Speckle tracking: distinction of physiologic from pathologic LVH?

Full text

Page 1

EDITORIAL COMMENT
Speckle tracking: distinction of physiologic
from pathologic LVH?
E. E. van der Wall•V. Delgado•E. R. Holman•
J. J. Bax
Received: 12 August 2010/Accepted: 13 August 2010/Published online: 24 August 2010
? The Author(s) 2010. This article is published with open access at Springerlink.com
Over the past years, echocardiography and magnetic
resonance imaging (MRI) have become important
imaging modalities in patients with a broad spectrum
of cardiomyopathies [1–20]. Both imaging modalities
have been shown to play a pivotal role in the accurate
evaluation of left ventricular function particularly in
patients with ischemic heart disease and different
forms of cardiomyopathy [21–36]. These methods are
needed to accurately identify and characterize patients
with various manifestations of left ventricular hyper-
trophy (LVH) [37–49]. The important question should
be resolved whether training-induced LVH in athletes
is a physiological rather than a pathophysiological
phenomenon [50–57]. In a meta-analysis using MRI,
involving 59 studies and 1,451 athletes (both endur-
ance-trained and strength-trained athletes), it was
reported that the athlete’s heart demonstrated normal
systolic and diastolic cardiac function, implying that
training-induced LVH in athletes is predominantly a
physiological phenomenon [58]. With respect to
echocardiography,two-dimensionalstrainhasbecome
a novel method to measure strain from standard two-
dimensional echocardiographic images by speckle
tracking. Speckle tracking offers the advantage of
being less angle-dependent and more reproducible
than conventional Doppler-derived strain [59–61].
This echocardiographic imaging technique allows
quantification of global and regional myocardial
deformation on the basis of tracking of acoustic
markers from frame-to-frame.
In the current issue of the International Journal of
Cardiovascular Imaging, Butz et al. [62] questioned
whether two-dimensional strain assessed by speckle
tracking was useful as an additional tool in differen-
tiating pathologic from physiologic LVH in high-level
athletes. The objective of the study was to identify and
characterize global and regional function abnormali-
ties in patients with pathological left ventricular
hypertrophy (LVH) caused by non-obstructive hyper-
trophiccardiomyopathy(HCM),inhigh-levelathletes,
and in healthy controls. The authors consecutively
studied53subjectsconsistingof15patientswithHCM
and 20 competitive top-level athletes. A control group
of 18 sedentary normal subjects was studied by
standard echocardiography according to standard
guidelines. Global longitudinal strain and regional
peak systolic strain were assessed by two-dimensional
strain in the apical four-chamber view. It turned out
that all components of strain were significantly
reduced in patients with HCM when compared to
athletes and control subjects. There was no significant
difference between thestrainvaluesofthe athletes and
the control group, but in some segments the strain
Editorial comment to the article of Butz et al.
(10.1007/s10554-010-9665-5).
E. E. van der Wall (&) ? V. Delgado ?
E. R. Holman ? J. J. Bax
Department of Cardiology, Leiden University Medical
Center, P.O. Box 9600, Leiden, The Netherlands
e-mail: e.e.van_der_wall@lumc.nl
123
Int J Cardiovasc Imaging (2011) 27:101–104
DOI 10.1007/s10554-010-9689-x

Page 2

values of the control group were significantly higher
than those in the athletes. A cut-off value of global
longitudinal strain less than -10% for the diagnosis of
HCM resulted in a sensitivity of 80% and a specificity
of 95%. The combination of tissue Doppler imaging
(averaged S0, E0) and global longitudinal strain cut-off
values for the detection of pathologic LVH in HCM
demonstrated asensitivity of100% anda specificityof
95%. The authors concluded that speckle tracking is a
new simple and rapid method to measure global
longitudinal strain and peak systolic strain as compo-
nents of systolic strain.
This novel and very interesting technique offers a
unique approach to quantify global as well as regional
systolic dysfunction, and might be used as new
additional tool for the differentiation between physi-
ologicandpathologicLVH.Thepresentstudyisoneof
the first that used the combined and comprehensive
tissue Doppler imaging analysis of systolic and early
diastolic velocities of the lateral and septal mitral
annulus as well as two-dimensional strain analysis for
thedifferentiationbetweenpathologicandphysiologic
LVH. The main results of this intriguing study show
that global strain is significantly reduced in patients
with HCM and that strain measurements can therefore
be used for differentiation between pathologic and
physiologic LVH. Especially, the combination of
tissue Doppler imaging and two-dimensional strain
assessmentallowsthedifferentiationofpathologicand
physiologic LVH with acceptable sensitivity and
specificity. This differentiation is extremely important
in terms of clinical well-being, treatment and progno-
sis. In physiologic hypertrophy, such as in athletes,
LVH reveals normal circumferential, radial, and
longitudinal profiles possibly indicating that myocar-
dial strain imaging might be useful as additional
echocardiographic modality for the differentiation
between athlete’s heart and HCM. In pathologic
hypertrophy, LVH appears to be associated with
subendocardial fibrosis, which might be a potential
mechanism for the failure of the hypertrophied myo-
cardium in due time. In another study by the same
group [63], peak systolic longitudinal strain of the
basal septum and the opposite lateral wall was
measured in addition to standard echocardiography
in 88 consecutive patients with obstructive HCM who
underwent a septal ablation procedure. Regional
myocardial deformation was assessed quantitatively
by speckle tracking. During a 12-month observation
period, no patient had a severe adverse event. Reduc-
tion of left ventricular afterload by elimination of the
outflow gradient followinga successful septal ablation
procedure resulted in improvement of systolic lateral
longitudinal function in patients with obstructive
HCM.
To summarize, two-dimensional strain analysis
by echocardiography is a new simple, rapid, and
reproducible method to measure systolic strain.
Echocardiographic speckle tracking allows accurate
quantitative assessment of regional myocardial defor-
mation. As a result, the speckle tracking technique
can be used as additional tool for (1) a comprehensive
cardiac evaluation in subjects with physiologic
hypertrophy versus pathologic hypertrophy, and (2)
an appropriate assessment of the effects of therapy in
patients with pathologic LVH.
Open Access
Creative Commons Attribution Noncommercial License which
permits any noncommercial use, distribution, and reproduction
in any medium, provided the original author(s) and source are
credited.
This article is distributed under the terms of the
References
1. Ten Cate FJ (2009) Cardiomyopathies: a revolution in
molecular medicine and cardiac imaging. Neth Heart J
17:456–457
2. Kleijn SA, Kamp O (2009) Clinical application of three-
dimensional echocardiography: past, present and future.
Neth Heart J 17:18–24
3. Kamp O (2008) History of echocardiography in The
Netherlands: 30 years of education and clinical applica-
tions. Neth Heart J 16:16–20
4. Nemes A, Geleijnse ML, van Geuns RJ et al (2008)
Dobutamine stress MRI versus threedimensional contrast
echocardiography: it’s all black and white. Neth Heart J
16:217–218
5. Cramer MM, De Boeck BW (2007) Three-dimensional
echocardiography and left bundle branch block: prime time
in cardiology. Neth Heart J 15:87–88
6. Schuijf JD, Bax JJ, van der Wall EE (2007) Anatomical
and functional imaging techniques: basically similar or
fundamentally different? Neth Heart J 15:43–44
7. van der Wall, Vliegen HW, de Roos A, Bruschke AV
(1995) Magnetic resonance imaging in coronary artery
disease. Circulation 92:2723–2739
8. van der Wall EE, Siebelink HM, Bax JJ (2010) Evaluation
of hypertrophic cardiomyopathy: new horizons for CMR?
Neth Heart J 18:116–117
9. Holman ER, Buller VG, de Roos A et al (1997) Detection
and quantification of dysfunctional myocardium by mag-
netic resonance imaging. A new three-dimensional method
102Int J Cardiovasc Imaging (2011) 27:101–104
123

Page 3

for quantitative wall-thickening analysis. Circulation 95:
924–931
10. van Rugge FP, van der Wall EE, Bruschke AV (1992) New
developments in pharmacologic stress imaging. Am Heart
J 124:468–485
11. van Rugge FP, Holman ER, van der Wall EE et al (1993)
Quantitation of global and regional left ventricular func-
tion by cine magnetic resonance imaging during dobuta-
mine stress in normal human subjects. Eur Heart J 14:
456–463
12. van Rugge FP, van der Wall EE, Spanjersberg SJ et al
(1994) Magnetic resonance imaging during dobutamine
stress for detection and localization of coronary artery
disease Quantitative wall motion analysis using a modifi-
cation of the centerline method. Circulation 90:127–138
13. Vliegen HW, Doornbos J, de Roos A, Jukema JW, Beke-
dam MA, van der Wall EE (1997) Value of fast gradient
echo magnetic resonance angiography as an adjunct to
coronary arteriography in detecting and confirming the
course of clinically significant coronary artery anomalies.
Am J Cardiol 79:773–776
14. Hoogendoorn LI, Pattynama PM, Buis B, van der Geest RJ,
van der Wall EE, de Roos A (1995) Noninvasive evalua-
tion of aortocoronary bypass grafts with magnetic reso-
nance flow mapping. Am J Cardiol 75:845–848
15. Groenink M, Lohuis TA, Tijssen JG et al (1999) Survival
and complication free survival in Marfan’s syndrome:
implications of current guidelines. Heart 82:499–504
16. Oosterhof T, van Straten A, Vliegen HW et al (2007)
Preoperative thresholds for pulmonary valve replacement
in patients with corrected tetralogy of Fallot using car-
diovascular magnetic resonance. Circulation 116:545–551
17. van der Geest RJ, de Roos A, van der Wall EE, Reiber JH
(1997) Quantitative analysis of cardiovascular MR images.
Int J Card Imaging 13:247–258
18. van der Geest RJ, Niezen RA, van der Wall EE, de Roos A,
Reiber JH (1998) Automated measurement of volume flow
in the ascending aorta using MR velocity maps: evaluation
of inter- and intraobserver variability in healthy volunteers.
J Comput Assist Tomogr 22:904–911
19. van der Laarse A, Kerkhof PL, Vermeer F et al (1988)
Relation between infarct size and left ventricular perfor-
mance assessed in patients with first acute myocardial
infarction randomized to intracoronary thrombolytic ther-
apy or to conventional treatment. Am J Cardiol 61:1–7
20. van der Wall EE, Vliegen HW, de Roos A, Bruschke AV
(1995) Magnetic resonance imaging in coronary artery
disease. Circulation 92:2723–2739
21. Bavelaar-Croon CD, Kayser HW, van der Wall EE et al
(2000) Left ventricular function: correlation of quantitative
gated SPECT and MR imaging over a wide range of val-
ues. Radiology 217:572–575
22. Bleeker GB, Schalij MJ, Boersma E et al (2007) Relative
merits of M-mode echocardiography and tissue Doppler
imaging for prediction of response to cardiac resynchro-
nization therapy in patients with heart failure secondary to
ischemic or idiopathic dilated cardiomyopathy. Am J
Cardiol 99:68–74
23. Bleeker GB, Bax JJ, Fung JW et al (2006) Clinical versus
echocardiographic parameters to assess response to cardiac
resynchronization therapy. Am J Cardiol 97:260–263
24. Bleeker GB, Holman ER, Steendijk P et al (2006) Cardiac
resynchronization therapy in patients with a narrow QRS
complex. J Am Coll Cardiol 48:2243–2250
25. Posma JL, Blanksma PK, van der Wall EE, Hamer HP,
Mooyaart EL, Lie KI (1996) Assessment of quantitative
hypertrophyscoresinhypertrophic
magnetic resonance imaging versus echocardiography. Am
Heart J 132:1020–1027
26. Vehmeijer JT, Christiaans I, van Langen IM et al (2009)
Risk stratification for sudden cardiac death in hypertrophic
cardiomyopathy: Dutch cardiologists and the care of
mutation carriers. Neth Heart J 17:464–469
27. Christiaans I, Nannenberg EA, Dooijes D et al (2010)
Foundermutations in
patients in The Netherlands. Neth Heart J 18:248–254
28. ICIN working group on Heriditary Heart Diseases (2010)
Genetic diagnostics and genetic counselling in Hypertro-
phic Cardiomyopathy (HCM). Neth Heart J 18:144–159
29. Pluim BM, Lamb HJ, Kayser HW, Leujes F et al (1998)
Functionalandmetabolicevaluationoftheathlete’sheartby
magnetic resonance imaging and dobutamine stress mag-
netic resonance spectroscopy. Circulation 97:666–67229
30. Pluim BM, Beyerbacht HP, Chin JC et al (1997) Com-
parison of echocardiography with magnetic resonance
imaging in the assessment of the athlete’s heart. Eur Heart
J 18:1505–1513
31. Pluim BM, Chin JC, De Roos A et al (1996) Cardiac
anatomy, function and metabolism in elite cyclists assessed
by magnetic resonance imaging and spectroscopy. Eur
Heart J 17:1271–1278
32. Schroeder J, Peterschroeder A, Vaske B et al (2009) Car-
diac volumetry in patients with heart failure and reduced
ejection fraction: a comparative study correlating multi-
slice computed tomography and magnetic resonance
tomography. Reasons for intermodal disagreement. Clin
Res Cardiol 98:739–747
33. Germans T, Nijveldt R, Brouwer WP et al (2010) The role
of cardiac magnetic resonance imaging in differentiating
the underlying causes of left ventricular hypertrophy. Neth
Heart J 18:135–143
34. Hoogsteen J, Hoogeveen A, Schaffers H, Wijn PF, van der
Wall EE (2003) Left atrial and ventricular dimensions in
highly trained cyclists. Int J Cardiovasc Imaging 19:
211–21734
35. Mihl C, Dassen WR, Kuipers H (2008) Cardiac remodel-
ling: concentric versus eccentric hypertrophy in strength
and endurance athletes. Neth Heart J 16:129–133
36. Nassenstein K, Breuckmann F, Lehmann N et al (2009)
Left ventricular volumes and mass in marathon runners and
their association with cardiovascular risk factors. Int J
Cardiovasc Imaging 25:71–79
37. van der Wall EE, den Hollander W, Heidendal GA, Wes-
tera G, Majid PA, Roos JP (1981) Dynamic myocardial
scintigraphy with 123I-labeled free fatty acids in patients
with myocardial infarction. Eur J Nucl Med 6:383–389
38. Braun S, van der Wall EE, Emanuelsson S, Kobrin I (1996)
Effects of a new calcium antagonist, mibefradil (Ro
40–5967), on silent ischemia in patients with stable chronic
angina pectoris: a multicenter placebo-controlled study.
The mibefradil international study group. J Am Coll Car-
diol 27:317–322
cardiomyopathy:
hypertrophic cardiomyopathy
Int J Cardiovasc Imaging (2011) 27:101–104 103
123

Page 4

39. de Roos A, Matheijssen NA, Doornbos J, van Dijkman PR,
van Rugge PR, van der Wall EE (1991) Myocardial infarct
sizing and assessment of reperfusion by magnetic reso-
nance imaging: a review. Int J Card Imaging 7:133–138
40. van der Wall EE, van Dijkman PR, de Roos A et al (1990)
Diagnostic significance of gadolinium-DTPA (diethylene-
triamine penta-acetic acid) enhanced magnetic resonance
imaging in thrombolytic treatment for acute myocardial
infarction: its potential in assessing reperfusion. Br Heart J
63:12–17
41. van Rugge FP, Boreel JJ, van der Wall EE et al (1991)
Cardiac first-pass and myocardial perfusion in normal
subjects assessed by sub-second Gd-DTPA enhanced MR
imaging. J Comput Assist Tomogr 15:959–965
42. Holman ER, van Jonbergen HP, van Dijkman PR, van der
Laarse A, de Roos A, van der Wall EE (1993) Comparison
of magnetic resonance imaging studies with enzymatic
indexes of myocardial necrosis for quantification of myo-
cardial infarct size. Am J Cardiol 71:1036–1040
43. Buller VG, van der Geest RJ, Kool MD, van der Wall EE,
de Roos A, Reiber JH (1997) Assessment of regional left
ventricular wall parameters from short axis magnetic res-
onance imaging using a three-dimensional extension to the
improved centerline method. Invest Radiol 32:529–539
44. Bakx AL, van der Wall EE, Braun S, Emanuelsson H,
Bruschke AV, Kobrin I (1995) Effects of the new calcium
antagonist mibefradil (Ro 40–5967) on exercise duration in
patients with chronic stable angina pectoris: a multicenter,
placebo controlled study. Ro 40–5967 International Study
Group. Am Heart J 130:748–757
45. Portegies MC, Schmitt R, Kraaij CJ et al (1991) Lack of
negative inotropic effects of the new calcium antagonist Ro
40–5967 in patients with stable angina pectoris. J Cardio-
vasc Pharmacol 18:746–751
46. van der Wall EE, Heidendal GA, den Hollander W, Wes-
tera G, Roos JP (1980) I-123 labeled hexadecenoic acid in
comparison with thallium-201 for myocardial imaging in
coronary heart disease. A preliminary study. Eur J Nucl
Med 5:401–405
47. de Nooijer R, Verkleij CJ, von der Thu ¨sen JH et al (2006)
Lesional overexpression of matrix metalloproteinase-9
promotes intraplaque hemorrhage in advanced lesions but
not at earlier stages of atherogenesis. Arterioscler Thromb
Vasc Biol 26:340–346
48. Nijveldt R, Beek AM, Hirsch A et al (2008) ‘No-reflow’
after acute myocardial infarction: direct visualisation of
microvascular obstruction by gadolinium enhanced CMR.
Neth Heart J 16:179–181
49. Oemrawsingh PV, Mintz GS, Schalij MJ, Zwinderman
AH, Jukema JW, van der Wall EE (2003) Intravascular
ultrasound guidance improves angiographic and clinical
outcome of stent implantation for long coronary artery
stenoses: final results of a randomized comparison with
angiographic guidance (TULIP Study). Circulation 107:
62–67
50. Ypenburg C, Roes SD, Bleeker GB et al (2007) Effect of
total scar burden on contrast-enhanced magnetic resonance
imaging on response to cardiac resynchronization therapy.
Am J Cardiol 99:657–660
51. Ypenburg C, Sieders A, Bleeker GB et al (2007) Myo-
cardial contractile reserve predicts improvement in left
ventricular function after cardiac resynchronization ther-
apy. Am Heart J 154:1160–1165
52. Ypenburg C, van der Wall EE, Schalij MJ, Bax JJ (2008)
Imaging in cardiac resynchronisation therapy. Neth Heart J
16:S36–S40
53. Ypenburg C, Westenberg JJ, Bleeker GB et al (2008)
Noninvasive imaging in cardiac resynchronization ther-
apy—part 1: selection of patients. Pacing Clin Electro-
physiol 31:1475–1499
54. Ypenburg C, Schalij MJ, Bleeker GB et al (2007) Impact
of viability and scar tissue on response to cardiac resyn-
chronization therapy in ischaemic heart failure patients.
Eur Heart J 28:33–41
55. Torn M, Bollen WL, van der Meer FJ, van der Wall EE,
Rosendaal FR (2005) Risks of oral anticoagulant therapy
with increasing age. Arch Intern Med 165:1527–1532
56. van der Laan A, Hirsch A, Nijveldt R et al (2008) Bone
marrow cell therapy after acute myocardial infarction: the
HEBE trial in perspective, first results. Neth Heart J 16:
436–439
57. Germans T, Wilde AA, van Echteld CJ, Kamp O, Pinto
YM, van Rossum AC (2007) Structural abnormalities of
the left ventricle in hypertrophic cardiomyopathy mutation
carriers detectable before the development of hypertrophy.
Neth Heart J 15:161–163
58. Pluim BM, Zwinderman AH, van der Laarse A, van der
Wall EE (2000) The athlete’s heart: a meta-analysis of
cardiac structure and function. Circulation 101:336–344
59. Tops LF, Suffoletto MS, Bleeker GB et al (2007) Speckle
tracking radial strain reveals left ventricular dyssynchrony
in patients with permanent right ventricular pacing. J Am
Coll Cardiol 50:1180–1188
60. Tops LF, Schalij MJ, Holman ER, van Erven L, van der
Wall EE, Bax JJ (2006) Right ventricular pacing can
induce ventricular dyssynchrony in patients with atrial
fibrillation after atrioventricular node ablation. J Am Coll
Cardiol 48:1642–1648
61. Roes SD, Mollema SA, Lamb HJ, van der Wall EE, de
Roos A, Bax JJ (2009) Validation of echocardiographic
two-dimensionalspeckle
imaging for viability assessment in patients with chronic
ischemic left ventricular dysfunction and comparison with
contrast-enhanced magnetic resonance imaging. Am J
Cardiol 104:312–317
62. Butz T, van Buuren F, Mellwig KP et al (2010) Two-
dimensional strain analysis of the global and regional
myocardial function for the differentiation of pathologic
and physiologic left ventricular hypertrophy: a study in
athletes and in patients with hypertrophic cardiomyopathy.
Int J Cardiovasc Imaging. doi:10.1007/s10554-010-9665-5
63. Faber L, Prinz C, Welge D et al (2010) Peak systolic
longitudinal strain of the lateral left ventricular wall
improves after septal ablation for symptomatic hypertro-
phic obstructive cardiomyopathy: a follow-up study using
speckle tracking echocardiography. Int J Cardiovasc
Imaging. doi:10.1007/s10554-010-9678-0
trackinglongitudinal strain
104Int J Cardiovasc Imaging (2011) 27:101–104
123