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Myocardial ImagingTissue Doppler and Strain Imaging

Steven J. Lester MD, FRCP(C), FACC, FASE

©2017 MFMER | 3682262-3

DISCLOSURE

Relevant Financial Relationship(s)

None

Off Label Usage

None

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Myocardial Imaging

WARNING

CHANGESAHEAD

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Doppler:Doppler Tissue Imaging

1. Turn wall filters off2. Turn down the gain

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Doppler Tissue ImagingSeptal Myocardial Velocity Traces

S1

S2

e’ a’

Velocity: Base to Apex gradientStrain: Apex to Base gradient

(small) FORESHORTENED IMAGES!

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Curved M-mode : DTI

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GoalTo Detect Regional Wall Motion

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Pulsed TDPulsed TD Color TDColor TDPeak VelocitiesPeak Velocities Mean VelocitiesMean Velocities

1411

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Pitfall (Velocity Analysis)Translation and Tethering

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Strain = deformation resulting from applied

force

Stress = force

Courtesy of Ted Abraham

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Myocardial strainUsed to describe elastic properties of cardiac

muscle (Mirsky and Parmley: Circ Res, 1973)

Strain () = L1-L0

L0

Strain () = L1-L0

L0

10cm

L0L0 L1L1

Strain rate 8cm

-20%-20%12cm

+20%+20%

10cm

0%0%

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Strain rate: Rate of deformation

High strain rate

Low strain rate

Equal strain

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Strain rate vs. Tissue Doppler

Apical

Mid wall

Basal

Basal

Mid wall

Apical

AoC

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Feature “Speckle” Tracking

Doppler

Movement of the myocardium relative to the sample volume fixed in space

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Velocity is estimated as a shift of each object divided by time between successive frames (or multiplied by Frame Rate)-->

2D vector: (Vx, Vy) = (dX, dY) * FR

Old location

dX

New location

X

dY

Y

0

Courtesy Peter Lysysanksy

Acoustic pattern trackingSpeckle Tracking

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Doppler Independent Techniques (Speckle Tracking)Potential Advantage?

• Signal noise

• Speckle tracking by principle is angle independent

• Gray scale (standard views)

• Monitor strain in two rather than one dimension

• Minimal user input

• Assessment of rotation: derived from circumferential strain at different levels in the heart (NO fixed sample volume)

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Myocardial MechanicsRotation/Twist/Torsion

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Rotation and Torsion

Basal

Apex

View from apex

Rotation

Rotation

Torsion

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Park et al: J Am Soc Echo Cardiogr 21:1129, 2008

Mitral flow

TissueDoppler

Apicalrotation

Basalrotation

LVtorsion

NormalAbnormalrelaxation

Pseudo-normalization Restriction

EE

E’E’ A’A’

AA

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Negative Values

Positive Values

✔✖✖

Routine Practice

Longitudinal

Radial

Circumferential

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Global Longitudinal Peak Systolic Strain

A3C A4C A2C

GLPSS = -24%

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Image Arena 2D Speckle Tracking(GE Vivid™ 7)

EchoInsight

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J Am Soc Echocardiogr 2012:25:1189-94

Echocardiographic Measures of MyocardialDeformation by Speckle-Tracking Technologies:

The Need for Standardization?

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Global Longitudinal Strain Among Various Vendors

Hitachi-A Esaote GE Philips Samsung Siemens Toshiba Epsilon Tomtec Mean of all

GLS

AV

(%)

-30

-20

-10

0

Farsalinos et al: J Am Soc Echocardiogr 28:1171, 2015

-18.8±3.4

-20.2±3.6

-21.0±3.9

-18.2±3.6

-20.0±3.6 -18.5

±3.2

-18.8±3.6

-18.5±3.1

-21.5±4.0 -19.4

±3.3

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J Am Soc Echocardiogr 2015;28:1-39

Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al

• “Optimize image quality, maximize frame rate and minimize foreshortening”.

• “When regional tracking is suboptimal in more than two myocardial segments in a single view the calculation of GLS should be avoided”.

Global Longitudinal Peak Systolic Strain (GLS)“in the range of -20%”

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Timing: End-Systole?Aortic Valve

closure

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Timing: End-Systole?

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Pitfall: Avoid The LVOT

Good Bad

-17% -8%

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Pitfall: Avoid The Atrium

Good Bad

-17%-14%

-16%-13%

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Pitfall: ROI To Wide

Good Bad

-16.6% -12.6%

24% Difference

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Global Longitudinal Peak Systolic Strain

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Mean Error in Measurements

12.2

19.7

11.6

8.2

17

6.9

0

5

10

15

20

E E/A IVS LVEDD PW GLS

Mea

n er

ror

(%)

● ● ● ● ●GLSAV

Farsalinos et al: J Am Soc Echocardiogr 28:1171, 2015

AV

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Interobserver Relative Mean Errors

5.9

8.6

6.5 6.2 6.5 6.8

5.4

8.1

5.3

10.1

0

2

4

6

8

10

12

Hitachi-A Esaote GE Philips Samsung Siemens Toshiba Epsilon Tomtec EF

Inte

robs

erve

rm

ean

erro

r (%

)

Farsalinos et al: J Am Soc Echocardiogr 28:1171, 2015

BI

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3D LV Volumes and Ejection Fraction

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Reproducibility of EchocardiographicTechniques for Sequential Assessment of

Left Ventricular Ejection Fraction and Volumes

“Our data suggest that the temporal variability in EF of 0.06 might occur with noncontrast 3DE due to physiological differences and measurement

variability, whereas this might be >0.10 with 2D methods. Overall, 3DE also had the best intra- and inter-observer as well as test-retest variability”

J Am Coll Cardiol 2013;61:77-84

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3D Strain AnalysisLower resolution

(spatial and temporal)

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Potential Clinical Applications

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Cardio-Oncology At The Heart Of Cancer

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Case

• 59-year-old male

• Acute Myeloid Leukemia

• No prior history of vascular disease.

• Hypertension treated with Amlodipine.

• About to begin chemotherapy based treatment

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Oncologist“Killer”

Cardiologist“Protector”

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Anthracyclines

The Oncologists Arrows

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Niccolo Machiavelli (1469-1527)

“…at the beginning a disease is easy to cure but difficult to diagnose; but as time passes, not having been recognized or treated at the outset, it becomes easy to diagnose but difficult to cure.”

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Cardinale et al: J Am Coll Cardiol 55:213, 2010

Percentage of Responders To Heart Failure TherapiesACEI & Beta Blockers

64

28

7

0 0 0 00

10

20

30

40

50

60

70

1-2 2-4 4-6 6-8 8-10 10-12 >12

Res

pond

ers

(%)

Months from anthracycline administration to onset of heart failure therapy

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SubclinicalChange

Overt HeartFailure

SymptomaticLV

DysfunctionAsymptomaticReduced LV

Function (LVEF)

AsymptomaticSubclinical Δin LV function

(Strain)

BiomarkerElevation

(Troponin)

Echocardiography

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Case

• 59-year-old male

• Acute Myeloid Leukemia

• No prior history of vascular disease.

• Hypertension treated with Amlodipine.

• About to begin chemotherapy based treatment

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Baseline Echocardiogram

LVEF = 66%, EDVI = 53 ml/m2

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Baseline EchocardiogramGlobal Longitudinal Peak Systolic Strain

GLPSS Avg = -17.3%LVEF = 66%

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1. CTRCD if decrease in LVEF >10% to a value <53%

2. In patients with available baseline strain measurements, a relative percentage reduction of GLS of <8% from baseline appears not to be meaningful, and those >15% from baseline are very likely to be abnormal.

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LVEF = 66% LVEF = 58%

Baseline 2 Months

CTRCD if decrease in LVEF >10% to a value <53%

(66-58) / 66 = 0.12 (12%)

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Baseline 2 Months

LVEF = 66% LVEF = 58%

GLPSS Avg = -14.3%Troponin T = 0.03

GLPSS Avg = -17.3%Troponin T = 0.02

GLS of <8% from baseline appears not to be meaningful, and those >15%

from baseline are very likely to be abnormal

Change In Strain: (17.3 – 14.3) / 17.3 = 17.3%

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Cardio-Oncology Screening Strategy

Baseline Evaluation of Patient, LVEF, GLS, Troponin

LVEF > 53%GLS (<) -18%**

Troponin -

Follow-UpEvery 3-6 months*

Drop of LVEF by > 10% point To LVEF <53%

Relative drop of GLS asCompared to baseline

>15%<8%

No evidence of Subclinical LV dysfunction

Subclinical LV dysfunction(Initiate Cardioprotection)

CTRCD

LVEF < 53%GLS (>) -18%**

Troponin +

Cardiology Consultation

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Case

• 64 year old woman

• HER2 positive infiltrating lobular carcinoma of the right breast

• HER2 positive ductal carcinoma insitu of the left breast.

• Preoperative chemotherapy with paclitaxel (80mg/m2) and trastuzumab. Paclitaxel discontinued after 8 infusions due to toxicity (neuropathy).

• Then preoperatively started Q3weekly doxorubicin/cyclophosphamide (discontinued after 2 cycles due fatigue and anorexia).

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Pre-Treatment Echocardiogram

LVEF = 65%

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Pre-Treatment: Strain Imaging

A3C A4C A2C

GLPSS = -24%

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3 Months Into Treatment Echocardiogram

LVEF = 59%LVEF = 65-59/65 = 9%

CTRCD if decrease in LVEF >10% to a value <53%

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3 Months Into Treatment: Strain Imaging

A3C A4C A2C

GLPSS = -17%

24-17 / 24 = 29%

GLS of <8% from baseline appears not to be meaningful, and those >15%

from baseline are very likely to be abnormal

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What should we do now?

• LVEF dropped from 65% to 59% (9% RRR)

• GLPSS dropped from -24% to -17% (29% RRR)

• Started treatment with Coreg and Enalapril

• Initiated adjuvant trastuzumab and anastrozole

• Serial echocardiograms Q2-3 months

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Completion of 1 year of adjuvant trastuzumab

LVEF = 59%

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Completion of 1 year of adjuvant trastuzumab

GLPSS = -18%

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Thick Walls Why?

HypertrophyGenetic

Hemodynamic, Endocrine

Amyloidosis

Glycogen Storage –Pompe, Danon

Mucopolysaccharidoses

Sphingolipidoses– Gaucher– Anderson-Fabry

Storage

Infiltrative

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Are They Really The Same?

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14mm 14mm 13mm

CardiacAmyloidosis

HypertensiveHeart

DiseaseHypertrophic

Cardiomyopathy

Mean Wall Left Ventricular Thickness

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Pattern Recognition

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• “LV dysfunction is frequently subclinical despitea normal ejection fraction. It may preceded the onsetof symptoms and portend a poor outcome…”

• “The advent of novel tissue-tracking echo techniqueshas unleashed new opportunities for the clinical identification of early abnormalities in LV function”.

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Asymptomatic Severe Aortic Stenosis and LVEF > 50%Survival from MACE

0

20

40

60

80

100

0 6 12 18 24

Follow-up Duration (Months)

Su

rviv

al (

%)

Log-rank: 9.91P=0.0016

2DGLS <-17.0

2DGLS ≥-17.0

Nagata et al. J Am Coll Cardiol Img 2015;8:235–45

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2D Global Longitudinal StrainAll Cause Mortality

0

20

40

60

80

100

0 4 8 12 16 20 24 28

Follow-up (Months)

Cu

mu

lati

ve S

urv

ival

(%

)

Ng et al. European Heart Journal - Cardiovascular Imaging (2017) 0, 1–9

Overall log rank P=0.004

Normal LVEF “Preserved” LV GLS (≤-14%)Normal LVEF “Impaired” LV GLS (>-14%)Impaired LVEF

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2D Global Longitudinal StrainSurvival from MACE

0.0

0.2

0.4

0.6

0.8

1.0

0 100 200 300 400 500 600 700

Follow-up (Days)

Eve

nt-

Fre

e S

urv

ival

P<0.001

Sato et al. Circ J 2014;78:2750-2759

LFLPG: Preserved GLSNFLPGLFLPG: Impaired GLSNFHPGLFHPG

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Echocardiographic Evaluation of Aortic Stenosis

Rule #7:The evaluation of left ventricular

function should include not only a measure of ejection fraction but alsoglobal longitudinal strain.

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Severe Valve DiseaseAsymptomatic (Stage C)

*ACC/AHA NOT ESC guidelines

ActiveSurveillance

LVEF > 50%LVESD < 50mmLVEDD < 65mm

LVEF > 50%Vmax <5m/s

ΔPmean <60mmHgNormal ETT

ΔVmax <0.3m/s/yr

LVEF >60%LVESD <40mmSinus Rhythm

PASP <50mmHgSuccessful Repair <95%

Or Mortality >1%

Valve Replacement

Very Severe MVA<1cm2 T1/2 > 220- Unfavorable morphology,

LA clot, > mild MRSevere MVA<1.5cm2 T1/2 > 150-Sinus rhythm

-Afib with Unfavorable morphology, LA clot, > mild MR

Aortic Regurgitation*Aortic StenosisMitral RegurgitationMitral Stenosis

? Rest LV GLS (>) -16%

PositiveStress Test

LVEF > 50%Vmax <5m/s

ΔPmean <60mmHgNormal ETT

ΔVmax <0.3m/s/yr

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Global Longitudinal Strain and Primary MR

Normal LV Size, LVEF > 60%

Estimated Risk of Death at 5 years for Resting LV GLS

Mentias et al. J Am Coll Cardiol 2016;68:1974–86

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Severe Valve DiseaseAsymptomatic (Stage C)

*ACC/AHA NOT ESC guidelines

ActiveSurveillance

LVEF > 50%LVESD < 50mmLVEDD < 65mm

LVEF > 50%Vmax <5m/s

ΔPmean <60mmHgNormal ETT

ΔVmax <0.3m/s/yr

LVEF >60%LVESD <40mmSinus Rhythm

PASP <50mmHgSuccessful Repair <95%

Or Mortality >1%

Valve Replacement /

Repair?

Very Severe MVA<1cm2 T1/2 > 220- Unfavorable morphology,

LA clot, > mild MRSevere MVA<1.5cm2 T1/2 > 150-Sinus rhythm

-Afib with Unfavorable morphology, LA clot, > mild MR

Aortic Regurgitation*Aortic StenosisMitral RegurgitationMitral Stenosis

? Rest LV GLS (>) -18% or

Δ from baseline

PositiveStress Test

LVEF >60%LVESD <40mmSinus Rhythm

PASP <50mmHgSuccessful Repair <95%

Or Mortality >1%

©2017 MFMER | 3682262-127

Indications for Surgery For MR

Nishimura et al: J Am Coll Cardiol; Valve Focused Update, 2017

Primary MR(Stage C)

LVEF 30-60%or LVESD > 40mm

(stage C2)

LVEF >60% andor LVESD < 40mm

(stage C1)

New onset AF or PASP > 50mmHg

(stage C1)

MV Surgery*(I)

MV Surgery(IIa)

MV Repair(IIa)

PeriodicMonitoring

Likelihood of successful repair > 95% and

expected mortality < 1%

Yes No

Progressive increasein LVESD or

decrease in LVEF

Relative Reduction In GLS > 15%

???

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1. Subclinical LV dysfunction

2. HCM Phenocopies

3. Valve Disease

4. …

5. …

Myocardial ImagingProven Utility & Potential

A Masterpiece in Echocardiography?

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