1/3/216 Strain, Strain Rate, and Torsion: Myocardial Mechanics Simplified and Applied VECTORS OF CONTRACTION John Gorcsan, MD University of Pittsburgh, Pittsburgh, PA Shortening Thickening Twisting No Financial Disclosures Gorcsan ASE FLA 216 Tissue Doppler: Velocity, Strain Rate and Strain STRAIN vs. VELOCITY STRAIN ISOLATES THICKENING L L Strain = (L-L ) / L L = Original Length L = Length of Deformed portion Thickening Frequency Shift (khz) Passive Movement Gorcsan J, JACC 211;58:141-13 L L Gorcsan ASE FLA 216 Calculation of Strain From Speckle Tracking Not Dependent on Doppler Angle Strain = Change in Length Original Length % Thickening % Thinning Longitudinal Strain LV Shortening End- Diastole End- Systole % Strain = % Change in Length Frame 1 Frame 1 + n Modified from Kawagishi, K End Diastole End Systole Gorcsan ASE FLA 216 1
1/3/216 Longitudinal Strain Global Longitudinal Strain (GLS) Average Strain End-Diastole End-Systole - 23% Apical 4-Chamber Apical 2-Chamber Apical Long-Axis Gorcsan ASE FLA 216 Gorcsan ASE FLA 216 Global Longitudinal Strain (GLS) Average Strain Apical 4-Chamber Polar (Bull s Eye) Plot Speckle Tracking Circumferential Strain REGION OF INTEREST Apical 2-Chamber Apical Long-Axis Gorcsan ASE FLA 216 Circumflential Strain Gorcsan ASE FLA 216 Speckle Tracking: CIRCUMFLENTIAL STRAIN Speckle Tracking Radial Strain REGION OF INTEREST Normal subject Gorcsan ASE FLA 216 Radial Strain Gorcsan ASE FLA 216 2
Rotation (degree) LV Torsion (degree) 1/3/216 SPECKLE TRACKING RADIAL STRAIN Normal Subject Strain and Torsion S P A L Contraction Counter-clockwise Apical Rotation as viewed from apex Contraction Basal Time Clockwise Systole Diastole Gorcsan ASE FLA 216 Notomi et al. Circulation 25; 111: 1141-7 TORSION IMAGING ROTATION Assessment of LV Torsion Basal Rotation Apical Rotation LV Torsion 2 Counterclockwise Rotation 15 1 5 Clockwise Rotation Basal Rotation Apical Rotation LV torsion calculated from speckle-tracking analysis of basal and apical short-axis routine echo images. Torsion was calculated as the maximum difference between LV rotation angles obtained from basal (clockwise) and apical (counterclockwise) planes. -5-1 What is The Normal Longitudinal Strain Value? n = 25 normal volunteers Gorcsan J. 216 3
1/3/216 Normal Global Longitudinal Strain N = 2,597 n = 2,597 normal subjects GLS: -15.7 to -21.1%, mean -19.7% JASE 213 Yingchoncharoen Marwick et al. JASE 213;26:185 Normal Global Circumferential Strain Longitudinal Echo Strain in 1,266 Healthy Individuals: Hunt Norwegian Study (Outlier ) N = 599 GCS: -2.9 to -27.8%, mean -23.3% Female Male Yingchoncharoen Marwick et al. JASE 213;26:185 Edvardesn Thor et al. JACC 213 GLS Values by Vendor, Gender and Age GE Philips Toshiba Summary, Normal Strain Values Global Longitudinal Strain Normal GLS:> -17% Borderline GLS: between -17% and -15% Clearly Abnormal GLS: < -15% Plana et al. J Am Soc Echocardiogr 214;27:911-39 Think greater or less than in absolute values Gorcsan ASE 216 4
Strain (%) Strain (%) Strain (%) Strain (%) 1/3/216 Summary, Normal Strain Values Global Circumferential Strain An Alternative to GLS Less in literature Normal GCS:> -21% Borderline GCS: between -19% and -21% What is The Relationship of Global Strain with EF? Clearly Abnormal GCS < -19% Think greater or less than in absolute values Gorcsan ASE 216 Global Strain Relates to Ejection Fraction LV Deformation = LV Blood Ejection Gorcsan ASE FLA 216 Linear Relationship of GLS to EF Linear Fit EF = 3 (GLS) Echo vs. Cardiac Magnetic Resonance Echocardiogram Normal Normal Heart Failure Patient -1-1 GLS -2 GLS -2 1ms Cardiac Magnetic Resonance -3 1ms Normal Systolic Function Time (ms) (CMR-EF=62%) -3 Systolic Dysfunction (CMR-EF=26%) Time (ms) -1-1 GLS -2 GLS -2 1ms -3 1ms Time (ms) -3 Time (ms) Basal-Septal Mid-Septal Apical-Septal Apical Lateral Mid-Lateral Basal-Lateral Global Longitudinal Strain (GLS) Onishi T, Gorcsan et al. ESC 211 5
FT CMR-GCS (%) Strain Strain Strain ST Echo-GCS (%) FT CMR-GLS (%) Strain (%) Strain (%) ST Echo-GLS (%) 1/3/216 Echo vs. Cardiac Magnetic Resonance Comparison Echo (SAX) Normal systolic function patient Circumferential strain in Echo Normal GLS vs. EF Echocardiogram - 1 GLS - 2 1ms Time (ms) - 3 n=73 n=68 CMR (SAX) -15-15 1ms Circumferential strain in CMR Time (ms) Time (ms) Onishi T, Gorcsan et al. ESC 211 Ant-Sep Anterior Lateral Posterior Inferior Septal Average (GCS) -1-2 p <.1 p <.1 R =.88 R =.85-3 -3 2 4 6 8 2 4 6 8 CMR-EF (%) CMR-EF (%) Onishi T, Gorcsan et al. ESC 211-1 -2 EF = 3* GLS + 8-1 5 1ms GCS vs. EF n=73 n=71-1 -1-2 -2-3 p <.1 p <.1 R =.95 R =.92-4 -4 2 4 6 8 2 4 6 8 CMR-EF (%) CMR-EF (%) Onishi T, Gorcsan et al. ESC 211-3 EF = 2.5* GCS + 8 Gorcsan ASE FLA 216 Association of Global Longitudinal and Global Circumferential Strain to EF Aortic Stenosis with LVH n N = 53 GLS GCS University of Pittsburgh Med Ctr. 215 6
INFARCT SIZE (G) 1/3/216 What Additional Information? GLS and GCS as Markers for Scar ENDOCARDIAL SCARRING Global Longitudinal Strain and Myocardial Infarct Size 59 patients 18 healthy subjects LS MIDMYOCARDIAL SCARRING Myocardial Scar by Late Gadolinium Enhancment CMR Kansal et al. Eur Heart J Cardiovasc Imaging 212 LS TRANSMURAL SCARRING LS CS CS GLOBAL STRAIN (%) 38 patients chronic ischemic heart disease GLS and Scar by Late Gadolinium Enhanced CMR Gjesdal et al.clinical Science (27) 113, 287 296 Contemporary Clinical Applications for Strain Imaging 216 Prognosis in Heart Failure Low EF Heart Failure Preserved EF (HEFpEF) Chemotherapy Cardiotoxicity Amyloid Heart Disease Aortic Stenosis Right Ventricular Strain in Pulmonary Hypertension Gorcsan J. ASE 216 GLS Predicts Survival N = 549 consecutive patients GLS is to Predict Survival N = 549 Stanton Marwick, et al, Circ Cardiovasc Imaging 29 GLS < -12% Tracks Similarly as EF < 35% Stanton Marwick, et al, Circ Cardiovasc Imaging 29 7
Strain (%) 1/3/216 GLS Appears to Add the Most to Predict Survival with Normal Wall Motion and/or EF > 35% Global Circumferential Strain & Prognosis in Heart Failure 21 HF patients EF = 23% HF Hospitalization or Death 5 yrs - 1-2 - 3 GCS Time (ms) 1ms Cho et al. J Am Coll Cardiol 29;54:618 N = 1,65 Heart Failure Clinic Patients N = 1,65 Heart Failure Clinic Patients * p<.1 vs. Controls and Hypertensive Heart Disease Kraigher-Krainer, Solomon et al. JACC 214;63:447 56 8
1/3/216 Association of GLS with Biomarkers for Heart Failure (NT-proBNP) GLS Predictive of Survival in Patients with ESRD and Preserved EF N = 48 African Americans with ESRD on Hemodialysis LV EF > 5% Baseline GLS Prospectively enrolled and followed 1.9 years GLS was predictive of All Cause Mortality Hazard ratio 1.15, 95% confidence interval 1.2 to 1.3, p =.2, Kraigher-Krainer, Solomon et al. JACC 214;63:447 56 Pressman G Gorcsan J et al. Am J Cardiol 215 Nov 15;116(1):161-4. Chemotherapy Associated with LV Dysfunction Chemotx Agent Incidence Frequency of use Antracyclines (Doxorubicin) 3-26% +++ Cyclophosphamide 7-28% +++ Trastuzumab (Herceptin) 2-28% ++ Yeh ET, Bickford CL. JACC 29;53:2231 47. Patients treated with Chemotherapy, as for Breast CA are having increased survival, cardiac toxicity is an increasing problem Objectives: To evaluate if more sensitive echocardiographic measurements and biomarkers could predict later cardiac dysfunction in chemo-treated patients. Sensitivity Specificity PPV NPV 1% decrease longitudinal strain 7/9 (78%) 27/34 (79%) 7/14 (5%) 27/29 (93%) Increased ctnl at 3 months 6/9 (67%) 28/34 (82%) 6/12 (5%) 28/31 (9%) 1% decrease Long strain and increased ctnl at 3 months 5/9 (55%) 33/34 (97%) 5/6 (83%) 33/37 (89%) 1% decrease Long strain or increased ctnl at 3 months 8/9 (89%) 22/34 (65%) 8/2 (4%) 22/23 (97%) GLS and Biomarker: Ultrasensitive Troponin I Am J Cardiology 211;17(9):1375-8 Chemotherapy Cardiotoxicity Plana et al. J Am Soc Echocardiogr 214;27:911-39 9
1/3/216 Progression of Cardiotoxicity with Chemotherapy GLS was Additive to EF to Predict Chemo Cardiotoxicity N = 24 patients with cardiotoxicity Thavendiranathan P et al. J Am Coll Cardiol 214 Jul 1;63 GLS < 11% Nigishi Marwick et al. JASE 213 CASE STUDY 62 year old man with 2 pound weight loss over 3 months and diagnosis of gastroparesis. New progressive dyspnea on exertion and new 1+ peripheral edema CASE STUDY 62 year old man with weight loss, gastroparesis, dyspnea and edema. Base Mid Apex Segmental Longitudinal Strain Normal Subject Our Patient Apical Sparing Basal Strain = - 21.1% Mid Strain = - 22.3% Apical Strain = -25.3% Basal Strain = - 5.% Mid Strain = - 5.8% Apical Strain = -17.2% Amyloid Heart Disease 1
1/3/216 Longitudinal Strain, Sparing Apex in Cardiac Amyloidosis Apical Longitudinal Strain Sparing in Amyloidosis Examples of Increase Wall Thickness No Amyloidosis Examples of Cardiac Amyloidosis Heart 212;98:1442 Phelan Thomas JD, Heart 212 Amyloid Heart Disease Apical / Basal+Mid Segmental Longitudinal Strain Ratio Avg. Apical LS Ratio Avg. Basal LS+Mid LS > 1. 93% Sensitive 82% Specific Phelan Thomas JD, Heart 212 Segmental Longitudinal Strain Our Patient Basal Strain = - 5.% Mid Strain = - 5.8% Apical Strain = -17.2% Avg. Apical LS Avg. Basal LS+Mid LS > 1. 93% Sensitive 82% Specific -17.2% -5.4% = 3.2 Phelan Thomas JD, Heart 212 Abnormal GLS in Cardiac Amyloidosis n = 172 patients with Cardiac Amyloidosis n=8 with Light Chain Immunoglogulins n=36 transthyretin-related mutant form n=56 Nonmutant transthyretin-related amyloidosis GLS (-%) 16 14 12 1 8 6 4 2-12+4% Light Chain - 15+4% Transthyretin Mutant Form - 11+3% Transthyretin Nonmutant Form Quarta, Solomon et al. Circulation. 214;129:18 184-1849 Prevalence of Abnormal Echo Indices in Cardiac Amyloidosis n = 172 patients with Cardiac Amyloidosis n=8 with Light Chain Immunoglogulins n=36 transthyretin-related mutant form n=56 Nonmutant transthyretin-related amyloidosis Quarta, Solomon et al. Circulation. 214;129:18 184-1849 11
1/3/216 GLS Predicts Survival in Cardiac Amyloidosis n = 125 patients with Severe AS Preop GLS GLS Quartile 1 and 2 GLS Quartile 3 GLS Quartile 4 Quarta, Solomon et al. Circulation. 214;129:18 184-1849 GLS was Additive to Clinical Features and EF n = 125 Future Clinical Applications of Strain Imaging APICAL TORSION 3D Speckle Tracing Strain DECREASED LV ROTATION IN HEART FAILURE- NORMAL EF Normal Control Heart Failure Patient Preserved EF Basal Rotation Untwist Untwist Apical Rotation Tan Sanderson et al. J Am Coll Cardiol 29;54:36 46 12
1/3/216 HFPEF has Blunted Increases in LV Function with Exercise n = 27 Normal Controls, n = 56 HFNEF, Untwist Rate 14 Rest 12 Exercise % 1 8 6 4 2 Longitudinal Strain * Radial Strain Normal HFPEF Normal HFPEF Normal HFPEF * Tan Sanderson et al. J Am Coll Cardiol 29;54:36 46 * Proposed Pathophysiology HFPEF Tan Sanderson et al. JACC 29;54:36 46 THE ECHO TIMELINE RV 3D AREA TRACKING STRAIN Normal Subject Pulmonary Hypertension Patient M-Mode 2D 3D/4D Base Base Free wall Free wall Septum We Are Now Septum Free wall Gorcsan J. 215 Strain Imaging into the Future J Am Soc Echocardiogr 215;28:183-93 ASE Announcement: Myocardial Strain Imaging Acceptance of New CPT Category III code, 39X9T Introduced January, 216. Category III codes are generally not reimbursed: Often lead to the adoption of payable codes by CMS and other payers. Take Home Messages Speckle Tracking Strain has emerged as the most useful new echocardiographic tool to assess myocardial function. Global Longitudinal Strain is best represented in the literature as being a sensitive measure additive to EF, followed by Global Circumferential Strain. Most Promising New Clinical Applications: Adding to EF to Enhance Prognosis Cardiochemotherapy Cardiac Amydoidosis Diastolic Function 3D applications for LV and RV strain are exciting! 13