Title: A Clinician’s Guide to Tissue Doppler Imaging
Abstract: HomeCirculationVol. 113, No. 10A Clinician’s Guide to Tissue Doppler Imaging Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBA Clinician’s Guide to Tissue Doppler Imaging Carolyn Y. Ho, MD and Scott D. Solomon, MD Carolyn Y. HoCarolyn Y. Ho From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, Mass. Search for more papers by this author and Scott D. SolomonScott D. Solomon From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, Mass. Search for more papers by this author Originally published14 Mar 2006https://doi.org/10.1161/CIRCULATIONAHA.105.579268Circulation. 2006;113:e396–e398Tissue Doppler imaging (TDI) is a relatively new echocardiographic technique that uses Doppler principles to measure the velocity of myocardial motion. We describe the principles behind and the clinical utility of TDI.Principles of TDIDoppler echocardiography relies on detection of the shift in frequency of ultrasound signals reflected from moving objects. With this principle, conventional Doppler techniques assess the velocity of blood flow by measuring high-frequency, low-amplitude signals from small, fast-moving blood cells. In TDI, the same Doppler principles are used to quantify the higher-amplitude, lower-velocity signals of myocardial tissue motion.There are important limitations to TD interrogation. As with all Doppler techniques, TDI measures only the vector of motion that is parallel to the direction of the ultrasound beam. In addition, TDI measures absolute tissue velocity and is unable to discriminate passive motion (related to translation or tethering) from active motion (fiber shortening or lengthening). The emerging technology of Doppler strain imaging provides a means to differentiate true contractility from passive myocardial motion by looking at relative changes in tissue velocity.TDI can be performed in pulsed-wave and color modes. Pulsed-wave TDI is used to measure peak myocardial velocities and is particularly well suited to the measurement of long-axis ventricular motion because the longitudinally oriented endocardial fibers are most parallel to the ultrasound beam in the apical views. Because the apex remains relatively stationary throughout the cardiac cycle, mitral annular motion is a good surrogate measure of overall longitudinal left ventricular (LV) contraction and relaxation.1To measure longitudinal myocardial velocities, the sample volume is placed in the ventricular myocardium immediately adjacent to the mitral annulus. The cardiac cycle is represented by 3 waveforms (Figure): (1) Sa, systolic myocardial velocity above the baseline as the annulus descends toward the apex; (2) Ea, early diastolic myocardial relaxation velocity below the baseline as the annulus ascends away from the apex; and (3) Aa, myocardial velocity associated with atrial contraction. The lower-case “a” for annulus or “m” for myocardial (Ea or Em) and the superscripted prime symbol (E′) are used to differentiate tissue Doppler velocities from conventional mitral inflow. Pulsed-wave TDI has high temporal resolution but does not permit simultaneous analysis of multiple myocardial segments. Download figureDownload PowerPointThe upper panel illustrates conventional Doppler interrogation of mitral inflow. The normal mitral valve inflow pattern is characterized by E>A and an E-wave deceleration time of 150 to 220 ms. Impaired LV relaxation or decreased LV compliance is associated with a reversal of E and A waves and prolongation of E-wave deceleration to >220 ms. Pseudonormalization of the E-A ratio can occur when increased left atrial pressure results in an increased driving pressure and a consequent increased E-wave velocity across the mitral valve into a noncompliant LV. With severe diastolic dysfunction, the mitral valve inflow pattern can become restrictive, reflecting rapid equilibration of elevated left atrial and LV diastolic pressures in the noncompliant LV. The lower panel illustrates the 3 basic waveforms of tissue Doppler interrogation: Sa (systolic myocardial motion), Ea (early diastolic motion), and Aa (atrial contraction). Other abbreviations are as defined in text.With color TDI, a color-coded representation of myocardial velocities is superimposed on gray-scale 2-dimensional or M-mode images to indicate the direction and velocity of myocardial motion. Color TDI mode has the advantage of increased spatial resolution and the ability to evaluate multiple structures and segments in a single view.Clinical Applications of TDIAssessment of LV Systolic FunctionSystolic myocardial velocity (Sa) at the lateral mitral annulus is a measure of longitudinal systolic function and is correlated with measurements of LV ejection fraction2 and peak dP/dt.3 A reduction in Sa velocity can be detected within 15 seconds of the onset of ischemia,4 and regional reductions in Sa are correlated with regional wall-motion abnormalities. Incorporation of TDI measures of systolic function in exercise testing to assess for ischemia, viability, and contractile reserve has been suggested5 because peak Sa velocity normally increases with dobutamine infusion and exercise6 and decreases with ischemia.7 The technical difficulties of timely acquisition of both 2-dimensional and TDI data during exercise represent the major limitations to routine integration in stress testing.Assessment of Diastolic FunctionTraditional echocardiographic assessment of LV diastolic function relied on Doppler patterns of mitral inflow. Reflecting the pressure gradient between the left atrium and LV, transmitral velocities are directly related to left atrial pressure (preload) and independently and inversely related to ventricular relaxation. Because mitral inflow patterns are highly sensitive to preload and can change dramatically as diastolic dysfunction progresses, the use of mitral valve inflow patterns to assess diastolic function remains limited.TDI assessment of diastolic function is less load dependent than that provided by standard Doppler techniques. Ea reflects the velocity of early myocardial relaxation as the mitral annulus ascends during early rapid LV filling. Peak Ea velocity can be measured from any aspect of the mitral annulus from the apical views, with the lateral annulus most commonly used. Because of intrinsic differences in myocardial fiber orientation, septal Ea velocities are slightly lower than lateral Ea velocities.Validated against invasive hemodynamic measures, TDI can be correlated with τ, the time constant of isovolumic relaxation.8 Lateral Ea velocities can be 20 cm/s or higher in children and healthy young adults, but these values decline with age. In adults >30 years old, a lateral Ea velocity >12 cm/s is associated with normal LV diastolic function.9 Reductions in lateral Ea velocity to ≤8 cm/s in middle-aged to older adults indicate impaired LV relaxation and can assist in differentiating a normal from a pseudonormal mitral inflow pattern. Unlike conventional mitral inflow patterns, Ea is resistant to changes in filling pressure, although preload dependence is more pronounced in structurally normal hearts.Novel Applications of TDIA number of emerging applications for TDI are under active investigation.Estimation of LV Filling PressuresSimultaneous cardiac catheterization and echocardiographic studies have shown that LV filling pressures are correlated with the ratio of the mitral inflow E wave to the tissue Doppler Ea wave (E/Ea).10,11 This relation is based on Ea velocities that “correct” E-wave velocities for the impact of relaxation. The E/Ea ratio can be used to estimate LV filling pressures as follows: E/lateral Ea>10 or E/septal Ea>15 is correlated with an elevated LV end-diastolic pressure, and E/Ea<8 is correlated with a normal LV end-diastolic pressure.Differentiation Between Constrictive and Restrictive PhysiologyBoth constrictive pericarditis and restrictive cardiomyopathy are associated with abnormal LV filling. With constrictive physiology, pericardial constraint impedes normal filling. In the absence of myocardial disease, Ea velocities typically remain normal. In contrast, the intrinsic myocardial abnormalities characteristic of restrictive cardiomyopathy result in impaired relaxation and reduced Ea velocities.Early Diagnosis of Genetic DiseaseAlthough unexplained LV hypertrophy is typically required to diagnose hypertrophic cardiomyopathy (HCM), the degree of hypertrophy and age of onset are highly variable. Abnormalities of diastolic function, as reflected by a reduction of Ea velocities, are present in individuals who have inherited a sarcomere gene mutation before the development of LV hypertrophy.12,13 Reduced Ea velocities have been similarly demonstrated in patients in the early stages of Fabry disease.14Differentiation of Athlete’s Heart From HCMApproximately 2% of elite athletes may have an abnormal degree of LV hypertrophy.15 Discriminating physiological hypertrophy due to intense athletic conditioning from pathological hypertrophy can be challenging. Athletes typically have highly compliant ventricles with brisk Ea velocities, in contrast to the reduced Ea velocities in individuals with HCM.16Assessment of Cardiac DyssynchronyIdentifying patients who will benefit from cardiac resynchronization therapy, which can improve heart failure morbidity and mortality rates, has been challenging. TDI can be used to assess the relative timing of peak systolic contraction in multiple myocardial regions.17 The standard deviation of the time to peak contraction represents a measure of overall ventricular synchrony and may help identify potential responders to cardiac resynchronization therapy.Assessment of Right Ventricular FunctionThe complexity of right ventricular anatomy and geometry challenges accurate assessment of right ventricular systolic function, an important prognostic indicator in patients with heart failure and in postinfarction patients.18 Reduced tricuspid annular velocities with TDI have been documented in a variety of disease settings, including postinferior myocardial infarction, chronic pulmonary hypertension, and chronic heart failure.19The online-only Data Supplement, which contains a movie, is available at http://circ.ahajournals.org/cgi/content/full/113/10/e396/DC1.DisclosuresNone.FootnotesCorrespondence to Scott D. Solomon, MD, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail [email protected] References 1 Vinereanu D, Khokhar A, Fraser AG. Reproducibility of pulsed wave tissue Doppler echocardiography. J Am Soc Echocardiogr. 1999; 12: 492–499.CrossrefMedlineGoogle Scholar2 Galiuto L, Ignone G, DeMaria AN. Contraction and relaxation velocities of the normal left ventricle using pulsed-wave tissue Doppler echocardiography. Am J Cardiol. 1998; 81: 609–614.CrossrefMedlineGoogle Scholar3 Yamada H, Oki T, Tabata T, Iuchi A, Ito S. Assessment of left ventricular systolic wall motion velocity with pulsed tissue Doppler imaging: comparison with peak dP/dt of the left ventricular pressure curve. J Am Soc Echocardiogr. 1998; 11: 442–449.CrossrefMedlineGoogle Scholar4 Edvardsen T, Skulstad H, Aakhus S, Urheim S, Ihlen H. Regional myocardial systolic function during acute myocardial ischemia assessed by strain Doppler echocardiography. J Am Coll Cardiol. 2001; 37: 726–730.CrossrefMedlineGoogle Scholar5 Marwick TH, Case C, Leano R, Short L, Baglin T, Cain P, Garrahy P. Use of tissue Doppler imaging to facilitate the prediction of events in patients with abnormal left ventricular function by dobutamine echocardiography. Am J Cardiol. 2004; 93: 142–146.CrossrefMedlineGoogle Scholar6 Pasquet A, Armstrong G, Beachler L, Lauer MS, Marwick TH. Use of segmental tissue Doppler velocity to quantitate exercise echocardiography. J Am Soc Echocardiogr. 1999; 12: 901–912.CrossrefMedlineGoogle Scholar7 Altinmakas S, Dagdeviren B, Uyan C, Keser N, Gumus V, Pektas O. Prediction of viability by pulsed-wave Doppler tissue sampling of asynergic myocardium during low-dose dobutamine challenge. Int J Cardiol. 2000; 74: 107–113.CrossrefMedlineGoogle Scholar8 Sohn DW, Chai IH, Lee DJ, Kim HC, Kim HS, Oh BH, Lee MM, Park YB, Choi YS, Seo JD, Lee YW. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol. 1997; 30: 474–480.CrossrefMedlineGoogle Scholar9 Yamada H, Oki T, Mishiro Y, Tabata T, Abe M, Onose Y, Wakatsuki T, Ito S. Effect of aging on diastolic left ventricular myocardial velocities measured by pulsed tissue Doppler imaging in healthy subjects. J Am Soc Echocardiogr. 1999; 12: 574–581.CrossrefMedlineGoogle Scholar10 Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quinones MA. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol. 1997; 30: 1527–1533.CrossrefMedlineGoogle Scholar11 Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation. 2000; 102: 1788–1794.CrossrefMedlineGoogle Scholar12 Nagueh SF, Bachinski LL, Meyer D, Hill R, Zoghbi WA, Tam JW, Quinones MA, Roberts R, Marian AJ. Tissue Doppler imaging consistently detects myocardial abnormalities in patients with hypertrophic cardiomyopathy and provides a novel means for an early diagnosis before and independently of hypertrophy. Circulation. 2001; 104: 128–130.CrossrefMedlineGoogle Scholar13 Ho CY, Sweitzer NK, McDonough B, Maron BJ, Casey SA, Seidman JG, Seidman CE, Solomon SD. Assessment of diastolic function with Doppler tissue imaging to predict genotype in preclinical hypertrophic cardiomyopathy. Circulation. 2002; 105: 2992–2997.LinkGoogle Scholar14 Pieroni M, Chimenti C, Ricci R, Sale P, Russo MA, Frustaci A. Early detection of Fabry cardiomyopathy by tissue Doppler imaging. Circulation. 2003; 107: 1978–1984.LinkGoogle Scholar15 Maron BJ. Sudden death in young athletes. N Engl J Med. 2003; 349: 1064–1075.CrossrefMedlineGoogle Scholar16 Cardim N, Oliveira AG, Longo S, Ferreira T, Pereira A, Reis RP, Correia JM. Doppler tissue imaging: regional myocardial function in hypertrophic cardiomyopathy and in athlete’s heart. J Am Soc Echocardiogr. 2003; 16: 223–232.CrossrefMedlineGoogle Scholar17 Yu CM, Fung JW, Zhang Q, Chan CK, Chan YS, Lin H, Kum LC, Kong SL, Zhang Y, Sanderson JE. Tissue Doppler imaging is superior to strain rate imaging and postsystolic shortening on the prediction of reverse remodeling in both ischemic and nonischemic heart failure after cardiac resynchronization therapy. Circulation. 2004; 110: 66–73.LinkGoogle Scholar18 Zornoff LA, Skali H, Pfeffer MA, St John Sutton M, Rouleau JL, Lamas GA, Plappert T, Rouleau JR, Moye LA, Lewis SJ, Braunwald E, Solomon SD. Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction. J Am Coll Cardiol. 2002; 39: 1450–1455.CrossrefMedlineGoogle Scholar19 Meluzin J, Spinarova L, Bakala J, Toman J, Krejci J, Hude P, Kara T, Soucek M. Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion; a new, rapid, and non-invasive method of evaluating right ventricular systolic function. Eur Heart J. 2001; 22: 340–348.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Boissier F and Aissaoui N (2022) Septic cardiomyopathy: Diagnosis and management, Journal of Intensive Medicine, 10.1016/j.jointm.2021.11.004, 2:1, (8-16), Online publication date: 1-Jan-2022. Al-Biltagi M, Elrazaky O, Mawlana W, Srour E and Shabana A (2022) Tissue Doppler, speckling tracking and four-dimensional echocardiographic assessment of right ventricular function in children with dilated cardiomyopathy, World Journal of Clinical Pediatrics, 10.5409/wjcp.v11.i1.71, 11:1, (71-84), Online publication date: 9-Jan-2022. Zhang Y, Wu F, Gao Y, Wu N, Yang G, Li M, Zhou L, Xu D and Chen M (2021) Bachmann bundle impairment following linear ablation of left anterior wall: impact on left atrial function, The International Journal of Cardiovascular Imaging, 10.1007/s10554-021-02362-5, 38:1, (41-50), Online publication date: 1-Jan-2022. Argirò A, Rosenblum H, Griffin J, Batra J, Cappelli F, Burkhoff D, Maurer M and Olivotto I (2022) Sex related differences in exercise performance in patients with hypertrophic cardiomyopathy: Hemodynamic insights through non-invasive pressure volume analysis, International Journal of Cardiology, 10.1016/j.ijcard.2021.12.045, 351, (78-83), Online publication date: 1-Mar-2022. Dammassa V, Colombo C, Greco A, Guida S, Boffi A, Mojoli F, Ghio S, Price S and Tavazzi G (2021) Right ventricular time intervals – Comparison between pulsed wave Doppler and tissue Doppler imaging, Echocardiography, 10.1111/echo.15209, 38:10, (1762-1768), Online publication date: 1-Oct-2021. Soliman-Aboumarie H, Pastore M, Galiatsou E, Gargani L, Pugliese N, Mandoli G, Valente S, Hurtado-Doce A, Lees N and Cameli M Echocardiography in the intensive care unit: an essential tool for diagnosis, monitoring and guiding clinical decision-making, Imaging, 10.1556/1647.2021.00055 Razpotnik M, Bota S, Wimmer P, Hackl M, Lesnik G, Alber H, Peck‐Radosavljevic M and Hernandez‐Gea V (2021) The prevalence of cirrhotic cardiomyopathy according to different diagnostic criteria, Liver International, 10.1111/liv.14769, 41:5, (1058-1069), Online publication date: 1-May-2021. Sanfilippo F, Huang S, Messina A, Franchi F, Oliveri F, Vieillard-Baron A, Cecconi M and Astuto M (2021) Systolic dysfunction as evaluated by tissue Doppler imaging echocardiography and mortality in septic patients: A systematic review and meta-analysis, Journal of Critical Care, 10.1016/j.jcrc.2020.12.026, 62, (256-264), Online publication date: 1-Apr-2021. Kahl U, Vens M, Pollok F, Menke M, Duckstein C, Gruetzmacher J, Schirren L, Yu Y, Fischer M, Zöllner C, Goepfert M and Roeher K (2020) Do Elderly Patients With Diastolic Dysfunction Require Higher Doses of Norepinephrine During General Anesthesia for Noncardiac Surgeries? A Prospective Observational Study, Anesthesia & Analgesia, 10.1213/ANE.0000000000005304, 132:2, (420-429), Online publication date: 1-Feb-2021. de Haas S, Spaanderman M, van Kuijk S, van Drongelen J, Mohseni Z, Jorissen L and Ghossein-Doha C (2021) Adaptation of left ventricular diastolic function to pregnancy: a systematic review and meta-analysis, Journal of Hypertension, 10.1097/HJH.0000000000002886, 39:10, (1934-1941), Online publication date: 1-Oct-2021. Soltani A, Lahti J, Järvelä K, Laurikka J and Hokka M (2020) Quantitative assessment of full field deformation of right ventricle during open heart surgery, Computer Methods in Biomechanics and Biomedical Engineering: Imaging & Visualization, 10.1080/21681163.2020.1827042, 9:2, (157-165), Online publication date: 4-Mar-2021. Gonzales R, Lamy J, Seemann F, Heiberg E, Onofrey J and Peters D (2021) TVnet: Automated Time-Resolved Tracking of the Tricuspid Valve Plane in MRI Long-Axis Cine Images with a Dual-Stage Deep Learning Pipeline Medical Image Computing and Computer Assisted Intervention – MICCAI 2021, 10.1007/978-3-030-87231-1_55, (567-576), . Lai S, Mangiulli M, Perrotta A, Gigante A, Napoleoni L, Cipolloni E, Mitterhofer A, Gasperini M, Muscaritoli M, Cianci R, Giovannetti A, Falco F, Mastroluca D and Mazzaferro S Cardiovascular Risk and Quality of Life in Autosomal Dominant Polycystic Kidney Disease Patients on Therapy With Tolvaptan: A Pilot Study, Current Vascular Pharmacology, 10.2174/1570161118999200918094809, 19:5, (556-564) Lai S, Amabile M, Mazzaferro S, Mitterhofer A, Mazzarella A, Galani A, Imbimbo G, Cianci R, Pasquali M and Molfino A (2020) Effects of sunitinib on endothelial dysfunction, metabolic changes, and cardiovascular risk indices in renal cell carcinoma, Cancer Medicine, 10.1002/cam4.2910, 9:11, (3752-3757), Online publication date: 1-Jun-2020. Lai S, Petramala L, Muscaritoli M, Cianci R, Mazzaferro S, Mitterhofer A, Pasquali M, D'Ambrosio V, Carta M, Ansuini M, Ramaccini C, Galani A, Amabile M, Molfino A and Letizia C (2020) α-lipoic acid in patients with autosomal dominant polycystic kidney disease, Nutrition, 10.1016/j.nut.2019.110594, 71, (110594), Online publication date: 1-Mar-2020. Quintana R, Palaskas N and Banchs J (2020) Hemodynamic Evaluation and Echocardiography in the Oncologic Intensive Care Unit Oncologic Critical Care, 10.1007/978-3-319-74588-6_64, (753-773), . 董 华 (2020) New EDITION Interpretation of ASE Guide to Adult Ultrasonic Cardiogram—Instrument Adjustment, Advances in Clinical Medicine, 10.12677/ACM.2020.105118, 10:05, (768-774), . Binka E and Urbina E (2022) Cardiovascular Assessment of Childhood Hypertension Pediatric Hypertension, 10.1007/978-3-319-31420-4_53-2, (1-19), . Leng S, Zhao X, Koh A, Zhao L, Allen J, Tan R, Ma X and Zhong L (2019) Age-related changes in four-dimensional CMR-derived atrioventricular junction velocities and displacements: Implications for the identification of altered annular dynamics for ventricular function assessment, IJC Heart & Vasculature, 10.1016/j.ijcha.2018.11.001, 22, (6-12), Online publication date: 1-Mar-2019. Mitchell C, Rahko P, Blauwet L, Canaday B, Finstuen J, Foster M, Horton K, Ogunyankin K, Palma R and Velazquez E (2019) Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography, Journal of the American Society of Echocardiography, 10.1016/j.echo.2018.06.004, 32:1, (1-64), Online publication date: 1-Jan-2019. Sobhy R, Samir M, Abdelmohsen G, Ibrahim H, Abd El Rahman M, Abdelrahman N, Behairy N, Imam O and Hamza H (2018) Subtle Myocardial Dysfunction and Fibrosis in Children with Rheumatic Heart Disease: Insight from 3D Echocardiography, 3D Speckle Tracking and Cardiac Magnetic Resonance Imaging, Pediatric Cardiology, 10.1007/s00246-018-2006-5, 40:3, (518-525), Online publication date: 1-Mar-2019. Zanardini C, D'Antonio F, Hvingel B, Vårtun Å, Prefumo F, Flacco M, Manzoli L and Acharya G (2019) Agreement between anatomical M‐mode and tissue Doppler imaging in the assessment of fetal atrioventricular annular plane displacement in uncomplicated pregnancies: A prospective longitudinal study, Journal of Obstetrics and Gynaecology Research, 10.1111/jog.14068, 45:11, (2150-2157), Online publication date: 1-Nov-2019. Abdelmohsen G, Mohamed H, Mohsen M, Abdelaziz O, Ahmed D, Abdelsalam M and Dohain A (2019) Evaluation of cardiac function in pediatric patients with mild to moderate bronchial asthma in the era of cardiac strain imaging, Pediatric Pulmonology, 10.1002/ppul.24485, 54:12, (1905-1913), Online publication date: 1-Dec-2019. Simpson T, Tyler J, Thomas R, Fang Q, Bibby D and Schiller N (2018) Mitral annular peak systolic and diastolic velocities are characteristic of healthy hearts: A Doppler tissue imaging study, Echocardiography, 10.1111/echo.14247, 36:3, (433-438), Online publication date: 1-Mar-2019. Quintana R, Palaskas N and Banchs J (2019) Hemodynamic Evaluation and Echocardiography in the Oncologic Intensive Care Unit Oncologic Critical Care, 10.1007/978-3-319-74698-2_64-1, (1-21), . Hiebert J, Vacek J, Shah Z, Rahman F and Pierce J (2019) Use of speckle tracking to assess heart failure with preserved ejection fraction, Journal of Cardiology, 10.1016/j.jjcc.2019.06.004, 74:5, (397-402), Online publication date: 1-Nov-2019. Ince M, Turgut K, Akar A, Naseri A, Sen I, Süleymanoglu H, Ertan M and Sagmanligil V Prognostic importance of tissue Doppler imaging of systolic and diastolic functions in dogs with severe sepsis and septic shock, Acta Veterinaria Hungarica, 10.1556/004.2019.051, 67:4, (517-528) Zhang X, Wu C, Ye P, Sheng L and Luo L (2019) Right ventricle may be involved in regional diastolic dysfunction earliest in primary hypertension patients, Journal of Cellular Biochemistry, 10.1002/jcb.29112, 120:10, (18088-18093), Online publication date: 1-Oct-2019. Wibowo N, Lestari P and Alexander E (2019) Hemodynamic Profile and Cardiac Morphometry in Normotensive and Severe Preeclamptic Pregnant Women, Journal of South Asian Federation of Obstetrics and Gynaecology, 10.5005/jp-journals-10006-1677, 11:2, (113-119), Online publication date: 1-Apr-2019. Naseri A, Sen I, Turgut K, Guzelbektes H and Constable P (2019) Echocardiographic assessment of left ventricular systolic function in neonatal calves with naturally occurring sepsis or septic shock due to diarrhea, Research in Veterinary Science, 10.1016/j.rvsc.2019.08.009, 126, (103-112), Online publication date: 1-Oct-2019. Leng S, Zhang S, Jiang M, Zhao X, Wu R, Allen J, He B, Tan R and Zhong L (2018) Imaging 4D morphology and dynamics of mitral annulus in humans using cardiac cine MR feature tracking, Scientific Reports, 10.1038/s41598-017-18354-2, 8:1, Online publication date: 1-Dec-2018. Morgan R, Jerosch-Herold M and Kwong R (2018) Comparison of T1 Mapping by Cardiac MRI to Non-cardiac MRI Methods to Evaluate Cardiac Fibrosis T1-Mapping in Myocardial Disease, 10.1007/978-3-319-91110-6_4, (45-59), . Vallabhajosyula S, Pruthi S, Shah S, Wiley B, Mankad S and Jentzer J (2018) Basic and Advanced Echocardiographic Evaluation of Myocardial Dysfunction in Sepsis and Septic Shock, Anaesthesia and Intensive Care, 10.1177/0310057X1804600104, 46:1, (13-24), Online publication date: 1-Jan-2018. Poonja S, Power A, Mah J, Fine N and Greenway S (2018) Current Cardiac Imaging Approaches in Duchenne Muscular Dystrophy, Journal of Clinical Neuromuscular Disease, 10.1097/CND.0000000000000204, 20:2, (85-93), Online publication date: 1-Dec-2018. Soltani A, Lahti J, Järvelä K, Curtze S, Laurikka J, Hokka M and Kuokkala V (2018) An Optical Method for the In-Vivo Characterization of the Biomechanical Response of the Right Ventricle, Scientific Reports, 10.1038/s41598-018-25223-z, 8:1, Online publication date: 1-Dec-2018. Naseri A, Turgut K, Sen I, Ider M and Akar A (2018) Myocardial depression in a calf with septic shock, Veterinary Record Case Reports, 10.1136/vetreccr-2017-000513, 6:1, Online publication date: 1-Jan-2018. Lai S, Amabile M, Bargagli M, Musto T, Martinez A, Testorio M, Mastroluca D, Lai C, Aceto P and Molfino A (2018) Peritoneal dialysis in older adults, Medicine, 10.1097/MD.0000000000011953, 97:35, (e11953), Online publication date: 1-Aug-2018. Lai S, Mastroluca D, Letizia C, Petramala L, Perrotta A, DiGaeta A, Ferrigno L, Ciccariello M, D'Angelo A and Panebianco V (2018) Magnetic resonance imaging 3T and total fibrotic volume in autosomal dominant polycystic kidney disease, Internal Medicine Journal, 10.1111/imj.14039, 48:12, (1505-1513), Online publication date: 1-Dec-2018. Khavandi K, Aghamohammadzadeh R, Luckie M, Brownrigg J, Alam U, Khattar R, Malik R, Heagerty A and Greenstein A (2017) Abnormal Remodeling of Subcutaneous Small Arteries Is Associated With Early Diastolic Impairment in Metabolic Syndrome, Journal of the American Heart Association, 6:4, Online publication date: 5-Apr-2017. Urbina E (2017) Vascular and Cardiac Imaging Techniques and their Applicability to Childhood Hypertension Pediatric Hypertension, 10.1007/978-3-319-31420-4_53-1, (1-17), . Hall M and Oxorn D (2017) Intraoperative and Procedural Echocardiography Practice of Clinical Echocardiography, 10.1016/B978-0-323-40125-8.00004-4, (59-78), . Richardson C, Amirtharaj C, Gruber D and Hayes D (2016) Assessing Myocardial Function in Infants with Pulmonary Hypertension: The Role of Tissue Doppler Imaging and Tricuspid Annular Plane Systolic Excursion, Pediatric Cardiology, 10.1007/s00246-016-1548-7, 38:3, (558-565), Online publication date: 1-Mar-2017. Shah S, Mahmood A and Coghlan J (2017) Cardiac Involvement: Evaluation and Management Scleroderma, 10.1007/978-3-319-31407-5_22, (331-356), . Hong J, Kim M, Cho M, Choi H, Kang D, Lee S, Lee G, Jeon E, Cho J, Kim K, Yoo B, Lee J, Kim W, Kim K, Chung W, Lee J, Cho M and Kim J (2017) Clinical features of idiopathic restrictive cardiomyopathy, Medicine, 10.1097/MD.0000000000007886, 96:36, (e7886), Online publication date: 1-Sep-2017. Gancheva R, Kundurdjiev A, Ivanova M, Kundurzhiev T and Kolarov Z (2016) Evaluation of cardiovascular risk in stages of gout by a complex multimodal ultrasonography, Rheumatology International, 10.1007/s00296-016-3556-6, 37:1, (121-130), Online publication date: 1-Jan-2017. Özdemir R, Korkmaz H, Küçük M, Karadeniz C, Meşe T and Özkan B (2016) Assessment of early atherosclerosis and left ventricular dysfunction in children with 21-hydroxylase deficiency, Clinical Endocrinology, 10.1111/cen.13275, 86:4, (473-479), Online publication date: 1-Apr-2017. Lai S, Mastroluca D, Matino S, Panebianco V, Vitarelli A, Capotosto L, Turinese I, Marinelli P, Rossetti M, Galani A, Baiocchi P, D’Angelo A and Palange P (2017) Early Markers of Cardiovascular Risk in Autosomal Dominant Polycystic Kidney Disease, Kidney and Blood Pressure Research, 10.1159/000486011, 42:6, (1290-1302), . Nadorlik H, Stiver C, Khan S, Miao Y, Holzer R, Cheatham J and Cua C (2017) Echocardiographic right ventricular function correlations with cardiac catheterisation data in biventri