How To Perform Strain Imaging; Step By Step Approach. Maryam Bo Khamseen Echotechnoligist II EACVI, ARDMS, RCS King Abdulaziz Cardiac Center- Riyadh
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1 How To Perform Strain Imaging; Step By Step Approach Maryam Bo Khamseen Echotechnoligist II EACVI, ARDMS, RCS King Abdulaziz Cardiac Center- Riyadh
2 Outlines: Introduction Describe the basic of myocardium architecture Basic term and definition for myocardium function Explain the three principle of vectors myocardium deformation Clinical applications of STE for assessment of LV deformation Take home message
3 Introduction: The interpretation of wall motion is an important component of echocardiography but remain a source of variation between the observers An accurate and reproducible measurement of left ventricle is available by automated LV quantification
4 Cardiac Architecture -Historical Description Two layer of muscle fibers which travel in opposite direction Richard Lower. Tractatut de corde London 1969
5
6 Clockwise rotation (-) Twist & Untwist (Due to helical structure of the heart) Counter-clockwise rotation (+)
7
8 Terms and definition: basic parameters of myocardium function Speckle Tracking echocardiography(ste): Has emerge as an alternative angle independent technique based on frame-by-frame tracking of tiny echo dense speckle within myocardium and subsequent measure of LV deformation
9 Strain(s): describe myocardium deformation that is, the fractional change in the length of myocardium segment. Strain can be positive or negative which reflect lengthening or shortening respectively Strain Rate(SR): is the rate of change of strain and express as 1/sec or sec-1
10 LV Rotation: refers to myocardial rotation around the long axis of the LV.It is rotational displacement and is expressed in degree or radians. Normally the base and the apex of the ventricle will rotate in opposite direction. Net LV Twist: (express in degree or radians) Referred to an absolute apex-to-base different in LV rotation (Normally=20 degree)
11 Strain: + 20% -20 % 0 % 10 cm 8 cm 12 cm 10 cm Strain is unit less and expressed as %
12 Strain Rate: SR=1/4=.25 sec SR=1/2=.5 sec 1/sec or sec-1
13 JASE, January 2015
14 ASE/EACVI cardiac chamber quantification, 2015
15 The mechanics of the heart
16 1- Longitudinal contraction:
17 Shortening negative Lengthening positive End-systole
18 Positive strain lengthening Negative strain Shortening
19 Shortening Lengthening
20 2-Circumferential contraction:
21 3- Radial contraction:
22 The Heart Has a Rotation: Winging of a linen cloth to squeeze out the water
23 Rotation: The basal LV clockwise rotation N=-7) Apical LV counter-clockwise rotation (N =13)
24 Net LV Twist : Base Apex -9 Degree 19 Degree (0) -9 degrees 19 degrees (0) Net LV twist angle = +28 degrees (Normal=20 degrees)
25 Base Apex
26 4-year-old healthy boy (0) (0) Basal rotation= + 3 degree Apical rotation= + 6 degrees
27 25 years old male (0) (0) Basal rotation= -7% Apical rotation= +10%
28 Clinical applications of STE for assessment of left ventricular deformation STE in early detection of cardiotoxicity during and after chemotherapy STE in amyloidosis STE in HOCM STE in Aortic stenosis
29 A 10% to 15% early reduction in GLS by STE appears to be the most useful parameter for the prediction of cardiotoxicity.
30 Conclusion : AFI Obtained global longitudinal strain has better correlation with Auto EF than Simpson's method EACVI, Istanbul, 2013
31 Case 1 53-year-old female with breast cancer on chemotherapy(herceptin)
32
33 Longitudinal Strain
34 Longitudinal Strain
35 Longitudinal Strain
36 Bull s eye
37 EF=54% Auto EF
38 F/U study one year later
39 Follow up after one year Baseline echo One year after chemotherapy GS= -20.3% GS= -14%
40 Follow up after one year Baseline echo One year after chemotherapy GS= -18% GS= -16.7%
41 Follow up after one year Baseline echo One year after chemotherapy GS= -19.2% GS= -13.7%
42 Follow up after one year Baseline echo One year after chemotherapy Reduce by 25% GLS_Avg= -19.3% GLS_Avg= -14.8%
43 STE in early detection of cardiotoxicity during and after chemotherapy STE in restrictive cardiomyopathy ( amyloidosis) STE in Aortic stenosis STE in HOCM
44 Case 2 82-year-old man presented to our center due to severe SOB and atrial fibrillation. No history of hypertension.
45
46
47
48
49
50
51 Longitudinal Strain
52 -5-4
53 Longitudinal Strain
54
55
56 Bullꞌs eye Cherry on top of the cake!!
57 STE in early detection of cardiotoxicity during and after chemotherapy STE in amyloidosis STE in Aortic stenosis STE in HOCM
58 Case 3 51-year-old male presented with SOB
59
60
61
62
63 Basal LV
64 Circumferential Strain
65 Global Rotation Basal LV, clockwise rotation -7 Degree
66 Mid LV
67 Circumferential Strain
68 Apical LV
69 Circumferential Strain
70 Global Rotation Apical counterclockwise rotation + 25 degree Net LV twist =23 degree
71 -32% -39% -21% Circumferential Strain and LV twist are preserved
72
73 Longitudinal Strain
74
75 Longitudinal Strain
76
77 Longitudinal Strain
78 Bulls eye Longitudinal Strain reduce
79 Conclusion: Following AVR significant improvement in LV myocardial strain both longitudinal and circumferential
80 Longitudinal Strain: Before AVR 6 Months later
81 Circumferential Strain: Before AVR 6 Months later
82 Case 4 67-year-old male with symptomatic HOCM
83
84 Circumferential Strain
85 Circumferential Strain
86 Longitudinal Strain
87 Longitudinal Strain
88 Take Home Message: Echocardiography measures of LV strain by speckle tracking (STE) have become a robust method to measure myocardial deformation Resolving the multidirectional components of LV deformation, offers important insights for detecting subclinical states that are likely to progress into either systolic or diastolic heart failure. As STE became widely available, it will be an important mission to ensure standardization of nomenclature, steps in data acquisition, and optimal training to reduce data variability.
89 Thank You
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