Introduction to Cardiac Strain for the ACUSON Juniper™ Ultrasound System

Continue Continue HOOD05162003129692 Effective Date:01Oct2020 ACUSON Juniper™ Ultrasound System Introduction to Cardiac Strain online training Understand speckle-tracking echocardiography (STE) methods 1 Examine STE deformation, timing, and mechanics 2 Master Template HOOD05162003052540 | Effective Date: 26-Nov-2019 In this course, you will be introduced to a high-level overview of two-dimensional (2D) speckle tracking methods used clinically to assess cardiac strain the ACUSON Juniper Ultrasound System. These two learning objectives will be covered. Welcome Base Layer- Welcome:VO file name: In this course, you will be introduced to a high-level overview of two-dimensional (2D) STE methods used clinically to assess cardiac strain on the ACUSON Juniper Ultrasound System. These two learning objectives will be covered. Speckle-tracking echocardiography (STE) The ACUSON Juniper Ultrasound system uses syngo® Velocity Vector Imaging™ (VVI) technology to assess myocardial motion, deformation, and mechanics non-invasively. Speckle-tracking echocardiography (STE) measures the change or deformation relationship of specific tissue speckles within the myocardium that occur during the cardiac cycle. This dynamic change in the myocardial length is used to measure cardiac strain and global heart function. STE is used to measure cardiac strain and expands the ability to noninvasively characterize the global function of the heart qualitatively and quantitatively. Introduction Base Layer – Introduction: VO file name: The ACUSON Juniper Ultrasound system uses syngo® Velocity Vector Imaging (VVI) technology to assess myocardial motion, deformation, and mechanics non-invasively. Speckle-tracking echocardiography (STE) measures the change or deformation relationship of specific tissue speckles within the myocardium that occur during the cardiac cycle. This dynamic change in the myocardial length is used to measure cardiac strain and global heart function. STE is used to measure cardiac strain and expands the ability to noninvasively characterize the global function of the heart qualitatively and quantitatively. Regional Wall Motion Analysis Doppler Tissue Imaging (DTI) is a Doppler modality that filters out the low level signals from the blood pool and measures the stronger signal that comes from the movement of the myocardial tissue. Color Doppler DTI provides a visual display of myocardial direction. Adding pulse wave (PW) Doppler to DTI provides a relatively fast way to compare velocities along the myocardium for regional wall motion changes. Learn more below. Learn More Regional Wall Motion Analysis Base Layer- Regional Wall Motion Analysis: 003.mp3 Doppler Tissue Imaging (DTI) is a Doppler modality that filters out the low level signals from the blood pool and measures the stronger signal that comes from the movement of the myocardial tissue. Color Doppler DTI provides a visual display of myocardial direction. Adding pulse wave (PW) Doppler to DTI provides a relatively fast way to compare velocities along the myocardium for regional wall motion changes. Learn more below. Layer- DTI DTI is a Doppler-based method that can analyze the direction and velocity at individual wall segments. This animation depicts the apical four-chamber view with color DTI initiated using a red toward and blue away from portrayal on the color scale. As the cardiac muscle (myocardium) contracts, the colors change from blue to red. Near the apex, there is a less noticeable change. With normal heart function, the base of the left ventricle (LV) and right ventricle (RV) is blue at relaxation and red as the base moves toward the apex. Cardiac motion and the general direction of the myocardium can be assessed subjectively with color DTI. Layer- PW DTI PW DTI can analyze the velocity at individual wall segments. And PW DTI waveforms can be useful to compare and detect peak velocity delay between wall segments for regional wall motion analysis. In this example the PW DTI spectral Doppler is being sampled from the septum of the heart. Select the marker on each of the images below for more information. Layer- Cursor Alignment PW DTI can analyze the velocity at individual wall segments. And PW DTI waveforms can be useful to compare and detect peak velocity delay between wall segments for regional wall motion analysis. However, the angle of intercept creates acquisition challenges. It is not possible to have parallel alignment in all segments of all of the cardiac wall tissues with the ultrasound Doppler beam, and some cardiac segments will be perpendicular. Therefore, PW DTI is not practical for a global assessment of LV function. Select the marker on each of the images below for more information. Layer- Cursor Alignment 2 Doppler does play a significant role in event timing for cardiac strain and will be discussed further in this course. Doppler does play a significant role in event timing for cardiac strain and will be discussed further in this course. Doppler Segmental Velocity PW DTI can analyze the velocity at individual wall segments. And PW DTI waveforms can be useful to compare and detect peak velocity delay between wall segments for regional wall motion analysis. However, the angle of intercept creates acquisition challenges. It is not possible to have parallel alignment in all segments of all of the cardiac wall tissues with the ultrasound Doppler beam, and some cardiac segments will be perpendicular. Therefore, PW DTI is not practical for a global assessment of LV function. Select the marker on each of the images below for more information. PW DTI Lateral Wall Left Ventricle (LV) Notice that the heart is adjusted to create better alignment. PW DTI Septal Wall Left Ventricle (LV). PW DTI is aligned with the septum of the LV. PW DTI Lateral Wall Right Ventricle (RV) PW DTI is aligned along the lateral right ventricle (RV). Next PW DTI can analyze the velocity at individual wall segments. And PW DTI waveforms can be useful to compare and detect peak velocity delay between wall segments for regional wall motion analysis. In this example the PW DTI spectral Doppler is being sampled from the septum of the heart. Select the marker on each of the images below for more information. Pulse Wave (PW) DTI PW Cursor Malaligned The PW cursor is highlighted in light orange. There is a misalignment of the cursor with the interventricular septum; see the orange and teal arrow showing the orientation of the interventricular septum. For this example, the angle of insonation is 40 degrees (the cosign of 40 degrees is 0.77), so the myocardial velocity is underestimated by about 23 percent. PW Cursor Aligned The PW cursor (also highlighted in orange) is over the interventricular septum; see the orange and teal arrow showing the orientation of Doppler to the interventricular septum. In this example the angle of insonation is 2 degrees (the cosign of 2 degrees is 0.999) so the myocardial velocity is underestimated by 0.001%. Next DTI is a Doppler-based method that can analyze the direction and velocity at individual wall segments. This animation depicts the apical four-chamber view with color DTI initiated using a red toward and blue away from portrayal on the color scale. As the cardiac muscle (myocardium) contracts, the colors change from blue to red. Near the apex, there is a less noticeable change. With normal heart function, the base of the left ventricle (LV) and right ventricle (RV) is blue at relaxation and red as the base moves toward the apex. Cardiac motion and the general direction of the myocardium can be assessed subjectively with color DTI. Next Color Doppler Tissue Imaging (DTI) Cardiac Dynamics Left Ventricle 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 With muscle contraction, the wall shortens from the original length, and the tangential arrangement of the myocardial muscle layers (endocardium, myocardium, and epicardium) combined to create the twisting action of the muscle layers in cross-section. Speckle-tracking methods can measure the strain at the endocardial interface, the endocardium, and myocardium or across the full wall of the myocardium. In this section, you can review the cardiac mechanics that impact the strain measurement. Select the numbered steps below to learn more about cardiac dynamics. Cardiac Dynamics Base Layer- Cardiac Dynamics: lv_dynamics.mp3 With muscle contraction, the wall shortens from the original length, and the tangential arrangement of the myocardial muscle layers (endocardium, myocardium, and epicardium) combined to create the twisting action of the muscle layers in cross-section. Speckle-tracking methods can measure the strain at the endocardial interface, the endocardium, and myocardium or across the full wall of the myocardium. In this section, you can review the cardiac mechanics that impact the strain measurement. Select the numbered steps below to learn more about cardiac dynamics. Layer- Rotation: slide1.mp3 The subendocardial and epicardial fiber alignment creates a wringing effect and moves the basal segment of the heart toward the apex. The base of the heart rotates clockwise against the counterclockwise twist at the apex.The mid and basal segments shorten more than they rotate, and the apex rotates more than is shortens. Layer- Aortic Valve Opens: slide2.mp3 The myocardium contracts and the muscle shortens, reducing the left ventricular (LV) cavity size. The LV pressure then rises, note the white arrow, this causes the aortic valve (AV) to open, note the orange arrow. The myocardium contracts and the muscle shortens, reducing the left ventricular (LV) cavity size. The LV pressure then rises, note the white arrow, this causes the aortic valve (AV) to open, note the orange arrow. Layer- Aortic Valve Closes: slide3.mp3. In diastole, the reverse occurs when the concentration of calcium falls and the myocardial muscle relaxes, lengthening the heart from base to apex. This cardiac action draws blood into the ventricle, and the aortic valve closes, note the green arrow. Layer- Cardiac Dynamics Timing: slide4.mp3 Review this graphic representation of normal waveforms. The R-wave is from the electrocardiographic (ECG) tracing. The aortic and left ventricular pressure curves are from the two previous slides. Note that peak strain occurs after the aortic valve close. The LV and AV tracing graphic seen in this example depicts an intracardiac LV and AV pressure tracing and is depicted here to describe timing events visually. Layer- syngo First Use: syngo_first_use.mp3 The deformation of the LV occurs across the cardiac cycle. Maximum LV length occurs at end-diastole and can be timed using the R-peak from the ECG tracing. syngo® Velocity Vector Imaging™ (syngo VVI) software will use the R-wave from the ECG to automate timing of end-systole and end-diastole. The syngo VVI software integrates the change in length across the myocardium to calculate parametric volume over the cardiac cycle for a volume time curve. Layer- syngo VVI Curves: syngo_vvi_curves.mp3 LV end-systole occurs when the aortic valve (AV) closes. Normal strain peaks just after the aortic valve close. The timing of events is estimated by the syngo® Velocity Vector Imaging™ VVI software using the ECG and deformation of the speckles to create the approximation of the volume curves. Layer- M-Mode Timing: m-mode_timing.mp3 If there is not a precise match of end-diastole on the ECG due to conduction delay, or the ECG is unreliable; the syngo® Velocity Vector Imaging™ (syngo VVI) software uses a derived M-mode as a supplement for absent or deficient ECG signals. M-mode from the LV seen in this example. Layer- Doppler Timing: doppler_timing.mp3 Additionally, timing can also be done by using pulse wave (PW) Doppler. AV closure using PW Doppler may also be necessary to accurately define AV closure and end-systole. Doppler described above is supplementary information for consideration of timing events. The syngo VVI software uses a derived M-mode as a supplement for absent or inadequate ECG signals. Doppler Timing 8 Additionally, timing can also be done by using pulse wave (PW) Doppler. AV closure using PW Doppler may also be necessary to accurately define AV closure and end-systole. Doppler described above is supplementary information for consideration of timing events. The syngo VVI software uses a derived M-mode as a supplement for absent or inadequate ECG signals. PW Doppler In this example, the Doppler signal is from the Aortic Valve outflow. M-Mode Timing 7 If there is not a precise match of end-diastole on the ECG due to conduction delay, or the ECG is unreliable; the syngo® Velocity Vector Imaging™ (syngo VVI) software uses a derived M-mode as a supplement for absent or deficient ECG signals. M-mode from the LV seen in this example. syngo VVI Curves 6 LV end-systole occurs when the aortic valve (AV) closes. Normal strain peaks just after the aortic valve close. The timing of events is estimated by the syngo® Velocity Vector Imaging™ syngo VVI software using the ECG and deformation of the speckles to create the approximation of the volume curves. syngo® Velocity Vector Imaging™ (syngo VVI) 5 The deformation of the LV occurs across the cardiac cycle. Maximum LV length occurs at end-diastole and can be timed using the R-peak from the ECG tracing. syngo® Velocity Vector Imaging™ (syngo VVI) software will use the R-wave from the ECG to automate timing of end-systole and end-diastole. syngo VVI software integrates the change in length across the myocardium to calculate parametric volume over the cardiac cycle for a volume time curve. Cardiac Dynamics Timing 4 Review this graphic representation of normal waveforms. The R-wave is from the electrocardiographic (ECG) tracing. The aortic and left ventricular pressure curves are from the two previous slides. Note that peak strain occurs after the aortic valve closes. AV Closes R-wave ECG AV Opens AV Doppler Mitral Valve (MV) Doppler Strain Curve R-wave ECG Aortic Valve Closes 3 In diastole, the reverse occurs when the concentration of calcium and the myocardial muscle relaxes, lengthening the heart from base to apex. This cardiac action draws blood into the ventricle, and the aortic valve closes, note the green arrow. LV Pressure Waves Simulated AV Pressure Wave Simulated Aortic Valve Opens 2 The myocardium contracts and the muscle shortens, reducing the left ventricular (LV) cavity size. The LV pressure then rises, note the white arrow, this causes the aortic valve (AV) to open, note the orange arrow. AV Pressure Wave Simulated Rotation 1 The subendocardial and epicardial fiber alignment creates a wringing effect and moves the base of the heart toward the apex. The base of the heart rotates clockwise against the counterclockwise twist at the apex.[1] The mid and basal segments shorten more than they rotate, and the apex rotates more than is shortens. Speckle Tracking Echocardiography Unlike Doppler imaging, speckle-tracking echocardiography (STE) is not affected by the angle of intercept. STE is an image-based method that is used to track or follow the same group of tissue speckles in the 2D image from frame to frame during the cardiac cycle. syngo VVI software analyzes the deformation, tissue velocity and other parameters related to movement of the myocardium. syngo VVI software can detect deformation in the left ventricle (LV), right ventricle (RV), left atrium (LA), and right atrium (RA). In this example, the software output shows STE parametric waveforms and values along with volume, LVEF, heart rate, and regional velocities. Speckle Tracking Echocardiography Base Layer- Speckle Tracking Echocardiography:ste1.mp3 Unlike Doppler imaging, speckle-tracking echocardiography (STE) is not affected by the angle of intercept. STE is an image-based method that is used to track or follow the same group of tissue speckles in the 2D image from frame to frame during the cardiac cycle. syngo VVI software analyzes for deformation, tissue velocity and other parameters related to movement of the myocardium. syngo VVI software can detect deformation in the left ventricle (LV), right ventricle (RV), left atrium (LA), and right atrium (RA). In this example, the software output shows STE parametric waveforms and values along with volume, LVEF, heart rate, and regional velocities. Speckle Tracking Echocardiography syngo® Velocity Vector Imaging™ technology (syngo VVI) is a clinical STE software application available on the ACUSON Juniper ultrasound system and is used to visualize, measure and assess the myocardial motion and mechanics from the tissue speckles in the two-dimensional (2D) cine-loop(s). A user-defined contour tracks the tissue, estimates the tissue velocity, motion mechanics and deformation parameters. Quantitative data derived from the syngo VVI software can include curved plots, parametric waveforms, volume analysis, M-mode graphs, parametric segmental diagrams, rotation, velocity, displacement, strain, and strain rate. The results are dependent on image quality of the views that are selected and used to draw the contour. The left ventricle, right ventricle, and the left and right atria can be analyzed in syngo VVI software. Speckle Tracking Echocardiography (continued) Base Layer- audio TBD temp voiceover (temp_ste2.wave) syngo® Velocity Vector Imaging™ technology (syngo VVI) is a clinical STE software application available on the ACUSON Juniper ultrasound system and is used to visualize, measure and assess the myocardial motion and mechanics from the tissue speckles in the two-dimensional (2D) cine-loop(s). A user-defined contour tracks the tissue, estimates the tissue velocity, motion mechanics and deformation parameters. Quantitative data derived from the syngo VVI software can include curved plots, parametric waveforms, volume analysis, M-mode graphs, parametric segmental diagrams, rotation, velocity, displacement, strain, and strain rate. The results are dependent on image quality of the views that are selected and used to draw the contour. The left ventricle, right ventricle, and the left and right atria can be analyzed in syngo VVI software. Cardiac strain is the deformation or change in length from one point to another and is measured as the change in length divided by the original length. Cardiac Strain is the measurement of change in the positive or negative direction. Introduction to Cardiac Strain Introduction to Cardiac Strain Measurement of strain detects speckle movement from one point to another within the myocardial muscle throughout contraction and relaxation. The speckle patterns are analyzed to identify movement either toward each other (shortening) or away from each other (lengthening). Location shift groups of the speckles are calculated within all the segments across the cardiac cycle. Strain is the measurement of change in the positive or negative direction between consecutive frames of the two-dimensional (2D) image. Strain is the deformation or change in length from one point another. To calculate strain, the deformation between two points are measured as the change in length divided by the original length. This suspended spring original length is 3 cm, then the spring expands to 5 cm. The change in length is 40%. Now, the spring original length is 7.5 cm, and the spring changes to 6 cm and this yields a deformation of –20%. The change in length is assessed from one frame to another using distinctive speckle-pattern recognition within the acoustic field. The deformation is being tracked with these colored points; the colored points represent a distinctive speckle pattern that moves from one point to another point. Watch the red dots as they track from the original spot through the contraction to the new location. This muscle is shortening, following just the red dots, see that the movement is toward the original location, and this yields a negative strain result. Strain rate is the speed at which the myocardium changes. Strain and strain rate provide precise values that can be used in conjunction with other physiological or clinical findings to aid in the diagnosis and treatment of cardiac dysfunction. Left Ventricular Strain Methods 2D speckle tracking methods used clinically include global longitudinal strain (GLS), global circumferential strain (GCS), and radial strain. Each strain method utilizes a region of interest or ROI. The ROI is a contour along the endocardium at the blood interface and is further expanded across to the myocardium and divided into segments. syngo VVI software analyzes and references the changes in movement within the contour. Review each of the speckle tracking methods in these exercises below. 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 Strain Methods - GLS and GCS Base Layer- Strain Methods 2D speckle tracking methods used clinically include global longitudinal strain (GLS), global circumferential strain (GCS), and radial strain. Each strain method utilizes a region of interest or ROI. The ROI is a contour along the endocardium at the blood interface and is further expanded across to the myocardium and divided into segments. syngo VVI software analyzes and references the changes in movement within the contour. Review each of the speckle tracking methods in these exercises below. Layer 1 – GLS 1 Speckles track movement for longitudinal strain along the length of the long axis of the heart. Longitudinal strain is the change in the length of a line that is drawn along the myocardium and mid or epicardial wall. The deformation in length is divided by the original length, and GLS strain results are displayed as negative values. The negative strain result may seem confusing because functionally, the walls are thickening but the difference is from the reduction in length, not the thickness. Layer 2 – GLS 2 The global longitudinal strain (GLS) is measured at Apical 4-chamber (A4), Apical 3-chamber (A3), and Apical 2-chamber (A2) views. The width of the contour can be expanded manually, semi-automatically, or automatically. The width of the contour can track the speckle shift within the endocardium, or the width can be expanded to include the endocardium and myocardium. The width of the contour can also be extended further to cover the full wall of the myocardium, which includes the endocardium, myocardium, and epicardial wall. A contour span that includes the full-wall will increase the speckles tracked; however, the most common and most reproducible GLS is just sampled at the endocardium as recommended by the Industry Strain Task Force. Layer 3 – Normal GLS In this graphic a normal GLS and reduced GLS strain curve are shown together. The vertical axis line intersects where the AV closes. The normal GLS and the reduced GLS track synchronously with each other across the heart cycle and peak GLS occurs after closure of the AV valve in both curves. Layer 4 – GLS 3 GLS is as a valuable complement to traditional echocardiographic parameters for monitoring patients at risk of heart failure because both support clinical diagnostic capabilities by providing mechanical deformation and contraction information. Speckle-tracking analysis extracts contour-fitting curves and parametric information from the tracking software with an output of LV volumes, wall velocity, displacement, LVEF, strain and strain rate across the cardiac cycle. Layer 5 – Abnormal GLS In populations without structural heart disease, the peak systolic strain correlates to the closure of the AV. Cardiac dyssynchrony, coronary artery disease (CAD), and ischemic heart disease have peak strains that are out of phase with aortic valve closure. Speckle-tracking analysis extracts contour-fitting curves that demonstrate the dispersion in timing from peak systolic strain (and volume) to AV closure. These changes can be measured accurately, and the waveforms provide a visual display of mechanical dispersion in patients with dyssynchrony and structural heart disease. Layer 6 – GCS 1 Global Circumferential Strain or GCS is measured is measured in the cross-sections of the heart from the parasternal short axis (PSAX) views. The strain contour for GCS is typically added at three PSAX views: mitral valve level, papillary muscle level, and at the PSAX apex. As discussed earlier, strain is the deformation (change in length) divided by the original length, multiplied by 100. In this example L1 is the original length, this deforms / shortens circumferentially to the length L2. Let's assign values to L1 and to L2. The original length of L1 is equal to 12 cm and L2 shortens to eight centimeters. This yields a -4 cm change in length. Negative four is divided by 12 and then multiplied by 100. The product is a deformation of -33% Layer 7 – GCS and GLS Methods GCS width can include the endocardium alone, the endocardium and myocardium, or the full wall. The strain contour at the papillary muscle level should avoid the papillary muscles, and the pericardial layer should be avoided at all levels. Layer 8 – GLS and GCS Clinical Longitudinal and circumferential strain methods, both depict relative shortening. However, there can be clinically abnormal longitudinal strain with normal circumferential strain because circumferential shortening can compensate for the decline in longitudinal strain in an effort to maintain LVEF. A comparison of longitudinal or circumferential strain is a useful clinical companion to LVEF. There are clinical circumstances where the longitudinal strain is not specific, and circumferential strain may be a useful 'tie-breaker.' For example, in a patient with heart failure with a preserved ejection fraction, adding global circumferential strain may be a useful biomarker. If there are disagreements in LVEF and longitudinal strain results, GCS can be a useful clinical companion with other clinical biomarkers when monitoring cardiac function and comparing serial studies. In this graph the global longitudinal strain is compared to the global circumferential strain. The longitudinal strain is shown as an orange curve and global circumferential strain is shown as a red curve. Both GLS and GCS demonstrate negative strain values. Comparing GLS and GCS 8 Longitudinal and circumferential strain methods, both depict relative shortening. However, there can be clinically abnormal longitudinal strain with normal circumferential strain because circumferential shortening can compensate for the decline in longitudinal strain in an effort to maintain LVEF. A comparison of longitudinal or circumferential strain is a useful clinical companion to LVEF. There are clinical circumstances where the longitudinal strain is not specific, and circumferential strain may be a useful 'tie-breaker.' For example, in a patient with heart failure with a preserved ejection fraction, adding global circumferential strain may be a useful biomarker. If there are disagreements in LVEF and longitudinal strain results, global circumferential strain can be a useful clinical companion with other clinical biomarkers when monitoring cardiac function and comparing serial studies. In this graph the global longitudinal strain is compared to the global circumferential strain. The longitudinal strain is shown as an orange curve and global circumferential strain is shown as a red curve. Both GLS and GCS demonstrate negative strain values. GCS and GLS Method 7 The GLS methods and the GCS methods can include the endocardium alone, the endocardium and myocardium, or the full wall. The strain contour at the papillary muscle level should avoid the papillary muscles, and the pericardial layer should be avoided at all levels. Global Circumferential Strain Global Circumferential Strain or GCS is measured is measured in the cross-sections of the heart from the parasternal short axis (PSAX) views. The strain contour for GCS is typically added at three PSAX views: mitral valve level, papillary muscle level, and at the PSAX apex. 6 As discussed earlier, strain is the deformation (change in length) divided by the original length, multiplied by 100. In this example L1 is the original length, this deforms / shortens circumferentially to the length L2. Let's assign values to L1 and to L2. Change in length Original length 100 The original length of L1 is equal to 12 cm and L2 shortens to 8 cm. This yields a -4 cm change in length. -4 is divided by 12 and then multiplied by 100. The product is a deformation of –33%. - 4 cm 12 100 = -33% GLS Curves Dispersion In populations without structural heart disease, the peak systolic strain correlates to the closure of the AV. Cardiac dyssynchrony, coronary artery disease (CAD), and ischemic heart disease have peak strains that are out of phase with aortic valve closure. Speckle-tracking analysis extracts contour-fitting curves that demonstrate the dispersion in timing from peak systolic strain (and volume) to AV closure. These changes can be measured accurately, and the waveforms provide a visual display of mechanical dispersion in patients with dyssynchrony and structural heart disease. 5 Dyssynchrony Dyssynchrony strain curve is shown in the aquamarine GLS shape. Dyssynchrony Dyssynchrony peak GLS. Normal GLS Red Peak GLS. Reduced GLS Blue Peak GLS. Dyssynchrony with premature shortening Premature shortening is shown in the orange curve. Y-Axis On the y-axis (vertical axis) is the strain percentage. X-Axis The x-axis (horizontal axis) is the displacement curve shown as a percentage of the entire cardiac cycle. +- GLS Strain Curves 4 GLS is as a valuable complement to traditional echocardiographic parameters for monitoring patients at risk of heart failure because both support clinical diagnostic capabilities by providing mechanical deformation and contraction information. Speckle-tracking analysis extracts contour-fitting curves and parametric information from the syngo VVI software with an output of LV volumes, wall velocity, displacement, LVEF, strain and strain rate across the cardiac cycle. GLS Strain Curves 3 In this graphic a normal GLS and reduced GLS strain curve are shown together. The vertical axis line intersects where the AV closes. The normal GLS and the reduced GLS track synchronously with each other across the heart cycle and peak GLS occurs after closure of the AV valve in both curves. Y-Axis On the y-axis (vertical axis) is the strain percentage. X-Axis The x-axis (horizontal axis) is the displacement curve shown as a percentage of the entire cardiac cycle. Reduced GLS Blue Peak GLS Normal GLS Red Peak GLS Global Longitudinal Strain 2 The global longitudinal strain (GLS) is measured at Apical 4-chamber (A4), Apical 3-chamber (A3), and Apical 2-chamber (A2) views. For GLS, a region of interest or ROI is defined at the apical views. Within the ROI, a contour is defined. The width of the contour defines the thickness of the myocardium, where the speckles will be tracked. The width of the contour can be expanded manually, semi-automatically, or automatically. The width of the contour can track the speckle shift within the endocardium, or the width can be expanded to include the endocardium and myocardium. The width of the contour can also be extended further to cover the full wall of the myocardium, which includes the endocardium, myocardium, and epicardial wall. A contour span that includes the full-wall will increase the speckles tracked; however, the most common and most reproducible GLS is just sampled at the endocardium as recommended by the Industry Strain Task Force. Industry Strain Task Force To help address the feasibility, accuracy, and reproducibility of cardiac strain methods for clinical practice across vendors, an industry Task Force was created. Thought leaders created the industry Strain Task Force along with The American Society of Echocardiography (ASE), the European Association of Cardiovascular Imaging (EACVI), scientists, and industry representatives (ASE/EACVI Task Force). Global Longitudinal Strain Speckles track movement for longitudinal strain along the length of the long axis of the heart. Longitudinal strain is the change in the length of a line that is drawn along the myocardium and mid or epicardial wall. The deformation in length is divided by the original length, and longitudinal strain results are displayed as negative values. The negative strain result may seem confusing because functionally, the walls are thickening but the difference is from the reduction in length, not the thickness. 1 Radial Strain Radial strain is deformation tracking that is assessed perpendicular to the long axis of the heart and perpendicular to the myocardium in the short axis views. Learn more below. Learn More Radial Strain Base Layer- Radial Strain During systole, the length of the ventricles decreases to compensate for the thickening of the myocardial wall. This thickening can be seen in short-axis views. When measured from end diastole to end systole the increased thickness measurement results in positive strain. Clinically, radial strain methods are not as robust as circumferential or longitudinal methods. Because of this, Radial strain is not recommended for clinical use. Layer 1- Radial Strain Methods During systole, the length of the ventricles decreases to compensate for the thickening of the myocardial wall. This thickening can be seen in short-axis views. When measured from end diastole to end systole the increased thickness measurement results in positive strain. Clinically, radial strain methods are not as robust as circumferential or longitudinal methods. Radial Strain Method During systole, the length of the ventricles decreases to compensate for the thickening of the myocardial wall. This thickening can be seen in short-axis views. When measured from end diastole to end systole the increased thickness measurement results in positive strain. Clinically, radial strain methods are not as robust as circumferential or longitudinal methods. GLS GLS is orange and results are negative. GCS GLS is red and results are negative. Radial Strain Radial Strain is the curve in the teal color and results are positive. Frame Rate Capturing the movement, contraction, and relaxation of the myocardial tissue requires adequate sampling frames to create an accurate analysis of the change in speckle patterns across the cardiac cycle. Learn more below. 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 Frame Rate Basel Layer – Frame Rate: frame_rate_base_layer.mp3 Capturing the movement, contraction, and relaxation of the myocardial tissue requires adequate sampling frames to create an accurate analysis of the change in speckle patterns across the cardiac cycle. Learn more below. Layer 1- Temporal Resolution: temporal_resolution.mp3 Clinicians must capture enough frames that are occurring across the cardiac cycle or R-R interval to consistently track the action of the speckle. This is done by adjusting the temporal resolution. Layer 2- 10 FPS: 10_fps.mp3 If the heart rate is 60 beats per minute, and the frame rate is 10 frames per second, then only 17% of the frames collected will represent the entire cycle. With a heart rate of 60 beats per min, it will take one second to collect one heart cycle or one R-R interval. By increasing the frame rate to 60 frames per second, then 60 frames will be collected across the entire cycle. This is approximate, one frame for every one millisecond. Increasing the frame rate to 90 fps will decrease the time interval between frames but will not necessarily capture more action across the heart cycle with a heart rate of 60 bpm. It will still take one second to complete one R to R interval with a heart rate of 60. And increasing the frame rate to 90 fps, one frame will be collected every 0.7 milliseconds. However, if the heart rate were significantly higher, this shorter interval might track effectively. Layer 3- : In general, speckle tracking settings are effective between 40 - 80 fps at normal heart rates and should be increased with higher heart rates. There is a frame rate limiter that is enabled by default on the ACUSON Juniper ultrasound system. This limiter is intended to reduce storage size. However, now that you understand that a slow frame rate can impact speckle tracking results, you will need to increase the acquisition frame rate. This is how you can change the acquisition frame rate prior to syngo VVI analysis. Begin by going to the system configuration and then select clip store. Layer 4- : You are now in the system configuration under clip store. You will need to change the acquisition rate from normal to high. Layer 5- Next you must complete the steps to change the acquisition rate. Layer 6- Please select the System Configuration to proceed. Then select Clip Store to proceed. Select the high acquisition rate to proceed. Layer 7- Next we will cover how to change the acquisition frame rate during an active exam but prior to syngo VVI analysis Layer 8- Select Clips settings from the 2D touch screen, then adjust the acquisition rate to high. Checklist Item Title 8 8 Insert picture/video here Checklist Item Title 7 7 Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Insert picture here Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua: list one list two list three list four Insert picture here Checklist Item Title 6 6 Checklist Item Title 5 Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Insert picture here 5 90 Frames Per Second 4 Increasing the frame rate to 90 fps will decrease the time interval between frames but will not necessarily capture more action across the heart cycle with a heart rate of 60 bpm. It will still take one second to complete one R to R interval with a heart rate of 60. And increasing the frame rate to 90 fps, one frame will be collected every 0.7 milliseconds. However, if the heart rate were significantly higher, this shorter interval might track effectively. 60 Frames Per Second 3 With a heart rate of 60 beats per min, it will take one second to collect one heart cycle or one R-R interval. By increasing the frame rate to 60 frames per second, then 60 frames will be collected across the entire cycle. This is approximate, one frame for every one millisecond. If the heart rate is 60 beats per minute, and the frame rate is 10 frames per second, then only 17% of the frames collected will represent the entire cycle. Frames Per Second 2 Temporal Resolution Clinicians must capture enough frames that are occurring across the cardiac cycle or R-R interval to consistently track the action of the speckle. This is done by adjusting the temporal resolution. 1 Managing Variability Quantification methods must be consistent for meaningful value comparisons of serial exams and monitoring. A clinician must be aware of the differences in methods and calculated values for LVEF and quantification of strain. Beyond the methods used, variability in STE is multi-factorial. Next, we will discuss clinical standards, applications, and some tips to minimize STE variability for GLS. 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 Managing Variability Base Layer – Managing Variability: tbd.mp3 Quantification methods must be consistent for meaningful value comparisons of serial exams and monitoring. A clinician must be aware of the differences in methods and calculated values for LVEF and quantification of strain. Beyond the methods used, variability in STE is multi-factorial. Next, we will discuss clinical standards, applications, and some tips to minimize STE variability for GLS. Layer 1- Method: tbd.mp3 GLS methods should use a consistent tracking contour to measure deformation. The contour within the region of interest or ROI should be consistently defined at the endocardium or across the endocardium and myocardium, or across the full wall. The ASE/EACVI Task Force has recommended that these are all acceptable as a sensitive indicator of dysfunction for clinical practice, but the method of choice should be maintained for the most reproducible results. Layer 2- Vendors and Software : tbd.mp3 Older versions of GLS software should not be considered because the ASE/EACVI Task Force only considered recent software to calculate GLS. The ASE/EACVI Task Force has also recognized that speckle tracking results will vary across various ultrasound platforms and different software levels. Layer 3- Normal Values: tbd.mp3 Guidelines from many subject expert authors and the ASE/EACVI Task Force suggest a normal baseline GLS value of -20% with a standard deviation of less than or equal to 2%. Keep in mind that the GLS values will vary depending on many technical factors. Layer 4-Cancer Therapeutic Related Cardiac Dysfunction : tbd.mp3 Long-term echocardiographic monitoring is recommended for cancer therapeutics-related cardiac dysfunction (CTRCD). CTRCD is defined as a ≥5% drop in LVEF in symptomatic patients and a decrease of ≥10% to an LVEF of 53%. The diminishing LVEF may be related to patient-loading conditions or related to early cardiac dysfunction. When the longitudinal shortening diminishes, circumferential mechanics may compensate for LVEF, and adding GCS to GLS may provide additional information as an early predictor of cardiotoxicity. Layer 5- Serial GLS: tbd.mp3 Clinicians should maintain the same system type and software level when performing serial GLS measurements as software algorithm differences will impact the results. Note any variations in apical views or omitted regions used for a particular GLS analysis. These differences can be taken into consideration for future follow-up exams. The Strain Task Force recommends using the same ultrasound platform and software for serial evaluation. Layer 6- Image Quality: tbd.mp3 Maintain a balanced gain and dynamic range. The overall image settings should be consistent between in serial examinations. Consider that variation in dynamic range and gain settings will impact the speckle. Variation in image quality and less distinct endocardial borders will cause uncertainty in the analysis of 2D strain because the tracking algorithm cannot differentiate between noise and structural speckle. Layer 7- Foreshortening: tbd.mp3 Care must be taken not to foreshorten the apical views as malalignment of the primary axis will introduce inaccuracies. The entire myocardium-endocardium, myocardium, to epicardium-should be seen. The pericardium border also should be in view as the pericardium should be the external boundary for strain analysis and not be included in the analysis of GLS. Layer 8- Translation: tbd.mp3 This is a lateral movement of the heart within the chest, typically caused by breathing, and will introduce uncertainties in tracking results. Clinicians should reduce translation motion as much as possible by collecting cine-loop image data from the end-expiration. Translation 8 This is a lateral movement of the heart within the chest, typically caused by breathing, and will introduce uncertainties in tracking results. Clinicians should reduce translation motion as much as possible by collecting cine-loop image data from the end-expiration. Foreshortening 7 Care must be taken not to foreshorten the apical views as malalignment of the primary axis will introduce inaccuracies. The entire myocardium-endocardium, myocardium, to epicardium-should be seen. The pericardium border also should be in view as the pericardium should be the external boundary for strain analysis and not be included in the analysis of GLS. Maintain a balanced gain and dynamic range. The overall image settings should be consistent between in serial examinations. Consider that variation in dynamic range and gain settings will impact the speckle. Variation in image quality and less distinct endocardial borders will cause uncertainty in the analysis of 2D strain because the tracking algorithm cannot differentiate between noise and structural speckle. Image Quality 6 Serial GLS Clinicians should maintain the same system type and software level when performing serial GLS measurements as software algorithm differences will impact the results. Note any variations in apical views or omitted regions used for a particular GLS analysis. These differences can be taken into consideration for future follow-up exams. The Strain Task Force recommends using the same ultrasound platform and software for serial evaluation. [5] 5 Cancer Therapeutic Related Cardiac Dysfunction 4 Long-term echocardiographic monitoring is recommended for cancer therapeutics-related cardiac dysfunction (CTRCD). CTRCD is defined as a ≥5% drop in LVEF in symptomatic patients and a decrease of ≥10% to an LVEF of 53%. The diminishing LVEF may be related to patient-loading conditions or related to early cardiac dysfunction. When the longitudinal shortening diminishes, circumferential mechanics may compensate for LVEF, and adding GCS to GLS may provide additional information as an early predictor of cardiotoxicity.[2-4] Normal Values 3 Guidelines from many subject expert authors and the ASE/EACVI Task Force suggest a normal baseline GLS value of -20% with a standard deviation of ~± 2%. [3, 4, 9, 10] Keep in mind that the GLS values will vary depending on many technical factors. Insert picture here Older versions of GLS software should not be considered because the ASE/EACVI Task Force only considered recent software to calculate GLS. The ASE/EACVI Task Force has also recognized that speckle tracking results will vary across various ultrasound platforms and different software levels. [7, 11] Insert picture here Vendors and Software 2 Method GLS methods should use a consistent tracking contour to measure deformation. The contour within the region of interest or ROI should be consistently defined at the endocardium or across the endocardium and myocardium, or across the full wall. The ASE/EACVI Task Force has recommended that these are all acceptable as a sensitive indicator of dysfunction for clinical practice, but the method of choice should be maintained for the most reproducible results.[4-8] Insert picture here 1 Examine STE deformation, timing, and mechanics Understand speckle-tracking echocardiography (STE) methods Course Review Congratulations. You have completed the course ACUSON Juniper™ Ultrasound System Introduction to Cardiac Strain. Select the objectives listed below to review the material before proceeding to the final assessment. 1 1 1 2 Course Review Examine STE deformation, timing, and mechanics The subendocardial and epicardial fiber alignment creates a wringing effect and moves the base of the heart toward the apex. The base of the heart rotates clockwise against the counterclockwise twist at the apex. Normally peak strain occurs after the aortic valve closes. Care must be taken not to foreshorten the apical views as malalignment of the primary axis will introduce inaccuracies. Visually assess the tracking contour and modify the contour as often as necessary to achieve maximum contour tracking. Avoid the pericardial layer; the GLS and GCS width can include the endocardium and mid-wall at the myocardium. Ignore the papillary muscles when creating the ROI. Avoid translation motion as much as possible by collecting clips from end-expiration. Understand speckle-tracking echocardiography (STE) methods Measurement of strain detects speckle movement from one point to another within the myocardial muscle throughout contraction and relaxation. Speckle-Tracking is an image based that is used to track or follow the same group of tissue speckles in an image from frame to frame during the cardiac cycle. Global Longitudinal Strain (GLS) and Global Circumferential Strain (GCS) both depict relative shortening of the and are negative value. The mechanics and deformation of longitudinal shortening and circumferential rotational shortening useful companion analysis along with LVEF. Do not include regions that do not track well. Serial GLS: Document any variation in the methods used to calculate GLS and GCS, maintain the same system type and software level when performing serial GLS measurements as software algorithm differences will impact the results. Endocardial GLS and GCS are the most consistent STE methods. Frame rate must be high enough to capture all of the frames across the R to R interval. Please note that the learning material is for training purposes only! For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator's Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Note: Some functions shown in this material are optional and might not be part of your system. Certain products, product related claims or functionalities (hereinafter collectively “Functionality”) may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. ACUSON Juniper™ is a trademark of Siemens Healthineers. All names and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Copyright © Siemens Healthcare GmbH 2020 Siemens Healthineers Headquarters\Siemens Healthcare GmbH\Henkestr. 127\ 91052 Erlangen, Germany\Telephone: +49 9131 84-0\siemens-healthineers.com Disclaimer Disclaimer Assessment This assessment will test your retention of the presented content. A passing score of 80% or higher is required to complete the course and earn your certificate. You may repeat the assessment as many times as needed. Start Assessment Endocardial GLS and GCS. GLS near the pericardium. Radial Strain methods. GCS near the pericardium, including the papillary muscles. What STE methods are the most reproducible? Question 1 of 6 Select the best answer. Question 1 Incorrect Including the papillary muscles and pericardium is not recommended. Incorrect Radial strain is the least consistent STE method. Incorrect The pericardium will underestimate STE values. Correct After the Aortic Valve closure. Before the closure of the Aortic Valve. After the opening of the Mitral Valve. In normal cardiac strain, when does peak strain occur? Question 2 of 6 Select the best answer. Question 2 Incorrect This is not specific to the occurrence of peak strain. Incorrect This is too soon for peak strain to occur. Correct A negative value. A positive value. A thickening of the cardiac wall. The segment will be thinner. The speckle pattern movement toward each other is shortening and away from each other is lengthening. Shortening will yield what strain value? Question 3 of 6 Select the best answer. Question 3 Incorrect The measurement is length not thickness. Incorrect The measurement is length not thickness. Incorrect Lengthening yields a positive value. Correct Approximately one frame for every one millisecond. Approximately one frame for every second. Approximately on frame for every 70 milliseconds. At 60 frames per second, how many frames are collected at one R-R interval with a heart rate of 60 beats per minute? Question 4 of 6 Select the best answer. Question 4 Incorrect This is too slow. Incorrect This is too slow. Correct Clockwise. Counterclockwise. Toward the apex. Twisting. The base of the heart rotates in one direction while the apex rotates in the other direction. What direction does the base of the heart rotate? Question 5 of 6 Select the best answer. Question 5 Incorrect This describes the action of not the rotation. Incorrect This is not the direction of the rotation. Incorrect This is the rotation on the apex. Correct Dynamic Range. Foreshortening. ECG quality. Frame Rate. Which of these ultrasound system image quality parameters will have an effect on the 2D speckle? Question 6 of 6 Select the best answer. Question 6 Incorrect Foreshortening will effect the speckles tracked the idea here is image quality and Dynamic Range impacts image quality. Incorrect Frame Rate will impact the speckles tracked depending on the heart rate. Incorrect ECG quality will impact the timing and speckle tracking. Correct Review Review Retry Assessment Results %Results.ScorePercent%% %Results.PassPercent%% Continue YOUR SCORE: PASSING SCORE: Assessment Results You did not pass the course. Take time to review the assessment then select Retry to continue. Congratulations. You passed the course. Exit To access your Certificate of Completion, select the Launch button drop down on the course overview page. You can also access the certificate from your PEPconnect transcript. You have completed the [Product Name] [Topic] Online Training. Completion Juniper Cardiac Strain - VVI 1.1 Welcome 1.2 Introduction 1.3 Regional Wall Motion Analysis 1.4 Cardiac Dynamics 1.5 Speckle Tracking Echocardiography 1.6 Speckle Tracking Echocardiography (continued) 1.7 Introduction to Cardiac Strain 1.8 Strain Methods - GLS and GCS 1.9 Radial Strain 1.10 Frame Rate 1.11 Managing Variability 1.12 Course Review 1.13 Disclaimer 1.14 Assessment 1.16 Question 2 1.17 Question 3 1.18 Question 4 1.19 Question 5 1.20 Question 6 1.22 Completion