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doi:10.1093/ehjci/jeu184
Received 3 February 2014; accepted after revision 11 August 2014; online publish-ahead-of-print 18 December 2014
Recognizing the critical need for standardization in strain imaging, in 2010, the European Association of Echocardiography (now the European
Association of Cardiovascular Imaging, EACVI) and the American Society of Echocardiography (ASE) invited technical representatives from
all interested vendors to participate in a concerted effort to reduce intervendor variability of strain measurement. As an initial product of the
work of the EACVI/ASE/Industry initiative to standardize deformation imaging, we prepared this technical document which is intended to
provide definitions, names, abbreviations, formulas, and procedures for calculation of physical quantities derived from speckle tracking echocar-
diography and thus create a common standard.
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Keywords Echocardiography Two-dimensional Deformation imaging Strain Strain rate Speckle tracking
Left ventricle Myocardial Standard Definitions
J.-U.V., G.P., and P.L. have equally contributed to the present paper.
undergoing chemotherapy for cancer or in those affected by heart such as tissue Doppler, which can provide comparable parameters
valve diseases.3 Over the years, a number of software packages and of comparable relevance.
algorithms have entered the market, but a practical limitation to
By providing clear definitions of the standard quantities that any soft-
the use of these techniques in routine clinical practice has been the
ware solution should report, the differences among different pro-
significant variability that exists among vendors. Such a variability
ducts should be limited to:
relates to several factors: differences in the terminology describing
myocardial mechanics; the type of stored data which is used for quan- Technical: accuracy and reproducibility of the proprietary approach
titative analysis (e.g. proprietary formats vs. standard DICOM to speckle tracking;
format); the modality of measuring basic parameters (tissue Marketing: choices about how and what different products report;
Doppler vs. speckle tracking); the definition of parameters (many Innovations: further parameters or representations beyond what is
vendors use proprietary speckle tracking algorithms or define differ- reported in this document.
ent tracking regions for the same parameter); and the results
output.1,4 8 Readers interested in a more in-depth description of the mathemat-
Recognizing the critical need for standardization in strain imaging,9 ics and physics are referred to the structural mechanics literature.12
in 2010, the European Association of Echocardiography (now the
European Association of Cardiovascular Imaging, EACVI) and the Geometry definitions
American Society of Echocardiography (ASE) invited technical repre-
sentatives from all interested vendors to participate in a concerted Region of interest
effort to reduce intervendor variability of strain measurement.10,11 The complete myocardial region of interest (ROI, Figure 1) is defined
As an initial product of the work of the EACVI/ASE/Industry initia- at end-diastole by:
tive to standardize deformation imaging, we prepared this document
Endocardial border: the inner contour of the myocardium;
which is intended to provide definitions, names, abbreviations, for-
Epicardial border: the outer contour of the myocardium;
mulas, and procedures for calculation of physical quantities derived
Myocardial midline: the middle ROI axis defined in the middle
from speckle tracking echocardiography and thus create a common
between inner and outer ROI contours.
Figure 1: Right panel: Speckle tracking-derived parameters are reported with reference to the endo epicardial or mid-myocardial line or to the
full wall independent from the way they are achieved. The longitudinal or circumferential component of any parameter is then directed tangentially to
the respective line (Ct), while the radial component is directed perpendicular to it (Cp). Left panel: Segmentation of the Region of Interest (ROI) in
apical views as applicable for a 16 or 18 segment model. See text for details.
2D speckle tracking standardization 3
Endocardial measurements pertain to the behaviour of the endo- the various instants of the cardiac cycle. Thus, segmentation is per-
cardial border and are represented there. Midline measurements, formed as follows:
when available, refer to the behaviour of the middle ROI axis and
Take the border at the user-defined or automatically selected
are represented there. Epicardial measurements pertain to the be-
frame,
haviour of the epicardial border and are represented there. In case
Define left and right ROIs,
of tracking results that represent the average of measurements
Divide each ROI into segments of equal length at the time point of
obtained over the full myocardial thickness, these are typically repre-
end-diastole.
sented with the mid-wall line specifying this full wall reference.
When the epicardial border is not drawn, then the measurements In the standard six-segment model (employed for global LV 16- or
typically refer to the single endocardial border and are presented 18-segment models), the length of the three left segments is equal
there. to the (left ROI length)/3, and the length of the three right segments
Task force recommendation: The key requirement for any software is equal to (right ROI length)/3.
solution is that it explicitly states what is being measured and the In case of a 17-segment model (which is not recommended for
spatial extent (in pixels or millimeters) over which the data is functional imaging, since the apical cap does not contract), the
sampled for a given ROI. Measurement definitions can be: endocar- basal, mid, and apical segments have the length of 2/7th of the right
dial, midline, epicardial, or full wall. and left ROI length, respectively, while the apical cap is composed
of 1/7th of the right plus 1/7th of the left ROI.
Note that when segmental lengths are different, this fact must be
Segment definitions taken into account when computing averages from segmental values.
Segments are the anatomical units of myocardium for which the Since the segments are presented with anatomical names corre-
results of the various strain analysis will be reported. sponding to the LV wall the image refers to, it is necessary that the
system recognizes or allows selection of the specific view under ana-
lysis. The system should also recognize or allow selection of whether
Apical views
an image is recorded as flipped left/right or inverted up/down.
Topographic definitions of the myocardial ROI in apical views are
Figure 2: Segmentation of the ROI in the short-axis view. Left panel: Six segments are used for basal and mid-levels in the 16-segment model as
well as for the apical level in the 18-segment model (608 segments). Right panel: Four segments for the apical level in the 16-segment model (908
segments). The red dot marks the anterior insertion of the right ventricular free wall, which defines the border between the (antero-)septal and
the anterior segment.
4 J.-U. Voigt et al.
Figure 3: Schematic diagram of the different LV segmentation models. Left panel: 16-segment model. Central panel: 17-segment model. Right
panel: 18-segment model. In all diagrams, the outer circle represents the basal segments, the mid one the segments at the mid-papillary muscle
level, and the inner circle the apical level. In the 17-segment model, an additional segment (apical cap) is added in the centre of the Bulls eye.
The anterior insertion of the right ventricular wall into the left ventricle defines the border between (antero-)septal and anterior segments (see
Figure 2). Starting from there, the ROI is subdivided into six equal segments of 608. In case, the circle is subdivided into four segments, (as used
for the apical level of the 16- and 17-segment models), the ROI is divided into four equal segments of 908, while the mid of the anterior segment
Segmentation models inward motion of one LV wall and the slower motion of opposite
Segmentation models are built to reflect coronary perfusion territor- wall will become smaller when the overall LV velocity is used for
ies, to result in segments with comparable myocardial mass, and to compensation.
allow comparison within echocardiography and with other imaging In the apical views, the velocity vector is projected in two
modalities. Accordingly, a 17-segment model is commonly used components:
(Figure 3, central panel).13 The 16-segment model (Figure 3, left
panel) divides the entire apex into four segments (septal, inferior, Vrthe radial component, which is perpendicular to the endocar-
lateral, and anterior). The 18-segment model (Figure 3, right panel) dial border (or any other reference border) and which is assumed
divides the apex into six segments similar to the basal and mid- to be positive when directed towards the cavity (contraction).
ventricular level. The last of these, the 18 segment model is simple Vlthe longitudinal component, which is tangential to the endo-
and well suited to describe myocardial mechanics from two- cardial border (or any other reference border) and which is
dimensional (2D) data, but results in an overweighting of the apical- assumed to be positive when directed from the base towards
region (distal) myocardium in the overall score. the apex (see definition in Figure 1).
Task force recommendations: Segment definitions refer to the
anatomy at the end-diastolic frame. If the segmentation is automatic- In the transversal/short-axis views, the velocity vector is projected in
ally proposed by the analysis software, a manual correction to modify two components as well:
the anatomy relative to the segments must be allowed to adjust for
varying anatomy. Furthermore, the selection of a specific view, Vrthe radial component, which is perpendicular to the endocar-
image inversion, or the possible left/right flip must be possible. dial border (or any other reference border) and which is assumed
to be positive when directed towards the cavity.
Vcthe circumferential component, which is tangential to the
Measurements endocardial border (or any other reference border). The tangen-
tial (rotational) component is assumed to be positive when coun-
Velocity terclockwise in a conventional short-axis view (i.e. probe on top of
Velocity is a vectorial quantity with a direction and amplitude. Veloci- the image, as if looking from the apex to the base). The circumfer-
ties are commonly reported just as measured, but sometimes they ential velocity may be reported as angular velocity (rotation rate).
are reported after subtracting the average velocity of the overall For this, velocity is normalized (divided) by the distance from the
LV. While in some cases this subtraction may correct for overall LV centre of the cavity and it is reported in radians per second or
translation, it may also mask or diminish segmental motion differ- degrees per second. The instantaneous centre of the cavity is cal-
ences in others. For example, the difference between the fast culated as the centre of gravity or centroid with respect to the
2D speckle tracking standardization 5
Tracking quality may reduce the resolution of the tracking results or may even com-
Speckle tracking works in general better along the ultrasound beam promise the validity of data. Proprietary filters may contribute to
than across beams. Furthermore, due to the beam divergence with the variation between vendors. Besides that, user-defined regulariza-
increasing depth in a sector image, tracking across beams works tion settings have become an important source of variation using the
better in regions close to the transducer than in the far field of the same machine.
image. Task force recommendations: Analysis software should inform the
Tracking quality may be suboptimal if regions of the myocardium user about measures, which are applied for regularization. Regular-
are poorly visualized, if stationary image artefacts (reverberations) ization should be limited to the necessary minimum. Options to
compromise speckle recognition or if spatial or temporal resolution control regularization settings should be available to the user. A
of the image acquisition is insufficient. record of the processing settings is prudent in longitudinal studies.
Task force recommendations: Analysis software should offer an auto-
mated measure of tracking quality. Furthermore, the user should be
always offered a display, where he/she is able to visually check track- Multidimensional deformation
ing quality by comparing the underlying image loop with the superim- Until now, all the concepts have been exposed assuming that the
posed tracking results, along with the actual curves derived from that deforming object has only one dimension. However, if the deforming
tracking. object is two-dimensional, then the deformation is not limited to
shortening and lengthening only. A 2D object can deform perpen-
dicular to the borders (Figure 6A and B). Furthermore, an object
Regularization can deform parallel to a border (Figure 6C and D). This type of deform-
Several vendors use models of normal cardiac deformation, spline- ation is called shear strain.
functions, or other types of spatial and temporal smoothing for the To define the deformation of a 2D object in a comprehensive way,
regularization of tracking results. Excessive regularization, however, all four strain components are written in a single matrix, which is
2D speckle tracking standardization 7
referred to as the strain tensor: Furthermore, from the principle of conservation of volume for in-
compressible material, it can be concluded that if two linear strain
components are known, the third can be calculated.
Sxx Sxy
, (6)
Syx Syy
Figure 8: Longitudinal strain curve with a selection of strain values at clinically relevant timings. P, peak positive strain; S, peak systolic strain; ES,
end-systolic strain; PSS, post-systolic strain. The yellow dashed line indicates begin of QRS; the green dashed line aortic valve closure (AVC).
The segmental strain or strain rate is defined as the average value Task force recommendations: The global strain or strain rate should
in the segment. This definition applies to any strain or strain rate be calculated by using the entire myocardial line length or using alter-
Table 1 Recommended names, abbreviations, and units for 2D speckle tracking-derived parameters
myocardial deformation imaging. The main purpose of this document strain rate, requires high frame rates (.100 fps) even at rest to
is to provide the theoretical basis to explain physiological significance resolve all relevant events. Since it might be very challenging with
and mathematical computation of the various parameters to clini- current imaging systems to adapt this further to higher heart rates,