9/28/2017

1

Strain Imaging: Myocardial Mechanics Simplified and Applied

John Gorcsan III, MD

Professor of Medicine

Director of Clinical Research Division of Cardiology

Disclosures: Research grant from Hitachi-Aloka, Medtronic, GE and Biotronik

Twisting

VECTORS OF CONTRACTION

ThickeningShortening

Gorcsan J. 2017

Calculation of Strain FromSpeckle Tracking

Not Dependent on Doppler Angle

Frame 1 Frame 1 + n

Strain =Change in Length

Original Length

Modified from Kawagishi, K

% Lengthening or Thinning

% Shortening or Thickening

LONGITUDINAL STRAIN IMAGING

Strain = Change in Length / Original Length

Longitudinal StrainLV Shortening

End Diastole End Systole

%

Strain =% Change in Length

End-Diastole

End-Systole

Gorcsan J. 2017

Longitudinal Strain

End-Diastole

End-Systole - 23%

Gorcsan J. 2017

9/28/2017

2

Apical Long-AxisApical 2-ChamberApical 4-Chamber

Global Longitudinal Strain (GLS)Average Strain

Gorcsan J. 2017

Global Longitudinal Strain (GLS)Average Strain

Apical 4-Chamber

Apical 2-Chamber

Apical Long-Axis

Polar(Bull’s Eye) Plot

Gorcsan J. 2017

What is Normal? Global Longitudinal Strain

GLS: -15.7 to -21.1%, mean -19.7%

N = 2,597

Yingchoncharoen…Marwick et al. JASE 2013;26:185

GLS Values Vary by Vendor, Gender and Age

Plana et al. J Am Soc Echocardiogr 2014;27:911-39

GE

Philips

Toshiba

Normal Strain ValuesThreshold for Abnormal

• Global Longitudinal Strain

Normal GLS:> -17%

Borderline GLS: between -17% and -15%

Clearly Abnormal GLS: < -15%

Think of GLS in absolute values(I Prefer to Forget the – sign)

Gorcsan J. 2017

Global Strain Must Relate to Ejection Fraction

LV Deformation = LV Blood EjectionGorcsan 2017

9/28/2017

3

Mathematical Linear Relationship of GLS to EF

Linear Fit EF = 3 (GLS)

Echocardiogram

Cardiac MagneticResonance

Str

ain

(%)

Time (ms)100msNormal Systolic Function(CMR-EF=62%)

-10

0

Systolic Dysfunction(CMR-EF=26%)

-20

-30

Time (ms)100ms Time (ms)

100ms

Time (ms)

100ms

Str

ain

(%)

-10

0

-20

-30

Str

ain

(%)

-10

0

-20

-30

Str

ain

(%)

-10

0

-20

-30

GLS

GLS

GLS

GLS

Basal-Septal Mid-Septal Apical-SeptalApical Lateral Mid-Lateral Basal-Lateral

Global Longitudinal Strain (GLS)

ECG

ECG

ECG

ECG

NormalNormal Heart Failure Patient

Echo vs. Cardiac Magnetic Resonance

Onishi T, …Gorcsan et al. JASE 2015

30

10

20

GLS vs. EF

0 20 40 60 800

10

20

30

FT

CM

R-G

LS

(%

)

R = 0.88p < 0.0001

CMR-EF (%) CMR-EF (%)

n=73

20 40 60 80

-

0

ST

Ech

o-G

LS

(%

)

R = 0.85p < 0.0001

n=68

Echocardiogram

Str

ain

(%)

Time (ms)100ms

-10

0

-20-30

Str

ain

(%)

GLS

ECG Normal

EF = 3* |GLS| + 8Onishi T, …Gorcsan et al. JASE 2015

Differences in EF and StrainLV Hypertrophy

Lumens et al. 2016

What Additional Information?GLS as a Marker for Scar

Kansal et al. Eur Heart J Cardiovasc Imaging 2012 

Myocardial Scar by Late Gadolinium Enhancment CMR

LS

LS

LS

ENDOCARDIAL SCARRING

MIDMYOCARDIAL SCARRING

TRANSMURAL SCARRING

Gjesdal et al.Clinical Science (2007) 113, 287–296

N = 59

GLOBAL STRAIN (%)

INFARCT SIZE (G)

N = 38

9/28/2017

4

Strain is Additive to EF

Ejection Fraction

Blood Displacement

Strain

Wall Properties of Disease

• Hypertrophy

• Fibrosis

More Reproducible than EFGorcsan J. 2017

Strain is Additive to EFFar Ends of Spectrum

High EFVery

Low EF

N = 1,065 Heart Failure Clinic Patients

Low EF Patients

N = 1,065 Heart Failure Clinic Patients

Echo Parameters

Two-site LV Pacing

Cardiac Resynchronization TherapyTreatment for Low EF Wide QRSHeart Failure

9/28/2017

5

Baseline Global Strain is Associated with Outcome After CRT

HF Hospitalization or Death

0 1 2 3 4

0

20

40

60

80

100

Follow-Up Time (years)

Su

rviv

al p

rob

abili

ty (

%)

GLS>-9% 112 69 52 42 33

GLS≤-9% 93 77 65 56 45

GLS≤-9%

GLS>-9%

p=0.0002 ; HR 2.10, 95% CI 1.45-3.05

N=205Routine CRT Indications QRS > 120m2

Global Longitudinal Strain

Delgado-Montero, … Gorcsan et al, Circ CV Imaging 2016 Ruschitzka et al. NEJM 2013 September 3

N = 809

• LVEF < 35%

• QRS < 130 ms

• Echo Dyssynchrony

Randomized to:

CRT Off

CRT On

EchoCRT: CRT in Narrow QRSIncrease in All-Cause Mortality

HR = 1.81 (1.11, 2.93)

p=0.02

GLS and Cardiovascular Mortality CRT On vs. CRT Off

* p = 0.008

< 6.2% 6.2-7.9% 7.9-10.1% >10.1%

n = 755

Global Longitudinal Strain (absolute values)

Car

dio

vas

cula

r D

eath

s (%

)

Bax… Gorcsan et al. EHJ 2016 (Figure Unpublished) 

*

GLS < 6.2%, CRT-OnGLS < 6.2%, CRT-OffGLS > 6.2%, CRT-OnGLS > 6.2%, CRT-Off

*p= 0.007 vs. other groups, HR=5.70 (95% CI 1.61-20.13),

n = 755

GLS < 6.2%, CRT-Off

GLS < 6.2%, CRT-On

GLS and Cardiovascular Mortality CRT On vs. CRT Off

Years from RandomizationBax… Gorcsan et al. EHJ 2016

Features of Additive Risk

LOW EF LOW GLS

J. Gorcsan Euro-Echo Imaging 2016

Dyssynchrony

9/28/2017

6

GLS and Asymptomatic Severe MR with Preserved EF

• 737 patients

• Severe MR

• LVEF > 60%

• Non‐dilated LV

– ESD < 4.0cm

– ESDi <  3.3cm/m2

GLS and Asymptomatic Severe MR with Preserved EF: Risk of Death

-20%

Risk of Deathn = 737

Worse Strain

Better Strain

Worse Strain

Neurocardiac Injury in Subarachnoid Hemorrhage

“Cerebral T Waves”

GLS to Assess Neurocardiac Injury in Subarachnoid Hemorrhage

Kagiyama…Gorcsan et al. ASE 2017

• 255 patients• 52±10 yrs

• 72% female

• GLS in ICU (mean 2 days from bleed)

• Strain feasible on 221

20

30

40

50

60

70

80

5 10 15 20 25 30

LVEF 

(%)

GLS (%) (absolute values)Kagiyama…Gorcsan et al. ASE 2017

Relationship of GLS to EF in Subarachnoid Hemorrhage 

N = 221

0

5

10

15

20

25

Mortality 

5‐10% 10‐15% 15‐20% 20‐25% 25‐30%

%

Linear relationship, P = 0.013

GLS (absolute values)

N = 221

GLS and In-Hospital Mortality with Subarachnoid Hemorrhage

Kagiyama…Gorcsan et al. ASE 2017

9/28/2017

7

Potential Factors in Neurocardiac Injury

Catecholamine Surge

SubarachnoidHemorrhage

Individual Susceptibility

Myocyte InjuryImpaired

Myocardial Perfusion Kagiyama…Gorcsan et al. 

0

5

10

15

20

25

Controls (n=50) Hypertensive Heart Disease (n=44)

HFpEF (n=219)

* p<0.001 vs. Controls and Hypertensive Heart Disease

Kraigher-Krainer,…Solomon et al. JACC 2014;63:447–56

**

Global Longitudinal Strain (%) absolute values%

Kraigher-Krainer,…Solomon et al. JACC 2014;63:447–56

Association of GLS with Biomarkers for Heart Failure (NT-proBNP)

GLS Predictive of Survival in Patients with ESRD and Preserved EF N = 48 African Americans with ESRD on Hemodialysis LV EF > 50% Baseline GLS – Prospectively enrolled and followed 1.9 years GLS was predictive of All Cause Mortality GLS Cut-Off < 16% (absolute values) Hazard ratio 1.15, 95% confidence interval 1.02 to 1.30, p = 0.02,

Pressman G…Gorcsan J et al. Am J Cardiol 2015 Nov 15;116(10):1601-4.

CASE STUDY• 62 year old man with weight loss,

gastroparesis, dyspnea and edema.

Apex

BaseMid

Gorcsan J. MSE 2017

9/28/2017

8

Segmental Longitudinal Strain

Basal Strain = - 5.0%Mid Strain = - 5.8%Apical Strain = -17.2%

Basal Strain = - 21.1%Mid Strain = - 22.3%Apical Strain = -25.3%

Amyloid Heart Disease

Normal SubjectOur Patient

Apical Sparing

Apical Longitudinal Strain Sparing in Amyloidosis

Examples of Increase Wall Thickness No Amyloidosis

Examples of Cardiac Amyloidosis

Phelan…Thomas JD, Heart 2012

Prevalence of Abnormal Echo Indices in Cardiac Amyloidosis

Quarta, Solomon et al. Circulation. 2014;129:18 1840-1849

n = 172 patients with Cardiac Amyloidosis n=80 with Light Chain Immunoglogulins n=36 transthyretin-related mutant form n=56 Nonmutant transthyretin-related amyloidosis

GLS Predicts Survival in Cardiac Amyloidosis

Quarta, Solomon et al. Circulation. 2014;129:18 1840-1849

An 85 year woman with progressive shortness of breath and syncope

Severe Aortic Stenosis Peak Velocity 5 m/secPeak Gradient 100 mmHg, Mean Gradient 69 mmHg

AVA = 0.6 cm2

n = 125 patients with Severe ASPreop GLS

GLS Quartile 1 and 2

GLS Quartile 3

GLS Quartile 4

9/28/2017

9

GLS was Additive to Clinical Features and EF

n = 125

Cardio-oncology Progress in Cancer Survival Rates

• Substantial improvements in cancer patient survival.

• 14.5 million cancer

survivors in the US

• Leads to a higher prevalence of patients with cancer and cardiovascular disease

DeSantis C.E., Lin C.C., Mariotto A.B., et al; Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014;64:252-271.

GLS was Additive to EF to Predict Chemo Cardiotoxicity

N = 24 patients with cardiotoxicity

Nigishi…Marwick et al. JASE 2013 GLS < 11%

Ultrasound system Fluoroscopy Angiographic SystemStrain New Directions: Fusion imaging

Strain Activation: Early Late

Fusion imaging

LAO ViewRAO View

RV 3D SPECKLE TRACKING

C3

C4

C5

9/28/2017

10

Normal Control RV Adapted Remodeled RV Adverse Remodeled

sPAP 86mmHgestimate sPAP 20mmHg sPAP 83mmHg

RV Adapted

End Systole End Systole End Systole

sPAP 44mmHg

End Systole

RVEF 18%G-AS -14%

volume curve

RVEF 41%G-AS -28%

volume curve

RVEF 50%G-AS -39%

volume curve

(ml)120

0

(ml)180

0

(ml)220

0

(ml)280

0

RVEF 27%G-AS -24%

volume curve

global area strain

global area strain

global areastrain

global area strain

RV 3D Strain and Volume in Pulmonary HypertensionPH Patients

Months

Pro

ba

bili

ty o

f F

ree

do

m F

rom

H

ospi

taliz

atio

n,

Dea

th o

r Lu

ng

Tra

nspl

anta

tion

0 1 2 3 4 5 6

0

10

20

30

40

50

60

70

80

90

100

51 47 44 43 43 39 37

28 20 18 16 14 13 13

13 7 7 5 2 2 2

(%)

Log rank P<0.0001

RV Adapted

RV Adapted Remodeled ‡

RV Adverse Remodeled †

‡P=0.0001 vs. RV Adapted†P=0.04 vs. RV Adapted Remodeled

n=92

RV Adapted

RV Adapted Remodeled

RV Adverse Remodeled

Number at risk

Pulmonary Hypertension PatientsHospitalization, Death or Lung Transplantation

Ryo…Gorcsan et al. Circ CV Imaging May 2015

3D RA Strain Analysis: Pulmonary Hypertension vs. Control

Normal Control

Pulmonary Hypertension Patient

3D RA Volume

3D RA Global AreaStrain

3D RA Volume

3D RA Global AreaStrain

Sugahara…Gorcsan et al.

3D RA Strain and Clinical OutcomesPulmonary Hypertension Patients

Hospitalization, Death or Lung TransplantationF

ree

do

mfr

om

Clin

ica

l Ev

en

ts(%

)

Follow up, Months

0 1 2 3 4 5 6

0

20

40

60

80

100

RA 3D Global Area Strain > 17%

RA 3D Global Area Strain ≤ 17%*

*P<0.001HR 13.04 (95%CI 3.7 - 45.8)

Fre

ed

om

fro

m C

linic

al E

ve

nts

(%)

0 1 2 3 4 5 6

0

20

40

60

80

100

Follow up, Months

*P<0.001HR 8.66 (95%CI 2.8 – 26.6)

RA max Volume Index < 56ml/m2

RA max Volume Index≥ 56ml/m2* F

ree

do

mfr

om

Clin

ica

l Ev

en

ts(%

)

0 1 2 3 4 5 6

0

100

20

40

60

80

Follow up, Months

*P<0.001HR 8.66 (95%CI 2.8 – 26.6)

RA Emptying Fraction> 19%

RA Emptying Fraction ≤ 19%*

N = 54 patients

Sugahara…Gorcsan et al.

J Am Soc Echocardiogr 2015;28:183-93

ASE Announcement: Myocardial Strain Imaging• Acceptance of New CPT Category III code, 039X9T• Introduced January, 2016.• Category III codes are not yet reimbursed: Often lead to the adoption of payable codes by CMS and other payers.

Strain Imaging into the Future Take Home Messages

• Speckle Tracking Strain has emerged as the most useful new echocardiographic tool to assess myocardial function.

• Global Longitudinal Strain is best represented in the literature as being a sensitive measure additive to EF.

• Most Promising New Clinical Applications:• Adding to EF in Heart Failure to Enhance Prognosis

• Cardiac Amydoidosis

• Valvular Heart Disease

• Neurocardiac Injury

• Cardio-oncology

• 3D Strain has promise for the future! Gorcsan J. 2017