Korean Circ J.  2019 Oct;49(10):908-931. 10.4070/kcj.2019.0200.

Two-dimensional Echocardiographic Assessment of Myocardial Strain: Important Echocardiographic Parameter Readily Useful in Clinical Field

Affiliations
  • 1Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea. jaehpark@cnu.ac.kr

Abstract

Echocardiography is the first and is the most-available imaging modality for many cardiovascular diseases, and echocardiographic parameters can give much important information for diagnosis, treatment, and prognostic evaluations. Left ventricular ejection fraction (LVEF) is the most commonly used echocardiographic parameter for left ventricular (LV) systolic function. Although LVEF is used routinely in daily practice, it is calculated from volumetric change without representing true myocardial properties. Recently, strain echocardiography has been used to objectively measure myocardial deformation. Myocardial strain can give accurate information about intrinsic myocardial function, and it can be used to detect early-stage cardiovascular diseases, monitor myocardial changes with specific therapies, differentiate cardiomyopathies, and predict the prognosis of several cardiovascular diseases. Although strain echocardiography has been applied to measure the right ventricle and left atrium, in addition to analyzing the LV, many cardiologists who are not imaging specialists are unaware of its clinical use and importance. Therefore, this review describes the measurement and clinical utility of 2-dimensional strain analysis in various cardiovascular diseases.

Keyword

Echocardiography, Strain; Prognosis; Diagnosis; Left ventricle; Right ventricle

MeSH Terms

Cardiomyopathies
Cardiovascular Diseases
Diagnosis
Echocardiography*
Heart Atria
Heart Ventricles
Prognosis
Specialization
Stroke Volume

Figure

  • Figure 1 Multidimensional strain measurement analysis by 2DSTE in a healthy individual. Arrows denote the direction of movements. Myocardial shortening shows in the longitudinal (A), circumferential (B), and radial directions (C). Myocardial contraction in the longitudinal and circumferential directions during the systolic period represents a negative strain value, and thickening and lengthening in the radial direction shows a positive strain value. 2DSTE = 2-dimensional strain echocardiography.

  • Figure 2 A demonstration of 3 different algorithms in a healthy individual. (A) EchoPAC PC software (GE Medical Systems, Milwaukee, WI, USA), (B) VVI (Siemens Medical Solutions, Mountain View, CA, USA), and (C) Tomtec software (Image Arena 4.6; TOMTEC Imaging Systems, Munich, Germany) are the 3 most commonly used algorithms in 2-dimensional speckle tracking echocardiography. Note the vendor differences in the measurement of GLS. GLS = global longitudinal strain; VVI = velocity vector imaging.

  • Figure 3 Demonstration of a 2-dimensional strain analysis with GE EchoPAC PC software. After tracing of the endocardial border, the software provides global and regional myocardial strain values automatically in apical 4 chamber (A), apical 2 chamber (B), and apical 3 chamber views (C). The GE EchoPAC algorithm can provide bull's eye maps of regional longitudinal strain values (D).

  • Figure 4 Two-dimensional speckle tracking echocardiography can produce bull's eye maps that show specific ischemia patterns in patients with ischemic heart disease of the LAD (A), the LCX (B), and the RCA (C). LAD = left anterior descending coronary artery; LCX = left circumflex coronary artery; RCA = right coronary artery.

  • Figure 5 The trend of GLS with treatment of HF in a patient with anthracycline- and trastuzumab-induced cardiotoxicity. GLS was −8.3% at initial presentation (A), improved after 3 months (−13.0%, B), and 6 months of HF management (−17.1%, C) (adapted and modified from Jung MH et al.57) with permission). GLS = global longitudinal strain; HF = heart failure.

  • Figure 6 Representative peak longitudinal strain echocardiographic bull's eye maps from patients with various diseases and a healthy person. (A) Healthy. (B) An athlete with compensatory mild left ventricular hypertrophy and a normal strain plot. (C) Cardiac amyloidosis showing severely reduced strain in the basal and midventricular segments with preservation of the apical segments. (D) Hypertensive heart disease with thickened myocardium. (E) Hypertrophic cardiomyopathy involving the whole ventricle. (F) Apical hypertrophic cardiomyopathy, with reduced strain in the apical segments.

  • Figure 7 Typical echocardiography features in a patient with cardiac amyloidosis. Thickened left ventricular wall, up to 14 mm on the conventional echocardiographic study (A). In this representative bull's eye map of longitudinal strain by speckle tracking echocardiography (B), the longitudinal strain of the apex is preserved, in contrast to those of the other midventricular or basal segments, suggesting ‘apical sparing’ or a ‘cherry-on-top’ pattern. GLS = global longitudinal strain.

  • Figure 8 A demonstration of the 2 different methods used to measure RV strain. RVGLS can be measured from the RVGLStotal (A) or from the RVGLSfree wall (B). RV = right ventricular; RVGLS = right ventricular global longitudinal strain.

  • Figure 9 Demonstration of longitudinal strain in the right ventricle of a patient with acute pulmonary embolism before (A) and after treatment (B). Before treatment, midventricular strain (arrows) decreased, as did the RVGLStotal (A). The midventricular strain (arrowheads) and RVGLStotal improved after treatment. RVGLS = right ventricular global longitudinal strain.

  • Figure 10 A left atrial strain analysis using 2DSTE in a healthy adult (A) and an illustration of the 3 phases of LA function (B) with an R-R gating analysis. LA = left atrium; PACS = peak atrial contraction strain; PALS = peak atrial longitudinal strain; 2DSTE = 2-dimensional strain echocardiography.


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