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The concept of point-of-care, problem-oriented focus cardiac ultrasound examination (FoCUS) is increasingly applied in the settings of medical emergencies, including cardiac diseases. The European Association of Cardiovascular Imaging (EACVI) recognizes that cardiologists are not the only medical professionals dealing with cardiovascular emergencies. In reality, emergency cardiac diagnostics and treatment are also carried out by a wide range of specialists. For the benefit of the patients, the EACVI encourages any medical professional, sufficiently trained to obtain valuable information from FoCUS, to use it in emergency settings. These medical professionals need to have the necessary knowledge to understand the obtained information entirely, and to use it correctly, thoughtfully and with care. In this document, the EACVI underlines major differences between echocardiography and FoCUS, and underscores the need for specific education and training in order to fully utilize advantages and minimize drawbacks of this type of cardiac ultrasound examination in the critically ill patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: Journals.permissions@oup.com.)

In continuation of a previous publication, the present study will take into account for each application and profile the clinical use, the minimal data settings, the echo data findings, the indications, the quality process, the accreditation requirements, educational tailored pathway contents and modalities. The aim of the present document was to define the main applications of echocardiography and to tailor for each application-derived profile, according with the previous definitions, requirements that clearly identify the indication, objective, clinical situation in which echocardiography is used, educational pathway and training, quality process and accreditation.

The quality management of an organization can be defined as the ability to identify, plan and implement programs of measure, analysis, verification and control that allow to monitor management, resources, activities, processes and output/outcome of the same organization, including the satisfaction of the customers. Whatever the model used, it is demonstrated that the management-quality system, either for professional quality or for organization, turns out to be effective even in the health organizations within and to any level of organizational-structural complexity. The present paper concerns the experience of the Italian Society of Cardiovascular Echography (SIEC) on quality certification, both as a scientific society compared to other health organizations and to cardiovascular echo laboratories, and the definition of minimum requirements for the accreditation of the same laboratories. The model most frequently used for quality management is represented by the ISO 9000: Vision 2000, that is a management model with specific reference to the organization and the customer satisfaction. The model applied to the health structure needs a rapid change in mentality that addresses the operators to define, share and achieve objectives to be brought on by means of an active collaboration, group activity and deep sense of belonging necessary to the attainment of expected objectives. When the model is applied by a scientific society, it is necessary to take into account the different structural and functional organization, the constitution and the operators differing on the point of view of origin, experiences, mentality, and roles. The ISO 9000: Vision 2000 model can be applied also to the cardiovascular echo laboratory which may be compared to a simple organization; for its corrected functioning, SIEC has defined minimal requirements for the accreditation, realization and modalities to carry out and manage quality. The quality system represents a new way of operating of an organization that enhances capability and performance of the operators, stimulates their creativity and facilitates the activities of all, to guarantee both the quality of the product and the satisfaction of operators and customers at the same time.

We studied by cineangiography and standard and subxiphoid echocardiography the left ventricular wall motion in 50 patients with old myocardial infarction and 10 normal subjects. Coronary artery angiography showed a good correlation with the electrocardiographic site of infarction and with the asynergic areas detected by cineventriculographic examination and bidimensional echocardiography. From the correlation of data related to the asynergic areas detected by angiographic and echocardiographic methods it was possible to establish that subxiphoid approach allows to visualize the posterior-lateral wall whereas the parasternal approach the posterior-inferior wall of the left ventricle. Two-dimensional echocardiography from the subxiphoid approach resulted to be a useful and reliable technique for detecting the apical asynergies. The left ventricular wall motion parameters detected by M-mode echocardiography showed significant modifications in all the groups either in the comparison SUBX versus ST or in that with the control group. The subxiphoid approach either M-mode or bidimensional was, therefore, useful in the evaluation of the asynergic areas of the left ventricular lateral wall. The association of SUBX with ST provides further information on the left ventricular wall motion and then, since different areas are visualized with the two techniques, on the extent of myocardial damage.

A series of 4260 consecutive echocardiographic examinations, performed in 5 Cardiological Centers was examined, identifying 125 intraventricular false tendons (FTs) in 100 cases (55 normals and 45 with heart disease) of whom 31 were female and 69 male, aged 3 to 82 years. An anatomo-morphological study was possible in 9 cases, dead for stroke or heart failure, on autopsy, and in 7, on heart surgery. A phonocardiogram was performed in all normals and in 20 patients. On echocardiography, FTs appeared as an echo-producing string-like structure, straight between the septum and the ventricular free wall, mobile during the cardiac cycle, without systolic thickening and any relation with the atrioventricular valvular apparatus. The prevalence of FTs was 2.3%; it was 3.2% to 5.3% in younger people. FTs were located in the right ventricle (4 cases), left ventricle (95 cases) or in both (1 case). Their site was left apical (45 FTs), right apical (2 FTs), right (3 FTs) and left (20 FTs), upper septum-to-free wall (55 cases). In 1 case hypertrophy of trabeculae of the left ventricle was detected. FTs were single (79 cases), double (19 cases), multiple (2 cases), short (42 cases), long (58 cases), thick (45 cases) and thin (55 cases). They showed a membrane-like motion (thick FTs-45 cases) and a valve-like motion (thin FTs-55 cases). Innocent murmur was detected in 50 of 55 normals and related to thin FTs. Of 16 cases examined anatomically and histologically, FTs were fibrous in their distal portion and fibro-muscular in the proximal one in 12 cases, whereas they were entirely fibrous-muscular in 4 cases. The site and location of FTs detected by echo were confirmed by anatomy in all cases. In 4 cases other 9 FTs, not detected on echocardiography, were found. These data suggest that echocardiography is a useful tool to detect intraventricular FTs and differentiate them from other echo-producing structures. Although a relationship between FTs and heart disease has not been found, their presence could be responsible of innocent murmur in many normal subjects.

The principal echocardiographic features of the main cardiovascular emergencies are discussed. After setting out a method of detailed analysis for echocardiography, the changes found in the main causes of severe chest pain, systemic embolisation and sudden heart failure are described. Special emphasis is laid on the signs of aortic root dissection, pericarditis and tamponade, ruptured valve, the mechanical complications of acute myocardial infarction and, in particular, on the assessment of residual myocardial function. Finally, the authors maintain that echocardiography should be a systematic complementary investigation for patients in the coronary care unit.

Echocardiography was used in 40 patients with atrial septal defect (ASD), diagnosed by cardiac catheterization. A dilated right ventricle and abnormal interventricular septal motion were observed at M-mode echocardiography in patients with large L-R shunt. The two-dimensional apical four chamber view was reliable to detect the ostium primum type but not the secundum type of ASD. Moreover the presence of false positives reduced the specificity and predictivity of this approach. The two-dimensional subcostal view provided a direct visualization of the interatrial communication (sensitivity, specificity and predictivity = 100%) and whether the defect was in the uppermost, lowermost or midportion of the septum. Subcostal two-dimensional echocardiography is considered valuable and reliable technique to detect atrial septal defect and the type of the defect itself.

Atrial septal aneurysm can be detected by subcostal echocardiography as a bulge of the intermediate interatrial septum, ballooning toward the right atrium. We retrospectively revised 5412 echo examinations, consecutively performed in our laboratory, and we found 14 cases of atrial septal aneurysm (0.26%), mean age 36 +/- 15 years, 9 males and 5 females. In 7 patients atrial septal aneurysm was wide, including the whole atrial septum; in 5, only cranial two-thirds of the septum were involved and in 2, it regarded only the intermediate septum. No patients referred to arrhythmias, syncope, embolism, endocarditis or transient ischemic neurologic disorders. Cardiac abnormalities or defects were associated to atrial septal aneurysm in 12/14 patients: they consisted of atrial septal defect, mitral valve prolapse, false ventricular tendons or persistent Chiari network. Atrial left-to-right shunt was detected in all 6 cases with atrial communication. Considering each single associated cardiac abnormality, the prevalence of atrial septal aneurysm was 7% in patients with atrial septal defect, 1.7% in those with mitral valve prolapse, 6.6% in persistent Chiari network and 0.9% in false ventricular tendons. In conclusion, echocardiography is the first-choice technique to detect atrial septal aneurysm and other related cardiac defects.

Of a total of 3654 echocardiographic and Doppler studies, found 95 left ventricular bands. We described the different Echo-patterns. Color-flow Doppler mapping demonstrated normal left ventricular inflow and outflow, and also lack of turbulence around the band. We conclude left ventricular bands are an abnormal but not Pathological finding.

Right and left ventricular systolic time intervals are measured in 40 cardiopathic subjects and compared with the respective values concerning 20 normal subjects. The results show a modification: a) of the values concerning the right ventricle in presence of pathology interesting this ventricle; b) of the values concerning the left ventricle in presence of pathology interesting this ventricle; c) of the values concerning both the ventricles in presence of left ventricular pathology which has, also, interested the right ventricle. The AA. emphasize the importance of the right and left ventricular systolic time intervals not only to separate pathology interesting the right ventricle from that interesting the left ventricle, but also, to evaluate the ventricular performance and the stage of evolution and extension of the cardiopathy.

15 normal subjects and 23 subjects with cardiac valve disease have been studied. All the subjects have undergone an echo-phonomechanocardiographic investigation with simultaneous recording of the tracings. The values of the systolic time intervals have been obtained from the echo-cardiographic tracings and compared with those obtained from the phonomechanocardiographic tracings evaluating the differences between them. The comparison has pointed out values nearly coincident, providing useful elements about the relations existing between the cardiac sounds and the moments of closure of the mitral and aortic valves. Moreover, the two techniques are considered useful and valid in the evaluation of the left ventricle performance by the systolic time intervals, especially when the recording is carried out simultaneously.

Twelve patients with dilated cardiomyopathy were studied in order to evaluate whether the favourable effect of Nifedipine on the right heart is due to a direct action of the drug on pulmonary resistances or is related to an improvement of left ventricular function. Echocardiographic examination of left and right heart was performed at basic conditions, after Nifedipine treatment--20 mg sublingually--and after 20 minutes of oxygen breathing (FiO2 75%). This was done in order to verify if oxygen vasodilating action could potentiate the Nifedipine effect. Echocardiographic date were obtained in basic conditions, 10, 20 and 30 minutes after Nifedipine and immediately after oxygen breathing. Ten normal subjects were used for comparison for basic data. Peak Nifedipine activity was observed 10 minutes after administration. At this time inferior vena cava emptying index and systolic pulsation were significantly increased, whereas left and right ventricle isometric contraction time, left and right ventricle ejection time, left and right ventricle isovolumetric relaxation time, end-diastolic left ventricular diameter, inferior vena cava diameters and systolic blood pressure had decreased, thus showing the favourable effect of Nifedipine of both heart sides. Heart rate did not significantly change. Oxygen inhalation induced a significant decrease of right ventricular isovolumetric relaxation and an increase of the inferior vena cava indexes, suggesting an improvement in right heart function, without any change in other parameters. No significant difference was found between data after-oxygen and data obtained 10' after Nifedipine, showing that the Nifedipine effect was not potentiated by oxygen.(ABSTRACT TRUNCATED AT 250 WORDS)

Using subcostal echocardiography, 97 patients with diseases involving the right side of the heart and 15 normal subjects were examined in order to study the inferior vena cava (IVC) wall motion. All cases had a diagnostic cardiac catheterization and routine echocardiogram. The jugular pulse (JP) was recorded in 35 random cases contemporary to the IVC and tricuspid valve (TV) tracings. The aim of the study was to evaluate the variations of the IVC diameters in different cardiopathies and in relation to the right atrial mean pressure and the time-relationship of the IVC wall motion related to the cardiac rhythm and cycle, respiratory events, and JP and TV waves. The a, b, v, and y waves were identified on the IVC tracings and related to the respective waves of the JP and the points of closure and opening of the TV. The IVC a and v waves were coincident with the TV closure and opening, and therefore, considered as moments of maximal presystolic and systolic filling of the IVC. The JP a wave inscribed before, whereas the v wave did so after the same IVC waves, respectively. The IVC a wave was due to the atrial contraction and influenced by the cardiac rhythm. The emptying index (EI) was calculated from the diameters in a and b as a - b/a X %, whereas the collapsability index (CI) was calculated from the expiratory and inspiratory diameters as Ex - In/Ex X %, obtaining a good correlation with the right atrial mean pressure. Finally, the percentage systolic pulsation (SP) was calculated from the diameters in b and v as b - v/b X %. The indices of function of the IVC have been very useful in the evaluation of patients with raised heart pressure, tricuspid regurgitation, and pericardial effusion. From the present investigation it results that the IVC wall motion, more so than the JP waves, is an expression of right atrial and ventricular events, and that the above indices are an expression of the atrial and ventricular function in relation to the hemodynamic situation.

The echocardiographic tracings of 40 subjects with pure or prevalent mitral stenosis are obtained. The modification of the isovolumetric relaxation time of the right (Pc-To) and the left (Ac-Mo) ventricle, measured from echocardiographic tracings, versus the values of systolic (PSP cat.) and wedge (PVCP cat.) pulmonary pressure are studied in 15 sinusal rhythm patients who underwent cardiac catheterization. The variations of Pc-To versus Ac-Mo and of Pc-To/Ac-Mo ratio versus the most important indices of mitral stenosis and right ventricular performance evaluation are studied in all the patients. Good correlation has been found between Pc-To and Ac-Mo ratio and PSP, PVCP, E-F, Wells index, Yigitbasi index, RICT/RVET, RPEP/RVET, mitral surface; poor correlation has been found between Pc-To/Ac-Mo ratio and left atrial dimension and stroke volume, while no-significant correlation has been found between this ratio and the ejection fraction, V cf, delta S%. For values of Pc-To/Ac-Mo ratio less than 1.20, 1.20 greater than and less than 1,50, greater than 1.50 the stenosis has been considered, respectively, mild, moderate and severe. The Pc-To/Ac-Mo ratio, obtained from echocardiographic tracings, is considered a useful index in the evaluation of the severity of the stenosis and of the pulmonary pressure variations in the presence of mitral stenosis.

M-mode and two-dimensional parasternal long axis view echocardiography, and left anterior oblique cineangiography were employed to assess the left ventricular wall motion in 10 normal subjects (N) and in 25 patients with hypertrophic cardiomyopathy: 7 patients with symmetric hypertrophy (SH) and 6 patients with apical cardiomyopathy (AHCM) and no intraventricular gradient; 12 patients with hypertrophic obstructive cardiomyopathy and asymmetric septal hypertrophy with resting intraventricular gradient (6 pts) (HOCM-R) or gradient occurring only after isoproterenol infusion (6 pts) (HOCM-I). The left ventricle was divided into five portions: upper and lower septum, upper and lower posterior wall and apex. The excursion and thickness of the upper and lower portions of the septum and posterior wall were measured in all patients and compared to 10 normal subjects (N). From the superimposed end-diastolic and end-systolic echo frames and angio silhouettes a chordal and a radial-chordal method were used, respectively, to measure the motion of the left ventricular wall segments. In SH the left ventricular wall motion was qualitatively similar to N but a little reduced; the thickness was increased and no pressure gradient was present. In AHCM the lower septum, posterior wall, and apex showed significantly increased thickness and motion compared to N and compared to the upper portions of the septum and posterior wall. No gradient was present. In HOCM-R the upper septum moved towards the apex, the lower septum, upper posterior wall and lower posterior wall moved towards the left ventricular cavity. The upper posterior wall was hyperkinetic compared to N and compared to the lower posterior wall, resting gradient and SAM was present in all. In HOCM-I the upper septum moved towards the apex; the posterior wall was hyperkinetic (the excursion was a little wider in the lower posterior wall than in the upper posterior wall). No gradient was recorded at rest, but it could be provoked by isoproterenol. Echocardiography provides precise information on left ventricular wall motion in hypertrophic cardiomyopathy. Hyperkinesis of the lower left ventricular wall is related to AHCM; hyperkinesis of the upper posterior wall and the motion of the upper septum towards the apex are related to HOCM-R. Hyperkinesis of the lower posterior wall is related to HOCM-I. SAM and pressure gradients may be related to the hyperkinesis of the upper posterior wall. Finally, the septum is not an immobile structure in HOCM, since it moves mainly from the base to the apex and a less (or not at all) towards the posterior wall.