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Innovation in coronary artery disease recommendations: deformation imaging is an option

ESC Congress Report

  • Deformation imaging helps differentiate patients with chest pain from ischemic origin from those with pain of non-ischemic origin in the emergency department and helps stratify risk.
  • The values of global longitudinal strain measured at hospital discharge were predictive of left ventricular remodelling and outcome.
  • The relationship between myocardial deformation and left ventricular ejection fraction is reviewed.
  • Global longitudinal strain can predict outcome as well as persistent microvascular obstruction at discharge and left ventricuar remodeling.



Professor Edvardsen from Oslo (NO) underlined the diagnostic yield of deformation imaging (i.e. longitudinal strain) in patients in whom visual analysis of ventricular wall motion is not diagnostic per se. In addition to an overall reduction of global longitudinal strain absolute values, the analysis of strain curve morphology showed important diagnostic yield. Two patterns (early systolic stretching and  post-systolic shortening) of segmental strain curves showed good accuracy in detecting ischemic myocardium.  The use of deformation imaging was not only useful to differentiate patients  with chest pain from ischemic origin from those with pain of non-ischemic origin in the emergency department, but it was also useful to stratify their risk by helping thecardiologist to identify patients with NSTEMI and corornary occlusions (who may benefit from an earlier angiographic study and rivascularization) and patients with multivessel disease.

Doctor Galderisi from Napoli (IT) showed that the absolute values of global longitudinal strain in patients with chronic ischemic disease were related to the infarct mass assessed with cardiac magnetic resonance and that the values of global longitudinal strain measured at hospital discharge were predictive of left ventricular remodeling and outcome.

Professor Voigt from Leuven (BE) illustrated the relationship between myocardial deformation and left ventricular ejection fraction. Despite there is an obvious and significant correlation between global longitudinal strain and ejection fraction, this correlation is not very close showing that the two parameters measure different entities. Indeed, global longitudinal strain have an additive prognostic value (e.g. to predict survival) over ejecion fraction in patients with chronic ischemic heart disease, however this additive prognostic value is significant only in patients with ejection fractions higher than 35%. The real problem that limits the use of strain in clinical routine is the significant intervendor variability of strain measurements. This issue will hopefully be solved by the upcoming standardization of the technique as the result to joing European Association of Cardiovascular Imaging/American Society of Echocardiography / Echocardiography manufacturer and software developer partners which will be published in the following weeks. Particularly interesting are the use of deformation imaging to diagnose inducible ischemia during stress echocardiography tests when visual assessment of wall motion is normal or controversial, and to assess intraventricular dyssynchrony to help in selecting patients who will benefit from cardiac resynchronization therapy.

Professor Derumeaux from Paris (FR) illustrated the role of deformation imaging in current guidelines to manage patients with stable coronary artery disease. Despite in current guidelines the role of deformation imaging is limited to assess patients with heart failure and preserved ejection fraction it is likely that in the next edition of the guidelines the role of deformation imaging will be expanded. Myocardial deformation is related to available myocardial blood flow and also small reductions of myocardial blood flow, which not affect regional wall motion, may affect its deformation. This is the pathophysiological explanation of the increased sensistivity of longitudinal myocardial deformation to ischemic damage over visually assessed wall motion and it can also explain the results of several studies showing that global longitudinal strain can identify patients with chronic angina and left main or three-vessel coronary artery disease from those with less severe coronary disease. In addition, there is a good amount of data showing that global longitudinal strain is a good surrogate of infarct size measured with cardiac magnetic resonance and can predict outcome as well as persistent microvascular obstruction at discharge (despite succesful recanalization) and  left ventricuar remodeling.  
A new myocardial deformation parameter has become available with three-dimensional echocardiography : area strain (a combination of longitudinal and circumferential strain) which has shown close correlations with infarct size assessed with cardiac magnetic resonance.  Further refinements of the technique allow to obtain layer specific (i.e. diffferentiating the function of subendocardial from subepicardial layers of myocardium) measurements  of myocardial function to predict the severity of coronary artery disease in NSTEMI patients

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Innovation in coronary artery disease recommendations: deformation imaging is an option

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.