**3.4 Important practical considerations**

Any echocardiographic examination consists of two main parts: (1) the acquisition of standardized echocardiographic images, and (2) the analysis of images for the quantification of relevant parameters [98, 99]. When conducting echocardiography during exercise, both parts require modified approaches to ensure that the conclusions drawn remain valid. Here, based upon our extensive practical experience, we present some "take-home-messages" that we consider essential for the echocardiographic assessment of myocardial deformation during exercises.


**21**

patient.

**Acknowledgements**

*Echocardiographic Assessment of Myocardial Deformation during Exercise*

this is expected to change in the near future.

move the transducer slightly during exercise.

misrepresentative data will be collected [24].

values.

cise recovery" state.

**4. Summary and conclusions**

depth, maximize imaging frame rates, only use one focal point and position this in the optimal location, and optimize the overall image to maximize the visibility of the endocardial border for speckle tracking analysis. Although 3D echocardiography may solve some of the limitations of 2D echocardiography, at present the frame rates are too low to obtain the necessary temporal resolution for quantification of myocardial deformation during exercise, although

• During exercise, when respiration and heart are increased, the quick location of the optimal echocardiographic window is necessary. Marking up the location on the chest after the resting assessment serves as a "quick help" during exercise. The sonographer must, however, still optimize the image and perhaps

• Since heart rate increases during exercise but imaging frame rates are already maximized, the effective frame rate (data points per cardiac cycle) decreases. Although this cannot be fully corrected, it seems advisable to perform cubic spline interpolation to attenuate some of these limitations [104]. Note that cubic spline interpolation will not only add points in time (for example for the more confident assessment of dyssynchrony), it also slightly adjusts the peak

• Data acquisition immediately following exercise is not the same as "during" exercise. With the cessation of exercise, especially after a strenuous effort with strong muscular contractions, instant changes in whole-body hemodynamics set in [105]. Hence, these data do not reflect an exercise challenge but a "exer-

• For the acquisition of LV twist, apical data must be obtained by moving the transducer close to the point of obtaining a 4-chamber view, otherwise severely

The assessment of LV and RV myocardial deformation during exercise is feasible and has contributed unique insight into cardiac physiology in health and disease. Inherent methodological challenges require appropriate training and a careful approach to image acquisition, analysis and interpretation. However, ongoing technological advancements and an increasing knowledge suggest that the echocardiographic assessment of myocardial deformation during exercise will play an ever-increasing role in future research and the clinical examination of the cardiac

The authors express their sincere gratitude to the publisher, IntechOpen, for

their very kind and generous financial support of this chapter.

*DOI: http://dx.doi.org/10.5772/intechopen.93002*

### *Echocardiographic Assessment of Myocardial Deformation during Exercise DOI: http://dx.doi.org/10.5772/intechopen.93002*

*Advanced Concepts in Endocarditis - 2021*

workload [100].

and expiration.

cardiac patients [102].

**3.4 Important practical considerations**

Any echocardiographic examination consists of two main parts: (1) the acquisition of standardized echocardiographic images, and (2) the analysis of images for the quantification of relevant parameters [98, 99]. When conducting echocardiography during exercise, both parts require modified approaches to ensure that the conclusions drawn remain valid. Here, based upon our extensive practical experience, we present some "take-home-messages" that we consider essential for the echocardiographic assessment of myocardial deformation during exercises.

• Typically, exercise tests are performed in a stepwise (constant intensity for some minutes, then increasing) or incremental (gradually increasing intensity with every second) manner. Because different protocols provoke different physiological responses, the correct protocol must be selected carefully.

• Exercise responses depend on the *relative* workload of an individual. Therefore, exercise intensities should be adjusted to an individual's anticipated capacity and patients' myocardial deformation interpreted in relation to the relative

• The individual adjustment of workload increments during the test should also acknowledge fitness, age, sex, medical history, and acute or chronic injuries.

• For the assessment of myocardial deformation during exercise, running or cycling modalities are the most common. For the reason of improved image quality and because it is relatively safe/feasible, the preferred choice for

• While it is generally accepted that gentle end-expiratory breath holds can be performed to obtain images, it is preferable to obtain echocardiographic cine loops during free breathing and average some cardiac cycles during inspiration

• It is important to distinguish between the physiological demands of different exercise modalities, categorized as: dynamic, static, and impact [101]. Consequently, certain types of exercise can be considered more as an "afterload challenge" than others, and the responses of myocardial deformation may vary greatly between these types of exercise. In this context, the reader is reminded that exercise training interventions for health will need to consider the same complexities, as evidenced by the potential for differential effects of moderate continuous exercise training *versus* high-intensity interval training in some

• One concern with regard to exercise testing is the risk of triggering adverse events. Although this will depend on the specific individual being tested and must be decided by qualified personnel on a case-by-case basis, as evidenced by a comprehensive study performed by Rognmo et al. [103], the overall risk for serious adverse events seems to be relatively low. Particular health and safety precautions should be taken in patients with overt or suspected arrhythmia and the decision "not allowed to perform an exercise test" may have to be taken.

• Standardization of echocardiographic data acquisition during exercise is absolutely necessary. Sonographers should minimize the sector width and

exercise echocardiography may be supine cycling.

**20**

depth, maximize imaging frame rates, only use one focal point and position this in the optimal location, and optimize the overall image to maximize the visibility of the endocardial border for speckle tracking analysis. Although 3D echocardiography may solve some of the limitations of 2D echocardiography, at present the frame rates are too low to obtain the necessary temporal resolution for quantification of myocardial deformation during exercise, although this is expected to change in the near future.

