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147]

Review Article

Global Longitudinal Strain: A Practical Step‑by‑Step Approach

to Longitudinal Strain Imaging
Govindan Vijayaraghavan1, Sivasubramonian Sivasankaran2
1
Department of Cardiology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India, 2Department of Cardiology, Sree Chitra Tirunal Institute for
Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Abstract
Global longitudinal strain imaging of the left ventricle is a simple bedside modality for objectively assessing the global and regional function of
the major pumping chamber of the heart, the left ventricle. Currently available echo machines provide good quality speckle‑tracking methods
with good computational facilities providing standard, comparable bull’s eye maps and parametric plots. This introductory chapter provides
a step‑by‑step approach for the beginner to utilize this additional facility in day‑to‑day practice to precisely understand the left ventricular
regional and global function for serial follow‑up and prognostication. Pattern recognition is illustrated in the following article. Essentially,
this article illustrates what the pictures mean and how to generate these meaningful echo pictures.

Keywords: Global longitudinal strain, peak systolic strain, postsystolic strain

Introduction
Longitudinal strain is an echocardiographic bedside method
to assess the regional and global left ventricular function.[1,2]
We conventionally assess the left ventricular function by
two‑dimensional (2D) echocardiography.[3] The Simpson’s
method of deriving ejection fraction of the ventricle is
well accepted for all clinical reports and for research
work.[4] The old M‑mode technique of measuring ejection
fraction has been discarded by the American Society of
Echocardiography (ASE) and is no longer used because of its
unreliability.[4] Laboratories, which use 3D echocardiographic
machines, use the 3D voxel volumes of the left ventricle, which
is more precise, as one can avoid foreshortening of the ventricle
and geometric assumptions in calculation. Short of advanced
3D echocardiographic machines and magnetic resonance
imaging, strain imaging has evolved as a cost‑effective simple
bedside tool, for objective evaluation and monitoring of global
and regional ventricular function.[4]
The regional wall motion is usually assessed by the operator by
visualizing (eyeballing) the left ventricular endocardial motion
as well as wall thickening. The left ventricle is divided into 17
segments representing the basal, mid, and apical segments of
the interventricular septum, anterior wall, lateral wall, and the
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inferior wall with the apical cap. The interventricular septum
is divided equally into inferior and anterior. The lateral wall
along the anterolateral papillary muscle is the anterolateral
wall and the rest is considered as the inferolateral segment of
the left ventricle. The terminologies advocated by the ASE
for wall motion are normal, hypokinetic, akinetic, dyskinetic,
aneurysmal, or hyperkinetic. Visual assessment of wall motion
requires individual expertise and is purely subjective.[3] The
wall motion could be labeled as one of the six types as termed
above. As the left ventricle contracts in systole, it shortens in
the longitudinal and circumferential direction (negative strain)
and thickens in the radial direction (positive strain).[1] The
change in length or thickness is measured and expressed as
a percentage of its diastolic length or thickness. This change
in length or thickness is called the strain or deformation.[2,5]
Longitudinal shortening [Figure 1] is responsible for 60%
of the left ventricular ejection and is the most important
component of systolic function. This longitudinal shortening
Address for correspondence: Dr. Govindan Vijayaraghavan,
Kerala Institute of Medical Sciences, Thiruvananthapuram ‑ 695 029,
Kerala, India.
E‑mail: drvijayaraghavan@gmail.com
Submitted: 08-Apr-2019 Accepted in Revised Form: 02-May-2019
Published: 11-Apr-2020
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix,
tweak, and build upon the work non‑commercially, as long as appropriate credit is given and
the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Vijayaraghavan G, Sivasankaran S. Global

10.4103/jiae.jiae_16_19 longitudinal strain: A practical step-by-step approach to longitudinal strain
imaging. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:22-8.

22 © 2020 Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging | Published by Wolters Kluwer - Medknow
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Vijayaraghavan and Sivasankaran: Introduction to global longitudinal strain imaging
varies from  −15% to  −30% from base to apex. [2] The
circumference of the left ventricle becomes small with systole.
This systolic shortening of circumference of the left ventricle
is circumferential strain which measures to − 20%–−30% of
its diastolic circumference. Left ventricular contraction causes
radial thickening in systole. The thickening is measured as a
positive strain of +30%–+60%.[6] In the short‑axis view during
left ventricular systole, basal segment of the left ventricle
rotates in an overall clockwise direction and apex rotates in a
counterclockwise direction when viewed from apex to base.[7]
This squeezing movement of the left ventricle is essential for the
systolic ejection and is termed as twist and has counterclockwise
movement of about 65° at the apex and clockwise movement
of the base for about 5° in a normal individual.[8] This left
ventricular torsion is followed by rapid untwisting, which
contributes to ventricular filling because LV torsion is directly
related to fiber orientation in the left ventricular wall. This
article will deal with only the longitudinal strain.
Longitudinal Strain[2]
The velocity of motion of the myocardium can be studied by
applying low‑velocity filters for the reflected signals in the echo
machine which is known as the tissue velocity or the tissue
Doppler imaging.[9] Like M‑mode evaluation, good resolution
and high‑frame rates can be achieved and hence the measures
are more objective than the visual assessment.[2] Pulse Doppler in
this mode depicts the peak velocity of the region of interest where
the sample volume is placed, whereas interrogation by color
tissue Doppler mode will define the mean velocities of multiple
sample volumes. Velocity and displacement are measures of wall
motion, but when different parts of a segment move with different
velocities, that segment will undergo deformation, which can be
studied as the strain and strain rate imaging. For example, if the
endocardial and epicardial velocities are different, the difference
in velocity of both the segments divided by the initial thickness
will give the strain rate or rate of deformation of that segment.
Myocardial deformation is derived using either tissue Doppler
imaging or by 2D speckle tracking. Using tissue Doppler strain
imaging the myocardial movement velocities are recorded and the
computer algorithm defines the difference in velocities between
Figure 1: Side‑by‑side display of diastolic (left) and systolic (right) images
of the apical four‑chamber view left ventricle showing the longitudinal
shortening of the left ventricle shown by large arrows in a normal individual
Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging  ¦  Volume 4 ¦ Issue 1 ¦ January-April 2020
the edges of adjacent segments. Since the velocity difference
between the two edges is compared, the translational movement
is negated and the deformation of that segment is depicted, as
shown in Figure 2. Electrocardiogram (ECG) is the timekeeper
for the systolic and diastolic events. Along with the beginning
of the QRS complex of the ECG, the strain curve shows a
small positive wave indicating lengthening of the myocardium
lasting few milliseconds and then a gradual negative wave. The
negative wave represents the systolic shortening percentage
of the myocardium in each segment. The maximal shortening
occurs at the end systole/peak systole and is more than 15%.[10]
This occurs toward the end of aortic systolic velocity curve, at
the peak of the T‑wave of the ECG. The shortening percentage or
strain increases as you move from base to apex.[1] From the end
systole, the curve gradually goes back to the resting level of 0%
till end diastole, to begin the next cardiac cycle. After the peak
systole, the curve may show a small wave in early diastole called
the postsystolic wave. This wave normally is less in magnitude
than the peak systolic strain. Normal ranges for these values are
now available on publications.[11] Strain or deformation represents
the systolic shortening of a segment of the myocardium and is
expressed as a percentage of the diastolic length. This mimics
the ejection fraction, where it is expressed as a percentage of the
diastolic volume ejected out in systole. However, peak systolic
strain is more related to contractility and occurs in the early part
of the systole.[9] Doppler tissue tracking is unidimensional and
measures the movement in relation to the transducer.
Speckle Tracking for Strain Imaging[12]
Conventionally, we were recording strain curves by tissue
Doppler echocardiography from various segments of the
myocardium.[13] For accurate measurements, the incident
ultrasound beam should be parallel to the myocardium
interrogated. With the normal and abnormal anatomy of the
left ventricle, this is not a practical proposition while using the
Figure 2: The strain curve: Peak systolic strain corresponds to the aortic
valve closure or peak of the T-wave. Small negative deflection after that
is termed or postsystolic strain
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Vijayaraghavan and Sivasankaran: Introduction to global longitudinal strain imaging
tissue Doppler. Speckle tracking in Doppler echocardiography
avoids this problem.[14] In 2D speckle tracking, acoustic
markers distributed in the myocardium are automatically
identified and tracked, and depending on the frame rate, their
velocities are calculated. Unlike tissue Doppler strain imaging,
speckle tracking is no longer angle dependent and hence
has less interobserver and intraobserver variability.[9] This
postprocessing computer algorithm uses the routine grayscale
digital images. Movement of the echo‑reflecting speckle patterns
in the myocardium is utilized to image the shortening of every
segment during various phases of the cardiac cycle. Within each
region of interest in the myocardium, the image‑processing
algorithm automatically subdivides regions into blocks of pixels
tracking stable patterns of speckles. Subsequent frames are then
automatically analyzed by searching for the new location of
the speckle patterns within each of the blocks using correlation
criteria and the sum of absolute differences.[15] The location shift
of these acoustic markers from frame to frame representing
tissue movement provides the spatial and temporal data used
to calculate velocity vectors.[16] Temporal alterations in these
stable speckle patterns are identified as moving farther apart
or closer together and create a series of regional strain vectors
and the sum of it as strain curves.[12] The strain measurements
are done by different software by various vendors. This article
describes the automatic functional imaging (AFI) protocol used
by the General Electric (GE) echo machines.[17]
Longitudinal Strain Imaging Protocol[18]
Longitudinal strain imaging [Figure 3] needs good quality
apical views, four‑chamber views, long‑axis views, and
two‑chamber views imaged with a good frame rate and can
be completed in four steps.[19]
1. Reduce the depth of the image and the width of the
sector to get a good quality image without any dropouts.
Increase the frame rate to more than 60 fps. Breath held
a b
c good peak systolic strain is depicted as red, suboptimal
Figure 3: Speckle‑tracking echocardiography showing the longitudinal
strain of the basal, mid, and apical segments in the three‑chamber, panel a,
four‑chamber, panel b and two‑chamber, panel c
24 Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging  ¦  Volume 4  ¦  Issue 1  ¦  January-April 2020
in expiration and minimizes the motion artifacts. Apical
long‑axis, four‑chamber, and two‑chamber images are
to be archived for three cardiac cycles. Aortic closure is
marked at the peak of the electrocardiographic T‑wave.
At this stage, choose the software for strain analysis
depending on the vendor. With the GE machines, the AFI
software forms the measurement protocol. Start with the
apical long‑axis view and follow the machine instructions.
The region of interest is marked by placing the points at the
base of the left ventricle near the atrioventricular posterior
and anterior annulus and finally the apex. The region of
interest should be chosen to include only the myocardium.
Avoid the pericardium and the valve annulus, especially
in the left ventricular outflow. The left ventricular walls
will be highlighted in colors depicting the basal, mid,
and apical segments. Apical long‑axis (three‑chamber)
view will show the anterior septum and the inferolateral
wall. Four‑chamber view shows the inferior septum and
anterolateral wall. Two‑chamber view shows the inferior
wall and the anterior wall. Thus, all the 17 segments
can be interrogated when the apical four‑chamber echo
window is good. If there are two or more segments in any
imaging plane, which are not acceptable by the machine
software for analysis, depicted as red by the machine, do
not proceed. On completion of the analysis, the machine
uses various types of color coding, one for the segments
analyzed and the others for the strain parameters of
interest. When the images display additional physiologic
phenomena, it constitutes parametric imaging. The
ingenious use of parametric images utilizes the color
coding of the segment as the borders and the degree of
strain as the color filling the segment, along with ECG
to highlight the timing of the strain measured, say peak
systole or postsystole, and generate the quad screen and
bull’s eye images
2. At this phase, each of the three imaging planes will
generate four pictures in the quad format, as shown
in Figures 4 and 5. At the upper left side [Figure 4a],
you can identify the myocardial segments each in
unique colors, the color‑coded sector image. Figure 4b
graphically shows the strain velocities of the various
segments in relation to ECG, and each curve carries the
same color as the segment they represent. Normally,
all segments move in parallel, with the basal segments
showing lesser excursion than the apical segments. In
parametric imaging, additional features of the reflected
beam such as attenuation and time delay are utilized to
understand the physiologic components of the segment.
Figure 4c depicts the parametric systolic frame with the
color coding of segments drawn on the border lines and
maximal strain achieved at the peak of the T‑wave, the
peak systolic strain image. The color coding is such that
strain as various shades of pink, and positive strain as
blue, meaning that segment is dyskinetic. Figure 4d is
the curved M‑mode of all the segments starting from
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Vijayaraghavan and Sivasankaran: Introduction to global longitudinal strain imaging
one base to the other with apex at the center. Red color
shows normal negative strain and blue color positive
strain or expansion of the segment, and the color ribbon
on either side of the picture shows the color coding of
the individual segments. The illustrative picture shows
the apical five‑chamber view, and hence, the curved
M‑modes start with the basal anterior septum at the top
and end with the basal lateral wall at the bottom
3. This sequence of image analysis is done for six segments
of the apical long‑axis view, apical four‑chamber view,
and apical two‑chamber view. Once all the three apical
images have been interrogated and saved, the AFI
software [Figure 6] will be able to display the bull’s
eye picture of 17 segments of the left ventricle with
measured peak systolic longitudinal strain values. This
image will give you the mean longitudinal strain of
each imaging plane and the mean of the peak global
longitudinal systolic strain [Figure 6a]. In a normal
individual, the strain curves reach its peak strain, at peak
systole, toward the aortic valve closure, in a coordinated
manner. You can select any segment of the bull’s eye
and highlight the respective colored strain curve so that
each curve could be analyzed in detail [Figure 6b]. The
color of each segment also represents the strain. Like the
color M‑mode, normal strain will be depicted in red and
reduction of strain will be seen as light pink, and if the
segments lengthen instead of shortening, it will be seen
as blue. One should always get a picture of the moving
images of the three imaging planes and the bull’s eye
picture so that correlation of each segment could be
a b
c d
Figure 4: The quad screen display of apical long axis view. (a) The color
coding from the lateral basal to the medial basal segment. (b) The strain
velocities of all these six segments with the electrocardiogram. All the
curves run parallel, reflecting synchrony. (c) The parametric image in
systole, where the segments are identified by the color‑coded border lines
with normal peak strain colored as red. (d) The curved M‑mode display of
the segmental strain of all the six segments with the lateral basal segment
at the bottom and the medial basal segment at the top
Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging  ¦  Volume 4 ¦ Issue 1 ¦ January-April 2020
done with the strain values and with the color of each
segment depicted in the bull’s eye. The measured average
peak systolic strain of each imaging plane as well as the
global average peak systolic strain will be depicted in
this picture
4. In addition to the peak systolic strain bull’s eye
map, you can choose to have a bull’s eye map of
postsystolic index (PSI) in a blue format, as well as
peak strain (postsystolic strain [PSS]) or time to peak
strain with strain curves to explain the respective bull’s
eye depiction. Figure 7 shows the bull’s eye map of
the various myocardial segments in a patient with
dyssynchrony. One can select bull’s eye view of the peak
systolic strain panel D or PSS index in various shades of
blue [Figure 7f] or see bull’s eye view of the time to peak
velocity format [Figure 7e], which will demonstrate the
timing of the peak strain from the onset of QRS complex.
The PSI is calculated as follows: ([maximum strain in
cardiac cycle − systolic peak strain]/[maximum strain
in cardiac cycle]) ×100, where the PSS is the maximum
strain in cardiac cycle. PSS will identify areas where
the contraction continued on to diastole in certain
myocardial segments as a pathological phenomenon.
Figures 8-10 display the bull’s eye pattern and quad
screen formats in different patients with dysfunctional
ventricles.
Ejection Fraction and Global Longitudinal
Strain
There is a wide criticism for the method of assessment
of left ventricular function by ejection fraction. M‑mode
echocardiographic calculation of ejection fraction is not used
a b
c d
Figure 5: Quad screen display of speckle tracking imaging of the apical
five chamber view which shows the dyssynchronous and abnormal strain
pattern in a patient with diseased ventricle. 5a shows the color coding of
the segments, and 5b shows the strain curves of the segments: Apical
septum is violet colored and its strain curve is above the base line,
reflecting dyskinesia. 5c shows the peak strain of the individual segments
and the apical septum is depicted blue (positive strain or dyskinesia). 5d is
the curved M mode of the individual segments. Basal segments are red
in systole with positive strain whereas the middle apical region is blue
because of positive strain or dyskinesia
25
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Vijayaraghavan and Sivasankaran: Introduction to global longitudinal strain imaging

a b
Figure 6: Bull’s eye map of the peak systolic strain. (a) The quad screen format of all the three views used to generate the bull’s eye image on the fourth
quadrant. (b) The strain velocity curves of the individual myocardial segments are displayed in three quadrants representing the apical four‑chamber,
two‑chamber, and three‑chamber views. The trapezoid cursor in the fourth quadrant bull’s eye map is on the inferior midsegment and the blue strain
curve gets automatically highlighted in the strain curves for the apical three‑chamber view

a b c

d e f
Figure 7: The bull’s eye images: (a‑c) The strain curves of the three apical views. There are hypokinesia and poor strain (thick vertical arrow) and
exaggerated postsystolic strain (oblique thin arrow) in the inferior and inferolateral segments. (d) The peak systolic strain which is poor in the inferior
and inferolateral segments. Time to peak is delayed in these segments, which is displayed in the time to peak bull’s eye map in panel e. Panel f shows
the postsystolic strain map showing delayed contraction

now and is replaced with 2D Simpson’s biplane method.[4]
Foreshortening is a major problem for apical imaging and
may underestimate ejection fraction. 3D method is ideal but
not universally available in every echo laboratory. Global
longitudinal strain (GLS) is more reliable for assessing the
systolic function in normal individuals as well as in patients
with heart failure.[18] The GLS strain is labeled as mildly
reduced when it is between −15% and −12.5%, moderately
reduced when it is between −8.1% and −12.5%, and severely
when it is <−8.0% [Table 1].[18] This assessment was found to
be statistically more reliable than the use of ejection fraction
in assessing the prognosis of patients with cardiac failure.
Figure 8b represents a patient with dilated cardiomyopathy
with markedly reduced GLS of −4.5%, of course with poor
prognosis for the patient. Figure 9 is from a patient who
presented to us with cardiac failure and left ventricular
ejection fraction of 19%. His average peak GLS value was
only −4.4%, obviously low ejection fraction correlated with
the average low strain value. The segmental abnormality
could be observed from the accompanying strain curves. In a

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Vijayaraghavan and Sivasankaran: Introduction to global longitudinal strain imaging

a b
Figure 8: Quad screen formats of ventricular strain imaging.  (a)  The time to peak bull’s eye map. The septal basal segments with normal activation
are colored green, rest being yellow, and red in a patient with extensive coronary artery disease multisegmental delay and scarring with poor strain
curves. (b) The bull’s eye map of postsystolic strain in a patient with viable myocardium. Basal anterior septum and anterior wall are intensely blue
with good postsystolic strain

a b e f

c d g h
Figure 9: Quad screen formats of strain imaging in left ventricular endomyocardial fibrosis (a -c) the apical 4 chamber, 2 chamber and 3 chamber
views respectively with the bull’s eye map of the peak systolic strain shown in (d). (e‑h) the strain waves of the apical views with the bull’s eye plot
of the peak systolic strain. Note that the reduced strain values of the fibrosed and calcified apical segments and the blue color indicating the systolic
lengthening of apical segments

Table 1: Grading of ventricular function by ejection Fallacies during Strain Imaging

fraction and global longitudinal strain compared Quad screen image of the three imaging planes depends on
Grading Ejection fraction Longitudinal strain the quality of each image you archive and analyze. If the
(global) (global and regional) images have many dropouts, we should repeat acquiring those
Normal >55% -15 to -25% images without any lapse of time. If the heart rate changes
Mildly reduced 40%-55% -15 to -12.5% due to delay in archiving, the machine cannot calculate the
Moderately reduced 30%-40% -12.5 to -8.1% bull’s eye. If there are two or more segments in any imaging
Severely reduced <30% <-8% plane, which are not acceptable for analysis (will be depicted
in red color during initial analysis), do not proceed but get
better quality images for strain analysis. Always repeat
month’s time, he improved remarkably and the global average
the image archiving and analysis to see whether the same
strain increased to −14.9%, near normal value, and the ejection operator gets comparable bull’s eye results. In the beginning,
fraction improved to 46%. The strain curve gives additional this will require a lot of patience on the operator. Unless you
information about those segments which are yet to recover, an have successfully completed at least 50 imaging sessions
information required for follow‑up imaging. This is superior to on patients and got comparable bull’s eye pictures on repeat
the information given by the global ejection fraction. imaging in the same patient, do not proceed to report the strain

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Vijayaraghavan and Sivasankaran: Introduction to global longitudinal strain imaging

a b e f

c d g h
Figure 10: Bull’s eye format of peak global longitudinal strain from the apical views in a patient with myocarditis. (a‑d) In the initial phase, note the
markedly reduced strain values of all myocardial segments. The inferolateral basal and mid segments show systolic lengthening (blue). (e‑h) The strain
curves of the same patient after 1 month showing near complete recovery of all myocardial segments with average global longitudinal peak systolic
strain value improved from −4.4% to −14.9%

imaging. This is the long learning curve, which improves the
precision and utility of strain imaging.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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