Subepicardial Longitudinal Strain Research Articles

Evaluation of isolated left ventricular noncompaction using cardiac magnetic resonance tissue tracking in global, regional and layer-specific strains

We used cardiac magnetic resonance tissue tracking (CMR-TT) to quantitatively analyze the global, regional and layer-specific strain of isolated left ventricular noncompaction (ILVNC). Combined with late gadolinium enhancement (LGE), we initially explored the effect of focal myocardial fibrosis on myocardial strain. CMR was performed in 63 patients with ILVNC and 52 patients without ILVNC (i.e., the control group). The ILVNC group was divided into an LGE(+) group (29 patients) and an LGE(−) group (34 patients) according to the presence or absence of late gadalinum enhancement (LGE). CVI42 software was used to measure global and regional (basal, middle, apical) radial strain (RS), circumferential strain (CS), longitudinal strain (LS), subendocardial LS and subepicardial LS. The basal–apical strain gradient was defined as the apical mean strain minus the basal mean strain. We then compared differences between these strain parameters. The subendocardial-subepicardial LS gradient was defined as the maximum subendocardial LS minus the subepicardial LS. Compared with the control group, the global and regional RS, CS, LS and the subendocardial, subepicardial LS of the ILVNC group were significantly diminished (P < 0.01). Compared with the LGE(−) group, the global and regional RS, CS, LS and the subendocardial, subepicardial LS of the LGE(+) group were significantly diminished (P < 0.05). In the ILVNC group, the basal–apical CS and LS gradient, and the subendocardial-subepicardial LS gradient were significantly lower than those in the control group (P < 0.01). There were significant differences in myocardial strain between patients with and without ILVNC. ILVNC revealed a specific pattern in terms of strain change. The myocardial strain of the cardiac apex and endocardium was significantly lower than that of the cardiac base and epicardium, respectively. Myocardial strain reduction was more significant in ILVNC patients with focal myocardial fibrosis.

Layer-specific speckle tracking analysis of left ventricular systolic function and synchrony in maintenance hemodialysis patients

BackgroundThis study investigated the value of layer-specific strain analysis by two-dimensional speckle tracking echocardiography (2D-STE) for evaluating left ventricular (LV) systolic function and synchrony in maintenance hemodialysis (MHD) patients.MethodsA total of 34 MHD patients and 35 healthy controls were enrolled in this study. Dynamic images were collected at the LV apical long-axis, the four- and two- chamber, and the LV short-axis views at the basal, middle, and apical segments. The layer-specific speckle tracking (LST) technique was used to analyze the longitudinal strain (LS) and circumferential strain (CS) of LV sub-endocardium, mid-myocardium, sub-epicardium, global longitudinal strain (GLS), global circumferential strain (GCS), the LV 17 segment time to peak LS (TTP), and the peak strain dispersion (PSD). The differences in these parameters were compared between control and MHD groups, and the correlation between PSD and each LS parameter was examined. The receiver operator characteristic (ROC) curve was used to evaluate the efficacy of three myocardial layer LS and CS in the assessment of LV systolic dysfunction in MHD patients.ResultsMHD patients had comparable left ventricular ejection fraction (LVEF), but significantly smaller LV GLS, GCS, and three-layer LS and CS compared to the control group. The three myocardial layer LS of the basal segment, middle segment, and apex segment was significantly reduced in the MHD patients compared to the normal subjects, while the three myocardial layer CS of the basal segment, middle segment, and apex segment was significantly reduced in the MHD patients compared to the normal subjects, except for the sub-endocardium of the middle and apex segment. MHD patients had significantly higher TTP of LV 17 segments and PSD compared to controls, and had delayed peak time in most segments. In addition, PSD of MHD patients was positively correlated with sub-endocardial and mid-myocardial LS and GLS, but not with sub-epicardial LS. The area under the curves (AUCs) of sub-endocardial, mid-myocardial, and sub-epicardial LS in MHD patients were 0.894, 0.852, and 0.870, respectively; the AUCs of sub-epicardial, mid-myocardial, and sub-endocardial CS were 0.852, 0.837, and 0.669, respectively.ConclusionsLST may detect early changes of all three-layer LS and CS and PSD in MHD patients, and is therefore a valuable tool to diagnose LV systolic dysfunction in MHD patients.

P1542 Reference values for multilayer longitudinal strain in children: preliminary findings from healthy individuals

Abstract BACKGROUND Strain echocardiography is a reliable echocardiographic modality to measure myocardial mechanical deformation and evaluate regional and global myocardial systolic function, and has been demonstrated to be a useful tool for the evaluation of cardiac function in children with acquired and congenital heart diseases. Recent advancements in echocardiographic technology allow to analyze myocardial strain in multiple layers. To our knowledge, there are no published reference values for echocardiographic multilayer-specific strain measurement. AIM OF THE STUDY Aim of our study was to establish normal reference values for left ventricular (LV) and right ventricular (RV) longitudinal strain (LS) in a wide population of Italian children and to provide normal reference values of layer-specific LS in a healthy pediatric population. METHODS AND RESULT At present we have analyzed data from two-hundred (target: n = 500) healthy, consecutive subjects (age &amp;lt;18 years, mean age 7.5 ± 4yrs; range from 1 month to 17,5 years). All subjects underwent a clinical cardiological evaluation including ECG and physical examination. Subsequently, a complete echo Doppler examination including LS evaluation using speckle-tracking echocardiography was performed. Individuals were excluded if any significant abnormality was found at echocardiography (e.g. valvular regurgitation more than trivial, any structural abnormalities including small ASDs or VSDs; patients with isolated PFO were included). Subendocardial, midwall, subepicardial LS, and strain gradient (LSsubepi - LSsubendo) were also determined. LS% analysis was considered acceptable if missing data were present in no more than one segment per echocardiographic view, according to current consensus. Echocardiographic yield for LS analysis was 98.5 % for 4-chamber views, 82.5% for 2-chamber views and 84.5% for 3-chamber views. Accordingly Global Longitudinal Strain (GLS) was available overall in 82% of the population analyzed so far (n= 164 children) on all layers, with a total of 8,872 echocardiographic available segments analyzed. Normal distribution was found for global subendocardial, midwall and subepicardial LS. As displayed in figure 1 (panels A-B-C), means ± SD were -20.8 ± 1.9% for LSsubendo, -19.2 ± 1.8% for LSsubepi and -19.9 ± 1.8% for LSmidwall. Accordingly higher value (95ile) for normal LS were -17.9%, -16.4% and -17.1% for LSsubepi, LSsubendo and LSmidwall, respectively. A significant subepicardial to subendocardial gradient was found in all children with higher absolute values found at the endocardial level, with a mean difference of 1.6 ± 0.9% (Panel D). CONCLUSIONS We provide preliminary data on 200 children to establish normal reference values for echocardiographic multilayer-specific strain measurement in a wide population of healthy italian children. Abstract P1542 Figure.

P1782 Left ventricular deformation proprieties in aortic coarctation: insights from multilayer strain imaging

Abstract Background Patients with coarctation of the aorta (CoA) have proven impaired left ventricular (LV) myocardial deformation that will persist even after successful transcatheter intervention compared to normal controls. However, little is known about layer specific contraction in this clinical setting. Purpose To investigate multi-layer longitudinal strain in patients with repaired CoA, compared with a control group of healthy subjects. Methods In a case-control study, 13 CoA patients (F/M = 9/4, age = 15.1 ± 4.4 years) and 13 healthy age- and sex-matched controls, underwent a complete echocardiogram, including speckle tracking assessment for quantification of LV transmural global longitudinal strain (GLS), subendocardial longitudinal strain (LSsubendo), subepicardial longitudinal strain (LSsubepi), and myocardial longitudinal strain gradient (LSsubendo - LSsubpepi). Results CoA patients had similar blood pressure, heart rate, and body surface area in comparison with healthy controls. The two groups did not differ for ejection fraction and LV diastolic indices. Increased maximal gradient (&amp;gt;20 mmHg) in descending aorta was found in 9 (69.2%) CoA patients. In CoA population, 5 (38.5%) had LV concentric remodeling (RWT &amp;gt; 0.42) and 2 (15.4%) LV hypertrophy (Z score &amp;gt;2.0). LV mass index (92.4 ± 31.1 vs. 60.9 ± 12.5 g/m^2.7, p = 0.002), septal wall thickness (8.7 ± 2.0 vs 6.6 ± 0.9 mm p = 0.002), posterior wall thickness (8.2 ± 1.7 vs. 6.6 ± 1.4 mm, p = 0.02) and RWT (0.38 ± 0.06 vs. 0.27 ± 0.08, p &amp;lt; 0.001) were greater in CoA patients. By multi-layer deformation analysis, GLS (21.2 ± 1.9 vs. 22.9 ± 1.4%, p &amp;lt; 0.01), LSsubepi (19.3 ± 1.6 vs. 21.0 ± 1.6%, p &amp;lt; 0.01), LSsubendo (22.9 ± 1.8 vs. 25.4 ± 1.9%, p = 0.003) and longitudinal strain gradient (3.6 ± 1.1 vs. 4.7 ± 1.1, p &amp;lt; 0.02) were lower in CoA patients than in healthy controls. Separate sub-analyses in patients without LV hypertrophy, substantially confirmed the same results: GLS 20.9 ± 1.6 vs. 22.8 ± 0.9%, p = 0.004; LSsubepi 19.0 ± 1.4 vs. 21.1 ± 1.3%, p = 0.004; and LSsubendo 22.4 ± 1.2 vs. 25.3 ± 1.4%, p &amp;lt; 0.0001; strain gradient 3.4 ± 1.0 vs. 4.6 ± 1.1, p = 0.02. Notably, LSsubepi (18.6 ± 1.4 vs. 20.6 ± 1.0%, p = 0.03) and, with greater significance, LSsubendo (22.1 ± 1.1 vs. 24.7 ± 1.8%, p &amp;lt; 0.0001) were lower in CoA patients with increased aortic gradient versus those without significant gradient increase. Conclusions In CoA patients, layer specific strain imaging highlights an impairment of LV longitudinal deformation, which mainly involves LSsubendo and causes reduction of longitudinal strain gradient. This preferential impairment of subendocardium is particularly evident in patients with residual aortic gradient and is independent of LV hypertrophy. Abstract P1782 Figure. Multilayer strain in CoA vs. controls

Layer-specific longitudinal strain in Anderson-Fabry diseaseat diagnosis: A speckle tracking echocardiography analysis.

Speckle tracking advancements makenow available the analysis of layer-specific myocardial deformation. This study investigated multilayer longitudinal strain in Anderson-Fabry disease (AFD) patients at diagnosis. In a case-control study, 33 newly diagnosed, untreated AFD patients and 33 healthy age- and sex-matched healthy controls underwent a complete echocardiogram, including assessment of left ventricular (LV) transmural global longitudinal strain (GLS), subendocardial longitudinal strain (LSsubendo), subepicardial longitudinal strain (LSsubepi), and strain gradient (LSsubendo-LSsubpepi). Anderson-Fabry disease patients had similar blood pressure, heart rate, and ejection fraction but higher body mass index in comparison with controls. LV mass index, maximal, and relative wall thickness were significantly greater in AFD patients. LSsubendo was significantly higher than LSsubepi in both groups, but GLS (P<0.0001), LSsubendo (P=0.003), and particularly LSsubepi (21.4±1.7 vs 18.8±1.4%, P<0.0001) were lower in AFD patients than in controls. Accordingly, LS gradient was higher in AFD patients (P=0.003). Three patients symptomatic for dyspnoea presented a combination of LV hypertrophy and reduced LSsubepi. After adjusting for confounders by multivariate analyses, LV mass index or maximal wall thickness were independently and inversely associated with transmural GLS and LSsubepi, but not with LSsubendo in the AFD group. At receiver operating curve curves, LSsubepi best discriminated AFD and normals. In newly diagnosed, untreated AFD patients, layer-specific strain imaging highlights an impairment of LV longitudinal deformation, mainly involving subepicardial strain and causing increase in longitudinal strain myocardial gradient. These findings could be useful for identifying the mechanisms underlying early LV dysfunction in AFD patients.

Normal reference values of multilayer longitudinal strain according to age decades in a healthy population: A single-centre experience.

Recent advancements in echocardiographic technology allow to analyse myocardial strain in multiple layers. Little is known about the impact of age on layer-specific longitudinal strain in healthy subjects. The aim of this study was to analyse the influence of age on multilayer longitudinal strain and establish normal reference values of layer-specific strain according to age decades in a healthy population referring to our echo laboratory using 2D speckle-tracking echocardiography with layer-specific software. Two-hundred sixty-six healthy, consecutive subjects (mean age = 39.2 ± 17.5 years, women/men = 137/129), free of cardiovascular risk factors, were enrolled. Subjects were divided according to six age decades: 10-19, 20-29, 30-39, 40-49, 50-59, >60 years. All subjects underwent a complete echo Doppler examination including quantitation of 2D global longitudinal strain (GLS). Subendocardial longitudinal strain (LSsubendo), subepicardial longitudinal strain (LSsubepi), and strain gradient (LSsubendo - LSsubepi) were also determined. GLS (P < 0.001), LSsubendo, and LSsubepi (both P < 0.0001) were all progressively reduced with increasing age decades, but post hoc intra-group analyses demonstrated that the decline of GLS, LSsubendo, and LSsubepi was significant in the decades 50-60 and ≥60 years. In separate multiple linear regression analyses, the effect of age on GLS, LSsubendo, and LSsubepi remained significant even after adjusting for clinical and echocardiographic confounders. Strain gradient remained unchanged in age decades. Ageing shows an independent effect on GLS, LSsubendo, and, particularly on, LSsubepi. Our data also provide normal reference values of layer-specific longitudinal strain for age decades.

Differential Myocardial Fibre Involvement by Strain Analysis in Patients With Aortic Stenosis

Aortic stenosis (AS) is the most common valvular heart disease and can result in left ventricular (LV) systolic impairment. LV myocardial fibres are organised in layers: the subendocardial layer is orientated longitudinally and the subepicardial layer circumferentially. We hypothesised that there is differential involvement of myocardial fibres in patients with aortic stenosis. We performed multi-directional, multi-layered systolic strain analysis in 70 patients (aged 72±10.7years) with varying grades of AS severity (mean gradient 32.3±20mmHg, aortic valve area 1.1±0.6cm2) and in 30 controls. Clinical, demographic and resting echocardiographic data were recorded. Left ventricular subendocardial and subepicardial systolic strains were measured in the longitudinal, radial and circumferential axes. Systolic subendocardial strain was significantly higher than subepicardial strain in all three axes in patients and in controls. There were significant differences in longitudinal, but not in circumferential and radial strain, or left ventricular ejection fraction (LVEF), between patient groups. Aortic valve mean gradient (MG) and valve area (AVA) correlated better with subendocardial longitudinal strain (r=0.548, p<0.001; r=-0.54, p<0.001 respectively) than with subepicardial longitudinal strain (r=0.496, p<0.001, r=-0.544, p<0.001 respectively). Correlations between circumferential and radial strain and MG or AVA were poor. There was differential impairment in LV systolic strain in all three cardiac axes in patients with AS. Left ventricular longitudinal strain impairment was proportional to AS severity. Subendocardial longitudinal strain correlated better with AS severity than subepicardial longitudinal strain while correlations between circumferential and radial strain and AS severity were weak.

Deformation Analysis of Myocardial Layers Detects Early Cardiac Dysfunction after Chemotherapy in Bone Marrow Transplantation Patients: A Continuous and Additive Cardiotoxicity Process

Chemotherapy-induced cardiotoxicity has not been extensively validated in bone marrow transplantation (BMT) patients. Speckle-tracking echocardiography is a sensitive method for the detection of subclinical cardiac dysfunction. Cardiac function was prospectively assessed in 80 patients (44 men; mean age, 45±11years) after BMT for non-Hodgkin's lymphoma and acute or chronic myeloid leukemia by means of various echocardiographic techniques. Before chemotherapy for BMT, 89% of the patients had previously been treated with anthracyclines. Patients had normal left ventricular ejection fraction (LVEF). Left ventricular (LV) global longitudinal strain (GLS), subendocardial and subepicardial longitudinal strain, circumferential strain, LV twist, and right ventricular GLS were measured by speckle-tracking, and (2) three-dimensionally derived LVEF and right ventricular ejection fraction were also assessed. Abnormal LVEF was defined as <53%. Studies were performed before (baseline) and 1, 3, 6, and 12months after chemotherapy conditioning followed by BMT. Impaired LV GLS values were observed at 1month after chemotherapy and at 3, 6, and 12months compared with baseline (-20 ±2.2% at baseline, -18.4 ±2.1% at 1month, -17.3 ±2.2% at 3months, -17.1 ±2.1% at 6months, and -17.1 ±2.2% at 12months; P=.001). Early LV GLS changes were driven mostly by changes in subendocardial longitudinal strain (-22.5 ±2.4% at baseline, -20.5 ±2.3% at 1month, -19.2 ±2.3% at 3months, -19.2 ±2.4% at 6months, and -19.1±2.4 at 12months; P=.001), whereas significant subepicardial strain changes were observed at 3months after BMT. Compared with baseline, right ventricular GLS was also impaired early after chemotherapy. Compared with baseline, LVEF was slightly reduced (P=.02) at the end of the follow-up. Among echocardiographic markers, LV GLS at 1month had the strongest predictive value for abnormal LVEF (<53%) at 12months (area under the curve 0.86; 95% CI, 0.76-0.96). A cutoff LV GLS value of -18.4% had sensitivity of 84.6% and specificity of 71.9% for the identification of abnormal LVEF at the end of follow-up. In BMT patients, myocardial deformation analysis detected early and progressive subclinical cardiac dysfunction. Impaired LV GLS had predictive value for the detection of abnormal LVEF at 12-month follow-up. Thus, myocardial deformation study should be applied early after BMT to prevent irreversible cardiac dysfunction by appropriate treatment.

P1270Effects of blood pressure variability on layer-specific longitudinal strain in hypertensionP1271 Left atrial dynamics and diastolic function in hypertensive patientsP1272Echocardiographic evaluation of right ventricular function in patients with chronic obstructive pulmonary disease in comparison with healthy groupP1273The impact of preeclampsia on myocardial recovery in women with peripartum cardiomyopahty - speckle tracking studyP1274Diagnostic accuracy of bedside lung ultrasonography in emergency (BLUE)

Our previous study showed sub-epicardial longitudinal strain (EpiLS) was an independent prognostic factor for worse outcome in regular treated hypertension but not global longitudinal strain (GLS) and sub-endocardial longitudinal strain (EndLS). Increased blood pressure variability (BPV) has been found associated with target organ damage in hypertension. However, effects of BPV on layer-specific longitudinal strain have not been well studied. The aim of this study was to investigate the effects of different blood pressure parameters on layer-specific longitudinal strain in hypertension. This study included 95 patients (57 men, age 65 ± 12 years) with uncomplicated hypertension who have been regularly treated for more than 1 year. Speckle tracking echocardiography was used for measurement of longitudinal deformation from 3 apical views of left ventricle. GLS was measured by automated function imaging (AFI). We further divided into sub-endocardial and sub-epicardial myocardium and measured their longitudinal strain by manual click-and-draw method and averaged from 3 apical views. Blood pressure parameters included office systolic blood pressure (SBP), office diastolic blood pressure (DBP), central SBP and DBP by tonometry, average 24-hour SBP and DBP, and BPV parameters by ambulatory blood pressure monitor. BPV parameters included standard deviation of daytime SBP (DSSD), standard deviation of nighttime SBP (NSSD), standard deviation of daytime DBP (DDSD), and standard deviation of nighttime DBP (NDSD). We divided subjects into low and high group according to median level of each strain. No blood pressure parameters were different between low and high EndLS group except week difference in NDSD (9.0 ± 3.4 vs. 7.8 ± 2.0 mmHg, p = 0.051). NSSD (11.2 ± 4.6 vs. 9.3 ± 2.9 mmHg, p = 0.027) and NDSD (9.1 ± 3.4 vs. 7.7 ± 2.0 mmHg, p = 0.031) were significant increased in low GLS group but not other parameters. DDSD (10.3 ± 3.0 vs. 9.0 ± 2.5 mmHg, p = 0.034), NSSD (11.4 ± 4.4 vs. 9.1 ± 3.1 mmHg, p = 0.006), and NDSD (9.2 ± 3.2 vs. 7.6 ± 2.2 mmHg, p = 0.012) were significantly increased in low EpiLS group. Only BPV parameters were associated with decreased longitudinal strain in hypertension. Effects of BPV were majorly noted in EpiLS.