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LAYER-SPECIFIC MYOCARDIAL SEGMENTAL LONGITUDINAL STRAIN

Layer-Specific Segmental Longitudinal


Strain Measurements: Capability of
Detecting Myocardial Scar and Differences
in Feasibility, Accuracy, and Reproducibility,
Among Four Vendors A Report From the
EACVI-ASE Strain Standardization
Task Force
€ u, MD, Oana Mirea, MD, PhD, Efstathios D. Pagourelias, MD, PhD, J€
Serkan Unl€ urgen Duchenne, PhD,
Stephanie Bezy, MSc, Jan Bogaert, MD, PhD, James D. Thomas, MD, PhD, Luigi P. Badano, MD, PhD, and
Jens-Uwe Voigt, MD, PhD, On behalf of the EACVI-ASE-Industry Standardization Task Force,
Leuven, Belgium; Chicago, Illinois; and Padua, Italy

Background: Segmental longitudinal strain (SLS) is reported to be vendor specific. Despite standardization ef-
forts, vendors still use different myocardial layers for strain measurements. It is unclear, however, which layer
is the most favorable for clinical purposes. Therefore, in this study we evaluated the reproducibility, accuracy,
and scar detection ability of SLS measurements from different myocardial layers.

Methods: In data sets of 58 patients with prior myocardial infarction and five healthy volunteers, we measured
the intervendor bias, the relative test-retest variability, and scar discrimination ability of endocardial and mid-
wall SLS, using software packages from four different companies (GE, Siemens, Toshiba, and TomTec). Car-
diac magnetic resonance delayed enhancement images were used as the reference standard of scar
definition.

Results: Variability of SLS measurements was significant among the vendors for both midwall and endocar-
dium. In addition, relative errors of SLS measurements varied considerably among vendors (P < .001 for
both layers). Comparisons of test-retest errors from different layers for individual vendors did not show any
significant differences. Regardless of the vendor, both endocardial and midwall strain values were decreased
in scarred segments. Endocardial to midwall ratio of strain measurements showed no difference between
scar-free and scarred segments. Endocardial and midwall strain parameters showed no significant difference
in scar detection capability.

Conclusions: Layer-specific SLS measurements vary significantly among vendors. Endocardial and midwall
SLS measurements have a high yet comparable test-retest variability. Combining layer-specific SLS measure-
ments does not provide additional information for detection of regional functional abnormalities. Our results
do not provide evidence to favor the use of one myocardial layer over another. (J Am Soc Echocardiogr
2019;32:624-32.)

Keywords: Intervendor, Layer-specific, Reproducibility, Speckle, Strain, Tracking

From the Department of Cardiovascular Diseases (S.U., O.M., E.D.P., J.D., S.B., Reprint requests: Prof. Dr. Jens-Uwe Voigt, MD, PhD, Department of Cardiovas-
J-U.V.) and Department of Radiology (J.B.), University Hospital Leuven, Leuven, cular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
Belgium; Bluhm Cardiovascular Institute, Northwestern University (J.D.T.), (E-mail: jens-uwe.voigt@uzleuven.be).
Chicago, Illinois; and Cardiac, Thoracic and Vascular Sciences (L.P.B.), 0894-7317/$36.00
University Padua, Padua, Italy.
Copyright 2019 by the American Society of Echocardiography.
Conflicts of Interest: None.
https://doi.org/10.1016/j.echo.2019.01.010
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Abbreviations
Two-dimensional speckle- Table 1 Vendors participating in the study
tracking echocardiography (2D
2D = Two-dimensional STE) allows the objective quanti- Ultrasound Software
ANOVA = Analysis of fication of left ventricular (LV) Vendor machine Type and version

variance global and regional function GE Vivid E9 High end EchoPac v201
in a convincingly simple and
AUC = Area under the curve Siemens Acuson S2000 CV system High end Syngo VVI 4.0
feasible way.1-3 The quantitative
assessment of LV regional Toshiba Artida High end ACP v3.2
CMR = Cardiac magnetic
resonance myocardial function by 2D STE TomTec* 2D CPA 1.3
segmental longitudinal strain *Software-only vendor.
DICOM = Digital Imaging and
Communications in Medicine
(SLS) has been reported to
potentially provide additional resonance (CMR) study performed after the myocardial infarction,
ES = End systolic information that might and (6) having no ischemic events or cardiac interventions before
GLS = Global longitudinal improve the detection of the image acquisitions for the present study. Patients were selected
strain regional function abnormalities. to achieve a wide range of segmental functional abnormalities.
Endocardial strain, in particular, Healthy volunteers without history, signs, or symptoms of cardiac pa-
LGE = Late gadolinium has been suggested to be thology and with good echocardiographic imaging windows were re-
enhancement cruited as stand-by subjects in case planned patients did not present
useful to detect subendocardial
LV = Left ventricular functional abnormalities in for the study. The study was approved by the ethical commission of
varying diseases.4-8 However, the University Hospitals Leuven, and all subjects gave written
PS = Peak systolic
SLS has been recently shown to informed consent prior to inclusion.
PSI = Postsystolic index be highly vendor specific with
limited reproducibility.9 Little is Industry Partner Recruitment
PSS = Postsystolic strain
known about whether SLS in All major vendors of echocardiography equipment and speckle-
ROC = Receiver operating different layers of the myocardial tracking analysis software were invited to participate in the study.
characteristic wall can be measured indepen- For this analysis, software packages from the four vendors that offer
STE = Speckle-tracking dently and whether it could pro- the option to analyze and report layer-specific SLS layers were
echocardiography vide feasible and sufficient used. Hitachi software could not be used in this study since the soft-
different information. ware allows layer-specific analysis of GLS but does not report layer-
SLS = Segmental longitudinal specific SLS measurements. Technical support was requested from
Currently, the approach for
strain
the assessment of strain is vendor application specialists of the involved companies to have a dedicated
specific.9-11 Some vendors track training on each vendor’s software. A list of participating vendors and
the endocardial region, some track both endo- and epicardium, and the respective software is provided in Table 1.
others use a region of interest that covers the full wall thickness. In
addition, some vendors choose to only report layer-specific strain Study Protocol
for global longitudinal strain (GLS). With respect to these vendors, Echocardiographic Imaging. The details of the echocardio-
we recently reported that no specific layer could be favored for the graphic imaging protocol followed in this study have been previously
assessment of GLS from a technical point of view. However, published.9 Briefly, 63 participants were scanned during nine sessions
layer-specific SLS measurements still need further evaluation.11 in 5 days. Each participant was scanned by one sonographer on all
In this study, we sought to (1) assess the intervendor bias of SLS machines. An application specialist from each company was present
measurements obtained from different myocardial layers, (2) to ensure optimal settings for image acquisition. Two sets of apical
compare the test-retest variability of SLS measurements from standard views in a test-retest scenario and Doppler traces from aortic
different myocardial layers, and (3) evaluate the discrimination power and mitral valve were acquired. All image data were stored in the stan-
of different myocardial layers and their combination for the detection dard Digital Imaging and Communications in Medicine (DICOM)
of regional dysfunction among vendors in a clinical setting to provide format and a vendor-specific, proprietary raw data format, if available,
evidence for future discussions within the EACVI/ASE/Industry Task for later offline postprocessing.
Force to Standardize Deformation Imaging. CMR Imaging. The details of the CMR imaging protocol have been
previously published.9,12 Briefly, all patients underwent a CMR study
on a 1.5T Philips Intera-CV (Philips, Best, The Netherlands) using
METHODS dedicated cardiac software, phased-array surface receiver coil, and
electrocardiogram triggering. The earliest CMR acquisitions were per-
Study Population formed at least 4 days after the myocardial infarction. Two-weighted
The study population was selected from the second Inter-Vendor short-tau inversion recovery imaging was also performed for evalua-
Comparison Study,9 for which patients had been prospectively re- tion of edema, and a clear assessment of infarcted myocardium,
cruited from the echocardiography laboratory of University defined by LGE, was obtained. Extent and transmurality of the scar
Hospital in Leuven. The main inclusion criteria were (1) being older were documented per segment using the standard 18-segment model
than 18, (2) ability to consent, walk, and lie in a supine position for recommended for functional echocardiographic measurements.1,2
2 hours, (3) having a good echocardiographic imaging window and The CMR images were analyzed by the consensus of three
regular heart rhythm, (4) having a documented history of myocardial observers (S.U., O.M., E.D.P.). The readings were supervised by a
infarction within a maximum of 2 years before the study, (5) the CMR specialist (J.B.). The presence of LGE was visually assessed
existence of a late gadolinium enhancement (LGE) cardiac magnetic from three short-axis projections (base, midventricular, and apex)
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Wilcoxon or paired t-test was used to compare relative errors of layers


HIGHLIGHTS within each company. One-way ANOVA with post hoc Bonferroni
analysis was used to compare layer-specific strain measurements
 Layer-specific SLS does not help with detection of scars. among segments with different degrees of scar and no scar. P < .05
 Layer-specific SLS shows significant differences among ven- was considered statistically significant.
dors. Since there is a gradient in strain measurements through myocardial
layers, with the highest strain endocardially, the ratio of endocardial to
 Test-retest variability of layer-specific SLS is similar for endocar-
midwall strain is used to test the hypothesis that scar and nontransmu-
dium and midwall.
ral scar differentially affect strain measurements in different layers. This
 No strong evidence favors the use of a certain myocardial layer unitless ratio was used to compare layer-specific strain changes in
for strain measurements. scarred and normal segments as well as among vendors using a one-
way ANOVA with post hoc Bonferroni analysis.
representing the middle of the echocardiographic segment. Segments Receiver operating characteristic (ROC) curves for PS, ES, PSS, and
were rated as having subendocardial scar if 1%-50% of the segment PSI were calculated to evaluate the ability to differentiate between
showed hyperenhancement in transmural direction. If the infarct normal segments and scars for both layers per vendor. The area under
covered the entire thickness of myocardium, segments were rated the ROC curve (AUC) was used as an overall measure of discrimina-
as having a transmural scar. The remaining segments with tion. AUC values were interpreted as follows: (1) AUC = 0.5, no
intermediate, nontransmural scar were not included in the analysis. discrimination; (2) 0.6 # AUC < 0.7, poor discrimination; (3)
Segments of healthy volunteers were assigned to the no-scar group 0.7 # AUC < 0.8, acceptable discrimination; (4) 0.8 # AUC < 0.9,
without CMR imaging. excellent discrimination; and (5) AUC > 0.9, outstanding discrimina-
tion. The comparison between ROC was performed using De Long
Data Analysis test13 (Medcalc Software, Mariakerke, Belgium). All data were
Ejection fraction was calculated based on the biplane modified analyzed using SPSS (IBM, Chicago, IL) version 24.0.
Simpson’s rule. Strain measurements were performed with software
from the four vendors who allow both endocardial and midwall
RESULTS
segmental strain assessment (GE, Siemens, Toshiba, and TomTec)
and the images of the respective scanner from the same company.
Image data sets of 58 patients and five volunteers were analyzed.
For TomTec software, DICOM images from GE were used. In the
Mean ejection fraction was 52.4% 6 10.0%, ranging from 28% to
following, the company names are used to refer to specific software.
73%. There was a minor increase in systolic blood pressure
End diastole was defined by the electrocardiogram R-wave trigger.
(128 6 20 to 135 6 17 mm Hg; P < .05) during the scanning, while
Time of aortic valve closure was measured from pulsed-wave
no change was observed in diastolic blood pressure (73 6 13 to
Doppler acquisitions of LVoutflow tract. To obtain layer-specific strain
74 6 9 mm Hg; P = .6). In total, 1,134 (63  18) segments were eval-
measurements, a region of interest covering the entire myocardium
uated by 2D STE. Overall feasibility was 86.7%, with the number
was created by delineating endocardial and epicardial contours of
of excluded segments varying significantly among vendors
the LV. In scarred and thin segments, particular care was taken to
(8.9%-16.9%, ANOVA P < .05; Supplemental Figure 1, available at
ensure the region of interest did not exceed the actual wall contours.
www.onlinejase.com).
Feasibility of speckle-tracking was evaluated visually. Segments were
All 1,044 (58  18) segments in clinical patients were evaluated for
rejected from further analysis if the tracking did not follow the myocar-
scar transmurality with CMR. Of these, 658 (66%) had no evidence
dial motion accurately. Peak systolic (PS), end systolic (ES), and post-
of scar, 143 (11.4%) had a subendocardial scar (#50% of wall thick-
systolic (PSS) endocardial and midwall strain was measured using an
ness), 211 (21.3%) had a transmural scar (100% of wall thickness), and
18-segment model.1,2 The postsystolic index (PSI) was calculated as
only 32 (1.4%) had nontransmural scar (ranging from 51% to
(PSS – ES)/PSS * 100. All strain measurements were performed by
99%).The distribution of 378 segments with scar was as follows:
observers with extensive experience in echocardiography and strain
147 apical (104 subendocardial, 8 nontransmural, 35 transmural),
analysis after a specific training in the respective software with an
124 midventricular (53 subendocardial, 12 nontransmural, 59 trans-
application specialist from each vendor.
mural), and 115 basal (55 subendocardial, 12 nontransmural, 48
transmural). All segments of the five healthy volunteers (90) were
Statistical Analysis included as having no scar.
Normality of distribution was tested by a Kolmogorov-Smirnov test.
Categorical data are presented as percentages, and continuous vari-
ables are presented as mean 6 SD or median and interquartile range. Scar Detection Capability of Layer-Specific SLS
Repeated measures analysis of variance (ANOVA) or Friedman test Measurements
was used to assess the feasibility of tracking and SLS values among The mean of PS values from segments with subendocardial scar
vendors per layer. Bonferroni analysis was used as a post hoc test. ranged from –12.7% to –13.8% and from –9.7% to –12.2% for endo-
Pearson correlation coefficients were used to show the relation cardium and midwall, respectively (Figure 1A for PS, Supplemental
among vendors per layer. Since there is no defined gold standard Figure 2, available at www.onlinejase.com for ES and PSS). All seg-
method for measuring strain, layer-specific strain from each vendor ments with scar (both subendocardial and transmural) showed signif-
was compared with the mean of all vendors. icantly lower strain values for each layer compared with normal
The relative error was expressed as a percent difference between segments (Supplemental Table 1, available at www.onlinejase.com;
repeated measurements (the ratio of absolute difference divided by P < .001). Strain traces of normal and scarred segments from different
average of the measurements) and used to assess test-retest variability. layers are presented in Figure 1B.
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Figure 1 (A) Average LV segmental longitudinal PS strain measurements with SDs per vendor and layer for normal segments (N) and
segments with subendocardial (SS) or transmural scar (TS). Dashed and dotted marks are used for transmural and subendocardial
scars, respectively. One-way ANOVA post hoc (Bonferroni) analysis for differences between different degrees of scar and normal
segments are presented with the asterisks. *P < .001 for each comparison for both layers in all vendors. (B) Examples of longitudinal
endocardial and midwall strain traces from apical four-chamber view of a patient with a normal segment (red) and segments with sub-
endocardial (yellow, blue) or transmural scar (purple, cyan, green). ENDO, Endocardium; MID, midwall.

Transmural strain gradients (endocardial to midwall ratio of PS, ES, both layers, SLS correlated moderately among vendors
and PSS measurements) are presented in Figure 2 and Supplemental (Supplemental Table 2, available at www.onlinejase.com).
Figure 3 (available at www.onlinejase.com). We found no significant Bias 6 SD among vendors are presented in Supplemental
differences in strain gradients between scarred and scar-free seg- Table 3 (available at www.onlinejase.com). Comparison of SLS
ments. measurements between each vendor and the mean of all ven-
ROC curves for the detection of scar are presented in Figure 3. dors showed high correlation for all vendors, in both layers
Comparison of AUCs for scar detection capability of PS showed no signif- (PS, Figure 5; for ES and PSS see Supplemental Figure 8, avail-
icant difference between endocardial and midwall measurements, but able at www.onlinejase.com). The comparison of layer-specific
transmural scars were better detected than subendocardial scars. Similar SLS among vendors per ventricular level (apical, mid, basal)
statistics for ES, PSS, and PSI are presented in Supplemental Figure 4 (avail- showed similar results (Supplemental Figure 9, available at
able at www.onlinejase.com; subendocardial scars) and Supplemental www.onlinejase.com).
Figure 5 (available at www.onlinejase.com; transmural scars).
Among vendors, we found significant differences in AUCs for each Reproducibility of Layer-Specific SLS Measurements
layer (P < .05 for both; Supplemental Figures 6 and 7, available at
The median of relative test-retest errors of endocardial PS measure-
www.onlinejase.com, for detection of subendocardial and transmural
ments ranged from 12.8% to 26.1% and for midwall measurements
scars, respectively).
from 12.7% to 27.8%, respectively. Relative test-retest errors of PS,
ES, and PSS measurements showed significant differences among
Agreement of Layer-Specific SLS Measurements among vendors for both layers (Figure 6). Within the individual vendors,
Vendors we found no significant differences in relative test-retest errors be-
The differences in SLS measurements among vendors were less tween layers and among the three strain parameters. Our analysis
for endocardium compared with midwall but were significant in of the same parameters per ventricular level showed similar results
both layers (ANOVA P # .001 for each layer; Figure 4). For (Supplemental Figure 10, available at www.onlinejase.com).
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Figure 2 Comparison of endocardial to midwall ratio (transmural gradient) of PS strain per vendor and layer for normal segments (N)
and segments with subendocardial (SS) or transmural scar (TS). No statistical significance is present.

Figure 3 ROC curves, AUC, and 95% CI for layer-specific PS strain indicating the ability of each layer to discriminate between normal
segments with subendocardial and transmural scars. ENDO, Endocardium.

DISCUSSION This distinction is relevant, as myocardial deformation differs significantly


in amplitude among these three sampling positions with highest values at
Main Findings the endocardium and lowest at the epicardium.11,14 Unfortunately, there
In this study, we investigated the intervendor variability and reproduc- is still no agreement on which approach is the most favorable for the
ibility of 2D STE layer-specific SLS measurements and their ability to clinical routine.11,15 Furthermore, layer-specific measurements of
detect regional dysfunction using software packages from four myocardial strain have been suggested for a better detection of subtle
different vendors. The main findings can be summarized as follows: myocardial pathology as this frequently affects the subendocardial layer
(1) 2D STE SLS measurements showed clinically relevant differences more.15-25 It is unclear, however, if such differential behavior occurs and
among vendors in both layers, (2) test-retest variability is high in all if current STE technology would be able to resolve such differences at
vendors and similar for endocardial and midmyocardial layers, and all.6,15 We have therefore investigated the variability and
(3) layer-specific SLS measurements from endocardial and midmyo- reproducibility of layer-specific longitudinal strain measurements and
cardial layers do not differ in the ability to detect subendocardial or tested their accuracy in detecting subendocardial and transmural scar.
transmural scar.
Detection of Segmental Dysfunction
Assessing Layer-Specific SLS In all vendors the segments with both subendocardial and transmural
In the EACVI/ASE Task Force on Strain Standardization, longitudinal scar had significantly lower SLS values and strain in segments with
strain has been defined as length change of a line representing either transmural scar was significantly lower than in those with subendocar-
the endocardium, the midwall line, or the epicardium of the ventricles.2 dial scar. Interestingly, the endocardial to midwall ratio of SLS
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Figure 4 Average LV SLS measurements with SDs per vendor and layer. Light colors are used for endocardial values, whereas dark
colors are used for midwall measurements. Repeated measures ANOVA post hoc (Bonferonni) analysis for differences between
individual vendors are presented in the table. A dot in the table indicates the significance of a post hoc test.

Figure 5 Comparison between average segmental PS longitudinal strain measurements of each vendor (y-axis) and the mean of all
vendors (x-axis) per layer. The correlation coefficient (R2) is indicated. P < .001 for each correlation plot. The line of identity is shown
in red.

measurements showed no significant differences between segments of layers could be better used to differentiate subendocardial
with scars and normal function. Even more, we found similar gradi- pathologies,6,26-28 in line with earlier work.29
ents in segments with subendocardial and transmural scars. Our re- The ability to detect scar segments varied significantly among ven-
sults indicate that the longitudinal deformation of the entire wall is dors and was particularly poor for subendocardial scars. Interestingly,
affected even if only the subendocardial part of the wall is dysfunc- a ROC analysis showed no difference between endocardial and mid-
tional. Our results appear logical from a mechanistic-geometric point wall strain measurements with regard to the detection of subendocar-
of view, since differential shortening of adjacent layers must result in dial and transmural scars. Our results again indicate that both layers
bending of the wall, which is never observed in real life. Furthermore, have comparable power for detecting segmental pathology so that
the lateral resolution of echocardiographic images is for physical rea- there is no argument to favor one measurement approach over the
sons too limited for a sufficient differentiation. Therefore, our results other. They make it further questionable whether layer-specific SLS
also challenge the concept that endocardial strain or a combination measurements with current technology provide additional insight at all.
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Figure 6 Relative test-retest error of the median SLS per vendor and layer. Color coding as in Figure 1. The dots indicate the signif-
icant post hoc tests among vendors. P values represented above the bars are indicate the comparison between layers (paired t-test)
within each vendor. ENDO, Endocardium; MID, midwall.

Comparison of Layer-Specific SLS Measurements among differences between endocardium and midwall. To obtain reproduc-
Vendors ibility values comparable between the layers, we have used relative
To the best of our knowledge, this study is the first to investigate the test-retest errors, which account for the expected difference in endo-
differences of layer-specific SLS among those vendors that can report cardial and midwall strain.
layer-specific SLS in their software. SLS measurements showed on Depending on the vendor, both myocardial layers had a median
average 25% relatively higher values in the endocardium than in test-retest variability of SLS measurements of more than 10% and
the midwall, which is in agreement with previous studies.17,30 For up to almost 30%, which is critical in daily practice. It must be noted,
both layers, strain measurements showed a moderate to strong however, that the interpretation of segmental deformation frequently
correlation among vendors. Since there is no gold standard for relies on a shape analysis of the strain curves, which is less affected by
measuring strain, we evaluated the correlation of SLS inaccuracies in absolute values.
measurements from each vendor with the mean of all vendors for a The reproducibility results provide no evidence to favor a specific
given segment. Our results indicate that the correlation is significant myocardial layer over another for routine SLS assessment.
but weaker than for layer-specific GLS measurements.11 One poten-
tial explanation for this finding is that for GLS measurements, infor-
mation from the entire LV contour can be integrated, while for SLS, Vendor Approaches to Strain Measurements
the capability and accuracy for local tracking becomes very relevant.
Our results indicate, that—in contrast to GLS measurements—the
This includes also the handling of regional image artifacts that affect
quality of SLS measurements differs among vendors and that it leaves
segmental measurements much more than one that can be smoothed
in general room for improvement. It must be noted that while details
over the entire ventricle.
of the differences in tracking technology between different vendors
Our results indicate that the software used to obtain layer-specific
are of academic interest, the robustness, accuracy, and repeatability
strain values has a strong impact on the measurements. This notion is
of measurements with a certain software are more important for clin-
even more confirmed when strain is measured using the same image
ical users. Consequently, the task force has agreed that the proprietary
data with software from different vendors. For example, measuring
technology used for measuring the deformation should be at the sole
layer-specific strain on GE images with both GE and TomTec software
discretion of the vendor provided that the vendor guarantees (and
resulted in, respectively, the highest and lowest layer-specific strain
proves) that endocardial strain values represent accurately the defor-
values compared with other vendors. Unfortunately, it is not possible
mation of the endocardial line and midwall strain values represent the
to deliver a technical explanation for the observed discrepancies, as
deformation of the midwall, regardless of how the values are ob-
the underlying technology for layer-specific strain assessment is pro-
tained.
prietary information and not communicated by the companies.
Nevertheless, an agreement on a standardized primary reporting of
either endocardial or midwall strain in software from all vendors
Reproducibility of Layer-Specific SLS Measurements would be desirable for the sake of the acceptance of this method in
According to our results, we observed that relative test-retest errors of the clinic. Our formal comparison of layered measurements provided
SLS measurements showed significant differences among companies no evidence in favor of one of the two approaches so that other
for both layers (Figure 3). The comparison of relative errors for criteria, such as robustness against foreshortening, behavior in certain
repeated measurements for individual vendors revealed no significant anatomy, and so on need to be considered.
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additional information for the detection of dysfunctional segments so 10. Farsalinos KE, Daraban AM, Unl€ € u S, Thomas JD, Badano LP, Voigt J-U,
that the concept of layer-specific SLS acquisitions must be questioned. et al. Head-to-head comparison of global longitudinal strain measurements
among nine different vendors The EACVI/ASE Inter-Vendor Comparison
Study. J Am Soc Echocardiogr 2015;28:1171-81.e2.
ACKNOWLEDGMENTS 11. Unlu S, Mirea O, Duchenne J, Pagourelias ED, Bezy S, Thomas JD, et al.
Comparison of feasibility, accuracy, and reproducibility of layer-specific
global longitudinal strain measurements among five different vendors: A
S.U., O.M., and E.D.P. received research grants from the European
report from the EACVI-ASE Strain Standardization Task Force. J Am Soc
Association of Cardiovascular Imaging. The study was further sup- Echocardiogr 2018;31:374-80.e1.
ported by a dedicated grant of the American Society of 12. Mirea O, Pagourelias ED, Duchenne J, Bogaert J, Thomas JD, Badano LP,
Echocardiography. J-U.V. holds a personal research mandate from et al. Intervendor differences in the accuracy of detecting regional func-
the Flemish Research Foundation (Flanders [FWO], Belgium) and tional abnormalities: A report from the EACVI-ASE Strain Standardization
received a research grant from the University of Leuven. Task Force. JACC Cardiovasc Imaging 2018;11:25-34.
13. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas un-
der two or more correlated receiver operating characteristic curves: a
SUPPLEMENTARY DATA nonparametric approach. Biometrics 1988;44:837-45.
14. Adamu U, Schmitz F, Becker M, Kelm M, Hoffmann R. Advanced speckle
tracking echocardiography allowing a three-myocardial layer-specific
Supplementary material for this article can be found at https://dx.doi.
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org/10.1016/j.echo.2019.01.010. 15. Tarascio M, Leo LA, Klersy C, Murzilli R, Moccetti T, Faletra FF. Speckle-
tracking layer-specific analysis of myocardial deformation and evaluation
of scar transmurality in chronic ischemic heart disease. J Am Soc Echocar-
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Journal of the American Society of Echocardiography € u et al 632.e1
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APPENDIX

Supplemental Figure 1 Percentage of excluded segments (red) per vendor. Tracking was performed on images acquired with high-
end machines from the respective vendor, for TomTec DICOM images from GE were used.
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Supplemental Figure 2 Average LV segmental longitudinal ES and PSS strain measurements with SDs per vendor and layer for
normal segments (N) and segments with subendocardial (SS) or transmural scar (TS). Dashed and dotted marks are used for trans-
mural and subendocardial scars, respectively. One-way ANOVA post hoc (Bonferroni) analysis for differences between different de-
grees of scar and normal segments are presented with the asterisks. P < .001 for each comparison for both layers in all vendors.
ENDO, Endocardium; MID, midwall.
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Supplemental Figure 3 Comparison of endocardial to midwall ratio (transmural gradient) of ES and PSS per vendor and layer for
normal segments (N) and segments with subendocardial (SS) or transmural scar (TS). No statistical significance is present.
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Supplemental Figure 4 ROC curves, AUC, and 95% CI for layer-specific ES, PSS, and PSI indicating the ability of each layer to
discriminate between normal segments with subendocardial scars. ENDO, Endocardium.
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Volume 32 Number 5

Supplemental Figure 5 ROC curves, AUC, and 95% CI for layer-specific ES, PSS, and PSI indicating the ability of each layer to
discriminate between normal segments with transmural scars. ENDO, Endocardium.

Supplemental Figure 6 ROC curves, AUC, and 95% CI for layer-specific PS, ES, PSS, and PSI indicating the differences on the abil-
ity to discriminate between normal segments with subendocardial scars among vendors for both layers. Dots indicate significant dif-
ferences between companies. ENDO, Endocardium.
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Supplemental Figure 7 ROC curves, AUC, and 95% CI for layer-specific PS, ES, PSS, and PSI indicating the differences on the abil-
ity to discriminate between normal segments with transmural scars among vendors for both layers. Dots indicate significant differ-
ences between companies. ENDO, Endocardium.
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Volume 32 Number 5

Supplemental Figure 8 Comparison between average segmental ES and PSS longitudinal strain measurements of each vendor
(y-axis) and the mean of all vendors (x-axis) per layer. The correlation coefficient (R2) is indicated. P < .001 for each correlation
plot. The line of identity is shown in red.
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Supplemental Figure 9 Average LV SLS measurements with SDs per vendor and layer for basal, midventricular, and apical levels of
LV. Light colors are used for endocardial (Endo) values, whereas dark colors are used for midwall measurements. Repeated measures
ANOVA post hoc (Bonferonni) analysis for differences between individual vendors are presented in the table.
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Volume 32 Number 5

Supplemental Figure 10 Relative test-retest error of the median SLS per vendor and layer for basal, midventricular, and apical levels
of LV. Color coding as in Supplemental Figure 9. The dots indicate the significant post hoc tests among vendors. P values represented
above the bars are indicating the comparison between layers (paired t-test) within each vendor. ENDO, Endocardium; MID, midwall.
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Supplemental Table 1 Average LV segmental longitudinal PS strain measurements with SDs per vendor and per layer for normal
segments and segments with subendocardial or transmural scar

Normal segments (n = 658) Segments with subendocardial scar (n = 143) Segments with transmural scar (n = 211)

Vendors\Layers Endocardium Midwall Endocardium Midwall Endocardium Midwall

GE –20.7 6 7.4 a,b,c


–17.8 6 5.3 a,b,c
–13.8 6 8.2 a,b,c
–12.2 6 6.8 a,c
–8.2 6 9.9 a,b
–6.9 6 8.4a,b,c
Siemens –18.9 6 7.4 a,d,e
–14.8 6 5.5 a,d,e
–12.7 6 8.4 a,e
–10.5 6 6.2 a,d
–10.6 6 10.3 a,e
–8.6 6 7.4a,e
Toshiba –18.2 6 5.4 b,d,f
–16.6 6 4.5 b,d,f
–12.9 6 6.1 b,d
–12.1 6 5.5 d
–10.1 6 6.7 b
–9.2 6 6.2b
TomTec –17.1 6 8c,e,f –12.5 6 5.7c,e,f –13.2 6 7.8c,e –9.7 6 5.9c,f –7.8 6 9.1e,f –5.3 6 6.7c,e,f
P (ANOVA) <.001 <.001 <.001 <.001 <.001 <.001
Symbols indicate a significant pairwise post-hoc test among companies at the level of P < .05.
a
GE vs. Siemens
b
GE vs. Toshiba
c
GE vs. TomTec
d
Siemens vs. Toshiba
e
Siemens vs. Tomtec
f
Toshiba vs. TomTec

Supplemental Table 2 Pearson correlation coefficients (R)


for PS, ES, postsystolic longitudinal strain measurements
among vendors per layer

Endocardium Midwall

Vendors Toshiba GE Siemens Toshiba GE Siemens

PS strain
GE 0.78 0.76
Siemens 0.71 0.71 0.65 0.66
TomTec 0.72 0.73 0.70 0.68 0.70 0.66
ES Strain
GE 0.77 0.74
Siemens 0.70 0.71 0.64 0.66
TomTec 0.72 0.74 0.70 0.68 0.71 0.66
PSS
GE 0.69 0.67
Siemens 0.63 0.67 0.58 0.61
TomTec 0.65 0.72 0.67 0.62 0.67 0.62
All P < .001.
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Supplemental Table 3 Bias 6 SD of PS, ES, postsystolic longitudinal strain values among all vendors per layer

Endocardium Midwall

Vendors Toshiba GE Siemens Toshiba GE Siemens

PS strain
GE –1.5 6 6.0 –0.5 6 4.9
Siemens –0.5 6 6.2 0.8 6 6.9 1.6 6 5.2 1.9 6 5.9
TomTec 1.0 6 6.4 2.4 6 6.8 1.54 6 7.04 3.6 6 5.1 4.0 6 5.6 2.1 6 5.5
ES Strain
GE –1.5 6 6.0 –0.6 6 4.9
Siemens 0.1 6 6.1 1.5 6 6.8 2.1 6 5.2 2.6 6 5.6
TomTec 0.9 6 6.4 2.4 6 6.7 0.88 6 6.8 3.5 6 5.0 4.1 6 5.4 1.6 6 5.3
PSS
GE –2.3 6 5.8 –1.1 6 4.6
Siemens –0.7 6 6.2 1.4 6 6.4 1.7 6 5.1 2.8 6 5.3
TomTec –0.4 6 6.5 1.9 6 6.2 0.4 6 6.6 2.6 6 5.0 3.8 6 4.9 0.9 6 5.1
All P < .001.