IMAGERIE DE DEFORMATION DE LA RECHERCHE A LA PRATIQUE Damien Coisne Http://www.coeurplus.fr JCP 19 Sep 2009

" Pubmed search : 2 ans" tissue velocity imaging =621 tissue velocity imaging heart =303 strain echo imaging =48 strain echo imaging heart =14 JCP 19 Sep 2009

L’imagerie de déformation Les différentes méthodes d’acquisition: TVI, Speckle trcking Les valeurs normales, la reproductibilité La fonction systolique globale longitudinale: GLS/AFI Strain et la viabilité, IDM transmural JCP 19 Sep 2009

Imagerie de déformation TVI 2D Speckle tracking JCP 19 Sep 2009 4 4

Imagerie de déformation Sur base de champs de vitesse TVI S E A JCP 19 Sep 2009 5 5

De la vitesse au déplacement: Intégration fn du temps. (cm/s -- cm) Time integral

Déformation sur base de TVI Grande sensibilité aux variations rapides du fait de la haute cadence d’analyse de la vitesse. Plus adapté au Strain Rate (dérivée temporelle de la déformation) Volume d’échantillonnage relativement faible. VD, paroi auriculaire, zones focales distales

Sur base de suivi de particules: Speckle Tracking JCP 19 Sep 2009 8 8

Déformation sur base de Speckle Tracking Etude directe de la déformation, pas d’intégration de la vitesse. Nécessité de cadence d’image minimale > 60i/s + Résolution spatiale Echogénicité. Adapté au zones proximales. Faible variabilité sauf pour strain radial ( parallèle à l’incidence des US)

Strain. Paramètre de fonction systolique globale STRAIN ET STRAIN RATE Strain. Paramètre de fonction systolique globale Strain rate. Relation étroite à l’inotropisme JCP 19 Sep 2009 10 10

En pratique 2D ST JCP 19 Sep 2009

Mini 50 I/s Angle d’exploration Résolution spatiale Harmonique JCP 19 Sep 2009

FAo Q OM FM OAo Timing valvulaires JCP 19 Sep 2009

En pratique le Strain longitudinal

Global strain longitudinal: - 13.5 %

Strain rate: -0.72

Strain circonférentiel et radial Accès à la déformation radial et circonférentielle

Résolution spatiale des zones lat et septales!!! -65% Radial Circ -22%

Global longitudinal Strain FEVg est un paramètre incontournable dans la prise de décision quotidienne en cardiologie. La FEVG en échographie (et ailleurs !!!) souffre d’imperfection liées à la méthode de mesure. GLS, paramètre particulièrement reproductible, cherche à apporter une information supplémentaire à celle de la FEVG. JCP 19 Sep 2009 22 22

GLS GLS et FEVG GLS et sportifs GLS et ins cardiaque GLS et valvulopathie

JCP 19 Sep 2009 24 24

Faisabilité Feasibility of strain measurements. Tracking quality 3 was obtained in 3,067 segments and 192 patients (79%). Tracking was best in the septum and inferior wall and worst in the anterolateral walls, especially in the apex. Qualité du strain Qualité: 1 optimal, 3 non analysable JCP 19 Sep 2009 25 25

GLS 16 segments 26

ROC analysis: LV global strain vs. LVEF Detection large MI >22% Comparison of left ventricular global strain and left ventricular ejection fraction as determinants of left ventricular injury in patients with acute myocardial infarction B. Sjolie1, S. Orn2, B. Grenne1, T. Vartdal3, O. Smiseth3, T. Edvardsen3 Objectif: Evaluer la valeur du GLS dans l’évaluation de l’étendue de la nécrose et le pronostic. Comparée à la FEVg N: 42, IDM thrombolysés, GLS: moyenne de SL/16 (AFI) ROC analysis: LV global strain vs. LVEF Detection large MI >22% Time-point   AUC   Sens (%)   Spec (%)   Cut-off value (%) Acute GLS 90 88 83 -16,5 LVEF 75 88 60 52 Discharge GLS 95 88 94 -16,0 LVEF 90 88 74 51 GLS plus reproductible, meilleure corrélation entre GLS et la taille de l’idm (IRM)

AFI: automated function imaging Relation Between Global Left Ventricular Longitudinal Strain Assessed with Novel Automated Function Imaging and Biplane Left Ventricular Ejection Fraction in Patients with Coronary Artery Disease Delgado V JASE 2008 AFI: automated function imaging Méthode automatique de calcul du GLS Basé sur 3 incidences apicales Moyenne des valeurs de tous les segments analysables Objective: Automated function imaging (AFI) is a novel algorithm based on speckle-tracking imaging that can be used for assessment of global longitudinal strain of the left ventricle. The purpose of this study was to evaluate the relation between global longitudinal peak systolic strain average (GLPSS Avg) assessed by AFI and left ventricular ejection fraction (LVEF). Methods: The study population consisted of 222 consecutive patients with coronary artery disease (99 patients with acute ST-segment elevation myocardial infarction [STEMI] and 123 patients with advanced ischemic heart failure) and 20 age-matched controls. LVEF was calculated by Simpson’s rule. The GLPSS Avg was obtained by AFI. Results: In the overall study group (65
10 years, 77% were men), mean GLPSS Avg was 11.1%
4.8% and mean LVEF was 37%
14%. Linear regression analysis showed a good correlation between GLPSS Avg and biplane LVEF for the overall study population (r  0.83; P  .001). However, in patients with STEMI or heart failure the correlations were less strong (r  0.42 and r  0.62, both P  .001). Conclusion: Systolic global longitudinal strain assessed by AFI was linearly related to biplane LVEF. In patients with STEMI or heart failure, less strong correlations were observed, suggesting that these 2 parameters reflect different aspects of systolic left ventricular function. (J Am Soc Echocardiogr 2008;21:1244-1250.) JCP 19 Sep 2009 28 28

Cas témoin GLS (6seg) : - 18.9 % 29

Effet dobutamine : cas clinique GLS (6)=-15.6% GLS (6)=-20.8% 30

N= 220, 20 témoins, 99 IDM, 123 ins card sévère Méthode . GLS par AFI Relation Between Global Left Ventricular Longitudinal Strain Assessed with Novel Automated Function Imaging and Biplane Left Ventricular Ejection Fraction in Patients with Coronary Artery Disease Delgado V JASE 2008 N= 220, 20 témoins, 99 IDM, 123 ins card sévère Méthode . GLS par AFI Objective: Automated function imaging (AFI) is a novel algorithm based on speckle-tracking imaging that can be used for assessment of global longitudinal strain of the left ventricle. The purpose of this study was to evaluate the relation between global longitudinal peak systolic strain average (GLPSS Avg) assessed by AFI and left ventricular ejection fraction (LVEF). Methods: The study population consisted of 222 consecutive patients with coronary artery disease (99 patients with acute ST-segment elevation myocardial infarction [STEMI] and 123 patients with advanced ischemic heart failure) and 20 age-matched controls. LVEF was calculated by Simpson’s rule. The GLPSS Avg was obtained by AFI. Results: In the overall study group (65
10 years, 77% were men), mean GLPSS Avg was 11.1%
4.8% and mean LVEF was 37%
14%. Linear regression analysis showed a good correlation between GLPSS Avg and biplane LVEF for the overall study population (r  0.83; P  .001). However, in patients with STEMI or heart failure the correlations were less strong (r  0.42 and r  0.62, both P  .001). Conclusion: Systolic global longitudinal strain assessed by AFI was linearly related to biplane LVEF. In patients with STEMI or heart failure, less strong correlations were observed, suggesting that these 2 parameters reflect different aspects of systolic left ventricular function. (J Am Soc Echocardiogr 2008;21:1244-1250.) JCP 19 Sep 2009 31 31

Pseudo AFI: GLS sur 13 segments ( et 4 cav) An Ultrasound Speckle Tracking (Two-Dimensional Strain) Analysis ofMyocardial Deformation in Professional Soccer Players Compared With Healthy Subjects Hypertrophic Cardiomyopathy 29 PSP, 17 control, Pseudo AFI: GLS sur 13 segments ( et 4 cav) GLS plus faible, « compensé » par radial et circ plus élevé V Richand Am J Cardiol 2007;100:128 –132 JCP 19 Sep 2009

GLS et Ins cardiaque

GLS et insuffisance cardiaque Elément pronostique? We sought to evaluate whether global 2-dimensional (2D) strain offers additional benefit over left ventricular ejection fraction (LVEF) to predict clinical events in heart failure. Background Although 2D strain based on speckle tracking has been proposed as a simple and reproducible tool to detect systolic dysfunction, the relationship of 2D strain and prognosis has not been studied. Methods Two hundred one patients (age 63 11 years, 34% female, LVEF 34 13%) hospitalized for acute heart failure underwent clinical evaluation and conventional and tissue Doppler echocardiography. Using dedicated software, we measured the global longitudinal strain (GLS) in apical 4- and 2-chamber views and the global circumferential strain (GCS) in a parasternal short-axis view. Cardiac events were defined as readmission for heart failure or cardiac death. Results There were 23.4% clinical events during 39 17 months of follow-up. In univariate analysis, age, left atrial volume, left ventricular volume, LVEF, ratio of early transmitral flow to early diastolic annular velocity (E/e=), and both GLS and GCS were predictive of cardiac events. In multivariate Cox models, age (hazard ratio [HR]: 1.06, 95% confidence interval [CI]: 1.01 to 1.10, p 0.017) and GCS (HR: 1.15, 95% CI: 1.04 to 1.28; p 0.006) were independently associated with cardiac events. By Cox proportional hazards model, the addition of GCS markedly improved the prognostic utility of a model containing ejection fraction, E/e=, and GLS. Conclusions GCS is a powerful predictor of cardiac events and appears to be a better parameter than ejection fraction in patients with acute heart failure. ( Y Cho, T Marwick .J Am Coll Cardiol 2009;54:618–24) JCP 19 Sep 2009 34 34

GLS et insuffisance cardiaque Elément pronostique? We sought to evaluate whether global 2-dimensional (2D) strain offers additional benefit over left ventricular ejection fraction (LVEF) to predict clinical events in heart failure. Background Although 2D strain based on speckle tracking has been proposed as a simple and reproducible tool to detect systolic dysfunction, the relationship of 2D strain and prognosis has not been studied. Methods Two hundred one patients (age 63 11 years, 34% female, LVEF 34 13%) hospitalized for acute heart failure underwent clinical evaluation and conventional and tissue Doppler echocardiography. Using dedicated software, we measured the global longitudinal strain (GLS) in apical 4- and 2-chamber views and the global circumferential strain (GCS) in a parasternal short-axis view. Cardiac events were defined as readmission for heart failure or cardiac death. Results There were 23.4% clinical events during 39 17 months of follow-up. In univariate analysis, age, left atrial volume, left ventricular volume, LVEF, ratio of early transmitral flow to early diastolic annular velocity (E/e=), and both GLS and GCS were predictive of cardiac events. In multivariate Cox models, age (hazard ratio [HR]: 1.06, 95% confidence interval [CI]: 1.01 to 1.10, p 0.017) and GCS (HR: 1.15, 95% CI: 1.04 to 1.28; p 0.006) were independently associated with cardiac events. By Cox proportional hazards model, the addition of GCS markedly improved the prognostic utility of a model containing ejection fraction, E/e=, and GLS. Conclusions GCS is a powerful predictor of cardiac events and appears to be a better parameter than ejection fraction in patients with acute heart failure. ( Altération de la fn long est plus précoce l’altération de la fonction circ plus en relation avec le pronostic Y Cho, T Marwick .J Am Coll Cardiol 2009;54:618–24) JCP 19 Sep 2009 35 35

GLS et IM

Importance of Left Ventricular Longitudinal Function and Functional Reserve in Patients With Degenerative Mitral Regurgitation: Assessment by Two-Dimensional Speckle Tracking Lancelotti P JASE Dec 2009 Cur off Value D GLS;1.8%

Cas clinique Patient âgé de 63 ans ayant présenté une décompensation cardiaque d’origine indéterminée il y a 6 mois Bilan écho . IM sévère , DTS à 45 et FEVG à 52% Revu 3 mois après . IM grade2 , SOR à 0.19, FR<30%, VG; 58/34, FEVG 53%, Paps à 35 mmHg. pauci symptomatique coro normale.. Echo à l’exercice. 75 watts, pas de dyspnée, SOR 0.19 à 0.39 cm2, Paps 35 à 57 mmHg, JCP 19 Sep 2009

GLS et RAO JCP 19 Sep 2009

Anthony DeMaria, Raymond Roudaut Impact of impaired myocardial deformations on exercise tolerance prognosis in patients with asymptomatic aortic stenosis Stephane Lafitte, Matthieu Perlant, Patricia Reant, Karim Serri, Herve Douard, Anthony DeMaria, Raymond Roudaut 65 Rao serrés asymptomatiques vs. témoins (FEVG=64%) Age moyen 70 ans Repos: GLS : -17.8 vs. -21.1% segment basal: -12.4 vs -18.4% Gradient base apex Pas de modification des strain circ et rad JCP 19 Sep 2009

Anthony DeMaria, Raymond Roudaut Impact of impaired myocardial deformations on exercise tolerance prognosis in patients with asymptomatic aortic stenosis Stephane Lafitte, Matthieu Perlant, Patricia Reant, Karim Serri, Herve Douard, Anthony DeMaria, Raymond Roudaut Rao intolérants effort: GLS repos: -14.7 vs. -19.3% basal: -10.7 vs -14.4%) (p< 0.05) Prédiction intolérance effort: GLS global -18% Se 68% Sp 75% basal -13% Se 77% Sp 83% Aims As assessed by tissue Doppler velocities, longitudinal contraction is commonly altered at an earlier stage than radial contraction in patients with severe aortic stenosis (AS). However, its relationship to exercise tolerance or to prognosis has not been clearly established. By using two-dimensional (2D) echo- cardiographic strain, we sought to evaluate values of deformation components in the setting of severe AS to correlate these values with exercise tolerance with patients’ outcome. Methods results Sixty-five asymptomatic patients with severe AS (aortic valve area ,1cm2 ) were studied by echocardiography exercise treadmill were compared with controls. Conventional echographic parameters as well as longitudinal, radial, circumferential deformations by 2D strain were measured at rest. During exercise treadmill, maximum tolerated workload, maximum heart rate, blood pressure, EKG ST variations were recorded. Patients were then followed during 12 months. Compared with controls, despite similar ejection fractions, AS patients presented with a significantly lower global longitudinal strain (GLS) (217.8+3.5 vs. 221.1+1.8%, P , 0.05) more pro- nounced in the basal segments (BLS) (212.4+2.9 vs. 218.4+2.5%, P , 0.05). No difference was observed in terms of radial or circumferential strains. In a subgroup of AS patients with abnormal response to exercise, GLS BLS were significantly lower (214.7+5.1 vs. 219.3+4.0% 210.7+2.5 vs. 214.4+2.1%, P , 0.05). With cut-offs of 218 213%, GLS BLS were able to determine an inadequate exercise response with a sensitivity specificity of 68 75% (AUC 0.77), 77 83% (AUC 0.81), respectively. Finally, patients with a basal strain below 213% pre- sented with more cardiac events in the follow-up. Conclusion In asymptomatic patients with severe AS, impaired longitudinal contraction assessed by 2D strain is associated with abnormal exercise response with an increased risk of cardiac events during follow-up. JCP 19 Sep 2009

Anthony DeMaria, Raymond Roudaut Impact of impaired myocardial deformations on exercise tolerance prognosis in patients with asymptomatic aortic stenosis Stephane Lafitte, Matthieu Perlant, Patricia Reant, Karim Serri, Herve Douard, Anthony DeMaria, Raymond Roudaut ↑°évènements cardiovasculaires JCP 19 Sep 2009

Réserve contractile positive JCP 19 Sep 2009

Evolution du Strain longitudinal Long strain global, basal= -9% Long strain global, dobutamine= -12.1% JCP 19 Sep 2009

Evolution de strain circonférentiel Circ strain global, basal= -11.25% Circ strain global, dobutamine= -13.5% JCP 19 Sep 2009

Dysfonction ventriculaire chronique et viabilité Estimation par Echo JCP 19 Sep 2009

Myocardial Deformation Imaging Based on Ultrasonic Pixel Tracking to Identify Reversible Myocardial Dysfunction Michael Becker, MD,* J Am Coll Cardiol 2008;51:1473–81 2D Strain Contrast-enhanced magnetic resonance imaging (ceMRI) image (left), color-coded short-axis radial strain images at end-systole (middle), radial strain tracings (right) for 1 cardiac cycle obtained from the same short-axis view in a patient with severe hypokinesia of the posterolateral wall. Contrast-enhanced magnetic resonance imaging indicates nontransmural infarction with less than 25% hyperenhancement. The 6 tracings for the 6 evaluated segments within the circumference demonstrate reduced peak negative systolic radial strain of the posterolateral wall. The segment demonstrated functional recovery after successful interventional revascularization of an occluded left circumflex artery. Rehaussement tardif: 5 niveaux Radial peak systolic strain 74 patients CMI, , MRI vs 2D strain, revasc: pontage (21), Dilat (34) JCP 19 Sep 2009

Myocardial Deformation Imaging Based on Ultrasonic Pixel Tracking to Identify Reversible Myocardial Dysfunction Michael Becker, MD,* J Am Coll Cardiol 2008;51:1473–81 Improvement of segmental function 22.9% 17.2% 11.4% 5.6% 0/ 25 / 50 / 75 / 100 JCP 19 Sep 2009

LHE > 50% related to peak circ strain < -12% Strain Mapping by Speckle Tracking Echocardiography: A Novel Approach for Detailed Quantification of Infarct Transmurality Irregularities After STEMI Thomas M. Helle-Valle ACC 2009 3 SAX views, basal mid apical: 12 segments per view LHE > 50% related to peak circ strain < -12% Rotation max located on the border of the infarct zone

Réponse biphasique +++ JCP 19 Sep 2009

Strain circ basal , segment med VG paroi inf: 12.8 % JCP 19 Sep 2009

Strain circ paroi inf : 18.7, Strain moyen à 21.5% JCP 19 Sep 2009

Conclusion L’imagerie de déformation entre dans sa phase de maturité. L’apport du 2D Strain, est important car dans bon nombres de situations, la reproductibilité de la méthode est meilleure. Outil plus robuste mais laissant quelques indications au Strain TVI. La GLS et AFI sont deux méthodes semi automatiques ont acquis leur légitimité dans bon nombre de situations cliniques. Le seuil pathologique pour le GLS est à considérer en fonction de la pathologie examinée. En ce qui concerne la pathologie ischémique,analyse régionale, la Strain circonférentiel semble être prometteur mais demande confirmation Http://www.coeurplus.fr JCP 19 Sep 2009