Table Of ContentAtlas of Tissue Doppler Echocardiography - TDE
R. Erbel H. J. Nesser J. Drozdz
(Eds.)
Atlas of Tissue Doppler
Echocardiography - TOE
With 130 Figures, Most in Color
STEINKOPFF Springer
Raimund Erbel, MD, FESC, FACC
Dept. of Cardiology, University-GHS Essen
Hufelandstrasse 55, D-45122 Essen, Germany
H. Joachim Nesser, MD
Division of Cardiology, K. d. Elisabethinen
Fadingerstrasse 1, A -4010 Linz, Austria
Jaroslaw Drozdz, MD
Dept. of Cardiology, University of Lodz
Jonscher Hospital, Milionowa 14
Lodz, 93-113, Poland
ISBN-13: 978-3-642-47069-1 e-ISBN-13: 978-3-642-47067-7
DOl: 10.1007/978-3-642-47067-7
Die Deutsche Bibliothek - CIP-Einheitsaufnahme
Atlas oftissue doppler echocardiography: TDE / R. Erbel ...
(ed.). - Darmstadt: Steinkopff, 1995
NE: Erbel, Raimund [Hrsg.]: TDE
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Preface
This is the first book to present an overview of the exciting new cardiac
imaging technique of tissue Doppler echocardiography (TDE).
In order to understand the background of this technique, it is necessary to
compare the physical properties of blood, which reflects ultrasound poorly
but moves with high velocity (up to 150 cm/s) with those of the myocar
dium, which reflects ultrasound strongly but moves with low velocity (less
than 10 cm/s). In tissue Doppler imaging, existing Doppler technology has
been modified to bypass the high-pass filter and enhance calculation of low
velocities, thus enabling selective visualization of the myocardium rather
than of the blood. Because the color Doppler tissue images are super
imposed on the conventional two-dimensional ultrasound images, this
technique is known as TDE.
Following a brief introduction, the history of ultrasound and Doppler
imaging is presented. It is now about 150 years since the death of Christian
Doppler, who described the "Doppler" effect, and more than 100 years
since Pierre Curie discovered the piezoelectric effects of crystals.
TDE was developed by Nobuo Yamazaki and Yoshitaka Mine at the Medi
cal Engineering Laboratory, Toshiba Corporation, Tochigi, Japan. En
gineers involved in the development of the technique have provided
important technical information, which the reader will find an invaluable
background to potential applications ofTDE.
An extensive chapter summarizes the normal features of TDE, which is
an important introduction to some of the pathological conditions describ
ed later. In order to properly appreciate the rapid changes in the magni
tude and direction of tissue velocities, TDE requires digital cine loop
archiving and frame-by-frame analysis. TDE is strongly angle dependent
and is influenced by total heart movement, a new aspect for echocardio
graphy.
Successive chapters document TDE images obtained in patients with coro
nary artery disease and with hypertrophic, dilated, and restrictive cardio
myopathies. The enhancement of structure identification by TDE is ex
plained, with particular reference to the measurement of right ventricular
wall thickness. Adjacent thoracic and pericardial structures are not color
coded, in contrast to the right ventricular myocardium, thus allowing pre
cise delineation.
The potential use ofTDE to assess regional systolic and diastolic function
is then discussed. M-mode TDE affords the possibility of measuring global
and regional systolic and diastolic time intervals (STIIDTI) of both the left
and right ventricles.
VI Preface
The final chapters explain how TDE may be useful in the assessment and
understanding of disturbances of cardiac rhythm and document expe
rience with a variety of subjects, including tumors and spontaneous echo
contrast.
Our first book on echocardiography, Fortschritte der Echokardiographie1,
which was published 10 years ago, included transesophageal and color
Doppler imaging; it was followed in 1989 by Transesophageal Echocardio
graphy -A New Window to the Hearf-. We hope that this new book, Tissue
Doppler Echocardiography, will demonstrate that a further chapter has
been opened in the history of echocardiography.
We wish to thank our collaborating authors for their intensive work. Parti
cular praise must go to Thomas Buck for organizing the publication; David
R. Wallbridge for his editorial assistance; Petra Merz for her secretarial
work; Christiane Plato for her work in the echo cardiographic laboratory;
and Ilse Scharein for her photographic work. The close cooperation of the
publishing staff, particularly Sabine Ibkendanz, is also acknowledged.
The pictures presented in this book would not have been possible without
the support of Toshiba Medical Systems. Mr. K. Machida (Europe), Mr.
U. StOcker, and Mr. W. Randhan (Germany) have been most generous in
their assistance.
R. Erbel H.I. Nesser J Drozdz
The work was supported by the Herz-Kreislaufzentrum Essen, Gesell
schaft fUr Herz-Kreislaufforschung e. V.
References
1. Erbel R, Meyer J, Brennecke R (eds) (1985) Fortschritte der Echokardiographie. Sprin
ger, Berlin Heidelberg New York
2. Erbel R, Khandheria D, Brennecke R, Meyer J, Seward JP, Tajik A (eds) (1989) Trans
esophageal echocardiography - a new window to the heart. Springer, Berlin Heidelberg
New York
List of Contents
Chapter 1 Introduction ............... . 1
R. Erbel
Chapter 2 Milestones in Cardiovascular Ultrasound 3
H. J. Nesser
Chapter 3 Principle of Doppler Tissue Velocity Measurements. 9
N.Yamazaki
Chapter 4 Image Processing .................... 17
H. U. Stocker
Chapter 5 Normal Pattern of Myocardial Velocity ........ 23
J. Drozdz, R. Erbel, D. Wallbridge
Chapter 6 Movement of the Total Heart . . . . . . 45
J. Drozdz
Chapter 7 Assessment of Right Ventricular Wall Thickness
by Tissue Doppler Echocardiography ...... 53
H. J. Nesser
Chapter 8 Ischemic Heart Disease ................. 69
J. Drozdz, R. Erbel
Chapter 9 TOE and Stress Echocardiography . . . . . . . . . . . 91
T. Buck
Chapter 10 Hypertrophic Cardiomyopathy 95
D. R. Wallbridge
Chapter 11 Cardiac Amyloidosis · 101
J. Drozdz, R. Erbel
Chapter 12 Aortic Wall Velocity . . . . . · 115
J. Drozdz, R. Erbel, J. Zamorano
Chapter 13 Hemodynamics by TOE .133
J. Zamorano
Chapter 14 Miscellaneous · 141
F. SchOn
Perspectives . · 167
R. Erbel
Subject Index .169
List of Contributors
Thomas Buck, MD David R. Wallbridge, MD
Dept. of Cardiology Dept. of Cardiology/Pathophysiology
University-GHS Essen University-GHS Essen
Hufelandstrasse 55 Hufelandstrasse 55
D-45112 Essen - Germany D-45112 Essen - Germany
Nobuo Yamazaki
Frank SchOn, MD Toshiba Corporation
Schwarzenbergstrasse 25 a Medical Engineering Laboratory
D-45472 Mtilheim an der Ruhr 1385, Shimoishigami
Germany Otawara-Shi, Toshigi-Ken
324 Japan
Hans Ulrich Stocker Jose Zamorano, MD
Toshiba Medical Systems Servicio de Cardiologia
(Germany) Hospital Clinico
Hellersbergstrasse 4 Plaza de Cristo Rey
D-41460 Neuss - Germany E-28040 Madrid - Spain
Chapter 1 Introduction
R. Erbel
Echocardiography has become the diagnostic r----------,a·Oem
workhorse in cardiology and has evolved to a
method enabling cardiovascular hemodynamics
to be analyzed. Ventricular function frequently
needs to be assessed in the echocardiographic
laboratory, and both global and regional indices
are currently derived from two-dimensional echo
cardiography. Guidelines for the analysis of left Diastole II'Ocm
r---------'a·Oem
ventricular volume and ejection fraction have
been published by the American Society of Echo
cardiography [1], but similar standards have yet to
be established for the right ventricle and the atria.
Regional wall motion is determined either semi
quantitatively, by dividing the left ventricle into 16
segments and scoring the degree of abnormality in
each of these, or quantitatively, using the center Systole II'Oem
line, radiant, and trajectory methods. The limita
tions of these methods, due to cardiac motion, Fig. 1.1. Successive cavity outlines from the left
rotation of the heart, and changes in the centre of ventriculogram showing inferior akinesia and an
gravity of the left ventricle, become more impor area of abnormal movement of the anterior wall
tant after myocardial infarction or cardiac surgery during diastole. (From [2])
or in subjects with cardiomyopathy.
While global diastolic function can be relatively
easily assessed by analyzing the transmitral and
pulmonary venous flow patterns, measurement of
regional diastolic function by echocardiography is
more problematic. Research in this field is called
diastology. Regional impairment of diastolic and
systolic function may precede changes in more
global indices of function due to compensatory
hyperactivity of healthy tissue.
The pioneering work of Gibson in the 1970s high
lighted the importance of ventricular asynchrony
in cardiac disease. Using frame-by-frame analysis
of ventricular angiograms, he demonstrated that o 9CO
Time (msl
abnormalities of early diastolic filling were pre
sent in subjects with coronary artery disease [2] Fig. 1.2. Plots of regional wall movement against
(Figs. 1.1, 1.2) and hypertrophic cardiomyopathy time from the left ventriculogram of a patient with
[3]. Echocardiographic methods that include only coronary artery disease. During isovolumic rela
end-diastolic and end-systolic frames are unable xation, indicated by the two bold lines, there is
to determine such changes. outward movement along the anterior border and
With the development of M-mode echocardiogra inward movement along the inferior border.
phy, attention was directed toward the quantifica- (From [2])
2 Chapter 1 Introduction
tion of the excursion of the left ventricular poste TDE shows potential in the assessment of abnor
rior wall. In retrospect, it is perhaps easy to under malities of ventricular function in patients with
stand why neither endocardial nor epicardial cardiomyopathies. Analysis of the patterns of
posterior wall velocities provided an accurate myocardial velocities may be helpful to distin
measure of total left ventricular performance in guish between amyloidosis and hypertrophic car
patients with coronary artery disease [4]. Never diomyopathy. Whether differences exist between
theless, interesting observations were made, such TDE patterns in hypertrophic cardiomyopathy
as the fact that exercise-induced angina was and arterial hypertension remains to be establish
accompanied by the development of abnormal ed.
diastolic velocities in the presence of preserved The role of TDE in the evaluation of cardiac
systolic function [5]. Somewhat later, Isaaz [6] tumors, thrombi, and vegetations requires further
showed that conventional pulsed Doppler imag evaluation. Measurements of wall thickness are
ing can be used for the direct analysis of the left improved, particularly for the right ventricle. The
ventricular posterior wall and that it appears to be aorta is also easily studied byTDE, with the possi
more informative than the M-mode technique for bility of new insights into altered aortic complian
systolic measurements. ce in systemic hypertension.
Tissue Doppler echo cardiography (TDE) displays It is hoped that the various chapters of the book
color-coded tissue velocities as an overlay on con will give the reader a first insight into the emerg
ventional images. After a short period of experi ing technique ofTDE.
mental validation, clinical applications continue to
emerge. The distribution of velocities across the
myocardium can be observed and transmural gra References
dients calculated. This may facilitate the study of
subendocardial function as an early indicator of 1. Schiller NB, Shah PM, Crawford M, DeMaria A,
myocardial ischemia or as a marker of viable myo Devereux R, Feigenbaum H, Gutgesell H, Reichek
N, Sahn D, Schnittger J, Silverman AH, Tajik AJ
cardium.
(1989) Recommendations for quantification of the
The ability of TDE to demonstrate ventricular left ventricle by two-dimensional echocardiography.
asynchrony with high temporal resolution is an J Am Soc Echocardiogr 2: 358-367
exciting step forward. This may prove very useful 2. Gibson DG, Prewitt TA, Brown DJ (1976) Analysis
of left ventricular wall movement during isovolumic
for assessing global and regional left ventricular
relaxation and its relation to coronary artery disease.
function, but it must take into account the whole
Br Heart J 38: 1010-1019
heart motion, a completely new area for echo 3. Sanderson JE, Gibson DG, Brown DJ, Goodwin JF
cardiography. The color interfaces of M-mode (1977) Left ventricular filling in hyertrophic car
TDE can be used to measure the duration of the diomyopathy. An angiographic study. Br Heart J
39:661--670
different phases of the cardiac cycle, including
4. Ludbrook P, Karliner JS, London A, Peterson KL,
regional systolic (STI) and diastolic time intervals Leopold GR, O'Rourke RA (1974) Posterior wall
(DTI) , for both left and right ventricles. velocity: an unreliable index of total left ventricular
Abnormal electrical activation of the heart, by an performance in patients with coronary artery disease.
Am J CardioI33:475-482
accessory pathway or ventricular ectopic focus,
5. Fogelman AM, Abbasi AS, Pearce ML, Kattus AA
may be recognized by TDE contraction patterns.
(1972) Echocardiographic study of the abnormal
It has already been shown that TDE can detect motion of the posterior left ventricular wall during
the position of accessory pathways in Wolff-Par angina pectoris. Circulation 46: 905-913
kinson-White (WPW) syndrome and that the 6. Isaaz K, Thompson A, Ethevenot G, Cloez JL,
Brembilla B, Pernot C (1989) Doppler echocardio
early signs of contraction disappear after ablation.
graphic measurement of low velocity motion of the
Thus TDE may be a useful noninvasive technique left ventricular posterior wall. Am J Cardiol 64:
for electrophysiology. 66-75
Chapter 2 Milestones in
Cardiovascular Ultrasound
H. 1. Nesser
The engineering aspects using ultrasound for In 1969, a very important contribution to the
diagnostic purposes date far back, to the year development of cardiac ultrasound was provided
1883, when Galton developed a pipe producing by Gramiak creating the contrast echo technique
vibrations as high as 25000 cycles per second. [30).
During the First World War, Langevin made It may be of interest that the term "Echocardio
experiments generating ultrasound waves by graphy" was introduced by the American Institute
quartz crystals. The intensity of the waves was of Ultrasound in accordance with the term
sufficient enough to kill fish in a water tank. The "Echoencephalography" .
first to describe an ultrasound technique to local
ize flaws in metals was Sokolov [67] in 1929.
During the Second World War, ultrasound was Two-dimensional Echocardiography
particularly used to fix the position of underwater
objects and was a goal of military research. It was Whereas M-mode echocardiography only pro
Firestone [26], who again initiated the technique duced small detailed images of the heart, two
for non destructive testing. dimensional sector scanning developed in the mid
One of the first to register reflected ultrasonic 1970s, allowed real-time tomographic images of
waves from cardiac structures was Keidel in 1950, cardiac morphology and function [1,81].
who measured cardiac volumes [43]. Ultrasonic two-dimensional imaging was prima
In 1954, the term "ultrasonic cardiogram" was rily used in radiological and obstetric applications
created by Hertz and Edler. Their early works [81]. Asberg described the first scanner operating
included descriptions of the left ventricular poste at seven frames per second already in 1967 [1].
rior wall and the anterior mitral leaflet [14). Dur Five years later, in 1972, King demonstrated two
ing the late 1950s Edler was engaged, with using dimensional imagings with a static contact B
the technique to analyze valve diseases such as scanner [45]. Eventually, this technique achieved
mitral valve stenosis [15, 16). A left atrial throm clinical importance, when Bom [4] and coworkers
bus was reported by him [17] in 1955, and by Effert constructed the linear array system. In 1974, the
[19] a left atrial myxoma in 1959. mechanical real-time sector scanner was intro
In 1957, Reid and Wild were the first in the United duced by Griffith and Henry [31]. The electronic
States to use medical ultrasound to examine excis phased array sector scanner was developed by
ed hearts [82). Reid and Joyner [40] worked to Somer [68] in 1968, but it was not until 1974 that
gether to start the first clinical applications of Thurstone and von Ramm [76] took the next steps
cardiac ultrasound in the USA. Their article deal to non invasively diagnose heart diseases with this
ing with mitral valve disease was published in Cir technology in the USA.
culation in 1963. Because of the increased diagnostic safety, myo
Feigenbaum and associates at Indiana University cardial infarction, cardiomyopathies and coronary
began to work with cardiac ultrasound in 1963. In artery disease were analyzed with the new tech
this year pericardial effusion was first detected in nique [39,71]. At present three-dimensional echo
his laboratory with the use of ultrasound [22). cardiography, clinically initiated by Wollschlager
Measurements of myocardial wall thickness [23], and coworkers [83], is one of the endpoints of a
left ventricular dimensions [24] and left ventricu long history of imaging cardiac structures and
lar stroke volume [25] were also first reported by function. Today, it is still under clinical investiga
the same group. tion.
