Strain Imaging Diastolic Index Research Articles

Diagnostic accuracy of left ventricular diastolic transverse strain imaging by speckle tracking echocardiography for diagnosing chest pain in diabetic patients

Abstract Background Two-dimensional speckle tracking echocardiography (2D-STE) has been reported to be useful for the diagnosis of myocardial ischemia by detecting delayed relaxation (diastolic stunning) after an episode of angina. 2D-longitudinal strain is not specific besides ischemia such as diastolic dysfunction, and diabetes have been associated with abnormal longitudinal fibers. The aim is to evaluate the diagnostic accuracy of Left ventricular (LV) diastolic transverse strain imaging by STE to detect the presence of acute coronary syndrome (ACS) in diabetic patients with acute chest pain. Methods 385 consecutive patients with acute chest pain and without wall motion abnormality, who were admitted to an emergency department (ED) at 1 of 12 clinical sites in Japan, were enrolled and underwent 2D-STE at ED. Left ventricular (LV) transverse strain values at aortic valve closure (A) and one-third of diastole duration (B) were measured. The strain imaging diastolic index (SI-DI) was value was determined as: (A − B)/A × 100% to assess the LV diastolic strain imaging and was used to identify the regional LV delayed relaxation. All patients underwent coronary CT or coronary angiography to establish the diagnosis of ACS. Clinicians were blinded to the 2D-STE results. Results Out of 385 patients, 2D-STE analysis was possible in 365 patients (94%). 76 patients were diabetic (DM+), and 289 patients were non-diabetic (DM-). With assessment of coronary CT or coronary angiography, ACS was diagnosed in 125 patients (34%). 2D-STE was obtained at a mean of 5.3 hours after chest pain episode. Transverse SI-DI of ischemic segments were significantly lower than those of non-ischemic segments (p value <0.001) in both diabetic and non-diabetic patients, and transverse SI-DI of both diabetic and non-diabetic patients demonstrated high area under curve (AUC) for detection of myocardial ischemia (Figure: RCA; right coronary artery, LAD; left anterior descending artery, LCX; left circumferencial artery). In diabetic patients, sensitivity, specificity, and negative predictive value for ACS of transverse SI-DI are 100%, 95%, 100% in RCA (a cut-off value of 36.2), and 86.4%, 95%, 93% in LAD (a cut-off value of 50.2), and 75%, 85%, 94% in LCX (a cut-off value of 52), respectively. Conclusion LV diastolic transverse strain imaging by 2D-STE at ED increase the sensitivity, specificity and accuracy to predict the presence of ACS in diabetic patients with chest pain, as well as non-diabetic patients. (UMIN000013859). Figure 1. Transverse Strain (SI-DI): AUC (95% CI) Funding Acknowledgement Type of funding source: None

Empagliflozin Ameliorates Diastolic Dysfunction and Left Ventricular Fibrosis/Stiffness in Nondiabetic Heart Failure: A Multimodality Study

ObjectivesThe purpose of this study was to investigate the effect of empagliflozin on diastolic function in a nondiabetic heart failure with reduced ejection fraction (HFrEF) scenario and on the pathways causing diastolic dysfunction. BackgroundThis group demonstrated that empagliflozin ameliorates adverse cardiac remodeling, enhances myocardial energetics, and improves left ventricular systolic function in a nondiabetic porcine model of HF. Whether empagliflozin also improves diastolic function remains unknown. Hypothetically, empagliflozin would improve diastolic function in HF mediated both by a reduction in interstitial myocardial fibrosis and an improvement in cardiomyocyte stiffness (titin phosphorylation). MethodsHF was induced in nondiabetic pigs by 2-h balloon occlusion of proximal left anterior descending artery. Animals were randomized to empagliflozin or placebo for 2 months. Cardiac function was evaluated with cardiac magnetic resonance (CMR), 3-dimensional echocardiography, and invasive hemodynamics. In vitro relaxation of cardiomyocytes was studied in primary culture. Myocardial samples were obtained for histological and molecular evaluation. Myocardial metabolite consumption was analyzed by simultaneous blood sampling from coronary artery and coronary sinus. ResultsDespite similar initial ischemic myocardial injury, the empagliflozin group showed significantly improved diastolic function at 2 months, assessed by conventional echocardiography (higher e′ and color M-mode propagation velocity, lower E/e′ ratio, myocardial performance Tei index, isovolumic relaxation time, and left atrial size), echocardiography-derived strain imaging (strain imaging diastolic index, strain rate at isovolumic relaxation time and during early diastole, and untwisting), and CMR (higher peak filling rate, larger first filling volume). Invasive hemodynamics confirmed improved diastolic function with empagliflozin (better peak LV pressure rate of decay (–dP/dt), shorter Tau, lower end-diastolic pressure-volume relationship (EDPVR), and reduced filling pressures). Empagliflozin reduced interstitial myocardial fibrosis at the imaging, histological and molecular level. Empagliflozin improved nitric oxide signaling (endothelial nitric oxide synthetase [eNOS] activity, nitric oxide [NO] availability, cyclic guanosine monophosphate (cGMP) content, protein kinase G [PKG] signaling) and enhanced titin phosphorylation (which is responsible for cardiomyocyte stiffness). Indeed, isolated cardiomyocytes exhibited better relaxation in empagliflozin-treated animals. Myocardial consumption of glucose and ketone bodies negatively and positively correlated with diastolic function, respectively. ConclusionsEmpagliflozin ameliorates diastolic function in a nondiabetic HF porcine model, mitigates histological and molecular remodeling, and reduces both left ventricle and cardiomyocyte stiffness.

Role of global longitudinal strain diastolic index in assessment of patients with suspected obstructive coronary artery disease and normal or mildly reduced ejection fraction

Objective – To examine the utility of global longitudinal strain imaging diastolic index (SI-DI) in the assessment of patients with suspected obstructive coronary artery disease (CAD). Methods – We performed rest 2D standard echocardiography and strain imaging in 30 healthy subjects and in 148 patients with normal or mildly reduced ejection fraction and indication for coronarography for suspected obstructive CAD. Standard echocardiographic and strain parameters were analysed. Results – Global SI-DI was signifi cantly lower in the selected vs control group (p <0.001). After coronarography patients were divided in three subgroups: 74 patients with more than 50% obstruction in any major artery, 26 patients with previous revascularisation but no significant obstructive lesions at present and 48 patients without obstructive artery disease. Average global SI-DI was significantly lower in the subgroup with obstructive CAD vs the other two subgroups (p<0.05). Global SI-DI lower than 0.5 had a good sensitivity (84%) and a reasonable positive predictive value (52%) for detection of obstructive CAD. Conclusions – Global SI-DI is significantly lower in patients with obstructive CAD and normal or mildly reduced ejection fraction compared with normal subjects. A cut off value lower than 0.5 selects patients with a higher probability of obstructive CAD.

1225 Diagnostic accuracy of left ventricular diastolic strain imaging by speckle tracking echocardiography in detecting ischemic etiology of acute chest pain

Abstract Funding Acknowledgements none OnBehalf A TRAC-SI Multicenter Trial Background Two-dimensional speckle tracking echocardiography (2D-STE) has been reported to be useful for the diagnosis of myocardial ischemia by detecting delay in regional myocardial expansion (diastolic stunning) up to many hours after an episode of angina. The aim is to evaluate the diagnostic accuracy of Left ventricular (LV) diastolic longitudinal, circumferential, transverse and radial strain imaging by STE to detect the presence of acute coronary syndrome (ACS) in patients with acute chest pain. Methods 388 consecutive patients with acute chest pain and without wall motion abnormality, who were admitted to an emergency department (ED) at 1 of 12 clinical sites in Japan, were enrolled and underwent 2D-STE at ED. Left ventricular (LV) longitudinal, circumferential, transverse and radial strain values at aortic valve closure (A) and one-third of diastole duration (B) were measured. The strain imaging diastolic index (SI-DI) was value was determined as: (A-B)/A × 100% to assess the LV diastolic strain imaging and was used to identify the regional LV delayed relaxation. All patients underwent coronary CT or coronary angiography to establish the diagnosis of ACS. Clinicians were blinded to the 2D-STE results. Results Out of 388 patients, 2D-STE analysis was possible in 358 patients (92%). With assessment of coronary CT or coronary angiography, ACS was diagnosed in 118 patients (33%). 2D-STE was obtained at a mean of 5.3 hours after chest pain episode. SI-DI of longitudinal, circumferential, transverse and radial strain of ischemic segments were significantly lower than those of non-ischemic segments (p value < 0.001), and transverse and radial SI-DI demonstrated high diagnostic accuracy, compared with longitudinal SI-DI (Figure 1). Sensitivity, specificity, and negative predictive value for ACS of transverse SI-DI are 87%, 88%, % and 95%, respectively, using a cut-off value of 63.3. Conclusion LV diastolic strain imaging by 2D-STE at ED increase the sensitivity, specificity and accuracy to predict the presence of ACS in patients with chest pain. Compared with longitudinal diastolic strain imaging, transverse diastolic strain imaging is more sensitive marker to detect the myocardial ischemic episode (UMIN000013859). Abstract 1225 Figure 1

0176 : LV diastolic function and mechanics adaptation during the transition from rest to exercise

During the transition from rest to exercise, heart rate (HR) immediately increase to provide a sufficient O2 delivery to active muscle. This adaptation of HR induces a dramatically decrease of left ventricular (LV) filling time, that requires a very fast adaptation of the LV diastolic function to maintain LV filling. Diastolic function depends on many factors including intrinsic cardiomyocytes relaxation, LV filling pressure and also LV untwisting that occurs very early in diastole. However, the kinetics of these underlying mechanisms of LV diastolic function during the transition from rest to exercise remain to be explore. 25 young males (23±4 years) were recruited. Each subject performed 5 similar 4-min constant load exercises on a dedicated ergometer in a semi-supine position. 2D cine loops were recorded every 15s from different echocardiographic views. LV longitudinal diastolic strain rate (SrL diast ), an index of LV relaxation, and LV end-diastolic volume (LV-EDV) were assessed from an apical 4-chamber view. LV rotations, twist and its subsequent untwist were assessed from basal and apical short-axis views. The global strain imaging diastolic index was used as a sensitive index of LV filling pressures. At the onset of exercise, LV-EDV increased during the first 60s despite rapid increase of HR. This adaptation was firstly driven by rapid increase of LV filling pressure in the first 15s, probably due to venous return induced by the pedaling. LV filling was also facilitated by a rapid increase of cardiomyocyte relaxation as evidenced by the increase of SrL diast . Moreover, the increase in LV twist and its subsequent untwist was major during the first min of exercise and increase of the untwisting rate/twist ratio until 90s underlined an improvement in elastic recoil very early in diastole. These findings bring new and original data regarding the adaptation of the LV diastolic function and mechanics during the transient from rest to exercise in healthy subjects. The author hereby declares no conflict of interest

The contrast research between left ventricular three dimensional strain and coronary angiography for coronary disease patients without segmental ventricular wall motion abnormalities

Objective To evaluate the left ventricular diastolic function in coronary artery disease(CAD) patients without regional wall motion abnormality by real-time three-dimensional specke tracking imaging(RT3D-STI), and to investigate the value of RT3D-STI in detecting CAD. Methods According on coronary angiography, 92 patients without regional wall motion abnormality were divided into two groups: control group(n=21), without coronary artery stenosis; case group(n=50), coronary stenosis group. Two dimensional images and the three-dimensional full volume dynamic images of left ventricle were collected. Routine parameters and end-systolic left ventricular globle longitudinal strain(GLS), globle circumferential strain (GCS), globle area strain (GAS), globle radial strain (GRS) and corresponding strain imaging diastolic index (SI-DI) were aquired, respectively. The parameters by RT3D-STI were analyzed to diagnose coronary artery stenosis. Results Compared with control group, there were no significant difference in routine parameters, GLS, GRS, GAS and GCS(P>0.05). Longitudinal SI-DI(L-SI-DI), area SI-DI(A-SI-DI), radial SI-DI(R-SI-DI), circumferential SI-DI(C-SI-DI) in case group were significantly reduced compared with control group (P<0.05). The sensitivity of L-SI-DI, A-SI-DI, R-SI-DI and C-SI-DI were 90.5%, 81.0%, 85.7%, 81.0%, and the specificity of them were 82.0%, 78.0%, 68%, 56%, respectively, L-SI-DI was the best in sensitivity and specificity. L-SI-DI, A-SI-DI, R-SI-DI were significantly correlated with Gensini score(r= -0.706, -0.547, -0.410 P<0.05). Conclusions RT3D-STI can quantitatively assess the early changes of left ventricular diastolic function, which has important significance for early diagnosis of coronary artery stenosis. Key words: Echocardiography, real-time three-dimensional; Coronary disease; Ventricular function, left; Speckle tracking imaging

Two-dimentional speckle tracking strain imaging in the assessment of myocardial diastolic function in patients with stable angina pectoris

Article type Systematic review article Introduction: Ischemic heart disease is caused mainly by obstruction of coronary arteries. The ischemic assessment through echocardiography is dependent on wall motion abnormality detection during systole. In patients with ischemic heart disease the diastolic function is impaired before systolic function and measurement of regional diastolic dysfunction if possible will be most sensitive for assessment of obstructed coronary artery region. This study was designed to determine whether regional left ventricular delayed relaxation diagnosis could be detected with strain imaging derived from two-dimensional speckle tracking echocardiography in patients with coronary artery disease. Methods: All the articles reviewed were obtained using MEDLINE & ScienceDirect (up to October 2014). All data extracted by speckle tracking echocardiography. The index which is used is strain imaging diastolic index which is calculated as: (A-B) A×100. A is the amount of strain at the time Aortic value closure and B is the amount of strain in first one-third point of diastolic duration. Result: Four articles were reviewed. Three articles assessed patients with echocardiography at rest and one with stress echocardiography. All articles showed the coronary artery tracking with significant stenosis is possible by regional deformation analysis through two-dimensional strain. Discussion: The usage of strain images obtained through two-dimensional speckle tracking has been validated for the quantitation assessment of regional dysfunction in ischemic heart disease. Regional LV delayed relaxation diagnosis with strain imaging is a reliable method after treadmill stress test. Conclusion: Strain imaging is reasonable for evaluation of ischemia as a low cost noninvasive test with high accuracy.

Assessment of Elevation of and Rapid Change in Left Ventricular Filling Pressure Using a Novel Global Strain Imaging Diastolic Index

The aim of this study was to determine whether global strain imaging diastolic index (SIDI) obtained using 2-D speckle tracking imaging (2DSI) could predict elevation in and rapid change of LV filling pressure. Patients (n=126) underwent echocardiography and 2DSI during simultaneous cardiac catheterization. There were 60 patients in whom the same measurements were repeated 5min after i.v. glyceryl trinitrate. LV pre-atrial contraction pressure (pre-A) was measured as a surrogate of LV filling pressure. SIDI was defined as the change of LV longitudinal strain measured using 2DSI during the first one-third of diastole. Then, longitudinal global SIDI (L-global SIDI) was calculated as the mean SIDI of 18 LV segments. Mitral inflow and tissue Doppler imaging were also assessed. Among 126 patients, 93 patients had LV pre-A ≥15mmHg. L-global SIDI had a better correlation with LV pre-A (P<0.001, r=-0.56) than E/e' (P<0.01, r=0.35). On receiver operating characteristic curve analysis, L-global SIDI <0.48 was the optimum cut-off to predict LV pre-A ≥15mmHg (sensitivity, 82%; specificity, 68%). In addition, the ratio of L-global SIDI (after nitrate/before nitrate) was correlated with the ratio of LV pre-A (after nitrate/before nitrate; P=0.02, r=-0.34). A novel L-global SIDI derived from 2DSI may reflect elevated LV filling pressure and its rapid change better than conventional diastolic parameters.

Prediction of Coronary Artery Stenosis at Rest in Patients With Normal Left Ventricular Wall Motion

Noninvasive detection of coronary artery stenosis usually requires a stress test in patients without left ventricular (LV) regional wall motion abnormalities (RWMA). In contrast, abnormal regional LV relaxation caused by ischemia may persist beyond recovery from transient ischemia. The aim of the present study was to determine whether segmental analysis of abnormal regional LV relaxation using the strain imaging diastolic index (SI-DI) at rest could predict coronary artery stenosis in the three major vessels in patients without LV dysfunction or RWMA. We performed 2D speckle tracking echocardiography and coronary angiography in 85 patients without RWMA with suspected coronary artery disease. Patients with LV dysfunction or acute coronary syndrome were excluded. Echocardiographic images of the LV were obtained in the apical 2-, 3-, and 4-chamber views and divided into 6 segments. In each segment, SI-DI derived from transverse strain imaging was determined. Forty-eight patients had significant coronary artery stenosis (≥ 70%). The optimal cutoff values of SI-DI were 60.5% in the mid anteroseptal segment for detecting left anterior descending artery stenosis (sensitivity, 83.3%; specificity, 81.1%), 60.5% in the basal anterolateral segment for detecting left circumflex artery stenosis (sensitivity, 80.9%; specificity, 90.3%), and 61.5% in the basal inferior segment for detecting right coronary artery stenosis (sensitivity, 74.1%; specificity, 77.8%). A segmental analysis of SI-DI at rest predicted coronary artery stenosis in the three major vessels in patients without RWMA. This noninvasive method may be useful for detecting coronary artery stenosis without a stress test.

Abstract 9419: A Novel Global Strain Imaging Diastolic Index for the Estimation of Left Ventricular Filling Pressure

Background: Recently, strain imaging diastolic index (SIDI) has been proposed to assess left ventricular (LV) regional abnormal relaxation induced by myocardial ischemia. We aimed to examine whether non-invasive global SIDI obtained using 2D speckle tracking imaging (2DSI) could predict elevated levels of LV filling pressure. Methods: One hundred and twenty patients (age 63±13 years) with suspected coronary artery disease underwent echocardiography and 2DSI during simultaneous cardiac catheterization. Mean LV ejection fraction was 46.3±17.6%. LV pressure curve was obtained to measure pre-atrial contraction (Pre-AC) pressure as a surrogate for LV filling pressure. SI-DI was defined as LV longitudinal changes during the first one-third of diastolic duration. In 2DSI, LV longitudinal SIDI of 18 LV segments were measured from the apical 2-, 3-, and 4-chamber views. Then, longitudinal global SIDI (L-global SIDI) was calculated as a mean SIDI of 18 LV segments. Mitral inflow and tissue Doppler imaging were also assessed. Results: Among 120 patients, 64 cases had Pre-AC pressure &gt; 15 mmHg. L-global SIDI had a significant and better correlation with pre-AC pressure (p&lt;0.001, R=0.47)(Figure 1), than E/e’ (p&lt;0.01, R=0.26) . In multiple stepwise regression analysis, L-global SIDI was the strongest independent determinant of pre-AC pressure (β=-0.66, P&lt;0.001), among E/A, left atrium volume index, E/e’, and e’. In addition, L-global&lt;0.50 was the optimum cutoff value to predict LV pre-AC pressure &gt;15mmHg (sensitivity, 89%; specificity, 51%)(Figure 2), while E/e’&gt;11.2, the optimum cutoff value of E/e’ predicted LV pre-A contraction pressure &gt;15mmHg (sensitivity, 65%; specificity, 75%). Conclusions: L-global SIDI derived from 2DSI can be used to estimate LV filling pressure noninvasively. Global SI-DI may provide more accurate estimation of LV filling pressure, compared with conventional mitral inflow and tissue speckle tracking.

A novel global strain diastolic index correlates with plasma NT-proBNP levels in asymptomatic hypertensive patients with preserved left ventricular ejection fraction.

The strain imaging diastolic index (SI-DI) was reported to be a sensitive marker of regional left ventricular (LV) delayed relaxation induced by ischemia. However, the clinical usefulness of the global SI-DI has not been evaluated. N-terminal pro-brain natriuretic peptide (NT-proBNP) is a sensitive biomarker for the detection of asymptomatic diastolic LV dysfunction. This study investigated the ability of a novel parameter, the global SI-DI, obtained using 2D speckle tracking imaging (2DSI) to correlate with the plasma NT-proBNP levels in asymptomatic hypertensive patients with preserved LV ejection fraction. We performed 2D echocardiography and 2DSI in 83 asymptomatic hypertensive patients with preserved ejection fraction (>45%) and in 37 control subjects. In 2DSI, the LV longitudinal peak strain and the SI-DI of 18 LV segments were measured. NT-proBNP was measured in all subjects. The data were compared between hypertensive patients and normal controls. The average peak strain and global SI-DI of 18 LV segments were significantly reduced in hypertensive patients compared with control subjects (P<0.05); however, only the global SI-DI was significantly correlated with log10 NT-proBNP (r=-0.469, P=0.001). In Pearson's correlation analyses, log10 NT-proBNP was significantly correlated with E/e', E/A ratio, early diastolic mitral annular velocity (e'), global peak strain, deceleration time of the E-wave, and LV ejection fraction. In the multiple stepwise regression analysis, the global SI-DI was the strongest independent determinant of log10 NT-proBNP (β=-0.386, P=0.008). The global SI-DI derived from 2DSI correlates well with plasma NT-proBNP levels and may have prognostic value in asymptomatic hypertensive patients with preserved ejection fraction.

Assessment of Myocardial Ischemic Memory Using Speckle Tracking Echocardiography

The aim of this study was to evaluate which regional myocardial parameters derived from speckle tracking echocardiography could demonstrate myocardial ischemic memory in a brief ischemia-reperfusion dog model. Myocardial ischemic memory imaging, denoting the visualization of abnormalities provoked by ischemia and sustained even after restoration of perfusion, can convey important clinical information. We previously reported that post-systolic shortening (PSS) remains in the risk area after recovery from brief ischemia. However, it is still unclear whether abnormalities in other regional deformation parameters persist after relief from brief ischemia. Echocardiographic data were chronologically acquired from 11 dogs during 2 min of coronary occlusion followed by reperfusion. Regional systolic and diastolic deformation parameters, including parameters related to PSS, were measured from radial and circumferential strain and from strain rate analyzed in the risk and normal areas. Strain imaging diastolic index (SI-DI), which had been proposed as a parameter for assessing ischemic memory, was also calculated. Peak systolic strain, end-systolic strain, and peak systolic strain rate decreased in the risk area during occlusion but recovered to the baseline level immediately after reperfusion. Strain rate during early diastole decreased during occlusion; however, the decrease did not persist after reperfusion. Post-systolic strain index (PSI) and time-to-peak strain index, which are parameters of PSS, increased during occlusion. These increases persisted until 10 to 20 min after reperfusion (circumferential PSI: 0.02 ± 0.04 [baseline] vs. 0.08 ± 0.04 [20 min], p < 0.05). SI-DI did not show a significant change during occlusion because of a large variation. Although abnormalities of PSS-related parameters alone persisted after recovery from 2-min occlusion, abnormalities of other deformation parameters, such as strain rate during early diastole, did not. These data suggest that assessment of PSS by speckle tracking echocardiography is useful for detecting myocardial ischemic memory.

Abstract 16710: Evidence of Ischemic Memory From Strain Rate Analysis of Diastolic Function During/After Percutaneous Coronary Intervention

Introduction The ability to detect ischemia occurring prior to the time of examination (ischemic memory) would be of great clinical value. Studies have shown that abnormal left ventricular (LV) diastolic function may be a sensitive marker of myocardial ischemia.HypothesisWe hypothesized that analysis of diastolic function by strain imaging (SI) could detect abnormalities due to myocardial ischemia for some time after percutaneous coronary intervention (PCI). Methods We performed echograms on 31 pts having angiography, 18 controls (CON) without obstructive CAD and 13 undergoing single vessel PCI (ISCH), at baseline, during balloon occlusion, and for 15, 30, and 60 minutes afterwards. SI analysis of the ischemic segment using speckle tracking was done in parasternal short axis views. The end systolic strain at the closure of the aortic valve (A) and at the time of one-third of diastole (B) were measured. A strain imaging diastolic index (SIDI) was calculated as A-B/Ax100% to examine diastolic performance. Results (see Table)Baseline characteristics for CON were similar to ISCH: mean age 61 ±14 years, HR 70 ±12, BP 135/70 ±27/13mmHg, male 69%, DM 38%, HTN 100%. SIDI values for ISCH decreased during balloon occlusion and remained low at 60 minutes after reperfusion. SIDI values in CON did not change significantly from baseline for 60 minutes after the procedure. (A) for ISCH decreased from 30.5 ±4% at baseline to 11.4 ±2% at 15 minutes after balloon occlusion and improved slightly to 15.8 ±2% at 60 minutes after reperfusion. (A) values in CON were unchanged from 22.6 ±8% at baseline to 20.8 ±9% at 60 minutes after procedure. Conclusions Abnormalities of systolic and diastolic strain (manifested by a decrease in SIDI values) occur in response to the induction of myocardial ischemia by PCI. As compared to the change in systolic strain, the change in SIDI values is of greater magnitude, is persistent at 60 minutes after reperfusion, and may be a useful marker of ischemic myocardial memory.

Prediction of coronary artery stenosis using strain imaging diastolic index at rest in patients with preserved ejection fraction

Post-ischemic myocardial diastolic stunning persists for a long time after transient ischemia even after systolic function has recovered. We sought to identify coronary artery stenosis in clinical patients using strain imaging diastolic index (SI-DI) at rest. We retrospectively examined 85 patients with suspected coronary artery disease and preserved ejection fraction (EF; >50%) who underwent both echocardiography and coronary angiography. Speckle tracking strains were measured in 3 apical views and parasternal left ventricular (LV) short-axis views at the papillary muscle level. LV segments with inadequate image quality and deficit segments in the movie were excluded by the blinded observer. After strain analysis, LV segments were classified into no stenosis (≤ 50%), mild stenosis (51-75%), and severe stenosis (>75%) groups on the bases of the coronary angiogram. SI-DI decreased significantly in severe stenosis segments (p<0.05, ANOVA), but none of the peak strains showed significant difference. The area under the curve for predicting severe stenosis in radial, longitudinal, and transverse SI-DI was 0.72, 0.74, and 0.80, respectively. A cut-off value of 49 for transverse SI-DI can predict LV segments with severe stenosis with sensitivity of 0.79 and specificity of 0.73. A screening cut-off value of 63 for transverse SI-DI shows sensitivity of 0.95 and specificity of 0.50. SI-DI at rest is a novel marker in predicting coronary stenosis even in patients with preserved EF. This index can be used to screen patients with suspected coronary artery disease in routine echocardiography and does not require stress provocation.

Abnormal Regional Left Ventricular Systolic and Diastolic Function in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention: Clinical Significance of Post-Ischemic Diastolic Stunning

This study was designed to characterize both regional left ventricular (LV) systolic and diastolic function after percutaneous coronary intervention by using strain imaging (SI) derived from 2-dimensional speckle-tracking echocardiography. Ischemic insult after coronary occlusion affects not only regional LV systolic but also diastolic function. Regional LV transverse peak strain and strain changes during the first one-third of diastole duration (strain imaging diastolic index [SI-DI]) were monitored in at-risk segments after percutaneous coronary intervention in 30 patients with coronary artery disease. The segments were divided into proximal and distal. Strain data in the at-risk segments were compared with values derived from remote nonischemic segments. Coronary occlusion induced a marked reduction in the systolic strain in both proximal and distal at-risk segments (from 36.9 +/- 6.0% to 12.0 +/- 3.9% and from 31.9 +/- 5.6% to 6.2 +/- 3.3%, respectively, p < 0.0001). Concomitantly, SI-DI values decreased (from 76.6 +/- 5.3% to -21.2 +/- 9.1% and from 72.5 +/- 5.9% to -48.7 +/- 20.8%, respectively, p < 0.0001). Upon reperfusion, systolic deformation parameters returned to near-normal pre-occlusion values. However, SI-DI values in the both proximal and distal at-risk segments decreased (43.2 +/- 9.5%, p < 0.01, and -17.3 +/- 11.1%, p < 0.0001, respectively) 30 min after reperfusion and were still lower (51.5 +/- 9.9%, p < 0.01) in the distal at-risk segment 24 h after reperfusion. SI analysis provides detailed mechanical characterization of regions with myocardial ischemic insult and can demonstrate post-ischemic diastolic stunning despite complete systolic functional recovery after reperfusion.

Exercise-Induced Post-Ischemic Left Ventricular Delayed Relaxation or Diastolic Stunning: Is it a Reliable Marker in Detecting Coronary Artery Disease?

The aim of this study was to determine whether post-ischemic left ventricular (LV) delayed relaxation could be detected by using strain imaging (SI) derived from 2-dimensional speckle-tracking echocardiography in patients with stable effort angina. Regional LV delayed relaxation during early diastole is a sensitive sign of acute myocardial ischemia and may persist beyond recovery of exercise-induced ischemia. Regional LV transverse strain changes during the first one-third of diastole duration (strain imaging diastolic index [SI-DI]) were determined at baseline and 5 and 10 min after the exercise test in 162 patients with stable effort angina. The ratio of SI-DI before and after exercise (SI-DI ratio) was used to identify regional LV delayed relaxation. A total of 117 patients had significant (> or =50% of luminal diameter) coronary stenoses. The mean SI-DI decreased from 78.0 +/- 9.7% to 27.6 +/- 16.0% (p < 0.0001) in 191 territories perfused by coronary arteries with significant stenoses 5 min after the treadmill exercise, whereas it remained unchanged in 280 territories perfused by arteries with nonsignificant stenoses. Ten minutes after exercise, regional delayed relaxation was still observed in 85% of territories perfused by stenotic coronary arteries. An SI-DI ratio with a cutoff value of 0.74 had a sensitivity of 97% and a specificity of 93% to detect significant coronary stenosis in the receiver-operator characteristic curve. Detection of post-ischemic regional LV delayed relaxation or diastolic stunning after treadmill exercise using SI is a sensitive and reliable method for the detection of coronary artery disease.

Letter by Weidemann et al Regarding Article, “Global Diastolic Strain Rate for the Assessment of Left Ventricular Relaxation and Filling Pressure”

HomeCirculationVol. 116, No. 14Letter by Weidemann et al Regarding Article, “Global Diastolic Strain Rate for the Assessment of Left Ventricular Relaxation and Filling Pressure” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Weidemann et al Regarding Article, “Global Diastolic Strain Rate for the Assessment of Left Ventricular Relaxation and Filling Pressure” Frank Weidemann and Joerg M. Strotmann Bart Bijnens Frank WeidemannFrank Weidemann Department of Internal Medicine I, University Hospital Wuerzburg, Germany Search for more papers by this author and Joerg M. StrotmannJoerg M. Strotmann Department of Internal Medicine I, University Hospital Wuerzburg, Germany Search for more papers by this author Bart BijnensBart Bijnens Medical School and Faculty of Electronic Engineering, University of Zagreb, Croatia Search for more papers by this author Originally published2 Oct 2007https://doi.org/10.1161/CIRCULATIONAHA.107.708784Circulation. 2007;116:e368To the Editor:We have read with interest the paper by Wang et al1 on diastolic function assessed by strain rate in the isovolumetric relaxation period (SRIVR) derived from 2-dimensional speckle tracking. In principle, 2-dimensional speckle tracking is a useful progression toward an automated assessment of left ventricular deformation.We would like to comment on the fact that the authors had some difficulties with patients with wall motion abnormalities. It is known from many studies that different conditions such as acute ischemia, regional fibrosis, and increased afterload result in ongoing (postsystolic) deformation during isovolumic relaxation (IVR).2,3 This deformation will change local SRIVR independently from tau, which thus limits the assessment of diastolic function by analysis of SRIVR in a wide range of important clinical conditions.In addition, we agree that E/Ea has some limitations when diastolic function is assessed, especially in the gray zone between 8 and 15. However, although it has merits in the assessment of strain, we think that 2-dimensional speckle tracking is not satisfactory when strain rate is assessed, especially during IVR. It is well known that speckle tracking can only be performed at relatively low frame rates. However, this low frame rate prevents resolution of the fast change in deformation (ie, strain rate) that occurs during IVR. This lack of resolution leads, as correctly mentioned in the paper,1 to an underestimation of peak strain-rate value. Thus, we would suggest use of Doppler-derived strain rate (with its high temporal resolution), and not speckle tracking strain rate, to accurately assess SRIVR.The authors could nicely show the limitations of diastolic function assessment by pulsed-wave tissue Doppler imaging and suggest a greater focus on diastolic deformation. However, we believe that assessment of strain rate during IVR with 2-dimensional speckle tracking and its inherent technical limitations will prove a real challenge in clinical conditions.DisclosuresNone.1 Wang J, Khoury DS, Thohan V, Torre-Amione G, Nagueh SF. Global diastolic strain rate for the assessment of left ventricular relaxation and filling pressures. Circulation. 2007; 115: 1376–1383.LinkGoogle Scholar2 Weidemann F, Dommke C, Bijnens B, Claus P, D’hooge J, Mertens P, Verbeken E, Maes A, Van de Werf F, De Scheerder I, Sutherland GR. Defining the transmurality of a chronic myocardial infarction by ultrasonic strain-rate imaging: implications for identifying intramural viability: an experimental study. Circulation. 2003; 107: 883–888.LinkGoogle Scholar3 Voigt JU, Lindenmeier G, Exner B, Regenfus M, Werner D, Reulbach U, Nixdorff U, Flachskampf FA, Daniel WG. Incidence and characteristics of segmental postsystolic longitudinal shortening in normal, acutely ischemic, and scarred myocardium. J Am Soc Echocardiogr. 2003; 16: 415–423.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Chiang S, Daimon M, Ishii K, Kawata T, Miyazaki S, Hirose K, Ichikawa R, Miyauchi K, Yeh M, Chang N and Daida H (2014) Assessment of Elevation of and Rapid Change in Left Ventricular Filling Pressure Using a Novel Global Strain Imaging Diastolic Index, Circulation Journal, 10.1253/circj.CJ-13-0513, 78:2, (419-427), . October 2, 2007Vol 116, Issue 14 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.708784PMID: 17909112 Originally publishedOctober 2, 2007 PDF download Advertisement SubjectsEchocardiography