Challenges associated with retrospective analysis of left ventricular function using clinical echocardiograms from a multicenter research study

Abstract

Background Retrospective multicenter research using echocardiograms obtained for routine clinical care can be hampered by issues of individual center quality. We sought to evaluate imaging and patient characteristics associated with poorer quality of archived echocardiograms from a cohort of childhood cancer survivors. Methods A single blinded reviewer at a central core laboratory graded quality of clinical echocardiograms from five centers focusing on images to derive 2D and M‐mode fractional shortening (FS), biplane Simpson's ejection fraction (EF), myocardial performance index (MPI), tissue Doppler imaging (TDI)–derived velocities, and global longitudinal strain (GLS). Results Of 535 studies analyzed in 102 subjects from 2004 to 2017, all measures of cardiac function could be assessed in only 7%. While FS by 2D or M‐mode, MPI, and septal E/E′ could be measured in >80% studies, mitral E/E′ was less consistent (69%), but better than EF (52%) and GLS (10%). 66% of studies had ≥1 issue, with technical issues (eg, lung artifact, poor endocardial definition) being the most common (33%). Lack of 2‐ and 3‐chamber views was associated with the performing center. Patient age <5 years had a higher chance of apex cutoff in 4‐chamber views compared with 16‐35 years old. Overall, for any quality issue, earlier era of echo and center were the only significant risk factors. Conclusion Assessment of cardiac function using pooled multicenter archived echocardiograms was significantly limited. Efforts to standardize clinical echocardiographic protocols to include apical 2‐ and 3‐chamber views and TDI will improve the ability to quantitate LV function.

Utility of apical four‐chamber longitudinal strain in the assessment of childhood cancer survivors: A multicenter study

“…This was the most common reason GLS as measured from three apical planes with 2D speckle tracking could not be determined in a previous GLS analysis. 23 This study suggests that A4LS can be used as a reasonable surrogate for GLS in retrospective analysis of CCS echocardiograms. in non-CCS adults.…”

“…A previous study from our group demonstrated that changes in CCS echocardiogram parameters are associated with development of clinical cardiomyopathy in pediatric patients 22 . However, in this retrospective case‐control study, only 10% of echocardiograms had adequate 2‐ and 3‐chamber apical views to assess GLS, limiting the ability to draw conclusions surrounding the predictive value of strain as measured by GLS 23 . Studies showing reduced GLS in this population have unsurprisingly also shown reduced apical 4‐chamber longitudinal strain (A4LS) measured from a single 2D apical plane as well 12,14,15,19 .…”

“…This study utilized an echocardiography biorepository stemming from previous multicenter studies done by this group that investigated the association between changes in echocardiograms of CCS and the development of chemotherapy‐induced cardiotoxicity 22,23 . A biorepository of 632 clinically obtained echocardiograms of CCS (diagnosed with cancer prior to age 21 years) at five participating sites (Children's Healthcare of Atlanta/Emory University, City of Hope, Hospital for Sick Children, Masonic Children's Hospital/University of Minnesota, and Seattle Children's Hospital) were reviewed for this study.…”

“…22 However, in this retrospective case-control study, only 10% of echocardiograms had adequate 2-and 3-chamber apical views to assess GLS, limiting the ability to draw conclusions surrounding the predictive value of strain as measured by GLS. 23 Studies showing reduced GLS in this population have unsurprisingly also shown reduced apical 4-chamber longitudinal strain (A4LS) measured from a single 2D apical plane as well. 12,14,15,19 Good correlation has been demonstrated between GLS and A4LS in adult patients with heart failure and during cancer therapy.…”

Myocardial Strain during Surveillance Screening Is Associated with Future Cardiac Dysfunction among Survivors of Childhood, Adolescent and Young Adult-Onset Cancer

“…However, several limitations should be noted when interpreting these results: (a) The largest limitation is the retrospective nature of this study, which caused variability in available retrospective echocardiogram images and image quality. Although this limitation is not unique to our study and is common to retrospective imaging studies in this population, this hindered our ability to perform a Simpsons’ bi-plane measurement of ejection fraction [ 29 ]. Future studies utilizing cardiac magnetic resonance imaging should be considered to address this limitation.…”