Echocardiography and cardiovascular magnetic resonance based evaluation of myocardial strain and relationship with late gadolinium enhancement

Abstract

Objectives: We sought to: (1) determine the agreement in cardiovascular magnetic resonance (CMR) and speckle tracking echocardiography (STE) derived strain measurements, (2) compare their reproducibility, (3) determine which approach is best related to CMR late gadolinium enhancement (LGE).

Background: While STE-derived strain is routinely used to assess left ventricular (LV) function, CMR strain measurements are not yet standardized. Strain can be measured using dedicated pulse sequences (strain-encoding, SENC), or post-processing of cine images (feature tracking, FT). It is unclear whether these measurements are interchangeable, and whether strain can be used as an alternative to LGE.

Methods: Fifty patients underwent 2D echocardiography and 1.5 T CMR. Global longitudinal strain (GLS) was measured by STE (Epsilon), FT (NeoSoft) and SENC (Myocardial Solutions) and circumferential strain (GCS) by FT and SENC.

Results: GLS showed good inter-modality agreement (r-values: 0.71-0.75), small biases (< 1%) but considerable limits of agreement (- 7 to 8%). The agreement between the CMR techniques was better for GLS than GCS (r = 0.81 vs 0.67; smaller bias). Repeated measurements showed low intra- and inter-observer variability for both GLS and GCS (intraclass correlations 0.86-0.99; coefficients of variation 3-13%). LGE was present in 22 (44%) of patients. Both SENC- and FT-derived GLS and GCS were associated with LGE, while STE-GLS was not. Irrespective of CMR technique, this association was stronger for GCS (AUC 0.77-0.78) than GLS (AUC 0.67-0.72) and STE-GLS (AUC = 0.58).

Conclusion: There is good inter-technique agreement in strain measurements, which were highly reproducible, irrespective of modality or analysis technique. GCS may better reflect the presence of underlying LGE than GLS.

Keywords: Cardiac imaging; Left ventricular function; Myocardial deformation; Myocardial scar.

Fig. 1

Schematic representation of the study design (see text details). Note: the images in the figure highlight the three techniques in a patient with a prior myocardial infarction in the territory of the left anterior descending coronary artery. The transmural late gadolinium enhancement in the mid-distal anterior, mid-distal anteroseptal and distal septum, suggesting lack of viability in these areas, is represented by different colors for the different techniques. FT, feature tracking; GCS, global circumferential strain; GLS, global longitudinal strain; LGE, late gadolinium enhancement; STE, speckle tracking echocardiography; SENC, strain encoding

Fig. 2

Example of STE (4Ch) images, showing tracing contours, and corresponding strain curves in a patient with no LGE (a) and a patient with cardiac manifestation of sarcoidosis (b)

Fig. 3

Example FT (4Ch, SAX Basal) images, showing tracing contours, and corresponding strain curves in the same two patients a and b as in Fig. 2

Fig. 4

Example of SENC (4-Ch, basal short axis) images, showing tracing contours, and corresponding strain curves in the same two patients a and b as in Figs. 2 and 3

Fig. 5

Example of LGE (short axis, 4Ch) in the same two patients as in Fig. 2. The ventricle of the patient (a) appears uniformly unenhanced, whereas in the sarcoidosis patient (b), there is diffuse, patchy enhancement in most myocardial segments

Fig. 6

Receiver operating characteristic (ROC)- curves depicting the relationship between strain parameters and the presence of LGE