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Fast long-axis strain: a simple, automatic approach for assessing left ventricular longitudinal function with cine cardiovascular magnetic resonance

  • Cardiac
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

In some cardiac pathologies, impairment of left ventricular (LV) longitudinal function may precede reduction in LV ejection fraction. This study investigates the effectiveness of a fast method to quantify long-axis LV function compared to conventional feature tracking and manual approaches.

Methods

The study consisted of 50 normal controls and 100 heart failure (HF) patients including 40 with reduced ejection fraction (HFrEF), 30 with mid-range ejection fraction (HFmrEF), and 30 with preserved ejection fraction (HFpEF). Parameters including fast long-axis strain (FLAS) at end-systole and peak strain rates during systole (FLASRs), early diastole (FLASRe), and atrial contraction (FLASRa) were derived by a fast semi-automated approach on cine cardiovascular magnetic resonance.

Results

FLAS exhibited good agreement with strain values obtained using conventional feature tracking (bias − 2.9%, limits of agreement ± 3.0%) and the manual approach (bias 0.6%, limits of agreement ± 2.1%), where FLAS was more reproducible and required shorter measurement time. The mean FLAS (HFrEF < HFmrEF < HFpEF < controls; 6.1 ± 2.4 < 9.9 ± 2.4 < 11.0 ± 2.5 < 16.9 ± 2.3%, all p < 0.0001) was decreased in all the HF patient groups. A FLAS of 12.3% (mean-2SD of controls) predicted the presence of systolic dysfunction in 67% of patients with HFpEF, and 87% with HFmrEF. Strain parameters using the fast approach were superior to those obtained by conventional feature tracking and manual approaches for discriminating HFpEF from controls. Notable examples are area under the curve, sensitivity, and specificity for FLAS (0.94, 93%, and 86%) and FLASRe (0.96, 90%, and 94%).

Conclusions

The fast approach–derived LV strain and strain rate parameters facilitate reproducible, reliable, and effective LV longitudinal function analysis.

Key Points

• Left ventricular long-axis strain can be rapidly derived from cine CMR with shorter measurement time and higher reproducibility compared to conventional feature tracking and the manual approach.

• Progressive reductions in left ventricular long-axis strain and strain rate measurements were observed from HFpEF, HFmrEF, to HFrEF group.

• Based on long-axis strain, systolic abnormalities were evident in HFmrEF and HFpEF indicating common coexistence of systolic and diastolic dysfunction in the HF phenotypes.

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Abbreviations

ANOVA:

Analysis of variance

AUC:

Area under ROC curve

CMR:

Cardiovascular magnetic resonance

CV:

Coefficient of variation

DRA:

Deformable registration–based analysis

EF:

Ejection fraction

FLAS:

Fast long-axis strain

FLASR:

Fast long-axis strain rate

FT:

Feature tracking

GTLS:

Global transmural longitudinal strain

GTLSR:

Global transmural longitudinal strain rate

HF:

Heart failure

HFmrEF:

Heart failure with mid-range ejection fraction

HFpEF:

Heart failure with preserved ejection fraction

HFrEF:

Heart failure with reduced ejection fraction

LA:

Left atrial

LV:

Left ventricular

MAPSE:

Mitral annular plane systolic excursion

MLAS:

Manual long-axis strain

ROC:

Receiver operating characteristic

SR:

Strain rate

STE:

Speckle tracking echocardiography

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Funding

This study received funding support from the National Medical Research Council Singapore (NMRC/OFIRG/0018/2016; NMRC/BnB/0017/2015; MOH-000358; MOH-000351; NMRC/TA/0031/2015; MOH-000153), SingHealth Duke-NUS Academic Medicine Research Grant (AM/TP015/2018 (SRDUKAMR1814)). The funder had no role in the design and conduct of the study; collection; management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Author information

Authors and Affiliations

  1. National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore

    Shuang Leng, Ru-San Tan, Xiaodan Zhao, Angela S. Koh & Liang Zhong

  2. Duke-NUS Medical School, National University of Singapore, 8 College Road, Singapore, 169857, Singapore

    Ru-San Tan, John C. Allen, Angela S. Koh & Liang Zhong

Authors
  1. Shuang Leng
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  2. Ru-San Tan
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  3. Xiaodan Zhao
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  4. John C. Allen
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  5. Angela S. Koh
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  6. Liang Zhong
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Corresponding author

Correspondence to Liang Zhong.

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Guarantor

The scientific guarantor of this publication is Liang Zhong.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise (John C. Allen, statistician, Duke-NUS Medical School, Singapore).

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Study subjects or cohorts have been reported in a previously published paper (Leng S et al Validation of a rapid semi-automated method to assess left atrial longitudinal phasic strains on cine cardiovascular magnetic resonance imaging. J Cardiovasc Magn Reson 2018;20:71). However, the prior report focused on the left atrial function assessment. The current study investigated the left ventricular function assessed by a fast method compared to conventional feature tracking and manual approaches.

Methodology

• Prospective

• Diagnostic or prognostic study

• Performed at one institution

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Electronic supplementary material

Supplementary Figure 1.

Correlation and Bland-Altman plots (Top) between FLAS and MLAS (Bottom) between FLAS and GTLS. In correlation plots, black solid line (equations shown in figure) and black dash lines denote Passing-Bablok non-parametric regression line and 95% confidence intervals, respectively; red dot line denotes the line of equality. FLAS, fast long-axis strain; MLAS, manual long-axis strain; GTLS, global transmural longitudinal strain. Supplementary Figure 2. Correlation and Bland-Altman plots of FLASRs versus GTLSRs (Top); FLASRe versus GTLSRe (Middle); and FLASRa versus GTLSRa (Bottom). In correlation plots, black solid line (equations shown in figure) and black dash lines denote Passing-Bablok non-parametric regression line and 95% confidence intervals, respectively; red dot line denotes the line of equality. FLASRs, peak systolic fast long-axis strain rate; FLASRe, peak early diastolic fast long-axis strain rate; FLASRa, peak fast long-axis strain rate during atrial contraction. GTLSRs, peak systolic global transmural longitudinal strain rate; GTLSRe, peak early diastolic global transmural longitudinal strain rate; GTLSRa, peak global transmural longitudinal strain rate during atrial contraction. Supplementary Figure 3. Example of tagging analysis using CIMTag2D in 2-chamber view in (Top) one normal control with longitudinal strain of 16.4% and (Bottom) one heart failure patient with longitudinal strain of 7.9%. Supplementary Figure 4. Correlation and Bland-Altman plots between FLAS and GLStag. In correlation plots, black solid line (equation shown in figure) and black dash lines denote Passing-Bablok non-parametric regression line and 95% confidence intervals, respectively; red dot line denotes the line of equality. FLAS, fast long-axis strain; GLStag, global longitudinal strain derived from CMR tagged images. Supplementary Table 1. Comparisons between results derived from fast approach and manual tracking (n = 40, 10 controls, 10 HFpEF, 10 HFmrEF, 10 HFrEF) (DOCX 787 KB)

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Leng, S., Tan, RS., Zhao, X. et al. Fast long-axis strain: a simple, automatic approach for assessing left ventricular longitudinal function with cine cardiovascular magnetic resonance. Eur Radiol 30, 3672–3683 (2020). https://doi.org/10.1007/s00330-020-06744-6

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