European Heart Journal (2009) 30, 2304–2307 CURRENT OPINION
doi:10.1093/eurheartj/ehp343
Three-dimensional speckle tracking
echocardiography: a novel approach
in the assessment of left ventricular
volume and function?
Willem-Jan Flu1, Jan-Peter van Kuijk 1, Jeroen J. Bax 2, John Gorcsan III 3,
and Don Poldermans 4*
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1
Department of Anaesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands; 2Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands;
3
Cardiovascular Institute, University of Pittsburgh, Pittsburgh, PA, USA; and 4Department of Vascular Surgery, Erasmus Medical Center, s-Gravendijkwal 230, Room H805,
3015 CE Rotterdam, The Netherlands
Received 17 July 2009; accepted 4 August 2009; online publish-ahead-of-print 27 August 2009
Left ventricular volume leading to left ventricular dilatation (eccentric remodelling) which is
associated with systolic left ventricular dysfunction.4 Progressive ven-
and function tricular dilatation can result in (i) distortion of the cavity shape and (ii)
Over the last decades, echocardiography has developed to be an disruption of the mitral annulus and sub-valvular apparatus, which is an
established non-invasive imaging technique, widely available for important cause of mitral regurgitation.5 Evaluating left ventricular
cardiovascular investigation. Determination of myocardial function volumes is, therefore, essential for optimal timing of surgical mitral
is vital for the clinical evaluation of cardiovascular diseases. Altered valve replacement. Left ventricular dilatation is associated with
cardiac function can be detected with echocardiography as global systolic left ventricular dysfunction, characterized by a
regional myocardial wall motion abnormalities, changes in left ven- reduced left ventricular ejection fraction.4 The left ventricular ejection
tricular volumes and global left ventricular dysfunction.1 fraction is widely used to diagnose systolic heart failure and in decision
Regional wall motion abnormalities can identify and quantify making of pacemaker or internal automatic defibrillator implantation.
areas of previous myocardial infarction. Visual assessment categor- The biplane Simpson’s method is considered to be the preferred
izes wall motion on the basis of the (i) degree of endocardial method to calculate left ventricular volumes and ejection fraction
excursion, (ii) degree of endocardial thickening during systole, and requires imaging in apical, four- or two-chamber views. First,
(iii) timing of motion, and (iv) shape of the left ventricle. Timing the endocardial border has to be outlined in end-diastole and end-
is particularly important and accurate wall motion assessment systole, and the left ventricular cavity is divided into a series of disks
requires a frame-by-frame review to overcome the limited tem- of equal height, along its long axis. When the central axis of the left
poral resolution of the human eye.2 ventricular cavity is defined and the endocardial border is identified,
Although there is tremendous variability in the coronary artery the volume of each disk can be automatically calculated. In addition,
blood supply to the myocardium, a model with 16-segments assigned the ventricular volume is calculated by summing the disk volumes,
to one of three major coronary arteries is recommended for visual which are equally spaced along the left ventricular long axis. Once
interpretation of regional wall motion.3 Therefore, individual myocar- the left ventricular volumes have been measured, left ventricular ejec-
dial segments can be assigned to one major coronary artery with rec- tion fraction can be calculated.6 However, in more than 15% of
ognition of anatomic variability. Normally, the endocardium thickens patients examined with ultrasound, poor ultrasonic windows pre-
during systole; however, ischaemic myocardium shows different pat- clude optimal visualization of the endocardial border.7
terns of wall thickening or even thinning during systole. Wall motion Analysing left ventricular volumes and function relies on the
abnormalities at rest represent scar tissue (irreversible myocardial identification of the endocardial border of the left ventricular
damage) or viable myocardium (reversible myocardial damage). cavity and is often performed subjectively with the use of visual
Echocardiographic assessment of left ventricular volumes plays an interpretation (‘eye-balling’). This approach is dependent on the
important role in the evaluation of pathological remodelling, a process eye of an experienced observer and can be misleading in situations
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
* Corresponding author. Tel: þ31 10 703 4613, Fax: þ31 10 703 4957, Email: d.poldermans@erasmusmc.nl
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.
Three-dimensional speckle tracking echocardiography 2305
of (i) irregular heart rhythm, (ii) very large or small left ventricle and function, which is angle-independent.15 Speckle tracking is a
size, and (iii) extreme heart rates.8,9 The biplane Simpson’s technique that tracks the movement of natural acoustic markers,
method is considered to be semi-objective because it requires or ‘speckles’, which are present on standard grey scale ultrasound
manual tracing of the endocardial border.8 tissue images.16 These speckles appear as a result of scattering,
Two-dimensional echocardiography, currently the most frequently reflection, and interference of the ultrasound beam in myocardial
used technique for the structural analysis of the heart, has limitations tissue. With the use of wall motion tracking software, speckle
regarding the observation of the cardiac anatomy. Two-dimensional movement (and therefore myocardial tissue movement) can be
estimation of left ventricular volumes and ejection fraction are visualized from frame-to-frame during the cardiac cycle.17
flawed due to foreshortening errors and reliance upon geometric Speckle tracking echocardiography has the advantage to assess
models. The development of three-dimensional echocardiography myocardial strain or active thickening, independent of Doppler
has improved the reproducibility and accuracy to determine left ven- angle of incidence used in tissue-Doppler strain methods. There-
tricular volumes and ejection fraction, compared with two- fore, it has been introduced for clinical applications, such as
dimensional echocardiography.10 In addition, measurements of dyssynchrony analysis.18
changes in left ventricular volumes and ejection fraction with three- However, speckle tracking applied to two-dimensional images is
dimensional echocardiography have shown to be similar to those limited because regions of the myocardium represented by speckle
obtained with cardiac magnetic resonance.9 patterns in reality move through three-dimensional space, rather
than being limited by the two-dimensional sector, resulting in
reliance on geometric modelling.10,19 Regardless of its limitations,
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Strain rate imaging in a study conducted by Nishikage et al.20 demonstrated a significant
echocardiography correlation between two-dimensional speckle tracking echocardio-
graphy and cardiac magnetic resonance for measuring left ventricu-
The main application of new technologies is to improve the quantifi- lar volumes. A good correlation for left ventricular ejection
cation of echocardiography. The interpretation of regional myocardial fraction was found, although a significant underestimation was
function is the most challenging aspect of echocardiography, as well as observed in two-dimensional speckle tracking echocardiography
the most difficult to quantify. Recent developments in tissue-Doppler, compared with cardiac magnetic resonance. The results demon-
strain rate imaging, and speckle tracking echocardiography may prove strated by Nishikage et al. are promising, however, one could ask
useful for this purpose. the question whether three-dimensional speckle tracking echocar-
Tissue-Doppler imaging is a technique which measures high ampli- diography provides better results.
tude signals of myocardial tissue motion. Echocardiographic tech- This question has recently been answered in a manuscript
niques utilizing tissue-Doppler imaging are more sensitive than conducted by Nesser et al.21 In this manuscript, the accuracy of
conventional echocardiography in the detection of subtle (regional) three- vs. two-dimensional speckle tracking echocardiography for
changes in left ventricular contractile function.11 However, because measuring end-systolic and end-diastolic left ventricular volumes
tissue-Doppler imaging is a Doppler-based technique, its angle depen- was compared. Cardiac magnetic resonance was used as the refer-
dency remains a serious limitation.12 The assessment of apical myo- ence technique for both two- and three-dimensional echocardio-
cardial segments, for instance, is known to be suboptimal with graphy. The main finding of this study was that the inter- and
tissue-Doppler imaging.13 Furthermore, due to is Doppler-based intra-observer variability was lower and less spread in measure-
properties, tissue-Doppler imaging velocity is unable to discriminate ments obtained from three-dimensional speckle tracking echocar-
active deformation of the left ventricle (as a result of myocardial diography compared with two-dimensional speckle tracking
fibre shortening and lengthening) from passive deformation. echocardiography. This might imply that three-dimensional
Strain and strain rate imaging have demonstrated to be a more speckle tracking echocardiography could be an attractive new
reliable method to quantify myocardial function. Essentially, myo- method, not only for the assessment of left ventricular volumes,
cardial strain represents the rate of myocardial deformation or however for the assessment of left ventricular function as well
stretch reflected by (i) longitudinal and circumferential strain (Figure 1).
(shortening of the myocardium) and (ii) radial strain (lengthening
of the myocardium).12 Myocardial strain measured with tissue-
Doppler imaging is dependent on the angle of incidence between Speckle tracking
the ultrasound beam and myocardial motion. At angles echocardiography and cardiac
greater than 208, Doppler-derived strain and strain rate are signifi-
cantly underestimated.14 Recently, myocardial stain and strain rate magnetic resonance
can be measured using speckle tracking derived parameters. In comparison with other non-invasive cardiac imaging procedures,
such as nuclear cardiology, cardiac computed tomography, and
cardiac magnetic resonance, echocardiography has both limitations
Speckle tracking and advantages. In patients with obstructive lung disease, obesity,
chest wall deformities, increases in heart rate, and hyperventilation
echocardiography image quality impairment may cause difficulties in analysis of echo-
In 1991, speckle tracking echocardiography was introduced, an cardiographic images. However, echocardiography has the advan-
imaging modality for the quantification of left ventricular volumes tage of being (i) safe (i.e. no radiation or ionizing substances
2306 W.-J. Flu et al.
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Figure 1 An example of a three-dimensional speckle tracking echocardiogram from a heart failure patient with ischaemic cardiomyopathy
demonstrating the representative long-axis and short-axis tomographic planes, the three-dimensional wire–mesh display, and the time –
volume curve. EDV, end-diastolic volume; ESV, end-systolic volume; and EF, ejection fraction.
required), (ii) widely available, (iii) non-invasive, (iv) feasible in Future perspective
almost all circumstances including interventional settings such as
catheterization laboratories or operating rooms, (v) at relatively The echo community has put lot of efforts in guidelines and stan-
low cost.22 Cardiac magnetic resonance has the ability to dardization in left ventricular function assessment, being aware of
provide information about cardiac anatomy, function, and per- the limitations of non-quantitative measurements as such eye-
fusion simultaneously and has a superior spatial resolution com- balling evaluation of ejection fraction and regional myocardial
pared with echocardiography. However, cardiac magnetic function. Objective quantification of left ventricular volumes and
resonance has a lower temporal resolution, usually requires function with three-dimensional speckle tracking echocardiography
breath-holding sequences during data acquisition, is relatively could be an attractive new method to complete standardization of
expensive and less available compared with echocardiography, left ventricular function assessment. In addition, three-dimensional
and may be limited in patients with implanted metallic prosthetics. speckle tracking echocardiography might prove it value over
Nesser et al. have compared three-dimensional speckle tracking cardiac magnetic resonance in interventional settings such as
echocardiography with cardiac magnetic resonance and found catheterization laboratories and operating rooms. During catheter-
that three-dimensional speckle tracking echocardiography ization or surgery, the use of cardiac magnetic resonance is limited,
measurements were in close agreement with the cardiac magnetic due to practical reasons. However, an immediate visual and quan-
resonance reference values, in the presence of an adequate trans- titative feedback of left ventricular function, without the need for
thoracic two-dimensional acoustic window. However, both inter- off-line analysis, is of utmost important in these clinical settings.23
and intra-observer variability were lower and less spread in To achieve automated assessment of left ventricular volumes
measurements obtained with cardiac magnetic resonance, com- and function with three-dimensional speckle tracking ultrasound,
pared with measurements obtained with three-dimensional shortcomings have to be overcome such as (i) low temporal res-
speckle tracking echocardiography.21 These findings are probably olution and (ii) random noise affecting the ability to track speckles
related to superior spatial and contrast resolution of cardiac mag- during the cardiac cycle.21 The positive results of Nesser et al.,
netic resonance. however, have provided an insight on how global and regional
Three-dimensional speckle tracking echocardiography 2307
left ventricular function could be evaluated in the decades lying 9. Jenkins C, Bricknell K, Hanekom L, Marwick TH. Reproducibility and accuracy of
echocardiographic measurements of left ventricular parameters using real-time
ahead.
three-dimensional echocardiography. J Am Coll Cardiol 2004;44:878 –886.
10. Jacobs LD, Salgo IS, Goonewardena S, Weinert L, Coon P, Bardo D, Gerard O,
Funding Allain P, Zamorano JL, de Isla LP, Mor-Avi V, Lang RM. Rapid online quantification
W.-J.F. and J.P.v.K. are supported by an unrestricted research grant of left ventricular volume from real-time three-dimensional echocardiographic
data. Eur Heart J 2006;27:460 –468.
from ‘Lijf en Leven’.
11. Gorcsan J III, Deswal A, Mankad S, Mandarino WA, Mahler CM, Yamazaki N,
Katz WE. Quantification of the myocardial response to low-dose dobutamine
Conflict of interest: none declared. using tissue Doppler echocardiographic measures of velocity and velocity gradi-
ent. Am J Cardiol 1998;81:615 – 623.
References 12. Urheim S, Edvardsen T, Torp H, Angelsen B, Smiseth OA. Myocardial strain by
1. Hauser AM, Gangadharan V, Ramos RG, Gordon S, Timmis GC. Sequence of Doppler echocardiography. Validation of a new method to quantify regional myo-
mechanical, electrocardiographic and clinical effects of repeated coronary cardial function. Circulation 2000;102:1158 –1164.
artery occlusion in human beings: echocardiographic observations during coron- 13. Edvardsen T, Skulstad H, Aakhus S, Urheim S, Ihlen H. Regional myocardial sys-
ary angioplasty. J Am Coll Cardiol 1985;5:193 –197. tolic function during acute myocardial ischemia assessed by strain Doppler echo-
2. Kvitting JP, Wigstrom L, Strotmann JM, Sutherland GR. How accurate is visual cardiography. J Am Coll Cardiol 2001;37:726 –730.
assessment of synchronicity in myocardial motion? An in vitro study with 14. Nesbitt GC, Mankad S, Oh JK. Strain imaging in echocardiography: methods and
computer-simulated regional delay in myocardial motion: clinical implications clinical applications. Int J Cardiovasc Imaging 2009;25 (Suppl. 1):9 –22.
for rest and stress echocardiography studies. J Am Soc Echocardiogr 1999;12: 15. Bohs LN, Trahey GE. A novel method for angle independent ultrasonic imaging of
698 –705. blood flow and tissue motion. IEEE Trans Biomed Eng 1991;38:280 –286.
3. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, 16. Leitman M, Lysyansky P, Sidenko S, Shir V, Peleg E, Binenbaum M, Kaluski E,
Pennell DJ, Rumberger JA, Ryan T, Verani MS. Standardized myocardial segmenta- Krakover R, Vered Z. Two-dimensional strain-a novel software for real-time
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on October 4, 2015
tion and nomenclature for tomographic imaging of the heart: a statement for quantitative echocardiographic assessment of myocardial function. J Am Soc
healthcare professionals from the Cardiac Imaging Committee of the Council Echocardiogr 2004;17:1021 – 1029.
on Clinical Cardiology of the American Heart Association. Circulation 2002;105: 17. Yeung F, Levinson SF, Parker KJ. Multilevel and motion model-based ultrasonic
539 –542. speckle tracking algorithms. Ultrasound Med Biol 1998;24:427 –441.
4. Cohn JN, Ferrari R, Sharpe N. Cardiac remodeling—concepts and clinical impli- 18. Suffoletto MS, Dohi K, Cannesson M, Saba S, Gorcsan J III. Novel speckle-tracking
cations: a consensus paper from an international forum on cardiac remodeling. radial strain from routine black-and-white echocardiographic images to quantify
Behalf of an International Forum on Cardiac Remodeling. J Am Coll Cardiol dyssynchrony and predict response to cardiac resynchronization therapy.
2000;35:569 –582. Circulation 2006;113:960 –968.
5. Mann DL. Mechanisms and models in heart failure: a combinatorial approach. 19. Meunier J. Tissue motion assessment from 3D echographic speckle tracking. Phys
Circulation 1999;100:999 – 1008. Med Biol 1998;43:1241 – 1254.
6. Stamm RB, Carabello BA, Mayers DL, Martin RP. Two-dimensional echocardio- 20. Nishikage T, Nakai H, Mor-Avi V, Lang RM, Salgo IS, Settlemier SH, Husson S,
graphic measurement of left ventricular ejection fraction: prospective analysis Takeuchi M. Quantitative assessment of left ventricular volume and ejection frac-
of what constitutes an adequate determination. Am Heart J 1982;104:136 –144. tion using two-dimensional speckle tracking echocardiography. Eur J Echocardiogr
7. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, 2009;10:82 –88.
Gutgesell H, Reichek N, Sahn D, Schnittger I. Recommendations for quantitation 21. Nesser HJ, Mor-Avi V, Gorissen W, Weinert L, Steringer-Mascherbauer R, Niel J,
of the left ventricle by two-dimensional echocardiography. American Society of Sugeng L, Lang RM. Quantification of left ventricular volumes using three-
Echocardiography Committee on Standards, Subcommittee on Quantitation of dimensional echocardiographic speckle tracking; comparison with MRI. Eur
Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 1989;2:358 –367. Heart J 2009;30:1565 – 1573.
8. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, 22. Pennell DJ, Sechtem UP, Higgins CB, Manning WJ, Pohost GM, Rademakers FE,
Picard MH, Roman MJ, Seward J, Shanewise J, Solomon S, Spencer KT, St John van Rossum AC, Shaw LJ, Yucel EK. Clinical indications for cardiovascular mag-
Sutton M, Stewart W. Recommendations for chamber quantification: a report netic resonance (CMR): Consensus Panel report. Eur Heart J 2004;25:1940 –1965.
from the American Society of Echocardiography’s Guidelines and Standards 23. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA,
Committee and the Chamber Quantification Writing Group, developed in con- Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT,
junction with the European Association of Echocardiography, a branch of the Sutton MS, Stewart WJ. Recommendations for chamber quantification. Eur J Echo-
European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440 –1463. cardiogr 2006;7:79 –108.
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