In the fields of

cardiology Cardiology () is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular h ...

and

medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to re ...

, speckle tracking echocardiography (STE) is an echocardiographic imaging technique. It analyzes the motion of tissues in the heart by using the naturally occurring speckle pattern in the

myocardium Cardiac muscle (also called heart muscle, myocardium, cardiomyocytes and cardiac myocytes) is one of three types of vertebrate muscle tissues, with the other two being skeletal muscle and smooth muscle. It is an involuntary, striated muscle tha ...

(or motion of blood when imaged by

ultrasound Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...

). This method of documentation of myocardial motion is a noninvasive method of definition for both vectors and velocity. When compared to other technologies seeking noninvasive definition of

ischemia Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems w ...

, speckle tracking seems a valuable endeavor. The speckle pattern is a mixture of

interference pattern In physics, interference is a phenomenon in which two waves combine by adding their displacement together at every single point in space and time, to form a resultant wave of greater, lower, or the same amplitude. Constructive and destructive ...

s and natural acoustic reflections. These reflections are also described as ''speckles'' or ''markers''. The pattern being random, each region of the myocardium has a unique speckle pattern (also called ''patterns'', ''features'', or ''fingerprints'') that allows the region to be tracked. The speckle pattern is relatively stable, at least from one frame to the next.Bohs LN, Trahey GE. A novel method for angle independent ultrasonic imaging of blood flow and tissue motion. IEEE Trans Biomed Eng. 1991 Mar;38(3):280-6.Kaluzynski K, Chen X, Emelianov SY, Skovoroda AR, O'Donnell M. Strain rate imaging using two-dimensional speckle tracking. IEEE Trans Ultrason Ferroelectr Freq Control. 2001 Jul;48(4):1111-23. In post processing this can be tracked consecutively frame to frame and ultimately resolved into angle-independent two-dimensional ( 2D) and three-dimensional strain-based sequences ( 3D).Leitman M, Lysyansky P, Sidenko S, Shir V, Peleg E, Binenbaum M, et al.Two-dimensional strain-a novel software for real-time quantitative echocardiographic assessment of myocardial function. JAm Soc Echocardiogr 2004;17:1021-9. These sequences provide both quantitative and qualitative information regarding tissue deformation and motion.

Basic principles

As the speckle pattern is random, any region of the myocardium has a unique speckle pattern: Within the picture, a defined area "kernel" can be defined, and as this speckle pattern is relatively stable, the kernel can be recognised in the next frame, within a larger search area, by a "best match" search algorithm. There are different search algorithms, the most commonly used is " sum of absolute differences", shown to be similarly accurate as

cross-correlation In signal processing, cross-correlation is a measure of similarity of two series as a function of the displacement of one relative to the other. This is also known as a ''sliding dot product'' or ''sliding inner-product''. It is commonly used f ...

, which is an alternative. The movement of the kernel across the image can thus be tracked, in principle independent of the beam angle, as opposed to

tissue Doppler Tissue Doppler echocardiography (TDE) is a medical ultrasound technology, specifically a form of echocardiography that measures the velocity of the heart muscle (myocardium) through the phases of one or more heartbeats by the Doppler effect (freque ...

. Speckle tracking can thus track in two dimensions. However, as the axial (in the direction of the beam) resolution of the ultrasound is far better than the transverse, the tracking ability is less in the transverse direction. Also, the transverse resolution (and hence, tracking ability) decreases with depth, in a sector scan were ultrasound beams diverge. Different commercial and non commercial operators then use different approaches to derive motion and deformation parameters. The motion of a single kernel can be resolved into displacement curves, and the distance between two kernels into strain (deformation).Amundsen BH, Crosby J, Steen PA, Torp H, Slørdahl SA, Støylen A. Regional myocardial long-axis strain and strain rate measured by different tissue Doppler and speckle tracking echocardiography methods: a comparison with tagged magnetic resonance imaging. Eur J Echocardiogr. 2009 Mar;10(2):229-37 Strain rate will then be time derivative of strain. In some commercial applications, the acoustic markers are tracked more individually, calculating the velocity from the motion and the sampling interval (inverse of frame rate) generating a velocity field. Unlike tissue Doppler, this velocity field in not limited to the beam direction. Strain rate and strain are then calculated from the velocities. Speckle tracking has been shown to be comparable to tissue Doppler derived strain, and has been validated against MR.Cho GY, Chan J, Leano R, Strudwick M, Marwick TH. Comparison of two-dimensional speckle and tissue velocity based strain and validation with harmonic phase magnetic resonance imaging. Am J Cardiol 2006; 97:1661-6

Strain

Strain is defined as the fractional or percentage change in an objects dimension in comparison to the object’s original dimension.Abraham TP, Dimaano VL, Liang HY. Role of tissue Doppler and strain echocardiography in current clinical practice. Circulation 2007;116: 2597-609. Similarly, strain rate can be defined as the speed at which deformation occurs. Mathematically, three components of normal strain (εx, εy, and εz) and three components of shear strain (εxy, εxz, and εyz) are recognized. Congruently, when applied to the left ventricle, left ventricular deformation is defined by the three normal strains (longitudinal, circumferential, and radial) and three shear strains (circumferential-longitudinal, circumferential-radial, and longitudinal-radial). The principal benefit of LV shear strains is amplification of the 15% shortening of

myocyte A muscle cell is also known as a myocyte when referring to either a cardiac muscle cell (cardiomyocyte), or a smooth muscle cell as these are both small cells. A skeletal muscle cell is long and threadlike with many nuclei and is called a mus ...

s into 40% radial LV wall thickening, which ultimately translates into a >60% change in LV

ejection fraction An ejection fraction (EF) is the volumetric fraction (or portion of the total) of fluid (usually blood) ejected from a chamber (usually the heart) with each contraction (or heartbeat). It can refer to the cardiac atrium, ventricle, gall bladder, ...

. Left ventricular shearing increases towards the subendocardium, resulting in a subepicardial to subendocardial thickening strain gradient. Similar to MRI, STE utilizes "Lagrangian strain" which defines motion around a particular point in tissue as it revolves through time and space.D’Hooge J, Heimdal A, Jamal F, Kukulski T, Bijnens B, Rademakers F, et al. Regional strain and strain rate measurements by cardiac ultrasound: principles, implementation and limitations. Eur J Echocardiogr 2000;1: 154-70. Throughout the

cardiac cycle The cardiac cycle is the performance of the human heart from the beginning of one heartbeat to the beginning of the next. It consists of two periods: one during which the heart muscle relaxes and refills with blood, called diastole, followin ...

, the end-diastolic tissue dimension represents the unstressed initial material length. Speckle tracking is one of two methods for Strain rate imaging, the other being

Tissue Doppler Tissue Doppler echocardiography (TDE) is a medical ultrasound technology, specifically a form of echocardiography that measures the velocity of the heart muscle (myocardium) through the phases of one or more heartbeats by the Doppler effect (freque ...

. Twist or torsional deformation define the base-to-apex gradient and is the result of myocardial shearing in the circumferential-longitudinal planes such that, when viewed from the apex, the base rotates in a counterclockwise direction. Likewise the LV apex concomitantly rotates in a clockwise direction. During ejection, LV torsion results in the storage of

potential energy In physics, potential energy is the energy held by an object because of its position relative to other objects, stresses within itself, its electric charge, or other factors. Common types of potential energy include the gravitational potenti ...

into the deformed

myofiber A muscle cell is also known as a myocyte when referring to either a cardiac muscle cell (cardiomyocyte), or a smooth muscle cell as these are both small cells. A skeletal muscle cell is long and threadlike with many nuclei and is called a muscl ...

s. This stored energy is released with the onset of relaxation similar to a spring uncoiling and results in suction forces. These forces are then used for rapid early diastolic restoration.

Applications and limitations

The utilities of STE are increasingly recognized. Strain results derived from STE have been validated using sonomicrometry and tagged MRI and results correlate significantly with

–derived measurements.Edvardsen T, Gerber BL, Garot J, Bluemke DA, Lima JA, Smiseth OA.Quantitative assessment of intrinsic regional myocardial deformation by Doppler strain rate echocardiography in humans: validation against three-dimensional tagged magnetic resonance imaging. Circulation 2002;106:50-6Amundsen BH, Helle-Valle T, Edvardsen T, Torp H, Crosby J, Lyseggen E,et al. Noninvasive myocardial strain measurement by speckle tracking echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol 2006;47:789-93Roes SD, Mollema SA, Lamb HJ, van derWall EE, de Roos A, Bax JJ. Validation of echocardiographic two-dimensional speckle tracking longitudinal strain imaging for viability assessment in patients with chronic ischemic left ventricular dysfunction and comparison with contrastenhanced magnetic resonance imaging. Am J Cardiol 2009;104:312-7

technology, the alternative method for strain rate imaging to speckle tracking technology, requires achieving sufficient parallel orientation between the direction of motion and the

beam. Its use has remained limited due to angle dependency, substantial intraobserver and interobserver variability and noise interference. Speckle tracking technology has to a certain degree overcome these limitations. In order to achieve sufficient tracking quality when single markers are used, however commercial algorithms very often resort to varieties of

spline smoothing Smoothing splines are function estimates, \hat f(x), obtained from a set of noisy observations y_i of the target f(x_i), in order to balance a measure of goodness of fit of \hat f(x_i) to y_i with a derivative based measure of the smoothness of ...

using available information from the strongest echoes, very oft the mitral annulus, so the regional measurements are not pure regional, but rather to a degree, spline functions of the global average. AS the method uses B-mode, frame rate of speckle tracking is limited to the relatively low frame rate of B-mode. If the frame rate is too low, the tracking quality becomes reduced, due to frame-to-frame decorrelation. This may also be a problem if the heart rate is high, (which in fact is a relative decrease in frame rate - fewer frames per heart cycle). Increasing frame rate in B-mode is done by reducing line density, i.e. lateral resolution, and thus making the method more angle dependent. Finally, the method on some applications is dependent on the ROI (Region Of Interest) size and shape. In principle Speckle tracking is available for deformation measurement in all directions, however, due to the limitation of lateral resolution in apical images, measuring circumferential and transmural deformation needs parasternal cross sectional views. On the other hand, compared to

, that method is mainly only available for longitudinal measures from the apical position. In the study by Cho et al, both TVI derived and speckle tracking derived longitudinal strain showed modest correlation with MRI derived strain. The

ROC analysis A receiver operating characteristic curve, or ROC curve, is a graphical plot that illustrates the diagnostic ability of a binary classifier system as its discrimination threshold is varied. The method was originally developed for operators of m ...

showed significantly higher AUC for speckle tracking for detecting dysfunctional segments. However, this study only included patients with coronary disease. The lower frame rate has been seen to be a problem in

stress echo A cardiac stress test (also referred to as a cardiac diagnostic test, cardiopulmonary exercise test, or abbreviated CPX test) is a cardiological test that measures the heart's ability to respond to external stress in a controlled clinical enviro ...

, as the peak stress shows a fairly high frame rate. The main problem with speckle tracking, however, is increasingly recognised: The lack of standardisation. Each vendor of ultrasound equipment, or analysis software, has different algorithms, that will perform differently during analysis. In head to head comparisons, biases between analysis may be substantial, especially when compared to an external reference.Costa SP, Beaver TA, Rollor JL, Vanichakarn P, Magnus PC, Palac RT.Quantification of the variability associated with repeat measurements of left ventricular two-dimensional global longitudinal strain in a real-world setting. J Am Soc Echocardiogr. 2014 Jan;27(1):50-4 Thus, measurements, normal limits and cut off values are only vendor specific. Due to industrial secrecy, the details of the different algorithms may also be largely unavailable, so a detailed investigation in modelling is difficult. ''Clinical Applications of Speckle Tracking Technology:'' *

Coronary Artery Disease Coronary artery disease (CAD), also called coronary heart disease (CHD), ischemic heart disease (IHD), myocardial ischemia, or simply heart disease, involves the reduction of blood flow to the heart muscle due to build-up of atherosclerotic pl ...

* Myocardial Infarctions * Stress Echocardiography * Revascularization * Valvular Disease *

Left Ventricular Hypertrophy Left ventricular hypertrophy (LVH) is thickening of the heart muscle of the left ventricle of the heart, that is, left-sided ventricular hypertrophy and resulting increased left ventricular mass. Causes While ventricular hypertrophy occurs ...

* Hypertensive Heart Disease *

Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy (HCM, or HOCM when obstructive) is a condition in which the heart becomes thickened without an obvious cause. The parts of the heart most commonly affected are the interventricular septum and the ventricles. This r ...

Dilated Cardiomyopathy Dilated cardiomyopathy (DCM) is a condition in which the heart becomes enlarged and cannot pump blood effectively. Symptoms vary from none to feeling tired, leg swelling, and shortness of breath. It may also result in chest pain or fainting. Co ...

* Stress Cardiomyopathy * Pericardial Disease/

Restrictive Cardiomyopathy Restrictive cardiomyopathy (RCM) is a form of cardiomyopathy in which the walls of the heart are rigid (but not thickened). Thus the heart is restricted from stretching and filling with blood properly. It is the least common of the three original s ...

* Diastolic Heart Disease * Left Ventricular dyssynchrony *

Congenital Heart Disease A congenital heart defect (CHD), also known as a congenital heart anomaly and congenital heart disease, is a defect in the structure of the heart or great vessels that is present at birth. A congenital heart defect is classed as a cardiovascular ...

* Drug-Induced Cardiotoxicity

References

External links

Asbjorn Stoylen: Website; Strain rate Imaging. Myocardial deformation imaging by ultrasound.
Cardiac imaging Medical ultrasonography

Basic principles

Strain

Applications and limitations

See also

References

Further reading

External links