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Exploring the Clinical Feasibility and Reliability of Three-Dimensional Echocardiography for Advanced Quantitative Analysis of Left Ventricular Myocardial Deformation
Full text linkBackground. Assessment of left ventricular (LV) function is a fundamental part of clinical cardiology, holding important diagnostic, prognostic and management implications. The most important advance in LV quantification over the last decade was the development of techniques aimed to quantify tissue motion and deformation from ultrasound images, such as tissue Doppler imaging (DTI) and two-dimensional speckle-tracking echocardiography (2DSTE). More recently, speckle-tracking algorithms have been applied to three-dimensional (3D) volumetric acquisitions of the LV (i.e. referred to as 3D speckle-tracking echocardiography, 3DSTE), making possible to analyze all LV myocardial strain components from the same dataset. At present, 3DSTE technology is a research tool in its infancy of development, and its potential clinical value still remains to be demonstrated. With respect to prior technologies (DTI and 2DSTE), 3DSTE comes with several advantages, but also with new challenges. It is currently unknown if the theoretical benefits of an additional third dimension to study the complex LV mechanics (no more “out-of-plane” motion of speckles, only a single acquisition needed etc) are not actually outweighted by the new technical challenges derived from using a volumetric acquisition of the LV (i.e. lower spatial and temporal resolution of speckles than with 2DSTE).
A major concern of 2DSTE strain is the large intervendor variability of strain measurements provided by various commercially-available software packages. At present, it is unclear if a similar problem may affect also 3DSTE, and to what extent. Furthermore, despite researchers are increasingly employing 3DSTE to study various pathologic conditions, the reference values and normal pattern of LV myocardial strain in healthy adults by 3DSTE, as well as the possible influence of various clinical and technical factors on LV strain values are currently unknown. Finally, the validation process of 3DSTE is difficult due to the lack of adequate three-dimensional gold standard that can be applied noninvasively in human subjects to validate regional LV function in 3D. Therefore, there is a great need for rigorous validation work, methodological and intervendor standardization to be undertaken before its application in clinical settings.
Methods and Results. Project design: single-centre, prospective, observational clinical study, aiming to explore the clinical feasibility and usefulness of LV 3D strain analysis using state-of-the-art commercially available 3DE equipment. The project involves a series of 4 clinical studies.
The aim of the Study #1 was to assess the intervendor consistency and variability of LV 3D strain values between the two 3DSTE equipments commercially available: VividE9 (GE, Vingmed, Horten, Norway) and Artida (Toshiba Medical Systems Corporation, Tokyo, Japan) ultrasound systems. Sixty patients (38 ± 12 years, 64% males) with a wide range of LV end-diastolic volumes and ejection fractions were enrolled. Global longitudinal (3DLɛ), radial (3DRɛ), circumferential (3DCɛ) and area (3DAɛ) strain values were obtained offline using the corresponding proprietary software package. Overall, the intervendor agreement of 3DRɛ, 3DCɛ and 3DAɛ measured with Artida and VividE9 was poor. 3DLɛ showed the closest values between the two platforms (bias = 1.5%, limits of agreement (LOA) from −2.9 to −5.9%, P < 0.05). Artida provided significantly higher values of both 3DCɛ and 3DAɛ than VividE9 (bias = 6.6% for 3DCɛ, 6.0% for 3DAɛ and -24% for 3DRɛ respectively, P < 0.001). All 3D strain components showed good reproducibility (intraclass correlation coefficients: 0.82–0.98), except for 3DRɛ by Artida, which showed only a moderate reproducibility. Therefore, reference values should be identified for each system, and baseline and follow-up data in longitudinal studies should be obtained using the same 3DSTE equipment.
The aim of the Study #2 was to assess the normative values for LV 3D strain in
218 healthy volunteers (age range 18-76, 57% women) by vendor-specific 3DSTE equipment (Vivid E9, 4D AutoLVQ software,). For comparison LV strain was also measured by vendor-specific 2DSTE software and by a vendor-independent 3DSTE software. Feasibility of global 3D strain analysis by 4D AutoLVQ was 89%, lower than 2DLε (95%) and similar to 2DCε (92%). Feasibility of segmental 3DSTE analysis ranged from 46% to 100%. Reference values of 3D strain parameters were identified according to gender and age group. 3DLε decreased, while 3DCε increased with ageing (p<0.001). Men had lower 3DLε, 3DRε, 3DAε and 2DLε than women (p<0.02). At stepwise multivariable linear regression analysis, demographic (age and gender), cardiac (LV size and mass) and technical (image quality and temporal resolution) factors accounted for the variance of LV 3D strain measurements. Since major inter-software differences in LV strain measurements were identified (p<0.001 for all), limits of normality for LV strain analysis by vendor-specific 3DSTE software should not be used interchangeably with those by 2DSTE or vendor-independent 3DSTE softwares.
The aim of the Study #3 was to assess if LV deformation by 3D STE in patients after ST-elevation myocardial infarction (STEMI) could provide an accurate and objective assessment of infarct size and transmurality, in comparison with magnetic resonance with late gadolinium enhancement (LGE-CMR). A total of 77 STEMI patients were enrolled by 2D and 3D echo, and in 46 patients LGE-CMR studies were performed within 24 hours. The relative amount of DE tissue per segment was used to define transmural necrosis (51-100% DE). LV function was assessed from three apical LV 2D views by measuring 2DLε, and from 3D LV full-volume datasets, assessing visual wall motion score (WMS) and measuring 3DLε, 3DCε, 3DAε and 3DRε. Strain parameters were correlated with conventional indices of LV systolic function (LVEF) and infarct size (troponin I, WMSI, infarct size index at LGE-CMR). Despite a good accuracy for 2DLε and 3D strain parameters (AUC=0.81-0.73), visual wall motion assessment by experienced reader on good-quality 3D data sets (AUC=0.87) was found to be superior than strain quantification to predict transmural necrosis at LGE-CMR.
The aims of the Study #4 to describe the LV myocardial mechanics in patients with hypertrophic cardiomyopathy (HCM) using 2DSTE and 3DSTE, and to compare it with the normal deformation pattern in healthy subjects. In 32 HCM pts and 32 age- and gender-matched controls, we analyzed peak global 2DLε and 3DLε, 3DCε, 3DRε, 3DAε. LV ejection fraction (LVEF), LV mass and outflow tract area (LVOTA) were measured by 3D echo. Symptomatic status was defined by NYHA class (II-IV). Although LVEF was similar in pts and controls (64±6% vs 62±4%, p=0.29), LV systolic strain was significantly impaired in pts (p<0.0001), except for 3DCε, which was only marginally lower. In HCM patients, all strain parameters were correlated with LV end-systolic volume (r=0.55 to 0.67), LVEF (r=-0.82 to -0.88) and mass (r=0.33 to 0.56). Symptomatic patients had more impaired 3DAε, 3DRε and 3DCε, but also had more LVOT obstruction and concentric remodelling, and higher E/e'. At ROC curve analysis, 3DAε, 3DRε and 3DCε had a good accuracy to identify symptomatic pts (AUCs 0.72-0.73). 3D LV mass had an inverse correlation with LV longitudinal deformation: r=-0.74 for 2DLε and -0.70 for 3DLε (p<0.001 for both). In HCM with preserved LVEF, the longitudinal strain was significantly reduced, however symptom development is multifactorial and related to the additional impairment of LV deformation in circumferential-radial direction.
Conclusions. This project addressed several issues of of pivotal importance for 3DSTE. It provided a comprehensive analysis of 3DSTE measurement variability (intra- and inter-observer, at test-retest, inter-vendor and inter-software), and reported on the feasibility of 3DSTE in clinical setting and on the comparison with LV strain by 2DSTE. In addition, it is the first to report normal ranges of 3D strain parameters by 3DSTE using both vendor-specific and vendor-independent software packages. Finally, this project presents the added value of 3DSTE in comparison with previous methods for assessing LV function in 2 common pathologic conditions (acute STEMI, as the prototype of regional necrotic transmural injury; and HCM, as the prototype of myocardial disease with impaired longitudinal systolic mechanics despite preserved LVEF). This series of studies contributes with original data to the current scientific evidence-based knowledge on 3DSTE, which is essential for the development and appropriate use of this novel technology
Quantitative analysis of the left ventricle by echocardiography in daily practice: As simple as possible, but not simpler
Full text linkAssessment of left ventricular volumes with echocardiography and cardiac magnetic resonance imaging: real-life evaluation of standard versus new semiautomatic methods
Subclinical Right Ventricular Dysfunction by Strain Analysis; Refining the Targets of Echocardiographic Imaging in Systemic Sclerosis
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The Good, the Bad, and the Ugly of Using Left Ventricular Longitudinal Myocardial Deformation by Speckle-Tracking Echocardiography to Assess Patients after an Acute Myocardial Infarction
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La aurícula izquierda como entidad tridimensional dinámica: consecuencias para la evaluación ecocardiográfica
No full textAssessment of functional tricuspid regurgitation
No full textFunctional tricuspid regurgitation (FTR) is characterized by structurally normal leaflets and is due to the deformation of the valvulo-ventricular complex. While mild FTR is frequent and usually benign, patients with severe FTR may develop progressive ventricular dysfunction and incur increased mortality. Therefore, FTR should not be ignored, should be appropriately diagnosed and quantified by Doppler echocardiography, and should be evaluated for corrective surgical procedures. At present, referral for surgical correction of FTR is often delayed until patients develop intractable heart failure. However, this strategy frequently translates in poor clinical outcome characterized by notable operative mortality and reduced long-term survival. Appropriate patient selection and proper timing for tricuspid valve (TV) repair or replacement are crucial for optimal outcome, but objective criteria for clinical decison-making remain poorly defined. In the present paper, we review the anatomy of the normal TV, the pathophysiology of FTR, the assessment of its severity and functional significance, and propose an algorithm for selecting patients for surgical treatment
Revisit of functional tricuspid regurgitation; Current trends in the diagnosis and management
Full text linkCurrent knowledge of functional tricuspid regurgitation (FTR) as a progressive entity, worsening the prognosis of patients irrespective of its aetiology, has led to renewed interest in the pathophysiology and assessment of FTR. For the proper management of FTR, not only its severity, but also the mechanisms, the mode of leaflet coaptation, the degree of tricuspid annulus enlargement and leaflet tenting, and the haemodynamic consequences for right atrial and right ventricular morphology and function have to be taken into account. A better assessment of the anatomy and function of tricuspid apparatus and tricuspid regurgitation severity should help with the appropriate selection of patients who will benefit from either surgical tricuspid valve repair/replacement or a percutaneous procedure, especially among patients who are to undergo or have undergone primary left-sided valvular surgery. In this article, we review the anatomy, pathophysiology and the use of imaging techniques to assess patients with FTR, as well as the various treatment options for FTR, including emerging transcatheter procedures. The limitations affecting the current approach to FTR patients and the unmet clinical needs for their management have also been discussed
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