November 2024 Issue
ISSN 2689-291X
ISSN 2689-291X
Apical Sparing In Amyloid Strain Imaging:
The Cherry-On-Top!
Description
Myocardial strain imaging has emerged as a valuable tool in the diagnosis and assessment of various cardiomyopathies [1]. The above two images demonstrate a bull’s eye plot of the global longitudinal peak strain (GLPS) showing a low average GLPS; normal being lower (more negative) than -16% to -18% [2].
In figure A, the size of the cherry-on-top is smaller, restricted mostly to the apical segments, with an average apical strain to average-mid plus average-basal strain ratio (relative apical sparing index; RASI) of 1.5 [3]. This satisfies the value of ≥ 1 suggested to reflect amyloid infiltrative cardiomyopathy [4].
In figure B, there is a large cherry-on-top extending into the mid to basal segments, causing the RASI to be 0.85, which is less than the value of ≥ 1 suggested to reflect amyloid heart disease.
Discussion
Echocardiographic myocardial strain from all cardiac chambers, especially the left atrium, was shown to have significant prognostic relation to survival in patients having biopsy-proven cardiac amyloidosis [5]. RASI calculation is important as it has the potential to differentiate between the different subtypes of cardiac amyloidosis [6]. In addition, RASI may change with time, likely due to disease progression, underscoring the importance of repeat negative measurements when the index of suspicion remains high [7].
References
Myocardial strain imaging has emerged as a valuable tool in the diagnosis and assessment of various cardiomyopathies [1]. The above two images demonstrate a bull’s eye plot of the global longitudinal peak strain (GLPS) showing a low average GLPS; normal being lower (more negative) than -16% to -18% [2].
In figure A, the size of the cherry-on-top is smaller, restricted mostly to the apical segments, with an average apical strain to average-mid plus average-basal strain ratio (relative apical sparing index; RASI) of 1.5 [3]. This satisfies the value of ≥ 1 suggested to reflect amyloid infiltrative cardiomyopathy [4].
In figure B, there is a large cherry-on-top extending into the mid to basal segments, causing the RASI to be 0.85, which is less than the value of ≥ 1 suggested to reflect amyloid heart disease.
Discussion
Echocardiographic myocardial strain from all cardiac chambers, especially the left atrium, was shown to have significant prognostic relation to survival in patients having biopsy-proven cardiac amyloidosis [5]. RASI calculation is important as it has the potential to differentiate between the different subtypes of cardiac amyloidosis [6]. In addition, RASI may change with time, likely due to disease progression, underscoring the importance of repeat negative measurements when the index of suspicion remains high [7].
References
- Smiseth OA, Rider O, Cvijic M, Valkovič L, Remme EW, Voigt JU. Myocardial Strain Imaging: Theory, Current Practice, and the Future. JACC Cardiovasc Imaging. 2024 Aug 26:S1936-878X(24)00301-2.
- Haji K, Marwick TH. Clinical Utility of Echocardiographic Strain and Strain Rate Measurements. Curr Cardiol Rep. 2021 Feb 16;23(3):18.
- Saijo Y, Yamada H, Yamaguchi N, Nishio S, Zheng R, Takahashi T, Hara T, Kadota M, Kawabata Y, Ueno R, Matsuura T, Ise T, Yamaguchi K, Yagi S, Soeki T, Wakatsuki T, Sata M. Diagnostic Utility of Relative Apical Sparing Index in Cardiac Amyloidosis Subtypes: A Comparative Study of Immunoglobulin Light Chain and Transthyretin Amyloid Cardiomyopathy. Echocardiography. 2025 Feb;42(2):e70087.
- Bravo PE, Fujikura K, Kijewski MF, Jerosch-Herold M, Jacob S, El-Sady MS, Sticka W, Dubey S, Belanger A, Park MA, Di Carli MF, Kwong RY, Falk RH, Dorbala S. Relative Apical Sparing of Myocardial Longitudinal Strain Is Explained by Regional Differences in Total Amyloid Mass Rather Than the Proportion of Amyloid Deposits. JACC Cardiovasc Imaging. 2019 Jul;12(7 Pt 1):1165-1173.
- Huntjens PR, Zhang KW, Soyama Y, Karmpalioti M, Lenihan DJ, Gorcsan J 3rd. Prognostic Utility of Echocardiographic Atrial and Ventricular Strain Imaging in Patients With Cardiac Amyloidosis. JACC Cardiovasc Imaging. 2021 Aug;14(8):1508-1519.
- Bavishi A, Witting C, Guo J, Wu E, John J, Jankowski M, Baldridge AS, Meng D, Maganti K. Predictive Value of Relative Apical Sparing of Longitudinal Strain on Echocardiography for Cardiac Amyloidosis. Am J Cardiol. 2023 Aug 1;200:66-71
- Usuku H, Yamamoto E, Sueta D, Noguchi M, Fujisaki T, Egashira K, Morioka M, Komorita T, Oike F, Fujisue K, Hanatani S, Arima Y, Takashio S, Oda S, Kawano H, Matsushita K, Ueda M, Matsui H, Tsujita K. Time-dependent change of relative apical longitudinal strain index in patients with wild-type transthyretin amyloid cardiomyopathy. Int J Cardiol Heart Vasc. 2022 Nov 5;43:101146.
Authors:
Alexis Parks, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Sanchitha Nagaraj, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mohammad As Sayaideh, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mariam Riad, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mustafeez Ur Rahman, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Brent Ruiz, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Hajira Malik, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Celestine Odigwe, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
Suganya Manoharan, M.D.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL
Alexis Parks, D.O.
Cardiology Fellow
University of South Alabama
Mobile, AL
Sanchitha Nagaraj, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mohammad As Sayaideh, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mariam Riad, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Mustafeez Ur Rahman, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Brent Ruiz, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Hajira Malik, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Celestine Odigwe, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
Suganya Manoharan, M.D.
Assistant Professor of Cardiology
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL