Tissue Doppler
Echocardiography(TDE)
S.R.Sruthi Meenaxshi MBBS,MD,PDF
• Tissue Doppler echocardiography (TDE) has
become an established component of the
diagnostic ultrasound examination; it permits
an assessment of myocardial motion using
Doppler ultrasound imaging.
• The technique uses frequency shifts of
ultrasound waves to calculate myocardial
velocity;
• focus on lower velocity frequency shifts
TECHNICAL ASPECTS
• Two techniques have been used to assess
myocardial function:
• pulsed-TDE
• color-coded TDE
• TDE modification of doppler of blood flow and
calculates velocity of frequency shifts in
similar manner
• A primary advantage of TDE is that Doppler
shifts of tissue motion are of high amplitude,
being approximately 40 dB higher than
Doppler signals from blood flow
• In instrumentation feature common to both
pulsed and color-coded TDE involves removal
of the high-pass filter used for routine
Doppler to assess blood flow
• This is to focus on the lower velocity values of
myocardial motion
Pulsed TDE
• similar to pulsed-Doppler of blood flow
• . The gate of the sample volume of pulsed-TDE
is usually opened to 1 cm and directed to
assess the region of interest
• Most commonly the mitral annulus at lateral
and medial sites from the apical four-chamber
view
Color-coded TDE
• instrumentation uses the autocorrelator
technique to calculate and display multigated
points of color-coded blood velocity along a
series of ultrasound scan lines within a two-
dimensional sector
• Color-coded blood velocity data are then
superimposed on conventional gray scale two-
dimensional images in real time.
Color-coded tissue velocities can be superimposed on
conventional M-mode and two-dimensional images
Pulse repetition frequencies can be increased
to enhance temporal resolution
Myocardial motion towards the transducer – red and orange
away from tranducer – blue and green
CLINICAL APPLICATIONS
• In the assessment of left ventricular (LV) systolic
and diastolic function.
• Pulsed TDE is routinely used in clinical practice
• measures of mitral annular velocity have
established usefulness for assessment of LV
systolic and diastolic function, estimation of LV
filling pressures, and in the diagnosis of
hypertrophic cardiomyopathy, cardiac
amyloidosis, and the athletic heart
• Mitral annular velocity alone or in
combination with mitral inflow velocity (E) to
estimate LV diastolic function are the most
commonly used clinical applications.
• TDE assessment of mitral annular velocity (e’)
has been widely accepted as a component of
determining left ventricular (LV) diastolic
function.
• TDE also may quantify regional and global LV
function through the assessment of
myocardial velocity data.
Assessment of global and regional systolic
left venticular function
• color-coded TDE objectively quantified a wide
range of alterations in regional contractility
induced by inotropic modulation with
dobutamine and esmolol.
• Dobutamine produced significant increases in
peak systolic endocardial velocity, systolic time
velocity integral (TVI), and diastolic TVI;
• infusion of esmolol, there were significant
decreases in these indices of myocardial
contractility.
Strain and strain rate imaging
• To quantify global and regional LV function
• Strain is the ratio of change in length over the original length
or the fraction or percentage change from the original or
unstressed dimension
• Quantification of deformation is applied to describe the
contraction/relaxation pattern of the myocardium
• strain rate is the rate of this deformation and is associated
with LV contractility
Use in dobutamine stress echocardiography
• Dobutamine stress echocardiography is a
technique for evaluating regional wall motion
abnormalities due to ischemia that is induced
by pharmacologic stress
• it is useful for the diagnosis of coronary heart
disease or determining the viability of
dysfunctional myocardium
To assess LV dyssynchrony for CRT
• TDE measures of the severity of LV
intraventricular dyssynchrony may provide
prognostic information to patients with heart
failure who typically have a delay in electrical
activation, such as left bundle branch block (LBBB)
• TDE may also play a role for evaluating the effect
of CRT or biventricular pacing on LV function and
reverse remodeling.
Mitral annular velocity to assess LV function
• Mitral annular motion assessed by M-mode
echocardiography has historically been used as an
index of global LV systolic function
• viewed from the apical windows
• Mitral annular descent reflects the longitudinal
shortening of the LV chamber and correlates with
other global measures of LV function, such as stroke
volume
Mitral annular descent velocity by pulsed-TDE can measure the
systolic velocity, or S wave, as a rapidly acquired index of global LV
function
• Peak mitral annular
descent velocity
average >5.4 cm/sec
had a sensitivity and
specificity of 88 and 97
percent for an ejection
fraction greater than 50
percent.
Use in evaluating chronic aortic
regurgitation
• TDE may be helpful for identifying subclinical LV
dysfunction in patients with chronic severe
aortic regurgitation who are asymptomatic but
may be candidates for surgery
• A systolic annular excursion <12 mm and a
resting mitral annular velocity <9.5 cm/sec were
the best indicators of subclinical LV dysfunction
Assessment of diastolic function
• Peak negative
myocardial
velocity can
provide a
quantitative
assessment of
diastolic
dysfunction.
TDE IN DD
• Segmental and global
function can be measured.
For global function, the
region of interest is placed at
the septal and lateral borders
of the mitral annulus.
• During systole, the annulus
descends towards the apex,
whereas it recoils back
toward the base in early (e')
and late (a') diastole
Discriminates normal from pseudonormal
diastolic filling pattern
An average E/e' ratio below 8 is associated with normal filling
pressures and ratio >14 is associated with elevated filling pressures
• 2016 American Society of Echocardiography and European Association of
Cardiovascular Imaging guidelines
• For Diastolic dysfunction
• -E/e’ >14; the E/e’ is the ratio of early mitral inflow velocity (E) to mitral annular early
diastolic velocity (e’)
• -Septal e’ velocity <7 cm/s or lateral e’ velocity <10 cm/s
• -TR velocity >2.8 m/s; this criterion should not be used in patients with significant
pulmonary disease.
• -LA maximum volume index >34mL/m2 (should not be applied in athletes, patients
with more than mild mitral valve stenosis or regurgitation, or those in atrial
fibrillation).
Prognostic utility in heart failure
• Mitral annular Ea (also called E’) has important
prognostic utility in heart failure patients.
• In patients with impaired systolic function
poor prognostic indicators were
S <3 cm/s
mitral deceleration time <140ms
E/E’ >15
Differentiating constrictive pericarditis and
restrictive cardiomyopathy
Differentiating restrictive cardiomyopathy and
constrictive pericarditis
• The early diastolic Doppler tissue velocity at the
mitral annulus (E') is decreased (<8 cm/sec) in
restrictive cardiomyopathy, due to an intrinsic
decrease in myocardial contraction and relaxation.
• In contrast, the transmitral E' is frequently
increased (>12 cm/sec) in constrictive pericarditis,
since the longitudinal movement of the
myocardium is enhanced because of constricted
radial motion
MITRAL ANNULUS REVERSUS IN CP
• mitral lateral (and tricuspid) annular E'
velocities are often relatively reduced in
patients with constrictive pericarditis ("annular
reversus")
• This reduction may be the result of lateral
adhesion of the pericardium while the
longitudinal movement of the septal annulus is
unimpeded
Annulus reversus in constrictive pericarditis
MYOCARDIAL VELOCITY GRADIENT
• pulsed-wave tissue Doppler
imaging may help to
distinguish between
constrictive pericarditis and
restrictive cardiomyopathy by
measuring the myocardial
velocity gradient, which is an
index of myocardial
contraction and relaxation that
quantifies the spatial
distribution of intramural
velocities across the
myocardium
TDE in differntiating constrictive pericarditis
and restrictive cardiomyopathy
• . Ea obtained by pulsed-TDE is useful to
distinguish patients with constrictive
pericarditis from restrictive cardiomyopathy
• Since restrictive cardiomyopathy is a disease of
the myocardium, e’ is reduced, usually <6.0
cm/sec, whereas constrictive pericarditis is a
disease of the pericardium and e’ velocity is
preserved or elevated >10 cm/sec.
HOCM shows lower systolic and diastolic
velocity in TDE
