IMAGE SECTION Imaging Cardiac Sarcoidosis: The Incremental Benefit of Speckle Tracking Echocardiography Benoy N. Shah, M.B.B.S.,*† Manuel De Villa, B.Sc.,* Rajdeep S. Khattar, M.D.,*† and Roxy Senior, M.D.,*† *Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; and †National Heart and Lung Institute, Imperial College, London, United Kingdom (Echocardiography 2013;0:E1-E3) Key words: myocardial strain, ejection fraction Assessment of left ventricular (LV) systolic function traditionally has relied heavily on the ejection fraction (EF). However, EF is both pre- load and after-load–dependent 1 and numerous studies have shown its limitations in detecting early myocardial dysfunction. Tissue Doppler imaging 2 and speckle tracking echocardiogra- phy 3 (STE) permit measurement of myocardial strain and strain rate. We present a case in which STE revealed LV dysfunction not detected during routine two-dimensional (2D) echocardiography. A 42-year-old man with pulmonary sarcoidosis was referred for investigation of palpitations, (“an irregular heartbeat”). He had been stable for years on corticosteroid therapy which had there- fore been recently weaned. There was no history of cardiovascular disease. His 24-hour ECG revealed several ventricular extrasystoles and epi- sodic nocturnal Wenkebach heart block only. 2D echocardiography revealed normal LV cavity size, wall thickness, and no regional abnormalities (movie clips S1 and S2) with a borderline normal EF (biplane Simpson’s method EF 57%). STE revealed markedly reduced longitudinal strain in the basal septum and posterolateral walls (see Fig. 1A–C). Global longitudinal strain was signifi- cantly reduced at À12.9% (Fig. 1D). Contrast- enhanced cardiovascular magnetic resonance (CE–CMR) also reported a borderline EF (53%) (movie clip S3). No fibrosis was seen in the pos- terolateral walls but there was prominent inferior LV/RV insertion-point fibrosis. In addition, a focal patch of fibrosis was seen in the basal inferior sep- tum (Fig. 2), which correlated with markedly reduced strain (À9%) in this segment by STE. The patient was consequently diagnosed with cardiac sarcoidosis and his palpitations settled completely with reinitiation of corticosteroid therapy. Speckle tracking echocardiography, STE is a valuable tool for the quantitative assessment of regional myocardial function and this case reemphasizes the limitations of relying on EF as the sole parameter of LV systolic performance. Regional strain abnormalities exceeded the distri- bution of scarring seen on CE–CMR, in keeping with a recent report, 4 and thus functional changes are not necessarily concordant with scar distribution seen on CE-CMR. Large-scale studies using advanced imaging techniques, such as STE, are warranted to clarify their potential clinical role in the detection of both early symptomatic and subclinical myocardial involvement in patients with systemic sarcoidosis. References 1. Manisty CH, Francis DP: Ejection fraction: A measure of desperation? Heart 2008;94:400–401. 2. Sutherland GR, Bijnens B, McDicken WN: Tissue Doppler echocardiography: Historical perspective and technologi- cal considerations. Echocardiography 1999;16:445–453. 3. Kawagishi T: Speckle tracking for assessment of cardiac motion and dyssynchrony. Echocardiography 2008; 25:1167–1171. 4. Kansal MM, Panse PM, Abe H, et al: Relationship of con- trast-enhanced magnetic resonance imaging-derived intramural scar distribution and speckle tracking echocar- diography-derived left ventricular two-dimensional strains. Eur Heart J Cardiovasc Imaging 2012;13:152–158. Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. Apical four-chamber view showing normal contractility of the inferoseptal and lateral walls. Movie clip S2. Apical three-chamber view showing normal contractility of the anteroseptal and posterior walls. Address for correspondence and reprint requests: Roxy Senior M.D., Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London – SW3 6NP, United King- dom. Fax: +44-207-351-8604; E-mail: roxysenior@cardiac-research.org E1 © 2013, Wiley Periodicals, Inc. DOI: 10.1111/echo.12208 Echocardiography