Echocardiographic measurement of cardiac function in breast cancer patients treated with anthracycline chemotherapy

Introduction Anthracyclines are the cornerstone of breast cancer chemotherapy, however anthracyclines can be cardiotoxic. Left ventricular (LV) ejection fraction (LVEF) is the key echocardiographic measurement for monitoring cardiotoxicity, although LVEF has limitations. Myocardial strain imaging is new technology that may improve the measurement of cardiac function. The aim of this research was to study strain imaging for potentially earlier detection of dysfunction than LVEF, in breast cancer patients treated with anthracyclines. Method Anthracycline naïve breast cancer patients were prospectively studied; 78 short-term (over 3 months), and 50 in the intermediate-term (over 12 months). Patients were treated with standard anthracycline regimens. Echocardiograms were performed at 4 time points; 1) 7 days before chemotherapy, 2) 7 days after chemotherapy, 3) 6 months after, and 4) 12 months after chemotherapy. Results Global LV longitudinal systolic strain (GLS) was significantly reduced in the short-term (p<0.001), without a clinically significant reduction in LVEF. In the intermediate-term, strain values remained significantly reduced at 6 months (p<0.01), but normalized 12 months after chemotherapy. GLS at the 4 time points was: -19.0% ± 2.3%, -17.5% ± 2.3%, -18.2% ± 2.2%, -19.1% ± 1.9%. Persistently reduced strain at 12 months (in 16% of participants) was related to significantly higher anthracycline doses. Conclusion Significantly reduced LV systolic strain was detected in the short and intermediate-term after anthracyclines, without discernible changes in LVEF. In the majority, LV systolic dysfunction was transient: persistently reduced systolic strain was associated with higher anthracycline doses. Strain imaging is a more sensitive measure than LVEF in the short and intermediate-term monitoring of cardiac function after anthracycline chemotherapy

Three-Dimensional Speckle-Tracking Echocardiography for the Global and Regional Assessments of Left Ventricle Myocardial Deformation in Breast Cancer Patients Treated with Anthracyclines

Background: Assessment of 2D/3D left ventricular ejection fraction (LVEF) and 2D global longitudinal strain (GLS) is the gold standard for diagnosing cancer therapeutics-related cardiac dysfunction (CTRCD). Although 3D speckle-tracking echocardiography (STE) has several advantages, it is not used in this setting. Methods: 105 breast cancer patients who underwent serial echocardiographic assessment during anthracycline therapy were included. STE was used to estimate 2D GLS, 3D GLS, 3D global circumferential strain (GCS), 3D global radial strain (GRS), and 3D global area strain (GAS). CTRCD was defined as an absolute decrease in 2D/3D LVEF > 10% to a value 15%. Results: 24 patients developed CTRCD. There was a significant worsening of all 3D strain parameters during chemotherapy. 3D strain regional analysis showed impaired contractility in the anterior, inferior, and septal walls. Variations of 3D GRS and 3D GCS were associated with a higher incidence of CTRCD and the variation of 3D GRS was an independent predictor of CTRCD. Variations of 3D GCS and 3D GRS had a good discrimination for predicting CTRCD, with optimal cutoff values of - 34.2% for 3D GCS and - 34.4% for 3D GRS. These variations were observed 45 and 23 days before the diagnosis of CTRCD, respectively. Conclusion: Variations of 3D strain parameters were predictive of and preceded CTRCD, and thus have added value over currently recommended 2D/3D LVEF and 2D GLS. Routine application of this technique should be considered to offer targeted monitoring and timely initiation of cardioprotective treatment.info:eu-repo/semantics/publishedVersio

Antineoplastic-related cardiotoxicity, morphofunctional aspects in a murine model: contribution of the new tool 2D-speckle tracking

Objective: Considering that global left ventricular systolic radial strain is a sensitive technique for the early detection of left ventricular dysfunction due to antineoplastics and the analysis of segmental myocardial contractility, we evaluated this technique for early detection of trastuzumab-related cardiotoxicity by comparing it with cardiac structural damage. Methods: Groups of six mice were injected with trastuzumab or doxorubicin, used either as single agents or in combination. Cardiac function was evaluated by transthoracic echocardiography measurements before and after treatment for 2 or 7 days, by using a Vevo 2100 high-resolution imaging system. After echocardiography, mice were euthanized, and hearts were processed for histological evaluations, such as cardiac fibrosis, apoptosis, capillary density, and inflammatory response. Results: Trastuzumab-related cardiotoxicity was detected early by 2D strain imaging. Radial strain was reduced after 2 days in mice treated with trastuzumab alone (21.2%±8.0% vs 40.5%±4.8% sham; P<0.01). Similarly, trastuzumab was found to induce apoptosis, capillary density reduction, and inflammatory response in cardiac tissue after 2 days of treatment, in a fashion similar to doxorubicin. On the contrary, fractional shortening reduction and cardiac fibrosis were observed only after 7 days of trastuzumab treatment, in contrast to doxorubicin treatment which induced early fibrosis and fractional shortening reduction. Conclusion: The reduction of left ventricular systolic strain after 2 days of trastuzumab treatment may indicate early myocardial functional damage before the reduction in left ventricular ejection fraction and this early dysfunction is well correlated with structural myocardial damage, such as apoptosis and inflammatory response. Fractional shortening reduction after 7 days of trastuzumab treatment is related to fibrosis in cardiac tissue

Cardiac monitoring in HER2-positive patients on trastuzumab treatment

Trastuzumab prolongs progression-free and overall survival in patients with human epidermal growth factor receptor 2 (HER2) positive breast cancer. However, trastuzumab treatment is hampered by cardiotoxicity, defined as a left ventricular ejection fraction (LVEF) decline with a reported incidence ranging from 3 to 27% depending on variable factors. Early identification of patients at increased risk of trastuzumab-induced myocardial damage is of great importance to prevent deterioration to irreversible cardiotoxicity. Although current cardiac monitoring with multi gated acquisition (MUGA) scanning and/or conventional 2D-echocardiography (2DE) have a high availability, their reproducibility are modest, and more sensitive and reliable techniques are needed such as 3D-echocardiography (3DE) and speckle tracking echocardiography (STE). But which other diagnostic imaging modalities are available for patients before and during trastuzumab treatment? In addition, what is the optimal frequency and duration of cardiac monitoring? At last, which biomarker monitoring strategies are currently available for the identification of cardiotoxicity in patients treated with trastuzumab

clinical application of 2d speckle tracking strain for assessing cardio toxicity in oncology

Echocardiography has recently undergone innovations due to the availability of deformation parameters as strain, strain rate, torsion and rotation that allow an accurate assessment of myocardial function. Because of this general progress, the importance of myocardial deformation parameters has been highlighted, and some aspects of their clinical and research applications have recently been considered for the daily management of many acute and chronic metabolic diseases. The deformation parameters are largely proposed for the early detection of myocardial dysfunction, especially in the case of patients being completely asymptomatic. Strain analysis is extensively applied to cardiomyopathies, to coronary artery disease, or to the evaluation of the "forgotten chambers", such as the right ventricles and atria. More recently, several other clinical contexts, like non-communicable chronic diseases (NCCD), have actually been benefitting from specific evaluation by strain analysis. Lately, some specific aspects of strain evaluation, particularly Global Longitudinal Strain (GLS) have been shown to provide useful information of clinical relevance in the case of cancer patients. This paper presents an initial review of the recent applications of strain analysis in cardio-oncology, in order to share the recent experience in this field and to support the role of these parameters in cardio-oncology

Subclinical Left Ventricular Dysfunction Detected by Speckle-Tracking Echocardiography in Breast Cancer Patients Treated With Radiation Therapy:A Six-Month Follow-Up Analysis (MEDIRAD EARLY‐HEART study)

Copyright © 2022 Locquet, Spoor, Crijns, van der Harst, Eraso, Guedea, Fiuza, Santos, Combs, Borm, Mousseaux, Gencer, Frija, Cardis, Langendijk and Jacob. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.Background: In the case of breast cancer (BC), radiotherapy (RT) helps reduce locoregional recurrence and BC-related deaths but can lead to cardiotoxicity, resulting in an increased risk of long-term major cardiovascular events. It is therefore of primary importance to early detect subclinical left ventricular (LV) dysfunction in BC patients after RT and to determine the dose-response relationships between cardiac doses and these events. Methods: Within the frame of the MEDIRAD European project (2017-2022), the prospective multicenter EARLY-HEART study (ClinicalTrials.gov Identifier: NCT03297346) included chemotherapy naïve BC women aged 40-75 years and treated with lumpectomy and adjuvant RT. Myocardial strain analysis was provided using speckle-tracking echocardiography performed at baseline and 6 months following RT. A global longitudinal strain (GLS) reduction >15% between baseline and follow-up was defined as a GLS-based subclinical LV dysfunction. Individual patient dose distributions were obtained using multi-atlas-based auto-segmentation of the heart. Dose-volume parameters were studied for the whole heart (WH) and left ventricle (LV). Results: The sample included 186 BC women (57.5 ± 7.9 years, 64% left-sided BC). GLS-based subclinical LV dysfunction was observed in 22 patients (14.4%). These patients had significantly higher cardiac exposure regarding WH and LV doses compared to patients without LV dysfunction (for mean WH dose: 2.66 ± 1.75 Gy versus 1.64 ± 0.96 Gy, p = 0.01). A significantly increased risk of subclinical LV dysfunction was observed with the increase in the dose received to the WH [ORs from 1.13 (V5) to 1.74 (Dmean); p <0.01] and to the LV [ORs from 1.10 (V5) to 1.46 (Dmean); p <0.01]. Based on ROC analysis, the LV-V5 parameter may be the best predictor of the short-term onset of subclinical LV dysfunction. Conclusion: These results highlighted that all cardiac doses were strongly associated with the occurrence of subclinical LV dysfunction arising 6 months after BC RT. Whether measurements of GLS at baseline and 6 months after RT combined with cardiac doses can early predict efficiently subclinical events occurring 24 months after RT remains to be investigated.The European Community’s Horizon 2020 Programme supported the EARLY-HEART study conducted in the frame of the MEDIRAD - Implications of Medical Low Dose Radiation Exposure - project spanning from 2017 to 2021 granted by the Euratom Research and Training Programme 2014-2014 under agreement No. 755523.info:eu-repo/semantics/publishedVersio

New perspectives in cardiac imaging based on novel echocardiographic techniques

The use of cardiac ultrasound has currently become a pivotal tool in the hand of the clinician that integrate sign and symptoms of the clinical examination and giving relevant information to diagnose and treat cardiovascular disease. It's high availability and the absence of radiation exposure made this diagnostic technique the preferred one in the setting of first diagnosis (i.e. screening) and follow up. The advancement in software and hardware empowered the accuracy and the resolution of the imaging overcoming almost entirely the main limitation of this tool; the inadequate acoustic windows. Another limitation that affect cardiac ultrasound is the suboptimal interobserver reproducibility due to subjective evaluation for most of the measurement computed during echocardiographic examination, particularly when assessing the global and regional systolic function of the left ventricle. Indeed, left ventricular ejection fraction (LVEF) is considered the most representative parameter of systolic function among cardiologist and non-cardiologist. However, its suboptimal reproducibility makes arduous to determine subtle changes in systolic function during the follow up. Additionally, LVEF is affected by changes in pre- and after-load, furtherly jeopardize the assessment of LV function in those conditions where dynamic changes in volume load are on the agenda, namely in valvular heart disease and in patients undergoing chemotherapy for cancer. Speckle tracking echocardiography (STE) meant to overcome mostly this limitation by using a semiautomated software that allows to determine the deformation (strain) of the myocardial fibers through the cardiac cycle. Among direction strain (i.e. longitudinal, circumferential, radial strain), the assessment of the global longitudinal strain (GLS) showed to be a pivotal diagnostic tool with prognostic impact in different conditions such as hypertension, cardiomyopathies, valvular heart disease and in the LV surveillance during anti- cancer treatment

Right Ventricle Free Wall Longitudinal Strain in Cancer Patients Following Chemotherapy

Introduction: The survival rate of cancer patients was high due to chemotherapy, but it can cause cardiotoxicity and increase morbidity and mortality. Most studies on cancer therapy-related cardiac dysfunction (CTRCD) focus more on the left ventricle. This study assesses chemotherapy's effect on the right ventricle, namely the right ventricle free wall longitudinal strain (RVFWLS). Methods: This study is a prospective cohort conducted from January to December 2022 on thirty-four cancer patients undergoing chemotherapy at Dr Wahidin Sudirohusodo Hospital Makassar. The RVFWLS was assessed before and after chemotherapy using echocardiographic. Result: The RVFWLS value after one cycle chemotherapy decreased compared pre-chemotherapy (4.40±4.84; p=0.001). Conclusion: The effect of chemotherapy is a decrease the RVFWLS value after the first cycle of chemotherapy. It should be considered for echocardiographic evaluation, especially the RVFWLS value every cycle of chemotherapy