ between the two groups of athletes but was lower in controls. ATS showed higher body surface area, sum of wall thickness (septum plus LV posterior wall), and circumferential end-systolic stress, while LV stroke volume and LV end-diastolic volume were greater in ATE. AR diameters at all levels and AR stiffness were significantly greater in ATS than in ATE and controls, while AR distensibility was significantly higher in ATE. However, AR dilatation was observed only in four male power athletes (1%). By multivariate analyses, in the overall population of athletes, age, LV stroke volume, endurance training, and duration of training were the only independent determinant of higher AR distensibility. On the other hand, age, circumferential end-systolic stress, strength training, and duration of training were independently associated with AR stiffness in ATS. Conclusions AR diameters and stiffness were significantly greater in strength-trained athletes, while aortic distensibility was higher in endurance athletes compared with age- and sex-matched healthy controls.

Heart failure is a common syndrome with multiple causes. Cardiovascular magnetic resonance (CMR), using the available range of technique, is establishing itself as the gold standard noninvasive test for determining the underlying causes, and adding prognostic value, guiding therapy. Progress is continuing and rapid with promising new techniques such as diffuse fibrosis assessment. This article discusses the diverse roles of CMR in heart failure.