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Perioperative echocardiographic strain analysis: what anesthesiologists should know

Analyse échocardiographique périopératoire de la déformation cardiaque: ce que les anesthésiologistes devraient savoir

  • Review Article/Brief Review
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Canadian Journal of Anesthesia/Journal canadien d'anesthésie Aims and scope Submit manuscript

Abstract

Purpose

Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined.

Clinical features

This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period.

Conclusion

Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.

Résumé

Objectif

L’analyse échocardiographique de la déformation cardiaque (strain analysis) par suivi des marqueurs acoustiques (speckle-tracking) permet d’évaluer la déformation du myocarde au cours du cycle cardiaque. Ses applications cliniques se sont considérablement développées au cours des deux dernières décennies en tant que marqueur sensible du dysfonctionnement myocardique, avec des valeurs diagnostiques et pronostiques importantes. L’analyse de la déformation cardiaque a le potentiel de devenir une partie intégrante de l’examen échocardiographique périopératoire de routine pour la plupart des anesthésiologistes-échocardiographes, mais son rôle exact dans le cadre périopératoire est encore en cours de définition.

Caractéristiques cliniques

Ce rapport clinique passe en revue les principes qui sous-tendent l’analyse de la déformation cardiaque et décrit ses principales utilisations cliniques pertinentes dans le domaine de l’anesthésiologie et de la médecine périopératoire. L’analyse de la déformation cardique pour l’évaluation de la fonction ventriculaire gauche et droite ainsi que de la déformation auriculaire sont décrites. Nous discutons également du rôle potentiel de l’analyse de la déformation cardiaque pour aider à la stratification du risque périopératoire, à la sélection des patients en chirurgie cardiaque, à l’orientation du choix des moniteurs anesthésiques, et à la prise de décision clinique en période périopératoire.

Conclusion

L’analyse échocardiographique de la déformation cardiaque est un outil puissant qui permet de voir ce que l’imagerie 2D conventionnelle ne parvient parfois pas à révéler. Elle fournit souvent un aperçu physiopathologique de diverses maladies cardiaques à un stade précoce. L’analyse de la déformation cardiaque est facilement réalisable et reproductible grâce à l’utilisation de plateformes logicielles hautement automatisées. Cette technique est potentiellement prometteuse et pourrait devenir un outil précieux dans l’arsenal de l’anesthésiologiste-échocardiographe et aider à la stratification du risque périopératoire et à la prise de décision clinique.

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Authors and Affiliations

  1. Department of Anesthesiology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, QC, Canada

    Adrian Costescu MD, FRCPC & Geneviève Riendeau Beaulac MD, FRCPC

  2. Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Dominik P. Guensch MD, FEACVI, DESAIC

  3. Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada

    Jean-Simon Lalancette MD, FRCPC

  4. Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada

    Pierre Couture MD, FRCPC

  5. Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada

    André Y. Denault MD, PhD, FRCPC

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  1. Adrian Costescu MD, FRCPC
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Correspondence to André Y. Denault MD, PhD, FRCPC.

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All authors contributed to all aspects of the manuscript including conception and design, conception and drafting of the figures, as well as reviewing and editing of the manuscript draft.

Disclosures

André Y. Denault is a speaker and consultant for CAE Healthcare, Inc. and speaker for Edwards Lifesciences and Masimo. He received a research grant from Edwards Lifesciences (2019).

Funding statement

André Y. Denault is supported by the Montreal Heart Institute Foundation (Montreal, QC, Canada) and Richard I. Kaufman Endowment Fund in Anesthesia and Critical Care. The funding sources had no role in the design of the study and collection, analysis, and interpretation of data or in writing the manuscript.

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This article is accompanied by an Editorial. Please see Can J Anesth 2024; https://doi.org/10.1007/s12630-024-02714-4.

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eVideo 1A Case 1. Normal 3D LVEF calculated at 56.8% in a 79-yr-old man with unstable angina and severe triple vessel disease scheduled for coronary artery bypass graft. EDV = end-diastolic volume; ESV = end-systolic volume; LVEF = left ventricular ejection fraction; SV = stroke volume (MP4 2093 KB)

eVideo 1B Case 1. Reduced LV GLS. The Avg Endo strain from the four-chamber, two-chamber and long-axis or three-chamber views were reduced with an Avg value −8.2% (normal −20%). A2C = apical two-chamber; A3C = apical three-chamber; A4C = apical four-chamber; Avg = average; Endo = endocardial; GLS = global longitudinal strain; HR = heart rate; LV = left ventricular (MP4 1174 KB)

eVideo 2A Case 2. ME4C view of a 77-yr-old man undergoing coronary revascularization. The right-sided chambers are contracting well based on the 2D imaging. The right ventricular FAC is normal, calculated at 36%. FAC = fractional area change; ME4C = midesophageal four-chamber (MP4 3696 KB)

eVideo 2B Case 2: Reduced right ventricular free wall strain longitudinal (MP4 1893 KB)

eVideo 3 Radial strain (MP4 2085 KB)

eVideo 4A Baseline right atrial strain. A4C = apical four-chamber; ED = end-diastole; LA = left atrial; RAScd = right atrial conduit strain; RASct = right atrial contraction strain; RASr = right atrial strain reservoir (MP4 1169 KB)

eVideo 4B Right atrial strain following inhaled prostacyclin and inhaled milrinone. ED = end-diastole; RAScd = right atrial conduit strain; RASct = right atrial contraction strain; RASr = right atrial strain reservoir (MP4 1222 KB)

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Costescu, A., Riendeau Beaulac, G., Guensch, D.P. et al. Perioperative echocardiographic strain analysis: what anesthesiologists should know. Can J Anesth/J Can Anesth 71, 650–670 (2024). https://doi.org/10.1007/s12630-024-02713-5

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