ABC | Volume 110, Nº3, March 2018

Original Article Kang et al Multi-layer strain analysis in lymphoma survivors Arq Bras Cardiol. 2018; 110(3):219-228 Endo MId Epi Trans Global Endo MId Epi Trans Global Control Chemotherapy Control Chemotherapy Control Chemotherapy 0 –10 –20 –30 0 –10 –20 –30 –40 –30 Longitudinal strain (%) Circumference strain (%) Radial strain (%) 50 40 30 20 10 0 * * * * * * Figure 1 – Strain values between two groups. *:p < 0.05. Anthracyclines are powerful cytotoxic agents, available to treat a wide spectrum of hematologic malignancies and solid tumors. However, life altering cardiac sequelae from anthracyclines remain a problem, with a range of 5-23% of patients developing late-onset heart failure secondary to anthracycline induced-cardiotoxicity. 11 Reliable, sensitive and non-invasive methods in detecting cardiac function are of vital importance in these patients. The present study demonstrated that subclinical cardiotoxicity existed in long-survivors after receiving anthracycline therapy albeit normal conventional echocardiographic findings, implicating the more sensitive nature of these parameters in monitoring anthracycline cardiotoxicity. Recently tagged magnetic resonance imaging provided a detailed quantitative analysis of left ventricular transmural differences in myocardial deformation. 12 Echocardiographic speckle-tracking strain analysis, which is angle-independent, provides a noninvasive method to assess left ventricular mechanics, thus translating clinically relevant aspects of cardiac performance from “bench to bedside”. Furthermore, the echocardiographic speckle tracking derived transmural gradients has recently been validated against sonomicrometry crystal in a sheep model. 13 As proved by previous studies, 14-16 our observations showed great interobserver and intraobserver agreement, suggesting reasonable reproducibility of the speckle tracking-derived multi-layer strain parameters. The present study confirmed the presence of transmural and translevel gradient in myocardial circumferential and longitudinal strains, with higher values in the subendocardial myocardial layer and in the apical level in both normal subjects and patients exposed to anthracycline, as is improved by Shi et al. 16 The difference in amplitude of myocardial contraction between the subendocardial and subepicardial regions was related to the orientation pattern of myocardial fiber in the heart. It has been described that in normal heart, contraction is greater in the subendocardial myocardium layer than in the subepicardial myocardium layer. 17 However, with greater contraction and higher energy requirements, subendocardial layer was more susceptible to injury, which can be detected by multi-layer speckle tracking strain analysis. Beck et al. 18 has demonstrated that a multi-layer analysis of myocardial deformation is highly accurate in the differentiation between different degrees of scar transmurality as assessed by MRI. In particular, multi-layer strain analysis provided higher accuracy to discriminate nontransmural versus noninfarction or trasmural versus nontransmural infarction compared with global strain. Altiok et al. 19 has also found that circumferential endocardial strain analysis allowed 223