Echocardiographic Strain Imaging Research Articles

Left atrial strain analysis in the realm of pediatric cardiology: Advantages and implications.

Left atrial (LA) strain analysis has emerged as a noninvasive technique for assessing LA function and early detection of myocardial deformation. Recently, its application has also shown promise in the pediatric population, spanning diverse cardiac conditions that demand accurate and sensitive diagnostic measures. This research article endeavors to explore the role of LA strain parameters and contribute to the growing body of knowledge in pediatric cardiology, paving the way for more effective and tailored approaches to patient care. A comprehensive literature review was conducted to gather evidence from studies using echocardiographic strain imaging techniques across pediatric populations. LA strain parameters exhibited greater sensitivity than conventional atrial function indicators, with early detection of diastolic dysfunction and LA remodeling in pediatric cardiomyopathy, children with multisystem inflammatory syndrome, rheumatic heart disease, as well as childhood renal insufficiency and obesity offering prognostic relevance as potential markers in these pediatric subpopulations. However, there remains a paucity of evidence concerning pediatric mitral valve pathology, justifying further exploration. LA strain analysis carries crucial clinical and prognostic implications in pediatric cardiac conditions, with reliable accuracy and sensitivity to early functional changes.

Do False Tendons Prevent Adverse Left Ventricular Remodeling After Anterior Wall Myocardial Infarction? An Echocardiographic Strain Imaging Study

The role of muscular left ventricular (LV) false tendons (FTs) is poorly understood. To gain insight into their pathophysiologic significance, we adapted echocardiographic LV strain imaging software to measure LVFT longitudinal strain in subjects with normal left ventricles and in patients who sustained previous anterior wall myocardial infarction (AWMI). GE EchoPAC software was used to measure longitudinal strain in LVFTs ≥0.3 cm in diameter. Tendinous strain was measured in 11 patients with LVFTs confined to the left anterior descending artery territory (connecting the anteroseptum or anterior wall to the apex) ≥6 months after AWMI (myocardial infarction [MI]+FT+ group) and in 25 patients with normal hearts containing LVFTs (MI-FT+ group). We also compared the indexed LV end-diastolic volumes in the MI+FT+ group to that of 25 patients with previous AWMI without LVFTs (MI+FT- group). The mean LVFT strain in MI+FT+ group was 5.5 ± 6.2% and -28.9 ± 4.7% in the MI-FT+ group (p <0.0001). The indexed LV end-diastolic volume in the MI+FT+ group did not differ from the MI+FT- group (88.4 ± 17.8 vs 87.9 ± 17 ml/m2, p = 0.90). In conclusion, the negative strain (contraction) developed by LVFTs in the MI-FT+ group may help maintain normal LV size and shape by generating inward restraining forces. The development of positive strain (stretch) in LVFTs in patients in the MI+FT+ group suggests they become infarcted after AWMI. This implies that they are incapable of generating inward restraining forces that might otherwise mitigate adverse remodeling. Of note, LV volumes after AWMI do not differ whether or not LVFTs are present.

External validation of a deep learning algorithm for automated echocardiographic strain measurements.

Echocardiographic strain imaging reflects myocardial deformation and is a sensitive measure of cardiac function and wall-motion abnormalities. Deep learning (DL) algorithms could automate the interpretation of echocardiographic strain imaging. We developed and trained an automated DL-based algorithm for left ventricular (LV) strain measurements in an internal dataset. Global longitudinal strain (GLS) was validated externally in (i) a real-world Taiwanese cohort of participants with and without heart failure (HF), (ii) a core-lab measured dataset from the multinational prevalence of microvascular dysfunction-HF and preserved ejection fraction (PROMIS-HFpEF) study, and regional strain in (iii) the HMC-QU-MI study of patients with suspected myocardial infarction. Outcomes included measures of agreement [bias, mean absolute difference (MAD), root-mean-squared-error (RMSE), and Pearson's correlation (R)] and area under the curve (AUC) to identify HF and regional wall-motion abnormalities. The DL workflow successfully analysed 3741 (89%) studies in the Taiwanese cohort, 176 (96%) in PROMIS-HFpEF, and 158 (98%) in HMC-QU-MI. Automated GLS showed good agreement with manual measurements (mean ± SD): -18.9 ± 4.5% vs. -18.2 ± 4.4%, respectively, bias 0.68 ± 2.52%, MAD 2.0 ± 1.67, RMSE = 2.61, R = 0.84 in the Taiwanese cohort; and -15.4 ± 4.1% vs. -15.9 ± 3.6%, respectively, bias -0.65 ± 2.71%, MAD 2.19 ± 1.71, RMSE = 2.78, R = 0.76 in PROMIS-HFpEF. In the Taiwanese cohort, automated GLS accurately identified patients with HF (AUC = 0.89 for total HF and AUC = 0.98 for HF with reduced ejection fraction). In HMC-QU-MI, automated regional strain identified regional wall-motion abnormalities with an average AUC = 0.80. DL algorithms can interpret echocardiographic strain images with similar accuracy as conventional measurements. These results highlight the potential of DL algorithms to democratize the use of cardiac strain measurements and reduce time-spent and costs for echo labs globally.

Subclinical left ventricular dysfunction demonstrated by strain imaging echocardiography in moderate to severe COVID-19 patients (Delta variant, single center study)

Abstract Background Cardiovascular complications in acute coronavirus disease 2019 (COVID-19) are well established and are the main contributors to morbidity and mortality. The echocardiographic investigation in these patients upon hospitalisation for COVID-19 infection, however, is relatively constrained due to the high contagiousness risk. Recent studies (1,2) have shown the subclinical myocardial dysfunction defined by left ventricular longitudinal strain (LV-GLS) but these studies were limited the number of patients. Numerous moderate to severe COVID-19 patients in our hospital were subjected to echocardiographic examination during admission in the delta variant period (full screening protocol). Therefore, this beneficial data ought to be made available to the public health. Objectives This study aims to demonstrate the prevalence of subclinical left ventricular (LV) dysfunction by strain imaging echocardiography, defined as LV-GLS, and its correlation to cardiac and inflammatory biomarkers in COVID-19 patients during admission in the delta variant era. Methods Retrospective historical review was performed from the track-care system. Post-processing analysis of strain imaging by speckle tracking echocardiography (STE) using Tomtec imaging system, COVID-19 patients who admitted in the intermediate care unit or intensive care unit and obtaining echocardiographic study during hospital stay with optimal echocardiographic imaging to provide STE (according to EACVI/ASE 2015 consensus)³ during April 2021 to March 2022, were enrolled into the study. LV-GLS &amp;gt; -18% was defined as subclinical LV dysfunction. We described the number and percentage of patients who had decreased left ventricular ejection fraction (LVEF) and expressed it in relation to the decreased LV-GLS and normal LV-GLS (Table 1). The correlation between LV-GLS and biomarkers (troponin-I, C-reactive protein, and interleukin-6) was analysed by Pearson correlation. Results Initially, 247 patients with COVID-19 confirmed by RT-PCR and having an echocardiogram were enrolled, but only 176 patients with adequate echocardiographic imaging (44.3% female) and a mean age of 69.1 ± 16.8 were analysed by an experienced cardiologist. Of 24 patients (13.6%) had decreased LVEF and all of patients in this group had decreased LV-GLS (-9.28% ±.3.7%). 98 of 152 patients (64.5%) in normal LVEF group had decreased LV-GLS (-14.1% ±.3.1%). The correlation between LV-GLS and biomarkers revealed only troponin-I had statistically significant correlation with LV-GLS (r = 0.52, p &amp;lt; 0.001), but C-reactive protein and interleukin-6 were not exhibited significant correlation with LV-GLS (r = 0.11, p = 0.17 and r = 0.09, p= 0.38, respectively). Conclusions Subclinical LV dysfunction as demonstrated by LV-GLS was not uncommon in patients with moderate to severe COVID-19 infection (delta variant era), especially if the patients had elevated cardiac troponin levels.Proportion of decreased LV-GLS in COVIDImpaired LV-GLS and troponin I level

Left atrial functional assessment a prime clue in solving the puzzle of stable angina symptoms in suspected coronary artery disease patients

Abstract Background Assessing clinically for significant coronary artery disease (CAD) in stable angina patients presents a formidable task. Routinely performed echocardiography is limited in diagnosing CAD with provision for the regional wall motion abnormality (RWMA) for left ventricle (LV) systolic dysfunction and altered mitral inflow velocities for LV diastolic dysfunction. However, the advent of two-dimensional (2D) speckle-tracking technique has established the era of strain imaging, opening new possibilities in echocardiography. It is now possible to have a detailed functional assessment of left atrium (LA). We utilised speckle tracking imaging to obtain strain parameters for LA function. Combining these strain parameters with the doppler myocardial velocities and mitral inflow velocities, may prove useful mode of imaging to diagnose significant CAD in stable angina patients. Purpose To study the parameters of left atrial functions utilising echocardiographic strain imaging and evaluate their correlation with the syntax score-II in patients with symptoms of stable angina. Methods 103 patients with symptoms of stable angina undergoing coronary angiography for suspected coronary artery disease(CAD), were considered for LA function assessment and compared with their syntax-II score. Results The LA reservoir function parameters, peak atrial longitudinal strain (PALS) and peak global systolic strain rate (LAsSR), decreased with increasing syntax-II score (p values 0.011 and 0.001 respectively) and the parameter of LA conduit function, peak global early diastolic strain rate (LAeSR) increased (p value &amp;lt;0.001). The LA filling pressures reflected by E/e`, also increased with more severe syntax-II score (p value &amp;lt;0.001). We, further, configured cut off values of &amp;lt; 23.56 for PALS, &amp;lt; 1.15 for LAsSR, &amp;gt; -1.09 for LAeSR, and E/e` ratio &amp;gt; 10.39 as predictors of significant CAD, with good sensitivity and specificity. Therefore, stable angina patients who had significant CAD on coronary angiogram represented by severe syntax score-II, had higher LA filling pressures and deranged LA function with transition from more of reservoir chamber to merely a conduit. Conclusion Our study shows a significant association between LA strain parameters (PALS, LAsSR, and LAeSR) and LA filling pressures (E/e`), with the presence of significant CAD in these patients. The stable angina patients with more severe CAD as quantified by their severe syntax score-II, have an impaired LA reservoir and LA functions more as a conduit, with elevated filling pressures. This study establishes a significant association between LA deformation strain variables and severity of CAD and hence LA strain imaging can be a useful tool to diagnose significant CAD in stable angina patients.

Abstract 11798: Comparison of Echocardiographic Measurements and Cardiac Biomarkers Between Neonates With Neonatal Encephalopathy Who Developed Brain Injury or Not During Therapeutic Hypothermia

Background: Despite therapeutic hypothermia (TH), many newborns with neonatal encephalopathy (NE) develop brain injury (BI). We hypothesis that newborns with NE have with brain injury have different echocardiographic (ECHO) parameters to those with no brain injury. Aims: To compare the ECHO parameters on day of life (DOL) 2 between neonates with NE undergoing TH developing or not brain injury. Methods: Prospective cohort study in a single tertiary unit enrolling neonate (born ≥36weeks and ≥1800 grams) undergoing TH for NE, between 2016 and 2020. All neonates presented on admission with moderate to severe NE by amplitude-integrated electroencephalogram (aEEG) profile and underwent a brain magnetic resonance (MRI) on DOL 2. ECHO was performed on the MRI day and data were extracted offline. Multiple logistic regression analyses were constructed to determine which parameters best predicted brain injury or not. Results: A total of 34 neonates were recruited, of which 19 (56%) had brain injury. Those with BI had a higher gestational age (GA) at birth (39.6±1.6 vs 38.2±1.5, p=0.01) and more severe pattern on aEEG (p=0.007) (Table 1). Mortality was also more frequent. Left and right ventricular performance were similar between groups by standard ECHO measures, strain and tissue Doppler imaging (Table 2). Although TAPSE was increased in those with brain injury (p=0.04), the Z-Score accounting for GA was similar. Initial aEEG pattern was the best predictor of brain injury, when accounting for GA and ECHO parameters/biomarkers. Conclusion: Initial aEEG pattern and not hemodynamic profile was most predictive of brain injury on MRI.

Echocardiographic Reference Ranges of Global Longitudinal Strain for All Cardiac Chambers Using Guideline-Directed Dedicated Views

BackgroundMyocardial deformation by echocardiographic strain imaging is a key measurement in cardiology, providing valuable diagnostic and prognostic information. Reference ranges for strain should be established from large healthy populations with minimal methodologic biases and variability. ObjectivesThe aim of this study was to establish echocardiographic reference ranges, including lower normal limits of global strains for all 4 cardiac chambers, by guideline-directed dedicated views from a large healthy population and to evaluate the influence of subject-specific characteristics on strain. MethodsIn total, 1,329 healthy participants from HUNT4Echo, the echocardiographic substudy of the 4th wave of the Trøndelag Health Study, were included. Echocardiographic recordings specific for each chamber were optimized according to current recommendations. Two experienced sonographers recorded all echocardiograms using GE HealthCare Vivid E95 scanners. Analyses were performed by experts using GE HealthCare EchoPAC. ResultsThe reference ranges for left ventricular (LV) global longitudinal strain and right ventricular free-wall strain were −24% to −16% and −35% to −17%, respectively. Correspondingly, left atrial (LA) and right atrial (RA) reservoir strains were 17% to 49% and 17% to 59%. All strains showed lower absolute values with higher age, except for LA and RA contractile strains, which were higher. The feasibility for strain was overall good (LV 96%, right ventricular 83%, LA 94%, and RA 87%). All chamber-specific strains were associated with age, and LV strain was associated with sex. ConclusionsReference ranges of strain for all cardiac chambers were established based on guideline-directed chamber-specific recordings. Age and sex were the most important factors influencing reference ranges and should be considered when using strain echocardiography.

The diagnostic accuracy of two-dimensional strain imaging echocardiography to detect the severity of coronary artery disease in non-ST segment elevation acute coronary syndrome

ObjectiveStrain imaging by two-dimensional speckle tracking echocardiography can detect severe coronary artery disease (CAD). This study aims to assess the diagnostic accuracy of various strain parameters in patients with non-ST segment acute coronary syndrome to detect the angiographic severity of CAD and also to compare among them. MethodsThis hospital-based observational study was conducted on 178 patients with NSTEACS and preserved left ventricular ejection fraction who presented in emergency or outdoor from July 2021 to December 2022. We excluded patients with prior coronary revascularization, heart failure, arrhythmia, more than trivial valvular heart disease, or poor acoustic window. Global longitudinal strain (GLS), peak systolic strain (SS), post systolic index (PSI), and systolic strain rate (SR) were calculated by speckle tracking with automated function imaging. Coronary angiography was done in all patients, and the syntax score was calculated. ResultsThe strain parameters showed a significant correlation with the syntax score. There was a statistically significant difference in strain parameters between patients with left main (LM) or triple vessel disease (TVD) and others. Receiver operating characteristic (ROC) curve analysis showed that GLS had a better diagnostic accuracy for detecting LM or TVD than other strain parameters. GLS with a cut-off value of −11.2% had a sensitivity of 85.7% and specificity of 53.5% for detecting LM or TVD. ConclusionStrain imaging can be a helpful bedside adjunct to conventional investigations for detecting severe CAD in patients with NSTEACS.

Current clinical use of speckle-tracking strain imaging: insights from a worldwide survey from the European Association of Cardiovascular Imaging (EACVI).

Speckle-tracking echocardiography (STE) strain imaging has been a major advancement in myocardial function quantification. We aimed to explore current worldwide clinical application of STE. Access, feasibility, access, and clinical implementation of STE were investigated with a worldwide open-access online survey of the European Association of Cardiovascular Imaging. Participants (429 respondents and 77 countries) from tertiary centres (46%), private clinics, or public hospitals (54%) using different vendors for data acquisition and analysis were represented. Despite almost universal access (98%) to STE, only 39% of the participants performed and reported STE results frequently (>50%). Incomplete training and time constraints were the main reasons for not using STE more regularly. STE was mainly used to assess the LV (99%) and less frequently the right ventricular (57%) and the left atrial (46%) function. Cardiotoxicity (88%) and cardiac amyloidosis (87%) were the most frequent reasons for the clinical use of LV STE. Left atrial STE was used most frequently for the diagnosis of diastolic dysfunction and right ventricular STE for the assessment of right ventricle (RV) function in pulmonary hypertension (51%). Frequency of STE use, adherence to optimal techniques, and clinical appropriateness of STE differed according to training experience and across vendors. Key suggestions outlined by respondents to increase the clinical use of STE included improved reproducibility (48%) and standardization of strain values across vendors (42%). Although STE is now readily available, it is underutilized in the majority of centres. Structured training, improved reproducibility, and inter-vendor standardization may increase its uptake.

External validation of a deep learning algorithm for automated echocardiographic strain measurements

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Us2ai. Background Echocardiographic strain imaging reflects myocardial deformation and is a sensitive measure of cardiac function and wall-motion abnormalities. Manual strain analysis is time-consuming, prone to error and requires considerable expertise. Deep learning (DL) algorithms could automate interpretation of echocardiographic strain imaging. Purpose To develop and externally validate automated DL-based measurement of the left ventricle (LV) global longitudinal strain (GLS) and regional strain. Methods We developed and validated an automated DL workflow using convolutional neural networks to automatically annotate and assess individual 2D videos of apical 4-chamber, 2-chamber and 3-chamber views. We trained the algorithm in an internal dataset and validated GLS externally in (1) a real-world general population dataset from Taiwan, (2) a core-lab measured dataset from the multinational PROMIS-HFpEF study, and regional strain in (3) the HMC-QU-MI study of patients with suspected myocardial infarction (MI). Results In the external datasets, the DL workflow successfully analysed 3741 (89%) studies in the real-world cohort, 176 (96%) in PROMIS-HFpEF and 158 (98%) in HMC-QU-MI. Automated GLS showed good agreement with manual measurements in the real-world dataset (mean ± SD −18.9±4.5% vs −.18.2±4.4%, respectively; bias 0.7±2.5%, root-mean-squared error [RMSE] 2.6, Pearson’s correlation 0.84; Figure 1A) and in PROMIS-HFpEF (−15.4±4.1% vs −15.9±3.6%, respectively; bias −0.6±2.7%, RMSE 2.8, Pearson’s correlation 0.76; Figure 1B). In the general population cohort, automated GLS measurements accurately identified patients with vs without heart failure (ROC-AUC 0.89 for total HF and 0.98 for HF with reduced ejection fraction). In patients with suspected MI, automated regional strain identified regional wall-motion abnormalities with average ROC-AUC 0.80 (range 0.74–0.86 for apical 4-chamber view [Figure 2A] and 0.69–0.90 for apical 2-chamber view [Figure 2B]). Conclusions DL algorithms can interpret cardiac strain images with similar accuracy compared with conventional measurements. These results highlight the potential of DL algorithms to democratize the use of cardiac strain measurements.

Trends in the clinical use of speckle tracking strain imaging: insights from a worldwide EACVI survey

Abstract Funding Acknowledgements Type of funding sources: None. Background Strain imaging has emerged as a sensitive measure of myocardial function and an early marker of myocardial involvement in different diseases. Purpose and Methods To evaluate the use of speckle tracking strain imaging in clinical practice, an open access online survey was conducted by the EACVI according to published criteria(1). The survey explored the feasibility, appropriate use and clinical implementation of echocardiographic strain imaging. Health care providers in cardiology from all levels of health care centres were encouraged to participate in this global survey. Results In all, 431 respondents from 77 countries participated. Most respondents worked within the cardiology and cardiothoracic departments (95%). Participants from tertiary centres (46%), and private clinics or public hospitals (54%) were also represented. Fifty eight percent of the participants were senior experienced echocardiographers, 40% were trained in strain imaging at an expert centre, 37% via research in strain imaging, 33% via the EACVI e-learning platform or hands-on courses and 29% via national teaching courses. Only 16% reported having no training. Despite almost universal access (98%) to speckle tracking strain quantification, only 39% performed and reported strain results frequently (more than half of their reports) and the majority (61%) reported it either infrequently (25–50% reports) or very rarely (&amp;lt;25% reports). The most common reason (65%) for not using the technology despite having access to it was related to post-processing difficulty. Strain quantification was used mainly to assess the left ventricle (LV)(99%), less frequently the right ventricle (RV)(57%), the left atrium (46%) and rarely the right atrium (8%). Eighty-six percent of users assessed LV global longitudinal strain (GLS) from the 3 apical views, with 88% preferring automated algorithms with manual correction to define the regions of interest. The most common clinical conditions where LV strain assessment was considered useful clinically included chemotoxicity (88%) amyloidosis (87%), hypertrophic cardiomyopathy (73%), heart failure with preserved ejection fraction (68%), ischaemic heart disease (63%) and the early phase of dilated cardiomyopathy (59%, Figure 1). Just over half of the respondents quantified RV strain in pulmonary hypertension. Finally, the key areas of improvements identified by the respondents included higher reproducibility of the results (48%) and the ability to readily compare strain values across vendors (42%) (Figure 2). Conclusion Strain imaging is now widely available and many imagers have been trained in its use. Although strain imaging is used in line with the scientific evidence, it is still underutilised in clinical practice. Improved reproducibility and interchangeability of results across vendors may increase the uptake of this technique.

Value of Left Ventricular Strain Imaging Echocardiography in Predicting Outcomes after Severe Mitral Valve Regurgitation Surgery

Purpose: A new indicator of measuring ventricular systolic function is myocardial strain. However, it is unclear if longitudinal strain following mitral valve surgery has any predictive utility in clinical settings. The best time of operation is usually detected through the left ventricular internal dimensions as well as the function.. So this study aimed to evaluate the utility of myocardial strain by echocardiogram with other parameters in forecasting postoperative outcomes after primary MR surgery.&#x0D; Methodology: This prospective study enrolled 514 patients (279 males and 235 females; mean age (SD) of male participants was 57.3 (12.9). Included patients had severe primary mitral valve regurgitation and were candidates for valve surgery from April 2018 to April 2022. Patients with combined valvular disease as severe mitral stenosis, redo mitral valve replacement, and previous CABG and ischemic heart disease were excluded. Global longitudinal strain (GLS) was performed. Hospital re-admission for heart failure symptoms, reoperation and mortality were followed up as Cardiac incidents.&#x0D; Findings: In median follow-up of about four years, Age, previous ischemia, concomitant CABG, left atrial size, LVEF%, atrial fibrillation and Global longitudinal strain were all predictive of heart incidents. Age, left atrial dimension, and GLS were independent predictors to heart incidents on multivariate analysis (HR: 1.386, 95% CI: 1.083-1.776; P &lt;0.004, HR: 1.003, 95% CI: 0.976-1.031; p value 0.018, HR: 1.192, 95% CI: 1.101-1.291; P &lt;0.001 respectively). All-cause mortality was linked to impaired GLS (HR: 0.003, 95% CI: 0.973-1.102; P =0.039).&#x0D; Recommendation: GLS has a substantial link to clinical outcomes and is a stronger forecaster to cardiac issues than standard measurements. Measuring pre-operative GLS among those with severe primary MR is essential for anticipating post-operative results and determining the ideal time to plan operation.

Identification of early cardiac dysfunction and heterogeneity after pressure and volume overload in mice by high-frequency echocardiographic strain imaging.

Aortic stenosis and regurgitation are clinically important conditions characterized with different hypertrophic types induced by pressure or volume overload, respectively, but with comparable cardiac function in compensated stage. Speckle-tracking based strain imaging has been applied to assess subtle alterations in cardiac abnormality, but its application in differentiating these two types of ventricular hypertrophy is still sparse. Here, we performed strain imaging analysis of cardiac remodeling in these two loading conditions. C57BL/6J mice were subjected to transverse aortic constriction (TAC)-induced pressure overload or aortic regurgitation (AR)-induced volume overload. Conventional echocardiography and strain imaging were comprehensively assessed to detect stimulus-specific alterations in TAC and AR hearts. Conventional echocardiography did not detect significant changes in left ventricular systolic (ejection fraction and fractional shortening) and diastolic (E/E') function in either TAC or AR mice. On the contrary, global strain analysis revealed global longitudinal strain and strain rate were remarkably impaired in TAC while preserved in AR mice, although global radial, and circumferential strain and strain rate were significantly reduced in both models. Regional strain analysis in the long axis demonstrated that longitudinal strain and strain rate in all or most segments were decreased in TAC but maintained or slightly dented in AR mice, while radial strain and strain rate indicated overt decline in both models. Moreover, decreased radial and circumferential strain and strain rate were observed in most segments of TAC and AR mice in the short axis. Strain imaging is superior to conventional echocardiography to detect subtle changes in myocardial deformation, with longitudinal strain and strain rate indicating distinct functional changes in pressure versus volume overload myocardial hypertrophy, making it potentially an advanced approach for early detection and differential diagnosis of cardiac dysfunction.

Echocardiographic strain imaging: what do paediatric cardiologists need to know?

: Assessment of systolic and diastolic function of both the left and right ventricles is an integral part of the assessment and management of children with heart disease. Despite corrective or palliative repair of congenital heart disease, dysfunction of the systemic ventricle, which may a morphologic left or a right ventricle, subpulmonary right ventricle, and the functional single ventricle may occur in the long term. Conventional echocardiographic indices of cardiac function can be regarded as parameters of indirect changes consequential to the shortening and lengthening of the myocardium in the cardiac cycle. Direct interrogation of myocardial deformation, on the other hand, may shed important lights on the understanding, diagnosis and prognosis of cardiac dysfunction in the paediatric cardiac population. In the past decade, technological advances in echocardiographic strain imaging have enabled direct interrogation of global and regional deformation of the myocardium. In this review, the concept of strain imaging, the evolution of echocardiographic strain imaging, the methods of ventricular and atrial strain quantification, and clinical applications of strain imaging in children and young adults with congenital heart disease are discussed. The gaps and challenges in the clinical translational use of echocardiographic strain imaging are also highlighted. Given the emerging data on potential prognostic values of strain measures in the prediction of occurrence of adverse cardiovascular outcomes in the congenital heart population, it is timely for paediatric cardiologists to consider the incorporation of strain imaging into the clinical management algorithm.

Evaluation of strain echocardiography and atrial electromechanical delay in patients with idiopathic carpal tunnel syndrome

Aim: Carpal tunnel syndrome (CTS) could be an early marker for amyloidosis before developing of overt symptoms of cardiac amyloidosis (CA). CA characterized with left ventricular (LV) diastolic dysfunction and impairment of LV deformation-based parameters. There is limited data about echocardiographic parameters such as strain value of LV, diastolic parameters and atrial EMD in patients with idiopathic CTS. In this study, we investigated LV strain values, diastolic parameters of LV and atrial EMD in patients with idiopathic CTS. Then, we compared these parameters in CTS patients to control group. Material and Method: Thirty-four patients with idiopathic CTS and twenty-four aged and sex matched volunteers were enrolled to study. Patients with known amyloidosis, heart failure, diabetes mellitus and secondary etiologic states for CTS such as trauma or rheumatologic disease were excluded from the study. ECG and echocardiographic examination of each patient were performed and recorded by cardiology specialist. Conventional and strain imaging echocardiography were performed. Atrial electromechanical delays (EMD) were measured. Results: Baseline characteristics features were not different in groups. Mitral inflow velocities (mitral E and A wave), mitral E wave deceleration time, tissue Doppler velocities (lateral annular E’ and A wave), E/A and E/E’ ratios were similar in two groups. Septal basal strain values increased in CTS group (-21.3±4.83% vs -25.7±2.96%, p&amp;lt;0.001). Septal apical to base ratio (SAB) and relative apical sparing (RELAPS) were increased in CTS group compared to control group (0.94±0.43 vs 0.66±0.12, 0.90±0.31 vs 0.73±0.08, p=0.004, p=0.013, respectively). PA lateral, PA septal, inter-atrial EMD and intra-atrial EMD were significantly higher in CTS group compared to control group (78.2±12.3 ms vs 70.6±9.9 ms, 64.1±8.42 ms vs 58.3±10.1 ms, 25.8±9.09 ms vs 20.7±5.31 ms, 11.68±5.11 ms vs 8.46±3.02 ms, p=0.015, p=0.023, p=0.009 and p=.008, respectively). Conclusion: In CTS group, mean basal strain decreased compared to control group. SAB and RELAPS which associate with CA, decreased in CTS group. Atrial EMD prolonged in CTS group. These changes may associate with increased risk of CA and AF in patients with CTS.

3D-speckle-tracking echocardiography correlates with cardiovascular magnetic resonance imaging diagnosis of acute myocarditis - An observational study.

The diagnostic importance of three-dimensional (3D) speckle-tracking strain-imaging echocardiography in patients with acute myocarditis remains unclear. The aim of this study was to test the diagnostic performance of 3D-speckle-tracking echocardiography compared to CMR (cardiovascular magnetic resonance imaging) for the diagnosis of acute myocarditis. 45 patients with clinically suspected myocarditis were enrolled in our study (29% female, mean age: 43.9±16.3years, peak troponin I level: 1.38±3.51 ng/ml). 3D full-volume echocardiographic images were obtained and offline 2D as well as 3D speckle-tracking analysis of regional and global LV deformation was performed. All patients received CMR scans and myocarditis was diagnosed in 29 subjects based on original Lake-Louise criteria. The 16 patients, in whom myocarditis was excluded by CMR, served as controls. Regional changes in myocardial texture (diagnosed by CMR) were significantly associated with regional impairment of circumferential, longitudinal, and radial strain, as well as regional 3D displacement and total 3D strain. Interestingly, the 2D and 3D global longitudinal strain (GLS) showed higher diagnostic performance than well-known parameters associated with myocarditis, such as LVEF (as obtained by echocardiography and CMR) and LVEDV (as obtained by CMR). In this study, we examined the use of 3D-speckle-tracking echocardiography in patients with acute myocarditis. Global longitudinal strain was significantly impaired in patients with acute myocarditis and correlated with CMR findings. Therefore, 3D echocardiography could become a useful diagnostic tool in the primary diagnosis of myocarditis.

Echocardiographic and Electrocardiographic Determinants of Atrial Cardiomyopathy Identify Patients with Atrial Fibrillation at Risk for Left Atrial Thrombogenesis.

Objective: Atrial cardiomyopathy (ACM) is associated with development of AF, left atrial (LA) thrombogenesis, and stroke. Diagnosis of ACM is feasible using both echocardiographic LA strain imaging and measurement of the amplified p-wave duration (APWD) in digital 12-lead-ECG. We sought to determine the thresholds of LA global longitudinal strain (LA-GLS) and APWD that identify patients with AF at risk for LA appendage (LAA) thrombogenesis. Methods: One hundred and twenty-eight patients with a history of AF were included. Left atrial appendage maximal flow velocity (LAA-Vel, in TEE), LA-GLS (TTE), and APWD (digital 12-lead-ECG) were measured in all patients. ROC analysis was performed for each method to determine the thresholds for LA-GLS and the APWD, enabling diagnosis of patients with LAA-thrombus. Results: Significant differences in LA-GLS were found during both rhythms (SR and AF) between the thrombus group and control group: LA-GLS in SR: 14.3 ± 7.4% vs. 24.6 ± 9.0%, p < 0.001 and in AF: 11.4 ± 4.2% vs. 16.1 ± 5.0%, p = 0.045. ROC analysis revealed a threshold of 17.45% for the entire cohort (AUC 0.82, sensitivity: 84.6%, specificity: 63.6%, Negative Predictive Value (NPV): 94.3%) with additional rhythm-specific thresholds: 19.1% in SR and 13.9% in AF, and a threshold of 165 ms for APWD (AUC 0.90, sensitivity: 88.5%, specificity: 75.5%, NPV: 96.2%) as optimal discriminators of LAA-thrombus. Moreover, both LA-GLS and APWD correlated well with the established contractile LA-parameter LAA-Vel in TEE (r = 0.39, p < 0.001 and r = −0.39, p < 0.001, respectively). Conclusion: LA-GLS and APWD are valuable diagnostic predictors of left atrial thrombogenesis in patients with AF.

A Clinical Approach to Multimodality Imaging in Pulmonary Hypertension.

Pulmonary hypertension (PH) is a clinical condition characterized by progressive elevations in mean pulmonary artery pressures and right ventricular dysfunction, associated with significant morbidity and mortality. For resting PH to develop, ~50–70% of the pulmonary vasculature must be affected, suggesting that even mild hemodynamic abnormalities are representative of advanced pulmonary vascular disease. The definitive diagnosis of PH is based upon hemodynamics measured by right heart catheterization; however this is an invasive and resource intense study. Early identification of pulmonary vascular disease offers the opportunity to improve outcomes by instituting therapies that slow, reverse, or potentially prevent this devastating disease. Multimodality imaging, including non-invasive modalities such as echocardiography, computed tomography, ventilation perfusion scans, and cardiac magnetic resonance imaging, has emerged as an integral tool for screening, classifying, prognosticating, and monitoring response to therapy in PH. Additionally, novel imaging modalities such as echocardiographic strain imaging, 3D echocardiography, dual energy CT, FDG-PET, and 4D flow MRI are actively being investigated to assess the severity of right ventricular dysfunction in PH. In this review, we will describe the utility and clinical application of multimodality imaging techniques across PH subtypes as it pertains to screening and monitoring of PH.

Global and Regional Variations in Transthyretin Cardiac Amyloidosis: A Comparison of Longitudinal Strain and 99mTc-Pyrophosphate Imaging.

There are limited data on the head-to-head comparison of 99mTc-pyrophosphate (99mTc-PYP) and echocardiographic strain imaging in the assessment of transthyretin (TTR) cardiac amyloidosis. Methods: At Mayo Clinic Arizona, patients who had undergone both a 99mTc-PYP scan and a transthoracic echocardiogram within a 90-d period were retrospectively identified for chart review and strain imaging analysis. Patients were divided into 2 groups according to their 99mTc-PYP results (PYP-positive [PYP+] or PYP-negative [PYP-]) for the comparison. A standard 17-segment model was used for segmental, regional, and global longitudinal strain comparison. A P value of less than 0.05 was deemed significant. Results: In total, 64 patients were included, the mean age was 75.1 ± 13.0 y, and 57 (89.1%) were male. Comparing the PYP+ to the PYP- group, the left ventricular global longitudinal strain was significantly worse in the former (PYP+ vs. PYP-, -10.5 ± 2.6 vs. -13.1 ± 4.1; P = 0.003). PYP+ patients also had worse regional basal strain (-4.6 ± 2.6 vs. -8.8 ± 4.0, P < 0.001) and a trend toward worse midventricular strain (-9.6 ± 4.0 vs. -11.7 ± 4.4, P = 0.07), but there was no statistical difference in the apical region (-17.6 ± 4.73 vs. -19.0 ± 6.46, P = 0.35). This is consistent with an apex-sparing pattern shown by the relative apical longitudinal strain index (1.3 ± 0.5 vs. 1.0 ± 0.3, P = 0.008). Segment-to-segment analysis demonstrated a significant difference in strain between PYP+ and PYP- segments in 4 segments: basal inferior (P = 0.006), basal anterolateral (P = 0.01), apical septal (P = 0.002), and apical inferior (P = 0.001). Left ventricular diastolic dysfunction was significantly different, with 17 (77.3%) patients in the PYP+ group versus 15 (36.6%) in PYP- participants (P = 0.002). Conclusion: Our study suggested that 99mTc-PYP uptake is related to overall worse LV segmental, regional, and global longitudinal strain function, as well as diastolic function, compared with patients without 99mTc-PYP uptake. These data are important for helping clinicians learn about the echocardiographic function features related to 99mTc-PYP uptake and can help generate hypotheses for future studies.

Echocardiographic strain imaging to assess immediate and short term effects of successful percutaneous balloon mitral valvotomy on left atrial and right ventricular mechanics

Echocardiographic strain imaging to assess immediate and short term effects of successful percutaneous balloon mitral valvotomy on left atrial and right ventricular mechanics