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Automated 4-dimensional regional myocardial strain evaluation using cardiac computed tomography

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Abstract

Evaluation of myocardial regional function is generally performed by visual “eyeballing” which is highly subjective. A robust quantifiable parameter of regional function is required to provide an objective, repeatable and comparable measure of myocardial performance. We aimed to evaluate the clinical utility of novel regional myocardial strain software from cardiac computed tomography (CT) datasets. 93 consecutive patients who had undergone retrospectively gated cardiac CT were evaluated by the software, which utilizes a finite element based tracking algorithm through the cardiac cycle. Circumferential (CS), longitudinal (LS) and radial (RS) strains were calculated for each of 16 myocardial segments and compared to a visual assessment, carried out by an experienced cardiologist on cine movies of standard “echo” views derived from the CT data. A subset of 37 cases was compared to speckle strain by echocardiography. The automated software performed successfully in 93/106 cases, with minimal human interaction. Peak CS, LS and RS all differentiated well between normal, hypokinetic and akinetic segments. Peak strains for akinetic segments were generally post-systolic, peaking at 50 ± 17% of the RR interval compared to 43 ± 9% for normokinetic segments. Using ROC analysis to test the ability to differentiate between normal and abnormal segments, the area under the curve was 0.84 ± 0.01 for CS, 0.80 ± 0.02 for RS and 0.68 ± 0.02 for LS. There was a moderate agreement with speckle strain. Automated 4D regional strain analysis of CT datasets shows a good correspondence to visual analysis and successfully differentiates between normal and abnormal segments, thus providing an objective quantifiable map of myocardial regional function.

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Abbreviations

CS:

Circumferential strain

LS:

Longitudinal strain

RS:

Radial strain

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Author information

Author notes

  1. Zvi Peled and Yechiel Lamash contributed equally to this work.

Authors and Affiliations

  1. Department of Cardiology, Rambam Health Care Campus, Haaliya Street, 31096, Haifa, Israel

    Shemy Carasso, Yoram Agmon, Diab Mutlak, Doron Aronson & Jonathan Lessick

  2. Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel

    Zvi Peled & Gil Bolotin

  3. Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel

    Shemy Carasso, Yoram Agmon, Diab Mutlak, Doron Aronson, Gil Bolotin & Jonathan Lessick

  4. Faculty of Mechanical Engineering, Technion, Israel Institute of Technology, Haifa, Israel

    Yechiel Lamash & Anath Fischer

Authors
  1. Zvi Peled
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Correspondence to Jonathan Lessick.

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The authors declare that they have no competing interests.

Ethics approval

The study was approved by the local Helsinki committee.

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The need for patient consent was waived due to a retrospective study design.

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Appendices

Appendix 1: causes for exclusion from study

In total, we evaluated 117 patients.

  • Of these 11 were ruled out in advance for the following reasons:

    • Two part of LV cut off.

    • Four AF with significant artifacts.

    • Two severe artifacts in image due to breathing or premature beats.

    • One large LV pseudoaneurysm.

    • One low contrast.

    • One very noisy.

  • Thirteen were attempted but failed for the following reasons:

    • Six the software failed to initialize (unknown cause).

    • Five rejected due to poor tracking of endocardium or epicardium despite reasonable image quality (unknown reason).

    • One failed due to high noise (sd in image 90HU).

    • One failed due to low LV contrast 150HU.

Appendix 2: The Strain Algorithm

A finite-element-based tracking algorithm [9], optimized for 4D cardiac CT data is utilized to evaluate the regional mechanical function of the LV. The tracking algorithm is based on a deformable LV model that contains both the myocardium and the blood pool regions and that accounts for the elasticity and incompressibility physiological features of the myocardium. The algorithm uses clues for the deformation and rotation of the myocardium from the endocardial edges, trabeculae and papillary muscles. The algorithm uses a deformable LV mesh (video 1) with defined myocardium and blood pool regions and labeled endocardial and epicardial surfaces to derive the deforming forces.

Appendix 3: Running the CT Strain Software

  1. 1.

    The CT data is loaded to the software.

  2. 2.

    The short axis slices at end-diastole are displayed on the screen.

  3. 3.

    The center of the LV blood pool is marked by the user in the most apical and basal slices.

  4. 4.

    The LV blood pool and myocardium are automatically segmented for all cardiac phases, creating a 3D mesh of the LV, and an initial set of endocardial and epicardial contours are marked on the short axis slices.

  5. 5.

    The user can edit the contours if required.

  6. 6.

    The software calculates regional deformations between contiguous temporal phases at the subendocardium and subepicardium.

  7. 7.

    Regional deformation vectors are displayed on the short axis contours (Fig. 1, video 2 and 3) during cine mode to enable user evaluation of the success of the algorithm, especially regarding tracking of the endocardial and epicardial contours and the degree and direction of deformation relative to visual impression.

  8. 8.

    If tracking quality is insufficient, the user has the possibility of rerunning the software after re-editing the initial endocardial and epicardial contours.

  9. 9.

    Regional strains are calculated in the circumferential, longitudinal and radial directions. Each ventricle was divided into 16 segments according to the ASE model. Segment 17 was not evaluated. Global strain was calculated as the mean of all segmental strains.

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Peled, Z., Lamash, Y., Carasso, S. et al. Automated 4-dimensional regional myocardial strain evaluation using cardiac computed tomography. Int J Cardiovasc Imaging 36, 149–159 (2020). https://doi.org/10.1007/s10554-019-01696-5

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  • DOI: https://doi.org/10.1007/s10554-019-01696-5

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