0506-800am -lester - tissue doppler and stain imaging · 4/19/2018 1 ©2017 mfmer | 3682262-2...
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Myocardial ImagingTissue Doppler and Strain Imaging
Steven J. Lester MD, FRCP(C), FACC, FASE
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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%
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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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