New modalities in clinical cardiac imaging Speckle Tracking Symposium 2009 Hartcentrum OLVG.

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New modalities in clinical cardiac imaging Speckle Tracking Symposium 2009 Hartcentrum OLVG

Transcript of New modalities in clinical cardiac imaging Speckle Tracking Symposium 2009 Hartcentrum OLVG.

Page 1: New modalities in clinical cardiac imaging Speckle Tracking Symposium 2009 Hartcentrum OLVG.

New modalities in clinical cardiac imaging

Speckle Tracking

New modalities in clinical cardiac imaging

Speckle Tracking

Symposium 2009 Hartcentrum OLVG

Page 2: New modalities in clinical cardiac imaging Speckle Tracking Symposium 2009 Hartcentrum OLVG.

Demonstrates in 1793 the use of echo-reflection by bats

L. Spallanzani (1729 – 1799)

Page 3: New modalities in clinical cardiac imaging Speckle Tracking Symposium 2009 Hartcentrum OLVG.

The supersonic reflectoscopeThe supersonic reflectoscope

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Malmö, May 1953Malmö, May 1953Kockum’s Shipbuilding Cie

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Malmö, May 1953Malmö, May 1953

C.H. Hertz (1920- 1990)

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First steps in cardiac evaluation

First steps in cardiac evaluation

First M-mode cardiogram Structure identification

I. Edler, H. Hertz

Edler I. Ultrasoundcardiography. Suppl to Acta Med Scand, 1961;170

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Dynamic two-dimensional echocardiography (1971)Dynamic two-dimensional echocardiography (1971)

Bom N et al. Biomed-Engng 1971; 6: 500-3

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Moore’s LawMoore’s Law

Gordon MooreElectronics, 1965:38:8

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New modalitiesNew modalities

2D Strain imaging◦ Speckle tracking

3D echocardiography◦ 3D EF◦ Valve pathology◦ 3D TEE

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ConstellationsConstellations

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2D strainNon-doppler strainTissue deformation

“natural acoustic tagging”

Peter Lysyansky and Zvi Friedman

Speckle tracking pattern recognition algorithm

Speckle TrackingSpeckle Tracking

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2D Strain2D Strain

Apical PSSAX

Strain can be evaluated as

Longitudinal Transversal Radial Circumferential

L0 ∆L

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Speckle tracking of successive two-dimensional imagesSpeckle tracking of successive two-dimensional images

Notomi, Y. et al. J Am Coll Cardiol 2005;4:2034-2041

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Left ventricular rotation (LVrot) at apical and basal levels during systoleLeft ventricular rotation (LVrot) at apical and basal levels during systole

Notomi, Y. et al. J Am Coll Cardiol 2005;45:2034-2041

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In practiceIn practice

Apical level Basal Level

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TorsionTorsion

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Clinical applications of 2D StrainClinical applications of 2D Strain

Coronary artery disease Stress testing Left ventricular dyssynchrony Cardiomyopathy

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Evaluation of coronary artery diseaseEvaluation of coronary artery disease

2D Strain Acuraat & reproduceerbaar Subtiele WBS

Kwantificatie Ontrafelen van complexe myocardiale

contractie patronen:

Akinesie <6% Hypokinesie 6-18% Normokinesie >18% Hyperkinesie >24% Dyskinesie stretching Dyssynchronie regional timing

Ischemic response

Echocardiography 2009;3:299-306

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Ontrafelen van complexe contractie patronen

Ontrafelen van complexe contractie patronen

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2D Strain in practice2D Strain in practice

Plain 2D APLAX APLAX using 2D strain imaging

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2D strain results2D strain results

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Stress testingStress testing

Limitations stress echo: Subjective interpretation High level of expertise Moderate reproducibility

2D strain: Post processing Longitudinal strain Reliable measurements

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Stress testingStress testing Ischemic response

Longitudinal Before radial

Subendocardial fibers are oriented longitidinally

Diffusion Tensor Imaging (DTI)

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Viability assessmentViability assessment

Gradual decrease in strain with increasing transmurality of MI

2D strain: Excellent prognostic value for

functional recovery after revascularzation

OLVG: confirmation study 2D strain vs MRI

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Left ventricular dyssynchronyLeft ventricular dyssynchrony

Methods RT3DE

TDI

Disadvantages Limited availability Low spatial resolution

Angle dependent Active vs passive High framerate (>130FPS)

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Left ventricular dyssynchronyLeft ventricular dyssynchrony

Method 2D Strain

Advantages Operator independent Less artifacts Not angle dependent Proper quantification Higher sensitivity and

specificity regarding CRT responders

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Example of dyssynchronyExample of dyssynchrony

Synchroon Dyssynchroon

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Left ventricular dyssynchronyLeft ventricular dyssynchrony Assessing dyssynchrony with 2D strain

Time-to-peak radial strain of 2 segments- ≥130ms

SD of time-to-peak longitudinal strain of 12 segments

- ≥35ms

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CRT optimalizationCRT optimalization

Voor CRT Na CRT

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CRT optimalizationCRT optimalization

Voor CRT Na CRT

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CardiomyopathyCardiomyopathy

LVEF Simplistic approach

2D strain Subtle dysfunction Global vs. regional Early identification

Cardiovascular ultrasound 2007;5:27

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Confirmatie OLVG dataConfirmatie OLVG data

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Subtiele afwijkingenSubtiele afwijkingen

Impaired longitudinal motion before EF.

Infiltratieve CM NC CMP HCM HT CMP ARVC

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2D strain in cardiomyopathy2D strain in cardiomyopathy

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Offline 2D strain analysisOffline 2D strain analysis

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Morbus FabryMorbus Fabry

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HCM vs LVH due to hypertensionHCM vs LVH due to hypertension

Differentiation by strain analysis

HCM Segmental abnormalities

- Hypokinesie- Prestretching- Post-systolic shortening

JASE 2003;16:233-239

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HCMHCM

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WMA’s bij HCMWMA’s bij HCM

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HCMHCM

Apical HCM; EF preserved Strain highlights the link between abnormality and

systolic mechanics

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Rechter ventrikel functieRechter ventrikel functie

Evaluatie RVMotion independent deformation parameters (S, SR) appear superior in the accurate description of regional RV function.

Heart. Published Online First: 30 August 2009. doi:10.1136

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ARCVARCV

2D strain superieur aan TAPSE

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Use 2D Strain for follow upUse 2D Strain for follow up

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Tips and TricksTips and Tricks

Image quality: noice & near field clutter Frame rate (40-90 Hz) Region of interest (ROI): dikte vh myocard Endocardiac border tracing: Visual confirmation Check AVC settings

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Future developments: 3D StrainFuture developments: 3D Strain

Jacc 2008;51 Suppl A, A116 (abstract)

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Keep watching the specklesThere is more to come!

Keep watching the specklesThere is more to come!