strain analysis by speckle tracking echocardiographystrain analysis by speckle tracking...
TRANSCRIPT
Strain Analysisby Speckle Tracking Echocardiography
Natesa G. Pandian, MD, FACCCo-DirectorHeart Valve Center & Noninvasive Cardiac ImagingHoag Hospital, Newport Beach, CA
Professor of Medicine and Staff CardiologistTufts University School of Medicine, Boston
Speaker – ToshibaSpeaker Bureau – Lantheus Inc.
LV Systolic and Diastolic Performance is Complex
Intramural pathology and dysfunction occur before detection by conventional parameters
Tissue Doppler Imaging !
Speckle Tracking Technique
Speckle Tracking
Why 3D Speckle Tracking?
2D Tracking
3D Tracking
What Parameters Can Be Obtained?
Radial 3D-strain
Speckle Tracking(Global and Segmental Information)
Segmental Information
Global volume and EF
STE Parameters
•Displacement
•Strain
•Strain Rate
•Rotation
•Twist, Twist Rate
•Untwist, Untwist Rate
•Torsion
LongitudinalCircumferentialRadial
Systolic Radial Strain (Thickening)
Circumferential Strain (Shortening)
Longitudinal Strain (Shortening)
3D Speckle Tracking
Twist Torsion
ED ES
Rotation
Basal and Apical RotationBasal
Rotation:
• Briefly initial
counter-
clockwise
rotation
• Globally
clockwise
rotationApical
Rotation:
• Counter-
clockwise
rotation
How correct
are they?
All These Numbers and Curves...
Validation
Author Year STE parameter Reference Std Subjects
Toyoda et al, JASE 2004 2D RSt sonomicrometry animal
Korninek et al, JASE 2005 2D Strain sonomicrometry animal
Notori et al, JACC 2005 2D Torsion tagged MRI human
Amundsen et al, JACC 2006 2D Strainsonomicrometryand tagged MRI
animal
Roes et al, AJC 20092D global
and regional LStMRI LGE
human (patients with isch. LVD)
Nesser HJ, EHJ 2009 3D-STE LV volumes MRI human
Seo Y, Circ-Img 2009 3D Strain sonomicrometry animal
Seo Y, JACC-Img 2011 3D area tracking sonomicrometry animal
Normal Values
303 Healthy SubjectsMales 51%, Females 49%
M F
3D Speckle Tracking Study of the Normal LV Mechanics
Heterogeneity
Evangelista/Patel/Pandian et al. JACC 2009
0
10
20
30
40
50
60
Base Mid Apical
Radial
Circum
Longitudinal
Ischemic Heart Disease
Radial 3D-strain
Speckle Tracking(Global and Segmental Information)
Segmental Information
Global volume and EF
Global Volume and EF
EDV 135.95 mL
ESV 43.85 mL
EF 67.74 %
Diastole to ...
...Systole.
Normal
Seo Y et al. Circ Cardiovasc Imaging 2009;2:451-459
LAD Occlusion
Speckle-tracking echocardiography correctly identifies segmental left ventricular dysfunction induced by scarring in a rat model of myocardial infarction
Zoran B. Popović et al Am J Physiol 2007
Esmaeilzadeh/Pandian
Relation Between Arterial Elastanceand Circumferential Strain
Esmaeilzadeh/Pandian
Relation Between Ventricular Elastanceand Circumferential Strain
CAD with RWMANormal
CAD with RWMANormal
CAD with RWMANormal
Michael Becker et al. European Heart Journal April, 2009
Impact of Transmurality onEndo and Epicardial Circumferencial Strain
Transmural MI
Subendocardial MI
Subendocardial
Subendocardial
Subepicardial
Subepicardial No Change
Salehi/Pandian
Deformation Changes in Myocardial Ischemia
Subendocardial Transmural
Global Longitudinal Strain ↓ ↓
Global Circumferential Strain — ↓
Global Radial Strain — ↓
Twist — ↓
Choi J. et. al. Eur J Echocardiography 2009;10:695-701.
Longitudinal Strain at Rest PredictsLeft Main and 3VD in Patients Without RWMA
Dammon et al. JACC Cardiovasc Interv 2012
NSTEMI
2/3 of NSTEMI patients undergo coronary angiography
2D Speckle for Detection of
Significant CAD – A Meta-analysis
• Sensitivity84%
• Specificity82%
Singh et al. JACC 2013
19 studies, 2189 patients
Detection of wall motion abnormalities
RADIAL STRAIN in a patient withIsc CMP, EF 25%
Distal septum and anterior wall akinesia (thinning)Lateral wall hypokinesia(reduced thickening)
Ischemic Cardiomyopathy
DyssynchronyCMP Patient
DyssynchronyCMP Patient
After CRT
Severe LV
DysfunctionNormal (-17 ± 5%)
Diastolic Strain and Strain Rate IndicesFor Estimation of LV Filling Pressure
Valve Disease
Illustrative cases of 2 patients with normal flow low gradient (left) and low flow low gradient (right) aortic
stenosis with normal EF
Adda J et al. Circ Cardiovasc
Imaging 2012;5:27-35
Cardiomyopathies
Anthracycline-induced cardiomyopathy
Normal EF
RES Vol 6, 2011
Detecting Preclinical Disease
Doxarubicin Cardiotoxity•Abnormal strain at half the “cardiotoxic” dose
•? Should trigger beta blocker or ACE inhibitor therapy
Infliximab (Remicaide) Cardiotoxity•Incidence of CHF 0.2%
•Asymptomatic low strain: 30%
•Normalization of strain with discontinuation of infliximab
Twist and Untwist in HCM vs Controls
Urbano Moral/Patel/Pandian AJC 2011
Longitudinal Strain: Cardiac Amyloidosis
Amyloid Normal
Urbano-Moral/Patel/Pandian, Echocardiography 2011
Cardiac Amyloidosis
Jose Angel Urbano-Morala,
, Dakshin Gangadharamurthya
, Raymond L. Comenzoa
, Natesa G. Pandiana
, Ayan R. Patela
Urbano-Moral/Patel/Pandian, Rev Esp Cardiol 2015;68:657
HCM Genotype (+) Normal
Urbano-Moral/Patel/Pandian, Echocardiography 2011
Diastolic Strain and Strain Rate IndexesFor Estimation of LV Filling Pressure
Dokainish H. et. Al. Am J Cardiol. 2008;101(10):1504-9.
Mechanics in Heart Failure
FunctionalImpairment
LongitudinalMechanics
Circumferential Mechanics
Radial Mechanics
Torsional Mechanics
Global EF
Predominant subendocardial
dysfunction
Marked impairment
PreservedPreserved/
minimalimpairment
PreservedPreserved/
minimalimpairment
Predominant subepicardial dysfunction
Preserved/ minimal
impairmentMarked impairment
Minimal impairment
Marked impairment
Preserved/minimal
impairment
Transmuraldysfunction
Marked impairment
Marked impairmentMarked
impairmentMarked
impairmentMarked
impairment
From Geyer et al, Assessment of Myocardial Mechanics Using Speckle Tracking Echocardiography:
Fundamentals and Clinical Applications; J Am Soc Echo 2010;23:351-69
How about theRight Ventricle?
Panetta/Pandian et al
Reference Range for RV Strain
RV Longitudinal Strain (%)
5
10
15
20
Proportion of Patients (%)
-45 -40 -35 -30 -25 -20 -15 -10 -5 0 5
Mean RV free wall strain = -25 ±5%
Fine, et al. Circ CV Img 2013 (in press)
N=169 patients with normal TTE
Panetta/Pandian et al, EuroEcho 2013
Longitudinal displacement:
Significantly different in Amyloid, HCM and Hypertensive Hypertrophy
Differentiating feature between HCM and Amyloid Heart
Right Ventricle - Global apical LD
p value< 0.001
Panetta/Pandian et al
RV Strain Predicts Outcomes in PH
All-cause mortality Time free of cardiac events or PH medical intervention
Fine et al. Circ CV Img 2013
Right Ventricular Pathology
• Measurement of RV strainis feasible
• RV contraction is predominently longitudinal
• RV strain is abnormal ina variety of disorders
Strain by Speckle Tracking
• Identification of subtle regional & global contractile
abnormalities
• Identification of dyssynchrony
• Evaluation of diastolic mechanics of the heart
• Prognostic value
Twist
Untwist
Torsion
Wringing Motion
Cardiac (patho)Physiology
Radial Strain
Circumferential Strain
Longitudinal Strain
Area Tracking
Myoc Deformation
Decision Making
Twist
Untwist
Torsion
Wringing Motion
Cardiac (patho)Physiology
Clinical Application
Radial Strain
Circumferential Strain
Longitudinal Strain
Area Tracking
Cardiomyopathies
Subclinical Heart Dysfunction
Stress Echo
LV volumes / EF / Mass
Valvular Surgery
Subclinical Heart Dysfunction
Resynchronization Therapy
LV volumes / EF / Mass
Myoc Deformation
Evaluation / Diagnosis
Future Directions
• Need robust prognostic data
• Need values to define therapy
• Real-time 3D quantitation
• Fusion Imaging
Thank you!