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The yellow curve shows normal contraction in a non-infarcted segment. The diagnosis of pathological hypertrophy in young healthy athletes is challenging and preliminary data suggest that strain imaging may be of help as reduction in systolic strain, which is typical for HCM, is not found in physiological hypertrophy.
Arrhythmogenic right ventricular cardiomyopathy ARVC is diagnosed according to the Task Force Criteria 33 using different modalities including imaging by echocardiography and cardiac magnetic resonance CMR. Reduced RV function by reduced RV-free wall strain and a dyssynchronous RV contraction pattern have been shown to be early markers of ARVC, 34 , 35 and may help diagnosis in early phases of disease. Uncomplicated diabetes mellitus is associated with reduced LV longitudinal strain, but preserved radial strain, 36—38 and reduced GLS may be a marker of risk of diabetic cardiomyopathy.
Myocardial toxic effects from chemotherapy has become a leading cause of morbidity and mortality in cancer survivors. Therefore, protection of the heart during chemotherapy by monitoring cardiac function and administration of appropriate therapy has become a major clinical issue.
There is, however, no high-level evidence to guide choice of imaging method, how frequently measurements should be done, and there is limited data on efficacy of medical therapy to prevent or reverse LV dysfunction due to chemotherapy.
It is general agreement that LVEF should be measured prior to chemotherapy using preferentially echocardiography. Radionuclide imaging is also used, but gives less diagnostic information and is associated with significant ionizing radiation. Patients who develop heart failure during chemotherapy are treated with standard guideline-based heart failure therapy just as any other heart failure patient.
When reduction in LVEF during chemotherapy is established, it may be too late for treatment. However, although strain imaging may detect sub-clinical myocardial changes, the value of these changes in predicting clinical outcome is still unknown.
A combination of strain imaging with ultrasensitive troponin has been proposed. Longitudinal strain curves from apical four-chamber view in a year-old male who was positive for a hypertrophic cardiomyopathy-related mutation in the MYBPC3 gene detected by family genetic screening. He was asymptomatic and had no hypertrophy by echocardiography, cardiac magnetic resonance nor by electrocardiography. Green vertical line indicates timing of AVC.
It is recommended to measure LVEF at least prior to chemotherapy, at completion of therapy and 6 months later. For laboratories with competence in strain imaging, it is recommended to measure GLS in addition to LVEF, which will be helpful in cases when LVEF is in the lower normal range and it is difficult to conclude about systolic function. In such cases, the finding of subnormal strain should result in closer monitoring of cardiac function.
Not all sub-clinical reduction in LV function may progress to significant dysfunction or heart failure, and there is need for studies which can help to define criteria for clinically relevant changes in strain. Due to lack of standardization of methodology between vendors, it is essential that each echocardiography laboratory defines a normal range of strain values and ensures high degree of reproducibility.
Furthermore, when doing serial evaluations, similar equipment and algorithms for calculating strain should be used. Prognosis in cardiac disease is closely related to systolic function which is commonly measured as LVEF. Strain imaging for early detection of sub-clinical left ventricular dysfunction during chemotherapy.
Modified from Plana et al. It was shown in patients with long QT syndrome LQTS , that large inter-segmental variability in contraction duration, named mechanical dispersion, was associated with increased risk of ventricular arrhythmias.
Patients with LQTS and high risk for arrhythmias have larger mechanical dispersion. Early papers recognized unsuspected mechanical alterations by M-mode echocardiography in LQTS, which were associated with risk of ventricular arrhythmias. The current evidence, however, is not strong enough to support use of mechanical dispersion as an additional criterion when decisions are made regarding implantable cardioverter-defibrillator implantation in LQTS patients.
Months on x axis. Modified from Ersboll et al. Mechanical dispersion is an index of inter-segmental discoordination of contraction and similar to some other velocity and strain indices which have been used to quantify LV dyssynchrony, it measures variability in time-to-peak shortening.
This approach is interesting in particular because it may represent a means to identify high-risk patients with normal or preserved LVEF. It remains to be determined if mechanical dispersion is superior to other indices of dyssynchrony to predict risk of ventricular arrhythmias.
One strength of mechanical dispersion is that the same recording may be used to measure GLS as a parameter of global systolic function. Most likely, the aetiology of mechanical dispersion is different in LQTS and in most other conditions.
In LQTS, mechanical dispersion may reflect inhomogeneous prolongation of action potential duration which in turn leads to different contraction durations. Potential aetiologies of mechanical dispersion in patients with cardiomyopathy are fibrosis or ischaemia which may cause local delays in electromechanical activation.
Furthermore, non-uniform loading conditions in a diseased ventricle may impacts timing of peak shortening. Since dyssynchrony is common in heart failure and is associated with increased risk, we should focus on understanding the underlying pathophysiology.
In principle, strain imaging is an excellent modality for evaluation of diastolic function in terms of early-diastolic strain rate which reflects myocardial lengthening rate and untwisting rate which is tightly coupled to restoring forces and diastolic suction.
Global longitudinal strain, however, is a very promising method to identify patients with mild systolic dysfunction which is not reflected in reduced EF. Left panel shows synchronous contraction by longitudinal strain in a patient after myocardial infarction. Mid panel shows heterogeneous timing of contraction and pronounced mechanical dispersion in a patient after myocardial infarction with ventricular arrhythmias. Deciding timing for surgery in asymptomatic moderate-to-severe valvular heart disease is still problematic and is based on symptoms, severity of the lesion and its impact on LV volume and function.
The most solid predictor of impaired outcome in regurgitant valvular heart diseases is LV volumes. Furthermore, when LVEF is reduced, it indicates depression of myocardial contractility. Reduction in EF, however, is often a late consequence of valve dysfunction and may even imply irreversible myocardial injury. Currently, there is a shift towards interventions earlier in the disease, and emerging data suggest that strain imaging may identify myocardial injury at an early stage and prior to reduction in EF.
As suggested by recent studies, quantification of myocardial function by strain imaging provides added clinical value in mitral- and aortic regurgitation and in aortic stenosis. Further validation is needed before firm recommendations can be made regarding routine use of strain imaging in decision making regarding timing of valve surgery and interventions.
Several attempts have been made to improve selection criteria for responders to cardiac resynchronization therapy CRT , including testing of various echocardiographic indices, but none of these approaches are proven to improve responder rate.
More recent studies have focused on the abnormal wall motion patterns which are typical for left bundle branch block using strain imaging. Furthermore, in patients with left bundle branch block in ECG, the absence of this contraction pattern is associated with a marked increase in risk of adverse events after CRT. It remains to be determined if these and other new insights based on strain imaging may be utilized to improve responder rate to CRT.
Future studies should also investigate if strain imaging may be useful in the evaluation of patients after implantation of CRT, as suggested by a recent study which showed that dyssynchrony measured several months after device implantation is associated with serious ventricular arrhythmias. Left ventricular strain in hypertension and heart failure with preserved ejection fraction HFpEF. Although, at the present stage, cardiac imaging has no proven value in selection of patients for CRT, there is evidence for applying strain imaging to find optimal position for the pacing lead in the LV-free wall.
Left atrial LA volume reflects the chronic effect of LV filling pressures over time, but may also be enlarged in healthy athletes and in patients with atrial arrhythmias when filling pressure is normal. Due to the exponential LA pressure—volume relationship, atrial compliance will decrease when pressure is elevated.
The method is somewhat limited by measurement problems related to the pulmonary vein outlets and the LA appendage. Recording of left ventricular longitudinal strain by speckle-tracking echocardiography in a patient with heart failure and left bundle branch block: AVC, aortic valve closure.
Modified from Risum et al. This implies that when measuring strain one should take into account the type of echo equipment in use when defining normal reference values. Furthermore, caution should be exerted when companies deliver upgrades of software since this may lead to changes in strain values. The figure illustrates how radial strain may be used to determine which segments have latest mechanical activation.
A left ventricular parasternal short-axis recording is displayed. Strain in anteroseptal segment shows early-systolic thickening yellow curve. Lateral light blue , posterior green and pink , and posterioseptal segments blue and red show late thickening, indicating latest activation. A major limitation of the current state of the technology is that segmental strains vary considerably in different publications and there is lack of sufficiently validated reference values for segmental strain.
Variability in segmental strains to a large extent reflects different methodologies between vendors, but differences depending on which wall layers are incorporated in the analysis also contributes. With 3D strain, sampling rates are relatively low and this may influence measurements. A and B Left atrial LA strain by two different speckle-tracking software. A Segmental traces of LA strain and average strain white-dashed trace. Yellow arrow indicates peak strain.
Modified from Cameli et al. The study was done in individuals with normal to severely impaired left ventricular function. Numerous studies have shown that myocardial strain imaging provides unique diagnostic information. The strain imaging methodology is still undergoing development and further clinical trials are needed to determine if clinical decisions based on strain imaging results in better outcome.
With this important limitation in mind, strain may be applied clinically as a supplementary diagnostic method and in the following conditions it appears to be useful. In unclear clinical cases, however, it may be considered as a supplementary method. Further development of strain imaging should be focused on even better standardization of the methodology between different vendors, and the ongoing development of 3D strain should improve the diagnostic potential from the technology.
Furthermore, automated image analysis which takes into account more information than just peak strain is expected to improve the diagnostic power of strain imaging. This applies in particular to myocardial ischaemia where there are so many well-defined features in the strain trace that differs from normal myocardium and this information is wasted when using GLS as the only parameter.
Since strain imaging can identify LV dysfunction earlier than conventional methods this opens a new perspective in heart failure prophylaxis and primary prevention with institution of therapeutic measures before the patients develop symptoms and irreversible myocardial dysfunction. Prospective clinical trials should be started to investigate the added clinical value that strain may represent in patient management.
In the meantime, strain may be applied in routine clinical diagnostics with the limitations of the technology kept in mind. Funding to pay the Open Access publication charges for this article was provided by University of Oslo, Institute of Clinical Medicine. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
Sign In or Create an Account. Close mobile search navigation Article navigation. Quantification of global and regional left ventricular function.
Cardiomyopathies and sub-clinical left ventricular dysfunction. Risk assessment and prognosis. Heart failure with preserved ejection fraction. Directions for the future. Abstract Myocardial strain is a principle for quantification of left ventricular LV function which is now feasible with speckle-tracking echocardiography.
Left ventricular function , Heart failure , Strain imaging , Left atrial strain , Ventricular arrhythmia , Chemotherapy , Cardiomyopathy , Hypertrophic cardiomyopathy.
View large Download slide. Transmural myocardial deformation in the canine left ventricle. Normal in vivo three-dimensional finite strains.
Myocardial strain by Doppler echocardiography. Validation of a new method to quantify regional myocardial function. Noninvasive myocardial strain measurement by speckle tracking echocardiography: Current state of three-dimensional myocardial strain estimation using echocardiography.
Age- and gender-related normal left ventricular deformation assessed by cardiovascular magnetic resonance feature tracking. Myocardial contractility by strain echocardiography: Doppler-derived myocardial systolic strain rate is a strong index of left ventricular contractility. Recommendations for cardiac chamber quantification by echocardiography in adults: Interpretation of systolic wall thickening.
Can thickening of a discrete layer reflect fibre performance? Acute regional myocardial ischemia identified by 2-dimensional multiregion tissue Doppler imaging technique. Identification of acutely ischemic myocardium using ultrasonic strain measurements. A clinical study in patients undergoing coronary angioplasty. Postsystolic shortening in ischemic myocardium: Myocardial strain analysis in acute coronary occlusion: Myocardial strain analysis by 2-dimensional speckle tracking echocardiography improves diagnostics of coronary artery stenosis in stable angina pectoris.
Strain-rate imaging during dobutamine stress echocardiography provides objective evidence of inducible ischemia. Strain echocardiography and wall motion score index predicts final infarct size in patients with non-ST-segment-elevation myocardial infarction.
Acute coronary occlusion in non-ST-elevation acute coronary syndrome: Effects of coronary occlusion on early ventricular diastolic events in conscious dogs. Mechanisms of improving regional and global ventricular function by preload alterations during acute ischemia in the canine left ventricle. Assessment of myocardial viability at dobutamine echocardiography by deformation analysis using tissue velocity and speckle-tracking.
Analysis of myocardial deformation based on ultrasonic pixel tracking to determine transmurality in chronic myocardial infarction. Relative merits of left ventricular dyssynchrony, left ventricular lead position, and myocardial scar to predict long-term survival of ischemic heart failure patients undergoing cardiac resynchronization therapy.
Validation of echocardiographic two-dimensional speckle tracking longitudinal strain imaging for viability assessment in patients with chronic ischemic left ventricular dysfunction and comparison with contrast-enhanced magnetic resonance imaging. Prognostic implications of global LV dysfunction: The relative impact of circumferential and longitudinal shortening on left ventricular ejection fraction and stroke volume.
Two-dimensional strain profiles in patients with physiological and pathological hypertrophy and preserved left ventricular systolic function: Differentiating left ventricular hypertrophy in athletes from that in patients with hypertrophic cardiomyopathy. Vigorous physical activity impairs myocardial function in patients with arrhythmogenic right ventricular cardiomyopathy and in mutation positive family members.
Right ventricular mechanical dispersion is related to malignant arrhythmias: Relationship between longitudinal and radial contractility in subclinical diabetic heart disease.
Findings from left ventricular strain and strain rate imaging in asymptomatic patients with type 2 diabetes mellitus. BMI, as a single measure, would not be expected to identify cardiovascular health or illness; the same is true for cholesterol, blood sugar, or blood pressure as a single measure.
For example, this study did not consider conditions that might also be relevant to an individual with an elevated BMI, such as liver disease or arthritis. As a single measure, BMI is clearly not a perfect measure of health.
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