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A 48-year-old man with AIDS/HIV and a previous history of tuberculous pericarditis 25 years earlier was admitted to our department of infectious diseases because of P. carinii pneumonia. A CT (computed tomography) scan described diffuse pericardial thickening with extensive pericardial calcifications on both ventricles. A transthoracic echocardiogram showed all the typical hemodynamic features of pericardial constriction. A review of the CT with 3D reconstruction revealed the presence of ring-shaped pericardial calcification at the basal segments of right and left ventricles extending over the inferior atrioventricular groove, the inferior interventricular groove and the cranial wall of the right atrium. Only a few cases of ring-shaped constrictive pericarditis have been reported and both global ventricular constriction and localized segmental constriction have been described. Our case wants to underline how important a comprehensive multi-modality imaging approach is to this rare form of constrictive pericarditis.

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BACKGROUND: low-density lipoprotein cholesterol (LDL-C) is a strong cardiovascular risk factor, but the methods used to correctly determine it are is still questioned. The aim of this study was to compare the direct determination of LDL-C levels, obtained with the Roche cobas c system, with LDL-C values calculated through Sampson's and Friedewald's equations in very high-risk patients with triglycerides concentrations of less than 2.25 mmol/L (<200 mg/dL). METHODS: in 127 consecutive patients with a recent diagnosis of acute coronary syndrome and triglycerides of less than 2.25 mmol/L, plasma LDL-C was measured directly and calculated with Sampson's and Friedewald's equations before hospital discharge, and the data were compared. RESULTS: median LDL values obtained with the Friedenwald and Sampson equations and with direct determination were 2.31 (IQR 1.59-3.21), 2.36 (IQR 1.66-3.26) and 2.64 (IQR 1.97-3.65) mmol/L, respectively. Direct measurements were higher by 0.35 and 0.40 mmol/L when compared to the levels calculated with Sampson's or Friedewald's equations, respectively (p < 0.01). The correlation between the two equations was almost perfect (rho 0.997) but decreased when the directly determined data were compared to those calculated with Sampson's equation (rho 0.954) or Friedewald's method (rho 0.939). CONCLUSION: direct determination generated higher values of LDL-C concentration through a probable systematic overestimation.

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Sacubitril/valsartan (SV) has been demonstrated to reduce cardiovascular mortality, hospitalization for heart failure and to induce reverse ventricular remodeling. The present study was designed to confirm the effects of SV in a selected population of patients with HFrEF and to evaluate the different responses between patients with an ischemic or a non-ischemic etiology. A total of 79 patients with indication of SV were recruited prospectively during a timelapse of 4 years. SV was overall associated to a reduction of end-diastolic and end-systolic volume, of NT-proBNP levels, furosemide dosage and NYHA functional class, together with an increase in EF. These changes were more evident in patients with non-ischemic dilated cardiomyopathy, who showed a significant improvement in ventricular volumes, ejection fraction, TAPSE and blood levels of NT-proBNP. Kaplan-Meier curves confirmed a greater benefit in terms of ejection-fraction improvement in non-ischemic patients compared to the ischemic group. The results of the present study confirm the positive effect of SV on NYHA functional class, NT- proBNP, left ventricular volumes and EF in HFrEF patients, showing evidence of association of SV with ventricular remodeling in patients with dilated cardiomyopathy of non-ischemic etiology compared to the ischemic group.

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Transesophageal iconic image of a large serpiginous thrombus crossing a patent foramen ovale.

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AIMS: (i) To validate a new software for right ventricular (RV) analysis by 3D echocardiography (3DE) against cardiac magnetic resonance (CMR); (ii) to assess the accuracy of different measurement approaches; and (iii) to explore any benefits vs. the previous software. METHODS AND RESULTS: We prospectively studied with 3DE and CMR 47 patients (14-82 years, 28 men) having a wide range of RV end-diastolic volumes (EDV 82-354 mL at CMR) and ejection fractions (EF 34-81%). Multi-beat RV 3DE data sets were independently analysed with the new software using both automated and manual editing options, as well as with the previous software. RV volume reproducibility was tested in 15 random patients. RV volumes and EF measurements by the new software had an excellent accuracy (bias ± SD: -15 ± 24 mL for EDV; 1.4 ± 4.9% for EF) and reproducibility compared with CMR, provided that the RV borders automatically tracked by software were systematically edited by operator. The automated analysis option underestimated the EDV, overestimated the ESV, and largely underestimated the EF (bias ± SD: -17 ± 10%). RV volumes measured with the new software using manual editing showed similar accuracy, but lower inter-observer variability and shorter analysis time (3-5') in comparison with the previous software. CONCLUSION: Novel vendor-independent 3DE software enables an accurate, reproducible and faster quantitation of RV volumes and ejection fraction. Rather than optional, systematic verification of border tracking quality and manual editing are mandatory to ensure accurate 3DE measurements. These findings are relevant for echocardiography laboratories aiming to implement 3DE for RV analysis for both research and clinical purposes.

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Three-dimensional echocardiography (3DE) is a unique cardiovascular imaging modality in terms of: ability to provide realistic anatomical views of cardiac structures in the beating heart and possibility to visualize cardiac structures from any desired perspective. Therefore, 3DE is emerging as an accurate imaging modality for a prompt diagnosis and detailed anatomical description of structural complications (SC) of acute myocardial infarction (AMI). We report 3 emblematic cases which show how both the transthoracic (TTE) and transesophageal (TEE) 3D imaging can provide precise anatomic information useful to address management of SC in AMI patients: (1) detailed assessment of size, location, and morphology of an apical ventricular septal defect (VSD) obtained with 3DTTE was pivotal in referring the patient to percutaneous closure of it; (2) size and location of a complex inferior VSD with irregular margins advised against percutaneous closure; and (3) 3DTEE assisted surgeons to choose between reparative or replacement surgery for an acute mitral regurgitation due to complete papillary muscle rupture.

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BACKGROUND: Right ventricular (RV) volumes and ejection fraction (EF) vary significantly with demographic and anthropometric factors and are associated with poor prognosis in several cardiovascular diseases. This multicenter study was designed to (1) establish the reference values for RV volumes and EF using transthoracic three-dimensional (3D) echocardiography; (2) investigate the influence of age, sex, and body size on RV anatomy; (3) develop normative equations. METHODS AND RESULTS: RV volumes (end-diastolic volume and end-systolic volume), stroke volume, and EF were measured by 3D echocardiography in 540 healthy adult volunteers, prospectively enrolled, evenly distributed across age and sex. The relation of age, sex, and body size parameters was investigated using bivariate and multiple linear regression. Analysis was feasible in 507 (94%) subjects (260 women; age, 45 ± 16 years; range, 18-90). Age, sex, height, and weight significantly influenced RV volumes and EF. Sex effect was significant (P<0.01), with RV volumes larger and EF smaller in men than in women. Older age was associated with lower volumes (end-diastolic volume, -5 mLdecade; end-systolic volume, -3 mL/decade; EF, -2 mL/decade) and higher EF (+1% per decade). Inclusion of body size parameters in the statistical models resulted in improved overall explained variance for volumes (end-diastolic volume, R(2)=0.43; end-systolic volume, R(2)=0.35; stroke volume, R(2)=0.30), while EF was unaffected. Ratiometric and allometric indexing for age, sex, and body size resulted in no significant residual correlation between RV measures and height or weight. CONCLUSIONS: The presented normative ranges and equations could help standardize the 3D echocardiography assessment of RV volumes and function in clinical practice, considering the effects of age, sex, and body size.

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Study aim To explore various sources of variability in the measurement of LV volumes and dyssynchrony by 3D echocardiography (3DE). Methods We studied 100 patients (58 ± 18 years, 51 men) to assess the impact of: (1) manual editing; (2) 3D data set temporal resolution; (3) LV 16- or 17-segmentation model; (4) software sensitivity for automated endocardial surface detection; and (5) image quality, on the measurement of LV end-diastolic (EDV) and end-systolic (ESV) volumes, sphericity indices (EDSI, ESSI), ejection fraction (EF) and dyssynchrony (SDI). Two- and 4-beat LV full-volume data sets were analyzed and compared. Cardiac magnetic resonance (CMR) was used as reference in 26 patients. Results Manual editing of endocardial surface improved the agreement of LV volumes with CMR, but increased SDI (SDI17: 5.6 ± 0.5% vs. 4.3 ± 0.3%; P < 0.0001). Data set temporal resolution had no significant impact on LV parameters. Adding the 17th to 16-segment LV model did not significantly increase SDI. Reducing software sensitivity in endocardial surface detection increased EDV (101 ± 46 ml vs. 118 ± 50 ml) and sphericity, decreased SDI (SDI 17: 6.7 ± 3.3% vs. 2.9 ± 3.7%) (P < 0.05 for all), and improved agreement of EDV and ESV with CMR. Impact of software sensitivity in LV endocardium detection on LV parameters was related to image quality: higher on SDI in pts with suboptimal quality (SDI 17 bias 4.5% vs. 3.2%, P < 0.05); higher on LV volumes in patients with optimal quality (EDV bias 14 ml vs. 19 ml, ESV bias 5 ml vs. 9 ml; P = 0.01). Conclusions Manual editing, software settings and image quality significantly impact on 3D LV volumes and dyssynchrony assessment.

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BACKGROUND: Compared with previous three-dimensional (3D) echocardiographic scanners, high-volume rate scanners allow higher temporal resolution and the possibility of displaying cropped images side by side. These new features make 3D echocardiography (3DE) even more attractive for application during stress. The aim of this study was to compare the feasibility and diagnostic accuracy of high-volume rate 3DE with state-of-the-art two-dimensional echocardiography (2DE) in detecting ischemia during dipyridamole-induced stress (DipSE). METHODS: One hundred seven consecutive patients with known or suspected coronary artery disease were examined using 2DE and 3DE during the same DipSE examination. RESULTS: Seventeen patients with inadequate images on 2DE requiring contrast infusion and 6 patients with inadequate detection of the endocardial borders on 3DE were excluded (feasibility of 3DE, 79%). The diagnostic accuracy of 3DE with DipSE was tested in the remaining 84 patients. Both acquisition time (65 +/- 30 s vs 16 +/- 3 seconds, respectively; P < .0001) and analysis time (176 +/- 63 vs 91 +/- 5 seconds, respectively; P < .0001) were significantly longer with 2DE than 3DE. Temporal resolution was significantly higher with 2DE than 3DE (75 +/- 5 frames/s vs 41 +/- 5 volumes/s, respectively; P < .0001). The wall motion score index (WMSI) at baseline was similar with 2DE and 3DE (1.041 +/- 0.023 vs 1.049 +/- 0.01, respectively; P = NS). In contrast, peak stress WMSI was significantly lower with 2DE than 3DE (1.21 +/- 0.025 vs 1.29 +/- 0.023, respectively; P = .011). In particular, mean apical peak stress WMSI was significantly lower with 2DE than 3DE (1.34 +/- 0.057 vs 1.55 +/- 0.078, respectively; P < .0001). In the 44 patients who underwent coronary angiography, the overall accuracy of 3DE was similar to that of 2DE (sensitivity, 80% vs 78%; specificity, 87% vs 91%). In the left anterior descending coronary artery territory, for which 3DE showed higher WMSI values, the sensitivity of 3DE was significantly higher than that of 2DE (87% vs 78%, P = .011), while specificity was similar. CONCLUSIONS: Three-dimensional echocardiography with DipSE is feasible and offers shorter acquisition and analysis times compared with 2DE, with similar overall diagnostic accuracy. However, the ability of 3DE to identify wall motion abnormalities in the apical region explains its higher sensitivity for the left anterior descending coronary artery territory.

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AIMS: To assess the accuracy and reproducibility of a novel automated software for left ventricular (LV) volumes and ejection fraction (EF) measurements using real-time three-dimensional echocardiography (3DE). METHODS AND RESULTS: A total of 103 patients with a wide range of LV volumes were analyzed with both 4D AutoLVQ and 4D TomTec software. In 23 patients, a side-by-side comparison of LV volume and EF measurements was done between 3DE, 2DE, and cardiac magnetic resonance (CMR). Excellent correlation was found between 4D AutoLVQ and 4D TomTec [r = 0.98 for end-diastolic volume (EDV), 0.99 for end-systolic volume (ESV), and 0.97 for EF, P < 0.0001], with small biases and narrow limits of agreement: EDV 5.2 mL (-14 to 25 mL), ESV 2.9 mL (-10 to 16 mL), EF -0.2% (-7 to 6%). Time of analysis was halved using 4D AutoLVQ with manual correction (1 min 52 s+/- 30 s) in comparison with 4D TomTec software (3 min 46 s +/- 1 min 24 s). Both softwares showed similar accuracy in comparison with CMR (4D AutoLVQ biases -11.0 mL, -9.1 mL, and 2.9%; 4D TomTec biases -8.3 mL, -7.4 mL, and 2.8% for EDV, ESV, and EF, respectively, P = NS for all) and good reproducibility. CONCLUSION: Novel 4D AutoLVQ software showed very good agreement with more time-consuming 4D TomTec software, having similar accuracy against CMR.

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