Developments in echocardiographic techniques for the evaluation of ventricular function in children

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  • Archives of Cardiovascular Disease (2010) 103, 603614

    REVIEW

    Developments in echocardiographic techniques forthe evaluation of ventricular function in children

    Lvaluation de la fonction ventriculaire chez lenfantnouvelles techniqueschocardiographiques

    Andreea Dragulescu, Luc L. Mertens

    KEYWOEchocarTissue DSpeckleVentricu

    Abbreviatduring isovoDoppler.

    CorrespE-mail a

    1875-2136/doi:10.1016Department of Cardiology, Hospital for Sick Children, 555 University Avenue,Toronto, ON, M5G 1X8 Canada

    Received 9 August 2010; received in revised form 7 September 2010; accepted 9 September2010Available online 25 November 2010

    RDSdiography;oppler;tracking;lar function

    Summary Echocardiography is a very important tool for the diagnosis and follow-up ofchildren with congenital and acquired heart disease. One of the challenges that remains inpaediatric heart disease is the assessment of systolic and diastolic function in children, asthis is inuenced by growth, morphology and loading conditions. New echocardiographic tech-niques, such as tissue Doppler, deformation imaging and three-dimensional echocardiography,have great potential application in this eld. They may provide new insights into the inuence ofgrowth, morphology and loading on cardiac mechanics, and could become useful clinical tools.In this review, we discuss the potential use and limitations of these new echocardiographictechniques in paediatric and congenital heart disease. 2010 Elsevier Masson SAS. All rights reserved.

    ions: 2D, two-dimensional; 3D, three-dimensional; ASD, atrial septal defect; EF, ejection fraction; IVA, myocardial accelerationlumic contraction; LV, left ventricle/ventricular; MRI, magnetic resonance imaging; RV, right ventricle/ventricular; TD, tissue

    onding author. Fax: +416 813 5857.ddresses: luc.mertens@sickkids.ca, luc.mertens@rogers.com (L.L. Mertens).

    $ see front matter 2010 Elsevier Masson SAS. All rights reserved./j.acvd.2010.09.004

  • 604 A. Dragulescu, L.L. Mertens

    MOTS CLSchocardiographie ;Doppler tissulaire ;Speckle tracking ;Fonctionventricu

    Rsum Lchocardiographie est un outil trs important dans le diagnostic et le suivi despatients avec cardiopathies congnitales et acquises. Lvaluation de la fonction systolique etdiastolique chez lenfant reste un problme due aux inuences lies la croissance, la mor-phologie ventriculaire et les conditions de charge. Les nouvelles techniques chographiques

    ie decadreans dions

    s rs

    Introduc

    Echocardiovasive techdisease inraphy alloand haemoare referrephy only.morphologof diagnostechocardioraphy labothat can be

    Cardiacmain imag(pulmonaryerly by echhas becomhaemodynaassessmentchallengesavailabilitydiastolic vein echocarthe morphheart defevariables,of growthloading conolated to pRV and thement is the

    Duringtechniquesdetailed ahave potenthe assesspatients. Tstrain imagmyocardialtry indepeinsight intoance in treechocardiovolumetric

    tione tewill

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    alysen ufor itquenctiohownion oestigousinsufvantthesliedouralten coies,al molour20iesaineis veovemimporatesn bents dlairecomme le Doppler tissulaire, limagertions potentielles importantes dans ceconcernant la mcanique cardiaque dcette revue, on prsente les indicatchographiques chez lenfant. 2010 Elsevier Masson SAS. Tous droit

    tion

    graphy has become the most important nonin-nique for the diagnosis and follow-up of heartchildren. Cross-sectional Doppler echocardiog-ws a detailed description of cardiac anatomydynamics. Currently, the majority of childrend for cardiac surgery based on echocardiogra-The diagnostic accuracy for describing cardiacy is extremely high, with a reported incidenceic errors of only 87 errors in more than 50,660grams in an established paediatric echocardiog-ratory [1], demonstrating the level of accuracyreached.MRI and cardiac computed tomography are theing techniques used for extracardiac anatomyarteries and aortic arch) if not visualized prop-

    ocardiography. Diagnostic cardiac catheterizatione more obsolete and is restricted mainly tomic assessment in more complex lesions and theof pulmonary vascular resistance. One of the

    remaining for paediatric echocardiography is theof good techniques for assessing systolic and

    ntricular function. Most functional variables useddiography were developed for the assessment ofologically normal LV. The diversity of congenitalcts complicates the interpretation of functionalbecause of the anatomical variability, the effecton myocardial function and the differences inditions. For the LV, adult techniques are extrap-aediatrics often without good validation. For thesingle ventricle, qualitative subjective assess-technique used routinely in most laboratories.

    the past decade, different echocardiographichave been developed that allow a more

    calculaof thesraphy

    Tissu

    The anhas be1990stechnidial fuwere sinducties invin variaorticThe adis thatbe app

    Colas anties. Ivelocitregionwhy cage 15velocitbe obtwhichdial mand isheartties casegmenalysis of cardiac function. These techniquestial application in and substantial benet for

    ment of ventricular dysfunction in paediatricD echocardiography and speckle-tracking-baseding provide direct quantitative information aboutmotion and deformation, which is more geome-

    ndent than measurement of EF; they give moremyocardial mechanics and could provide guid-atment and response to therapies. Current 3Dgraphic techniques enable the acquisition of fulldatasets, which can be analysed ofine for the

    comparisonevents betsame cardevaluation.

    The limits angle dmensionalcircumfereentire heameasuremesegments;dformation et lchographie 3D ont des applica-. Elles peuvent apporter des nouvelles informationsiffrentes conditions pendant la croissance. Danspotentielles et les limitations de ces techniques

    ervs.

    of ventricular volumes, mass and EF. The impactchnologies on paediatric functional echocardiog-be discussed in the current review.

    oppler velocities

    is of pulsed TD signals to interpret cardiac motionsed since the early 1960s [2]. It took until theto be recognized as a potentially useful clinical

    for the assessment of global and regional myocar-n [3]. In a pig ischaemic model, tissue velocitiesto change very quickly and consistently after the

    f ischaemia [4]. Several subsequent clinical stud-ated the use of regional myocardial velocities

    adult diseases, such as ischaemic heart disease,ciency and hypertrophic cardiomyopathy [4,5].age for paediatric and congenital heart diseasee techniques are geometry independent and canto any chamber morphology.TD imaging was introduced in the early 1990srnative technique for measuring tissue veloci-ntrast to pulsed Doppler, which measures peakit uses autocorrelation techniques to measure

    ean velocities. This technical difference explainsTD-derived myocardial velocities are on aver-

    % lower than pulsed wave-derived myocardial[6] (Fig. 1A and B). Very high frame rates cand by image optimization (> 250 frames/second),ry useful for the analysis of short-lived myocar-ents, such as during the isovolumetric periods,rtant for adequate temporal resolution at higher. An advantage of colour TD is that tissue veloci-recorded simultaneously in different myocardialuring the same cardiac cycle. This allows the

    of regional wall motion and timing of cardiac

    ween different myocardial segments during theiac cycle, which is important for dyssynchrony

    itations of TD velocity imaging are related toependency (Doppler technique) and the unidi-assessment of myocardial motion (longitudinal,ntial or radial). Global cardiac translation of thert during the cardiac cycle will also affect thent and tethering effects between myocardialif a dysfunctional segment is moved by a healthy

  • New echocardiographic techniques in children 605

    Figure 1.basal segmeof the systeDoppler-der

    segment, tregional dy

    Clinicalchildren

    One of thinto paedimust be vestablishmgroups. Noby differenthat tissueet al. incluTD velocitiespeciallyindicatingindependethis methowhere theApart froming conditipreload chTissue Doppler imaging in a patient after Fontan completion for hypont of the lateral wall with reduced systolic and diastolic velocities. (B)mic ventricle. The absolute value for each segment is lower than the cived strain and strain rate for the same ventricle with abnormal curves f

    his can also contribute to regional motion maskingsfunction.

    application of tissue velocities in

    e challenges when introducing new techniquesatric echocardiography is that the methodologyalidated rst for paediatric use, especially theent of normal values for different paediatric agermal paediatric TD data have been publishedt groups [79]. In these studies, it was shownvelocities vary with age and heart rate. Eidemded 325 children and showed that pulsed-wavees also correlate with cardiac growth variables,the LV end-diastolic dimension and LV mass [7],that tissue velocities are not entirely geometrynt. This has important implications when applyingdology to children with congenital heart disease,re is a large variability in ventricular geometry.

    the inuence of geometry, changes in load-ons also affect TD velocity measurements. Acuteanges clearly affect tissue velocities [10], while

    this is lesswhere theStudies in ca ventriculdocumentewith normaload resultadaptationin decreaseprocess. Ingitudinal vsegments owall. This csubendocartic stenosiswas shownLV and wareplacemenwith aorticreduced mMore reseafor adaptaferent in th

    As congdata on rigplastic left heart syndrome. (A) Pulse Doppler in theSimultaneous tissue Doppler velocities in six segmentsorresponding pulse Doppler velocity. (C and D) Tissueor the septal segments (not involved in ej