Tissue Doppler echocardiography
- John Gorcsan, III, MD
John Gorcsan, III, MD
- Professor of Medicine
- University of Pittsburgh School of Medicine
Tissue Doppler echocardiography (TDE) has become an established component of the diagnostic ultrasound examination; it permits an assessment of myocardial motion using Doppler ultrasound imaging, often with color coding. The technique uses frequency shifts of ultrasound waves to calculate myocardial velocity; this is similar to routine Doppler ultrasound to assess blood flow, but its technological features focus on lower velocity frequency shifts. (See "Principles of Doppler echocardiography".)
Although Doppler ultrasound has been in widespread clinical use to assess intracardiac blood flow and noninvasive hemodynamics for many years, interest in TDE increased significantly when the color-coded TDE method was introduced [1-6]. Routine echocardiographic assessment of regional left ventricular (LV) wall motion is subjective because it is determined by visual determination of endocardial excursion and wall thickening. TDE offers the promise of an objective measure to quantify regional and global LV function through the assessment of myocardial velocity data.
Two techniques are used to assess myocardial function: pulsed-TDE and color-coded TDE, which is an extension of the pulsed-Doppler technique. This modality has been applied in several clinical settings, particularly in the assessment of global and regional LV systolic function. Other uses include assessment of LV diastolic function, estimation of LV filling pressures, determination of LV dyssynchrony for cardiac resynchronization therapy (CRT), and the distinction of different cardiac diseases.
Tissue Doppler ultrasonography utilizes modifications of blood flow Doppler technology and calculates velocity from frequency shifts in received ultrasound data in a similar manner. Thus, the fundamental units are velocity observed from the echocardiographic transducer as a frame of reference. A primary advantage of tissue Doppler echocardiography (TDE) is that Doppler shifts of tissue motion are of high amplitude, being approximately 40 dB higher than Doppler signals from blood flow [1,7]. An instrumentation feature common to both pulsed and color-coded TDE involves removal of the high-pass filter used for routine Doppler to assess blood flow in order to focus on the lower velocity values of myocardial motion [1,2,7].
Pulsed-TDE — Pulsed-TDE is available on most commercial echocardiography systems. The details of TDE set-up are unique to each system, but TDE is generally executed though a system preset feature. Operation is then very similar to routine pulsed-Doppler, with adjustments of the scale and sweep speed to optimize the spectral display, similar to pulsed-Doppler of blood flow. The gate of the sample volume is usually opened to 1 cm and directed to assess the region of interest. Routine color flow instrumentation uses the autocorrelator technique to calculate and display multigated points of color-coded blood velocity along a series of ultrasound scan lines within a two-dimensional sector . Color-coded blood velocity data are then superimposed on conventional gray scale two-dimensional images in real time.
- Sutherland GR, Stewart MJ, Groundstroem KW, et al. Color Doppler myocardial imaging: a new technique for the assessment of myocardial function. J Am Soc Echocardiogr 1994; 7:441.
- Miyatake K, Yamagishi M, Tanaka N, et al. New method for evaluating left ventricular wall motion by color-coded tissue Doppler imaging: in vitro and in vivo studies. J Am Coll Cardiol 1995; 25:717.
- Pellerin D, Cohen L, Larrazet F, et al. Preejectional left ventricular wall motion in normal subjects using Doppler tissue imaging and correlation with ejection fraction. Am J Cardiol 1997; 80:601.
- Palka P, Lange A, Fleming AD, et al. Doppler tissue imaging: myocardial wall motion velocities in normal subjects. J Am Soc Echocardiogr 1995; 8:659.
- Gorcsan J 3rd, Gulati VK, Mandarino WA, Katz WE. Color-coded measures of myocardial velocity throughout the cardiac cycle by tissue Doppler imaging to quantify regional left ventricular function. Am Heart J 1996; 131:1203.
- Gorcsan J 3rd, Strum DP, Mandarino WA, et al. Quantitative assessment of alterations in regional left ventricular contractility with color-coded tissue Doppler echocardiography. Comparison with sonomicrometry and pressure-volume relations. Circulation 1997; 95:2423.
- Isaaz K, Thompson A, Ethevenot G, et al. Doppler echocardiographic measurement of low velocity motion of the left ventricular posterior wall. Am J Cardiol 1989; 64:66.
- Sahn DJ. Instrumentation and physical factors related to visualization of stenotic and regurgitant jets by Doppler color flow mapping. J Am Coll Cardiol 1988; 12:1354.
- Derumeaux G, Ovize M, Loufoua J, et al. Doppler tissue imaging quantitates regional wall motion during myocardial ischemia and reperfusion. Circulation 1998; 97:1970.
- Mirsky I, Parmley WW. Assessment of passive elastic stiffness for isolated heart muscle and the intact heart. Circ Res 1973; 33:233.
- Abraham TP, Nishimura RA. Myocardial strain: can we finally measure contractility? J Am Coll Cardiol 2001; 37:731.
- Greenberg NL, Firstenberg MS, Castro PL, et al. Doppler-derived myocardial systolic strain rate is a strong index of left ventricular contractility. Circulation 2002; 105:99.
- Sutherland GR, Di Salvo G, Claus P, et al. Strain and strain rate imaging: a new clinical approach to quantifying regional myocardial function. J Am Soc Echocardiogr 2004; 17:788.
- Gorcsan J 3rd, Tanaka H. Echocardiographic assessment of myocardial strain. J Am Coll Cardiol 2011; 58:1401.
- Uematsu M, Miyatake K, Tanaka N, et al. Myocardial velocity gradient as a new indicator of regional left ventricular contraction: detection by a two-dimensional tissue Doppler imaging technique. J Am Coll Cardiol 1995; 26:217.
- Uematsu M, Nakatani S, Yamagishi M, et al. Usefulness of myocardial velocity gradient derived from two-dimensional tissue Doppler imaging as an indicator of regional myocardial contraction independent of translational motion assessed in atrial septal defect. Am J Cardiol 1997; 79:237.
- Edvardsen T, Skulstad H, Aakhus S, et al. Regional myocardial systolic function during acute myocardial ischemia assessed by strain Doppler echocardiography. J Am Coll Cardiol 2001; 37:726.
- Pislaru C, Belohlavek M, Bae RY, et al. Regional asynchrony during acute myocardial ischemia quantified by ultrasound strain rate imaging. J Am Coll Cardiol 2001; 37:1141.
- Hoffmann R, Altiok E, Nowak B, et al. Strain rate measurement by doppler echocardiography allows improved assessment of myocardial viability inpatients with depressed left ventricular function. J Am Coll Cardiol 2002; 39:443.
- Katz WE, Gulati VK, Mahler CM, Gorcsan J 3rd. Quantitative evaluation of the segmental left ventricular response to dobutamine stress by tissue Doppler echocardiography. Am J Cardiol 1997; 79:1036.
- Nishino M, Tanouchi J, Tanaka K, et al. Dobutamine stress echocardiography at 7.5 mg/kg/min using color tissue Doppler imaging M-mode safely predicts reversible dysfunction early after reperfusion in patients with acute myocardial infarction. Am J Cardiol 1999; 83:340.
- Cain P, Baglin T, Case C, et al. Application of tissue Doppler to interpretation of dobutamine echocardiography and comparison with quantitative coronary angiography. Am J Cardiol 2001; 87:525.
- Hanekom L, Jenkins C, Jeffries L, et al. Incremental value of strain rate analysis as an adjunct to wall-motion scoring for assessment of myocardial viability by dobutamine echocardiography: a follow-up study after revascularization. Circulation 2005; 112:3892.
- Feigenbaum H, Zaky A, Nasser WK. Use of ultrasound to measure left ventricular stroke volume. Circulation 1967; 35:1092.
- Jones CJ, Raposo L, Gibson DG. Functional importance of the long axis dynamics of the human left ventricle. Br Heart J 1990; 63:215.
- Pai RG, Bodenheimer MM, Pai SM, et al. Usefulness of systolic excursion of the mitral anulus as an index of left ventricular systolic function. Am J Cardiol 1991; 67:222.
- Gulati VK, Katz WE, Follansbee WP, Gorcsan J 3rd. Mitral annular descent velocity by tissue Doppler echocardiography as an index of global left ventricular function. Am J Cardiol 1996; 77:979.
- Gorcsan J 3rd, Deswal A, Mankad S, et al. Quantification of the myocardial response to low-dose dobutamine using tissue Doppler echocardiographic measures of velocity and velocity gradient. Am J Cardiol 1998; 81:615.
- Shimizu Y, Uematsu M, Shimizu H, et al. Peak negative myocardial velocity gradient in early diastole as a noninvasive indicator of left ventricular diastolic function: comparison with transmitral flow velocity indices. J Am Coll Cardiol 1998; 32:1418.
- Vinereanu D, Ionescu AA, Fraser AG. Assessment of left ventricular long axis contraction can detect early myocardial dysfunction in asymptomatic patients with severe aortic regurgitation. Heart 2001; 85:30.
- Bax JJ, Bleeker GB, Marwick TH, et al. Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol 2004; 44:1834.
- Yu CM, Chau E, Sanderson JE, et al. Tissue Doppler echocardiographic evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure. Circulation 2002; 105:438.
- Gorcsan J 3rd, Kanzaki H, Bazaz R, et al. Usefulness of echocardiographic tissue synchronization imaging to predict acute response to cardiac resynchronization therapy. Am J Cardiol 2004; 93:1178.
- Ansalone G, Giannantoni P, Ricci R, et al. Doppler myocardial imaging to evaluate the effectiveness of pacing sites in patients receiving biventricular pacing. J Am Coll Cardiol 2002; 39:489.
- Suffoletto MS, Dohi K, Cannesson M, et al. Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation 2006; 113:960.
- Gorcsan J 3rd, Oyenuga O, Habib PJ, et al. Relationship of echocardiographic dyssynchrony to long-term survival after cardiac resynchronization therapy. Circulation 2010; 122:1910.
- Sohn DW, Chai IH, Lee DJ, et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol 1997; 30:474.
- Nagueh SF, Middleton KJ, Kopelen HA, et al. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 1997; 30:1527.
- Rodriguez L, Garcia M, Ares M, et al. Assessment of mitral annular dynamics during diastole by Doppler tissue imaging: comparison with mitral Doppler inflow in subjects without heart disease and in patients with left ventricular hypertrophy. Am Heart J 1996; 131:982.
- Hill JC, Palma RA. Doppler tissue imaging for the assessment of left ventricular diastolic function: a systematic approach for the sonographer. J Am Soc Echocardiogr 2005; 18:80.
- Ommen SR, Nishimura RA, Appleton CP, et al. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study. Circulation 2000; 102:1788.
- Nagueh SF, Lakkis NM, Middleton KJ, et al. Doppler estimation of left ventricular filling pressures in patients with hypertrophic cardiomyopathy. Circulation 1999; 99:254.
- Wang M, Yip G, Yu CM, et al. Independent and incremental prognostic value of early mitral annulus velocity in patients with impaired left ventricular systolic function. J Am Coll Cardiol 2005; 45:272.
- Hillis GS, Møller JE, Pellikka PA, et al. Noninvasive estimation of left ventricular filling pressure by E/e' is a powerful predictor of survival after acute myocardial infarction. J Am Coll Cardiol 2004; 43:360.
- Dokainish H, Zoghbi WA, Lakkis NM, et al. Incremental predictive power of B-type natriuretic peptide and tissue Doppler echocardiography in the prognosis of patients with congestive heart failure. J Am Coll Cardiol 2005; 45:1223.
- Motoki H, Borowski AG, Shrestha K, et al. Incremental prognostic value of assessing left ventricular myocardial mechanics in patients with chronic systolic heart failure. J Am Coll Cardiol 2012; 60:2074.
- Garcia MJ, Rodriguez L, Ares M, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy: assessment of left ventricular diastolic velocities in longitudinal axis by Doppler tissue imaging. J Am Coll Cardiol 1996; 27:108.
- Rajagopalan N, Garcia MJ, Rodriguez L, et al. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol 2001; 87:86.
- Ha JW, Ommen SR, Tajik AJ, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy using mitral annular velocity by tissue Doppler echocardiography. Am J Cardiol 2004; 94:316.
- Palka P, Lange A, Donnelly JE, Nihoyannopoulos P. Differentiation between restrictive cardiomyopathy and constrictive pericarditis by early diastolic doppler myocardial velocity gradient at the posterior wall. Circulation 2000; 102:655.
- Perk G, Tunick PA, Kronzon I. Non-Doppler two-dimensional strain imaging by echocardiography--from technical considerations to clinical applications. J Am Soc Echocardiogr 2007; 20:234.
- Langeland S, D'hooge J, Wouters PF, et al. Experimental validation of a new ultrasound method for the simultaneous assessment of radial and longitudinal myocardial deformation independent of insonation angle. Circulation 2005; 112:2157.
- Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 2009; 22:107.
- Abraham TP, Pinheiro AC. Speckle-derived strain a better tool for quantification of stress echocardiography? J Am Coll Cardiol 2008; 51:158.
- TECHNICAL ASPECTS
- Color-coded TDE
- CLINICAL APPLICATIONS
- Assessment of global and regional left ventricular systolic function
- - Strain and strain rate imaging
- - Use during dobutamine stress echocardiography
- - Mitral annular velocity to assess LV function
- - Use in evaluating chronic aortic regurgitation
- - Use in heart failure and resynchronization therapy
- Assessment of diastolic function
- - Use of mitral annular velocity
- Estimation of LV filling pressures
- Prognostic utility in heart failure
- Differentiation of constrictive pericarditis from restrictive cardiomyopathy
- Differentiation of hypertrophic cardiomyopathy from left ventricular hypertrophy
- COMPARISON WITH SPECKLE TRACKING
- INFORMATION FOR PATIENTS