Three-dimensional deformation imaging to detect myocardial scar
Authors: Da Silva Mota R , Theodoropoulos K C , Marvaki A , Queiros S , Dhooge J , Masoero G , Pagnano G , Huang M , Dancy L , Sado D , Shah A , Murgatroyd F D , Papachristidis A 
Published: October 2024

Abstract

Introduction
Myocardial scar or fibrosis has significant implications in patient management and prognosis. Currently, cardiovascular magnetic resonance (CMR) is the reference technique for detection and quantification of scar though other imaging modalities have been proven to be useful as well.

Purpose
This study aims to investigate the usefulness of 3D strain echocardiography to identify myocardial scar in patients with ischaemic and non-ischaemic myocardial fibrosis using late gadolinium enhancement (LGE) CMR as a reference.

Methods
149 individuals with ischaemic (89), non-ischaemic scar (26) and no scar (34) on LGE CMR underwent 3D transthoracic echocardiography. The 3D data sets were processed with the 4D LV analysis tool by TOMTEC Imaging Systems GmbH, Germany. The longitudinal, circumferential, radial, and principal tangential strain were calculated. Using a 16 LV-segment model the areas of LGE were assessed on CMR images, and a correlation between 3D strain values and LGE was investigated.

Results
A multivariate binary logistic regression model was built with the conditional backward elimination method using LGE as the dependent variable. The predictors made a significant contribution to the model (Wald test: 49.985, p&lt;0.001). The Cox & Snell R-square was 0.141, and Nagelkerke R-square was 0.232, suggesting that the final model explains 14.1% or 23.2% of LGE variability. By logistic regression analysis, less negative peak principal tangential strain (P-PTS), peak circumferential strain (P-SC), and end-systolic circumferential strain (ES-CS) increased the odds, whereas increased peak radial strain (P-RS) decreased the likelihood of LGE (Table 1).
The LGE extent was calculated as the average LGE transmurality of all 16 segments and was used as the dependent variable in linear regression models. The LGE extent was significantly correlated with all strain indices (Table 2). By stepwise linear regression analysis, P-PTS (B=0.029, 95%CI:0.019-0.040, P&lt;0.001) outperformed the remaining strain variables in terms of linear association with LGE extent.
Association between strain indices and the presence or absence of myocardial fibrosis in each of the 16 segments was tested by point biserial correlation (Table 3). PTS and CS indices were associated with myocardial fibrosis in 10/16 segments; RS indices were associated with LGE in 9/16 segments, and LS was not related to the presence of LGE in 15/16 segments. Septal (basal-mid-apical) and mid/apical anterior and inferior segmental strain showed more consistent associations with corresponding myocardial fibrosis.

Conclusion
3D strain echocardiography is a promising and easily accessible technique, that can be used to identify areas of myocardial scar as it correlates well with LGE in many LV segments. Echocardiography is a bedside and widely available technique, and it could be used in patients with contraindications or no access to CMR or myocardial perfusion scan.Table 3