A Practical Approach to Using

Strain Echocardiography to
Evaluate the Left Ventricle
Harvey Feigenbaum MD
No conflicts of interest to report
Echocardiography 2020: Opportunities and Challenges
Alan S. Pearlman, MD, FASE, Editor JASE
JASE Volume 23, Issue 8, Pages 898-900, August 2010

To me, an additional concern is that using only older tried and true
technology is absolutely the antithesis of the exciting opportunities
offered by the array of diagnostic tools available to the echocardiographer,
as Dr. Zoghbi (ASE keynote address) so clearly demonstrated. If
echocardiographers are to stand still, depend on standard 2D echo
imaging using equipment produced a decade ago and not upgraded since,
perform ejectionfractionograms, focus primarily on the left ventricle and
simply eyeball the other chambers, and avoid new methods such as
strain imaging and contrast echo because they are perceived as a waste
of time, then I fear that echocardiography will be passed by. As the
dinosaurs illustrated, we need to adapt and continue to evolve, or face the
consequences.

Echo Assessment of Left Ventricle
Linear dimensions: LVIDd LVIDs FS
Areas: FAC
Volumes: LVVd LVVs EF
2D Regional Wall Motion
M-mode motion of walls, septum & valves
Doppler measurements: Hemodynamics, MPI
Tissue Doppler: Annular motion
Strain and Strain Rate


Strain/Strain Rate
The relationship between two points as if they
were connected by a rubber band
When the two points move away from each
other (e.g. diastole) strain is increased
(positive strain).
When the two points move toward each other
(e.g. systole) strain is decreased (negative
strain).

Strain Rate
Using tissue Doppler which is a form of pulsed
Doppler, specific points in the myocardium
can be identified
Tracking these point permits the
meassurement of strain
Since Doppler is velocity or distance/time, the
initial measurement is strain rate
Integrating strain rate gives strain
L
L
Strain Rate = Vel (L) Vel(L + L)
L
Strain Rate = Rate of change of length of tissue region
or shortening velocity per fiber length (1/sec)
Negative SR = shortenng Positive SR = lengthening
Strain Rate Imaging
Changes in Strain Rate with Ischemia
Limitations With Doppler Based Strain Rate
As with all Doppler applications, strain rate is
angle dependent
The Doppler strain rate sample volume is fixed
while the myocardium is moving
Strain rate is the derivative of strain and tends
to be noisy
The strain rate curved M-mode display is
only semi quantitative, noisy, can be difficult
to interpret and is not popular
Strain
2D and 3D Speckle Tracking
Speckle Tracking
The raw (radiofrequency or RF) ultrasonc image
consists of numerous random speckles
Any given point on an ultrasonic image can be
identified by a unique speckle pattern
Using these speckle patterns (speckle tracking) to
identify specific points in the myocardium, strain
can be recorded
Since 2D echo is distance, the initial
measurement is strain
The derivative of strain will give strain rate

Normal Strain Displays
Quantitative Parametric Overlay
Wave Forms
Curved M-mode
Normal Strain
Bullseye Presentation (base of LV
outer ring, apex at center)
All segments red and all but one in
upper teens or 20s
Abnormal Strain
Quantitative Parametric Overlay
Wave Forms
Curved M-mode
Abnormal Strain
Bullseye presentation
Several segments light red or pink
and of lower values
Advantages of Strain/Strain Rate Imaging
Avoids some of the limitations of wall motion analysis:
tethering, off-axis false positive, subtle wall motion
More sensitive in detecting myocardial dysfunction
Quantitative
Technically feasible with stress
Closer to assessing true regional contraction than is wall
motion or Tissue Doppler
May assist in assessing viability with stress and at rest
Represents an independent supplement to wall motion for LV
mechanics

Longitudinal strain is a great tool to evaluate the real systolic function especially
in cases like HCM. This population appears to have a normal EF but the global
longitudinal strain is decreased (<-20%). I have to clarify that the strain is best
when is obtained by tissue tracking and not by the TDI. The speckle tissue
tracking is reproducible and has less intraobserver and interobserver variability.
Also the RV systolic function can be assess by longitudinal strain. This
information is important in pulmonary HTN, RV infarct, pulmonary embolism,
ARVD, systemic RV, TOF, etc.
Like every other emerging tool the secret is to put it in practice and master it!.
Strain analysis has opened the window to evaluate the myocardium inside out.
Start using it and be amazed.

Maria Alexandra Pernetz RDCS, RVT
Echo lab Technical Director
Emory University Hospital
ASE Open Forum

Current Status of Strain
Echocardiography
Hundreds of articles over the past 10 years
have demonstrated the feasibility and
potential clinical value of strain imaging
Yet only a few academic centers have
incorporated it into the everyday practice of
echocardiography and even then only on a
limited basis
Noninvasive myocardial strain measurement by speckle tracking echocardiography:
validation against sonomicrometry and tagged magnetic resonance imaging.
Amundsen BH, Helle-Valle T, Edvardsen T, Torp H, Crosby J, Lyseggen E et al.
J Am Coll Cardiol 2006;47(4):789-93.
The potential clinical role of strain and strain rate imaging in diagnosing
acute rejection after heart transplantation.
Marciniak A, Eroglu E, Marciniak M. et al.
Eur J Echocardiogr 2007;8(3):213-21.
Early detection of doxorubicin cardiomyopathy using two-dimensional strain
echocardiography.
Migrino RQ, Aggarwal D, Konorev E et al.
Ultrasound Med Biol 2007;Oct 10;
Myocardial strain imaging for early detection of cardiac involvement in patients
with Duchennes progressive muscular dystrophy.
Mori K, Hayabuchi Y, Inoue M et al.
Echocardiography 2007;24(6):598-608.
Detection of subclinical cardiac involvement in systemic sclerosis
by echocardiographic strain imaging.
Kepez A, Akdogan A, Sade LE et al.
Echocardiography 2008;25:191-97.
Association of myocardial strain with left ventricular
geometry and progression of hypertensive heart disease.
Hare JL, Brown JK, Marwick TH.
Am J Cardiol 2008;102(1):87-91.
Partial List of References Demonstrating the Value of Echocardiographic
Strain in Patients With Known or Suspected Heart Disease
Global 2-Dimensional Strain as a New
Prognosticator in Patients With Heart Failure
Goo-Yeong Cho, MD, PhD
*
,
*
, Thomas H. Marwick, MD, PhD, Hyun-Sook
Kim, MD, PhD, Min-Kyu Kim, MD, Kyung-Soon Hong, MD, PhD and Dong-Jin
Oh, MD, PhD J Am Coll Cardiol, 2009; 54:618-624

Conclusions: Strain is a powerful predictor of cardiac
events and appears to

be a better parameter than
ejection fraction in patients with

acute heart failure.



Global Longitudinal Strain as a Major
Predictor of Cardiac Events in Patients
with Depressed Left Ventricular
Function: A Multicenter Study
Erwan Donal, MD, PhDc, Amira Zaroui, MDa, Patricia Reant, MDa, Adrien Salem, MDb, Cecile Hamon, MDc, Severine Monzy, MDa, Raymond Roudaut, MD, PhDa, Gilbert Habib, MD, PhDb, Stphane Lafitte, MD, PhDa

Lafitte, MD, PhDa

J Am Soc Echocardiogr Volume 23 Pages
1019-1024 October 2010
Strain assessment is highly feasible and
reliable in patients with LV dysfunction and
allows for cardiovascular risk stratification in
patients with heart failure with greater
accuracy than LV EF
Prediction of All-Cause Mortality From Global Longitudinal Speckle Strain
Comparison With Ejection Fraction and Wall Motion Scoring
Stanton, Leano and Marwick Circulation Cardiovascular Imaging 2009;2:356-64

Of 546 consecutive individuals undergoing echocardiography for assessment of
resting left ventricular function, 91 died over a period of 5.21.5 years. In
addition to Simpson biplane EF, WMSI was determined by 2 experienced
readers and GLS was calculated from 3 standard apical views using 2D speckle
tracking. The incremental value of EF, WMSI, and GLS to significant clinical
variables was assessed in nested Cox models. Clinical factors associated with
outcome (model
2
=20.2) were age (hazard ratio [HR], 1.46; P<0.01), diabetes
(HR, 1.88; P=0.01), and hypertension (HR, 1.59; P<0.05). Although addition of
EF (HR, 1.23; P=0.03) or WMSI (HR, 1.28; P<0.01) added to the predictive
power of clinical variables, the addition of GLS (HR, 1.45; P<0.001) caused the
greatest increment in model power (
2
=34.9, P<0.001). GLS also provided
incremental value in subgroups with EF >35% and those with and without wall
motion abnormalities. A GLS 12% was found to be equivalent to an EF 35%
for the prediction of prognosis. Intraobserver and interobserver variations for EF
and GLS were similar.
Conclusions GLS is a superior predictor of outcome to either EF or WMSI
and may become the optimal method for assessment of global left ventricular
systolic function.
Why Isnt Strain Echocardiography Being Used
More Clinically
Most articles in the literature use strain in time
consuming and complicated ways
There is longitudinal, radial, circumferential and
twist all of which makes clinical use complicated
Deformation may be scientifically accurate but
is clinically confusing
Analyzing multiple wave forms is not appealing
The fact that systolic strain or contraction is a
negative number is confusing e.g. is a strain of
-10 more or less than a strain of -20?
Simplified More Practical Approach to Strain
Echocardiography
We avoid manually adjusting the sampling of segments to
quicken the analysis and enhance the reproducibility
The Bullseye presentation is the primary display for analysis
Systolic strain is stated as a positive number
Only longitudinal systolic strain is utilized
Global strain is labeled Global Systolic Strain (GSS) instead of
Global Longitudinal Peak Systolic Strain (GLPSS) or Global
Longitudinal Peak Strain Average (GLPS-A)
Basal Systolic strain (BSS), Mid Systolic Strain (MSS) and Apical
Systolic Strain (APSS) are calculated
The Bullseye is analyzed by pattern recognition as well as
quantitation

Current Status of Strain Echocardiography at
IU/UH/WMH
Over 3,000 studies done at the three
institutions
Success rate is still unclear but is at least
approximately 80-85% (average patient >200
lb and many >250 lb)
Takes 2-4 minutes to generate the strain data
Intraobserver and interobserver
reproducibility as good or better that EF
Strain Echocardiography
Bullseye Patterns
Concentric Hypertrophy
There is a Need to Identify
People With Hypertension
Cardiac LVH indicates significant
hypertension that is affecting the
heart
Nearly 20% Of Young Adults In US May Have High Blood Pressure.
ABC World News (5/25, story 6, 0:25, Sawyer) reported that research published online in Epidemiology indicates that nearly
one-fifth "of Americans who are 24 to 32 years old have high blood pressure."
USA Today (5/26, Marcus) reports, "For the National Longitudinal Study of Adolescent Health, dubbed Add Health, funded by
the National Institutes of Health, researchers from the University of North Carolina-Chapel Hill asked 14,000 men and women between
the ages of 24 and 32 about their high blood pressure history and then took blood pressure readings of participants." The investigators
"found that 19% of participants had high blood pressure." These "findings...are significantly higher than other recent research from another
large, ongoing health study, the National Health and Nutrition Examination Survey (NHANES), which found only 4% of adults 20 to 39 have high blood pressure."
The CNN (5/25) "The Chart" blog reported that lead study author Kathleen Mullan Harris said that "among those measured with high
blood pressure, only 25% had been told previously that they had high blood pressure."
Also covering the story were
the Raleigh News & Observer (5/26, Price), Reuters (5/26, Steenhuysen), WebMD (5/25, Mann), HealthDay (5/25, Dallas), and MedPage Today (5/25, Neale).
Masked Hypertension May Be Prevalent In 45% Of African Americans.
HeartWire (5/25, O'Riordan) reported that research "presented this week" at the American Society of Hypertension 2011 Scientific Meeting
confirm the high prevalence of masked hypertension in African Americans, with investigators reporting that masked hypertension is prevalent in
45% of African Americans during any single office visit." The findings "suggest that blood-pressure monitoring in the office might not be
sufficient to assess cardiovascular-risk exposure in this population and that out-of-office blood pressure monitoring might be
needed to expose underlying hypertension
Nearly 20% Of Young Adults In US May Have High Blood Pressure.
ABC World News (5/25, story 6, 0:25, Sawyer) reported that research published online
in Epidemiology indicates that nearly one-fifth "of Americans who are 24 to 32 years
old have high blood pressure."
USA Today (5/26, Marcus) reports, "For the National Longitudinal Study of
Adolescent Health, dubbed Add Health, funded by the National Institutes of Health,
researchers from the University of North Carolina-Chapel Hill asked 14,000 men and
women between the ages of 24 and 32 about their high blood pressure history and
then took blood pressure readings of participants." The investigators "found that 19%
of participants had high blood pressure." These "findings...are significantly higher than
other recent research from another large, ongoing health study, the National Health
and Nutrition Examination Survey (NHANES), which found only 4% of adults 20 to 39
have high blood pressure."

Masked Hypertension May Be Prevalent In 45% Of African Americans.
HeartWire (5/25, O'Riordan) reported that research "presented this week" at the
American Society of Hypertension 2011 Scientific Meeting "confirm the high
prevalence of masked hypertension in African Americans, with investigators reporting
that masked hypertension is prevalent in 45% of African Americans during any single
office visit." The findings "suggest that blood-pressure monitoring in the office might
not be sufficient to assess cardiovascular-risk exposure in this population and that out-
of-office blood pressure monitoring might be needed to expose underlying
hypertension."
Strain Presentation of LV
Hypertrophy
Basal strain segments decrease (become light
red or pink)
BSS below 17
Apical segments remain normal
Strain bullseye donut
HTN: GSS 17.6 BSS 13.7
HTN: GSS 17.8 BSS 10.2
Hypertrophic Cardiomyopathy
Septal Strain Segments Decrease in
Value (become pink)
HOCM: GSS 17.8 BSS 13.3
Amyloidosis
Extreme Form of Strain LVH Pattern
Severe Amyloid Heart
Amyloidosis: GSS 10.8 BSS 4.3
Less Severe Amyloid Heart
Amyloidosis: GSS 19.2 BSS 11.2
2D Images of Amyloid Heart
Same Patient One Year Later
Is there any change?
Strain Bullseye of the Same
Amyloid Heart Images
The change in strain is not as subtle
as the change in wall thickness
Amyloidosis Follow Up
GSS 15.9 BSS 9.7 EF 64

GSS 13.1 BSS 7.7 EF 72

Inferior Lateral Ischemia
Inferior Ischemia: GSS 17.4 BSS 10.3
LAD Ischemia
Strain of Same Patient
Numerous segments likely nonviable
(strain <10)

LAD Infarction: GSS 9.6 BSS 12.3
Another Patient with Anterior
Myocardial Infarction
2D images very similar
Strain Abnormalities Not nearly
as Severe or Extensive
Fewer segments likely nonviable
(strain < 10)
LAD Ischemia: GSS 12.3 BSS 14.7
Patient asymptomatic leading
very active life
EF 38% but exercised over 10 mets
on treadmill
Nonischemic Cardiomyopathy
Abnormal strain segments do not fit
a coronary artery distribution
NICM: GSS 14.1 BSS 16.5 EF 37
Patient With More Severe
Cardiomyopathy
NICM: GSS 8.0 BSS 6.5 EF 18
Post Chemotherapy
Growing Awareness Of Cardiovascular Adverse Effects Of
Anticancer Drugs Spawns New Clinical Discipline.
Medscape (10/7, Chustecka) reported, "Growing awareness of the
cardiovascular adverse effects of anticancer drugs, plus the fact
that cancer patients are surviving and living longer, has given
birth to the new clinical discipline of cardioncology." According
to a paperrin Progress in Cardiovascular Disease, "patients with
early-stage breast cancer are now more likely to die from heart
disease than cancer, highlighting the need for a new discipline
that focuses on the treatment of cardiovascular disease in cancer
patients. The special issue of the journal celebrates the first year
of existence of the International Society of Cardioncology."
, has given birth to the new clinical discipline of cardioncology." According to a paper in Progress in Cardiovascular Disease, "patients with early-stage breast cancer are now more likely to die from heart disease than cancer, highlighting the need for a new discipline that focuses on the treatment of cardiovascular disease in cancer patients. The special issue of the journal celebrates the first year of existence of the International Society of Cardioncology."
Guidelines To Manage Heart Disease Risk In Cancer Patients Expected In 2012.
HeartWire (10/13, O'Riordan) reports, "The American Society of Echocardiography is
currently working on new guidelines to manage the risk of heart disease in cancer
patients." These "recommendations will guide clinicians in using strain echocardiography
in the early detection of cardiac toxicity resulting from therapies used to treat cancer,
such as doxorubicin and trastuzumab in breast-cancer patients with the HER2 genetic
mutation." HeartWire points out that "the new guidelines...expected in 2012, will be
written in collaboration with the European Association of Echocardiography and the
American Society of Clinical Oncology."
Reproducibility Study
43 year old breast cancer patient
On continuous chemotherapy
Echocardiograms with strain
2/17/2010
5/14/2010
3/14/2011
9/18/2011
All Strain Studies Essentially
Normal and Unchanged
Frequent Effect of Chemotherapy
on Strain
Strain Before and After Chemotherapy
Before GSS 18.5 BSS 17.0 EF 65 After GSS 16.5 BSS 14.7 EF 59
Strain Before and After Chemotherapy
Before GSS 22.2 BSS 20.0 EF 59 After GSS 21.9 BSS 14.8 EF 69
Strain Changes Post Chemotherapy
(No Follow Up Since 4/11/2011)
GSS 17.8 BSS 14.8 EF 61 GSS 11.1 BSS 9.5 EF 57
Abnormal Strain is Reversible
Improved Strain Following Successful
BMT for CLL
Pre BMT GSS 17.7 BSS 14.7 2 Mo Post BMT GSS 19.3 BSS 17.7
156 Echocardiograms on Chemotherapy
Patients
25 before chemo 131 after chemo
EF Before 61.3 After 57.5 p=0.068
GSS Before 19.6 After 17.1 p=0.002
BSS Before 18.0 After 15.3 p=0.009

130 Chemotherapy Patients with Strain
Echocardiography
Died 22 (17%)
EF Living 57 .9 Died 56.3 p= 0.508
GSS Living 17.5 Died 15.7 p= 0.04
BSS Living 15.8 Died 13.3 p= 0.03
73 Patients with BSS < 17 : 18 died 25%
57 Patients with BSS => 17: 4 Died 7%
p= 0.009

49 YO Female
Lymphoma
Post chemotherapy
Pre bone marrow transplant
Ejection Fraction 60
GSS 12.4 BSS 5.8
3 Months Later After BMT
Ejection Fraction 22
GSS 9.7 BSS 10.5
Patient died one week later
No Test is Perfect
Strain is not the first exception
False Positives
Isolated single abnormal segment
surrounded by normal segments
False Positive
Abnormal segment which has totally
unphysiologic value
e.g. +21, repeat -5
Current Speckle Strain Not
Reliable with Rapid Heart Rates
e.g. Normal dobutamine echo with
false positive segments at peak dose
with HR of 147
Strain Echocardiography: a sensitive indicator of
myocardial dysfunction
Ischemia
Hypertrophy
Infiltration
Hypoxia
Cardiotoxic drugs
Myocardial rejection
Severe systemic illness
Patients Benefiting From Strain
Echocardiography
Known or suspected CAD
Hypertension
Heart failure
Significant mitral or aortic regurgitation
Aortic stenosis
Any form of cardiomyopathy
Diabetes
Chemotherapy
Cardiac transplant

Strain as a Useful Supplement to Routine
Transthoracic Echocardiography
Wall motion analysis is subjective with high
inter observer variability: Strain is quantitative
with ease of interpretation
Wall thickness measurements are difficult
with high inter observer variability: Strain is an
independent indicator of hypertrophy
Ejection fraction has significant limitations:
Strain overcomes many of them
Speckle tracing strain is also possible with
other cardiac chambers e.g. RV, LA
Limitations of Speckle Tracking 2D Strain
Echocardiography
Quality of 2D image is a factor
Poor speckle tracking can lead to false positive
results
2D strain limited by frame rate and HR
If HR varies Bullseye not generated
So far only one manufacturer supplying and
displaying reliable strain data
Comparison between Different Speckle Tracking
and Color Tissue Doppler Techniques to Measure
Global and Regional Myocardial Deformation in
Children


JASE , Volume23 Pages 919-928 (September
2010)
Laurens Koopman, et al
Some deformation measurements (e.g.,
longitudinal and circumferential ) are comparable
among different ultrasound machines and
software packages, whereas others are
significantly different (e.g., radial and strain rate).
This study stresses the need for an industry
standard for these techniques.
Strain From Different
Instruments on Same Patient
Normal subject
Marked differences between green
and red bullseye
Strain From Different
Instruments on Same Patient
Abnormal patient
Marked differences between green
and red bullseye
We have been attempting to do speckle tracking in our lab for the past couple of
years and have pretty much given up on it until recently. We have an iE33 with
version 7 QLAB software. Reproducibility of measurements has been poor, and I do
not feel very confident in the measurements we were obtaining
I have been told that the Vivid 7 software is better for this type of analysis
(and seems to be the machine of choice by the researchers publishing data
on this technique), but have no personal experience.


Russ Tonkovic MD, FASE,FACC
Barrington IL

ASE Open Forum
3D Speckle Strain
Limited now by frame (volumes) rate
As frame (volumes) rate increases, speckle strain
should be simpler (only need to place two points on
one view vs three points on three views) and will
overcome some of current limitations of 2D speckle
strain (basal twist, variations in heart rate of views
e.g. atrial fibrillation)
3D speckle strain will probably be the preferred
technique in the future, but 2D speckle is proving to
be so valuable and relatively inexpensive, that it will
be the practical approach for some time.
Role of Strain Echocardiography in Todays
Practice of Medicine
Although it is possible that strain could be
considered to be separate like Doppler, it is unlikely
that there will be an added reimbursement for strain
The major benefit will be to make echocardiograms
more objective and quantitative thus producing a
more accurate and complete cardiac evaluation
Multiple complimentary imaging studies are very
costly, screening examinations may be eliminated
To be cost effective and competitive,
echocardiography must be a definitive examination.
Recording strain is a major step in this direction