Background: Mitral annular disjunction (MAD), a mitral annular abnormality involving the whole mitral valve annulus circumference, commonly detected in individuals with mitral valve prolapse (MVP), has been recently recognized as a potential risk factor for malignant ventricular arrhythmias (VAs) and sudden cardiac death. Recent evidence indicates that a multimodality imaging assessment comprehensive of echocardiography, cardiac magnetic resonance (CMR), and cardiac computed tomography angiography (CCTA) may improve MAD detection. To date, no previous author has considered the potential influence of chest wall conformation on MAD presence. Considering the strong association between MVP and anterior chest wall deformities and the increased prevalence of MAD among MVP individuals, we have hypothesized that MAD presence might be more frequently detected among MVP individuals with a narrow anteroposterior (A-P) thoracic diameter and/or concave-shaped chest wall conformation, as noninvasively assessed by the modified Haller index (MHI). Methods: Herein, we present a case of MVP female with relevant MAD distance and moderate mitral regurgitation (MR) who underwent a diagnostic study comprehensive of transthoracic echocardiography, transesophageal echocardiography, CMR, CCTA, and exercise stress echocardiography. Results: The patient was found with a concave-shaped chest wall conformation (MHI > 2.5) and narrow A-P thoracic diameter (<13.5 cm), with a moderate and non-hemodynamically significant MR, without areas of LGE on CMR and with low arrhythmic profile. Conclusions: A preliminary chest shape assessment by the MHI might improve the prognostic risk stratification of MVP patients with MAD, potentially identifying a benign phenotype of MVP individuals, i.e., those with a narrow A-P thoracic diameter.

Mitral annular disjunction (MAD), a mitral annular abnormality involving the whole mitral valve annulus circumference, commonly detected in individuals with mitral valve prolapse (MVP), has been recently recognized as a potential risk factor for ma-lignant ventricular arrhythmias (VAs) and sudden cardiac death. Recent evidence in-dicates that a multimodality imaging assessment comprehensive of echocardiography, cardiac magnetic resonance (CMR) and cardiac computed tomography angiography (CCTA) may improve the MAD detection. To date, no previous author considered the potential influence of chest wall conformation on MAD presence. Considering the strong association between MVP and anterior chest wall deformities and the increased prevalence of MAD among MVP individuals, we have hypothesized that MAD pres-ence might be more frequently detected among MVP individuals with a narrow ante-ro-posterior (A-P) thoracic diameter and/or concave-shaped chest wall conformation, as noninvasively assessed by the modified Haller index (MHI). Herein, we present a case of MVP female with relevant MAD distance and moderate mitral regurgitation (MR), who underwent a diagnostic study comprehensive of transthoracic echocardi-ography, transesophageal echocardiography, CMR, CCTA and exercise stress echocar-diography. The patient was found with a concave-shaped chest wall conformation (MHI >2.5) and narrow A-P thoracic diameter (< 13.5 cm), with a moderate and non-hemodynamically significant MR, without areas of LGE on CMR and with low arrhythmic profile. A preliminary chest shape assessment by the MHI might improve the prognostic risk stratification of MVP patients with MAD, potentially identifying a benign phenotype of MVP individuals, i.e. those with a narrow A-P thoracic diameter.

Background: Patients with idiopathic pulmonary fibrosis (IPF) have a high prevalence of cardiovascular (CV) risk factors and an increased CV disease burden. The aim of this study was to investigate the prognostic role of the ascending aorta (AA) diameter in patients with mild-to-moderate IPF and to identify the main determinants of AA dilatation. Methods: All IPF patients without severe pulmonary hypertension who underwent a multi-instrumental evaluation, comprehensive of high-resolution computed tomography (HRCT) and transthoracic echocardiography (TTE), between September 2017 and November 2023, were retrospectively analyzed. The primary endpoint was the composite of “all-cause mortality or re-hospitalization for all causes”, over a medium-term follow-up. The secondary endpoint was to evaluate the independent predictors of AA dilatation. Additionally, Bland–Altman analysis was used to assess the accuracy and precision of echocardiography-derived AA diameters compared with non-ECG gated HRCT measurements. Results: A total of 105 IPF patients and 102 age-, sex-, and CV risk factor-matched controls without IPF were evaluated retrospectively. Over a follow-up of 3.9 ± 1.9 yrs, 31 patients died and 47 were re-hospitalized. AA/height (HR 1.15, 95% CI 1.06–1.25, p < 0.001) was independently associated with the primary endpoint, whereas unindexed AA (HR 1.01, 95% CI 0.96–1.06, p = 0.83) and AA/BSA (HR 1.00, 95% CI 0.89–1.11, p = 0.39) were not. An AA/height > 20 mm/m showed 100% sensitivity and 63% specificity (AUC = 0.78) for predicting the primary endpoint. C-reactive protein (OR 1.87; 95% CI 1.21–2.89, p = 0.005) and left ventricular mass index (OR 1.13, 95% CI 1.04–1.24, p = 0.006) were independently associated with an AA/height > 20 mm/m in the whole study group. The Bland–Altman analysis revealed a bias of +2.51 mm (with the 95% limits of agreement ranging from −3.62 to 8.65 mm) for AA estimation, suggesting a general overestimation of the AA diameter by TTE in comparison to HRCT. Conclusions: AA dilatation is predictive of poor outcomes in IPF patients without advanced lung disease over a mid-term follow-up. The AA/height assessment may improve the prognostic risk stratification of IPF patients.

Right ventricular thrombosis (RVT) is rarely detected in clinical practice. Depending on its etiology, RVT may originate from a deep venous thrombosis (type A) or in situ (type B). The type A is characterized by increased mobility and frequent pulmonary embolization, whereas the type B is nonmobile and is associated with significant right ventricular (RV) dilatation and dysfunction. The third RVT type is the type C, with intermediate characteristics between type A and type B. Herein, we present a case of type C RVT, originated in situ and complicated by subsegmental pulmonary embolism (PE), diagnosed in a 46-year-old man with acute-on-chronic respiratory failure secondary to acute exacerbation of interstitial lung disease. He underwent a multimodality imaging assessment of the RV mass comprehensive of TTE, TEE, contrast-enhanced chest CT and LGE-CMR. During the clinical course, a serial echocardiographic assess-ment of the RV mass allowed to provide a dynamic evaluation of its features and cardiac hemodynamics. Conventional TTE was implemented with color-tissue Doppler imaging (TDI) and pulsed wave (PW) TDI to improve the visualization of RV mass and to objectively measure its mobility. The increased RVT mass peak antegrade velocity (>10 cm/s) was predictive of the subsequent RVT fragmentation and pulmonary embolization. In conclusion, color-TDI and PW-TDI may aid in the differential diagnosis of RV masses and may improve the prognostic risk stratification of patients with right-sided intracardiac masses.

Background: Right ventricular thrombosis (RVT) is rarely detected in clinical practice. Depending on its aetiology, RVT may originate from a deep venous thrombosis (type A) or in situ (type B). Type A is characterized by increased mobility and frequent pulmonary embolization, whereas type B is nonmobile and is associated with significant right ventricular (RV) dilatation and dysfunction. Methods: A type B RVT complicated by subsegmental pulmonary embolism (PE) was diagnosed in a 46-year-old man with acute-on-chronic respiratory failure secondary to acute exacerbation of interstitial lung disease. He underwent a multimodality imaging assessment of the RV mass that comprehensively incorporated TTE, TEE, contrast-enhanced chest CT, and LGE-CMR. Results: During the clinical course, a serial echocardiographic assessment of the RV mass allowed for a dynamic evaluation of its features and cardiac haemodynamics. Conventional TTE was implemented with colour tissue Doppler imaging (TDI) and pulsed wave (PW) TDI to improve the visualization of the RV mass and to objectively measure its mobility. The increased RVT mass peak antegrade velocity (>10 cm/s) was predictive of subsequent RVT fragmentation and PE. Conclusions: Colour TDI and PW-TDI may aid in the differential diagnosis of RV masses and may improve the prognostic risk stratification of patients with right-sided intracardiac masses.

Background: No previous study was specifically focused on the ascending aorta (AA) diameter assessment in patients with idiopathic pulmonary fibrosis (IPF). The aim of this study was to investigate the prognostic role of the AA diameter in patients with mild-to-moderate IPF and to identify the main determinants of the AA dilatation. Methods: All IPF patients without severe pulmonary hypertension who underwent a multi-instrumental evaluation, comprehensive of high-resolution computed tomography (HRCT) and transthoracic echocardiography (TTE), between September 2017 and No-vember 2023, were retrospectively analyzed. The primary endpoint was the composite of “all-cause mortality or re-hospitalization for all causes”, over a medium-term follow-up. The secondary endpoint was to evaluate the independent predictors of AA dilatation. Additionally, Bland-Altman analysis was used to assess the accuracy and precision of echocardiography-derived AA diameters compared with non-ECG gated HRCT meaurements. Results: A total of 105 IPF patients and 102 age-, sex- and cardiovascular risk factors-matched controls without IPF were retrospectively evaluated. Over a follow-up of 3.9±1.9 yrs, 31 patients died and 47 were re-hospitalized. AA/height (HR 1.15, 95% CI 1.06-1.25, p < 0.001) was independently associated with the primary endpoint, whereas unindexed AA (HR 1.01, 95% CI 0.96-1.06, p = 0.83) and AA/BSA (HR 1.00, 95% CI 0.89-1.11, p = 0.39) were not. An AA/height >20 mm/m showed 100% sensitivity and 63% specificity (AUC = 0.78) for predicting the primary endpoint. C-reactive protein (OR 1.87; 95% CI 1.21-2.89, p = 0.005) and left ventricular mass index (OR 1.13, 95% CI 1.04-1.24, p = 0.006) were independently associated with an AA/height >20 mm/m in the whole study group. The Bland-Altman analysis revealed a bias of +2.51 mm (with the 95% limits of agreement ranging –3.62 to 8.65 mm) for AA estimation, suggesting a general overestimation of the AA diameter by TTE in comparison to HRCT. Conclusions: The AA dilatation is predictive of poor outcome in IPF patients without advanced lung disease, over a mid-term follow-up. The AA/height assessment may improve the prognostic risk stratification of IPF patients.