In 2007, Società Italiana di Ecocardiografia e CardioVascular Imaging (SIECVI) already SIEC, published the document on the organization of echocardiography in Italy. In the years following the technological evolution, cultural and health factors have changed “the way, we do echo” as a tool for the different clinical pathways. The SIECVI Accreditation Area and Board 2017–2019 considered necessary to review and update the document in the light of innovation in the application of ultrasound for the heart disease assessment. In the document, we have considered the role of SIECVI in multimodal imaging, the need of training and certification of operators, the quality of echo machines, the accreditation of laboratories, the compilation of the report and its responsibility, and the presence of the sonographers in the EchoLab.

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.

Infective endocarditis (IE) is a rare disease with a significant impact and an increasing mortality despite earlier diagnosis and surgical intervention. It is related to several and the main etiological agents are the Gram-positive cocci. The new guidelines propose new diagnostic criteria that consider the potentiality on integrated multimodality imaging. Echocardiography (TTE) plays a key role for the diagnosis of IE and must be performed as soon as IE is suspected. It allows to identify vegetation, abscess, new dehiscence of prosthetic valve and assesses the number, size, shape, location, echogenicity and mobility of vegetations so it also useful for prediction embolic risk. Transesophageal echocardiography (TEE) is indicated when TTE is positive or non diagnostic, in case of suspected complications and when intracardiac device leads are present. We underline the increasing role of three-dimensional (3D) echocardiography in overcoming the limit of 2DTEE in selecting the maximum true diameter of irregular masses (ie, vegetation). We also underline the diagnostic value of multislice computed tomograpfy (MSCT), cerebral magnetic resonance (RMI) and nuclear imaging and also emphasize the emerging role of particular types of endocarditis specially Lead Endocarditis. The aim of this review is to provide an overview of the imaging techniques useful for the diagnosis and identification of any complications. In our opinion, the management of IE is complex, based on an “Endocarditis team “ composed by several specialist and an integrated multimodality imaging is essential for the diagnostic approach.

Background: To assess the extent of transmurality in non-ST elevation myocardial infarction (NSTEMI) patients using speckle-tracking echocardiography (STE) in relation to their risk categorization to improve the risk stratification of NSTEMI patients through detecting the presence of transmural infarction. Patients and Methods: It included 96 patients with NSTEMI. All patients were subjected to GRACE score (GS) calculation, transthoracic and speckle-tracking echocardiography (STE): To detect left ventricular ejection fraction and myocardial global longitudinal strain [GLS]and circumferential strain [CS]. Results: As compared to low-GS group; high-risk group was older with the increased prevalence of hypertension (HTN), diabetes, and smoking. There was no significant difference between both groups regarding LS and CS of all 17 segments except for apex where longitudinal strain (LS) was significantly decreased in low-risk group (−17.2 ± 1.1) as compared to high-risk group (−18.6 ± 1.4). GLS was significantly decreased in high-risk group (15.4 ± 0.6) as compared to low-risk group (16 ± 0.8), P = 0.02 with no significant difference in the global CS (P = 0.8). Transmural infarction constitutes 37.5% of all patients. The prevalence of transmural infarction was increased in the low-risk group without significant difference. GS showed a positive correlation with age, male, HTN, diabetes, and smoking and negative correlation with GLS. There was no significant correlation between GS and global CS. Age, GS, and LS were significantly related to transmural infarction. None was found to predict the occurrence of transmural infarction. Conclusion: Transmural extent as detected by STE had been found in a relatively substantial number of patients with NSTEMI, and it may serve as a tool in conjunction with risk stratification scores for the selection of high-risk patients.

Background and Aim: End-stage heart failure (HF) patients are at high risk for mortality and morbidity. We aimed to study the role of cardiac output (CO) assessed by Doppler as a noninvasive tool, to predict mortality, rehospitalization rate, and left ventricular assist device (LVAD) implantation at 6 months. Methods and Results: We retrospectively analyzed the data of 60 patients with end-stage HF from different etiologies and an LV ejection fraction ≤20%. Patients were divided into two groups, according to the cardiac index (CI) measured by cardiac ultrasound and Doppler – Group 1: low CO or CI <2 l/min/m² and Group 2: preserved CO or CI ≥2 l/min/m². Group 1 included 30 patients with mean CI of 1.52 ± l/min/m². Group 2 included 30 patients with mean CI of 2.27 ± l/min/m². At 6 months of follow-up, mortality was significantly higher in Group 1 compared to Group 2 (16% vs. 5%, P = 0.0001). Patients in Group 1 had higher hospitalization rate at 6 months compared to patients in Group 2 (3.5 ± 0.9 vs. 1.9 ± 0.6, P = 0.013). There was significantly more LVAD implantation in 16 patients (26%) in Group 1 versus seven patients (12%) in Group 2 (P = 0.04). Conclusion: CI measured noninvasively by cardiac ultrasound is a simple and useful tool in HF patients' risk stratification and in predicting prognosis and outcome.

Current guidelines consider thrombosis as a potential (and reversible) cause of cardiorespiratory arrest (CA). However, cardiac thrombus formation (TF) is likely to be the consequence of the forward blood flow ceasing during cardiac standstill. We present the case of a young man who was hospitalized for infective endocarditis, complicated by multiorgan disease and sudden CA on the 5^th day. Prompt cardiopulmonary resuscitation (CPR) warranted a return of spontaneous circulation in 16 min but, unexpectedly, a TF was recognized in the right atrium at echocardiography. The blood clot resolved with rapid administration of endovenous heparin and continued chest compressions. Even though cardiac ultrasound is not ready for a routine use during CPR, the present study confirms a key role in the management of CA patients.

There are few clinical reports of elderly patients with paradoxical embolism in the current literature. Herein, we describe the case of a nonagenarian patient with paradoxical embolism of stroke-related patent foramen ovale (PFO). A 95-year-old woman was admitted to our hospital because of dysarthria. Her medical history included cerebral infarction, hypertension, and dyslipidemia. Magnetic resonance imaging performed in the emergency room revealed cerebral infarction of the left temporal lobe. After hospitalization in the neurosurgery department, we performed further clinical investigations to diagnose the type of stroke. There was no significant stenosis with plaque of the carotid and cerebral arteries, and there were no sources of cardiac embolism or an episode of atrial arrhythmia. Transesophageal echocardiography (TEE) showed PFO with separation and the Eustachian valve. In addition, spontaneous bidirectional shunt flow through the PFO was detected by TEE with the patient at rest. Ultrasonography of the leg vein revealed a thrombus in the deep vein. Therefore, she was diagnosed as having paradoxical embolism of stroke-related PFO and prescribed a direct oral anticoagulant (DOAC). This very rare case in which stroke-related PFO was diagnosed in a nonagenarian patient demonstrates that PFO is the cause of paradoxical embolism of stroke regardless of age.

The draining of the right superior vena cava (SVC) into the left atrium is a very rare anomaly of systemic vein drainage. This case report describes a term male infant presenting with central cyanosis diagnosed with right SVC drainage into the left atrium. The diagnosis was performed using conventional echocardiography and computed tomography angiography. Surgical correction with translocation of the right SVC to the right atrium was necessary to treat the symptom of cyanosis and prevent further complications, including brain abscesses and paradoxical embolization.

Sinus of Valsalva aneurysm (SOVA) is rare and can occur in diseases with progressive aortic dilation. We report an adolescent male with DiGeorge syndrome who presented with fever and wide pulse pressure mimicking endocarditis. A timely diagnosis of ruptured SOVA using echocardiography enabled optimal treatment. Our case highlights the need to assess for this rare condition in this high-risk population.

We describe a case of an 88-year-old woman with a severe bluntly ematic pericardial effusion. Radiological and laboratory examinations excluded all the most common causes of hemopericardium, and the diagnosis of spontaneous hemopericardium associated with the treatment with rivaroxaban was made. This is the first case report describing a hemopericardium in a patient treated with rivaroxaban who did not take other herbal products or drugs that may significantly increase rivaroxaban blood levels. This report emphasizes the need for the careful use of new oral anticoagulants, and the importance of taking in mind uncommon side effects. Spontaneous hemopericardium should be considered in these patients.

Aortic location of infective endocarditis is a risk factor for perivalvular extension of infection, even when a native valve is involved. We report the case of a 50-year-old man with a systolic murmur and a history of previous aortic valve infective endocarditis requiring cardiac surgery. A thorough echocardiographic assessment, including three-dimensional transesophageal echocardiography, clearly demonstrated the presence of two distinct postinfective complications, i.e., a fistula of the mitral-aortic intervalvular curtain communicating in systole with the left atrium and an acquired Gerbode-type ventricular septal defect. Our case highlights the pivotal role of echocardiography for a correct and comprehensive diagnostic assessment in the complex scenarios frequently encountered after infective endocarditis.