Download Simultaneous Longitudinal Strain in All 4 Cardiac Chambers

Ventricular Structure and Function
Simultaneous Longitudinal Strain in All
4 Cardiac Chambers
A Novel Method for Comprehensive Functional Assessment of the Heart
Karima Addetia, MD; Masaaki Takeuchi, MD, PhD; Francesco Maffessanti, PhD;
Yasufumi Nagata, MD; James Hamilton, PhD; Victor Mor-Avi, PhD; Roberto M. Lang, MD
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Background—Simultaneous assessment of longitudinal strain (LS) by 2D speckle-tracking echocardiography in all 4
cardiac chambers has not yet been explored. Our goal was to study LS curves obtained simultaneously from all 4 cardiac
chambers in healthy subjects to gain insight into interchamber functional relationships.
Methods and Results—We studied 259 healthy subjects (age 44±15; 118 men) in whom it was possible to obtain apical
4-chamber views that contained the entire left and right ventricles and both atria in the same sector. 2D speckle-tracking
echocardiography was performed in all 4 chambers in the same cardiac cycle, while considering the interventricular
septum as part of the left ventricle and including the interatrial septum in the LS measurements for both atria. LS was
measured over time using vendor-independent software (Epsilon), resulting in peak LS and time-to-peak strain. Strain
curves of the right ventricle and right atrium were larger in magnitude than those of the left ventricle and left atrium,
whereas time-to-peak values were shorter. LS for the ventricles peaked earlier than the LS for the corresponding atria.
Peak systolic LS values were larger in magnitude in women than in men. For both atria, LS declined with age and timeto-peak increased. Left ventricle LS declined minimally with age, but right ventricle free-wall LS augmented with age
until the sixth decade.
Conclusions—Simultaneous measurement of LS provides new insights into interchamber relationships. This new tool may
prove useful in evaluating diseases that affect cardiac chambers differently. (Circ Cardiovasc Imaging. 2016;9:e003895.
DOI: 10.1161/CIRCIMAGING.115.003895.)
Key Words: atrial function ◼ cardiac function ◼ longitudinal strain ◼ strain ◼ ventricular function
R
ecent technological advancements have enabled direct
measurements of myocardial deformation indices, such
as strain and strain rate. Over the past decade, a multitude
of studies have reported myocardial deformation measurements in a variety of disease states, advancing our knowledge of cardiac physiology and improving prediction of
clinical outcomes.1–3 Although it is widely recognized that
the ventricles and atria are functionally inter-related, currently, deformation assessment can only be performed for
each chamber sequentially using different cardiac cycles.
This limitation could affect the ability to study interchamber coupling because of the physiological beat-to-beat variability. Comprehensive functional assessment of the heart
by simultaneous strain measurement of all cardiac chambers
during the same cardiac cycle would eliminate this limitation
and, thus, improve the evaluation of interchamber relationships. Accordingly, new software was recently developed for
simultaneous strain measurements of all cardiac chambers
using 2-dimensional (2D) speckle-tracking echocardiography from apical 4-chamber views.
See Editorial by Baron and Flachskampf
See Clinical Perspective
It has been shown that left ventricular (LV) deformation indices are age- and sex-dependent.4,5 However, little is
known about age- and sex-related differences in deformation
measurements of the other cardiac chambers. Our goal was
to study the normal interchamber functional relationships in
a large group of healthy subjects over a wide age range using
this new software and to determine age- and sex-specific differences in combined all-chamber strain assessment.
Methods
Study Population
We studied 259 normal subjects over a wide range of ages (118
men, 141 women; age 44±15), who underwent 2D transthoracic
echocardiography. Care was taken to record apical 4-chamber views
encompassing the entire LV and right ventricle (RV), as well as the
respective left atrium (LA) and right atrium (RA) in the same sector. Study subjects were enrolled at 2 institutions. Normal subjects
were defined as healthy volunteers or patients referred for cardiac
Received July 20, 2015; accepted January 25, 2016.
From the Department of Medicine, Section of Cardiology, University of Chicago, IL (K.A., F.M., V.M.-A., R.M.L.); School of Medicine, University of
Occupational and Environmental Health, Kitakyushu, Japan (M.T., Y.N.); and Epsilon Imaging, Ann Arbor, MI (J.H.).
Correspondence to Karima Addetia, MD, Section of Cardiology, University of Chicago Medical Center, 5841 South Maryland Ave, MC5084, Chicago,
IL 60637. E-mail [email protected]
© 2016 American Heart Association, Inc.
Circ Cardiovasc Imaging is available at http://circimaging.ahajournals.org
1
DOI: 10.1161/CIRCIMAGING.115.003895
2 Addetia et al Simultaneous All-4-Chamber Strain
ultrasound with no documented cardiovascular history and symptoms
and patients on no medications. All participants were nonathletes and
had normal echocardiograms defined as normal LV and RV size and
function, not more than mild valvular regurgitation, normal right and
left atrial sizes, and systolic pulmonary pressure <35 mm Hg. This
study was approved by the Institutional Review Board with a waiver
of consent.
Conventional Echocardiographic Measurements
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Comprehensive 2D and color Doppler echocardiograms were performed using the iE33 imaging system equipped with an S5 transducer (Philips Healthcare, Andover, MA; frequency range 1–5
MHz). 2D 4-chamber views were obtained on each participant from
the apical transducer position. These views were acquired so as to
contain the entire LV and RV and both atria in the same sector.
Frame rate was maximized by increasing the depth and decreasing
the sector width to the extent possible. The focal point was maintained at the midventricular level. Digital loops were stored and
analyzed offline (Xcelera Workstation, Philips). LV ejection fraction was calculated from LV volumes obtained using the Simpson’s
biplane method of disks. RV fractional area change was determined from RV chamber area data extracted from Epsilon software.
Chamber areas also extracted from the software were indexed to
body surface area (BSA)6 and presented in Table 1.
Four-Chamber Speckle-Tracking Strain Analysis
2D speckle-tracking echocardiography was used to measure longitudinal strain (LS) simultaneously in all 4 chambers throughout
the identical cardiac cycle using vendor-independent software
(Epsilon Imaging, Ann Arbor, MI; Figure 1). Strain analysis was
performed by manually tracing a region of interest along the endocardial border of each chamber with subsequent adjustment
of the region of interest to match the thickness of the individual
chamber wall. The software then tracked the endocardial contours
throughout the cardiac cycle. Manual adjustments were made to the
contours as needed to optimize tracking. Segments that were inadequately tracked despite the adjustments were excluded. The interventricular septum was considered part of the LV, and RV strain
was only measured in the free-wall segments.7 In contrast, the interatrial septum was included in the LS measurements of both the
LA and RA. Strain measurements were made by 2 level III echocardiographers with extensive experience performing these measurements who met, discussed, compared, and standardized their
approaches. The LV, LA, and RA were divided into 6 segments,
whereas the RV free-wall was divided into 3 segments (Figure 1).
Global strain was measured for each chamber by including only
the relevant, well-tracked segments. Global strain curves as well as
the time-to-peak (TTP) strain data and chamber area information
were exported from the software for further analysis. TTP values
were corrected for heart rate by dividing by the R-R interval (in
ms) and multiplying by 100% to account for interpatient differences in heart rate. In addition, we calculated the ratios of both left
and right atrial/ventricular peak strains, as well as left/right atrial
and ventricular peak strains, as potential quantitative measures of
interchamber functional relationships.
Statistical Analysis
Continuous variables were expressed as mean±SD. Categorical variables were expressed in numeric values or percent. A P value <0.05
was considered statistically significant. The association of peak systolic LS and TTP with age and sex was studied using a general linear
model, entering sex and number of excluded segments as fixed factors and age as a covariate. Subpopulations studied included males
and females and age brackets (20–30, 30–40, 40–50, 50–60, and
≥60 years). To study differences in peak systolic LS values and TTP
estimates between age groups, an analysis of variance analysis was
performed followed by, when a significant difference was noted, pairwise comparison with 2-tailed student’s t test and Bonferroni correction. Comparison between peak LS and TTP in different chambers
were performed using analysis of variance for repeated measures,
followed by post hoc test with Bonferroni correction in presence of
significant global effect. When comparing chamber differences between populations, unpaired t tests were used, whereas paired t tests
were used when making comparisons between chambers. Chi-square
analysis was used for categorical variables. In addition, a separate
analysis was performed in which chamber areas obtained from
Epsilon software were indexed to BSA and allometrically scaled6 by
dividing chamber areas by height and height2.7 Regression analysis
was then used to study the relationship between allometrically scaled
chamber size and strain.
Measurement Reproducibility
To assess interobserver variability in peak LS, 4-chamber strain measurements were performed in a subset of 22 subjects (8% of the total population) by 2 independent observers at 2 different institutions
(K. Addetia and M. Takeuchi), who were blinded to each other’s results and independently selected the best cardiac cycle for analysis.
These measurements were also repeated by the same observer who
was blinded to the results of the previous measurements and was also
free to select the best cardiac cycle each time. Both inter- and intraobserver variability were expressed in terms of intraclass correlation
coefficient and percent variability defined as the mean of the absolute
differences between pairs of repeated measurements divided by their
mean.
Table 1. Baseline Characteristics of all Study Subjects and the Subgroups
All
n
Age, y
Men, n (%)
From US
R-R, ms
BSA, m2
LVEF, %
RVFAC, %
LVAi,
cm2/m2
RVAi,
cm2/m2
LAAi,
cm2/m2
RAAi,
cm2/m2
259
44±15
118 (46%)
113 (44%)
957±170
1.7±0.3
62±6
37±4
18±3
10±2
11±2
9±2
Sex
Men
118
44±16
…
48 (41%)
950±165
1.9±0.2
60±6
39±8
18±2
11±2
11±2
9±2
Women
141
44±14
…
65 (46%)
964±177
1.6±0.2*
64±5*
36±7*
18±3*
10±2*
11±2
8±2*
Age groups, y
20–30
52
25±3
25 (48%)
19 (37%)
976±157
1.7±0.3
61±6
36±7
19±2
11±2
11±2
8±1
30–40
60
34±3
31 (52%)
27 (45%)
987±194
1.7±0.3
61±5
36±7
18±3
11±2
11±2
8±1
40–50
51
44±3
19 (37%)
25 (49%)
908±163
1.8±0.3
61±5
39±8
18±2
10±2
10±2
8±2
50–60
51
54±3
24 (47%)
27 (53%)
959±180
1.8±0.3
63±6
41±8
18±2
10±2
11±2
9±2
≥60
45
68±6
19 (42%)
15 (33%)
946±141
1.6±0.2
64±6
36±8
17±3
10±2
11±2
9±2
BSA indicates body surface area; LAAi, left atrial area indexed to BSA; LVAi, left ventricular area indexed to BSA; LVEF, left ventricular ejection fraction; RAAi, right
atrial area indexed to BSA; RVAi, right ventricular area indexed to BSA; RVFAC, right ventricular fractional area change; and US, United States.
*P<0.05 between men and women.
3 Addetia et al Simultaneous All-4-Chamber Strain
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Figure 1. Measurement of longitudinal strain (LS) in all 4 cardiac chambers. Once the endocardium for all 4 chambers was manually
traced, a plot of 4 global LS curves was generated (top, right). Peak strain was obtained from these curves. Note that measurements
from the RV septal segments were not used during final analysis.
Results
Baseline demographic and echocardiographic characteristics
of the study population are presented in Table 1. BSA and
indexed RV and RA areas were smaller in women than in men,
and LV ejection fraction and RV fractional area changes were
higher in women.
Mean frame rate was 52±6 Hz. Out of a total of 5439
segments traced, 36 (0.7%) were excluded because of poor
tracking. Strain curves of the RV and RA were larger in magnitude than those from the corresponding left heart chambers
(Figures 2 and 3 and Table 2 top, first row). Also, atrial strains
were significantly larger than ventricular strains. LS curves for
the RV free wall and RA peaked earlier than the corresponding LV and LA strain curves (Figures 2 and 3 and Table 2
bottom, first row). Normal ranges for peak LS±2SD were
−18±4% for the LV, −23±12% for the RV, 38±26% for the LA,
and 44±38% for the RA. Ratios in peak strain between chambers were 1.1±0.2 for RV/LV, 2.2±0.7 for LA/LV, 2.4±0.9 for
RA/RV, and 1.2±0.4 for RA/LA. In other words, peak RV
free-wall peak strain was on average 10% higher in magnitude than LV peak strain. These ratios provide information on
interchamber relationships in peak LS in the normal population we studied. Of note, there was no significant correlation
between BSA-indexed chamber areas or allometrically scaled
chamber areas to strain for any chamber, suggesting that strain
measurements were independent of chamber size.
Sex Differences in LS Patterns
Sex differences were found in the LV, RV free-wall, and LA
peak strain values (Figure 4 and Table 2 top, second and third
rows). Peak systolic LS values were significantly larger in
magnitude in females compared with males (−18±2% versus −17±2%, P<0.01 for the LV; −24±6% versus −22±6%,
P<0.01 for the RV free-wall; and 40±13% versus 36±13%,
P=0.05 for the LA). Although, on average, females had larger
RA peak LS, when compared with males, these differences
did not reach statistical significance. Interestingly, LS in all
chambers tended to peak later in women compared with men
(Figure 4 and Table 2 bottom, second and third rows).
Age Differences in LS Patterns
Age was associated with peak LS values for LV (0.20% per
10 years), LA (−3.1% per 10 years), and RA (−3.5% per 10
years). For all chambers, age was associated with prolonged
TTP (1.0, 0.09, 1.3, and 0.11 ms per decade for LV, RV freewall, LA, and RA, respectively). The number of excluded segments was not associated with peak LS nor with TTP values.
When comparing age groups, LV peak LS varied minimally,
reaching significance only between the 30 to 40 year and the
≥60 years age groups (Figure 5). RV free-wall LS increased
progressively with each decade until the sixth decade when it
declined, which was associated with a prolongation of TTP
(Figures 5 and 6). LS for both atria progressively declined
with increasing age, which was associated with a prolongation of the TTP.
Inter- and Intraobserver Variability
Interobserver variability for peak LS was low, as reflected by
intraclass correlations equal to 0.93, 0.75, 0.90, and 0.83 for
the LV, RV free wall, LA, and RA. Percent variability was
worst for the atria than for the LV and RV free wall, measuring
3%, 7%, 9%, and 9% for the LV, RV free wall, LA, and RA
respectively. Intraobserver variability for peak LS was also
low with intraclass correlations of 0.97, 0.96, 0.98, and 0.94
for the LV, RV free wall, LA, and RA and percent variability
of 2%, 4%, 4%, and 9%, respectively.
Discussion
This study is the first to suggest that simultaneous assessment
of LS in all 4 cardiac chambers provides new insight into the
interchamber relationships. In this study, performed on a large
group of normal subjects spanning a wide age range, we found
4 Addetia et al Simultaneous All-4-Chamber Strain
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Figure 2. Mean left ventricular (LV; top, left), right ventricular (RV) free wall (top, right), left atrium (LA; bottom, left), and right atrium (RA;
bottom, right) longitudinal strain (LS) over time curves (solid lines) with standard deviations (dotted lines). These curves were obtained by
averaging data from the whole population of normal subjects (N=259).
that LS curves for the right heart chambers were higher in
magnitude than the curves for the corresponding left heart
chambers. In addition, RA and RV free-wall strain curves
peaked earlier than the corresponding left heart chambers. Sex
differences were also noted, with women having higher peak
LS values for all cardiac chambers compared with men. With
aging, LV strain minimally changed, whereas RV free-wall
strain progressively increased in magnitude until the sixth
decade. In contrast, both LA and RA peak strain progressively
decreased with age.
Figure 3. Mean longitudinal strain (LS) curves for
all 4 cardiac chambers superimposed to show relationships between chambers.
5 Addetia et al Simultaneous All-4-Chamber Strain
Table 2. Peak Systolic Longitudinal Strain (Top) and Time to Peak (Bottom) Values for All Four Cardiac
Chambers
LV*
RVFW†
LA†
RA†
RVFW*
LA‡
RA‡
LA*
RA§
RA*
44±19
Peak longitudinal strain, %
All
−18±2
<0.01
<0.01
<0.01
−23±6
<0.01
<0.01
38±13
<0.01
Men
−17±2
<0.01
<0.01
<0.01
−22±6
<0.01
<0.01
36±13
0.01
42±18
Women
−18±2
<0.01
<0.01
<0.01
−24±6
<0.01
<0.01
40±13
<0.01
46±20
Corrected time-to-peak strain (TTP/RR%)
All
40±6
<0.01
<0.01
0.08
39±7
<0.01
0.03
41±7
<0.01
40±7
Men
40±6
<0.01
0.06
0.31
37±6
<0.01
<0.01
40±6
<0.01
39±6
Women
41±6
0.67
<0.01
0.77
40±7
<0.01
1.00
42±7
<0.01
41±7
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LA indicates left atrium; LV, left ventricle; RA, right atrium; and RVFW, right ventricular free wall. P values refer to pairwise
comparisons between chambers with Bonferroni adjustments for multiple comparisons.
*Values for this chamber.
†P values indicate comparisons between this chamber and the LV.
‡P values indicate comparisons between this chamber and the RVFW.
§P values indicate comparisons between this chamber and the LA.
The speckle tracking–based strain analysis used in our
study has been validated in several studies ranging from simulated data to human subjects. D’hooge et al compared the performance of EchoInsight against other strain measurements
using simulated heart models8 and found good agreement
with reference strain values that closely matched measurements of other vendors. Ex-vivo validation was done using
sonomicrometry crystals in pump-driven, excised pig hearts,9
which were imaged using 3 different scanners (GE, Philips,
and Siemens), and the results showed excellent agreement
with strain determined by sonomicrometry (r>0.93). There
was also low variation between global strain measurements
derived from different scanners (<6%). A large, multivendor
comparison human study done under the guidance of the strain
standardization task force10 showed good agreement in global
LS values with other vendors (r=0.84). Although speckletracking quality can be affected by image quality, frame rate,
and heart rate, our testing has shown no strong dependence on
frame rate in the range of 40 to 70 Hz. Finally, this software
has been used in several studies to distinguish between health
and varying degrees of disease, including myocardium scarring11 and diastolic heart failure.12
Assessment of LV LS has been shown to be clinically
useful in a variety of cardiac diseases. In all previous studies,
deformation imaging has been used for each chamber separately. For example, in the setting of myocardial infarction, LV
LS correlates well with scar burden, which has been shown
to be associated with outcomes2 providing incremental value
for the detection of viable myocardium during dobutamine
stress echocardiography.13 LV LS has also been studied in valvular heart disease to better appreciate the impact of load on
cardiac function. In patients with severe aortic stenosis and
preserved LV ejection fraction, speckle tracking–derived LS
has been shown to be abnormal preoperatively and to improve
Figure 4. Sex differences in peak longitudinal strain values for women (blue bars) and men (yellow bars). Women had higher peak longitudinal strain (LS) values than men in all cardiac chambers (left). Differences reached statistical significance for the LV, RV free wall, and
LA (stars; P<0.05). Right, TTP strain (corrected for R-R interval) for all cardiac chambers in the 2 sex. The corrected TTP strain was significantly higher in women than in men for all chambers. LA indicates left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; and
TTP, time to peak.
6 Addetia et al Simultaneous All-4-Chamber Strain
Figure 5. Age differences in peak longitudinal strain
(LS) values for the different age groups (see text
for details). Colored stars above different columns
indicate significance of differences vs other groups
depicted in the corresponding color. LA indicates
left atrium; LV, left ventricle; RA, right atrium; and RV,
right ventricle.
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after aortic valve replacement.14 In these patients, LS has been
shown to have incremental prognostic value beyond that of
standard risk factors.15,16 In addition, subendocardial ischemia17 and cardiotoxicity associated with chemotherapy18
seem to predominantly affect the longitudinal myocardial
fibers which are responsible for longitudinal deformation.
When evaluating the RV, RV free-wall LS has been shown
to provide prognostic information in the setting of pulmonary
hypertension.7,19 Recent studies have also suggested that LA
strain may be an important predictor of successful radiofrequency catheter ablation of atrial fibrillation.20 LA strain has
also been explored as a measure of LA stiffness, which may be
important in the transition from hypertensive heart disease to
heart failure2 and perhaps also valuable to guide optimization
of antihypertensive therapy.21,22 Although there is only sparse
data on RA strain in the literature, results published to date
suggest that it may be a useful adjunct to functional assessment of the right heart.23
Essentially, multiple studies have shown that when LS is
studied individually for each of the 4 cardiac chambers, the
information obtained is incrementally useful. The rationale
behind our study is that if all this information could be combined for all 4 chambers, it could potentially improve the
echocardiographic assessment while providing untapped
prognostic information for individual patients.
LS and Sex
We found that women had higher peak LS values in all cardiac
chambers when compared with men. This may be associated
with the fact that women have smaller chambers and smaller
BSA. In the case of LV and RV strain, this is also in keeping with the higher LV and RV ejection fractions, which have
been recently reported in women.6,24,25 Additionally, higher
LV mass reported in men may also explain the lower LV LS26
(Table 1). Similar sex differences in LS have previously only
been described for the LV using echocardiographic data and
CMR.4,27 To our knowledge, this is the first report concerning
sex differences in strain in the other 3 chambers.
LS and Age Groups
The lack of significant difference in LV LS with aging warrants some discussion. Previous published data have been
Figure 6. Age differences in corrected time-to-peak
(TTP) values for the different age groups (see text
for details). Colored stars above different columns
indicate significance of differences vs other groups
depicted in the corresponding color. LA indicates
left atrium; LV, left ventricle; RA, right atrium; and RV,
right ventricle.
7 Addetia et al Simultaneous All-4-Chamber Strain
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Figure 7. Simultaneous 4-chamber strain assessment in a 62-year-old man with idiopathic pulmonary hypertension treated with Remodulin and Tadalafil. The patient had a supranormal LV ejection fraction. The RV was severely dilated and hypokinetic. There was severe
tricuspid regurgitation with no mitral regurgitation. Left atrial size was normal, whereas the right atrium was severely dilated. Estimated
systolic pulmonary artery pressure was 89 mm Hg (as obtained from the tricuspid regurgitation gradient and measure of right atrial pressure from the collapsibility of the inferior vena cava). LA indicates left atrium; LV, left ventricle; PSLS, peak systolic longitudinal strain; RA,
right atrium; and RV, right ventricle.
inconsistent when describing the relationship between age
and global LV LS. Some studies reported that there is no difference in LS between age groups,28 whereas others describe
that global LS decreases with increasing age.29 Some of these
differences have been attributed to intervendor differences
in algorithms used to measure strain.5 We used a new software platform for which no previous data exists. In our study,
LS for all 4 chambers was measured only in the 4-chamber
view. This may be important when attempting to compare our
results with those obtained from other studies because most
previous studies measured global LV LS in all 3 apical views.
The relationship between RV free-wall LS and age has not
been well studied. In our cohort, the magnitude of RV freewall LS increased with age. This difference between the 2
ventricles may reflect a differential ventricular adaptation to
age-related changes. Age-related structural changes in the LV
myocardium lead to systolic and diastolic alterations, which
in turn impact RV remodeling.30 Myocardial wall thickness,
for instance, increases with age, resulting in a higher myocardial wall-to-cavity ratio.31 This is associated with increased
myocardial relaxation time and stiffness and slightly elevated
end-diastolic pressures secondary to subclinical diastolic
dysfunction and stiffness.32–35 The RV may respond to this
afterload increase with a compensatory, more vigorous performance, which declines in the elderly (age >60 years). This
finding may reflect interchamber physiological coupling that
can only otherwise be appreciated using currently available
tools when the R-R interval is not variable. The drop in RV
free-wall LS in the oldest age group noted in our study could
also probably be explained by the fact that this group included
a higher proportion of Japanese subjects, who were found to
have lower magnitude RV free-wall LS compared with the US
subjects.
With respect to the atria, LS decreased progressively
with each successive decade of life. The decline in peak LA
strain between the youngest and the oldest age groups probably reflects the increased stiffness of the LA with age in
response to the changes in the LV outlined earlier.30 In addition, early diastolic filling declines with age to the point that
the LV filling depends more on atrial contraction. This may
also explain the fall in peak systolic LA LS with age. A similar
reasoning can be applied to explain the decrease in RA LS,
although our knowledge of right-heart diastology is limited.
In summary, these findings in the atria most probably reflect
adaptation to age-related changes in the ventricles. These
changes become evident only when assessing strain in all 4
chambers simultaneously.
Clinical Implications
Measurement of LS in all 4 chambers simultaneously is
relatively straightforward when suitable images are available. Using this novel tool, it can be possible to assess the
interchamber functional relationships in different cardiac diseases states, such as heart failure, pulmonary hypertension,
restrictive and infiltrative cardiomyopathies, and ischemic
heart disease. As an example, we used this new tool to study
a clinically stable patient with idiopathic pulmonary hypertension (Figure 7). His peak strain ratios for RV/LV, LA/LV,
RA/RV, and RA/LA were 1.2, 1.7, 2.4, and 1.7, respectively.
Compared with the normal values obtained in this study, the
peak LS RA/LA and RV/LV ratios were elevated, suggesting
that right heart function is hypercontractile when compared
with left heart function. It is theoretically possible that if the
ratio decreased toward normal, it could mean that the patient
is decompensating. Testing this hypothesis requires further
study. Indeed, this tool may provide incremental information
on outcomes, particularly when incorporating functional information from all 4 chambers because there is already evidence
that deformation parameters in the individual chambers have
prognostic significance in a multitude of cardiac diseases.
Limitations
The main limitation of the new tool is that it can best be
applied when the images are of adequate quality with all 4
chambers included in the imaging sector, and the software
is able to successfully track wall motion in all 4 chambers.
We did not assess radial and circumferential strains in this
study. We focused on LS only because this index has proven
8 Addetia et al Simultaneous All-4-Chamber Strain
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to be the most promising in the clinical arena, with the largest
body36 of literature supporting its use, while providing incremental prognostic information in a variety of disease states.2
Subgroup analyses performed in this study involve smaller
groups and therefore may not be sufficiently powered to
generalize the results. These results need to be confirmed in
larger-scale studies. Similar to single-chamber assessment of
LS, multichamber simultaneous strain assessment as studied
here also falls prey to the universal limitation of 2D strain.
Specifically, single plane strain measurement fails to take into
account motion outside the imaging plane, resulting in underestimated strain values. This has been previously demonstrated in several publications.37 However, the vast majority
of the strain-related publications are based on 2D measurements, which have been validated extensively, including
established normal values. Although simultaneous 3D strain
measurements in all 4 cardiac chambers are theoretically not
impossible, software implementation of this approach has yet
to be developed.
Conclusions
Simultaneous measurement of LS in all 4 cardiac chambers
provides new insight into interchamber coupling. This novel
tool may prove useful in the evaluation and follow-up of different cardiac disease states.
Disclosures
Dr Lang serves on the speakers’ and advisory bureau of and has received research grants from Philips Medical Imaging. The remaining
authors have no disclosures.
References
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CLINICAL PERSPECTIVE
Longitudinal strain has been studied for each cardiac chamber individually, and, at least for the left ventricle, the right
ventricular free wall, and the left atrium, strain assessment has been shown to be of potential clinical value in a variety of
disease states. We explored the concept of simultaneous all-4-chamber strain assessment within a single cardiac cycle in a
large population of normal subjects as a means for understanding normal interchamber functional relationships. We were
able to show that when combined, strain curves for all 4 chambers followed specific patterns. Peak longitudinal strain for the
right ventricle was 10% higher in magnitude, on average, than that for the left ventricle, whereas left and right atrial peak
longitudinal strain was 70% and 90% higher than measured in the left and right ventricles, respectively. Right atrial peak
longitudinal strain was 4% higher in magnitude than left atrial peak strain. Peak longitudinal strain values were larger in
women than in men. Longitudinal strain declined with age for both atria. Right ventricular free-wall strain augmented with
age until the sixth decade, whereas left ventricular strain changed minimally with age. This initial study provides insight into
normal interchamber relationships which can, in the future, be used to study atrial and ventricular coupling in diseases, such
as pulmonary arterial hypertension, cardiomyopathy, and valvular heart disease.
Simultaneous Longitudinal Strain in All 4 Cardiac Chambers: A Novel Method for
Comprehensive Functional Assessment of the Heart
Karima Addetia, Masaaki Takeuchi, Francesco Maffessanti, Yasufumi Nagata, James Hamilton,
Victor Mor-Avi and Roberto M. Lang
Downloaded from http://circimaging.ahajournals.org/ by guest on May 11, 2017
Circ Cardiovasc Imaging. 2016;9:e003895
doi: 10.1161/CIRCIMAGING.115.003895
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