1. Tissue Doppler ImagingTissue Doppler Imaging
Dr.Hafeez AhmedDr.Hafeez Ahmed

2. DOPPLER SIGNALSDOPPLER SIGNALS
• Blood flow Doppler signalsBlood flow Doppler signals ►► highhigh
velocities and low amplitudevelocities and low amplitude
• Myocardial wall Doppler signalsMyocardial wall Doppler signals ►► lowlow
velocities & high amplitudevelocities & high amplitude
• Amplitude of tissue motion is about 40 dbAmplitude of tissue motion is about 40 db
greater than the flow amplitudegreater than the flow amplitude

3. • For conventional DopplerFor conventional Doppler →→ high-passhigh-pass
filterfilter →→ prevent high-amplitude signalprevent high-amplitude signal
detection from myocardiumdetection from myocardium
• For TDIFor TDI
• ►► this filter is bypassedthis filter is bypassed
• ►►high frequency blood flow signalshigh frequency blood flow signals
eliminated by gain adjustmenteliminated by gain adjustment

5. • Spectral gain settings must be reducedSpectral gain settings must be reduced
• Scale must be corrected (<25 cm/sec)Scale must be corrected (<25 cm/sec)
• Myocardial area of interest should be placed inMyocardial area of interest should be placed in
the center of the US beamthe center of the US beam
• Nyquist limit -20 to 30 cm/secNyquist limit -20 to 30 cm/sec
Instrumentation & TechniqueInstrumentation & Technique

6. High spectral gain

7. Types of Tissue DopplerTypes of Tissue Doppler
• Pulsed wave tissue dopplerPulsed wave tissue doppler
• Color tissue dopplerColor tissue doppler
– M modeM mode
– 2D2D
●● Strain Rate imagingStrain Rate imaging
●● Myocardial velocity GradientMyocardial velocity Gradient

8. Color TDIColor TDI
• Doppler signalsDoppler signals →→ frequencyfrequency →→ digitaldigital
• formatformat →→ autocorrelationautocorrelation →→ differentdifferent
velocitiesvelocities →→ preset color schemepreset color scheme →→
superimposed on 2-D gray scalesuperimposed on 2-D gray scale

10. • Color TDI :Color TDI :
• Increased spatial resolutionIncreased spatial resolution
• Evaluate multiple structures and segmentsEvaluate multiple structures and segments
in a single viewin a single view

11. Tissue velocityTissue velocity
• Upper limit of measurable velocities isUpper limit of measurable velocities is
determined by the pulse repetitiondetermined by the pulse repetition
frequencyfrequency
• 2D-Color TDI measures average tissue2D-Color TDI measures average tissue
velocityvelocity
• Wall motion velocity at rest : 10 cm/s orWall motion velocity at rest : 10 cm/s or
lessless
• During stress:During stress: ↑ 15 cm/s↑ 15 cm/s
• Aliasing unlikelyAliasing unlikely

12. Frame RateFrame Rate
• Temporal and spatial resolutionTemporal and spatial resolution
dependent ondependent on → doppler shift →→ doppler shift → frameframe
raterate→→ 1)probe frequency 2) pulse1)probe frequency 2) pulse
repetition frequency 3) sector anglerepetition frequency 3) sector angle
• Frame rates of up to 240/s can beFrame rates of up to 240/s can be
obtainedobtained

13. How to Optimize Color DopplerHow to Optimize Color Doppler
RecordingsRecordings
• Velocities are always measured in-lineVelocities are always measured in-line
with the ultrasound beamwith the ultrasound beam
• Narrowing the sector angle and reducingNarrowing the sector angle and reducing
image depth increases the tissue Dopplerimage depth increases the tissue Doppler
frame rate and, thus, temporal resolutionframe rate and, thus, temporal resolution
of the reconstructed velocity curvesof the reconstructed velocity curves
• Frame rates of at least 120 frames/Frame rates of at least 120 frames/
second are recommendedsecond are recommended

15. Pulsed Wave Tissue DopplerPulsed Wave Tissue Doppler
ImagingImaging
• Pulsed-wave-TDI measures peak velocityPulsed-wave-TDI measures peak velocity
instantaneouslyinstantaneously
• High temporal resolutionHigh temporal resolution
• Lower reproducibilityLower reproducibility

17. Sample volumeSample volume
• Sample volumesSample volumes→→ positioned into thepositioned into the
region of interest within the myocardiumregion of interest within the myocardium
• An average of all mean velocities ofAn average of all mean velocities of
tissues moving within the sample regiontissues moving within the sample region
are determinedare determined
• Small sample volumeSmall sample volume

18. • Doppler signals are converted into singleDoppler signals are converted into single
or multiple velocity curvesor multiple velocity curves
• By Fourier analysis mean peak systolicBy Fourier analysis mean peak systolic
and diastolic velocities are generatedand diastolic velocities are generated
• velocities are measured as cm/s and timevelocities are measured as cm/s and time
intervals in millisecondsintervals in milliseconds
• adjustments of the scale and sweep speedadjustments of the scale and sweep speed
to optimize the spectral displayto optimize the spectral display

20. • The systolic phase represented by a positiveThe systolic phase represented by a positive
wave (S) preceded by isovolumic contractionwave (S) preceded by isovolumic contraction
(RIVCT) spike(RIVCT) spike
• The diastolic phase:The diastolic phase:
►► Isovolumic relaxation (RIVRT);Isovolumic relaxation (RIVRT);
►► Rapid filling period characterized by aRapid filling period characterized by a
negative wave (E’)negative wave (E’)
►► diastasisdiastasis
►► filling due to atrial contraction, a secondfilling due to atrial contraction, a second
negative wave (A’)negative wave (A’)

22. Pulsed-wave TDIPulsed-wave TDI
• Multiple myocardial segments cannotMultiple myocardial segments cannot
analyzed simultaneouslyanalyzed simultaneously

23. Color M-modeColor M-mode
• Anatomical M-Mode means a line whichAnatomical M-Mode means a line which
can be placed anywhere and in anycan be placed anywhere and in any
direction in the imagedirection in the image
• Curved M-Mode line is not even just aCurved M-Mode line is not even just a
straight line, but can be drawn by hand,straight line, but can be drawn by hand,
e.g. along the curvature of the ventriculare.g. along the curvature of the ventricular
myocardium, and then be moved in ordermyocardium, and then be moved in order
to follow the myocardial motionto follow the myocardial motion

25. Curved M-ModeCurved M-Mode

26. Anatomical M-ModeAnatomical M-Mode

27. M-ModeM-Mode
• Various length of myocardium can beVarious length of myocardium can be
analyzedanalyzed
• Wall movement is depicted color codedWall movement is depicted color coded
• Spatial informationSpatial information →→ y axisy axis
• Temporal informationTemporal information →→ x-axisx-axis
• Myocardial velocity gradients between epi-Myocardial velocity gradients between epi-
and endocardium may be obtained withand endocardium may be obtained with
highest velocity at endocardiumhighest velocity at endocardium

28. During systole basal and mid segmentsDuring systole basal and mid segments
move inwards & longitudinally towards amove inwards & longitudinally towards a
center of gravitycenter of gravity
• Centre of gravity of heart located betweenCentre of gravity of heart located between
the second and third part of the long axisthe second and third part of the long axis
• Contraction of subendocardial longitudinalContraction of subendocardial longitudinal
fibers can be reliably assessed by TDIfibers can be reliably assessed by TDI
from the apical viewsfrom the apical views

30. Applications of TDIApplications of TDI
• Global and regional left ventricular systolicGlobal and regional left ventricular systolic
functionfunction
• Left ventricular diastolic functionLeft ventricular diastolic function
• Left ventricular filling pressuresLeft ventricular filling pressures
• LV dyssynchrony for CRTLV dyssynchrony for CRT
• Distinction of different cardiac diseasesDistinction of different cardiac diseases

31. During ischaemiaDuring ischaemia
• Longitudinal endocardial fibers areLongitudinal endocardial fibers are
primarily affectedprimarily affected
• Peak systolic velocities reducedPeak systolic velocities reduced
• Reversal of isovolemic relaxation velocityReversal of isovolemic relaxation velocity
• Reduction of early and late diastolicReduction of early and late diastolic
velocitiesvelocities

32. Longitudinal velocity profiles areLongitudinal velocity profiles are
similar in all wall segmentssimilar in all wall segments

33. Stress echocardiographyStress echocardiography
• Katz et al. found significantly lower systolicKatz et al. found significantly lower systolic
velocities at peak stress in abnormal segmentsvelocities at peak stress in abnormal segments
(3.1 ± 1.2 cm/s vs. 7.2 ± 1.9 cm/s)(3.1 ± 1.2 cm/s vs. 7.2 ± 1.9 cm/s)
• In apical abnormal segments the velocityIn apical abnormal segments the velocity
response could not be distinguished from normalresponse could not be distinguished from normal
• A peak stress velocity response of ≤ 5.5 cm/sA peak stress velocity response of ≤ 5.5 cm/s
may be useful in identifying abnormal segmentsmay be useful in identifying abnormal segments
in all except apical segmentsin all except apical segments

34. Markers of ischaemiaMarkers of ischaemia
►►Reduced rise in systolic velocityReduced rise in systolic velocity
►►An altered motion pattern during IVRTAn altered motion pattern during IVRT
►►An inverted E:A ratioAn inverted E:A ratio
• Reduction in Sa velocity can be detectedReduction in Sa velocity can be detected
within 15 seconds of the onset of ischemiawithin 15 seconds of the onset of ischemia
• Regional reductions in Sa are correlatedRegional reductions in Sa are correlated
with regional wall motion abnormalitieswith regional wall motion abnormalities

36. Global Systolic FunctionGlobal Systolic Function
• Measurement of longitudinal shortening ofMeasurement of longitudinal shortening of
the left ventriclethe left ventricle
• This is reflected in mitral annular descentThis is reflected in mitral annular descent
• A six-site peak mitral annular descentA six-site peak mitral annular descent
velocity of >5.4 cm/s identified LVEFvelocity of >5.4 cm/s identified LVEF
within normal range with reasonablewithin normal range with reasonable
sensitivity and specificitysensitivity and specificity

37. • Mitral annulus-TDI velocities areMitral annulus-TDI velocities are
dependent on loading conditions, atrialdependent on loading conditions, atrial
haemodynamics and heart ratehaemodynamics and heart rate
• At the lateral mitral annulus is a measureAt the lateral mitral annulus is a measure
of longitudinal systolic function and isof longitudinal systolic function and is
correlated with LV ejection fractioncorrelated with LV ejection fraction

39. Six Mitral Annular SitesSix Mitral Annular Sites

41. Diastolic FunctionDiastolic Function
1) discriminate a normal from a1) discriminate a normal from a
pseudonormal filling patternpseudonormal filling pattern
2) to estimate diastolic function in atrial2) to estimate diastolic function in atrial
fibrillationfibrillation
3) to differentiate restrictive3) to differentiate restrictive
cardiomyopathy from constrictivecardiomyopathy from constrictive
pericarditispericarditis

42. • Mitral inflow reflects global diastolic functionMitral inflow reflects global diastolic function
while TDI enables regional diastolic functionwhile TDI enables regional diastolic function
• Areas of interestAreas of interest →→ Mitral annulus & BasalMitral annulus & Basal
segments in 4 and 2-chamber Apical viewsegments in 4 and 2-chamber Apical view
• Since apex is relatively fixed throughout theSince apex is relatively fixed throughout the
cardiac cyclecardiac cycle
• Measured velocities are nearly entirely due toMeasured velocities are nearly entirely due to
contraction and relaxation of the cardiac basecontraction and relaxation of the cardiac base

44. • Global diastolic function can be expressedGlobal diastolic function can be expressed
by averaging velocities in four segmentsby averaging velocities in four segments
• Normal early (E’) diastolic velocity range isNormal early (E’) diastolic velocity range is
> 10 cm/s in the young and > 8 cm/s in> 10 cm/s in the young and > 8 cm/s in
the older patientthe older patient
• Late diastolic velocities (A’) increase withLate diastolic velocities (A’) increase with
ageage

45. • Mitral inflow E wave decreases in the earlyMitral inflow E wave decreases in the early
stages of diastolic dysfunction --delayedstages of diastolic dysfunction --delayed
relaxationrelaxation
• Increases again in the more advancedIncreases again in the more advanced
pseudonormal phasepseudonormal phase
• Both phases lead to a reduction of E’ to <Both phases lead to a reduction of E’ to <
8 cm/s, decreasing more in the restrictive8 cm/s, decreasing more in the restrictive
phasephase

47. • Mitral inflow patterns are highly sensitiveMitral inflow patterns are highly sensitive
to preloadto preload
• TDI assessment of diastolic function isTDI assessment of diastolic function is
less load dependentless load dependent
• Septal Ea velocities are slightly lower thanSeptal Ea velocities are slightly lower than
lateral Ea velocities because of intrinsiclateral Ea velocities because of intrinsic
differences in myocardial fiber orientationdifferences in myocardial fiber orientation

48. Estimation of LV fillingEstimation of LV filling
pressurespressures
Measure transmitral early rapid diastolicMeasure transmitral early rapid diastolic
filling (E) by PW conventional dopplerfilling (E) by PW conventional doppler
• measures Ea by pulsed-TDE samplemeasures Ea by pulsed-TDE sample
volume placed in the lateral annulusvolume placed in the lateral annulus
• An E/Ea >10 is predictive of a meanAn E/Ea >10 is predictive of a mean
pulmonary capillary wedge pressurepulmonary capillary wedge pressure
above 15 mmHg with a sensitivity andabove 15 mmHg with a sensitivity and
specificity of 92 and 80 percentspecificity of 92 and 80 percent

49. For Medial AnnulusFor Medial Annulus
• Patients with E/E’ >15 can be classified asPatients with E/E’ >15 can be classified as
having elevated filling pressurehaving elevated filling pressure
• An E/E’ < 8 suggests normal fillingAn E/E’ < 8 suggests normal filling
pressurepressure
• In the range of E/E’ of 8 to 15, otherIn the range of E/E’ of 8 to 15, other
information neededinformation needed

50. E/Ea RatioE/Ea Ratio
• Early diastolic velocity at the mitralEarly diastolic velocity at the mitral
annulus (Ea) reflect LV relaxation and isannulus (Ea) reflect LV relaxation and is
less influenced by left atrial pressureless influenced by left atrial pressure
• The ratio E/Ea can correct for theThe ratio E/Ea can correct for the
influence of relaxation on transmitral Einfluence of relaxation on transmitral E
and relates strongly to filling pressuresand relates strongly to filling pressures
• Lateral annular velocities are higher andLateral annular velocities are higher and
easier to record than the septal velocitieseasier to record than the septal velocities

51. Mitral inflow to annular ratioMitral inflow to annular ratio

53. Diastology investigatorsDiastology investigators
• IVRT / T E-Ea < 2 found to have aIVRT / T E-Ea < 2 found to have a
sensitivity of 91% and a specificity of 89%sensitivity of 91% and a specificity of 89%
for detecting PCWP >15 mm Hgfor detecting PCWP >15 mm Hg
• 2 for patients with sinus rhythm without2 for patients with sinus rhythm without
mitral valve diseasemitral valve disease
• 3 for patients with mitral regurgitation3 for patients with mitral regurgitation
• 4.16 for patients with mitral stenosis4.16 for patients with mitral stenosis
• 5.59 for patients with atrial fibrillation5.59 for patients with atrial fibrillation

54. constrictive pericarditisconstrictive pericarditis
Versus restrictiveVersus restrictive
cardiomyopathycardiomyopathy
• General guidelines -- Ea less than 10 cm/sGeneral guidelines -- Ea less than 10 cm/s
by pulsed-TDE and less than 7 cm/s byby pulsed-TDE and less than 7 cm/s by
color-coded TDE are supportive ofcolor-coded TDE are supportive of
restrictive pathophysiologyrestrictive pathophysiology
• In a series of 75 patients, an E' of moreIn a series of 75 patients, an E' of more
than 8 cm/s had a 95 percent sensitivitythan 8 cm/s had a 95 percent sensitivity
and 96 percent specificity for the diagnosisand 96 percent specificity for the diagnosis
of constrictive pericarditisof constrictive pericarditis

56. HypertrophicHypertrophic
CardiomyopathyCardiomyopathy
• Significantly reduced peak velocities in theSignificantly reduced peak velocities in the
hypertrophied septum and the posteriorhypertrophied septum and the posterior
wallwall
• In the septum, transmural velocity profilesIn the septum, transmural velocity profiles
are also less uniform than in the posteriorare also less uniform than in the posterior
wall, possibly reflecting the degree ofwall, possibly reflecting the degree of
myocardial disarraymyocardial disarray

57. Early diagnosis ofEarly diagnosis of
hypertrophic cardiomyopathyhypertrophic cardiomyopathy
• Myocardial contraction and relaxation velocitiesMyocardial contraction and relaxation velocities
significantly reduced in those with an overtsignificantly reduced in those with an overt
hypertrophic cardiomyopathy and those with ahypertrophic cardiomyopathy and those with a
mutation compared to controlsmutation compared to controls
• The sensitivity and specificity of TDE forThe sensitivity and specificity of TDE for
identifying patients with a mutation who did notidentifying patients with a mutation who did not
have left ventricular hypertrophy was 100 and 93have left ventricular hypertrophy was 100 and 93
percent, respectivelypercent, respectively
(Tissue Doppler imaging consistently detects myocardial abnormalities in patients with(Tissue Doppler imaging consistently detects myocardial abnormalities in patients with
hypertrophic cardiomyopathy and provides a novel means for an early diagnosis before andhypertrophic cardiomyopathy and provides a novel means for an early diagnosis before and
independently of hypertrophy. Circulation 2001; 104:128.)independently of hypertrophy. Circulation 2001; 104:128.)

58. TDI Technique For AsynchronicityTDI Technique For Asynchronicity
• Pulsed-wave TDIPulsed-wave TDI
• Color-coded TDIColor-coded TDI
• Tissue trackingTissue tracking
• Displacement mappingDisplacement mapping
• Strain and strain rate imagingStrain and strain rate imaging
• Tissue synchronization imaging (TSI)Tissue synchronization imaging (TSI)

60. • Søgaard et al. focuses on late- or post-Søgaard et al. focuses on late- or post-
systolic longitudinal motion towards thesystolic longitudinal motion towards the
transducer (“contraction”)transducer (“contraction”)

62. • Yu et al. looked at regional differencesYu et al. looked at regional differences
between the interval from QRS onset tobetween the interval from QRS onset to
peak systolic velocitypeak systolic velocity

64. • Pulsed-wave TDIPulsed-wave TDI
• Color-coded TDIColor-coded TDI
• With pulsed-wave TDI, only one regionWith pulsed-wave TDI, only one region
can be interrogated at a time--- time-can be interrogated at a time--- time-
consuming and precludes comparison ofconsuming and precludes comparison of
segments simultaneouslysegments simultaneously

65. Color coded TDIColor coded TDI
• Velocity tracings derived from the basalVelocity tracings derived from the basal
septal and lateral segmentsseptal and lateral segments
• Septal-to-lateral delay measuredSeptal-to-lateral delay measured
• A delay 60 ms is predictive of acuteA delay 60 ms is predictive of acute
response to CRTresponse to CRT

66. LV DyssynchronyLV Dyssynchrony
Tissue Velocity assessment for Septal-lateral delay (95ms)Tissue Velocity assessment for Septal-lateral delay (95ms)

69. Temporal inhomogeneities of myocardial motionTemporal inhomogeneities of myocardial motion
are recognized at best by using the Curved M-are recognized at best by using the Curved M-
Mode displayMode display

70. 6 Basal & 6 Mid segments6 Basal & 6 Mid segments
• Yu et al used a 12-segment modelYu et al used a 12-segment model
• Tracings derived from 12 segmentsTracings derived from 12 segments
• LV dyssynchrony index derived from theLV dyssynchrony index derived from the
standard deviation of all 12 time intervalstandard deviation of all 12 time interval
• Standard deviation of time-to-peak systolicStandard deviation of time-to-peak systolic
velocity Yu Index, > 33 ms also predictsvelocity Yu Index, > 33 ms also predicts
clinical outcome and reverse remodelingclinical outcome and reverse remodeling
following CRTfollowing CRT

71. Tissue synchronization imagingTissue synchronization imaging
• Signal-processing algorithm of the tissueSignal-processing algorithm of the tissue
Doppler dataDoppler data
• Detect peak positive velocityDetect peak positive velocity
• Color-code the time to peak velocities inColor-code the time to peak velocities in
green for normal timing, yellow-orange forgreen for normal timing, yellow-orange for
moderate delay, and red for severe delaysmoderate delay, and red for severe delays
in peak longitudinal velocityin peak longitudinal velocity

73. ArrhythmiasArrhythmias
• Frame rates of > 200 and temporal resolution ofFrame rates of > 200 and temporal resolution of
5 ms can be achieved by reducing the sector5 ms can be achieved by reducing the sector
angleangle
• TDI able to detect early contraction sitesTDI able to detect early contraction sites
effective for localizing left sided accessoryeffective for localizing left sided accessory
pathway in particular in the anterior,pathway in particular in the anterior,
anterolateral and inferior wallsanterolateral and inferior walls
• Curved M-Mode is useful to investigateCurved M-Mode is useful to investigate
conduction abnormalities such as bundle branchconduction abnormalities such as bundle branch
blocks or pre-excitation syndromesblocks or pre-excitation syndromes

74. Right Ventricle FunctionRight Ventricle Function
• Reduced tricuspid annular velocitiesReduced tricuspid annular velocities
demonstrated in Postinferior myocardialdemonstrated in Postinferior myocardial
infarction, chronic pulmonaryinfarction, chronic pulmonary
hypertension, and chronic heart failurehypertension, and chronic heart failure

75. LimitationsLimitations
• For pulsed wave TDI inter observerFor pulsed wave TDI inter observer
reproducibilities for peak systolic velocityreproducibilities for peak systolic velocity
have been reported from 4 % for thehave been reported from 4 % for the
lateral annulus to 24 % for the short axislateral annulus to 24 % for the short axis
• Reproducibility better in the long axis thanReproducibility better in the long axis than
in the short axis viewin the short axis view

76. • Minor changes in transducer positionMinor changes in transducer position
during image acquisition can lead toduring image acquisition can lead to
significant changessignificant changes
• Sample volume position has to beSample volume position has to be
“standardized” when comparison of“standardized” when comparison of
images is requiredimages is required

77. • Whole cardiac motion and tetheringWhole cardiac motion and tethering
effects in scar regions may limit accuracyeffects in scar regions may limit accuracy
by substantial “false” velocity increase ofby substantial “false” velocity increase of
dysfunctional segmentdysfunctional segment

78. Strain Rate Imaging (SRI)Strain Rate Imaging (SRI)
• Strain means tissue deformation due toStrain means tissue deformation due to
applied stressapplied stress
• Elongation of the myocardium is positiveElongation of the myocardium is positive
strain whereas shortening is negativestrain whereas shortening is negative
strainstrain
• S = ΔL / L0S = ΔL / L0
• where S = strain, ΔL = change in lengthwhere S = strain, ΔL = change in length
and L0 = basal lengthand L0 = basal length

79. • Strain rate (SR) measures the rate ofStrain rate (SR) measures the rate of
deformation, which is equivalent to thedeformation, which is equivalent to the
MVGMVG
• Strain rate imaging has better spatialStrain rate imaging has better spatial
resolutionresolution
• Help to decide what is seen in wall motion,Help to decide what is seen in wall motion,
whether there is true contractionwhether there is true contraction
(deformation) or only motion (tethering)(deformation) or only motion (tethering)

80. ArtifactsArtifacts

81. Automated analysisAutomated analysis
• Manual or automatic placement ofManual or automatic placement of
anatomical landmarks, such as the mitralanatomical landmarks, such as the mitral
plane and the apex orplane and the apex or
• Draw a curve along the myocardiumDraw a curve along the myocardium
• Walls are then automatically segmentedWalls are then automatically segmented
• Strain rate calculated according to theStrain rate calculated according to the
application usedapplication used

85. • SRI is based on calculation of DopplerSRI is based on calculation of Doppler
signals and measures distances along thesignals and measures distances along the
ultrasound beam and not in tissueultrasound beam and not in tissue
• Consecutively, angle dependent errorsConsecutively, angle dependent errors
can occur, leading to reduced or evencan occur, leading to reduced or even
inverted strain ratesinverted strain rates
• segments with different elastic properties,segments with different elastic properties,
and also different loading conditions canand also different loading conditions can
influence SR valuesinfluence SR values

86. • Random noise frequently occurs,Random noise frequently occurs,
rendering interpretation of strain raterendering interpretation of strain rate
tracings difficulttracings difficult
• Myocardial strain rate: dividing theMyocardial strain rate: dividing the
longitudinal TDI velocities by the distancelongitudinal TDI velocities by the distance
from the point of measurement to the apexfrom the point of measurement to the apex

88. • TDI and StrainTDI and Strain
• A. Tissue Doppler imaging from basal(yellow), mid(blue) and apical(red) segments of the ventricular septum in a patient withA. Tissue Doppler imaging from basal(yellow), mid(blue) and apical(red) segments of the ventricular septum in a patient with
Hypertrophic cardiomyopathy. Systolic (Ss) velocities for all three segments are decreased equally to 4cm/s. are markedlyHypertrophic cardiomyopathy. Systolic (Ss) velocities for all three segments are decreased equally to 4cm/s. are markedly
• B. Strain recordings from the same 3 segments different.B. Strain recordings from the same 3 segments different.
• Strain (arrows) was normal at the apex(red -30%) and decreased at the base(yellow -10%) and lengthened at the mid septumStrain (arrows) was normal at the apex(red -30%) and decreased at the base(yellow -10%) and lengthened at the mid septum
(blue+5%)(blue+5%)

89. Assessment of Myocardial ViabilityAssessment of Myocardial Viability
• MVG can be used to differentiate viable from nonviable myocardiumMVG can be used to differentiate viable from nonviable myocardium
in patients with acute MI treated with acute perfusion.in patients with acute MI treated with acute perfusion.
• It has been observed that myocardial shortening occurs even afterIt has been observed that myocardial shortening occurs even after
Aortic valve closure, called post systolic shortening. This maybe anAortic valve closure, called post systolic shortening. This maybe an
indication of asynchronous motion during IVR period.indication of asynchronous motion during IVR period.
• TDI and strain imaging are able to demonstrate this unusual cardiacTDI and strain imaging are able to demonstrate this unusual cardiac
motion.motion.
• Post systolic shortening of stunned myocardium may disappearPost systolic shortening of stunned myocardium may disappear
with gradual infusion of Dobutamine.with gradual infusion of Dobutamine.
• Presence of Post systolic shortening after acute myocardialPresence of Post systolic shortening after acute myocardial
ischaemia also predicts functional recovery after reperfusionischaemia also predicts functional recovery after reperfusion
therapy.therapy.

90. Strain Rate and Strain ImagingStrain Rate and Strain Imaging
• Assessment ofAssessment of
Myocardial ViabilityMyocardial Viability
• Strain rate A and strainStrain rate A and strain
imaging B of a patient withimaging B of a patient with
post systolic shorteningpost systolic shortening
(arrow)(arrow)
• Post systolic shortening wasPost systolic shortening was
present in the midpresent in the mid
septum(aqua colour)septum(aqua colour)
• AVC- Aortic valve closureAVC- Aortic valve closure
• AVO- Aortic Valve OpeningAVO- Aortic Valve Opening

92. Calculation of the myocardialCalculation of the myocardial
velocity gradientvelocity gradient