ABC | Volume 112, Nº3, March 2019

Review Article Jorge et al Imaging for chemotherapy-related ventricular dysfunction Arq Bras Cardiol. 2019; 112(3):309-316 Table 1 – Advantages, disadvantages, and applicability of imaging methods for detecting chemotherapy-related cardiotoxicity Method Advantages Disadvantages Applicability 2D ECHO • Available • Allows for serial repetition • Evaluates anatomy and function • High variability • Late detection of alterations • Screening exam • Established diagnosis of disease 2D ECHO + Simpson + Contrast • Improves accuracy with respect to 2D ECHO • Higher cost • Longer exam time • Allows for accurate evaluation with simpler, more accessible technology 3D ECHO • Accuracy and reproducibility close to that of CMRI • Low availability • Accurate detection 2D STE • Detects subclinical dysfunction • Low availability • Depends on echocardiographic window • Initial screening of patients who will need monitoring RNV • Excellent accuracy and reproducibility • Low availability • Does not evaluate other structures, such as valves, pericardium • In doubts regarding ECHO measurements of LVEF • Inadequate ECHO image quality CMRI • Gold standard for evaluating volumes and LVEF • Allows for diagnosis of other etiologies of cardiomyopathy • Allows for tissue characterization • Low availability • Long exam time • Cost • In etiological doubts • In doubts regarding ECHO measurements of LVEF 2D ECHO: two-dimensional echocardiography; 3D ECHO: three-dimensional echocardiography; 2D STE: ecocardiograma bidimensional com strain; RNV: radionuclide ventriculography; CMRI: cardiac magnetic resonance imaging; LVEF: left ventricular ejection fraction (c) diagnostic methods such as echocardiography, computed tomography, nuclear medicine, or magnetic resonance imaging were used. The following were excluded: case reports, articles with other types of oncological therapy, and duplicate articles. Two hundred and twenty-one abstracts in the databases fulfilled the search criteria, and 162 articles were excluded. Hereafter, we will critically analyze each of the methods, highlighting their advantages, disadvantages, and clinical applicability regarding the detection of CT-induced CTX. A summary of this analysis is given in Table 1. Two-dimensional echocardiography Two-dimensional echocardiography (2D ECHO) with Doppler is the method most frequently used before, during, and after CT, given that it is not invasive; it does not use ionizing radiation; it is highly available and cost-effective. It evaluates systolic and diastolic function, cardiac valves, and the pericardium, thus offering an analysis of diverse manifestations of CTX. 11 The quantification of LVEF is the most accepted for measuring LV systolic function, and it is an important parameter in the algorithm for monitoring CT-induced CTX, capable of diagnosis and prognosis of clinical results, supporting the decision to continue or stop antineoplastic therapy. 8 It is important that this measure be accurate, with minimal temporal variability. However, LVEF measured by 2D ECHO has an elevated temporal variability, approximately 10% [9,1%–11,8%], and in order to be able to detect a 10% alteration in LVEF safely, the measure should have a lower temporal variability. It is thus possible to affirm that LVEF measured by 2D ECHO is less reliable. 12 Reduced LVEF following CT is considered a late finding that may indicate irreversible myocardial aggression and impede evolution with adequate therapy. Diastolic dysfunction may precede and predict late systolic dysfunction; however, no parameter of diastolic function has definitively shown to be predictive of CTX, and the studies are conflicting. 13-17 The right ventricle (RV) is commonly affected by CT, in an early manner, with a higher number of affected segments than the LV, predominantly in the interventricular septum. 18 Its routine evaluation should follow the recommendations set forth by Lang et al. 19 In this manner, the quantification of RV systolic and diastolic function would be important for serial monitoring, but there is a significant technical difficulty which restricts its routine use in clinical practice. In summary, a disadvantage of 2D ECHO is the elevated intra- and inter-examiner variability that compromises the method’s reproducibility. Three-dimensional echocardiography Unlike 2D ECHO, the evaluation of LVEF volumes by 3D ECHO is not based on geometrical suppositions; it is not affected by shortened views, 20 and it is quantified by an automated edge-tracking algorithm. 21 Studies with CMRI have shown that evaluations of LVEF and LV volumes by 3D ECHO have better accuracy and reproducibility, 22,23 as well as lower temporal variability for serial monitoring of LVEF. 12 The study by Walker et al. 23 evaluated the accuracy of measuring LVEF with 2D ECHO, RNV, and 3D ECHO with relation to CMRI, in patients who used Doxorubicin (DOX) and TZU. The left ventricle final diastolic volume (LVFDV) showed a modest correlation between 2D ECHO and CMRI (r = 0.64 baseline, r = 0.69 at 12 months); the correlation of LVFDV between 3D ECHO and CMRI was shown to be stronger (r = 0.87 baseline; r = 0.95 at 12 months); LVEF measured by 2D ECHO had a weak correlation with CMRI (r = 0.31 baseline, r = 0.42 at 12 months). Both 3D ECHO and RNV showed a strong correlation when comapred with CMRI (r = 0.91 baseline, r = 0.90 at 12 months). When compared with RNV, the serial measurement of LVEF via 3D ECHO was shown to be more viable, accurate, and reproducible for serial LVEF monitoring in these patients. 310