Gorcsan Strain Strain Rate Handout - American … 13 (Sunday)/Main Conference/4...10/01/2013 1...

10/01/2013

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Strain, Strain Rate, Torsion What are They and

When Should We Use Them?

John Gorcsan, MD

University of Pittsburgh,

Pittsburgh, PA

Disclosures: Research Grant Support from GE, Toshiba, Medtronic, St. Jude and Biotronik

Vectors of Myocardial Strain

Gorcsan J, JACC 2011;58:1401-13Gorcsan J, Do Not Copy

Tissue Doppler: Velocity, Strain Rate and Strain

Frequency Shift(kHz)

Gorcsan J, JACC 2011;58:1401-13Gorcsan J, Do Not Copy

PROBLEMS WITH TISSUE DOPPLER STRAINTissue Doppler

Strain is measured along scan lines !

Myofiber Orientation Is Complex

Gorcsan J, Do Not Copy

STRAIN IMAGING BY TISSUE DOPPLER IS AFFECTED BY DOPPLER ANGLE

Urheim, Smitheth et al. Circulation 2000;102:1158-1164Gorcsan J, Do Not Copy

Tissue Doppler Longitudinal Strain Analysis

Septal Lateral

Normal subjectGorcsan J, Do Not Copy

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STRAIN vs. VELOCITY

Strain = (L-L0) / L0

L0 L

L0

L

L0 = Original LengthL = Length of Deformed portion

STRAIN ISOLATES THICKENING

Thickening

Passive Movement


What Is Speckle Tracking ?


Calculation of Strain FromSpeckle Tracking

Not Dependent on Doppler Angle

Frame 1 Frame 1 + n

Strain =Change in Length Original Length

% Thickening

% Thinning

Modified from Kawagishi, KGorcsan J, Do Not Copy

Speckle Tracking Longitudinal Strain


APPLICATION OF SPECKLE TRACKING TO ROUTINE ECHO IMAGES

Radial Strain

REGION OF INTEREST


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Speckle Tracking: RADIAL STRAIN ANALYSIS

Normal subject

% T

hic

ken

ing

Time

% Thickening

% Thinning


REGION OF INTEREST

APPLICATION OF SPECKLE TRACKING TO ROUTINE ECHOIMAGES

Circumflential StrainGorcsan J, Do Not Copy

Speckle Tracking: CIRCUMFLENTIAL STRAIN ANALYSIS

Normal subject


Apical Long-AxisApical 2-ChamberApical 4-Chamber

DYSSYNCHRONY ANALYSISLongitudinal Strain


Speckle Tracking Longitudinal Strain


TRANSVERSE STRAINImpossible for Tissue Doppler


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Normal

Apical Long Axis viewApical 4-Chamber viewSpeckle Tracking Transverse Strain

Thickening

Thinning

Early Diastolic Strain Rate vs. Interstitial Fibrosis

Park, Nagueh et al2006 Am J PhysiolHeart Circ Physiol290: H724–H731


CONTRACTION-RELAXATION COUPLING

Ca ++

Actin

Myosin

Actin

Myosin

Contraction Active Relaxation

ATP ATP

Myofibril-Systole Myofibril-Diastole


Longitudinal and Radial Strain and Strain Rate

Tamuro…Ito et al. J Am Soc Echocardiogr 2010;23:747-54. Tamuro…Ito et al. J Am Soc Echocardiogr 2010;23:747-54.

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Systolic-Diastolic Coupling

Tamuro…Ito et al. J Am Soc Echocardiogr 2010;23:747-54.

Ant-SepAnteriorLateralPosteriorInferiorSeptalAverage

Echo vs. Cardiac Magnetic Resonance Comparison

Echo (SAX)

CMR (SAX)

ECG

Time (ms)

Circumferential strain in Echo

Circumferential strain in CMR

(GCS)

100ms

0

-15

Str

ain

ECG

Time (ms)

0

-15

Str

ain

Normal systolic function patient

Onishi T, Saha S, …Gorcsan et al. ESC 2011


Reproducibility of Global Circumferential strain by CMR & ECHO

0 10 20 30 40 50

50

40

30

20

10

0

GCS by echo speckle tracking (%)

GC

S b

y C

MR

(%

)

0 10 20 30 40 50

15

10

5

0

-5

-10

-15

Mean

0.5

-1.96 SD

-12.0

+1.96 SD

13.0

Mean GCS (%)

GC

S E

CH

O -

CM

R (

%)

r = 0.85

p < 0.001

Onishi T, Saha S, …Gorcsan et al. ESC 2011Gorcsan J, Do Not Copy

Echocardiogram

Global Longitudinal Strain

Cardiac MagneticResonance

Str

ain

(%)

Time (ms)100ms

Normal Systolic Function(CMR-EF=62%)

-10

0

Systolic Dysfunction(CMR-EF=26%)

-20

-30

Time (ms)100ms Time (ms)

100ms

Time (ms)

100msS

trai

n (%

)

-10

0

-20

-30

Str

ain

(%)

-10

0

-20

-30

Str

ain

(%)

-10

0

-20

-30

GLS

GLS

GLS

GLS

Basal-Septal Mid-Septal Apical-SeptalApical Lateral Mid-Lateral Basal-Lateral

Global Longitudinal Strain (GLS)

ECG

ECG

ECG

ECG


0 20 40 60 80-30

-20

-10

0

0 20 40 60 80-30

-20

-10

0

FT

CM

R-G

LS (

%)

ST

Ech

o-G

LS (

%)

R = 0.88p < 0.0001

R = 0.85p < 0.0001

CMR-EF (%) CMR-EF (%)

n=73 n=68

-40

-30

-20

-10

0

CMR-EF (%)

FT

CM

R-G

CS

(%

)

-40

-30

-20

-10

0

CMR-EF (%)

ST

Ech

o-G

CS

(%

)

0 20 40 60 80 0 20 40 60 80

R = 0.95p < 0.0001

R = 0.92p < 0.0001

n=73 n=71

Global Longitudinal Strain vs. CMR EF

Global Circumferential Strain vs. CMR EF


Global Circumferential Strain & Prognosis in Heart Failure

• 201 HF patients• EF = 23%• HF Hospitalization

or Death 5 yrs

Cho et al. J Am Coll Cardiol 2009;54:618

Str

ain

(%)

-10

0

-20

-30

-40

Time (ms)100ms

GCS

ECG

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Objectives: To evaluate if more sensitive echocardiographic measurements and biomarkers could predict later cardiac dysfunction in chemo-treated patients.

Sensitivity Specificity PPV NPV

10% decrease longitudinal strain 7/9 (78%) 27/34 (79%) 7/14 (50%) 27/29 (93%)

Increased cTnl at 3 months 6/9 (67%) 28/34 (82%) 6/12 (50%) 28/31 (90%)

10% decrease Long strain andincreased cTnl at 3 months 5/9 (55%) 33/34 (97%) 5/6 (83%) 33/37 (89%)

10% decrease Long strain orincreased cTnl at 3 months 8/9 (89%) 22/34 (65%) 8/20 (40%) 22/23 (97%)











Am J Cardiology 2011;107(9):1375-80Gorcsan J, Do Not Copy

Speckle Tracking Left Atrial Strain

Positive PeakStrain

Negative PeakStrain

Total Strain

Left Atrial Function Predicts Atrial FibrillationRecurrence After Catheter Ablation

No Recurrence Group

(n = 34; 54%)

Atrial FibrillationRecurrence Group

(n = 29; 46%)

Mirza M, Caracciolo et al. J Interv Card Electrophysiol 2011

63 pts. AFIB Cathelter Ablation 75% PAF, 25% Persistent AF 18±12 months of follow-up


MYOFIBER ORIENTATION IS THREE DIMENSIONAL


The Advantage of Echocardiographic 3D Tracking2D Imaging, Myocardium Moves In and out of Plane

3D Imaging, Entire Myocardium Is Tracked


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3D SPECKLE TRACKING ANALYSIS

Thickening

Thinning

Radial Strain

C1

C1

C3

4-Chamber View 2-Chamber View

NORMAL 3D STRAIN

NORMALDilated CardiomyopathyLBBB

AnteriorSeptal

Posterior

3D Speckle TrackingWire Mesh View

Tanaka, H… Gorcsan J et al. Am J Cardiol 2009 Gorcsan J, Do Not Copy

APICAL TORSION

3D Speckle Tracing Strain


DECREASED LV ROTATION IN HEART FAILURE- NORMAL EF

Basal Rotation

Apical Rotation Tan…Sanderson et al. J Am Coll Cardiol 2009;54:36–46

Heart Failure PatientNormal EFNormal Control

Untwist Untwist

HFNEF has Blunted Increases in LV Function with Exercise

0

20

40

60

80

100

120

140n = 27 Normal Controls, n = 56 HFNEF,

Normal HFNEF Normal HFNEF Normal HFNEF

RestExercise

Longitudinal Strain

RadialStrain

Untwist Rate

Tan…Sanderson et al. J Am Coll Cardiol 2009;54:36–46

%

*

*

*

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Proposed Pathophysiology HFNEF

Tan…Sanderson et al. JACC 2009;54:36–46


NORMAL RV Longitudinal Strain


RV Strain and Outcomes in PH

Fine, Kane et al. Circ CV Img 2013

Time free of cardiac events or PH medical intervention


Right Ventricular 3D Speckle Tracking Strain

NormalPulmonary Hypertension

Thickening

Thinning


NORMAL CONTROL

End-systoleEnd-diastole

Right Ventricle

3D Global Strain 35%

SEVERE PH PATIENT

End-systole End-diastole

Right Ventricle

3D Global Strain 15%

RV AREA TRACKING STRAINEXAMPLES


Strain, Strain Rate, Torsion• Speckle tracking strain has emerged as the

echocardiographic method of choice for advanced quantification of cardiac function.

• Emerging clinical applications include Global Longitudinal Strain, and Global Circumferential Strain to assess LV function.

• Torsion is helpful to understand diastolic function.

• Newer potential applications include 3D strain and RV strain imaging.

Gorcsan Strain Strain Rate Handout - American … 13 (Sunday)/Main Conference/4...10/01/2013 1...

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