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Is three-dimensional speckle-tracking echocardiography able to identify different patterns of left atrial dysfunction in selected disorders?
International Journal of Cardiology 220 (2016) 535–537
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Is three-dimensional speckle-tracking echocardiography able to identify different patterns of left atrial dysfunction in selected disorders? Short summary of the MAGYAR-Path Study Attila Nemes ⁎, Péter Domsik, Anita Kalapos, Tamás Forster 2nd Department of Medicine and Cardiology Center, Medical Faculty, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
a r t i c l e
i n f o
Article history: Received 20 May 2016 Accepted 22 June 2016 Available online 24 June 2016 Keywords: Three-dimensional Speckle-tracking Echocardiography Left atrial Function
cycle including systolic reservoir, early diastolic conduit and late diastolic active contraction phases [2]. Due to ability of 3DSTE in assessing LA volume changes respecting cardiac cycle, end-systolic maximum LA volume (Vmax, largest LA volume before mitral valve opening), early diastolic pre-atrial contraction LA volume (VpreA, at time of P wave on ECG) and end-diastolic minimum LA volume (Vmin, smallest LA volume before mitral valve closure) could be calculated [4–9]. From these LA volumes, several volume-based functional properties could be measured using the following equations: For systolic reservoir function: - Total Atrial Stroke Volume (TASV): Vmax − Vmin. - Total Atrial Emptying Fraction (TAEF): TASV / Vmax × 100.
Echocardiography is the most widely used non-invasive imaging modality in recent clinical practice, which is useful in determination of left atrial (LA) size and functional properties [1]. Although several echocardiographic techniques were demonstrated to have diagnostic role in assessing LA, some of them are based on geometric assumptions and suffer in inaccuracy. It is well-known that echocardiographyderived LA dimensions and functional features have been found to be a significant predictor of cardiovascular morbidity and mortality [2]. One of the main focuses of recent clinical ultrasound research is on speckle-tracking echocardiography-derived (STE) myocardial deformation analysis by strain assessments which is angle-independent and allows fast and reproducible analysis of LA volumes and functional properties [1]. Moreover, three-dimensional (3D) echocardiography coupled with STE capability tries to merge advantages of both techniques due to its ability making measurements in 3D space [1,3]. 3DSTE technique is based on block-matching algorithm of the myocardial speckles and is able to calculate uni- and multidirectional LA strains together with volumes respecting cardiac cycle. This sort of approach of chamber assessment could proceed into a complex detailed evaluation of LA function respecting cycling motion of the LA by calculating volume-based functional properties and strain parameters at the same time from the same acquired 3D dataset. LA function has different phases during cardiac
⁎ Corresponding author at: 2nd Department of Medicine and Cardiology Center, Medical Faculty, Albert Szent-Györgyi Clinical Center, University of Szeged, H-6725 Szeged, Semmelweis street 6, P.O. Box 427, Hungary. E-mail address: [email protected] (A. Nemes).
http://dx.doi.org/10.1016/j.ijcard.2016.06.122 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
For early diastolic conduit function: - Passive Atrial Stroke Volume (PASV): Vmax − VpreA. - Passive Atrial Emptying Fraction (PAEF): (PASV/Vmax × 100. For late-diastolic active contraction: - Active Atrial Stroke Volume (AASV): VpreA − Vmin. - Active Atrial Emptying Fraction (AAEF): AASV / VpreA × 100. Together with volume measurements, several unidirectional strain parameters could be assessed including radial (RS), longitudinal (LS) and circumferential (CS) strains. Complex multidirectional variables could also be measured [area (AS) and 3D (3DS) strains]. Moreover, not only global, but mean segmented and segmental peak strains featuring LA reservoir function could be measured for each patient (Fig. 1). The present short review tried to partially summarize results of MAGYAR-Path Study (Motion Analysis of the heart and Great vessels bY three-dimensionAl speckle-tRacking echocardiography in Pathological cases) which has been organized at our department to examine diagnostic and prognostic significance of 3DSTEderived variables including LA volumetric and functional parameters. Data acquisition and analysis followed recent practices as described in more details in previous studies [4–9]. Shortly, all 3D echocardiographic data acquisitions were performed with a Toshiba Artida echocardiography equipment using a 1–4 MHz PST-25SX
536
Correspondence
Fig. 1. Extracts from three-dimensional speckle-tracking echocardiography-derived datasets: apical four-chamber (A), two-chamber views (B) and short-axis views at basal (C3), midventricular (C5) and superior (C7) levels. A 3D cast of the left atrium (LA) (red D) and calculated volumetric LA parameters are also shown (red E). A time-global longitudinal strain curve (white line) together with time-volume curve (dashed line) respecting cardiac cycle is also demonstrated in a certain case (red F). Abbreviations: EDV and ESV = calculated LA volumes, EF = ejection fraction, est. MASS = LA estimated mass, Vmax = maximum LA volume, VpreA = pre-atrial contraction LA volume, Vmin = minimum LA volume.
matrix phased-array transducer (Toshiba Medical Systems, Tokyo, Japan). Full volume 3D datasets were created from 6 wedge-shaped subvolumes during a single breathhold. The 3D Wall Motion Tracking software version 2.7 (Toshiba Medical Systems, Tokyo, Japan) was used for quantification of LA [3]. During assessments a five plane-view was created by the software including apical two(AP2CH) and four-chamber (AP4CH) views and three short-axis views at different levels of the LA. Endocardial border was traced by setting several reference points at the edges of the mitral valve and at the apex (superior LA region) on AP2CH and AP4CH views. Subsequently, 3D wall motion tracking was then automatically performed through the entire cardiac cycle. LA volumes and functional parameters were measured in a number of different disorders to examine alterations in these parameters and to compare variables to that of age- and gender-matched healthy subjects as a part of MAGYAR-Path Study by our working group [4–9]. LA volumes, volume-based functional properties and peak strains showed different alterations in selected disorders demonstrating specific patterns of LA dysfunction (see Table 1). Moreover, some disorders were associated reduction in only some phases of LA function, but in most of diseases all LA functional phases were deteriorated with increased LA volumes respecting cardiac cycle (Table 2). Differences in variables could be explained by the differences in volume and pressure overloads related to specific diseases and associated left ventricular dysfunction, the presence and degree of mitral regurgitation, alterations in wall tissue quality (fibrosis, infiltration, circulation-related abnormalities etc.), disorder-related low grade inflammation and focal oedema,
deterioration in vegetative autonomic neuropathy, hormonal discrepancies, etc. Our results could highlight our attention on the ability of
Table 1 Three-dimensional speckle-tracking echocardiography-derived left atrial volumes, volume-based functional properties and global peak strain parameters in different disorders.
LA volumes (ml) Vmax Vmin VpreA LA stroke volumes (ml) Total atrial SV Passive atrial SV Active atrial SV LA emptying fraction (%) Total atrial EF Passive atrial EF Active atrial EF LA global peak strains (%) Radial strain Circumferential strain Longitudinal strain 3D strain Area strain
T1DM (4)
HES (5)
Sport (6)
HCM (7)
NCCM (8)
CA (9)
↑ ↑ ↑
↑ ↑ ↑
↑ ↑ ↑
↑ ↑ ↑
↑ ↑ ↑
↑ ↑ ↑
↑ – –
↑ – ↑
↑ ↑ –
↑ – ↑
– – –
– – –
– – –
– – –
↓ – ↓
↓ ↓ –
↓ ↓ ↓
↓ ↓ ↓
– – – – –
– ↓ – – –
– ↓ – – –
↓ – ↓ ↓ –
↓ ↓ ↓ – ↓
↓ ↓ ↓ ↓ ↓
Abbreviations: CA = cardiac amyloidosis, HCM = hypertrophic cardiomyopathy, HES = hypereosinophilic syndrome, NCCM = noncompaction cardiomyopathy, T1DM = type 1 diabetes mellitus, ↓ means decrease, ↑ means increase, – means no changes as compared to age- and gender-matched healthy controls.
Correspondence
537
Table 2 Different patterns of left atrial dysfunction as assessed by three-dimensional speckle-tracking echocardiography in different disorders.
Systolic reservoir function Diastolic conduit function Diastolic active contraction
T1DM (4)
HES (5)
Sport (6)
HCM (7)
NCCM (8)
CA (9)
+ − −
+ − +
+ + +
+ + +
+ + +
+ + +
Abbreviations: CA = cardiac amyloidosis, HCM = hypertrophic cardiomyopathy, HES = hypereosinophilic syndrome, NCCM = noncompaction cardiomyopathy, T1DM = type 1 diabetes mellitus, + means alterations, − means no alterations as compared to age- and gender-matched healthy controls.
3DSTE in detecting differences in LA dysfunction in certain disorders (Tables 1–2). Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] A. Nemes, T. Forster, Assessment of left atrial size and function — from M-mode to 3D speckle-tracking echocardiography, Orv. Hetil. 155 (2014) 1624–1631. [2] B.D. Hoit, Left atrial size and function: role in prognosis, J. Am. Coll. Cardiol. 63 (2014) 493–505. [3] A. Nemes, A. Kalapos, P. Domsik, T. Forster, Three-dimensional speckle-tracking echocardiography — a further step in non-invasive three-dimensional cardiac imaging, Orv. Hetil. 153 (2012) 1570–1577. [4] A. Nemes, G.A. Piros, C. Lengyel, P. Domsik, A.. Kalapos, T.T. Várkonyi, et al., Complex evaluation of left atrial dysfunction in patients with type 1 diabetes mellitus by threedimensional speckle tracking echocardiography: results from the MAGYAR-Path Study, Anatol. J. Cardiol. (2015), http://dx.doi.org/10.5152/AnatolJCardiol.2015.6225.
[5] A. Nemes, I. Marton, P. Domsik, A. Kalapos, É. Pósfai, S. Modok, et al., Characterization of left atrial dysfunction in hypereosinophilic syndrome — Insights from the Motion analysis of the heart and great vessels by three-dimensional speckle tracking echocardiography in pathological cases (MAGYAR-Path) Study, Rev. Port. Cardiol. 35 (2016) 277–283. [6] A. Nemes, P. Domsik, A. Kalapos, A. Orosz,M. Oszlánczi, L. Török, et al., Volumetric and functional assessment of the left atrium in young competitive athletes without left ventricular hypertrophy. Insights from the three-dimensional speckle-tracking echo-cardiographic MAGYAR-Sport Study, J. Sports Med. Phys. Fitness (in press). [7] P. Domsik, A. Kalapos, S. Chadaide, R. Sepp, P. Hausinger, T. Forster, et al., Threedimensional speckle tracking echocardiography allows detailed evaluation of left atrial function in hypertrophic cardiomyopathy—insights from the MAGYAR-Path Study, Echocardiography 31 (2014) 1245–1252. [8] A. Nemes, G.Á. Piros, P. Domsik, A. Kalapos, T. Forster, Left atrial volumetric and strain analysis by three-dimensional speckle-tracking echocardiography in noncompaction cardiomyopathy: results from the MAGYAR-Path Study, Hell. J. Cardiol. 57 (2016) 23–29. [9] A. Nemes, P. Domsik, A. Kalapos, R. Sepp, D. Foldeak, Z. Borbenyi, et al., Different patterns of left atrial dysfunction in cardiac amyloidosis and hypertrophic cardiomyopathy as assessed by three-dimensional speckle-tracking echocardiography, Eur. Heart J. Cardiovasc. Imaging 16 (Suppl. 2) (2015) S1–S239.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Is three-dimensional speckle-tracking echocardiography able to identify different patterns of left atrial dysfunction in selected disorders? Short summary of the MAGYAR-Path Study Attila Nemes ⁎, Péter Domsik, Anita Kalapos, Tamás Forster 2nd Department of Medicine and Cardiology Center, Medical Faculty, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
a r t i c l e
i n f o
Article history: Received 20 May 2016 Accepted 22 June 2016 Available online 24 June 2016 Keywords: Three-dimensional Speckle-tracking Echocardiography Left atrial Function
cycle including systolic reservoir, early diastolic conduit and late diastolic active contraction phases [2]. Due to ability of 3DSTE in assessing LA volume changes respecting cardiac cycle, end-systolic maximum LA volume (Vmax, largest LA volume before mitral valve opening), early diastolic pre-atrial contraction LA volume (VpreA, at time of P wave on ECG) and end-diastolic minimum LA volume (Vmin, smallest LA volume before mitral valve closure) could be calculated [4–9]. From these LA volumes, several volume-based functional properties could be measured using the following equations: For systolic reservoir function: - Total Atrial Stroke Volume (TASV): Vmax − Vmin. - Total Atrial Emptying Fraction (TAEF): TASV / Vmax × 100.
Echocardiography is the most widely used non-invasive imaging modality in recent clinical practice, which is useful in determination of left atrial (LA) size and functional properties [1]. Although several echocardiographic techniques were demonstrated to have diagnostic role in assessing LA, some of them are based on geometric assumptions and suffer in inaccuracy. It is well-known that echocardiographyderived LA dimensions and functional features have been found to be a significant predictor of cardiovascular morbidity and mortality [2]. One of the main focuses of recent clinical ultrasound research is on speckle-tracking echocardiography-derived (STE) myocardial deformation analysis by strain assessments which is angle-independent and allows fast and reproducible analysis of LA volumes and functional properties [1]. Moreover, three-dimensional (3D) echocardiography coupled with STE capability tries to merge advantages of both techniques due to its ability making measurements in 3D space [1,3]. 3DSTE technique is based on block-matching algorithm of the myocardial speckles and is able to calculate uni- and multidirectional LA strains together with volumes respecting cardiac cycle. This sort of approach of chamber assessment could proceed into a complex detailed evaluation of LA function respecting cycling motion of the LA by calculating volume-based functional properties and strain parameters at the same time from the same acquired 3D dataset. LA function has different phases during cardiac
⁎ Corresponding author at: 2nd Department of Medicine and Cardiology Center, Medical Faculty, Albert Szent-Györgyi Clinical Center, University of Szeged, H-6725 Szeged, Semmelweis street 6, P.O. Box 427, Hungary. E-mail address: [email protected] (A. Nemes).
http://dx.doi.org/10.1016/j.ijcard.2016.06.122 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
For early diastolic conduit function: - Passive Atrial Stroke Volume (PASV): Vmax − VpreA. - Passive Atrial Emptying Fraction (PAEF): (PASV/Vmax × 100. For late-diastolic active contraction: - Active Atrial Stroke Volume (AASV): VpreA − Vmin. - Active Atrial Emptying Fraction (AAEF): AASV / VpreA × 100. Together with volume measurements, several unidirectional strain parameters could be assessed including radial (RS), longitudinal (LS) and circumferential (CS) strains. Complex multidirectional variables could also be measured [area (AS) and 3D (3DS) strains]. Moreover, not only global, but mean segmented and segmental peak strains featuring LA reservoir function could be measured for each patient (Fig. 1). The present short review tried to partially summarize results of MAGYAR-Path Study (Motion Analysis of the heart and Great vessels bY three-dimensionAl speckle-tRacking echocardiography in Pathological cases) which has been organized at our department to examine diagnostic and prognostic significance of 3DSTEderived variables including LA volumetric and functional parameters. Data acquisition and analysis followed recent practices as described in more details in previous studies [4–9]. Shortly, all 3D echocardiographic data acquisitions were performed with a Toshiba Artida echocardiography equipment using a 1–4 MHz PST-25SX
536
Correspondence
Fig. 1. Extracts from three-dimensional speckle-tracking echocardiography-derived datasets: apical four-chamber (A), two-chamber views (B) and short-axis views at basal (C3), midventricular (C5) and superior (C7) levels. A 3D cast of the left atrium (LA) (red D) and calculated volumetric LA parameters are also shown (red E). A time-global longitudinal strain curve (white line) together with time-volume curve (dashed line) respecting cardiac cycle is also demonstrated in a certain case (red F). Abbreviations: EDV and ESV = calculated LA volumes, EF = ejection fraction, est. MASS = LA estimated mass, Vmax = maximum LA volume, VpreA = pre-atrial contraction LA volume, Vmin = minimum LA volume.
matrix phased-array transducer (Toshiba Medical Systems, Tokyo, Japan). Full volume 3D datasets were created from 6 wedge-shaped subvolumes during a single breathhold. The 3D Wall Motion Tracking software version 2.7 (Toshiba Medical Systems, Tokyo, Japan) was used for quantification of LA [3]. During assessments a five plane-view was created by the software including apical two(AP2CH) and four-chamber (AP4CH) views and three short-axis views at different levels of the LA. Endocardial border was traced by setting several reference points at the edges of the mitral valve and at the apex (superior LA region) on AP2CH and AP4CH views. Subsequently, 3D wall motion tracking was then automatically performed through the entire cardiac cycle. LA volumes and functional parameters were measured in a number of different disorders to examine alterations in these parameters and to compare variables to that of age- and gender-matched healthy subjects as a part of MAGYAR-Path Study by our working group [4–9]. LA volumes, volume-based functional properties and peak strains showed different alterations in selected disorders demonstrating specific patterns of LA dysfunction (see Table 1). Moreover, some disorders were associated reduction in only some phases of LA function, but in most of diseases all LA functional phases were deteriorated with increased LA volumes respecting cardiac cycle (Table 2). Differences in variables could be explained by the differences in volume and pressure overloads related to specific diseases and associated left ventricular dysfunction, the presence and degree of mitral regurgitation, alterations in wall tissue quality (fibrosis, infiltration, circulation-related abnormalities etc.), disorder-related low grade inflammation and focal oedema,
deterioration in vegetative autonomic neuropathy, hormonal discrepancies, etc. Our results could highlight our attention on the ability of
Table 1 Three-dimensional speckle-tracking echocardiography-derived left atrial volumes, volume-based functional properties and global peak strain parameters in different disorders.
LA volumes (ml) Vmax Vmin VpreA LA stroke volumes (ml) Total atrial SV Passive atrial SV Active atrial SV LA emptying fraction (%) Total atrial EF Passive atrial EF Active atrial EF LA global peak strains (%) Radial strain Circumferential strain Longitudinal strain 3D strain Area strain
T1DM (4)
HES (5)
Sport (6)
HCM (7)
NCCM (8)
CA (9)
↑ ↑ ↑
↑ ↑ ↑
↑ ↑ ↑
↑ ↑ ↑
↑ ↑ ↑
↑ ↑ ↑
↑ – –
↑ – ↑
↑ ↑ –
↑ – ↑
– – –
– – –
– – –
– – –
↓ – ↓
↓ ↓ –
↓ ↓ ↓
↓ ↓ ↓
– – – – –
– ↓ – – –
– ↓ – – –
↓ – ↓ ↓ –
↓ ↓ ↓ – ↓
↓ ↓ ↓ ↓ ↓
Abbreviations: CA = cardiac amyloidosis, HCM = hypertrophic cardiomyopathy, HES = hypereosinophilic syndrome, NCCM = noncompaction cardiomyopathy, T1DM = type 1 diabetes mellitus, ↓ means decrease, ↑ means increase, – means no changes as compared to age- and gender-matched healthy controls.
Correspondence
537
Table 2 Different patterns of left atrial dysfunction as assessed by three-dimensional speckle-tracking echocardiography in different disorders.
Systolic reservoir function Diastolic conduit function Diastolic active contraction
T1DM (4)
HES (5)
Sport (6)
HCM (7)
NCCM (8)
CA (9)
+ − −
+ − +
+ + +
+ + +
+ + +
+ + +
Abbreviations: CA = cardiac amyloidosis, HCM = hypertrophic cardiomyopathy, HES = hypereosinophilic syndrome, NCCM = noncompaction cardiomyopathy, T1DM = type 1 diabetes mellitus, + means alterations, − means no alterations as compared to age- and gender-matched healthy controls.
3DSTE in detecting differences in LA dysfunction in certain disorders (Tables 1–2). Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] A. Nemes, T. Forster, Assessment of left atrial size and function — from M-mode to 3D speckle-tracking echocardiography, Orv. Hetil. 155 (2014) 1624–1631. [2] B.D. Hoit, Left atrial size and function: role in prognosis, J. Am. Coll. Cardiol. 63 (2014) 493–505. [3] A. Nemes, A. Kalapos, P. Domsik, T. Forster, Three-dimensional speckle-tracking echocardiography — a further step in non-invasive three-dimensional cardiac imaging, Orv. Hetil. 153 (2012) 1570–1577. [4] A. Nemes, G.A. Piros, C. Lengyel, P. Domsik, A.. Kalapos, T.T. Várkonyi, et al., Complex evaluation of left atrial dysfunction in patients with type 1 diabetes mellitus by threedimensional speckle tracking echocardiography: results from the MAGYAR-Path Study, Anatol. J. Cardiol. (2015), http://dx.doi.org/10.5152/AnatolJCardiol.2015.6225.
[5] A. Nemes, I. Marton, P. Domsik, A. Kalapos, É. Pósfai, S. Modok, et al., Characterization of left atrial dysfunction in hypereosinophilic syndrome — Insights from the Motion analysis of the heart and great vessels by three-dimensional speckle tracking echocardiography in pathological cases (MAGYAR-Path) Study, Rev. Port. Cardiol. 35 (2016) 277–283. [6] A. Nemes, P. Domsik, A. Kalapos, A. Orosz,M. Oszlánczi, L. Török, et al., Volumetric and functional assessment of the left atrium in young competitive athletes without left ventricular hypertrophy. Insights from the three-dimensional speckle-tracking echo-cardiographic MAGYAR-Sport Study, J. Sports Med. Phys. Fitness (in press). [7] P. Domsik, A. Kalapos, S. Chadaide, R. Sepp, P. Hausinger, T. Forster, et al., Threedimensional speckle tracking echocardiography allows detailed evaluation of left atrial function in hypertrophic cardiomyopathy—insights from the MAGYAR-Path Study, Echocardiography 31 (2014) 1245–1252. [8] A. Nemes, G.Á. Piros, P. Domsik, A. Kalapos, T. Forster, Left atrial volumetric and strain analysis by three-dimensional speckle-tracking echocardiography in noncompaction cardiomyopathy: results from the MAGYAR-Path Study, Hell. J. Cardiol. 57 (2016) 23–29. [9] A. Nemes, P. Domsik, A. Kalapos, R. Sepp, D. Foldeak, Z. Borbenyi, et al., Different patterns of left atrial dysfunction in cardiac amyloidosis and hypertrophic cardiomyopathy as assessed by three-dimensional speckle-tracking echocardiography, Eur. Heart J. Cardiovasc. Imaging 16 (Suppl. 2) (2015) S1–S239.