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