Novel echocardiographic modalities: 3D echo, speckle tracking and strain rate imaging. Potential roles in sports cardiology. Stefano Caselli, MD, PhD Ospedale San Pietro Fatebenefratelli Rome, Italy
Differential diagnosis of the athlete s heart Up to 15% of athletes may develop left ventricular enlargement which rises the differential diagnosis with DCM Up to 2% of athletes show LV wall thickening which rises the differential diagnosis with HCM Other forms of LVH DCM Athlete s Heart HCM
Beyond ECG and conventional Echo HCM patients Normal EKG, 6% Abnormal EKG, 94% Pelliccia et al NEJM 2008 McLeod et al JACC 2009
The need for new diagnostic tools!
Speckle Tracking Echocardiography Relative distance
Strain is a measure of deformation. Strain rate is the velocity of deformation Strain(%), ε = (L 0 L 1 ) L 0 Strain rate = ε / sec
Components of myocardial strain Radial strain: thickening (+) Longitudinal strain: shortening (-) Transverse strain: thickening (+) Circumferential strain: shortening (-) S. Caselli, MD
Longitudinal Strain
Longitudinal Strain Rate Peak E Peak A Peak S
Myocardial Strain in Athletes Longitudinal Strain (Negative) Controls Athletes Nottin S et al J Physiol 2008
Longitudinal Strain (%) Effects of EXTREME EXERCISE on LV strain in athletes 23 triathlon athletes participating the Ironman competition. STE was performed before and soon after the race. All components of strain were reduced in systole, after the race. Nottin S et al. Circ Cardiovasc Imaging 2009
Left Ventricular Strain in pathologic left ventricular hypertrophy (LVH) Controls Rowers Hypertension Longitudinal -21 ± 2-22 ± 3-17 ± 3* Circumferential -18 ± 3-18 ± 2-16 ± 4* Radial 46 ± 16 48 ± 19 46 ± 17 Galderisi et al. J Am Soc Echocardiogr 2010
Left Ventricular Strain in pathologic left ventricular hypertrophy (LVH) 30 Hypertensive pts, 30 Power athletes 48 controls Hypertensive pts had: Global longitudinal strain Peak systolic strain rate Early diastolic strain rate Saghir M et al J Am Soc Echocardiogr 2007
Hypertrophic Cardiomyopathy
Strain imaging in HCM Controls HCM p<0.001 p<0.001 p<0.001 p<0.001 20 18 16 14 12 10 8 6 4 2 0 40 35 30 25 20 15 10 5 0 Transverse Radial Transverse Radial Longitudinal Circumferential Transverse Radial Serri et al. J Am Coll Cardiol 2006
Strain imaging in HCM 29 Soccer players, 26 nhcm and 17 controls Circumferential, transverse and radial strain significantly reduced in HCM patients compared to athletes and controls. Longitudinal strain reduced in hypertrophied segments. Richand V, Am J Cardiol 2007
Strain rate in HCM 56 nhcm patients All strain components reduced compared to controls. All underwent cardiopulmonary exercise test. Reduced Strain Rate predicts reduced exercise capacity in nhcm patients. Peak VO2 was reduced in nhcm patients. Longitudinal strain rate correlated significantly with peak VO2 Abozguia K et al. Am Heart J 2010
Live 3D Echocardiography
Quantitative Analysis Volumes & EF LV Shape LV Mass LV regional function / synchronicity
3D echo in athletes.
3D echo in athletes. Upper limits for LV end-diastolic volume and mass Caselli S et al. Am J Cardiol 2011 (in press)
3D echo in athletes. LV Mass EDV ESV Controls Skill Strength Combined Endurance Caselli S et al. Am J Cardiol 2011 (in press)
Left Ventricular Remodelling Index LVRI = LV Mass End diastolic Volume
LV Mass LV Mass Left Ventricular Remodelling Index LVRI = 2.0 Healthy Volunteers Competitive Athletes Hypertrophic Cardiomyopathy LVRI = 0.5 Dilated Cardiomyopathy End-Diastolic Volume De Castro S Caselli S - Heart 2007
Left Ventricular Remodelling Index Patterns of LV adaptations are similar in all athletes, regardless to the specific sport discipline End-Diastolic Volume Caselli S et al. Am J Cardiol 2011 (in press)
Myocardial Dispersion Index 68 subjects including controls, athletes, hypertensive and HCM. Septum Anterior LV was divided in a 12 segments model. MDI was calculated as the mean Standard Deviation at the basal medium and apical segments. Inferior Lateral Apical Medium Basal Caselli S et al. Am J Cardiol 2008
Caselli S et al. Am J Cardiol 2008 Myocardial Dispersion Index MDI > 1.13 Sensitivity 93% Specificity 100%
Left Ventricular Non Compaction
Left Ventricular Non Compaction
Left Ventricular Non Compaction 17 patients with LVNC. Analysis of Trabecular Volume by 3D echocardiography. No differences between Athletes and controls LVNC patients had a 4-fold increase in Trabecular Volume. Caselli S et al. Euroecho 2010
Beyond EKG In the majority of cases the screening of the athletes with EKG and conventional echocardiography allows the correct definition of athlete s heart and differential diagnosis with cardiomyopathies. There is however a smaller percentage of young athletes who fall in the so called grey zone. Speckle tracking echocardiography allows a deeper and accurate investigation of myocardial mechanics in systole and diastole. 3-dimensional echo allows a better description of the anatomy and geometry of the heart chambers.
Thank you Stefano Caselli