European Heart Journal Cardiovascular Imaging (2012) 13, 152158 doi:10.

1093/ejechocard/jer163

CLINICAL/ORIGINAL PAPERS

Relationship of contrast-enhanced magnetic resonance imaging-derived intramural scar distribution and speckle tracking echocardiography-derived left ventricular two-dimensional strains
Mayank M. Kansal 1, Prasad M. Panse 2, Haruhiko Abe 3, Giuseppe Caracciolo 3, Susan Wilansky 3, A. Jamil Tajik 4, Bijoy K. Khandheria 4, and Partho P. Sengupta 3*
1 Division of Cardiovascular Diseases, University of Illinois at Chicago, Chicago, IL, USA; 2Department of Radiology, Mayo Clinic, Scottsdale, AZ, USA; 3Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ, USA; and 4Division of Cardiology, Aurora St. Lukes Medical Center, Milwaukee, WI, USA

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Received 16 August 2011; accepted after revision 18 August 2011; online publish-ahead-of-print 1 October 2011

Aims

Information is limited regarding the functional correlates of intramural scar burden in myopathic hearts. We aimed to explore the use of speckle tracking echocardiography selectively at three intramural locations, to investigate the variance in cardiac strains and their relationship to contrast-enhanced magnetic resonance imaging-derived scar distribution and global left ventricular systolic function. ..................................................................................................................................................................................... Methods Fifty-nine patients with evidence of myocardial brosis on contrast-enhanced magnetic resonance imaging and 18 healthy subjects underwent speckle tracking echocardiography for measuring subendocardial, midmyocardial, and and results subepicardial strains in longitudinal, circumferential, and radial directions. Patients were divided into three categories of scar distribution: Group A, endocardial and midmyocardial; Group B, midmyocardial and epicardial; and Group C, transmural. When these patients were compared with 18 healthy control subjects, longitudinal left ventricular deformation was attenuated equally for all three groups, whereas circumferential strain was relatively well preserved. On multivariate analysis, circumferential strain and scar burden were independent determinants of left ventricular ejection fraction (R 2 0.57; P 0.003 for strain burden and P 0.01 for scar burden). ..................................................................................................................................................................................... Conclusion Longitudinal strains are attenuated independent of myocardial scar location. This alteration in left ventricular deformation is associated with circumferential mechanics becoming a key determinant of global left ventricular pump function in myopathic hearts.

----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Cardiomyopathies Myocardial function Myocardial scar Speckle tracking echocardiography

Introduction
Structural delineation of myocardial scar burden by contrast-enhanced magnetic resonance imaging provides prognostic information.1 3 However, information is limited about the relation between myocardial scar distribution and the layerdependent multidimensional mechanics of the left ventricle.4,5

The recently introduced technique of two-dimensional speckle tracking echocardiography delineates movement of natural acoustic markers in the myocardial wall. Preliminary reports are available regarding the applicability of speckle tracking echocardiography for assessing the mechanics selectively within the three layers of the left ventricle.6 8 The present investigation similarly explored the use of speckle tracking echocardiography selectively at three

Present address. Cardiovascular Division, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY, USA.

* Corresponding author. Tel: +1-212-659-9121; Fax: +1-212-659-9033. Email: partho.sengupta@mssm.edu Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2011. For permissions please email: journals.permissions@oup.com

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while still determining two-dimensional motion. A preliminary onedimensional tracking of the mitral annulus is also used in the analysis of long-axis views. The software requires the operator to manually trace the endocardium and automatically places an epicardial trace. After analysis of the endocardial and epicardial strain values, the epicardial trace is adjusted by moving the entire trace to the midmyocardial position without readjusting individual points, to analyse midmyocardial strain. To ensure spatial coherence in the trace, the software uses a three-point median lter and a three-point Gaussian lter (of weights 0.25, 0.5, and 0.25) for transmural displacement computed at neighbouring points. This software algorithm allows pixel resolution sufcient to resolve the acquired data between the endocardial, midmyocardial, and epicardial contours. We measured longitudinal systolic strain and circumferential strain from subendocardial, midmyocardial, and subepicardial regions and radial strain from full thickness of the myocardium and between subendocardial and midmyocardial layers (endocardial radial strain), respectively. Parameters dening left ventricular mechanics were averaged from 12 segments in the two short-axis views (base and midventricle) and 18 segments in the three apical long-axis views of the left ventricle. The longitudinal strain data obtained from the 18 segments were recalculated to 16 segments by combining the apical anterolateral and inferolateral segments into an apical lateral segment and the apical anteroseptal and inferoseptal segments into an apical septal segment. Combining these apical segments allowed consistency with matching the segmental speckle tracking echocardiography data to the 16 magnetic resonance imaging segments (no apical cap). Assessment of left ventricular strain was regarded as suboptimal when speckle tracking could not be obtained in at least four of the six myocardial segments in each apical or short-axis view. The 2-Dimensional Cardiac Performance Analysis software is an extended version of Velocity Vector Imaging (syngo VVI; Siemens Medical Solutions), which previously has been validated with sonomicrometry and demonstrated good correlations for measuring circumferential strain and longitudinal strain (r 0.88 and r 0.83, respectively; P , 0.0001).9

intramural locations to investigate the variance in cardiac strains and their relationship to contrast-enhanced magnetic resonance imaging-derived scar distribution and global left ventricular systolic function. We hypothesized that left ventricular strains at varying transmural depths in myopathic hearts are related to the transmural distribution of left ventricular segmental scar burden.

Methods
Study population
The study was approved by the Mayo Clinic Institutional Review Board. To identify patients who have myocardial brosis, we reviewed electronic data of 229 consecutive patients between February 2005 and November 2009 who underwent cardiac magnetic resonance imaging for evaluation of suspected pathologic changes. In this group, 33 studies did not have contrast agent administered and were excluded. Of the other 196 contrast-enhanced magnetic resonance imaging studies, 131 did not show late gadolinium enhancement, and 6 patients with positive late gadolinium enhancement did not undergo transthoracic echocardiography. The remaining 59 patients formed the study group and, along with 18 age-matched control subjects, underwent three-layered speckle tracking echocardiography. Control subjects were identied from a previously stored DICOM database of images from normal studies collected at our institution. Non-ischaemic aetiology was the underlying diagnosis of 42 patients: hypertrophic cardiomyopathy, 32 (54%); idiopathic non-ischaemic cardiomyopathy, 5 (8%); amyloidosis, 3 (5%); sarcoidosis, 1 (2%); and radiation-induced cardiomyopathy, 1 (2%). Ischaemic aetiology was present in 17 patients (29%). Baseline clinical variables, echocardiography-Doppler variables, and variations in global normal strains were obtained from each myocardial layer and related to the extent of hyperenhancement and global left ventricular ejection fraction quantied on contrast-enhanced magnetic resonance imaging.

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Echocardiography and speckle tracking echocardiography

Clinically indicated echocardiographic examinations were acquired on two commercially available ultrasound systems (Acuson Sequoia, Siemens Medical Solutions, Mountain View, CA, USA and Vivid 7, GE Healthcare, Milwaukee, WI, USA). Echocardiographic images were obtained according to the standard method recommended by the American Society of Echocardiography. Ultrasonographic settings were adjusted to optimize endocardial denition. Parasternal shortaxis views at the base and midventricle, as well as three apical long-axis views (i.e. two-, three-, and four-chamber views) were acquired for three cardiac cycles. Doppler and two-dimensional data were collected, including wall thickness, left ventricular systolic and diastolic dimensions, mitral inow characteristics, and septal and lateral wall tissue Doppler. The echocardiographic images were stored in digital cineloop format (Prosolv CardioVascular Solutions, Indianapolis, IN, USA) for ofine analysis by vendor-customized 2-Dimensional Cardiac Performance Analysis software (TomTec Imaging Systems, Munich, Germany) that uses speckle tracking echocardiography technology for angle-independent measures of two-dimensional strain. This software tracks local features by nding the motion that maximizes the local frame-to-frame correlations subject to the constraint that the motion be periodic with the period equal to the R R interval for that particular heart beat. Iterative one-dimensional correlations are applied in orthogonal directions to improve the speed of the algorithm

Contrast-enhanced magnetic resonance imaging

Contrast-enhanced magnetic resonance imaging was performed in all study subjects on a commercially available 1.5 T whole-body magnetic resonance scanner. Median time difference between echocardiography and contrast-enhanced magnetic resonance imaging acquisition was 12 days (range, 0 132 days). Images were obtained at end-expiration 10 min after intravenous injection of gadolinium diethylenetriamine pentaacetic acid (0.1 mmol/kg; Magnevist; Schering AG, Berlin, Germany). Late enhancement was visualized with three-dimensional inversion recovery turbo gradient-echocardiographic sequence with inversion time optimized to null the myocardium. Positive hyperenhancement was visually dened as .2 standard deviations of the signal intensity of the non-enhanced myocardium. The left ventricular myocardium was divided into four equal layers as previously dened10 and was segmented according to a 16-segment model (no apical cap). Myocardial scar involvement as a percentage distance from the subendocardial surface was determined by two observers (M.M.K. and P.M.P.). Scar location was classied as follows: subendocardial, the inner 25%; subepicardial, the outer 25%; and midmyocardial, the middle two zones. From this scar distribution, patients with non-transmural involvement were divided into two groupssubendocardial involvement with or without midmyocardial hyperenhancement (Group A) and subepicardial hyperenhancement with or without midmyocardial involvement (Group B). However, patients with hyperenhancement in all three

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regions were referred to as transmural scarring (Group C). In the study population, the non-ischaemic etiologic factors showed more epicardial and midmyocardial enhancement in 23 of 42 patients; the ischaemic etiologic factors showed the typical endocardial advancing to epicardial (transmural) distribution for late gadolinium enhancement in 16 of 17 patients. The arithmetic sum of the number of myocardial segments, from 1 to 16 segments, demonstrating late gadolinium enhancement scar was calculated as the total scar score.

M.M. Kansal et al.

their mean for each patient and then averaged for 18 randomly selected patients. Bonferroni correction was applied to adjust for multiple comparisons. Statistical signicance for each analysis was dened as a P-value of ,0.05.

Results
The three patient groups were comparable in baseline clinical data and two-dimensional and Doppler echocardiographic characteristics (Table 1). Speckle tracking echocardiography was feasible in 1518 (90%) of 1690 segments available for analysis in the three patient groups. It could be performed for all left ventricular segments in all views in the control patients. The speckle tracking echocardiography values for each patient group and the myocardial layers of two-dimensional strain echocardiography are shown in Table 2. In comparison with control subjects, subendocardial, midmyocardial, and subepicardial longitudinal strain was markedly attenuated in all three groups: 212.9% (4.3%), 212.6% (4.0%), and 210.5% (2.7%) for Groups A, B, and C, respectively, vs. 216.8% (3.3%) for control subjects at the subendocardial layer (P , 0.001 for each). An example of magnetic resonance imaging scar, endocardial longitudinal and circumferential strain, and full-thickness radial strain in each group is shown in Figure 1. In comparison with control subjects, circumferential strain obtained from the midmyocardial and epicardial layers was attenuated only in Group C (P , 0.05 for both) and was preserved in the

Statistical analysis
Statistical analysis was performed with Excel software version 11 (Microsoft Corp., Seattle, WA, USA) and MedCalc for Windows version 9.5.0.0 (MedCalc Software, Mariakerke, Belgium). All continuous data were reported as mean (SD), and categorical data as number and percentage. Wilcoxon rank sum, x2, and t-tests were used for paired comparisons between patient and control groups. Kruskal Wallis and Mann Whitney tests were used for comparison of continuous variables among the patient groups. Univariate relationships between clinical data, echocardiographic and magnetic resonance imaging measurements, global and segmental myocardial strain measurements, and myocardial scar score were assessed with Pearson product moment correlation and linear regression. Independent predictors of ejection fraction and transmural scar were assessed with multiple linear and logistic regression analyses, respectively. Receiver-operating characteristic analysis was performed to determine the optimal cut-off values for strain parameters in differentiating transmural from non-transmural scar. Interobserver and intraobserver variability of endocardial and epicardial layer-based measurements was calculated as the absolute difference of the corresponding pair of repeated measurements in per cent of

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Table 1

Clinical, two-dimensional, and Doppler characteristics in the study groups

Group A (n 5 13) 59 (13) 11 (85) 3 (23) 7 (54) 6 (46) 7 (54) 6 (46) 4 (31) 3 (23) 236 (224) 14.8 (6.2) 11.8 (2.5) 38 (15) 187 (68) 56.6 (18.6) 0.7 (0.3) 1.3 (0.5) 0.06 (0.02) 11.3 (8.4) Group B (n 5 24) 57 (15) 17 (71) 1 (4) 11 (46) 1 (4) 23 (96) 10 (42) 10 (42) 4 (17) 408 (817) 18.8 (6.0) 14.5 (4.4) 27 (5) 149 (52) 65.8 (7.6) 0.8 (0.2) 1.2 (0.5) 0.06 (0.03) 14.6 (8.7) Group C (n 5 22) 55 (17) 16 (73) 6 (27) 8 (36) 10 (45) 12 (55) 9 (41) 10 (45) 3 (14) 202 (192) 15.8 (5.7) 12.6 (2.8) 32 (11) 197 (76) 50.6 (17.0) 0.9 (0.3) 1.4 (0.6) 0.06 (0.02) 12.7 (6.4) P-value 0.38 0.41 0.13 0.34 0.03 0.008 0.82 0.82 0.82 0.64 0.32 0.38 0.10 0.051 0.72 0.20 0.67 0.53 0.48

Characteristica Age, years Male sex

...............................................................................................................................................................................

Diabetes mellitus Hypertension Etiologic factors ICM NICM NYHA class I II III BNP, ng/L Septal wall thickness, mm Posterior wall thickness, mm End-systolic diameter, mm End-diastolic volume, mL Ejection fraction, % E wave velocity, m/s E/A ratio e -medial, m/s E/e

BNP, B-type natriuretic peptide; ICM, ischaemic cardiomyopathy; NICM, non-ischaemic cardiomyopathy; NYHA, New York Heart Association. a Continuous data are expressed as value (SD); categorical data are expressed as number and percentage of patients.

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Table 2

Comparison of longitudinal, circumferential, and radial strain in study Groups and control group
Group A (n 5 13) Group B (n 5 24) Group C (n 5 22) P-valueb Control group (n 5 18)

Strain characteristics, %a Longitudinal Endocardial layer Midmyocardial layer Epicardial layer P-value Circumferential Endocardial layer Midmyocardial layer Epicardial layer P-valueb Radial Full thickness Subendocardial layer P-valued
a

...............................................................................................................................................................................
212.88 (4.32) 212.98 (4.33) 210.76 (3.63) 0.30 219.97 (8.37) 212.35 (4.55) 26.97 (2.94) ,0.001 21.03 (8.24) 24.93 (13.51) 0.52 212.58 (4.04) 212.54 (4.79) 29.77 (4.09) 0.04 216.80 (6.02) 29.32 (4.17) 25.68 (2.34) 0.0001 17.37 (8.20) 21.94 (10.24) 0.11 210.50 (2.69) 210.48 (2.95) 28.48 (2.66) 0.03 214.09 (4.85) 28.22 (2.51) 25.30 (1.72) 0.0001 14.33 (6.13) 19.63 (9.28) 0.10 ,0.07 0.49 0.08 0.03 0.27 0.12 0.10 0.18 216.81 (3.34)c 219.33 (3.98)c 217.01 (2.98)c ,0.18 217.67 (6.31)c 211.95 (4.67)c 27.13 (3.53) ,0.0001

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25.16 (11.35)c 30.34 (15.03) 0.27

Data expressed as value (SD). Comparison of study groups with KruskalWallis test. c P , 0.05 vs. Group A, B, and C, respectively, with t-test. d Comparison of study groups with MannWhitney test.
b

non-transmural groups (Groups A and B). Circumferential strain obtained from midmyocardial layer demonstrated a trend toward proportionate reduction with increasing intramural burden of myocardial scarring (212.35 [4.55], 29.32 [4.17], and 28.22 [2.51] for Groups A, B, and C, respectively; P 0.03). The radial strain was preserved in Group A and attenuated in the non-transmural Group B and the transmural Group C (P , 0.05 for each). Attenuation of radial strain with increasing intramural scar burden was not signicant (P , 0.07). On comparing patients with hypertrophic cardiomyopathy patients and patients with ischaemic cardiomyopathy, we found no signicant difference in strains (values of mid-longitudinal strain, mid-circumferential strain, and radial strain, 212.4 [4.3], 29.9 [3.8], and 16.6 [7.6], respectively, for hypertrophic cardiomyopathy vs. 12.4 [3.2], 27.9 [3.5], and 16.2 [6.9], respectively, for ischaemic cardiomyopathy). However, strain values for both groups were signicantly decreased when compared with controls (P , 0.001 for each comparison of mid-longitudinal strain, midcircumferential strain, and radial strain).

of left ventricular ejection fraction (R 2 0.57; P 0.003 and P 0.001 for circumferential strain and scar score, respectively).

Segmental strain correlates of transmural scar

On logistic regression, segmental strain at each myocardial layer for longitudinal strain, circumferential strain, and radial strain were predictive of the presence of transmural scar (Table 4). With multivariate stepwise logistic regression, the midmyocardial longitudinal strain, epicardial circumferential strain, and fullthickness radial strain were each independent predictors of the presence of segmental transmural scar (odds ratio, 1.13 and P 0.001; odds ratio, 1.11 and P 0.02; and odds ratio, 0.96 and P 0.02, respectively). With receiver-operating characteristic analysis, this multivariable model showed a diagnostic ability (area under the curve, 0.77; P , 0.001) to detect the presence or absence of transmural scar (Figure 2).

Global strain correlates of left ventricular ejection fraction

Global strain values for each myocardial layer were correlated with left ventricular ejection fraction (Table 3). On univariate analysis, ejection fraction correlated with all three components of strain at each myocardial level, deceleration time, left ventricular mass, and myocardial scar score in each layer, as well as total myocardial scar score. The strongest relationships were seen with endocardial circumferential strain (R 20.62; P , 0.001), midmyocardial circumferential strain (R 20.46; P , 0.001), and total scar score (R 20.57; P , 0.001). On multiple regression analysis, circumferential strain and scar score were independent determinants

Interobserver and intraobserver variability

The absolute intraobserver differences for endocardial longitudinal strain, epicardial longitudinal strain, endocardial circumferential strain, epicardial circumferential strain, and full-thickness radial strain were 0.6% (2.2%), 0.1% (1.6%), 2.5% (2.1%), 2.2% (1.7%), and 8.3% (7.8%), respectively. The corresponding intraobserver variabilities were calculated as 10% (7%), 8% (7%), 11% (10%), 25% (22%), and 24% (20%), respectively. Absolute interobserver differences for each measurement were 2.5% (1.3%), 1.9% (1.2%), 3.5% (2.9%), 2.2% (1.7%), and 9.1% (8.6%), respectively; corresponding interobserver variabilities were calculated as 213.6% (6.3%), 212.6% (7.9%), 16% (15%), 26% (21%), and 28% (29%), respectively.

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Figure 1 Example of global strain by patient group. Longitudinal strain obtained from the endocardial layer is similarly attenuated in each
group (A, B, and C) regardless of distribution of scar. Circumferential strain obtained from the endomyocardial layer shows a graded attenuation of strain from Group A through Group C and is predominantly impaired in Group C patients. Full-thickness radial strain also shows graded attenuation of strain from Group A through Group C. Arrows in short-axis magnetic resonance imaging scans note areas of scar. Bold, black strain curve represents global strain at the endocardial layer (for longitudinal strain and circumferential strain; full thickness for radial strain).

Discussion
To our knowledge, this study is the rst to explore the functional interrelationship between myocardial brosis detected with late gadolinium enhancement on contrast-enhanced magnetic resonance imaging and speckle tracking echocardiography-derived myocardial deformation in the three myocardial layers of a heterogeneous group of patients with both ischaemic and non-ischaemic myocardial involvement. The principal ndings were the following: (i) global longitudinal strain is markedly attenuated regardless of the location of myocardial brosis, suggesting that the burden of functional impairment in myopathic hearts exceeds the structural involvement delineated with contrast-enhanced magnetic resonance imaging; and (ii) global circumferential strain is relatively better preserved and is an independent determinant of left ventricular ejection fraction, implying an adaptive mechanism in the clinical setting of attenuated longitudinal strain. These data provide insight into the mechanistically diverse phenotypic patterns of remodelling and the spectrum of altered cardiac muscle

mechanics seen in patients with cardiomyopathies that have varying burden of myocardial brosis.

Myocardial structure and function

Myocardial bre orientation changes continuously, from an obliquely oriented right-handed helical arrangement in the subendocardium to an obliquely oriented left-handed helical arrangement in the subepicardium.11 The midmyocardial layer is oriented in the circumferential direction predominantly.11 This arrangement results in longitudinal mechanics mainly governed by the subendocardial layer while circumferential and twist mechanics are governed predominantly by the midmyocardial and subepicardial layers, respectively.12 Our data suggest that subendocardial function is susceptible to the presence of disease and that longitudinal strains typically are diminished in myopathic hearts, regardless of any evidence of subendocardial myocardial scarring. By comparison, epicardial function is preserved and provides compensation through circumferential strains to preserve the global left ventricular pump

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Table 3 Univariate and multivariate predictors of ejection fraction

Univariate analysis Predictor

................................................................................ ................................................................................
Longitudinal strain Circumferential strain Radial strain Total scar score Left ventricular mass Deceleration time Multivariate analysis Predictor Longitudinal strain Circumferential straina Radial strain Total scar scorea Left ventricular mass Deceleration time
a

R2

P-value ,0.001 ,0.001 ,0.001 ,0.001 ,0.001 0.001

0.18 0.38 0.18 0.32 0.07 0.11 R 20.43 20.65 0.43 20.50 0.31 0.39

P-value

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0.22 0.003 0.17 0.01 0.84 0.30

Figure 2 Multivariate segmental strain model predictive of presence or absence of segmental transmural scar. Receiver-operating characteristic analysis combining midmyocardial longitudinal strain, epicardial circumferential strain, and full-thickness radial strain shows a diagnostic ability to detect the presence or absence of transmural scar (y 0.12a + 0.11b 2 0.03c 2 0.05, where a indicates midmyocardial longitudinal strain; b, epicardial circumferential strain; and c, full-thickness radial strain). A cut-off value .0.10 results in 80% specicity and 64% sensitivity to detect transmural scar in a segment. AUC, area under the curve.

Global R 2 0.57.

Table 4 Univariate and multivariate segmental strain predictors of presence of transmural scar
Predictor

................................................................................
Univariate logistic regression Endocardial LS Midmyocardial LS Epicardial LS Endocardial CS Midmyocardial CS Epicardial CS Full-thickness RS Midmyocardial LS Epicardial CS Full-thickness RS 1.10 (1.05 1.14) 1.12 (1.07 1.17) 1.11 (1.06 1.17) 1.05 (1.02 1.08) 1.06 (1.02 1.11) 1.13 (1.04 1.22) 0.95 (0.93 0.98) 1.13 (1.05 1.19) 1.11 (1.01 1.22) 0.96 (0.93 0.99) ,0.001 ,0.001 ,0.001 0.004 0.007 0.005 0.002 ,0.001 0.03 0.01

OR (95% CI)

P-value

relatively preserved in the occurrence of anterior wall myocardial infarction and normal left ventricular function but attenuated when function is compromised.14 Thus, the extent of longitudinal strain and circumferential strain is helpful in dening the transmural burden of disease. Functional impairment often exceeds the burden of structural changes as dened on contrast-enhanced magnetic resonance imaging.

Multivariate stepwise logistic regression

Global and segmental three-layer strain and transmurality of scar

Previous studies have suggested that Doppler strain imaging and speckle strain echocardiography can differentiate transmural from non-transmural scar in ischaemic populations.7,15 21 However, previous studies used speckle tracking echocardiography for the entire thickness of the left ventricular wall, showing modest accuracy (area under the curve, 0.71).15,17 Since myocardial layers are variably affected by different disease processes, multilayered assessment may be useful. Becker et al. 7 demonstrated that epicardial circumferential strain had a good diagnostic ability for the distinction of transmural from non-transmural scar (area under the curve, 0.819) in an ischaemic population and that epicardial circumferential strain was signicantly more accurate than full-thickness circumferential strain (area under the curve, 0.774; P , 0.0001 for comparison). The present study extends these observations and explores the relationship between three-layered speckle tracking echocardiography analysis and transmural scar burden. A model that uses

CI, condence interval; CS, circumferential strain; LS, longitudinal strain; OR, odds ratio; RS, radial strain.

function. Indeed, a subgroup of patients with epicardial disease had marked attenuation of both longitudinal strain and circumferential strain, and the gradation in amount of systolic dysfunction of a left ventricular segment in the epicardium correlated with the extent of myocardial scarring seen in the midmyocardium and epicardial regions. This nding is consistent with observations in several investigations.13,14 For example, in hypertrophic cardiomyopathy with preserved left ventricular function, compensatory circumferential strain has been shown in the presence of attenuated longitudinal strain.13 Circumferential strain also has been shown to be

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midmyocardial longitudinal strain, epicardial circumferential strain, and full-thickness radial strain was useful in differentiating the presence or absence of segmental transmural scar (area under the curve, 0.77; P , 0.001). However, determining the exact diagnostic utility of these ndings would require further prospective evaluation.

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Limitations
The patient population reects the referral pattern at our institution, with a large proportion of patients with hypertrophic cardiomyopathy undergoing contrast-enhanced magnetic resonance imaging evaluation. Thus, our ndings may not have generalizability to other disease states not represented in our population. Also, due to the small sample size, comparison of strain parameters between the ischaemic and non-ischaemic subjects was not possible. Although the study was powered to detect differences between the transmural and non-transmural scar groups, it was underpowered for detection of differences between the normal and non-transmural scar groups. Data variability was increased particularly for radial strain measurements, which is consistent with previous observations.22

Conclusion
Myocardial deformation is attenuated in myopathic hearts, regardless of any evidence of myocardial scarring. This disparity in transmural function results in an increased percentage of left ventricular segmental shortening being accounted for by circumferential, rather than longitudinal, mechanics. Mapping relative variations in global and segmental layer-based strain with multilayered speckle tracking echocardiography may have a role in predicting the transmural scar burden. Conict of interest: none declared.

Funding
None.

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