SHA24/070003

Samir Saha, MD. PhD, FACC The Karolinska Institute, Stockholm, Sweden

Global left ventricular circumferential strain is a marker for both systolic and diastolic myocardial function Toshinari Onishi1, Samir K. Saha2, Daniel Ludwig1, Erik B. Schelbert1, David Schwartzman1, John Gorcsan, III1 1 University of Pittsburgh, Pittsburgh, PA, USA 2 Sundsvall Hospital, Sundsvall, Sweden Best moderated poster prize, ESC , Paris, 2011

METHODS • Consecutive 51 subjects with suspected heart failure who had both CMR and echocardiography • Age 53±15 years • 33 male (65%)

• Standard Echocardiography (Echo) • Echocardiography was performed with either a Vivid 7 (GE Vingmed, Horten, Norway) or an iE33 (Philips Medical Systems, Andover, Mass).

• Strain measurements by Echo • Echocardiographic images were used from the apical 4 and 2 chamber and long axis views, and parasternal short axis view mid-LV level using the papillary muscles as an internal anatomic landmark.

• Strain was analyzed from routine DICOM data sets using a software (2D Cardiac Performance Analysis©, TomTec, Germany).

• A region of interest was manually placed on endocardial and epicardial borders.

• Strain measurements by CMR • CMR images were selected from the digital DICOM data set using the similar LV images to ECHO as an internal anatomic landmark.

• Strain was analyzed from routine digital DICOM data sets using the novel software (2D Cardiac Performance Analysis MR©, TomTec, Germany).

• A region of interest was manually placed on endocardial and epicardial borders.

• Patients Data 22 patients EF<50% and Group1 (n=27): having evidence of either systolic or diastolic function

E/E’≥12

6 ischemic cardiomyopathy 16non- ischemic cardiomyopathy

• • •

1 hypertrophic cardiomyopathy 2 paroxysmal atrial fibrillation 2 non-cardiac disease

• • • • •

5 ischemic heart disease 1 hypertensive heart disease 2 hypertrophic cardiomyopathy 4 paroxysmal atrial fibrillation 12 non-cardiac disease

or

E/E’<12 5 patients EF≥50% and

E/E’≥12 Group2 (n=24): having no evidence of myocardial dysfunction

• •

24 patients EF≥50% and

E/E’<12

METHODS E

E’

• The mitral inflow to annular velocity ratio (E/E’) estimated filling pressures

• Systolic dysfunction was defined as LVEF<50% and diastolic dysfunction was defined as E/E’≥12 • Patients were divided into two groups: • Group1- having evidence of either systolic or diastolic function (E/E´≥12 or LVEF<50%) • Group2- having no evidence of myocardial dysfunction (E/E´<12 and LVEF≥50%)

Longitudinal strain CMR vs.

Echo

Radial strain CMR vs. Echo

Circumferential strain……

RESULTS

â&#x20AC;˘ Imaging data were suitable for quantitative analysis in 100% (51/51) of CMR images and 90% (47/51) of echo images.

Variability of Global Longitudinal Strain Between CMR and ECHO 30

GLS by Echo - CMR (%)

0

GLS by CMR (%)

-10 -20 -30

p < 0.0001 r = 0.68

-40 -50 -50

-40

-30

-20

-10

0

GLS by Echo speckle tracking (%)

20

+1.96 SD 14.1 10 Mean 4.3 0 -5.4 -10 -1.96 SD -20 -30 -60

-50

-40

-30

-20

Mean GLS (%)

-10

0

Variability of Global Radial Strain Between CMR and ECHO 30

GRS by Echo - CMR (%)

50

GRS by CMR (%)

40 30 20

p < 0.05 r = 0.37

10

+1.96 SD 24.7

20 10

Mean

0

0.4

-10 -20

-23.9 -1.96 SD

-30

0 0

10

20

30

40

50

GRS by Echo speckle tracking (%)

0

10

20

30

40

Mean GRS (%)

50

60

Variability of Global Circumferential Strain Between CMR and Echo 30

GCS by Echo - CMR (%)

0

GCS by CMR (%)

-10 -20 -30

p < 0.0001 r = 0.85

-40 -50 -50

-40

-30

-20

-10

0

GCS by Echo speckle tracking (%)

20 +1.96 SD 10 12.5 0

Mean 0.2

-10 -12.2 -1.96 SD -20 -30 -60

-50

-40

-30

-20

Mean GCS (%)

-10

0

Comparison Between the Groups Group1 (n=27)

Group2 (n=24)

P

57±14

50±15

0.1

19 (70%)

14 (58%)

0.5

EF, %

38±17

62±6

<0.001

E/E’

14±5

8±2

<0.001

Global Longitudinal Strain

-10.7±4.2

-16.7±3.6

<0.001

Global Radial Strain

17.4±11.3

29.5±16.7

0.005

Global Circumferential Strain

-14.7±8.0

-27.1±8.2

<0.001

Global Longitudinal Strain

-13.8±5.8

-22.2±3.8

<0.001

Global Radial Strain

16.9±9.1

27.7±14.6

0.003

-13.0±6.1

-27.7±6.1

<0.001

Age, yrs Gender (Male), n (%)

Echo

Cardiac MR

Global Circumferential Strain

ROC Analyses of GLS, GRS and GCS for Predicting Myocardial Dysfunction by Echo and CMR

40

Cut off: -13.3% Sensitivity: 79% Specificity: 83%

20 0

20

40

60

80

60

Echo-GRS AUC 0.77

40

Cut off: 20.4% Sensitivity: 73% Specificity: 77%

20 0 0

100

100-Specificity (%)

100

20

40

60

80

60

CMR-GLS AUC 0.88

40

Cut off: -16.3% Sensitivity: 71% Specificity: 100%

20 0 0

20

40

60

80

100

100-Specificity (%)

80 60

Echo-GCS AUC 0.85

40

Cut off: -16.4% Sensitivity: 69% Specificity: 96%

20 0

0

100

100-Specificity (%)

100

80

Sensitivity (%)

Echo-GLS AUC 0.88

80

20

40

60

80

100

100-Specificity (%)

100

80 60

CMR-GRS AUC 0.76

40

Cut off: 15.7% Sensitivity: 56% Specificity: 88%

20 0 0

20

40

60

80

100

100-Specificity (%)

Sensitivity (%)

Sensitivity (%)

60

Sensitivity (%)

Sensitivity (%)

80

0

Sensitivity (%)

100

100

100

80 60

CMR-GCS AUC 0.96

40

Cut off: -18.4% Sensitivity: 88% Specificity: 100%

20 0 0

20

40

60

80

100

100-Specificity (%)

CONCLUSIONS â&#x20AC;˘ GCS appears to be the most sensitive non-invasive method to detect either systolic or diastolic myocardial dysfunction in patients with suspected HF, and has promise for future clinical applications.

Ejection fraction (>55% normal.

2D Echo, 3D Echo, CMR) Global strain ( >18% normal) Validation studies Normative data (multicenter, multi ethnic)  Prognostic values made Left ventricle

easy!!

•

Complex geometry

•

Imaging problem (technical)

•

No universal validation data

•

Some prognostic data, not as much as in LV

•

Quite under studied

Right ventricle? Not so easy

Right and left ventricle: macro anatomy

Right ventricular ejection fraction (Kwuat SM, Circ 2011)

Age and gender issues in right ventricular mass Kawut SM, et al Circulation 2011;123:2542-2551

• Sundsvall “Normal” population ( N= 36): Soft wares: Tomtec (Germany), Echopac ( Norway)

Velocity vector imaging ( VVI): A normal RV (left) and a normal LV ( right)

Right atrial strain: example of an acceptable strain

VVI of right atrium (a normal RAâ&#x20AC;&#x201D;left) and an abnormal RA ( right)

TAPSE, mm. Shapiro Wilk P = 0.4

RA AEF%. Shapiro Wilk P = 0.9

Echo-PASP, mmHg. Shapiro Wilk P = 0.00005 RV basal %, Shapiro Wilk P = 0.05

Basic characteristics of the Sundsvall â&#x20AC;&#x153;normalâ&#x20AC;? population (N= 36)

Normal values: RV, RA mechanics, volumes; Sundsvall population.

Association between RA reservoir strain and RV global strain RV global strain

40 35 30 25 20 15 10

R=0.6; R=0.6;RR22=0.3;p<0.001 =0.3;p<0.001

5 0 0

10

20 30 40 RA reservoir strain

50

60

TAPSE,mm vs. RA AEF%

R=0.4; R=0.4;RR22=0.2;p<0.01 =0.2;p<0.01

Comparison Sundsvall “normal” vs. NUS Pulmonary hypertension Visare Norr Project 1 B: Regional collaboration

Unpaired t test normal control vs. pulmonary arterial hypertension Variables

Mean Normal

SD Normal

Mean PAH

SD PAH

p

N= Normal

N= PAH

Age

56.21053

17.04432

64.35714

11.66893

0.057630

19

28

RAEF%

69.31579

10.65652

49.95652

18.03652

0.000186

19

23

RA S%

66.15789

34.56116

36.17391

21.48710

0.001382

19

23

RV EF%

58.10526

10.98936

37.31818

13.87147

0.000006

19

22

RV BS%

29.10526

14.33293

25.04000

12.81757

0.327700

19

25

RV mid S%

24.63158

9.52896

13.12000

8.57477

0.000134

19

25

RV apical S%

19.10526

10.08792

9.64000

8.18983

0.001344

19

25

RVS% average

24.28070

6.63908

14.22619

8.21023

0.000058

19

28

TAPSE, mm

23.10526

2.33083

18.90909

4.36931

0.001798

19

11

LVEF %

61.73684

6.30557

55.86667

7.67991

0.019995

19

15

7.89474

2.13163

8.53333

1.84649

0.364976

19

15

25.36842

4.80983

59.61538

28.85174

0.000017

19

13

14

2

23

14

0.007

19

11

E/E´ Echo PASP, mmHg RA area, cm2

ROC data showing relative discriminatory power of the right heart volumes and mechanics: Normal vs. PAH

S c a tte rp lo t: R A S S vi

v s. S v i

(C a se w ise M D d e l e ti o n )

= 5 2 .0 1 9 + .5 2 3 7 6 * R A S C o rre l a ti o n : r = .5 8 6 0 6

X : R A S N = 22 M e a n = 3 5 .5 4 5 4 5 5 S td .D v. = 2 1 .7 7 5 3 1 9 M a x. = 8 9 .0 0 0 0 0 0 M in . = 3 .0 0 0 0 0 0 Y : S N M S M M

8 4

vi = 22 e a n = 7 0 .6 3 6 3 6 4 td .D v. = 1 9 .4 6 0 6 9 4 a x . = 1 0 8 .0 0 0 0 0 0 in . = 4 3 .0 0 0 0 0 0

0 120 Stroke volume (indexed)

110 100 90 80 70 60 50

P= 0.02

40 30 -2 0

0

20

40

60

R i g h t a tri a l stra i n %

80

100

120

0

4 8 0 .9 5 C o n f.In t.

S c a tte rp l o t o f R A P i a g a i n st R A S B la d 1 in U m e 책 D a ta 2 6 v *2 8 c R A P i = 1 2 .6 4 8 4 -0 .1 1 1 6 * x ; 0 .9 5 C o n f.In t.

20

Right atrial pressure, mmHg (indexed)

18 16 14

P= 0.03

12 10 8 6 4 2 0 -1 0

0

10

20

30

40

50

R i g h t a tri a l stra i n %

60

70

80

90

100

1. The data show importance of evaluation of mechanics and volumetric functions of the right atrium and right ventricle in IPAH

2. There is a positive and significant correlation between right atrial strain and stroke volume

3. A significant negative correlation was found between right atrial strain and right ventricular systolic pressure.

4. Echo-Doppler estimation of right ventricular systolic pressure is quite reliable to separate the normal from IPAH subjects.

Conclusion Ume책 data base registry

Strucutural Remodeling of Left Atrium Electro-anatomical mapping of the left atrium

Left atrial fibrosis and strain %

â&#x20AC;˘ Spatial anisotropy in left atrial (LA) tissue has been suggested as a key pre-requisite for atrial arrhythmias â&#x20AC;˘ However it is not known how anisotropy of LA S% could predict risk of stroke vis a vis indexed LA volume

Methods • 99 non-consecutive patients • Original database • 31 controls • Patients with SINUS rhythm: CONTROLS • Most were in-patients • Sundsvalls Hospital, Sweden • Most of the patients underwent routine echocardiography on an IE 33 Apparatus (Philips) during 2008 • Post processing done on Xcelera SW (Philips)

Speckle Tracking Echocardiography • Out of the entire database, images of 77 patients were feasible for left atrial (4C, 2C projections) longitudinal strain (S, %) measurements • Novel software (2D CPA, TomTec, Munich, Germany) used to compute LA longitudinal strain • LA emptying fraction (%) caluclated using the same software • ROC analyses were performed to assess the role of LA S% for prediciting CHADS score ≥2 contra the LA volume-indexed to BSA

LA Dynamics by Speckle Tracking Control

AF

Longitudinal Strain Control

Longitudinal Velocity Control

ESR

SSR AF

ESR

AF

SSR

Univariate and Multivariable Predictors of CHADS2 Score ≥2 Univariate Analysis Variable

Odds Ratio

95% CI

Multivariable Analysis P Value

Odds Ratio

95% CI

P Value

LVEF

0.89

0.83 to 0.95

0.001

–

–

–

E/E´

1.18

1.00 to 1.40

0.046

–

–

–

PASP

1.05

1.00 to 1.10

0.05

–

–

–

LA Min. vol

1.02

1.00 to 1.04

0.004

–

–

–

TAPSE

0.90

0.80 to 1.01

0.09

–

–

–

Global LA S%

0.91

0.86 to 0.96

0.0004

0.82

0.69 to 0.97

0.026

SD, Global S%

0.89

0.82 to 0.96

0.004

–

–

–

ROC Analysis for Predicting CHADS2 â&#x2030;Ľ 2 100

Global LS%

LA volume (indexed)

Sensitivity

80 60

GLS% <21% Sensitivity 89% Specificity 77%

40 P = 0.017

20 0 0

20

Global LS% LA volume (indexed)

40 60 100-Specificity

80

100

AUC

SEa

95% CIb

0.79 0.63

0.059 0.073

0.67 to 0.88 0.50 to 0.74

a

DeLong et al., 1988; bBinomial exact

Conclusion from our AFIB study • LA strain provides incremental prognostic information in patients with AFIB • LA strain is feasible, though no dedicated SW is available yet • LA strain is superior to LAVI as a marker of disease progression Saha, Sengupta et al, JASE 2010

Right Atrial Booster Strain During An Index Beat Is The Strongest Predictor Of Maintenance Of Sinus Rhythm 1 Year Post Cardioversion In Subjects With Paroxysmal Atrial Fibrillation Author Block: Samir K. Saha, Malini Govindan, Anatoli Kiotsekoglou, John Camm, Saint George ´s University, London, United Kingdom, Sundsvalls Hospital, Sundsvall, Sweden

ACC 2013, San Francisco

Identifying the index beat

Index beat

Govindan, Kiotsekoglou, Saha, Camm et al, JASE 2011

Index beat vs. avg of 17 beats for LA volumes, and EI

Govindan, Kiotsekoglou, Saha, Camm et al, JASE 2011

Right atrial strain tracking (left), right atrial strain curve (right) Reservoir strain Conduit strain

Booster strain

2D speckle tracking of RV ( left), RV strain profile ( right)

Background: Background: Atrial Atrial fibrillation fibrillation isis the the commonest commonest form form of of arrhythmia arrhythmia affecting affecting millions millions of of people. people.

We We sought sought to to study study whether whether advanced advanced echocardiographic echocardiographic imaging, imaging, using using 2D 2D speckle speckle tracking tracking (2DSTE), (2DSTE), of of the the right right atrium atrium (RA) (RA) & & right right ventricle ventricle (RV) (RV) could could predict predict recurrence recurrence of of AF AF 11- year year post post successful successful cardioversion, cardioversion, since since right right sided sided heart heart has has not not been been studied studied non-invasively non-invasively in in AF AF

Results Results 1: 1: Of Of the the 30 30 patients patients 25 25 were were available available for for follow follow up up 2DSTE. 2DSTE. 15 15 patients patients were were in in SR SR and and 10 10 continued continued to to have have AF. AF. Patients Patients with with SR SR had had significantly significantly greater greater RV RV basal basal (28±6 (28±6 vs. vs. 22± 22± 5), 5), mid mid (26± (26± 66 vs. vs. 20± 20± 5), 5), apical apical S% S% (24± (24± 44 vs. vs. 17 17 ±± 5) 5) (all (all p=0.01). p=0.01).

RA RA reservoir reservoir && RA RA booster booster S% S% were were also also greater greater in in SR SR compared compared with with AF AF (( 28±9 28±9 vs.16± vs.16± 44 and and 10 10 ±3 ±3 vs. vs. 2± 2± 0.8 0.8 respectively; respectively; all all pp <0.0001). <0.0001).

Well maintained RA booster strain in a pat with restored SR ( left), and in a pat with contd AF (right)

Odds of AF recurrance 1 year post cardioversion

LVEF%

E/Eâ&#x20AC;&#x2122;

RA booster S%

Conclusion: Conclusion: Use Use of of index index beat beat to to quantify quantify RA, RA, RV RV mechanics mechanics in in PxAF PxAF isis feasible. feasible. RV RV S% S% was was significantly significantly lower lower in in AF AF but but the the RA RA booster booster S% S% remained remained the the strongest strongest predictor predictor of of maintenance maintenance of of SR SR 11 -year -year post post cardioversion. cardioversion.

Whether Whether altered altered RA RA mechanics mechanics detected detected by by 2DSTE 2DSTE could could act act as as aa substrate substrate responsible responsible for for perpetuation perpetuation of of AF AF remains remains to to be be studied. studied.

General Conclusion â&#x20AC;˘ The modern post processing of digitized images offline allows comprehensive mechanical information of the cardiac chambers in various clinical conditions â&#x20AC;˘ Strain imaging helps to better understand the pathophysiology and natural history of many cardiac illnesses.

Thank you