Organization and Activity of Italian Echocardiographic Laboratories: A Survey of the Italian Society of Echocardiography and Cardiovascular Imaging

Abstract

Background: The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand better how different echocardiographic modalities are used and accessed in Italy.

Methods: We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved via an electronic survey based on a structured questionnaire, uploaded on the SIECVI website.

Results: Data were obtained from 228 echocardiographic laboratories: 112 centers (49%) in the northern, 43 centers (19%) in the central, and 73 (32%) in the southern regions. During the month of observation, we collected 101,050 transthoracic echocardiography (TTE) examinations performed in all centers. As concern other modalities there were performed 5497 transesophageal echocardiography (TEE) examinations in 161/228 centers (71%); 4057 stress echocardiography (SE) examinations in 179/228 centers (79%); and examinations with ultrasound contrast agents (UCAs) in 151/228 centers (66%). We did not find significant regional variations between the different modalities. The usage of picture archiving and communication system (PACS) was significantly higher in the northern (84%) versus central (49%) and southern (45%) centers (P < 0.001). Lung ultrasound (LUS) was performed in 154 centers (66%), without difference between cardiology and noncardiology centers. The evaluation of left ventricular (LV) ejection fraction was evaluated mainly using the qualitative method in 223 centers (94%), occasionally with the Simpson method in 193 centers (85%), and with selective use of the three-dimensional (3D) method in only 23 centers (10%). 3D TTE was present in 137 centers (70%), and 3D TEE in all centers where TEE was done (71%). The assessment of LV diastolic function was done routinely in 80% of the centers. Right ventricular function was evaluated using tricuspid annular plane systolic excursion in all centers, using tricuspid valve annular systolic velocity by tissue Doppler imaging in 53% of the centers, and using fractional area change in 33% of the centers. When we divided into cardiology (179, 78%) and noncardiology (49, 22%) centers, we found significant differences in the SE (93% vs. 26%, P < 0.001), TEE (85% vs. 18%), UCA (67% vs. 43%, P < 0001), and STE (87% vs. 20%, P < 0.001). The incidence of LUS evaluation was similar between the cardiology and noncardiology centers (69% vs. 61%, P = NS).

Conclusions: This nationwide survey demonstrated that digital infrastructures and advanced echocardiography modalities, such as 3D and STE, are widely available in Italy with a notable diffuse uptake of LUS in the core TTE examination, a suboptimal diffusion of PACS recording, and conservative use of UCA, 3D, and strain. There are significant differences between northern and central-southern regions and echocardiographic laboratories that pertain to the cardiac unit. This inhomogeneous distribution of technology represents one of the main issues that must be solved to standardize the practice of echocardiography.

Keywords: Diastolic function; echocardiography activities; left and right ventricular function; lung ultrasound.

Figure 1

Echocardiographic laboratories activities during study period (November 2022): number of examinations and % of centers that performed: TTE = Transthoracic echocardiography, TEE = Transesophageal echocardiography, SE = Stress echocardiography, UCA = Ultrasound contrast agent, 3D TTE = Three-dimensional transthoracic echocardiography, LUS = Lung ultrasound

Figure 2

Percentage of centers that evaluated: LV EF (top on the left) using qualitative method, Simpson method or with TTE – 3D; right ventricular function (top on the right) using TAPSE, TDI, and FAC, in 75 centers (33%); diastolic function (bottom on the left) using transmitral pattern, Doppler tissue imaging of mitral annulus (TDI) and left atrial volume, and principal indication of LUS (bottom on the right) in heart failure, dyspnea, and in hemodynamic instability in ED. LV EF = Left ventricular ejection fraction, TTE 3D = Transthoracic echocardiography three-dimensional, TAPSE = Tricuspid annular plane systolic excursion, TDI = Tissue Doppler imaging, FAC = Fractional area change, LUS = Lung ultrasound, ED = Emergency department

Figure 3

The departments (Dpt) involved in the survey

Figure 4

Percentage of the SE, TEE, UCA, and LUS performed in cardiology (blue bar) and noncardiology (red bar) centers. TEE = Transesophageal echocardiography, SE = Stress echocardiography, UCA = Ultrasound contrast agent, LUS = Lung ultrasound