Regional Left Ventricular Myocardial Dysfunction After Cardiac Surgery Characterized by 3-Dimensional Strain

Abstract

BACKGROUND: Three-dimensional (3D) strain is an echocardiographic modality that can characterize left ventricular (LV) function with greater accuracy than ejection fraction. While decreases in global strain have been used to predict outcomes after cardiac surgery, changes in regional 3D longitudinal, circumferential, radial, and area strain have not been well described. The primary aim of this study was to define differential patterns in regional LV dysfunction after cardiac surgery using 3D speckle tracking strain imaging. Our secondary aim was to investigate whether changes in regional strain can predict postoperative outcomes, including length of intensive care unit stay and 1-year event-free survival. METHODS: In this prospective clinical study, demographic, operative, echocardiographic, and clinical outcome data were collected on 182 patients undergoing aortic valve replacement, mitral valve repair or replacement, coronary artery bypass graft, and combined cardiac surgery. Three-dimensional transthoracic echocardiograms were performed preoperatively and on the second to fourth postoperative day. Blinded analysis was performed for LV regional longitudinal, circumferential, radial, and area strain in the 17-segment model. RESULTS: Regional 3D longitudinal, circumferential, radial, and area strains were associated with differential patterns of myocardial dysfunction, depending on the surgical procedure performed and strain measure. Patients undergoing mitral valve repair or replacement had reduced function in the majority of myocardial segments, followed by coronary artery bypass graft, while patients undergoing aortic valve replacement had reduced function localized only to apical segments. After all types of cardiac surgery, segmental function in apical segments was reduced to a greater extent as compared to basal segments. Greater decrements in regional function were seen in circumferential and area strain, while smaller decrements were observed in longitudinal strain in all surgical patients. Both preoperative regional strain and change in regional strain preoperatively to postoperatively were correlated with reduced 1-year event-free survival, while postoperative strain was not predictive of outcomes. Only preoperative strain values were predictive of intensive care unit length of stay. CONCLUSIONS: Changes in regional myocardial function, measured by 3D strain, varied by surgical procedure and strain type. Differences in regional LV function, from presurgery to postsurgery, were associated with worsened 1-year event-free survival. These findings suggest that postoperative changes in myocardial function are heterogeneous in nature, depending on the surgical procedure, and that these changes may have long-term impacts on outcome. Therefore, 3D regional strain may be used to identify patients at risk for worsened postoperative outcomes, allowing early interventions to mitigate risk.

Left Ventricular Systolic Impairment after Pediatric Cardiac Surgery Assessed by STE Analysis

“…In a small study [9] of 25 children (age 9.4 ± 9.8 years), evaluating 3D LV ventricular strain at 1 week and 1 month after cardiac surgery for CHD, no significant differences in regional deformation were noted, except for a more pronounced reduction in strain values in the LV-free wall middle segments for cyanotic patients (p = 0.037). Curiously, the trend in postoperative apical hypercontractility we described herein is opposite to the one previously reported in adult [25,26] patients. In 182 patients, following different types of cardiac surgery (e.g., aortic valve replacement, mitral valve repair or replacement, coronary artery bypass graft), segmental function evaluated by 3D strain was greatly impaired in apical when compared to basal segments.…”

“…In 182 patients, following different types of cardiac surgery (e.g., aortic valve replacement, mitral valve repair or replacement, coronary artery bypass graft), segmental function evaluated by 3D strain was greatly impaired in apical when compared to basal segments. In this study [25], however, many patients had left anterior descending coronary artery disease; thus, the differences in regional strain may be attributed to pre-existing coronary artery disease. The basal and middle segment strain values, in fact, seem to be ameliorated after coronary artery bypass surgery due to revascularization [25,26].…”

“…In this study [25], however, many patients had left anterior descending coronary artery disease; thus, the differences in regional strain may be attributed to pre-existing coronary artery disease. The basal and middle segment strain values, in fact, seem to be ameliorated after coronary artery bypass surgery due to revascularization [25,26]. Thus, a comparison of adult data with those of children who usually have a normal coronary artery bed is difficult and should be avoided.…”

Clinical Utility of Three-Dimensional Speckle-Tracking Echocardiography in Heart Failure

“…It allows a non-Doppler angle-independent analysis and is not influenced by adjacent myocardial segments and cardiac motion; therefore, feasibility, reproducibility, and accuracy of the 2D-STE data appear to be superior to traditional echocardiographic parameters [ 13 , 19 , 23 , 24 , 25 ]. A large number of studies have demonstrated that 2D-STE is a powerful technique for myocardial function quantification and can provide valuable diagnostic and prognostic information in clinical practice [ 26 , 27 , 28 , 29 , 30 , 31 ]. However, 2D-STE has several inherent limitations: it appears to work best at frame rates between 50 frames/s and 70 frames/s and may lead to under-sampling with tachycardia; whereas an increase in frame rate is detrimental to spatial resolution; inherent disadvantages of its 2D characteristics include the failure to track speckles that move out of the 2D spatial planes due to cardiac motion (through-plane phenomenon), and foreshortened views difficult to accurately assess myocardial deformation [ 11 , 20 , 26 , 27 , 32 , 33 , 34 ].…”

Global Left Ventricular Strain: Exciting Applications In Perioperative Practice

“…Further trials have explored the roles for global longitudinal strain and threedimensional regional strain in the prediction of clinical outcomes after cardiac surgery as part of the ongoing echocardiographic journey beyond ejection fraction as the gold standard for left ventricular function. [24][25][26] In summary, Labus and colleagues should be congratulated for highlighting the natural history of strain imaging in the perioperative period for cardiac surgical patients. 12 They have pointed out the value of and confounders for strain imaging and analysis with perioperative echocardiography.…”