22 nd Annual Conference of the Saudi Heart Association Riyadh, Saudi Arabia
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1 22 nd Annual Conference of the Saudi Heart Association Riyadh, Saudi Arabia New Echocardiographic Modalities to Evaluate Ventricular Function in Congenital Heart Disease: Tissue Doppler & Strain Rate Imaging Benjamin W Eidem, MD, FACC, FASE Professor of Pediatrics & Medicine Divisions of Pediatric Cardiology& Cardiovascular Diseases Mayo Clinic No Disclosures
2 Overview
3 Evaluation of Ventricular Function Intrinsic myocyte function Ventricular pump function Wall properties Elasticity Fiber structure Global geometry Active force development (pressure generation) Deformation (volume ejection) Peripheral circulation Loading conditions
4 Evaluation of LV Systolic Function Volumetric parameters LVSF % and LVEF % Readily performed Load dependent Do not evaluate Regional function Longitudinal function Echocardiography
5 Evaluation of LV Diastolic Function
6 Evaluation of RV Function Echocardiography h Unique challenges with RV Geometry Anatomic location Different hemodynamics compared to LV Right - left heart interaction Effects of co-existing congenital heart disease Loading conditions
7 Evaluation of Ventricular Function Congenital Heart Disease Challenges in congenital heart disease Complex anatomy Variable loading conditions Regional myocardial function RV function as relevant as LV function
8 Evaluation of Congenital Heart Disease Segmental Approach Situs & Position Systemic & Pulmonary Venous Connections Atrial & AV Connection Ventricular morphology VA Connection Great Arteries Hypoplastic Left Heart
9 Evaluation of Ventricular Function Echocardiographic Segmental Approach LV systolic function M-mode parameters Stress-velocity index LVSF % and LVEF % LV diastolic function Mitral inflow Doppler Pulmonary venous Doppler Color flow propagation LA volume LV global function Myocardial performance index LV longitudinal function Tissue Doppler LV regional function Strain and strain rate LV torsion
10 Evaluation of Ventricular Function 3-Dimensional Echocardiography Courtesy Phillips & G Shirali
11 Evaluation of Ventricular Function New Echo Modalities Tissue Doppler Strain & strain rate imaging
12 Tissue Doppler & Strain Rate Imaging Potential ti Advantages Quantitative evaluation of myocardial motion & deformation Less geometric limitations Less impacted by loading conditions Better suited to serial evaluation Enable early identification of ventricular dysfunction Facilitate earlier and better treatment modalities
13 Tissue Doppler Imaging Systole 20 cm/s IVC Peak systole 20 cm/s IVRT E A Diastole
14 Tissue Doppler Imaging Background Longitudinal and radial shortening and lengthening Load independent Myocardial Systolic & diastolic components Heterogeneous distribution of TDI velocities Cardiac translation & tethering Orientation of myocardial fibers Systolic and diastolic velocity gradients CP
15 Pulsed Wave Tissue Doppler Longitudinal Velocities Lateral mitral annulus Septal annulus Tricuspid annulus
16 Tissue Doppler Imaging Assessment of LV Diastolic Function Magnitude of Ea velocity blunted with diastolic dysfunction (cath-derived tau) Loading conditions Ea less influenced by loading conditions Diastolic dysfunction Pseudonormal mitral inflow Elevated LV filling pressures Constriction vs restriction
17 Tissue Doppler in Normal Children TDI velocities impacted by cardiac growth LV end-diastolic diastolic dimension LV mass TDI velocities also impacted by Age Heart rate TDI not influenced by Gender Mitral inflow Doppler LV SF, LV EF, LV & RV MPI Eidem et al: JASE, 2004 Mit ral annula ar E-wave velocity (c cm/sec) tral annu lar E-wav ve velocity (cm/sec) Mi LVEDD (cm) Age (yr)
18 Clinical Outcome in DCM Variable OR 5-95% CI P Multivariate analysis Tricuspid Ea velocity LVEF Univariate analysis Tricuspid Ea velocity <0.001 RV Tei index LVEF < LVEF in DCM Tricuspid Ea in DCM fraction (% %) Ejection Cntl DCM P- DCM P+ Tri icuspid late eral annulus Ea velocit ty (cm/s) N NH H/I D/T PEP+ McMahon CJ: Br Heart J, 2004
19 Tissue Doppler in HCM Myocardial velocities in HCM VO 2 max (ml/min/kg) Myocardial velocities &VO 2 max y=54-2x r=-0.74 P< Septal E/Ea
20 Tissue Doppler Preclinical Diagnosis of HCM 21 Peak Systolic Septal Velocities Septal Sa (cm/s) 18 Reduced peak systolic 15 velocities in M+ with normal wall thickness Normal M + LVH - M + LVH + n=30 n=13 n=30 Nagueh SF: Circulation, 2001
21 Assessment of Ventricular Function Tissue Doppler - IVA Tissue Doppler Velocities Affected by loading Isovolumic Acceleration Begins at initial onset of LV pressure rise Earliest of systolic events Vogel M et al, Circ 2003
22 Assessment of Ventricular Function Tissue Doppler - IVA LV & RV Contractility Independent of physiologic s in preload & afterload Correlates with invasive E es and dp/dt max Correlates with s s in contractile state Force - frequency Atrial pacing Esmolol Vogel M et al, Circ 2002 & 2003
23 Tissue Doppler Detection of Allograft Rejection Baseline Sa, Ea vs controls IVA similar with rejection FS% M-mode score Sa, Ea IVA Pauliks et al: JHLT 2005 Baseline tissue Doppler Tissue Doppler with rejection
24 Tissue Doppler Limitations Angle dependency Influenced by global heart motion Cardiac translation & torsion V Myocardial motion 2 influenced by adjacent V segments (tethering) V 1 Load dependency
25 Strain Rate Imaging Elastic Deformation Properties Strain = myocardial deformation caused by fiber contraction ti I Strain = I I (L L 0 ) / L 0 0 V 1 Strain rate = rate of regional d I myocardial shortening & 0 V2 V 2 V 1 -V 2 lengthening Strain rate = d Myocardial Doppler velocities at 2 different locations spatial L/L SR = 0 v(i 0 ) - v ( L + L 0 ) = velocity gradient t L 0 Less load dependent Less variation in different (t) = t L (t + dt) - L(t) myocardial wall segments t0 L(t)
26 Strain Rate Imaging Velocities Natural Strain Rate Natural Strain r v 1 v.. v 2 Calculate spatial gradient Integrate temporally Strain (rate) estimation = velocity estimation + post processing
27 Strain Rate Imaging Radial Function Peak systolic strain rate Thickening Thinning SYS AVC MVO DIAST Strain rate (sec -1 ) Peak systolic strain Strain (%) Courtesy L Mertens
28 Strain Rate Imaging Longitudinal Function Shortening Lengthening Peak systolic strain rate SYS DIAST Strain rate (sec -1 ) Peak systolic strain -20 Strain (%) Courtesy L Mertens
29 Strain Imaging in Children Normal Longitudinal Deformation Systolic Strain LV Sept LV Lat LV Inf RV Free b m a b m a b m a b m a -20% -20% -40% -40% -60% -60% Weidemann: JASE, 2002
30 Case Presentation 4 month old presents to local ER Poor feeding & weight gain Tachypnea, pallor Physical exam Tachycardic, hypotensive III/VIHSMapex-- --> axilla Poor distal pulses & perfusion CXR cardiomegaly & pulmonary edema ECG Q-waves in leads I and AVL Echocardiogram performed in ER
31 Echocardiogram
32 ALCAPA Strain Rate Imaging Clinical Outcome in CHD Causes global LV ischemia LV histological changes of hibernating myocardium Re-implantation of coronary artery results in normalization of LV function Courtesy BCH
33 ALCAPA Radial LV Function % 80 Preop 1 week postop 5 mo postop Strain 40 Mertens L, Cardiol Young 2001
34 ALCAPA Longitudinal Strain I Normal ALCAPA II III DiSalvo G, AJC 2004 AVC Strain curve [%] AVC
35 ALCAPA Longitudinal Strain Rate Normal 2 2 I -2-2 ALCAPA II -2 2 III 2-2 AVC -2 AVC DiSalvo G: AJC, 2004
36 Strain Rate Imaging Clinical Outcome in Cardiomyopathy Duchene Muscular Dystrophy Mutation in dystrophin gene Genetic model for dilated cardiomyopathy Young patients often have normal LV function > 90% develop DCM later in life
37 Routine Echocardiographic Results DMD <12 yr Normals Age 7.4± ±2.8 Heart rate 102.2± ±13.8* LVEDD/BSA 4.3± ±0.6 LVESD/BSA 2.9± ±0.4 LV FS (%) 33.7± ±3.7 LV EF (%) 64.9± ±5.6 Mitral E 1.0± ±0.1 Mitral A 0.5± ±0.1 E/A ratio 2.1± ±0.6 Deceleration time 126.6± ±22.8 Mertens L: AEPC, 2004 *P<
38 Correlation of Strain & Age in DMD DMD 3-6 yr %) Strain ( 70 r= P<0.05 train (% %) DMD 7-11 yr Controls S Age Age Mertens L, AEPC 2004
39 Hypertrophic p Cardiomyopathy y Echocardiography
40 Strain Rate Imaging g in HCM Septal Deformation Strain (%) apex mid Ao Ac Mc base Mid septal lengthening was found in 50 % of the HCM s patients t time (ms) Yang H, JASE 2003
41 Strain in Pediatric HCM Strain vs Z score for IVSD thickness
42 LV Deformation in Pediatric HCM 0.0 SR S basal SR mid S mid SR basal S basal septum septum septum septum lateral lateral * HCM Controls * * P<0.001 vs controls; *P<0.01 vs controls Ganame: JASE, 2005
43 Hypertrophic Cardiomyopathy Strain & Strain Rate Imaging Strain in HCM Strain Family history of HCM
44 Strain & Strain Rate Imaging Limitations 1-dimensional technique Load dependent Angle dependent - a r l Frame rate >150 fps Aliasing + a Reverberation artifacts Data processing l r
45 Strain & Strain Rate Imaging Myocardial Twist & Torsion
46 Strain & Strain Rate Imaging Speckle Tracking
47 Strain & Strain Rate Imaging Myocardial Twist & Torsion
48 Strain & Strain Rate Imaging g g Myocardial Twist & Torsion
49 Strain & Strain Rate Imaging Myocardial Twist & Torsion Myocardial twist mechanics Subendocardium Right handed helix Subepicardium Left handed helix Clockwise twist of base vs CCW at cardiac apex Systole - global LV twist related to ejection + stored energy Diastole -2 phases Early rapid recoil Gradual later untwisting
50 Myocardial Deformation Imaging Age, Loading Conditions & LV Twist LV twist from childhood adulthood Apical CCW rotation ti constant t Base CW rotation changes with age Infancy CCW rotation Childhood d neutral Adolescence CW rotation Sengupta, JACC 2008
51 Hypertrophic p Cardiomyopathy y Deformation Imaging Richland et al, AJC 2007
52 Evaluation of Systemic RV Function Pressure - Volume Relationship RV Pressure - Volume Loop LV Pressure - Volume Loop Redington A, Cardiol Clin 2002
53 Evaluation of Systemic RV Function Strain & Strain Rate Systemic RV Circumferential > longitudinal RV strain Similar to normal LV strain pattern Circumferential > longitudinal SR compared to normal llvsr Petterson E, JACC 2007
54 TDI & Strain Rate Imaging in CHD Conclusions Sensitive techniques for detecting regional abnormalities New insights into pathophysiology of CHD Early identification and treatment of ventricular dysfunction Ongoing clinical validation studies
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