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. 2025 Oct 16;54(3):642–649. doi: 10.1002/jcu.70108

Investigation Into the Utility of 3D Speckle‐Tracking Echocardiography in Detecting Coronary Artery Microcirculation Dysfunction in Ischemia With Non‐Obstructive Coronary Artery Disease

Yuexia Ma 1,2, Lina Guan 2,3, Xiaohong Li 4, Jianqiang Zhang 1, Xiaomei Li 5, Yuming Mu 2,3,✉
PMCID: PMC12967686  PMID: 41099165

ABSTRACT

Aim

To assess the utility of three‐dimensional speckle‐tracking echocardiography (3D‐STE) in detecting coronary artery microcirculation dysfunction (CMCD) with non‐obstructive coronary artery (INOCA) disease.

Materials and Methods

Twenty‐one patients diagnosed with INOCA were enrolled and underwent echocardiography and [18F]fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT) myocardial metabolic imaging, which is used as the gold standard for diagnosing CMCD. Further, a total of 357 myocardial segments across these 21 participants were categorized into the control group and the CMCD group according to the results of [18F]FDG PET/CT. Subsequently, 2D regional systolic peak longitudinal strain (2D‐RLS), 2D regional systolic peak circumferential strain (2D‐RCS), regional systolic peak 3D main strain (R3D strain), longitudinal strain (3D‐RLS), circumferential strain (3D‐RCS), and radial strain (3D‐RRS) of the left ventricle were assessed. At last, the receiver operating characteristic (ROC) curves of 3D‐STE parameters were calculated to evaluate the diagnostic value of 3D‐STE for CMCD.

Results

The absolute value of total R3D strain is decreased in the CMCD group (p < 0.05). In addition, R3D and 3D‐RLS in the CMCD group exhibited a significant reduction in the basal, middle, and apical segments compared to the control group (p < 0.05). No difference was observed in 2D strain parameters between the CMCD group and the control group. Among all strain parameters, the R3D strain in the apical segments had the highest diagnostic efficacy, with an optimal cutoff of −41.5 (sensitivity, 88.4%; specificity, 80.5%).

Conclusion

Our findings indicate that the 3D‐STE could serve as an advantageous diagnostic instrument for discriminating individuals with CMCD.

Keywords: coronary artery microcirculation dysfunction, ischemia with no obstructive coronary artery disease, left ventricular segmental systolic function, three‐dimensional speckle‐tracking echocardiography

By detecting the subtle regional contractile dysfunction, 3D‐STE can efficiently distinguish CMCD and present a novel strategy for diagnosing INOCA.

graphic file with name JCU-54-642-g002.jpg

1. Introduction

Owing to the clinical focus on ischemic heart disease and the maturity of percutaneous coronary angiography technology, accurate diagnosis and treatment of obstructive coronary artery disease is no longer the primary clinical challenge. Nevertheless, recent investigations revealed that more than half of the patients experiencing chest pain suffer from ischemia without the evidence of obstructive coronary arterial disease; a condition classified as non‐obstructive coronary artery disease (INOCA) (Ford and Berry 2019). Besides, coronary artery microcirculation dysfunction (CMCD) has attracted increasing clinical attention as a major cause of myocardial ischemia in patients with angina without obstructive coronary artery disease (Tamis‐Holland et al. 2019) and an independent risk factor for future adverse cardiovascular events in INOCA patients (Aldiwani et al. 2020). However, CMCD manifests with minimal signs and symptoms, and the existing diagnostic methods lack the capacity for direct observation or precise pathological analysis, leading to potential misdiagnosis and consequently delayed therapeutic interventions. Indeed, positron emission tomography/computed tomography (PET/CT) is currently the gold standard for evaluating coronary artery microcirculation dysfunction (Zhang et al. 2017), still, there are several limitations and challenges associated with PET/CT in clinical practice such as high cost, radiation exposure, and time‐consuming procedure. Therefore, a noninvasive way to accurately evaluate CMCD is urgently needed. Speckle‐Tracking Echocardiography (STE) presents a powerful, reliable, and exacting criterion for the noninvasive, precise quantification of subclinical myocardial injury (Gao et al. 2021; Curigliano et al. 2020), the diagnostic value of strain parameters in discerning INOCA patients with CMCD remains unclear. According to the previous studies, [18F] Fluorodeoxyglucose (FDG) is considered one of the gold standards for evaluating ischemic substrates in addition to its conventional use for metabolic imaging (Zuo et al. 2021; Czernin et al. 1993). Moreover, in our previous study, we used FDG‐PET/CT as gold standard and proved that myocardial contrast echocardiography can assess left ventricular myocardial perfusion in patients with CMCD both quantitatively and qualitatively (Zhang et al. 2023). In this regard, we, using FDG‐PET/CT as gold standard, reflect myocardial perfusion by metabolic activity, aimed at elucidating the significance of 2D and 3D strain assessments for detecting INOCA individuals with CMCD.

2. Materials and Methods

2.1. Patients

In the current investigation, we employed the identical cohort utilized in our prior study (Value of Myocardial Contrast Echocardiography in Detecting Coronary Microcirculatory Dysfunction in Ischemia With Non‐obstructive Coronary Artery Disease). Twenty‐one patients (15 male and 6 female) clinically diagnosed with INOCA were prospectively enrolled in this at the hospital on the basis of coronary angiography or coronary CTA (coronary artery stenosis ≤ 50%). All patients underwent [18F]FDG PET/CT myocardial metabolic imaging and 2D, 3D echocardiography. Furthermore, all myocardial segments of the 21 subjects were divided into the CMCD group and the control group in accordance with the outcomes of PET/CT. Patients were excluded when they met the following criteria: (a) segmental ventricular wall motion abnormality, valvular heart disease, congenital heart disease, or other conditions that may affect the research results; (b) major diseases, such as cancer; (c) diabetes or poor blood sugar control; (d) peripheral vascular diseases, such as aortic dissection; and (e) poor image quality.

This study was approved by the Ethics Committee of the hospital and performed in accordance with the principles of the Helsinki Declaration. All patients signed informed consent forms before the examination.

2.2. 18F‐FDG PET/CT Myocardial Metabolic Imaging

PET/CT myocardial metabolic imaging was performed with Discovery VCT (GE Healthcare, USA), utilizing [18F]FDG as a tracer. All subjects were fasted for 6–12 h before the scan, and baseline blood sugar was checked. The blood glucose was adjusted to 7.9–8.8 mmol/L by oral glucose load, and then [18F]FDG was injected intravenously immediately according to the standard of 0.15 mCi/kg. First, attenuation correction of the data was performed by transmission scanning with computed tomography, and then electrocardiogram (ECG)‐gated PET imaging was performed. We used the special computer software filtered reflection projection method to reconstruct the 3D image and obtain the 17‐segment bull's‐eye diagram. PET/CT myocardial metabolic imaging was performed after 60 min of rest, and the acquisition time was 8 min.

The results for glucose metabolism of each segment were analyzed using the standard segment score (American Heart Association 17‐segment score). We used visual analysis to classify the activity of cardiomyocytes as normal, reduced, or inactive, with reference to active images of the normally active myocardium. The segments with reduced activity were assigned to the CMCD group, while those displaying normal activity were categorized as the control group. All images were analyzed independently by two senior nuclear medicine doctors blinded to the patient's medical history. When the evaluation results were inconsistent, the final decision was reached through consensus.

2.3. Echocardiographic Image Acquisition

A medical ultrasonic diagnostic apparatus (Epiq7, Philips Medical Systems, Andover, MA, USA) equipped with S5‐1 and X5‐1 probes was used for examination. All the subjects underwent a 2D and 3D echocardiographic examination during the same session performed by a single experienced cardiac ultrasound diagnostic specialist. The patient was placed in the left lateral position, and the ECG was recorded synchronously. First, the S5‐1 probe was used to obtain 2D images. After conventional measurement, standard three parasternal short‐axis views (basal, middle, and apical levels) were obtained for the assessment of circumferential strain (CS), and three apical views (three‐chamber, four‐chamber, and two‐chamber) were obtained for the assessment of longitudinal strain (LS). Then, the 3D volume probe X5‐1 was applied to obtain 3D images (frame rate > 15 frames/s). In the 3D mode, the apical four‐chamber view was captured, the full‐volume mode was initiated to obtain a dynamic 3D image of the LV, the image quality was adjusted, the sampling range covered all regions of interest, and the endocardial boundary was verified to be clearly displayed. A full‐volume dynamic image of the LV was stored for offline software analysis. Experienced cardiac ultrasound doctors blinded to the clinical data acquired all images and performed measurements from standard views, as recommended by the American Society of Echocardiography (Zhang et al. 2023).

2.4. 2D STE Strain Analysis

The 2D images were analyzed by QLAB 10.8 software. Firstly, the positions at the roots of the anterior and posterior lobes of the mitral valve and apex in the long‐axis view were manually marked, as well as the geometric center of the LV lumen and the midpoint of the septum in the short‐axis view. The system automatically delineated the endocardial and epicardial boundaries, which could be manually adjusted if necessary. After the correct envelope was determined, the system automatically calculated the 2D regional systolic peak longitudinal strain (2D RLS) and 2D regional systolic peak circumferential strain (2D RCS) of each myocardial segment. The results are displayed as a bull's‐eye diagram and strain–time curve.

2.5. 3D STE Strain Analysis

The 3D images were analyzed by a TomTec Imaging System. The software automatically recognized the apical three‐chamber, four‐chamber, and two‐chamber images, automatically drew the endocardial and epicardial boundaries, and could be adjusted manually if necessary. After determining the correct envelope, the software automatically calculated the regional systolic peak 3D main strain (R3D strain), longitudinal strain (3D RLS), circumferential strain (3D RCS), and radial strain (3D RRS) of each myocardial segment. The results are displayed as a bull's‐eye diagram and strain–time curve (Figure 1).

FIGURE 1.

FIGURE 1

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LV systolic peak 3D main strain measured by 3D STE offline analysis software and the result was displayed as a bull's‐eye diagram and strain–time curve. LV, left ventricular; 3D, 3‐dimensional; STE, speckle‐tracking echocardiography. Basal: Basal segment; Mid: Middle segment; Apical: Apical segment; Ant: Anterior wall; Ant/lat: Anterior‐lateral wall; Inf/lat: Inferior‐lateral wall; Inf: Inferior wall; Ant/sept: Anterior septum; Inf/sept: Inferior septum.

All the strain values were measured three times, and the averages were calculated, and the absolute values were recorded. All ultrasonic image analyses were performed independently by two senior cardiac ultrasound doctors who were blinded to the PET/CT results and the medical history. The quality of tracking was subjectively classified as favorable or unfavorable by the operator. Both 2D STE and 3D STE analyses were deemed feasible only when both cardiac ultrasound doctors simultaneously designated them as favorable.

2.6. Repeatability Test

Ten randomly selected patients were reanalyzed to assess the reproducibility of the strain measurements. The strain values of each parameter for each segment were read by the same physician and another physician with similar qualifications following the same method. Intraobserver discrepancies between the evaluation of the two physicians and interobserver variances between their initial and subsequent evaluations of the same patient were identified through calculation of the intragroup correlation coefficient (ICC). Both physicians were blinded to all clinical and imaging data. Limits of agreement are set as: when 0.4 < kappa < 0.6, it indicates a moderate level of consistency; when 0.6 < kappa < 0.8, it suggests a relatively high level of consistency; when kappa > 0.8, it shows an excellent level of consistency; and when kappa < 0.4, the consistency is poor.

2.7. Statistical Analysis

Measurement data that conformed to a normal distribution are expressed as the mean ± standard deviation (SD), and variables deviating from normality are expressed as median and interquartile range. Categorical variables were expressed as counts (percentages). The normality of data distributions was evaluated using the Shapiro–Wilk test. Independent samples t‐tests were used for normally distributed continuous variables and Mann–Whitney U tests for non‐normally distributed ones. Correlation between 2D and 3D strain parameters was analyzed using Pearson correlation. The ICC was used to evaluate the repeatability of strain parameter measurements within and between observers. A receiver operating characteristic (ROC) curve was used to analyze the diagnostic efficacy of strain parameters to predict CMCD. All the strain parameters were analyzed in absolute values, and all data were analyzed using SPSS version 25.0 (IBM, Armonk, NY, USA), and p < 0.05 (two‐tailed) was considered statistically significant.

3. Results

3.1. Clinical Characteristics

According to the inclusion and exclusion criteria, a total of 21 patients (15 men and 6 women) were enrolled, and the clinical characteristics of these patients were displayed in Table 1. All study participants were in sinus rhythm.

TABLE 1.

General characteristics.

Variable Data
Male, (%) 15 (71.4)
Female, n (%) 6 (28.6)
Average heart rate(beat/min) 65 ± 14
Body mass index, (kg/m2) 23.97 ± 3.22
Mean left ventricular ejection fraction (%) 62.57 ± 4.68
Left ventricular end‐diastolic volume(mL) 108.02 ± 16.56
Left ventricular end‐systolic volume(mL) 39.92 ± 9.79
Drug, n (%) 6 (28.57)
Hypertension, n (%) 9 (42%)
Hyperlipemia, n (%) 4 (19%)
Smoking history, n (%) 5 (23.8)
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3.2. [ 18F]FDG PET/CT Myocardial Metabolic Imaging

A total of 357 myocardial segments were analyzed by PET/CT. According to the results of PET/CT, 235 myocardial segments displaying normal metabolic activity were categorized as the control group, and 122 myocardial segments with reduced metabolic activity were assigned to the CMCD group.

3.3. Quantitative Analysis of STE

The 2D‐RLS of 353 segments and 2D‐RCS of 329 segments were successfully measured by QLAB A‐CMQ. In addition, the R3D strain, 3D‐RLS, 3D‐RCS, and 3D‐RRS of 326 segments were successfully calculated using TomTec 4D LV‐Analysis.

As presented in Figure 2. In addition to global R3D strain, the absolute values of the 3D‐RLS and R3D strain in the basal, middle, and apical segments of the CMCD group were significantly decreased in comparison to those of the control group (p < 0.05). On the contrary, the absolute value of 3D RRS in the apical segments was significantly increased compared with that of the control group (p < 0.05). Nevertheless, 2D‐STE and 3D‐RCS parameters showed no significant differences between the two groups.

FIGURE 2.

FIGURE 2

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Box diagram of three horizontal strain parameters of the basal, middle, and apical segment between the CMCD group and the control group. All the strain parameters were analyzed in absolute values. (A) 2D RLS, two‐dimensional regional systolic peak longitudinal strain. (B) 2D RCS, two‐dimensional regional systolic peak circumferential strain. (C) R3D strain, three‐dimensional regional systolic peak three‐dimensional main strain. (D) 3D RLS, three‐dimensional regional systolic peak longitudinal strain. (E) 3D RCS, three‐dimensional regional systolic peak circumferential strain. (F) 3D RRS, three‐dimensional regional systolic peak radial strain. P value < 0.05 indicates that there is a statistically significant difference between the control group and the CMCD group. CMCD, coronary artery microcirculation dysfunction; Total, total segment; Bas, basal segment; Mid, middle segment; Ap, apical segment.

3.4. Correlation Between 2D and 3D Strain Parameters

As shown in Supporting Information Figure S1, except for the RCS of the middle segment (p = 0.015), no obvious correlation was found between 2D and 3D strain parameters. The R value is 0.22 between 2D RCS and 3D RCS.

3.5. Analysis of Receiver Operating Characteristic Curve

Sensitivity, specificity, and area under the curve value of each parameter was displayed in Figure 3. Our results indicate that the segmental strain parameters were more accurate when detecting CMCD than the global strain parameters. Notably, R3D strain in the apical segments had the best predictive value for CMCD, with a sensitivity of 88.4%, a specificity of 80.5%, and AUC of 0.89 (cutoff of −41.5%). p < 0.05 for all strain parameters.

FIGURE 3.

FIGURE 3

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Results of ROC curve analysis. (A) total. (B) basal segments. (C) middle segments. (D) apical segments. All the strain parameters were analyzed in absolute values. R3D strain, three‐dimensional regional systolic peak three‐dimensional main strain; 3D RLS, three‐dimensional regional systolic peak longitudinal strain; 3D RRS, three‐dimensional regional systolic peak radial strain.

3.6. Repeatability Test

As presented in Table 2, all strain parameters were highly repeatable within and between observers (p < 0.05).

TABLE 2.

Analysis of Intra‐observer and Inter‐observer consistency of strain parameter.

Parameter Intra observer 95% CI P value Inter observer 95% CI P value
2D RLS 0.877 0.594–0.968 < 0.01 0.828 0.445–0.954 < 0.01
2D RCS 0.845 0.491–0.959 < 0.01 0.806 0.382–0.948 < 0.01
R3D strain strstrainstrain 0.997 0.991–0.999 < 0.01 0.984 0.952–0.994 < 0.01
3D RLS 0.984 0.946–0.995 < 0.01 0.976 0.912–0.994 < 0.01
3D RCS 0.960 0.863–0.989 < 0.01 0.956 0.835–0.989 < 0.01
3D RRS 0.937 0.828–0.978 < 0.01 0.897 0.699–0.965 < 0.01
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Note: 95% CI: 95% confidence interval.

4. Discussion

In this prospective study, we revealed that the presence of CMCD causes LV segmental systolic dysfunction, and more importantly, these subtle changes could be accurately detected by a thorough 3D‐STE evaluation. These findings highlight that 3D STE and 3D strain parameters are able to act as an alternative modality to evaluate the status of myocardial microcirculation and should be incorporated into the assessment of LV segmental systolic function to optimize the diagnostic strategy of INOCA with CMCD.

The coordinated movement of epicardial and endocardial longitudinal muscle fibers and middle circular muscle fibers supports the normal contractions and diastates of the heart in 3D space (Liu et al. 2022). However, myocardial contractile function is not only related to the inherent contractile ability of the myocardium itself but also closely related to the blood supply of the coronary artery. CMCD has been used referring to the structural and functional alterations at the level of coronary microcirculation, leading to an impaired coronary blood flow and ultimately resulting in myocardial ischemia. The pathology of CMCD is characterized by the structural alterations of coronary microvessels (arteriole remodeling, decreased capillary density, etc.) and/or their dysfunction (endothelial and smooth muscle cell dysfunction) that ultimately lead to varying degrees of decreased myocardial perfusion, which plays an important role in the pathogenesis of INOCA. After myocardial injury, disarrangement of muscle fibers and coronary microvascular remodeling (Tao et al. 2020), which mainly manifest as vascular wall thickening and narrowing of the vessel lumen (Elgendy and Pepine 2019), further aggravates reduced myocardial perfusion followed by reduced myocardial contractile function and deformability (Lindemann et al. 2018).

In this respect, we postulated that a precise assessment of myocardial contractile function could serve as a diagnostic indicator for INOCA with CMCD. However, because of the subjective judgment of segmental wall motion abnormalities and the poor reliability and repeatability of conventional echocardiography parameters including LV ejection fraction, these parameters cannot objectively reflect the early impairment of LV myocardial systolic function (Liu et al. 2021). With STE, deformability of the myocardium can be quantitatively evaluated with an angle‐independent segmental quantification all over the cardiac cycle in multiple dimensions (Abou et al. 2020). Previous studies have also confirmed that STE is strongly correlated and highly consistent with cardiac magnetic resonance and PET (Jiang et al. 2020). Thus, aimed at elucidating the significance of 2D and 3D strain assessments for detecting INOCA individuals with CMCD. To our expectation, our results revealed that 3D‐STE parameters, especially for R3D strain, 3D‐RLS were significantly decreased in myocardial segments that presented perfusion impairment, which is confirmed by PET/CT evaluation, regardless of the location of the specific segment (basal, middle, or apical). It was a more sensitive and reliable parameter that reflected CMCD. Whereas, 3D‐RCS and 3D‐RRS did not show significant differences between the CMCD group and the control group.

The subendocardial myocardium is most easily involved (Sun et al. 2019) because it is located at the distal end of coronary circulation where the microvessel distribution is sparse (Zhou et al. 2019). Longitudinal muscle fibers are mainly distributed in the endocardium; hence, abnormalities in longitudinal motion typically manifest initially. The LV myocardium is composed of 70% longitudinal and 30% circular fibers. Consequently, the longitudinal deformability of LV myocardium plays a key role in LV systolic function (Pastore et al. 2021). Above theory might properly explain our findings, which were highlighted by decreased 3D‐RLS in CMCD segments, while 3D‐RCS did not, indicating that even if there is regional systolic dysfunction in INOCA with CMCD, it may not reach the middle circular muscle fibers. In addition, 2D‐STE parameters did not show the proper ability to distinguish segments with impaired perfusion from normal ones. 2D STE tracks myocardial acoustic spots in a 2D plane, such that the spots moving out of the plane cannot be accurately tracked (Zuo et al. 2021), In contrast, 3D‐STE overcomes this deficiency by tracking spots across multiple planes (Papadopoulos et al. 2021; Ji and Qiu 2022), enable it to objectively and efficiently reflect subclinical changes in impaired LV systolic function (Liu et al. 2020).

To further determine the diagnostic value of 3D‐STE parameters, we conduct the ROC analysis. Our results showed both R3D strain and 3D‐RLS demonstrate favorable diagnostic efficiency. Of note, regional strain parameters were superior to global strain parameters. The global systolic function of the LV is the sum of the contractile function of all myocardial segments. There are essentially differences in the contractile forces of myocardial fibers in different radial planes of the same axial plane. When the small number of segmental myocardial fibers' systolic function is impaired in different radial planes, false negative results easily appear in the evaluation of myocardial systolic dysfunction using the global strain due to the existence of an inherent longitudinal systolic force gradient. Hence, segmental myocardial systolic function is impaired in the early stage; global systolic function might still be normal. The evaluation of global systolic function is not applicable to INOCA with CMCD. Herein, the quantitative evaluation of segmental myocardial deformation by 3D‐STE is a more sensitive and reliable measurement (Trivedi et al. 2019) for INOCA with CMCD. In addition, R3D strain, a more comprehensive parameter that integrates longitudinal and radial information, had the highest diagnostic efficiency in the apical segments in predicting INOCA with CMCD. The 3D RRS displayed a significant increase in the apical segments from the CMCD group to the control group because of the compensatory increase in circumferential fiber function in the presence of longitudinal dysfunction, whereby the LV ejection fraction is maintained in the normal range (Liu et al. 2021).

Additionally, both 2D and 3D strain parameters had good intraobserver and interobserver repeatability. Moreover, the 3D strain had higher repeatability than the 2D strain, which may be related to the highly automatic evaluation of 3D STE (Dogdus et al. 2020) and the strain values of each dimension from the same cardiac cycle.

5. Limitations

The limitations of this study are as follows: (1) Due to the small sample size, there was no one‐to‐one comparison of each segment, and only the three cross‐sectional levels were compared. (2) No stress test was conducted to evaluate the reserve capacity of the coronary artery. In the future, to further explore the diagnostic value of 3D‐STE for CMCD, a large, multicenter, randomized controlled trial is still needed.

6. Conclusion

By detecting the subtle regional contractile dysfunction, 3D‐STE can efficiently distinguish CMCD and present a novel strategy for diagnosing INOCA.

Author Contributions

  1. Guarantor of integrity of the entire study: Yuming Mu.

  2. Study concepts and design: Yuming Mu and Lina Guan.

  3. Literature research Yuexia Ma and Jianqiang Zhang.

  4. Clinical studies: Yuexia Ma, Xiaohong Li and Xiaomei Li.

  5. Experimental studies/data analysis: Yuexia Ma and Jianqiang Zhang.

  6. Statistical analysis: Yuexia Ma and Jianqiang Zhang.

  7. Manuscript preparation: Yuexia Ma.

  8. Manuscript editing: Yuming Mu and Lina Guan.

Ethics Statement

This study was approved by the Ethics Committee of the First Affiliated Hospital of Xinjiang Medical University (Approval No. K202302‐27) and performed in accordance with the principles of the Helsinki Declaration. All patients signed informed consent forms before the examination.

Consent

Written informed consent has been obtained from the patient(s) to publish this paper.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Figure S1: Correlation between 2D and 3D strain parameters.

JCU-54-642-s001.png (255.4KB, png)

Acknowledgments

The authors would like to specially thank Baihetiya Tayier, Lingjie Yang, Yang Wu, Guodong Wang and ZihangWang for their help and support in case collection, software use, image processing and data analysis.

Ma, Y. , Guan L., Li X., Zhang J., Li X., and Mu Y.. 2026. “Investigation Into the Utility of 3D Speckle‐Tracking Echocardiography in Detecting Coronary Artery Microcirculation Dysfunction in Ischemia With Non‐Obstructive Coronary Artery Disease.” Journal of Clinical Ultrasound 54, no. 3: 642–649. 10.1002/jcu.70108.

Funding: This work was supported by National Natural Science Foundation of China, 32071459.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Figure S1: Correlation between 2D and 3D strain parameters.

JCU-54-642-s001.png (255.4KB, png)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Articles from Journal of Clinical Ultrasound are provided here courtesy of Wiley

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