strain imaging: vectors of contraction myocardial...
TRANSCRIPT
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Strain Imaging: Myocardial Mechanics Simplified and Applied
John Gorcsan III, MD
Professor of Medicine
Director of Clinical Research Division of Cardiology
Disclosures: Research grant from Hitachi-Aloka, Medtronic, GE and Biotronik
Twisting
VECTORS OF CONTRACTION
ThickeningShortening
Gorcsan J. 2017
Calculation of Strain FromSpeckle Tracking
Not Dependent on Doppler Angle
Frame 1 Frame 1 + n
Strain =Change in Length
Original Length
Modified from Kawagishi, K
% Lengthening or Thinning
% Shortening or Thickening
LONGITUDINAL STRAIN IMAGING
Strain = Change in Length / Original Length
Longitudinal StrainLV Shortening
End Diastole End Systole
%
Strain =% Change in Length
End-Diastole
End-Systole
Gorcsan J. 2017
Longitudinal Strain
End-Diastole
End-Systole - 23%
Gorcsan J. 2017
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Apical Long-AxisApical 2-ChamberApical 4-Chamber
Global Longitudinal Strain (GLS)Average Strain
Gorcsan J. 2017
Global Longitudinal Strain (GLS)Average Strain
Apical 4-Chamber
Apical 2-Chamber
Apical Long-Axis
Polar(Bull’s Eye) Plot
Gorcsan J. 2017
What is Normal? Global Longitudinal Strain
GLS: -15.7 to -21.1%, mean -19.7%
N = 2,597
Yingchoncharoen…Marwick et al. JASE 2013;26:185
GLS Values Vary by Vendor, Gender and Age
Plana et al. J Am Soc Echocardiogr 2014;27:911-39
GE
Philips
Toshiba
Normal Strain ValuesThreshold for Abnormal
• Global Longitudinal Strain
Normal GLS:> -17%
Borderline GLS: between -17% and -15%
Clearly Abnormal GLS: < -15%
Think of GLS in absolute values(I Prefer to Forget the – sign)
Gorcsan J. 2017
Global Strain Must Relate to Ejection Fraction
LV Deformation = LV Blood EjectionGorcsan 2017
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Mathematical Linear Relationship of GLS to EF
Linear Fit EF = 3 (GLS)
Echocardiogram
Cardiac MagneticResonance
Str
ain
(%)
Time (ms)100msNormal Systolic Function(CMR-EF=62%)
-10
0
Systolic Dysfunction(CMR-EF=26%)
-20
-30
Time (ms)100ms Time (ms)
100ms
Time (ms)
100ms
Str
ain
(%)
-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
NormalNormal Heart Failure Patient
Echo vs. Cardiac Magnetic Resonance
Onishi T, …Gorcsan et al. JASE 2015
30
10
20
GLS vs. EF
0 20 40 60 800
10
20
30
FT
CM
R-G
LS
(%
)
R = 0.88p < 0.0001
CMR-EF (%) CMR-EF (%)
n=73
20 40 60 80
-
0
ST
Ech
o-G
LS
(%
)
R = 0.85p < 0.0001
n=68
Echocardiogram
Str
ain
(%)
Time (ms)100ms
-10
0
-20-30
Str
ain
(%)
GLS
ECG Normal
EF = 3* |GLS| + 8Onishi T, …Gorcsan et al. JASE 2015
Differences in EF and StrainLV Hypertrophy
Lumens et al. 2016
What Additional Information?GLS as a Marker for Scar
Kansal et al. Eur Heart J Cardiovasc Imaging 2012
Myocardial Scar by Late Gadolinium Enhancment CMR
LS
LS
LS
ENDOCARDIAL SCARRING
MIDMYOCARDIAL SCARRING
TRANSMURAL SCARRING
Gjesdal et al.Clinical Science (2007) 113, 287–296
N = 59
GLOBAL STRAIN (%)
INFARCT SIZE (G)
N = 38
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Strain is Additive to EF
Ejection Fraction
Blood Displacement
Strain
Wall Properties of Disease
• Hypertrophy
• Fibrosis
More Reproducible than EFGorcsan J. 2017
Strain is Additive to EFFar Ends of Spectrum
High EFVery
Low EF
N = 1,065 Heart Failure Clinic Patients
Low EF Patients
N = 1,065 Heart Failure Clinic Patients
Echo Parameters
Two-site LV Pacing
Cardiac Resynchronization TherapyTreatment for Low EF Wide QRSHeart Failure
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Baseline Global Strain is Associated with Outcome After CRT
HF Hospitalization or Death
0 1 2 3 4
0
20
40
60
80
100
Follow-Up Time (years)
Su
rviv
al p
rob
abili
ty (
%)
GLS>-9% 112 69 52 42 33
GLS≤-9% 93 77 65 56 45
GLS≤-9%
GLS>-9%
p=0.0002 ; HR 2.10, 95% CI 1.45-3.05
N=205Routine CRT Indications QRS > 120m2
Global Longitudinal Strain
Delgado-Montero, … Gorcsan et al, Circ CV Imaging 2016 Ruschitzka et al. NEJM 2013 September 3
N = 809
• LVEF < 35%
• QRS < 130 ms
• Echo Dyssynchrony
Randomized to:
CRT Off
CRT On
EchoCRT: CRT in Narrow QRSIncrease in All-Cause Mortality
HR = 1.81 (1.11, 2.93)
p=0.02
GLS and Cardiovascular Mortality CRT On vs. CRT Off
* p = 0.008
< 6.2% 6.2-7.9% 7.9-10.1% >10.1%
n = 755
Global Longitudinal Strain (absolute values)
Car
dio
vas
cula
r D
eath
s (%
)
Bax… Gorcsan et al. EHJ 2016 (Figure Unpublished)
*
GLS < 6.2%, CRT-OnGLS < 6.2%, CRT-OffGLS > 6.2%, CRT-OnGLS > 6.2%, CRT-Off
*p= 0.007 vs. other groups, HR=5.70 (95% CI 1.61-20.13),
n = 755
GLS < 6.2%, CRT-Off
GLS < 6.2%, CRT-On
GLS and Cardiovascular Mortality CRT On vs. CRT Off
Years from RandomizationBax… Gorcsan et al. EHJ 2016
Features of Additive Risk
LOW EF LOW GLS
J. Gorcsan Euro-Echo Imaging 2016
Dyssynchrony
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GLS and Asymptomatic Severe MR with Preserved EF
• 737 patients
• Severe MR
• LVEF > 60%
• Non‐dilated LV
– ESD < 4.0cm
– ESDi < 3.3cm/m2
GLS and Asymptomatic Severe MR with Preserved EF: Risk of Death
-20%
Risk of Deathn = 737
Worse Strain
Better Strain
Worse Strain
Neurocardiac Injury in Subarachnoid Hemorrhage
“Cerebral T Waves”
GLS to Assess Neurocardiac Injury in Subarachnoid Hemorrhage
Kagiyama…Gorcsan et al. ASE 2017
• 255 patients• 52±10 yrs
• 72% female
• GLS in ICU (mean 2 days from bleed)
• Strain feasible on 221
20
30
40
50
60
70
80
5 10 15 20 25 30
LVEF
(%)
GLS (%) (absolute values)Kagiyama…Gorcsan et al. ASE 2017
Relationship of GLS to EF in Subarachnoid Hemorrhage
N = 221
0
5
10
15
20
25
Mortality
5‐10% 10‐15% 15‐20% 20‐25% 25‐30%
%
Linear relationship, P = 0.013
GLS (absolute values)
N = 221
GLS and In-Hospital Mortality with Subarachnoid Hemorrhage
Kagiyama…Gorcsan et al. ASE 2017
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Potential Factors in Neurocardiac Injury
Catecholamine Surge
SubarachnoidHemorrhage
Individual Susceptibility
Myocyte InjuryImpaired
Myocardial Perfusion Kagiyama…Gorcsan et al.
0
5
10
15
20
25
Controls (n=50) Hypertensive Heart Disease (n=44)
HFpEF (n=219)
* p<0.001 vs. Controls and Hypertensive Heart Disease
Kraigher-Krainer,…Solomon et al. JACC 2014;63:447–56
**
Global Longitudinal Strain (%) absolute values%
Kraigher-Krainer,…Solomon et al. JACC 2014;63:447–56
Association of GLS with Biomarkers for Heart Failure (NT-proBNP)
GLS Predictive of Survival in Patients with ESRD and Preserved EF N = 48 African Americans with ESRD on Hemodialysis LV EF > 50% Baseline GLS – Prospectively enrolled and followed 1.9 years GLS was predictive of All Cause Mortality GLS Cut-Off < 16% (absolute values) Hazard ratio 1.15, 95% confidence interval 1.02 to 1.30, p = 0.02,
Pressman G…Gorcsan J et al. Am J Cardiol 2015 Nov 15;116(10):1601-4.
CASE STUDY• 62 year old man with weight loss,
gastroparesis, dyspnea and edema.
Apex
BaseMid
Gorcsan J. MSE 2017
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Segmental Longitudinal Strain
Basal Strain = - 5.0%Mid Strain = - 5.8%Apical Strain = -17.2%
Basal Strain = - 21.1%Mid Strain = - 22.3%Apical Strain = -25.3%
Amyloid Heart Disease
Normal SubjectOur Patient
Apical Sparing
Apical Longitudinal Strain Sparing in Amyloidosis
Examples of Increase Wall Thickness No Amyloidosis
Examples of Cardiac Amyloidosis
Phelan…Thomas JD, Heart 2012
Prevalence of Abnormal Echo Indices in Cardiac Amyloidosis
Quarta, Solomon et al. Circulation. 2014;129:18 1840-1849
n = 172 patients with Cardiac Amyloidosis n=80 with Light Chain Immunoglogulins n=36 transthyretin-related mutant form n=56 Nonmutant transthyretin-related amyloidosis
GLS Predicts Survival in Cardiac Amyloidosis
Quarta, Solomon et al. Circulation. 2014;129:18 1840-1849
An 85 year woman with progressive shortness of breath and syncope
Severe Aortic Stenosis Peak Velocity 5 m/secPeak Gradient 100 mmHg, Mean Gradient 69 mmHg
AVA = 0.6 cm2
n = 125 patients with Severe ASPreop GLS
GLS Quartile 1 and 2
GLS Quartile 3
GLS Quartile 4
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GLS was Additive to Clinical Features and EF
n = 125
Cardio-oncology Progress in Cancer Survival Rates
• Substantial improvements in cancer patient survival.
• 14.5 million cancer
survivors in the US
• Leads to a higher prevalence of patients with cancer and cardiovascular disease
DeSantis C.E., Lin C.C., Mariotto A.B., et al; Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014;64:252-271.
GLS was Additive to EF to Predict Chemo Cardiotoxicity
N = 24 patients with cardiotoxicity
Nigishi…Marwick et al. JASE 2013 GLS < 11%
Ultrasound system Fluoroscopy Angiographic SystemStrain New Directions: Fusion imaging
Strain Activation: Early Late
Fusion imaging
LAO ViewRAO View
RV 3D SPECKLE TRACKING
C3
C4
C5
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Normal Control RV Adapted Remodeled RV Adverse Remodeled
sPAP 86mmHgestimate sPAP 20mmHg sPAP 83mmHg
RV Adapted
End Systole End Systole End Systole
sPAP 44mmHg
End Systole
RVEF 18%G-AS -14%
volume curve
RVEF 41%G-AS -28%
volume curve
RVEF 50%G-AS -39%
volume curve
(ml)120
0
(ml)180
0
(ml)220
0
(ml)280
0
RVEF 27%G-AS -24%
volume curve
global area strain
global area strain
global areastrain
global area strain
RV 3D Strain and Volume in Pulmonary HypertensionPH Patients
Months
Pro
ba
bili
ty o
f F
ree
do
m F
rom
H
ospi
taliz
atio
n,
Dea
th o
r Lu
ng
Tra
nspl
anta
tion
0 1 2 3 4 5 6
0
10
20
30
40
50
60
70
80
90
100
51 47 44 43 43 39 37
28 20 18 16 14 13 13
13 7 7 5 2 2 2
(%)
Log rank P<0.0001
RV Adapted
RV Adapted Remodeled ‡
RV Adverse Remodeled †
‡P=0.0001 vs. RV Adapted†P=0.04 vs. RV Adapted Remodeled
n=92
RV Adapted
RV Adapted Remodeled
RV Adverse Remodeled
Number at risk
Pulmonary Hypertension PatientsHospitalization, Death or Lung Transplantation
Ryo…Gorcsan et al. Circ CV Imaging May 2015
3D RA Strain Analysis: Pulmonary Hypertension vs. Control
Normal Control
Pulmonary Hypertension Patient
3D RA Volume
3D RA Global AreaStrain
3D RA Volume
3D RA Global AreaStrain
Sugahara…Gorcsan et al.
3D RA Strain and Clinical OutcomesPulmonary Hypertension Patients
Hospitalization, Death or Lung TransplantationF
ree
do
mfr
om
Clin
ica
l Ev
en
ts(%
)
Follow up, Months
0 1 2 3 4 5 6
0
20
40
60
80
100
RA 3D Global Area Strain > 17%
RA 3D Global Area Strain ≤ 17%*
*P<0.001HR 13.04 (95%CI 3.7 - 45.8)
Fre
ed
om
fro
m C
linic
al E
ve
nts
(%)
0 1 2 3 4 5 6
0
20
40
60
80
100
Follow up, Months
*P<0.001HR 8.66 (95%CI 2.8 – 26.6)
RA max Volume Index < 56ml/m2
RA max Volume Index≥ 56ml/m2* F
ree
do
mfr
om
Clin
ica
l Ev
en
ts(%
)
0 1 2 3 4 5 6
0
100
20
40
60
80
Follow up, Months
*P<0.001HR 8.66 (95%CI 2.8 – 26.6)
RA Emptying Fraction> 19%
RA Emptying Fraction ≤ 19%*
N = 54 patients
Sugahara…Gorcsan et al.
J Am Soc Echocardiogr 2015;28:183-93
ASE Announcement: Myocardial Strain Imaging• Acceptance of New CPT Category III code, 039X9T• Introduced January, 2016.• Category III codes are not yet reimbursed: Often lead to the adoption of payable codes by CMS and other payers.
Strain Imaging into the Future Take Home Messages
• Speckle Tracking Strain has emerged as the most useful new echocardiographic tool to assess myocardial function.
• Global Longitudinal Strain is best represented in the literature as being a sensitive measure additive to EF.
• Most Promising New Clinical Applications:• Adding to EF in Heart Failure to Enhance Prognosis
• Cardiac Amydoidosis
• Valvular Heart Disease
• Neurocardiac Injury
• Cardio-oncology
• 3D Strain has promise for the future! Gorcsan J. 2017