Tissue Doppler and Strain Flashcards
Define tissue doppler
- an extension of pulsed Doppler
- focus on measuring regional tissue velocities rather than blood flow velocities
What is the main principal in acquisition of tissue Doppler velocities?
- Elimination of a high-pass filter
- used for PW Doppler assessment of blood flow
- focus on the lower velocity signals of tissue
What are disadvantages/limitations of TDI?
- high frame rates are required to accurately collect tissue Doppler imaging (TDI)
- Angle-dependent technique
- influenced by cardiac translational motion and tethering
- Load depdendent
What is the relationship with age and TDI mitral annular velocity?
decreases with age
E/e’ has been established as a correlate for these findings:
LVEDP
or
PCWP
This TDI finding in patients with heart failure carries an unfavorable five-year survival rate?
e’ < 3 cm/s
Elevated E/e’ > 15 - also carries poor prognosis
What is a sensitive and specific marker for cardiac amyloidosis on strain imaging?
apical sparing pattern
- on longitudinal strain imaging
- “cherry on top”
What additional findings on TDI are consistent with cardiac amyloidosis?
Lower e’ and mean LV strain peak
- both were lower than age matched controls
What is a useful parameter (on TDI) to differntiate pathological LVH (HOCM/hypertensive LVH) from physiologic LVH?
s’ < 9 cm/s
s’ = systolic ejection velocity
What is one measure that may differentiate athletic heart from HOCM?
-
E/e’
- E/e’ > 12 = elevated LAP in HOCM patients
- E/e’ < 8 = trained athletes with normal function
What are disadvantages of speckle tracking?
Requires good image quality
- Cannot be sucessfully applied to approximately 10% of US images
What frame rate is speck tracking performed at?
lower frame rates 40-90 frames/s
as compared to TDI > 100 frames/s
What parameter can show a relatively normal value when the myocardium is akinetic?
TDI
You perform an Echo on a college hockey player for palpitations. LV wall thickenss is increased. What parameter is consistent with Athlete’s Heart?
Septal e’ 15 cm/s
What is one advantage of strain imaging over TDI?
Not affected by tethering of segments
What movement indicates a negative number in strain imaging?
shortening = negative value
What is the scale for Global Longitudinal Peak systolic strain (16 LV segments)?
- Normal = greater than (more negative than) - 18%
- Borderline = -16% to -18%
- Abnormal = less than (less negative than) - 16%
What are strengths of GLS?
- Superiority in predication of all-cause mortality in the general population compared with LVEF
- Improved risk stratification in patients with HF
- Ability to recognize early LV dysfunction in patients undergoing cardiotoxic therapy and prognosticate subsequent CTRCD
- Reproducible when performed by trained operators
What are the limitations of GLS?
- Heavy depdendence on 2D Echo quality
- Influenced by Loading conditions
- Lack of long term clinical trials
- Lack of data on reproducibility
- Vendor and software specific
Describe the findings
- Bull’s eye plot showing GLS
- A - baseline GLS
- B - GLS at 3 months durting trastuszumab-based therapy after anthracyclines
- GLS has decreased from -20.6% –> - 14.4% (30% decrease)
What is considered a significant change in GLS?
> 15% from baseline
What is the first step after a significant change in GLS is noted?
repeat Echo with GLS to ensure findings are accurate
What is the stepwise progression / algorithm for evaluation of suspected CTRCD?
What are typical Echo features of Athletic heart?
- Normal tissue Doppler E’
- Normal, pseudorestrictive mitral inflow pattern
- Normal / mildly increased LA size
- Strain normal (higher than HCM)
What is the normal GLS of the RV?
> -25%
Strain rate for tissue Doppler is defined as:
Change in velocity between two points divided by their distance
- SR = (V1-V2) / L
- V1 = velocity at point 1
- V2 = velocity at point 2
- L = length
When compared with two-dimensional based strain, the biggest disadvantage of TDI-based strain is?
Angle depdendency
- Like all doppler techniques, is sensitive to alignment
*
What is the relationship of TDI-based strain to tethering?
-
Not susceptible to tethering to adjacent tissue
- as myocardial motion is measured relative to the adjacent myocardium and not relative to the transducer
If two-dimensional based strain imaging is used to evaluate pathologic processes involving the subendocardium, the preferred modality should be:
Longitudinal strain
- In the subendocardium, the fibers are roughly longitudinally oriented
- With an angle of 80 degrees with resepect to the circumferential direction of the fibers located in the mid-aspect of the thickness of the myocardium
What hemodynamic parameter betst correlates with a combination of mitral E-wave velocity and early diastolic longitudinal velocities of the myocardium (e’)?
Mean left atrial pressure
When reporting GLS, it is imporant to bear in mind the impact of these parameters?
- Vendor
- Age
- Gender
What radial strain rate obtained at the mid inferior wall during systole of a patient with ischemic cardiomyopathy is consistent with dyskinesis?
Negative rate
- negative values for radial strain =
- relaxation (if measured during diastole)
- dyskinesis (if measured during systole)
- Positive values for radial strain = active contraction
Describe LV torsion
- During isovolumic contraction (phase 1), the apex shows a brief clockwise rotation and the base a short couterclockwise rotation
- During ejection (phase 2), the direction of the rotation changes to counterclockwise at the LV apex and clockwise at the LV base
What is one disadvantage of TDI in regards to motion?
It is unable to differentiate between active motion (like myocardial contraction) and passive motion (like tethering)
Based on the Expert consensus for the multimodality imaging of the adult patient during and after cancer therapy, subclinical LV dysfunction is defined as:
15% reduction in GLS when compared to baseline value
In asymmetric septal hypertrophic cardiomyopathy, tissue Doppler e’:
Has an inverse relationship with septal thickness
In diabetic patients, what does HbA1c correlate with?
HbA1c correlates wtih E/e’
- glycemic control –> microvascular complications –> ischemia and subsequent impaired LV relaxation and increased myocardial stiffness
In what condition has e’ been shown to improve after treatment?
Aortic stenosis
- Global LV dysfunction is common secondary to increased afterload
What tissue doppler value has been shown to carry the most prognostic value after myocardial infarction (MI)?
E/e’ ratio
- E/e’ > 17 –> mortality rate 40% at 36 months
- E/e’ < 17 –> mortality rate 5% at 36 months
- E/e’ > 15 in Echo 1.6 days after MI, followed for 13 months –> most powerful predictor of survival
In patients with acute heart failure, this is a powerful predictor of cardiac events and appears to be a better parameter than ejection fraction
Global circumferential strain (GCS)
This cardiac condition is associated with a normal or high e’?
Athletes heart
In a patient with a localized basal lateral infarct with evidence of akinesis by two-dimensional Doppler imaging, the expected longitudinal tissue Doppler velocities (m/s) and strain rate (1/s) would be:
Tissue Doppler Velocity = 0.2, Strain Rate = 0
- Strain rate of zero –> akinesis
- Velocities may be recorded in akinetic segments that are tethered by adjacent moving segments
What is the best prediction of mortality for paradoximal severe AS and preserved EF patients?
Symptoms + Euroscore + GLS
Describe the findings
Radial strain map demosntrating Anteroseptal akinesis
Describe the findings
- Strain rate imaging with regions of interest selected in the septum (yellow circle) and lateral wall (blue circle) in A4C view
- Anteroseptal infarct - selected area of the septum (yellow) maintains a strain rate of approximately zero throughout systole and diastole –> finding consistent with akinesis and scar formation
- Selected area (blue) demonstrates a negative strain rate in systole, signifying appropriate myocardial compressiona dna positive strain rate in diastole, signifying myocardial expansion
Describe strain rate values
- Strain rate > 0 = expansion
- Strain rate < 0 = compression
46 year old woman with previous history of breast cancer treated with mastectomy, chemotherapy, and radiation therapy presents for evaluation of symptoms of fatigue. On examination, she has a heart rate (HR) of 100 bpm, BP 85/60 mmHg, elevated JVP, decreased breath sounds at the lung bases, ascites, and 3+ peripheral edema. TEE and TTE Doppler images are shown. What is the most likely diagnosis?
Constrictive Pericarditis
68 year old woman presents for evaluation of dyspnea on exertion. Tissue Doppler images are shown, what is the most likely diagnosis?
Asymmetric septal hypertrophic cardiomyopathy
- Key finding is reduction in e’ velocity that is much more pronounced in the septum –> consistent with hypertrophic cardiomyopathy
41 year old woman with a diagnosis of recurrent triple negative breast cancer who has received a cumulative dose of anthracyclines of 450 mg/m2 undergoes an Echocardiogram with strain.
Describe the image and recommendations
- Radial strain, usuing a short-axis image at the level of the papillary muscles
-
Discontinue anthracycline, finish treatment with a nonanthracycline containing regimen, and initiate beta-blockers
- radial strain is abnormal at 11% (normal is 40%-60%) –> suggestive of subclinical LV dysfunction
64 year old diabetic woman is referred fro evaluation of heart failure symptoms. 2D Echo, Color Tissue Doppler images and strain from A4C view are shown. What is the diagnosis?
Ischemic heart disease
- 2D Echo: dilated LV cavity consitent with dilated or ischemic cardiomyopathy
- TDI Color: shows different color velocity pattern in the septum and lateral wall
- Strain: reduced deformation in the apical septum (yellow curve) compared with the apical lateral wall (red curve) –> findings consistent with septal MI
What findings are indicative of subsequent cardiotoxity in chemotherapy patients?
GLS < 19%
or
Troponin I > 30 pg/mL
62 year old man with history of rheumatic disease and previous mitral valve repair undergoes Echo for a heart murmur. 2D Echo and color M-mode tissue Doppler are consistent with this:
Normal postoperative findings
Paradoxical anterior systolic motion of the interventricular septum
*****Normal finding post pericardiotomy
