Strain Imaging in Pediatrics
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1 Strain Imaging in Pediatrics Dr Moceri Pamela CHU Nice Hôpitaux pédiatriques de Nice Lenval
2 None Disclosures
3 Myocardial deformabon imaging Study of the myocardial mobon Longitudinal deformabon Radial deformabon CircumferenBal deformabon LV Twist With a consistent and reproducible method
4 Myocardial deformabon imaging CMR Bssue tagging «Gold standard» Not always available, sedabon ooen required, expensive Echocardiography: TDI imaging: limits SpaBal resolubon Doppler effect / angle dependence 2D strain / Speckle tracking Independent of the insonabon angle and cardiac translabon AlternaBve method to tagged CMR Radial, circumferenbal, longitudinal deformabon from the same acquired loop torsion But : dependent on 2D image quality and frame rate 3D speckle tracking
5 Speckle Tracking Echocardiography
6 Why should we use STE in children? Assessment of regional myocardial funcbon Regional myocardial ischemia? TGA aoer arterial switch, ALCAPA, Ross, Early detecbon of myocardial impairment HCM, Duchenne, QuanBtaBve assessment of RV funcbon Fallot, Systemic RV FuncBon DetecBon of myocardial dyssynchrony Timing
7
8 When can we (technically) use STE??? Too young? Too small? Too turbulent??? Yes We Can!
9 Strain imaging of the fetal heart Feasible Reproducible: Intra- and inter- observer variability : 3 and 6% Longitudinal funcbon : Ready for roubne clinical pracbce?? Peak strain increases with the gestabonal age. Di Salvo G, et al. Eur J Echocardiogr. 2008;9:
10 Speckle tracking feasibility is low when imaging condibons are challenging Vector velocity imaging also used in the fetus In recipient fetuses of twin- to- twin transfusion syndrome Feasibility 61% Decreased RV strain compared with controls RelaBonship with fetal death was not assessed LimitaBons : low frame rate used Imaging quality Van Mieghem T, et al. J Am Soc Echocardiogr. 2010;23:301-8.
11 STE in neonates Feasible Values: Nestaas E, et al. Cardiol Young. 2008;18: Within the 1st month: Decrease LV peak systolic longitudinal strain Increase RV peak systolic longitudinal strain Pena JL, et al. JASE 2010;23:
12 Cardiomyopathy Dilated CM Decreased Longitudinal ε Radial ε also and increased radial dyssynchrony Friedberg MK, et al. Am J Cardiol. 2008;102: Hypertrophic CM Basal septum : Decreased peak systolic strain and SR Strain inversely correlated with exercise capacity The paoern of hypertrophy influences myocardial deformabon Ganame J, et al. Eur Heart J. 2007;28: Ganame J, et al. Eur J Echocardiogr. 2008; 9:
13 Congenital heart disease Different fiber orientabon Different 3D deformabon! Ex : a middle layer in the RV is only found in case of TOF different paoern of contracbon! Sanchez- Quintana D, et al. Heart. 1996;76: Effects of the absence of RV on LV wall mechanics Increased LV radial strain - Decreased LV twist Fogel MA, et al. Circula8on. 1998;98:
14 STE in hypoplasbc leo heart Comparison of LV and RV aoer Fontan AOer Norwood stage 1 with RV- PA conduit RV scar reduced strain / anterior wall and apex ++ But: RV- PA > BT shunt AOer Norwood: RV more spherical Decreased longitudinal strain Same circumferenbal strain Dyssynchrony Petko C, et al. Congenit Heart Dis In press. Menon SC, et al. J Am Soc Echocardiogr. 2011;24: Petko C, et al. J Am Soc Echocardiogr. 2011;24: Khoo NS, et al. JACC CI. 2011;4: Hughes M, et al. Heart 2004;90:191-4
15 Systemic RV In CCTGA: Clinical deteriorabon is linked to RV dysfuncbon Roos- Hesselink, et al. EHJ 2004; 25:1264 Reduced RV free wall strain aoer Senning Eyskens B, et al. Cardiol Young 2004;14: «ContracBon paoern of the systemic right ventricle: shio from longitudinal to circumferenbal shortening and absent global ventricular torsion» Peoersen E, et al. JACC 2007;49:
16 TOF pabents aoer repair Fallot RV/LV strain Reduced RV free wall longitudinal strain Reduced LV longitudinal strain (with normal EF) NegaBve impact of RV dilatabon on LV funcbon LV circumferenbal strain and basal rotabon " EvaluaBon of RV before and aoer catheter PVR Increased RV deformabon «No effect on LV» Whereas in ASD pabents, acute unloading RV Improves LV twist by increasing basal rotabon AOer surgical PVR ReducBon of RV strain at 1 month, stable at 6m. Weidemann F, et al. Am J Cardiol 2002;90: Kempny A, et al. IJC In press. Cheung, et al. Am J Cardiol 2009;104: Moiduddin, et al. Am J Cardiol 2009;104:862 Dong L, et al. Int J Cardiovasc Imaging 2009;25: Knirsch W, et al. Pediatr Cardiol 2008;29:
17 Myocardial deformabon imaging for early detecbon of myocardial impairment
18 Indicator of subclinical myocardial impairment SepBc shock Affects both circumferenbal and longitudinal strain «Before» abnormal EF Kawasaki disease Acute phase Decreased longitudinal strain (swelling from myocardibs?) AOer anthracycline therapy Even aoer low- dose Reduced systolic myocardial deformabon Basu S, et al. Pediatr crit care. 2011, In press. Yu JJ, et al. Pediatr Cardiol. 2010;31: Ganame J, et al. J Am Soc Echocardiogr. 2007;20: Cheung YF, et al. Heart. 2010;96:
19 Duchenne Muscular Dystrophy Remodeling paoern different than DCM Myocardial strain abnormalibes despite normal EF CircumferenBal strain is reduced (MR study)* Strain values conbnue to decline with age Early deformabon abnormalibes**: Infero- and antero- lateral wall AffecBng both longitudinal and radial strain * Hor KN, et al. J Am Coll Cardiol. 2009;53: ** Mertens L, et al. J Am Soc Echocardiogr. 2008;21:
20 Fabry disease Prior to the development of LVH, funcbonal abnormalibes could be detected StarBng in the infero- lateral wall Weidemann, F. et al. Eur Heart J. 2005;26: Also in Becker muscular dystrophy, Pompe disease, Pre- clinical myocardial impairment
21 Normal values of strain? 284 consecubve pabents: 0 18 years Longitudinal strain did not change significantly with maturabon and declining heart rate Systolic and early diastolic SR declined unbl age 5 to 10 Longitudinal strain was significantly correlated with leo ventricular growth From Lorch, JASE 2008.
22 Problems in clinical pracbce Technical acquisibon Normal values vary between techniques and studies Inter- and intra- observer variability VariaBon compared to reference methods Load- dependency Regional vs global funcbon Should we use strain or strain rate? Need for standardizabon Further of acquisibon studies needed and processing Time consuming (processing Bme) IncorporaBon of results into clinical decision making PredicBve value of STE not known yet
23 Conclusion The use of strain imaging, parbcularly STE, show great potenbal in pediatrics. In the assessment of CHD In the diagnosis of subclinical myocardial impairment It s now Bme for larger prospecbve studies To establish clearly the ublity for clinical decision making and prognosbcabon
24 Thank you for your aoenbon!
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