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Perioperative Assessment of Myocardial Deformation

Duncan, Andra E. MD; Alfirevic, Andrej MD; Sessler, Daniel I. MD; Popovic, Zoran B. MD; Thomas, James D. MD

doi: 10.1213/ANE.0000000000000088
Cardiovascular Anesthesiology: Review Article

Evaluation of left ventricular performance improves risk assessment and guides anesthetic decisions. However, the most common echocardiographic measure of myocardial function, the left ventricular ejection fraction (LVEF), has important limitations. LVEF is limited by subjective interpretation that reduces accuracy and reproducibility, and LVEF assesses global function without characterizing regional myocardial abnormalities. An alternative objective echocardiographic measure of myocardial function is thus needed. Myocardial deformation analysis, which performs quantitative assessment of global and regional myocardial function, may be useful for perioperative care of surgical patients. Myocardial deformation analysis evaluates left ventricular mechanics by quantifying strain and strain rate. Strain describes percent change in myocardial length in the longitudinal (from base to apex) and circumferential (encircling the short-axis of the ventricle) direction and change in thickness in the radial direction. Segmental strain describes regional myocardial function. Strain is a negative number when the ventricle shortens longitudinally or circumferentially and is positive with radial thickening. Reference values for normal longitudinal strain from a recent meta-analysis by using transthoracic echocardiography are (mean ± SD) −19.7% ± 0.4%, while radial and circumferential strain are 47.3% ± 1.9% and −23.3% ± 0.7%, respectively. The speed of myocardial deformation is also important and is characterized by strain rate. Longitudinal systolic strain rate in healthy subjects averages −1.10 ± 0.16 s−1. Assessment of myocardial deformation requires consideration of both strain (change in deformation), which correlates with LVEF, and strain rate (speed of deformation), which correlates with rate of rise of left ventricular pressure (dP/dt). Myocardial deformation analysis also evaluates ventricular relaxation, twist, and untwist, providing new and noninvasive methods to assess components of myocardial systolic and diastolic function. Myocardial deformation analysis is based on either Doppler or a non-Doppler technique, called speckle-tracking echocardiography. Myocardial deformation analysis provides quantitative measures of global and regional myocardial function for use in the perioperative care of the surgical patient. For example, coronary graft occlusion after coronary artery bypass grafting is detected by an acute reduction in strain in the affected coronary artery territory. In addition, assessment of left ventricular mechanics detects underlying myocardial pathology before abnormalities become apparent on conventional echocardiography. Certainly, patients with aortic regurgitation demonstrate reduced longitudinal strain before reduction in LVEF occurs, which allows detection of subclinical left ventricular dysfunction and predicts increased risk for heart failure and impaired myocardial function after surgical repair. In this review, we describe the principles, techniques, and clinical application of myocardial deformation analysis.

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From the Departments of Cardiothoracic Anesthesia, Outcomes Research, and Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.

Accepted for publication November 22, 2013.

Funding: Supported by NIH HL093065 (Dr. Duncan) and the Departments of Cardiothoracic Anesthesia, Outcomes Research, and Cardiovascular Medicine Cleveland Clinic, Cleveland, Ohio.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s web site.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Andra E. Duncan, MD, Department of Cardiothoracic Anesthesia, Cleveland Clinic, 9500 Euclid Ave. J4, Cleveland, OH 44195. Address e-mail to duncana@ccf.org.

© 2014 International Anesthesia Research Society