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.,
J-U.V.) and Department of Radiology (J.B.), University Hospital Leuven, Leuven,
Belgium; Bluhm Cardiovascular Institute, Northwestern University (J.D.T.),
Chicago, Illinois; and Cardiac, Thoracic and Vascular Sciences (L.P.B.),
University Padua, Padua, Italy.
Conflicts of Interest: None.
624
Reprint requests: Prof. Dr. Jens-Uwe Voigt, MD, PhD, Department of Cardiovas-
cular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
(E-mail: jens-uwe.voigt@uzleuven.be).
0894-7317/$36.00
Copyright 2019 by the American Society of Echocardiography.
https://doi.org/10.1016/j.echo.2019.01.010
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Unl€
Volume 32 Number 5

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)
 € u et al
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HIGHLIGHTS
 Layer-specific SLS does not help with detection of scars.
 Layer-specific SLS shows significant differences among ven-
dors.
 Test-retest variability of layer-specific SLS is similar for endocar-
dium and midwall.
 No strong evidence favors the use of a certain myocardial layer
for strain measurements.
representing the middle of the echocardiographic segment. Segments
were rated as having subendocardial scar if 1%-50% of the segment
showed hyperenhancement in transmural direction. If the infarct
covered the entire thickness of myocardium, segments were rated
as having a transmural scar. The remaining segments with
intermediate, nontransmural scar were not included in the analysis.
Segments of healthy volunteers were assigned to the no-scar group
without CMR imaging.
Data Analysis
Ejection fraction was calculated based on the biplane modified
Simpson’s rule. Strain measurements were performed with software
from the four vendors who allow both endocardial and midwall
segmental strain assessment (GE, Siemens, Toshiba, and TomTec)
and the images of the respective scanner from the same company.
For TomTec software, DICOM images from GE were used. In the
following, the company names are used to refer to specific software.
End diastole was defined by the electrocardiogram R-wave trigger.
Time of aortic valve closure was measured from pulsed-wave
Doppler acquisitions of LVoutflow tract. To obtain layer-specific strain
measurements, a region of interest covering the entire myocardium
was created by delineating endocardial and epicardial contours of
the LV. In scarred and thin segments, particular care was taken to
ensure the region of interest did not exceed the actual wall contours.
Feasibility of speckle-tracking was evaluated visually. Segments were
rejected from further analysis if the tracking did not follow the myocar-
dial motion accurately. Peak systolic (PS), end systolic (ES), and post-
systolic (PSS) endocardial and midwall strain was measured using an
18-segment model.1,2 The postsystolic index (PSI) was calculated as
(PSS – ES)/PSS * 100. All strain measurements were performed by
observers with extensive experience in echocardiography and strain
analysis after a specific training in the respective software with an
application specialist from each vendor.
Statistical Analysis
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.
Repeated measures analysis of variance (ANOVA) or Friedman test
was used to assess the feasibility of tracking and SLS values among
vendors per layer. Bonferroni analysis was used as a post hoc test.
Pearson correlation coefficients were used to show the relation
among vendors per layer. Since there is no defined gold standard
method for measuring strain, layer-specific strain from each vendor
was compared with the mean of all vendors.
The relative error was expressed as a percent difference between
repeated measurements (the ratio of absolute difference divided by
average of the measurements) and used to assess test-retest variability.
Journal of the American Society of Echocardiography
May 2019
Wilcoxon or paired t-test was used to compare relative errors of layers
within each company. One-way ANOVA with post hoc Bonferroni
analysis was used to compare layer-specific strain measurements
among segments with different degrees of scar and no scar. P < .05
was considered statistically significant.
Since there is a gradient in strain measurements through myocardial
layers, with the highest strain endocardially, the ratio of endocardial to
midwall strain is used to test the hypothesis that scar and nontransmu-
ral scar differentially affect strain measurements in different layers. This
unitless ratio was used to compare layer-specific strain changes in
scarred and normal segments as well as among vendors using a one-
way ANOVA with post hoc Bonferroni analysis.
Receiver operating characteristic (ROC) curves for PS, ES, PSS, and
PSI were calculated to evaluate the ability to differentiate between
normal segments and scars for both layers per vendor. The area under
the ROC curve (AUC) was used as an overall measure of discrimina-
tion. AUC values were interpreted as follows: (1) AUC = 0.5, no
discrimination; (2) 0.6 # AUC < 0.7, poor discrimination; (3)
0.7 # AUC < 0.8, acceptable discrimination; (4) 0.8 # AUC < 0.9,
excellent discrimination; and (5) AUC > 0.9, outstanding discrimina-
tion. The comparison between ROC was performed using De Long
test13 (Medcalc Software, Mariakerke, Belgium). All data were
analyzed using SPSS (IBM, Chicago, IL) version 24.0.
RESULTS
Image data sets of 58 patients and five volunteers were analyzed.
Mean ejection fraction was 52.4% 6 10.0%, ranging from 28% to
73%. There was a minor increase in systolic blood pressure
(128 6 20 to 135 6 17 mm Hg; P < .05) during the scanning, while
no change was observed in diastolic blood pressure (73 6 13 to
74 6 9 mm Hg; P = .6). In total, 1,134 (63  18) segments were eval-
uated by 2D STE. Overall feasibility was 86.7%, with the number
of excluded segments varying significantly among vendors
(8.9%-16.9%, ANOVA P < .05; Supplemental Figure 1, available at
www.onlinejase.com).
All 1,044 (58  18) segments in clinical patients were evaluated for
scar transmurality with CMR. Of these, 658 (66%) had no evidence
of scar, 143 (11.4%) had a subendocardial scar (#50% of wall thick-
ness), 211 (21.3%) had a transmural scar (100% of wall thickness), and
only 32 (1.4%) had nontransmural scar (ranging from 51% to
99%).The distribution of 378 segments with scar was as follows:
147 apical (104 subendocardial, 8 nontransmural, 35 transmural),
124 midventricular (53 subendocardial, 12 nontransmural, 59 trans-
mural), and 115 basal (55 subendocardial, 12 nontransmural, 48
transmural). All segments of the five healthy volunteers (90) were
included as having no scar.
Scar Detection Capability of Layer-Specific SLS
Measurements
The mean of PS values from segments with subendocardial scar
ranged from –12.7% to –13.8% and from –9.7% to –12.2% for endo-
cardium and midwall, respectively (Figure 1A for PS, Supplemental
Figure 2, available at www.onlinejase.com for ES and PSS). All seg-
ments with scar (both subendocardial and transmural) showed signif-
icantly lower strain values for each layer compared with normal
segments (Supplemental Table 1, available at www.onlinejase.com;
P < .001). Strain traces of normal and scarred segments from different
layers are presented in Figure 1B.
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Volume 32 Number 5

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

Main Findings
In this study, we investigated the intervendor variability and reproduc-
ibility of 2D STE layer-specific SLS measurements and their ability to
detect regional dysfunction using software packages from four
different vendors. The main findings can be summarized as follows:
(1) 2D STE SLS measurements showed clinically relevant differences
among vendors in both layers, (2) test-retest variability is high in all
vendors and similar for endocardial and midmyocardial layers, and
(3) layer-specific SLS measurements from endocardial and midmyo-
cardial layers do not differ in the ability to detect subendocardial or
transmural scar.
Assessing Layer-Specific SLS
In the EACVI/ASE Task Force on Strain Standardization, longitudinal
strain has been defined as length change of a line representing either
the endocardium, the midwall line, or the epicardium of the ventricles.2
in amplitude among these three sampling positions with highest values at
the endocardium and lowest at the epicardium.11,14 Unfortunately, there
is still no agreement on which approach is the most favorable for the
clinical routine.11,15 Furthermore, layer-specific measurements of
myocardial strain have been suggested for a better detection of subtle
myocardial pathology as this frequently affects the subendocardial layer
more.15-25 It is unclear, however, if such differential behavior occurs and
if current STE technology would be able to resolve such differences at
all.6,15 We have therefore investigated the variability and
reproducibility of layer-specific longitudinal strain measurements and
tested their accuracy in detecting subendocardial and transmural scar.
Detection of Segmental Dysfunction
In all vendors the segments with both subendocardial and transmural
scar had significantly lower SLS values and strain in segments with
transmural scar was significantly lower than in those with subendocar-
dial scar. Interestingly, the endocardial to midwall ratio of SLS
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Volume 32 Number 5

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
with scars and normal function. Even more, we found similar gradi-
ents in segments with subendocardial and transmural scars. Our re-
sults indicate that the longitudinal deformation of the entire wall is
affected even if only the subendocardial part of the wall is dysfunc-
tional. Our results appear logical from a mechanistic-geometric point
of view, since differential shortening of adjacent layers must result in
bending of the wall, which is never observed in real life. Furthermore,
the lateral resolution of echocardiographic images is for physical rea-
sons too limited for a sufficient differentiation. Therefore, our results
also challenge the concept that endocardial strain or a combination
of layers could be better used to differentiate subendocardial
pathologies,6,26-28 in line with earlier work.29
The ability to detect scar segments varied significantly among ven-
dors and was particularly poor for subendocardial scars. Interestingly,
a ROC analysis showed no difference between endocardial and mid-
wall strain measurements with regard to the detection of subendocar-
dial and transmural scars. Our results again indicate that both layers
have comparable power for detecting segmental pathology so that
there is no argument to favor one measurement approach over the
other. They make it further questionable whether layer-specific SLS
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
Vendors
To the best of our knowledge, this study is the first to investigate the
differences of layer-specific SLS among those vendors that can report
layer-specific SLS in their software. SLS measurements showed on
average 25% relatively higher values in the endocardium than in
the midwall, which is in agreement with previous studies.17,30 For
both layers, strain measurements showed a moderate to strong
correlation among vendors. Since there is no gold standard for
measuring strain, we evaluated the correlation of SLS
measurements from each vendor with the mean of all vendors for a
given segment. Our results indicate that the correlation is significant
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,
the capability and accuracy for local tracking becomes very relevant.
This includes also the handling of regional image artifacts that affect
segmental measurements much more than one that can be smoothed
over the entire ventricle.
Our results indicate that the software used to obtain layer-specific
strain values has a strong impact on the measurements. This notion is
even more confirmed when strain is measured using the same image
data with software from different vendors. For example, measuring
layer-specific strain on GE images with both GE and TomTec software
resulted in, respectively, the highest and lowest layer-specific strain
values compared with other vendors. Unfortunately, it is not possible
to deliver a technical explanation for the observed discrepancies, as
the underlying technology for layer-specific strain assessment is pro-
prietary information and not communicated by the companies.
Reproducibility of Layer-Specific SLS Measurements
According to our results, we observed that relative test-retest errors of
SLS measurements showed significant differences among companies
for both layers (Figure 3). The comparison of relative errors for
repeated measurements for individual vendors revealed no significant
Journal of the American Society of Echocardiography
May 2019
differences between endocardium and midwall. To obtain reproduc-
ibility values comparable between the layers, we have used relative
test-retest errors, which account for the expected difference in endo-
cardial and midwall strain.
Depending on the vendor, both myocardial layers had a median
test-retest variability of SLS measurements of more than 10% and
up to almost 30%, which is critical in daily practice. It must be noted,
however, that the interpretation of segmental deformation frequently
relies on a shape analysis of the strain curves, which is less affected by
inaccuracies in absolute values.
The reproducibility results provide no evidence to favor a specific
myocardial layer over another for routine SLS assessment.
Vendor Approaches to Strain Measurements
Our results indicate, that—in contrast to GLS measurements—the
quality of SLS measurements differs among vendors and that it leaves
in general room for improvement. It must be noted that while details
of the differences in tracking technology between different vendors
are of academic interest, the robustness, accuracy, and repeatability
of measurements with a certain software are more important for clin-
ical users. Consequently, the task force has agreed that the proprietary
technology used for measuring the deformation should be at the sole
discretion of the vendor provided that the vendor guarantees (and
proves) that endocardial strain values represent accurately the defor-
mation of the endocardial line and midwall strain values represent the
deformation of the midwall, regardless of how the values are ob-
tained.
Nevertheless, an agreement on a standardized primary reporting of
either endocardial or midwall strain in software from all vendors
would be desirable for the sake of the acceptance of this method in
the clinic. Our formal comparison of layered measurements provided
no evidence in favor of one of the two approaches so that other
criteria, such as robustness against foreshortening, behavior in certain
anatomy, and so on need to be considered.
Journal of the American Society of Echocardiography
Volume 32 Number 5
Limitations
In our study, factors that can cause errors were minimized by
acquiring high-quality standard echocardiographic images, having
the same sonographer scanning the patients on all machines, and hav-
ing the technical support of a company representative during image
acquisition. Therefore, even higher variability and worse reproduc-
ibility of SLS measurements might be expected in the clinical routine.
In this study, we only compared what was defined as midwall and
endocardial strain according to the consensus of the task force.
Epicardial strain was not within the scope of this study as it appeared
less relevant for clinical use: it is most difficult to define, prone to
tracking problems due to the bright epi-/pericardium, and hampered
with low signal-to-noise ratio.
Since not all companies have the option for measuring SLS from
different layers, the study was performed with software from four
companies only. The data were investigated using only the latest
commercially available software of each vendor at the beginning of
the study. The effect of software upgrades on layer-specific strain re-
mains a question for further studies.
Misalignment between magnetic resonance imaging and echocar-
diography data sets as well as edema and nontransmural scar are chal-
lenges for a clear definition of scar extent. We therefore excluded all
segments with an intermediate scar (51%-99%). Nevertheless, as the
primary aim of this study was the comparison among vendors, a po-
tential wrong assignment of a small number of segments would affect
all vendors in the same way and would therefore have little influence
on the study results.
CONCLUSION
Layer-specific SLS measurement results vary significantly among ven-
dors. Endocardial and midwall SLS measurements have a high yet
comparable test-retest variability. Our results provide no evidence to
favor the diagnostic use of one myocardial layer over another.
Layer-specific SLS measurements or their combination do not provide
additional information for the detection of dysfunctional segments so
that the concept of layer-specific SLS acquisitions must be questioned.
ACKNOWLEDGMENTS
S.U., O.M., and E.D.P. received research grants from the European
Association of Cardiovascular Imaging. The study was further sup-
ported by a dedicated grant of the American Society of
Echocardiography. J-U.V. holds a personal research mandate from
the Flemish Research Foundation (Flanders [FWO], Belgium) and
received a research grant from the University of Leuven.
SUPPLEMENTARY DATA
Supplementary material for this article can be found at https://dx.doi.
org/10.1016/j.echo.2019.01.010.
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Volume 32 Number 5

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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Volume 32 Number 5

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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May 2019

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.