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2D and 3D Echo-Derived Indices of LV Function and Shape
Study Questions:
What is the relative prognostic value of two- (2DE) and three- (3DE) dimensional echocardiography for assessment of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS)?
Methods:
A total of 416 patients who had undergone both 2DE and 3DE as inpatients were retrospectively evaluated for multiple echocardiographic parameters and outcomes. Patients were studied between 2006 and 2010 and all had high-quality imaging studies. Patients with atrial fibrillation were excluded. Data for overall and cardiac mortality were collected through 2016. LVEF and GLS were separately analyzed from 2DE and 3DE images. 3DE images were also used to obtain information regarding LV sphericity and conicity and regional curvature of the anterior, septal, inferior, and lateral walls.
Results:
Patient age was 60 ± 18 years. Hypertension was recorded in 69%, diabetes in 26%, coronary artery disease in 44%, ischemic cardiomyopathy in 25%, nonischemic cardiomyopathy in 21%, and pulmonary hypertension in 26%. Over a follow-up of 5 ± 3 years, 208 of 416 patients died (50%), 94 (23%) of noncardiovascular causes. Of the remaining 322 patients, 114 died of cardiovascular causes (35%). Cox regression analysis identified age and body surface area as well as all four indices of LV function and regional septal and inferior wall curvature as independently associated with increased risk of cardiovascular mortality. GLS either with 2DE or 3DE was superior to LVEF for mortality prediction. LVEF by 2DE was the weakest predictor of the four functional indices. A decrease of 1% in GLS was associated with an 11.3% increase in cardiovascular mortality. When each parameter of LV function was stratified by tertiles, there was a statistically significant separation of the tertiles of GLS. Both 2DE and 3DE EF separated only the lowest strata as statistically significant with respect to outcome.
Conclusions:
GLS determined by either 2DE or 3DE is superior to EF for predicting cardiovascular mortality. Ventricular shape indices provide incremental information as well.
Perspective:
This rather large retrospective single-center study demonstrates that parameters of LV function and deformation (GLS) are predictive of outcome when employed in patients undergoing echocardiography at the time of an index hospitalization. All four parameters including EF and GLS by either 2DE or 3DE were predictive; however, GLS was superior to EF, and 3DE LVEF was superior to 2DE.
GLS has been evaluated for its prognostic value in a number of other situations including ischemic and nonischemic cardiomyopathy, cardiac amyloid, and other isolated entities. This study employed the same techniques in a broad range of patients initially evaluated at the time of an inpatient hospitalization. While the prevalence of comorbidities such as hypertension and diabetes are outlined, and there was a substantial proportion of patients with established cardiovascular disease, the indication for the initial hospitalization was not stated and no information is provided regarding specific mechanisms of death. Overall this study nicely supports the smaller more targeted application of GLS for prognostication in specific cardiac disease and broadens its potential utilization to (presumably) a wider patient population.
Keywords: Cardiomyopathies, Coronary Artery Disease, Diabetes Mellitus, Diagnostic Imaging, Echocardiography, Echocardiography, Three-Dimensional, Hypertension, Hypertension, Pulmonary, Inpatients, Myocardial Ischemia, Stroke Volume, Ventricular Function, Left
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