Evaluation of segmental
myocardial work in the
left ventricle
Eigil Samset, PhD
1
GE Healthcare, 2University of Oslo
Introduction
Left ventricular (LV) function can be quantified with echocardiography by
measuring the strain experienced by individual segments during the heart
cycle. The resulting strain traces reveal information about global function,
dyssynchrony and poorly contracting segments.
Automated Functional Imaging (AFI) employs speckle tracking to allow
quantification of LV strain. The tool provides the user with capabilities to
track “natural acoustic markers” in the myocardial tissue in any direction
within the tracking plane throughout the heart cycle.
GE Healthcare has, through a series of breakthroughs, continued to lead
the development of quantitative ultrasound based technologies.
Recently a new index to evaluate myocardial work was introduced.
Myocardial Work augments AFI by taking dynamic LV pressure into
account. This adds an important dimension to the assessment of
LV function and facilitates interpretation of strain traces in relation
to LV pressure dynamics.
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Stroke work Segmental work The global values are calculated as the
average of all segmental values.
As the heart is pumping blood into the Stroke work, as defined by the pressure-
circulatory system it is performing work volume area, should be equal to the Along with segmental and global values
on the blood for every beat. This work is work performed by the myocardium for myocardial work, a set of additional
often denoted the stroke work. The stroke (when neglecting energy losses), which indices are also provided:
work can be explained as the area of the for each segment can be expressed as
pressure-volume loop (Figure 1). The the segmental strain – LV pressure area • Constructive work: work performed
systolic stroke work is the pattern filled (Figure 2). This simplification provides a by a segment during shortening in
area in the figure, which does not include surrogate for the work performed by systole adding negative work during
the work performed by the blood on the each segment, as LV pressure does lengthening in IVR
ventricle during diastole (negative work). not fully explain the force developed by
• Wasted work: negative work
each segment.
200 performed by a segment during
200 lengthening in systole adding work
performed during shortening in IVR
LV Pressure
100 • Myocardial work efficiency:
(mmHg) Stroke LV Pressure
Work (mmHg)
100 constructive work divided by the
sum of constructive and wasted work
0 (0-100%) (Figure 4)
0 100 200
0
LV Volume (ml) -30% 0 30%
Figure 1. Stroke work, the area of the LV pressure- Segmental strain (%)
volume loop. The figure also indicates the systolic Figure 2. Regional contractile work represented by
stroke work (larger than stroke work as negative the area of the strain – pressure loop
work during diastole is not included)
Estimation of LV pressure Myocardial Work
The Myocardial Work module in AFI
Russel et.al.1 described a simple method
asks the user to provide blood pressure
that can estimate LV pressure non-
and valvular event times as input to the Figure 4. Myocardial Work Efficiency. These values
invasively based on measurement of
myocardial work estimation. Only the will not be affected by peak LV pressure. 0 Wasted
cuff pressure and the timing of valvular Work will give 100% Myocardial Work efficiency,
systolic cuff pressure measurement is
events. The method was validated in equal amounts of Wasted and Constructive Work
used in the calculation as an estimate will give 50% Cardiac work efficiency, while 0
a variety of pathologies (not including
of peak LV pressure. A bull’s eye (Figure Constructive Work will give 0% efficiency.
severe stenosis and regurgitation).
3) with the segmental myocardial work
A normalized pressure curve was
values and global values are provided.
obtained by pooling invasive pressure
Work is evaluated from Mitral Valve
measurements from a number of
Closure (MVC) to Mitral Valve Opening
patients with different pathologies,
(MVO), in other words: mechanical systole
normalized to equal durations of
including isovolumetric relaxation (IVR).
isovolumetric contraction, ejection and
isovolumetric relaxation as well as peak
pressure. To individualize this normal
pressure curve, it is scaled in amplitude
with measured systolic cuff pressure
and warped in time by aligning valvular
event times.
Figure 3. The Myocardial Work bull’s eye shows
areas of negative work as blue, green indicates
normal values while red shows areas of high work.
Myocardial Work values Literature
Assuming normal systolic pressure Early literature on cardiac physiology
(120 mmHg) and normal global introduced the concept of pressure-
longitudinal strain (-20%) Myocardial volume loops and stroke work.
Work will be approximately 2400 mmHg%. Regional work, looking at fiber stress,
With all segments contracting during has been studied in-vitro and in-vivo
systole the Myocardial Work Efficiency (Delhaas et.al.3).
will be 100%.
Boe et.al.2 showed increased sensitivity
An increase in afterload may lead to and specificity in identifying acute
reduced strain (Boe et al.2) while the coronary occlusion in patients with
myocardial work may be preserved or non-ST-segment elevation using regional
even increased. Myocardial Work can be Figure 5. Segmental work, approximated as the cardiac work index.
seen as a less load dependent measure area of the strain-pressure loop. The red curve
of LV function than mere strain. is the global curve for the LV, while the green J. Vecera et.al.4 showed a marked
curve shows the septum contracting early and decrease in wasted work in the septum
performing mostly wasted work.
In patient follow-up (such as during after CRT for responders while no
oncology treatment), the Global The hallmarks of myocardial infarction, significant change for non-responders
myocardial Work Index allows for when reading strain traces, are: early to CRT.
quantification of global function systolic lengthening, reduced peak
controlled for systolic blood pressure at Russel et. al.1 used a qualitative
systolic strain, and post-systolic
the time of each examination. This may assessment of wasted work ratio
shortening. These hallmarks will all
be of importance in patients with variable (corresponding to Cardiac Work
contribute to reduced Myocardial
blood pressure from exam to exam. Efficiency) distribution over the
Work Efficiency and reduced
LV to discern dyssynchrony from
Constructive work.
In dyssynchrony, such as left bundle re-synchronized LV function.
branch block (LBBB), the septum
contracts early (against a low LV
pressure) and lengthens as the lateral
wall contracts late. This will result
in elevated wasted work values in
the septum and reduced Myocardial
Work Efficiency (possibly below 50%
if Wasted work > Constructive work)
while the lateral wall will provide a
larger contribution to constructive work.
This may result in a (partial) clock-wise
rotation pattern of the strain-pressure
loop, which can be visualized on a per
segment basis while comparing to the
global loop (Figure 5).
Note: Myocardial Work is covered by patent 2013-535297 (Japan), 201180059482.2 (China) and patent
pending 11793651.8 (PCT)
1. Russell K, Eriksen M, Aaberge L, Wilhelmsen N, Skulstad H, Gjesdal O, Edvardsen T, Smiseth OA:
«Assessment of wasted myocardial work: a novel method to quantify energy loss due to uncoordinated
left ventricular contractions.» Am J Physiol Heart Circ Physiol 305: H996-1003, 2013
2. Boe E, Russel K, Eek C, Eriksen E, Remme EW, Smiseth OA, Skulstad H: «Non-invasive myocardial work
index identifies acute coronary occlusion in patients with non-ST-segment elevation-acute coronary
syndrome.” European Heart Journal – Cardiovascular Imaging (2015) 16, 1247-1255
3. Delhaas T, Arts T, Prinzen FW, Reneman RS: “Regional fibre stress-fibre strain area as an estimate
of regional blood flow and oxygen demand in canine heart.” Journal of Physiology (1994), 447.3,
pp.481-496
4. Vecera J, Penicka M, Eriksen M, Russell K, Bartunek J, Vanderheyden M, Smiseth OA: “Wasted septal
Imagination at work work in left ventricular dyssynchrony: a novel principle to predict response to cardiac resynchronization
therapy”; European Heart Journal – Cardiovascular Imaging (2016) 17(6): 624-632
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