Echocardiography in Cardio-Oncology

Updated March 25, 2021

Introduction

• Echocardiography plays a central role in the field of cardio-oncology
• Many of the trials use LVEF in the definition for cardio-toxicity
• Ongoing area of research to determine how early and how best to predict cardiac complications of cancer therapy

Cardiac Complications of Chemotherapy and Radiation

• Cardiomyopathies
  • LV dysfunction (HFpEF or HFrEF)
  • Myocarditis
  • Takotsubo
  • Thrombus
  • Infiltration
• Vascular Disease
  • Arterial stiffness
  • Accelerated athersclerosis
• Pericardial Disease
  • Tamponade
  • Constriction

• Pulmonary Hypertension
• • RV Dysfunction
• Valvular Disease
  • Regurgitation
  • Stenosis
  • Endocarditis
• Arrhythmias
  • QTC prolongation

Frequency of Monitoring

• Surveillance is initially stratified by baseline risk (low, medium, high) and then frequency is determined by chemotherapy cycles while on treatment and monthly after treatment
• Recommendations vary greatly between guidelines
• CCS does not have any recommendation for anthracyclines and recommends q3months for Anti-HER2
• Example surveillance protocols below from ESC

Echo Assessment

Definition of Cancer Treatment Related Cardiac Dysfunction (CRTCD)

• EF drop of >10% from baseline and <50% (or 50%)
  
• Relative reduction in GLS > 15% from baseline
  

Echo Protocol

LV Systolic Function

2D EF

• Acquisition
  • Images should be acquired at end-respiration
  • Simpsons method preferred
  • In atrial fibrillation use beats with similar R-R interval

3D EF

• Acquisition:
  • High-quality ECG with clear R-wave (used for software to trigger full volume)
  • Recommend breath hold with shallow breathing, preferably end-expiration (if deep inspiration needed, recommended to document and recreate at next exam)
  • Review images before patient patient leaves to look for stitch artifact and ensure if contouring possible
  • Some variations between software thus should use same machine and analysis software for serial echo
  • Sensitive to image quality thus 2D and 3D images should be taken
• Benefits:
  • No assumptions made about LV geometry (ie. short axis view of ventricle is circular)
  • Ability to discriminate smaller % changes (5-8%)
  • Semi-automated and thus better intra- and interobserver variability

Contrast

• Poor endocardial definition can occur in patients post mastectomy, chest radiation or breast reconstruction surgery)
• Contrast should be used when 2 contiguous LV segments from any apical view are no adequately visualized

LV Diastolic Function

• Diastolic dysfunction may appear earlier than systolic dysfunction so important to acquire on each exam

Global Longitudinal Strain

• Acquisition:
  • GLS is calculated using A3C/A4c/A2c views with optimal image quality and frame rate 40-90
  • If more than 2 segments have poor tracking, GLS should not be calculated
  • Some variations between software thus should use same machine and analysis software for serial echo
  • Great article to learn how to acquire strain: JACC 2015: Practical Guidance in Echocardiographic Assessment of Global Longitudinal Strain
• Interpretation
• • ASE 2015: “peak GLS in the range of -20% can be expected in a healthy person, and the lower the absolute value of strain is below this value, the more likely it is to be abnormal”
  • Cardiotoxicity defined as relative reduction in GLS > 15% from baseline
  • Currently being studied how well GLS can predict cardiotoxicity (SUCCOUR study + commentary)

Right Heart

• Not officially included in the definition of cancer treatment related cardiac dysfunction
• Recommended parameters as expected: RV dimenions, RV S’, TAPSE, TR Velocity, FAC
• Certain cancer treatments can cause PH (dasatinib) and/or RV dysfunction (anthracycline, anti-HER2, cyclophosphamide, dasatinib)

Radiation Related Cardiac Dysfunction

• Pericardial disease is the most frequent radiation related complication
  • Can occur months to years later 
  • Should assess for constriction and pericardial effusion
• Valvular disease can occur with radiation
  • Fibrotic process which can cause leaflet thickening, shortening and calcifications that may result in stenosis or regurgitation
  • More often left-sided valves
  • Recommended to image 5 years after RT in high risk patients and 10 years in non high risk followed by q5years

Multimodal Imaging

• CT
  • Useful in non-invasive evaluation of coronary disease, pericardial disease, and cardiac tumours
• MRI
  • Useful in patients with poor echocardiographic windows
  • Great inter- intrareader variability and thus sensitive in detecting small changes in EF

Tutorials

Phillips EPIQ Strain Tutorial

Phillips Dynamic Heart Model (Single-Beat) Tutorial

Case

Further Reading

• 2020 HFA/EACVI/ESC: Role of cardiovascular imaging in cancer patients receiving cardiotoxic therapies (html) (pdf)
• 2021 BSE/BCOS: Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab (html) (pdf)
• 2015 ASE/EACVI: Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults (html) (pdf)
• 2015 JACC: Practical Guidance in Echocardiographic Assessment of Global Longitudinal Strain (html) (pdf)

Authors

• Author: Atul Jaidka (MD, FRCPC, Cardiology Fellow)
• Last Updated: March 24, 2021
• Comments or questions please email feedback@cardioguide.ca