Κλινικές εφαρμογές του Speckle Tracking

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1 Κλινικές εφαρμογές του Speckle Tracking ΙΓΝΑΤΙΟΣ ΟΙΚΟΝΟΜΙΔΗΣ MD, PhD, FESC ΑΝΑΠΛΗΡΩΤΗΣ ΚΑΘΗΓΗΤΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ Β ΚΑΡΔΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ, ΕΘΝΙΚΌ ΚΑΙ ΚΑΠΟΔΙΣΤΡΙΑΚΌ ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΘΗΝΩΝ ΝΟΣΟΚΟΜΕΙΟ ΑΤΤΙΚΟΝ

2 Επιμήκης (Longitudinal) Κυκλοτερής (Circumferential) Ακτινική (Radial)

3 Speckle tracking

4 Speckle tracking Normal values: LV NORMAL VALUES Longitudinal strain >18 % Longitudinal strain rate > 1.1/s. Radial strain > 44% Radial strain rate > 2.43/s Reduced with older age RV NORMAL VALUES Horton et al J Am Soc Echocardiogr 2009;22: Kuznetsova et al. European Heart Journal 2008;29:

5 Η Ελικοειδής παραμόρφωση % % Στροφική κίνηση κορυφής (αντιωρολογιακή φορά) Στροφική κίνηση βάσης (ωρολογιακή φορά)

6 ΚΛΙΝΙΚΕΣ ΕΦΑΡΜΟΓΕΣ SPECKLE TRACKING Μυοκαρδιοπάθειες Στεφανιαία νόσος Μεγέθος ΟΕΜ Πρόγνωση μετά ΟΕΜ Βιωσιμότητα Πρόβλεψη αρρυθμιολογικού κινδύνου Mυοκαρδίτιδα Απεικόνιση μυοκαρδιακής ίνωσης -Ανίχνευση υποκλινικής δυσλειτουργίας της ΑΡ κοιλίας Xημειοθεραπεία,ΑΥ,ΣΔ Καρδιακή ανεπάρκεια (HFLEF, HFpEF) Βαλβιδοπάθειες Μελέτη ΔΕ κοιλίας

7 Example of impaired segmental strain measured by speckle tracking in the apical long-axis view in a mutation carrier without HCM phenotype expression. Yiu KH, Atsma DE, Delgado V, Ng ACT, et al. (2012) Myocardial Structural Alteration and Systolic Dysfunction in Preclinical Hypertrophic Cardiomyopathy Mutation Carriers. PLoS ONE 7(5): e doi: /journal.pone

8 Segmental strain measured by speckle tracking of the basal anteroseptal and posterior walls in each group: controls, mutation carriers without phenotype expression (Mut+/Phen ) N=46 mutation carrier with phenotype expression (Mut+/Phen+). N=47 Yiu KH, Atsma DE, Delgado V, Ng ACT, et al. (2012) Myocardial Structural Alteration and Systolic Dysfunction in Preclinical Hypertrophic Cardiomyopathy Mutation Carriers. PLoS ONE 7(5): e doi: /journal.pone

9 Association of GLS with fibrosis in HCM European Heart Journal Cardiovascular Imaging (2012) 13,

10 HCM- FH sudden death

11

12 RESTRICTIVE CARDIOMYOPATHY

13 Restrictive

14 HARMONIC 79 y HF Cardiomyopathy AL amyloid FUNDAMENTAL

15 Amyloidosis

16 NORMAL FOOTBALL PLAYER Differential diagnosis: LongS<-10%, LongSR<-1.1l/s AMYLOID HOCM

17

18 MRI+ΓΑΔΟΛΙΝΙΟ 2D-STRAIN 4CH 2CH 3CH Το επίμηκες strain (-4%) είναι ο δείκτης απουσίας βιωσιμότητας μετά OEM Migrino R Am J Cardiol 2009;104:

19 REST

20 Longitudinal and Circumferential Strain Rate is related with LV Remodeling,and Prognosis after AMI during 20-month f/up: VALIANT Investigators J Am Coll Cardiol 2010;56:

21 Early Echocardiographic Deformation Analysis for the Prediction of Sudden Cardiac Death and Life-Threatening Arrhythmias After AMI GLS> -12% MMD >61,5ms GLS< -15.5% MMD <49ms Ersbøll J Am Coll Cardiol Img 2013;6:851 60

22 Independent and additive prognostic value of radial strain at rest and ΔGLS post dobutamine in ADHF during 4y f/u Paraskevaidis I Ikonomidis I Parissis J et al Eur J Heart Fail 2017

23 DSE: 3-Chamber PATIENT WITH ALCHOHOL ABUSE AND 2VESSEL CAD LOW DSE PEAK DSE

24 Baseline LDSE Peak DSE Low dose Peak dose

25 ΔΙΑΚΟΠΗ ΑΛΚΟΟΛ ΦΑΡΜΑΚΕΥΤΙΚΗ ΑΓΩΓΗ F/U1

26 BASELINE LOW DOB F/U1 ΤΙΜΕΣ LGS < -5% ΑΝΤΙΣΤΟΙΧΟΥΝ ΣΕ ΟΥΛΗ (>75% ΙΝΩΣΗ ΣΕ MRI)

27 Layer-Specific Quantification of Myocardial Deformation by Strain Echocardiography May Reveal Significant CAD in Patients With Non ST- Segment Elevation Acute Coronary Syndrome J Am Coll Cardiol Img 2013;6:535 44

28 Myocardial Deformation in Acute Myocarditis With Normal LV Wall Motion:Validation with MRI DE In patients with acute myocarditis, evidence of subepicardial damage and no wall motion abnormalities, longitudinal deformation is diffusely impaired, whereas circumferential is regionally sited in the areas of subepicardial damage. G.Di Bella et al.circ J 2010; 74:

29 Admission MYOCARDITIS DD FROM AMI 2 months

30 admission 2 months

31 DCM RIGID BODY ROTATION Adverse prognosis Normal

32 Nakai et al.european Journal of Echocardiography 2009;10: Subclinical LV dysfunction in asymptomatic diabetic patients assessed by 2D ST: correlation with diabetes duration In addition to diastolic dysfunction, -Longitudinal strain was significantly lower in diabetic patients compared with control subjects -The decrease in LS correlated with duration of diabetes. -Subclinical LV longitudinal dysfunction is frequently observed in asymptomatic diabetes patients with normal LVEF

33 GLS greater than -18% of subendocardial LS greater than -19.5% and ptw less than 16 deg differentiated FDR with LV dysfunction from normal controls with sens 70% spec 75% Ikonomidis I et al Int J Cardiol 2017

34 Association of postprandial glucose with LV deformation in first degree relatives of DM Ikonomidis I et al Int J Cardiol 2017

35 J Am Soc Echocardiogr 2013;26: *Heart 2010;96: Incremental Value of Deformation Indices for Predicting Subsequent Reduction in EF>10% at 1year post chemotherapy ΔGLS>11% at 6m ΔGLS>10% at 3m*

36 Baseline

37 1 month

38 Kraigher-Krainer et al. J Am Coll Cardiol 2014;63: Impaired Systolic Function by Strain Imaging in HFpEF 219 HFpEF patients Ιmpaired systolic function GLS, GCS despite preserved global LVEF in HFpEF

39 Prognostic value of GLS in HEPEF: KaReN study Donal E EHJ-CVI 2017 in press

40 Ikonomidis I et Eur J Heart Fail 2015 Diastolic suction Control ptw Δ1:33% UntwMVO Δ2:79% A A Hypertensive ptw Δ1:26 % Δ2:64 % B UntwMVO UtwEDF UtwEDF MVO MVO EDF EDF

41 Exercise capacity in hypertensives A reverse association between PWV and VO2PEAK was revealed in hypertensives with delayed BPRR Increased LV untwisting rate was associated with increased NTproBNP and reduced VO2 peak Triantafyllidi H, Ikonomidis I Blood Pressure Monit, 2013 Ikonomidis I, Eur J Heart Failure 2015

42 Healthy MVO EEF 33% 75 % 70 msec Ikonomidis et al Circulation Cardiovascular Imaging 2015 RA without CAD MVO EEF 26 % 64 % RA with CAD MVO EEF 20 % 50 % 85 msec 100 msec

43 Atrial deformation a sensitive marker of Diastolic Dysfunction RA/LA Contractile phase strain =0 normal

44 LA Deformation Predicts Eventful Course Atrial fibrillation Total Left Atrial Strain >21% Total Left Atrial Strain <21% Paraskevaidis I, Ikonomidis I et al,. Am Heart J 2009;158:444

45 NOVEL INDICES OF LV DIASTOLIC FUNCTION

46 AR

47 2D STRAIN IN AR PROGRESSION AND SURGICAL OUTCOME Olsen NT, JACC Cardiovasc Imaging Mar;4(3):

48 GLS predicts LV dysfunction after mitral valve repair cut-off value LV GLS 19.9% predicts long-term postoperative LV dysfunction sensitivity 90% specificity 79% A GLS of independent predictor of long-term LV dysfunction after adjustment for parameters currently implemented into guidelines. European Heart Journal Cardiovascular Imaging 2012

49 GLS is a strong independent predictor of all-cause mortality in patients with AOS pef GLS detects subclinical dysfunction and has incremental prognostic value over traditional risk markers including haemodynamic severity, symptom class, and LVEF in patients with AS. Independent predictor of all-cause mortality (HR: 1.38, P=0.001) Incorporation of GLS into risk models may improve the identification of the optimal timing for AV replacement. European Heart Journal Cardiovascular Imaging 2012;13:

50 Amyloid RV infiltration

51 Prognostic Value of RV Longitudinal Peak Systolic Strain in Patients With PH 142 PH patients (37% PAH) 2,6y f-up Death 37 In patients with PH, RV LPSS is significantly associated with all-cause mortality. RV LPSS may be a valuable parameter for risk stratification of these patients Haeck et al. Circ Cardiovasc Imaging. 2012;5:

52 RVGLS Provides Prognostic Value Incremental to LVEF in Patients with HF 171 patients HFLEF RV strain <-14.8% predicted adverse events after adjustment for age, LVEF, RV S, E/Ee septal, and right atrial volume index. Worse RV strain provides prognostic value incremental to LV function. Moroki et al. J Am Soc Echocardiogr 2014;27:726-32

53 Increased benefit of IL-1 inhibition in RA-CAD(EF=45%) Anakinra:IL-1ra? Ikonomidis I Lekakis J. Circulation Cardiovasc Imaging 2014

54 IMPAIRED LONGITUDINAL DEFORMATION IN PSORIASIS IMPROVEMENT AFTER IL12/23 INHIBITION Ikonomidis I,Makavos Canadian Journal of Cardiology 2015 Circ Cardiovasc Imag 2017

55 Percentage changes in NYHA and BNP levels 48 hours after levosimendan infusion in CR+ versus CR- ADHF patients as assessed by changes in longitudinal strain rate using speckle tracking imaging Paraskevaidis J, Ikonomidis I, Parissis J, Kremastinos DT 20 p = p = % change CR+ CR NYHA (class) X 100 BNP Am J Cardiol 2008;102:

56 LV-RV function ASE/EACVI European Heart Journal Cardiovascular Imaging (2015) 16,

57 Συμπεράσματα Η μέτρησή του 2D strain είναι ιδιαίτερα χρήσιμη Εκτίμηση παρουσίας μυοκαρδιακής ουλής και τμηματικών διαταραχών κινητικότητας σε ασθενείς με στεφανιαία νόσο Διαφορική Διάγνωση μυοκαρδιοπάθειας από αθλητική καρδιά Διάγνωση καρδιακής ανεπάρκειας με διατηρημένο κλάσμα εξώθησης Διαστρωμάτωση κίνδυνου σε ασθενείς με οξύ έμφραγμα του μυοκαρδίου, μυοκαρδιοπαθειες, βαλβιδοπαθειες Παρακολούθηση ασθενών σε χημειοθεραπευτικα σχήματα για την έγκαιρη διάγνωση καρδιοτοξικοτητας Έλεγχος αποτελεσματικότητας θεραπευτικών παρεμβάσεων σε ασθενείς με υπέρταση,καρδιακή ανεπάρκεια και συστηματικές νόσους Έλεγχος λειτουργικότητας δεξιάς κοιλιας σε ασθενείς με πνευμονική υπέρταση και αριστερή καρδιακή ανεπάρκεια

58 ΕΥΧΑΡΙΣΤΩ ΓΙΑ ΤΗΝ ΠΡΟΣΟΧΗ ΣΑΣ!

59 Effect of treatment with GLP-1 RA liraglutide versus treatment with metformin Liraglutide (n=30) Metformin (n=30) Time, months GLS, % -15.4±3-16.6±2.7* -15.5± ±3.2 GLSR, 1/sec 0.77± ±0.2* 0.79± ±0.3 ptw, deg 15.5±4 13.2±6* 16.2±5 15.0±6 Utw velocity,deg/sec -97±49-112±52* -100±41-98±43 %dptw-utw MVO 31±10 40±14* 29±18 30±18 %dptw-utw PEF 43±19 53±22* 45±19 50±16 E/A 0.92± ± ± ±0.4 E/E 7.0± ± ± ±3

60

61 Trends of GLS in three different chemo regimens, with or without beta-blocker European Heart Journal Cardiovascular Imaging (2014) 15,

62 Trends of EF in three different chemo regimens, with or without beta-blockers European Heart Journal Cardiovascular Imaging (2014) 15,

63 Plana et al.j Am Soc Echocardiogr 2014;27: Early detection of subclinical LV dysfunction after chemotherapy using GLS

64 TRANSTUZUMAB-anthracycline

65 3D-STRAIN

66 3D speckle tracking allows the quantification of 2 new 3-dimensional indexes: -3-dimensional strain obtained by the sum of radial, circumferential, and longitudinal vectors -area strain that assesses endocardial area changes. ED end diastole; ES end systole; L length; L0 initial length; Lr radial length. Am J Cardiol 2012;109:

67 Longitudinal strain by 3D, but not by 2D, differentiated non transmural segments with scar <25%. Am J Cardiol 2012;109:

68 Normal reference values of LV strain using 3-D speckle tracking echocardiography: results from a multicentre study European Heart Journal Cardiovascular Imaging (2015) 16,

69 Aρχιτεκτονική μ.ινών-σύνθετη η συστολή της ΑΚ subendocardium: longitudinally right handed helix subepicardium: left handed helix rotation and torsion Russel et al. J am Coll Cardiol Img 2009;2:648 55

70 NORMAL Ikonomidis I Heart 2009, Circulation Cardiovasc Imaging 2014 RA no CAD