ACUSON Maple System Cardiac Strain

Continue Continue Continue Continue Continue Continue ACUSON Maple Cardiac Strain ACUSON Maple™ Ultrasound System Introduction to Cardiac Strain Online Training Understand STE and speckle tracking methods 1 Examine STE deformation, timing, and mechanics 2 This course is a high-level clinical overview of two-dimensional speckle tracking echocardiography (STE) methods. The course objectives are listed here. No audio accompanies this page, select Next. ? Welcome Speckle tracking Echocardiography The ACUSON Maple system uses syngo® Velocity Vector Imaging™ Technology (syngo VVI) to assess myocardial motion, deformation, and mechanics non-invasively. syngo VVI is used to measure cardiac strain and expands the ability to noninvasively characterize the global function of the heart qualitatively and quantitatively. ? Introducing Maple STE The ACUSON Maple Ultrasound system uses syngo® Velocity Vector Imaging™ Technology (syngo VVI) to assess myocardial motion, deformation, and mechanics non-invasively. syngo VVI 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 pulsed wave (PW) Doppler to DTI provides a relatively fast way to compare velocities along the myocardium for regional wall motion changes. Select the tab arrows to learn more about DTI and PW Doppler. No audio accompanies the tab arrow layers. Doppler Tissue Imaging (DTI) Pulsed Wave (PW) DTI PW DTI for Segmental Velocity ? Regional Wall Motion Analysis Base Layer- Regional Wall Motion Analysis: dti.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 pulsed wave (PW) Doppler to DTI provides a relatively fast way to compare velocities along the myocardium for regional wall motion changes. Select the tab arrows to learn more about DTI and adding PW Doppler to DTI. Please note, no audio accompanies the tab arrows. Layer 1- DTI: No Audio 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 2- PW DTI: No Audio 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 3- Cursor Alignment: No Audio PW DTI is not practical for a global assessment of LV function but can be used to 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. Each view will need to be properly adjusted to create alignment with the ultrasound Doppler beam and it may not be possible to have a zero-degree alignment in all segments of all of the cardiac wall tissues. Select the marker on each of the images below for more information. Select each marker for mor information. PW DTI for Segmental Velocity PW DTI is not practical for a global assessment of LV function but can be used to 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. Each view will need to be properly adjusted to create a better alignment with the ultrasound Doppler beam and it may not be possible to have a zero-degree alignment in all segments of all of the cardiac wall tissues. Select Next to proceed. Select to return to Regional Wall Motion Analysis or Next to proceed ? Pulsed Wave (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. Hover on the markers located on each of the images below for more information. PW DTI Cursor Misaligned The PW cursor is indicated by the orange line. There is a misalignment of the cursor with the interventricular septum; see the orange and teal lines showing the orientation of the PW cursor to 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 DTI Cursor Aligned The PW cursor is indicated by the orange line. In this example there is a better alignment of the PW cursor with the interventricular septum; see the orange and teal lines that are showing the orientation of the PW cursor to the interventricular septum. In this example, the angle of insonation is two degrees (the cosign of two degrees is 0.999), so the myocardial velocity is underestimated by 0.001%. Select to return to Regional Wall Motion Analysis ? 40º 2º Color Doppler Tissue Imaging (DTI) DTI is a Doppler-based method that can analyze the direction and velocity at individual wall segments. 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. ? Speckle Tracking Echocardiography Unlike Doppler imaging, speckle tracking echocardiography (STE) is an image-based method that is used to track or follow the same group of tissue speckles between consecutive frames of the two dimensional (2D) image during the cardiac cycle. ? 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 between consecutive frames of the two-dimensional (2D) image during the cardiac cycle. Cardiac Dynamics Left Ventricle 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 In this section, you can review the cardiac mechanics that impact the strain measurement. Speckle tracking methods can measure strain at the endocardial interface, the endocardium, and myocardium or across the full wall of the myocardium. Select the numbered steps below to learn more about cardiac dynamics. ? Cardiac Dynamics Left Ventricle Base Layer- Cardiac Dynamics: lv_dynamics.mp3 In this section, you can review the cardiac mechanics that impact the strain measurement. 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. Select the numbered steps below to learn more about cardiac dynamics. Layer 1- 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 it shortens. Layer 2 – Strain Equation: intro_strain1. 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). The 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. Layer 3- Cardiac Dynamics Timing: slide4.mp3 Review this graphic representation of normal waveforms. The R-wave is from the electrocardiographic (ECG) tracing. Select each marker for mor information. Note that peak strain occurs after the aortic valve closes. Layer 4- syngo AV close and ECG: 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 VVI software using the ECG and deformation of the speckles to create the approximation of the volume curves. Layer 5 - M-mode Timing: m-mode_timing.mp3 However, if there is not a precise match of end-diastole on the ECG due to conduction delay, or the ECG is unreliable; 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- 6 – Doppler Timing: doppler_timing.mp3 Additionally, timing can also be done by using pulsed wave (PW) Doppler. AV closure using pulsed wave (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. 6 Doppler Timing AV closure using PW Doppler may also be necessary to accurately 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. Select Next to proceed. ? 5 M-mode Timing If there is not a precise match of end-diastole on the ECG due to conduction delay, or the ECG is unreliable; 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. Select number six to continue. ? 4 syngo VVI Timing LV end-systole (ES) 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 VVI software using the ECG and deformation of the speckles to create the approximation of the volume curves. Select number five to continue. ? Cardiac Dynamics Timing 3 Review this graphic representation of normal waveforms. The R wave is from the electrocardiographic (ECG) tracing. Note that peak strain occurs after the aortic valve closes. Hover on each marker for more information. Select number four to continue. AV Closes End-Systole (ES) AV Opens Systole begins Aortic (AV) Doppler Diagram of AV Doppler Strain Curve R-wave ECG Peak Strain After AV closes during the isovolumetric period R-wave ECG MV Opens Diastole begins MV Closes End-Diastole Mitral Valve (MV) Doppler Diagram of MV Doppler ? 2 Measurement of strain detects speckle movement from one point to another within the myocardial muscle throughout contraction and relaxation. Strain is the measurement of change in the positive or negative direction between consecutive frames of the 2D image. To calculate strain, the deformation between two points are measured as the change in length divided by the original length. Select number three to continue. Strain Equation Strain = X 100 L1 – LO LO L1 = Change in length = Original length LO ? 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 it shortens. Select number two to continue. ? 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. Left Ventricular Strain Methods ? Introduction Strain Methods Base Layer – Left Ventricular Strain Methods: strain_one_page.wav 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. Global Circumferential Strain (GCS) Global Circumferential Strain or GCS is measured is 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. Change in length Original length 100 - 4 cm 12 cm 100 = -33% ? 12 cm 8 cm LV Methods GCS Base Layer– LV Methods GCS: gcs_page1.mp3 Global Circumferential Strain or GCS is measured is 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 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%. 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. Radial speckle patterns are moving away, lengthening so the strain results are positive. LV Methods Radial Base Layer – LV Methods Radial: radial_main_pageV2.mp3 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. Radial speckle patterns are moving away, lengthening so the strain results are positive. Left Ventricular Strain Methods 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 In this section we will review the global longitudinal strain (GLS) methods and the consensus relevant industry standards. Please review each of the numbered steps below. Please note, no audio accompanies the numbered steps. LV Strain Methods GLS In this section we will review the global longitudinal strain (GLS) methods and the consensus relevant industry standards. Select the numbered steps below. Please note, no audio accompanies the numbered steps. 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 European Association of Cardiovascular Imaging (EACVI), the American Society of Echocardiography (ASE), scientists, and industry representatives. (ASE/EACVI Task Force or Industry Strain Task Force). Select Next to proceed. Industry Task Force 5 GLS Contour 4 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 track the speckle shift within the endocardium or expanded further to cover the full wall of the myocardium. However, the most common and most reproducible GLS is just sampled at the endocardium as recommended by the Industry Strain Task Force. Select number five to continue. GLS Curves Dispersion Cardiac dyssynchrony, coronary artery disease (CAD), and ischemic heart disease have peak strains that are out of phase with AV closure. STE analysis provides waveforms that provide a visual display of mechanical dispersion in patients with dyssynchrony and structural heart disease. Hover on each of the markers for more information. Select number four to continue. 3 +- Dyssynchrony The strain curve that is shown in the aquamarine color is a dyssynchronous GLS shape. Note the swing in the positive direction and then within the same cycle, the curve have a delayed negative peak. Normal GLS Red Peak GLS. Reduced GLS Blue Peak GLS. Dyssynchrony with premature shortening The GLS strain curve shown in orange has a premature peak in the positive direction and a delayed peak after the AV closes in the positive direction. Y-Axis On the y-axis (vertical axis) is the negative or positive strain. X-Axis The x-axis (horizontal axis) is the displacement curve shown as a percentage of the entire cardiac cycle. 2 GLS Strain Curves 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. Hover on each of the markers for more information. Select number three to continue. 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. 1 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 walls are thickening but the difference is from the reduction in length yielding a negative result. Select number two to continue. Image Acquisition 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. Select the tab arrows to learn more about adjusting the temporal resolution. No audio accompanies the tab arrow layers. Acquisition Rate Configure from the Beginning Frame Rate On The Fly ECG Beat Capture Unsupported Acquisition Types ? Image Acquisition 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. Select the tab arrows to learn more about adjusting the temporal resolution. Please note, no audio accompanies the tab arrows. Layer 1- Acquisition Rate No Audio. 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 or the Acquisition Rate on the ACUSON Maple System. There is a frame rate limiter that is enabled by default on the ACUSON Maple ultrasound system. The ACUSON Maple system’s factory default setting is an Acquisition Rate of Normal, and this limits the clip capture rate to 30 frames per second. This limit is intended to reduce image/study storage size. However, the syngo VVI analysis software must have the 2D cardiac clip captured at frame rates higher than 30 frames per second (fps). Configuring the Acquisition Rate to High enables a clip capture rate of 60 frames per second. The steps to enable the Acquisition Rate to High can be done from the beginning of the exam or during the exam, but prior to collecting cardiac strain cine-loops. Layer 2- Configure From Acquisition: No Audio Adjusting the clip store Acquisition Rate before collecting 2D clips for STE analysis on syngo VVI. From the Touch Screen, Select System Configuration. Select Clip Store. Select High under Acquisition Rate and this will enable 60 fps. Layer 3- Configure On The Fly: No Audio The clip store Acquisition Rate setting may also be adjusted “on the fly” during an active exam. From the Touch Screen, select Clip Settings. Press the Acquisition Rate until High is shown enabling 60 fps. Layer 4- ECG Beat Capture: No Audio When obtaining a clip for cardiac strain acquisition, it is recommended to use a Beat capture. However, clip capture acquisitions without an ECG are allowed for STE analysis. Without the ECG the frames are limited to 700 frames and further cardiac timing modifications to ES and ED are necessary for analysis. This will be covered in the next segment of this course. syngo VVI software does not support the following acquisition types: 2D color Doppler clips Secondary capture images or clips M-mode of Doppler images Static captures 2D live Dual clips 2D Dual clips Unsupported Acquisition Types ? When obtaining a clip for cardiac strain acquisition, it is recommended to use a Beat capture. However, clip capture acquisitions without an ECG are allowed for STE analysis. Without the ECG the frames are limited to 700 frames and further cardiac timing modifications to ES and ED are necessary for analysis. This will be covered in the next segment of this course. ECG Beat Capture Select to return to Image Acquisition ? Frame Rate On The Fly The clip store Acquisition Rate setting may also be adjusted “on the fly” during an active exam. From the Touch Screen select Clip Settings. On the Touch Screen select the Acquisition Rate until High is shown enabling 60 fps. ? Configure Acquisition from the Beginning 60 fps 90 fps Adjusting the clip store Acquisition Rate before collecting 2D clips for STE analysis on syngo VVI. From the Touch Screen Select System Configuration. Select Clip Store. Select High under Acquisition Rate and this will enable 60 fps. Select to return to Image Acquisition ? Acquisition Rate 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 or the Acquisition Rate on the ACUSON Maple system. There is a frame rate limiter that is enabled by default on the ACUSON Maple ultrasound system. The ACUSON Maple system factory default setting is an Acquisition Rate of Normal, and this limits the clip capture rate to 30 frames per second. This limit is intended to reduce image/study storage size. However, the syngo VVI analysis software must have the 2D cardiac clip captured at frame rates higher than 30 frames per second (fps). Configuring the Acquisition Rate to High enables a clip capture rate of 60 frames per second and must be done prior to collecting cardiac strain cine-loops. Enable the high acquisition rate from the configuration menu at the beginning of the exam or ‘on the fly’ during the active exam. ? ? Checklist introduction statement. Add instructional statement “Select the numbered steps below to learn more about [XXX].” 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 syngo VVI Workflow syngo® Velocity Vector Imaging™ technology (syngo VVI) is a clinical STE software application available that tracks tissue with a contour and assesses motion mechanics and deformation parameters. Select number one to begin the syngo VVI workflow. Please note, no audio accompanies the numbered steps. syngo VVI Workflow syngo® Velocity Vector Imaging™ technology (syngo VVI) is a clinical STE software application available on the ACUSON Maple 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. The results are dependent on image quality of the views that are selected and used to draw the contour. Select the numbered steps below to learn more about syngo VVI software. Please note, no audio accompanies the numbered steps. 8 This is the analysis main page. Hover on the marker to learn more about the Segmental Analysis page. Select Next to proceed. Analysis Main Page ? 8 Segmental Analysis This page provides segmental values for radial or transverse strain when an Endo+Epi trace is performed. Along the top of the page are options for velocity, displacement, strain average, strain rate, and global strain values. Segments may be removed from the display and the average value will reflect the edit. The diagrams include time-to-peak, phase values, and curve graphs are provided for each segments. The results analyze the segments for dyssynchrony. 7 syngo VVI Tools The right column contains various control settings that are available when syngo VVI analysis has been initialized. Some of these controls were discussed previously. Hover on markers shown here to read about the syngo VVI tools. Select number eight continue. Endo+Epi Activates the endocardial and epicardial traces. Gamma Slider Controls the brightness and contrast settings. End-Systole End-Diastole With a single click go to the end-systolic or end-diastolic frame. Zoom In/Out Toggles the 2D clip with contour panel to full screen. Pictures Mirroring Reverses the orientation of the displayed image. Contours or Vectors Switches parametric over B-mode and toggles contours / vectors / trajectories / B-mode. Sequence M-mode Allows manual edit of R-R wave markers, end diastolic (ED) and end systolic (ES) markers. Bkg MMode Toggles the M-mode display off/on behind the curve graphs (Note: This button only appears when the M-mode drawing tool is used for editing cardiac timing). ? Height of Contours or Vectors Tools Once the vectors are activated, the height can be increased, decreased, or reset. New Trace Begin a new trace, correct the end-systolic or end-diastolic border. Remember that is important to delete a previous contour or else the contours will be averaged and cause inaccurate results. Segmental Analysis Activates the Segmental Analysis page. Swap 3D/2D Toggles between 2D border shell and 3D shape shell (Note: This button only appears with a completed bull’s eye and the default is 2D border). Correct ED Border Allows correction of the contour borders at end-diastole. Correct ES Border Allows correction of the contour borders at end-systole. 7 6 Freeze the reference 2D clip on the control panel. Move the trackball cursor into the 2D clip region and press the Set key and draw the M-line across the ventricles. Within the M-mode, hover the Trackball cursor over the eD red bar and press the Set key to drag and reposition to end-diastole. To anchor the eD bar click the Set key again. Repeat these steps to adjust eS bar at end-systole. There will be a grey arrow on the top right corner, this grey arrow proceeds to the analysis page. Hover on the markers for more information. Select the number seven to continue. M-mode Creation and Timing ? M-mode with Curves When M-mode display is used for editing cardiac timing markers, this M-mode display will also appear on curve graph analysis. To toggle M-mode display off of the curve graphs, select Bkg MMode display button. This button only appears when M-mode drawing tool is used for modifying cardiac timing. No ECG syngo VVI will display the following message (shown framed in orange) when trying to analyze a clip with an absent ECG signal. To analyze a clip with an absent or poor ECG signal. Using the Set key select and drag the R1 and then the R2 blue markers to adjust the R to R interval within the grey box. Press the Set key to select and drag the red bars for end-diastolic (ED) and end-systolic (ES) to the desired location. 6 5 5 Modifying Cardiac Timing Markers End-diastolic marker (eD) should align with the peak on red Volume curve. End-systolic marker (eS) should align with the trough on the red Volume curve. Select number six to learn how to use M-mode for timing. ? 4 4 Endocardial and Epicardial Trace Select the Endo+Epi box to create an endocardial and epicardial trace simultaneously. Adjust the width with the green arrows to increase or decrease thickness between endocardial and epicardial traces. To process the trace double click the Set key or select the Start Analysis button for systole and diastole analysis. Hover on the marker to learn how to delete a contour. Select number five to continue. ? Delete a Contour To delete a contour that has been analyzed, first select the X next to the thumbnail view (shown here framed in orange). A confirmation window will appear, select OK to delete the selected contour. The user will be returned to begin a new contour to replace the view that was deleted. Note: If a new contour is drawn without deleting the previous contour, the results will be averaged and therefore inaccurate. 3 3 Manual Trace Method Start at the basal septum, using the Set key, place markers in a clockwise pattern and complete the trace markers by anchoring the final marker with the Update key. To begin analysis double click the Set key or click on the Start Analysis button (shown here framed in orange) located under the Contour section to proceed to analysis page. Select the number four to continue. ? 2 2 Three-Point Method Identify the placement guide for position trace markers. Trackball controls note the position for each trace marker. Press Set key to place the first and second marker and press Update to anchor the final marker. To begin the trace either double click the Set key or click on the Start Analysis button to proceed to analysis page. Hover on each marker to learn about the three point method. Select the number three to continue. Second Marker Press the Set key. First Marker Press the Set key. Third Marker Place the final marker at the apex and click on Update or End. Start Analysis ? 1 Selecting Images Begin by pressing Review (1) on the left side of the Control Panel. Select all of the images (2) that are needed for GLS or GCS analysis and press Show Selected (3). After choosing the images and pressing Show Selected, the images will be outlined in white. Confirm the thumbnails for STE analysis and then select syngo VVI (4). Hover on the markers for more important information about image selection. Select number two to continue. ? Additional Image Selection Once syngo VVI is activated additional images cannot be chosen without exiting syngo VVI and beginning with Review again. Assigning Images Select image(s) from the thumbnails and assign the images to the corresponding views. To delete an image, select the X in the upper right of the image and reassign another image. When all of the views have been properly identified, select the grey arrow in the lower right corner of the screen (shown here framed in orange) to create the tracking ROI. Review to Begin Show Selected After choosing the images and pressing Show Selected, the images will be outlined in white. Confirm the thumbnails for STE analysis and then select syngo VVI. ? syngo VVI Analysis 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. Select the numbered steps below to learn more about syngo VVI software. Please note, no audio accompanies the numbered steps. 1 1 1 2 2 2 3 3 3 4 4 4 syngo VVI Analysis Base Layer – syngo VVI Analysis: syngo_vvi_analysis.mp3 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 left ventricle, right ventricle, and the left and right atria can be analyzed in syngo VVI software. Select the numbered steps below to learn more about syngo VVI software. Please note, no audio accompanies the numbered steps. Layer 1 – Main Analysis Page: No Audio When a contour is processed quantitative data is derived. A bull's eye display is also available, and analysis options include peak strain and systolic strain, time to peak and phase. Note that in order to obtain a complete bull’s eye, strain must be performed on all three apical views. In this example all three apical views have been analyzed. Review each of the markers on this analysis page then press the number two to continue. Layer 2 – EF_GLS_Shape_1: No Audio We will begin a review of the graph by discussing the blue line. EF and GLS have a linear relationship which is represented by the blue line. We can determine a correlation between EF and GLS by evaluating where the white dot is plotted. Notice that EF values fall along the horizontal x-axis and GLS values fall along the vertical y-axis. Review each of the markers on the graph. Layer 3 – EF_GLS_Shape_2: No Audio GLS and EF are represented as seen in the previous graph. When the syngo VVI Shape Function (SF) is plotted in the orange region, this indicates that both EF and GLS are abnormal. When SF is plotted in the blue region, both EF and GLS are normal. In the grey region, the EF is reduced and GLS is reduced. The next step in LV analysis that would clarify this is to perform GCS. Review each of the markers on this graph for more information. Layer 4 – GCS: No Audio With normal EF and a reduced GLS, then GCS should be performed. To preserve EF the circumferential function of the heart elevates to compensate for the drop in longitudinal function. If the EF is normal and GLS is truly reduced, GCS should be elevated. If GCS is not elevated, then you may want to consider that the original GLS contour and analysis might be incorrect. Layer 5 – EF_GLS_Shape_3: No Audio The shape function of the LV is represented by the green line. As the LV contracts, the shape should change from end-diastole to end-systole and the apex should become more conical (narrowed). Review each of the markers for more information. Layer 6 – EF_GLS_Shape_4: No Audio Research suggests that the subtle variations of the shape (shape dynamics) with a preserved or slight LV volume change are generally-non detectable using EF alone and shape dynamics are often sensitive precursors of the macroscopic changes of overt disease. Review each marker for more information. After reviewing the markers, please select the illustration framed in orange for detailed description of Shape Function (SF). Pedrizzetti, G., et al., The Relationship Between EF and Strain Permits a More Accurate Assessment of LV Systolic Function - JACC: Cardiology Imaging, 2019. 12(9) p. 1893 - 1895. Layer 6a – EF_GLS_Shape_5: No Audio These contraction shapes all have the same EF. From left to right the GLS decreases and the SF increases. In a normal ventricle, the shape becomes smaller at end-systole and the apex becomes more conical (normal shape dynamics). The LV is more rounded with abnormal SF. Each of the four illustrations has different GLS and SF values but all four have the same EF. Review each marker for details. Please select the illustration framed in orange once more to review the EF, GLS, and SF relationship. Layer 6b – EF_GLS_Shape_6: No Audio When the SF is reduced, the GLS appears to be elevated to compensate. This also provides an explanation as to why the EF is still normal. The GLS and EF are working together to make up for a lack and SF (shape dynamics). Next select the number seven to continue. Layer 7 – EF_GLS_Shape_7: No Audio When SF result falls above the green curve, the SF is normal. If the SF result falls on the green curve, there is no significant change in SF which can be an early indicator of LV failure. If the SF result is below the green curve the LV shape became more rounded in systole which is and abnormal SF. Note: The EF and GLS may still be normal even though the SF is abnormal. This is because the LV compensates when there is an abnormal SF (shape dynamics). Review each marker for more information. Layer 8 – EF_GLS_Shape_8: No Audio In this example, the EF, GLS, and SF within normal limits, indicated by the SF result being plotted above the green curve. The SF volume graphic also appears normal. Note that when the endo epi trace is performed, the myocardial GLS number is used for graph results. When just the endocardial trace is performed, the endocardial GLS number is used. Analysis 4 With normal EF and a reduced GLS, then GCS should be performed. To preserve EF the circumferential function of the heart elevates to compensate for the drop in longitudinal function. If the EF is normal and GLS is truly reduced, GCS should be elevated. If GCS is not elevated, then you may want to consider that the original GLS contour and analysis might be incorrect. Select Next to proceed. ? Analysis 3 GLS and EF are represented as seen in the previous graph. When the syngo VVI Shape Function (SF) is plotted in the orange region, this indicates that both EF and GLS are abnormal. When SF is plotted in the blue region, both EF and GLS are normal. In the grey region, the EF is reduced and GLS is reduced. The next step in LV analysis that would clarify this is to perform GCS. Hover on each of the markers on this graph for more information then select number four to continue. Abnormal Both EF and GLS are abnormal if both EF and GLS are plotted in this orange area. Normal Both EF and GLS are normal if both EF and GLS are plotted in this blue area. The Grey Area In the grey area EF is normal and GLS is reduced. ? We will begin a review of the graph by discussing the blue line. EF and GLS have a linear relationship which is represented by the blue line. We can determine a correlation between EF and GLS by evaluating where the white dot is plotted. Notice that EF values fall along the horizontal x-axis and GLS values fall along the vertical y-axis. Hover on each of the markers on the graph then select number three to continue. Insert picture here Analysis 2 GLS Y-Axis EF X-Axis Blue Line Relationship of EF and GLS ? Main Analysis Page 1 Contour A graphic animation representing the contour is displayed onto the mode image. Graphic GLS, GCS, and Radial strain. If Endo+Epi trace is performed the curve results will be shown for endocardium. Remove Curves Curves can be removed from the display by simply deselecting any of the options to the right of the curves. Ventricular Volumes The bottom curved graph displays curves for ventricular volumes throughout the cardiac cycle. Volume Shell Once all three apical views are completed, a volume shell displays the shape of the ventricle at the end, diastole and systole. EF and Shape Function The graph represents the relationship between EF, GLS, and the shape function of the ventricle. Bull’s Eye The graph represents the relationship between EF and the shape function of the ventricle. When a contour is processed quantitative data is derived. A bull's eye display is also available, and analysis options include peak strain and systolic strain, time to peak and phase. Note that in order to obtain a complete bull’s eye, strain must be performed on all three apical views. In this example all three apical views have been analyzed. Hover on each of the markers on this analysis page then select number two to continue. ? ? 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 Insert picture here Select the numbered steps to continue to learn more about syngo VVI analysis. No audio accompanies the numbered steps. syngo VVI Analysis - Continued syngo VVI Analysis - Continued Select the numbered steps below to learn more about syngo VVI software. Please note, no audio accompanies the numbered steps. 6 Normal Example The EF, GLS, and SF are within normal limits, indicated by the SF result being plotted above the green curve. The SF volume graphic also appears normal. Note that when the Endo+Epi trace is performed, the myocardial GLS number is used for graph results. When just the endocardial trace is performed, the endocardial GLS number is used. Select Next to proceed. Combining GLS and LVEF helps to stratify risk factors in cardiac pathologies that do not cause a significant change to the LVEF. Also, adding circumferential strain will help provide additional information. ? 5 Curve Analysis When SF result falls above the green curve, the SF is normal. If the SF result falls on the green curve, there is no significant change in SF which can be an early indicator of LV failure. If the SF result is below the green curve the LV shape became more rounded in systole which is an abnormal SF. Note: The EF and GLS may still be normal even though the SF is abnormal. This can occur when the LV compensates when there is an abnormal SF. Hover on each marker shown on the graph for more information and then select number six to continue. SF Result Above Green Curve the SF is normal. SF Result On Green Curve There is no significant change in SF which can be an early indicator of LV failure. SF Result below Green Curve LV shape became more rounded during systole which is abnormal. ? 4 GLS and EF When the SF is reduced, the GLS appears to be elevated to compensate. This also provides an explanation as to why the EF is still normal. The GLS and EF are working together to make up for a lack and SF. Select the number five to continue. Table with 4 columns and 1 rows EF= 60% GLS= -30% SF= -5% EF= 60%, GLS= -26%, SF= 0% EF= 60%, GLS= -23%, SF= 5% EF= 60%, GLS= -19%, SF= 10% ? 3 Contraction Shapes These contraction shapes all have the same EF. From left to right the GLS decreases and the SF increases. In a normal ventricle, the shape becomes smaller at end-systole and the apex becomes more conical (normal shape dynamics). The LV is more rounded with abnormal SF. Each of the four illustrations has different GLS and SF values but all four have the same EF. Please select number four to continue. ? Table with 4 columns and 1 rows EF= 60% GLS= -30% SF= -5% EF= 60%, GLS= -26%, SF= 0% EF= 60%, GLS= -23%, SF= 5% EF= 60%, GLS= -19%, SF= 10% 2 Shape Dynamics Research suggests that the subtle variations of the shape (shape dynamics) with a preserved or slight LV volume change are generally-non detectable using EF alone and shape dynamics are often sensitive precursors of the macroscopic changes of overt disease. Please select number three to continue. Pedrizzetti, G., et al., The Relationship Between EF and Strain Permits a More Accurate Assessment of LV Systolic Function - JACC: Cardiology Imaging, 2019. 12(9) p. 1893 - 1895. Table with 4 columns and 1 rows EF= 60% GLS= -30% SF= -5% EF= 60%, GLS= -26%, SF= 0% EF= 60%, GLS= -23%, SF= 5% EF= 60%, GLS= -19%, SF= 10% ? 1 Analysis Insert picture here The Shape Function of the LV is represented by the green line. As the LV contracts, the shape should change from end-diastole to end-systole and the apex should become more conical (narrowed). Hover on each of the markers for more information then select number two to continue. Green Line Shape function relationship of the LV. End-Diastole Green color cast of the LV at end-diastole. End-Systole Yellow/Gold color cast of the LV at end-diastole. Shape Function (SF) Volume Graphic Shape Function (SF) Result ? 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. Select the numbered steps below to learn more about clinical standards, applications, and some tips to minimize STE variability. Please note, no audio accompanies the numbered steps. 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 ? Managing Variability Base Layer – Managing Variability: managing_variability.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, select the numbered steps below to learn more about clinical standards, applications, and some tips to minimize STE variability. Please note, no audio accompanies the numbered steps. Layer 1- Method and Normal Values: No Audio 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. Review the marker above for more information on the Industry Strain Task Force. Layer 2- Vendors and Software : No Audio 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: No Audio 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. Normal GCS is –23 with a standard deviation of less than or equal to 3%. Layer 4-Cancer Therapeutic Related Cardiac Dysfunction : No Audio 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: No Audio 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: No Audio The overall image settings should be consistent between in serial examinations. Variations in dynamic range and gain settings will impact the speckle. Unclear endocardial borders will cause uncertainty in the STE analysis because syngo VVI cannot differentiate between noise and structural speckle. Next, select the area highlighted in orange to learn about gain control using the Gamma slider. Layer 6a. – Gamma Slider: No Audio The Gamma slider control allows the user to optimize the gain setting while in the syngo VVI software application. To adjust the Gamma slider, click and drag the slider to the right or to the left to make any necessary adjustments to gain. Next, select the image to learn about foreshortening. . Layer 6b. – Foreshortening: No Audio 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 within the image sector throughout the entire cardiac cycle. 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. Select the apical-4 chamber view to proceed. Layer 6c. – Translation: No Audio This is a lateral movement of the heart within the chest, typically caused by breathing. Translation moves the 2D speckles into and out of the image plane 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. Select the number seven to continue. Layer 7- Acquisition: No Audio Image acquisition must include the entire area of interest because syngo VVI analyzes 2D images to determine motion within the imaging plane. Ensure entire area of interest is maintained in field of view. Optimize 2D image settings so the myocardial speckle patterns are well visualized for tracking. A full R-R wave must be contained in data set for quality analysis. Clips should not exceed 10 heart cycles or 10 seconds. Select the number eight to continue. Layer 8- Cine-loop Clips: No Audio Acquisition with ECG: Acquisition Rate set to High. Use Beat capture. Multiple heart cycles are allowed. Recommended clips should contain between 6-700 frames. Acquisition without ECG: Use Timed capture. Frames limited to 700. 7 ? Cine-loop Clips Acquisition with ECG: Acquisition Rate set to High. Use Beat capture. Multiple heart cycles are allowed. Recommended clips should contain between 6-700 frames. Acquisition without ECG: Use Timed capture. Frames limited to 700. Select Next to proceed. 6 ? Acquisition Image acquisition must include and maintain the entire field of view. Optimize 2D image settings so the myocardial speckle patterns are well visualized for tracking. A full R-R wave must be contained in data set for quality analysis. Clips should not exceed 10 heart cycles or 10 seconds. Select number seven to continue. 5 ? Variations in dynamic range and gain settings will impact the speckle. Unclear endocardial borders will cause uncertainty in the STE analysis because syngo VVI cannot differentiate between noise and structural speckle. Next, hover on each marker to learn about gain control, foreshortening, and translation. Select number six to continue. Image Quality ? Gamma Slider and Gain The Gamma slider control (framed in orange) allows the user to optimize the gain setting while in the syngo VVI software application. To adjust the Gamma slider, click and drag the slider to the right or to the left to make any necessary adjustments to gain. Foreshortening Care must be taken not to foreshorten the apical views as malalignment will introduce inaccuracies. The entire myocardium must be seen within the image sector throughout the entire cardiac cycle. 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. Translation This is a lateral movement of the heart within the chest, typically caused by breathing. Translation moves the 2D speckles into and out of the image plane 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. 4 ? 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 Select number five to continue. 3 ? Cancer Therapeutic Related Cardiac Dysfunction 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 Select number four to continue. The ASE/EACVI Task Force has also recognized that speckle tracking results will vary across various ultrasound platforms and different software levels.7-11 In patients with subclinical ventricular dysfunction, compensatory mechanisms may preserve the LVEF or there may be non-significant changes in LVEF. Combining GLS and LVEF helps to stratify risk factors in cardiac pathologies that do not cause a significant change to the LVEF. Also, adding circumferential strain will help provide additional information. Select number three to continue. Vendors and Software 2 ? Method and Normal Values The ASE/EACVI Task Force has recommended an ROI defined at the endocardium or across the endocardium and myocardium, or across the full wall are 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 Normal Values Guidelines from many subject expert authors and the ASE/EACVI Task Force suggest a normal baseline GLS value of -20% with a standard deviation (std dev) of ± 2%. Normal GCS is –23% with a std dev ± 3%.2, 3,4,9,10 Keep in mind that the GLS and GCS values will vary depending on many technical factors. Hover on the marker above for more information on the Industry Strain Task Force then select number two to continue. 1 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 Task force along with the European Association of Cardiovascular Imaging (EACVL), the American Society of Echocardiography (ASE), scientist, and industry representatives. (ASE/EACVI Task Force or Industry Task Force). ? Examine STE deformation, timing, and mechanics Understand STE and speckle tracking methods Course Review Congratulations. You have completed the course ACUSON Maple Ultrasound System Introduction to Cardiac Strain. Select the objectives listed below to review the material. 1 2 ? Course Review Base layer – Course Review: No Audio Congratulations. You have completed the course ACUSON Maple™ Ultrasound System Introduction to Cardiac Strain. Select the objectives listed below to review the material before proceeding to the final assessment. Layer 1 – Objective 1: No Audio Understand speckle tracking echocardiography speckle tracking 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. 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. Layer 2 – Objective 2: No Audio 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. 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. Examine STE Deformation, Timing, and Mechanics Select to return the Course Objectives. 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. 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 STE and Speckle-Tracking 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. 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. Select to return the Course Objectives. ? References ? Janssen, P.M.L., Myocardial contraction-relaxation coupling. 2010: p. H1741 - H1749. Larsen, C.M. and S.L. Mulvagh, Cardio-oncology: what you need to know now for clinical practice and echocardiography. Echo Res Pract, 2017. 4(1): p. R33-r41. Plana, J.C., et al., Expert Consensus for Multimodality Imaging Evaluation of Adult Patients during and after Cancer Therapy: A Report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography, 2014. 27(9): p. 911-939. Lancellotti, P., et al., Expert Consensus for Multi-Modality Imaging Evaluation of Cardiovascular Complications of Radiotherapy in Adults: A Report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Journal of the American Society of Echocardiography, 2013. 26(9): p. 1013-1032. Farsalinos, K.E., et al., Head-to-Head Comparison of Global Longitudinal Strain Measurements among Nine Different Vendors: The EACVI/ASE Inter-Vendor Comparison Study. Journal of the American Society of Echocardiography, 2015. 28(10): p. 1171-1181.e2. Klein, P., et al., A Test in Context: Myocardial Strain Measured by Speckl-Tracking Echocardiography. Journal of the American College of Cardiology, 2017. 69: p. 1043 - 1054. Chung, C.S., How myofilament strain and strain rate lead the dance of the cardiac cycle. Archives of Biochemistry and Biophysics, 2019. 664: p. 62-67. Janssen, P.M.L., Myocardial contraction-relaxation coupling. 2010: p. H1741 - H1749. Potter, E. and T.H. Marwick, Assessment of left ventricular function by echocardiography: the case for routinely adding global longitudinal strain to ejection fraction. JACC: Cardiovascular Imaging, 2018. 11(2): p. 260-274. Starling, E.H., The Linacre lecture on the law of the heart. 1918: Longmans, Green, & Company. References 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. Please 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 Maple and VVI are trademarks of Siemens Medical Solutions USA, Inc and syngo® is a registered trademark of Siemens Healthcare GmbH. 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 2023 Siemens Healthineers Headquarters\Siemens Healthcare GmbH\Henkestr. 127\ 91052 Erlangen, Germany\Telephone: +49 9131 84-0\siemens-healthineers.com Disclaimer ? Disclaimer Congratulations! ? You have completed this learning activity. Select Exit to return to the training area. Exit Congratulations! Audio: xxx.mp4; xxx.vtt Audio script: Time: 00:00:00 USE THIS SLIDE FOR A CME OFFERING. Navigation Help Select the icon above to open the table of contents. Click Next to continue. Next Welcome Slide No audio. The timeline displays the slide progression. Slide the orange bar backwards to rewind the timeline. Click Next to continue. Next Timeline No audio. Select the CC icon to display closed captioning (subtitles). Click Next to continue. Next Caption Icon No audio. Select the buttons to learn more about a topic. Be sure to review all topics before navigating to the next slide. Click Next to continue. Next Tab Arrow Slide No audio. Select the X to close the pop-up. Click Next to continue. Next Layer Slide No audio. Some images may have a magnifier icon. Select the image to see an enlarged view. Select it again to return to the normal view. Click Next to continue. Next Zoom Slide No audio. Select Submit to record your response. Click the X in the upper right corner to exit the navigation help. Assessment Slide No audio. ACUSON Maple System Cardiac Strain QR700000761 l 27-Sep-2023 References ASE/EACVI Task Force or Industry 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. AV Aortic Valve Clockwise Twist The base of the heart rotates clockwise against the counterclockwise twist at the apex. Counterclockwise Twist The apex of the heart twists counterclockwise. DTI Color Doppler Tissue Imaging (DTI) is a Doppler-based method that can analyze the direction and velocity at individual wall segments. End-Diastole (ED) End-diastole occurs when the mitral valve (MV) closes. ED can also be called eD within the syngo VVI software. End-Systole (ES) End-systole occurs when the aortic valve (AV) closes. ES can also be called eS in the syngo VVI software. Full Wall of Myocardium The endocardium, myocardium, and epicardium. Gamma Slide This control increases or decreases the overall brightness of the 2D image in the syngo VVI software application. GCS 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. GLS Global Longitudinal Strain (GLS) is the change in the length divided by the original length. 2D tissue speckles track movement for GLS along the length of the long axis of the heart. GLS is analyzed from the apical views. LV Left Ventricle LVEF Left Ventricular Ejection Fraction MV Mitral Valve Peak Systolic Strain The peak systolic strain occurs during the isovolumetric contraction period and correlates to a period after the closure of the AV. PW DTI Pulse Wave (PW) DTI is used to measure the velocity of the tissue and is clinically useful for regional wall-motion analysis. Radial Strain Radial strain is deformation that is tracked perpendicular to the long axis of the heart and is also perpendicular to the myocardium. Radial strain is analyzed from the parasternal short axis views. Shape Function The relationship of the shape dynamics throughout systole and diastole along with the GLS and EF. The shape dynamics are often sensitive precursors of the macroscopic changes of overt disease. Speckle-Tracking Echocardiography (STE) STE is an image-based method that is used to track or follow the same group of tissue speckles in an image from frame to frame during the cardiac cycle. STE software analyzes the deformation, tissue velocity, and other parameters related to the movement of the myocardium in the 2D image. Strain The deformation or change in length from one point to another. To calculate strain, the deformation between two points are measured as the change in length divided by the original length. 1.1 Welcome 1.2 Introducing Maple STE 1.3 Regional Wall Motion Analysis 1.4 Speckle Tracking Echocardiography 1.5 Cardiac Dynamics Left Ventricle 1.6 Introduction Strain Methods 1.7 LV Methods GCS 1.8 LV Methods Radial 1.9 LV Strain Methods GLS 1.10 Image Acquisition 1.11 syngo VVI Workflow 1.12 syngo VVI Analysis 1.13 syngo VVI Analysis - Continued 1.14 Managing Variability 1.15 Course Review 1.16 References 1.17 Disclaimer 1.18 Congratulations!