Tissue Doppler Imaging

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Eur J Pediatr. 2008 Jan;167(1):1-8. Epub 2007 Jul 10.
What is new in pediatric cardiac imaging?
Mertens L, Ganame J, Eyskens B.
Pediatric Cardiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium, luc.mertens@uzleuven.be.

Cardiac imaging has had significant influence on the science and practice of pediatric cardiology. Especially the development and improvements made in noninasive imaging techniques, like echocardiography and cardiac magnetic resonance imaging (MRI), have been extremely important. Technical advancements in the field of medical imaging are quickly being made. This review will focus on some of the important evolutions in pediatric cardiac imaging. Techniques such as intracardiac echocardiography, 3D echocardiography, and tissue Doppler imaging are relatively new echocardiographic techniques, which further optimize the anatomical and functional aspects of congenital heart disease. Also, the current standing of cardiac MRI and cardiac computerized tomography will be discussed. Finally, the recent European efforts to organize training and accreditation in pediatric echocardiography are highlighted.

J Cardiovasc Med (Hagerstown). 2007 Dec;8(12):997-1006.
New echocardiographic technologies in the clinical management of hypertensive heart disease.
Di Bello V, Galderisi M, de Gregorio C, Ansalone G, Dini FL, Di Salvo G, Gallina S, Mele D, Sciomer S, Montisci R, Mondillo S, Marino PN; Working Group of Echocardiography of the Italian Society of Cardiology (SIC), Italy.
Cardiac Ultrasound Laboratory, Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy. vdibello@med.unipi.it

Doppler echocardiography is a fundamental instrument to understand heart damage during essential arterial hypertension. Left ventricular (LV) hypertrophy may also be conveniently studied in its morphological and functional aspects by ultrasound application. Echocardiography can also provide important morphological and functional information in hypertensive patients for therapeutic management and prognostic stratification. In recent years, echocardiography has been enriched by very refined techniques that are capable of studying the physiopathological intramyocardial phenomena: (i) tissue Doppler (which studies intramyocardial velocities and time intervals and allows the analysis of strain and strain rate); (ii) integrated backscatter (which analyzes variations of myocardial reflectivity in decibels); (iii) transthoracic Doppler derived coronary flow reserve (which quantifies the vasodilator response of coronary velocities to a hyperaemic stimulation); (iv) myocardial echo-contrast-echocardiography (which studies the kinetics of ultrasound contrast microbubbles at the intramyocardial level); and (v) real-time three-dimensional (3-D) echocardiography [which allows a more precise evaluation of left ventricular (LV) volumes and LV mass]. These new methodological approaches have recently been used in the hypertensive clinical setting to provide a deeper knowledge of the complex physiopathological and histopathological mechanisms underlying the modifications induced by arterial hypertension at the myocardial tissue level (myocytes, collagen, microcirculation). This review shows the advancement of high-tech ultrasound applied to hypertensive heart disease, pointing out limitations and incremental potentialities in comparison with conventional echocardiography.

Heart. 2007 Nov;93(11):1461-70.
Multi-modality imaging to assess left atrial size, anatomy and function.
Tops LF, van der Wall EE, Schalij MJ, Bax JJ.
Department of Cardiology, Leiden University Medical Centre, The Netherlands. l.f.tops@lumc.nl

The left atrium (LA) anterior-posterior diameter was one of the first standardised echocardiographic parameters. However, the clinical importance of LA size assessment has been neglected for some time. Recent population-based studies have demonstrated the prognostic value of LA size for long-term outcome. Furthermore, with new dedicated techniques such as tissue Doppler imaging, it has become feasible to assess (regional) LA function. In addition, the introduction of catheter ablation procedures has changed the treatment of patients with drug-refractory atrial fibrillation (AF) dramatically. New image integration systems have become available for these catheter ablation procedures. With the use of image integration systems, a real anatomical "roadmap" of the LA is provided for catheter ablation procedures. All these factors may explain the renewed interest in LA anatomy. In this article, the importance of assessment of LA size and LA anatomy is discussed. Furthermore, the various imaging modalities that are available for the non-invasive visualisation of the LA will be reviewed. In addition, the role of these imaging techniques in catheter ablation procedures for AF will be discussed.

Can J Cardiol. 2007 Oct;23(12):983-9.
Combining tissue Doppler echocardiography and B-type natriuretic peptide in the evaluation of left ventricular filling pressures: review of the literature and clinical recommendations.
Dokainish H.
Baylor College of Medicine, Houston, TX 77030, USA. hishamd@bcm.tmc.edu

Tissue Doppler imaging is an echocardiographic technique that directly measures myocardial velocities. Diastolic tissue Doppler velocities reflect myocardial relaxation, and in combination with conventional Doppler measurements, ratios (transmitral early diastolic velocity/mitral annular early diastolic velocity [E/Ea]) have been developed to noninvasively estimate left ventricular (LV) filling pressure. Consequently, mitral E/Ea can help to establish the presence of clinical congestive heart failure in patients with dyspnea. However, E/Ea has a significant 'gray zone', and is not well validated in nonsinus rhythm and mitral valve disease. B-type natriuretic peptide (BNP) is a protein released by the ventricles in the presence of myocytic stretch, and has been correlated to LV filling pressure and, independently, to other cardiac morphological abnormalities. In addition, BNP is significantly affected by age, sex, renal function and obesity. Given its correlation with multiple cardiac variables, BNP has high sensitivity, but low specificity, for the detection of elevated LV filling pressures. Taking into account the respective strengths and limitations of BNP and mitral E/Ea, algorithms combining them can be used to more accurately estimate LV filling pressures in patients presenting with dyspnea.

Cardiovasc Ultrasound. 2007 Sep 6;5:28.
Doppler echocardiography and myocardial dyssynchrony: a practical update of old and new ultrasound technologies.
Galderisi M, Cattaneo F, Mondillo S.
Division of Cardioangiology, Department of Clinical and Experimental Medicine, Federico II University Hospital, Naples, Italy. mgalderi@unina.it

Morbidity and mortality rates are higher in patients with severe left ventricular (LV) systolic dysfunction and ECG-derived prolonged QRS interval than in those with normal QRS duration. QRS duration is currently used on the grounds that it reflects the presence of ventricular dyssynchrony. However, 30-40% of patients selected on the basis of a prolonged QRS do not receive benefit by cardiac resynchronization therapy (CRT) since they do not show any significant inverse LV remodeling and QRS duration does not accurately distinguish responders to CRT. Consequently, mechanical dyssynchrony (particularly intra-ventricular dyssynchrony) seems to be much more important than electrical dyssinchrony. Pre- and post-echocardiographic assessment should require the combination of conventional and specific applications ranging from M-mode and pulsed/continuous Doppler, to pulsed Tissue Doppler, the off-line analysis of colour Tissue Velocity Imaging, Strain Rate Imaging, and real time three-dimensional reconstruction However, there is not no consensus about the best approach and the best ultrasound parameter for selecting candidates to CRT and ECG representation of abnormal cardiac conduction still remains as the main criterion in guidelines. This review is a practical update of ultrasound methods and measurements of atrio-ventricular, inter-ventricular and intra-ventricular dyssynchrony and describes experiences which used either conventional Doppler echocardiography and more advanced techniques. By these experiences, the global amount of LV dyssynchrony seems to be critical: the greater intra-ventricular dyssynchrony, the higher the possibility of significant LV inverse remodeling. After CRT, it is necessary also to evaluate the optimal atrio-ventricular delay and ventricular-ventricular delay setting that maximizes LV systolic function.

Cardiovasc Ultrasound. 2007 Aug 30;5:27.
Echocardiographic quantification of myocardial function using tissue deformation imaging, a guide to image acquisition and analysis using tissue Doppler and speckle tracking.
Teske AJ, De Boeck BW, Melman PG, Sieswerda GT, Doevendans PA, Cramer MJ. Department of Cardiology, University Medical Centre Utrecht, The Netherlands. a.j.teske@gmail.com

Recent developments in the field of echocardiography have allowed the cardiologist to objectively quantify regional and global myocardial function. Regional deformation (strain) and deformation rate (strain-rate) can be calculated non-invasively in both the left and right ventricle, providing information on regional (dys-)function in a variety of clinical settings. Although this promising novel technique is increasingly applied in clinical and preclinical research, knowledge about the principles, limitations and technical issues of this technique is mandatory for reliable results and for implementation both in the clinical as well as the scientific field. In this article, we aim to explain the fundamental concepts and potential clinical applicability of strain and strain-rate for both tissue Doppler imaging (TDI) derived and speckle tracking (2D-strain) derived deformation imaging. In addition, a step-by-step approach to image acquisition and post processing is proposed. Finally, clinical examples of deformation imaging in hypertrophic cardiomyopathy (HCM), cardiac resynchronization therapy (CRT) and arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) are presented.

Clin Res Cardiol. 2007 Aug 29
Use of tissue Doppler imaging to identify and manage systemic diseases.
Weidemann F, Strotmann JM.
Medizinische Klinik und Poliklinik I, Herz- und Kreislaufzentrum der Universität Würzburg, Josef-Schneider-Str. 2, D20, 97080, Würzburg, Germany, weidemann_f@medizin.uni-wuerzburg.de.

In systemic diseases such as amyloidosis, sarcoidosis, Friedreich's ataxia, Fabry's disease and muscular dystrophy the clinician has to judge the presence and the amount of cardiac involvement. In most of these patients conventional echocardiographic parameters are not sensitive enough to detect sub-clinical dysfunction. Tissue Doppler imaging and in addition strain rate imaging has proven to be very sensitive for the assessment of myocardial dysfunction. This review explores the impact of these new techniques to identify and to manage cardiac aspects of the different systemic diseases.

Echocardiography. 2007 Aug;24(7):697-701.
Effect of heart rate on tissue Doppler measures of diastolic function.
Burns AT, Connelly KA, La Gerche A, Mooney DJ, Chan J, MacIsaac AI, Prior DL. Cardiac Investigation Unit, St. Vincent's Hospital, Melbourne, Victoria, Australia. andrew.burns@svhm.org.au

BACKGROUND: Our aim was to study the independent effect of heart rate (HR) on parameters of diastolic function, particularly mitral annular velocities measured by tissue Doppler imaging (TDI), an effect which is not well understood. METHODS: Sixteen patients with dual chamber pacemakers attending for routine pacemaker review underwent detailed echocardiographic assessment during atrial pacing with intact atrioventricular conduction at baseline and accelerated HRs. Mitral inflow and annular tissue Doppler velocities and systolic strain parameters were compared. RESULTS: Parameters of systolic function were unaffected by increased HR. When these parameters were compared at baseline (mean 67 bpm) and accelerated HR (mean 80 bpm), the following was observed: a significant decrease in early mitral inflow (E) wave (70.5 +/- 5.5 cm/s vs 63.5 +/- 4.9 cm/s, P < 0.02) and early mitral annular (E') velocities (7.0 +/- 0.5 cm/s vs 6.3 +/- 0.6 cm/s, P < 0.003) and a significant increase in mitral inflow A wave (70.3 +/- 4.5 cm/s vs 77.3 +/- 4.4 cm/s, P < 0.05) and late mitral annular (A') velocities (9.3 +/- 0.6 cm/s vs 10.8 +/- 0.5, P < 0.00004). CONCLUSION: Changes in HR have previously unrecognized significant effects on tissue Doppler parameters of diastolic function. Further study is required to determine if tissue Doppler derived annular velocities should be corrected for HR.

Thyroid. 2007 Jul;17(7):625-30.
Cardiovascular effects of mild hypothyroidism.
Biondi B.
Department of Clinical and Molecular Endocrinology and Oncology, University of Naples Federico II, Naples, Italy. bebiondi@unina.it

The cardiovascular risk is increased in patients with overt hypothyroidism, and several potential cardiovascular risk factors were similarly reported in patients with subclinical hypothyroidism. Only recently have more data become available about the effects of mild hypothyroidism on the cardiovascular system. An impaired left ventricular diastolic function, which is characterized by slowed myocardial relaxation and impaired ventricular filling, is the most consistent cardiac abnormality in patients with mild thyroid hormone deficiency. Impaired left ventricular diastolic function on effort was also documented by radionuclide ventriculography. Studies performed by ultrasonic myocardial textural analysis suggest an altered myocardial composition in patients with mild hypothyroidism. Moreover, pulsed tissue Doppler analysis revealed that patients with mild hypothyroidism had changes in myocardial time intervals in several left ventricular segments. Finally, alterations in cardiac hemodynamic were documented by cardiac magnetic resonance imaging in presence of mild disease. Vascular function is impaired in patients with mild and subclinical hypothyroidism, as documented by the increase in systemic vascular resistance and arterial stiffness and by the impaired endothelial function. The negative effect induced by mild hypothyroidism on cardiovascular system can be reverted restoring euthyroidism with levothyroxine (L-T4) therapy. Based on the data available, it appears that L-T4 replacement should be considered in patients with mild hypothyroidism in presence of associated cardiovascular risk factors in the attempt to reverse these negative prognostic factors and improve the cardiovascular risk.

Eur J Echocardiogr. 2007 Jun 21
Echocardiography in the assessment of right heart function.
Lindqvist P, Calcutteea A, Henein M.
Department of Clinical Physiology, Heart Centre, Umeĺ, Sweden.

Assessment of right heart function remains difficult despite rapid technological echocardiographic developments. This review addresses the anatomical and physiological basis for assessment of right ventricular function. It also addresses advantages and limitations of individual echocardiographic techniques currently used in clinical and academic practice. The review concludes that volume calculation and estimation of ejection fraction is not ideal for clinical assessment of right ventricular function. Regional myocardial wall motion detection by M-mode and tissue Doppler velocities are probably the best useful methods in clinical practice. 1D and 2D strain, velocity vector imaging and 4D echocardiography need further evaluation before considering them as routine investigations. A global interest needs to be given to a very important neglected entity 'right ventricle' which has been shown to predict exercise tolerance and outcome in a number of syndromes.

Echocardiography. 2007 May;24(5):522-32.
Right ventricular tissue Doppler and strain imaging: ready for clinical use?
Gondi S, Dokainish H.
Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas 77030, USA.

Although tissue Doppler (TD) imaging of the left ventricle is now commonly used in clinical settings, TD imaging of the right ventricle (RV) is not routinely practiced. Yet, there are significant data on clinical uses of RV TD imaging, including established normal values using both color and spectral TD. In acute left ventricular (LV) inferior wall myocardial infarction, depressed RV TD velocities have been shown to correlate with the presence of RV impairment, and with patient outcome. In patients with LV heart failure, TDimaging has been correlated to RV ejection fraction by radionuclide angiography, and is an independent predictor of outcome. In patients with congenital heart disease, RV TD has been especially valuable for assessing RV function, and has been correlated to invasive hemodynamic indices, and RV ejection fraction by magnetic resonance imaging. The RV performance (Tei) index has been calculated and validated using TD-derived, rather than conventional pulsed Doppler time intervals. RV TD indices have been shown to be useful in the detection of subclinical and clinical disease in morbid obesity, chronic pulmonary, and systemic disease. TD-derived RV strain imaging can detect segmental myocardial dysfunction, overcoming limitations to conventional TD imaging resulting from tethering. For both TD velocity and strain imaging, however, appreciation of the limitations of these techniques is necessary for their appropriate use. Given its rapid acquisition times, reproducibility, and ease of addition to standard transthoracic echocardiographic protocols, RV TD and strain imaging are important additional modalities in the comprehensive echo-Doppler assessment of RV function.

Rev Med Suisse. 2007 May 30;3(113):1383-4, 1386-90.
Echocardiographic approaches for the identification of patients with ventricular asynchrony
Pascale P, Jeanrenaud X. Service de cardiologie, Departement de médecine interne, CHUV, 1011 Lausanne. Patrizio.Pascale@chuv.ch

The beneficial effect of cardiac resynchronization therapy has been demonstrated in large clinical trials. However, on an individual basis 20% to 30% of patients receiving this therapy will lack improvement or even deteriorate. A better selection of patients to predict response to cardiac resynchronization therapy is therefore needed. Echocardiographic studies have clearly demonstrated that the presence of intra-ventricular dyssynchrony is an important factor determining response to resynchronization therapy, whereas interventricular dyssynchrony appears to be of less importance. Of the different echocardiographic approaches aimed at prediction of response to resynchronization therapy, literature suggests that tissue Doppler imaging may represent the best method. Ongoing research trials will further define the role of other new bi- or three-dimensional echocardiographic tools in the clinical management of patients with heart failure.

J Am Coll Cardiol. 2007 May 15;49(19):1903-14. Epub 2007 Apr 30.
Comment in: J Am Coll Cardiol. 2007 Oct 16;50(16):1614; author reply 1615.
Tissue Doppler imaging a new prognosticator for cardiovascular diseases.
Yu CM, Sanderson JE, Marwick TH, Oh JK.
Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China. cmyu@cuhk.edu.hk

Tissue Doppler imaging (TDI) is evolving as a useful echocardiographic tool for quantitative assessment of left ventricular (LV) systolic and diastolic function. Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as heart failure, acute myocardial infarction, and hypertension. In these conditions, myocardial mitral annular or basal segmental (Sm) systolic and early diastolic (Ea or Em) velocities have been shown to predict mortality or cardiovascular events. In particular, those with reduced Sm or Em values of <3 cm/s have a very poor prognosis. In heart failure and after myocardial infarction, noninvasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/Ea or E/Em) is a strong prognosticator, especially when E/Ea is > or =15. In addition, systolic intraventricular dyssynchrony measured by segmental analysis of myocardial velocities is another independent predictor of adverse clinical outcome in heart failure subjects, even when the QRS duration is normal. In heart failure patients who received cardiac resynchronization therapy, the presence of systolic dyssynchrony at baseline is associated with favorable LV remodeling, which in turn predicts a favorable long-term clinical outcome. Finally, TDI and derived deformation parameters improve prognostic assessment during dobutamine stress echocardiography. A high mean Sm value in the basal segments of patients with suspected coronary artery disease is associated with lower mortality rate or myocardial infarction and is superior to the wall motion score.

J Am Soc Echocardiogr. 2007 May;20(5):539-51.
Left ventricular form and function revisited: applied translational science to cardiovascular ultrasound imaging.
Sengupta PP, Krishnamoorthy VK, Korinek J, Narula J, Vannan MA, Lester SJ, Tajik JA, Seward JB, Khandheria BK, Belohlavek M.
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.

Doppler tissue imaging (DTI) and DTI-derived strain imaging are robust physiologic tools used for the noninvasive assessment of regional myocardial function. As a result of high temporal and spatial resolution, regional function can be assessed for each phase of the cardiac cycle and within the transmural layers of the myocardial wall. Newer techniques that measure myocardial motion by speckle tracking in gray-scale images have overcome the angle dependence of DTI strain, allowing for measurement of 2-dimensional strain and cardiac rotation. DTI, DTI strain, and speckle tracking may provide unique information that deciphers the deformation sequence of complexly oriented myofibers in the left ventricular wall. The data are, however, limited. This review examines the structure and function of the left ventricle relative to the potential clinical application of DTI and speckle tracking in assessing the global mechanical sequence of the left ventricle in vivo.

Cardiovasc Ultrasound. 2007 Mar 26;5:16.
Current clinical applications of spectral tissue Doppler echocardiography (E/E' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved left ventricular systolic function.
Arques S, Roux E, Luccioni R.
Department of Cardiology, Aubagne Hospital, Aubagne, France. sarques@ch-aubagne.fr

Congestive heart failure with preserved left ventricular systolic function has emerged as a growing epidemic medical syndrome in developed countries, which is characterized by high morbidity and mortality rates. Rapid and accurate diagnosis of this condition is essential for optimizing the therapeutic management. The diagnosis of congestive heart failure is challenging in patients presenting without obvious left ventricular systolic dysfunction and additional diagnostic information is most commonly required in this setting. Comprehensive Doppler echocardiography is the single most useful diagnostic test recommended by the ESC and ACC/AHA guidelines for assessing left ventricular ejection fraction and cardiac abnormalities in patients with suspected congestive heart failure, and non-invasively determined basal or exercise-induced pulmonary capillary hypertension is likely to become a hallmark of congestive heart failure in symptomatic patients with preserved left ventricular systolic function. The present review will focus on the current clinical applications of spectral tissue Doppler echocardiography used as a reliable noninvasive surrogate for left ventricular diastolic pressures at rest as well as during exercise in the diagnosis of heart failure with preserved left ventricular systolic function. Chronic congestive heart failure, a disease of exercise, and acute heart failure syndromes are characterized by specific pathophysiologic and diagnostic issues, and these two clinical presentations will be discussed separately.

Clin Geriatr Med. 2007 Feb;23(1):31-59.
Republished in: Heart Fail Clin. 2007 Oct;3(4):403-22.
Role of echocardiography in the diagnostic assessment and etiology of heart failure in the elderly--opacify, quantify, and rectify.
Sorrell VL, Nanda NC.
Division of Medicine, Section of Cardiology, University of Arizona, Sarver Heart Center, 1501 N. Campbell Avenue, Tucson, AZ 85724-5037, USA.

Echocardiography offers comprehensive, noninvasive, and relatively inexpensive tools for diagnosing cardiac pathology in the elderly. With an organized approach using two-dimensional echocardiography and Doppler echocardiography, clinicians can determine the systolic and diastolic left ventricular performance;estimate the cardiac output, pulmonary artery, and ventricular fill-ing pressures; and identify surgically correctable valve disease.Meanwhile, real-time three-dimensional echocardiography provides unprecedented volume data to quantify the left ventricular status. Tissue Doppler-derived myocardial velocity and strain imaging data provide extremely fine details about the regional variations in myocardial synchrony and predict responders to cardiac resynchronization therapy. Thus, echocardiographic tools provide the basis for determining when to attempt to rectify the left ventricular dysfunction with strategically placed, biventricular pace-maker leads.

G Ital Cardiol (Rome). 2007 Feb;8(2):92-101.
Pulsed tissue Doppler illustrated to a resident in cardiology
Galderisi M, Nistri S, Ansalone G, Dini FL, Di Salvo G, Gallina S, Mele D, Montisci R, Sciomer S, Mondillo S, Di Bello V, Marino PN; Gruppo di Studio di Ecocardiografia della Societŕ Italiana di Cardiologia.
Laboratorio di Ecocardiografia, Divisione di Cardioangiologia-UTIC, Dipartimento di Medicina Clinica e Sperimentale, Universitel degli Studi Federico II, Via S. Pansini, 5 80131 Napoli. mgalderi@unina.it

Tissue Doppler is an ultrasound tool representing a useful completion of standard Doppler echocardiographic examination, The placement of pulsed tissue Doppler sample volume at the level of the different sites of the mitral annulus allows to obtain information on left ventricular global longitudinal (systolic and diastolic) function, whereas the sampling of tricuspid lateral annulus gives similar information on the right ventricular chamber. Myocardial early diastolic velocity (Em) is a marker of ventricular diastolic relaxation and the ratio obtainable between transmitral (or transtricuspid) E velocity and annular Em (E/Em ratio) is an accurate index of the level of filling pressure of the assessed ventricular chamber. Myocardial systolic velocity (Sm) as well as the frequency of acceleration of presystolic velocity, occurring during isovolumic contraction time, are indexes of systolic performance and their reduction is evident in several cardiac pathologies. Tissue Doppler-derived systolic and diastolic indexes have a recognized prognostic value in heart failure and after acute myocardial infarction. In these conditions they are able to predict both left ventricular remodeling and mortality.

Magy Seb. 2007 Jan;60(1):481-7.
Resynchronization therapy of heart failure
Merkely B, Róka A, Szilágyi S, Zima E, Kutyifa V, Apor A, Szücs G, Gellér L. Semmelweis Egyetem Er- és Szívsebészeti Klinika.

Heart failure has a high prevalence and it has a poor prognosis despite the advances in pharmacological treatment. Cardiac resynchronization therapy with biventricular pacemaker has a clinically proven efficacy in the treatment of heart failure with intraventricular dyssynchrony. Conventionally the therapy is indicated in severe drug refractory heart failure (NYHA III-IV) with optimal drug treatment, increased QRS duration (> or = 120 ms), echocardiographic parameters (left ventricular ejection fraction at most 35%). Implementation of new methods (tissue doppler echocardiography, CT, MRI, electroanatomical mapping) can help to select potentially responding patients. Individual optimization of therapy can be performed with non-invasive and invasive methods, the efficacy can be improved even in responding patients. Due to the outstanding efficiency widening the indications is a must. Currently, the efficacy is being investigated in mild heart failure and patients with narrow QRS. Several other questions (transvenous or surgical implantation, need of an implantable defibrillator) will be answered in future trials.

Tunis Med. 2007 Jan;85(1):84-90.
Doppler echocardiographic diagnosis of ventricular asynchrony. Present situation and future perspectives
Ben Khalfallah A.
Service De Cardiologie, Hopital Menzel Bourguiba, Tunisie.

Heart failure is among the most common chronic diseases in the modem era. It is the major cause of morbi--mortality and hospitalization in patients aged more than 60 years. Dilatation of left ventricle frequently induces intracardiac conduction delays resulting. in asynchronous left ventricular motion. Showing as left bundle branch block in the surface EKG. Diagnosis of asynchrony based only on electrocardiogram criteria (wide QRS complex and left bundle branch block(LBBB)) proves to be non satisfactory considering the absence of parallelism between conduction unrests and cardiac dyssynchrony: 35% of LBBB are not associated with interventricular asynchrony and 20% without intraventricular asynchrony. So there is a necessity to define new criteria of asynchrony linked more directly to cardiac mechanical activity then EKG. Doppler Echocardiography brings more informative parameters concerning inter and intra ventricular asynchrony. Doppler tissue imaging can provide accurate information on electromechanical coupling and also assess interventricular and intraventricular dyssynchrony. It seems to be very promising for the prediction of the most satisfactory response to cardiac resynchronization therapy.

Curr Opin Cardiol. 2006 Sep;21(5):438-42.
Tissue Doppler and innovative myocardial-deformation imaging techniques for assessment of myocardial viability.
Hoffmann R.
Medical Clinic I, University Hospital RWTH Aachen, Germany. RHoffman@UKAACHEN.de

PURPOSE OF REVIEW: Visual analysis of stress echocardiography allows evaluation of myocardial viability in acutely and chronically impaired left-ventricular function. Tissue Doppler and derived echocardiographic imaging techniques provide a tool for quantification of regional left-ventricular function which overcomes the limitations of subjective, experience-dependent reading of stress echocardiography. RECENT FINDINGS: Regional systolic and diastolic myocardial velocities as well as the derived myocardial-deformation parameters strain and strain rate are impaired in patients with left-ventricular dysfunction. Increase of myocardial velocities, strain and strain rate during stress stimulation are indicators of functional reserve in viable segments, while failure to increase indicates nonviability. Previous studies with very precise determination of regional myocardial deformation have shown that even analysis of resting function without evaluation of the functional reserve during stimulation allows assessment of myocardial viability. New two-dimensional echocardiography-based tissue-tracking techniques yield an angle-independent imaging modality that is likely to further improve the clinical applicability of echocardiographic imaging techniques to define regional myocardial viability. SUMMARY: This review attempts to define the role of tissue Doppler and new innovative myocardial-deformation imaging techniques for identification of myocardial viability in patients with impaired left-ventricular function.

Curr Opin Cardiol. 2004 Sep;19(5):464-71.
Tissue Doppler imaging in the evaluation of patients with cardiac amyloidosis.
Sallach JA, Klein AL.
Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.

PURPOSE OF REVIEW: Although two-dimensional, M-mode, and Doppler echocardiography have played a major role in the assessment of amyloid deposition in the heart, diagnosis of cardiac amyloidosis (CA) based on these conventional techniques is often only possible once the disease is in a relatively advanced stage. To optimize survival, early diagnosis and institution of therapy are essential. Recently, tissue Doppler imaging (TDI) and myocardial strain rate (SR) have emerged as important clinical tools in the assessment of CA. RECENT FINDINGS: Tissue Doppler imaging-derived modalities including TDI velocities, strain, and SR are currently being used in the early diagnosis and evaluation of patients with CA. Although these new indices have been examined in relatively few patients, findings suggest an important and expanding role of TDI in amyloid infiltration of the heart. SUMMARY: This review summarizes the recent literature addressing the role of TDI velocities, strain, and SR in the diagnosis and assessment of CA.

Curr Opin Cardiol. 2004 Sep;19(5):421-9.
Tissue Doppler imaging for the diagnosis of coronary artery disease.
Smiseth OA, Stoylen A, Ihlen H.
Department of Cardiology, Rikshospitalet University Hospital, Oslo, Norway. o.a.smiseth@klinmed.uio.no

PURPOSE OF REVIEW: Tissue Doppler imaging (TDI) is a diagnostic method that provides quantitative data about myocardial function. The present review discusses the most recent developments in the application of TDIin coronary artery disease. RECENT FINDINGS: The most widely used TDI modality is velocity imaging, and systolic function is measured as peak velocity during LV ejection. Several recent studies show that TDI measurements during the LV isovolumic phases provide unique information regarding myocardial dysfunction. Since velocity imaging is confounded by influence from velocities in other segments, the TDI-based modalities strain- and strain rate imaging (SRI) have been introduced to measure regional shortening fraction and shortening rate, respectively.Velocity imaging during stress echocardiography has been validated clinically and appears equivalent, but not superior to conventional visual assessment of grey scale images. Potentially, more comprehensive evaluation that includes the use of SRI may improve the diagnostic power of TDI further. Preliminary reports suggest that TDI may have an important role in the assessment of viability in acute coronary occlusion, but this needs to be demonstrated in appropriately designed clinical trials. SUMMARY: At the present time tissue Doppler velocity imaging can be recommended for clinical use, especially the pulsed mode. Strain rate imaging may be useful as additional imaging, but needs further refinement before it is ready for routine clinical use.

Circulation. 2002 Jan 29;105(4):438-45.
Tissue Doppler echocardiographic evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure.
Yu CM, Chau E, Sanderson JE, Fan K, Tang MO, Fung WH, Lin H, Kong SL, Lam YM, Hill MR, Lau CP.
Division of Cardiology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong. cmyua@hkucc.hku.hk

BACKGROUND: Biventricular pacing has been proposed to improve symptoms and exercise capacity in patients with advanced heart failure and wide electrocardiographic wave complexes. This study investigated the effect of biventricular pacing on reverse remodeling and the underlying mechanisms. METHODS AND RESULTS: Twenty-five patients with NYHA class III to IV heart failure and electrocardiographic wave complex duration >140 ms receiving biventricular pacing therapy were assessed serially up to 3 months after pacing and when pacing was withheld for 4 weeks. Tissue Doppler echocardiography was performed using a 6-basal, 6-mid segmental model to assess the time to peak sustained systolic contraction (T(S)). There was significant improvement of ejection fraction, dP/dt, and myocardial performance index; decrease in mitral regurgitation, left ventricular (LV) end-diastolic (205+/-68 versus 168+/-67 mL, P<0.01) and end-systolic volume (162+/-54 versus 122+/-42 mL, P<0.01); and improved 6-minute hall-walk distance and quality of life score after pacing for 3 months. The mechanisms of benefits were as follows: (1) improved LV synchrony, as evident by homogeneous delay of T(S) to a timing close to the latest (usually the lateral) segment abolishing the intersegmental difference in T(S) and decreasing the standard deviation of T(S) within the left ventricle (37.7+/-10.9 versus 29.3+/-8.3 ms, P<0.05); (2) improved interventricular synchrony; and (3) shortened isovolumic contraction time (122+/-57 versus 82+/-36 ms, P<0.05) but increased diastolic filling time. These benefits are pacing dependent, because withholding the pacing resulted in varying speeds in the loss of cardiac improvements. CONCLUSIONS: Biventricular pacing reverses LV remodeling and improves cardiac function. Improvement of LV mechanical synchrony seems to be the predominant mechanism.

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