Original Contribution
Comparison of Longitudinal and Apical Foetal Speckle Tracking Echocardiography Using Tissue Motion Annular Displacement and Segmental Longitudinal Strain

https://doi.org/10.1016/j.ultrasmedbio.2018.09.013Get rights and content

Abstract

The aim of our prospective pilot study with exploratory analysis was to compare longitudinal and apical foetal speckle tracking echocardiography (STE) using tissue motion annular displacement (TMAD) and segmental longitudinal strain (SLS). We compared two different STE quantification tools in a longitudinal and apical four-chamber view in 57 normal foetuses between 20 and 40 wk of gestation. Myocardial mechanical dyssynchrony and strain were assessed using offline quantification software (QLab Version 10.3, Philips Medical Systems, Andover, MA, USA). We compared the dyssynchrony measurements with TMAD and SLS in longitudinal and apical four-chamber views. Furthermore, we examined the segmental strain values of both ventricles with SLS and compared the differences between longitudinal and apical measurements. Dyssynchrony measurements with TMAD and SLS and strain measurements with SLS were feasible in all cases. In the apical view, the dyssynchrony measurements with TMAD were systematically greater than those achieved with SLS (p < 0.001). For the longitudinal view, no differences were observed between tools (p = 0.153). The application of SLS provided similar results for dyssynchrony in both views (intra-class correlation coefficient [ICC] = 0.281, p = 0.623), but the strain measurements in the left and right ventricles differed significantly between views (ICC = –0.082, p = 0.011, and ICC = –0.061, p = 0.024, respectively). For TMAD, we found large differences in the dyssynchrony values between longitudinal and apical assessment (ICC = –0.060, p = 0.03). Furthermore, TMAD exhibited reduced accuracy in the system's automatic tracking algorithm, limiting the data quality. The dyssynchrony assessment is affected less by the foetal position in SLS than in TMAD. The strain readings in SLS varied depending on the view in which they were assessed. The application of TMAD cannot be recommended for foetal STE.

Introduction

In recent years, echocardiography has become an important tool for the assessment of foetal cardiac function and identification of structural or functional heart diseases, resulting, for example, from maternal diabetes mellitus (Kulkarni et al. 2017), intrauterine growth restriction (Krause et al. 2017) or twin–twin transfusion syndrome (Rychik et al. 2012). The clinical application of different measurement techniques has become the focus of several studies with the aim to improve the detection of cardiac dysfunction and to influence the foetal outcome positively (Donofrio et al., 2014, Komisar et al., 2017, Van Mieghem et al., 2014). These studies focused on different potential parameters, such as strain, strain rate (Crispi et al., 2012, Krause et al., 2017) and myocardial performance index (MPI) (Bhorat et al., 2017, Leung et al., 2017), and techniques, such as tissue Doppler imaging (TDI) (Crispi et al., 2012, Cruz-Lemini et al., 2013), velocity vector imaging (Alsolai et al. 2017), speckle tracking echocardiography (STE) (Crispi et al., 2012, Krause et al., 2017) and 3-D STE (Enzensberger et al. 2014a). Still, as the assessment depends in particular on the different available tools (Crispi et al., 2012, Herberg et al., 2014), no consensus has been reached with respect to clinical standards and suitable parameters for foetal cardiac assessment (Enzensberger et al., 2014b, Hernandez-Andrade et al., 2012, Tutschek and Schmidt, 2012), although several approaches have been proposed (DeVore et al., 2016, Ge, 2013).

Two-dimensional STE is an elegant non-invasive technique for the evaluation of cardiac function with good feasibility and reproducibility in adults, children and foetuses (Altun et al., 2016, Di Salvo et al., 2008, Friedberg et al., 2007, Godfrey et al., 2012). This method examines myocardial deformation by comparing changes in position of one and the same acoustic speckle within the myocardial wall throughout the normal cardiac cycle from end-diastole to end-systole. The following parameters of cardiac function can thereby be deduced: strain, strain rate and displacement (Chiu et al. 2016). STE permits online and offline analysis of global longitudinal strain (GLS), as well as segmental longitudinal strain (SLS) and dyssynchrony (defined as the absolute time difference between the peaks in strain or in displacement within the right and left ventricles in milliseconds) (Dandel et al. 2009). Offline analysis may be performed either with SLS, which is already operational in specialised research centres such as in Paris, Stockholm or Barcelona in the clinical implementation, or with tissue motion annular displacement (TMAD), which might provide a feasible and quick alternative for cardiac evaluation (Black et al., 2014, Chiu et al., 2016). Both tools apply the tracking modus previously mentioned, but in TMAD the valve plane is used as a reference point, whereas in SLS the endocardial borders of the right and the left ventricle serve as benchmarks (Chiu et al. 2016). Compared with previously established ultrasound techniques such as tissue Doppler imaging (TDI), STE offers a reliable method for cardiac evaluation that is less susceptible to external influence (e.g., angle of insonation) (Bansal et al. 2008).

The application of STE to the evaluation of foetal cardiac function, especially in terms of maternal or foetal diseases, has been a central topic of various studies (Krause et al., 2017, Kulkarni et al., 2017, Miranda et al., 2017), although the general or rather technical applicability of STE and the offline analysis with QLab SLS and TMAD remain challenging.

In the past, SLS has been reported to be a feasible tool for foetal cardiac examination, but neither TMAD nor the influence of an apical or longitudinal view has been explored in this context. The aim of our study was to assess strain and dyssynchrony in longitudinal and apical measurements and compare these in TMAD and SLS in healthy foetuses to evaluate the functional interconnectivity of the individual methods.

Section snippets

Study population

We recorded four-chamber view raw respectively unprocessed data clips in longitudinal as well as apical views in a cross-sectional cohort of 57 foetuses between January 2015 and November 2017 by using 2-D echocardiography with STE. In this collective, gestational age ranged from 20 to 40 wk. The women included in this study were assessed while attending their routine second-or third-trimester screening at the Department of Obstetrics and Gynecology, University Hospital Münster. The study

Results

The median gestational age and median BMI within the study population were 26.3 (22.1, 30.1) wk or rather 26 + 2 wk (22 + 1, 30 + 1) and 23.7 kg/m² (21.7, 26.8) respectively. Data were stored with a median frame rate of 199.0 (193.0, 199.0) per second for the apical view and 199.0 (194.0, 199.0) per second for the longitudinal view. The frame rates achieved did not differ significantly between views (p = 0.783).

Speckle tracking echocardiography and analysis of dyssynchrony and strain with TMAD

Discussion

This research is the first to compare measurements made with SLS and TMAD and to explore the effect of the view on strain and dyssynchrony values looking at the foetal heart. There were three main findings. First, we found that in the apical view, the dyssynchrony readings in TMAD were higher than those in SLS. In the longitudinal view, the differences between tools was less pronounced. Second, we found that SLS provided similar results for dyssynchrony in both views, whereas in TMAD,

Conclusions

Segmental longitudinal strain dyssynchrony measurement is feasible for foetal cardiac assessment as it is in general less dependent on the view of the cardiac axis. For strain analysis, a possible dependency of the foetal position should be considered during evaluation. The TMAD application cannot be recommended for foetal examination. The determination of standards as well as gestational age-related normal values for the application of SLS to foetal examination and the technique's role in

Acknowledgments

The authors thank all patients of the Department of Obstetrics and Gynecology, University Hospital Münster, who have taken part in this study, as well as all other participants who dedicated time and effort and thereby helped to carry out this research.

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