Principal strain orientation in the normal human left ventricle

Dilated Cardiomyopathy: Normalized Multiparametric Myocardial Strain Predicts Contractile Recovery

BACKGROUND

Left ventricular contractile injury in dilated cardiomyopathy (DCM) may occur in a consistently heterogeneous distribution, suggesting that early-injury sentinel regions may have prognostic significance. Heightened surveillance of these regions with high-resolution contractile metrics may predict recovery in DCM.

METHODS

Multiple three-dimensional strain parameters were calculated at each of 15,300 left ventricular grid points from systolic displacement data obtained from cardiac magnetic resonance imaging in 124 test subjects. In 24 DCM patients, Z-scores for two strain parameters at each grid point were calculated by comparison of patient-specific strain values to respective point-specific mean and standard deviation values from a normal human strain database (n = 100). Multiparametric strain Z-scores were averaged over six left ventricular regions at basilar, mid, and apical levels (18 subregions). Patients with DCM were stratified into three groups on the basis of a blinded review of clinical contractile recovery (complete, n = 7; incomplete, n = 7; none, n = 10).

RESULTS

Basilar-septal subregions were consistently heavily injured. Basilar-septal Z-scores were significantly larger (worse) than those for the rest of the left ventricle (2.73 ± 1.27 versus 2.22 ± 0.83; p = 0.011) and lateral wall (2.73 ± 1.27 versus 1.44 ± 0.72; p < 0.001). All patients with sentinel region average multiparametric strain Z-scores less than two standard deviations (n = 6) experienced complete recovery, whereas 17 of 18 DCM patients with Z-scores greater than two standard deviations experienced incomplete or no contractile recovery.

CONCLUSIONS

Contractile injury in DCM is heterogeneous, with basilar-septal regions injured more than lateral regions. The targeting of early-injury sentinel regions for heightened surveillance with high-resolution metrics of microregional contractile function may accurately predict recovery on medical therapy. A two standard deviation Z-score threshold may predict contractile recovery.

Quantifying "normalized" regional left ventricular contractile function in ischemic coronary artery disease

OBJECTIVE

When significant coronary lesions are identified by angiography, regional left ventricular (LV) contractile function often plays a role in determining candidacy for revascularization. To improve on current subjective and nonquantitative metrics of regional LV function, we tested a z-score "normalization" of regional strain information quantified from clinically acquired high-resolution LV geometric datasets.

METHODS

Test subjects (n = 120) underwent cardiac MRI with multiple 3-dimensional strain parameters calculated from tissue tag-plane displacement data. Sixty healthy volunteers contributed strain parameter data at each of 15,300 LV grid points, to form a normal human strain database. Point-specific database comparisons were made in 60 patients who had documented coronary artery disease (CAD), by angiography. Patient-specific, color-coded 3-dimensional LV maps of z-score-normalized contractile function were generated.

RESULTS

Blinded clinical review indicated that 55% (33 of 60) of the patients with CAD had significant regional contractile abnormalities by 1 of 3 "gold-standard" criteria: (1) Q waves on electrocardiography (ECG); (2) infarct on radionuclide single-photon emission computed tomography (SPECT); or (3) akinesia or dyskinesia on echocardiography. Consistency among all gold-standard metrics was found for only 19% (6 of 31) of patients with CAD who had ≥2 available metrics. Blinded MRI-based, multiparametric, strain z-score localization of contractile abnormalities was accurate in 89% (ECG), 97% (SPECT), and 95% (echocardiography).

CONCLUSIONS

Nonsubjective normalization of regional LV contractile function by z-score calculation from a normal human strain database can localize and quantitatively display regional wall motion abnormalities in patients with CAD. This high-resolution localization of regional wall motion abnormalities may help improve the accuracy of therapeutic intervention in patients who have CAD.

Regional myocardial three-dimensional principal strains during postinfarction remodeling

BACKGROUND

The purpose of this study was to quantify myocardial three-dimensional (3D) principal strains as the left ventricle (LV) remodels after myocardial infarction (MI). Serial quantification of myocardial strains is important for understanding the mechanical response of the LV to MI. Principal strains convert the 3D LV wall-based strain matrix with three normal and three shear elements, to a matrix with three nonzero normal elements, thereby eliminating the shear elements, which are difficult to physically interpret.

METHODS

The study was designed to measure principal strains of the remote, border zone, and infarct regions in a porcine model of post-MI LV remodeling. Magnetic resonance imaging was used to measure function and strain at baseline, 1 week, and 4 weeks after infarct. Principal strain was measured using 3D acquisition and the optical flow method for displacement tracking.

RESULTS

Principal strains were altered as the LV remodeled. Maximum principal strain magnitude decreased in all regions, including the noninfarcted remote, while maximum principal strain angles rotated away from the radial direction in the border zone and infarct. Minimum principal strain magnitude followed a similar pattern; however, strain angles were altered in all regions. Evolution of principal strains correlated with adverse LV remodeling.

CONCLUSIONS

Using a state-of-the-art imaging and optical flow method technique, 3D principal strains can be measured serially after MI in pigs. Results are consistent with progressive infarct stretching as well as with decreased contractile function in the border zone and remote myocardial regions.

Longitudinal strain from velocity encoded cardiovascular magnetic resonance: a validation study

BACKGROUND

Regional myocardial function is typically evaluated by visual assessment by experienced users, or by methods requiring substantial post processing time. Visual assessment is subjective and not quantitative. Therefore, the purpose of this study is to develop and validate a simple method to derive quantitative measures of regional wall function from velocity encoded cardiovascular magnetic resonance (CMR), and provide associated normal values for longitudinal strain.

METHOD

Both fast field echo (FFE) and turbo field echo (TFE) velocity encoded CMR images were acquired in three long axis planes in 36 healthy volunteers (13 women, 23 men), age 35±12 years. Strain was also quantified in 10 patients within one week after myocardial infarction. The user manually delineated myocardium in one time frame and strain was calculated as the myocardium was tracked throughout the cardiac cycle using an optimization formulation and mechanical a priori assumptions. A phantom experiment was performed to validate the method with optical tracking of deformation as an independent gold standard.

RESULTS

There was an excellent agreement between longitudinal strain measured by optical tracking and longitudinal strain measured with TFE velocity encoding. Difference between the two methods was 0.0025 ± 0.085 (ns). Mean global longitudinal strain in the 36 healthy volunteers was -0.18 ± 0.10 (TFE imaging). Intra-observer variability for all segments was 0.00 ± 0.06. Inter-observer variability was -0.02 ± 0.07 (TFE imaging). The intra-observer variability for radial strain was high limiting the applicability of radial strain. Mean longitudinal strain in patients was significantly lower (-0.15± 0.12) compared to healthy volunteers (p<0.05). Strain (expressed as percentage of normal strain) in infarcted regions was lower compared to remote areas (p<0.01).

CONCLUSION

In conclusion, we have developed and validated a robust and clinically applicable technique that can quantify longitudinal strain and regional myocardial wall function and present the associated normal values for longitudinal strain.

MRI-based multiparametric strain analysis predicts contractile recovery after aortic valve replacement for aortic insufficiency

BACKGROUND

Guidelines for referral of chronic aortic insufficiency (AI) patients for aortic valve replacement (AVR) suggest that surgery can be delayed until symptoms or reduction in left ventricular (LV) contractile function occur. The frequent occurrence of reduced LV contractile function after AVR for chronic AI suggests that new contractile metrics for surgical referral are needed.

METHODS

In 16 chronic AI patients, cardiac MRI tagged images were analyzed before and 21.5 ± 13.8 months after AVR to calculate LV systolic strain. Average measurements of three strain parameters were obtained for each of 72 LV regions, normalized using a normal human strain database (n = 63), and combined into a composite index (multiparametric strain z score [MSZ]) representing standard deviation from the normal regional average.

RESULTS

Preoperative global MSZ (72-region average) correlated with post-AVR global MSZ (R(2) = 0.825, p < 0.001). Preoperative global MSZ also predicts improvement of impaired regions (N = 271 regions from 14 AI patients, R(2) = 0.392, p < 0.001). Preoperative MRI-based LV ejection fraction (LVEF) is also predictive (r = 0.410, p < 0.001). Although global preoperative MSZ had a significantly higher correlation than preoperative LVEF with improvement of injured regions (p < 0.001), both measures convey the same phenomenon.

CONCLUSIONS

Global preoperative MRI-based multiparametric strain predicts global strain postoperatively, as well as improvement of regions (n = 72 per LV) with impaired contractile function. Global contractile function is an important correlate with improvement in regionally impaired contractile function, perhaps reflecting total AI volume-overload burden (severity/duration of AI).

Heterogeneous distribution of left ventricular contractile injury in chronic aortic insufficiency

BACKGROUND

Global systolic strain has been described previously in patients with chronic aortic insufficiency (AI). This study explored regional differences in contractile injury.

METHODS

Tagged magnetic resonance images of the left ventricle (LV) were acquired and analyzed to calculate systolic strain in 42 patients with chronic AI. Multiparametric systolic strain analysis was applied to relate cardiac function in AI patients to a normal strain database (N = 60). AI patients were classified as having normal or poor function based on their results. A two-way repeated-measures analysis of variance was applied to analyze regional differences in injury.

RESULTS

The mean and standard deviation of raw strain values (circumferential strain, longitudinal strain, and minimum principal strain angle) are presented over the entire LV in our normal strain database. Of the 42 patients with AI, 15 could be defined as having poor function by multiparametric systolic strain analysis. In AI patients with poor function, statistical analysis showed significant differences in injury between standard LV regions (F(3.69,44.33) = 3.47, p = 0.017) and levels (F(1.49,17.88) = 4.41, p = 0.037) of the LV, whereas no significant differences were seen in the group with normal cardiac function.

CONCLUSIONS

Patients with poor function, as defined by multiparametric systolic strain z scores, exhibit a consistent, heterogeneous pattern of contractile injury in which the septum and posterior regions at the base are most injured.

Regional myocardial contractile function: multiparametric strain mapping

Magnetic resonance imaging (MRI) with tissue tagging enables the quantification of multiple strain indices that can be combined through normalization into a single multiparametric index of regional myocardial contractile function. The aim of this study was to test the ability of multiparametric strain analysis to quantify regional differences in contractile function in an ovine model of myocardial injury. Regional variance in myocardial contractile function was induced in eight sheep by the ligation of the blood supply to the anterior and apical left ventricular (LV) myocardial walls. LV systolic strain was obtained from tissue tagged MRI images. A normal strain database (n=50) defines all parameters of systolic strain and allows normalization of regional function at 15,300 LV points by calculation of a z-score. Multiparametric systolic strain z-scores were therefore determined for 15,300 points in each injured sheep left ventricle. Multiparametric z-scores were found to vary significantly by region (P<0.001). z-Scores in regions remote to the infarct were found to be significantly smaller than those in the regions most likely to include infarcted myocardium. In this pre-clinical evaluation of MRI-based multiparametric strain analysis, it accurately quantified and visually defined regional differences in myocardial contractile function.

Magnetic resonance imaging-based multiparametric systolic strain analysis and regional contractile heterogeneity in patients with dilated cardiomyopathy

BACKGROUND

Myocardial systolic strain patterns in dilated cardiomyopathy are considered non-homogeneous but have not been investigated with magnetic resonance imaging (MRI)-based multiparametric systolic strain analysis. Left ventricular (LV) 3-dimensional (3D) multiparametric systolic strain analysis is sensitive to regional contractility and is generated from sequential MRI of tissue-tagging gridline-point displacements.

METHODS

Sixty normal human volunteers underwent MRI-based 3D systolic strain analysis to supply normal average and standard deviation values for each of three strain parameters at each of 15,300 individual LV grid-points. Patient-specific multiparametric systolic strain data from each dilated cardiomyopathy patient (n = 10) were then subjected to a point-by-point comparison (n = 15,300 LV points) to the normal strain database for three individual strain components (45,900 database comparisons per patient). The resulting composite multiparametric Z-score values (standard deviation from normal average) were color contour mapped over patient-specific 3D LV geometry to detect the normalized regional contractile patterns associated with dilated cardiomyopathy.

RESULTS

Average multiparametric strain Z-score values varied significantly according to ventricular level (p = 0.001) and region (p = 0.003). Apical Z-scores were significantly less than those in both the base (p = 0.037) and mid-ventricle (p = 0.002), whereas anterolateral wall Z-scores were less than those in the anteroseptal (p = 0.023) and posteroseptal walls (p = 0.028).

CONCLUSIONS

MRI-based multiparametric systolic strain analysis suggests that myocardial systolic strain in patients with dilated cardiomyopathy has a heterogeneous regional distribution and, on average, falls almost 2 standard deviations from normal.

Myocardial viability mapping by magnetic resonance-based multiparametric systolic strain analysis

BACKGROUND

Regional myocardial contractility can be characterized by three-dimensional left ventricular (LV) multiparametric strain maps generated from sequential magnetic resonance imaging of radiofrequency tissue-tagging grid point displacements.

METHODS

Normal average and standard deviation values for each of three strain indices at 15,300 LV points were determined from a normal volunteer human strain database (n = 50) by application of magnetic resonance-based three-dimensional strain analysis. Patient-specific multiparametric strain data from each ischemic cardiomyopathy patient (n = 20) were then submitted to a point-by-point comparison (n = 15,300 LV points) to the normal strain database. The resulting 15,300 composite multiparametric Z-score values (standard deviation from normal average) were color-contour mapped over patient-specific three-dimensional LV geometry to detect the abnormal contractile patterns associated with myocardial infarction and nonviable myocardium.

RESULTS

The average multiparametric strain composite Z-score from each LV region (n = 120) was compared with the respective clinical standard viability testing result and used to construct a receiver-operator characteristic curve. The area under the curve was 0.941 (p < 0.001; 95% confidence interval: 0.897 to 0.985). A regional average Z-score threshold of 1.525 (> 1.525 being nonviable) resulted in a sensitivity of 90% and a specificity of 90%. Corresponding positive and negative predictive values were 84% and 95%, respectively.

CONCLUSIONS

The clinical application of magnetic resonance-based multiparametric strain analysis allowed accurate regional characterization and visualization of LV myocardial viability.

Nonhomogeneous strain from sparse marker arrays for analysis of transmural myocardial mechanics

BACKGROUND

Knowledge of normal cardiac kinematics is important when attempting to understand the mechanisms that impair the contractile function of the heart during disease. The complex kinematics of the heart can be studied by inserting radiopaque markers in the cardiac wall and study the pumping heart with biplane cineradiography. In order to study the local strain, the bead array was developed where small radiopaque beads are inserted along three columns transmurally in the left ventricle.

METHOD

This paper suggests a straightforward method for strain computation, based on polynomial least-squares fitting and tailored for combined marker and bead array analyses.

RESULTS

This polynomial method gives small errors for a realistic bead array on an analytical test case. The method delivers an explicit expression of the Lagrangian strain tensor as a polynomial function of the coordinates of material points in the reference configuration. The method suggested in this paper is validated with analytical strains on a deforming cylinder resembling the heart, compared to a previously suggested finite element method, and applied to in vivo ovine data. The errors in the estimated strain components are shown to remain unchanged on an analytical test case when evaluating the effects of one missing bead. In conclusion, the proposed strain computation method is accurate and robust, with errors smaller or comparable to the current gold standard when applied on an analytical test case.

A novel, view-independent method for strain mapping in myocardial elastography: eliminating angle and centroid dependence

Robust indices of regional and global cardiac function are a key factor in detection and treatment of heart disease as well as understanding of the fundamental mechanisms of a healthy heart. Myocardial elastography provides a noninvasive method for imaging and measuring displacement and strain of the myocardium for the early detection of cardiovascular disease. However, two-dimensional in-plane axial and lateral strains measured depend on the sonographic view used. This becomes especially critical in a clinical setting and may induce large variations in the measured strains, potentially leading to false diagnoses. A novel method in myocardial elastography is proposed for eliminating this view dependence by deriving the polar, principal and classified principal strains. The performance of the proposed methodology is assessed by employing 3D finite-element left-ventricular models of a control and an ischemic canine heart. Although polar strains are angle-independent, they are sensitive to the selected reference coordinate system, which requires the definition of a centroid of the left ventricle (LV). In contrast, principal strains derived through eigenvalue decomposition exhibit the inherent characteristic of coordinate system independence, offering view (i.e., angle and centroid)-independent strain measurements. Classified principal strains are obtained by assigning the principal components in the physical ventricular coordinate system. An extensive strain analysis illustrates the improvement in interpretation and visualization of the full-field myocardial deformation by using the classified principal strains, clearly depicting the ischemic and non-ischemic regions. Strain maps, independent of sonographic views and imaging planes, that can be used to accurately detect regional contractile dysfunction are demonstrated.