NON-invasive imaging: Two dimensional speckle tracking echocardiography: Basic principles

Abstract

Two dimensional (2D) speckle tracking echocardiography (STE) is a promising new imaging modality. Similar to tissue Doppler imaging (TDI), it permits offline calculation of myocardial velocities and deformation parameters such as strain and strain rate (SR). It is well accepted that these parameters provide important insights into systolic and diastolic function, ischaemia, myocardial mechanics and many other pathophysiological processes of the heart. So far, TDI has been the only echocardiographic methodology from which these parameters could be derived. However, TDI has many limitations. It is fairly complex to analyse and interpret, only modestly robust, and frame rate and, in particular, angle dependent. Assessment of deformation parameters by TDI is thus only feasible if the echo beam can be aligned to the vector of contraction in the respective myocardial segment. In contrast, STE uses a completely different algorithm to calculate deformation: by computing deformation from standard 2D grey scale images, it is possible to overcome many of the limitations of TDI. The clinical relevance of deformation parameters paired with an easy mode of assessment has sparked enormous interest within the echocardiographic community. This is also reflected by the increasing number of publications which focus on all aspects of STE and which test the potential clinical utility of this new modality. Some have already heralded STE as ‘the next revolution in echocardiography’. This review describes the basic principles of myocardial mechanics and strain/SR imaging which form a basis for the understanding of STE. It explains how speckle tracking works, its advantages to tissue Doppler imaging, and its limitations.

### Deformation parameters—strain and strain rate

Strain is a dimensionless quantity of myocardial deformation. The so-called Langrangian strain (e) is mathematically defined as the change of myocardial fibre length during stress at end-systole compared to its original length in a relaxed state at end-diastole=(l-l)/l (figure 1). …

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doi: 10.1136/hrt.2007.141002
2010 96: 716-722Heart
Hermann Blessberger and Thomas Binder
echocardiography: basic principles
Two dimensional speckle tracking
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NON-INVASIVE IMAGING
Two dimensional speckle tracking
echocardiography: basic principles
Hermann Blessberger,
1
Thomas Binder
2
Two dimensional (2D) speckle tracking echocardi-
ography (STE) is a promising new imaging
modality. Similar to tissue Doppler imaging (TDI),
it permits offline calculation of myocardial veloci-
ties and deformation parameters such as strain and
strain rate (SR). It is well accepted that these
parameters provide important insights into systolic
and diastolic function, ischaemia, myocardial
mechanics and many other pathophysiological
processes of the heart. So far, TDI has been the only
echocardiographic methodology from which these
parameters could be derived. However, TDI has
many limitations. It is fairly complex to analyse
and interpret, only modestly robust, and frame rate
and, in particular, angle dependent. Assessment of
deformation parameters by TDI is thus only
feasible if the echo beam can be aligned to the
vector of contraction in the respective myocardial
segment. In contrast, STE uses a completely
different algorithm to calculate deformation: by
computing deformation from standard 2D grey
scale images, it is possible to overcome many of the
limitations of TDI. The clinical relevance of defor-
mation parameters paired with an easy mode of
assessment has sparked enormous interest within
the echocardiographic community. This is also
reflected by the increasing number of publications
which focus on all aspects of STE and which test
the potential clinical utility of this new modality.
Some have already heralded STE as ‘the next
revolution in echocardiography’. This review
describes the basic principles of myocardial
mechanics and strain/SR imaging which form
a basis for the understanding of STE. It explains
how speckle tracking works, its advantages to
tissue Doppler imaging, and its limitations.
BACKGROUND
Deformation parametersdstrain and strain rate
Strain is a dimensionless quantity of myocardial
deformation. The so-called Langrangian strain (
e
)is
mathematically defined as the change of myocar-
dial fibre length during stress at end-systole
compared to its original length in a relaxed state at
end-diastole¼(l-l
0
)/l
0
(figure 1).
1
Strain is usually
expressed in per cent (%). The change of strain per
unit of time is referred to as strain rate (SR).
Negative strain indicates fibre shortening or
myocardial thinning, whereas a positive value
describes lengthening or thickening.
As SR (1/s) is the spatial derivative of tissue
velocity (mm/s), and strain (%) is the temporal
integral of SR, all of these three parameters are
mathematically linked to each other (figure 2).
1 2
Basically, strain measures the magnitude of
myocardial fibre contraction and relaxation. In
contrast to TDI, it only reflects active contraction
since the STE derived deformation parameters are not
influenced by passive traction of scar tissue
by adjacent vital myocardium (tethering effect) or
cardiac translation.
3
Since contraction is three
dimensional and myocardial fibres are oriented differ-
ently throughout the myocardial layers, deformation
can also be described with respect to the different
directional components of myocardial contraction. To
truly understand deformation it is therefore essential
to consider myocardial mechanics.
Basics of myocardial mechanics
The sophisticated myocardial fibre orientation of
the left ventricular (LV) wall provides an equal
distribution of regional stress and strains.
4
In
healthy subjects, the left ventricle undergoes
a twisting motion which leads to a decrease in the
radial and longitudinal length of the LV cavity.
During isovolumetric contraction the apex initially
performs a clockwise rotation. During the ejection
phase the apex then rotates counterclockwise while
the base rotates clockwise when viewed from the
apex.
5
In diastole relaxation of myocardial fibres
and subsequent recoiling (clockwise apical rotation)
contributes to active suction.
5
Thus, the contrac-
tion of the heart is similar to the winding (and
unwinding) of a towel. From a mathematical point
of view several parameters of myocardial mechanics
can be described (figure 3):
<Rotation (degrees)¼angular displacement of
a myocardial segment in short axis view around
the LV longitudinal axis measured in a single
plane.
<Twist or torsion (degrees) which is the net
difference between apical and basal rotation
(calculated from two short axis cross-sectional
planes of the LV).
67
<Torsional gradient (degrees/cm) which is defined
as twist/torsion normalised to ventricular length
from base to apex and accounts for the fact that
a longer ventricle has a larger twist angle.
8
LV twist can be quantified in short axis views by
measuring both apical and basal rotation with the
help of STE (figure 4). In addition, it is possible to
calculate time intervals of contraction/relaxation
with respect to torsion or rotation and therefore
measure the speed of ventricular winding and
unwinding. In particular, the speed of apical recoil
1
AKH Linz, Department of
Internal Medicine I - Cardiology,
Krankenhausstrasse, Austria
2
Department of Cardiology,
Medical University of Vienna,
Internal Medicine II, AKH,
Waehringerguertel, Vienna,
Austria
Correspondence to
Professor Dr Thomas Binder,
Department of Cardiology,
Medical University of Vienna,
Internal Medicine II, AKH,
Waehringerguertel 18-20, 1090
Vienna, Austria; thomas.
binder@meduniwien.ac.at
716 Heart 2010;96:716e722. doi:10.1136/hrt.2007.141002
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during early diastole seems to reflect diastolic
dysfunction.
9 10
Several studies have demonstrated that disturbed
rotational mechanics can be found in many cardiac
disease states and that specific patterns describe
specific pathologies.
9e14
While these parameters are assessed with the
help of STE derived deformation parameters and
describe the ‘mechanics’of the entire heart, defor-
mation parameters can also be calculated for indi-
vidual segments and specific vectors of direction.
Three different components of contraction have
been defined: radial, longitudinal, and circumferen-
tial (figure 5).
<Longitudinal contraction represents motion from
the base to the apex.
<Radial contraction in the short axis is perpen-
dicular to both long axis and epicardium. Thus,
radial strain represents myocardial thickening
and thinning.
<Circumferential strain is defined as the change of
the radius in the short axis, perpendicular to the
radial and long axes.
Longitudinal deformation is assessed from the
apical views while circumferential and radial defor-
mation are assessed from short axis views of the left
ventricle. The description of these three aforemen-
tioned ‘normal strains’dwhich can be measured
using current STE technologydallows a good
approximation of active cardiac motion. However,
they still represent a simplification. When consid-
ering myocardial deformation during contraction in
three dimensional space, six more ‘shear strains’can
be defined in addition to the normal strains.
1
Normal
strains are caused by forces that act perpendicular to
the surface of a virtual cylinder within the myocar-
dial wall, resulting in en bloc stretching or contrac-
tion without skewing of the volume. Conversely,
forces causing shear strain act parallel to the surface
of such a myocardial block and lead to a shift of
volume borders relative to one another as delineated
by a shear angle
a
(figure 6).
Reference values for segmental strain were
established for the left ventricle and the left
atrium.
15e19
Normal paediatric strain values are
also available.
18
However, clear cut-offs for peak
systolic strain to define pathologic conditions are
still missing. Marwick et al enrolled 242 healthy
individuals without cardiovascular risk factors or
a history of cardiovascular disease in their multi-
centre study and defined normal LV longitudinal
strain values as displayed in table 1.
19
Global
reference values (mean6SEM) for the longitudinal
peak systolic strain (GLPSS: 18.660.1%), peak
systolic SR (1.1060.01/s), early diastolic SR
(1.5560.01/s), as well as for the global late diastolic
SR (1.0260.01/s) were also established.
19
Circum-
ferential and radial LV strain reference values were
determined by Hurlburt et al (table 2).
15
It appears
that longitudinal strain values in the basal
segments are less than in the mid and apical
segments. It remains unclear if this truly reflects
less contractility or if it is a methodological issue.
According to current data, it does not seem neces-
sary to adjust STE based strain or SR parameters for
sex or indices of LV morphology. Studies investi-
gating this issue only found a weak relationship or
yielded conflicting results.
15 19e21
However, it has
been shown that with age, LV twisting motion
increases, whereas diastolic untwisting is delayed
and reduced when compared to young individ-
uals.
22
Possibly this is caused by the higher inci-
dence of diastolic dysfunction with age.
Strain and SR change throughout the cardiac
cycle. To describe systolic myocardial function, it is
best to use peak systolic strain (which reflects
Figure 1 Elastic deformation properties. Strain¼change
of fibre length compared to original length, strain
rate¼difference of tissue velocities at two distinctive
points related to their distance. ΔL, change of length; L
o
,
unstressed original length; L, length at the end of
contraction; blue arrow, direction of contraction; v
1
,
velocity point 1; v
2
, velocity point 2; d, distance.
Figure 2 Mathematical relationship between different deformation parameters and
mode of calculation for speckle tracking echocardiography (STE) and tissue Doppler
imaging (TDI). STE primarily assesses myocardial displacement, whereas TDI primarily
assesses tissue velocity. Modified from Pavlopoulos et al.
1
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systolic shortening fraction) and peak systolic SR.
23
For timing of contraction the time to peak systolic
strain and SR have been used (beginning of QRS
complex to max peak of strain/SR curve, see figure 7).
By defining the time of aortic valve closure it is
also possible to determine if peak strain in certain
regions occurs before or after the end of systole.
This may be particularly important for the assess-
ment of dyssynchrony.
24
Such computations can be made for radial,
circumferential, and longitudinal function, either
for individual segments, a cut plane or the entire
ventricle (using averaged values). Thus, strain and
SR provide valuable information on both global and
regional systolic and diastolic function and their
timing.
How does 2D speckle tracking work?
STE was introduced by Reisner, Leitman, Friedman,
and Lysyansky in 2004.
25 26
It is performed as an
offline analysis from digitally recorded and ECG
triggered cine loops. The algorithm uses speckle
artefacts in the echo image which are generated at
random due to reflections, refraction, and scattering
of echo beams. Such speckles in the LV wall are
tracked throughout the cardiac cycle. Some of these
speckles stay stable during a part of the heart cycle
and can be used as natural acoustic markers for
tagging the myocardial motion during the cardiac
cycle. The post-processing software defines
a‘cluster of speckles’(called a ‘kernel’) and follows
this cluster frame to frame (figure 8).
1
Detection of
spatial movement of this ‘fingerprint’during the
heart cycle now allows direct calculation of
Langrangian strain. Tissue velocity is estimated
from the shift of the individual speckles divided by
the time between successive frames. Strain rate can
be calculated from tissue velocity as well (figure 2).
Before strain analysis can be performed, it is essen-
tial to correctly track the endocardial and epicardial
borders of the left ventricle, and thereby correctly
define the region of interest (ROI) (figure 9).
After definition of ROI in the long or short axis
view, the post-processing software automatically
divides the ventricle into six equally distributed
Figure 3 Rotation of left ventricular apex and base during the heart cycle. Rot, rotation;
l, length; diast, diastole; syst, systole; ap, apical; diff, difference.
Figure 4 Apical and basal rotation during heart cycle. Ordinate, rotation in degrees;
abscissa, time.
Figure 5 Different types of left ventricular myocardial wall strains.
Basic principles of 2D speckle tracking
echocardiography (STE): key points
<STE is a novel imaging modality that overcomes
many of the limitations associated with tissue
Doppler imaging.
<STE allows easy assessment of segmental and
global longitudinal, radial, and circumferential
strain and strain rate as well as LV rotation,
torsion, and dyssynchrony.
<Reference values for all LV segments are already
available.
<STE is a valuable tool in evaluating LV systolic
function and provides information on top of
ejection fraction.
<STE also proved useful to investigate LV
diastolic dysfunction.
<Application of STE is limited by image quality,
out-of-plane motion of speckles, lack of clear
cut-off values for clinical decision making, and
software issues (correct definition of ROI, inter-
vendor comparability of values).
718 Heart 2010;96:716e722. doi:10.1136/hrt.2007.141002
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segments. Several different approaches and
varying degrees of user interaction are required
depending on the scanner type and the echocar-
diographic view (parasternal vs apical). Endocar-
dial tracking also allows computation of LV area
changes during the cardiac cycle and can, thus,
also be used to define end-systole and end-dias-
tole.
The raw data are filtered and mathematical algo-
rithms are applied to generate values. Several
different display formats have been used to represent
the data both using strain and SR curves and
graphical colour encoded displays. STE proved to be
highly robust and reproducible.
27
Intra- as well as
inter-observer variability between skilled echo
examiners were negligible.
27
From a practical point it
is essential to choose a sector width and transducer
position which provides visibility of the apical and
lateral segments, but which still guarantees frame
rates above 30 Hz, ideally around 50 Hz.
Speckle tracking versus tissue Doppler imaging
and MRI
STE has several important advantages compared to
other modalities which are able to measure defor-
mation. In contrast to MRI, STE is much more
available, cost efficient, can be used ‘bedside’, and
has a shorter procedure and post-processing time.
In comparison to TDI, STE is insonation angle
independent and does not require such high frame
rates, is not subjected to the tethering effect, and
allows straightforward measurement of radial and
circumferential strain in addition to longitudinal
strain.
2
The ‘tethering effect’is a phenomenon
encountered when TDI is used to assess strain. Scar
tissue which is unable to contract is ‘dragged’by
adjacent viable myocardium during systole. Since
TDI strain is calculated on the basis of tissue
velocities, this motion is falsely assigned with
a negative strain value, and thus assumed to be
actively contracting tissue. In STE, this effect does
not occur as strain is directly calculated from the
frame to frame motion of speckle patterns and not
from myocardial velocities.
Strain and systolic function
While both strain and LV ejection fraction (LVEF)
measure LV function, there is a fundamental
difference between the two: strain calculates the
contractility of the myocardium, while LVEF is
a surrogate parameter that describes myocardial
pump function. Even if contractility is reduced,
compensatory mechanisms (ie, ventricular dilata-
tion, geometry changes) can still assure that stroke
volume remains normal (at least at rest). Thus, STE
is especially suited for the assessment of global and
regional systolic function in patients with heart
failure and apparently normal ejection fraction
(HFNEF).
28
Furthermore, regional dysfunction is
not as apparent when using a global parameter
such as LVEF. In addition, exact calculation of LVEF
requires good image quality, operator experience,
and has a large error of measurement. LVEF is also
much more load dependent than strain.
29
Hooke’s
law
30
summarises the relationship between the
forces contributing to tissue deformation:
Passive wall stressðtÞcontractile forceðtÞ
¼elasticity 3deformationðtÞ
According to this law, passive wall stress and
elasticity both interfere with direct translation of
segmental contractile force into deformation
(strain). Passive wall stress is influenced by LV
loading conditions (LV pressure), ventricle geom-
etry, and segment to segment interaction, whereas
elasticity is defined by tissue properties.
In summary, strain could be an important
parameter for LV function which can display
cardiac dysfunction on a more fundamental level in
an early stage of disease.
STE longitudinal strain and EF correlate well in
healthy individuals; however, in ST elevation
myocardial infarction survivors and heart failure
patients, for example, the correlation is less strong.
Figure 6 Shear strain. A, surface area; F, force; Δx, border shift; L, height;
a
, shear angle.
Table 1 Reference values for segmental longitudinal peak systolic strain
LV segment
(apical 4
chamber view)
Mean peak systolic
longitudinal strain
(%)±SD*
Mean peak systolic
longitudinal strain
(%)±SDy
LV segment
(apical 2
chamber view)
Mean peak systolic
longitudinal strain
(%)±SD*
LV segment (apical
3 chamber view)
Mean peak
systolic longitudinal
strain (%)±SD*
Basal septal 13.764.0 1764 Basal anterior 20.164.0 Basal anteroseptal 18.363.5
Mid septal 18.763.0 1964 Mid anterior 18.863.4 Mid anteroseptal 19.463.2
Apical septal 22.364.8 2366 Apical anterior 19.465.4 Apical anteroseptal 18.865.9
Apical lateral 19.265.4 2167 Apical inferior 22.564.5 Apical posterior 17.766.0
Mid lateral 18.163.5 1966 Mid inferior 20.463.5 Mid posterior 16.865.0
Basal lateral 17.865.0 1966 Basal inferior 17.163.9 Basal posterior 14.667.4
*Mean left ventricular longitudinal peak systolic segmental strain values calculated from 242 healthy subjects aged 51612 years (between 18 and 80 years) by Marwick et al.
19
Scanner: Vivid
7, GE Medical Systems, Horten, Norway. Software: EchoPAC PC, version 6.0.0, GE Healthcare, Chalfont St Giles, UK.
yMean left ventricular longitudinal peak systolic segmental strain values calculated from 60 healthy subjects aged 39615 years by Hurlburt et al.
15
Scanner: Vivid 7, GE Medical Systems,
Milwaukee, Wisconsin, USA. Software: EchoPac Advanced Analysis Technologies, GE Medical Systems.
LV, left ventricular.
Heart 2010;96:716e722. doi:10.1136/hrt.2007.141002 719
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This suggests that EF and STE strain reflect
different parameters of systolic LV function. Thus,
STE strain provides information on top of LVEF.
31
Deformation and diastolic function
Diastolic dysfunction in patients with normal
systolic function results in impaired myocardial
relaxation and reduced filling of the left ventricle
during early diastole. This state is reflected by
a change of the early diastolic LV (un-) twist
pattern.
9
A decrease of early diastolic apical
untwisting rate (rotR) as well as a shortening or
negativity of time from peak apical diastolic
untwist to mitral valve opening (t
rotR to MVO
) can
be observed (figure 10).
10
Thereby, rotR and t
rotR to MVO
both become less
as diastolic dysfunction progresses. RotR correlates
well with established parameters of diastolic
dysfunction like early diastolic tissue velocity of
septal mitral annulus (e’) and ratio of early diastolic
mitral inflow to tissue velocity of septal mitral
annulus (e:e’).
10
LIMITATIONS OF 2D STRAIN
<Image quality: Even though 2D STE is fairly
robust, image quality is still an issue. In young
healthy subjects, approximately 6% of all LV
segments cannot be analysed due to poor image
quality.
15
<Out of plane motion caused by movement of
the heart during the cardiac cycle: It is unclear
how out of plane motion of speckles and frame
Figure 7 Longitudinal strain curve with peak longitudinal strain occurring in early
diastole. AVC, aortic valve closure; N, peak systolic longitudinal strain.
Figure 8 Displacement of acoustic markers from frame to frame. Green dots represent
the initial position and red the final position of the speckles.
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Table 2 Mean left ventricular circumferential and radial peak systolic segmental strain
values calculated from 60 healthy subjects aged 39615 years by Hurlburt et al
15
LV segment (short axis view
at a basal level, just below
mitral valve)
Mean peak systolic
circumferential strain
(%)±SD
Mean peak systolic
radial strain
(%)±SD
Anterior 246639616
Lateral 226737618
Posterior 216737617
Inferior 226637617
Septal 246637619
Anteroseptal 26611 39615
Scanner: Vivid 7, GE Medical Systems. Software: EchoPac Advanced Analysis Technologies, GE Medical
Systems.
720 Heart 2010;96:716e722. doi:10.1136/hrt.2007.141002
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rate affect the accuracy of STE. This short-
coming could be overcome by the use of 3D
speckle tracking technology.
<Unknown software algorithms: To track
speckles and compute strain and SR values,
filtering algorithms are used. The effect of this
filtering on the results represents a ‘black box’
and may vary from vendor to vendor. It is, thus,
unclear how values from different scanners and
software versions compare. Cross platform
comparisons and a clear definition of global
and regional norm values are essential for
a broad application of STE.
<Correct tracing of myocardial region of
interest: One of the major limitations is the
exact detection of borders. Even though speckle
tracking itself seems to enhance the capabilities
of endocardial delineation, it is still necessary to
correct contours manually. In addition, assess-
ment of strain and SR also requires definition of
the epicardial borders. In most software versions
a uniform thickness of the myocardium is
assumeddan assumption which is not true.
<Size of left ventricle: A further limitation,
encountered in large ventricles, is that it is often
difficult to image the entire myocardium,
especially the apical segments.
FUTURE PERSPECTIVES
STE is rapidly evolving both on the investigational
and the technological front. It will be necessary to
clearly define normal values and clinical settings
where STE is useful. A primary goal will be the
definition of cut-off values for medical decision
making and to correlate these with hard end points.
This will also require standardisation among
different scanners to assure cross platform repro-
ducibility and clear guidelines for the integration of
STE into routine echocardiography.
Optimisation of the algorithms for strain and SR
assessment will certainly occur. This will include
a more flexible endo- and epicardial border detec-
tion algorithm that accounts for differences in
myocardial thickness and enhanced mathematical
models and filtering techniques.
Three dimensional STE applications will help to
improve the understanding of myocardial motion.
The current practice of just measuring longitudinal,
radial, and circumferential strain is a simplification
of the complex myocardial fibre contraction
pattern, and neglects ‘shear strains’and out-of-
plane motion. These problems may be overcome
with three dimensional technology.
32e35
Finally, more advanced technologies will allow
LV rotation/torsion and strain/SR measurement of
the endocardial, midwall, and epicardial myocardial
layers and thus deliver a deeper insight into the
physiology of myocardial mechanics, and permit
the study of global and local processes within the
LV wall.
36
CONCLUSION
STE has developed rapidly from a research tool to
a technique which is on the verge of becoming an
important part of routine echocardiography. STE
uses the 2D image to calculate deformation
parameters and is in many aspects superior to TDI.
STE is easy to use, robust and provides a multitude
of new insights into the mechanics and deforma-
tion processes of the myocardium. In particular,
STE could provide important information on
regional and global systolic and diastolic function
Figure 9 Semi-automated definition of left ventricular
endocardial and epicardial borders (ROI) in an apical four
chamber view.
Figure 10 Speckle tracking derived apical rotation rate of a subject with normal diastology (A) and with pseudonormal
filling pattern. White lines indicate mitral valve opening, arrows indicate peak rotation rate during early diastole.
Reproduced with permission from Perry et al.
10
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which could translate into improved diagnostics of
heart disease.
Competing interests In compliance with EBAC/EACCME guidelines,
all authors participating in Education in Heart have disclosed potential
conflicts of interest that might cause a bias in the article. The
authors have no competing interests.
Provenance and peer review Commissioned; not externally peer
reviewed.
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722 Heart 2010;96:716e722. doi:10.1136/hrt.2007.141002
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