Tissue Doppler and Strain Imaging Steven J. Lester MD, FRCP(C), FACC, FASE Relevant Financial Relationship(s) None Off Label Usage None 1
Objective way with which to quantify the minor amplitude and temporal subtleties in motion 2
1. What is myocardial imaging? 2. Potential Clinical Applications 3. Impediments to widespread clinical adoption? Doppler Tissue Imaging 1. Turn wall filters off 2. Turn down the gain 3
Septal Myocardial Velocity Traces S1 S2 e a Normal 4
To Detect Regional Wall Motion Peak Pulsed Velocities TD Mean Color Velocities TD 14 11 5
Translation and Tethering Strain = deformation resulting from applied force Stress = force Courtesy of Ted Abraham 6
Used to describe elastic properties of cardiac muscle (Mirsky and Parmley: Circ Res, 1973) Strain ( ) = L 1 -L 0 L 0 10 cm L 0 L 1-20% Strain rate 8 cm +20% 12 cm 0% 10 cm Rate of deformation High strain rate Low strain rate Equal strain Courtesy of Andreas Heimdal 7
AoC Basal Mid wall Apical Basal Mid wall Apical Movement of the myocardium relative to the sample volume fixed in space 8
Speckle Tracking Velocity is estimated as a shift of each object divided by time between successive frames (or multiplied by Frame Rate)--> 2D vector: (Vx, Vy) = (dx, dy) * FR Y dy 0 dx New location Old location X Courtesy Peter Lysysanksy Potential Advantage? Signal noise Speckle tracking by principle is angle independent Gray scale (standard views) Monitor strain in two rather than one dimension Minimal user input Assessment of rotation: derived from circumferential strain at different levels in the heart (NO fixed sample volume) 9
Rotation/Twist/Torsion Rotation Rotation and Torsion Basal Rotation Torsion Apex View from apex 10
Normal Abnormal relaxation Pseudonormalization Restriction Mitral flow E A Tissue Doppler E A Apical rotation Basal rotation LV torsion Park et al: J Am Soc Echo Cardiogr 21:1129, 2008 Potential Clinical Applications 11
Strain (%) Impaired Systolic Function by Strain Imaging in Heart Failure With Preserved Ejection Fraction Strain Imaging detects impaired systolic function despite preserved global LVEF in HFpEF that may contribute to the pathophysiology of the HFpEF syndrome. J Am Coll Cardiol 2014;63:447-56 0 Controls Hypertensive Heart Disease HFpEF -5-10 Longitudinal Circumferential -15-20 * * -25-30 * * *p<0.0001 compared to controls and between HHD and HFpEF J Am Coll Cardiol 2014;63:447-56 12
Longitudinal Strain NT-proBNP 13
Cardio-Oncology 76 year old male CMML/MDS with associated myeloid sarcoma skin lesions Experimental Chemotherapy ABT-348 14
Baseline 2 Months LVEF = 66% LVEF = 58% Baseline 2 Months LVEF = 66% LVEF = 58% GLPSS Avg = -17.8% Troponin T = 0.02 GLPSS Avg = -14.3% Troponin T = 0.03 15
Global Longitudinal Peak Systolic Strain (GLS) Members of the in Chamber the range Quantification of -20% Writing Group are: Roberto M. Lang, MD, FASE, et al - Optimize image quality, maximize frame rate and minimize foreshortening. - When regional tracking is suboptimal in more than two J Am myocardial Soc Echocardiogr segments 2015;28:1-39 in a single view the calculation of GLS should be avoided. Aortic Valve closure 16
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Anthracyclines and Trastuzumab Can we predict a later (3 months) decline in LVEF? No decrease in GLS > 10% or elevated hstni have a 3% probability of a decrease in LVEF. If either a decrease in GLS or elevated hstni have a 9X increased risk for cardiotoxicity compared to those with no changes in either of these markers. - CRTCD GLS is the if decrease optimal parameter in LVEF >10% of deformation to a value <53% for the early -Reversible: detection of to subclinical within 5 percentage LV dysfunction. points of baseline - In patients with available baseline strain measurements, -Partially reversible: a relative improved percentage by >10 reduction percentage of points GLS from of <8% the nadir from but baseline remaining appears >5 percentage not to be points below meaningful, baseline and those >15% from baseline are very likely -Irreversible: to be abnormal. improved by <10 percentage points from the nadir and remaining >5 percentage points below baseline 18
Athlete HTN HCM Infiltrative -amyloid Storage -Fabry The Thinker Auguste Rodin 19
Application of a Parametric Display of Two-Dimensional Speckle-Tracking Longitudinal Strain to Improve the Etiologic Diagnosis of Mild to Moderate Left Ventricular Hypertrophy J Am Soc Echocardiogr 2014;27:888-95 20
Cardiac Amyloidosis Hypertensive Heart Disease Hypertrophic Cardiomyopathy 14mm 14mm 13mm Mean Wall Left Ventricular Thickness 21
Up to 50% with asymptomatic severe AS and preserved LVEF will have subclinical LV dysfunction as noted by reduced longitudinal strain. Low longitudinal strain Independent predictor of symptom development More likely to have an abnormal BP response to exercise J Am Coll Cardiol Img 2014;7:1151-66 Higher rates of cardiac events at follow up LVEF > 50% LVESD < 50mm LVEDD < 65mm LVEF > 50% Vmax <5m/s ΔPmean <60mmHg Normal ETT ΔVmax <0.3m/s/yr LVEF >60% LVESD <40mm Sinus Rhythm PASP <50mmHg Successful Repair <95% Or Mortality >1% Asymptomatic (Stage C) Positive Stress Test Rest LV GLS (<) -18% Aortic Regurgitation* Aortic Stenosis Mitral Regurgitation Mitral Stenosis Valve Periodic Replacement / Monitoring Repair? Very Severe MVA<1cm 2 T 1/2 > 220 - Unfavorable morphology, LA clot, > mild MR Severe MVA<1.5cm 2 T 1/2 > 150 -Sinus rhythm -Afib with Unfavorable morphology, LA clot, > mild MR *ACC/AHA NOT ESC guidelines 22
Impediments to Clinical Adoption? 1. Standardization 2. Workflow 23
-30-18.8 ±3.4-20.2 ±3.6-21.0 ±3.9-18.8 ±3.6-18.2 ±3.6-20.0 ±3.6-18.5 ±3.2-18.5 ±3.1-21.5 ±4.0-19.4 ±3.3-20 GLS AV, % -10 0 Hitachi-A Esaote GE Philips Samsung Siemens Toshiba Epsilon Tomtec Mean of All Farsalinos et al. J Am Soc Echocardiogr 2015;28:1171-81 20 19.7 17.0 Mean Error, % 15 10 12.2 11.6 8.2 6.9 5 0 GLS AV E E/A IVS LVEDD PW GLS AV Farsalinos et al. J Am Soc Echocardiogr 2015;28:1171-81 24
12 10.1 10 8.6 8.1 GLS AV, % 8 6 5.9 6.5 6.5 6.8 6.2 5.4 5.3 4 2 0 Hitachi-A Esaote GE Philips Samsung Siemens Toshiba Epsilon Tomtec EF BI Farsalinos et al. J Am Soc Echocardiogr 2015;28:1171-81 Any innovation in imaging must be paralleled or exceeded by an innovation in workflow. 25
Fully Automated Versus Standard Tracking of Left Ventricular Ejection Fraction and Longitudinal Strain The Fast-EFs Multicenter Study J Am Coll Cardiol 2015;66:1456-66 26
1. AutoLV measurements were feasible in 98% of studies. 2. Average analysis time was 8+1 sec/patient. 3. Interobserver variability was higher for both visual and manual EF, but not different for LS. Lower resolution (spatial and temporal) 27
a promising approach J Am Soc Echocardiogr 2012;25:68-79 What s Next Starts Soon Standardization Workflow Efficiency 28
Confucius It doesn t matter how slowly you go as long as you do not stop 29