Speckle-tracking echocardiography (STE) is a technique that uses ultrasound to track speckles in the myocardium frame-by-frame to quantify myocardial deformation. STE can measure longitudinal, circumferential and radial strain as well as ventricular rotation and torsion. The software automatically divides the left ventricle into segments and generates strain curves. STE is more angle-independent than tissue Doppler imaging and not subject to tethering effects. STE is useful for detecting subtle changes in cardiac function and has applications in evaluating coronary artery disease, valvular heart disease, cardiomyopathies and response to treatments like cardiac resynchronization therapy.

1. Speckle-tracking
echocardiography (STE)
CHAIR Dr.MATHEW IYPE sir Dr.vidyasagar
Senior resident

2. STRAIN
STRAIN RATE
MYOCARDIAL DEFORMATION
SPECKLE TRACKING

5. Strain rate
0 2 4 6 8
Category 1
Category 2
Series 1
Series 2

6. SCORE 100 100 STRAIN
BALLS 50 100
STRIKE RATE 200 100 STRAIN RATE

7. •
Strain imaging, or ‘myocardial deformation imaging’,
offers a means to directly quantify the extent of
myocardial contraction .
Strain :
percentage change in the length of a myocardial
segment during a given period of time and has a unit
of %.
Strain rate :
rate at which shortening or lengthening is taking place
and has a unit of 1/s.

8. • Myocardium shortens during systole, the
strain and strain rate have negative value but
when there is stretch or lengthening of the
myocardium, the strain and strain rate
become positive.

9. Myocardial deformation:
a multidimensional
process

10. Longitudinal strain
shortening of the LV
along its long-axis

11. circumferential
strain
reduction in the
circumference of the LV
cavity during the cardiac
cycle
radial strain
denotes the thickening
of the LV wall along its
radius.

13. Viewed from apex, during systole
Apex rotates - Anticlockwise direction
base rotates - clockwise direction

14. • This opposite rotation of the LV apex and base
during systole produces a wringing motion or
twist of the LV which is critical to the normal
systolic functioning of the LV.
• The subsequent untwist during diastole
generates a suction force that appears to be
the key mechanism driving the early diastolic
filling of the LV.

15. • The inner sub endocardial fibres are oriented
relatively parallel to the long-axis of the LV
and determine predominantly the longitudinal
contraction.
• In contrast, the fibres in the mid-myocardial
and subepicardial layers are arranged more
parallel to the circumference of the LV and
hence govern the radial, circumferential and
rotational mechanics

16. • Speckle-tracking echocardiography (STE)
is a recently developed technique for the
characterization and quantification of
myocardial deformation

17. A gray-scale image on echocardiography is composed
of several bright speckles that are produced as a result
of the scatter of the ultrasound beam by the tissue

18. • The STE software identifies these speckles and
then tracks them frame-by-frame using a ‘sum-of-
the absolute differences’ algorithm.
• From this data, the software automatically resolves
the magnitude of myocardial deformation in
different directions and generates strain and strain
rate curves

19. Comparsion with LVEF
• provides indirect estimate of myocardial
contractile function and does not measure it
directly.
• Influenced by a number of factors including
loading conditions, heart rate, etc.
• not sensitive enough to detect subtle changes in
the contractile function and therefore not suitable
for detecting subclinical myocardial damage which
may have major therapeutic and prognostic
implications in a variety of clinical conditions

20. STE VS MRI AND TDI
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,
• insonation angle independent and
• 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.

21. TETHERING EFFECT
• 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.

22. Image acquisition
• ECG gating is must. High-quality ECG signal is
required to allow proper gating of the images.
• All the images should be acquired in breath-hold
and nearly identical heart rates
• The gain settings should be optimized.
• The depth should be reduced so that the LV
occupies most of the image sector
• Minimum three cardiac cycles should be acquired
for each loop

23. • Images from apical 4C ,2C and 3C -measurement of
LV longitudinal strain
• short-axis views at basal, mid and apical levels are
needed for the - measurement of radial and
circumferential strain.
• The basal and apical short-axis images are also used
for the measurement of LV rotation and torsion.

25. Image quality

26. • In long-axis views, care should be taken to avoid
foreshortening of the LV
• In short-axis views, the LV cavity should be as
circular as possible to ensure that the imaging
plane is perpendicular to the long-axis of the LV.
• The gray-scale frame-rate should be kept between
30 and 70 frames/s.
• At lower frame rates, large displacement of
speckles - tracking difficult
higher frame rates - resolution of the image gets
compromised

27. IMAGE ANALYSIS
• It is advisable to analyze the apical long-axis image (i.e.
three-chamber view) first.
• In this view, the movement of aortic valve leaflets helps in
timing the aortic valve closure which is essential for the
software to be able to perform the deformation analysis.
• Once the images are transferred to the workstation, the
speckle-tracking application is launched and the image is
opened in the application
• When the image is opened in the software, the software
automatically brings up the end-systolic frame of the cardiac
cycle.
• If the automated frame selection seems inaccurate, the
same can be adjusted manually.

28. LV endocardial surface will be traced manually and the
speckle tracking width will be modified to cover the whole
LV wall thickness so as to obtain curves for the peak
longitudinal strain of :
FOUR CHAMBER
VIEW(4C-PLS)
THREE CHAMBER
VIEW(3C-PLS)
TWO CHAMBER
VIEW(2C-PLS)
INFERIOR
SEPTUM
INFERIOR INFERIOR
LATERAL
ANTERO LATERAL
WALL
ANTERIOR WALLS ANTERIOR
SEPTUM
LV global longitudinal systolic strain (GLS) was calculated
by averaging the peak systolic values of the six LV walls.
GLS

29. Steps involved in speckle-tracking echocardiography.
A)The endocardial border is manually traced in the endsystolic frame. The automated
software creates a region-of-interest that includes the entire myocardial thickness.
B) The operator is prompted to review and approve the adequacy of tracking for each
segment.

31. • The software then tracks the myocardial
speckles frame-by frame and generates
moving images displaying the tracking.
• If the tracking does not seem to be accurate,
one can go back and readjust the ROI or select
an altogether new ROI.
• Once the satisfactory tracking is achieved, the
same is approved by clicking on the approve
button

33. • The software then divides the LV myocardium into
six segments and generates segmental and global
longitudinal strain, strain rate, velocity and
displacement curves.
• From these curves, peaksystolic longitudinal strain
and strain rate can be recorded for each of the
myocardial segments.
• A color-coded parametric images is also generated
by some systems

34. • The same process is then repeated with the
apical four - chamber and two-chamber
images also.
• The strain values for all the segments are
recorded and averaged to obtain the global
longitudinal strain (GLS) and strain rate.
• Some systems also provide Bull’s eye display
of the regional and global longitudinal strain

35. • short-axis images are also analyzed in the same
manner to derive the segmental and global radial
and circumferential strain and strain rate.
• It is important to recognize that during systole,
the LV circumference usually shortens whereas
the myocardial thickness increases.
• Hence, the normal circumferential strain is
negative but the normal radial strain is positive

36. • The rotation and rotation rate are
automatically measured when the short-axis
images are analyzed for strain measurement
and no extra step is required.
• By convention, anticlockwise rotation is
displayed above the baseline and is assigned a
positive value whereas the opposite is true for
the clockwise rotation.
• Thus, the normal apical rotation is positive
and the basal rotation is negative

37. • LV twist : BASAL - APICAL rotation
• Torsion : dividing twist with the LV length (twist/length)
• For example,
if the apical rotation is 6.2
basal rotation - 3.4
LV length 6.4 cm
then the net twist angle will be 6.2 - (-3.4) is 9.6 and
LV torsion will be 1.5/cm

38. • The normal GLS is usually in the range of 16 to 18%
or more (i.e. more negative).
• The rotation and torsion have much greater
variability which makes it difficult to define the
normal ranges for the same.
• However, it should be noted that the apical rotation
is normally much greater than the basal rotation
which is limited by the tethering effect of the mitral
annulus.

40. As the myocardium usually shortens in longitudinal direction
during systole, the longitudinal strain and strain rate curves are
displayed below the baseline

41. The circumferential strain is usually greater than the
longitudinal strain with average values in excess of - 20%.
The average radial strain is in the range of 40 to 60%.

45. STE - CAD
ACUTE ISCHEMIA
• Ischaemic and scarred tissue shows a reduction and
delay of peak segmental strain and SR.

46. GLS IN AWMI

47. POST-SYSTOLIC THICKENING
• An important additional phenomenon which
occurs early after the onset of ischaemia is
POST-SYSTOLIC THICKENING.
• Post-systolic thickening can be defined as
continued myocardial thickening which is
present even after aortic valve closure delay of
peak segmental strain and SR

49. • While some degree of post-systolic thickening also
occurs in the normal myocardium, it is significantly
more pronounced in the setting of acute ischaemia and
stunning
• Magnitude of post-systolic thickening is proportional to
the severity of ischaemia.
• During the time course of acute ischaemia there is a
gradual decrease of the systolic component and an
increase in the post-systolic component of
Deformation.
• During reperfusion, deformation returns to normal.

51. • In contrast, chronic myocardial ischaemia is
characterised by a reduction in peak systolic
strain and SR with only mild post-systolic
thickening
• ‘Ischaemia imaging’ using the time delay of
‘thickening’/contraction could become an
important future application of STE.

52. • Reduction in peak systolic strain also in
patients with severe CAD (3VD or left main
CAD) at rest and in the absence of manifest
ischaemia or RWMA -sensitivity and specificity
of STE were both 79%.
• This suggests that STE is more sensitive than
the ‘eye’ in detecting contraction abnormalities

53. • Stress tests (ie, dobutamine) in combination
with tissue deformation imaging allows even
better identification of ischaemic segments
and further discrimination of ischaemic
syndromes.

54. STE -SCAREED MYOCARDIUM
• Scarred myocardium impairs the twisting and
untwisting of the LV.
• Patients with AWMI and EF <45% :
• a reduction in apical rotation
peak LV twist
peak positive and
negative twist velocity.
• After revascularisation, LV torsion improves. These
changes can be studied with STE and help us to
understand the hemodynamic sequel of myocardial
infarction.

55. VALVULAR HEART DISEASE
• In Aortic stenosis,the early stages of this
process LV impairment may be subtle and
undetectable by calculations of EF.
• Thus, early detection of LV dysfunction could
play an important role in the timing of aortic
valve replacement and in the management of
patients with AS.

56. • The reduction of longitudinal strain appears to
be most prominent in the basal segments
• Conversely, radial and circumferential strain
values do not reflect early impairment of LV
function.
• A basal longitudinal strain below 13% was
associated with a more severe degree of AS in
terms of effective orifice area and higher cardiac
event rate during a 12 month follow-up period

60. Hcm and htn hypertrophy

61. • Patients with HCM and hypertensive heart disease
display a specific regional and directionalstrain/SR
pattern and a prolonged time to peaksystolic strain
(strain index).
• Moreover, patients with HCM and hypertensive
heart disease show disturbed myocardial
mechanics. LV systolic torsion is increased due to
increased rotation of the basal segments.
• In contrast, untwisting of the LV during early
diastole is significantly delayed and Reduced. This
effect seems to be related to the degree of LVH.

62. STE IN DILATED CARDIOMYOPATHY
• DCMdisplays an abnormal apical and basal
rotationpattern (opposite basal or apical
rotation).
• An interesting finding is that of a reduction in
peak atrial systolic strain in the setting of
idiopathic DCM.
• suggests that the atrial myocardium is also
affected
• aid in the differential diagnosis between
ischaemic and dilated cardiomyopathy

64. STE – CRT
• Since STE can distinguish between actively and
passively stretched LV segments, it could allow
quantification of scar burden in potential CRT
candidates with ischaemic cardiomyopathy
better than MRI.
• This is important since the magnitude of scar
burden is inversely correlated to CRT response.

65. • STE derived strain could be a valuable
parameter for defining CRT response.
• This is a relevant issue, since it could help
explain why many patients exhibit a clinical
response to CRT but no measureable increase
in EF.
• temporal curves of strain/SR also show the
magnitude of resynchronisation with CRT

66. STE – CRT RESPONSE

67. STE IN OTHER CONDITIONS
• used to monitor LV systolic function in several
disease entities.
• For example, longitudinal peak systolic strain is
reduced in patients with type 2 diabetes.
• Other conditions in which STE has been studied
include: patients with heart failure and normal EF,
catheter ablation for atrial fibrillation, tako-tsubo
cardiomyopathy, Cushing syndrome rheumatoid
arthritis, atrial septum defect or Fabry disease

68. STE –CARDIAC ONCOLOGY
• Able to detect the immediate and long term
effects of drug treatment on the heart.
• For example, STE and TDI based strain/SR
imaging has been used to study the
cardiotoxic effects of chemotherapies and
monoclonal antibody therapy

70. • Interesting further application of STE is the
assessment of atrial function, which is still in
its early stages but which could open an
entirely new array of indications

71. STE AND THE RIGHT VENTRICLE
• Most experience with STE in the setting of RV
function has been gathered by using regional and
global peak systolic longitudinal strain.
• Deformation parameters are reduced in pulmonary
hypertension in a graded manner
• RV segmental and global longitudinal peak systolic
strain is reduced and delayed in patients with acute
pulmonary thromboembolism.
• All these effects are reversible upon treatment

73. • Deformation abnormalities are present in
patients with systemic sclerosis even in the
absence of pulmonary hypertension.
• Longitudinal strain values improve after
pulmonic valve replacement.
• Patients with atrial septal defects have elevated
global peak systolic strain values which normalise
after interventional occlusion.
• Patients with arrhythmogenic right ventricular
cardiomyopathy show an abnormal contraction
pattern.

74. FABRYS DISEASE

81. THANK YOU