Thusfar it isn't in our clinical routine, however it is as you and Feigenbaum stated easy to implement, especialliy in cancer patients. I mainly utilize it in my scientific work focussed on genetics, heart failure and cancer treatment. Using the automated function imaging (AFI) traces are set automatically the only thing you need to do is check the tracing and the curves. This all takes some getting to know the curves and knowing the pitfalls. However much literature is at hand mainly by Bart Bijnens, George Sutherland and Frank Weidemann on the background of using 2D strain and all strain modalities.

Its easy to do if you do the scan with the machine having AFI software. Main draw back on this is endocardial definition or suboptimal imaging. Mainly in patients with cancer, if they had undergone mastectomy the surgical scar does not allow to have an adequate window for imaging. Those cases need to be excluded as AFI does not work on this subset of patients. Also with variable HR you cannot do AFI.

I think the implementation of 2D longitudinal strain in the follow up of cancer patients is not only easy with nowdays software but valuable, since it is more sensitive than standard EF. In my opinion we should not rely on a cut off value but on the baseline value of "that" patient and consider significant a decrease >10% from the basal value.

With the current technology this needs to be done by using the same machine and the same software.

I always ask to my technicians to have a good short axis image and 2-3-4Ch to fillup a wallmotion score analysis and after to do the strain and compare and confirm. It is easy to do strain even on forshortened image .I am alway reluctant to leave the machine choose (automatic evaluation by the machine) for me the image so I double check

R. Lebeau md

Speaking on behalf of Dr. Feigenbaum, it is becoming more mainstream and will likely be considered "best practice" in the next 5 years or so. Directly acting on information gathered from strain must be put into a cliical context, but it is nevertheless valuable. See the accepted manuscript in JACC from Thavendiranathan et al. "Use of Myocardial Strain Imaging by Echocardiography for the Early Detection of

Cardiotoxicity in Patients During and After Cancer Chemotherapy – A Systematic

Review"

I think we should do 2D longitudinal strain -LS- (LS enough because there are validated values and subendocardium is usually firstly affected by ischaemia..) in those kind of patients not only to assess whether there is any subclinical systolic dysfunction (systolic function is not only left ventricular ejection fraction), but to do a comprehensive follow-up. 2D LS is nowadays easy, to obtain and to do the analysis with the proper software.

I agree with Dr. Di Salvo, you must use the baseline longitudinal global strain in the individual patient. In our experience, we often use the 2DS in cancer patients with good technical quality of the images. The assessment of ventricular function, beyond the EF, is accurate. Some limitations of the evaluation 2DS we have found in women after left mastectomy for a loss of image quality.

Yes, its good and easy enough, strain imaging helps to follow up patients on chemotherapy ...

Although currently it apears that 2D volumes derived with contrast enhancement seem to be the most sensitve indicator of a LV problem strain is certatinly easy to collect and analyze if captured correctly.  Changes in long strain can be challenging but offer a sensitive marker for myocardial health.

Thanks to everyone. The problem I've been noticing is the acquisition of suboptimal images (prostheses) and worsening throughout time. I guess that this will add some unreliability to serial evaluation

Dear Daniele, I agree with you; the problem of prosthesis should not be underestimated because it significantly reduces the technical quality of the images. However, I believe that the quantification of the chemotherapy effect  on LV function may be possible at least "at short-term". In fact, the coupling of breast implants occurs later, after the healing of the surgical wound and a few cycles of chemotherapy. This is not the best but ....

We use the same echo machine to do our serial measurement in the surveillance of patients with cardiotoxicity drug because there are variability in the LV 2D global longitudinal strain between different company. SP Costa Jase  2014: 27:50-54

There are a subgroup of patients with normal strain value and reduced LVEF particulary with EF between 50-55% W. HE Jase 2014: 27 : abstract B5 (s1A-4)

We use LVEF derived from the WMSI. This EF is more  precise than the biplane Simpson method because it include the apical 3 Chambers in is calculation.

Web: drlebeau.info

Absolutely correct. Unfortunately we always have to use the same machine when performing the follow-up, hoping that the acoustic interface hasn't changed.

Secondly, it could be  "a matter of taste" trying to explore a 5% interval in EF and comparing it to 2D strain. Nonetheless, this could be the first subtle issue in the evaluation of cardiotoxicity.

Last (but noy least), I deeply apologize but I never calculated EF from WMSI ( I just read you proposed the method in 2003)

We are going to implement a routine-procedure to evaluate the mentioned group of patients as we do in the huge amount of pat. with severe heart failure. So using EF is only one tool. Therefore we 1. only give a range for that parameter with a width of 5-10%, never one number as EF in Echo is relativly unprecise. The calculation is done by biplane measurements (auto-EF or by hand) for quick evaluations in daily routine 2. We are applying speckle tracking to include global strain etc. using also the polardiagram/bull eye diagram to estimate the seemingly distribution of the possibly affected LV segments. In this setting it is easy and quick to measure using strain etc.

In recent years one the student of our department had his dissertation on use of 2D strain in follow up of patients undergoing chemotherapy.

We found that it was not difficult on his part to perform 2D strain during the follow up.

(In some studies revealed that, in performaning 2D strain :fellows are better than faculty.)

I think every centre can have a dedicated Echocardiographer for this purpose and possibly 2D strain is a must do part of echocardiographic examination for the patients receiving chemotherapy .