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Measurement of Strain and Strain Rate by Echocardiography Ready for Prime Time? Journal of the American College of Cardiology Vol. 47, No. 7, 2006 © 2006 by the American College of Cardiology Foundation ISSN 0735-1097/06/$32.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2005.11.063 STATE-OF-THE-ART PAPER Measurement of Strain and Strain Rate by Echocardiography Ready for Prime Time? Thomas H. Marwick, MD, PHD Brisbane, Australia Strain and strain rate (SR) are measures of deformation that are basic descriptors of both the nature and the function of cardiac tissue. These properties may now be measured using either Doppler or two-dimensional ultrasound techniques. Although these measurements are feasible in routine clinical echocardiography, their acquisition and analysis nonetheless presents a number of technical challenges and complexities. Echocardiographic strain and SR imaging has been applied to the assessment of resting ventricular function, the assessment of myocardial viability using low-dose dobutamine infusion, and stress testing for ischemia. Resting function assessment has been applied in both the left and the right ventricles, and may prove particularly valuable for identifying myocardial diseases and following up the treatment response. Although the evidence base is limited, SR imaging seems to be feasible and effective for the assessment of myocardial viability. The use of the technique for the detection of ischemia during stress echocardiography is technically challenging and likely to evolve further. The clinical availability of strain and SR measurement may offer a solution to the ongoing need for quantification of regional and global cardiac function. Nonetheless, these techniques are susceptible to artifact, and further technical development is necessary. (J Am Coll Cardiol 2006;47:1313–27) © 2006 by the American College of Cardiology Foundation The usual indices of global left ventricular (LV) function, lengthening or shortening process an initial measurement of such as ejection fraction and volumes, are load-dependent, length is required (Lagrangian strain), and the same find- and standard volumetric approaches to their measurement ings may not necessarily be obtained by the measurement of may be influenced by image quality, technical considerations instantaneous strain during contraction (Eulerian or natural such as off-axis imaging, and measurement error. The strain). Second, tissue deformation occurs in three planes, in assessment of regional function is more difficult, remains addition to which shearing motion involves a number of highly subjective, and requires significant training. other tensors, so our current measurement approaches are a The echocardiographic measurement of myocardial strain vast simplification of the true motion of the heart. Third, ⑀ ( ) offers a series of regional and global parameters that may the assumption that tissue is incompressible is not com- be useful in the assessment of systolic and diastolic function. pletely true, and for example ignores the variation in The purpose of this review is to examine the technical and myocardial blood volume between diastole and systole. clinical aspects of incorporating this measurement into daily Fourth, the complexities of fiber direction cause a longitu- clinical practice. dinal shortening of 20% to 30% to generate radial shorten- ing of 50% to 70% (1). TECHNICAL ASPECTS Strain rate (SR) measures the time course of deformation, Background. Strain is a measure of tissue deformation. As and is the primary parameter of deformation derived from the ventricle contracts, muscle shortens in the longitudinal tissue Doppler (see later text). Indeed, SR seems to be a and circumferential dimensions (a negative strain) and correlate of rate of change in pressure (dP/dt), a parameter thickens or lengthens in the radial direction (a positive that is used to reflect contractility, whereas strain is an strain). The application of strain to measure deformation is analog of regional ejection fraction (2). As would be constrained by a number of complexities when the param- expected with ejection fraction, increasing pre-load is asso- eter is measured by echocardiography. First, to quantify the ciated with increasing strain at all levels of wall stress, and increasing after-load is associated with a reduction of strain. From the University of Queensland Department of Medicine, Princess Alexandra Although LV cavity size close to the normal range has a Hospital, Brisbane, Australia. Supported in part by a project grant (210218) from the National Health and Medical Research Council of Australia, Canberra, Australia. limited impact on strain, radial strain is increased and The author’s research group has collaborative research projects with General Electric longitudinal strain is reduced in small left ventricles. In Medical Systems. Manuscript received August 8, 2005; revised manuscript received November 21, contrast, SR is thought to be less related to pre-load and 2005, accepted November 22, 2005. after-load. 1314 Marwick JACC Vol. 47, No. 7, 2006 Echocardiographic Strain and Strain Rate April 4, 2006:1313–27 Tissue Doppler-based strain. TECHNICAL ASPECTS. The Abbreviations and Acronyms velocity of movement of myocardium can be recorded by 2D ϭ two-dimensional tissue Doppler techniques and displayed as a parametric LV ϭ left ventricle/ventricular color image in which each pixel represents the velocity ϭ RV right ventricle/ventricular relative to the transducer. These data may also be expressed SR ϭ strain rate SRI ϭ strain rate image/imaging graphically as the velocity of the myocardium relative to time (on the x axis). These recordings have documented that a descending gradation of velocity exists from the LV base Myocardial strain may be measured using a variety of to apex, reflecting the contraction of the base toward a echocardiographic techniques. Although M-mode tech- relatively fixed apex. Figure 1A shows the gradation of peak niques provide both accurate temporal and accurate spatial velocities at different locations along the LV wall. Although resolution, and may therefore be used to measure strain in a these velocity recordings provide information about the single dimension, the current era of myocardial strain motion of the wall, the ability of contraction in adjacent measurement began with the measurement of SR from segments to influence the velocity in any given segment comparison of adjacent tissue velocities by Heimdal et al. limits the site-specificity of velocity data. (3). Subsequently, strain has been measured using speckle Rather than examine the motion of a segment relative to tracking techniques (4,5). Each of these methodologies the transducer, which is susceptible to tethering to adjacent presents its own clinical challenges. tissue, myocardial motion may be measured relative to the Figure 1. Derivation of strain rate (SR) and strain from tissue Doppler data. A series of velocity curves (comprising isovolumic contraction [IVC], systolic [S] and diastolic [E and A] components) show a velocity gradient along a length of the wall (labeled d in the color Doppler image in A). A regression calculation between adjacent tissue velocity data points along this length generates the strain rate curve (B), which is then integrated to calculate strain (C). Timing of end-systole can be confirmed from the tissue Doppler waveform—in a separate example, the aortic valve closure (AVC) is marked by a transient wave in the adjacent septum and anterior mitral leaflet (D).ESϭ end-systolic; IVR ϭ isovolumic relaxation. Continued on next page. JACC Vol. 47, No. 7, 2006 Marwick 1315 April 4, 2006:1313–27 Echocardiographic Strain and Strain Rate adjacent myocardium. The instantaneous gradient of veloc- closure (marked by a transient shock wave in the septum and ity along a sample length may be quantified by performing mitral valve), and mitral valve opening (readily detectible from a regression calculation between the velocity data from gray-scale imaging in all apical views). adjacent sites along the scan line, and these instantaneous Like tissue velocity, strain parameters are most commonly data may then be combined to generate an SR curve (Fig. used to assess myocardial motion in a base-to-apex direc- 1B) (6,7). Integration of this curve provides instantaneous tion, which is sensitive to mild subendocardial damage. In data on deformation—shortening or lengthening—that rep- contrast, the measurement for radial strain from tissue resent strain (Fig. 1C). These data therefore reflect the velocity data is unsuitable for clinical use. It is difficult to movement of one tissue site relative to another within the accommodate the optimal inter-site distance required for sample volume, in contrast to tissue velocity data, which SR measurements (12 mm) in a ventricle of normal thick- merely reflect movement of one site relative to the trans- ness, and the use of a shorter offset distance is associated ducer. A number of experimental and clinical articles have with greater noise levels. Moreover, the requirement for the attested to the benefits of site specificity in avoiding motion adjacent points to lie along a single regression line means caused by tethering to adjacent segments, which is especially that only anteroseptal and posterior segments can be ana- important when dealing with coronary artery disease (8,9). lyzed with this technique, and because of the combination Our approach is first to examine the tissue velocity of right ventricular (RV) and LV myocardial structure in the waveform, because this represents the primary data, and this septum,
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