European Journal of Echocardiography (2008) 10, 46–47
doi:10.1093/ejechocard/jen241
Let’s twist
Marcel L. Geleijnse* and Bas M. van Dalen
Department of Cardiac Imaging, Erasmus Medical Center, Thoraxcenter Room Ba304, ‘s-Gravendijkwal 230, 3015 CE
Rotterdam, The Netherlands
Received 11 August 2008; accepted after revision 25 August 2008; online publish-ahead-of-print 17 September 2008
In the 16th century, Leonardo DaVinci already described the
rotational motion of the left ventricle (LV)1,2 and in 1669,
Richard Lower observed that myocardial contraction could
be compared with ‘the wringing of a linen cloth to
squeeze out the water’.3 Three centuries later, the use of
radiopaque markers in cineradiographic studies made it
possible to measure this wringing motion in the human
heart, as was shown by Ian McDonald and Neil Ingels.4,5
The mechanistic basis for this wringing motion or twist lies
in the complex spiral architecture of the LV as revealed by
the anatomical studies of Streeter et al. 6 and Greenbaum
et al. 7 The LV consists of obliquely oriented muscle fiber(s)
that vary from a small-radius, right-handed helix at the sub-
endocardium to a larger-radius, left-handed helix at the
subepicardium. The functional result of this three-
dimensional helical structure is a cyclic systolic twisting
and diastolic untwisting of the LV apex relative to the
base. LV twist plays a pivotal role in the mechanical effi-
ciency of the heart, making it possible that only 15%
fiber(s) shortening results in a 60% reduction in LV volume,8
and untwist plays a crucial role in diastolic suction.9
Studies on LV twist may yield new or additional information
about cardiac (patho-)physiology, beyond the traditional
measurements of radial and longitudinal function.
In the last decades, LV rotation has mainly been studied
with tagged magnetic resonance imaging. However, lack of
availability, limited temporal resolution, and the time-
consuming and complex data analysis have precluded its
use in routine clinical practice. More recently, it became
also possible to study LV rotation with tissue Doppler tech-
niques and two-dimensional (2D) speckle tracking echocar-
diography. This latter technique offers the opportunity to
track myocardial deformation independently of both
cardiac translation and the insonation angle.
The contribution of Gustafsson et al. 10 in this issue is the
first article in the European Journal of Echocardiography
describing LV rotation. In 40 healthy volunteers with
The opinion expressed in this article are not necessarily these of the Editors
of EJECHO, the European Heart Rhythm Association or the European society
of Cardiology.
* Corresponding author. Tel: þ31 10 703 35 33; fax: þ31 10 703 54 98.
E-mail address: m.geleijnse@erasmusmc.nl
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008.
For permissions please email: journals.permissions@oxfordjournals.org.
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structurally normal hearts and no history of hypertension,
‘regional’ LV rotation was studied for the first time with
speckle tracking echocardiography. Their main findings are
(i) systolic rotation at the basal level (but not at the
apical level) is increased in the posterior segments and (ii)
there is a temporal dispersion in apical and basal de-rotation
during diastole. In magnetic resonance studies on ‘regional’
rotation conflicting results have been reported.11–13
However, unpublished data from the ‘Thoraxcenter’
confirm the findings presented by Gustafsson et al. More
importantly, the presence of relatively more oblique
fiber(s) in the posterior segments may provide an anatomical
base for their finding of increased rotation in the posterior
segments.7 As shown in other studies, 40% of LV de-
rotation occurred during the isovolumic relaxation phase.
Interestingly, in particular at the LV basal level, there was
still profound de-rotation from mitral valve opening until
the peak velocity of passive LV inflow. This may be explained
by the temporal dispersion in basal and apical repolariza-
tion. Since the basal endocardial fiber(s) are the latest to
be repolarized, an extra de-rotating force may still be
present during this period at the basal level. After the
peak velocity of passive LV inflow, there is still de-rotation
at the apical level but a brief period of re-rotation at the
basal level. Since rotation is related to an increase in LV
pressure and de-rotation is related to a decrease in LV
pressure, this may facilitate blood flow to the apex.
Although the results of this study are of great interest,
and the investigators should be congratulated for their
study, there are a few considerations and some caveats
that should be considered before widely applying LV rotation
and twist measurements in larger groups of patients. First of
all, there should be consensus on the used nomenclature.
Twist and torsion are currently often mixed-up in the litera-
ture. Twist describes the instantaneous difference between
LV basal and apical rotation (expressed in degrees) and
torsion describes twist corrected for the distance between
the two measured short-axis plains (expressed in degrees
per cm). Because with 2D speckle tracking echocardiography
this latter distance is actually not known, only twist can be
calculated from the rotational data. Second, longitudinal
motion of the LV causes through plane motion of the basal
 Guest Editorial
short-axis image, so that the originally defined speckles
move out of the plane. Furthermore, the imaged epicardium
is sometimes too bright, causing signal saturation, which
precludes discrimination of the subtleties of image contrast
that allows speckle tracking to work. Also, the size of a
tracking point is in reality larger as the one that is displayed.
Therefore, placement of a tracking point in the epicardium
can potentially result in stationary artefacts by tracking of
non-moving speckles outside the heart. Motion of the
mitral valve leaflets in the area of tracking points placed
on the endocardium will potentially interfere with proper
speckle tracking as well. Finally, and probably most impor-
tantly, in a significant number of patients, true apical
rotation will be underestimated to a variable extent
because of inability to visualize the true LV apex. The short-
axis recordings and analyses should be done meticulously.
Currently, the anatomical landmarks are to loosely defined
and in particular attention should be made to record the
correct cross-section at the LV apical level.14 This may par-
tially explain the differences between measured LV twist
in normal middle-aged human subjects in the literature
(ranging from 8º to 20º).15,16 Despite proposed distance
normalization algorithms, only 3D speckle tracking echo-
cardiography can definitely solve this important limitation.
Chubby Checker’s song ‘The Twist’ changed dancing forever
by separating the dancers and is one of only two songs to
re-enter the Hot 100 list and return to the number 1 position.
After an era of LV rotation research with magnetic resonance
imaging, echocardiography may bring cardiac twisting and
untwisting back into the spotlight again and provide new
insights into cardiac (patho)physiology.
References
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USA: Academic Press; 1983.
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47
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