Clinical applications of strain rate imaging

doi:10.1067/j.echo.2003.09.004

Journal of the American Society of Echocardiography

Volume 16, Issue 12, December 2003, Pages 1334-1342

https://doi.org/10.1067/j.echo.2003.09.004 Get rights and content

Abstract

Myocardial strain (ϵ) is a dimensionless index of change in myocardial length in response to an applied force. ϵ Rate (SR) is the rate of change of length and is usually obtained as the time derivative of the ϵ signal. In echocardiography, SR is calculated as the difference between 2 velocities normalized to the distance between the 2 velocities. SR imaging (SRI) has a theoretic advantage over Doppler tissue imaging in that SRI is relatively immune to cardiac translational motion and tethering. Therefore, SRI may be superior to Doppler tissue imaging in quantitative assessment of regional myocardial function and may find clinical application in the interrogation of coronary artery disease. The high frame rates of SRI have also renewed interest in timings of global and regional mechanical events, and their potential clinical applications. The high temporal resolution allows SRI to depict regional systolic and diastolic asynchrony. Ongoing clinical trials will determine the sensitivity, specificity, and accuracy of SRI parameters for a variety of clinical conditions. Potential clinical applications include investigation of ischemia (at rest and with stress), myocardial viability, and altered global and regional systolic and diastolic function in cardiomyopathies. Suboptimal signal quality remains a major limitation of strain imaging, and advances in data acquisition and postprocessing capabilities will help determine its future incorporation into standard regional myocardial assessment.

Section snippets

Measurement of the myocardial strain

Initial measurements of intrinsic myocardial deformation or strain involved tracking the movement of implanted radio-opaque markers (eg, metallic beads) by biplane cineangiography3, 4 or video⁵ measuring mutual motion and angulation of 3 needles pierced into the myocardial wall, using an electromagnetic inductive technique,⁶ or by sonomicrometric crystals embedded in the myocardium.⁷

More recently, strain parameters can be derived noninvasively from either magnetic resonance imaging (MRI)

Myocardial velocity gradient

Myocardial velocity gradient was first described by Fleming et al¹⁵ and was originally obtained from slope of linear regression line formed by multiple velocity points (or pixels) across myocardial wall obtained from M-mode Doppler tissue measurements. It was further validated and defined by Uematsu et al¹⁶ as (Vendo − Vepi)/L × cos θ. Where Vendo − Vepi is the differential velocity between the endocardium and the epicardium, L is myocardial wall thickness, and θ is the Doppler angle of

Strain echocardiography versus mri strain techniques

The strain derived from SRI differs from that by tagged MRI in the choice of original reference length and planes of measurements. MRI tagging techniques and the M-mode echocardiography measure Lagrangian strain wherein the end-diastolic dimension is used in lieu of the unstressed length as the initial length. Doppler tissue imaging (DTI)-derived strain measures natural strain, which uses instantaneous length as the reference length and is calculated as the temporal integral of the DTI-derived

Image acquisition

Doppler tissue velocity images of 3 to 4 cardiac cycles are acquired at end-expiration. To optimize the tissue velocity signals, the 2-dimensional image is optimized using the gain controls to obtain a clear differentiation between the myocardium and the blood pool. Adjustments are also made in the pulse repetition frequency setting to avoid any aliasing within the myocardial wall (usually 1-2 kHz). The frame rate is maximized using the machine frame rate controls and reducing sector size if

Limitations of strain echocardiography

Similar to any Doppler techniques, SRI signals are highly dependent on angle of insonation. Every effort is made to ensure the tissue direction is less than 30 degrees from the beam direction but this is technically challenging in the apical segments as the angle becomes wider. The narrow sector angle approach on an individual wall obviates some of the above problems. But this approach precludes concurrent comparison of contralateral segments. Also the signal-to-noise ratio of SR measurement

Myocardial strain and sr in control subjects

Strain echocardiography was feasible and reproducible in both children and adults.17, 23, 24, 25, 26 Normally, the longitudinal segmental strain and SR are homogeneous within a left ventricular (LV) wall from the base to apex and are lower than their radial counterparts (by about half) and also the corresponding right ventricular wall. However, the longitudinal SRs in the anterior and septal walls are comparable but higher than those in the anterolateral and inferolateral walls.²⁵ Furthermore,

Ischemic heart disease

From animal experiments, the regional strain values have been validated to correlate with those obtained from sonomicrometry in acute coronary ischemia.²² In canine models, reduced systolic strain appears earlier and, therefore, is more sensitive than Doppler tissue velocity abnormality and semiquantitative visual wall-motion score in acute ischemia.³⁴ Moreover, the radial peak systolic strain of normal myocardium correlates linearly with M-mode ejection fraction calculated with the Teichholz

Future directions

There is increasing evidence that abnormal wall motions during the IVC and IVR are better measures of regional LV function than peak wall motion during systole.55, 62 Segmental IVC motion represents asynchronous and rapid myocardial contraction after ventricular activation but before aortic valve opening, resulting in minor changes in the LV volume and wall thickness. Similar to PST in the IVR period, they are also sensitive to acute myocardial ischemia and correlate with transmural MI. It has

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Review articleClinical applications of strain rate imaging

Abstract

Section snippets

Measurement of the myocardial strain

Myocardial velocity gradient

Strain echocardiography versus mri strain techniques

Image acquisition

Limitations of strain echocardiography

Myocardial strain and sr in control subjects

Ischemic heart disease

Future directions

J Biomech

J Biomech

Am Heart J

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Ultrasound Med Biol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Eur J Ultrasound

Review article
Clinical applications of strain rate imaging