Edwin S.

Tucay, MD FPSE FAsCC

Noninvasive Cardiac Laboratory
Philippine Heart Center

INA Echo Pre convention

19 April 2018
Cardiotoxicity Exists
FORMS OF CARDIOVASCULAR CHEMOTOXICITY

CTRCD
Pulmonary
Hypertension

PAD and Stroke

Screening Tool for Cardiotoxicity
• Detect sign of injury before LV impairment/symptoms
• Highly predictive of clinically significant outcome
• Guide in therapy

• Reproducible
• Widely available
• Noninvasive
• SAFE
Chemotherapy Related Cardiac Dysfunction
Definition
• Decline in LVEF from baseline of > 10 %
• To a value < 53% (normal reference value for 2DE)
• Confirmed by repeat imaging 2-3 weeks later after the
first decline
• Symptomatic vs. Asymptomatic
• Reversible vs. Irreversible
• Type 1 vs. Type 2
Plana J. J Am Soc Echocardiogr 2014;27:911
Classification Based On Reversibility
• Reversible: to within 5 percentage points of baseline EF
• Partially reversible: improved by >/=10 percentage points
from the nadir but remaining >5 percentage points below
baseline
• Irreversible: improved by <10 percentage points from the
nadir and remaining >5 percentage points below baseline
• Indeterminate: patient not available for re-evaluation

Plana J. J Am Soc Echocardiogr 2014;27:911

Chemotherapy Related Cardiac Dysfunction and
Heart Failure - CTRCD
• Most concerning CV
complications of
chemotherapy.
• Relatively common and cause
an increase in morbidity and
mortality.
• More is unknown than known
in the field.
MONITORING PARAMETERS FOR
CRTD
• EJECTION FRACTION
• GLOBAL LONGITUDINAL STRAIN
• TROPONIN
 DIAGNOSTIC TOOLS

ESC CPG POSITION PAPER 2016 European Heart Journal (2016) 37, 2768–2801
 EJECTION FRACTION
VISUAL ESTIMATE
LIMITATIONS
• Subjective
• Experience dependent
• Lack of standardization
• Large inter- and
intraobserver variability
 EJECTION FRACTION
LINEAR MEASUREMENT

LIMITATION:
Large inter- and intraobserver variability
 EJECTION FRACTION
BIPLANE SUMMATION OF DISC METHOD
ADVANTAGES :
• Corrects for shape distortions
• Less geometrical assumptions
compared with linear dimensions
LIMITATIONS
• Apex frequently foreshortened
• Endocardial dropout
• Blind to shape distortions not
visualized in the apical two- and
four-chamber planes
 EJECTION FRACTION
2D BIPLANCE IMAGING : ISSUES

• Geometry dependence
• Foreshortening
• Tracing variability
 EJECTION FRACTION
• LVEF is a robust predictor of WHY?
cardiac outcomes in the 1. LV geometric assumptions
general population, BUT it has 2. Inadequate visualization of
low sensitivity for the detection the true LV apex
of small changes in LV function. 3. lack of consideration of
• Upper limit of the 95% confidence subtle regional wall motion
interval for longitudinal variability abnormalities
of 2D LVEF measurement was 4. inherent variability of
9.8% (range, 9.0%–10.8%) measurement.
Otterstad JE. Accuracy and reproducibility of biplane two-dimensional echocardiographic
measurements of left ventricular dimensions and function. Eur Heart J 1997;18:507-13
Thavendiranathan P. Reproducibility of echocardiographic techniques for sequential assessment of left ventricular
ejection fraction and volumes: application to patients undergoing cancer chemotherapy. J Am Coll Cardiol
2013;61:77-84.
EJECTION FRACTION

J Am Coll Cardiol 2013;61:77–84

 Reproducibility of Echocardiographic Techniques for
Sequential Assessment of Left Ventricular Ejection Fraction
and Volumes
• Objective: to identify the best echocardiographic method for
sequential quantification of LVEF and volumes in patients undergoing
cancer chemotherapy.
• P- 56 patients (all female, 54 =/- 13 years of age); stable global
longitudinal strain (GLS) at up to 5 time points (baseline, 3, 6, 9,
and 12 months); changes in EF were considered to reflect
temporal variability of measurements rather than cardiotoxicity.
• I- EF and volumes were measured with 2D-biplane Simpson’s
method, 2D triplane, and 3-dimensional echocardiography
(3DE), Inter-, intra-,and test-retest variability were assessed in a
subgroup
J Am Coll Cardiol 2013;61:77–84)
 Temporal Variability of EF
Temporal variability is defined as the standard error of measurement (SEM) and 95%
confidence intervals (CIs) for each technique for the entire follow-up period.

Noncontrast 3D
had significantly
lower temporal
variability than all
other methods
for Ejection
Fraction (p 0.01)

J Am Coll Cardiol 2013;61:77–84

 Temporal Variability in EDV and ESV

Noncontrast 3D had significantly lower temporal

variability than all other methods for EDV and ESV

J Am Coll Cardiol 2013;61:77–84

RESULT
• Noncontrast 3D EF, end-diastolic volume, and endsystolic
volume had significantly lower temporal variability than all
other methods.
• Our data suggest that a temporal variability in EF of 0.06
might occur with noncontrast 3DE due to physiological
differences and measurement variability, whereas this might
be >0.10 with 2D methods.
• Overall, 3DE also had the best intra- and inter-observer as
well as test-retest variability.

J Am Coll Cardiol 2013;61:77–84)

 EJECTION FRACTION
• 3D ECHO 3DE Advantages :
- More accurate than 2D
- No geometric assumption
- Avoid foreshortening
- Semi/Automated border detection
Disadvantages:
- Dependent on image quality
- Experience with software
- Availability
3D LVEF more accurate that 2D LVEF

Mor-Avi V. Circulation 2004;110:1814

Sources of Error

Mor-Avi V, Lang RM et al., JACC Imaging

2008 ;1(4):413-423.
Improved Image Quality and Automaticity
4D LV ANALYSIS
 3D Volumes Validated with MRI
• (r²>0.85)
EDV, ESV, EF

Excellent correlation
(r²>0.85)

• Ahmad M, et al. J Am Coll Cardiol 2001; 37:1303-9

• Qin JX, et al. J Am Coll Cardiol 2000; 36:900-7
• Arai K, et al. Am J Cardiol 2004; 94:552-8
• Jenkins C, et al. J Am Coll Cardiol 2004; 44:878-86
• Kuhl HP, et al. J Am Coll Cardiol 2004; 43:2083-90.
• Gutierrez-Chico JL, et al. Am J Cardiol 2005; 95:809-13
STRAIN IMAGING IN HEART FAILURE

Shah AM. Eur Heart J 2012;33:1716-7

Plana et al. J Am Soc Echocardiogr 2014;27:911-39
Plana et al. J Am Soc Echocardiogr 2014;27:911-39
Early detection of subclinical LV dysfunction using
GLS.
LVEF fails to detect subtle alterations
in LV function.>>> too late to detect
and reverse the course of the
myopathy.
 DIASTOLIC fUNCTION
The use of Doppler-derived diastolic indices is not useful in the early
detection of CTRCD because of their inability to predict subsequent HF
 MESSAGE
• Echocardiography is the method of choice for the
evaluation of patients before, during, and after cancer
therapy.
• Accurate calculation of LVEF should be done with the best
method available (ideally 3DE).
• When using 2DE, the modified biplane Simpson’s technique
is the method of choice.
• LVEF assessed by 2DE often fails to detect small changes in
LV contractility.
Expert Consensus for Multimodality Imaging Evaluation of Adult Patients during and after Cancer Therapy
J Am Soc Echocardiogr 2014;27:911-39
MESSAGE

•Subclinical Chemotherapy related cardiac

dysfunction could be detected with reduced
GLS (>15% from baseline)
MESSAGE

•Do we need 3D?

YES WHEN IT IS AVAILABLE