The strain and strain rate imaging paradox in echocardiography: overabundant literature in the last two decades but still uncertain clinical utility in an individual case

Abstract

Almost two decades ago strain and strain rate imaging were proposed as a new, potentially more sensitive modality for quantifying both regional and global myocardial function. Until now, however, strain and strain rate imaging have been slow to be incorporated into everyday clinical practice. More recently, two dimensional strain has been claimed as of greater clinical utility, given that it is angle independent, with improved feasibility and reproducibility as compared to tissue Doppler strain. Nevertheless, speckle tracking strain is reliant on 2D image quality and frame rates. Three dimensional speckle tracking could eliminate the problem of through-plane motion inherent in 2D imaging, but 3D strain is currently limited by low frame rates. Another limitation of strain imaging is that the results are dependent on the ultrasound machine on which analyses are performed, with variability in measurements between different vendors. Despite the diagnostic and prognostic advantages of 2D strain, there is a lack of specific therapeutic interventions based on strain and a paucity of long-term large-scale randomized trial evidence on cardiovascular outcomes. After overabundant literature the same definition of normal cut-off values is controversial and not univocal. Further studies are needed, involving both manufacturers and medical professionals, on the additive contribution, possibly different case by case, of interfering and artifactual factors, aside from myocardial function per se. These artifactual determinants and motion artifacts components could be dominant in individual cases and should always be taken into account in the clinical decision making process in a single case.

Keywords: global and regional function; non-invasive cardiac function by ultrasound; strain and strain rate echocardiography; ventricular function.

Figure 1

A – Schematic representation of longitudinal, radial and circumferential strain. Basal and apical rotation are also depicted, from which twisting and untwisting are calculated. Echocardiographic apical and short axis imaging planes are represented in gray. B – While the imaging plane is maintained in a fixed position, the heart is moving through the plane during the cardiac cycle, due to contraction, relaxation, translational, rocking or swinging motion, or even dyssynchrony (LS – longitudinal strain, RS – radial strain, CS – circumferential strain, CBR – clockwise basal rotation, CCAR – counter clockwise apical rotation)