Echocardiographic Techniques For Evaluating Left Ventricular Myocardial Function

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New Echocardiographic Techniques for Evaluating Left Ventricular Myocardial Function

Carlo Marcucci, Ryan Lauer and Aman Mahajan SEMIN CARDIOTHORAC VASC ANESTH 2008 12: 228 originally published online 24 November 2008 DOI: 10.1177/1089253208328581 The online version of this article can be found at: http://scv.sagepub.com/content/12/4/228
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Articles
New Echocardiographic Techniques for Evaluating Left Ventricular Myocardial Function
Seminars in Cardiothoracic and Vascular Anesthesia Volume 12 Number 4 December 2008 228-247 2008 SAGE Publications 10.1177/1089253208328581 http://scv.sagepub.com hosted at http://online.sagepub.com
Carlo Marcucci, MD, Ryan Lauer, MD, and Aman Mahajan, MD, PhD
Ultrasound imaging of the heart continues to play an important role in diagnosis and management of patients with cardiovascular diseases. Recent advances in ultrasound technology and introduction of newer imaging modalities have enabled improved assessment of left ventricular myocardial function. Tissue Doppler imaging and 2-dimensional speckle tracking allow more objective quantification of myocardial function in the form of tissue velocities, displacement, strain, and strain rate. Similarly, contrast-enhanced echocardiography and 3-dimensional echocardiography have provided a unique insight into left ventricular form and function that was not possible by unenhanced 2-dimensional echocardiography. In this review, the authors discuss the clinical application of these new imaging techniques in the assessment of left ventricular myocardial function. Keywords: ultrasound; echocardiography; tissue Doppler imaging; speckle tracking; contrast; 3-dimensional echocardiography; transesophageal
n 1954, Hertz and Edler1 first reported the use of an ultrasonic reflectoscope to record signals from the heart, taking the first steps in what became the discipline of echocardiography. The reflectoscope, produced by Siemens Corporation, was used in shipyards to detect flaws in the hull of ships. As ultrasound technology evolved, equipment of higher resolution allowed for more accurate estimations of ventricular size and function. Initially, the signal could only be displayed in M-mode, making identification of the underlying cardiac structure difficult. In 1969, Harvey Feigenbaum developed an index to assess left ventricular (LV) function based on the anteriorposterior diameter of the heart.2
From the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina (CM, RL); Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California (AM). Dr Mahajan is supported by grants from NIH/NHLBI P01 HL078931 and NIH RO1-HL084261. There was no other external financial support for this article. Address correspondence to: Aman Mahajan, MD, PhD, Division of Cardiac Anesthesiology, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Westwood Plaza Suite 757, 3302, Los Angeles, CA 90095; e-mail: amahajan@mednet.ucla.edu.
Subsequently, several groups developed formulas to calculate cardiac volumes and ejection fractions (EFs) based on simplified 3-dimensional (3D) models of the heart.2-4 By assuming a constant relationship between the long and short axes of a symmetrically shaped ventricle, the measurement of 1 diameter allowed for the calculation of the volume of the chamber. These methods are easy to perform but the results are only valid in the absence of regional wall motion abnormalities and for ventricles with symmetrical configurations. The development of 2-dimensional (2D) echocardiography, in the 1970s,5 allowed more precise measurements that could be preformed using the dimensions and areas contained in these images (eg, Simpsons method of discs). Although more cumbersome, these methods have a higher precision as regional wall motion abnormalities can be accounted for, and by manually tracing the endocardium in different views of the ventricle, fewer assumptions of the shape and symmetry of the ventricle are needed. Parallel to the development of Bmode echocardiography, spectral Doppler was added to the armamentarium of the echocardiographer, allowing noninvasive measurements of flow and the calculation of hemodynamic variables.6
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For years, 2D imaging and spectral Doppler analysis were the only methods available for the quantification of ventricular function. Recent technological advancementstissue Doppler imaging, Doppler strain imaging and speckle tracking, contrast echocardiography, and 3D echocardiographyprovide more accurate quantification of global and regional ventricular function. Though these techniques have been more extensively studied in transthoracic ehocardiography (TTE), increasing use of these tools in transesophageal echocardiography (TEE) is being reported. The high degree of accuracy and reproducibility makes these techniques good candidates for monitoring global and regional ventricular function in the perioperative settings. The improved temporal and spatial resolution of cardiac imaging techniques allows us to examine the myocardial structure almost at the level of the individual fibers and has given us new insights in the organization and function of the ventricle. For the echocardiographer it is important to be familiar with the structure of the LV and the dynamic mechanical sequence of contraction to interpret the data provided by these imaging modalities. In this article, we will provide an overview of current concepts of the structurefunction relationship of the LV and introduce strain, strain rate, twist, and torsion as measurable variables of ventricular function. Furthermore, we will discuss the principles, validity, and limitations of these new technologies for the evaluation of global and regional LV function.
Figure 1. Helicoidal structure of the heart. From Holrege,8 with permission. The fibers of the left ventricular myocardium are arranged in 2 longitudinal helices with opposite orientation: right handed in the subendocardium and left handed near the epicardium. In the midwall, fibers have a more circumferential orientation. 1, subendocardial fibers; 2, papillary muscle; 3, vortex cordis; 4, circumferential fibers; 5, subepicardial fibers.
Left Ventricular Structure and Function

Structural Organization of the Myocardium
Myocardial muscle fibers are organized in 2 counterdirectional helices with opposite orientation or handedness. From the epicardium inward, the fibers first have a longitudinal arrangement in a lefthanded helix, then the orientation becomes circumferential in the midwall, and finally the fibers are arranged longitudinally in a right handed helix at the subendocardial level (Figure 1).7 The myofibers are bundled in myofiber sheets and separated from each other by cleavage planes. Different sheets are not aligned parallel; rather, their direction depends on their localization within the ventricular wall. In a long-axis section, the fibers at the base of the heart can be seen to run cephalad
from endocardial to epicardial, whereas the apical fibers have a caudad orientation (Figure 2A). The angle between these fibers and the epicardial plane varies during the cardiac cycle.9 In a short-axis section, the fibers 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 different angulations, producing different backscatter intensities. Ultrasound reflecting from fibers that are oriented perpendicular to the sound beam will create greater backscatter, resulting in a brighter area on the image (Figure 3). The resulting speckled pattern of the reconstructed image can be used by speckle tracking programs to analyze displacement and velocities in the myocardial segments.
Activation and Contraction

The insulated Purkinje fibers run from the base of the septum to the LV apex, where they transmit the action potential to the subendocardial myocardium in the apical septal and LV free wall regions. The
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Figure 2. Transmural orientation of myocardial fibers. (A) At the base of the heart fibers have a cephalad course from the endocardium to the epicardium. The apical fibers show a caudad orientation. The angulation of the fibers to epicardial plane varies during the cardiac cycle.9 (B) The myocardial fibers fan out toward the endocardium and epicardium in their circumferential course. From Sengupta et al,10 with permission.
electrical wave front travels from the endocardium toward the epicardium along the myofibril orientation and from the apex toward the base, making the subepicardial region of the basal posterior LV wall being the last to depolarize.11 Repolarization occurs from the base to apex without significant transmural differences, the apical subepicardium being the last region to repolarize.12 Contraction of the subendocardial right-handed helix follows the rapid spread of the depolarizing front. The shortening of the subendocardial layers produces rapid buildup of pressure in the LV that coincides with the isovolumic contraction (IVC) phase. During this brief period, the outer lefthanded helix is passively stretched out. The concurrent shortening of the subendocardium with the stretching of the subepicardium during IVC produces a typical biphasic signal in myocardial velocities and strain rates measured with ultrasound.13 Contraction of the left-handed subepicardial helix coincides with the end of the IVC and the onset of ventricular ejection. During the ejection phase, both subendocardial and subepicardial fibers shorten from apex to base, resulting in a reduction of the size of the LV cavity in all directions. However, strain or shortening shows transmural and apex-to-base gradients, with shortening being larger in the subendocardium than subepicardium and larger in the apical than basal segments.12 Just before aortic valve closure, the apical subendocardium relaxes from apex to base, whereas subepicardial relaxation occurs just after aortic valve closure and spreads form base to apex. Thus, the subepicardial apex is the last to lengthen and continues shortening into the isovolumic relaxation (IVR) phase and early diastolic filling. This phenomenon represents an active component of ventricular relaxation, facilitating ventricular expansion and creating ventricular suction in early diastole.12
Strain, Strain Rate, Twist, and Torsion

Myocardial tissue is virtually incompressible. During the cardiac cycle, longitudinal and circumferential motions are obligatorily accompanied by thickening or thinning in the radial dimension (Figure 4A). Myocardial deformation produced as a result of these motions can be quantified by the dimensionless parameter strain (). Strain, in an object that is its size, is the ratio of the change in length to the initial length.
Figure 3. Backscatter and fiber orientation. Circumferential Myofibers (indicated by the arrows pointing to the midportion of the septum), have a near perpendicular angle with the interrogating sound wave resulting in more backscatter and brightness when compared with the longitudinal subendocardial fibers (indicated by white arrows).
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L0 L1
A
2 3 1
SR =/
L1 L0 = L0
1 Longitudinal strain 2 Circumferential strain 3 Radial strain
Figure 4. Myocardial strain, strain rate, twist, and torsion. (A) Strain () is defined as the change of length of an object divided by its original length. Lengthening corresponds with positive strain, shortening with negative strain. Strain rate (SR) is the change of strain over time (/t). (B) Myocardial deformation or strain occurs in 3 dimensions. Longitudinal and circumferential systolic shortening (negative strain) is accompanied by lengthening or thickening in the radial dimension (positive strain).
Imagine a rubber band with length L0 being stretched out to length L1. The strain is than defined as the ratio of L1 L0 to L0 (Figure 4B). Because the rubber band got stretched out, L1 is larger than L0, and is positive; in the event that an object shortens, will be negative. The rate at which the length of the rubber band changes is the strain rate (SR = /t). When myocardial strain is plotted against time on a strain curve, myocardial length and thickness are at baseline at the end of diastole (Figure 5). During systole, longitudinal and circumferential shortening give negative strain values, reaching their minimum negative values (shortest myocardial length) at peak systole, around aortic valve closure. After the onset of diastole, early ventricular filling brings the curve back up to a less negative value where it will plateau during diastole. The atrial contraction completes ventricular filling and brings the strain curves back to baseline. SR curves usually contain much more noise. During the IVC phase (between mitral valve closure and aortic valve opening), the curve has atypical biphasic shape. After aortic valve opening, myocardial shortening accelerates to a reach its peak in midsystole and slows down to reach 0 at aortic valve closure. Although at this point fiber length (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 at the end of diastole. Longitudinal strain rate (thin line) is negative during systole and returns to 0 at aortic valve closure. In diastole 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 biphasic aspect. MVC, mitral valve closure; AVO, aortic valve opening; MVO, mitral valve opening; AVC, aortic valve closure; ECG signal is represented at the bottom.
has reached its most negative peak, there is no further shortening and the rate of shortening, SR, drops back to 0. Between aortic valve closure and mitral valve opening (IVR phase), the curve is again biphasic. In early diastole, the LV myocardium lengthens soon after mitral valve opening, resulting in a positive peak (E peak) on the SR curve, whereas in late diastole the 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 do not lengthen, resulting in an SR of 0. Thus, longitudinal and circumferential SRs are negative during systole and have 2 positive peaks in diastole, whereas longitudinal and circumferential strain shows only negative values. In the presence of dyskinesia and positive longitudinal and circumferential strain values, quantify the lengthening of the myocardium beyond its end diastolic value. Radial thickening in systole and thinning in
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diastole produce similar strain and SR curves except for the reversed directions. Finally, not only does the left ventricle shorten and thicken during systole, it also twists around the longitudinal axis. Seen from the apex, the base of the heart turns clockwise during systole whereas the apex turns counterclockwise. These opposite movements create a wringing effect or torsion (like the wringing of a wash cloth) and can be quantified with some of the new techniques in ultrasound that will be discussed. Twist and untwist are defined as the number of angular degrees a given point in the myocardium turns during systole and diastole, respectively. Twist is also referred to as rotation. Counterclockwise twist or rotation is by convention denoted as positive, clockwise twist as negative. Torsion is the gradient between apex and base, and it is calculated as the net difference between basal and apical twists.
New Echocardiographic Imaging Modalities

Tissue Doppler Imaging (TDI)
Imaging technique. Doppler echocardiography is a well-established technique to calculate pressure gradients, quantify valvular stenosis, and measure diastolic function. In 1989, Isaaz et al14 described the application of Doppler echocardiography for the evaluation of myocardial motion and TDI was born. Routine Doppler echocardiography employs a low-velocity, high-amplitude filter to remove the artifact produced by the highly reflective blood tissue interface. When this filtering strategy is reversed, these low-velocity, high-amplitude signals from tissue motion are displayed. Tissue Doppler velocities can be displayed as a spectral trace (pulsed TDI, Figure 6A), representing the peak velocities, or as a color map superimposed on the 2D image similar to color Doppler (color TDI).15 The advantage of pulsed TDI is that the sample volume can be placed in a small select area, providing data with an excellent temporal resolution. The color TDI has the advantage of displaying velocities over a wide area of myocardium at the same time, thus allowing multiple segments to be analyzed simultaneously, though this comes at the expense of decreasing temporal resolution. As with color Doppler, the velocities from color TDI are mean velocities whereas those from pulsed Doppler and pulsed TDI are peak velocities. TDI has some important limitations. First, as with all 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 between baseline and maximum velocity in the isovolumic contraction phase (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 during isovolumic contraction (IVC). (C) Tissue strain imaging. By placing the sampler in different segments of the myocardium, the software will produce strain curves for regional strain of the selected segments.
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between the tissue motion and ultrasound beams is greater than 20, the peak values will be significantly reduced. The second limitation is that the velocities of the tissue along the Doppler beam are in reference to the transducer. TDI is unable to resolve the difference in motion of a myocardial segment that could be actively contracting or merely being displaced due to the tethering effect from the adjacent segment. Previously described parameters of SR and strain can also be derived from myocardial velocity data (Figure 6B and C). The data displayed by color TDI represent the velocity of each pixel at a given distance from the transducer in reference to the transducer. A difference between the velocities of any 2 points along the beam implies that the points are moving in relationship to each other, producing compression or expansion of the tissue. The first point in a region of interest can be called V1, the second point V2, and the distance between them L. The SR of the region of interest is defined as V2 V1/L with units of second1.16 Calculations of strain and SR from TDI data have several pitfalls. First, if the TDI data are poor, the strain/SR measurements will contain errors. For instance, if a myocardial segment suffers from echo dropout, the TDI will encode that segment as having a lower velocity than it may truly have, leading to erroneously low strain and SR and a suggestion of hypokinesia or akinesia. Reverberations and side lobes can also introduce error that may overestimate, underestimate, or simply generate random noise in the strain/SR values.17 The second limitation of TDI-derived strain values comes from deviation in the angle of interrogation. Deviation from the intended angle is even more important for strain calculation than it is for TDI velocity data. If one deviates from the true direction of contraction when measuring velocities, the peak velocities will simply be reduced. If one alters the angle for strain measurements, the type of strain being measured will change. Assessment of global function. TDI has been used to measure global ventricular function in numerous ways. During normal LV ejection, the base of the heart moves toward the apex, which is relatively fixed in its position. This base-to-apex motion can be quantified at the level of the mitral annulus. The first echocardiographic quantification attempts used M-mode but the technique was tedious and relied on off-line analysis. In 1995, Gulati et al18 compared the descent velocity of the mitral annulus by TDI with the standard of
radionuclide ventriculographic EF. They applied TDI to 6 points around the annulus and found that the 6site average compared linearly with EF. An average mitral annular descent velocity of >5.4 cm/s was 88% sensitive and 97% specific for EF > 50%. The authors themselves point out the largest criticism of using this TDI method to quantify ventricular functionload dependency. Another study, using intraoperative TEE data, showed that the peak systolic velocity of the mitral annulus (Sm) was subject to variable preload conditions.19 The limitation of all TDI velocity measures is the potentially confounding influence of ventricular translational and rotational movement. Several studies have attempted to remove this confounder by using SR imaging of the LV wall.20,21 In an openchest dog model, Greenberg et al20 compared the peak SR of the interventricular septum and the more load-independent parameters of dP/dtmax, peak elastance (Emax), and preload recruitable stroke work at various hemodynamic conditions. Peak SR proved to be a much more reliable estimate of these invasively derived parameters than Sm. The variable most highly correlated with peak SR was Emax (r = .92). Other investigators have also attempted to define load-independent measures of contractility using TDI. In an animal model, Vogel et al22,23 applied TDI first to the RV free wall and then to the LV free wall and examined the myocardial acceleration during isovolumic contraction (isovolumic acceleration [IVA]). IVA is an attractive measure of ventricular performance because it reflects the earliest events of the cardiac cycle that may be less dependent on loading conditions. IVA is measured as the difference between the baseline and peak velocity divided by their time interval during the isovolumic period. Vogel et al compared IVA with the gold standards of Emax and dP/dtmax during multiple loading conditions, during infusion of esmolol and dobutamine, and with varied heart rate. They found that IVA and Emax were unaffected by changes in preload and afterload, whereas peak isovolumic velocity and dP/dtmax were significantly affected. Esmolol infusion significantly decreased IVA, whereas dobutamine significantly increased it. The authors suggest that IVA may be a clinically useful measure of myocardial performance given its load independence, sensitivity to contractile state, and ease of acquisition. In a follow-up study, Lyseggen et al24 attempted to determine whether IVA also reflects regional ventricular function. They found that IVA is not a good measure of regional function; during ischemia, segments that by
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other measures were severely impaired showed no change in myocardial acceleration. They did confirm the early finding that IVA is increased parallel to dP/dtmax with increasing doses of dobutamine. They contradict the early findings of load independence of IVA by showing a decrease in IVA with an increase in LV end-diastolic pressure. This finding has been criticized because the degree of change in preload was outside normal physiologic values.25 Lyseggen et al contend that it is in patients with abnormal values that load-independent measures of contractility will have the most benefit.25 IVA remains an attractive measure of global myocardial contractility, but further validation needs to be done before it can be routinely applied clinically. Other investigators have gone beyond IVA and looked at SR during IVC as a potential measure of myocardial function.21 Peak SR during IVC shows a good correlation with dP/dt during various hemodynamic conditions. SR imaging can also differentiate between subendocardial, midmyocardial, and subepicardial layers. The subendocardium has the highest SR values when assessed by TDI, because the fibers in that region are mostly longitudinal in orientation and, hence, optimally aligned for TDI. Other data agree and suggest that the biphasic tissue velocities seen during IVC are a result of counterdirectional movements in the LV wall during that time period.13 An increased understanding of the helical nature of the heart has lead to other investigations of global ventricular function using TDI. Ventricular twist/torsion as measured using TDI has been validated against the gold standard of tagged magnetic resonance imaging (MRI).26 Peak torsion correlated very well (r = .95). Evaluation of torsion by TDI has several potential advantages when compared with MRI. First, echocardiography is more readily available and serially performed during repeat examinations. Second, TDI velocities can be followed over several cardiac cycles, whereas MRI tagging fades with time. These TDI-derived torsion data may facilitate an understanding of how systolic torsion is linked to diastolic suction. Finally, TDI has a much better temporal resolution than MRI and may be able to resolve the events of early diastole. Notomi et al27 have used TDI to quantify this link between ventricular systolic twist and diastolic untwist during exercise. Their data suggest that the potential energy stored during LV torsion is responsible for the early diastolic intraventricular pressure gradient. TDI is routinely applied in the assessment of diastolic function. The early diastolic tissue velocity,
Ea (also E), correlates with the invasive measure of diastolic function, .28,29 Though somewhat preload dependant in hearts with normal systolic function,30 it is much less preload dependant than the early transmitral Doppler wave (E).31 This decrease in preload dependency allows Ea to differentiate a normal and pseudonormal pattern on the transmitral Doppler flow trace.32 The E/Ea ratio can predict LV filling pressures.29,31 In patients with EF < 50%, Ea < 3 cm/s is a powerful predictor of mortality,33 whereas E/Ea 15 is an independent predictor of future heart failure.34 Pulsed TDI-derived velocities from the lateral annulus are higher than from the septal annulus and both decline with age.35 With TTE, the region of interest is generally placed over the lateral mitral annulus, but with TEE it may be best to place the region of interest over the septal annulus if it aligns better with the Doppler beam. Although normal values for TTE have been published,36 those for TEE while under general anesthesia can be decreased by up to 15%.37 The use of TEE for estimation of LV filling pressures by E/Ea in intubated ICU patients has been further validated.38,39 Dyssynchrony. Another measure of global cardiac function is the synchrony between different segments during contraction of the heart. The past 10 years have seen an enormous amount of research into dyssynchrony and the means to correct it, called cardiac resynchronization therapy (CRT). Up to 30% of heart failure patients exhibit an intraventricular conduction delay that causes inefficient contraction of the ventricle. CRT has been shown to acutely decrease mitral regurgitation, increase contractility, and decrease LV filling pressures.40 CRT, with or without defibrillation, has been shown to significantly improve morbidity and mortality from heart failure.41-43 Despite a lack of echocardiographic indication for CRT, echocardiography with TDI is an integral part of the assessment of dyssynchrony and CRT. There is little relationship between electrical and mechanical dyssynchrony.44-46 Mechanical dyssynchrony, as assessed by echocardiography, is a strong predictor of morbidity and mortality independent of QRS width47,48 and is predictive of which patients will likely benefit from CRT.49,50 TDI is an excellent tool to assess mechanical dyssynchrony because of its good temporal and spatial resolution. In normal hearts, all segments of the ventricle contract nearly simultaneously. In diseased
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hearts, the lateral or posterior segments demonstrate peak contraction later than the septum, which results in inefficient ejection. TDI can quantify the timing of contraction by segment. Multiple indices of mechanical dyssynchrony exist, but those that employ color TDI to assess longitudinal velocities have recently been recommended.51 Two methods are commonly employed. The simpler method simply compares septal to lateral delay in peak systolic velocity and defines a delay of 65 ms as dyssynchrony.49 The more detailed method requires calculation of the standard deviation of the time to peak systolic velocity from 12 sites and considers a standard deviation of 33 ms as dyssynchrony.50 Despite its usefulness in predicting response to CRT, absence of echocardiographic dyssynchrony should not be used as sole criterion to withhold CRT from an otherwise eligible patient.51 Assessment of regional function. Assessment of regional myocardial function by visual inspection of 2D images is not consistent among experienced cardiologists and anesthesiologists.52,53 TDI provides a means of quantitatively assessing regional function through both tissue velocities and strain analysis. Most often, color TDI is used, allowing the region of interest to be moved to various locations in the myocardium for evaluation of myocardial velocities. Low TDI velocities correlate with abnormal myocardial thickening by visual inspection and M-mode analysis.54 Tissue velocities diminish significantly with regional ischemia55,56 and can help differentiate transmural from nontransmural infarction.57 In dobutamine stress echocardiography (DSE), TDI is more sensitive to changes in LV function when compared with other qualitative or quantitative measures.58,59 Low tissue velocities during stress are predictive of angiographic disease.60,61 Quantification of tissue velocities during DSE can help predict outcomes after myocardial infarction,62 identify false-positive wall motion abnormalities,63 and help identify viable myocardium.64 Translational motion and tethering are a frequent concern when evaluating regional function via TDI velocitiesthese are problems that can be overcome with strain/SR imaging. Modern echocardiographic systems can easily provide users with strain/SR data. One must digitally acquire a loop of color TDI data from the region of interest taking care to align the segment with the Doppler beam. Care must be taken to have a good electrocardiogram (ECG) signal and to
acquire 3 complete cardiac cycles during apnea. As the optimal frame rate for strain calculation is >120 frames per second, it is necessary to acquire multiple narrow segments of the various ventricular walls.17 Off-line analysis includes defining regions of interest within the myocardium and tracking them with the wall through the cardiac cycle. The software then displays the velocity, strain, or SR curves where the data can be analyzed. TDI-derived strain and SR measurements have been validated using tagged MRI.65 Strain and SRs also diminish significantly with regional ischemia and can differentiate infracted and ischemic from normal myocardium.66,67 They can identify the extent of transmural infarction.68 During DSE they compare well with perfusion scintigraphy,69 help identify viable myocardium,70 and can predict recovery after revascularization.71 TDI evaluation of regional ischemia with TEE is feasible in the operating room, although incompletely studied.72,73
Two-Dimensional Speckle Tracking

Imaging technique. One of the most important limitations of Doppler-based techniques for evaluating myocardial deformation and ventricular function is the angle dependency of the ultrasound beams with respect to tissue motion. Particularly in TEE, it can be difficult to properly align the interrogating sound beam with the region of interest. Recently introduced 2D speckle tracking technology has the advantage of measuring tissue velocities and deformation in an angle-independent fashion (Figure 7).74,75 When an ultrasound pulse interacts with tissue, the pulse gets distorted in a way that is highly dependent on the structure of that tissue. Within the myocardium, there are ultrasound reflectors that will distort the sound wave relatively consistently throughout the cardiac cycle, resulting in a consistent grayscale pattern being attributed to the same speckle. A speckle comprises a group of 20 to 40 pixels, each with its distinct grayscale shade, and serves as a natural acoustic marker. Speckles can be characterized throughout the myocardium.74 Using pattern recognition algorithms, the position of these speckles can be tracked from frame to frame in a digitally stored cine-loop of a cardiac cycle. The displacement of the speckle in both dimensions of the 2D image can thus be measured throughout diastole and systole. By tracking different speckles in the same myocardial segment, the distance between the speckles can be measured and segmental shortening or strain
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Figure 7. Speckle tracking. The distortion of the ultrasound pulse by tissue defines the grayscale tone attributed to the pixel in the 2D image. A group of 20 to 40 pixels is called a speckle. If the grayscale distribution within a speckle remains constant throughout the cardiac cycle, it can be tracked by the speckle tracking software and its displacement calculated in 2 dimensions.
can be calculated. Because the analysis is not based on the Doppler shift of the reflected sound wave, it is not angle dependent, and it can be performed on regular 2D grayscale images. Speckle tracking has, however, some limitations of its own. Because the software tracks features in the 2D image, the quality of speckle tracking depends highly on the spatial resolution of the image and on the frame rate of the cine-loop. Myocardial deformation occurs in the 3 spatial dimensions, resulting in speckles moving out of the 2D scanning plane. The computer compensates for this out-ofplane motion by tracking new speckles as they move in while previous ones fade out of the scanning plane.76 Low frame rates will lead to undersampling, and speckles will move out of the search area too soon for digital compensation. High frame rates will reduce this problem but may lead to inadequate tracking due to reduced spatial resolution. Currently, the optimal frame rate for adequate speckle tracking seems to be about 90 frames per second, which is considerably lower than Doppler-based techniques and may lead to inadequate detection of shorter events, such as the isovolumetric phases of the cardiac cycle.17 Another limitation is the dependency on high image quality that might not be consistently obtained. Stationary artifacts, such as reverberations, can be mistaken by the software as myocardium and
will get tracked, resulting in falsely low strain calculations or drift. Drift occurs when, at the end of the cycle, strain does not return to baseline. The computer software will correct the difference by drift compensation. Strong reflectors in the near field, such as a calcified mitral annulus, can cast an acoustic shadow and cause dropout, leading to the inability of the software to track the segments in the far field. Apart from the temporal, radial, and lateral resolution, accurate tracking also depends on the orientation of the myocardial fibers and the blood tissue interface. In the transesophageal short-axis views in TEE, for example, the fiber orientation and the endocardial border of the septal and lateral walls are parallel to the ultrasound beam, frequently resulting in low resolution with inadequate tracking. The software evaluates the tracking quality using several criteria: the position of the speckles in the first frame of the loop should coincide with the position of the speckles in the last frame, the velocity of adjacent speckles should be similar, and drift compensation should be low. Based on these criteria, the software will grade the tracking, and one can accept or reject the result. Visual control of the process remains necessary to correct misinterpretation of artifacts by the software. Although speckle tracking can be performed on any 2D grayscale image, the images acquired in the
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harmonics mode allow superior endocardial border delineation. When obtaining images, special attention must be given to image quality and frame rate. Changing gain, compression, and reject settings can be helpful in optimizing the grayscale distribution. The optimal frame rate can be obtained by reducing the sector width and depth of the scanning field, by using the single focus mode and if necessary by changing the number of scan lines. For adequate timing of cardiac events, a constant heart rate in sinus rhythm and a clear ECG signal as well as aortic valve opening and closure times are necessary. Assessment of global ventricular function. After manually delineating the endocardial border, the software automatically divides the LV myocardium into 6 segments that are color coded and display velocity, displacement, strain, and SR curves for the entire ventricle or for the individual segments (Figure 8). The global ventricular strain values, in the longitudinal, radial, or circumferential dimension, are calculated as an average of all the strains measured over the entire myocardium in the respective directions. Compared with techniques calculating derived parameters representing global ventricular function, such as mitral annular velocity, this technique has the advantage of evaluating the entire visible myocardium in its calculation of global function. EF calculated using speckle tracking techniques has been shown to correlate closely with visual estimation and Simpsons method (r = .82) for TTE.76 And several studies reported the technique to have low interobserver variability (8.6% to 11.8%) and intraobserver variability (5.2% to 8.8%).77,78 Global longitudinal strain has been proposed as a new index for LV systolic function, with a high specificity and sensitivity for the diagnosis of myocardial infarction.79 Reductions in global longitudinal strain closely correlate with infarct size in chronic ischemic heart disease.80 Speckle tracking has also been shown to demonstrate early decreases in global longitudinal, radial, and circumferential strain in patients with subclinical hypertrophic cardiomyopathy.81 Global diastolic SRs in the IVR phase correlate with diastolic function as assessed by intraventricular pressure measurements.82 By tracking angular displacement in the shortaxis views, speckle tracking allows for the quantification of ventricular twist and torsion.83 This unique feature has been used to study changes in ventricular rotation and rotation rate in the elderly84 and in patients with essential hypertension,85 myocardial
Figure 8. Global and regional strain and strain rate curves. (A) Global longitudinal and regional strain curve. (B) Global longitudinal and regional strain rate curves. The myocardium is divided into ASE defined segments (left upper panel). Global strain and strain rate curves are presented in a white dotted line while segmental strain and strain rate curves are presented as continuous lines (right panel). The computer also generates a an M-mode, semiquantitative display of strain and stain rates for the various segments (left lower panel).
ischemia,86 ventricular hypertrophy,87 dilated cardiomyopathy,88 and chronic mitral regurgitation.89 In one study, the rate of early diastolic untwist has been shown to correlate with the degree of diastolic dysfunction as defined by classic echocardiographic measures.90 All the previously mentioned studies relate to TTE. TEE transducers, however, use a higher ultrasound frequency with a shallower focus, leading to lower lateral resolution at greater depthsa property that affects imaging of the far-field LV segments. Also, interposition of the mitral valve apparatus between the transducer and the LV myocardium results in more shadowing and artifacts at the level of the left ventricle. We compared
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the results of speckle tracking on images obtained by TTE and TEE using EchoPac software (GE, Vingmed, Horten, Norway) in anesthetized patients under identical hemodynamic conditions. We found that the number of segments tracked is similar for the long-axis views (83% for TEE and 76% for TTE) but significantly lower for the short-axis views (59% for TEE and 74% for TTE) with a slightly better tracking quality in TTE. There was a good correlation for global longitudinal strain in the midesophageal 4-chamber view (r = .9) and the midesophageal 2-chamber view (r = .8) but only moderate for the midesophageal long-axis view (r = .5). In the short-axis views, only circumferential strain of the apical segments showed good correlation (r = .7). The outof-plane motion of the midpapillary, and particularly the basal segments, accounts for the poor correlation found for these parts of the ventricle (r = .5 and r = .1, respectively). For all imaging planes, strain calculated on the TEE images showed a small positive bias compared with TTE (3.7 3.3 for longitudinal strain and 4.8 5.3 for circumferential strain). We also compared global longitudinal strain calculated by speckle tracking in TEE with visual estimation of global ventricular function and the modified Simpsons method and found a good correlation in both comparisons (r = .7). Assessment of regional ventricular function. Probably the most attractive feature of speckle tracking is the possibility to assess regional myocardial deformation in an angle-independent manner. This allows for simultaneous qualification and quantification of regional wall motion abnormalities in all the myocardial segments of the 2D image. Moreover, the timing and duration of systolic and diastolic events of the different segments can be measured and compared to assess contraction sequence and intraventricular dyssynchrony. The calculation of regional myocardial strain and SR by speckle tracking has been validated in vitro using ultrasound phantoms77 and in vivo against TDI,74 microsonometry,75,78 and tagged cardiac MRI.78 All studies showed good correlations with low variability. Speckle tracking correctly identifies infarcted segments after induced regional myocardial ischemia in animal models.91 In humans, regional reductions in strain correlate well with angiographic findings of coronary artery disease, and speckle tracking can distinguish different states of transmurality of myocardial infarctions.76,92,93 Cardiac resynchronization therapy has been shown to improve heart failure functional class, exercise capacity, quality of life, and survival in
patients with heart failure and dyssynchrony.51 Yet about 25% to 35% of patients do not respond to therapy. Proper diagnosis and quantification of dyssynchrony by echocardiographic techniques is likely to improve patient selection for CRT. Speckle tracking offers the possibility to time myocardial deformation in 6 segments simultaneously, and it is used in numerous trials as a tool to diagnose dyssynchrony and guide CRT.94,95 Nevertheless, because of the much lower temporal resolution compared with tissue Doppler measurements, speckle tracking may be less adapted to distinguish events separated by only a few milliseconds. Another limitation is that the regional strain and SRs are the mean of all the speckles tracked in 1 segment. Subsegmental pathology will thus not be detected by speckle tracking. Currently, the software is designed for TTE imaging and is, therefore, in some minor aspect, not adapted to TEE. This does not impede its use, and the newer versions will probably deal with this problem. Moreover, speckle tracking can be performed in real time, providing a relatively rapid quantification of global and regional ventricular function.
Contrast-Enhanced Echocardiography (CEE)

Imaging technique. Opacifying the blood volume in the imaging plane by an ultrasound contrast agent can improve the quality of the image and can generate information that might not be obtained from the standard 2D grayscale images. Anesthesiologists frequently use agitated saline as a contrast agent to opacify the right side of the heart and assess the presence of a patent foramen ovale. However, after passage through the pulmonary vasculature, the density of these airfilled microbubbles is too low to produce the same effect on the left side. In the past few years, synthetic microspheres have been developed that have much higher stability; and a significant portion of the dose will reach the LV.96 The shells of these microspheres are made of phospholipids or albumin and are filled with fluorinated hydrocarbon gases.97 A single intravenous injection of only a small dose of these microspheres will produce intense opacification of the LV cavity. Subsequent passage into the coronary circulation will opacify the entire myocardium. The opacification of the ventricular cavity leads to a highly detailed demarcation of the endocardial border consistently improving the echocardiographers ability to measure
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global ventricular function by visual estimation or semiquantitative techniques based on endocardial border tracing (Figure 9). Filling of the myocardium will allow for the detection of filling delays or defects in the presence of coronary artery stenosis. To differentiate reflections generated by tissue from those generated by the contrast agent, specific imaging modalities have been developed based on the physical and mechanical properties of the contrast agents. Not only are microspheres strong reflectors of sound, they also act as ultrasound sources. When interacting with sound waves, the microbubbles react by rapidly changing size and shape. These oscillations, in turn, produce ultrasonic sound waves at the second or higher harmonic of the original frequency of the incoming pulse. The mechanical deformation of the bubbles will eventually lead to their destruction if the interrogating sound source has a high mechanical index. With the earlier high-power modalities (mechanical index >1.0), bubble destruction was inevitable and imaging was intermittent. The image had to be reconstructed out of several loops taken at different time points, leading to artifacts and increased duration of the exam. Harmonic imaging using a lower mechanical index (>0.6) has been developed for use in contrast echocardiography to better balance backscatter enhancement with microbubble survival. More recently, very low power (mechanical index <0.2) modalitiespower modulation imaging and power pulse inversion imaginghave been developed that do not destroy the microbubbles. These modalities produce highly defined, real-time images that only show echoes from the contrast agent without interference from tissue backscatter. In power modulation imaging, the output power or amplitude of every second wave is doubled while the returning echoes from the original, low-powered pulses are amplified. When subtracting the echoes from each consecutive pair of pulses, all the echoes from linear scatterers (tissue) will be canceled. Echoes from nonlinear scatterers (microbubbles) are more chaotic and will not cancel out. The resultant image only shows echoes reflected from the contrast agent. Power pulse inversion is a technique in which 2 ultrasound pulses are transmitted simultaneously. The pulses are identical but have opposite polarity. The tissue reflections of these pulses will cancel each other out, whereas the reflections from microbubbles, which are chaotic, will not cancel. Again, the result is an image in which all backscatter from tissue is blacked out
Figure 9. (A) Transthoracic apical 4-chamber view showing poor delineation of the endocardial border of the left ventricle. (B) After opacification of the left ventricular cavity with an intravenous perfluorocarbon-based contrast agent, the same view shows a highly detailed demarcation of the endocardial border over almost the entire ventricle. Form Hundley et al,98 with permission.
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 very good safety profile for different contrast media,99,100 the US Food and Drug Administration issued a black box warning on its use in October 2007 following the report of 199 serious, nonfatal reactions and 11 deaths associated with the use of Definity and Optison contrast agents.101 After reexamining the available data and reevaluating the riskbenefit ratio of contrast-enhanced echocardiography, the restrictions on the use of intravenous contrast have been relaxed in May 2008, and new labeling guidelines have been issued.102 Assessment of global ventricular function. Opacification of the LV cavity using contrast consistently results in a superior delineation of the endocardial border in all patients, but it is particularly useful in patients with poor acoustic windows.103 It can also improve the quality of the exam by optimizing image alignment by avoiding off-axis scanning. Compared with MRI and cineventriculography, 2D CEE using Simpsons method of discs demonstrates a higher degree of correlation with LV volumes and EF. Also, CEE has been shown to
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be superior in the identification of low EF and shows less interobserver variability compared with unenhanced echocardiography.98,104,105 Contrast can be used to identify other pathologies related to ventricular dysfunction, such as the presence of an apical ventricular mass or thrombus, or to diagnose LV noncompaction. In TEE, the long distance between the transducer and the LV apex can impede the clear visualization of an apical thrombus. When contrast is used, thrombus typically is seen as a nonopacified structure.103 Isolated ventricular noncompaction is the third most frequent cardiomyopathy (CMP) after dilated and hypertrophic CMP and accounts for nearly 10% of all primary CMPs in children.106 Prevalence of this pathology in adults is substantially lower.107 On echocardiographic examination, the LV presents as a thin compacted outer layer and a much thicker, heavily trabeculated, noncompacted inner layer. CEE accentuates the intertrabecular spaces and facilitates the diagnosis by clearly delineating the compacted from the noncompacted layer.108 Assessment of regional ventricular function. After a bolus injection or a continuous infusion of contrast agent, the entire myocardium will brighten as the blood volume in the coronary circulation gets saturated with contrast. Because the coronary vessels contain only 7% of the cardiac blood volume, the myocardium will opacify less than the ventricular cavity.103 Using a high-power ultrasound pulse, all microbubbles are destroyed, after which the myocardium will fill up again with contrast-laden blood. Areas distal to coronary stenoses will show a delay in replenishment or absence of contrast (filling defects). The signal intensity can be quantified and displayed in destruction/refilling curves that correlate closely with coronary blood flow.109 Real-time myocardial CEE accurately estimates the risk area and infarction area in acute coronary syndromes.110-112 After revascularization and restoration of antegrade coronary flow, the persistence of a perfusion defect or no-reflow area in the infarct zone is predictive of lack of recovery of ventricular function and poor outcome.113,114 Use of myocardial CEE in TEE is still to be thoroughly established, but one can imagine its use in the setting of coronary bypass surgery where it could identify immediate restoration of myocardial perfusion (or lack thereof) distal to bypassed coronary stenoses and discriminate stunned myocardium (noncontractile, perfused) from ischemic myocardium (noncontractile, not perfused).
Real-Time 3D Echocardiography
Imaging technique. The possibility of creating a 3D echocardiographic image of the heart was initially explored in the 1970s.115 These earlier versions of 3D echo were based on the reconstruction of a 3D image out of multiple 2D slices and were time consuming and impractical. Since then several studies have demonstrated the superiority of 3D imaging over 2D for the evaluation of LV structure and function.116-118 The recent advancements in computational power and miniaturization of ultrasound equipment have allowed for the development of realtime 3D echocardiography (RT3DE). The matrix array ultrasound transducer has up to 3000 ultrasound elements that reproduce a real-time, pyramidshaped, 3D image of the interrogated region of the heart. At the present time, the size of the imaged volume is not enough to contain the entire adult LV. Therefore, a series of 4 or more gated cycles need to be combined to recreate a full-volume image of the ventricle, resulting in a maximum frame rate of 25 Hz.119 Real-time 3D TEE is comprehensively reviewed elsewhere in this issue. The currently available RT3DE for TEE offers 3 different modalities (Figure 10): live 3D, 3D zoom, and full volume. The first and second provide a realtime, ungated 3D image of a portion of the heart, whereas the latter necessitates the summation of several gated cycles. Live 3D gives a 50 30 volume and can best be described as a thick 2D slice. In our experience, this is the preferred modality for structural evaluation of the aortic valve. Three-dimensional zoom provides a truncated pyramid of variable size and is the preferred view for the structural evaluation of the mitral valve. Only the gated full-volume 3D view encompasses the whole left ventricle and can be used for the volumetric assessment of global and regional LV function. For the acquisition of a high-quality full-volume loop, manipulation of the patient and surgical interference must be paused and the ventilation paused. The ultrasound machine acquires 4 to 7 ECG-gated images that will be summed to create the full-volume projection of the heart. The accuracy of the gating process can be verified by evaluating the superposition of the different ECG tracings. Improper alignment of the images due to movement or artifacts will show up as stitch lines in the 3D image. Assessment of global ventricular function. When a fullvolume 3D image is acquired, only the outer surface of the pyramid shape is displayed (Figure 11A). The image
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can then be cropped in different planes to expose the structures within and to evaluate wall motion of the different segments (Figure 11B). Several semiautomated algorithms have been developed to calculate LV volumes.120 After identifying several landmarks, the endocardium is traced by an automated endocardial border detection algorithm, which can be visually inspected and manually corrected if needed. Based on these data, an endocardial cast and its displacement throughout the cardiac cycle is generated to be displayed as the jellybean image (Figure 11C). Ventricular volumes are numerically and graphically displayed as timevolume curves and end-diastolic volume, end-systolic volume, and EF can be calculated. The accuracy of the calculated volumes and EF depends on the number of elements in the transducer, the spatial and temporal resolution of the image, and the accuracy of the endocardial border delineation. The accuracy and reproducibility of RT3DE has been established in several studies. Global LV volume and EF measurements using RT3DE correlate highly with cardiac MRI (r = .98) with minimal bias (1.4 mL) and narrow limits of agreement (20 mL).121 In fact, the correlation with cardiac MRI is better for RT3DE than for single-photon emission computed tomography and cardiac computed tomography, albeit with higher variability.122,123 The limited temporal and spatial resolution of the technology accounts for some of the reported underestimation and variability of LV volumes by RT3DE. Nevertheless, interobserver and intraobserver variability is significantly lower for RT3DE than for 2D echocardiography.124 Its superiority to 2D echocardiographic imaging is largely due to the fact that no geometrical assumptions and no extrapolation of the endocardial border for the regions in between scanning planes are necessary. Assessment of regional ventricular function. The volume enclosed in the ventricular cavity is divided in 16 pyramidal segments according to the 16-segment nomenclature. The endocardial border of the segment defines the base of every pyramid, and the tip is a point on the longitudinal axis of the ventricle. The difference between the end-diastolic volume and the end-systolic volume of this pyramid is defined as the regional EF for the segment. On the computergenerated endocardial cast, the 16 segments can be displayed in different colors, and for every segment, a timevolume curve can be displayed.
Figure 10. Real-time 3D echocardiographic imaging modalities. (A) Live 3D. Ungated, 50 30 pyramidal volume. (B) 3D zoom. Ungated, a truncated pyramid, whose size can be changed by the operator. (C) Full-volume 3D, 100 100 pyramidal volume. Four to seven ECG-gated images are summarized to encompass the full left ventricle. The ECG tracing are superposed at the bottom of the image allowing visual inspection.
Automated quantification of regional EF using RT3DE correlates well with cardiac MRIderived measurements with r > .8 for regional volumes and r = .71 for regional EF, with minimal bias (0.2 mL) and tight limits of agreement (7 mL).125 Compared with visual assessment of regional ventricular function, where segmental function was graded as normal or abnormal by an experienced echocardiographer, RT3DE has a sensitivity of 0.84, a specificity of 0.78, a positive predictive value of 0.95, a negative predictive value of 0.47, and an accuracy of 0.84.121,125 Finally, regional volumetric RT3DE has been compared with gated myocardial perfusion to evaluate intraventricular dyssynchrony of the LV and showed good correlation (r = .80), with excellent interobserver agreement (mean difference of 0.1% for dyssynchrony index and of 0.4% for EF).126 Real-time 3D assessment of ventricular function is still a bit unwieldy to be of routine use as an intraoperative monitor of LV volumes and function. Multiple steps with manual correction of the tracing of the endocardial borders and adjustments of the orientation of the axes prolong the acquisition time of the data. Furthermore, the acquisition of multiple gated images makes the technique prone to artifacts due to movement and ventilation of the patient and electrical interference. Fortunately, this technology
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is evolving very rapidly. We can expect the scanning angles to become large enough for the entire left ventricle to be comprised in a single cardiac cycle, full-volume loop, and the introduction of more powerful endocardial border detection algorithms will make this technique a valuable tool for the rapid evaluation and quantification of global and regional ventricular function.
Conclusions
Recent advancements in echocardiography imaging have allowed an improved appreciation of the structure and function of the heart and provide an opportunity to objectively assess the dynamic cardiac motions influencing LV function. Imaging modalities such as TDI and speckle tracking allow improved characterization of tissue displacement and strain, aiding understanding of rotational, longitudinal, and transverse motions that are so apparent during ventricular ejection. Similarly, 3D and contrast echocardiography provide enhanced ability to measure ventricular shape and volumes, improving the clinicians ability to diagnose alterations in cardiac structure and function. Continued developments in these technologies and methodical validation of the various new measurement algorithms in clinical trials will lead to improved ability of assessing ventricular function.
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New Echocardiographic Techniques for Evaluating Left Ventricular Myocardial Function

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New Echocardiographic Techniques for Evaluating Left Ventricular Myocardial Function

Evaluation of Left Ventricular Myocardial Function / Marcucci et al

Left Ventricular Structure and Function

Activation and Contraction

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Strain, Strain Rate, Twist, and Torsion

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Evaluation of Left Ventricular Myocardial Function / Marcucci et al

1 Longitudinal strain 2 Circumferential strain 3 Radial strain

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New Echocardiographic Imaging Modalities

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Evaluation of Left Ventricular Myocardial Function / Marcucci et al

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Evaluation of Left Ventricular Myocardial Function / Marcucci et al

Two-Dimensional Speckle Tracking

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Evaluation of Left Ventricular Myocardial Function / Marcucci et al

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Contrast-Enhanced Echocardiography (CEE)

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Evaluation of Left Ventricular Myocardial Function / Marcucci et al

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Evaluation of Left Ventricular Myocardial Function / Marcucci et al

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