Speckle Tracking-derived Strain Research Articles

Galectin-3 and sST2: associations to the echocardiographic markers of the myocardial mechanics in systemic sclerosis – a pilot study

BackgroundProgressive cardiac fibrosis is the central aspect of the myocardial involvement in systemic sclerosis (SSc). We hypothesized that circulating biomarkers of the cardiac fibrosis may be useful in the early diagnosis of the cardiac manifestation in this disease. Thus, we investigated the potential correlations between the levels of galectin-3, soluble suppression of tumorigenicity-2 (sST2) and the echocardiographic markers of the myocardial mechanics in SSc patients.MethodsForty patients (57.3 ± 13.7 years, 36 female) were investigated. In addition to the conventional echocardiography, tissue Doppler and speckle tracking-derived strain techniques were used to assess the function of both ventricles and atria. To estimate the correlations between galectin-3 and sST2 levels and the echocardiographic variables, partial correlation method was used with age as correcting factor.ResultsIn age adjusted analysis galectin-3 level showed significant correlation with left ventricular global longitudinal strain (r = 0.460, p = 0.005); grade of left ventricular diastolic dysfunction (r = 0.394, p = 0.013); septal e’ (r = − 0.369, p = 0.021); septal E/e’ (r = 0.380, p = 0.017) and with the grade of mitral regurgitation (r = 0.323, p = 0.048). No significant correlation was found between sST2 levels and the echocardiographic variables.ConclusionsGalectin-3 levels, but not sST2 levels show significant correlation with the parameters of the left ventricular systolic and diastolic function. Galectin-3 may be a useful biomarker for the screening and early diagnosis of SSc patients with cardiac involvement.

Psöriyazis Hastalarında Subklinik Sol Ventriküler Disfonksiyonun Speckle Tracking Ekokardiyografi ile Değerlendirilmesi

Objective: Psoriasis, which is a chronic inflammatory disease is associated with an increased risk of cardiovascular (CV) diseases (CVD). Currently, no method is available to evaluate subclinical CV dysfunction in patients with psoriasis. The aim of the study was to evaluate left ventricular (LV) function in patients with untreated psoriasis but no risk factors for CV disease (CVD). Material and Methods: Thirty patients with psoriasis without any CVD or risk factors for CVD and 20 age- and gender-matched controls were recruited. All patients underwent detailed transthoracic echocardiography, including speckle tracking-derived strain analysis. Results: Speckle tracking echocardiography showed significantly lower global circumferential strain in psoriatic patients compared to healthy controls (mean ±SD: -23.34±6.74% vs. -27.53±4.11%, respectively, p<0.001). No significant differences were found in terms of global longitudinal strain, aortic flow velocity, pulmonary arterial flow velocity, LV end-systolic volume, LV end-diastolic volume, LV ejection fraction, peak of early diastolic (E) and late diastolic (A) flow velocity, E⁄A ratio, and levels of biochemical markers, including C-reactive protein, between the patients and controls (p>0.05). Conclusion: Subclinical myocardial dysfunction was seen in the patients with psoriasis who had no conventional risk factors for CVD using two-dimensional strain imaging. We believe that this imaging technique may be useful for early detection of CVD development in patients with psoriasis.

Added clinical value of applying myocardial deformation imaging to assess right ventricular function.

Right heart dysfunction has been found to be a strong prognostic factor predicting adverse outcome in various cardiopulmonary diseases. Conventional echocardiographic measurements can be limited by geometrical assumptions and impaired reproducibility. Speckle tracking-derived strain provides a robust quantification of right ventricular function. It explicitly evaluates myocardial deformation, as opposed to tissue Doppler-derived strain, which is computed from tissue velocity gradients. Right ventricular longitudinal strain provides a sensitive tool for detecting right ventricular dysfunction, even at subclinical levels. Moreover, the longitudinal strain can be applied for prognostic stratification of patients with pulmonary hypertension, pulmonary embolism, and congestive heart failure. Speckle tracking-derived right atrial strain, right ventricular longitudinal strain-derived mechanical dyssynchrony, and three-dimensional echocardiography-derived strain are emerging imaging parameters and methods. Their application in research is paving the way for their clinical use.

Left ventricular systolic dysfunction during septic shock: the role of loading conditions.

The clinical significance of septic myocardial dysfunction is controversial, a fact that may be explained by the influence of loading conditions. Many indices may be useful to characterize cardiac function during septic shock, but their feasibility and physiological coherence in the clinical setting are unknown. Hemodynamic and echocardiographic data with tissue Doppler and speckle tracking were prospectively recorded on the first 3days of human septic shock. Hypokinesia, normokinesia, and hyperkinesia were defined as a left ventricular ejection fraction (LVEF) of<45, 45-60, and>60%, respectively. Twelve hemodynamic indices exploring contractility and loading conditions were assessed and analyzed. Two hundred and ninety-seven echocardiographies were performed in 132 patients. During the first 24h (H1-24), 48 (36.4%) patients were hyperkinetic, 55 (41.7%) were normokinetic, and 29 (22.0%) patients were hypokinetic. Thirteen patients had a secondary hypokinesia absent at H1-24 but present at H25-48 or H49-72, for an overall incidence of 42 (31.8%) during the first 3days. Despite a limited feasibility (<50%), global LV longitudinal peak systolic strain was impaired in a majority (>70%) of the patients assessed, including all those with depressed LVEF, and declined early in patients whose LVEF secondarily deteriorated. Most contractility indices were inversely correlated with afterload indices. Hyperkinetic patients exhibited the worst reduction in afterload indices. Hospital mortality was significantly higher in patients with LV hyperkinesia than in their counterparts: 30 (62.5%) vs. 35 (41.7%), p=0.02. Speckle tracking-derived strain was reduced in the majority of patients with septic shock, revealing covert septic myocardial dysfunction, but had poor feasibility. We found an inverse correlation between most of the contractility and afterload indices. Precise evaluation of afterload is crucial for adequate interpretation of LV systolic function in this setting.

Abstract 13596: Magnetic Resonance - Derived Pre-contrast T1 Relaxation Time is the Accurate Marker of Diffuse Myocardial Fibrosis in Severe Aortic Valve Disease: A Comparison With Left Ventricular Myocardial Biopsy

Introduction: Diffuse myocardial fibrosis (DFM) is the major mechanism in the pathophysiology of the aortic stenosis and its complications. DMF is detectable by magnetic resonance imaging (MRI) using the T1 mapping technique. Hypothesis: The MRI derived native T1 relaxation time and myocardial extracellular volume fraction (ECV) will be significantly related to the extent of DMF et targeted myocardial left ventricular (LV) biopsy. Methods: The study population consisted of 40 consecutive patients (age 63±8y, 65% males) undergoing surgery for severe aortic stenosis (77.5%), aortic root dilatation (7.5%) or valve regurgitation (15%). All patients underwent MRI-derived T1 mapping and 2D-, 3D speckle tracking-derived strain analysis prior to surgery. The T1 relaxation time was assessed in basal interventricular septum pre and 10 min post contrast administration using the modified Look-Locker Inversion recovery sequence. A LV myocardial biopsy specimen was obtained during surgery from basal interventricular septum under the guidance of the MRI operator to assure spatial concordance with the MRI assessment. The percentage of myocardial collagen was quantified as a ratio of Picrosirius Red-positive area over total sample area using the Image J. Results: The average percentage of myocardial collagen was 22 ± 14.8 %. The average native T1 relaxation time and ECV was 1010 ± 48 ms and 0.288 ± 0.055, respectively. Both native T1 relaxation time with cutoff value of ≥ 1010 ms (Ss=90%, Sp=73%, AUC =0.82) and ECV with cutoff value of ≥ 0.315 (Ss=80%, Sp=90%, AUC =0.85) showed high accuracy to identify extensive (&gt; 30%) myocardial collagen content (Figure 1A, 1B). The native T1 mapping showed significant correlation with LV mass, 2D and 3D global longitudinal strain (all p&lt;0.05) while the ECV did not (p=NS). Conclusions: Native T1 relaxation time is the accurate marker of diffuse myocardial fibrosis with the significant relationship with LV morphology and myocardial function.

Speckle Tracking Echocardiography of the Right Atrium: The Neglected Chamber.

The right atrium (RA) plays a pivotal role in electromechanical and endocrine regulation of the heart. Its peculiar anatomical features and phasic mechanical function make it distinct from ventricles. Various invasive and noninvasive techniques have been used to elucidate RA structure and function. Of these modalities, echocardiography has distinct advantages over others. Several conventional measures of RA function through echocardiography have been described in the literature, but they are load dependent. A relatively new technique is speckle tracking-derived strain, which is relatively less dependent on loading conditions. Speckle tracking echocardiography tracks acoustic scatters (speckles) of myocardium frame-by-frame to calculate strain or deformation of the myocardium. Speckle tracking echocardiography has been used extensively for strain assessment of the right and left ventricle to detect subtle disease pathology, to gain mechanistic insight, as a marker of ischemic metabolic memory, as an endpoint in clinical trials, and as a functional assessment tool. The RA is a relatively neglected chamber, as it is mostly studied for assessment of atrial mass lesions, for electrophysiological studies, and in animal models for physiological assessment. However, its role in the systolic and diastolic function of the right heart, pulmonary vascular pathology, congenital heart diseases, and combined electromechanical activation phenomena has been less explored or unexplored. Speckle tracking echocardiography is an ideal tool for the assessment of the RA because of its regional and global functional characterization, angle independence, and high temporal resolution.

The Influence of the Region of Interest Width on Two‐Dimensional Speckle Tracking–Based Measurements of Strain and Strain Rate

There are significant variations in the published normal values of two-dimensional speckle tracking-derived strain and strain rate. These occur even when authors use the same software. To measure strain, the operator creates a region of interest (ROI) to define the myocardium to be analyzed. The purpose of this study was to test the hypothesis that measurements vary significantly with the chosen ROI width. In 20 healthy subjects (11 males, mean age 17.6 ± 6.18 years) an apical four-chamber view (4CH) and parasternal short-axis view (SAX) were analyzed. Initially ROI width was set automatically by the software. Two subsequent measurements were obtained from each cine loop by choosing the ROI width one step narrower and one step wider than the automatic ROI width. The mean differences between the measurements of narrower and automatic ROI and between automatic and wider ROI were -1.8 ± 0.7% and -0.9 ± 0.5% for global longitudinal strain (SL), -2.2 ± 0.6% and -1.7 ± 0.7% for global circumferential strain (SC), -0.10 ± 0.06/sec and -0.07 ± 0.06/sec for global longitudinal strain rate (SrL), and -0.15 ± 0.09/sec and -0.12 ± 0.07/sec for global circumferential strain rate (SrC) (all P < 0.000). This corresponds to a relative difference to the mean of both measurements of -4.4 to -11.0%. Layer-specific myocardial deformation and curvature dependency lead to an inverse correlation between the chosen ROI width and strain and strain rate measurements. Just one step of ROI-width change leads to a significant bias. Precise ROI-width definition is essential but technical factors limit its feasibility.

Evaluation of left atrial deformation to predict left atrial stasis in patients with non-valvular atrial fibrillation – a pilot-study

BackgroundSpeckle tracking-derived strain and strain rate are recently available parameters to assess left atrial (LA) deformation. We hypothesized that such new parameters could be of interest to evaluate the risk of LA stasis among patients with atrial fibrillation (AF).MethodsSingle-centre study enrolling all patients with non-valvular AF lasting longer than 48 hours for whom no therapeutic anticoagulation was given in the preceding 3 weeks and who were assessed through transesophageal and transthoracic echocardiogram during a 6 month time interval. LA deformation was assessed by transthoracic echocardiogram through speckle tracking analysis, whereas LA stasis parameters were sought on transesophageal echocardiogram.ResultsAmong the 82 assessed patients, LA appendage thrombi or sludge were found in 16 (19.5%). A moderate positive correlation was found between peak positive strain rate and maximum emptying velocity (r = 0.589; P <0.001) and peak positive strain rate and maximum filling velocity of the LA appendage (r = 0.651; P <0.001). Peak negative strain rate was also found to be associated with both maximum emptying velocity (r = -0.513; P <0.001) and maximum filling velocity of the LAA (r = -0.552; P <0.001). AF duration, peak negative strain rate and time-to-peak positive strain were independent predictors of LAA thrombi or sludge on multivariate analysis logistic regression. The area under the curve for the estimated probabilities using the obtained logistic regression model was 0.89 (95%CI 0.81-0.96; P <0.001).ConclusionOur findings suggest that LA mechanical dysfunction assessed through speckle tracking may be of interest to predict LA stasis in the setting of AF.

Two-Dimensional Speckle Tracking-Derived Strain to Distinguish Acute Coronary Syndrome from a Marked Early Repolarization in a Patient with Chest Pain: A Fancy Gadget or a Useful Tool?

With a potential of detecting subtle myocardial injury, two-dimensional (2D) speckle tracking-derived strain could help to distinguish between ischemic and nonischemic ST-segment elevation. Little is known if limitations of strain imaging could prevent its applicability in acute cardiac care settings. We present a 56-year-old male with persistent ST-segment elevation in the inferolateral leads and suspected hypokinesia of the inferior wall. Semiautomated 2D speckle tracking strain analysis showed normal longitudinal peak systolic strain (LPSS) in all segments of the inferior wall, ruling out wall-motion abnormalities in this region. Stationary reverberations and spuriously low values of LPSS in the posterolateral wall required operator's expertise to distinguish pathological myocardial deformation from artifacts. Additional workup revealed that early repolarization pattern was mistaken for the inferior wall acute myocardial infarction in our patient. Semiautomated quantification of regional left ventricular function by 2D speckle tracking echocardiography could facilitate decision making even in the emergency settings. Due to intrinsic limitations of this novel method, its actual clinical value in acute cardiac care settings may depend on the expertise of the operator and is yet to be determined.

From speckle tracking echocardiography to torsion

Speckle tracking is the latest available technology in echocardiography. However, the technology is still mainly used as a research tool. The potential applications of speckle tracking are many, including cardiac synchronization, regional wall motion analysis, and in the areas of cardiac mechanic studies. This review presents the background theory of speckle tracking echocardiography (STE) and how this technology can be extended to velocity vector analysis, strain, and torsion measurements. The interpretations of these measurements are covered. We also present some potential applications in the critical care setting. Speckle tracking is almost always available in high-end ultrasound machines. The technology has been applied to velocity vector analysis, strain and strain rate measurements, and twist and torsion analysis. Torsion analysis and velocity vector analyses are impossible without using speckle tracking. Speckle tracking-derived strain is superior to tissue Doppler strain because it is angle-independent. A number of studies demonstrated that STE is useful in left and right heart assessments and can be used in assessing preload and afterload. Speckle tracking can be used to measure instantaneous myocardial contractility, strain, and left ventricular torsion. It is still a research tool at present, but shows the promise of being a clinical tool in the future.

Longitudinal strain curves in the RV free wall differ in morphology in patients with pulmonary hypertension compared to controls

BackgroundPrevious studies using speckle tracking-derived strain for quantification of right ventricular (RV) function in pulmonary hypertension (PHT) have focused on the magnitude of global and regional peak longitudinal systolic strains (PLSS) and systolic strain-related indices of dyssynchrony. The aim of our study was to investigate the pattern of RV contraction and relaxation with the use of the contour and timing of strain and velocity curves in PHT. MethodsThe study population consisted of thirty‐seven patients with PHT (45±18years, 16 women) and thirty‐seven controls. A complete two-dimensional echo with speckle-tracking-derived longitudinal strain of the basal RV free wall and interventricular septum (IVS) was performed and the cycle length-corrected time to PLSS (SST) and time from PLSS to 50% of PLSS (systolic strain half time—SSHT) in both regions were calculated. ResultsPatients with PHT had significantly reduced PLSS (−24.9±2.0% vs −43.2±3.0%, p<0.001) and increased SST (0.47±0.02 vs 0.39±0.02, p=0.043) and SSHT (0.22±0.02 vs 0.16±0.02, p=0.047) in the basal RV free wall compared to controls. Furthermore, peak systolic velocities were observed earlier in the cardiac cycle in both regions in patients with PHT compared to controls. ConclusionsLongitudinal strain curves in the RV free wall reach peak values later in the cardiac cycle and return slower towards the baseline in PHT. Furthermore, peak systolic velocities are observed earlier in the cardiac cycle in both the basal RV free wall and the basal IVS. The above observations effectively illustrate changes in patterns of RV contraction and relaxation caused by PHT.

Abnormal Cardiac Strain in Children and Young Adults with HIV Acquired in Early Life

Traditional measures of cardiac function are now often normal in adolescents and young adults treated with antiretroviral therapy for human immunodeficiency virus (HIV) infection. There is, however, evidence of myocardial abnormalities in adults with HIV. Cardiac strain analysis may detect impairment in cardiac function that may be missed by conventional measurements in this population. This was a retrospective study in which echocardiograms of HIV-infected subjects (n = 28) aged 7 to 29 years who participate in a natural history study of HIV acquired early in life were analyzed and compared with matched controls. Standard echocardiographic measures, along with speckle tracking-derived strain and strain rate, were assessed. Among the HIV-infected subjects, the median CD4 count was 667 cells/mm(3), and the mean duration of antiretroviral therapy was 14.6 years. Ejection fractions and fractional shortening were normal. There were no significant differences in measures of systolic or diastolic function between the groups. The HIV-infected group had borderline increased left ventricular mass indices. Global longitudinal and circumferential strain and strain rate, as well as global radial strain rate, were significantly impaired in the HIV-infected group compared with controls. There were no associations identified between left ventricular mass index or strain indices and current CD4 count, CD4 nadir, HIV viral load, or duration of antiretroviral therapy. HIV-infected participants demonstrated impaired strain and strain rate despite having normal systolic function and ejection fractions. Strain and strain rate may prove to be prognostic factors for long-term myocardial dysfunction. Therefore, asymptomatic children and young adults with long-standing HIV infection may benefit from these more sensitive measures.

Timing and Magnitude of Regional Right Ventricular Function: A Speckle Tracking-Derived Strain Study of Normal Subjects and Patients with Right Ventricular Dysfunction

The aim of this study was to evaluate the timing and magnitude of global and regional right ventricular (RV) function by means of speckle tracking-derived strain in normal subjects and patients with RV dysfunction. Peak longitudinal systolic strain (PLSS) and time to PLSS in 6 RV segments (the basal, mid, and apical segments of the RV free wall and septum) were obtained in 100 healthy volunteers and 76 patients with RV dysfunction by tracking speckles inside the myocardium using grayscale images. Global PLSS and time to PLSS were based on the average of the 6 regional values. There was a significant and close correlation between RV contractility as measured by PLSS and tricuspid annular plane systolic excursion (r = -0.83, P < .001). In normal subjects, PLSS was significantly greater in the free wall than in the septum (-28.7 + or - 4.1% vs -19.8 + or - 3.4%, P < .001), whereas time to PLSS was similar in the different regions of the right ventricle. In patients with RV dysfunction, global and regional PLSS was significantly less than in normal subjects (-13.7 + or - 3.6% vs -24.2 + or - 2.9%, P < .001), and a global PLSS cutoff value of -19% was helpful in distinguishing the two groups. Furthermore, time to PLSS in all of the RV septal segments and dispersion in RV contraction timing were significantly longer. Global PLSS in the patients with RV dysfunction was also significantly less in the presence of moderate to severe pulmonary hypertension (-12.7 + or - 3.6% vs -14.4 + or - 3.4%, P = .038). Speckle tracking not only makes it possible to quantify global RV function but also illustrates the physiology of RV contraction and the pattern of activation at regional level. Speckle tracking-derived strain could become an important new means of assessing and following up patients with impaired RV function and increased pulmonary pressure.

Chronic Mitral Regurgitation: A Pilot Study to Assess Preoperative Left Ventricular Contractile Function Using Speckle-Tracking Echocardiography

The development of postoperative left ventricular (LV) dysfunction is a frequent complication in patients with chronic severe mitral regurgitation (MR) and implies a poor prognosis. The aim of this study was to evaluate the predictive value of preoperative regional LV contractile function assessment using two-dimensional echocardiography-based speckle-tracking analysis in patients with chronic severe MR. Thirty-eight consecutive patients with chronic severe MR scheduled for mitral valve replacement were prospectively enrolled. Preoperative two-dimensional echocardiography-based speckle-tracking analysis at the level of the interventricular septum (IVS) was carried out, and strain and strain rate values were obtained. LV dP/dt and Doppler tissue imaging-derived strain and strain rate measurements were also obtained. LV volumes and LV ejection fraction (LVEF) were defined using three-dimensional echocardiography. Preoperative speckle tracking-derived longitudinal strain and strain rate values at the level of the IVS strongly predicted a postoperative LVEF decrease of >10%. Their predictive values were greater than those obtained for preoperative LV volumes and LVEF, LV dP/dt, and Doppler tissue imaging-derived strain and strain rate. The best discriminant parameter to detect a postoperative LVEF reduction of >10% with speckle tracking was a longitudinal strain rate at the level of the mid IVS < -0.80 s(-1) (area under the receiver operating characteristic curve, 0.88; sensitivity, 60%; specificity, 96.5%; positive predictive value, 90%; negative predictive value, 82.35%). IVS longitudinal speckle tracking-derived strain rate allows the accurate detection of early abnormalities in LV contractile function. It is a powerful predictor of early postoperative LVEF decreases in patients with chronic severe MR. Furthermore, speckle-tracking technology is more accurate than other methods. This new tool might assist clinicians in the optimal timing of surgery in patients with chronic severe MR.