Purpose: We developed a feature-tracking algorithm for use with electrocardiography-gated high-resolution ^<13>N-ammonia positron emission tomography (PET) imaging, and we hypothesized it could be use
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FIGURE LEGENDS
Fig.1 Semi-automatic feature-tracking in cine imaging of positron emission tomography
Images from left to right indicate the flow of the image processing. First, the endocardial border was manually
defined as a freehand line at end-diastole (green square). Then, the line was replaced with 7 points, and the
template image centered on each point was tracked through a cardiac cycle. The upper row indicates the
tracking of the right ventricular free wall on horizontal long-axis images (magenta square). The lower row
indicates the tracking of the left ventricular inferior wall on vertical long-axis images (yellow square).
Fig.2 Systolic longitudinal strain values according to myocardial flow reserve status
(a) Right ventricular free-wall longitudinal strain values in patients with RCA-MFR<2.0 (purple/dark purple),
with LAD/LCx-MFR<2.0 (blue/dark blue), with regional
for all territories (red/dark red), and
control (green/dark green). (b) Left ventricular inferior-wall longitudinal strain values in patients with RCAMFR<2.0 (purple/dark purple), with LAD/LCx-MFR<2.0 (blue/dark blue), with regional
for all
territories (red/dark red), and control (green/dark green).
**P<0.01, *P<0.05. RV, right ventricular; LV, left ventricular; MFR, myocardial flow reserve; RCA, right
coronary artery; LAD, left anterior descending artery; LCx, left circumflex coronary artery.
Fig.3 Systolic longitudinal strain values according to the presence of ischemic image findings
Right ventricular free-wall longitudinal strain values in patients with RCA ischemia (purple/dark purple), with
LAD/LCx ischemia (blue/dark blue), without ischemia (red/dark red), and control (green/dark green).
**P<0.01, *P<0.05. RV, right ventricular; RCA, right coronary artery; LAD, left anterior descending artery;
LCx, left circumflex coronary artery
Fig.4 13N-ammonia PET images (left) and the RV-LS curve (right) for a woman in her 50s with RCAMFR=1.20 (blue) and for a man in his late 60s with RCA-MFR
.0 (red)
In the patients with RCA-MFR=1.20, stressed RV-LS (blue solid curve) was reduced compared to the resting
state (blue dashed line). In patients with RCAto that in the resting state (red dashed line).
3.0, stressed RV-LS (red solid curve) increased compared
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PET, positron emission tomography; RV-LS, right ventricular longitudinal strain; RCA, right coronary artery;
MFR, myocardial flow reserve.
Fig.5 Correlations between right ventricular free-wall strains and regional myocardial flow reserves
Scatter plots show the correlations between longitudinal strain and regional myocardial flow reserve. Plots in
the upper and lower rows indicate the values in the stressed and resting states, respectively.
rS
, right ventricular; MFR,
myocardial flow reserve; RCA, right coronary artery; LAD, left anterior descending artery; LCx, left
circumflex coronary artery.
Fig.6 Correlations between left ventricular inferior-wall strains and regional myocardial flow reserves.
Scatter plots show the correlations between longitudinal strain and regional myocardial flow reserve. Plots in
the upper and lower rows indicate the values in the stressed and resting states, respectively.
rS
, left ventricular; MFR,
myocardial flow reserve; RCA, right coronary artery; LAD, left anterior descending artery; LCx, left
circumflex coronary artery.
Endocardial line
End-diastole
End-systole
Mid-diastole
RV free-wall tracking
LV inferior-wall tracking
FIGURE 1. Semi-automatic feature-tracking in cine imaging of positron emission tomography.
Images from left to right indicate the flow of the image processing. First, the endocardial border was manually defined as a
freehand line at end-diastole (green square). Then, the line was replaced with 7 points, and the template image centered on
each point was tracked through a cardiac cycle. The upper row indicates the tracking of the right ventricular free wall on
horizontal long-axis images (magenta square). The lower row indicates the tracking of the left ventricular inferior wall on
vertical long-axis images (yellow square).
a. RV free-wall strain
b. LV inferior-wall strain
FIGURE 2. Systolic longitudinal strain values according to myocardial flow reserve status.
(a) Right ventricular free-wall longitudinal strain values in patients with RCA-MFR<2.0 (purple/dark purple), with
LAD/LCxgreen). (b) Left ventricular inferior-wall longitudinal strain values in patients with RCA-MFR<2.0 (purple/dark purple), with
LAD/LCxgreen).
**P<0.01, *P<0.05. RV, right ventricular; LV, left ventricular; MFR, myocardial flow reserve; RCA, right coronary artery;
LAD, left anterior descending artery; LCx, left circumflex coronary artery.
FIGURE 3. Systolic longitudinal strain values according to presence of ischemic image findings.
Right ventricular free-wall longitudinal strain values in patients with RCA ischemia (purple/dark purple), with LAD/LCxischemia (blue/dark blue), without ischemia (red/dark red), and control (green/dark green).
**P<0.01, *P<0.05. RV, right ventricular; RCA, right coronary artery; LAD, left anterior descending artery; LCx, left
circumflex coronary artery.
End-systole
RV longitudinal strain [%]
RCA-MFR=1.20
End-diastole
R-R duration [%]
FIGURE 4. 13N-ammonia PET images (left) and the RV-LS curve (right) for a woman in her 50s with RCAMFR=1.20 (blue) and for a man in his late 60s with RCAIn the patients with RCA-MFR=1.20, stressed RV-LS (blue solid curve) was reduced compared to the resting state (blue
dashed line). In patients with RCA-LS (red solid curve) increased compared to that in the resting
state (red dashed line).
PET, positron emission tomography; RV-LS, right ventricular longitudinal strain; RCA, right coronary artery; MFR,
myocardial flow reserve.
RV free-wall strain vs. RCA-MFR
RV free-wall strain vs. LAD-MFR
rS
P <0.0001
-40
-50
-10
RV longitudinal strain [%]
RV longitudinal strain [%]
RV longitudinal strain [%]
Stress state
-30
-20
-30
-40
-50
-60
P = 0.74
-30
-40
-50
Myocardial flow reserve
-20
-30
-40
-60
rS
P = 0.67
-10
-50
Myocardial flow reserve
RV longitudinal strain [%]
-20
-40
-60
P = 0.72
RV longitudinal strain [%]
RV longitudinal strain [%]
Resting state
-10
-30
Myocardial flow reserve
-10
-60
-20
-50
Myocardial flow reserve
rS
P <0.0001
-10
-20
-60
rS
P <0.0001
-10
RV free-wall strain vs. LCx-MFR
-20
-30
-40
-50
Myocardial flow reserve
-60
Myocardial flow reserve
FIGURE 5. Correlations between right ventricular free-wall strains andregional myocardial flow reserves.
Scatter plots show the correlations between longitudinal strain and regional myocardial flow reserve. Plots in the upper and
lower rows indicate the values in the stressed and resting states, respectively.
rS
reserve; RCA, right coronary artery; LAD, left anterior descending artery; LCx, left circumflex coronary artery.
rS
P = 0.22
-10
-20
-30
-40
-10
-20
-30
-40
-50
P = 0.15
-30
-40
Myocardial flow reserve
-10
-20
-30
-40
-50
P = 0.07
-10
-20
-30
-40
-50
Myocardial flow reserve
Myocardial flow reserve
rS
P = 0.42
LV longitudinal strain [%]
-20
LV longitudinal strain [%]
LV longitudinal strain [%]
Resting state
-10
-50
rS
P = 0.10
Myocardial flow reserve
Myocardial flow reserve
LV inferior-wall strain vs. LCx-MFR
rS
P = 0.09
LV longitudinal strain [%]
LV longitudinal strain [%]
Stress state
-50
LV inferior-wall strain vs. LAD-MFR
LV longitudinal strain [%]
LV inferior-wall strain vs. RCA-MFR
-10
-20
-30
-40
-50
Myocardial flow reserve
FIGURE 6. Correlations between left ventricular inferior-wall strains and regional myocardial flow reserves.
Scatter plots show the correlations between longitudinal strain and regional myocardial flow reserve. Plots in the upper and
lower rows indicate the values in the stressed and resting states, respectively.
rS
reserve; RCA, right coronary artery; LAD, left anterior descending artery; LCx, left circumflex coronary artery.
a. RV free-wall strain
b. LV inferior-wall strain
FIGURE 3. Systolic longitudinal strain values according to presence of ischemic image findings.
(a) Right ventricular free-wall longitudinal strain values in patients with RCA ischemia (purple/dark purple), with LAD/LCxischemia (blue/dark blue), without ischemia (red/dark red), and control (green/dark green). (b) Left ventricular inferior-wall
longitudinal strain values in patients with RCA ischemia (purple/dark purple), with LAD/LCx-MFR ischemia (blue/dark
blue), without ischemia (red/dark red), and control (green/dark green).
**P<0.01, *P<0.05. RV, right ventricular; LV, left ventricular; RCA, right coronary artery; LAD, left anterior descending
artery; LCx, left circumflex coronary artery.
TABLE 1 Baseline patient characteristics and 13N-ammonia PET measurements
Characteristics
Number
RCA-MFR<2.0
LAD-MFR<2.0 or
Control
LCx-MFR<2.0
34
11
48
10
69 ± 11
68 ± 11
67 ± 10
41 ± 15
20/14
7/4
34/14
6/4
Hypertension
24
36
Dyslipidemia
15
23
Diabetes mellitus
20
38
Smoking
15
22
Positive family history
13
History of myocardial infarction
Previous PCI
Previous CABG
SSS
9±9
8±8
2±3
2±3
SRS
3±4
3±4
1±1
1±1
SDS
6±8
5±5
2±3
1±2
Stress MBF [mL/g/min]
1.60 ± 0.56
1.98 ± 0.40
2.43 ± 0.54
2.43 ± 1.00
Resting MBF [mL/g/min]
1.05 ± 0.29
1.00 ± 0.21
0.92 ± 0.22
1.06 ± 0.28
Global-MFR
1.5 ± 0.4
2.0 ± 0.1
2.7 ± 0.6
2.2 ± 0.6
RCA-MFR
1.5 ± 0.4
2.3 ± 0.2
2.8 ± 0.5
2.3 ± 0.6
LAD-MFR
1.6 ± 0.4
2.0 ± 0.2
2.7 ± 0.6
2.3 ± 0.6
LCx-MFR
1.6 ± 0.4
1.8 ± 0.3
2.7 ± 0.6
2.2 ± 0.6
Stress LVEDV [mL]
105 ± 33
101 ± 27
99 ± 25
76 ± 15
Age [year]
Male/Female
Cardiovascular risk factor
Clinical history of CAD
Ammonia PET measurements
Stress LVESV [mL
44 ± 29
38 ± 20
30± 16
17 ± 5
Stress LVEF [%]
62 ± 16
64 ± 12
71 ± 9
78 ± 4
Resting LVEDV [mL]
92 ± 35
89 ± 28
85 ± 23
71 ± 15
Resting LVESV [mL]
38 ± 29
31 ± 20
25 ± 13
17 ± 5
Resting LVEF [%]
66 ± 15
67 ± 14
72 ± 9
76 ± 5
Unless otherwise indicated, data are presented as the mean ± standard deviation. CAD, coronary artery
disease; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; PET, positron
emission tomography; SSS, summed stress score; SRS, summed rest score; SDS, summed difference score;
MBF, myocardial blood flow; MFR, myocardial flow reserve; RCA, right coronary artery; LV, left ventricular;
EDV, end-diastolic volume; ESV, end-systole volume; EF, ejection fraction.
TABLE 2 Reproducibility of longitudinal strain analyses
Intra-observer reproducibility
Parameter
Bias (LOA)
Stress
1.40 ( 16.8
RV-LS
to 14.1)
Resting
0.3 ( 14.0
RV-LS
to 13.4)
Stress
0.8 ( 4.0 to
LV-LS
5.5)
Resting
0.46 ( 4.4
LV-LS
to 3.5)
SDD
7.9
7.0
2.4
2.0
ICC (95%
CI)
Inter-observer reproducibility
Bias (LOA)
0.85 (0.83 to
1.0 ( 18.3
0.87)
to 16.3)
0.88 (0.85 to
0.03( 16.1
0.90)
to 16.1)
0.97 (0.83 to
0.29 ( 4.97
0.99)
to 4.39)
0.98 (0.97 to
0.15 ( 4.24
0.98)
to 3.94)
SDD
8.8
8.2
2.5
2.1
ICC (95%
CI)
0.82 (0.80 to
0.87)
0.83 (0.80 to
0.86)
0.97 (0.96 to
0.97)
0.97 (0.97 to
0.98)
RV, right ventricular; LV, left ventricular; LS, longitudinal strain; LOA, limit of agreement; SDD, standard
deviation of the difference; ICC, intraclass correlation coefficient; CI, confidence interval.
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