Evaluation of global left ventricular systolic function using three-dimensional echocardiography speckle-tracking strain parameters

Myocardial strain of the left ventricle by speckle tracking echocardiography: From physics to clinical practice

Speckle tracking echocardiography (STE) is a reliable imaging technique of recognized clinical value in several settings. This method uses the motion of ultrasound backscatter speckles within echocardiographic images to derive myocardial velocities and deformation parameters, providing crucial insights on several cardiac pathological and physiological processes. Its feasibility, reproducibility, and accuracy have been widely demonstrated, being myocardial strain of the various chambers inserted in diagnostic algorithms and guidelines for various pathologies. The most important parameters are Global longitudinal strain (GLS), Left atrium (LA) reservoir strain, and Global Work Index (GWI): based on large studies the average of the lower limit of normality are -16%, 23%, and 1442 mmHg%, respectively. For GWI, it should be pointed out that myocardial work relies primarily on non-invasive measurements of blood pressure and segmental strain, both of which exhibit high variability, and thus, this variability constitutes a significant limitation of this parameter. In this review, we describe the principal aspects of the theory behind the use of myocardial strain, from cardiac mechanics to image acquisition techniques, outlining its limitation, and its principal clinical applications: in particular, GLS have a role in determine subclinical myocardial dysfunction (in cardiomyopathies, cardiotoxicity, target organ damage in ambulatory patients with arterial hypertension) and LA strain in determine the risk of AF, specifically in ambulatory patients with arterial hypertension.

Evaluation of left atrial and left ventricular functions with 3D speckle-tracking echocardiography in patients with coronary artery tortuosity

BACKGROUND

Tortuosity in the coronary arteries is a very common entity encountered during angiography. The effect of coronary artery tortuosity (CAT) on the myocardium has not been completely investigated. The aim of the current study was to assess the effects of CAT on left atrial (LA) and left ventricular (LV) myocardial functions by 3D speckle-tracking echocardiography (3D-STE).

METHODS

Seventy-five patients with CAT and 80 age- and gender-matched controls who proved to have normal coronary angiograms (CAG) were enrolled into the study. Following CAG, the 2D images were obtained first, and then 3D images were obtained for strain analysis.

RESULTS

The LAS-r, LAS-active, and LV-GLS were significantly depressed in the CAT (+) group (p < .001, p < .001, p = .012, respectively). The multivariate regression models demonstrated that LAS-r (p < .001), LAS-active (p = .009), and LV-GLS (p = .024) were found to be independent factors predicting CAT.

CONCLUSION

The current study is the first to focus on the assessing both LA and LV myocardial dynamics in CAT (+) patients by strain echocardiography. The results of our study support the patients with CAT may have subclinical LA and LV myocardial involvements.

Clinical Usefulness of Speckle-Tracking Echocardiography in Patients with Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is defined as HF with left ventricular ejection fraction (LVEF) not less than 50%. HFpEF accounts for more than 50% of all HF patients, and its prevalence is increasing year to year with the aging population, with its prognosis worsening. The clinical assessment of cardiac function and prognosis in patients with HFpEF remains challenging due to the normal range of LVEF and the nonspecific symptoms and signs. In recent years, new echocardiographic techniques have been continuously developed, particularly speckle-tracking echocardiography (STE), which provides a sensitive and accurate method for the comprehensive assessment of cardiac function and prognosis in patients with HFpEF. Therefore, this article reviewed the clinical utility of STE in patients with HFpEF.

Contribution of Ventricular Motion and Sampling Location to Discrepancies in Two-Dimensional Versus Three-Dimensional Fetal Ventricular Strain Measures

BACKGROUND

Echocardiographic quantification of fetal cardiac strain is important to evaluate function and the need for intervention, with both two-dimensional (2D) and three-dimensional (3D) strain measurements currently feasible. However, discrepancies between 2D and 3D measurements have been reported, the etiologies of which are unclear. This study sought to determine the etiologies of the differences between 2D and 3D strain measurements.

METHODS

A validated cardiac motion-tracking algorithm was used on 3D cine ultrasound images acquired in 26 healthy fetuses. Both 2D and 3D myocardial strain quantifications were performed on each image set for controlled comparisons. Finite element modeling of 2 left ventricle (LV) models with minor geometrical differences were performed with various helix angle configurations for validating image processing results.

RESULTS

Three-dimensional longitudinal strain (LS) was significantly lower than 2D LS for the LV free wall and septum but not for the right ventricular (RV) free wall, while 3D circumferential strain (CS) was significantly higher than 2D CS for the LV, RV, and septum. The LS discrepancy was due to 2D long-axis imaging not capturing the out-of-plane motions associated with LV twist, while the CS discrepancy was due to the systolic motion of the heart toward the apex that caused out-of-plane motions in 2D short-axis imaging. A timing mismatch between the occurrences of peak longitudinal and circumferential dimensions caused a deviation in zero-strain referencing between 2D and 3D strain measurements, contributing to further discrepancies between the 2.

CONCLUSIONS

Mechanisms for discrepancies between 2D and 3D strain measurements in fetal echocardiography were identified, and inaccuracies associated with 2D strains were highlighted. Understanding of this mechanism is useful and important for future standardization of fetal cardiac strain measurements, which we propose to be important in view of large discrepancies in measured values in the literature.

Relationship Between Image Quality and Bias in 3D Echocardiographic Measures: Data From the SABRE (Southall and Brent Revisited) Study

Background

Image‐quality (IQ) compromises left ventricle assessment by 3‐dimensional echocardiography (3DE). Sicker/frailer patients often have suboptimal IQ, and therefore observed associations may be biased by IQ. We investigated its effect in an observational study of older people and when IQ was modified experimentally in healthy volunteers.

Methods and Results

3DE feasibility by IQ was assessed in 1294 individuals who attended the second wave of the Southall and Brent Revisited study and was compared with 2‐dimensional (2D)‐echocardiography feasibility in 147 individuals. Upon successful analysis, means of ejection fraction (3D‐EF) and global longitudinal strain (3D‐GLS) (plus 2D‐EF) were compared in individuals with poor versus good IQ. In 2 studies of healthy participants, 3DE‐IQ was impaired by (1) intentionally poor echocardiographic technique, and (2) use of a sheet of ultrasound‐attenuating material (neoprene rubber; 2–4 mm). The feasibility was 41% (529/1294) for 3DE versus 61% (89/147) for 2D‐EF, P<0.0001. Among acceptable images (n=529), good IQ by the 2015 American Society of Echocardiography/European Association of Cardiovascular Imaging criteria was 33.6% (178/529) and 71.3% (377/529) for 3D‐EF and 3D‐GLS, respectively. Individuals with poor IQ had lower 3D‐EF and 3D‐GLS (absolute) than those with good IQ (3D‐EF: 52.8±6.0% versus 55.7±5.7%, Mean‐Δ −2.9 [−3.9, 1.8]; 3D‐GLS: 18.6±3.2% versus 19.2±2.9%, Mean‐Δ −0.6 [−1.1, 0.0]). In 2 experimental models of poor IQ (n=36 for both), mean differences were (−2.6 to −3.2) for 3D‐EF and (−1.2 to −2.0) for 3D‐GLS. Similar findings were found for other 3DE left ventricle volumes and strain parameters.

Conclusions

3DE parameters have low feasibility and values are systematically lower in individuals with poor IQ. Although 3D‐EF and 3D‐GLS have potential advantages over conventional echocardiography, further technical improvements are required to improve the utility of 3DE in clinical practice.

Myocardial Deformation Imaging by Speckle Tracking Echocardiography for Assessment of Cardiotoxicity in Children During and After Chemotherapy: A Systematic Review and Meta-analysis

BACKGROUND

Childhood cancer patients and childhood cancer survivors (CCS) are at risk of developing chemotherapy-induced cardiomyopathy. Myocardial deformation imaging has shown potential in the early detection of subclinical myocardial damage with implications on therapeutic interventions and improvement of outcomes. We aimed to perform a systemic review and meta-analysis of literature on the assessment of left (LV) and right ventricular (RV) myocardial deformation by speckle tracking echocardiography (STE) at rest and during stress in childhood cancer patients during and in survivors after chemotherapy.

METHODS

A systematic review was performed through searching MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and Scopus. Search hedges were created to cover the concepts of childhood cancer, chemotherapy, radiotherapy, anthracycline, cardiotoxicity, speckle tracking, myocardial strain, and myocardial deformation. Two independent investigators reviewed the eligibility of the articles for inclusion. Weighted mean difference in ventricular strain between pre-and post-chemotherapy treatment and that between long-term CCS and healthy subjects were estimated by random-effect models with 95% confidence intervals. Heterogeneity and publication bias were assessed by I2 statistics and Egger test, respectively.

RESULTS

Of the total of 8703 records initially identified, 42 studies with a total of 430 childhood cancer patients were included. Of these 42 studies that showed heterogeneities, 9 assessed early myocardial injury during chemotherapy, 30 assessed late myocardial injury after chemotherapy with no publication bias, and 3 studied myocardial mechanics during stress. The main findings were 1) impairment of LV systolic deformation in childhood cancer patients during the initial treatment phase and among long-term CCS, while data on changes in RV deformation are limited and inconclusive, 2) the predictive value of early reduction of myocardial strain imaging in forecasting subsequent development of cardiotoxicity is unknown as it has not been studied, 3) limited data suggest possibility of impaired LV contractile mechanics during stress in CCS, and 4) cumulative anthracycline dose and chest-directed radiotherapy are consistently identified as factors associated with impaired myocardial deformation.results CONCLUSIONS: Myocardial strain imaging by STE unveils early evidence of myocardial injury in childhood cancer patients and long-term CCS. To support its adoption for clinical use, more data are required for the better understating of myocardial deformation parameters in the risk stratification of childhood cancer patients and prediction of development of cardiomyopathy among CCS.

Assessment of sacubitril/valsartan effects on left ventricular dynamics using 3D echocardiography and 3D strain in heart failure with reduced ejection fraction patients

BACKGROUND

Three-dimensional (3D) echocardiography and 3D strain parameters have been used for a comprehensive quantitative assessment of left ventricular (LV) myocardial dynamics. So far, there are no data on sacubitril/valsartan effects on cardiac functions and LV reverse remodeling using 3D echocardiography. This study aimed to evaluate the effects of sacubitril/valsartan on the LV functions using two-dimensional (2D) echocardiography, 3D echocardiography, and the 3D strain parameters.

METHODS

A single-center prospective cohort study which included 100 heart failure with reduced ejection fraction (HFrEF) patients with guidelines-approved indications for sacubitril/valsartan treatment. Patients received a short course (3-month) of sacubitril/valsartan. 3-month follow-up 2D, 3D echocardiographic parameters, and 3D strain were compared to baseline parameters.

RESULTS

The results of the study revealed a significant improvement in left ventricular dynamic functions at 3-month follow-up with an improvement in left ventricular systolic function (mean left ventricular ejection fraction (LVEF) increased from 27.65 ± 4.98% to 32.89 ± 6.03%, P<0.001). Comparison of HFrEF patients with ischemic and non-ischemic etiologies showed that echocardiographic parameters significantly improved in both groups after 3 months of sacubitril/valsartan treatment. There was no statistically significant difference between both groups regarding echocardiographic parameters at baseline and 3-month follow-up.

CONCLUSIONS

In a single-center prospective observational cohort study evaluating the effects of short-term (3-month course) sacubitril/valsartan treatment on LV dynamics assessed by 3D echocardiography and 3D strain, sacubitril/valsartan was associated with a significant improvement of LV systolic functions and reverse remodeling effects in both ischemic and non-ischemic HFrEF patients.

Pivotal Role of Heart for Orthostasis: Left Ventricular Untwisting Mechanics and Physical Fitness

Augmentation of left ventricular (LV) untwisting due to central hypovolemia is likely to be a compensatory mechanism for maintaining stroke volume, which is reduced by a decrease in cardiac filling during orthostatic stress. Orthostatic intolerance observed in both high and low fitness levels may be explained by the impaired response of LV untwisting due to central hypovolemia.

Fragmented QRS complexes are associated with subclinical left ventricular dysfunction in patients with Behcet's disease: Four-dimensional speckle tracking echocardiography

BACKGROUND

Behcet's disease (BD) is a chronic systemic inflammatory disease in which early detection of cardiac involvement is essential. The aim of this study was to assess the left ventricular (LV) functions in BD patients using four-dimensional (4D) speckle tracking echocardiography (STE) and to test the correlation between LV dysfunction and the presence of QRS fragmentation.

METHODS

This cross-sectional study included 64 Behcet's patients and 48 healthy volunteers. The BD group was divided into two subgroups depending on the presence (fQRS+) or absence (fQRS-) of fragmented QRS (fQRS). In both groups, left ventricular global area strain (LV-GAS), global radial strain (GRS), global longitudinal strain (GLS), and global circumferential strain (GCS) were obtained with 4D echocardiography.

RESULTS

GAS, GRS, GLS, and GCS values were significantly different in Behcet's patients and in healthy volunteers. GLS and GAS values were lower in the fQRS+ than in the fQRS- group (-15.8 ± 1.8 and -17.9 ± 1.6, P = .001 vs -25.0 ± 3.1 and -29.2 ± 4.2, P < .001, respectively). The duration of disease was longer in fQRS+ than in fQRS- patients (120.8 ± 67.4 vs 71.0 ± 40.5, P < .001). Multiple linear regression analysis showed that fQRS and disease duration were independent predictors of LV-GAS.

CONCLUSIONS

Four-dimensional STE may be helpful for the prediction of early cardiac dysfunction in patients with BD. The presence of fQRS may be an indicator of subclinical LV dysfunction.

[Comparative capabilities of the speckle-tracking echocardiography technologiesin two-dimensional and three-dimensional modes in the detection of subclinical cardiotoxicity in patients with breast cancer]

AIM

The study was to assess the deformation properties of the left ventricle (LV) myocardium in patients with breast cancer initially and after anthracycline chemotherapy according to 2D and 3D speckle-tracking echocardiography (STE).

MATERIAL AND METHODS

the study included 99 patients with triple negative breast cancer with hypertensionandnormotension. All patients underwent standard transthoracic echocardiography with assessment of systolic function of the LV. To assess the indicator of global longitudinal strain (GLS), as a marker of cardiotoxicity, STE was used in two-and three-dimensional modes. In the three-dimensional STE mode, a new strain parameter, the global area strain (GAS) was evaluated.

RESULTS

The study showed that in patients with breast cancer for a more accurate assessment of LV systolic function (ejection fraction) it is advisable to use 3D-echocardiography. A comparative analysis revealed statistically significantly lower values of the GLS according to the three-dimensional mode of STE compared to two-dimensional. The study also evaluated a new strain parameter GAS (%). In patients with breast cancer during ROC analysis with a value of -14.0, the GAS indicator for the development of subclinical cardiotoxicity showed a sensitivity of 81.5% and a specificity of 73.3%. Сonclusion.the advantage of the STE in the three-dimensional mode, in contrast to the two-dimensional mode, is the simultaneous and more accurate assessment of LVEF. The value of the additional parameter of LV deformation the area of deformation requires further study.

Use of spectral tracking technique to evaluate the changes in left ventricular function in patients undergoing chemotherapy for colorectal cancer

To evaluate the changes in left ventricular myocardial function in patients with colorectal cancer undergoing chemotherapy with mFOLFOX6 (oxaliplatin + 5-fluorouracil + calcium folinate) using three-dimensional speckle-tracking echocardiography (3D-STE). Data were collected from 30 patients diagnosed with colorectal cancer in our hospital treated with mFOLFOX6. We used 3D-STE to measure the following parameters of left ventricle function: global longitudinal strain (GLS), global area strain (GAS), global circumferential strain (GCS), global radial strain (GRS), and left ventricular twist (LVtw). Myocardial composite index (MCI) was calculated from measured values (MCI = GLS × LVtw). The above listed parameters were compared before and after chemotherapy. Receiver operating curves (ROC) were prepared for each parameter and analyzed to identify correlations among MCI, LVEF, GLS, and cTnT. Compared with the pre-chemotherapy state, the absolute values of MCI, LVtw, GLS, GAS, GCS, and GRS decreased with increasing cumulative doses of chemotherapeutic drugs. The absolute values of GAS, GLS, MCI, and LVtw decreased after the first cycle of chemotherapy (P < 0.05). The areas under the ROC curves for MCI and GLS were 0.903 and 0.838, respectively. The correlation observed between MCI and cTnT (r = - 0.7228) was found to be stronger than that between GLS and cTnT (r = - 0.6008). In conclusion, 3D-STE may help detect early changes in left ventricular myocardial function caused by mFOLFOX6 treatment in patients with colorectal cancer. MCI is a relatively sensitive index among the various measurable parameters.

Four-Dimensional Echocardiographic Evaluation of Left Ventricular Systolic Functions in Patients with Chronic Myeloid Leukaemia Receiving Tyrosine Kinase Inhibitors

Tyrosine kinase inhibitors (TKIs) are established treatment for haematological malignancies. However, cardiac adverse effects, including the reduction in left ventricular ejection fraction and symptomatic heart failure remain clinical problems. The purpose of this study was to evaluate the left ventricular systolic functions in patients with chronic myeloid leukaemia receiving TKIs. A cross-sectional and observational study was conducted of 37 patients with chronic myeloid leukaemia receiving dasatinib or nilotinib after imatinib failure. Left ventricular systolic functions were evaluated using four-dimensional speckle tracking echocardiography derived global longitudinal (GLS), circumferential (GCS), radial (GRS), and area (GAS) strain indices. Mean ejection fraction, stroke volume, cardiac output and left ventricular mass index were similar between control and patient groups and within normal limits. GLS (- 16.7% vs - 20.8%, p < 0.001), GCS (- 13.0% vs - 15.6%, p = 0.002), and GAS (- 26.2% vs - 31.0, p < 0.001) values were significantly higher in the patient population than those of the controls. Dasatinib and nilotinib groups did not show differences regarding strain indices. In multivariate regression analysis, only the usage of dasatinib or nilotinib was found to be an independent risk factor for diminished GAS (β = 4.406, p = 0.016), GLS (β = 3.797, p = 0.001), and GCS (β = 2.404, p = 0.040). Although imatinib, nilotinib, and dasatinib seem to be clinically safe in terms of cardiac function, monitoring of systolic functions using strain imaging, and long-term observation of patients may provide early detection of the possible cardiac toxicity.

Subclinical left ventricular dysfunction in Sjögren's syndrome assessed by four-dimensional speckle tracking echocardiography

OBJECTIVE

The aim of this study was to evaluate the left ventricular (LV) systolic strain by four-dimensional speckle tracking echocardiography (4D-STE) in order to provide the early detection of myocardial dysfunction in patients with Sjögren's syndrome (SS).

METHODS

Forty consecutive patients with primary SS diagnosed at the rheumatology outpatient clinic and 35 age- and sex-matched healthy volunteers were included in the study. 4DSTE was performed, and global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) were measured. 4DSTE results were compared with the healthy volunteers.

RESULTS

No significant differences were observed between the GRS and GCS values of the two groups. A significant difference was observed in the GLS and GAS measurements between the two groups (P = .005 for GLS, P < .001 for GAS). Positive correlation was detected between disease duration and LV-GLS and LV-GAS.

CONCLUSION

We demonstrated subclinical systolic dysfunction in SS patients by 4DSTE, which is a sensitive marker of ventricular dysfunction. Deterioration of the LV became more evident as duration of the disease increased. Therefore, we believe that a cardiac evaluation will be of benefit to patients with long-term SS.

Evaluation of left atrial and ventricular myocardial functions by three-dimensional speckle tracking echocardiography in patients with euthyroid Hashimoto's thyroiditis

Hashimoto's Thyroiditis (HsT) is one of the most frequently occurring autoimmune diseases, characterized by lymphocytic infiltration, destruction and fibrosis of thyroid tissue and the presence of antibodies to thyroid peroxidase and thyroglobulin. The effects of euthyroid Hashimoto's thyroiditis (eHsT) on cardiovascular system are unclear. We aimed to identify if any deteriorations in LA and LV myocardial functions in patients with eHsT by 3D-STE in the current study. Fifty eight patients with eHsT and 60 age- and gender-matched controls were enrolled into the study. All participants underwent laboratory analyses which included thyroid hormones and thyroid autoantibody levels; and conventional 2D echocardiographic and 3D-STE analyses were performed. The mean age of the study patients was 34.5 ± 9 years, and 68.6% were female. Left ventricular global longitudinal strain (LV-GLS) was significantly depressed in the eHsT (+) group than in the control group (- 15.3 ± 3.6 vs. - 22.8 ± 3.8, p < 0.001). The LV-GLS was found to be disrupted linearly as thyroid autoantibodies increased (r = 0.684 for anti-TPO-ab and LV-GLS; r = 0.649 for anti-Tg-ab and LV-GLS). The present study demonstrated that 3D-STE is useful in the early detection of LV myocardial dysfunction in patients with eHsT. We found that eHsT had a negative effect on LV myocardial dynamics. According to these findings, these myocardial alterations that are present early in the disease process may be considered as a reason to start medical treatment earlier, even at the euthyroid stage to prevent LV myocardial impairment.

A review of current trends in three-dimensional analysis of left ventricular myocardial strain

Three-dimensional (3D) left ventricular (LV) myocardial strain measurements using transthoracic 3D echocardiography speckle tracking analysis have several advantages over two-dimensional (2D) LV strain measurements, because 3D strain values are derived from the entire LV myocardium, yielding more accurate estimates of global and regional LV function. In this review article, we summarize the current status of 3D LV myocardial strain. Specifically, we describe how 3D LV strain analysis is performed. Next, we compare characteristics of 2D and 3D strain, and we explain validation of 3D strain measurements, feasibility and measurement differences between 2D and 3D strain, reference values of 3D strain, and its applications in several clinical scenarios. In some parts of this review, we used a meta-analysis to draw reliable conclusions. We also describe the added value of 3D over 2D strain in several specific pathologies and prognoses. Finally, we discuss novel techniques using 3D strain and suggest its future directions.

Assessment of left atrial mechanics and left ventricular functions using 3D speckle-tracking echocardiography in patients with inappropriate sinus tachycardia

PURPOSE

Inappropriate sinus tachycardia (IST) is defined as a sinus heart rate > 100 bpm at rest (with a mean 24-h heart rate > 90 bpm not due to primary causes) and is associated with distressing symptoms of palpitations. The effect of IST on left atrial (LA) and left ventricular (LV) myocardial dynamics is uncertain. Thus, the aim of this study was to identify early changes in LA mechanics and LV myocardial functions in patients with IST using 3D-STE.

METHODS

Sixty patients with IST and 65 age- and gender-matched controls were enrolled into the study. Conventional 2D echocardiography and 3D-STE were performed, and LAS-r, LAS-active, LAS-passive, LAEF, LAEF-active, LAEF-passive, LV-GLS, LV-GCS, LV-GAS, and LV-GRS were obtained for every patient.

RESULTS

The LAS-r and LAS-active were significantly decreased in the IST group than in the control group (p < 0.001, p = 0.004, respectively). The multivariate logistic regression models revealed that LAS-r (p = 0.008, Odds ratio (OR) 5.98, 95% confidence interval (CI) 2.36-11.18), and LAS-active (p = 0.032, OR 2.16, 95% CI 1.97-4.69) were found to be independent factors for predicting IST.

CONCLUSIONS

The present study is the first to evaluate the left atrial mechanics and left ventricular functions in the patients with IST using 3D-STE. We found that IST had a negative effect on left atrial mechanics. According to our findings, we can say that IST is not a completely innocent, benign clinical condition, but rather, it causes subclinical left atrial dysfunction.

Speckle tracking echocardiography in patients with systemic lupus erythematosus: A meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE), is characterized by a systemic involvement including myocardial dysfunction. Being standard echocardiography not able at fully detecting subclinical alterations, speckle tracking echocardiography (STE) has recently emerged as a quantitative ultrasound technique to accurately estimate myocardial function.

METHODS

We conducted a systematic review with meta-analysis of studies reporting STE parameters in patients with SLE.

RESULTS

A total of 9 studies were included in the analysis. Left ventricle global longitudinal strain (GLS) was significantly lower in SLE patients than in non-SLE controls (MD: -2.331, 95% CI: -3.083, -1.580, p < 0.001). In addition, we found significant differences between SLE patients and non-SLE controls in left ventricle GLS rate (MD: -0.115, 95% CI: -0.177 to 0.063, p < 0.001), left ventricle circumferential strain(MD: -1.841, 95% CI: -3.160 to 0.521, p = 0.006) and left ventricle radial strain(MD: -11.03, 95% CI: -13.819 to 8.241, p < 0.001). Right ventricle strain was significantly lower in SLE patients than in non-SLE controls (MD: -5.814, 95% CI: -7.347, -4.281, p < 0.001). Meta-regression models showed a lower difference in left ventricle GLS between SLE cases and controls for studies with a higher prevalence of female gender and higher prevalence of hypertension.

CONCLUSIONS

SLE patients have lower STE parameters than controls, thus suggesting the presence of an impaired myocardial function involving both left and right ventricle.

Regional myocardial strain analysis via 2D speckle tracking echocardiography: validation with sonomicrometry and correlation with regional blood flow in the presence of graded coronary stenoses and dobutamine stress

Background

Quantitative regional strain analysis by speckle tracking echocardiography (STE) may be particularly useful in the assessment of myocardial ischemia and viability, although reliable measurement of regional strain remains challenging, especially in the circumferential and radial directions. We present an acute canine model that integrates a complex sonomicrometer array with microsphere blood flow measurements to evaluate regional myocardial strain and flow in the setting of graded coronary stenoses and dobutamine stress. We apply this unique model to rigorously evaluate a commercial 2D STE software package and explore fundamental regional myocardial flow-function relationships.

Methods

Sonomicrometers (16 crystals) were implanted in epicardial and endocardial pairs across the anterior myocardium of anesthetized open chest dogs (n = 7) to form three adjacent cubes representing the ischemic, border, and remote regions, as defined by their relative locations to a hydraulic occluder on the mid-left anterior descending coronary artery (LAD). Additional cardiac (n = 3) and extra-cardiac (n = 3) reference crystals were placed to define the cardiac axes and aid image registration. 2D short axis echocardiograms, sonometric data, and microsphere blood flow data were acquired at baseline and in the presence of mild and moderate LAD stenoses, both before and during low-dose dobutamine stress (5 μg/kg/min). Regional end-systolic 2D STE radial and circumferential strains were calculated with commercial software (EchoInsight) and compared to those determined by sonomicrometry and to microsphere blood flow measurements. Post-systolic indices (PSIs) were also calculated for radial and circumferential strains.

Results

Low-dose dobutamine augmented both strain and flow in the presence of mild and moderate stenoses. Regional 2D STE strains correlated moderately with strains assessed by sonomicrometry (R_radial = 0.56, p < 0.0001; R_circ = 0.55, p < 0.0001) and with regional flow quantities (R_radial = 0.61, R_circ = 0.63). Overall, correspondence between 2D STE and sonomicrometry was better in the circumferential direction (Bias ± 1.96 SD: − 1.0 ± 8.2% strain, p = 0.06) than the radial direction (5.7 ± 18.3%, p < 0.0001). Mean PSI values were greatest in low flow conditions and normalized with low-dose dobutamine.

Conclusions

2D STE identifies changes in regional end-systolic circumferential and radial strain produced by mild and moderate coronary stenoses and low-dose dobutamine stress. Regional 2D STE end-systolic strain measurements correlate modestly with regional sonomicrometer strain and microsphere flow measurements.

Coronary tortuosity affects left ventricular myocardial functions: a 3D-speckle tracking echocardiography study

Coronary artery tortuosity (CAT) is a common finding in coronary angiography, and is defined as three fixed bends during both systole and diastole in at least one epicardial coronary artery, with each bend showing a 45° change in vessel direction. The impact of CAT on the myocardial deformation has not been completely evaluated using 3D-STE. As a result of this, we aimed to assess the effects of CAT on LV functions using 3D-STE in the present study. Eighty-two patients with CAT and 80 age- and gender-matched controls who proved to have normal coronary angiograms were enrolled into the study. 3D-STE was performed and LV-GLS, LV-GCS, LV-GAS, and LV-GRS were obtained for every patient after coronary angiography. The LV-GLS was significantly depressed in the CAT ( +) group than in the control group (p = 0.001). ROC analysis was performed to find out ideal LV-GLS cut off value to predict the presence of CAT. A LV-GLS value of > - 17 has 81.3% sensitivity, 56.7% specificity to detect the presence of CAT. The present study is the first to focus on the assessing LV myocardial functions in patients with CAT by 3D-STE. CAT has a considerable negative effect on LV myocardial longitudinal deformation as evaluated by 3D strain parameters. Our results support that patients with CAT may have subclinical LV longitudinal deformation abnormalities even though they are apparently healthy.

Assessment of left ventricular function in type 2 diabetes mellitus patients with non-alcoholic fatty liver disease using three-dimensional speckle-tracking echocardiography

Objective:

Using three-dimensional speckle-tracking echocardiography (3D-STE), we aimed to evaluate left ventricular (LV) function in type 2 diabetes mellitus (T2DM) patients with non-alcoholic fatty liver disease (NAFLD).

Methods:

In total, 97 T2: DM patients were categorized into three groups based on hepatic ultrasonography group A (those without NAFLD, n=30), group B (those with mild NAFLD, n=32), and group C (those with moderate-to-severe NAFLD, n=35). Our conventional echocardiographic parameters included transmitral peak early and late diastolic velocity (E and A), septal and lateral early (e’) mitral annular diastolic tissue velocities, and left atrial maximum volume index (LAVImax). LV end-diastolic and -systolic volume, LV mass index (LVMI), and LV ejection fraction were measured using real-time three-dimensional echocardiography. The 3D-STE parameters included LV global radial strain (GRS), global longitudinal strain (GLS), global area strain (GAS), and global circumferential strain (GCS).

Results:

Our results showed that in group C, GCS, GRS, GLS, GAS, and septal and lateral e’ velocity decreased, whereas average E/e’ and LAVImax increased compared to groups B and A (p<0.05). Multiple linear regression analysis showed that NAFLD is independently associated with 3D-STE parameters, and glycosylated hemoglobin also has negative impacts on all LV 3D strains.

Conclusion:

When combined with conventional echocardiography, 3D-STE can assess LV function effectively in T2DM patients with NAFLD. Additionally, the severity of LV dysfunction in the moderate-to-severe NAFLD group (group C) was worse than the mild and absent NAFLD groups (groups A and B).

Assessment of the impact of isolated coronary artery ectasia on left ventricular functions with 3D speckle-tracking echocardiography

BACKGROUND

Coronary artery ectasia (CAE) is an angiographic definition of coronary artery pathology in which the diameter of the ectatic segment measures more than 1.5 times the diameter of an adjacent healthy reference segment. No previous study has reported on the use of 3D-STE for assessing the left ventricular (LV) functions in patients with isolated CAE. As a result of this, we aimed to evaluate the effects of isolated CAE on LV functions using 3D-STE in the present study.

METHODS

Ninety-one patients with isolated CAE and 90 controls who proved to have normal coronary angiograms were enrolled to the study. 3D-STE was performed and GLS, GCS, GAS, and GRS were obtained for every subject after coronary angiography.

RESULTS

The mean age of the patients was 61.75 ± 10.02 years, and 71.8% were male. GLS, GCS, GAS, and GRS were significantly depressed in the isolated CAE group than in the control group (P < .001; P < .001; P = .001; and P = .001, respectively). ROC analyses were performed to find out the ideal strain cut off values to predict the presence of isolated CAE. A GLS value of >-16 has 92.1 % sensitivity, 88.5 % specificity; and a GCS value of >-20 has 86.7 % sensitivity, 89.2 % specificity to detect the presence of isolated CAE.

CONCLUSION

Isolated CAE has a considerable negative effect on LV functions as evaluated by 3D-strain parameters, and 3D-STE could be an effective method to detect early stage myocardial impairment in patients with isolated CAE.

Predictive value of left ventricular myocardial strain by four-dimensional speckle tracking echocardiography combined with red cell distribution width in heart failure with preserved ejection fraction

OBJECTIVES

The diagnostic difficulty of heart failure with preserved ejection fraction (HFpEF) is differentiating it in patients with similar symptoms and signs. This study aimed to assess the potential predictive value of left ventricular global longitudinal strain (GLS), global radial strain (GRS), global circumferential strain (GCS), and global area strain (GAS) measured by four-dimensional speckle tracking echocardiography (4DSTE) combined with red cell distribution width (RDW) in patients with HFpEF.

METHODS

One hundred and sixty-nine patients with symptoms or signs indicative of chronic heart failure and a left ventricular ejection fraction (LVEF) ≥ 50% and fifty controls with normal LVEF were recruited in this study. Standard echocardiography and 4DSTE examinations were performed. Laboratory examinations including RDW were performed on the same day as the echocardiographic study.

RESULTS

GLS, GCS, GRS, and GAS in the patient cohort were significantly lower, and RDW was significantly higher than those in the control cohort (P < 0.01), and the strain parameters in definite HFpEF patients were also dramatically lower than the rest patients (P < 0.01). The associations of age, gender, NYHA classification, hypertension history, left ventricular end-diastolic volume index, interventricular septal thickness, and diastolic dysfunction with HFpEF were significantly improved by adding 4DSTE parameters (P < 0.01) and further improved by adding RDW (P < 0.01).

CONCLUSIONS

In suspected HFpEF patients, who have symptoms or signs of heart failure, even without other conventional evidence of this diagnosis, GLS, GRS, and GCS have potential independent predictive value, while RDW has independent incremental predictive value for HFpEF.

Regional Left Ventricular Myocardial Dysfunction After Cardiac Surgery Characterized by 3-Dimensional Strain

BACKGROUND

Three-dimensional (3D) strain is an echocardiographic modality that can characterize left ventricular (LV) function with greater accuracy than ejection fraction. While decreases in global strain have been used to predict outcomes after cardiac surgery, changes in regional 3D longitudinal, circumferential, radial, and area strain have not been well described. The primary aim of this study was to define differential patterns in regional LV dysfunction after cardiac surgery using 3D speckle tracking strain imaging. Our secondary aim was to investigate whether changes in regional strain can predict postoperative outcomes, including length of intensive care unit stay and 1-year event-free survival.

METHODS

In this prospective clinical study, demographic, operative, echocardiographic, and clinical outcome data were collected on 182 patients undergoing aortic valve replacement, mitral valve repair or replacement, coronary artery bypass graft, and combined cardiac surgery. Three-dimensional transthoracic echocardiograms were performed preoperatively and on the second to fourth postoperative day. Blinded analysis was performed for LV regional longitudinal, circumferential, radial, and area strain in the 17-segment model.

RESULTS

Regional 3D longitudinal, circumferential, radial, and area strains were associated with differential patterns of myocardial dysfunction, depending on the surgical procedure performed and strain measure. Patients undergoing mitral valve repair or replacement had reduced function in the majority of myocardial segments, followed by coronary artery bypass graft, while patients undergoing aortic valve replacement had reduced function localized only to apical segments. After all types of cardiac surgery, segmental function in apical segments was reduced to a greater extent as compared to basal segments. Greater decrements in regional function were seen in circumferential and area strain, while smaller decrements were observed in longitudinal strain in all surgical patients. Both preoperative regional strain and change in regional strain preoperatively to postoperatively were correlated with reduced 1-year event-free survival, while postoperative strain was not predictive of outcomes. Only preoperative strain values were predictive of intensive care unit length of stay.

CONCLUSIONS

Changes in regional myocardial function, measured by 3D strain, varied by surgical procedure and strain type. Differences in regional LV function, from presurgery to postsurgery, were associated with worsened 1-year event-free survival. These findings suggest that postoperative changes in myocardial function are heterogeneous in nature, depending on the surgical procedure, and that these changes may have long-term impacts on outcome. Therefore, 3D regional strain may be used to identify patients at risk for worsened postoperative outcomes, allowing early interventions to mitigate risk.

Two- and three-dimensional myocardial strain imaging in the interrogation of sex differences in cardiac mechanics of long-term survivors of childhood cancers

We aimed to interrogate sex differences in cardiac mechanics using two-(2D) and three-(3D) dimensional speckle tracking echocardiography (STE) in survivors of childhood cancers. 83 survivors (43 males) aged 25.6 ± 6.1 years at 16.0 ± 6.1 years after anthracycline therapy and 42 healthy controls (21 males) were studied. 2D STE was performed to assess LV linear deformation in three principal directions, while 3D STE was performed to assess LV ejection fraction, global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS). Receiver operating characteristic (ROC) curves were generated to to determine the usefulness of 2D and 3D echocardiographic indices to discriminate between survivors and controls. Survivors of both sex had significantly lower 2D and 3D strain indices compared with sex-specific controls (all p < 0.05). Among survivors, 2D GLS and GRS and all of the 3D indices were similar between males and females (all p > 0.05). Among cancer survivors, multivariate analysis revealed age at study (β = - 0.26, p = 0.022) as a significant determinant of 3D GLS. The area under the ROC curve for 3D GLS was the largest at 0.89 amongst all 3D and 2D strain parameters, while that of 2D GLS was 0.83. For 3D GLS, a cut-off of 16.4% had a sensitivity of 85.7% and a specificity of 80.7% of differentiating survivors from controls. Notwithstanding the finding of impaired LV myocardial mechanics, the present study did not reveal evidence of sexual dimorphism in cardiac mechanics in long term survivors of childhood cancers.

Comparison of the predictive value of four-dimensional speckle tracking imaging risk classification and the TIMI system after STEMI reperfusion therapy

The predictive value of four-dimensional speckle tracking imaging (4D-STI) risk classification and TIMI risk scores for the prognosis of patients with ST-segment elevation myocardial infarction (STEMI) after reperfusion therapy were investigated. One hundred and twenty patients with STEMI after reperfusion therapy were involved. At 12 h after reperfusion therapy, 2nd and 3rd day, the three-dimensional longitudinal strain (LS), circumferential strain (CS) and radial strain (RS), area strain (AS), as well as other 4D-STI detection indicators, were collected. The patients were followed up for one year, and were divided into good prognosis group and poor prognosis group. LS, CS, RS and AS indicators were analyzed between these two groups. The ROC curve was drawn to establish the 4D-STI risk classification and its predictive value for poor prognosis and mortality were compared with TIMI risk scores. AS, LS and RS at 12 h after reperfusion treatment, and AS and RS at 2nd and 3rd day had a certain degree of prediction accuracy in STEMI patients in the poor prognosis group. In the 4D-STI and TIMI risk scores, the risk of death and adverse prognosis significantly increased as the risk scores increased (P<0.01). The 4D-STI risk score for predicting poor prognosis and mortality was greater than the TIMI risk score. 4D-STI risk scores are superior to TIMI risk scores in predicting poor prognosis and mortality in patients with STEMI after reperfusion therapy.

Quantitative Assessment of the Effect of the Out-of-Plane Movement of the Homogenous Ellipsoidal Model of the Left Ventricle on the Deformation Measures Estimated Using 2-D Speckle Tracking-An In-Silico Study

Effect of the out-of-plane (OOP) movement amplitude on estimates of global displacements (radial, circumferential) and strains (radial , circumferential ) was studied in an ellipsoidal model of the left ventricle using finite-element modeling (FEM), synthetic ultrasonic data, and short-axis view. This effect was assessed using median of the absolute relative error (RE) of the global parameters. FEM provided node displacements for synthetic ultrasonic data and reference data generation. Displacements were estimated using block-matching (BM) and B-spline (BS) methods. FEM-derived data analysis, free from errors resulting from speckle tracking, indicated that the tissue motion introduced REs of global strain estimates below 4.5%. The effect of the OOP motion amplitude on strain estimates was strain specific and depended on the displacement estimation method. In the case of , the increase of the OOP amplitude resulted in quasi-linear increase of the RE from approximately 10% to 15%. The modulus of the end-systolic (ES) errors of the estimates almost linearly increased with increasing OOP amplitude approximately from 10% to 16%. REs of the estimate were close to 80% and 40%, respectively, in the case of the BM and BS methods, and increased with increasing OOP amplitude. The modulus of the ES errors of the estimates in the case of the BS method was about -40% and showed low sensitivity to the OOP amplitude; in the BM case, these errors varied approximately from -70% to -58% for OOP amplitude from 0 to 15 mm.

Ultrasonic image analysis of longitudinal strain in uremic patients with preserved left ventricular ejection fraction

Background

Patients with uremia have high cardiovascular disease morbidity and mortality despite having normal left ventricular ejection fraction (LVEF). Longitudinal strain (LS) can be associated with subtle changes in LV systolic function. The aim of this study was to use two-dimensional speckle-tracking echocardiography (2DSTE) to assess subclinical LV myocardial dysfunction and to explore strain-changing regularities in uremic patients with LVEF ≥ 55%.

Methods

The study population included 40 uremic patients and 40 healthy volunteers. 2DSTE was performed on all participants to assess peak LS in the basal, mid and apical LV (BLS, MLS and ALS) and the respective time to peak LS (T-BLS, T-MLS, T-ALS).

Results

BLS, MLS, and ALS were significantly decreased in the uremic group relative to healthy controls and LS increased going in a basal to apical direction in both groups. T-BLS, T-MLS and T-ALS was significantly increased in the uremic group compared with the control group. In uremic patients, T-BLS, but not T-MLS or T-ALS, was significantly delayed relative to the control group. Bivariate analysis of creatinine (Cr) or urea nitrogen and strain parameters revealed a correlation only between ALS and Cr.

Conclusion

2DSTE can identify LV myocardial abnormalities in uremic patients with preserved LVEF at early stage, as well as some changing regularities of LS and T-LS in the left ventricle.

Normal Values and Growth-Related Changes of Left Ventricular Volumes, Stress, and Strain in Healthy Children Measured by 3-Dimensional Echocardiography

Normal pediatric values of three-dimensional (3D) left ventricular (LV) volumes and strain are not well established; moreover, no reports exist of the stress-strain relation and the heart rate-corrected velocity of circumferential fiber shortening (VCFc) based upon 3D imaging in children. Three-dimensional LV datasets were obtained in pediatric patients (≤18 years of age) with structurally normal hearts. Ventricular volumes and strain components (longitudinal, GLS; circumferential, GCS; and 3D strain, 3DS) were analyzed using a commercial 3D speckle-tracking analysis package. LV mid-wall global average end-systolic fiber stress was calculated from 3D LV volumes. A total of 238 patients were included in the analysis with a median age of 13.1 years (range 0.4 to 17.9 years). Regression equations were derived for 3D volume parameters, permitting body surface area-based Z score calculation. Overall, 3DS values were more negative than GLS and GCS (mean ± SD = -33.8 ± 2.8; -27.8 ± 2.9; and -21.7 ± 3.1, respectively); only GLS varied significantly with age (r = 0.22; p <0.001). Both global average end-systolic fiber stress and 3D VCFc increased significantly with age (p <0.001 for both). Stress-adjusted 3DS and VCFc both varied with age (p <0.001 for both), consistent with increased contractility. In conclusion, 3D echocardiography may be used to calculate LV stress, strain, and volumes in pediatric patients with strong reproducibility. Among strain parameters, significant age-related changes were seen only in GLS. Both indexes of contractility investigated (3DS and VCFc indexed to wall stress) improved with age. Future studies of the 3D echocardiography stress-strain relation may yield new insights into maturational changes in myocardial contractility.

Regional myocardial strain measurements from 4DCT in patients with normal LV function

BACKGROUND

CT SQUEEZ is a new automated technique to evaluate regional endocardial strain by tracking features on the endocardium from 4D cine CT data. The objective of this study was to measure the range of endocardial regional strain (RS_CT) values obtained with CT SQUEEZ in the normal human left ventricle (LV) from standard clinical 4D coronary CTA exams.

METHODS

RS_CT was measured over the heart cycle in 25 humans with normal LV function using cine CT from three vendors. Mean and standard deviation of RS_CT values were computed in 16 AHA LV segments to estimate the range of values expected in the normal LV.

RESULTS

Curves describing RS_CT vs. time were consistent between subjects. There was a slight gradient of decreasing minimum RS_CT value (increased shortening) from the base to the apex of the heart. Mean RS_CT values at end-systole were: base = -32% ± 1%, mid = -33% ± 1%, apex = -36% ± 1%. The standard deviation of the minimum systolic RS_CT in each segment over all subjects was 5%. The average time to reach maximum shortening was 34% of the RR interval.

CONCLUSIONS

Regional strain (RS_CT) can be rapidly obtained from standard gated coronary CCTA protocols using 4DCT SQUEEZ processing. We estimate that 95% of normal LV end-systolic RS_CT values will fall between -23% and -43%; therefore, we hypothesize that an RS_CT value higher than -23% will indicate a hypokinetic segment in the human heart.

Three-dimensional speckle-tracking echocardiography: benefits and limitations of integrating myocardial mechanics with three-dimensional imaging

Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is an advanced imaging technique designed for left ventricular (LV) myocardial deformation analysis based on 3D data sets. 3DSTE has the potential to overcome some of the intrinsic limitations of two-dimensional STE (2DSTE) in the assessment of complex LV myocardial mechanics, offering additional deformation parameters (such as area strain) and a comprehensive quantitation of LV geometry and function from a single 3D acquisition. Albeit being a relatively young technique still undergoing technological developments, several experimental studies and clinical investigations have already demonstrated the reliability and feasibility of 3DSTE, as well as several advantages of 3DSTE over 2DSTE. This technique has provided new insights into LV mechanics in several clinical fields, such as the objective assessment of global and regional LV function in ischemic and non-ischemic heart diseases, the evaluation of LV mechanical dyssynchrony, as well as the detection of subclinical cardiac dysfunction in cardiovascular conditions at risk of progression to overt heart failure. However, 3DSTE generally requires patient's breathhold and regular rhythm for enabling an ECG-gated multi-beat 3D acquisition. In addition, the measurements, normal limits and cut-off values pertaining to 3D strain parameters are currently vendor-specific and highly dependent on the 3D ultrasound equipment used. Technological advances with improvement in spatial and temporal resolution and a standardized methodology for obtaining vendor-independent 3D strain measurements are expected in the future for a widespread application of 3DSTE in both clinical and research arenas. The purpose of this review is to summarize currently available data on 3DSTE methodology (feasibility, accuracy and reproducibility), strengths and weaknesses with respect to 2DSTE, as well as the main clinical applications and future research priorities of this emerging technology.

Evolution of subclinical myocardial dysfunction detected by two-dimensional and three-dimensional speckle tracking in asymptomatic type 1 diabetic patients: a long‑term follow-up study

Background

We sought to assess the long-term evolution of left ventricular (LV) function using two-dimensional (2D) and three-dimensional (3D) speckle tracking echocardiography (STE) for the detection of preclinical diabetic cardiomyopathy, in asymptomatic type 1 diabetic patients, over a 6-year follow-up.

Design and methods

Sixty-six asymptomatic type 1 diabetic patients with no cardiovascular risk factors were compared to 26 matched healthy controls. Conventional, 2D and 3D-STE were performed at baseline. A subgroup of 14 patients underwent a 6-year follow-up evaluation.

Results

At baseline, diabetic patients had similar LV ejection fraction (60 vs 61%; P = NS), but impaired longitudinal function, as assessed by 2D-global longitudinal strain (GLS) (−18.9 ± 2 vs −20.5 ± 2; P = 0.0002) and 3D-GLS (−17.5 ± 2 vs −19 ± 2; P = 0.003). At follow-up, diabetic patients had worsened longitudinal function compared to baseline (2D-GLS: −18.4 ± 1 vs −19.2 ± 1; P = 0.03). Global circumferential (GCS) and radial (GRS) strains were unchanged at baseline and during follow-up. Metabolic status did not correlate with GLS, whereas GCS and GRS showed a good correlation, suggestive of a compensatory increase of circumferential and radial functions in advanced stages of the disease – long-term diabetes (GCS: −26 ± 3 vs −23.3 ± 3; P = 0.008) and in the presence of microvascular complications (GRS: 38.8 ± 9 vs 34.3 ± 8; P = 0.04).

Conclusions

Subclinical myocardial dysfunction can be detected by 2D and 3D-STE in type 1 diabetic patients, independently of any other cardiovascular risk factors. Diabetic cardiomyopathy progression was suggested by a mild decrease in longitudinal function at the follow-up, but did not extend to a clinical expression of the disease, as no death or over heart failure was reported.

3D and 4D Ultrasound: Current Progress and Future Perspectives

PURPOSE OF REVIEW

Three-dimensional (3D) echocardiography (3DE) and 4-dimensional echocardiography (4DE), also known as real-time (RT) 3DE (RT3DE), are rapidly emerging technologies which have made significant impact in the clinical arena over the years. This review will discuss the recent applications of 3DE in diagnosing and treating different types of cardiovascular disease.

RECENT FINDINGS

Recent studies using 3DE expanded on prior findings and introduced additional applications to different cardiac conditions. Some studies have used 3D parameters to prognosticate long-term outcomes. Numerous innovative software designs including fully automated algorithms have been introduced to better evaluate valvular heart disease and cardiac function.

SUMMARY

With further evolution of 3DE technologies, this imaging modality will emerge as a powerful tool and likely become the imaging modality of choice in the diagnosis and management of various cardiac disorders.

Early Right Ventricular Apical Pacing-Induced Gene Expression Alterations Are Associated with Deterioration of Left Ventricular Systolic Function

The chronic high-dose right ventricular apical (RVA) pacing may have deleterious effects on left ventricular (LV) systolic function. We hypothesized that the expression changes of genes regulating cardiomyocyte energy metabolism and contractility were associated with deterioration of LV function in patients who underwent chronic RVA pacing. Sixty patients with complete atrioventricular block and preserved ejection fraction (EF) who underwent pacemaker implantation were randomly assigned to either RVA pacing (n = 30) group or right ventricular outflow tract (RVOT) pacing (n = 30) group. The mRNA levels of OPA1 and SERCA2a were significantly lower in the RVA pacing group at 1 month's follow-up (both p < 0.001). Early changes in the expression of selected genes OPA1 and SERCA2a were associated with deterioration in global longitudinal strain (GLS) that became apparent months later (p = 0.002 and p = 0.026, resp.) The altered expressions of genes that regulate cardiomyocyte energy metabolism and contractility measured in the peripheral blood at one month following pacemaker implantation were associated with subsequent deterioration in LV dyssynchrony and function in patients with preserved LVEF, who underwent RVA pacing.

A preliminary comparison of two-dimensional speckle tracking echocardiography and pressure-volume loop analysis in patients with Fontan physiology: The role of ventricular morphology

OBJECTIVE

Speckle tracking echocardiography (STE) may be a useful modality for assessing ventricular performance in patients with single ventricle physiology. However, STE's ability to accurately assess ventricular performance in this population is unknown. The objective of this study was to perform a preliminary comparison of STE measures of myocardial deformation to reference standard measures of function derived from pressure-volume loop (PVL) analysis.

DESIGN

This was a secondary analysis of a prospective study investigating PVLs in patients with Fontan physiology. PVLs were recorded using microconductance catheters. PVL indices included end-systolic elastance (Ees), arterial elastance (Ea), ventriculo-arterial coupling (Ea/Ees), and the isovolumic relaxation time constant (tau). Patients were included if they had an echocardiogram within 1 month of their catheterization. STE was performed retrospectively using vendor independent software.

RESULTS

Seventeen patients had echocardiograms available for analysis, 12 were right ventricular (RV) dominant. The median age was 8 years (IQR 5-17 years). Circumferential strain (r=-.72, P≤.01) and strain rate (r=-.61, P=.04) correlated with Ea/Ees in those with RV-dominant morphology. Longitudinal strain rate correlated with Ees in those with LV-dominant morphology (r=-.98, P≤.01). Longitudinal EDSR correlated with tau in those with LV-dominant morphology (r=-.90, P=.04).

CONCLUSIONS

In this limited sample, circumferential measures of deformation correlated with PVL measures better in patients with RV morphology, while longitudinal measures correlated better with PVL measures in patients with LV morphology. Further validation and investigation into the clinical usefulness of these measures are warranted.

Global Longitudinal Strain or Left Ventricular Twist and Torsion? Which Correlates Best with Ejection Fraction?

Background

Estimative of left ventricular ejection fraction (LVEF) is a major indication for echocardiography. Speckle tracking echocardiography (STE) allows analysis of LV contraction mechanics which includes global longitudinal strain (GLS) and twist/torsion, both the most widely used. Direct comparison of correlations between these novel parameters and LVEF has never been done before.

Objective

This study aims to check which one has the highest correlation with LVEF.

Methods

Patients with normal LVEF (> 0,55) and systolic dysfunction (LVEF <0,55) were prospectively enrolled, and underwent echocardiogram with STE analysis. Correlation of variables was performed by linear regression analysis. In addition, correlation among levels of LV systolic impairment was also tested.

Results

A total of 131 patients were included (mean age, 46 ± 14y; 43%, men). LVEF and GLS showed a strong correlation (r = 0.95; r² = 0.89; p < 0.001), more evident in groups with LV systolic dysfunction than those with preserved LVEF. Good correlation was also found with global longitudinal strain rate (r = 0.85; r² = 0.73; p < 0.001). Comparing to GLS, correlation of LVEF and torsional mechanics was weaker: twist (r = 0.78; r² = 0.60; p < 0.001); torsion (r = 0.75; r² = 0.56; p < 0.001).

Conclusion

GLS of the left ventricle have highly strong positive correlation with the classical parameter of ejection fraction, especially in cases with LV systolic impairment. Longitudinal strain rate also demonstrated a good correlation. GLS increments analysis of LV systolic function. On the other hand, although being a cornerstone of LV mechanics, twist and torsion have a weaker correlation with LV ejection, comparing to GLS.

Assessment of left ventricular systolic function in patients with iron deficiency anemia by three-dimensional speckle-tracking echocardiography

Objective:

The present study aimed to evaluate left ventricular (LV) systolic function in patients with iron deficiency anemia (IDA) by 3-dimensional speckle-tracking echocardiography (3DSTE).

Methods:

Participants were grouped by hemoglobin (Hb) levels in order to study the effect of anemia on cardiac function. Group A included 40 healthy volunteers. Eighty-three patients who were diagnosed with IDA were divided into 2 groups according to the Hb level. Group B (Hb 9 g/dL) included 44 patients, while group C (Hb 6–9 g/dL) included 39 patients. Left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular mass index (LVMI), and left ventricular ejection fraction (LVEF) were calculated by real-time 3-dimensional echocardiography (RT3D). Left ventricular global longitudinal strain (GLS), global area strain (GAS), global radial strain (GRS), and global circumferential strain (GCS) were obtained by 3DSTE.

Results:

LVMI, LVEDV and LVESV of group C increased and GCS, GRS, GLS, and GAS of group C decreased compared with those of groups A and B (all p<0.05). GAS and GLS decreased significantly compared with other parameters (both p<0.01).

Conclusion:

LV remodeling and LV systolic dysfunction occurred in patients when the hemoglobin level was in the range of 6–9 g/dL. 3DSTE can evaluate LV systolic function in patients with IDA, and GAS and GLS are more sensitive than other parameters.

Pilot study using 3D-longitudinal strain computation in a multi-parametric approach for best selecting responders to cardiac resynchronization therapy

BACKGROUND

Almost all attempts to improve patient selection for cardiac resynchronization therapy (CRT) using echo-derived indices have failed so far. We sought to assess: the performance of homemade software for the automatic quantification of integral 3D regional longitudinal strain curves exploring left ventricular (LV) mechanics and the potential value of this tool to predict CRT response.

METHODS

Forty-eight heart failure patients in sinus rhythm, referred for CRT-implantation (mean age: 65 years; LV-ejection fraction: 26%; QRS-duration: 160 milliseconds) were prospectively explored. Thirty-four patients (71%) had positive responses, defined as an LV end-systolic volume decrease ≥15% at 6-months. 3D-longitudinal strain curves were exported for analysis using custom-made algorithms. The integrals of the longitudinal strain signals (I _L,peak) were automatically measured and calculated for all 17 LV-segments.

RESULTS

The standard deviation of longitudinal strain peak (SDI _L,peak ) for all 17 LV-segments was greater in CRT responders than non-responders (1.18% s^-1 [0.96; 1.35] versus 0.83% s^-1 [0.55; 0.99], p = 0.007). The optimal cut-off value of SDI _L,peak to predict response was 1.037%.s^-1. In the 18-patients without septal flash, SDI _L,peak was significantly higher in the CRT-responders.

CONCLUSIONS

This new automatic software for analyzing 3D longitudinal strain curves is avoiding previous limitations of imaging techniques for assessing dyssynchrony and then its value will have to be tested in a large group of patients.

Age- and Sex-Related Influences on Left Ventricular Mechanics in Elderly Individuals Free of Prevalent Heart Failure: The ARIC Study (Atherosclerosis Risk in Communities)

BACKGROUND

Advanced age is related to left ventricular (LV) remodeling. We sought to investigate the relationships between aging, elevated hemodynamic load, cardiac mechanics, and LV remodeling in an elderly community-based population.

METHODS AND RESULTS

We studied 1105 subjects (76±5 years, 61% women) without prevalent heart failure, who attended the visit 5 of the ARIC study (Atherosclerosis Risk in Communities). LV global longitudinal strain, global circumferential strain, and torsion indices were analyzed using 3-dimensional echocardiography. Advanced age was associated with greater LV concentricity, lower myocardial diastolic relaxation, reduced global longitudinal strain (adjusted estimate, 0.39±0.19% (SE)/decade; P=0.038), borderline greater global circumferential strain (adjusted estimate, -0.59±0.36% (SE)/decade; P=0.08), and higher torsion indices (adjusted estimate for torsion, 0.33±0.04° (SE)/decade; P<0.001). In addition, greater concentricity was associated with decreased global longitudinal strain and greater torsion in multivariable models (all P<0.001). Women showed smaller LV cavity size, greater concentricity, lower myocardial relaxation velocity E', though demonstrated greater global longitudinal strain, global circumferential strain, and torsion than men (all P<0.05). Overall, subjects with hypertension and increasing age were more likely to have higher torsion, though the association between advanced age and greater torsion was more pronounced in women than in men (both interaction P<0.05).

CONCLUSIONS

In an asymptomatic, senescent community-dwelling population, we observed a distinct, sex-specific pattern of cardiac remodeling. Although we observed worse diastolic and longitudinal function with advanced age or elevated load in both sexes, a significant increase of torsion was more pronounced in women.

Early marker of regional left ventricular deformation in patients with hypertrophic cardiomyopathy evaluated by MRI tissue tracking: The effects of myocardial hypertrophy and fibrosis

PURPOSE

To evaluate the regional left ventricular (LV) myocardial strain of early stage hypertrophic cardiomyopathy (HCM) patients by magnetic resonance (MR) tissue tracking.

MATERIALS AND METHODS

In all, 114 adult HCM patients classified as NYHA I or II and 32 healthy volunteers were enrolled and underwent 3.0T MR examination. Vertical 2-chamber long axis, horizontal 4-chamber, and short axis cine sequence as well as late gadolinium enhancement images (LGE) were scanned. The cardiac function, regional LV tissue tracking variables, end-diastolic wall thickness (EDTH), and LGE extent were measured.

RESULTS

In the HCM group, 38 were NYHA I and 76 were NYHA II. By regional analysis, peak strain (PS) and peak displacement (PD) with radial, circumferential direction of hypertrophic segments (n = 283) were significantly lower than nonhypertrophic segments (n = 1541) (all P < 0.05). Radial PS was significantly correlated with LVEDTH (r = -0.467, P < 0.0001). Radial PD was negatively associated with LVEDTH (r = -0.331, P < 0.0001). The PS and PD of all directions were decreased in segments with LGE (n = 723) compared with those without LGE (n = 1101) (all P < 0.05). In addition, radial PS and PD were negatively associated with LGE extent (radial PS, r = -0.441; radial PD, r = -0.274; both P < 0.0001). All strain parameters showed excellent inter- and intraobserver agreements.

CONCLUSION

Decreased regional LV myocardial strain hypertrophic and fibrotic segments of early-stage HCM patients can be measured by MR tissue tracking based on routine cine images. Moreover, myocardial strain may decrease with the increasing of myocardial hypertrophy as well as fibrosis.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1368-1376.

In-vivo validation of a new clinical tool to quantify three-dimensional myocardial strain using ultrasound

Three-dimensional (3D) strain analysis based on real-time 3-D echocardiography (RT3DE) has emerged as a novel technique to quantify regional myocardial function. The goal of this study was to evaluate accuracy of a novel model-based 3D tracking tool (eSie Volume Mechanics, Siemens Ultrasound, Mountain View, CA, USA) using sonomicrometry as an independent measure of cardiac deformation. Thirteen sheep were instrumented with microcrystals sutured to the epi- and endocardium of the inferolateral left ventricular wall to trace myocardial deformation along its three directional axes of motion. Paired acquisitions of RT3DE and sonomicrometry were made at baseline, during inotropic modulation and during myocardial ischemia. Accuracy of 3D strain measurements was quantified and expressed as level of agreement with sonomicrometry using linear regression and Bland-Altman analysis. Correlations between 3D strain analysis and sonomicrometry were good for longitudinal and circumferential strain components (r = 0.78 and r = 0.71) but poor for radial strain (r = 0.30). Accordingly, agreement (bias ± 2SD) was -5 ± 6 % for longitudinal, -5 ± 7 % for circumferential, and 15 ± 19 % for radial strain. Intra-observer variability was low for all components (intra-class correlation coefficients (ICC) of respectively 0.89, 0.88 and 0.95) while inter-observer variability was higher, in particular for radial strain (ICC = 0.41). The present study shows that 3D strain analysis provided good estimates of circumferential and longitudinal strain, while estimates of radial strain were less accurate between observers.