Transverse Cine Imaging-based Strain Analysis for Patients with Congenital Heart Disease as a New Approach to Assess Myocardial Strain

Background: Global longitudinal strain (GLS) is a sensitive marker for left ventricular (LV) myocardial dysfunction and a strong predictor for clinical events and future ventricular deterioration, which can be acquired by echocardiography or cardiac magnetic resonance imaging (cMRI). GLS gold standard quantification is performed in LV long-axis views (LAX), which are two-, three-, and four-chamber views. Strain measurements of the right ventricle (RV) are performed in four-chamber views. In patients with complex congenital heart disease (CHD), the required imaging planes for quantifying GLS have often not been included in the standard cMRI protocol in the past or are impossible to perform in atypical ventricular anatomy in univentricular hearts. Transverse cine imaging (TRA) on the contrary, is routinely performed in these patients. The aim of this study was to analyze RV and LV strain in TRA images compared with standard GLS in patients with CHD.

Methods: We retrospectively analyzed 50 patients (n = 20 Fontan, n = 20 ToF and n = 10 healthy controls). cMRI strain imaging analysis was performed by two observers using both the conventional method and the new TRA-based approach. The analysis was repeated for half of the patients after 6 months by the main observer to test for intraobserver variability. The reproducibility was measured using the intraclass correlation coefficient (ICC), Pearson correlation coefficient, and Bland–Altman analysis.

Results: The study demonstrates excellent ICC for intra- and interobserver reproducibility for LV and RV strain derived from LAX and TRA in all patients (ICC >0.75, p < 0.05 for all patients). Compared with the gold standard quantification of LAX-based LV and RV strain, TRA-based strain showed good correlation in the Fontan group (ICC = 0.75, p < 0.001 for LV strain, ICC = 0.68, p = 0.006 for RV strain) and excellent correlation in the ToF group for RV strain (ICC >0.75, p < 0.001), whereas the LV strain showed a systematic bias with higher LV strain derived from TRA.

Conclusion: The TRA-based strain analysis for patients with CHD may offer a new methodological approach to assess myocardial strain in cases where conventional imaging planes are not available. In patients with ToF or univentricular physiology with a special interest in RV strain, the TRA-based strain analysis could serve as an additional marker for long-term cardiac monitoring of the RV. Further studies are needed to validate this new approach and perform correlations to clinical outcomes.

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Artikel online veröffentlicht:
11. Februar 2025