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How to apply new echocardiographic methods in
management of heart failure
Otto A. Smiseth, FESC, FACC, FASE
Head and Professor, Division of Cardiovascular and Pulmonary Diseases
Oslo University Hospital, Norway
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Conflicts of interest
• There are no conflicts of interest to disclose
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Evaluation of Left Ventricular Function
Systolic function
Diastolic function
Otto A. Smiseth 2013
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Otto A. Smiseth 2013
Which methods?
Myocardial velocities by tissue Doppler
echocardiography
Myocardial strain by speckle tracking
echocardiography
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Otto A. Smiseth 2013
Myocardial velocities by tissue Doppler
Myocardial
velocities
Blood velocities
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LV early-diastolic lengthening velocity (e’)
Myocardial
velocities
(cm/s)
ECG
e’
Smiseth 2013
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Ca++
Ca++ Ca++
Ca++
Ca++
L0Lmin
Modified from www.phy-061062.blogspot.com
LV relaxation
Restoring forces
LV lengthening load
Determinants of LV lengthening velocity (e’)
Decay in active fibre force
Analogous to a compressed spring
which recoils passively.
Left atrial pressure represents a force
which pushes blood into the ventricle,
thereby causing LV lengthening.
Based upon Opdahl/Smiseth et al.,
Circulation. 2009;119:2578-2586.
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Transmitral
flow velocity00Mitral annulus
velocity
E
e’
E/e’ ratio
Tricuspid
regurgitation velocity
0
Natriuretic
peptides
Cardiac structural
changes
Normal values
virtually excludes
heart failure
Elevated in most patients with diastolic heart
failure, but not sufficient stand alone evidence
Enlarged left atrium and LV hypertrophy
supports the diagnosis diastolic heart failure
Increasing E/e’ ratio E/e’ > 15 is consistent with elevated LV filling pressure
Pulmonary venous
flow velocity 0
D
Ar
S
Smiseth et al., European Cardiology 2012
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What is ”strain”?
End-systole
Time
End-diastole
0
-20
%
OA Smiseth, 2013
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Systolic strain = (L-L0)/L0
Time
L0
L
Dimension crystals
(experimental studies)
9
MRI-tissue tagging
Tissue Doppler Speckle tracking
Strain methodologies
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Speckle tracking
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Speckle tracking echocardiography
Courtesy of Thomas Helle-Valle
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Strain by speckle tracking echocardiography
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Global Systolic Strain
Global strain = average of all segmental strain values
Modified from Ola Gjesdal
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Global Strain in a Normal Heart
Global strain = average of all segmental strain values
Global strain= -20 %
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Normal ranges of global left ventricular
longitudinal strain
A meta-analysis: 2,597 subjects from 24 studies.
Reported normal values of GLS varied from -15.9% to
-22.1% (mean, -19.7%; 95% CI, -20.4% to -18.9%).
Yingchoncharoen T, Agarwal S, Popović ZB, Marwick TH.
J Am Soc Echocardiogr. 2013 Feb;26(2):185-91.
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Global Strain - LAD Infarct
Global strain = average of all segmental strain values
Global strain = -9 %
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Stanton T et al. Circ Cardiovasc Imaging 2009;2:356-364
”Global longitudinal strain measurement by 2DS was superior to EF and
WMSI for the prediction of outcome and may become the optimal method
for assessment of global LV systolic function. Guidelines incorporating
measures of LV function may need to be revised to incorporate global
longitudinal strain in light of this finding.”
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Twisting motion
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A Opdahl/OA Smiseth et al. Circulation 2012;126:1441-1451
Determinants of LV untwisting rate
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Important features of the strain trace
• Peak strain
• Post-systolis shortening
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Distribution of circumferential strain in the ischemic LV
Courtesy of Thomas Helle-Valle
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Modified from Voigt J et al. Circulation 2003;107:2120-2126
Post-systolic shortening in ischemic myocardium
2ch
Stress response
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Case 1
61 yr. old male
Previously healthy
Admitted after midnight, general discomfort and nausea
ECG non-conclusive
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Tissue Doppler velocities (cm/s)
Septum LV lateral wall
LV inferior wall LV anterior wall
s
e’ a’
s
e’ a’
e’
e’
e’
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Strain
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-10
-20
Strain curves 2 chamber (%)2 chamber
AVC
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Speckle strain (%) 2ch
Stenosis (90%)
RCA
-20
-10
10Stenosis (90%)
RCA
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Case 2
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Case 2
20 yr. old male
Chest pain.
Hypotensive
Suspected pulmonary embolism, confirmed by CT
I.v. thrombolysis
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ACUTE PULMONARY EMBOLISM
BASELINE THROMBOLYSIS
Strain Doppler (%) Strain Doppler (%)
Strain Doppler (%)
-10 (%)
-10 (%)
-20 (%)
0 % 0 %
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Case 3
19 yr. old male
Fainted shortly after a soccer match
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TISSUE DOPPLER
RIGHT VENTRICULAR FREE WALL
e’
a’ e’
a’
LEFT VENTRICULAR FREE WALL
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Doppler strain RV free wall
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S. Sarvari et al., Eur Heart J (2011) 32 (9): 1089-1096.
Healthy individuals
Arrhythmogenic right ventricular cardiomyopathy and
subclinical right ventricular dysfunction
ARVC patients with
arrhythmia (n = 42)
Asymptomatic mutation
carriers (n = 27)
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Case 4
• 50 yr. old male
• Highly active in sports
• No symptoms
• Referred due to SD in younger brother
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Case 4
• Echo: Bordeline LV
• Normal ECG and Holter
• Normal exercise stress test
• Normal scintigraphy
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Slightly dilated LV, 6.2 cm
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Tissue Doppler velocities (cm/s)
LV free wall
Septum
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2D speckle strain (%)
AVC
AVC
AVC
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Conclusions
LV lengthening velocity (e’) by tissue Doppler should be used in evaluation of diastolic funcion.
Global LV strain appear to be a sensitive measure of LV systolic function, but added
clinical value not yet proven.
In selected patients strain is clinically usefulIn CAD
In CMP
In subclinical heart disease