Myocardial strain measurement with 2-dimensional speckle-tracking echocardiography: definition of normal range.
TL;DR: This multicenter study of nearly 250 volunteers without evidence of cardiovascular disease showed an average LV peak systolic strain of -18.6 +/- 0.1% and there was significant segmental variation of regional strain to necessitate the use of site-specific normal ranges.
Abstract: The interpretation of wall motion is an important component of echocardiography but remains a source of variation between observers. It has been believed that automated quantification of left ventricular (LV) systolic function by measurement of LV systolic strain from speckle-tracking echocardiography might be helpful. This multicenter study of nearly 250 volunteers without evidence of cardiovascular disease showed an average LV peak systolic strain of −18.6 ± 0.1%. Although strain was influenced by weight, blood pressure, and heart rate, these features accounted for only 16% of variance. However, there was significant segmental variation of regional strain to necessitate the use of site-specific normal ranges.
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University of Chicago1, University of Padua2, Mayo Clinic3, Claude Bernard University Lyon 14, University of Naples Federico II5, Cleveland Clinic6, Houston Methodist Hospital7, University of California, Irvine8, National Research Council9, University of Oslo10, University of Texas Health Science Center at Houston11, University of Occupational and Environmental Health Japan12, Ohio State University13, Katholieke Universiteit Leuven14
TL;DR: Currently available techniques that allow quantitative assessment of myocardial function via image-based analysis of local myocardials dynamics, including Doppler tissue imaging and speckle-tracking echocardiography, as well as integrated backscatter analysis are described.
Abstract: Echocardiographic imaging is ideally suited for the evaluation of cardiac mechanics because of its intrinsically dynamic nature. Because for decades, echocardiography has been the only imaging modality that allows dynamic imaging of the heart, it is only natural that new, increasingly automated techniques for sophisticated analysis of cardiac mechanics have been driven by researchers and manufacturers of ultrasound imaging equipment.Several such technique shave emerged over the past decades to address the issue of reader's experience and inter measurement variability in interpretation.Some were widely embraced by echocardiographers around the world and became part of the clinical routine,whereas others remained limited to research and exploration of new clinical applications.Two such techniques have dominated the research arena of echocardiography: (1) Doppler based tissue velocity measurements,frequently referred to as tissue Doppler or myocardial Doppler, and (2) speckle tracking on the basis of displacement measurements.Both types of measurements lend themselves to the derivation of multiple parameters of myocardial function. The goal of this document is to focus on the currently available techniques that allow quantitative assessment of myocardial function via image-based analysis of local myocardial dynamics, including Doppler tissue imaging and speckle-tracking echocardiography, as well as integrated backscatter analysis. This document describes the current and potential clinical applications of these techniques and their strengths and weaknesses,briefly surveys a selection of the relevant published literature while highlighting normal and abnormal findings in the context of different cardiovascular pathologies, and summarizes the unresolved issues, future research priorities, and recommended indications for clinical use.
1,205 citations
University of Chicago1, University of Padua2, Mayo Clinic3, Claude Bernard University Lyon 14, University of Naples Federico II5, Cleveland Clinic6, Houston Methodist Hospital7, University of California, Irvine8, National Research Council9, University of Oslo10, University of Texas at Austin11, Ohio State University12, Katholieke Universiteit Leuven13
TL;DR: This document describes the current and potential clinical applications of these techniques and their strengths and weaknesses, briefly surveys a selection of the relevant published literature while highlighting normal and abnormal findings in the context of different cardiovascular pathologies, and summarizes the unresolved issues, future research priorities, and recommended indications for clinical use.
Abstract: Echocardiographic imaging is ideally suited for the evaluation of cardiac mechanics because of its intrinsically dynamic nature. Because for decades, echocardiography has been the only imaging modality that allows dynamic imaging of the heart, it is only natural that new, increasingly automated techniques for sophisticated analysis of cardiac mechanics have been driven by researchers and manufacturers of ultrasound imaging equipment. Several such techniques have emerged over the past decades to address the issue of reader's experience and inter-measurement variability in interpretation. Some were widely embraced by echocardiographers around the world and became part of the clinical routine, whereas others remained limited to research and exploration of new clinical applications. Two such techniques have dominated the research arena of echocardiography: (1) Doppler-based tissue velocity measurements, frequently referred to as tissue Doppler or myocardial Doppler, and (2) speckle tracking on the basis of displacement measurements. Both types of measurements lend themselves to the derivation of multiple parameters of myocardial function. The goal of this document is to focus on the currently available techniques that allow quantitative assessment of myocardial function via image-based analysis of local myocardial dynamics, including Doppler tissue imaging and speckle-tracking echocardiography, as well as integrated back- scatter analysis. This document describes the current and potential clinical applications of these techniques and their strengths and weaknesses, briefly surveys a selection of the relevant published literature while highlighting normal and abnormal findings in the context of different cardiovascular pathologies, and summarizes the unresolved issues, future research priorities, and recommended indications for clinical use.
779 citations
TL;DR: A meta-analysis of normal ranges found variations between different normal ranges seem to be associated with differences in systolic blood pressure, emphasizing that this should be considered in the interpretation of strain.
Abstract: Background The definition of normal values of left ventricular global longitudinal strain (GLS), global circumferential strain, and global radial strain is of critical importance to the clinical application of this modality. The investigators performed a meta-analysis of normal ranges and sought to identify factors that contribute to reported variations. Methods MEDLINE, Embase, and the Cochrane Library database were searched through August 2011 using the key terms "strain," "speckle tracking," "left ventricle," and "echocardiography" and related phrases. Studies were included if the articles reported left ventricular strain using two-dimensional speckle-tracking echocardiography in healthy normal subjects, either in the control group or as a primary objective of the study. Data were combined using a random-effects model, and effects of demographic, hemodynamic, and equipment variables were sought in a meta-regression. Results The search identified 2,597 subjects from 24 studies. Reported normal values of GLS varied from −15.9% to −22.1% (mean, −19.7%; 95% CI, −20.4% to −18.9%). Normal global circumferential strain varied from −20.9% to −27.8% (mean, −23.3%; 95% CI, −24.6% to −22.1%). Global radial strain ranged from 35.1% to 59.0% (mean, 47.3%; 95% CI, 43.6% to 51.0%). There was significant between-study heterogeneity and inconsistency. The source of variation was sought between studies using meta-regression. Blood pressure, but not age, gender, frame rate, or equipment, was associated with variation in normal GLS values. Conclusions The narrowest confidence intervals from this meta-analysis were for GLS and global circumferential strain, but individual studies have shown a broad range of strain in apparently normal subjects. Variations between different normal ranges seem to be associated with differences in systolic blood pressure, emphasizing that this should be considered in the interpretation of strain.
668 citations
TL;DR: A relative ‘apical sparing’ pattern of LS is an easily recognisable, accurate and reproducible method of differentiating CA from other causes of LV hypertrophy.
Abstract: Background The diagnosis of cardiac amyloidosis (CA) is challenging owing to vague symptomatology and non-specific echocardiographic findings. Objective To describe regional patterns in longitudinal strain (LS) using two-dimensional speckle-tracking echocardiography in CA and to test the hypothesis that regional differences would help differentiate CA from other causes of increased left ventricular (LV) wall thickness. Methods and results 55 consecutive patients with CA were compared with 30 control patients with LV hypertrophy (n=15 with hypertrophic cardiomyopathy, n=15 with aortic stenosis). A relative apical LS of 1.0, defined using the equation (average apical LS/(average basal LS + mid-LS)), was sensitive (93%) and specific (82%) in differentiating CA from controls (area under the curve 0.94). In a logistic regression multivariate analysis, relative apical LS was the only parameter predictive of CA (p=0.004). Conclusions CA is characterised by regional variations in LS from base to apex. A relative ‘apical sparing’ pattern of LS is an easily recognisable, accurate and reproducible method of differentiating CA from other causes of LV hypertrophy.
662 citations
TL;DR: Cardiac troponin plasma concentrations and longitudinal strain predict the development of cardiotoxicity in patients treated with anthracyclines and trastuzumab, and the 2 parameters may be useful to detect chemotherapy-treated patients who may benefit from alternative therapies, potentially decreasing the incidence ofCardiotoxicity and its associated morbidity and mortality.
Abstract: As breast cancer survival increases, cardiotoxicity associated with chemotherapeutic regimens such as anthracyclines and trastuzumab becomes a more significant issue. Assessment of the left ventricular (LV) ejection fraction fails to detect subtle alterations in LV function. The objective of this study was to evaluate whether more sensitive echocardiographic measurements and biomarkers could predict future cardiac dysfunction in chemotherapy-treated patients. Forty-three patients diagnosed with breast cancer who received anthracyclines and trastuzumab therapy underwent echocardiography and blood sampling at 3 time points (baseline and 3 and 6 months during the course of chemotherapy). The LV ejection fraction; peak systolic myocardial longitudinal, radial, and circumferential strain; echocardiographic markers of diastolic function; N-terminal pro–B-type natriuretic peptide; and high-sensitivity cardiac troponin I were measured. Nine patients (21%) developed cardiotoxicity (1 at 3 months and 8 at 6 months) as defined by the Cardiac Review and Evaluation Committee reviewing trastuzumab. A decrease in longitudinal strain from baseline to 3 months and detectable high-sensitivity cardiac troponin I at 3 months were independent predictors of the development of cardiotoxicity at 6 months. The LV ejection fraction, parameters of diastolic function, and N-terminal pro–B-type natriuretic peptide did not predict cardiotoxicity. In conclusion, cardiac troponin plasma concentrations and longitudinal strain predict the development of cardiotoxicity in patients treated with anthracyclines and trastuzumab. The 2 parameters may be useful to detect chemotherapy-treated patients who may benefit from alternative therapies, potentially decreasing the incidence of cardiotoxicity and its associated morbidity and mortality.
578 citations
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TL;DR: In this paper, the authors assess the feasibility of 2D strain, a software for real-time quantitative echocardiographic assessment of myocardial function, which is based on the estimation that a discrete set of tissue velocities are present per each of many small elements on the ultrasound image.
Abstract: Objectives We sought to assess the feasibility of 2-dimensional strain, a novel software for real-time quantitative echocardiographic assessment of myocardial function Methods Conventional and a novel non-Doppler–based echocardiography technique for advanced wall-motion analysis were performed in 20 patients with myocardial infarction and 10 healthy volunteers from the apical views Two-dimensional strain is on the basis of the estimation that a discrete set of tissue velocities are present per each of many small elements on the ultrasound image This software permits real-time assessment of myocardial velocities, strain, and strain rate These parameters were also compared with Doppler tissue imaging measurements in 10 additional patients Results In all, 803% of infarct and 978% of normal segments could be adequately tracked by the software Peak systolic strain, strain rate, and peak systolic myocardial velocities, calculated from the software, were significantly higher in the normal than in the infarct segments In the 10 additional patients, velocities, strain, and strain rate obtained with the novel software were not significantly different from those obtained with Doppler tissue imaging Conclusion Two-dimensional strain can accomplish real-time wall-motion analysis, and has the potential to become a standard for real-time automatic echocardiographic assessment of cardiac function
1,136 citations
TL;DR: The present study demonstrates the ability of Doppler echocardiography to measure myocardial strains in a clinical setting and may represent a new powerful method for quantifying left ventricular function noninvasively in humans.
Abstract: Tissue Doppler echocardiography-derived strain rate and strain measurements (SDE) are new quantitative indices of intrinsic cardiac deformation. The aim of this study was to validate and compare these new indices of regional cardiac function to measurements of 3-dimensional myocardial strain by tagged MRI.
542 citations
TL;DR: SR/epsilon imaging appears to be a robust technique for quantifying regional myocardial deformation, and values describing radial deformation were higher than the corresponding SR/ep silon values obtained for longitudinal deformation.
Abstract: Strain rate (SR) and strain (epsilon) have been proposed as new ultrasound (US) indices for quantifying regional wall deformation, and can be measured from color Doppler myocardial data by determining the local spatial velocity gradient. The aim of this study was to define normal regional SR/epsilon values for both radial and longitudinal myocardial deformation. SR/epsilon profiles were obtained from 40 healthy volunteers. For radial deformation, posterior left ventricular (LV) wall SR/epsilon were calculated. For longitudinal, they were determined for basal, mid- and apical segments of the 1. septum; 2. lateral, 3. posterior and 4. anterior LV walls and for the 5. right ventricular (RV) lateral wall. SR/epsilon values describing radial deformation were higher than the corresponding SR/epsilon values obtained for longitudinal deformation. Longitudinal SR/epsilon were homogeneous throughout the septum and all LV walls. This was in contrast to the normal base-apex velocity gradient. The RV segmental SR/epsilon values were higher than those obtained from the corresponding LV wall and inhomogeneous (higher in the apical segments). SR/epsilon imaging appears to be a robust technique for quantifying regional myocardial deformation.
296 citations
TL;DR: Although myocardial velocities and strain rate showed significant dependence on age, displacement and peak systolic strain measures were less affected, and Doppler tissue echocardiography measurements showed a strong dependence on wall segment position.
Abstract: Quantification of regional function can be performed using Doppler tissue echocardiography to evaluate myocardial velocity, tissue displacement, strain, and strain rate. Although these techniques have been validated in animal experiments and early clinical trials, there are only limited measurements in healthy populations to use as reference data. In 100 healthy volunteers, left ventricular myocardial velocity, displacement, strain, and strain rate were measured using Doppler tissue echocardiography. Measurements were obtained from basal, mid, and apical segments of walls visualized from left ventricular apical 4- and 2-chamber views. Analysis of covariance was used to examine the effects of age and wall segment position. All parameters showed a strong dependence on wall segment position. Although myocardial velocities and strain rate showed significant dependence on age, displacement and peak systolic strain measures were less affected. Like pulsed Doppler mitral inflow velocity, tissue velocity and strain rate show age-related changes.
183 citations