Stress Echocardiography in Italian Echocardiographic Laboratories: A Survey of the Italian Society of Echocardiography and Cardiovascular Imaging

Background

The Italian Society of Echography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand the volumes of activity, modalities and stressors used during stress echocardiography (SE) in Italy.

Methods

We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved through an electronic survey based on a structured questionnaire, uploaded on the SIECVI website.

Results

Data were obtained from 228 echocardiographic laboratories, and SE examinations were performed in 179 centers (80.6%): 87 centers (47.5%) were in the northern regions of Italy, 33 centers (18.4%) were in the central regions, and 61 (34.1%) in the southern regions. We annotated a total of 4057 SE. We divided the SE centers into three groups, according to the numbers of SE performed: <10 SE (low-volume activity, 40 centers), between 10 and 39 SE (moderate volume activity, 102 centers) and ≥40 SE (high volume activity, 37 centers). Dipyridamole was used in 139 centers (77.6%); exercise in 120 centers (67.0%); dobutamine in 153 centers (85.4%); pacing in 37 centers (21.1%); and adenosine in 7 centers (4.0%). We found a significant difference between the stressors used and volume of activity of the centers, with a progressive increase in the prevalence of number of stressors from low to high volume activity (P = 0.033). The traditional evaluation of regional wall motion of the left ventricle was performed in all centers, with combined assessment of coronary flow velocity reserve (CFVR) in 90 centers (50.3%): there was a significant difference in the centers with different volume of SE activity: the incidence of analysis of CFVR was significantly higher in high volume centers compared to low - moderate - volume (32.5%, 41.0% and 73.0%, respectively, P < 0.001). The lung ultrasound (LUS) was assessed in 67 centers (37.4%). Furthermore for LUS, we found a significant difference in the centers with different volume of SE activity: significantly higher in high volume centers compared to low - moderate - volume (25.0%, 35.3% and 56.8%, respectively, P < 0.001).

Conclusions

This nationwide survey demonstrated that SE was significantly widespread and practiced throughout Italy. In addition to the traditional indication to coronary artery disease based on regional wall motion analysis, other indications are emerging with an increase in the use of LUS and CFVR, especially in high-volume centers.

Organization and Activity of Italian Echocardiographic Laboratories: A Survey of the Italian Society of Echocardiography and Cardiovascular Imaging

Background

The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand better how different echocardiographic modalities are used and accessed in Italy.

Methods

We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved via an electronic survey based on a structured questionnaire, uploaded on the SIECVI website.

Results

Data were obtained from 228 echocardiographic laboratories: 112 centers (49%) in the northern, 43 centers (19%) in the central, and 73 (32%) in the southern regions. During the month of observation, we collected 101,050 transthoracic echocardiography (TTE) examinations performed in all centers. As concern other modalities there were performed 5497 transesophageal echocardiography (TEE) examinations in 161/228 centers (71%); 4057 stress echocardiography (SE) examinations in 179/228 centers (79%); and examinations with ultrasound contrast agents (UCAs) in 151/228 centers (66%). We did not find significant regional variations between the different modalities. The usage of picture archiving and communication system (PACS) was significantly higher in the northern (84%) versus central (49%) and southern (45%) centers (P < 0.001). Lung ultrasound (LUS) was performed in 154 centers (66%), without difference between cardiology and noncardiology centers. The evaluation of left ventricular (LV) ejection fraction was evaluated mainly using the qualitative method in 223 centers (94%), occasionally with the Simpson method in 193 centers (85%), and with selective use of the three-dimensional (3D) method in only 23 centers (10%). 3D TTE was present in 137 centers (70%), and 3D TEE in all centers where TEE was done (71%). The assessment of LV diastolic function was done routinely in 80% of the centers. Right ventricular function was evaluated using tricuspid annular plane systolic excursion in all centers, using tricuspid valve annular systolic velocity by tissue Doppler imaging in 53% of the centers, and using fractional area change in 33% of the centers. When we divided into cardiology (179, 78%) and noncardiology (49, 22%) centers, we found significant differences in the SE (93% vs. 26%, P < 0.001), TEE (85% vs. 18%), UCA (67% vs. 43%, P < 0001), and STE (87% vs. 20%, P < 0.001). The incidence of LUS evaluation was similar between the cardiology and noncardiology centers (69% vs. 61%, P = NS).

Conclusions

This nationwide survey demonstrated that digital infrastructures and advanced echocardiography modalities, such as 3D and STE, are widely available in Italy with a notable diffuse uptake of LUS in the core TTE examination, a suboptimal diffusion of PACS recording, and conservative use of UCA, 3D, and strain. There are significant differences between northern and central-southern regions and echocardiographic laboratories that pertain to the cardiac unit. This inhomogeneous distribution of technology represents one of the main issues that must be solved to standardize the practice of echocardiography.

Intracardiac thrombus in a patient with mitral bioprosthesis and atrial fibrillation treated with direct oral anticoaugulant: A case report

RATIONALE

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased morbidity, especially stroke and heart failure. There is also increasing awareness that atrial fibrillation is a major cause of embolic events which in 75% of cases are complicated by cerebrovascular accidents.

PATIENT CONCERNS

A 50-year-old woman with mitral bioprosthesis under warfarin for nonvalvular atrial fibrillation was referred to our Coronary Intensive Care Unit due to acute myocardial infarction without evidence of significant coronary artery stenosis.

DIAGNOSES

Cardiovascular examination showed an irregular pulse and a grade II diastolic murmur was audible at the apical area. The patient underwent coronary angiography showing absence of obstructive coronary artery disease. We decided to replace Warfarin with direct oral anticoagulants as anticoagulant therapy.

INTERVENTIONS

Transoesophageal echocardiography revealed a thrombus in left atrial appendage that was treated by replacing warfarin with an oral direct thrombin inhibitor.

OUTCOMES

At 2-month follow-up, the therapy showed to be effective for thrombus resolution.

LESSONS

Our case demonstrated how AF has high risk of thromboembolic complications, not only in terms of stroke but also of myocardial infarction and death.The use of direct oral anticoagulants in AF patients with bioprosthetic heart valves is still debated due to an unclear definition of "nonvalvular" AF.

Lethal infective endocarditis due to Streptococcus agalactiae in a man with a history of alcohol abuse: A case report

RATIONAL

Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium.

PATIENT CONCERNS

A 53-years-old man with a history of alcohol abuse was admitted in hospital for fever, paroxysmal atrial fibrillation cardioverted by Amiodarone and pulmonary infection.

DIAGNOSIS

A case of recurrent severe endocarditis, with neurological complications both ischemic and hemorrhagic and heart failure caused by Streptococcus agalactiae in healthy man we reported.

INTERVENTIONS

Surgery was performed 2 weeks after admission.

OUTCOMES

The onset of intracranial hemorrhage delayed second cardiac surgery and the patient died because of end-stage heart failure.

CONCLUSIONS

Infective endocarditis caused by S. agalactiae is very rare, particularly in patients without underlying structural heart disease. This study showed that IE due to S. Agalactiae is a disease with high mortality when associated with neurological complication, heart failure but especially when it is recurrent and hits valve prosthesis.

AVALIAÇÃO DA SENSIBILIDADE DE ZIGOTOS MURINOS A BRUCELLA ABORTUS PARA O ESTABELECIMENTO DE UM MODELO EXPERIMENTAL EM ESTUDOS DE INTERAÇÕES EMBRIÕES-PATÓGENOS

RESUMO O objetivo desse trabalho foi avaliar in vitro a sensibilidade de zigotos murinos à Brucella abortus, a fim de estabelecer um modelo acessível para o estudo de interações embriões-patógenos. Para a coleta dos zigotos, foram utilizados camundongos fêmeas (Swiss Webster) acasaladas com machos inteiros, após superestimulação ovariana. Para a infecção foi utilizada a bactéria B. abortus 1119.3 e a suspensão foi preparada no momento da inoculação (diluição de 106 bactérias/mL). Os zigotos foram separados em controle e infectados (30 µL da suspensão de bactérias), e após 24 e 96h foram analisados quanto à morfologia e taxa de clivagem. No grupo controle não foram verificadas alterações morfológicas, já no infectado foi possível verificar a presença de blastômeros irregulares, falha de divisão, citoplasma com granulação e aspecto degenerativo. As taxas de clivagem após 24h foram de 77,4% (controle) e 59,2% (infectados) (χ2 de 0,001674; p < 0,05) e após 96h de infecção 14,5% (controle) e 7% (infectados) (χ2 de 0,141616; p < 0,05). Considerando os resultados pode-se concluir que os zigotos murinos são sensíveis à B. abortus após exposição in vitro. Provavelmente os zigotos murinos possam ser utilizados como modelo experimental, de baixo custo e fácil acesso, para estudos da interação embrião-B. abortus.

AVALIAÇÃO DA SENSIBILIDADE DE ZIGOTOS MURINOS AO HERPESVÍRUS BOVINO-1: UM MODELO EXPERIMENTAL PARA ESTUDOS DE INTERAÇÕES EMBRIÃO-VÍRUS

RESUMO O objetivo desse trabalho foi avaliar a sensibilidade de zigotos murinos ao herpesvírus bovino tipo 1 (BoHV-1), visando a obtenção de um modelo in vitro para estudos sobre a interação embriãovírus e sobre o potencial risco de transmissão de viroses através da técnica de fertilização in vitro (FIV). Foram utilizados camundongos fêmeas (Balb C) entre 6-8 semanas de idade, superovuladas com os hormônios eCG e hCG, acasaladas com machos inteiros para colheita dos zigotos. Esses foram separados em 3 grupos, controle e exposto 24h a duas concentrações da suspensão viral (10 µL e 30 µL). Cada grupo foi dividido para análise da morfologia e para avaliação da presença de partículas virais empregando a reação em cadeia pela polimerase (PCR), após o procedimento de lavagens seqüenciais e tratamento com tripsina. De acordo com os resultados obtidos, os zigotos murinos poderão fornecer subsídios como modelo experimental para estudos sobre a biologia das interações embrião-vírus, uma vez que se apresentaram sensíveis ao BoHV-1.