Skip to main content
    • Aa
    • Aa
  • Get access
    Check if you have access via personal or institutional login
  • Cited by 6
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Järvelä, Liisa S. Saraste, Markku Niinikoski, Harri Hannukainen, Jarna C. Heinonen, Olli J. Lähteenmäki, Päivi M. Arola, Mikko and Kemppainen, Jukka 2016. Home-Based Exercise Training Improves Left Ventricle Diastolic Function in Survivors of Childhood ALL: A Tissue Doppler and Velocity Vector Imaging Study. Pediatric Blood & Cancer, Vol. 63, Issue. 9, p. 1629.

    Li, Vivian Wing-yi Cheuk, Daniel Ka-leung Cheng, Frankie Wai-tsoi Yang, Janet Yee-kwan Yau, Jeffrey Ping-wa Ho, Karin Ka-huen Li, Chi-kong Li, Rever Chak-ho Yuen, Hui-leung Ling, Alvin Siu-cheung Chan, Godfrey Chi-fung and Cheung, Yiu-fai 2016. Myocardial stiffness as assessed by diastolic wall strain in adult survivors of childhood leukaemias with preserved left ventricular ejection fraction. European Heart Journal – Cardiovascular Imaging, p. jew098.

    Taqatqa, Anas Bokowski, John Al-Kubaisi, Maytham Khalil, Ahmad Miranda, Carlos Alaksham, Hamad Fughhi, Ibtihaj Kenny, Damien and Diab, Karim A. 2016. The Use of Speckle Tracking Echocardiography for Early Detection of Myocardial Dysfunction in Patients with Duchenne Muscular Dystrophy. Pediatric Cardiology,

    Mele, Donato Rizzo, Paola Pollina, Alberto V. Fiorencis, Andrea and Ferrari, Roberto 2015. Cancer Therapy-Induced Cardiotoxicity: Role of Ultrasound Deformation Imaging as an Aid to Early Diagnosis. Ultrasound in Medicine & Biology, Vol. 41, Issue. 3, p. 627.

    Webb, Melissa K. Auerbach, Scott R. Younoszai, Adel K. Patel, Sonali S. and Landeck, Bruce F. 2015. Strain and Strain Rate Measured on Echocardiogram 1-3 Weeks after Starting Treatment Is Worse in Acute Dilated Cardiomyopathy Pediatric Patients with Poor Outcomes at One Year. Echocardiography, Vol. 32, Issue. 11, p. 1688.

    Vandenbroucke, Tineke Verheecke, Magali Van Calsteren, Kristel Han, Sileny Claes, Laurence and Amant, Frédéric 2014. Fetal outcome after prenatal exposure to chemotherapy and mechanisms of teratogenicity compared to alcohol and smoking. Expert Opinion on Drug Safety, Vol. 13, Issue. 12, p. 1653.


Left ventricular strain and strain rates are decreased in children with normal fractional shortening after exposure to anthracycline chemotherapy

  • Thomas J. Moon (a1), Shelley D. Miyamoto (a1), Adel K. Younoszai (a1) and Bruce F. Landeck (a1)
  • DOI:
  • Published online: 18 September 2013

Anthracycline chemotherapeutic agents carry the well-recognised risk of cardiotoxicity. Previous methods to evaluate cardiac function are useful, but have significant limitations. We sought to determine the left ventricular strain and strain rate of paediatric cancer patients with normal fractional shortening treated with anthracyclines using the latest ultrasound feature-tracking technology.

Patients and methods

Echocardiograms on cancer patients before anthracycline exposure and following completion of treatment were retrospectively analysed using Velocity Vector Imaging software in the circumferential and longitudinal planes. The same analysis was performed on matched controls. Only patients with a fractional shortening ≥28% were included.


In all, 71 patients were identified with an age at diagnosis of 10.5 ± 4.7 years. The time from diagnosis to follow-up was 3.9 ± 4.0 years and the cumulative anthracycline dose was 356 ± 106 mg/m2. Following anthracycline exposure, paediatric cancer patients had a higher heart rate and a lower longitudinal strain, longitudinal diastolic strain rate, circumferential strain, and circumferential systolic and diastolic strain rate when compared with controls. Diastolic strain rate showed the greatest percent difference following anthracycline exposure versus controls.


Despite having a normal fractional shortening, children exposed to anthracyclines have subclinical derangement of their left ventricular deformation as measured by decreases in strain and strain rate in both the circumferential and longitudinal axis. In particular, there was a profound decrease in diastolic strain rate following anthracycline exposure compared with controls. Whether the decline of strain or strain rate can predict future risk of developing cardiomyopathy requires further investigation.

Corresponding author
Correspondence to: B. Landeck, MD, Department of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado-Denver, 13123 East 16th Avenue, Aurora, Colorado, United States of America. Tel: 720-777-2943; Fax: 720-777-7290; E-mail:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

1.DD Von Hoff , M Rozencweig , M Layard , M Slavik , FM Muggia . Daunomycin-induced cardiotoxicity in children and adults. A review of 110 cases. Am J Med 1977; 62: 200208.

3.SE Lipshultz , JA Alvarez , RE Scully . Anthracycline associated cardiotoxicity in survivors of childhood cancer. Heart 2008; 94: 525533.

4.SE Lipshultz , SD Colan , RD Gelber , AR Perez-Atayde , SE Sallan , SP Sanders . Late cardiac effects of doxorubicin therapy for acute lymphoblastic leukemia in childhood. N Engl J Med 1991; 324: 808815.

5.SE Lipshultz , SR Lipsitz , SM Mone , et al. Female sex and drug dose as risk factors for late cardiotoxic effects of doxorubicin therapy for childhood cancer. N Engl J Med 1995; 332: 17381743.

8.PK Singal , N Iliskovic . Doxorubicin-induced cardiomyopathy. N Engl J Med 1998; 339: 900905.

10.SE Lipshultz , SR Lipsitz , SE Sallan , et al. Chronic progressive cardiac dysfunction years after doxorubicin therapy for childhood acute lymphoblastic leukemia. J Clin Oncol 2005; 23: 26292636.

11.SM Shankar , N Marina , MM Hudson , et al. Monitoring for cardiovascular disease in survivors of childhood cancer: report from the Cardiovascular Disease Task Force of the Children's Oncology Group. Pediatrics 2008; 121: e387e396.

12.GG Sandor , M Puterman , P Rogers , KW Chan , S Pritchard , R Popov . Early prediction of anthracycline cardiomyopathy using standard M-mode and digitized echocardiography. Am J Pediatr Hematol Oncol 1992; 14: 151157.

13.D Iarussi , M Galderisi , G Ratti , et al. Left ventricular systolic and diastolic function after anthracycline chemotherapy in childhood. Clin Cardiol 2001; 24: 663669.

14.L Elbl , H Hrstkova , V Chaloupka . The late consequences of anthracycline treatment on left ventricular function after treatment for childhood cancer. Eur J Pediatr 2003; 162: 690696; Epub 2003 August 7.

15.LC Kremer , HJ van der Pal , M Offringa , EC van Dalen , PA Voûte . Frequency and risk factors of subclinical cardiotoxicity after anthracycline therapy in children: a systematic review. Ann Oncol 2002; 13: 819829.

16.J Ganame , P Claus , A Uyttebroeck , et al. Myocardial dysfunction late after low-dose anthracycline treatment in asymptomatic pediatric patients. J Am Soc Echocardiogr 2007; 20: 13511358.

17.G Perk , PA Tunick , I Kronzon . Non-Doppler two-dimensional strain imaging by echocardiography – from technical considerations to clinical applications. J Am Soc Echocardiogr 2007; 20: 234243.

18.B Pirat , DS Khoury , CJ Hartley , et al. A novel feature-tracking echocardiographic method for the quantitation of regional myocardial function: validation in an animal model of ischemia-reperfusion. J Am Coll Cardiol 2008; 51: 651659.

19.J Korinek , J Wang , PP Sengupta , et al. Two-dimensional strain–a Doppler-independent ultrasound method for quantitation of regional deformation: validation in vitro and in vivo. J Am Soc Echocardiogr 2005; 18: 12471253.

20.GY Cho , J Chan , R Leano , M Strudwick , TH Marwick . Comparison of two-dimensional speckle and tissue velocity based strain and validation with harmonic phase magnetic resonance imaging. Am J Cardiol 2006; 97: 16611666.

21.Y Li , CD Garson , Y Xu , et al. Quantification and MRI validation of regional contractile dysfunction in mice post myocardial infarction using high resolution ultrasound. Ultrasound Med Biol 2007; 33: 894904.

22.J Korinek , J Kjaergaard , PP Sengupta , et al. High spatial resolution speckle tracking improves accuracy of 2-dimensional strain measurements: an update on a new method in functional echocardiography. J Am Soc Echocardiogr 2007; 20: 165170.

23.M Dandel , R Hetzer . Echocardiographic strain and strain rate imaging – clinical applications. Int J Cardiol 2009; 132: 1124.

24.S Sitia , L Tomasoni , M Turiel . Speckle tracking echocardiography: a new approach to myocardial function. World J Cardiol 2010; 2: 15.

25.A Dragulescu , LL Mertens . Developments in echocardiographic techniques for the evaluation of ventricular function in children. Arch Cardiovasc Dis 2010; 103: 603614.

26.YF Cheung , WJ Hong , GC Chan , SJ Wong , SY Ha . Left ventricular myocardial deformation and mechanical dyssynchrony in children with normal ventricular shortening fraction after anthracycline therapy. Heart 2010; 96: 11371141.

27.AM Mavinkurve-Groothuis , J Groot-Loonen , KA Marcus , et al. Myocardial strain and strain rate in monitoring subclinical heart failure in asymptomatic long-term survivors of childhood cancer. Ultrasound Med Biol 2010; 36: 17831791.

28.P Boettler , M Hartmann , K Watzl , et al. Heart rate effects on strain and strain rate in healthy children. J Am Soc Echocardiogr 2005; 18: 11211130.

29.L Kapusta , JM Thijssen , J Groot-Loonen , T Antonius , J Mulder , O Daniëls . Tissue Doppler imaging in detection of myocardial dysfunction in survivors of childhood cancer treated with anthracyclines. Ultrasound Med Biol 2000; 26: 10991108.

30.N Fallah-Rad , JR Walker , A Wassef , et al. The utility of cardiac biomarkers, tissue velocity and strain imaging, and cardiac magnetic resonance imaging in predicting early left ventricular dysfunction in patients with human epidermal growth factor receptor II-positive breast cancer treated with adjuvant trastuzumab therapy. J Am Coll Cardiol 2011; 57: 22632270.

31.H Sawaya , IA Sebag , JC Plana , et al. Early detection and prediction of cardiotoxicity in chemotherapy-treated patients. Am J Cardiol 2011; 107: 13751380.

32.L Mertens , J Ganame , P Claus , et al. Early regional myocardial dysfunction in young patients with Duchenne muscular dystrophy. J Am Soc Echocardiogr 2008; 21: 10491054.

33.RQ Migrino , D Aggarwal , E Konorev , T Brahmbhatt , M Bright , B Kalyanaraman . Early detection of doxorubicin cardiomyopathy using two-dimensional strain chocardiography. Ultrasound Med Biol 2008; 34: 208214.

34.H Geyer , G Caracciolo , H Abe , et al. Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications. J Am Soc Echocardiogr 2010; 23: 351369.

35.M Becker , E Bilke , H Kühl , et al. Analysis of myocardial deformation based on pixel tracking in two dimensional echocardiographic images enables quantitative assessment of regional left ventricular function. Heart 2006; 92: 11021108.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Cardiology in the Young
  • ISSN: 1047-9511
  • EISSN: 1467-1107
  • URL: /core/journals/cardiology-in-the-young
Please enter your name
Please enter a valid email address
Who would you like to send this to? *