echocardiographic techniques for evaluating left ventricular myocardial function

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2008 12: 228 originally published online 24 November 2008SEMIN CARDIOTHORAC VASC ANESTHCarlo Marcucci, Ryan Lauer and Aman Mahajan

New Echocardiographic Techniques for Evaluating Left Ventricular Myocardial Function

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228

Subsequently, several groups developed formulas tocalculate cardiac volumes and ejection fractions(EFs) based on simplified 3-dimensional (3D) mod-els of the heart.2-4 By assuming a constant relation-ship between the long and short axes of asymmetrically shaped ventricle, the measurement of1 diameter allowed for the calculation of the volumeof the chamber. These methods are easy to performbut the results are only valid in the absence ofregional wall motion abnormalities and for ventri-cles with symmetrical configurations.

The development of 2-dimensional (2D)echocardiography, in the 1970s,5 allowed more pre-cise measurements that could be preformed usingthe dimensions and areas contained in these images(eg, Simpson’s method of discs). Although morecumbersome, these methods have a higher precisionas regional wall motion abnormalities can beaccounted for, and by manually tracing the endo-cardium in different views of the ventricle, fewerassumptions of the shape and symmetry of the ven-tricle are needed. Parallel to the development of B-mode echocardiography, spectral Doppler was addedto the armamentarium of the echocardiographer,allowing noninvasive measurements of flow and thecalculation of hemodynamic variables.6

In 1954, Hertz and Edler1 first reported the useof an ultrasonic reflectoscope to record signalsfrom the heart, taking the first steps in what

became the discipline of echocardiography. Thereflectoscope, produced by Siemens Corporation,was used in shipyards to detect flaws in the hull ofships. As ultrasound technology evolved, equipmentof higher resolution allowed for more accurate esti-mations of ventricular size and function. Initially,the signal could only be displayed in M-mode, mak-ing identification of the underlying cardiac structuredifficult. In 1969, Harvey Feigenbaum developed anindex to assess left ventricular (LV) function basedon the anterior–posterior diameter of the heart.2

New Echocardiographic Techniques forEvaluating Left Ventricular MyocardialFunction

Carlo Marcucci, MD, Ryan Lauer, MD, and Aman Mahajan, MD, PhD

Ultrasound imaging of the heart continues to play animportant role in diagnosis and management of patientswith cardiovascular diseases. Recent advances in ultra-sound technology and introduction of newer imagingmodalities have enabled improved assessment of left ven-tricular myocardial function. Tissue Doppler imaging and2-dimensional speckle tracking allow more objectivequantification of myocardial function in the form of tissuevelocities, displacement, strain, and strain rate. Similarly,contrast-enhanced echocardiography and 3-dimensional

echocardiography have provided a unique insight into leftventricular form and function that was not possible byunenhanced 2-dimensional echocardiography. In thisreview, the authors discuss the clinical application ofthese new imaging techniques in the assessment of leftventricular myocardial function.

Keywords: ultrasound; echocardiography; tissue Dopplerimaging; speckle tracking; contrast; 3-dimensional echocar-diography; transesophageal

Seminars in Cardiothoracicand Vascular Anesthesia

Volume 12 Number 4December 2008 228-247

© 2008 SAGE Publications10.1177/1089253208328581

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From the Department of Anesthesiology, Duke University School ofMedicine, Durham, North Carolina (CM, RL); Department ofAnesthesiology, David Geffen School of Medicine at UCLA, LosAngeles, California (AM).

Dr Mahajan is supported by grants from NIH/NHLBI P01HL078931 and NIH RO1-HL084261. There was no otherexternal financial support for this article.

Address correspondence to: Aman Mahajan, MD, PhD, Divisionof Cardiac Anesthesiology, Ronald Reagan UCLA MedicalCenter, David Geffen School of Medicine at UCLA, WestwoodPlaza Suite 757, 3302, Los Angeles, CA 90095; e-mail: [email protected].

Articles



For years, 2D imaging and spectral Doppleranalysis were the only methods available for the quantification of ventricular function. Recent techno-logical advancements—tissue Doppler imaging, Dopplerstrain imaging and speckle tracking, contrast echocar-diography, and 3D echocardiography—provide moreaccurate quantification of global and regional ventricularfunction. Though these techniques have been moreextensively studied in transthoracic ehocardiography(TTE), increasing use of these tools in transesophagealechocardiography (TEE) is being reported. The highdegree of accuracy and reproducibility makes these techniques good candidates for monitoring global and regional ventricular function in the perioperativesettings.

The improved temporal and spatial resolution ofcardiac imaging techniques allows us to examine themyocardial structure almost at the level of the indi-vidual fibers and has given us new insights in theorganization and function of the ventricle. For theechocardiographer it is important to be familiar withthe structure of the LV and the dynamic mechanicalsequence of contraction to interpret the data pro-vided by these imaging modalities. In this article, wewill provide an overview of current concepts of thestructure–function relationship of the LV and intro-duce strain, strain rate, twist, and torsion as measur-able variables of ventricular function. Furthermore,we will discuss the principles, validity, and limita-tions of these new technologies for the evaluation ofglobal and regional LV function.

Left Ventricular Structure and Function

Structural Organization of theMyocardium

Myocardial muscle fibers are organized in 2 coun-terdirectional helices with opposite orientation orhandedness. From the epicardium inward, the fibersfirst have a longitudinal arrangement in a left-handed helix, then the orientation becomes circum-ferential in the midwall, and finally the fibers arearranged longitudinally in a right handed helix at thesubendocardial level (Figure 1).7

The myofibers are bundled in myofiber sheetsand separated from each other by cleavage planes.Different sheets are not aligned parallel; rather,their direction depends on their localization withinthe ventricular wall. In a long-axis section, the fibersat the base of the heart can be seen to run cephalad

from endocardial to epicardial, whereas the apicalfibers have a caudad orientation (Figure 2A). The anglebetween these fibers and the epicardial plane variesduring the cardiac cycle.9 In a short-axis section, thefibers fan out in their radial course through the LV wall(Figure 2B). Due to the variable myofiber orientation,the ultrasound waves interact with them at differentangulations, producing different backscatter intensi-ties. Ultrasound reflecting from fibers that are orientedperpendicular to the sound beam will create greaterbackscatter, resulting in a brighter area on the image(Figure 3). The resulting speckled pattern of the recon-structed image can be used by speckle tracking pro-grams to analyze displacement and velocities in themyocardial segments.

Activation and Contraction

The insulated Purkinje fibers run from the base ofthe septum to the LV apex, where they transmit theaction potential to the subendocardial myocardiumin the apical septal and LV free wall regions. The

Evaluation of Left Ventricular Myocardial Function / Marcucci et al 229

Figure 1. Helicoidal structure of the heart. From Holrege,8

with permission. The fibers of the left ventricular myocardiumare arranged in 2 longitudinal helices with opposite orientation:right handed in the subendocardium and left handed near theepicardium. In the midwall, fibers have a more circumferentialorientation. 1, subendocardial fibers; 2, papillary muscle; 3, vor-tex cordis; 4, circumferential fibers; 5, subepicardial fibers.



230 Seminars in Cardiothoracic and Vascular Anesthesia / Vol. 12, No. 4, December 2008

electrical wave front travels from the endocardiumtoward the epicardium along the myofibril orienta-tion and from the apex toward the base, making thesubepicardial region of the basal posterior LV wallbeing the last to depolarize.11 Repolarization occursfrom the base to apex without significant transmuraldifferences, the apical subepicardium being the lastregion to repolarize.12

Contraction of the subendocardial right-handedhelix follows the rapid spread of the depolarizingfront. The shortening of the subendocardial layersproduces rapid buildup of pressure in the LV thatcoincides with the isovolumic contraction (IVC)phase. During this brief period, the outer left-handed helix is passively stretched out. The concur-rent shortening of the subendocardium with thestretching of the subepicardium during IVC pro-duces a typical biphasic signal in myocardial veloci-ties and strain rates measured with ultrasound.13

Contraction of the left-handed subepicardial helixcoincides with the end of the IVC and the onset ofventricular ejection. During the ejection phase, bothsubendocardial and subepicardial fibers shortenfrom apex to base, resulting in a reduction of the sizeof the LV cavity in all directions. However, strain orshortening shows transmural and apex-to-base gra-dients, with shortening being larger in the subendo-cardium than subepicardium and larger in the apicalthan basal segments.12

Just before aortic valve closure, the apicalsubendocardium relaxes from apex to base, whereassubepicardial relaxation occurs just after aortic valveclosure and spreads form base to apex. Thus, thesubepicardial apex is the last to lengthen and con-tinues shortening into the isovolumic relaxation(IVR) phase and early diastolic filling. This phenom-enon represents an active component of ventricularrelaxation, facilitating ventricular expansion andcreating ventricular suction in early diastole.12

Strain, Strain Rate, Twist, and Torsion

Myocardial tissue is virtually incompressible. Duringthe cardiac cycle, longitudinal and circumferentialmotions are obligatorily accompanied by thickening or thinning in the radial dimension (Figure 4A).Myocardial deformation produced as a result of thesemotions can be quantified by the dimensionless param-eter strain (ε). Strain, in an object that is its size, is theratio of the change in length to the initial length.

Figure 2. Transmural orientation of myocardial fibers. (A) Atthe base of the heart fibers have a cephalad course from theendocardium to the epicardium. The apical fibers show a cau-dad orientation. The angulation of the fibers to epicardial planevaries during the cardiac cycle.9 (B) The myocardial fibers fanout toward the endocardium and epicardium in their circumfer-ential course. From Sengupta et al,10 with permission.

Figure 3. Backscatter and fiber orientation. CircumferentialMyofibers (indicated by the arrows pointing to the midportionof the septum), have a near perpendicular angle with the inter-rogating sound wave resulting in more backscatter and bright-ness when compared with the longitudinal subendocardialfibers (indicated by white arrows).



Imagine a rubber band with length L0 being stretchedout to length L1. The strain is than defined as the ratioof L1 − L0 to L0 (Figure 4B). Because the rubber bandgot stretched out, L1 is larger than L0, and ε is positive;in the event that an object shortens, ε will be negative.The rate at which the length of the rubber bandchanges is the strain rate (SR = Δε/Δt).

When myocardial strain is plotted against timeon a strain curve, myocardial length and thicknessare at baseline at the end of diastole (Figure 5).During systole, longitudinal and circumferentialshortening give negative strain values, reaching theirminimum negative values (shortest myocardiallength) at peak systole, around aortic valve closure.After the onset of diastole, early ventricular fillingbrings the curve back up to a less negative valuewhere it will plateau during diastole. The atrial con-traction completes ventricular filling and brings thestrain curves back to baseline.

SR curves usually contain much more “noise.”During the IVC phase (between mitral valve closureand aortic valve opening), the curve has atypicalbiphasic shape. After aortic valve opening, myocar-dial shortening accelerates to a reach its peak inmidsystole and slows down to reach 0 at aortic valveclosure. Although at this point fiber length (strain)

has reached its most negative peak, there is no fur-ther shortening and the rate of shortening, SR,drops back to 0. Between aortic valve closure andmitral valve opening (IVR phase), the curve is againbiphasic.

In early diastole, the LV myocardium lengthenssoon after mitral valve opening, resulting in a positivepeak (E peak) on the SR curve, whereas in late diastolethe atrial contraction brings a second positive SR peak(A peak). During diastasis, between the E and A peaks,the ventricle does not fill and the myocardial fibers donot lengthen, resulting in an SR of 0. Thus, longitudi-nal and circumferential SRs are negative during systoleand have 2 positive peaks in diastole, whereas longitu-dinal and circumferential strain shows only negative val-ues. In the presence of dyskinesia and positivelongitudinal and circumferential strain values, quantifythe lengthening of the myocardium beyond its end dias-tolic value. Radial thickening in systole and thinning in


A

B

L0

L1

1

2

3

1 Longitudinal strain 2 Circumferential strain 3 Radial strain

L1 – L0

L0=ε

SR =Δε/Δt

Figure 4. Myocardial strain, strain rate, twist, and torsion. (A)Strain (ε) is defined as the change of length of an object dividedby its original length. Lengthening corresponds with positivestrain, shortening with negative strain. Strain rate (SR) is thechange of strain over time (Δε/Δt). (B) Myocardial deformation orstrain occurs in 3 dimensions. Longitudinal and circumferentialsystolic shortening (negative strain) is accompanied by lengthen-ing or thickening in the radial dimension (positive strain).

Figure 5. Longitudinal and circumferential strain and strain rate curves. Longitudinal strain (bold line) reaches its peak negative value at aortic valve closure and returns back to baseline atthe end of diastole. Longitudinal strain rate (thin line) is neg-ative during systole and returns to 0 at aortic valve closure. Indiastole is shown an early positive peak (E) corresponding with early ventricular filling, returning to 0 in diastasis, and showing a late positive peak (A) corresponding with atrial contraction. In the isovolumetric phases strain rate has a typical biphasicaspect. MVC, mitral valve closure; AVO, aortic valve opening;MVO, mitral valve opening; AVC, aortic valve closure; ECG sig-nal is represented at the bottom.




diastole produce similar strain and SR curves except forthe reversed directions.

Finally, not only does the left ventricle shorten andthicken during systole, it also twists around the longitu-dinal axis. Seen from the apex, the base of the heartturns clockwise during systole whereas the apex turnscounterclockwise. These opposite movements create awringing effect or torsion (like the wringing of a washcloth) and can be quantified with some of the new tech-niques in ultrasound that will be discussed. Twist anduntwist are defined as the number of angular degrees agiven point in the myocardium turns during systole anddiastole, respectively. Twist is also referred to as rota-tion. Counterclockwise twist or rotation is by conven-tion denoted as positive, clockwise twist as negative.Torsion is the gradient between apex and base, and it iscalculated as the net difference between basal and api-cal twists.

New Echocardiographic ImagingModalities

Tissue Doppler Imaging (TDI)

Imaging technique. Doppler echocardiography is awell-established technique to calculate pressure gra-dients, quantify valvular stenosis, and measure dias-tolic function. In 1989, Isaaz et al14 described theapplication of Doppler echocardiography for theevaluation of myocardial motion and TDI was born.

Routine Doppler echocardiography employs alow-velocity, high-amplitude filter to remove theartifact produced by the highly reflective blood–tissue interface. When this filtering strategy isreversed, these low-velocity, high-amplitude signalsfrom tissue motion are displayed. Tissue Dopplervelocities can be displayed as a spectral trace (pulsedTDI, Figure 6A), representing the peak velocities, oras a color map superimposed on the 2D image simi-lar to color Doppler (color TDI).15 The advantage ofpulsed TDI is that the sample volume can be placedin a small select area, providing data with an excel-lent temporal resolution. The color TDI has theadvantage of displaying velocities over a wide area ofmyocardium at the same time, thus allowing multi-ple segments to be analyzed simultaneously, thoughthis comes at the expense of decreasing temporalresolution. As with color Doppler, the velocities fromcolor TDI are mean velocities whereas those frompulsed Doppler and pulsed TDI are peak velocities.

TDI has some important limitations. First, as withall Doppler-derived data, if the angle of interrogation

Figure 6. (A) Tissue velocity imaging. The sampler is placed over the mitral annulus. Isovolumic acceleration in the isovolumic contraction phase is defined by the difference betweenbaseline and maximum velocity in the isovolumic contractionphase (A) divided by the time (B). Maximum systolic velocity of the mitral annulus is indicated by the dashed arrow. (B) Tissue strain rate imaging. Arrow indicates maximum strain duringisovolumic contraction (IVC). (C) Tissue strain imaging. Byplacing the sampler in different segments of the myocardium,the software will produce strain curves for regional strain of theselected segments.



between the tissue motion and ultrasound beams isgreater than ∼20°, the peak values will be significantlyreduced. The second limitation is that the velocities ofthe tissue along the Doppler beam are in reference tothe transducer. TDI is unable to resolve the differencein motion of a myocardial segment that could beactively contracting or merely being displaced due to thetethering effect from the adjacent segment.

Previously described parameters of SR andstrain can also be derived from myocardial velocitydata (Figure 6B and C). The data displayed by colorTDI represent the velocity of each pixel at a givendistance from the transducer in reference to thetransducer. A difference between the velocities ofany 2 points along the beam implies that the pointsare moving in relationship to each other, producingcompression or expansion of the tissue. The firstpoint in a region of interest can be called V1, the sec-ond point V2, and the distance between them L. TheSR of the region of interest is defined as V2 − V1/Lwith units of second−1.16

Calculations of strain and SR from TDI data haveseveral pitfalls. First, if the TDI data are poor, thestrain/SR measurements will contain errors. Forinstance, if a myocardial segment suffers from echodropout, the TDI will encode that segment as having alower velocity than it may truly have, leading to erro-neously low strain and SR and a suggestion of hypoki-nesia or akinesia. Reverberations and side lobes canalso introduce error that may overestimate, underesti-mate, or simply generate random noise in the strain/SRvalues.17 The second limitation of TDI-derived strainvalues comes from deviation in the angle of interroga-tion. Deviation from the intended angle is even moreimportant for strain calculation than it is for TDI veloc-ity data. If one deviates from the true direction of con-traction when measuring velocities, the peak velocitieswill simply be reduced. If one alters the angle for strainmeasurements, the type of strain being measured willchange.

Assessment of global function. TDI has been used tomeasure global ventricular function in numerousways. During normal LV ejection, the base of the heartmoves toward the apex, which is relatively fixed in itsposition. This base-to-apex motion can be quantifiedat the level of the mitral annulus. The first echocar-diographic quantification attempts used M-mode butthe technique was tedious and relied on off-line analy-sis. In 1995, Gulati et al18 compared the descent veloc-ity of the mitral annulus by TDI with the standard of

radionuclide ventriculographic EF. They applied TDIto 6 points around the annulus and found that the 6-site average compared linearly with EF. An averagemitral annular descent velocity of >5.4 cm/s was 88%sensitive and 97% specific for EF > 50%. The authorsthemselves point out the largest criticism of using thisTDI method to quantify ventricular function—loaddependency. Another study, using intraoperative TEEdata, showed that the peak systolic velocity of themitral annulus (Sm) was subject to variable preloadconditions.19

The limitation of all TDI velocity measures is thepotentially confounding influence of ventriculartranslational and rotational movement. Several stud-ies have attempted to remove this confounder byusing SR imaging of the LV wall.20,21 In an open-chest dog model, Greenberg et al20 compared thepeak SR of the interventricular septum and the moreload-independent parameters of dP/dtmax, peak elas-tance (Emax), and preload recruitable stroke work atvarious hemodynamic conditions. Peak SR proved tobe a much more reliable estimate of these invasivelyderived parameters than Sm. The variable mosthighly correlated with peak SR was Emax (r = .92).

Other investigators have also attempted to defineload-independent measures of contractility using TDI.In an animal model, Vogel et al22,23 applied TDI first tothe RV free wall and then to the LV free wall andexamined the myocardial acceleration during isovolu-mic contraction (isovolumic acceleration [IVA]). IVA isan attractive measure of ventricular performancebecause it reflects the earliest events of the cardiaccycle that may be less dependent on loading condi-tions. IVA is measured as the difference between thebaseline and peak velocity divided by their time inter-val during the isovolumic period. Vogel et al comparedIVA with the gold standards of Emax and dP/dtmax dur-ing multiple loading conditions, during infusion ofesmolol and dobutamine, and with varied heart rate.They found that IVA and Emax were unaffected bychanges in preload and afterload, whereas peak isovo-lumic velocity and dP/dtmax were significantly affected.Esmolol infusion significantly decreased IVA, whereasdobutamine significantly increased it. The authorssuggest that IVA may be a clinically useful measure ofmyocardial performance given its load independence,sensitivity to contractile state, and ease of acquisition.

In a follow-up study, Lyseggen et al24 attempted todetermine whether IVA also reflects regional ventricularfunction. They found that IVA is not a good measure ofregional function; during ischemia, segments that by




other measures were severely impaired showed nochange in myocardial acceleration. They did confirmthe early finding that IVA is increased parallel to dP/dtmax

with increasing doses of dobutamine. They contradictthe early findings of load independence of IVA by show-ing a decrease in IVA with an increase in LV end-dias-tolic pressure. This finding has been criticized becausethe degree of change in preload was outside normalphysiologic values.25 Lyseggen et al contend that it is inpatients with abnormal values that load-independentmeasures of contractility will have the most benefit.25

IVA remains an attractive measure of global myocardialcontractility, but further validation needs to be donebefore it can be routinely applied clinically.

Other investigators have gone beyond IVA andlooked at SR during IVC as a potential measure ofmyocardial function.21 Peak SR during IVC shows agood correlation with dP/dt during various hemody-namic conditions. SR imaging can also differentiatebetween subendocardial, midmyocardial, and subepi-cardial layers. The subendocardium has the highest SRvalues when assessed by TDI, because the fibers in thatregion are mostly longitudinal in orientation and,hence, optimally aligned for TDI. Other data agree andsuggest that the biphasic tissue velocities seen duringIVC are a result of counterdirectional movements inthe LV wall during that time period.13

An increased understanding of the helicalnature of the heart has lead to other investigationsof global ventricular function using TDI. Ventriculartwist/torsion as measured using TDI has been vali-dated against the gold standard of tagged magneticresonance imaging (MRI).26 Peak torsion correlatedvery well (r = .95). Evaluation of torsion by TDI hasseveral potential advantages when compared withMRI. First, echocardiography is more readily avail-able and serially performed during repeat examina-tions. Second, TDI velocities can be followed overseveral cardiac cycles, whereas MRI tagging fadeswith time. These TDI-derived torsion data may facil-itate an understanding of how systolic torsion islinked to diastolic suction. Finally, TDI has a muchbetter temporal resolution than MRI and may beable to resolve the events of early diastole. Notomiet al27 have used TDI to quantify this link betweenventricular systolic twist and diastolic untwist dur-ing exercise. Their data suggest that the potentialenergy stored during LV torsion is responsible forthe early diastolic intraventricular pressure gradient.

TDI is routinely applied in the assessment ofdiastolic function. The early diastolic tissue velocity,

Ea (also E′), correlates with the invasive measure ofdiastolic function, τ.28,29 Though somewhat preloaddependant in hearts with normal systolic function,30

it is much less preload dependant than the earlytransmitral Doppler wave (E).31 This decrease inpreload dependency allows Ea to differentiate a nor-mal and pseudonormal pattern on the transmitralDoppler flow trace.32 The E/Ea ratio can predict LVfilling pressures.29,31 In patients with EF < 50%, Ea <3 cm/s is a powerful predictor of mortality,33 whereasE/Ea ≥ 15 is an independent predictor of futureheart failure.34

Pulsed TDI-derived velocities from the lateralannulus are higher than from the septal annulus andboth decline with age.35 With TTE, the region ofinterest is generally placed over the lateral mitralannulus, but with TEE it may be best to place theregion of interest over the septal annulus if it alignsbetter with the Doppler beam. Although normal val-ues for TTE have been published,36 those for TEEwhile under general anesthesia can be decreased byup to 15%.37 The use of TEE for estimation of LVfilling pressures by E/Ea in intubated ICU patientshas been further validated.38,39

Dyssynchrony. Another measure of global cardiacfunction is the synchrony between different seg-ments during contraction of the heart. The past 10years have seen an enormous amount of researchinto dyssynchrony and the means to correct it, calledcardiac resynchronization therapy (CRT). Up to30% of heart failure patients exhibit an intraventric-ular conduction delay that causes inefficient con-traction of the ventricle. CRT has been shown toacutely decrease mitral regurgitation, increase con-tractility, and decrease LV filling pressures.40 CRT,with or without defibrillation, has been shown tosignificantly improve morbidity and mortality fromheart failure.41-43 Despite a lack of echocardio-graphic indication for CRT, echocardiography withTDI is an integral part of the assessment of dyssyn-chrony and CRT. There is little relationship betweenelectrical and mechanical dyssynchrony.44-46 Mechani-cal dyssynchrony, as assessed by echocardiography,is a strong predictor of morbidity and mortality inde-pendent of QRS width47,48 and is predictive of whichpatients will likely benefit from CRT.49,50

TDI is an excellent tool to assess mechanicaldyssynchrony because of its good temporal and spa-tial resolution. In normal hearts, all segments of theventricle contract nearly simultaneously. In diseased




hearts, the lateral or posterior segments demon-strate peak contraction later than the septum, whichresults in inefficient ejection. TDI can quantify thetiming of contraction by segment. Multiple indicesof mechanical dyssynchrony exist, but those thatemploy color TDI to assess longitudinal velocitieshave recently been recommended.51 Two methodsare commonly employed. The simpler method sim-ply compares septal to lateral delay in peak systolicvelocity and defines a delay of ≥65 ms as dyssyn-chrony.49 The more detailed method requires calcu-lation of the standard deviation of the time to peaksystolic velocity from 12 sites and considers a stan-dard deviation of ≥33 ms as dyssynchrony.50 Despiteits usefulness in predicting response to CRT,absence of echocardiographic dyssynchrony shouldnot be used as sole criterion to withhold CRT froman otherwise eligible patient.51

Assessment of regional function. Assessment ofregional myocardial function by visual inspection of2D images is not consistent among experienced car-diologists and anesthesiologists.52,53 TDI provides ameans of quantitatively assessing regional functionthrough both tissue velocities and strain analysis.Most often, color TDI is used, allowing the region ofinterest to be moved to various locations in themyocardium for evaluation of myocardial velocities.Low TDI velocities correlate with abnormal myocar-dial thickening by visual inspection and M-modeanalysis.54 Tissue velocities diminish significantlywith regional ischemia55,56 and can help differentiatetransmural from nontransmural infarction.57 In dobu-tamine stress echocardiography (DSE), TDI is moresensitive to changes in LV function when comparedwith other qualitative or quantitative measures.58,59

Low tissue velocities during stress are predictive ofangiographic disease.60,61 Quantification of tissuevelocities during DSE can help predict outcomesafter myocardial infarction,62 identify false-positivewall motion abnormalities,63 and help identify viablemyocardium.64

Translational motion and tethering are a frequentconcern when evaluating regional function via TDIvelocities—these are problems that can be overcomewith strain/SR imaging. Modern echocardiographicsystems can easily provide users with strain/SR data.One must digitally acquire a loop of color TDI datafrom the region of interest taking care to align the seg-ment with the Doppler beam. Care must be taken tohave a good electrocardiogram (ECG) signal and to

acquire 3 complete cardiac cycles during apnea. As theoptimal frame rate for strain calculation is >120 framesper second, it is necessary to acquire multiple narrowsegments of the various ventricular walls.17 Off-lineanalysis includes defining regions of interest within themyocardium and tracking them with the wall throughthe cardiac cycle. The software then displays the veloc-ity, strain, or SR curves where the data can be analyzed.

TDI-derived strain and SR measurements havebeen validated using tagged MRI.65 Strain and SRsalso diminish significantly with regional ischemiaand can differentiate infracted and ischemic fromnormal myocardium.66,67 They can identify theextent of transmural infarction.68 During DSE theycompare well with perfusion scintigraphy,69 helpidentify viable myocardium,70 and can predict recov-ery after revascularization.71 TDI evaluation ofregional ischemia with TEE is feasible in the oper-ating room, although incompletely studied.72,73

Two-Dimensional Speckle Tracking

Imaging technique. One of the most important limi-tations of Doppler-based techniques for evaluatingmyocardial deformation and ventricular function isthe angle dependency of the ultrasound beams withrespect to tissue motion. Particularly in TEE, it canbe difficult to properly align the interrogating soundbeam with the region of interest. Recently intro-duced 2D speckle tracking technology has theadvantage of measuring tissue velocities and defor-mation in an angle-independent fashion (Figure7).74,75 When an ultrasound pulse interacts with tis-sue, the pulse gets distorted in a way that is highlydependent on the structure of that tissue. Withinthe myocardium, there are ultrasound reflectors thatwill distort the sound wave relatively consistentlythroughout the cardiac cycle, resulting in a consis-tent grayscale pattern being attributed to the same“speckle.” A speckle comprises a group of 20 to 40pixels, each with its distinct grayscale shade, andserves as a natural acoustic marker. Speckles can becharacterized throughout the myocardium.74 Usingpattern recognition algorithms, the position of thesespeckles can be tracked from frame to frame in adigitally stored cine-loop of a cardiac cycle. The dis-placement of the speckle in both dimensions of the 2Dimage can thus be measured throughout diastoleand systole. By tracking different speckles in the samemyocardial segment, the distance between the specklescan be measured and segmental shortening or strain





can be calculated. Because the analysis is not basedon the Doppler shift of the reflected sound wave, itis not angle dependent, and it can be performed onregular 2D grayscale images.

Speckle tracking has, however, some limitationsof its own. Because the software tracks features inthe 2D image, the quality of speckle trackingdepends highly on the spatial resolution of the imageand on the frame rate of the cine-loop. Myocardialdeformation occurs in the 3 spatial dimensions,resulting in speckles moving out of the 2D scanningplane. The computer compensates for this out-of-plane motion by tracking new speckles as they movein while previous ones fade out of the scanningplane.76 Low frame rates will lead to undersampling,and speckles will move out of the search area toosoon for digital compensation. High frame rates willreduce this problem but may lead to inadequatetracking due to reduced spatial resolution. Currently,the optimal frame rate for adequate speckle trackingseems to be about 90 frames per second, which isconsiderably lower than Doppler-based techniquesand may lead to inadequate detection of shorterevents, such as the isovolumetric phases of the car-diac cycle.17 Another limitation is the dependency onhigh image quality that might not be consistentlyobtained. Stationary artifacts, such as reverberations,can be mistaken by the software as myocardium and

will get tracked, resulting in falsely low strain calcu-lations or drift. Drift occurs when, at the end of thecycle, strain does not return to baseline. The com-puter software will correct the difference by driftcompensation. Strong reflectors in the near field,such as a calcified mitral annulus, can cast anacoustic shadow and cause dropout, leading to theinability of the software to track the segments in thefar field. Apart from the temporal, radial, and lateralresolution, accurate tracking also depends on the ori-entation of the myocardial fibers and the blood–tissue interface. In the transesophageal short-axisviews in TEE, for example, the fiber orientation andthe endocardial border of the septal and lateral wallsare parallel to the ultrasound beam, frequentlyresulting in low resolution with inadequate tracking.

The software evaluates the tracking quality usingseveral criteria: the position of the speckles in thefirst frame of the loop should coincide with the posi-tion of the speckles in the last frame, the velocity ofadjacent speckles should be similar, and drift com-pensation should be low. Based on these criteria, thesoftware will grade the tracking, and one can acceptor reject the result. Visual control of the processremains necessary to correct misinterpretation ofartifacts by the software.

Although speckle tracking can be performed onany 2D grayscale image, the images acquired in the

Figure 7. Speckle tracking. The distortion of the ultrasound pulse by tissue defines the grayscale tone attributed to the pixel in the2D image. A group of 20 to 40 pixels is called a speckle. If the grayscale distribution within a speckle remains constant throughoutthe cardiac cycle, it can be tracked by the speckle tracking software and its displacement calculated in 2 dimensions.



harmonics mode allow superior endocardial borderdelineation. When obtaining images, special atten-tion must be given to image quality and frame rate.Changing gain, compression, and reject settings canbe helpful in optimizing the grayscale distribution.The optimal frame rate can be obtained by reducingthe sector width and depth of the scanning field, byusing the single focus mode and if necessary bychanging the number of scan lines. For adequatetiming of cardiac events, a constant heart rate insinus rhythm and a clear ECG signal as well as aor-tic valve opening and closure times are necessary.

Assessment of global ventricular function. After manuallydelineating the endocardial border, the software auto-matically divides the LV myocardium into 6 segmentsthat are color coded and display velocity, displacement,strain, and SR curves for the entire ventricle or for theindividual segments (Figure 8). The global ventricularstrain values, in the longitudinal, radial, or circumfer-ential dimension, are calculated as an average of all thestrains measured over the entire myocardium in therespective directions. Compared with techniques calcu-lating derived parameters representing global ventricu-lar function, such as mitral annular velocity, thistechnique has the advantage of evaluating the entire vis-ible myocardium in its calculation of global function.EF calculated using speckle tracking techniques hasbeen shown to correlate closely with visual estimationand Simpson’s method (r = .82) for TTE.76 And severalstudies reported the technique to have low interobservervariability (8.6% to 11.8%) and intraobserver variability(5.2% to 8.8%).77,78

Global longitudinal strain has been proposed as anew index for LV systolic function, with a high speci-ficity and sensitivity for the diagnosis of myocardialinfarction.79 Reductions in global longitudinal strainclosely correlate with infarct size in chronic ischemicheart disease.80 Speckle tracking has also been shownto demonstrate early decreases in global longitudinal,radial, and circumferential strain in patients with sub-clinical hypertrophic cardiomyopathy.81

Global diastolic SRs in the IVR phase correlatewith diastolic function as assessed by intraventricu-lar pressure measurements.82

By tracking angular displacement in the short-axis views, speckle tracking allows for the quantifi-cation of ventricular twist and torsion.83 This uniquefeature has been used to study changes in ventricu-lar rotation and rotation rate in the elderly84 and inpatients with essential hypertension,85 myocardial

ischemia,86 ventricular hypertrophy,87 dilated car-diomyopathy,88 and chronic mitral regurgitation.89 Inone study, the rate of early diastolic untwist has beenshown to correlate with the degree of diastolic dys-function as defined by classic echocardiographicmeasures.90

All the previously mentioned studies relate to TTE.TEE transducers, however, use a higher ultrasound fre-quency with a shallower focus, leading to lower lateralresolution at greater depths—a property that affectsimaging of the far-field LV segments. Also, interpositionof the mitral valve apparatus between the transducerand the LV myocardium results in more shadowing andartifacts at the level of the left ventricle. We compared


Figure 8. Global and regional strain and strain rate curves.(A) Global longitudinal and regional strain curve. (B) Globallongitudinal and regional strain rate curves. The myocardium isdivided into ASE defined segments (left upper panel). Globalstrain and strain rate curves are presented in a white dotted linewhile segmental strain and strain rate curves are presented ascontinuous lines (right panel). The computer also generates aan M-mode, semiquantitative display of strain and stain ratesfor the various segments (left lower panel).




the results of speckle tracking on images obtained byTTE and TEE using EchoPac software (GE, Vingmed,Horten, Norway) in anesthetized patients under identi-cal hemodynamic conditions. We found that the num-ber of segments tracked is similar for the long-axis views(83% for TEE and 76% for TTE) but significantly lowerfor the short-axis views (59% for TEE and 74% for TTE)with a slightly better tracking quality in TTE. There wasa good correlation for global longitudinal strain in themidesophageal 4-chamber view (r = .9) and the mides-ophageal 2-chamber view (r = .8) but only moderatefor the midesophageal long-axis view (r = .5). In theshort-axis views, only circumferential strain of the api-cal segments showed good correlation (r = .7). The out-of-plane motion of the midpapillary, and particularly thebasal segments, accounts for the poor correlation foundfor these parts of the ventricle (r = .5 and r = −.1, respec-tively). For all imaging planes, strain calculated on theTEE images showed a small positive bias compared withTTE (3.7 ± 3.3 for longitudinal strain and 4.8 ± 5.3 forcircumferential strain). We also compared global longi-tudinal strain calculated by speckle tracking in TEEwith visual estimation of global ventricular function andthe modified Simpson’s method and found a good cor-relation in both comparisons (r = .7).

Assessment of regional ventricular function. Probably themost attractive feature of speckle tracking is the possi-bility to assess regional myocardial deformation in anangle-independent manner. This allows for simultane-ous qualification and quantification of regional wallmotion abnormalities in all the myocardial segments ofthe 2D image. Moreover, the timing and duration of systolic and diastolic events of the different segmentscan be measured and compared to assess contractionsequence and intraventricular dyssynchrony. The calcu-lation of regional myocardial strain and SR by speckletracking has been validated in vitro using ultrasoundphantoms77 and in vivo against TDI,74 microsonome-try,75,78 and tagged cardiac MRI.78 All studies showedgood correlations with low variability.

Speckle tracking correctly identifies infarctedsegments after induced regional myocardial ischemiain animal models.91 In humans, regional reductionsin strain correlate well with angiographic findings ofcoronary artery disease, and speckle tracking can dis-tinguish different states of transmurality of myocardialinfarctions.76,92,93

Cardiac resynchronization therapy has beenshown to improve heart failure functional class,exercise capacity, quality of life, and survival in

patients with heart failure and dyssynchrony.51 Yetabout 25% to 35% of patients do not respond totherapy. Proper diagnosis and quantification of dys-synchrony by echocardiographic techniques is likelyto improve patient selection for CRT. Speckle track-ing offers the possibility to time myocardial defor-mation in 6 segments simultaneously, and it is usedin numerous trials as a tool to diagnose dyssyn-chrony and guide CRT.94,95 Nevertheless, because ofthe much lower temporal resolution compared withtissue Doppler measurements, speckle tracking maybe less adapted to distinguish events separated byonly a few milliseconds. Another limitation is that theregional strain and SRs are the mean of all the speck-les tracked in 1 segment. Subsegmental pathology willthus not be detected by speckle tracking.

Currently, the software is designed for TTEimaging and is, therefore, in some minor aspect, notadapted to TEE. This does not impede its use, andthe newer versions will probably deal with this prob-lem. Moreover, speckle tracking can be performed inreal time, providing a relatively rapid quantificationof global and regional ventricular function.

Contrast-Enhanced Echocardiography(CEE)

Imaging technique. Opacifying the blood volume in theimaging plane by an ultrasound contrast agent canimprove the quality of the image and can generateinformation that might not be obtained from the stan-dard 2D grayscale images. Anesthesiologists frequentlyuse agitated saline as a contrast agent to opacify theright side of the heart and assess the presence of apatent foramen ovale. However, after passage throughthe pulmonary vasculature, the density of these air-filled microbubbles is too low to produce the sameeffect on the left side. In the past few years, syntheticmicrospheres have been developed that have muchhigher stability; and a significant portion of the dosewill reach the LV.96 The shells of these microspheresare made of phospholipids or albumin and are filledwith fluorinated hydrocarbon gases.97 A single intra-venous injection of only a small dose of these micros-pheres will produce intense opacification of the LVcavity. Subsequent passage into the coronary circula-tion will opacify the entire myocardium. The opacifica-tion of the ventricular cavity leads to a highly detaileddemarcation of the endocardial border consistentlyimproving the echocardiographer’s ability to measure




global ventricular function by visual estimation orsemiquantitative techniques based on endocardial bor-der tracing (Figure 9). Filling of the myocardium willallow for the detection of filling delays or defects in thepresence of coronary artery stenosis.

To differentiate reflections generated by tissuefrom those generated by the contrast agent, specificimaging modalities have been developed based onthe physical and mechanical properties of the con-trast agents. Not only are microspheres strongreflectors of sound, they also act as ultrasoundsources. When interacting with sound waves, themicrobubbles react by rapidly changing size andshape. These oscillations, in turn, produce ultra-sonic sound waves at the second or higher harmonicof the original frequency of the incoming pulse. Themechanical deformation of the bubbles will eventu-ally lead to their destruction if the interrogatingsound source has a high mechanical index. With theearlier high-power modalities (mechanical index>1.0), bubble destruction was inevitable and imag-ing was intermittent. The image had to be recon-structed out of several loops taken at different timepoints, leading to artifacts and increased duration ofthe exam. Harmonic imaging using a lower mechan-ical index (>0.6) has been developed for use in con-trast echocardiography to better balance backscatterenhancement with microbubble survival.

More recently, very low power (mechanical index<0.2) modalities—power modulation imaging andpower pulse inversion imaging—have been developedthat do not destroy the microbubbles. These modalitiesproduce highly defined, real-time images that only showechoes from the contrast agent without interferencefrom tissue backscatter. In power modulation imaging,the output power or amplitude of every second wave isdoubled while the returning echoes from the original,low-powered pulses are amplified. When subtractingthe echoes from each consecutive pair of pulses, all theechoes from linear scatterers (tissue) will be canceled.Echoes from nonlinear scatterers (microbubbles) aremore chaotic and will not cancel out. The resultantimage only shows echoes reflected from the contrastagent. Power pulse inversion is a technique in which 2ultrasound pulses are transmitted simultaneously. Thepulses are identical but have opposite polarity. The tis-sue reflections of these pulses will cancel each otherout, whereas the reflections from microbubbles, whichare chaotic, will not cancel. Again, the result is an imagein which all backscatter from tissue is blacked out

and only the contrast is visible. These new modalities,however, are currently not available for use with TEE.

Safety. Although several trials have reported a verygood safety profile for different contrast media,99,100

the US Food and Drug Administration issued a blackbox warning on its use in October 2007 followingthe report of 199 serious, nonfatal reactions and 11deaths associated with the use of Definity andOptison contrast agents.101 After reexamining theavailable data and reevaluating the risk–benefit ratioof contrast-enhanced echocardiography, the restric-tions on the use of intravenous contrast have beenrelaxed in May 2008, and new labeling guidelineshave been issued.102

Assessment of global ventricular function. Opacificationof the LV cavity using contrast consistently results in asuperior delineation of the endocardial border in allpatients, but it is particularly useful in patients withpoor acoustic windows.103 It can also improve the qual-ity of the exam by optimizing image alignment by avoid-ing off-axis scanning. Compared with MRI andcineventriculography, 2D CEE using Simpson’s methodof discs demonstrates a higher degree of correlationwith LV volumes and EF. Also, CEE has been shown to

Figure 9. (A) Transthoracic apical 4-chamber view showingpoor delineation of the endocardial border of the left ventricle.(B) After opacification of the left ventricular cavity with anintravenous perfluorocarbon-based contrast agent, the sameview shows a highly detailed demarcation of the endocardialborder over almost the entire ventricle. Form Hundley et al,98

with permission.




be superior in the identification of low EF and showsless interobserver variability compared with unen-hanced echocardiography.98,104,105

Contrast can be used to identify other pathologiesrelated to ventricular dysfunction, such as the presenceof an apical ventricular mass or thrombus, or to diag-nose LV noncompaction. In TEE, the long distancebetween the transducer and the LV apex can impede theclear visualization of an apical thrombus. When con-trast is used, thrombus typically is seen as a nonopaci-fied structure.103 Isolated ventricular noncompaction isthe third most frequent cardiomyopathy (CMP) afterdilated and hypertrophic CMP and accounts for nearly10% of all primary CMPs in children.106 Prevalence ofthis pathology in adults is substantially lower.107 Onechocardiographic examination, the LV presents as athin compacted outer layer and a much thicker, heavilytrabeculated, noncompacted inner layer. CEE accentu-ates the intertrabecular spaces and facilitates the diag-nosis by clearly delineating the compacted from thenoncompacted layer.108

Assessment of regional ventricular function. After abolus injection or a continuous infusion of contrastagent, the entire myocardium will brighten as theblood volume in the coronary circulation gets satu-rated with contrast. Because the coronary vesselscontain only 7% of the cardiac blood volume, themyocardium will opacify less than the ventricularcavity.103 Using a high-power ultrasound pulse, allmicrobubbles are destroyed, after which themyocardium will fill up again with contrast-ladenblood. Areas distal to coronary stenoses will show adelay in replenishment or absence of contrast (“fill-ing defects”). The signal intensity can be quanti-fied and displayed in destruction/refilling curvesthat correlate closely with coronary blood flow.109

Real-time myocardial CEE accurately estimatesthe risk area and infarction area in acute coronarysyndromes.110-112 After revascularization andrestoration of antegrade coronary flow, the persist-ence of a perfusion defect or “no-reflow” area inthe infarct zone is predictive of lack of recovery ofventricular function and poor outcome.113,114

Use of myocardial CEE in TEE is still to be thor-oughly established, but one can imagine its use in thesetting of coronary bypass surgery where it could iden-tify immediate restoration of myocardial perfusion (orlack thereof) distal to bypassed coronary stenoses anddiscriminate stunned myocardium (noncontractile, per-fused) from ischemic myocardium (noncontractile, notperfused).

Real-Time 3D Echocardiography

Imaging technique. The possibility of creating a 3Dechocardiographic image of the heart was initiallyexplored in the 1970s.115 These earlier versions of3D echo were based on the reconstruction of a 3Dimage out of multiple 2D slices and were time con-suming and impractical. Since then several studieshave demonstrated the superiority of 3D imagingover 2D for the evaluation of LV structure and func-tion.116-118 The recent advancements in computa-tional power and miniaturization of ultrasoundequipment have allowed for the development of real-time 3D echocardiography (RT3DE). The matrixarray ultrasound transducer has up to 3000 ultra-sound elements that reproduce a real-time, pyramid-shaped, 3D image of the interrogated region of theheart. At the present time, the size of the imaged vol-ume is not enough to contain the entire adult LV.Therefore, a series of 4 or more gated cycles need tobe combined to recreate a full-volume image of theventricle, resulting in a maximum frame rate of 25Hz.119 Real-time 3D TEE is comprehensivelyreviewed elsewhere in this issue.

The currently available RT3DE for TEE offers 3different modalities (Figure 10): live 3D, 3D zoom,and full volume. The first and second provide a real-time, ungated 3D image of a portion of the heart,whereas the latter necessitates the summation of sev-eral gated cycles. Live 3D gives a 50° × 30° volumeand can best be described as a thick 2D slice. In ourexperience, this is the preferred modality for struc-tural evaluation of the aortic valve. Three-dimen-sional zoom provides a truncated pyramid of variablesize and is the preferred view for the structural eval-uation of the mitral valve. Only the gated full-volume3D view encompasses the whole left ventricle andcan be used for the volumetric assessment of globaland regional LV function. For the acquisition of ahigh-quality full-volume loop, manipulation of thepatient and surgical interference must be paused andthe ventilation paused. The ultrasound machineacquires 4 to 7 ECG-gated images that will besummed to create the full-volume projection of theheart. The accuracy of the gating process can be ver-ified by evaluating the superposition of the differentECG tracings. Improper alignment of the images dueto movement or artifacts will show up as “stitchlines” in the 3D image.

Assessment of global ventricular function. When a full-volume 3D image is acquired, only the outer surface ofthe pyramid shape is displayed (Figure 11A). The image



can then be cropped in different planes to expose thestructures within and to evaluate wall motion of the dif-ferent segments (Figure 11B).

Several semiautomated algorithms have beendeveloped to calculate LV volumes.120 After identify-ing several landmarks, the endocardium is traced byan automated endocardial border detection algo-rithm, which can be visually inspected and manuallycorrected if needed. Based on these data, an endo-cardial cast and its displacement throughout thecardiac cycle is generated to be displayed as the“jellybean image” (Figure 11C).

Ventricular volumes are numerically and graphicallydisplayed as time–volume curves and end-diastolic volume, end-systolic volume, and EF can be calculated.The accuracy of the calculated volumes and EFdepends on the number of elements in the transducer,the spatial and temporal resolution of the image, andthe accuracy of the endocardial border delineation. Theaccuracy and reproducibility of RT3DE has been estab-lished in several studies. Global LV volume and EFmeasurements using RT3DE correlate highly with car-diac MRI (r = .98) with minimal bias (1.4 mL) and nar-row limits of agreement (±20 mL).121 In fact, thecorrelation with cardiac MRI is better for RT3DE thanfor single-photon emission computed tomography andcardiac computed tomography, albeit with higher vari-ability.122,123 The limited temporal and spatial resolutionof the technology accounts for some of the reportedunderestimation and variability of LV volumes byRT3DE.

Nevertheless, interobserver and intraobservervariability is significantly lower for RT3DE than for2D echocardiography.124 Its superiority to 2Dechocardiographic imaging is largely due to the factthat no geometrical assumptions and no extrapola-tion of the endocardial border for the regions inbetween scanning planes are necessary.

Assessment of regional ventricular function. The vol-ume enclosed in the ventricular cavity is divided in16 pyramidal segments according to the 16-segmentnomenclature. The endocardial border of the seg-ment defines the base of every pyramid, and the tipis a point on the longitudinal axis of the ventricle.The difference between the end-diastolic volume andthe end-systolic volume of this pyramid is defined asthe regional EF for the segment. On the computer-generated endocardial cast, the 16 segments can bedisplayed in different colors, and for every segment,a time–volume curve can be displayed.

Automated quantification of regional EF usingRT3DE correlates well with cardiac MRI–derived meas-urements with r > .8 for regional volumes and r = .71 forregional EF, with minimal bias (0.2 mL) and tight limitsof agreement (7 mL).125 Compared with visual assess-ment of regional ventricular function, where segmentalfunction was graded as normal or abnormal by an expe-rienced echocardiographer, RT3DE has a sensitivity of0.84, a specificity of 0.78, a positive predictive value of0.95, a negative predictive value of 0.47, and an accu-racy of 0.84.121,125 Finally, regional volumetric RT3DEhas been compared with gated myocardial perfusion toevaluate intraventricular dyssynchrony of the LV andshowed good correlation (r = .80), with excellent inter-observer agreement (mean difference of 0.1% for dys-synchrony index and of 0.4% for EF).126

Real-time 3D assessment of ventricular functionis still a bit unwieldy to be of routine use as an intra-operative monitor of LV volumes and function.Multiple steps with manual correction of the tracingof the endocardial borders and adjustments of theorientation of the axes prolong the acquisition timeof the data. Furthermore, the acquisition of multiplegated images makes the technique prone to artifactsdue to movement and ventilation of the patient andelectrical interference. Fortunately, this technology


Figure 10. Real-time 3D echocardiographic imaging modali-ties. (A) Live 3D. Ungated, 50° × 30° pyramidal volume. (B) 3Dzoom. Ungated, a truncated pyramid, whose size can be changedby the operator. (C) Full-volume 3D, 100° × 100° pyramidalvolume. Four to seven ECG-gated images are summarized toencompass the full left ventricle. The ECG tracing are super-posed at the bottom of the image allowing visual inspection.




is evolving very rapidly. We can expect the scanningangles to become large enough for the entire leftventricle to be comprised in a single cardiac cycle,full-volume loop, and the introduction of more pow-erful endocardial border detection algorithms willmake this technique a valuable tool for the rapidevaluation and quantification of global and regionalventricular function.

Conclusions

Recent advancements in echocardiography imaginghave allowed an improved appreciation of the structureand function of the heart and provide an opportunity toobjectively assess the dynamic cardiac motions influ-encing LV function. Imaging modalities such as TDIand speckle tracking allow improved characterization oftissue displacement and strain, aiding understanding ofrotational, longitudinal, and transverse motions that areso apparent during ventricular ejection. Similarly, 3Dand contrast echocardiography provide enhanced abilityto measure ventricular shape and volumes, improvingthe clinicians’ ability to diagnose alterations in cardiacstructure and function. Continued developments inthese technologies and methodical validation of the var-ious new measurement algorithms in clinical trials will lead to improved ability of assessing ventricularfunction.

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