Three-dimensional Evaluation of Dobutamine-induced Changes in Regional Myocardial Deformation in Ischemic Myocardium Using Ultrasonic Strain Measurements: The Role of Circumferential Myocardial Shortening

doi:10.1016/j.echo.2007.03.010

Journal of the American Society of Echocardiography

Volume 20, Issue 11, November 2007, Pages 1294-1299

https://doi.org/10.1016/j.echo.2007.03.010 Get rights and content

Early identification of myocardial ischemia during high-dose dobutamine stress (DOB) has important clinical implications. Myocardial strain imaging can evaluate regional myocardial contractility in the radial, longitudinal, and circumferential directions. The aim of this study was to assess precisely the differences in deterioration of myocardial deformation among the 3 directions in patients with newly developed myocardial ischemia during high-dose (40 μg/kg/min) DOB infusion. Color Doppler tissue 2-dimensional images were recorded during DOB infusion in 20 patients without myocardial ischemia and 25 patients with scintigraphically diagnosed myocardial ischemia caused by left anterior descending coronary artery stenosis. In the offline analysis, systolic radial strain (Sr), longitudinal strain (Sl), and circumferential strain (Sc) were determined in the anteroseptal and anterolateral left ventricular walls. In 20 patients without myocardial ischemia, the peak systolic strains significantly increased in all 3 directions during DOB infusion at rates between 5 and 10 μg/kg/min (Sr 50%-69%, Sl 27%-36%, Sc 29%-38%, all P < .01) with a greater rate of change in the Sr (1.8 and 1.9 times, respectively, P < .001) than in the Sl and Sc. However, the peak systolic strains decreased significantly during DOB infusion at rates between 5 and 10 μg/kg/min in all 3 directions (Sr 56%-35%, Sl 27%-13%, both P < .01; Sc 29%-7%, P < .001) with the greatest rate of change in the Sc in 25 patients with newly developed myocardial ischemia. In conclusion, circumferential myocardial shortening deteriorated to a greater extent during DOB infusion in patients with coronary artery stenosis, and its measurement is a promising tool for detecting newly developed myocardial ischemia.

Section snippets

Study Population

Between 2003 and 2005, 300 patients in our hospitals underwent diagnostic cardiac catheterization and coronary angiography. Of these patients, 25 (20 men and 5 women; mean age 63 ± 8 years) who had undergone both DOB echocardiographic and nuclear studies within 3 days were enrolled in this study because they met the following criteria: (1) significant (≥75%) reduction, but not total or subtotal occlusion, of only segment 6 of the LAD on the basis of recent coronary angiographic results; (2)

Baseline

Mean peak systolic Sr in the anteroseptal and anterolateral walls were significantly greater compared with the mean peak systolic Sc and Sl in both the control and myocardial ischemia groups (Figure 3, Figure 4).

DOB

All mean peak systolic strains along the radial, longitudinal, and circumferential directions increased significantly during dobutamine administration, particularly systolic Sr and Sc, in the anteroseptal and anterolateral walls in the control group (Figure 3). All mean peak systolic

Discussion

In this study, we demonstrated that ultrasonic strain imaging can evaluate the nonuniformity of the radial, longitudinal, and circumferential directions on changes in regional myocardial deformation during dobutamine-induced ischemia. Specifically, dobutamine infusion identified the differences in the change in strain in the radial, longitudinal, and circumferential directions in the setting of myocardial ischemia.

During DOB echocardiography, low-dose infusion is used to detect myocardial

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Stressing the Limits of Strain Echocardiography
2015, Journal of the American Society of Echocardiography
Longitudinal Strain by Automated Function Imaging Detects Single-Vessel Coronary Artery Disease in Patients Undergoing Dipyridamole Stress Echocardiography
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The aim of this study was to investigate the incremental value of global longitudinal strain (GLS) by automated function imaging in respect to wall motion (WM) for the detection of coronary artery disease (CAD) during dipyridamole stress echocardiography.
Fifty-two patients (mean age, 65.3 ± 8.7 years; 22 men) underwent dipyridamole stress echocardiography followed by coronary angiography within 1 week. Diagnostic accuracy for the identification of single-vessel CAD was evaluated for WM and GLS. The study population was divided into two groups according to coronary angiographic findings: those with CAD (n = 38; mean age, 67.2 ± 5.9 years; 19 men) and those without CAD (n = 14; mean age, 63.3 ± 6.4 years; three men).
A trend toward lower resting GLS values was found in patients with CAD than in those without (−18.7 ± 2.2% vs −20 ± 2.8%, P = .061). In patients without CAD, GLS progressively increased up to peak dose (from −20 ± 2.8% at rest to −20.7 ± 1.9% at low dose, P = .045; from −20.7 ± 1.9% at low dose to −21.5 ± 3.1% at peak dose, P = .032), whereas in patients with CAD, an increase of GLS from rest to low dose (from −18.7 ± 2.2% to −19.2 ± 3.9%, P = .046) followed by a decrease from low to peak dose (from −19.2 ± 3.9% to −17.5 ± 2.4%, P = .007) was observed. In addition, with regard to diagnostic accuracy in detecting CAD, WM yielded sensitivity of 44%, specificity of 55%, positive predictive value of 73%, and negative predictive value of 26%, whereas GLS, alternatively evaluated as the difference between peak dose and resting values or between peak and low-dose values, provided sensitivity of 61%, specificity of 90%, positive predictive value of 94%, and negative predictive value of 47% (respectively, P = .020, P = .001, P = .023, and P = .031, all vs WM) and sensitivity of 84%, specificity of 92%, positive predictive value of 96%, and negative predictive value of 68% (respectively, P < .001, P < .001, P = .001, P < .001, all vs WM).
GLS analysis, particularly performed by comparing peak-dose with low-dose values, improves the accuracy of dipyridamole stress echocardiography in the detection of single-vessel CAD compared with the sole assessment of WM changes.
Prediction of functional recovery by cardiac magnetic resonance feature tracking imaging in first time ST-elevation myocardial infarction. Comparison to infarct size and transmurality by late gadolinium enhancement
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To investigate whether myocardial deformation imaging, assessed by feature tracking cardiac magnetic resonance (FTI-CMR), would allow objective quantification of myocardial strain and estimation of functional recovery in patients with first time ST-elevation myocardial infarction (STEMI).
Cardiac magnetic resonance (CMR) imaging was performed in 74 consecutive patients 2–4 days after successfully reperfused STEMI, using a 1.5 T CMR scanner (Philips Achieva). Peak systolic circumferential and longitudinal strains were measured using the FTI applied to SSFP cine sequences and were compared to infarct size, determined by late gadolinium enhancement (LGE). Follow-up CMR at 6 months was performed in order to assess residual ejection fraction, which deemed as the reference standard for the estimation of functional recovery.
During the follow-up period 53 of 74 (72%) patients exhibited preserved residual ejection fraction ≥ 50%. A cut-off value of − 19.3% for global circumferential strain identified patients with preserved ejection fraction ≥ 50% at follow-up with sensitivity of 76% and specificity of 85% (AUC = 0.86, 95% CI = 0.75–0.93, p < 0.001), which was superior to that provided by longitudinal strain (ΔAUC = 0.13, SE = 0.05, z-statistic = 2.5, p = 0.01), and non-inferior to that provided by LGE (ΔAUC = 0.07, p = NS). Multivariate analysis showed that global circumferential strain and LGE exhibited independent value for the prediction of preserved LV-function, surpassing that provided by age, diabetes and baseline ejection fraction (HR = 1.4, 95% CI = 1.0–1.9 and HR = 1.4, 95% CI = 1.1–1.7, respectively, p < 0.05 for both).
Estimation of circumferential strain by FTI provides objective assessment of infarct size without the need for contrast agent administration and estimation of functional recovery with non-inferior accuracy compared to that provided by LGE.
Prognostic value of global left ventricular strain for conservatively treated patients with symptomatic aortic stenosis
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Impaired left ventricular (LV) strain is associated with an increased risk of cardiac events in asymptomatic severe aortic stenosis (AS). We aimed to evaluate the prognostic value of global LV strain in conservatively treated patients with symptomatic AS.
This cohort study retrospectively reviewed symptomatic AS patients who were treated conservatively or surgically between July 2007 and April 2010. We measured their global longitudinal strain (GLS) and global circumferential strain (GCS). Clinical events were defined as readmission for heart failure or all-cause death for 2 years. GLS and GCS could predict a worse outcome in the conservatively treated group at cut-offs of =−16.5% (77% sensitivity and 67% specificity) and =−22.2% (92% sensitivity and 83% specificity), respectively. By univariate Cox regression analysis, age, logistic EuroSCORE, aortic valve area, GLS, and GCS were significant predictors. When adjusted for age, logistic EuroSCORE, and aortic valve area, impaired GLS and GCS were independently associated with a higher risk of clinical events.
In conservatively treated patients with symptomatic AS, impaired GLS and GCS were associated with an increased risk of cardiac events during a 2-year follow-up. Global LV strain may help to define a higher risk subset; therefore, a larger and prospective observation study would be necessary.
Subclinical left ventricular dysfunction revealed by circumferential 2D strain imaging in patients with coronary artery disease and fragmented QRS complex
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Citation Excerpt :
In this study, patients with CAD with fQRS complex had decreased circumferential but not radial strain and strain rate indices. Previous studies28 have shown that the level of contribution of circumferential fibers to LV myocardial thickening is greater than that of longitudinal fibers. As a result, circumferential myocardial shortening deteriorates to a greater extent during myocardial ischemia among 3-dimensional deformations.
Fragmented QRS (fQRS) complexes on a routine 12-lead electrocardiogram were associated with adverse cardiac events, including sudden death in patients with coronary artery disease (CAD).
To investigate the relationship between the fQRS complex and global and regional left ventricular (LV) functions in patients with CAD.
The study consisted of 176 patients (68 ± 9 years; 145 [82%] men) with CAD with narrow QRS duration and preserved LV ejection fraction (>45%). All patients underwent detailed 2-dimensional speckle-tracking echocardiography to determine global and segmental (basal, middle, and apical) LV strains and strain rates and were prospectively followed-up in the outpatient clinic.
Fifty-five patients (31%) had fQRS complexes. Global, middle, and apical LV longitudinal, radial, and circumferential strains and strain rates were significantly lower in the fQRS group than in the non-fQRS group (all P <.05). Multivariate logistic regression analysis revealed that the fQRS complex was associated with decreased global circumferential strain (odds ratio 1.19; 95% confidence interval 1.06−1.33; P = .003) and multivessel disease (odds ratio 3.69; 95% confidence interval 1.35−10.08; P = .011). Kaplan-Meier analysis revealed that event-free survival for cardiac events was significantly lower in the fQRS group than in the non-fQRS group (P = .036).
Our results demonstrated that the fQRS complex in patients with CAD with preserved LV ejection fraction was associated with subclinical global and regional LV dysfunctions as detected by 2-dimensional speckle-tracking imaging, and the results also predicted adverse cardiac events.
Strain-encoded cardiac magnetic resonance during high-dose dobutamine stress testing for the estimation of cardiac outcomes: Comparison to Clinical Parameters and Conventional Wall Motion Readings
2011, Journal of the American College of Cardiology
Citation Excerpt :
In this regard, the visual evaluation of strain on SENC images without the need for quantification assessment offered incremental prognostic information beyond the assessment of clinical variables and resting or inducible WMA on cine images. That may be attributed to the higher sensitivity of circumferential and longitudinal strain to detect dynamic changes in myocardial function (17–20), compared to cine images, which primarily track radial function of the myocardium. Thus, the implementation of color maps provided by SENC in the clinical routine may further aid not only the diagnostic classification but also the risk stratification of patients with ischemic heart disease.
The purpose of this study was to determine the prognostic value of strain-encoded magnetic resonance imaging (SENC) during high-dose dobutamine stress cardiac magnetic resonance imaging (DS-MRI) compared with conventional wall motion readings.
Detection of inducible ischemia by DS-MRI on the basis of assessing cine images is subjective and depends on the experience of the readers, which may influence not only the diagnostic classification but also the risk stratification of patients with ischemic heart disease.
In all, 320 consecutive patients with suspected or known coronary artery disease underwent DS-MRI, using a standard protocol in a 1.5T MR scanner. Wall motion abnormalities (WMA) and myocardial strain were assessed at baseline and during stress, and outcome data including cardiac deaths, nonfatal myocardial infarctions (“hard events”), and revascularization procedures performed >90 days after the MR scans were collected.
Thirty-five hard events occurred during a 28 ± 9 month follow-up period, including 10 cardiac deaths and 25 nonfatal myocardial infarctions, and 32 patients underwent coronary revascularization. Using a series of Cox proportional-hazards models, both resting and inducible WMA offered incremental information for the assessment of hard cardiac events compared to clinical variables (chi-square = 13.0 for clinical vs. chi-square = 26.1 by adding resting WMA, p < 0.001, vs. chi-square = 39.3 by adding inducible WMA, p < 0.001). Adding visual SENC or quantitative strain rate reserve to this model further improved the prediction of outcome (chi-square = 50.7 vs. chi-square = 52.5, p < 0.001 for both). In a subset of patients (n = 175) who underwent coronary angiography, SENC yielded significantly higher sensitivity for coronary artery disease detection (96% vs. 84%, p < 0.02), whereas specificity and accuracy were not significantly different (88% vs. 94% and 93% vs. 88%, p = NS for both).
Strain-encoded MRI aids the accurate identification of patients at high risk for future cardiac events and revascularization procedures, beyond the assessment of conventional atherogenic risk factors and resting or inducible WMA on cine images. (Strain-Encoded Cardiac Magnetic Resonance Imaging as an Adjunct for Dobutamine Stress Testing; NCT00758654)

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Original articleThree-dimensional Evaluation of Dobutamine-induced Changes in Regional Myocardial Deformation in Ischemic Myocardium Using Ultrasonic Strain Measurements: The Role of Circumferential Myocardial Shortening

Section snippets

Study Population

Baseline

DOB

Discussion

J Am Coll Cardiol

J Am Soc Echocardiogr

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Symptoms, adverse effects, and complications associated with dobutamine stress echocardiography: experience in 1118 patients

Circulation

The wavefront phenomenon of ischemic cell death, 1: myocardial infarct size vs duration of coronary occlusion in dogs

Circulation

The relative role of subendocardium and subepicardium in left ventricular mechanics

Am J Physiol

Nonuniformity of inner and outer systolic wall thickening in conscious dogs

Am J Physiol

Original article
Three-dimensional Evaluation of Dobutamine-induced Changes in Regional Myocardial Deformation in Ischemic Myocardium Using Ultrasonic Strain Measurements: The Role of Circumferential Myocardial Shortening