Disclosures Contemporary Assessment of Cardiac I have nothing to - PDF document

12/17/16 Disclosures Contemporary Assessment of Cardiac I have nothing to disclose Function by Echocardiography Ann Bolger, MD William Watt Kerr Professor of Medicine Systolic function in the echo lab: LV function in context What is the question? What is the EF? Best systolic function matches the LV to the periphery is the heart healthy? is the function normal? Optimizes efficiency over output can the heart cope with what we need to do? Preserves the necessary margin to respond to increased need: Are there clues to a subclinical problem? • Heart rate • Volume change Is EF the parameter of choice? • Incremental pressure Contractility (intrinsic) versus work (output) Decreases the risk of adverse remodeling and long Compensation preserves work in the face of term heart failure impairment 1

12/17/16 Indices of Left Ventricular Systolic Function The Charisma of LVEF Index Sensitive Dependence Dependence 1. It's a number to Inotropic on Preload on Afterload Changes 2. It's easy to measure Ejection ++ ++ +++ Fraction 3. It's based on the LV cavity, which is easy to End Systolic + - +++ see and to think about Volume Preload +++ - - 4. It is based on a common test that is cheap Recruitable (although profitable), harmless and widely Stroke Work available dP/dT ++++ ++ ++ Has it shaped how we think about the LV? Does the body care about LVEF? LVEF ≠ LV function Overall LV systolic function 1. Very dependent on Preload and Afterload Wall motion 2. Not based on accurate volumes or areas Preload (size, pressure), heart rate and 3. Not very sensitive to Contractility thickness 4. Can be misleading in hypertrophy and valve disease Annular motion 5. Not reproducible Flow based assessments Contrast: change greater 10% in 17% of patients compared to non- contrast studies; improves correlation of echo LV volume and EF Stroke volume with MRI Multiple views: 3D LVEF Strain - Doppler and Speckle tracking 2

12/17/16 How to build a ventricle How to build a ventricle Longitudinal fibers Circumferential Fibers LVEF 15% LVEF 30% Neil Ingels, PhD, Palo Alto Research Foundation How to build a ventricle How to build a ventricle Opposing endocardial and epicardial spiral fibers Spiral Fibers equalizes wall stress across endocardium, LVEF 100% midwall, and epicardium (depending on pitch and minimizes net global torsion radius of curvature) 3

12/17/16 How to build a ventricle Subendocardial Subepicardial Opposing Midwall Stroke volume spirals Longitudinal Annular motion Circumferential Pressure End Result: Work distributed through all myocardial layers Good EF Good pressure generation Tissue Doppler Long axis shortening reflected in mitral annular descent correlates with preload recruitable stroke work 4

12/17/16 Myocardial Deformation Strain Imaging Imaging One dimensional strain: Tissue Doppler Imaging Avoids effects of Limitations: translation and Angle dependent tethering single directional component Neighborhood effects Improves regional Strengths: assessment and excellent temporal resolution timing Site specificity Identifies changes Best for structures with primary motion on axis associated with Best applications: ischemia, viability, Mitral and tricuspid annular excursion fibrosis, infiltration Dyssynchrony The concept of Speckle Strain: tracking: Squish and Stretch Strain: Myocardial deformation can occur in any direction in response to contraction or adjacent forces Strain (%) the amount of deformation caused by an applied force Tissue Doppler approaches: ε = ∆ L/L 0 Axial velocity component only = -25% Insensitive to twist or non-axial velocities L 0 L 1 Speckle tracking: L 1 L 0 3 dimensional tissue sample Follow myocardial deformation in 2 dimensions with natural Translational motion that effects both sites will be cancelled acoustic “ Tagging ” out 5

12/17/16 Myocardial deformation Longitudinal Radial Circumferential 123Sonography.com 6

12/17/16 Deformation imaging in CAD Detection: GLS impaired with increasing severity of ischemia Value of > –17% predicts ischemic myocardium with good sensitivity, specificity and accuracy Viability: Radial strain > 17.2% has been reported to predict viability with similar accuracy as CMR. GLS < –13.7% correlates with SPECT viability index post-MI Addition of SR to WMSI improves detection of ischemic myocardium during DSE Prognosis: SR predicts mortality and add incremental value to clinical data and WMSI Pokharel P et al. Clinical applications and prognostic implication of strain and strain rate imaging. Expert Rev Cardiovasc Ther 2015;13(7) 7

12/17/16 Deformation imaging in Cardiac Cardiac Amyloid Amyloid and Dyssynchrony Cardiac Amyloid: Deformation parameters detect myocardial involvement earlier than traditional 2D echocardiography GLS progressively worsens with increasing cardiac involvement Typical apical sparing pattern Impaired left ventricular LS and GLS has been reported to predict all-cause mortality and cardiac transplantation Ventricular Dyssynchrony: Various S and SR imaging-derived parameters are used to assess dyssynchrony to better predict CRT responders Pokharel P et al. Clinical applications and prognostic implication of strain Pokharel P et al. Clinical applications and prognostic implication of strain and strain rate imaging. Expert Rev Cardiovasc Ther 2015;13(7) and strain rate imaging. Expert Rev Cardiovasc Ther 2015;13(7) Dyssynchrony: M-mode No LBBB Dilated Cardiomyopathy with Dyssynchrony Anteroseptal infarction LBBB Pokharel P et al. Clinical applications and prognostic implication of strain and strain rate imaging. Expert Rev Cardiovasc Ther 2015;13(7) 8

12/17/16 Deformation imaging in Pre-CRT Onco-cardiotoxicity, HCM, and CHF Onco-cardiotoxicity: Myocardial deformation parameters are sensitive Global Strain -10% markers of cardiotoxicity Early 10–15% decrease in GLS during chemotherapy predicts cardiotoxicity Cardiomyopathy and HCM: GLS is impaired in fibrotic segments and can serve as Post-CRT surrogate marker of myocardial fibrosis GLS associated with increased cardiac events in HCM CHF: Each SD improvement in GLS was associated with Global Strain -14% 1.62 times greater reduction in mortality than a similar improvement in LVEF GLS and circumferential strain are depressed in HFrEF Pokharel P et al. Clinical applications and prognostic implication of strain and strain rate imaging. Expert Rev Cardiovasc Ther 2015;13(7) Surveillance in Onco-Cardiology: Proposed Algorithm including GLS Plana JC, et al. Eur Heart J Cardiovasc Imaging. 2014 Oct;15(10):1063-1093 9

12/17/16 HRpEF Pokharel P et al. Clinical applications and prognostic implication of strain and strain rate imaging. Expert Rev Cardiovasc Ther 2015;13(7) Deformation imaging in Valvular Disease Aortic Stenosis: GLS worsens with increasing severity of AS GLS predicts morality in AS GLS and peak longitudinal stain and strain rate with DSE predicts mortality in LFLG AS Aortic Insufficiency: GLS and GLS normalized to LVEDV are impaired in AI GLS can return to normal after AVR Mitral Regurgitation: GLS and SR in MR predicts less postoperative decrease in LVEF Pokharel P et al. Clinical applications and prognostic implication of strain and strain rate imaging. Expert Rev Cardiovasc Ther 2015;13(7) 10

12/17/16 2D Strain: Intraobserver Interobserver Variability Variability of Conventional and Strain Parameters Farsalinos KE, et al. REPRODUCIBILITY OF LEFT VENTRICULAR STRAIN Farsalinos KE, et al. REPRODUCIBILITY OF LEFT VENTRICULAR STRAIN Head-to-Head Comparison of Global Longitudinal Head-to-Head Comparison of Global Longitudinal Strain Measurements among Nine Different Vendors Strain Measurements among Nine Different Vendors The EACVI/ASE Inter-Vendor Comparison Study. J Am Soc Echocardiogr 2015;28:1171-81 The EACVI/ASE Inter-Vendor Comparison Study. J Am Soc Echocardiogr 2015;28:1171-81 Deformation Imaging: Limitations Main issues relate to inter-vendor issues! Test-retest performance is good, and better than conventional echo parameters. Proprietary nature of the software and resulting inter- vendor variability creates a lack of reproducibility Major roadblock for routine clinical use of Deformation Imaging. International efforts by professional societies are ongoing to establish norms and procedures to improve utility Pokharel P et al. Clinical applications and prognostic implication of strain and strain rate imaging. Expert Rev Cardiovasc Ther 2015;13(7) 11