Assessment of Segmental Myocardial Viability Using Regional 2-Dimensional Strain Echocardiography

doi:10.1016/j.echo.2006.09.011

Journal of the American Society of Echocardiography

Volume 20, Issue 4, April 2007, Pages 342-351

https://doi.org/10.1016/j.echo.2006.09.011 Get rights and content

We determined whether 2-dimensional strain echocardiography can identify viable from infarcted myocardium in a rat ischemia-reperfusion model. A total of 16 male Sprague-Dawley rats underwent left anterior descending coronary artery occlusion for 12 or 30 minutes followed by 60-minute reperfusion. Short-axis 2-dimensional strain echocardiography was performed at the midventricle 60 minutes postreperfusion. Postsacrifice, triphenyl tetrazolium chloride was infused to the coronary circulation. Regional end-systolic radial and circumferential strain, and time to peak strain, were measured using software in all 96 segments and correlated with areas of infarct in corresponding histologic slices. Segments with greater than 50% area of infarct had lower end-systolic radial and circumferential strain and longer time to peak strain versus areas with 50% or less strain or no infarct. Extent of infarct correlates with radial and circumferential strain. End-systolic radial strain less than 2% has 88% sensitivity and 95% specificity for detecting infarcted area greater than 50%. Two-dimensional strain echocardiography–derived strain is useful in distinguishing infarcted from viable myocardium.

Section snippets

Experimental Animals

Sixteen male Sprague-Dawley rats (270-370 g) were anesthetized with sodium pentobarbital (40 mg/kg intraperitoneal), underwent tracheotomy, were intubated, and were placed on a rodent ventilator (Hugo Sachs Elektronik-Harvard Apparatus, March-Hugstetten, Germany). A left thoracotomy was performed to expose the heart. The proximal left anterior descending coronary artery was occluded by a suture for 12 minutes (n = 6) or 30 minutes (n = 10). This was followed by removal of the suture and

Histology and Serial Regional Strain

Variable degrees of infarction were produced after 30 minutes of ischemia, most notably in the midanteroseptum, midanterior, and midanterolateral segments (Table 1 and Figure 1). There were corresponding marked reductions in end-systolic radial and circumferential strain in these segments. At a lesser magnitude, areas not known to be supplied by the occluded artery also demonstrated reduction in strain with significant reduction in end-systolic radial strain in the inferolateral, inferior, and

Discussion

The study demonstrated that 2DSE is useful at identifying viable/noninfarcted myocardium versus nonviable/infarcted myocardium, as determined by TTC histology. Viable myocardium demonstrates greater end-systolic radial and circumferential strain and shorter time to peak radial and circumferential strain. The ability to detect viability in this rat model of infarction is associated with high sensitivity and specificity.

Viability assessment after MI remains challenging but is important for

References (43)

J.L. Monin et al.
Prediction of functional recovery of viable myocardium after delayed revascularization in postinfarction patients: accuracy of dobutamine stress echocardiography and influence of long-term vessel patency
J Am Coll Cardiol
(1999)
I. Afridi et al.
Myocardial viability during dobutamine echocardiography predicts survival in patients with coronary artery disease and severe left ventricular systolic dysfunction
J Am Coll Cardiol
(1998)
M. Leitman et al.
Two-dimensional strain–a novel software for real-time quantitative echocardiographic assessment of myocardial 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)
R.M. Lang et al.
Recommendations for chamber quantification: a report from the American Society of Echocardiography’s guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology
J Am Soc Echocardiogr
(2005)
S.A. Reisner et al.
Global longitudinal strain: a novel index of left ventricular systolic function
J Am Soc Echocardiogr
(2004)
T.P. Abraham et al.
Time to onset of regional relaxation: feasibility, variability and utility of a novel index of regional myocardial function by strain rate imaging
J Am Coll Cardiol
(2002)
J.J. Bax et al.
Accuracy of currently available techniques for prediction of functional recovery after revascularization in patients with left ventricular dysfunction due to chronic coronary artery disease: comparison of pooled data
J Am Coll Cardiol
(1997)
M.C. Fishbein et al.
Early phase acute myocardial infarct size quantification: validation of the triphenyl tetrazolium chloride tissue enzyme staining technique
Am Heart J
(1981)
F. Jamal et al.
Abnormal postsystolic thickening in acutely ischemic myocardium during coronary angioplasty: a velocity, strain, and strain rate Doppler myocardial imaging study
J Am Soc Echocardiogr
(1999)

G.F. Mitchell et al.

Left ventricular remodeling in the year after first anterior myocardial infarction: a quantitative analysis of contractile segment lengths and ventricular shape

J Am Coll Cardiol

(1992)

1999 Heart and stroke statistical update

(1999)

R.Q. Migrino et al.

End-systolic volume index at 90 to 180 minutes into reperfusion therapy for acute myocardial infarction is a strong predictor of early and late mortality: the global utilization of streptokinase and t-PA for occluded coronary arteries (GUSTO)-I angiographic investigators

Circulation

(1997)

E. Picano et al.

Prognostic value of myocardial viability in medically treated patients with global left ventricular dysfunction early after an acute uncomplicated myocardial infarction: a dobutamine stress echocardiographic study

Circulation

(1998)

L. Hanekom et al.

Incremental value of strain rate analysis as an adjunct to wall-motion scoring for assessment of myocardial viability by dobutamine echocardiography: a follow-up study after revascularization

Circulation

(2005)

J. Garot et al.

Spatially resolved imaging of myocardial function with strain-encoded MR: comparison with delayed contrast-enhanced MR imaging after myocardial infarction

Radiology

(2004)

M. Becker et al.

Analysis of myocardial deformation based on pixel tracking in 2D echocardiographic images allows quantitative assessment of regional left ventricular function

Heart

(2006)

R.J. Kim et al.

The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction

N Engl J Med

(2000)

Y. Pawitan

In all likelihood: statistical modeling and inference using likelihood

(2001)

S.L. Zeger et al.

Models for longitudinal data: a generalized estimating equation approach

Biometrics

(1988)

B.L. Gerber et al.

Accuracy of contrast-enhanced magnetic resonance imaging in predicting improvement of regional myocardial function in patients after acute myocardial infarction

Circulation

(2002)

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Global left ventricular (LV) myocardial work (MW) indices (GLVMWI) are derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure measurements. Changes in global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) after ST-segment elevation myocardial infarction (STEMI) have not been explored. The aim of present study was to assess the evolution of GLVMWI in STEMI patients from baseline (index infarct) to 3 months’ follow-up. Three-hundred and fifty patients (265 men; mean age 61 ± 10 years) with STEMI treated with primary percutaneous coronary intervention (PCI) and guideline-based medical therapy were retrospectively evaluated. Clinical variables, conventional echocardiographic measures and GLVMWI were recorded at baseline within 48 hours post-primary PCI and 3 months’ follow-up. LV ejection fraction (from 54 ± 10% to 57 ± 10%, p < 0.001), GWI (from 1449 ± 451 mm Hg% to 1953 ± 492 mm Hg%, p < 0.001), GCW (from 1624 ± 519 mm Hg% to 2228 ± 563 mm Hg%, p < 0.001) and GWE (from 93% (interquartile range (IQR) 86%-95%) to 95% (IQR 91%-96%), p < 0.001) improved significantly at 3 months’ follow-up with no significant difference in GWW (from 101 mm Hg% (IQR 63-155 mm Hg%) to 96 mm Hg% (IQR 64-155 mm Hg%); p = 0.535). On multivariable linear regression analysis, lower values of troponin T at baseline, increase in systolic blood pressure and improvement in LV global longitudinal strain were independently associated with higher GWI and GCW at 3 months’ follow-up. In conclusion, the evolution of GWI, GCW and GWE in STEMI patients may reflect myocardial stunning, whereas the stability in GWW may reflect permanent myocardial damage and the development of non-viable scar tissue.
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Citation Excerpt :
In chronic ischemic cardiomyopathy, myocardial viability is an important determinant of functional outcome after revascularization (Schinkel et al. 2007). It has been reported that strain and strain rate imaging may be useful in identifying transmural and subendocardial myocardial injury both after an acute MI (Migrino et al. 2007; Orii et al. 2015; Sjøli et al. 2009) and in chronic ischemic LV dysfunction (Chan et al. 2006; Ishikawa et al. 2012; Weidemann et al. 2003). In particular, more severe reductions in CS and CSr have been found in the presence of transmural than in subendocardial chronic MI in patients (Chan et al. 2006) or in a pig model (Ishikawa et al. 2012).
We evaluated the relationships between regional myocardial strain measured by speckle tracking echocardiography and viability, fibrosis, hypertrophy and oxygen consumption in the infarcted or remote myocardium in a pig model of chronic myocardial infarction (MI). Thirteen farm pigs with surgical occlusion of the left anterior descending coronary artery and five sham-operated pigs were studied 3 mo post-MI. Computed tomography revealed significant left ventricle remodeling. Reduced radial or circumferential strain identified areas of transmural infarction (area under the curve: 0.82 and 0.79, respectively). In the remote non-infarcted area, radial strain correlated inversely with the amount of fibrosis (r = –0.66, p = 0.04) and myocyte hypertrophy (r = –0.68, p = 0.03). Radial strain rate inversely correlated with myocardial resting oxygen consumption assessed with ¹¹C-labeled acetate positron emission tomography (r = –0.71, p = 0.006). In conclusion, myocardial strain and strain rate reflect fibrosis, hypertrophy and oxygen consumption of the remote areas after MI.
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Coronary artery disease (CAD) continues to be a leading cause of morbidity and mortality worldwide. Although invasive coronary angiography has previously been the gold standard in establishing the diagnosis of CAD, there is a growing shift to more appropriately use the cardiac catheterization laboratory to perform interventional procedures once a diagnosis of CAD has been established by noninvasive imaging modalities rather than using it primarily as a diagnostic facility to confirm or refute CAD. With ongoing technological advancements, noninvasive imaging plays a pre-eminent role in not only diagnosing CAD but also informing the choice of appropriate therapies, establishing prognosis, all while containing costs and providing value-based care. Multiple imaging modalities are available to evaluate patients suspected of having coronary ischemia, such as stress electrocardiography, stress echocardiography, single-photon emission computed tomography myocardial perfusion imaging, positron emission tomography, coronary computed tomography (CT) angiography, and magnetic resonance imaging. These imaging modalities can variably provide functional and anatomical delineation of coronary stenoses and help guide appropriate therapy. This review will discuss their advantages and limitations and their usage in the diagnostic pathway for patients with CAD. We also discuss newer technologies such as CT fractional flow reserve, CT angiography with perfusion, whole-heart coronary magnetic resonance angiography with perfusion, which can provide both anatomical as well as functional information in the same test, thus obviating the need for multiple diagnostic tests to obtain a comprehensive assessment of both, plaque burden and downstream ischemia. Recognizing that clinicians have a multitude of tests to choose from, we provide an underpinning of the principles of ischemia detection by these various modalities, focusing on anatomy vs physiology, the database justifying their use, their prognostic capabilities and lastly, their appropriate and judicious use in this era of patient-centered, cost-effective imaging.
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Advances in echocardiography, including 2-D speckle tracking to quantitate myocardial strain and strain rate, have improved myocardial functional and mechanical evaluation and may provide a more sensitive assessment of cardiac functional and mechanical changes. Additionally, evaluating myocardial performance induced by a pharmacologic stress test (dobutamine infusion) may further improve the evaluation of potential changes in cardiac function. This study evaluates the use of 2-D speckle tracking strain echocardiography (2DSE) combined with a dobutamine stress test to detect doxorubicin induced cardiomyopathy in the rat.
Rats were dosed once per week with 2 mg/kg doxorubicin for 6 weeks. Echocardiography was performed weekly at rest and during dobutamine infusion (20 mcg/kg/min IV).
Throughout the study there were no differences between control and doxorubicin treated groups at rest for radial strain, circumferential strain, fractional shortening (FS), or heart rate (HR). During dobutamine infusion, radial strain, circumferential strain, FS, and HR similarly increased significantly in both the control and doxorubicin treated groups at weeks 0, 1, and 2. At week 3 there was a significant attenuation of the increase in radial strain in the doxorubicin treated group, and at weeks 4 and 6 there was significant attenuation in radial strain and circumferential strain. No significant differences were detected in FS or HR between the two groups at any time points. Histology of the left ventricle at week 7 showed mild changes (mild cardiomyocyte vacuolation with minimal inflammation and no fibrosis) in the doxorubicin treated animals as compared to the control animals, which were consistent with mild doxorubicin induced injury.
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: Supported by a local Medical College of Wisconsin Grant (Dr Migrino) and by the American Heart Association Scientist Development Grant Award 0435147N (Dr Zhao).

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Original articleAssessment of Segmental Myocardial Viability Using Regional 2-Dimensional Strain Echocardiography

Section snippets

Experimental Animals

Histology and Serial Regional Strain

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

J Am Soc Echocardiogr

J Am Coll Cardiol

1999 Heart and stroke statistical update

End-systolic volume index at 90 to 180 minutes into reperfusion therapy for acute myocardial infarction is a strong predictor of early and late mortality: the global utilization of streptokinase and t-PA for occluded coronary arteries (GUSTO)-I angiographic investigators

Circulation

Prognostic value of myocardial viability in medically treated patients with global left ventricular dysfunction early after an acute uncomplicated myocardial infarction: a dobutamine stress echocardiographic study

Circulation

Incremental value of strain rate analysis as an adjunct to wall-motion scoring for assessment of myocardial viability by dobutamine echocardiography: a follow-up study after revascularization

Circulation

Spatially resolved imaging of myocardial function with strain-encoded MR: comparison with delayed contrast-enhanced MR imaging after myocardial infarction

Radiology

Analysis of myocardial deformation based on pixel tracking in 2D echocardiographic images allows quantitative assessment of regional left ventricular function

Heart

The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction

N Engl J Med

In all likelihood: statistical modeling and inference using likelihood

Models for longitudinal data: a generalized estimating equation approach

Biometrics

Accuracy of contrast-enhanced magnetic resonance imaging in predicting improvement of regional myocardial function in patients after acute myocardial infarction

Circulation

Original article
Assessment of Segmental Myocardial Viability Using Regional 2-Dimensional Strain Echocardiography