Strain Analysisby Speckle Tracking Echocardiography

Natesa G. Pandian, MD, FACCCo-DirectorHeart Valve Center & Noninvasive Cardiac ImagingHoag Hospital, Newport Beach, CA

Professor of Medicine and Staff CardiologistTufts University School of Medicine, Boston

Speaker – ToshibaSpeaker Bureau – Lantheus Inc.

LV Systolic and Diastolic Performance is Complex

Intramural pathology and dysfunction occur before detection by conventional parameters

Tissue Doppler Imaging !

Speckle Tracking Technique

Speckle Tracking

Why 3D Speckle Tracking?

2D Tracking

3D Tracking

What Parameters Can Be Obtained?

Radial 3D-strain

Speckle Tracking(Global and Segmental Information)

Segmental Information

Global volume and EF

STE Parameters

•Displacement

•Strain

•Strain Rate

•Rotation

•Twist, Twist Rate

•Untwist, Untwist Rate

•Torsion

LongitudinalCircumferentialRadial

Systolic Radial Strain (Thickening)

Circumferential Strain (Shortening)

Longitudinal Strain (Shortening)

3D Speckle Tracking

Twist Torsion

ED ES

Rotation

Basal and Apical RotationBasal

Rotation:

• Briefly initial

counter-

clockwise

rotation

• Globally

clockwise

rotationApical

Rotation:

• Counter-

clockwise

rotation

How correct

are they?

All These Numbers and Curves...

Validation

Author Year STE parameter Reference Std Subjects

Toyoda et al, JASE 2004 2D RSt sonomicrometry animal

Korninek et al, JASE 2005 2D Strain sonomicrometry animal

Notori et al, JACC 2005 2D Torsion tagged MRI human

Amundsen et al, JACC 2006 2D Strainsonomicrometryand tagged MRI

animal

Roes et al, AJC 20092D global

and regional LStMRI LGE

human (patients with isch. LVD)

Nesser HJ, EHJ 2009 3D-STE LV volumes MRI human

Seo Y, Circ-Img 2009 3D Strain sonomicrometry animal

Seo Y, JACC-Img 2011 3D area tracking sonomicrometry animal

Normal Values

303 Healthy SubjectsMales 51%, Females 49%

M F

3D Speckle Tracking Study of the Normal LV Mechanics

Heterogeneity

Evangelista/Patel/Pandian et al. JACC 2009

0

10

20

30

40

50

60

Base Mid Apical

Radial

Circum

Longitudinal

Ischemic Heart Disease

Radial 3D-strain

Speckle Tracking(Global and Segmental Information)

Segmental Information

Global volume and EF

Global Volume and EF

EDV 135.95 mL

ESV 43.85 mL

EF 67.74 %

Diastole to ...

...Systole.

Normal

Seo Y et al. Circ Cardiovasc Imaging 2009;2:451-459

LAD Occlusion

Speckle-tracking echocardiography correctly identifies segmental left ventricular dysfunction induced by scarring in a rat model of myocardial infarction

Zoran B. Popović et al Am J Physiol 2007

Esmaeilzadeh/Pandian

Relation Between Arterial Elastanceand Circumferential Strain

Esmaeilzadeh/Pandian

Relation Between Ventricular Elastanceand Circumferential Strain

CAD with RWMANormal

CAD with RWMANormal

CAD with RWMANormal

Michael Becker et al. European Heart Journal April, 2009

Impact of Transmurality onEndo and Epicardial Circumferencial Strain

Transmural MI

Subendocardial MI

Subendocardial

Subendocardial

Subepicardial

Subepicardial No Change

Salehi/Pandian

Deformation Changes in Myocardial Ischemia

Subendocardial Transmural

Global Longitudinal Strain ↓ ↓

Global Circumferential Strain — ↓

Global Radial Strain — ↓

Twist — ↓

Choi J. et. al. Eur J Echocardiography 2009;10:695-701.

Longitudinal Strain at Rest PredictsLeft Main and 3VD in Patients Without RWMA

Dammon et al. JACC Cardiovasc Interv 2012

NSTEMI

2/3 of NSTEMI patients undergo coronary angiography

2D Speckle for Detection of

Significant CAD – A Meta-analysis

• Sensitivity84%

• Specificity82%

Singh et al. JACC 2013

19 studies, 2189 patients

Detection of wall motion abnormalities

RADIAL STRAIN in a patient withIsc CMP, EF 25%

Distal septum and anterior wall akinesia (thinning)Lateral wall hypokinesia(reduced thickening)

Ischemic Cardiomyopathy

DyssynchronyCMP Patient

DyssynchronyCMP Patient

After CRT

Severe LV

DysfunctionNormal (-17 ± 5%)

Diastolic Strain and Strain Rate IndicesFor Estimation of LV Filling Pressure

Valve Disease

Illustrative cases of 2 patients with normal flow low gradient (left) and low flow low gradient (right) aortic

stenosis with normal EF

Adda J et al. Circ Cardiovasc

Imaging 2012;5:27-35

Cardiomyopathies

Anthracycline-induced cardiomyopathy

Normal EF

RES Vol 6, 2011

Detecting Preclinical Disease

Doxarubicin Cardiotoxity•Abnormal strain at half the “cardiotoxic” dose

•? Should trigger beta blocker or ACE inhibitor therapy

Infliximab (Remicaide) Cardiotoxity•Incidence of CHF 0.2%

•Asymptomatic low strain: 30%

•Normalization of strain with discontinuation of infliximab

Twist and Untwist in HCM vs Controls

Urbano Moral/Patel/Pandian AJC 2011

Longitudinal Strain: Cardiac Amyloidosis

Amyloid Normal

Urbano-Moral/Patel/Pandian, Echocardiography 2011

Cardiac Amyloidosis

Jose Angel Urbano-Morala,

, Dakshin Gangadharamurthya

, Raymond L. Comenzoa

, Natesa G. Pandiana

, Ayan R. Patela

Urbano-Moral/Patel/Pandian, Rev Esp Cardiol 2015;68:657

HCM Genotype (+) Normal

Urbano-Moral/Patel/Pandian, Echocardiography 2011

Diastolic Strain and Strain Rate IndexesFor Estimation of LV Filling Pressure

Dokainish H. et. Al. Am J Cardiol. 2008;101(10):1504-9.

Mechanics in Heart Failure

FunctionalImpairment

LongitudinalMechanics

Circumferential Mechanics

Radial Mechanics

Torsional Mechanics

Global EF

Predominant subendocardial

dysfunction

Marked impairment

PreservedPreserved/

minimalimpairment

PreservedPreserved/

minimalimpairment

Predominant subepicardial dysfunction

Preserved/ minimal

impairmentMarked impairment

Minimal impairment

Marked impairment

Preserved/minimal

impairment

Transmuraldysfunction

Marked impairment

Marked impairmentMarked

impairmentMarked

impairmentMarked

impairment

From Geyer et al, Assessment of Myocardial Mechanics Using Speckle Tracking Echocardiography:

Fundamentals and Clinical Applications; J Am Soc Echo 2010;23:351-69

How about theRight Ventricle?

Panetta/Pandian et al

Reference Range for RV Strain

RV Longitudinal Strain (%)

5

10

15

20

Proportion of Patients (%)

-45 -40 -35 -30 -25 -20 -15 -10 -5 0 5

Mean RV free wall strain = -25 ±5%

Fine, et al. Circ CV Img 2013 (in press)

N=169 patients with normal TTE

Panetta/Pandian et al, EuroEcho 2013

Longitudinal displacement:

Significantly different in Amyloid, HCM and Hypertensive Hypertrophy

Differentiating feature between HCM and Amyloid Heart

Right Ventricle - Global apical LD

p value< 0.001

Panetta/Pandian et al

RV Strain Predicts Outcomes in PH

All-cause mortality Time free of cardiac events or PH medical intervention

Fine et al. Circ CV Img 2013

Right Ventricular Pathology

• Measurement of RV strainis feasible

• RV contraction is predominently longitudinal

• RV strain is abnormal ina variety of disorders

Strain by Speckle Tracking

• Identification of subtle regional & global contractile

abnormalities

• Identification of dyssynchrony

• Evaluation of diastolic mechanics of the heart

• Prognostic value

Twist

Untwist

Torsion

Wringing Motion

Cardiac (patho)Physiology

Radial Strain

Circumferential Strain

Longitudinal Strain

Area Tracking

Myoc Deformation

Decision Making

Twist

Untwist

Torsion

Wringing Motion

Cardiac (patho)Physiology

Clinical Application

Radial Strain

Circumferential Strain

Longitudinal Strain

Area Tracking

Cardiomyopathies

Subclinical Heart Dysfunction

Stress Echo

LV volumes / EF / Mass

Valvular Surgery

Subclinical Heart Dysfunction

Resynchronization Therapy

LV volumes / EF / Mass

Myoc Deformation

Evaluation / Diagnosis

Future Directions

• Need robust prognostic data

• Need values to define therapy

• Real-time 3D quantitation

• Fusion Imaging

Thank you!