R E V I E W

A R T I C L E

Introduction of Tissue Doppler Imaging

EchocardiographyBased on
Pulsed-wave Mode
Fen-Chiung Lin*, I-Chang Hsieh, Cheng-Hung Lee, Ming-Sien Wen

Noninvasive evaluation of global left ventricular (LV) myocardial contractile function using
echocardiography has depended on M-mode and two-dimensional measurement of the
LV dimension and area changes between diastolic and systolic phases, which provide an
estimation of volume changes between diastole and systole, to calculate the ejection frac-
tion as an index of LV contractile function. The LV ejection fraction represents a contrac-
tile function in summary of several LV myocardial segments. Noninvasive evaluation by
echocardiography for regional myocardial contractile function depends mainly on visual
assessment of the segmental myocardial motion velocity, especially the endocardial inward
motion velocity. Human visual assessment is subjective and, hence, has a certain degree
of intraobserver and interobserver variability. Tissue Doppler imaging (TDI) echocardiog-
raphy, a technique which can have a frame rate of up to 200 frames per second (fps), is
far beyond the capability of human vision (30 fps). TDI can detect the high-intensity, low-
velocity motion of regional myocardium, mainly on the LV longitudinal axis using three
apical views. The myocardium of the LV basal segments moves towards the apex during
systole; hence, the systolic motion velocity is highest in the basal segments, middle in the
LV mid-segments, and lowest in apical segments. The strain (S) image calculates regional
myocardial deformation and is defined as the change in length divided by the original
length, (L1L0)/L0. The S is expressed as the percentage change, that is, the degree of
regional deformation. A negative S represents a regional myocardial shortening, and a
positive S represents a regional myocardial lengthening. The rate at which the S change
occurs is called the strain rate (SR) image. The SR is expressed as 1/second and a negative
value represents a regional rate of change in deformation during systolic shortening. A
total displacement (D) at end-systole of a certain segment can also represent a regional
myocardial contractile function. A segmental mean D can be acquired quickly and coded
in colors to represent a semi-quantitative regional myocardial contractile function index
display using a color bar. Recently, a tissue synchronization image mode has been devel-
oped for a more convenient quantification of time-to-peak velocity on several myocardial
segments. In this context, examples on each mode acquired from normal and diseased

Received: August 19, 2008 Accepted: August 25, 2008

Second Section of Cardiology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Chung Gung
University, Taoyuan, Taiwan.
*Address correspondence to: Dr. Fen-Chiung Lin, Second Section of Cardiology, Department of Internal
Medicine, Chang Gung Medical Center, Lin-Kou Medical Center, Chang Gung University, Medical College,
5 Fu-Xing Street, Guwei-San Siang, Taoyuan Sien, Taiwan. E-mail: fclin1952@yahoo.com.tw

202 J Med Ultrasound 2008 Vol 16 No 3 Elsevier & CTSUM. All rights reserved.

regional myocardium will be shown. Thus, TDI will hopefully be more easily and widely
accepted by echocardiographers and in clinical applications.
KEY WORDS strain and strain rate, tissue Doppler image, tissue synchronization
image
J Med Ultrasound 2008;16(3):202209
Introduction
Conventional evaluation of global and regional
myocardial contractile function using noninvasive
echocardiography mainly depends on visual assess-
ment of the degree of myocardial thickening and
endocardial inward motion, as well as M-mode
and two-dimensional echocardiographic measure-
ments of left ventricular (LV) ejection fraction (LVEF)
[1]. Visual assessment is known to be very subjec-
tive and, hence, has a high degree of intraobserver
and interobserver variability. A certain degree of
disagreement has also been noted for LVEF meas-
urements made by echocardiography [24]. Tissue
Doppler imaging (TDI) echocardiography has been
used for several decades; however, its clinical appli-
cation has been controversial.
In contrast to conventional Doppler color ultra-
sound, TDI can detect low-velocity, high-intensity
myocardial tissue motion to depict low-intensity,
high-velocity blood flow, mainly red blood cell flow
motion velocity. TDI has a frame rate of 90200
frames per second (fps), thus has the advantages
of high temporal resolution up to 5 milliseconds
and high spatial resolution up to 1 mm. This high
spatial and temporal resolution is far beyond the
capabilities of human vision but has the disadvan-
tage of invisibility, and thus limits its clinical appli-
cability [59].
Tissue Doppler Imaging (TDI)
The digitized data sets acquired by various TDI
modes, defined by various names, and by different
echo instrument companies, have mostly emphasized
Introduction to Tissue Doppler Echocardiography
the convenience of data retrieval and its off-line
analysis capability using various analytical software
[8,9]. However, the data acquired by those TDI
modes are the mean myocardial motion velocities
[10,11]. A tiny variation in the sample volume
placement during off-line analysis can result in a
big difference in the velocity-time integral (VTI)
expression, which then causes further variation in
the VTI-derived parametric data. The parametric
data includes strain (S), and strain rate (SR) which
are derived from the TDI examination [1220].
Hence, the introduction of various modes of TDI
and its derived parametric images in the present
study will be based on the pulsed-wave TDI (PWTDI)
mode [10].
TDI examination can detect LV myocardial
motion velocity in its longitudinal axis. Therefore,
a TDI examination is usually performed via an api-
cal approach using three apical views. The LV myo-
cardium is divided into 16 segments according to
the coronary artery supply, as recommended by
the American Society of Echocardiography [1].
A segmental longest time-to-peak velocity (TpV)
of the basal septal and mid-septal segments can
be detected on the medial side myocardium by
an apical four-chamber view, along with basal
and mid-lateral segments on the left lateral side
myocardium by an apical four-chamber view. The
basal, middle segmental TpV of the inferior and
anterior segmental TpV can be detected by an apical
two-chamber view. Likewise, the TpV of the basal,
middle posterior segments and anteroseptal seg-
ments of the LV myocardium can be detected on
an apical long-axis view (Figs. 1 and 2). The trans-
ducer should be aligned to the myocardial region
of interest as parallel as possible to obtain an optimal
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 F.C. Lin, I.C. Hsieh, C.H. Lee, et al
Mid septum Mid lateral
Mid
inferior
Basal septum
Basal lateral
Basal
inferior
Apical four-chamber view Apical two-chamber view
Fig. 1. Three apical views (the apical four-chamber, the apical two-chamber view and the apical long-axis view). The left ventricle
is divided into 16 segments as recommended by the American Society of Echocardiography. The nomenclature of the basal and mid
segments shown on the figure relate to the 12 non-apical segments.
Diastole
Systole
Longitudinal axis
Fig. 2. Figure illustrates the principle direction of left ventric-
ular myocardial deformation during systole (black arrows) and
diastole (red arrows) on the longitudinal axis, view from the apex.
maximal VTI, so as to define an optimal peak
velocity for a precise TpV measurement [1219].
In normal functioning regional myocardial seg-
ments, the myocardium of the base moves to-
wards the apex during systole, on a longitudinal
axis. The myocardial motion velocity is maximal at
the base, lower in the mid-segment, and least at
the apex, which can be obtained by TDI mode
[2026]. The PWTDI mode acquires the maximal
velocity (Fig. 3A), the color flow M-mode depicts
the mean velocity of the entire sector image
[2732] (Fig. 4).
204 J Med Ultrasound 2008 Vol 16 No 3
Mid
Mid Mid
anterior
posterior anteroseptal
Basal
Basal Basal
anterior posterior anteroseptal
Apical long-axis view
The total displacement of the basal anterior
segment is between 4 and 6 mm at end-systole,
shown as green, which correlates with the semi-
quantitative scale color bar shown on the left upper
two-dimensional sector frame (Fig. 5).
Strain and Strain Rate Image
The strain (S) is defined as the percent change,
shortening or lengthening, relative to its original
length. A normal S on the longitudinal axis is a
negative % value, representing normal myocardial
shortening during systole (Fig. 6). The myocardial
tissue motion velocity gradient is used to calculate
the strain rate (SR). SR is the velocity difference
between two points along the ultrasound beam
parallel to the myocardial wall, divided by the dis-
tance between the two points (Figs. 7 and 8). The
two points move closer to each other in systole and
away from each other in diastole.
Tissue synchronization image mode is a semi-
quantitative color-coded mode which depicts the
segmental peak mean velocity, using color bar to
code the TpV as green to red according to the time
sequence.

A A
B B
Fig. 3. (A) Pulsed-wave tissue Doppler imaging (PWTDI) mode
acquired segmental time-to-peak velocity (TpV) of the basal
anterior segment on apical two-chamber view. TpV = 85 milli-
seconds by PWTDI. The peak velocity (Vp) = 6.66 cm/s, as
shown on the left upper column. This figure was designed to
compare these values with those in (B). The TpV of the basal
anterior segment was shorter than the mid-inferior segment,
and there was no postsystolic shortening (PSS) in (A). The Vp
was higher in the basal anterior segment shown in (A), than the
Vp in the mid-inferior segment shown in (B). (B) PWTDI mode
examination, with the sample volume placed at the mid-inferior
segment to acquire a TpV of 439.9 milliseconds with a PSS,
and Vp was 3.59 cm/s as shown on the left upper column.
The following figures show examples in a pa-
tient case, which were used to illustrate the possi-
ble clinical application of each image mode. All the
parametric images were calculated and derived
from PWTDI. The figures shown in pairs were de-
signed to compare a normal functioning myocar-
dial segment (basal anterior segment) and an
abnormal VTI acquired by PWTDI on the LV
mid-inferior segment of this patient.
Introduction to Tissue Doppler Echocardiography
Fig. 4. (A) Color flow M (CFM) mode depicted the mean
velocity of the entire sector of the myocardium. The velocity-
time integral shown on the left, with the time-to-peak mean
velocity (t) of 280 milliseconds, the peak mean velocity was
3.07 cm/s. Mean velocity is lower than the peak velocity
acquired by pulsed-wave tissue Doppler imaging (PWTDI)
mode. The yellow circle indicated the myocardial region of inter-
est in the basal anterior segment on apical two-chamber view.
The region of interest by CFM mode correlated with the sam-
ple volume placement location using PWTDI mode in Fig. 3A.
(A) was designed to contrast with (B), to demonstrate a
higher-peak mean velocity of the basal anterior segment com-
pared with the lower-peak mean velocity of the mid-inferior
segment, and to demonstrate (B) the tissue Doppler imaging
examination by CFM mode. The CFM mode demonstrated a
delay in time-to-peak velocity (TpV)(t) of the mid-inferior seg-
ment measured from the onset of electrocardiogram R-wave
to the peak mean velocity on time-velocity integral was 440
milliseconds, shown on the left frame. The yellow circle in both
two-dimensional frames indicates the region of interest in the
mid-inferior myocardial segment, which correlated with the
sample volume placement on PWTDI mode shown in Fig. 3B.
The TpV showed that a delay occurred after aortic valve clo-
sure. The peak velocity (v) was 3.69 cm/s, as shown in the
right upper area of the figure.
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 F.C. Lin, I.C. Hsieh, C.H. Lee, et al

A B

Fig. 5. (A) Total displacement at end-systole of the basal-anterior segment was between 4 and 6 mm, expressed in green, and correlated
with the color bar shown on the right of the left frame. (A) was designed to contrast with (B), which showed a smaller total displace-
ment (1.9 mm) of the mid-inferior segment, compared with the larger total displacement (46 mm) of the basal-anterior segment
at end-systole. The time point at the end of the electrocardiogram T-wave is shown at the bottom of the right frame. (B) The total
segmental displacement (D) of the mid-inferior segment was 1.9 mm at end-systole. The time frame was frozen and is shown on the
electrocardiogram at the bottom of each frame. In the right upper area of the figure, the time to maximal displacement is shown.
The color bar to the right on the left upper area represents the total displacement by color display.

A B

Fig. 6. (A) Strain image (SI) of the basal anterior segment shows that the peak strain (S) was 19% before aortic valve closure
(AVC), and was 20% after AVC. When (A) and (B) were compared, the peak S was 31% for the mid-inferior segment, which
was higher than the peak S for the basal anterior segment. (B) The SI of the mid-inferior segment showed an S of 31% on longi-
tudinal axis, before AVC. A delayed second peak S was 28% at the time (t) of postsystolic shortening after AVC. The time to
delayed second peak S was 305 milliseconds, shown in the right upper area of the figure. The SI measures the percentage change in
dimension or length, normalized to the initial length, and was negative in percentage during systole on longitudinal axis on apical
two-chamber view, which represented myocardial shortening during systole. The S value would be positive in percentage if the
myocardial showed an abnormal lengthening during systole, which would usually represent myocardial aneurysm formation.

The legend for each figure illustrates the differ-
ent results obtained using each parametric mode
derived from TDI. A sample volume was placed at
the same region of interest on the same segment,
as similar as possible, in the different modes, which
made the comparison more meaningful.
Explaining Various TDI Modes, Including
Parametric Derivatives, Using the
Following Patient as an Example
The 50-year-old male patient suffered an acute ante-
rior wall myocardial infarction 4 years previously.

206 J Med Ultrasound 2008 Vol 16 No 3

 Introduction to Tissue Doppler Echocardiography

A B

Fig. 7. (A) Strain rate (SR) image showed a normal peak SR of 1.0 for the basal anterior segment. In a comparison of (A) and (B),
the second peak SR shown on (A) occurred at the time of aortic valve closure (AVC). The mid-inferior segment had a higher positive
SR of +1.5 on (B) than the smaller +0.3 for the basal anterior segment on (A) at the turning point before the second negative SR.
This was suggestive of a higher myocardial deformation in the mid-inferior segment, more than that in the basal anterior segment.
(B) SR imaging of the mid-inferior segment on longitudinal axis showed a peak SR of 2.2 before AVC, and there was another
peak SR of 1.3 after AVC, at the time of postsystolic shortening. SRI depicts the rate of velocity change (1/second) along the
distance between the two velocities.

A B

Fig. 8. (A) Tissue synchronization image (TSI) mode examination of the basal anterior segment depicted a shorter time-to-peak
velocity (TpV) of around 85 milliseconds, coded as green, comparable to the color bar scale shown at the upper part of the left
frame in the two-dimensional color sector. Comparing the color coded as red by TSI mode in the mid-inferior segment shown on
both (A) and (B), the time velocity integral on the left in (B) showed a delayed TpV of 440 milliseconds at the time of postsystolic
shortening. (B) TSI mode depicted the time scale of segmental TpV expressed by color bar green to red, as shown in the right upper
area on the left upper frame. The electrocardiogram phasic scale is shown at the bottom of the right frame. The red mark on the
electrocardiogram represented the total time scale on the present TSI mode. The TpV of the mid-inferior segment was coded as red,
which correlated with a TpV of around 440 milliseconds, more than 330 milliseconds.

The patient received percutaneous coronary inter-
vention for left anterior descending coronary artery
stenosis. LVEF was 46% by ventriculography, and
the patient showed hypokinesia of the anterior
and anteroseptal segments. LVEF improved to 65%
on ventriculography at 1-year follow-up, and cor-
onary angiography showed no restenosis at the
previous stent site. Two-dimensional echocardiog-
raphy 4 years later showed an adequate global LV
contractility, without any segmental wall motion

J Med Ultrasound 2008 Vol 16 No 3 207

 F.C. Lin, I.C. Hsieh, C.H. Lee, et al
abnormality. However, PWTDI examination demon-
strated a delay in segmental TpV of the mid-inferior
segment (Fig. 3B).
Conclusion
Using PWTDI mode as the basic TDI examination
to derive other parametric images would allow this
novel technique more clinical applicability. Possible
tedious and time-consuming work off-line after
processing for data analysis may also become easier.
More importantly, the fixed sample volume location
inside the same myocardial segment performed by
PWTDI may increase the intraobserver and inter-
observer agreement, thus making TDI a more com-
prehensive tool in interpreting the parametric data
derived from PWTDI examinations. The data analysis
in each mode would be more meaningful and could
be helpful in patient decision making, and would
be more widely accepted in clinical applications.
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