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Strain, Strain Rate, Torsion What are They and
When Should We Use Them?
John Gorcsan, MD
University of Pittsburgh,
Pittsburgh, PA
Disclosures: Research Grant Support from GE, Toshiba, Medtronic, St. Jude and Biotronik
Vectors of Myocardial Strain
Gorcsan J, JACC 2011;58:1401-13Gorcsan J, Do Not Copy
Tissue Doppler: Velocity, Strain Rate and Strain
Frequency Shift(kHz)
Gorcsan J, JACC 2011;58:1401-13Gorcsan J, Do Not Copy
PROBLEMS WITH TISSUE DOPPLER STRAINTissue Doppler
Strain is measured along scan lines !
Myofiber Orientation Is Complex
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STRAIN IMAGING BY TISSUE DOPPLER IS AFFECTED BY DOPPLER ANGLE
Urheim, Smitheth et al. Circulation 2000;102:1158-1164Gorcsan J, Do Not Copy
Tissue Doppler Longitudinal Strain Analysis
Septal Lateral
Normal subjectGorcsan J, Do Not Copy
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STRAIN vs. VELOCITY
Strain = (L-L0) / L0
L0 L
L0
L
L0 = Original LengthL = Length of Deformed portion
STRAIN ISOLATES THICKENING
Thickening
Passive Movement
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What Is Speckle Tracking ?
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Calculation of Strain FromSpeckle Tracking
Not Dependent on Doppler Angle
Frame 1 Frame 1 + n
Strain =Change in Length Original Length
% Thickening
% Thinning
Modified from Kawagishi, KGorcsan J, Do Not Copy
Speckle Tracking Longitudinal Strain
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APPLICATION OF SPECKLE TRACKING TO ROUTINE ECHO IMAGES
Radial Strain
REGION OF INTEREST
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Speckle Tracking: RADIAL STRAIN ANALYSIS
Normal subject
% T
hic
ken
ing
Time
% Thickening
% Thinning
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REGION OF INTEREST
APPLICATION OF SPECKLE TRACKING TO ROUTINE ECHOIMAGES
Circumflential StrainGorcsan J, Do Not Copy
Speckle Tracking: CIRCUMFLENTIAL STRAIN ANALYSIS
Normal subject
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Apical Long-AxisApical 2-ChamberApical 4-Chamber
DYSSYNCHRONY ANALYSISLongitudinal Strain
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Speckle Tracking Longitudinal Strain
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TRANSVERSE STRAINImpossible for Tissue Doppler
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Normal
Apical Long Axis viewApical 4-Chamber viewSpeckle Tracking Transverse Strain
Thickening
Thinning
Early Diastolic Strain Rate vs. Interstitial Fibrosis
Park, Nagueh et al2006 Am J PhysiolHeart Circ Physiol290: H724–H731
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CONTRACTION-RELAXATION COUPLING
Ca ++
Actin
Myosin
Actin
Myosin
Contraction Active Relaxation
ATP ATP
Myofibril-Systole Myofibril-Diastole
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Longitudinal and Radial Strain and Strain Rate
Tamuro…Ito et al. J Am Soc Echocardiogr 2010;23:747-54. Tamuro…Ito et al. J Am Soc Echocardiogr 2010;23:747-54.
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Systolic-Diastolic Coupling
Tamuro…Ito et al. J Am Soc Echocardiogr 2010;23:747-54.
Ant-SepAnteriorLateralPosteriorInferiorSeptalAverage
Echo vs. Cardiac Magnetic Resonance Comparison
Echo (SAX)
CMR (SAX)
ECG
Time (ms)
Circumferential strain in Echo
Circumferential strain in CMR
(GCS)
100ms
0
-15
Str
ain
ECG
Time (ms)
0
-15
Str
ain
Normal systolic function patient
Onishi T, Saha S, …Gorcsan et al. ESC 2011
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Reproducibility of Global Circumferential strain by CMR & ECHO
0 10 20 30 40 50
50
40
30
20
10
0
GCS by echo speckle tracking (%)
GC
S b
y C
MR
(%
)
0 10 20 30 40 50
15
10
5
0
-5
-10
-15
Mean
0.5
-1.96 SD
-12.0
+1.96 SD
13.0
Mean GCS (%)
GC
S E
CH
O -
CM
R (
%)
r = 0.85
p < 0.001
Onishi T, Saha S, …Gorcsan et al. ESC 2011Gorcsan J, Do Not Copy
Echocardiogram
Global Longitudinal Strain
Cardiac MagneticResonance
Str
ain
(%)
Time (ms)100ms
Normal Systolic Function(CMR-EF=62%)
-10
0
Systolic Dysfunction(CMR-EF=26%)
-20
-30
Time (ms)100ms Time (ms)
100ms
Time (ms)
100msS
trai
n (%
)
-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
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0 20 40 60 80-30
-20
-10
0
0 20 40 60 80-30
-20
-10
0
FT
CM
R-G
LS (
%)
ST
Ech
o-G
LS (
%)
R = 0.88p < 0.0001
R = 0.85p < 0.0001
CMR-EF (%) CMR-EF (%)
n=73 n=68
-40
-30
-20
-10
0
CMR-EF (%)
FT
CM
R-G
CS
(%
)
-40
-30
-20
-10
0
CMR-EF (%)
ST
Ech
o-G
CS
(%
)
0 20 40 60 80 0 20 40 60 80
R = 0.95p < 0.0001
R = 0.92p < 0.0001
n=73 n=71
Global Longitudinal Strain vs. CMR EF
Global Circumferential Strain vs. CMR EF
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Global Circumferential Strain & Prognosis in Heart Failure
• 201 HF patients• EF = 23%• HF Hospitalization
or Death 5 yrs
Cho et al. J Am Coll Cardiol 2009;54:618
Str
ain
(%)
-10
0
-20
-30
-40
Time (ms)100ms
GCS
ECG
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Objectives: To evaluate if more sensitive echocardiographic measurements and biomarkers could predict later cardiac dysfunction in chemo-treated patients.
Sensitivity Specificity PPV NPV
10% decrease longitudinal strain 7/9 (78%) 27/34 (79%) 7/14 (50%) 27/29 (93%)
Increased cTnl at 3 months 6/9 (67%) 28/34 (82%) 6/12 (50%) 28/31 (90%)
10% decrease Long strain andincreased cTnl at 3 months 5/9 (55%) 33/34 (97%) 5/6 (83%) 33/37 (89%)
10% decrease Long strain orincreased cTnl at 3 months 8/9 (89%) 22/34 (65%) 8/20 (40%) 22/23 (97%)
Sensitivity Specificity PPV NPV
10% decrease longitudinal strain 7/9 (78%) 27/34 (79%) 7/14 (50%) 27/29 (93%)
Increased cTnl at 3 months 6/9 (67%) 28/34 (82%) 6/12 (50%) 28/31 (90%)
10% decrease Long strain andincreased cTnl at 3 months 5/9 (55%) 33/34 (97%) 5/6 (83%) 33/37 (89%)
10% decrease Long strain orincreased cTnl at 3 months 8/9 (89%) 22/34 (65%) 8/20 (40%) 22/23 (97%)
Sensitivity Specificity PPV NPV
10% decrease longitudinal strain 7/9 (78%) 27/34 (79%) 7/14 (50%) 27/29 (93%)
Increased cTnl at 3 months 6/9 (67%) 28/34 (82%) 6/12 (50%) 28/31 (90%)
10% decrease Long strain andincreased cTnl at 3 months 5/9 (55%) 33/34 (97%) 5/6 (83%) 33/37 (89%)
10% decrease Long strain orincreased cTnl at 3 months 8/9 (89%) 22/34 (65%) 8/20 (40%) 22/23 (97%)
Am J Cardiology 2011;107(9):1375-80Gorcsan J, Do Not Copy
Speckle Tracking Left Atrial Strain
Positive PeakStrain
Negative PeakStrain
Total Strain
Left Atrial Function Predicts Atrial FibrillationRecurrence After Catheter Ablation
No Recurrence Group
(n = 34; 54%)
Atrial FibrillationRecurrence Group
(n = 29; 46%)
Mirza M, Caracciolo et al. J Interv Card Electrophysiol 2011
63 pts. AFIB Cathelter Ablation 75% PAF, 25% Persistent AF 18±12 months of follow-up
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MYOFIBER ORIENTATION IS THREE DIMENSIONAL
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The Advantage of Echocardiographic 3D Tracking2D Imaging, Myocardium Moves In and out of Plane
3D Imaging, Entire Myocardium Is Tracked
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3D SPECKLE TRACKING ANALYSIS
Thickening
Thinning
Radial Strain
C1
C1
C3
4-Chamber View 2-Chamber View
NORMAL 3D STRAIN
NORMALDilated CardiomyopathyLBBB
AnteriorSeptal
Posterior
3D Speckle TrackingWire Mesh View
Tanaka, H… Gorcsan J et al. Am J Cardiol 2009 Gorcsan J, Do Not Copy
APICAL TORSION
3D Speckle Tracing Strain
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DECREASED LV ROTATION IN HEART FAILURE- NORMAL EF
Basal Rotation
Apical Rotation Tan…Sanderson et al. J Am Coll Cardiol 2009;54:36–46
Heart Failure PatientNormal EFNormal Control
Untwist Untwist
HFNEF has Blunted Increases in LV Function with Exercise
0
20
40
60
80
100
120
140n = 27 Normal Controls, n = 56 HFNEF,
Normal HFNEF Normal HFNEF Normal HFNEF
RestExercise
Longitudinal Strain
RadialStrain
Untwist Rate
Tan…Sanderson et al. J Am Coll Cardiol 2009;54:36–46
%
*
*
*
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Proposed Pathophysiology HFNEF
Tan…Sanderson et al. JACC 2009;54:36–46
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NORMAL RV Longitudinal Strain
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RV Strain and Outcomes in PH
Fine, Kane et al. Circ CV Img 2013
Time free of cardiac events or PH medical intervention
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Right Ventricular 3D Speckle Tracking Strain
NormalPulmonary Hypertension
Thickening
Thinning
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NORMAL CONTROL
End-systoleEnd-diastole
Right Ventricle
3D Global Strain 35%
SEVERE PH PATIENT
End-systole End-diastole
Right Ventricle
3D Global Strain 15%
RV AREA TRACKING STRAINEXAMPLES
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Strain, Strain Rate, Torsion• Speckle tracking strain has emerged as the
echocardiographic method of choice for advanced quantification of cardiac function.
• Emerging clinical applications include Global Longitudinal Strain, and Global Circumferential Strain to assess LV function.
• Torsion is helpful to understand diastolic function.
• Newer potential applications include 3D strain and RV strain imaging.