Background: Pulmonary regurgitation is the key hemodynamically significant lesion in repaired tetralogy of Fallot contributing to progressive right ventricular (RV) dilatation and biventricular dysfunction. The timing for pulmonary valve replacement remains a controversial topic, and the decision to intervene depends on assessment of RV size and RV function. Objectives: This review aims to discuss the echocardiographic techniques that can be used to assess patients with pulmonary regurgitation after the repair of tetralogy of Fallot defect. While cardiac magnetic resonance (CMR) imaging is the clinical reference method, there is an important role of echocardiography in identifying patients with significant pulmonary regurgitation and assessing the RV size and function. The different echocardiographic techniques that can be used in this context are discussed. Newer techniques for assessing RV size and function include three-dimensional (3D) echocardiography, tissue Doppler and strain imaging. 3D RV volumetric reconstruction based on two-dimensional imaging is a promising new technique that could potentially replace CMR for RV volumetric assessment. Conclusions: Developments in echocardiographic techniques provide new insights into the impact of pulmonary regurgitation on RV structure and function. Echocardiography and CMR are complementary modalities and further research is required to define the optimal use of both techniques for this indication.

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Objective: This paper aims to explain the main mechanisms that cause ischaemic mitral regurgitation (MR), the pathophysiology, and the role played by stress echocardiography in the evaluation of the dynamic component of MR. Introduction: Chronic ischaemic MR is a frequent complication of myocardial infarction (MI), and is associated with a poor prognosis and outcome. The more the severity of ischaemic MR, the lower is the survival rate. In recent times, improvements in the management of the acute phase of MI, has increased the survival rate after MI. This, combined with an increase in the incidence of MI, will probably lead to a higher prevalence of ischemic MR in the next decades. As a consequence, ischaemic MR should be thoroughly understood and promptly identified. Furthermore, it is well recognized that ischaemic MR is dynamic. The best way to explore the dynamic nature of ischaemic MR is exercise stress echocardiography, and this test should probably be integrated in the evaluation and the management of patients with chronic ischaemic MR. Conclusion: Based on our experience, exercise stress echocardiography might be of interest in the following subsets of patients: 1) in patients with left ventricular (LV) dysfunction who present exertional dyspnea out of proportion to the severity of resting LV dysfunction or MR severity, 2) in patients in whom acute pulmonary oedema occurs without any obvious cause; 3) to unmask patients at high risk of mortality and heart failure 4) before surgical revascularization in patients with moderate ischaemic MR and, 5) following surgery, to identify persistence of pulmonary hypertension and explain the absence of functional class improvement.

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Performing a good echocardiographic examination requires intensive training and highly qualified technical staff personnel, which, in many countries, is represented by the Cardiac Sonographer. Being an operator-dependent diagnostic method, a long debate has been held to help identifying the most appropriate curriculum for the training of this professional profile. Although guidelines for the education of the Cardiac Sonographers have been suggested by the American Society of Echocardiography (ASE) several years ago and many scientific publications have given credibility, trust and enhance to this professional profile in Italy, this figure is not yet recognized by the National Health System. It is encouraging that in the last decade, national authorities, such as the SIEC (Societΰ Italiana di Ecografia Cardiovascolare), have expressed interest in recognizing the Cardiac Sonographers as professionals in our country. Per their guidelines, the Cardiocirculatory Physiopathology Cardiovascular Perfusion technicians (TFCPCs) seem to be, among the professionals, the most suitable, due to their educational training and the role they play. Taking inspiration from the positive experience of this professional figure in the USA and in the Anglo Saxon countries, it could aims to be a valid support in terms of cost and quality for the Italian health system.

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Objectives: In our study, we aimed to identify early markers of cardiac dysfunction in patients treated with mitoxantrone. We also looked at cardiac functional changes during therapy by analyzing longitudinal deformation and by measuring left ventricular (LV) and left atrial (LA) global strain. Materials and Methods: LA and LV global longitudinal strain were analyzed in 20 patients affected by multiple sclerosis and treated with mitoxantrone. Patients underwent echocardiography before treatment, after every drug administration during the 12-months treatment period, and finally after 6 and 12 months of drug discontinuation. Results: Compared with baseline values, patients showed a significant reduction of both LA and LV longitudinal global strain at the end of treatment with mitoxantrone (LA_GS% T10 vs. T0 values: 15,2 ± 12,5 vs. 20,2 ± 11,1; LV_GS%: ─16,4 ± 2,5 vs. ─17,4 ± 3,8). Strain reduction reverted after treatment discontinuation (LA_GS% FU vs. T0 values: 20,4 ± 15,7 vs. 20,2 ± 11,1; LV_GS%: ─17,3 ± 3,3 vs. ─17,4 ± 3,8). Conclusions: Impairment of longitudinal deformation during mitoxantrone therapy may indicate a dysfunction related to early myocardial damage. These findings appear to be reversible after treatment discontinuation.

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Introduction: A 71 year old asymptomatic woman came for an echocardiogram because of a left bundle branch block. A much dilated coronary sinus (CS) with an entering large vessel was found along with a mild left ventricular systolic dysfunction. Cardiac Magnetic Resonance (CMR) showed a persistent left superior vena cava (PLSVC), and an absent right superior vena cava (ARSVC). PLSVC drained into the dilated CS. No other cardiac abnormalities were found. Any late Gadolinium enhancement was also not seen. PLSVC and ARSVC are associated with sinus node and conduction tissue maldevelopment and atrial arrhythmias, and thus clinical follow up is indicated. Conclusion: CMR is a useful addition to echocardiogram to search for further cardiac abnormalities, and outline the anatomy with precision in doubtful cases.

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Objective: Respect of "appropriateness" is considered an essential requirement, both on the clinical and the economic profile, and also as it helps to shorten the waiting list. However, only a few studies have dealt with the control of appropriateness in clinical practice, and most of them have focused only on hospital admissions and invasive procedures. Materials and Methods: INDICARD-out is a prospective, multicenter study carried out by A.R.C.A. (Associazioni Regionali Cardiologi Ambulatoriali) cardiologists from 13 Italian Regions, providing information on indications, utility and appropriateness of echocardiography in outpatient cardiology. Results: A total of 2110 prescriptions for echocardiogram were evaluated. Hypertension (23%) and the screening of asymptomatic subjects (17%) by far were the most frequent indications to echocardiography. Overall, 54% of the tests resulted appropriate, 30% were of uncertain appropriateness and 16% were inappropriate. Besides, 31% of the echocardiograms were not useful, and 28% were non pertinent for patient management. The vast majority of prescriptions (72%) came from non-cardiologist physicians (54% from general practitioners). The echocardiograms prescribed by cardiologists were significantly more appropriate, more useful and more pertinent than the tests prescribed by non-cardiologists. Conclusions: The appropriateness, utility and pertinence of the echocardiography are still suboptimal in practice cardiology, especially when indicated by non-cardiologists. The cardiologist, from mere executor of tests prescribed and managed by other physicians, should gain the role of the clinician who takes care of all the cardiologic needs of the patient community.

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Introduction: We report the case of a 58-year-old woman with intracranial hemorrhage associated with stress-induced cardiomyopathy. Results: Left ventricular dysfunction was confined to midventricular segments, and manifested with transient anterolateral wall aneurysm. Although wall motion was severely impaired in the mid-segments, an almost preserved global midventricular radial strain forecasted rapid improvement of ventricular function. Conclusions: This case highlights how deformation imaging can help in clinical practice to interpret the subtle signs of recovery from left ventricular dysfunction.

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