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Quantitative Texture Analysis in Two‐Dimensional Echocardiography

Background: Myocardial reflectivity is abnormally increased in patients with thalassemia major under transfusion treatment, probably due to myocardial iron deposits and / or secondary structural changes. Such increased reflectivity has been detected by both qualitative and subjective analysis of two‐dimensional echocardiographic (2‐D echo) images and quantitative assessment of integrated backscatter amplitude with noncommercially available ultrasound prototypes. The purpose of this study was to assess the acoustic properties of myocardium in patients with beta‐thalassemia major and iron overload by means of quantitative computerized offline textural analysis of conventionally recorded 2‐D echo images, and to compare textural data with other qualitative (visual assessment) and quantitative (ultrasound backscatter analysis) approaches for myocardial ultrasound tissue characterization simultaneously applied to these patients. Methods and Results: Thirty‐five young patients with thalassemia major, without clinical signs of cardiac failure, and 20 age and sex matched normal controls were studied by echocardiography. Each patient was receiving blood transfusion every 2‐3 weeks. Two‐dimensional echo images, obtained with a commercially available echocardiograph using the parasternal long‐axis view, were digitized offline and analyzed by first and second order texture algorithms applied to regions of interest in the myocardium (septal and posterior wall). The mean gray level value was higher in thalassemic patients than in controls on both the septum (110 ± 25 vs 57 ± 13, arbitrary units on a 0‐255 scale; P > 0.01) and posterior wall (91 ± 25 vs 67 ± 18; P > 0.01). Among second order statistical parameters, contrast and angular second moment significantly (P > 0.01) differentiated septal and posterior walls of patients and controls. In thalassemic patients, no consistent correlation was found between wall texture parameters and hematologic (years of transfusions and chelation, number of transfusions), 2‐D echo (posterior wall thickness, left ventricular end‐diastolic diameter), and Doppler (transmitral E/A waves ratio) parameters. Myocardial walls with visually assessed increased echo reflectivity showed a trend toward higher values of mean gray level when compared with myocardial segments with qualitatively assessed normal reflectivity (septum: 121 ± 26 vs 106 ± 24; posterior wall: 105 ± 23 vs 87 ± 23). Although radiofrequency integrated backscatter has been demonstrated to be capable of identifying thalassemic patients, no significant correlation was found between mean gray level (by texture analysis) and radiofrequency data (septum: r = 0.03; posterior wall: r = 0.09; P = NS for both). Conclusions: Myocardial walls affected by hemochromatosis show ultrasound image texture alterations that may be quantified with digital image analysis techniques and appear mostly unrelated to hematologic and conventional, as well as radiofrequency‐based, echocardiographic parameters. These changes in quantitatively evaluated echo reflectivity are present even before the development of clinical and echocardiographic signs of cardiac dysfunction.