”Principle and Practice of Cardiac

Mechanics for Assessing LV function”

Nina Ajmone Marsan, MD, PhD, FESC
Cardiology Department, Leiden University Medical Center
The Netherlands
 What we use now: LVEF
• Diagnose/Classify heart failure patients: HFPEF vs. HFREF

• Guide treatment:

• Valvular heart disease

• Device therapy

• Revascularization

• Prognosis
White et al. NEJM 1986
What we use now: LVEF
• How accurate is LVEF by echo?

• How reproducible is LVEF?

• How much operator-dependent is LVEF?

• What is the effect of imaging quality and FR?

• How much is it dependent on loading conditions?

• How much it reflects real myocardial contractility??

Improving assessment of LV systolic function

D Refractory
heart failure

Refining diagnosis, medical and

C Heart failure
syndrome
device treatment,
risk stratification
Structural heart disease
B LV remodeling, Previous MI,
Valvular heart disease

A High risk patients

Hypertension, Diabetes, Metabolic syndrome,
Detection of
Atherosclerosis, Obesity subclinical disease

Jessup et al. Circ 2009. ACC/AHA Guidelines

Improve assessment of LV systolic function

New technique should be as much as possible:

• Available and cost- effective
• Easy to use
• Reliable: accurate and reproducible
• Sensitive
• Strain = myocardial deformation normalized for the
original size

• Strain Rate (SR) = rate of myocardial deformation

V1
LV SR = V1 – V2
ΔL ΔL
V2
V1

V2

(+) = Thickening / lengthening

(-) = Thinning / shortening

Stoylen 2011; http://folk.ntnu.no/stoylen/strainrate

 How do we assess myocardial deformation?
Tissue Doppler Imaging
Velocity gradient of two points over a segment with a fixed
distance; spatial derivation and temporal integration are
possible to derive strain and strain rate
Assessment along the ultrasound beam (one dimension)

Excellent temporal resolution and relatively available

Insonation angle dependent

Velocity can be influenced by global heart motion (translation,

rotation), by adjacent region (tethering) and by blood flow
Strain and strain rate are extremely noisy and therefore
operator-dependent
 Speckle tracking analysis
• Fingerprint
Each peace of myocardium
scatters the sound waves in a
unique, irregular speckle pattern.

kernel
Myocardial strain = deformation in 3 directions
Study of cardiac mechanics

Buckberg Circulation 2008

ST analysis: parasternal window

1 longitudinal strain

2 circumferential strain

3 radial strain

Courtesy Dr. B Delamarre, HAGA Hospital, The Hague, The Netherlands

ST analysis: apical window

1 longitudinal strain

2 circumferential strain

3 radial strain

Courtesy Dr. B Delamarre, HAGA Hospital, The Hague, The Netherlands

Radial strain Circumferential strain Longitudinal strain

Tangential
Shortening
shortening

Thickening
ST analysis: GLS
ST analysis: GLS

JASE 2015
 ST analysis: GLS
Open issues:
- Normal ranges
- Differences among vendors
- How to optimize accuracy and reproducibility:
- Image quality
- Frame rate
ST analysis: GLS
ST analysis: GLS Inter-vendor analysis

• Normal heart
• LVH
• Dilated heart
• Different noise level
Acceptable accuracy with relative
error below 10%

Intra-vendor reproducibility below

5%
Good accuracy already with
FpC>30 (50-60 Hz)
By HR >160/min, need for >85 Fps
Stage A of Heart Failure

Hypertension, Diabetes,
Metabolic syndrome, Obesity,
Cardiotoxicity,
Atherosclerosis
 Relationship between myocardial fibrosis
vs. LVEF vs. Global longitundinal strain

T1 time 425 ± 72 ms
LVEF 58 ± 4.6%
Global longitudinal strain -16.1±1.4%

Ng et al. Circ Cardiovasc Imag 2011

Cardiotoxicity: chemotherapy

Hare et al Am Heart J 2009

Stress echocardiography

Ng et al. AHJ 2009

 Stress echocardiography
Rest Low-dose Peak-dose

GLS -13% GLS -15% GLS -11%

Stage B of Heart Failure

Previous MI, valvular

disease, LVH/HCM
Detection of subclinical LV dysfunction in
valvular heart disease

LVEF = 68%
LVESD = 39 mm
GLS: -15%
Detection of subclinical LV dysfunction in
valvular heart disease

Hiemstra et al , submitted
Detection of subclinical LV dysfunction in
valvular heart disease
420 patients with aortic stenosis
LVEF > 50%

Ng et al. Eur H eart J 2011

Strain analysis in HCM

Hiemstra et al, Circuation Cv Img 2017

Stages in the development of HF / Treatment for each stage

Jessup et al. AHA/ACC

Focused Update on Heart Failure JACC 2010
Speckle tracking strain analysis in LV dysfunction:
prognostic value
Speckle tracking strain analysis in LV dysfunction:
LV dyssynchrony
 Strain imaging for myocardial viability
detection

• Clinical goal:

• Identify patients with viable tissue

• With potential to recover function

• To justify increased surgical risk

 Conclusions
“The much needed process of
transforming echocardiography from a
subjective art of image interpretation
to a set of objective diagnostic tools... ”

ASE/EAE Consensus statement on cardiac mechanics 2011