Andrea Fisicaro

Lung Ultrasound Characteristics of Community-Acquired Pneumonia in Hospitalized Children

The diagnosis of community‐acquired pneumonia (CAP) is based mainly on the patients medical history and physical examination. However, in severe cases a further evaluation including chest X‐ray (CXR) may be necessary. At present, lung ultrasound (LUS) is not included in the diagnostic work‐up of pneumonia.

Lung ultrasound in bronchiolitis: comparison with chest X-ray

The diagnosis of bronchiolitis is based mainly on the patient’s medical history and physical examination. However, in severe cases, a further evaluation including chest X-ray (CXR) may be necessary. At present, lung ultrasound (LUS) is not included in the diagnostic work-up of bronchiolitis. This study aimed to compare the diagnostic accuracy of LUS and CXR in children with bronchiolitis, and to evaluate the correlation between clinical and ultrasound findings. Only patients with a diagnosis of bronchiolitis, who had undergone a CXR, were enrolled in the study. Fifty-two infants underwent LUS and CXR. LUS was also performed in 52 infants without clinical signs of bronchiolitis. LUS was positive for the diagnosis of bronchiolitis in 47/52 patients, whereas CXR was positive in 38/52. All patients with normal LUS examination had a normal CXR, whereas nine patients with normal CXR had abnormal LUS. In these patients, the clinical course was consistent with bronchiolitis. We found that LUS is a simple and reliable tool for the diagnosis and follow-up of bronchiolitis. It is more reliable than CXR, can be easily repeated at the patient’s bedside, and carries no risk of irradiation. In some patients with bronchiolitis, LUS is able to identify lung abnormalities not revealed by CXR. Furthermore, there is a good correlation between clinical and ultrasound findings. Given the short time needed to get a US report, this technique could become the routine imaging modality for patients with bronchiolitis.

Coronary microvascular dysfunction in primary cardiomyopathies

Myocardial ischaemia is usually caused by abnormalities of the epicardial coronary arteries. In the past 30 years, however, several studies have shown that abnormalities in the coronary microcirculation may also cause or contribute to myocardial ischaemia in several conditions. In a number of patients who present with anginal attacks in the absence of any apparent cardiac or systemic disease, coronary microvascular dysfunction (CMD) has been suggested to be the unique cause of symptoms.w1 Myocardial blood flow (MBF) abnormalities and the consequent myocardial alterations related to CMD may differ substantially from those caused by flow limiting stenoses in epicardial coronary arteries. In the latter case, the impairment of MBF is generally regional and distributed within the territories subtended by the stenosed artery, resulting in detectable segmental impairment of contractile function. In contrast, in the case of CMD, the abnormality may not necessarily involve the territory subtended by a major coronary branch, but it may affect the whole left ventricle diffusely or be distributed in a scattered manner.1 w1 CMD may be sustained by several pathogenetic mechanisms including structural, functional, and extravascular alterations that can contribute to the condition in different ways. On the basis of the clinical settings in which it occurs, CMD can be classified into four types: (1) dysfunction occurring in the absence of coronary artery disease (CAD) and myocardial diseases; (2) dysfunction occurring in the absence of CAD, but in the presence of myocardial diseases; (3) dysfunction occurring concomitantly with CAD; (4) iatrogenic dysfunction.1 CMD in the presence of myocardial diseases is sustained in most instances by adverse remodelling of intramural coronary arterioles, and can be identified by invasive or non-invasive assessment of coronary flow reserve (CFR). CFR—the ratio of MBF during near maximal coronary vasodilatation to basal MBF—is an integrated measure of flow through both …

Usefulness of contrast-enhanced transoesophageal echocardiography to guide thoracic endovascular aortic repair procedure

AIMS Thoracic endovascular aortic repair (TEVAR) is commonly considered as a valid alternative to surgery. Endoleaks occurrence is one of the principal limitations of TEVAR. Transoesophageal echocardiography (TEE) is often adopted in adjunct to fluoroscopy and angiography (ANGIO) during stent-graft implantation. In the present study, we compare intraprocedural ANGIO, TEE, and contrast-enhanced TEE (cTEE), and we also evaluate their accuracy in early endoleaks detection and characterization. METHODS AND RESULTS Fifty-four patients with thoracic aortic disease suitable for TEVAR were prospectively enrolled in the study. After stent placement, the result of the procedure was assessed by ANGIO, TEE, and cTEE. The use of contrast (Sonovue, Bracco) significantly improved TEE quality (P = 0.0001). cTEE was superior in entry tears, false and true lumen and aneurysm thrombosis identification, and microtears and ulcer-like projections detection before stent deployment. After stent deployment, cTEE was more accurate than TEE and ANGIO in the detection of slow flow in the false lumen and in the aneurismal sac (P = 0.0001), and in the remaining flow identification (P = 0.0001). Notably, cTEE is more accurate in the endoleaks detection (P = 0.0001) and in the incomplete stent expansion diagnosis and need for a further balloon inflation (P 0.002), or a further stent implantation (P 0.006), compared with TEE and ANGIO. CONCLUSION TEVAR procedures are improved by the complimentary use of contrast fluoroscopy, multiplane TEE with Doppler flow interrogation, and cTEE. This triple imaging approach provides additional information in all phases of the procedure improving safety of stent-grafting and the procedural outcomes.

Prevalence of thoracic ascending aortic aneurysm in adult patients with known abdominal aortic aneurysm: an echocardiographic study.

Aortic aneurysms (AAs) can develop in all parts of the aorta and a lot of them remain undetected unless incidentally discovered or until a lifethreatening complication occurs [1,2]. Thoracic aorta is usually studied with computed tomographic imaging (CT),magnetic resonance imaging and echocardiography [1,2]. Transthoracic echocardiography (TE) is commonly performed prior to abdominal AA (AAA) repair to evaluate the cardiac structure and function. In a recent paper, a highprevalence of thoracicAA(ATA) inpatientswithAAAassessedbyCThas been reported [3]. In our study we retrospectively enrolled 1942 patients in order to evaluate the prevalence of the ascending thoracic aortic and aortic arch dilatation/aneurysm in patients with AAA that underwent transthoracic echocardiography (TE) prior to surgery. The exclusion criteriawere: the presence of bicuspid aortic valve, previous aortic valve and/or ascending aortic surgery, genetic syndromes (Marfan syndrome, Ehlers–Danlos syndrome and others), and inflammatory and traumatic diseases. Thus, 1305 patients were considered eligible for the study. The aortic root and the proximal ascending aorta segments were visualized in the left and rightparasternal long-axis views. Inparasternal view the Valsalva sinuses and the proximal portion of the ascending aorta were measured. In the parasternal short axis bicuspid aortic valve was rule out. The aortic arch was evaluated by suprasternal view between the innominate and left carotid artery. Standardmeasurements were made by the leading edge-to-leading edge diameter in enddiastole taking care to obtain a true perpendicular dimension and appropriate gain settings [4]. Views used for measurements were those that showed the largest diameter of the aortic segment and in particular the maximum diameter measured perpendicular to the long axis of the vessel in that view. All the measurements were achieved in twodimensional mode. We used the absolute values as normal standard references of aortic sizes as follows: 1. Valsalva sinuses: 37 mm inmen and 33 inwomen; 2. Proximal ascending aorta: 34 mm inmen and 31 mm inwomen; and 3. Aortic arch: 32 mm in men and 29 mm in women. Sex-specific criteria wereused todefineanascendingaortic aneurysm:womenN42 mmand men N47 mm, and aortic arch aneurysm: women N32 mm and men N37 mm [5–7]. The study complies with the principles and guidelines of the Declaration of Helsinki. The clinical characteristics of the study population and the median diameters of the aorta are reported in Tables 1 and 2. 50% of the population had increased diameters of the Valsalva sinuses and proximal portion of ascending aorta, and 25% had the diameter of the aortic arch greater than normal range. Valsalva sinuses were increased in 25% of men and 75% of women. 50% of men and 75% of women had increased diameter of the proximal ascending aorta. The aortic arch diameter was above the normal range in 25% ofmen and 50% ofwomen. On the basis of sex-specific criteria for aneurysm4% of the patients had an ascending aortic aneurysm and 6.5% an aortic arch aneurysm. Furthermore, 2% men had an ascending aortic aneurysm compared with 25.8% of the women (p b 0.0001), and 6.6% men had an aortic arch aneurysm compared with 10.5% of the women (p b 0.4). Thus, we demonstrate a high prevalence of dilatation/aneurysm of the ascending aorta and the aortic arch in patients with AAA evaluated by TE during pre-operative risk stratification. Our study supports the common idea that ATA is commonly misdiagnosed because of its lack of symptoms. Itani et al. estimated the prevalence of asymptomatic ATA between 0.16 and 0.34% [8]. Larrson et al. evaluated the prevalence of ATA in AAA with CT scan, and they reported the presence of thoracic aorta dilatation in more than 25% of 422 patients [3]. Other retrospective studies had already assessed a higher incidence of thoracic aorta repair in patients that had previously undergone to abdominal aortic repair, although in their reports patients with connective disease were included as well. Alegret et al. stated that

Effects of functional tricuspid regurgitation on renal function and long-term prognosis in patients with heart failure.

Aims Renal dysfunction is common in heart failure. Recent evidence suggests a pivotal role for systemic venous congestion and functional tricuspid regurgitation (FTR) in the pathophysiology of renal dysfunction. We investigated the role of FTR as a determinant of renal dysfunction and a predictor of long-term prognosis in chronic systolic heart failure patients. Methods and results Four hundred and thirteen consecutive patients (mean age 74.2 ± 11 years) with chronic heart failure and left ventricular ejection fraction below 50% were enrolled. The FTR severity was quantified by transthoracic echocardiography. Renal function was evaluated with the estimated glomerular filtration rate measured by the simplified Modification of Diet in Renal Disease formula. The association between moderate/severe FTR and renal dysfunction, and its impact on heart failure episodes and overall mortality were also assessed. The median follow-up was 36 months (range 1–144 months). Through multivariate analysis, the interaction between moderate/severe FTR with tricuspid annular plane systolic excursion less than 16 mm was found to be an independent determinant of renal dysfunction [odds ratio 1.2, 95% confidence interval (CI) 1.1–1.5, P = 0.04]. Moderate/severe FTR (hazard ratio 1.3, 95% CI 1.2–2.7, P = 0.02) and tricuspid annular plane systolic excursion below 16 mm (hazard ratio 1.2, 95% CI 1.0–3.7, P = 0.01) were significantly related to the heart failure episodes. Moreover, the Kaplan–Meier analysis showed a worse outcome in patients with moderate/severe FTR (log-rank test 8.6, P = 0.003). Conclusions The combination of significant FTR and right ventricular dysfunction, but not FTR and right ventricular dysfunction alone, is independently associated with renal dysfunction. The presence of significant FTR is related to an excess event rate of heart failure and has significant impact on outcome.

Acute Pulmonary Edema Caused by a Giant Atrial Myxoma

Atrial myxoma is the most common primary cardiac tumor. Its clinical presentation spreads from asymptomatic incidental mass to serious life-threatening cardiovascular complications. We report the case of a 44-year-old man with evening fever and worsening dyspnea in the last weeks, admitted to our hospital for acute pulmonary edema. The cardiac auscultation was very suspicious for mitral valve stenosis, but the echocardiography revealed a huge atrial mass with a diastolic prolapse into mitral valve orifice causing an extremely high transmitral gradient pressure. Awareness of this uncommon acute presentation of atrial myxoma is necessary for timely diagnosis and prompt surgical intervention.

Live Myxoma Embolism

![Figure][1] [![Graphic][3] ][3] A 47-year-old man presented to the emergency department for 2 episodes of twitching in the left arm that occurred in the last 24 hours. The neurological evaluation, electroencephalographic monitoring, computed tomographic (CT) scan, carotid arteries

Contrast-Enhanced TEE During Thoracic Endovascular Aortic Repair Procedure.

Thoracic endovascular aortic repair (tevar) is commonly performed in selected patients to treat thoracic aortic pathologies. Transesophageal echocardiography (TEE) is often used as adjunct to fluoroscopy and angiography (ANGIO) during TEVAR, mainly reducing radiation exposure and contrast load.

Culture of the Aspirated Coronary Thromboembulus Specimen: A Peculiar Diagnostic Method for Infective Endocarditis

A 69-year-old man was admitted to our hospital for persistent fever, myalgias, articular pain, headache, and hypoaesthesia of the scalp. The clinical scenario was typical for giant-cell arteritis. During hospital stay, patient developed fugax amaurosis, stroke, and acute coronary syndrome. The definitive diagnosis of infective endocarditis, supported by transesophageal echocardiography, was confirmed only by culturing the material obtained during angiography and coronary thromboaspiration.