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Prof. José-Luis Zamorano
Ms Adriana Saltijeral
Prof. Leopoldo Perez de Isla ,
If the aim of the examination is LV contractility, 3D-WMT is a new technique that can assess global and regional left ventricular function in a fast and complete way. Its use may help the clinician to spare time without prescinding from a complete and accurate analysis. 3D-WMT is a potential clinical bedside tool for quantifying global and regional LV function.
Left ventricular (LV) volumes and ejection fraction (EF) are important parameters for the diagnosis and prognosis of patients with heart disease (1-3). They can be evaluated using different noninvasive imaging techniques. Currently two-dimensional echocardiography (2DE) is the most widely used. However, 2DE depends on the observer’s interpretation and heart analysis is limited to a small number of anatomical views.
Real time three-dimensional echocardiography (RT-3DE) provides greater nearness to real anatomy (4, 5). It was compared with 64 slice-ultrafast cardiac tomography and a good correlation between LVEF, end-diastolic volume and end-systolic volume (r: 0.7888, r: 0.7695, r: 0.8119, p<0.0001, respectively) was found (6,7). When RT-3DE was compared with CMR to calculate LV volumes and EF, it was comparable and superior to 2D-echo (8).
LVEF depends not only on LV contractility but on other parameters as well such as pre-load and after-load. The direct evaluation of contractility would be valuable. New three-dimensional wall motion tracking (3D-WMT) technology provides a novel approach to analyzing the left ventricle (LV) and a new concept to assess its function.
It is one of the main advantages of 3D-WMT because all segments are calculated in a single analysis step. Within 20 seconds, the result of the 3D WMT is available providing a variety of parameters to evaluate the myocardial function.
2D and 3D-WMT are also different in that 2D-WMT employs 2D movement or the projection of 3D movement into a 2D plane, whereas 3D tracking assesses real movement in 3D space, not just a projection. 3D-WMT can be used for regional wall motion analysis of the entire LV and allows to obtain real 3D indices and to assess 3D wall motion specifically with an improved integration of heart structure. It is capable of displaying results for the entire myocardium using a single dataset to assess truly global LV, new indices (eg, twist, torsion), true 3D strain, and a host of other previously unobserved parameters (11) (Figure 1). With this method, all vectors of tissue are tracked within the full volume. It provides a better vector calculation, which is more adequate for clinical scanning conditions and there is no loss of the speckle particle in 3D. The 3D-WMT technique is a simple, feasible, and reproducible method to measure longitudinal, circumferential, and radial strain values (8, 9).
3D-WMT not only provides information regarding the segmentary analysis of the left ventricular myocardium, it also provides a robust evaluation of LV volume during the heart cycle. The detection of the endocardium for wall motion purposes is used to obtain the inner dimensions of the LV 3D shape and the myocardial volume. The system informs on LV volumes and LVEF, and the related volume curves are presented time-aligned with the segmental parametric imaging curves (Figure 2). The 3D shapes can be corrected when needed in 5 orthogonal planes. Thus, the assessment of LV volume is anatomicaly correct and robust.
3D-WMT has a promising role in the evaluation of different heart diseases such as dilated cardiomyopathy, LV asynchrony evaluation, and ischemic heart disease (12-14).
Area tracking is a new parameter of regional and global LV function provided by 3D-WMT on the ARTIDA premium class ultrasound system from Toshiba Medical Systems. Area Tracking reflects the 3D radial strain and is based only on endocardial changes, which makes the method very sensitive for detecting ischemic reactions in the myocardium which are most detectable in the sub-endocardial layers (Figure 3). This new parameter reflects the deformation of the endocardial surface during LV contraction and relaxation. This application in combination with stress echo is a very promising tool to quantify stress echo readings. Figure 1: Different parameters (longitudinal strain, rotation, circumferential strain and torsion-basal) displayed in different formats.
Figure 2: Final representation of a normal heart, after automatic software detection of endocardium and epicardium. Figure 3: This polar map shows the area tracking analysis in a patient with a severely depressed left ventricular ejection fraction.
1. Mandinov L, Eberli FR, Seiler C, Hess OM: Diastolic heart failure. Cardiovasc Res 2000, 45(4):813-825. 2. Taylor G, Humphries J, Mellits E, Pitt B, Schulze R, Griffith L, Achuff S: Predictors of clinical course, coronary anatomy and left ventricular function after recovery from acute myocardial infarction. Circulation 1980, 62(5):960-970. 3. White H, Norris R, Brown M, Brandt P, Whitlock R, Wild C: Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction. Circulation 1987, 76:44-51. 4. Kisslo J, Firek B, Ota T, Kang DH, Fleishman CE, Stetten G, et al. Real-time volumetric echocardiography: the technology and the possibilities. Echocardiography. 2000; 17: 773-9. 5. Ahmad M. Real-time three-dimensional echocardiography in assessment of heart disease. Echocardiography. 2001; 18 (1): 73-7. 6. Vieira ML, Nomura CH, Tranchesi Junior B, Oliveira WA, Naccarato G, Serpa BS, Passos RB, Funari MB, Fischer CH, Morhy SS. Left ventricular ejection fraction and volumes as measured by 3d echocardiography and ultrafast computed tomography. Arq Bras Cardiol. 2009 Apr;92(4):294-301. English, Portuguese, Spanish 7. Sugeng L, Mor-Avi V, Weinert L, Niel J, Ebner C, Steringer-Mascherbauer R, et al. Quantitative assessment of left ventricular size and function: side-by-side comparison of real-time three-dimensional echocardiography and computed tomography with magnetic resonance reference. Circulation. 2006; 114 (7): 654-61. 8. Gutiérrez-Chico JL, Zamorano JL, Pérez de Isla L, Orejas M, Almería C, Rodrigo JL, Ferreirós J, Serra V, Macaya C. Comparison of left ventricular volumes and ejection fractions measured by three-dimensional echocardiography versus by two-dimensional echocardiography and cardiac magnetic resonance in patients with various cardiomyopathies. Am J Cardiol. 2005 Mar 15;95(6):809-13 9. Pérez de Isla L, Balcones DV, Fernández-Golfín C, et al. Three-dimensional-wall motion tracking: a new and faster tool for myocardial strain assessment: comparison with two-dimensional-wall motion tracking. J Am Soc Echocardiogr. 2009 Apr;22(4):325-30 10. Ken Saito, MD, Hiroyuki Okura, MD et al. Comprehensive Evaluation of Left Ventricular Strain Using Speckle Tracking Echocardiography in Normal Adults: Comparison of Three-Dimensional and Two-Dimensional Approaches. J Am Soc Echocardiogr 2009;Sep:22(9):1025-30. 11. Pérez de Isla L, Vivas D, Zamorano J.Three-Dimensional Speckle Tracking. Current Cardiovascular Imaging Reports 2008, 1:25-29. 12. Ingul CB, Torp H, Aase SA, et al. Automated analysis of strain rate and strain: feasibility and clinical applications. J Am Soc Echocardiogr 2005, 18:411-418. 13. Seo Y, Ishizu T et al. Mechanical Dyssynchrony Assessed by Speckle Tracking Imaging as a Reliable Predictor of Acute and Chronic Response to Cardiac Resynchronization Therapy. J Am Soc Echocardiogr 2009; 22:839-846. 14. Delgado V, Ypenburg C et al. Changes in Global Left Ventricular Function by Multidirectional Strain Assessmentin Heart Failure Patients Undergoing Cardiac Resynchronization Therapy. J Am Soc Echocardiogr 2009; 22:688-694.
Leopoldo Pérez de Isla, Adriana Saltijeral and José ZamoranoInstituto Cardiovascular Hospital Clínico San Carlos. Madrid, Spain.
Correspondence: Leopoldo Pérez de Isla Unidad de Imagen Cardiovascular Hospital Clínico San Carlos Plaza Cristo Rey 28040-Madrid, Spain Tel: 0034913303290 Fax: 0034913303290 email@example.com
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