Abstract
Echocardiography is the most common diagnostic method for assessing cardiac functions. However, echocardiographic measures are subjective, semi-quantitative, and relatively insensitive when detecting subtle perturbations in contractility. Furthermore, early detection of abnormalities is crucial and may often influence treatments and establish prognosis. Echocardiographic- and Doppler-derived strain and strain rate imaging are relatively newer and more comprehensive techniques. They characterize the mechanics of myocardial contraction and relaxation (deformation imaging) more precisely and find applications in many cardiac pathologies. They are especially useful for assessing longitudinal myocardial deformation, which is otherwise difficult to assess using standard echocardiographic visual inspection. This review describes the fundamental concepts of strain imaging derived from tissue Doppler and two-dimensional speckle tracking and investigates how these methods can be incorporated into echocardiographic examinations and highlights their clinical applications. The considerable potentiality of imaging modalities for numerous cardiac conditions is thereby shown.
Similar content being viewed by others
References
Curtis JP, Sokol SI, Wang Y et al (2003) The association of left ventricular ejection fraction, mortality, and cause of death in stable outpatients with heart failure. J Am Coll Cardiol 42(4):736–742. doi:10.1016/S0735-1097(03)00789-7
Greenbaum RA, Ho SY, Gibson DG et al (1981) Left ventricular fibre architecture in man. Br Heart J 45(3):248–263. doi:10.1136/hrt.45.3.248
Pellikka PA, Nagueh SF, Elhendy AA et al (2007) American society of echocardiography recommendations for performance, interpretation and application of stress echocardiography. J Am Soc Echocardiogr 20(9):1021–1041. doi:10.1016/j.echo.2007.07.003
Hoffmann R, Lethen H, Marwick T et al (1996) Analysis of interinstitutional observer agreement in interpretation of dobutamine stress echocardiograms. J Am Coll Cardiol 27(2):330–336. doi:10.1016/0735-1097(95)00483-1
Gorcsan J 3rd, Deswal A, Mankad S et al (1998) Quantification of the myocardial response to low-dose dobutamine using tissue Doppler echocardiographic measures of velocity and velocity gradient. Am J Cardiol 81(5):615–623. doi:10.1016/S0002-9149(97)00973-9
Heimdal A, Stoylen A, Torp H et al (1998) Real-time strain rate imaging of the left ventricle by ultrasound. J Am Soc Echocardiogr 11(11):1013–1019. doi:10.1016/S0894-7317(98)70151-8
Mirsky I, Parmley WW (1973) Assessment of passive elastic stiffness for isolated heart muscle and the intact heart. Circ Res 33(2):233–243
Urheim S, Edvardsen T, Torp H et al (2000) Myocardial strain by Doppler echocardiography validation of a new method to quantify regional myocardial function. Circulation 102(10):1158–1164
Aurigemma GP, Douglas PS, Gaasch HW (2002) Quantitative evaluation of left ventricular structure, wall stress and systolic function. In: Otto CM (ed) The practice of clinical echocardiography. WB Saunders Company, Philadelphia, pp 65–87
Stoylen A, Heimdal A, Bjornstad K et al (1999) Strain rate imaging by ultrasound in the diagnosis of regional dysfunction of the left ventricle. Echocardiography 16(4):321–329. doi:10.1111/j.1540-8175.1999.tb00821.x
Zerhouni EA, Parish DM, Rogers WJ et al (1988) Human heart: tagging with MR imaging—a method of noninvasive assessment of myocardial motion. Radiology 169(1):59–63
Axel L, Dougherty L (1989) MR imaging of motion with spatial modulation of magnetization. Radiology 171(3):841–845
Sutherland GR, Steward MJ, Groundstroem KW et al (1994) Color Doppler myocardial imaging: a new technique for the assessment of myocardial function. J Am Soc Echocardiogr 7:441–458
Uematsu M, Miyatake K, Tanaka N et al (1995) Myocardial velocity gradient as a new indicator of regional left ventricular contraction: detection by a two-dimensional Doppler imaging technique. J Am Coll Cardiol 26(1):217–223. doi:10.1016/0735-1097(95)00158-V
Edvardsen T, Gerber BL, Garot J et al (2002) Quantitative assessment of intrinsic regional myocardial deformation by Doppler strain rate echocardiography in humans: validation against three-dimensional tagged magnetic resonance imaging. Circulation 106(1):50–56. doi:10.1161/01.CIR.0000019907.77526.75
Amundsen BH, Helle-Valle T, Edvardsen T et al (2006) Noninvasive myocardial strain measurement by speckle tracing echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol 47(4):789–793. doi:10.1016/j.jacc.2005.10.040
Hanekom L, Cho GY, Leano R et al (2007) Comparison of two-dimensional speckle and tissue Doppler strain measurement during dobutamine stress echocardiography: an angiographic correlation. Eur Heart J 28(14):1765–1772. doi:10.1093/eurheartj/ehm188
Perk G, Tunick PA, Kronzon I (2007) Non-Doppler two-dimensional strain imaging by echocardiography—from technical considerations to clinical applications. J Am Soc Echocardiogr 20(3):234–243. doi:10.1016/j.echo.2006.08.023
Pirat B, Khoury DS, Hartley CJ et al (2008) A novel feature-tracking echocardiographic method for the quantitation of regional myocardial function: validation in an animal model of ischemia–reperfusion. J Am Coll Cardiol 51(6):651–659. doi:10.1016/j.jacc.2007.10.029
Voigt JU, Arnold MF, Karlsson M et al (2000) Assessment of regional longitudinal myocardial strain rate derived from Doppler myocardial imaging indexes in normal and infarcted myocardium. J Am Soc Echocardiogr 13(6):588–598. doi:10.1067/mje.2000.105631
Weidemann F, Wacker C, Rauch A et al (2006) Sequential changes of myocardial function during acute myocardial infarction, in the early and chronic phase after coronary intervention described by ultrasonic strain rate imaging. J Am Soc Echocardiogr 19(7):839–847. doi:10.1016/j.echo.2006.01.024
Weidemann F, Jung P, Hoyer C et al (2007) Assessment of contractile reserve in patients with intermediate coronary lesions: a strain imaging study validated by invasive myocardial fractional flow reserve. Eur Heart J 28(12):1425–1432. doi:10.1093/eurheartj/ehm082
Park TH, Nagueh SF, Khoury DS et al (2006) Impact of myocardial structure and function postinfarction on diastolic strain measurements: implications for assessment of myocardial viability. Am J Physiol Heart Circ Physiol 209(2):H724–H731
Edvardsen T, Skulstad H, Aakhus S et al (2001) Regional myocardial systolic function during acute ischemia assessed by strain Doppler echocardiography. J Am Coll Cardiol 37(3):726–730. doi:10.1016/S0735-1097(00)01160-8
Abraham TP, Nishimura RA, Holmes DR Jr et al (2002) Strain rate imaging for assessment of regional myocardial function: results from a clinical model of septal ablation. Circulation 105(12):1403–1406. doi:10.1161/01.CIR.0000013423.33806.77
Armstrong G, Pasquet A, Fukamachi K et al (2000) Use of peak systolic strainas an index of regional myocardial function: comparison with tissue Doppler velocity during dobutamine stress and myocardial ischemia. J Am Soc Echocardiogr 13(8):731–737. doi:10.1067/mje.2000.105912
Yip G, Khandheria B, Belohlavek M et al (2004) Strain echocardiography tracks dobutamine-induced decrease in regional myocardial perfusion in nonocclusive coronary stenosis. J Am Coll Cardiol 44(8):1664–1671. doi:10.1016/j.jacc.2004.02.065
Hoffmann R, Altiok E, Nowak B et al (2002) Strain rate measurement by Doppler echocardiography allows improved assessment of myocardial viability in patients with depressed left ventricul function. J Am Coll Cardiol 39(3):443–449. doi:10.1016/S0735-1097(01)01763-6
Hanekom L, Jenkins C, Jeffries L et al (2005) Incremental value of strain rate analysis as an adjunct to wall-motion scoring for assessment of myocardial viability by dobutamine echocardiography: a follow-up study after revascularization. Circulation 112(25):3892–3900. doi:10.1161/CIRCULATIONAHA.104.489310
Zhang Y, Chan AK, Yu CM et al (2005) Strain rate imaging differentiates transmural from non-transmural myocardial infarction: a validation study using delayed-enhancement magnetic resonance imaging. J Am Coll Cardiol 46(5):864–871. doi:10.1016/j.jacc.2005.05.054
Dandel M, Wellnhofer E, Lehmkuhl H et al (2006) Early detection of left ventricular wall motion alterations in heart allografts with coronary artery disease: diagnostic valvue of tissue Doppler and two-dimensional (2D) strain echocardiography. Eur J Echocardiogr 7:S127–S128. doi:10.1016/S1525-2167(06)60477-0
Dandel M, Wellnhofer E, Hummel M et al (2003) Early detection of left ventricular dysfunction related to transplant coronary artery disease. J Heart Lung Transplant 22(12):1353–1364. doi:10.1016/S1053-2498(03)00055-X
Marciniak A, Eroglu E, Marciniak M et al (2007) The potential clinical role of strain and strain rate imaging in diagnosing acute rejection after heart transplantation. Eur J Echocardiogr 8(3):213–221. doi:10.1016/j.euje.2006.03.014
Falk RH (2005) Diagnosis and management of the cardiac amyloidoses. Circulation 112(13):2047–2060. doi:10.1161/CIRCULATIONAHA.104.489187
Koyama J, Ray-Sequin PA, Falk RH (2003) Longitudinal myocardial function assessed by tissue velocity, strain, and strain rate tissue Doppler echocardiography in patients with AL (primary) cardiac amyloidosis. Circulation 107(19):2446–2452. doi:10.1161/01.CIR.0000068313.67758.4F
Bellavia D, Pellikka PA, Abraham TP et al (2008) Evidence of impaired left ventricular systolic function by Doppler myocardial imaging in patients with systemic amyloidosis and no evidence of cardiac involvement by standard two-dimensional and Doppler echocardiography. Am J Cardiol 101(7):1039–1045. doi:10.1016/j.amjcard.2007.11.047
Bellavia D, Abraham TP, Pellikka PA et al (2007) Detection of left ventricular systolic dysfunction in cardiac amyloidosis with strain rate echocardiography. J Am Soc Echocardiogr 20(10):1194–1202. doi:10.1016/j.echo.2007.02.025
Dubrey SW, Cha K, Skinner M et al (1997) Familial and primary (AL) cardiac amyloidosis: echocardiography similar diseases with distinctly different clinical outcomes. Heart 78(1):74–82
Ogiwara F, Koyama J, Ikeda S et al (2005) Comparison of the strain Doppler echocardiographic features of familial amyloid polyneuropathy (FAP) and light-chain amyloidosis. Am J Cardiol 95(4):538–540. doi:10.1016/j.amjcard.2004.10.029
Wigle ED, Rakowski H, Kimball BP et al (1995) Hypertrophic cardiomyopathy clinical spectrum and treatment. Circulation 92(7):1680–1692
Seidman C (2002) Genetic causes of inherited cardiac hypertrophy: Robert L. Fyre lecture. Mayo Clin Proc 77(12):1315–1319
Maron BJ, Towbin JA, Thiene G et al (2006) Contemporary definitions and classification of the cardiomyopathies:an American Heart association scientific statement from the council on clinical cardiology, heart failure and transplantation committee; quality of care and outcomes research and functional genomics and translational biology interdisciplinary working groups;and council on epidemiology and prevention. Circulation 113(14):1807–1816. doi:10.1161/CIRCULATIONAHA.106.174287
Palka P, Lange A, Fleming AD et al (1997) Differences in myocardial velocity gradient measured throughout the cardiac cycle in patients with hypertrophic cardiomyopathy, athletes, and patients with left ventricular hypertrophy due to hypertension. J Am Coll Cardiol 30(3):760–768. doi:10.1016/S0735-1097(97)00231-3
Kato TS, Noda A, Izawa H et al (2004) Discrimination of nonobstructive hypertrophic cardiomyopathy from hypertensive left ventricular hypertrophy on the basis of strain rate imaging by tissue Doppler ultrasonography. Circulation 110(25):3808–3814. doi:10.1161/01.CIR.0000150334.69355.00
Nagueh SF, Bachinski LL, Meyer D et al (2001) Tissue Doppler imaging consistently detects myocardial abnormalities in patients with hypertrophic cardiomyopathy and provides a novel means for an early diagnosis before and independently of hypertrophy. Circulation 104(2):128–130
Maier SE, Fischer SE, McKinnon GC et al (1992) Evaluation of left ventricular segmental wall motion in hypertrophic cardiomyopathy with myocardial tagging. Circulation 86(6):1919–1928
Yang H, Sun JP, Lever HM et al (2003) Use of strain imaging in detecting segmental dysfunction in patients with hypertrophic cardiomyopathy. J Am Soc Echocardiogr 16(3):233–239. doi:10.1067/mje.2003.60
Kato TS, Izawa H, Komamura K et al (2008) Heterogeneity of regional systolic function detected by tissue Doppler imaging is linked to impaired global left ventricular relaxation in hypertrophic cardiomyopathy. Heart 94(10):1302–1306. doi:10.1136/hrt.2007.124453
Carasso S, Yang H, Woo A et al (2008) Systolic myocardial mechanics in hypertrophic cardiomyopathy: novel concepts and implications for clinical status. J Am Soc Echocardiogr 21(6):675–683. doi:10.1016/j.echo.2007.10.021
Carasso S, Woo A, Yang H et al (2008) Myocardial mechanics explains the time course of benefit for septal ethanol ablation for hypertrophic cardiomyopathy. J Am Soc Echocardiogr 21(5):494–499. doi:10.1016/j.echo.2007.08.020
Rakowski H, Carasso S (2007) Quantifying diastolic function in hypertrophic cardiomyopathy: the ongoing search for the holy grail. Circulation 116(23):2662–2665. doi:10.1161/CIRCULATIONAHA.107.742395
Corrado D, Fontaine G, Marcus FI et al (2000) Arrhythmogenic right ventricular dysplasia/cardiomyopathy: need for an international registry. Study Group on arrhythmogenic right ventricular dysplasia/cardiomyopathy of the working groups on myocardial and pericardial disease and arrhythmias of the European society of cardiology and of the scientific council on cardiomyopathies of the World heart federation. Circulation 101(11):E101–E106
Prakasa KR, Wang J, Tandri H et al (2007) Utility of tissue Doppler and strain echocardiography in arrhythmogenic right ventricular dysplasia/cardiomyopathy. Am J Cardiol 100(3):507–512. doi:10.1016/j.amjcard.2007.03.053
Pirat B, McCulloch ML, Zoghbi WA (2006) Evaluation of global and regional right ventricular systolic function in patients with pulmonary hypertension using a novel speckle tracking method. Am J Cardiol 98(5):699–704. doi:10.1016/j.amjcard.2006.03.056
Agmon Y, Connolly HM, Olson LJ et al (1999) Noncompaction of the ventricular myocardium. J Am Soc Echocardiogr 12(10):859–863. doi:10.1016/S0894-7317(99)70192-6
Alizad A, Seward JB (2000) Echocardiographic features of genetic diseases: part 1. Cardiomyopathy. J Am Soc Echocardiogr 13((1):73–86
Williams RI, Masani ND, Buchalter MB et al (2003) Abnormal myocardial strain rate in noncompaction of the left ventricle. J Am Soc Echocardiogr 16(3):293–296. doi:10.1067/mje.2003.47
Child JS, Perloff JK, Bach PM et al (1986) Cardiac Involvement in Friedreich’s ataxia: a clinical study of 75 patients. J Am Coll Cardiol 7(6):1370–1378
Weidemann F, Eyskens B, Mertens L et al (2003) Quantification of regional right and left ventricular function by ultrasonic strain rate and strain indexes in Friedreich’s ataxia. Am J Cardiol 91(5):622–626. doi:10.1016/S0002-9149(02)03325-8
Dutka DP, Donnelly JE, Palka P et al (2000) Echocardiographic characterization of cardiomyopathy in Friedreich’s ataxia with tissue Doppler echocardiographically derived myocardial velocity gradients. Circulation 102(11):1276–1282
Schiffmann R, Kopp JB, Austin HA 3rd et al (2001) Enzyme replacement therapy in Fabry disease: a randomized controlled trial. JAMA 285(21):2743–2749. doi:10.1001/jama.285.21.2743
Pieroni M, Chimenti C, Ricci R et al (2003) Early detection of Fabry cardiomyopathy by tissue Doppler imaging. Circulation 107(15):1978–1984. doi:10.1161/01.CIR.0000061952.27445.A0
Weidemann F, Breunig F, Beer M et al (2003) Improvement of cardiac function during enzyme replacement therapy in patients with Fabry disease: a prospective strain rate imaging study. Circulation 108(11):1299–1301. doi:10.1161/01.CIR.0000091253.71282.04
Epstein AE, DiMarco JP, Ellenbogen KA et al (2008) ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. Heart Rhythm 5(6):e1–e62. doi:10.1016/j.hrthm.2008.04.014
Abraham WT, Fisher WG, Smith AL et al (2002) Cardiac resynchronization in chronic heart failure. N Engl J Med 346(24):1845–1853. doi:10.1056/NEJMoa013168
Cleland JG, Daubart JC, Erdmann E et al (2005) The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 352(15):1539–1549. doi:10.1056/NEJMoa050496
Chung ES, Leon AR, Tavazzi L et al (2008) Results of the predictors of response to CRT (prospect) trial. Circulation 117(20):2608–2616. doi:10.1161/CIRCULATIONAHA.107.743120
Yu CM, Zhang Q, Chan YS et al (2006) Tissue Doppler velocity is superior to displacement and strain mapping in predicting left ventricular reverse remodeling response after cardiac resynchronisation therapy. Heart 92(10):1452–1456. doi:10.1136/hrt.2005.083592
Yu CM, Gorcsan J 3rd, Bleeker GB et al (2007) Usefulness of tissue Doppler velocity and strain dyssynchrony for predicting left ventricular reverse remodeling response after cardiac resynchronization therapy. Am J Cardiol 100(8):1263–1270. doi:10.1016/j.amjcard.2007.05.060
Knebel F, Schattke S, Bondke H et al (2007) Evaluation of longitudinal and radial two-dimensional strain imaging versus Doppler tissue echocardiography in predicting long-term response to cardiac resynchronization therapy. J Am Soc Echocardiogr 20(4):335–341. doi:10.1016/j.echo.2006.09.007
Miyazaki C, Lin G, Powell BD et al (2008) Strain dyssynchrony index correlates with improvement in left ventricular volume after cardiac resynchronization therapy better than tissue velocity dyssynchrony indexes. Circ Cardiovasc Imaging 1:14–22. doi:10.1161/CIRCIMAGING.108.774513
Miyazaki C, Powell BD, Bruce CJ et al (2008) Comparison of echocardiographic dyssynchrony assessment by tissue velocity and strain imaging in subjects with or without systolic dysfunction and with or without left bundle-branch block. Circulation 117(20):2617–2625. doi:10.1161/CIRCULATIONAHA.107.733675
Mele D, Pasanisi G, Capasso F et al (2006) Left intraventricular myocardial deformation dyssynchrony identifies responders to cardiac resynchronization therapy in patients with heart failure. Eur Heart J 27(9):1070–1078. doi:10.1093/eurheartj/ehi814
Dohi K, Suffoletto MS, Schwartzman D et al (2005) Utility of echocardiographic radial strain imaging to quantify left ventricular dyssynchrony and predict acute response to cardiac resynchronization therapy. Am J Cardiol 96(1):112–116. doi:10.1016/j.amjcard.2005.03.032
Suffoletto MS, Dohi K, Cannesson M et al (2006) Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation 113(7):960–968. doi:10.1161/CIRCULATIONAHA.105.571455
Delgado V, Ypenburg C, van Bommel RJ et al (2008) Assessment of left ventricular dyssynchrony by speckle tracking strain imaging comparison between longitudinal, circumferential, and radial strain in cardiac resynchronization therapy. J Am Coll Cardiol 51(2):1944–1952. doi:10.1016/j.jacc.2008.02.040
Lim P, Buakhamsri A, Popovic ZB et al (2008) Longitudinal strain delay index by speckle tracking imaging: a new marker of response to cardiac resynchronization therapy. Circulation 118(11):1130–1137. doi:10.1161/CIRCULATIONAHA.107.750190
Park SJ, Miyazaki C, Bruce CJ et al (2008) Left ventricular torsion by two-dimensional speckle tracking echocardiography in patients with diastolic dysfunction and normal ejection fraction. J Am Soc Echocardiogr 21(10):1129–1137. doi:10.1016/j.echo.2008.04.002
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Nesbitt, G.C., Mankad, S. & Oh, J.K. Strain imaging in echocardiography: methods and clinical applications. Int J Cardiovasc Imaging 25 (Suppl 1), 9–22 (2009). https://doi.org/10.1007/s10554-008-9414-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10554-008-9414-1