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• W2971384104 abstract "HomeCirculation: Cardiovascular ImagingVol. 12, No. 8Global and Regional Longitudinal Strain Assessment in Hypertrophic Cardiomyopathy Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBGlobal and Regional Longitudinal Strain Assessment in Hypertrophic CardiomyopathyStandardization Is Yet to Come Victoria Delgado, MD, PhD and Nina Ajmone Marsan, MD, PhD Victoria DelgadoVictoria Delgado Victoria Delgado, MD, PhD; Department of Cardiology; Leiden University Medical Center; Albinusdreef 2 2300 RC Leiden, the Netherlands Email E-mail Address: [email protected] Department of Cardiology, Leiden University Medical Center; the Netherlands. Search for more papers by this author and Nina Ajmone MarsanNina Ajmone Marsan Department of Cardiology, Leiden University Medical Center; the Netherlands. Search for more papers by this author Originally published15 Aug 2019https://doi.org/10.1161/CIRCIMAGING.119.009586Circulation: Cardiovascular Imaging. 2019;12:e009586See Article by Sperry et alLeft ventricular (LV) global longitudinal strain (GLS) has established as a robust measure of LV systolic function. Various studies have shown that the reproducibility of LV GLS measurement is superior to that of 2-dimensional LV ejection fraction measurement.1,2 In addition, LV GLS is an important prognostic marker in various cardiac diseases and has incremental value over LV ejection fraction.3 In specific cardiac diseases, such as ischemic cardiomyopathy, regional LV systolic function is more informative than global systolic function and is usually assessed by evaluating the presence of wall motion abnormalities. However, this analysis is subjective, requires high expertise, and the use of contrast media to enhance the endocardial border is often needed to improve its accuracy. Furthermore, wall motion abnormalities assessment does not accurately reflect the severity of myocardial damage (scar or fibrosis), even when the wall thickness is taken into consideration. In contrast, regional longitudinal strain has demonstrated good accuracy to discriminate transmural myocardial infarction as assessed with late gadolinium contrast-enhanced cardiovascular magnetic resonance.4,5 Although the use of LV GLS has become routine clinical practice, the assessment of regional longitudinal strain has not been widely embraced.One of the reasons for the low use of regional longitudinal strain in clinical practice is the higher variability of the measurements as compared with LV GLS.4,6 In a test-retest analysis, Mirea et al6 showed that the average absolute difference between peak longitudinal strain values for the same segment ranged between 2.6% to 4.9%. Furthermore, the agreement to measure regional longitudinal strain across various vendors ranged from poor to good (0.52–0.79), leading to the conclusion that regional longitudinal strain should be measured on data acquired with the same equipment and using vendor-specific package to limit the variability of the measurement.6In the current issue of the Journal, Sperry et al7 provide additional evidence on the between-vendor agreement of regional longitudinal strain in a different clinical scenario: cardiomyopathies with increased wall thickness of the left ventricle. Eighteen patients with cardiac amyloidosis, 30 patients with septal hypertrophic cardiomyopathy (HCM), and 6 with apical HCM were prospectively evaluated. In addition, 15 controls without structural heart disease and normal systolic and diastolic LV function were included. Two-dimensional data for LV longitudinal strain analysis were acquired with 3 different ultrasound systems (General Electric, Siemens and Philips) keeping probe location, image depth and zoom, and frame rate consistent across the 3 sets of images. Peak systolic longitudinal strain was measured by a single observer using the software package specific for each ultrasound system (EchoPAC, Vector Velocity Imaging, and QLab, respectively). Subsequently, longitudinal strain was calculated for 18 LV segments, whereas regional longitudinal strain was defined as the average of longitudinal strain values in each LV cross-sectional region (basal, mid and apical). There was good correlation between vendors for the measurement of LV GLS, although QLab provided GLS values of higher magnitude (more negative) than the other 2 software packages. Similarly, vector velocity imaging and EchoPAC provided comparable regional values of longitudinal strain, whereas the measurement using the QLab yielded significantly higher magnitude of regional longitudinal strain as compared to the other vendors, particularly in the apical regions. It is well known that the underlying pathophysiology of LV hypertrophy leads to characteristics patterns of regional LV longitudinal strain: whereas cardiac amyloidosis is characterized by better values of longitudinal strain in the apical region as compared to the base (apical sparing), apical HCM is characterized by the opposite pattern. These patterns were well depicted by EchoPAC and Vector Velocity Imaging. In contrast, QLab provided comparable values of apical longitudinal strain in patients with apical HCM to those observed in controls and the typical pattern of impaired apical longitudinal strain compared with the mid and basal longitudinal strain in this type of HCM was not systematically detected.The magnitude of the wall thickness and the underlying structural changes, such as myocardial fibrosis and infiltration, are important determinants of impaired global and regional LV longitudinal strain in cardiomyopathies with LV hypertrophy.8,9 In 59 patients with HCM, Urbano-Moral et al8 demonstrated that impaired LV GLS was significantly associated with the magnitude of LV hypertrophy. Pagourelias et al9 showed that impairment in segmental longitudinal strain was significantly associated to the magnitude of wall thickness, location of the most thickened segments, and type of underlying histological changes in patients with cardiomyopathies with LV hypertrophy (30 with biopsy-proven cardiac amyloidosis and 50 with HCM, 4 of them with apical HCM). For the same magnitude of wall thickness, segmental longitudinal strain was more impaired in patients with apical HCM than patients with other phenotypes of HCM. This finding could be explained by the more pronounced disarray and the shorter length of the myofibers in apical HCM.9 In addition, for the same magnitude of wall thickness, segmental longitudinal strain was 5.94% more reduced in cardiac amyloidosis than in HCM and this could be explained by the different underlying histology: infiltration by amyloid deposits versus myofiber disarray, myocyte apoptosis and replacement fibrosis.9 In the current study, Sperry et al7 also showed that regional values of longitudinal strain were more impaired at all levels (base, mid, and apical segments) in patients with cardiac amyloidosis as compared to patients with septal HCM, regardless of the software package used to measure segmental longitudinal strain. In contrast, patients with apical HCM showed consistently more impaired values of apical longitudinal strain as compared to patients with cardiac amyloidosis when regional longitudinal strain was measured with EchoPAC or Vector Velocity Imaging but not when using QLab. The explanation for this finding remains elusive, but it has been suggested that differences in image quality of data acquired with various ultrasound systems and postprocessing algorithms may impact on the intervendor variability of the measurements. The variability of these measures should, therefore, be further explored also for vendor-independent software packages to assess their potential role in this clinical setting. The results of the study by Sperry et al7 are important and underscore the pivotal role of the clinical history for the adequate interpretation of the regional longitudinal strain analysis and diagnostic and therapeutic management of the patients with cardiomyopathies with LV hypertrophy. These data are also important to continue the constructive work and dialogue between scientific societies and industry partners on the standardization of strain imaging.DisclosuresDrs Ajmone Marsan and Delgado receive speaker fees from Abbott Vascular. The department of Cardiology of the Leiden University Medical Center receives unrestricted research grants from Biotronik, Boston Scientific, Edwards Lifesciences, GE Healthcare and Medtronic.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Victoria Delgado, MD, PhD; Department of Cardiology; Leiden University Medical Center; Albinusdreef 2 2300 RC Leiden, the Netherlands Email v.[email protected]nlReferences1. Barbier P, Mirea O, Cefalù C, Maltagliati A, Savioli G, Guglielmo M. Reliability and feasibility of longitudinal AFI global and segmental strain compared with 2D left ventricular volumes and ejection fraction: intra- and inter-operator, test-retest, and inter-cycle reproducibility.Eur Heart J Cardiovasc Imaging. 2015; 16:642–652. doi: 10.1093/ehjci/jeu274CrossrefMedlineGoogle Scholar2. Farsalinos KE, Daraban AM, Ünlü S, Thomas JD, Badano LP, Voigt JU. Head-to-head comparison of global longitudinal strain measurements among nine different vendors: the EACVI/ASE inter-vendor comparison study.J Am Soc Echocardiogr. 2015; 28:1171–1181, e2. doi: 10.1016/j.echo.2015.06.011CrossrefMedlineGoogle Scholar3. Kalam K, Otahal P, Marwick TH. Prognostic implications of global LV dysfunction: a systematic review and meta-analysis of global longitudinal strain and ejection fraction.Heart. 2014; 100:1673–1680. doi: 10.1136/heartjnl-2014-305538CrossrefMedlineGoogle Scholar4. Amzulescu MS, Langet H, Saloux E, Manrique A, Boileau L, Slimani A, Allain P, Roy C, de Meester C, Pasquet A, et al. Head-to-head comparison of global and regional two-dimensional speckle tracking strain versus cardiac magnetic resonance tagging in a multicenter validation study.Circ Cardiovasc Imaging. 2017; 10:e006530. doi: 10.1161/CIRCIMAGING.117.006530LinkGoogle Scholar5. Cimino S, Canali E, Petronilli V, Cicogna F, De Luca L, Francone M, Sardella G, Iacoboni C, Agati L. Global and regional longitudinal strain assessed by two-dimensional speckle tracking echocardiography identifies early myocardial dysfunction and transmural extent of myocardial scar in patients with acute ST elevation myocardial infarction and relatively preserved LV function.Eur Heart J Cardiovasc Imaging. 2013; 14:805–811. doi: 10.1093/ehjci/jes295MedlineGoogle Scholar6. Mirea O, Pagourelias ED, Duchenne J, Bogaert J, Thomas JD, Badano LP, Voigt JU. Variability and reproducibility of segmental longitudinal strain measurement: a report from the EACVI-ASE strain standardization task force.JACC Cardiovasc Imaging. 2018; 11:15–24. doi:10.1016/j.jcmg.2017.01.027CrossrefMedlineGoogle Scholar7. Sperry BM, Sato K, Phelan D, Grimm R, Desai MY, Hanna M, Jaber WA, Popvic ZB. Regional variability in longitudinal strain across vendors in patients with cardiomyopathy due to increased left ventricular wall thickness.Circ Cardiovasc Imaging. 2019; 12:e008973. doi: 10.1161/CIRCIMAGING.119.008973LinkGoogle Scholar8. Urbano-Moral JA, Rowin EJ, Maron MS, Crean A, Pandian NG. Investigation of global and regional myocardial mechanics with 3-dimensional speckle tracking echocardiography and relations to hypertrophy and fibrosis in hypertrophic cardiomyopathy.Circ Cardiovasc Imaging. 2014; 7:11–19. doi: 10.1161/CIRCIMAGING.113.000842LinkGoogle Scholar9. Pagourelias ED, Mirea O, Vovas G, Duchenne J, Michalski B, Van Cleemput J, Bogaert J, Vassilikos VP, Voigt JU. Relation of regional myocardial structure and function in hypertrophic cardiomyopathy and amyloidois: a combined two-dimensional speckle tracking and cardiovascular magnetic resonance analysis.Eur Heart J Cardiovasc Imaging. 2019; 20:426–437. doi:10.1093/ehjci/jey107CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kotby A, Ebrahim S and Al-Fahham M (2022) Reference centiles for left ventricular longitudinal global and regional systolic strain by automated functional imaging in healthy Egyptian children, Cardiology in the Young, 10.1017/S1047951122000129, (1-9) August 2019Vol 12, Issue 8 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.119.009586PMID: 31412721 Originally publishedAugust 15, 2019 Keywordscardiovascular magnetic resonancestrainamyloidosiscardiomyopathiesEditorialsPDF download Advertisement SubjectsEchocardiographyHypertrophy" @default.
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