Tissue Doppler and Strain

Question 1

Define tissue doppler

Answer 1

• an extension of pulsed Doppler
• focus on measuring regional tissue velocities rather than blood flow velocities

Question 2

What is the main principal in acquisition of tissue Doppler velocities?

Answer 2

• Elimination of a high-pass filter
  
  • used for PW Doppler assessment of blood flow
• focus on the lower velocity signals of tissue

Question 3

What are disadvantages/limitations of TDI?

Answer 3

• high frame rates are required to accurately collect tissue Doppler imaging (TDI)
• Angle-dependent technique
  
  • influenced by cardiac translational motion and tethering
• Load depdendent

Question 4

What is the relationship with age and TDI mitral annular velocity?

Answer 4

decreases with age

Question 5

E/e’ has been established as a correlate for these findings:

Answer 5

LVEDP

or

PCWP

Question 6

This TDI finding in patients with heart failure carries an unfavorable five-year survival rate?

Answer 6

e’ < 3 cm/s

Elevated E/e’ > 15 - also carries poor prognosis

Question 7

What is a sensitive and specific marker for cardiac amyloidosis on strain imaging?

Answer 7

apical sparing pattern

• on longitudinal strain imaging
• “cherry on top”

Question 8

What additional findings on TDI are consistent with cardiac amyloidosis?

Answer 8

Lower e’ and mean LV strain peak

• both were lower than age matched controls

Question 9

What is a useful parameter (on TDI) to differntiate pathological LVH (HOCM/hypertensive LVH) from physiologic LVH?

Answer 9

s’ < 9 cm/s

s’ = systolic ejection velocity

Question 10

What is one measure that may differentiate athletic heart from HOCM?

Answer 10

• E/e’
  
  • E/e’ > 12 = elevated LAP in HOCM patients
  • E/e’ < 8 = trained athletes with normal function

Question 11

What are disadvantages of speckle tracking?

Answer 11

Requires good image quality

• Cannot be sucessfully applied to approximately 10% of US images

Question 12

What frame rate is speck tracking performed at?

Answer 12

lower frame rates 40-90 frames/s

as compared to TDI > 100 frames/s

Question 13

What parameter can show a relatively normal value when the myocardium is akinetic?

Answer 13

TDI

Question 14

You perform an Echo on a college hockey player for palpitations. LV wall thickenss is increased. What parameter is consistent with Athlete’s Heart?

Answer 14

Septal e’ 15 cm/s

Question 15

What is one advantage of strain imaging over TDI?

Answer 15

Not affected by tethering of segments

Question 16

What movement indicates a negative number in strain imaging?

Answer 16

shortening = negative value

Question 17

What is the scale for Global Longitudinal Peak systolic strain (16 LV segments)?

Answer 17

• Normal = greater than (more negative than) - 18%
• Borderline = -16% to -18%
• Abnormal = less than (less negative than) - 16%

Question 18

What are strengths of GLS?

Answer 18

• Superiority in predication of all-cause mortality in the general population compared with LVEF
• Improved risk stratification in patients with HF
• Ability to recognize early LV dysfunction in patients undergoing cardiotoxic therapy and prognosticate subsequent CTRCD
• Reproducible when performed by trained operators

Question 19

What are the limitations of GLS?

Answer 19

• Heavy depdendence on 2D Echo quality
• Influenced by Loading conditions
• Lack of long term clinical trials
• Lack of data on reproducibility
• Vendor and software specific

Question 20

Describe the findings

Answer 20

• Bull’s eye plot showing GLS
  
  • A - baseline GLS
  • B - GLS at 3 months durting trastuszumab-based therapy after anthracyclines
• GLS has decreased from -20.6% –> - 14.4% (30% decrease)

Question 21

What is considered a significant change in GLS?

Answer 21

> 15% from baseline

Question 22

What is the first step after a significant change in GLS is noted?

Answer 22

repeat Echo with GLS to ensure findings are accurate

Question 23

What is the stepwise progression / algorithm for evaluation of suspected CTRCD?

Answer 23

Question 24

What are typical Echo features of Athletic heart?

Answer 24

• Normal tissue Doppler E’
• Normal, pseudorestrictive mitral inflow pattern
• Normal / mildly increased LA size
• Strain normal (higher than HCM)

Question 25

What is the normal GLS of the RV?

Answer 25

\> -25%

Question 26

Strain rate for tissue Doppler is defined as:

Answer 26

Change in velocity between two points divided by their distance * SR = (V1-V2) / L * V1 = velocity at point 1 * V2 = velocity at point 2 * L = length

Question 27

When compared with two-dimensional based strain, the biggest disadvantage of TDI-based strain is?

Answer 27

**Angle depdendency** * Like all doppler techniques, is sensitive to alignment *

Question 28

What is the relationship of TDI-based strain to tethering?

Answer 28

* **Not susceptible to tethering to adjacent tissue** * as myocardial motion is measured relative to the adjacent myocardium and not relative to the transducer

Question 29

If two-dimensional based strain imaging is used to evaluate pathologic processes involving the subendocardium, the preferred modality should be:

Answer 29

**Longitudinal strain** * In the subendocardium, the fibers are roughly longitudinally oriented * With an angle of 80 degrees with resepect to the circumferential direction of the fibers located in the mid-aspect of the thickness of the myocardium

Question 30

What hemodynamic parameter betst correlates with a combination of mitral E-wave velocity and early diastolic longitudinal velocities of the myocardium (e')?

Answer 30

**Mean left atrial pressure**

Question 31

When reporting GLS, it is imporant to bear in mind the impact of these parameters?

Answer 31

* Vendor * Age * Gender

Question 32

What radial strain rate obtained at the mid inferior wall during systole of a patient with ischemic cardiomyopathy is consistent with dyskinesis?

Answer 32

**Negative rate** * negative values for radial strain = * relaxation (if measured during diastole) * dyskinesis (if measured during systole) * Positive values for radial strain = active contraction

Question 33

Describe LV torsion

Answer 33

* During isovolumic contraction (phase 1), the apex shows a brief clockwise rotation and the base a short couterclockwise rotation * During ejection (phase 2), the direction of the rotation changes to **counterclockwise at the LV apex** and clockwise at the LV base

Question 34

What is one disadvantage of TDI in regards to motion?

Answer 34

**It is unable to differentiate between active motion (like myocardial contraction) and passive motion (like tethering)**

Question 35

Based on the Expert consensus for the multimodality imaging of the adult patient during and after cancer therapy, subclinical LV dysfunction is defined as:

Answer 35

**15% reduction in GLS when compared to baseline value**

Question 36

In asymmetric septal hypertrophic cardiomyopathy, tissue Doppler e':

Answer 36

**Has an inverse relationship with septal thickness**

Question 37

In diabetic patients, what does HbA1c correlate with?

Answer 37

**HbA1c correlates wtih E/e'** * glycemic control --\> microvascular complications --\> ischemia and subsequent impaired LV relaxation and increased myocardial stiffness

Question 38

In what condition has e' been shown to improve after treatment?

Answer 38

**Aortic stenosis** * Global LV dysfunction is common secondary to increased afterload

Question 39

What tissue doppler value has been shown to carry the most prognostic value after myocardial infarction (MI)?

Answer 39

**E/e' ratio** * E/e' \> 17 --\> mortality rate 40% at 36 months * E/e' \< 17 --\> mortality rate 5% at 36 months * E/e' \> 15 in Echo 1.6 days after MI, followed for 13 months --\> most powerful predictor of survival

Question 40

In patients with acute heart failure, this is a powerful predictor of cardiac events and appears to be a better parameter than ejection fraction

Answer 40

**Global circumferential strain (GCS)**

Question 41

This cardiac condition is associated with a normal or high e'?

Answer 41

**Athletes heart**

Question 42

In a patient with a localized basal lateral infarct with evidence of akinesis by two-dimensional Doppler imaging, the expected longitudinal tissue Doppler velocities (m/s) and strain rate (1/s) would be:

Answer 42

**Tissue Doppler Velocity = 0.2, Strain Rate = 0** * Strain rate of zero --\> akinesis * Velocities may be recorded in akinetic segments that are **tethered by adjacent moving segments**

Question 43

What is the best prediction of mortality for paradoximal severe AS and preserved EF patients?

Answer 43

**Symptoms + Euroscore + GLS**

Question 44

Describe the findings

Answer 44

Radial strain map demosntrating **Anteroseptal akinesis**

Question 45

Describe the findings

Answer 45

* Strain rate imaging with regions of interest selected in the septum (yellow circle) and lateral wall (blue circle) in A4C view * **Anteroseptal infarct** - selected area of the septum (yellow) maintains a strain rate of approximately zero throughout systole and diastole --\> finding consistent with akinesis and scar formation * Selected area (blue) demonstrates a negative strain rate in systole, signifying appropriate myocardial compressiona dna positive strain rate in diastole, signifying myocardial expansion

Question 46

Describe strain rate values

Answer 46

* Strain rate \> 0 = **expansion** * Strain rate \< 0 = **compression**

Question 47

46 year old woman with previous history of breast cancer treated with mastectomy, chemotherapy, and radiation therapy presents for evaluation of symptoms of fatigue. On examination, she has a heart rate (HR) of 100 bpm, BP 85/60 mmHg, elevated JVP, decreased breath sounds at the lung bases, ascites, and 3+ peripheral edema. TEE and TTE Doppler images are shown. What is the most likely diagnosis?

Answer 47

**Constrictive Pericarditis**

Question 48

68 year old woman presents for evaluation of dyspnea on exertion. Tissue Doppler images are shown, what is the most likely diagnosis?

Answer 48

**Asymmetric septal hypertrophic cardiomyopathy** * Key finding is reduction in e' velocity that is much more pronounced in the septum --\> consistent with hypertrophic cardiomyopathy

Question 49

41 year old woman with a diagnosis of recurrent triple negative breast cancer who has received a cumulative dose of anthracyclines of 450 mg/m2 undergoes an Echocardiogram with strain. Describe the image and recommendations

Answer 49

* Radial strain, usuing a short-axis image at the level of the papillary muscles * **Discontinue anthracycline, finish treatment with a nonanthracycline containing regimen, and initiate beta-blockers** * ​radial strain is abnormal at 11% (normal is 40%-60%) --\> suggestive of subclinical LV dysfunction

Question 50

64 year old diabetic woman is referred fro evaluation of heart failure symptoms. 2D Echo, Color Tissue Doppler images and strain from A4C view are shown. What is the diagnosis?

Answer 50

**Ischemic heart disease** * 2D Echo: dilated LV cavity consitent with dilated or ischemic cardiomyopathy * TDI Color: shows different color velocity pattern in the septum and lateral wall * Strain: reduced deformation in the apical septum (yellow curve) compared with the apical lateral wall (red curve) --\> findings consistent with **septal MI**

Question 51

What findings are indicative of subsequent cardiotoxity in chemotherapy patients?

Answer 51

**GLS \< 19%** or **Troponin I \> 30 pg/mL**

Question 52

62 year old man with history of rheumatic disease and previous mitral valve repair undergoes Echo for a heart murmur. 2D Echo and color M-mode tissue Doppler are consistent with this:

Answer 52

**Normal postoperative findings** **Paradoxical anterior systolic motion of the interventricular septum** \*\*\*\*\*Normal finding post pericardiotomy