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. 2003 Nov;89(Suppl 3):iii9–iii17. doi: 10.1136/heart.89.suppl_3.iii9

Tissue Doppler, strain, and strain rate echocardiography for the assessment of left and right systolic ventricular function

D Pellerin, R Sharma, P Elliott, C Veyrat
PMCID: PMC1876304  PMID: 14594870

Abstract

Tissue Doppler (TDE), strain, and strain rate echocardiography are emerging real time ultrasound techniques that provide a measure of wall motion. They offer an objective means to quantify global and regional left and right ventricular function and to improve the accuracy and reproducibility of conventional echocardiography studies. Radial and longitudinal ventricular function can be assessed by the analysis of myocardial wall velocity and displacement indices, or by the analysis of wall deformation using the rate of deformation of a myocardial segment (strain rate) and its deformation over time (strain). A quick and easy assessment of left ventricular ejection fraction is obtained by mitral annular velocity measurement during a routine study, especially in patients with poor endocardial definition or abnormal septal motion. Strain rate and strain are less affected by passive myocardial motion and tend to be uniform throughout the left ventricle in normal subjects. This paper reviews the underlying principles of TDE, strain, and strain rate echocardiography and discusses currently available quantification tools and clinical applications.

Full Text

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Figure 1.

Figure 1

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Tissue Doppler echocardiography (TDE), strain rate, and strain profiles of a normal subject obtained from an apical four chamber view. Time is on the horizontal axis. The region of interest is located in the mid inferoseptal segment. The TDE waveform consists of a first positive wave during the pre-ejection period, a systolic inward wall motion (S), followed by the isovolumic relaxation waves and by the outward wall motions Ea and Aa related to ventricular filling. Longitudinal strain rate profile is obtained from the same region of interest during the same cardiac cycle and shows corresponding waves. Negative systolic strain indicates longitudinal compression.

Figure 2.

Figure 2

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Quantitative analysis of a dobutamine stress echocardiographic study performed in a 53 year old patient who presented with atypical chest pain. Baseline, low dose, and peak dose dobutamine infusion have been recorded using colour high frame rate TDE. Strain rate and strain images were obtained and analysed off-line. The region of interest was located in the inferobasal segment where visual interpretation of changes in wall thickening and endocardial motion proved difficult. At baseline, longitudinal TDE, strain rate, and strain profiles showed a normal pattern with peak systolic velocity 5 cm/s, peak systolic strain rate -1.9 s-1, and peak systolic strain -30%. During low dose dobutamine infusion, TDE velocity and deformation rate increased. Peak systolic TDE velocity was 11 cm/s and peak systolic strain rate was -3.1 s-1. In contrast, peak systolic strain mildly decreased to -25%. During peak dose dobutamine infusion, peak systolic TDE velocity was reduced to 7.8 cm/s. The basal inferior region showed longitudinal expansion in systole with inverted and positive peak systolic strain rate +1.2 s-1 followed by pronounced negative strain rate during isovolumic relaxation (post-systolic shortening). Systolic strain was clearly positive as opposed to baseline and low dose dobutamine profiles. This segment, therefore, became ischaemic at peak stress and showed a biphasic response during incremental doses of dobutamine.

Figure 3.

Figure 3

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Colour curved M mode longitudinal strain rate images in the same patient as in fig 2 obtained in the inferobasal segment at baseline and peak dose dobutamine infusion. At baseline, there is negative systolic strain rate (red encoded) showing normal longitudinal shortening. During peak dose dobutamine infusion, there is positive systolic strain rate (blue encoded) showing longitudinal expansion or lengthening. The systolic strip is followed by a red encoded strip (*) occurring after aortic valve closure showing post-systolic shortening, another marker of ischaemia. Curved M mode reconstruction provides a visual analysis of segmental deformation rate of myocardial segments.

Figure 4.

Figure 4

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Quantitative analysis of stress echocardiography for the detection of viable myocardium in a 63 year old man with severe three vessel coronary artery disease and a left ventricular ejection fraction of 32%. Transmural myocardial velocities across the thickness of the wall were measured in a severely hypokinetic but viable segment assessed by echocardiography and rest–reinjection thallium tomography. The highest velocities were located in the mid layer conferring a bell shaped pattern to the myocardial velocity gradient in contrast with the usual pattern of linearly decreasing velocity from endocardium to epicardium. During low dose dobutamine infusion contractile reserve was mainly caused by increased mid wall velocity.

Selected References

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