DTI and Speckle Tracking Current Application - Dr Pio Caso MD, FESC Non Invasive Cardiology,Naples,Italy
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EUROECHO 2010
Teaching Course
Specialized Technique
Advanced Course
DTI and Speckle Tracking Current Application
Dr Pio Caso MD, FESC
Non Invasive Cardiology,Naples,Italy
Copenhagen Friday ,10 December 2010
Tissue Velocity Imaging from
Doppler to Grey Scale
PW-DMI
1989 2D-Color DMI
2001 Color M-Mode
2003 Strain/S-Rate
2005 Speckle tracking
2007 Speckle tracking
The First Paper on Velocity Motion
“ Doppler echocardiographic measurement of low
velocity motion of the left ventricular posterior wall ”
Mitral annulus
Sample vol 10 mm
Filter 100 Hz
Gain - 4 dB
Posterior wall
Isaaz K et al,
Am J Cardiol 1989; 64: 66-75
DMI :European Technique
Out of Europes
Gorcsan USA
•Hatle
Yu Hong-Kong
•Sutherland Quinones,Garcia USA
•Stoylen Marwick AustraliaWA
•Sutherland Zoghbi USA
Sogaard
•Mc Dickens Trondheim
Vannan USA
•Palka Sutherland
Hatle Sanderson Hong-Kong
Fraser Edinburgh Brodin
Fraser Bijnens
Eriksonn
Vinereau
Vinereanu
Cardiff D’hoodge
Kukulski Von Bibra
London
Voight
Sutherland LeuvenMertens
Azevedo Herbots Strotman
Pellerin
Pinto Dambrauskaite Weidmann
Nihoyannopoulos
Eroglu Vogel
Bijnens
Rademekers
Caso
Lisbon Derumeaux
Galderisi
Mele
Pellerin
Di Salvo
D ‘Andrea
Ga rcia Fernandez Tonti
Desco Trambaiolo
Azevedo Citro
Hardware Modifications
Doppler Myocardial
Doppler Flow Setting
Imaging Setting
•To eliminate high pass filter
•To reduce the range of velocity encoded
•To reduce the overall gain
MA Garcia-Fernandez 1998
PW DMI
QUANTIFICATION
Sm
Am
Em
•Garcia-Fernandez MA
Eur Heart J 1999
•Galderisi M Am J Cardiol 2002
•Tuchnitz J. J Am Soc Echo 1999 PCTm ATm RTm
CTm
PW DMI CORRELATION
REGIONAL
INFORMATION
GLOBAL
INFORMATION
MA Garcia-Fernandez et al
Doppler Tissue Imaging Echocardiographic 1998
Higher Frame Rate with PW-DMI and M-Mode DMI
Temporal
Resolution
3-5 msec
Q-S: 85 msec
Q-PEAK: 140 msec
ET: 287 msec
IRT: 53 msec
ICT: 67 msec
DIAST: 590 msec
C-O: 447 msec
7 msec 14 msec 28 msec 50 msec
Sutherland Doppler Myocardial Imaging Book
Sutherland Doppler Myocardial Imaging Book Hasselt Belgium 2006
Third Generation Machine
All Information in one beat
Septal Lateral Wall
Mean
Velocity
Mon-Avi V ASE /EAE Consensus Statment for Quantitative Evaluation of Cardiac Mechanics
in pRess in Textbook on Echocardiography. Ed . Oxford: Oxford University Press; 2010
ANGLE DEPENDENCY OF TDI
• Doppler signal is analyzed only
along the scanline
• Measured velocities are
understimated if us beam is not
adequately aligned with the
movement direction of the
examined structure
• Narrow sector single wall
acquisition may help minimizing
this problem
• 3 components of myocardial
motion can be interrogated by
Doppler techniques
Longitudinal
Radial
Cinrcumferential
Velocity: traslocation ,rotation ,thetering
Galiuto et al. EAE Textbook on Echocardiography. (in press) ed. Oxford: Oxford University Press; 2010Strain Rate Imaging
Strain Rate
Velocidad regional
v2
d SR
v1
V 2 – V1 V cm/sec 1
Strain Rate = = = =
d d cm sec (JUV-98)Strain / Strain Rate - Timing
Velocity
Septum
Strain
Rate
Strain
4-
Diastasi
chamber
view s
Early Late
ICT Systole IVRT
filling filling
Sutherland J Am Soc Echo 2004;17:788-802Definiciònes
Regional
La velocidad
Strain Rate
de
deformaciòn
integral
dP/dt
Regional
Strain La % local
deformaciòn
Ejection Fraction (%)
(Weidemann et al. Am J Physiol Heart Circ Physiol 2002)Summary
Normal Velocity and Strain-Strain Rate
Limitations
•pw/color
• frame rate
• angle
• optimal image
• roy
• noise
• reverberations
• artifacts
Sutherland J Am Soc Echo 2004;17:788-802Clinical Applications
Apex
Regional
Function
Left
Ventricular
Function
Intramural
Function CRT
LAA
Right Function
Ventricular
function
Left Atrial Global
Function Strain
Trambaiolo P Salustri A, JASEClinical Applications
Subclinical Heart Failure
Clinical Heart Disesase
• Diastolic function •Amyloidosis
• End diastolic pressure •Fabry Disease
• Ischaemic Heart Disease •Diastolic Heart failure
• Atrial Function •Thalassemia
• Atrial Fibrillation •Heart Transplant
• Right Ventricular function •Diabetes
• CRT •Hypertension
•Hypertrophic Card.
•Valvulopathy
•CardiotoxicityPatterns of Mitral Inflow and Mitral Annulus
Velocity from Normal to Restrictive Physiology
Sohn DW et al. JACC 1997;30:474-80Relation Myocardial Velocities with
Beta Adrenergic
Normal Dysfuctional Receptor and Fibrosis
beta -
adrenoreceptors
fibrosis
Shan K et al. JACC 2000; 36:884-90Difference in Early Diastolic Velocity in
Pathological and Phisioloical Hypertrophy
NORMAL ATHLET
HCM
HYPERTENSION D‟Andrea A. abs Italian Heart Journal 2000Diastolic Heart Failure
TDI Derived Myocardial Velocity
Definition
Signs or symptoms heart
failure
Left ventricular systolic
function normal or mild
reduced
Evidence of abnormal LV
relaxation, filling, and
distensibility indices
Cheuk-Man Yu.Circulation 2002;1195-1201LV Systolic Dysfunction of the LV Muscular Pump in Heart Failure with Preserved EF Brutsaert et Al.Curr Opin Cardiol 21:240–248. 2006
Correlation:E flow/Em ratio
and PCWP
Nagheh SF et al. JACC 1997;30:1527-33
Relation Confirmed in:
• Hypertrophic cardiomyopathy
Nagueh Circulation1999
• Sinus tachicardia
Nagueh Circulation 1998
• Atrial fibrilation
Sohn J Am Soc Echo 1999
• Heart Transpl. Sundereswaran Am J Cardiol 1998Estimation of left Ventricular Diastolic Pressure by Tissue Doppler Imaging
Estimation of left ventricular filling pressures with
Tissue Doppler Imaging
E Mitral Flow/ E‟ Septal Annulus
Black Circles EF>50% ; White Circles EF< 50%
Ommen SR Circulation 2000;102:1788-1794B-Type natriuretic Peptide
Comparative Accuracy of BNP and Tissue Doppler Echo in the Diagnosis
of Congestive Heart Failure
Relation
Beetween
BNP ed E/Ea
Ratio
BNP or
Echocardiography
for Monitoring
Heart Failure ?
Sanderson J
E Eur Heart J
2004;25,1263-1264 (Dokainish H, Am J Cardiol 2004;93:1130–1135)Clinical Applications
Subclinical Heart Failure
Clinical Heart Disesase
• Diastolic function
• End diastolic pressure •Amyloidosis
• Ischaemic Heart Disease •Fabry Disease
• Atrial Function
•Diastolic Heart failure
•Thalassemia
• Atrial Fibrillation
•Heart Transplant
• Right Ventricular function •Diabetes
• CRT •Hypertension
•Hypertrophic Card.
•Valvulopathy
•CardiotoxicityPW-DMI
Acute Ischemia
S
E A
Normale
Peak Velocities IschemiaStrain Rate: Anterior Infarction
PRE
Septal
Wall
E A
Lateral Apical delayed
Wall Deformation
S
PSSSutherland J Am Soc Echo 2004;17:788-802
Clinical Applications
Subclinical Heart Failure
Clinical Heart Disesase
• Diastolic function •Amyloidosis
• End diastolic pressure •Fabry Disease
• Ischaemic Heart Disease •Diastolic Heart failure
• Atrial Function •Thalassemia
• Atrial Fibrillation •Heart Transplant
•Diabetes
• Right Ventricular function
•Hypertension
• CRT •Hypertrophic Card.
•Valvulopathy
•CardiotoxicityNormal Atrial Strain
The measurement of changes in atrial strain rate during passive
atrial filling could provide an index of atrial compliance
Sutherland. Doppler Myocardial Imaging 2004SINUS RYTHMN
Recurrence of Atrial Fibrillation
LA STRAIN
CURVES
LV
ATRIAL FIBRILLATION
LA
LVNormals STRAIN % Atrial Fibrillation
(n=40)
(n=68)
79±16 26±21*
165±61 98±31 44±26* 26±18*
*pStrain < 22% has Sensibility 76.9% and Spec 85.7% in
discovering PTS with Recurrence of Atrial Fibrillation
MSR AFR
MSR: Maintenance of
Synus Rithm
AFR: Atrial Fibrillation ROC CURVE
Recurrence
Di Salvo,Caso,D „Onofrio et al Circulation 2005;112:387-393Clinical Applications
Subclinical Heart Failure
Clinical Heart Disesase •Amyloidosis
•Fabry Disease
• Ischaemic Heart Disease •Diastolic Heart failure
• End diastolic pressure •Thalassemia
• Atrial Function •Heart Transplant
• Atrial Fibrillation •Diabetes
• Right Ventricular function •Hypertension
• CRT •Hypertrophic Card.
•Valvulopathy
•CardiotoxicityPW-TISSUE DOPPLER OF THE RIGHT
VENTRICLE IN HEART FAILURE
Università Federico II
S
m
Em
Am
Sm < 11.5 cm/s is predictive of RV
systolic dysfunction (RV EF < 45 %)
Correlation between right ventricular ejection fraction (EF) and
Sensitivity = 90 % the peak tricuspid annular systolicvelocity (Sa)
Specificity = 85 %
Meluzin J, Eur Heart J 2001;22:340Mean Right Atrial Pressure using Tissue Doppler
Imaging
E/Ea ratio >6 for
mean RAP10mmHg
Nagueh et al Am J Cardiol 1999,84 :1448-50Estimated Right Ventricular Filling Pressure
Utsunomiya et al . J Am Soc Echocardiogr 2009;22:1368-74CORREALION BETWEEN RIGHT
VENTRICULAR SYSTOLIC
PRESSURE AND PW DMI IVRT NORMAL
Sm
Am
Em
Em
MILD
PULMONARY PULMONARY
HYPERTENSION HYPERTENSION
Sm
Sm
Em
Em Am Am
RTm = 50 ms RTm = 136 ms Caso P et al. JASE 2001Right
Ventricular
Dyslasia
Herbots L Eur J Echo 2003;4:101-107Clinical Applications
Clinical Heart Disesase Subclinical Heart Failure
• Ischaemic Heart •Amyloidosis
Disease •Fabry Disease
•Diastolic Heart failure
• End diastolic pressure •Thalassemia
• Atrial Function •Heart Transplant
• Atrial Fibrillation •Diabetes
• Right Ventricular •Hypertension
function •Hypertrophic Card.
• CRT •Valvulopathy
•CardiotoxicityBabel tower rivisited: The Prospec Effect
CRT
Marwick Circulation 2008;117;2573-2576INTER-VENTRICULAR DALAY in LBBB: 80 msec Q(ecg) Sist Wave Tricuspid 120 msec - Q(ecg) Sist wave in Inferior 200
Time to Peak and Standard Deviation of Time to Peak
Time to
Peak
After CRT
Before
CRT
Cheuk-Man Yu et al Circulation 2002;105:438-445PITFALLS: “WHERE IS THE PEAK?”
peak
optimal cutoff value of 65 ms for LV
dyssynchronyColor-M-mode and PW-DTI
Intraventricular
21 pts nonisch
asynchrony
QRS 120ms
10/21
CO Better LV
Synchrony
=
CO :590 msec Improvement
LV performance
EA :270 msec
Ansalone
ICT:200 msec Am Heart J
2001;142:881-96
IRT:190 msec
LBBB : Inf. Wall unsynchronised pattern IIPROSPECT :Sensitivity and Specificity of
Echocardiographic Predictors to CRT
PRE CRT
POST CRT
Chung et al. Circulation.2008; 117: 2608-2616PROSPECT
Chung et al. Circulation.2008; 117: 2608-2616
Gorcsan et al J Am Soc Echo 2008“… a study of laboratory error
rather than a test of a hypothesis
1) training DTI eco: one day (!!)
2) “Core” echo Lab selcted on numer of implanted PM and not in
experience on DTI or un Papers on CRT( !)
3) Variability expression of low experience in measures on CRT.
4) Variability of EVS (14.5%), mesured only in 286/426 patients
5) Differents echo machine((GE 37%, Philips 50% , Siemens 12%) !
6) EF of core lab 29% in local Lab 23%
7) 20% of Patients in core Lab had EF > 35%( out of Guidelines) !
8) Not Used data by Speckle tracking and 3D
JACC 2009 Vol.53,1960-64Cardiac Mechanism
“exceedling simple in principle but wonderfully complicated in detail”
• Radial Contraction
• Longitudinal Contraction
• Circumferential Contraction
• Rotation Apex
Single
• Rotation Base myocardial
ventricular band
• Torsion
Francisco (Paco)
Torrent-Guasp
(1931-2005)
(da Kocica ML. Eur J Cardio-Thorac Surg 2006; 29:221-40).Speckle Tracking and
Transmurality
Chan J JACC 2006Gray Scale Velocity Estimation by
Speckle Tracking
Speckle:
many small
elements,
natural fingerprints
acoustic
markersDifference between Myocardial Velocity
by Doppler and by Speckle tracking
• Higher frame rate
• Great experience in many studies
• Angle Dependence
Doppler
• Higher temporal resolution
• No angle dependence
• Possibility to analyze the apex
• Better lateral resolution
• More automated and applied
2D Speckle
• More reproducible
• Usable on previous exams stored(Grey scale)What kind of informations does give us 2D Strain?
•Strain
•Strain Rate
•Displacement
•Rotational
(Twist)
•Rotational
Rate2D Strain Interventricular Device
C. Rost et al. Eur J Echocardiogr 2010: 11, 584-589
Limitations of 2D Speckle Tracking
Hypertrophic Cardiomyopathy
• The optimal frame rate for speckle tracking seems to
be 50-70 frame per seconds which is lower
compared to TDI(>180 frame).this could result in
undersampling especially in patients with
tachicardia
• Rapid events during the cardiac cycle (ICT,IVRT)
may disappear all together and peak SR and vel
values may be reduced due to under sampling
especially in isovolumic phases and in early diastole
• Calculated parametres are averaged over the
myocardial segment when using the result page of
the software.
Right Ventricular Dysplasia
• Small regions of myocardial dysfunction such as
early stages of hypertrophic cardiomyopathy or
arrhythmogenic right ventricular dysplasia the
averaging could result in normal deformation
• Software programs designed for speckle tracking
are new and are subjected to periodical improvment
• Different tracking algorithms produce different
resultsStrain 2D -HCM
Speckle Tracking and HCM
2D Speckle Tracking to Calculate
Bull’s eye plots generated
Strain in Infarction by semiautomated strain
analysis using 2-
dimensional speckle
tracking technique to
calculate strain
A : Normal Volunteer
B: Antero-lateral infarction
C: Infero-lateral Infarction
D: non ischemic cardiomyopathy
Abraham TP et al Circulation 2007;
116: 2597-2609Global Strain:Acute Infarct 1° gg 2° gg 5° gg
Anterior Infarctus 24 h 48 h
Angio-Coro
ESORDIO 24h AFTER 48h
Presentation AFTER 24h
Peak
AFTER 48h
Systolic
strainPresentation AFTER 24h
AFTER 48h
Time to Peak
Longitudinal StrainPresentation AFTER 24h
AFTER 48h
Post Systolic IndexLBBB
LBBB-HF
CMI-HF
Metodi Ecocardiografici per la Valutazione del
Dissincronismo Speckle Tracking Echocardiography
PRE CRT POST CRTCombined Longitudinal and Radial Dyssynchrony
Predicts Ventricular Response After Resynchronization Therapy
Bax J J Am Coll Cardiol 2007 ;50:1476-1483What kind of informations does give us
Velocity Vectors Imaging?
• Velocities
• Strain Rate
• Strain
• Displacement
• Twist and untwist
• Volumes
• Ejection fractionWe can Study: Asinchrony and Asinergy Sinchrony for repetitive events is a fixed time relationship to a corresponding instant in another event;\ Sinergy refers to the phenomenon in which two or more segments create an effect greater than the sum of the effects each
Velocity Vectors Imaging in patient with suspected
sistemic amylodosisStrain Normal subject Patient with amiloidosys
Tangential Displacement Normal subject Patient with amiloidosys
Normal Strain and Torsion
P
S L Contraction
A
Counter-clockwise Apical
Contraction Basal
Rotation
as viewed Time
from apex
Clockwise
Systole Diastole
Notomi et al. Circulation March, 2005TORSION
Torsion from 2D Echo Rotation Apex
8°
7°
Rest Apical twist
18°
18°
Exercise
Apical twist
Notomi et al. JACC orVelocity Vectors Imaging and Twist
Torsion VS=
21+10=31°
divided for 8 cm
(LV max lenght)
Torsion =31/8=
3,9°/cm
Base Apex
Clockwise Counter-Clockwise
Tor VS= Q apex-Q base
Twist angle of the apex (Q apex°) – twist angle of the base (Qbase°)PHYSIOLOGICAL VARIABLES INFLUENCING LEFT VENTRICULAR TWIST MECHANICS Sengupta PP JACC IMG 2008
Systole-Twist and Diastole-Untwist
• MVC mitral valve
closure
• AVO aortic
valve opening
• AVC aortic
valve closure
• MVO mitral
valve opening
Late
filling
• PSTV peak systolic torsional velocity
• PUV peak untwisting velocity
• Red line: systole (2 peaks, early and late)
• Blue line: diastole (peak untwist, peak early filling, peak of late filling)
(modified from Borg AN et al. Heart 2007;10:1136.)LEFT VENTRICULAR TWIST DYNAMICS IN
DIFFERENT PATHOLOGIES
Mor-Avi V, Lang RM, Badano L et al. Eur J of Echo (in press) 2010.
EUROECHO CONGRESS - COPENHAGEN -
TEACHING COURSE 2010CIRCONFERENTIAL ROTATION STRAIN NORMAL IMA
NORMAL LBBB-HF
BASE
VELOCITY
VECTOR
IMAGING
Sinchrony and
Sinergy
APEXCIRCONFERENTIAN ROTATION STRAIN CMI
3D Displacement
3D - STRAIN
3D - STRAIN
Left Ventricular Strain by Speckle Tracking 3D and 2D
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