Regional Left Ventricular Systolic Function Research Articles

GW24-e0649 Assessment of left ventricular regional systolic function in patients with hypertrophic cardiomyopathy by real-time three-dimensional echocardiography

ObjectivesThe aim of our study is to assess left ventricular regional systolic function in patients with hypertrophic cardiomyopathy (HCM) using real-time three-dimensional echocardiography (RT-3DE).MethodsRT-3DE was performed in 25 HCM patients...

GW24-e3685 Three-dimensional speckle tracking imaging in assessment of left ventricular regional systolic function after transcatheter aortic valve implantation

ObjectivesTranscatheter aortic valve implantation (TAVI) is a new medical technology developed in recent years. It solves the problem of high operation risk of aortic valve stenosis undergoing thoracotomy replacement, its...

GW24-e0648 Clinical application of left ventricular systolic function in patients with rheumatic disease by three-dimensional ultrasound speckle tracking imaging

ObjectivesThe aim of our study is to assess left ventricular global and regional systolic function in patients with pure mild to moderate rheumatic mitral stenosis (MS) by 3-dimensional ultrasound speckle...

Assessment of regional left ventricular systolic function in patients with hypertrophic cardiomyopathy by real-time three-dimensional echocardiography

Objective To assess regional left ventricular systolic function in patients with hypertrophic cardiomyopathy (HCM) using real-time three-dimensional echocardiography (RT-3DE).Methods Twenty-five patients with HCM which was asymmetric septal hypertrophy,and twenty healthy subjects were enrolled in the study.The apical four-chamber view of left ventricular was acquired by RT-3DE.The left ventricular volume-time curves were analyzed quantitatively with Tomtec 4D LV-Analysis 3.0,and regional end-diastolic volume and end-systolic volume of left ventricular (rEDV,rESV),the time to minimum systolic volume (rESVT),regional stroke volume (rSV),regional ejection fraction (rEF),regional-global ejection fraction (rgEF) and the parameters of left ventricular dyssynchrony were measured.Results In the HCM group,the values of Tmsv16-Dif,Tmsv16-SD,Tmsv16-Dif％,Tmsv16-SD％ were significantly lower compared with the control group (P ＜ 0.01),and rEDV,rSV,rEF and rgEF in hypertrophic segments were lower than those in non-thickening and mild-thickening segments (P ＜0.05).In the control group,there were no significant difference of those parameters among all segments (P ＞0.05).The values of rEDV,rSV and rgEF in hypertrophic segments decreased in the HCM group (P ＜0.05),at the basal level,rEF in hypertrophic segments decreased,at the apical level,it increased,but the differences at the mid-ventricular level between the two groups were not significant;the values of rEF and rgEF in non-thickening and mild-thickening segments increased (P ＜0.05).Conclusions RT-3DE could sensitively detect left ventricular dyssynchrony and accurately assess regional left ventricular volume and function of different segments in patients with HCM. Key words: Echocardiography, real-time three-dimensional; Cardiomyopathy, hypertrophic; Ventricular function, left

Prognostic value of unrecognised myocardial infarction detected by late gadolinium-enhanced MRI in diabetic patients with normal global and regional left ventricular systolic function

To determine whether the detection of unrecognised myocardial infarction (MI) using late gadolinium-enhanced (LGE)-magnetic resonance imaging (MRI) can provide prognostic information in diabetic patients with normal ECG as well as normal global and regional left ventricular (LV) function. From 449 diabetic patients who had complete cine- and LGE-MRI, 321 patients with histories of CAD, ischaemic ECG changes and abnormal cine MRI findings (LV ejection fraction <50% or presence of regional wall motion abnormality) were excluded. The presence and extent of LGE were determined in the remaining 128 patients. Follow-up information was obtained for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death, acute MI, heart failure, unstable angina and significant ventricular arrhythmias in 120 patients. Of 120 patients, 18 (15%) had LGE. During follow-up (median, 27months), six patients with LGE (33.3%) and four patients without LGE (3.9%) experienced MACE, resulting in an annualised event rate of 7.7% and 0.9%, respectively (log-rank P <0.001). The presence of LGE was associated with an eight-fold increased hazard for MACE (HR, 8.84; P = 0.001). LGE-MRI can detect unrecognised MI and may improve the risk stratification of diabetic patients with no CAD history, normal ECG and normal LV systolic function. • Late gadolinium-enhanced magnetic resonance imaging (LGE-MRI) can identify subtle myocardial abnormalities. • LGE-MRI can detect myocardial infarction missed by ECG and cine-MRI. • Unrecognised MI detected by LGE-MRI was associated with adverse cardiac events. • LGE-MRI helps clinicians to assess diabetic patients with unrecognised MI.

Evalution of left ventricular function before and after coronary artery bypass grafting by speckle tracking imaging

Objective To evaluate regional and global left ventricular systolic function after coronary artery bypass grafting (CABG) by speckle tracking imaging (STI).Methods Transthoracic echocardiography (TTE) was performed in 32 patients with coronary heart disease (CHD) preoperative and 3 months after CABG.The two-dimensional data were obtained in apical 4-chamble,2-chamble and long axis view.Peak systolic longitudinal strain (SLs),global longitudinal systolic strain (GLS) and average global strain(GLS-Avg) were measured using STI.30 healthy volunteers were involved as controls.Results SLs in the control group increased from the basal to the apical ventricular.SLs in the control group and CHD group apical segment were significantly higher than the basal and middle segments.Compared to the control group,SLs,GLS in part of myocardial ischemic segments were lower in CHD group before CABG (P ＜0.05).SLs and GSL in the corresponding segments showed significantly improving 3 months after CABG in CHD group (P ＜ 0.05).There was good relationship between GSL-Avg and left ventricular ejection fraction.Conclusions STI technology can be used to objectively and quantitatively evaluate the change of regional and global left ventricular systolic function.Therefore,it provide a non-invasive means for evaluation of curative effect and prognosis judgement of CHD after CABG. Key words: Echocardiography; Coronary artery bypass; Ventricular function, left; Strain; Speckle tracking imaging

Abstract 19284: Clinical Determinants of Global and Regional Left Ventricular Systolic Function by Cardiac Magnetic Resonance Imaging: The Jackson Heart Study

Introduction: Cardiac MRI (CMRI) provides high-resolution images, along with accurate and reproducible measurements of global and regional left ventricular (LV) systolic function (including LV ejection fraction, stroke volume, global and regional systolic strain). We examined the cross-sectional association of traditional cardiovascular (CV) risk factors with CMRI determined systolic function in a community-based cohort of African Americans (AAs). Methods: We evaluated 1,322 Jackson Heart Study participants (63% women, mean age 57 years) who had MRI exams performed at Examination 2. Measures of LV systolic function included ejection fraction, stroke volume, global strain (considered the mean peak systolic midwall Eularian strain -averaged for the base, mid-ventricle and apex in all segments) and regional strain (averaged for the mid-ventricle or apex only). Clinical covariates included age, sex, systolic and diastolic BP, BMI, fasting glucose (FG), diabetes status (DM), lipids, smoking, alcohol use, hypertension (HTN) medication, lipid lowering medication, education and income. Multiple stepwise linear regression analysis was used to model the association of clinical covariates (independent variables) with global and regional measures of LV systolic function. Results: Regression analysis demonstrated that LV ejection fraction was independently and positively associated with systolic BP (p= 0.0002) but inversely associated with male sex and FG (p &lt; 0.0001 and p = 0.011 respectively). Stroke volume was independently and positively associated with male sex, systolic BP, and BMI (p &lt; 0.001 for all) but inversely related to age, diastolic BP, and smoking (p= &lt;0.01 for all). More optimal (more negative) global and mid wall systolic strain were inversely associated with older age, male sex, BMI, and smoking (all p &lt;0.002). Lower (more optimal) apical strain was inversely associated with older age, male sex, HTN status, higher BMI, and smoking (p &lt;0.02 for all) but was positively associated with DM (p= 0.049). Conclusions: In our cross-sectional study of a large AA community-based cohort, we identified several modifiable CV risk factors (BP, BMI, FG, smoking) associated with global and regional measures of LV systolic function as assessed by CMRI.

STUDY OF LEFT VENTRICULAR ROTATION AND TORSION IN HYPERTHYROID BY SPECKLE TRACKING IMAGING

ObjectivesQuantitative analysis of hyperthyroidism in patients with left ventricular rotation and torsion motion by speckle tracking imaging (STI) to explore the hyperthyroidism in patients with left ventricular systolic function.MethodsSelect the...

STUDY OF LEFT VENTRICULAR ROTATION AND TORSION IN HYPERTHYROID BY SPECKLE TRACKING IMAGING

ObjectivesQuantitative analysis of hyperthyroidism in patients with left ventricular rotation and torsion motion by speckle tracking imaging (STI) to explore the hyperthyroidism in patients with left ventricular systolic function.MethodsSelect the...

CLINICAL APPLICATION OF LEFT VENTRICULAR SYSTOLIC FUNCTION IN PATIENTS WITH RHEUMATIC MILD TO MODERATE MITRAL STENOSIS BY THREE-DIMENSIONAL ULTRASOUND SPECKLE TRACKING IMAGING

ObjectivesTo assess left ventricular (LV) global and regional systolic function in patients with pure mild to moderate rheumatic mitral stenosis (MS) by 3-dimensional ultrasound speckle tracking imaging (3D-STI)MethodsFifty patients with...

Resveratrol Preserves Myocardial Function and Perfusion in Remote Nonischemic Myocardium in a Swine Model of Metabolic Syndrome

Resveratrol has been shown to reverse some of the detrimental effects of metabolic syndrome (MetS). We sought to define the impact of supplemental resveratrol on normal myocardium remote from an ischemic territory in a swine model of MetS and chronic myocardial ischemia. Yorkshire swine were fed a normal diet (control), a high cholesterol diet (HCD), or a high cholesterol diet with orally supplemented resveratrol (HCD-R; 100 mg/kg/day). Four weeks after diet modification, myocardial ischemia was induced by ameroid constrictor placement. Seven weeks later, myocardial tissue from a territory remote from the ischemia was harvested. Animals in the HCD and HCD-R groups underwent functional cardiac MRI before ischemia and before sacrifice. Tissue was harvested for protein expression analysis. After 7 weeks of ischemia, regional left ventricular systolic function was significantly increased in HCD-R as compared with HCD animals. During ventricular pacing the HCD group had significantly decreased flow (p = 0.03); perfusion in the HCD-R was preserved as compared with the control. There was no difference in microvascular relaxation. Expression of metabolic proteins Sirt-1 (p = 0.002), AMPkinase (p = 0.02), and carnitine palmitoyltransferase-I (p = 0.002) were upregulated in the HCD-R group. Levels of protein oxidative stress were significantly increased in the HCD and HCD-R groups, as compared with the controls (p = 0.003). Activated endothelial nitric oxide synthase (eNOS) was increased in the HCD-R group (p = 0.01). There was no difference in myocardial endothelial cell density between the groups; however, dividing endothelial cells were decreased in the HCD and HCD-R groups (p = 0.006). Resveratrol supplementation improves regional left ventricular function and preserves perfusion to myocardium remote from an area of ischemia in an animal model of metabolic syndrome and chronic myocardial ischemia.

Cardiac β-adrenergic receptor density and myocardial systolic function in the remote noninfarcted region after prior myocardial infarction with left ventricular remodelling

After myocardial infarction (MI), left ventricular (LV) remodelling is observed in noninfarcted LV myocardium. LV remodelling is closely associated with systolic heart failure. Since myocardial dysfunction is related to the downregulation of cardiac postsynaptic beta-adrenergic receptors (β-AR), we hypothesized that a reduction in β-AR density may be manifested in the remote noninfarcted region and such reduction may be related to myocardial systolic dysfunction. Accordingly, we assessed β-AR density with a focus on the remote noninfarcted region. Cardiac PET was performed in 15 patients with a prior MI and 10 age-matched healthy controls using (11)C-CGP 12177, a radioligand for β-receptors. The maximum number of available specific (11)C-CGP 12177 binding sites per gram of tissue was calculated in regions of interest using an established graphical method. LV regional systolic function was assessed based on peak systolic myocardial strain on the LV wall in the longitudinal direction using two-dimensional ultrasound speckle tracking imaging. LV volumes and LV ejection fraction (EF) were also measured. The LV end-diastolic volume index was significantly larger in patients than in controls (67.8 ± 16.9 vs. 49.1 ± 12.3 ml/m(2), p < 0.01). Significant differences in β-AR density were observed among three areas: the apical area in controls (where the lowest β-AR density was observed), the remote noninfarcted region of patients and LVEF ≥ 55 %, and the remote noninfarcted region of patients and LVEF <55 % (5.8 ± 2.1 vs. 4.2 ± 0.7 vs. 3.3 ± 0.7 pmol/ml, p < 0.01, ANOVA). Peak systolic myocardial strain was significantly reduced in the remote noninfarcted LV wall in patients with a prior anterior wall MI compared with that in the corresponding wall in controls (-15.5 ± 2.5 vs. -20.1 ± 2.2 %, p < 0.001). A similar finding was also observed in patients with a prior inferior wall MI. In the remote noninfarcted region in patients, β-AR downregulation was observed, which was related to deterioration of local myocardial systolic function.

Impaired Regional Myocardial Function Detection Using the Standard Inter-Segmental Integration SINE Wave Curve On Magnetic Resonance Imaging

OBJECTIVE. 1. To quantify the value of myocardial regional wall motion and to study the inter-segmental integration pattern of the circumferential regional wall motion of the left ventricle using Magnetic Resonance Imaging (MRI) in patients with normal global and regional left ventricular systolic function (LVEF ≥ 55%) and compare results to groups with impaired left ventricular systolic function (LVEF ≤ 55%). 2. To prove that the inter-segmental integration pattern of normal myocardial regional wall motion is consistent and can be used effectively as a complimentary tool with visual estimation method to detect the impaired myocardial regional wall motion.

092 Left ventricular systolic dysfunction in tako-tsubo cardiomyopathy: is it transmural and really regional and reversible? A two-dimensional speckle tracking echocardiographic study

OBJECTIVE typical tako-tsubo cardiomyopathy (TT) is characterized by a transient mid-apical left ventricular (LV) systolic dysfunction assessed by the wall motion score (WMS) and LV ejection fraction (EF). Two-dimensional strain by speckle tracking echocardiography (2DS) is a more sensitive marker of regional and global LV systolic function. Therefore, our aim was to assess systolic LV mechanics in all myocardial directions by 2DS, in patients (pts) with TT. METHODS 2DS was performed in 15 consecutive pts with TT (78 ± 8 years, 93% women) at the acute phase (within 24 h after symptom onset) and after recovery (one month later). Ten control (C) pts matched for age and sex were compared to TT pts. From the apical long-axis, 4-and 2-chamber views, global longitudinal strain (LS) and strain-rate (LSR), post-systolic shortening index (PSS), and from the parasternal basal, mid and apical short-axis planes, global circumferential strain (CS), and strain-rate (CSR), and radial strain (RS), were obtained. Regional evaluation was also performed for each parameter. LV twist was defined as the net difference in degrees of apical (Ar) and basal rotation. RESULTS

A proinflammatory monocyte response is associated with myocardial injury and impaired functional outcome in patients with ST-segment elevation myocardial infarction: Monocytes and myocardial infarction

In patients with ST-segment elevation myocardial infarction (STEMI), the importance of a well-balanced inflammatory reaction has been recognized for years. Monocytes play essential roles in regulating inflammation. Hence, we investigated the association between inflammatory characteristics of monocytes and myocardial injury and functional outcome in patients with STEMI. Using flow cytometry, the levels of classical (CD14(++)CD62L(+)) and nonclassical (CD14(+)CD62L(-)) monocytes were analyzed in peripheral blood in 58 patients with STEMI at a median of 5 days (4-6 days) after primary percutaneous coronary intervention. In addition, the monocytic expression of several surface molecules and formation of monocyte-platelet complexes were measured. All patients underwent cardiovascular magnetic resonance imaging at baseline and 4-month follow-up. At baseline, patients with high levels of classical monocytes had impaired left ventricular (LV) ejection fraction (P = .002), larger infarct size (P = .001), and, often, presence of microvascular obstruction (P = .003). At follow-up, high levels of classical monocytes were negatively associated with the regional systolic LV function independent of the transmural extent of infarction. In contrast, positive associations for the levels of nonclassical monocytes were observed. Finally, up-regulation of macrophage 1 by blood monocytes and increased formation of monocyte-platelet complexes were associated with enhanced myocardial injury at baseline and impaired LV function at follow-up. This study shows an association between a proinflammatory monocyte response, characterized by high levels of classical monocytes, and severe myocardial injury and poor functional outcome after STEMI. Future studies are required to investigate the biologic nature of this association and therapeutic implications.

Relationship between central and peripheral atherosclerosis and left ventricular dysfunction in a community population

We aimed to determine the relationships between resting left ventricular (LV) wall motion abnormalities (WMAs), aortic plaque, and peripheral artery disease (PAD) in a community cohort. A total of 1726 Framingham Heart Study Offspring Cohort participants (806 males, 65 ± 9 years) underwent cardiovascular magnetic resonance with quantification of aortic plaque volume and assessment of regional left ventricular systolic function. Claudication, lower extremity revascularization, and ankle-brachial index (ABI) were recorded at the most contemporaneous examination visit. WMAs were associated with greater aortic plaque burden, decreased ABI, and claudication in age- and sex-adjusted analyses (all p < 0.001), which were not significant after adjustment for cardiovascular risk factors. In age- and sex-adjusted analyses, both the presence (p < 0.001) and volume of aortic plaque were associated with decreased ABI (p < 0.001). After multivariable adjustment, an ABI ≤ 0.9 or prior revascularization was associated with a threefold odds of aortic plaque (p = 0.0083). Plaque volume significantly increased with decreasing ABI in multivariable-adjusted analyses (p < 0.0001). In this free-living population, associations of WMAs with aortic plaque burden and clinical measures of PAD were attenuated after adjustment for coronary heart disease risk factors. Aortic plaque volume and ABI remained strongly negatively correlated after multivariable adjustment. Our findings suggest that the association between coronary heart disease and non-coronary atherosclerosis is explained by cardiovascular risk factors. Aortic atherosclerosis and PAD remain strongly associated after multivariable adjustment, suggesting shared mechanisms beyond those captured by traditional risk factors.

Assessment of left ventricular regional myocardial systolic function after bone marrow mesenchymal stem cells injection in rabbits with acute myocardial infarction by speckle tracking imaging

Objective To assess the left ventricular(LV) regional myocardial systolic function after bone marrow mesenchymal stem cells (BMSCs) injection in rabbits with acute myocardial infarction(AMI) by 2-dimensional ultrasound speckle-tracking imaging.Methods Twenty-four healthy rabbits were randomly divided into three groups:group of sham-operated,group of masculine control (AMI was induced by ligation of left anterior descending coronary artery),and group of cell infusion(after two weeks of AMI,bone marrow mesenchymal stem cells were injected to the region of AMI).Four weeks after cell deliver two-dimensional strain images were acquired from LV short-axis view(at the levels of mitral annulus,muscle papillary and apex),radial strain rate (SrR),circumference strain rate (SrC),rotation rate (RotR) and rotation (Rot) of three levels in short-axis views were measured by speckle-tracking imaging.The conventional echocardiography indices included LV diameter of end diastole(LVEDd),LV ejection fraction(LVEF),LV fractional shortening(LVFS).The catheter indices included LV systolic pressure(LVSP),LV end diastolic pressure (LVEDP)and maximum rate of rise and descend of LV pressure(LVdp/dtmax).ResultsCompared with sham-operated group,rabbits had significantly larger LVEDd,lower LVEF and LVFS,lower LVSP and LVdp/dtmax,higher LVEDP in control group,SrR,SrC,RotR and Rot of LV anterior regional myocardial function and global myocardial function of three levels in short-axis views were lower.Compared with control group,the rabbits had significantly smaller LVEDd,larger LVEF and LVFS,larger LVSP and LVdp/dtmax,lower LVEDP,SrR,SrC,RotR and Rot of LV anterior regional myocardial function and global myocardial function of three levels in short-axis views were larger in group of cell infusion.There was no significant between group of cell infusion and group of sham-operated.Conclusions Speckle tracking imaging can evaluate the regional myocardial systolic function of the area of BMSCs transplantation accurately. Key words: Echocardiography; Myocardial infarction; Mesenchymal stem cell transplantation; Ventricular function; Speckle tracking imaging

Transplantation of expanded bone marrow‐derived very small embryonic‐like stem cells (VSEL‐SCs) improves left ventricular function and remodelling after myocardial infarction

Adult bone marrow-derived very small embryonic-like stem cells (VSEL-SCs) exhibit a Sca-1+/Lin–/CD45– phenotype and can differentiate into various cell types, including cardiomyocytes and endothelial cells. We have previously reported that transplantation of a small number (1 × 106) of freshly isolated, non-expanded VSEL-SCs into infarcted mouse hearts resulted in improved left ventricular (LV) function and anatomy. Clinical translation, however, will require large numbers of cells. Because the frequency of VSEL-SCs in the marrow is very low, we examined whether VSEL-SCs can be expanded in culture without loss of therapeutic efficacy. Mice underwent a 30 min. coronary occlusion followed by reperfusion and, 48 hrs later, received an intramyocardial injection of vehicle (group I, n= 11), 1 × 105 enhanced green fluorescent protein (EGFP)-labelled expanded untreated VSEL-SCs (group II, n= 7), or 1 × 105 EGFP-labelled expanded VSEL-SCs pre-incubated in a cardiogenic medium (group III, n= 8). At 35 days after myocardial infarction (MI), mice treated with pre-incubated VSEL-SCs exhibited better global and regional LV systolic function and less LV hypertrophy compared with vehicle-treated controls. In contrast, transplantation of expanded but untreated VSEL-SCs did not produce appreciable reparative benefits. Scattered EGFP+ cells expressing α-sarcomeric actin, platelet endothelial cell adhesion molecule (PECAM)-1, or von Willebrand factor were present in VSEL-SC-treated mice, but their numbers were very small. No tumour formation was observed. We conclude that VSEL-SCs expanded in culture retain the ability to alleviate LV dysfunction and remodelling after a reperfused MI provided that they are exposed to a combination of cardiomyogenic growth factors and cytokines prior to transplantation. Counter intuitively, the mechanism whereby such pre-incubation confers therapeutic efficacy does not involve differentiation into new cardiac cells. These results support the potential therapeutic utility of VSEL-SCs for cardiac repair.

Impact of acoustic window on accuracy of longitudinal global strain: a comparison study to cardiac magnetic resonance

To evaluate the impact of acoustic window on the feasibility and accuracy of longitudinal global strain (global-ε) by speckle tracking for assessing left ventricular (LV) systolic function. The study included 70 patients (57 ± 17 years, 64% men), 28 selected patients with a suboptimal image quality (IQ) defined by three or more segments (4 ± 3 segments/patient) with wall motion score not analysable visually and 42 patients with an optimal two-dimensional (2D) echocardiography IQ. Left ventricular ejection fraction (LVEF) by Simpson's biplane method (2D-EF), global-ε by speckle tracking, and peak systolic mitral annulus velocity [systolic tissue Doppler imaging (S-TDI)] were compared with LVEF by cardiac magnetic resonance (EF-CMR; 45 ± 18%, range 9-76%). Speckle-tracking analysis was feasible in all segments with an optimal acoustic window and in 85% (103/121) of segments poorly visualized. Global-ε similarly correlated with LVEF by CMR in patients with and without optimal IQ (r = 0.81 vs. 0.82 for good vs. poor IQ). In contrast, 2D-EF (r = 0.76) and S-TDI (r = 0.64) less correlated with LVEF by CMR in patients with a suboptimal IQ. Importantly, IQ only impacted on 2D-EF inter-observer reproducibility (9 ± 5 vs. 24 ± 22% for good vs. poor IQ) but not on global-ε reproducibility (9 ± 1 vs. 8 ± 7% for good vs. poor IQ). In patients with a limited acoustic window, longitudinal strain by speckle tracking remains accurate and reproducible for assessing global and regional LV systolic function.

How should we measure global and regional left ventricular systolic function?

The assessment of left ventricular (LV) systolic function is frequently the most important task during the echocardiography examination. LV ejection fraction (EF) is the most commonly used measure to assess LV systolic function. EF is well established, with strong prognostic and therapeutic implications, but, nevertheless, it may not always be satisfactory in all patients. Other measures of myocardial contractility can provide valuable additive information in some patients. This is particularly true in patients with suspected heart failure but normal EF. The measurement of longitudinal function using M-mode and/or deformation analysis from tissue Doppler data or speckle tracking algorithms can be useful in this respect. Regional LV dysfunction can be difficult to detect using visual semi-quantitative assessment of regional wall motion. Contrast echocardiography can be most helpful in delineating the LV endocardial border and, thus, increasing sensitivity for detecting wall motion abnormalities. Deformation analysis can also be helpful for detecting subtle wall motion abnormalities, but these methods should be used with caution due to measurement variability and image quality dependence.