Tissue Doppler echocardiography allows assessment of myocardial motion using Doppler ultrasound. It uses frequency shifts of ultrasound waves to calculate myocardial velocity, focusing on lower velocities than blood flow Doppler. There are two techniques: pulsed TDE uses a sample volume gate while color-coded TDE uses autocorrelation to display multigated velocity data superimposed on images. TDE is useful for evaluating systolic and diastolic left ventricular function by measuring velocities of the mitral annulus, and can help distinguish conditions like constrictive pericarditis from restrictive cardiomyopathy.

1. Tissue Doppler
Echocardiography(TDE)
S.R.Sruthi Meenaxshi MBBS,MD,PDF

2. • 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

3. TECHNICAL ASPECTS
• Two techniques have been used to assess
myocardial function:
• pulsed-TDE
• color-coded TDE

4. • 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

5. • 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

6. 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

7. 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.

8. Color-coded tissue velocities can be
superimposed on conventional M-
mode and two-dimensional images

9. Pulse repetition frequencies can be
increased to enhance temporal
resolution

10. Myocardial motion towards the
transducer – red and orange
away from tranducer – blue and green

11. 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

12. • 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.

13. Assessment of global and regional
systolic left venticular function

14. • 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.

15. 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

17. 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

18. 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.

19. 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

20. 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.

22. 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

23. Assessment of diastolic function
• Peak negative
myocardial
velocity can
provide a
quantitative
assessment of
diastolic
dysfunction.

24. 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

25. Discriminates normal from
pseudonormal diastolic filling pattern

26. 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).

27. 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

28. Differentiating constrictive and
restrictive pericarditis

29. 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

31. 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

32. Annulus reversus in constrictive
pericarditis

33. 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

34. TDE in differntiating constrictive pericarditis
and restrictive cardiomyopathy

35. • . 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.

36. HOCM shows lower systolic and
diastolic velocity in TDE