Speckle tracking stress echocardiography in children: interobserver and intraobserver reproducibility and the impact of echocardiographic image quality

The mechanics of congenital heart disease: from a morphological trait to the functional echocardiographic evaluation

Advances in pediatric cardiac surgery have resulted in a recent growing epidemic of children and young adults with congenital heart diseases (CHDs). In these patients, congenital defects themselves, surgical operations and remaining lesions may alter cardiac anatomy and impact the mechanical performance of both ventricles. Cardiac function significantly influences outcomes in CHDs, necessitating regular patient follow-up to detect clinical changes and relevant risk factors. Echocardiography remains the primary imaging method for CHDs, but clinicians must understand patients' unique anatomies as different CHDs exhibit distinct anatomical characteristics affecting cardiac mechanics. Additionally, the use of myocardial deformation imaging and 3D echocardiography has gained popularity for enhanced assessment of cardiac function and anatomy. This paper discusses the role of echocardiography in evaluating cardiac mechanics in most significant CHDs, particularly its ability to accommodate and interpret the inherent anatomical substrate in these conditions.

Influence of ultrasound transmit frequency on measurement of global longitudinal strain on 2D speckle tracking echocardiography

The reproducibility of longitudinal strain measured by 2D speckle tracking echocardiography (2DSTE) may be affected by ultrasound settings. This study investigated the effect of transmit ultrasound frequency on global longitudinal strain (GLS) by 2DSTE. Apical, 2- and 4-chamber, and long-axis views were obtained in consecutive 162 patients using Philips ultrasound devices. Three different frequency presets were used sequentially: high resolution (HRES, 1.9 to 2.1 MHz), general (HGEN, 1.6 to 1.8 MHz), and penetration mode (HPEN, 1.3 to 1.6 MHz). GLS values were determined for each preset using the Philips Q-station software, resulting in GLS-HRES, GLS-HGEN, and GLS-HPEN. Among the 151 patients with successfully measured GLS, a significant difference in GLS was observed among the three presets (p < 0.0001). GLS-HRES (- 17.9 ± 4.4%) showed a slightly smaller magnitude compared to GLS-HGEN (- 18.8 ± 4.5%, p < 0.0001) and GLS-HPEN (- 18.8 ± 4.5%, p < 0.0001), with absolute differences of 1.1 ± 1.0% and 1.1 ± 1.2%, respectively. This variation in GLS with frequency was evident in patients with both optimal (n = 104) and suboptimal (n = 47) image quality and remained consistent regardless of ultrasound devices, ischemic etiology, or ejection fraction. In conclusion, ultrasound frequency had only a modest effect on GLS measurements. GLS may be reliably assessed in most cases regardless of the ultrasound frequency used.

Impact of Cancer Type and Treatment Protocol on Cardiac Function in Pediatric Oncology Patients: An Analysis Utilizing Speckle Tracking, Global Longitudinal Strain, and Myocardial Performance Index

Pediatric hemato-oncology patients undergoing anthracycline therapy are at risk of cardiotoxicity, with disease type and treatment intensity potentially affecting cardiac function. Novel echocardiographic measures like speckle tracking echocardiography (STE), global longitudinal strain (GLS), and the myocardial performance index (MPI) may predict early changes in cardiac function not detected by traditional methods. This study aimed to assess the impact of cancer type and treatment protocol on these parameters and their potential in predicting long-term cardiac complications. We conducted a single-center, retrospective cohort study of 99 pediatric oncology patients and 46 controls that were assessed at 3, 6, and 12 months. The median age was 10.7 ± 4.4 years for cases and 10.2 ± 3.6 years for controls. STE, GLS, and MPI were measured, and statistical analyses were performed to determine any significant correlations with cardiotoxicity. Significant variations were observed in traditional cardiac function measurements between the patient and control groups, with a lower average ejection fraction (EF) of 62.8 ± 5.7% in patients vs. 66.4 ± 6.1% in controls (p < 0.001), poorer GLS of -16.3 ± 5.1 in patients compared to -19.0 ± 5.4 in controls (p = 0.004), and higher MPI values of 0.37 ± 0.06 in patients compared to 0.55 ± 0.10 in controls, indicating worse overall cardiac function (p < 0.001). However, differences in cardiac function measurements by cancer histology or treatment protocol were not statistically significant. Regression analyses showed that the combination of GLS, SMOD, and MPI increased the odds of cardiac toxicity with an odds ratio of 7.30 (95% CI: 2.65-12.81, p < 0.001). The study underscores the predictive value of the combined GLS, SMOD, and MPI measurements in pediatric oncology patients undergoing anthracycline treatment for cardiotoxicity. Although variations across cancer types and treatment protocols were not significant, the study emphasizes the potential utility of these novel echocardiographic measures in early detection and long-term prediction of anthracycline-induced cardiotoxicity. Further studies in larger, multi-center cohorts are required for validation.

Abnormal Global Longitudinal Strain During Anthracycline Treatment Predicts Future Cardiotoxicity in Children

Global longitudinal strain (GLS) is a sensitive predictor of cardiotoxicity in adults with cancer. However, the significance of abnormal GLS during childhood cancer treatment is less well-understood. The objective was to evaluate the use of GLS for predicting later cardiac dysfunction in pediatric cancer survivors exposed to high-dose anthracyclines. This was a retrospective study of pediatric patients exposed to a doxorubicin isotoxic equivalent dose of ≥ 225 mg/m2. Transthoracic echocardiograms (TTE) were obtained prior to chemotherapy (T1), during anthracycline therapy (T2), and following completion of therapy (T3). Cardiotoxicity was defined as meeting at least one of the following criteria after anthracycline therapy: a decrease in left ventricle ejection fraction (LVEF) by 10% from baseline to a value < 55%, fractional shortening < 28%, or a decrease in GLS by ≥ 15% from baseline. Nineteen of 57 (33%) patients met criteria for cardiotoxicity at T3. Cardiotoxicity was associated with a lower LVEF at T2 (p = 0.0003) and a decrease in GLS by ≥ 15% at T2 compared to baseline (p =  < 0.0001). ROC analysis revealed that the best predictor of cardiotoxicity at T3 was the percent change in GLS at T2 compared to baseline (AUC 0.87). A subgroup analysis revealed that a decrease in GLS by ≥ 15% from baseline at 0-6 months from completion of anthracycline therapy was associated with cardiotoxicity > 1-year post-treatment (p = 0.017). A decline in GLS during chemotherapy was the best predictor of cardiotoxicity post-treatment. GLS serves as an important marker of cardiac function in pediatric patients undergoing treatment with anthracyclines.

Uncovering Cardiac Involvement in Childhood Diabetes: Is it Time to Move Toward Speckle Tracking Echocardiography in Childhood Diabetes Management?

Context:

One of the most common endocrine disorders in children is diabetes which is the leading cause of premature cardiovascular disease in adulthood.

Aims:

This study is aimed to investigate the extend of cardiac involvement in diabetic children by speckle tracking echocardiography (STE) in comparison to two-dimensional (2D) echocardiography and routine laboratory data.

Settings and Design:

A cross-sectional study conducted on patients under 18 years of age who deal with type one diabetes mellitus for more than 5 years.

Subjects and Methods:

To compare the STE results, we included the STE data of 25 normal age-matched children. All patients underwent laboratory analysis for lipid profile, blood sugar, and 2D echocardiography plus STE.

Statistical Analysis Used:

Two-sample independent t-test, Chi-square test, logistic regression test, Spearman's rank correlation coefficient, and the Pearson correlation coefficient.

Results:

From March 2018 to 2019, we included 53 patients, mean age 15.8 ± 0.39 years and 52.8% female, and 25 nondiabetic control in this study. STE revealed global longitudinal strain (LS) −18.4 versus − 24.2 for patient (44 valid cases) versus control group, respectively, with significant statistical difference. Diabetic patients had lower LS in all segments compared to the control group.

Conclusions:

STE has very high sensitivity to detect cardiac involvement far earlier than 2D echocardiography. None of the routine biomarkers or demographic features can predict cardiac involvement based on segmental abnormalities of STE. Active investigation to clear the remote impact of STE abnormalities and its practical role in childhood diabetes management is highly recommended.

Assessment of left ventricular dyssynchrony by speckle tracking echocardiography in children with duchenne muscular dystrophy

Prognosis of Duchenne muscular dystrophy (DMD) is related to cardiac dysfunction. Two dimensional-speckle tracking echocardiography (2D-STE) has recently emerged as a non-invasive functional biomarker for early detection of DMD-related cardiomyopathy. This study aimed to determine, in DMD children, the existence of left ventricle (LV) dyssynchrony using 2D-STE analysis. This prospective controlled study enrolled 25 boys with DMD (mean age 11.0 ± 3.5 years) with normal LV ejection fraction and 50 age-matched controls. Three measures were performed to assess LV mechanical dyssynchrony: the opposing-wall delays (longitudinal and radial analyses), the modified Yu index, and the time-to-peak delays of each segment. Feasibility and reproducibility of 2D-STE dyssynchrony were evaluated. All three mechanical dyssynchrony criteria were significantly higher in the DMD group than in healthy subjects: (1) opposing-wall delays in basal inferoseptal to basal anterolateral segments (61.4 ± 45.3 ms vs. 18.3 ± 50.4 ms, P < 0.001, respectively) and in mid inferoseptal to mid anterolateral segments (58.6 ± 35.3 ms vs. 42.4 ± 36.4 ms, P < 0.05, respectively), (2) modified Yu index (33.3 ± 10.1 ms vs. 28.5 ± 8.1 ms, P < 0.05, respectively), and (3) most of time-to-peak values, especially in basal and mid anterolateral segments. Feasibility was excellent and reliability was moderate to excellent, with ICC values ranging from 0.49 to 0.97. Detection of LV mechanical dyssynchrony using 2D-STE analysis is an easily and reproducible method in paediatric DMD. The existence of an early LV mechanical dyssynchrony visualized using 2D-STE analysis in children with DMD before the onset of cardiomyopathy represents a perspective for future paediatric drug trials in the DMD-related cardiomyopathy prevention.Clinical Trial Registration Clinicaltrials.gov NCT02418338. Post-hoc study, registered on April 16, 2015.

Left Ventricular Strain and Strain Rate during Submaximal Semisupine Bicycle Exercise Stress Echocardiography in Healthy Adolescents and Young Adults: Systematic Protocol and Reference Values

OBJECTIVE

Combining stress echocardiography with strain analysis is a promising approach for early detection of subclinical cardiac dysfunction not apparent at rest. Data on normal myocardial strain and strain rate (SR) response to exercise in adolescents and young adults are contradictory and limited. The aim of this study was to propose a standardized protocol for semisupine bicycle stress echocardiography and to provide corresponding reference values of left ventricular (LV) two-dimensional speckle-tracking echocardiography (2D STE) strain and SR in adolescents and young adults.

METHODS

Fifty healthy adolescents and young adults (mean age, 17.8 ± 3.2 years, 44% female) were prospectively assessed. Images were acquired at rest, low stress, submaximal stress, and during recovery. Optimal image quality for offline strain analysis was pursued, and image quality was rated. Global longitudinal strain and SR from apical four-/two-/three-chamber views and short-axis circumferential strain and SR were analyzed using vendor-independent software. Interobserver variability was assessed.

RESULTS

Strain and SR increased during progressive exercise stress. Mean LV global longitudinal strain was -20.4% ± 1.3%, SR -1.1 ± 0.15/sec at rest (heart rate, 79.4 ± 12.0 beats/minute), increasing to -22.6% ± 1.6% and -1.5 ± 0.16/sec at low stress level (heart rate, 117.1 ± 8.7 beats/minute) and -23.7% ± 1.1% and -1.9 ± 0.29/sec at submaximal stress level (heart rate, 154.2 ± 7.0 beats/minute), respectively, returning to -20.6% ± 1.4% and -1.2 ± 0.16/sec postexercise (heart rate, 90.1 ± 9.4 beats/minute). Restriction on submaximal stress level ensured adequate image quality for 2D STE strain analysis. Interobserver variability for strain was acceptable even during submaximal stress.

CONCLUSIONS

This study provides a systematic, standardized protocol and corresponding reference data for 2D LV STE-derived strain and SR during semisupine bicycle exercise testing in adolescents and young adults. According to our results, global longitudinal strain and SR appear to be the most comprehensible parameters for cross-sectional studies.

Time to shape up - assessment and reporting standards for data quality in clinical research using echocardiographic imaging techniques require improvement

Advanced echocardiography techniques such as speckle tracking imaging are sensitive diagnostic tools frequently used in various clinical and scientific scenarios. Importantly, imperfect reproducibility and dependence of post-processing algorithms on echocardiographic image quality are potential methodological limitations. Therefore, meticulous assessment of data quality and detailed reporting of study methodology, sample specifics, technical peculiarities and measurement conditions are crucial. Unfortunately, despite the recognized importance of this, there is still no broadly accepted standard for assessing the quality of echocardiographic images in clinical research reports. This article quintessentially highlights important shortcomings of data quality assessment and methodological study design, commonly occurring in clinical research reports using advanced echocardiography techniques. Finally, suggestions are made as to how researchers, scientific communities and biomedical journals can contribute to the ever-lasting process of improving the quality of clinical research in cardiovascular imaging.