Name: transthoracic speckle tracking echocardiography for the quantitative assessment of left ventricular myocardial deformation
Uploaded: 2016-10-20T15:00:00
Description: Watch this Scientific Journal Video about Transthoracic Speckle Tracking Echocardiography for the Quantitative Assessment of Left Ventricular Myocardial Deformation at JoVE.com

The authors thank the echocardiographic study subject for volunteering in the video as well as Witten/Herdecke University and HELIOS Research Center (HRC-ID 000416 assigned to Kai O. Hensel) for funding.

The protocol content has been ethically approved by the Witten/Herdecke University Ethics Committee.
1. Technical Requirements
<ol>
	<li>Utilize an echocardiography device featuring speckle tracking technology equipped with an adequate sector array tissue harmonic imaging transducer.</li>
	<li>During image acquisition, record and connect a standard 3-lead EKG directly to the echocardiography device in order to synchronize echocardiographic motion images to electromechanical activity. This is mandatory for timing...

<ol>
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O., 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=Subclinical+Alterations+of+Cardiac+Mechanics+Present+Early+in+the+Course+of+Pediatric+Type+1+Diabetes+Mellitus:+A+Prospective+Blinded+Speckle+Tracking+Stress+Echocardiography+Study.">Subclinical Alterations of Cardiac Mechanics Present Early in the Course of Pediatric Type 1 Diabetes Mellitus: A Prospective Blinded Speckle Tracking Stress Echocardiography Study.</a> J Diabetes Res. 2016, 2583747 (2016).</li><li>Kalam, K., Otahal, P., Marwick, T. 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H., Aksakal, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two-Dimensional+Strain+Imaging:+Basic+principles+and+Technical+Consideration.">Two-Dimensional Strain Imaging: Basic principles and Technical Consideration.</a> Eurasian J Med. 46, 126-130 (2014).</li><li>Cameli, M., Lisi, M., Righini, F. M., Mondillo, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+echocardiographic+techniques+to+assess+left+atrial+size,+anatomy+and+function.">Novel echocardiographic techniques to assess left atrial size, anatomy and function.</a> Cardiovasc. Ultrasound. 10 (4), (2012).</li><li>Pellikka, P. A., Nagueh, S. F., Elhendy, A. A., Kuehl, C. A., Sawada, S. 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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=Recommendations+for+cardiac+chamber+quantification+by+echocardiography+in+adults:+an+update+from+the+American+Society+of+Echocardiography+and+the+European+Association+of+Cardiovascular+Imaging.">Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.</a> J. Am. Soc. Echocardiogr. 28, 1-39 (2015).</li><li>Curtis, J. 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=The+association+of+left+ventricular+ejection+fraction,+mortality,+and+cause+of+death+in+stable+outpatients+with+heart+failure.">The association of left ventricular ejection fraction, mortality, and cause of death in stable outpatients with heart failure.</a> J. Am. Coll. Cardiol. 42, 736-742 (2003).</li><li>Liebson, P. R., 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+correlates+of+left+ventricular+structure+among+844+mildly+hypertensive+men+and+women+in+the+Treatment+of+Mild+Hypertension+Study+(TOMHS).">Echocardiographic correlates of left ventricular structure among 844 mildly hypertensive men and women in the Treatment of Mild Hypertension Study (TOMHS).</a> Circulation. 87, 476-486 (1993).</li><li>Hensel, K. O., Jenke, A., Leischik, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Speckle-tracking+and+tissue-Doppler+stress+echocardiography+in+arterial+hypertension:+a+sensitive+tool+for+detection+of+subclinical+LV+impairment.">Speckle-tracking and tissue-Doppler stress echocardiography in arterial hypertension: a sensitive tool for detection of subclinical LV impairment.</a> Biomed Res Int. , 472562 (2014).</li><li>Gorcsan, J., Tanaka, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Echocardiographic+assessment+of+myocardial+strain.">Echocardiographic assessment of myocardial strain.</a> J. Am. Coll. Cardiol. 58, 1401-1413 (2011).</li><li>Holmes, A. A., Taub, C. C., Garcia, M. J., Shan, J., Slovut, D. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Increased+Apical+Rotation+in+Severe+Aortic+Stenosis+is+Associated+with+Reduced+Survival:+A+Speckle-Tracking.">Increased Apical Rotation in Severe Aortic Stenosis is Associated with Reduced Survival: A Speckle-Tracking.</a> J. Am. Soc. Echocardiogr. , (2015).</li><li>Auger, 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=Effect+of+cardiac+resynchronization+therapy+on+the+sequence+of+mechanical+activation+assessed+by+two-dimensional+radial+strain+imaging.">Effect of cardiac resynchronization therapy on the sequence of mechanical activation assessed by two-dimensional radial strain imaging.</a> Am. J. Cardiol. 113, 982-987 (2014).</li><li>To, A. C., 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=Strain-time+curve+analysis+by+speckle+tracking+echocardiography+in+cardiac+resynchronization+therapy:+Insight+into+the+pathophysiology+of+responders+vs.+non-responders.">Strain-time curve analysis by speckle tracking echocardiography in cardiac resynchronization therapy: Insight into the pathophysiology of responders vs. non-responders.</a> Cardiovasc. Ultrasound. 14 (14), (2016).</li><li>Seo, Y., 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=Three-dimensional+propagation+imaging+of+left+ventricular+activation+by+speckle-tracking+echocardiography+to+predict+responses+to+cardiac+resynchronization+therapy.">Three-dimensional propagation imaging of left ventricular activation by speckle-tracking echocardiography to predict responses to cardiac resynchronization therapy.</a> J. Am. Soc. 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Significance of the technique with respect to alternative methods
The current gold standard for the echocardiographic assessment of LV systolic function is the LV ejection fraction (EF)13. However, determination of EF is based on a simplistic approach that is closely correlated to the radial component of myocardial contraction but does not take into consideration the important longitudinal and circumferential planes. Hence, EF oversimplifies the three-dimensional co...

Scientific and clinical scenarios in cardiovascular medicine are more and more addressed by continuous variables and cutoff values rather than simplistic &#34;yes or no&#34; algorithms. Imaging techniques have evolved to be able to assess cardiac function in ever increasing detail. Speckle tracking echocardiography (STE) is an emerging diagnostic tool for the quantitative evaluation of myocardial performance. While conventional echocardiography is limited by subjective image interpretation and a strong dependence on the individual examiner&#39;s expertise, STE has been introduced as a reproducible and more objective method to quantify global and regional systolic and diastolic function1,2.
Left ventricular (LV) myocardial deformation &#8212; longitudinal and circumferential shortening as well as radial thickening in systole and vice versa in diastole &#8212; can be described measuring the parameters strain (&#949;) and strain rate (SR). &#949; is a dimensionless percent change in myocardial length. SR is a time derivate of &#949;3. These important indices of myocardial function have been shown to be able to identify myocardial ischemia4, predict response to cardiac resynchronization therapy5 and to detect subclinical myocardial dysfunction while conventional echocardiographic parameters still remain normal6. In a systematic meta-analysis, global longitudinal &#949;, the most frequently used quantitative LV systolic function parameter, has been shown to have superior prognostic value for the prediction of major adverse cardiac events then LV ejection fraction (EF), the current gold standard for the assessment of LV systolic function7. Even very subtle alterations such as the effect of short term metabolic changes on myocardial mechanics in asymptomatic patients can be detected utilizing STE8.
Technically, STE uses greyscale 2D or 3D B-mode motion images recorded in standard echocardiography views. Several consecutive cardiac cycles are recorded in apical 4-, 3- and 2-chamber views to measure longitudinal deformation and in the parasternal short axis view for circumferential and radial deformation9. Moreover, by capturing the short axis view at the level of the mitral valve, the papillary muscles and the apex, LV torsion can be assessed3. Subsequently to image acquisition and storage as digital loops, myocardial deformation is measured on an off-line work station or on the ultrasound device itself. The software detects unique myocardial pixel patterns in the recorded greyscale images, so-called &#34;speckles&#34; and traces them throughout the analyzed cardiac cycle. Vectors are measured and deformation parameters are subsequently calculated. This way regional and global myocardial deformation can be assessed in systole and diastole for both the left and right ventricle and atrium10.

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			<td height="21" style="height:21px;width:373px;">Phillips iE33 ultrasound system</td>
			<td style="width:155px;">Philips Healthcare</td>
			<td style="width:155px;"></td>
			<td style="width:619px;">http://www.umiultrasound.com/ultrasound-machine/philips/ie33</td>
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			<td height="42" style="height:42px;width:373px;"> 
			S5-1 broadband sector array transducer&#160;</td>
			<td style="width:155px;">Philips Healthcare</td>
			<td style="width:155px;"></td>
			<td>5-1 MHz, http://www.usa.philips.com/healthcare/product/HC989605412081/s5-1</td>
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			<td height="21" style="height:21px;">QLAB Advanced Quantification Software Version 10.5</td>
			<td style="width:155px;">Philips Healthcare</td>
			<td style="width:155px;"></td>
			<td>Q-App: Automated Cardiac Motion Quantification (aCMQ), www.philips.com/QLAB-cardiology</td>
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			<td height="21" style="height:21px;">Xcelera R3.3L1 (Version 3.3.1.1103)&#160;</td>
			<td style="width:155px;">Philips Healthcare</td>
			<td style="width:155px;"></td>
			<td>http://www.usa.philips.com/healthcare/product/HC830038/xcelera-r41-cardiology-information-management-system</td>
		</tr>
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transthoracic speckle tracking echocardiography for the quantitative assessment of left ventricular myocardial deformation

The value of conventional echocardiography is limited by differences in inter-individual image interpretation and therefore largely dependent on the examiners&#39; expertise. Speckle tracking Echocardiography (STE) is a promising but technically challenging method that can be used to quantitatively assess regional and global systolic and diastolic myocardial performance. Myocardial strain and strain rate can be measured in all three dimensions&#160;&#8212; radial, circumferential, longitudinal &#8212; of myocardial deformation. Standard cross-sectional two-dimensional B-mode images are recorded and subsequently postprocessed by automated continuous frame-by-frame tracking and motion analysis of speckles within the myocardium. Images are recorded as digital loops and synchronized to a 3-lead EKG for timing purposes. Longitudinal deformation is assessed in the apical 4-, 3-, and 2-chamber views. Circumferential and radial deformation are measured in the parasternal short axis plane.
Optimal image quality and accurate tissue tracking are paramount for the correct determination of myocardial performance parameters. Utilizing transthoracic STE in a healthy volunteer, the present article is a detailed outline of the essential steps and potential pitfalls of quantitative echocardiographic myocardial deformation analysis.

The principle parameters for the quantitative assessment of myocardial performance are &#949; and SR. Technically, all cardiac chambers can be analyzed using STE. However, since speckle tracking methodology has been mostly used to study the LV, the focus of this article is on LV myocardial mechanics. Generally, longitudinal &#949; and SR are the most commonly assessed LV deformation parameters. Longitudinal &#949; and SR describe systolic shortening (and diastolic lengthening) of the myoc...

Watch this Scientific Journal Video about Transthoracic Speckle Tracking Echocardiography for the Quantitative Assessment of Left Ventricular Myocardial Deformation at JoVE.com

Transthoracic Speckle Tracking Echocardiography for the Quantitative Assessment of Left Ventricular Myocardial Deformation

Speckle tracking echocardiography is an emerging diagnostic imaging technique for the quantitative assessment of global and regional myocardial performance. Standard view echocardiographic motion images are recorded and deformation parameters are subsequently measured by automated continuous frame-by-frame tracking and motion analysis of speckles within the B-mode images of the myocardium.

The value of conventional echocardiography is limited by differences in inter-individual image interpretation and therefore largely dependent on the ...

The overall goal of this tutorial is to describe how transthoracic speckle tracking echocardiography is performed in a healthy volunteer. This method can be used to quantitatively assess both segmental and global myocardial deformation. The main advantage of this technique is that it is more sensitive than conventional echocardiography, especially for the detection of subtle alterations.Detecting subclinical dysfunction in asymptomatic patients is one example of its incremental value in myocardial imaging. Though this method is mainly utilized to measure left ventricular function, it can also be applied to assess the myocardial performance of the left atrium or the right heart. Generally, individuals new to this method might struggle because it requires impeccable image quality.Furthermore, post-processing can be time-consuming at first. Begin by acquiring an echocardiography device featuring speckle tracking technology, or STE, equipped with an adequate sector array tissue harmonic imaging transducer. Escort the subject into the testing room and connect them to a standard three-lead electrocardiogram, or EKG.Then plug the EKG wires directly into the echocardiography device in order to synchronize echocardiographic motion images to electromechanical activity. Unfreeze the ultrasound image to start detecting the EKG signal. Ask the patient to lie on their left side with their left arm stretched above the head, so that they are in a left lateral decubitus position.In order to optimize image quality and guarantee accurate assessment of myocardial deformation, adjust the frame rate between 60 to 80 frames per second using the adjust frame rate option. Capture standard apical four-three-and two-chamber views by positioning the transducer at the apex of the heart near the apical impulse, in order to assess longitudinal strain and strain rate. Aim towards the right shoulder, and angulate the transducer until all anatomical structures of interest become visible.Next, place the probe at the left parasternal border at the second or third intercostal space, and angulate until you obtain a cross-sectional, perpendicular view of the left ventricle. Finally, record images in the parasternal short axis view at the level of the mitral valve, the papillary muscles, and the apex, to detect circumferential and radial strain, and strain rate. Begin post-processing by opening the quantitative echocardiography analysis software.Click file and open, and choose the desired echocardiographic study data. Select a patient, and pick an echocardiographic plane to analyze. Next, click the Q icon in the right, lower corner of the selected image, and press the aCMQ button on the left.Choose the cardiac cycle of the highest image quality by using the green QRS skip keys at the bottom of the screen. Use the keyboard space bar to play and pause the loop. Select a region of interest, or ROI, to be analyzed by confirming the echocardiographic view on the left side of the screen.In this case, the parasternal, short axis view at the level of the mitral valve. Then, have the software automatically detect the timing of end diastole, and suggest an ROI which automatically divides the myocardium into six segments. Start the speckle tracking analysis by pressing the compute button on the left side of the screen.Click strain rate below the graphs to visualize segmental and global strain rate. Visually verify the tracking quality suggested by the software. If necessary, manually reposition the entire ROI by clicking edit on the left side of the screen.Move each segment margin as well as the endocardial and epicardial borders individually with the cursor. Utilize a dot in the center of the ROI for orientation when moving the ROI in its entirety. In the apical four-three-and two-chamber view, have the software automatically determine a possible ROI by dividing the myocardium into seven segments.If necessary, manually reposition the entire ROI by clicking edit on the left side of the screen. Move each segment margin as well as the endocardial and epicardial borders individually with the cursor. Utilize an orthogonal line pointing toward the apex for orientation when moving the ROI in its entirety.Additionally, if ROI redefinition is necessary, click draw on the left, and start out tagging the endocardial border at three reference points, the two opposing insertion points of the atrioventricular valve, and the left ventricular wall, starting with the basal inferosepta part of the valve, finishing with the center of the apex. Display segmental and global strain and strain rate by clicking the preferences button at the bottom left corner of the screen. Select the desired wave form and display options from this menu.Verify the tracking quality. If manual repositioning of the ROI is not sufficient to achieve appropriate overall speckle tracking quality, redefine the ROI, or select a different cardiac cycle, and reanalyze the data. Once optimal quality of the speckle tracking has been achieved, save and export the data for subsequent statistical analyses by clicking save at the bottom left corner of the screen.Furthermore, export cine-loops and still frames as illustrations by clicking export at the bottom left corner of the screen, and select the desired format and file directory. Here, a correct, STE-derived longitudinal strain assessment is shown. Note that optimal image quality and adequate tissue coverage of the region of interest are essential for adequate strain analysis.In contrast, this example demonstrates poor tissue tracking quality in the apical and mid-lateral segments, which results in the misinterpretation of myocardial deformation. Furthermore, a well-performed radial strain analysis is shown here, which reflects the systolic myocardial thickening. In contrast, incorrect tissue tracking of the anteroseptal myocardial segments results in inaccurate radial strain values in an asymptomatic, healthy patient.While attempting this procedure, it's important to minimize artifacts, and always optimize echocardiographic image quality. Once mastered, this technique can be done within a few minutes for each echocardiogaphic plane if it's performed properly. In addition, novel echocardiographic devices provide the possibility to assess measurements instantly at the patient's bedside.Following this procedure, speckle tracking can be combined with pharmacological or ergometer stress testing to unmask wall motion abnormalities that might remain undiscovered.

Research

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