We wish to acknowledge the Neonatal intensive care department of the John Hunter Hospital for allowing our ongoing work to be performed, along with the parents of our very small and precious participants.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants&#39; families included in the study. All images and video clips were de-identified following the acquisition.
1. Patient preparation
<ol>
	<li>Set up th...

Advancements in Echocardiography-Derived Blood Speckle Imaging Technology

<ol>
	<li>de Waal, K., Costley, N., Phad, N., Crendal, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+ventricular+diastolic+dysfunction+and+diastolic+heart+failure+in+preterm+infants.">Left ventricular diastolic dysfunction and diastolic heart failure in preterm infants.</a> Pediatric Cardiology. 40 (8), 1709-1715 (2019).</li><li>Lahmers, S., Wu, Y., Call, D. R., Labeit, S., Granzier, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Developmental+control+of+titin+isoform+expression+and+passive+stiffness+in+fetal+and+neonatal+myocardium.">Developmental control of titin isoform expression and passive stiffness in fetal and neonatal myocardium.</a> Circulation Research. 94 (4), 505-513 (2004).</li><li>Chung, C. S., Hoopes, C. W., Campbell, K. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Myocardial+relaxation+is+accelerated+by+fast+stretch,+not+reduced+afterload.">Myocardial relaxation is accelerated by fast stretch, not reduced afterload.</a> Journal of Molecular and Cellular Cardiology. 103, 65-73 (2017).</li><li>Pedrizzetti, G., La Canna, G., Alfieri, O., Tonti, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+vortex-an+early+predictor+of+cardiovascular+outcome.">The vortex-an early predictor of cardiovascular outcome.</a> Nature Reviews Cardiology. 11 (9), 545-553 (2014).</li><li>Rodriguez Munoz, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+ventricular+vortex+following+atrial+contraction+and+its+interaction+with+early+systolic+ejection.">Left ventricular vortex following atrial contraction and its interaction with early systolic ejection.</a> European Heart Journal. 34 (1), 1104 (2013).</li><li>Schmitz, L., Koch, H., Bein, G., Brockmeier, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+ventricular+diastolic+function+in+infants,+children,+and+adolescents.+Reference+values+and+analysis+of+morphologic+and+physiologic+determinants+of+echocardiographic+Doppler+flow+signals+during+growth+and+maturation.">Left ventricular diastolic function in infants, children, and adolescents. Reference values and analysis of morphologic and physiologic determinants of echocardiographic Doppler flow signals during growth and maturation.</a> Journal of the American College of Cardiology. 32 (5), 1441-1448 (1998).</li><li>Marchese, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+ventricular+vortex+analysis+by+high-frame+rate+blood+speckle+tracking+echocardiography+in+healthy+children+and+in+congenital+heart+disease.">Left ventricular vortex analysis by high-frame rate blood speckle tracking echocardiography in healthy children and in congenital heart disease.</a> International Journal of Cardiology. Heart &amp; Vasculature. 37, 100897 (2021).</li><li>Pierrakos, O., Vlachos, P. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+vortex+formation+on+left+ventricular+filling+and+mitral+valve+efficiency.">The effect of vortex formation on left ventricular filling and mitral valve efficiency.</a> Journal of Biomechanical Engineering. 128 (4), 527-539 (2006).</li><li>Mele, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intracardiac+flow+analysis:+techniques+and+potential+clinical+applications.">Intracardiac flow analysis: techniques and potential clinical applications.</a> Journal of the American Society of Echocardiography. 32 (3), 319-332 (2019).</li><li>Nyrnes, S. A., Fadnes, S., Wigen, M. S., Mertens, L., Lovstakken, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Blood+speckle-tracking+based+on+high-frame+rate+ultrasound+imaging+in+pediatric+cardiology.">Blood speckle-tracking based on high-frame rate ultrasound imaging in pediatric cardiology.</a> Journal of the American Society of Echocardiography. 33 (4), 493-503 (2020).</li><li>de Waal, K., Crendal, E., Boyle, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+ventricular+vortex+formation+in+preterm+infants+assessed+by+blood+speckle+imaging.">Left ventricular vortex formation in preterm infants assessed by blood speckle imaging.</a> Echocardiography. 36 (7), 1364-1371 (2019).</li><li>Nagueh, S. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Recommendations+for+the+evaluation+of+left+ventricular+diastolic+function+by+echocardiography:+an+update+from+the+American+Society+of+Echocardiography+and+the+European+Association+of+Cardiovascular+Imaging.">Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.</a> Journal of the American Society of Echocardiography. 29 (4), 277-314 (2016).</li><li>Takahashi, H., Hasegawa, H., Kanai, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Temporal+averaging+of+two-dimensional+correlation+functions+for+velocity+vector+imaging+of+cardiac+blood+flow.">Temporal averaging of two-dimensional correlation functions for velocity vector imaging of cardiac blood flow.</a> Journal of Medical Ultrasonics. 42 (3), 323-330 (2015).</li><li>Kheradvar, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Echocardiographic+particle+image+velocimetry:+a+novel+technique+for+quantification+of+left+ventricular+blood+vorticity+pattern.">Echocardiographic particle image velocimetry: a novel technique for quantification of left ventricular blood vorticity pattern.</a> Journal of the American Society of Echocardiography. 23 (1), 86-94 (2010).</li><li>Phad, N. S., de Waal, K., Holder, C., Oldmeadow, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dilated+hypertrophy:+a+distinct+pattern+of+cardiac+remodeling+in+preterm+infants.">Dilated hypertrophy: a distinct pattern of cardiac remodeling in preterm infants.</a> Pediatric Research. 87 (1), 146-152 (2020).</li><li>Kheradvar, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+and+prognostic+significance+of+cardiovascular+vortex+formation.">Diagnostic and prognostic significance of cardiovascular vortex formation.</a> Journal of Cardiology. 74 (5), 403-411 (2019).</li><li>Cantinotti, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intracardiac+flow+visualization+using+high-frame+rate+blood+speckle+tracking+echocardiography:+Illustrations+from+infants+with+congenital+heart+disease.">Intracardiac flow visualization using high-frame rate blood speckle tracking echocardiography: Illustrations from infants with congenital heart disease.</a> Echocardiography. 38 (4), 707-715 (2021).</li><li>Henry, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bicuspid+aortic+valve+flow+dynamics+using+blood+speckle+tracking+in+children.">Bicuspid aortic valve flow dynamics using blood speckle tracking in children.</a> European Heart Journal-Cardiovascular Imaging. 22, 356 (2021).</li><li>Mawad, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Right+ventricular+flow+dynamics+in+dilated+right+ventricles:+energy+loss+estimation+based+on+blood+speckle+tracking+echocardiography-a+pilot+study+in+children.">Right ventricular flow dynamics in dilated right ventricles: energy loss estimation based on blood speckle tracking echocardiography-a pilot study in children.</a> Ultrasound in Medicine &amp; Biology. 47 (6), 1514-1527 (2021).</li><li>Kass, D. A., Bronzwaer, J. G. F., Paulus, W. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=What+mechanisms+underlie+diastolic+dysfunction+in+heart+failure.">What mechanisms underlie diastolic dysfunction in heart failure.</a> Circulation Research. 94 (12), 1533-1542 (2004).</li><li>Nagueh, S. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+ventricular+diastolic+function:+understanding+pathophysiology,+diagnosis,+and+prognosis+with+echocardiography.">Left ventricular diastolic function: understanding pathophysiology, diagnosis, and prognosis with echocardiography.</a> JACC. Cardiovasc Imaging. 13, 228-244 (2020).</li><li>Carroll, J. D., Lang, R. M., Neumann, A. L., Borow, K. M., Rajfer, S. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+differential+effects+of+positive+inotropic+and+vasodilator+therapy+on+diastolic+properties+in+patients+with+congestive+cardiomyopathy.">The differential effects of positive inotropic and vasodilator therapy on diastolic properties in patients with congestive cardiomyopathy.</a> Circulation. 74 (4), 815-825 (1986).</li></ol>

The importance of visualizing and understanding the intracardiac vortex 
There are many possible clinical applications of high-frame rate echocardiography-derived vortex imaging. Their ability to provide valuable insight into intracardiac flow dynamics has been the interest of recent studies16. Moreover, vortex imaging may allow the detection of pre-symptomatic changes in LV architecture and function in neonates, which may have a bearing on long-term cardiac remodeling into a...

An erratum was issued for:&#160;<a href="https://www.jove.com/t/65189">Assessing Intracardiac Vortices with High Frame-Rate Echocardiography-Derived Blood Speckle Imaging in Newborns</a>. The Authors section was updated. The affiliation for author Damien Vitiello has been updated to:&#160;Institute of Sport and Health Sciences of Paris (IS3P - URP 3625), Universit&#233; Paris Cit&#233;&#160;

An erratum was issued for:&#160;<a href="https://www.jove.com/t/65189">Assessing Intracardiac Vortices with High Frame-Rate Echocardiography-Derived Blood Speckle Imaging in Newborns</a>. The Authors section was updated.

Erratum: Assessing Intracardiac Vortices with High Frame-Rate Echocardiography-Derived Blood Speckle Imaging in Newborns

Intracardiac blood flow patterns play a key role in cardiac development, starting in fetal morphogenesis and continuing throughout the lifespan1. Hemodynamic shear stress plays a pivotal role in the stimulation of cardiac chamber growth and architecture via the activation of specific genes2,3. This occurs at both the intrauterine stage and in the early stages of life, thus highlighting the importance of hemodynamic influence on early cardiac development and the carry-over into adulthood3.
The laws of fluid dynamics state that blood passing along a vessel wall move slower when closest to the wall and faster when in the center of a vessel, where resistance is lower. This phenomenon can be demonstrated in any large vessel with pulse wave Doppler as the typical Doppler velocity time integral envelope4. When blood enters a larger cavity such as the heart, the blood farthest from the endocardial surface continues to increase its velocity relative to the blood closest to that surface and create a rotational body of fluid, known as a vortex. Once created, vortices are self-propelling flow structures that typically draw in surrounding fluid via negative pressure gradients. Thus, a vortex can move a greater volume of blood than an equivalent straight jet of fluid, promoting greater cardiac efficiency4,5.
The literature suggests that the evolutionary purpose of vortices is to conserve kinetic energy, minimize shear stress, and maximize flow efficiency4,5,6. Specifically for the heart, this includes storing hemodynamic energy in a rotary motion, facilitating valve closure, and the propagation of blood flow toward the outflow tract, as seen in Figure&#160;1. Altered intracardiac blood flow patterns are expected in pathological situations such as volume-overloaded states and in cases with artificial valves7,8. Thus, herein lies the true diagnostic potential of vortices as early predictors of cardiovascular outcomes in adults.
Intracardiac hemodynamics have gained increasing interest in the literature in both adult and pediatric populations. Several modalities are available for the qualitative and quantitative assessment of intracardiac hemodynamics and were comprehensively summarised in a recent review, with a specific emphasis on the intracardiac vortex9. One modality with great promise is echocardiography-derived blood speckle imaging (BSI), which offers the ability to noninvasively measure a number of qualitative and quantitative vortex characteristics, described below, at a relatively low cost and with excellent reproducibility10. BSI is currently commercially available using a high-end cardiac ultrasound system with an S12 or S6 MHz probe. The speckle-tracking features are analogous to those used in tissue speckle tracking to study myocardial deformation11,12,13. Since red blood cells tend to move faster and with a higher Doppler frequency than the surrounding tissue, the two signals can be separated by applying a temporal filter. BSI uses a best-match algorithm to quantify the movement of blood speckles directly without using contrast agents. The blood velocity measurements can be visualized as arrows, streamlines, or path lines with or without underlying color Doppler images, and can highlight areas of complex flow10.
BSI has been shown to have good feasibility and accuracy for quantifying intracardiac blood flow patterns, with excellent validity compared to a reference phantom instrument and pulsed-Doppler7,10,11. Whilst still very novel, BSI is a promising clinical tool for the early diagnosis of various cardiac pathophysiologies. The clinical application of vortex imaging has shown promise in newborn infants. Specifically, the behavior of a vortex in the left ventricle (LV) may have long-term implications on cardiac remodeling and predisposition toward heart failure.
The mechanism linking vortices to left ventricular remodeling is still relatively unexplored, but has been recently investigated in our laboratory and is the subject of ongoing work11. This methodology article aims to describe the use of BSI in exploring intracardiac vortices and discuss the practical and clinical uses of vortices in assessing diastolic function in various populations. A secondary aim is to discuss the clinical relevance of BSI and present some of the work previously performed in neonates.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Tomtec Imaging Systems GmbH</td>
			<td>Phillips</td>
			<td>GmbH Corporation</td>
			<td>Offline ultrasound image processing tool, used for calculating all vortex measurements</td>
		</tr>
		<tr>
			<td>Vivid E95</td>
			<td>General Electrics</td>
			<td>NA</td>
			<td>Cardiac Ultrasound device used to capture Echocardiography-derived Blood Speckle Imaging</td>
		</tr>
	</tbody>
</table>

assessing intracardiac vortices with high frame-rate echocardiography-derived blood speckle imaging in newborns

The left ventricle (LV) has a unique pattern of hemodynamic filling. During diastole, a rotational body or ring of fluid known as a vortex is formed due to the chiral geometry of the heart. A vortex is reported to have a role in conserving the kinetic energy of blood flow entering into the LV. Recent studies have shown that LV vortices may have prognostic value in describing diastolic function at rest in neonatal, pediatric, and adult populations, and may help with earlier subclinical intervention. However, the visualization and characterization of the vortex remain minimally explored. A number of imaging modalities have been utilized for visualizing and describing intracardiac blood flow patterns and vortex rings. In this article, a technique known as blood speckle imaging (BSI) is of particular interest. BSI is derived from high-frame rate color Doppler echocardiography and provides several advantages over other modalities. Namely, BSI is an inexpensive and noninvasive bedside tool that does not rely on contrast agents or extensive mathematical assumptions. This work presents a detailed step-by-step application of the BSI methodology used in our laboratory. The clinical utility of BSI is still in its early stages, but has shown promise within the pediatric and neonatal populations for describing diastolic function in volume-overloaded hearts. A secondary aim of this study is thus to discuss recent and future clinical work with this imaging technology.

Author Spotlight: Advancing Neonatal Cardiac Diagnostics with Echocardiography-Derived Blood Speckle Imaging 

Assessing Intracardiac Vortices with High Frame-Rate Echocardiography-Derived Blood Speckle Imaging in Newborns

We're try to explore why preterm babies when they're born preterm and grow into adults have a significant higher risk of heart failure. We think it has to do with an abnormal cardiac development because they were born 10 or sometimes 15 weeks early and where pressure in the heart has changed. We can now capture this kind of changes with looking at intracardiac blood flow patterns with blood speckle imaging.Hopefully we'll be able to select babies very early on in this crucial period of cardiac development and maybe apply some preventive strategies with a future goal to also prevent heart failure when they grow up to be adults. Well, from a practical point of view, the challenges always fall back on image quality and the acquisition of clear cardiac structures in an echo. And what's more, it's additionally challenging because we're dealing with babies and we sometimes have very unsettled patients.So we did two studies with blood speckle imaging, one to look if the technique was actually feasible in this population and the answer was yes, it's very feasible. It's very nice images of intracardiac blood flow patterns in these preterm population. And the second we followed the cohort of 80 preterm infant, and we measured them at day five to seven and then again at discharge.And then we categorized them in the babies who had this cardiac remodeling of prematurity and the ones who did not. And we found out that the babies who had cardiac modeling also had abnormal vortex formations at day seven. The vortexes were way more larger and rounder than in the babies who did not develop cardiac remodeling.This might be a very important clue moving forward in exploring which babies might be amenable to preventive treatments. Well, currently there's limited research available on the use of echo derived blood speckle imaging and neonates. So what we've currently been doing is looking at cardiac development after preterm birth.But what remains to be explored is the association between diastolic dysfunction and intracardiac blood flow, like vortices and vortex exclamation. Echo derived blood speckle imaging is a completely non-invasive tool compared to other technologies like MRI. It's also fairly cheap to use and it's very useful as a bedside tool, meaning it can be brought into the rooms next to patients and minimizing inconvenience to the patients.

The acquisition of vortex clips is comparable to the standard methodology universally employed in obtaining color Doppler clips. Pioneering studies in adults have described vortices using the apical two-, three-, and four-chamber views14. The LV vortex is a ring-like structure that moves from base to apex. BSI visualizes the internal diameter of the ring (Figure 2). A vortex ring is usually not symmetrical in shape, hence alternative imaging planes can show variable v...

Watch this Scientific Journal Video about Advancing Neonatal Cardiac Diagnostics with Echocardiography-Derived Blood Speckle Imaging at JoVE.com

The present protocol uses echocardiography-derived blood speckle imaging technology to visualize intracardiac hemodynamics in newborns. The clinical utility of this technology is explored, the rotational body of fluid within the left ventricle (known as a vortex) is accessed, and its significance in understanding diastology is determined.

The left ventricle (LV) has a unique pattern of hemodynamic filling. During diastole, a rotational body or ring of fluid known as a vortex is formed due ...