Comprehensive Evaluation of Left Ventricular Strain Using Speckle Tracking Echocardiography in Normal Adults: Comparison of Three-Dimensional and Two-Dimensional Approaches

doi:10.1016/j.echo.2009.05.021

Journal of the American Society of Echocardiography

Volume 22, Issue 9, September 2009, Pages 1025-1030

https://doi.org/10.1016/j.echo.2009.05.021 Get rights and content

Objective

The two-dimensional speckle tracking (2DT) method is based on the measurements of strain on two-dimensional (2D) images, ignoring actual three-dimensional (3D) myocardial movements. We sought to investigate the feasibility of the newly developed three-dimensional speckle tracking (3DT) method to assess longitudinal, circumferential, and radial strain values, and then compared the data with those measured by 2DT.

Methods

Echocardiographic examinations were performed in 46 volunteers. In the apical 3D volumetric images, 3 vectors of the strains were analyzed in 16 myocardial segments. 2D longitudinal strain was assessed in apical 4-, 3-, and 2-chamber views, and circumferential and radial strains were measured in parasternal short-axis view.

Results

The average time for 3D image acquisition and 3D strain analysis by 3DT was significantly shorter than for 2DT. Longitudinal strain value by 3DT was significantly smaller than by 2DT (−17.4% ± 5.0% vs −19.9% ± 6.7%, P < .0001), and circumferential strain value by 3DT was significantly larger than by 2DT (−30.1% ± 7.1% vs −26.3% ± 6.9%, P < .0001). Intraobserver and interobserver variabilities were 10.1% and 10.9% in 3DT, and 9.9% and 11.1% in 2DT, respectively.

Conclusion

3DT is a simple, feasible, and reproducible method to measure longitudinal, circumferential, and radial strains. The discordant results between 3DT and 2DT may be explained by the 3D cardiac motion that has been ignored in current 2DT.

Section snippets

Study Population

This study was approved by the local ethical committee, and all subjects gave written, informed consent. Fifty-six healthy volunteers were consecutively enrolled. Ten subjects were excluded from this study because of poor image quality for analysis. Finally, 46 subjects (40 male, aged 29 ± 7 years) were studied. All studied subjects were (1) normotensive, (2) in normal sinus rhythm, and (3) without structural and functional abnormalities (including valvular heart disease) on transthoracic

Average Analysis Time

Average times for acquisition of the echocardiographic images and for the analysis per subject are shown in Table 1. The time for both the image acquisition and the analysis per subject by 3DT was significantly shorter than by 2DT (P < .0001).

Comparison between 3D and 2D Strain Values

Table 2 shows the LV volumes and left ventricular ejection fraction (LVEF) measured by 3D and 2D echocardiography. The end-diastolic volume measured by 2D echocardiography was significantly larger than by 3D echocardiography (P < .0001). However, the

Discussion

This study assessed the different components of strain (longitudinal, radial, and circumferential) values in 16 LV segments by using a newly developed 3D strain imaging and then compared the data with those measured by conventional 2D strain imaging. Our results showed that 1) the newly developed 3D myocardial tracking technique is a simple, feasible, and reproducible method to measure the strains; 2) the mean strain values of 16 segments between 3DT and 2DT showed discordant values in part;

Study Limitations

3DT has a material limitation in time and spatial resolution. However, there was no significant difference in the time to peak strain between 3DT and 2DT. In addition, equivalent reproducibilities of 3DT were demonstrated compared with 2DT. Another limitation of the present study is its small population, with only normal and relatively young individuals. Therefore, prospective studies are needed to clarify the strain values with more elderly, normal subjects and those with cardiac disease.

Conclusions

3DT is a simple, feasible, and reproducible method to measure longitudinal, circumferential, and radial strain values. The discordant results between 3DT and 2DT may be explained by the 3D cardiac motion that has been ignored in current 2DT. 3DT is a promising technique, which has the advantage of measuring real myocardial movement, including twisting motion of the heart, compared with conventional 2DT.

References (25)

P. Reant et al.
Experimental validation of circumferential, longitudinal, and radial 2-dimensional strain during dobutamine stress echocardiography in ischemic conditions
J Am Coll Cardiol
(2008)
B.H. Amundsen et al.
Noninvasive myocardial strain measurement by speckle tracking echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging
J Am Coll Cardiol
(2006)
K. Serri et al.
Global and regional myocardial function quantification by two-dimensional strain: application in hypertrophic cardiomyopathy
J Am Coll Cardiol
(2006)
M. Leitman et al.
Two-dimensional strain-a novel software for real-time quantitative echocardiographic assessment of myocardial function
J Am Soc Echocardiogr
(2004)
S.A. Reisner et al.
Global longitudinal strain: a novel index of left ventricular systolic function
J Am Soc Echocardiogr
(2004)
Y. Notomi et al.
Measurement of ventricular torsion by two-dimensional ultrasound speckle tracking imaging
J Am Coll Cardiol
(2005)
M. Becker et al.
Impact of left ventricular loading conditions on myocardial deformation parameters: analysis of early and late changes of myocardial deformation parameters after aortic valve replacement
J Am Soc Echocardiogr
(2007)
J.U. Voigt et al.
Assessment of regional longitudinal myocardial strain rate derived from Doppler myocardial imaging indexes in normal and infarcted myocardium
J Am Soc Echocardiogr
(2000)
M. Kowalski et al.
Can natural strain and strain rate quantify regional myocardial deformation? A study in healthy subjects
Ultrasound Med Biol
(2001)
J. Korinek et al.
Two-dimensional strain—a Doppler-independent ultrasound method for quantitation of regional deformation: validation in vitro and in vivo
J Am Soc Echocardiogr
(2005)

T. Helle-Valle et al.

New noninvasive method for assessment of left ventricular rotation: speckle tracking echocardiography

Circulation

(2005)

R.H. Helm et al.

Cardiac dyssynchrony analysis using circumferential versus longitudinal strain: implications for assessing cardiac resynchronization

Circulation

(2005)

Cited by (215)

Advanced Echocardiography Techniques: The Future Stethoscope of Systemic Diseases
2022, Current Problems in Cardiology
Cardiovascular disease (CVD) has been showing patterns of extensive rise in prevalence in the contemporary era, affecting the quality of life of millions of people and leading the causes of death worldwide. It has been a provocative challenge for modern medicine to diagnose CVD in its crib, owing to its etiological factors being attributed to a large array of systemic diseases, as well as its non-binary hideous nature that gradually leads to functional disability. Novel echocardiography techniques have enabled the cardiac ultrasound to provide a comprehensive analysis of the heart in an objective, feasible, time- and cost-effective manner. Speckle tracking echocardiography, contrast echocardiography, and 3D echocardiography have shown the highest potential for widespread use. The uses of novel modalities have been elaborately demonstrated in this study as a proof of concept that echocardiography has a place in routine general practice with supportive evidence being as recent as its role in the concurrent COVID-19 pandemic. Despite such evidence, many uses remain off-label and unexploited in practice. Generalization of echocardiography at the point of care can become a much-needed turning point in the clinical approach to case management. To actualize such aspirations, we recommend further prospective and interventional studies to examine the effect of implementing advanced techniques at the point of care on the decision-making process and evaluate their effectiveness in prevention of cardiovascular morbidities and mortalities.
Normal Values of Left Ventricular Size and Function on Three-Dimensional Echocardiography: Results of the World Alliance Societies of Echocardiography Study
2022, Journal of the American Society of Echocardiography
Echocardiography remains the most widely used modality to assess left ventricular (LV) chamber size and function. Currently this assessment is most frequently performed using two-dimensional (2D) echocardiography. However, three-dimensional (3D) echocardiography has been shown to be more accurate and reproducible than 2D echocardiography. Current normative reference values for 3D LV analysis are based predominantly on data from North America and Europe. The World Alliance Societies of Echocardiography study was designed to sample normal subjects from around the world to provide more universal global reference ranges. The aim of this study was to assess the worldwide feasibility of LV 3D echocardiography and report on size and functional measurements.
A total of 2,262 healthy subjects were prospectively enrolled from 19 centers in 15 countries. Three-dimensional LV full-volume data sets were obtained and analyzed offline using vendor-neutral software. Measurements included LV end-diastolic and end-systolic volumes, LV ejection fraction (LVEF), global longitudinal strain (GLS), and global circumferential strain. Results were categorized by age (18-40, 41-65, and >65 years), sex, and race.
A total of 1,589 subjects (feasibility 70%) had adequate LV data sets for analysis. Mean normal values for indexed end-diastolic volume, end-systolic volume, and LVEF in men and women were 70 ± 15 and 65 ± 12 mL/m², 28 ± 7 and 25 ± 6 mL/m², and 60 ± 5% and 62 ± 5%, respectively. Men had larger LV volumes and lower LVEFs than women. GLS and global circumferential strain were higher in magnitude in women. In both sexes, LV volumes were lower and LVEF tended to be higher with increasing age, especially considering the differences between the youngest and oldest age groups. Although GLS was similar across age groups in men, in women, the youngest and middle-age cohorts revealed higher magnitudes of GLS compared with the oldest age group. Global circumferential strain was higher in magnitude at older age in both men and women. Finally, Asians had smaller chamber sizes and higher LVEFs and absolute strain values than both blacks and whites.
Age, sex, and race should be considered when defining normal reference values for LV dimension and functional parameters obtained by 3D echocardiography.
Assessment of Myocardial Fibrosis Using Two-Dimensional and Three-Dimensional Speckle Tracking Echocardiography in Dilated Cardiomyopathy With Advanced Heart Failure
2021, Journal of Cardiac Failure
Citation Excerpt :
The 2D-STE tracks the speckles only within the 2-dimensional plane and ignored the apex-to-base shortening and thickening with simultaneous twisting motion of the LV.18 In particular, out-of-plane motion has been reported to be more censorious in the short axis than that in apical views,30,31 which might be partly responsible for the exhibition of a relatively low correlation in GRS between 2D and 3D modalities. Similar findings on the correlation of strain parameters between 2D and 3D modalities were depicted in children with DCM.32
This study aimed to depict strain parameters derived from 2-dimensional (2D)- and 3-dimensional (3D) speckle tracking echocardiography and to explore which may best reflect myocardial fibrosis (MF) in dilated cardiomyopathy with advanced heart failure by comparing with histologic fibrosis.
We analyzed 75 patients with dilated cardiomyopathy with advanced heart failure who underwent echocardiographic examination before heart transplantation. Strain parameters derived from 2D- and 3D speckle tracking echocardiography were as follows: left ventricular global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS) and tangential strain (TS). The degree of MF was quantified using Masson's staining in left ventricular myocardial samples obtained from all patients. Seventy-five patients were divided into 3 groups according to the tertiles of histologic MF (mild, moderate, and severe MF groups). Patients with severe MF had lower 3DGLS, 3DGRS, 3DTS, and 2DGLS than those with mild and moderate MF. MF strongly correlated with 3DGLS (r = 0.72, P < .001), weakly with 3DGRS (r = –0.39, P = .001), 3DGCS (r = 0.30, P = .009), 3DTS (r = 0.47, P < .001), and 2DGLS (r = 0.44, P < .001), but did not correlate with 2DGCS and 2DGRS. Receiver operating characteristic analysis revealed that the area under the curve of 3DGLS for detecting severe MF was significantly larger than that of other strain parameters (0.86 vs 0.59–0.70, P < .05 for all). The multivariate linear regression models using 3DGLS (R² = 0.76; Akaike information criterion = 331) was found to be a more accurate indicator to predict MF than that with 3DTS (R² = 0.65, Akaike information criterion = 354) and 2DGLS (R² = 0.66, Akaike information criterion = 352).
Three-dimensional GLS may be an optimal surrogate marker for reflecting MF in patients with dilated cardiomyopathy with advanced heart failure.
Strain Imaging: An Everyday Tool for the Perioperative Echocardiographer
2020, Journal of Cardiothoracic and Vascular Anesthesia
Strain analysis allows for global and regional analysis of myocardial function and has been shown to be an independent predictor of outcomes after cardiac surgery. Strain imaging offers advantages over traditional EF measurements in that it is relatively angle independent, it is less dependent upon loading conditions, it is reproducible, it does not rely on geometric assumptions, and it can detect subclinical systolic dysfunction. Limitations of strain analysis include high temporal resolution requirements, a strong dependence on image quality, and inter-vendor variability. In addition, there is a paucity of data on the intraoperative applications of strain. The ASE has defined a global longitudinal strain of –20% measured by transthoracic echocardiography to be considered normal, with less negative values considered abnormal. Presently, there are no published guidelines on the normal values of strain with transesophageal echocardiography (TEE). However, multiple studies have shown that a reduction in intraoperative strain assessed with TEE has been shown to be an independent predictor of complications during cardiac surgery. Accordingly, further incorporation of intraoperative strain analysis with TEE could aid in prognostication for patients undergoing cardiac surgery. As perioperative strain analysis continues to advance, an understanding of these concepts is imperative for perioperative echocardiographers. It is the authors’ goal to show that strain imaging can provide a reliable and objective measure that can be performed in real time to aid in decision-making and perioperative risk stratification.
Role and application of three-dimensional transthoracic echocardiography in the assessment of left and right ventricular volumes and ejection fraction: a UK nationwide survey
2024, Echo Research and Practice
3D-based strain analysis and cardiotoxicity detection in cancer patients received chemotherapy
2023, BMC Cancer

View all citing articles on Scopus

View full text

Clinical InvestigationVentricular Mechanics: Strain and TwistComprehensive Evaluation of Left Ventricular Strain Using Speckle Tracking Echocardiography in Normal Adults: Comparison of Three-Dimensional and Two-Dimensional Approaches

Objective

Methods

Results

Conclusion

Section snippets

Study Population

Average Analysis Time

Comparison between 3D and 2D Strain Values

Discussion

Study Limitations

Conclusions

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Ultrasound Med Biol

J Am Soc Echocardiogr

New noninvasive method for assessment of left ventricular rotation: speckle tracking echocardiography

Circulation

Cardiac dyssynchrony analysis using circumferential versus longitudinal strain: implications for assessing cardiac resynchronization

Circulation

Clinical Investigation
Ventricular Mechanics: Strain and Twist
Comprehensive Evaluation of Left Ventricular Strain Using Speckle Tracking Echocardiography in Normal Adults: Comparison of Three-Dimensional and Two-Dimensional Approaches