Left ventricular dyssynchrony using three-dimensional speckle-tracking imaging as a determinant of torsional mechanics in patients with idiopathic dilated cardiomyopathy

Cardiac Resynchronization Therapy in Non-Ischemic Cardiomyopathy: Role of Multimodality Imaging

Non-ischemic cardiomyopathy encompasses a heterogeneous group of diseases, with a generally unfavorable long-term prognosis. Cardiac resynchronization therapy (CRT) is a useful therapeutic option for patients with symptomatic heart failure, currently recommended by all available guidelines, with outstanding benefits, especially in non-ischemic dilated cardiomyopathy. Still, in spite of clear indications based on identifying a dyssynchronous pattern on the electrocardiogram (ECG,) a great proportion of patients are non-responders. The idea that multimodality cardiac imaging can play a role in refining the selection criteria and the implant technique and help with subsequent system optimization is promising. In this regard, predictors of CRT response, such as apical rocking and septal flash have been identified. Promising new data come from studies using cardiac magnetic resonance and nuclear imaging for showcasing myocardial dyssynchrony. Still, to date, no single imaging predictor has been included in the guidelines, probably due to lack of validation in large, multicenter cohorts. This review provides an up-to-date synthesis of the latest evidence of CRT use in non-ischemic cardiomyopathy and highlights the potential additional value of multimodality imaging for improving CRT response in this population. By incorporating all these findings into our clinical practice, we can aim toward obtaining a higher proportion of responders and improve the success rate of CRT.

How His bundle pacing prevents and reverses heart failure induced by right ventricular pacing

Ideal heart performance demands vigorous systolic contractions and rapid diastolic relaxation. These sequential events are precisely timed and interdependent and require the rapid synchronous electrical stimulation provided by the His-Purkinje system. Right ventricular (RV) pacing creates slow asynchronous electrical stimulation that disrupts the timing of the cardiac cycle and results in left ventricular (LV) mechanical asynchrony. Long-term mechanical asynchrony produces LV dysfunction, remodeling, and clinical heart failure. His bundle pacing preserves synchronous electrical and mechanical LV function, prevents or reverses RV pacemaker-induced remodeling, and reduces heart failure.

Echocardiographic tissue imaging evaluation of myocardial characteristics and function in cardiomyopathies

Current echocardiography techniques have allowed more precise assessment of cardiac structure and function of the several types of cardiomyopathies. Parameters derived from echocardiographic tissue imaging (ETI)-tissue Doppler, strain, strain rate, and others-are extensively used to provide a framework in the evaluation and management of cardiomyopathies. Generally, myocardial function assessed by ETI is depressed in all types of cardiomyopathies, non-ischemic dilated cardiomyopathy (DCM) in particular. In hypertrophic cardiomyopathy (HCM), ETI is useful to identify subclinical disease in family members of HCM, to differentiate HCM from other conditions causing cardiac hypertrophy and to predict cardiac events. ETI also for HCM allows addressing the mechanism behind left ventricular outflow tract obstruction and its improvement after therapeutic options. ETI provides cardiac amyloidosis with unique and specific findings such as "apical sparing." Nevertheless, ETI does not seem to provide as much information amenable to histological findings as recently emerging techniques of cardiac magnetic resonance imaging. This review introduces usefulness of ETI and some other ultrasound techniques for detecting clinical and subclinical characteristics of cardiomyopathies, focusing on DCM, HCM, and cardiac amyloidosis.

Assessment of Biventricular Function by Three-Dimensional Speckle Tracking Echocardiography in Adolescents and Young Adults with Human Immunodeficiency Virus Infection: A Pilot Study

BACKGROUND

The purpose of the study was to assess biventricular parameters of wall deformation with three-dimensional speckle tracking echocardiography (3DSTE) in adolescents and young adults with human immunodeficiency virus (HIV) infection on antiretroviral therapy in order to detect a possible subclinical myocardial dysfunction.

METHODS

Twenty-one patients aged 12-39 years with HIV, 21 normal controls of the same age and sex, and 21 patients with idiopathic nonischemic dilated cardiomyopathy (DCM) were studied with 3DSTE. All HIV patients were stable in terms of HIV infection, with no history of heart disease or other chronic systemic disease except HIV infection, and were on highly active antiretroviral therapy with good immunological control. Standard echocardiographic measures of left ventricular (LV)-right ventricular (RV) function were assessed. 3D LV global longitudinal strain (GLS), circumferential strain, radial strain, and LV twist were calculated. Global area strain (GAS) was calculated by 3DSTE as percentage variation in surface area defined by the longitudinal and circumferential strain vectors. 3D RV global and free-wall longitudinal strain (FWLS) were obtained.

RESULTS

LV GLS and GAS were lower in HIV patients compared to normal controls (p = 0.002, and p = 0.01, respectively). There were no significant differences in LV ejection fractions between the groups. There was a weak positive correlation between LV GLS and age (r = 0.215, p = 0.034) and a weak negative correlation between LV GLS and nadir-CD4 T-cells count (r = 0.198, p = 0.043). DCM patients had more marked and widespread reduction in LV GLS and GAS compared to controls (p < 0.001), whereas in HIV patients LV strain impairment (p < 0.05) was more localized in basal and apical regions. RV FWLS was significantly reduced in HIV patients when compared with the control group (p = 0.03). No patient had pulmonary systolic pressure higher than 35 mm Hg.

CONCLUSIONS

3DSTE may help to identify HIV patients at high cardiovascular risk allowing early detection of biventricular dysfunction in the presence of normal LV ejection fraction and in the absence of pulmonary hypertension. LV strain impairment in HIV patients is less prominent and widespread compared to DCM patients.

Reproducibility of Left Ventricular Dyssynchrony Indices by Three-Dimensional Speckle-Tracking Echocardiography: The Impact of Sub-optimal Image Quality

Background: 3D speckle-tracking echocardiography (3D-STE) is a novel method to quantify left ventricular (LV) mechanical dyssynchrony. 3D-STE is influenced by image quality, but studies on the magnitude of its effect on 3D-STE derived LV systolic dyssynchrony indices (SDIs) and their test-retest reproducibility are limited. Methods: 3D-STE was performed in two groups, each comprising 18 healthy volunteers with good echocardiographic windows. In study 1, optimal and inferior-quality images, by intentionally poor echocardiographic technique, were acquired. In study 2, sub-optimal quality images were acquired by impairing ultrasound propagation using neoprene rubber sheets (thickness 2, 3, and 4 mm) mimicking mildly, moderately, and severely impaired images, respectively. Measures (normalized to cardiac cycle duration) were volume- and strain-based SDIs defined as the standard deviation of time to minimum segmental values, and volume- and strain-derived dispersion indices. For both studies test-retest reproducibility was assessed. Results: Test-retest reproducibility was better for most indices when restricting the analysis to good quality images; nevertheless, only volume-, circumferential strain-, and principal tangential strain-derived LV dyssynchrony indices achieved fair to good reliability. There was no evidence of systematic bias due to sub-optimal quality image. Volume-, circumferential strain-, and principal tangential strain-derived SDIs correlated closely. Radial strain- and longitudinal strain-SDI correlated moderately or weakly with volume-SDI, respectively. Conclusions: Sub-optimal image quality compromised the reliability of 3D-STE derived dyssynchrony indices but did not introduce systematic bias in healthy individuals. Even with optimal quality images, only 3D-STE indices based on volume, circumferential strain and principal tangential strain showed acceptable test-retest reliability.

Current role of echocardiography in cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure and left ventricular systolic dysfunction. Patients are usually assessed by echocardiography, which provides a number of anatomical and functional information used for cardiac dyssynchrony assessment, prognostic stratification, identification of the optimal site of pacing in the left ventricle, optimization of the CRT device, and patient follow-up. Compared to other cardiac imaging techniques, echocardiography has the advantage to be non-invasive, repeatable, and safe, without exposure to ionizing radiation or nefrotoxic contrast. In this article, we review current evidence about the role of echocardiography before, during, and after the implantation of a CRT device.

[Time course of changes in left ventricular twist in the presence of idiopathic left bundle branch block during exercise testing]

AIM

To investigate left ventricular (LV) deformation properties, rotation, and twist during a bicycle ergometer exercise test among patients with idiopathic left bundle branch block (LBBB).

SUBJECTS AND METHODS

Thirty-four patients with idiopathic LBBB having a mean QRS duration of 153±24 msec were examined. A control group included 18 apparently healthy volunteers. All the patients and apparently healthy individuals underwent echocardiography to determine LV hemodynamic parameters, deformity, rotation and twist at rest and after exercise test.

RESULTS

As compared with the control, the idiopathic LBBB group at rest showed decreases in LV global longitudinal deformity (-15.6±4.7 and -18.4±3.1%, respectively; p=0.037), apical rotation (4.59±4.2° and 8.99±3.68°; p=0.0067) and twist (9.08±4.59° and 13.96±4.61°; p=0.0156), whereas there were no differences in LV ejection fraction and end-systolic and end-diastolic volumes. After exercise testing there were no augmentations in basal and apical rotation and resulting ΔTwist in the idiopathic LBBB group compared with the control (-2.05±8.35 and 4.66±8.49%; p=0.0463). The described changes in LV rotation and twist during exercise testing occurred in the presence of elevated pulmonary artery systolic pressure (PASP) in the LBBB group compared with the control (41.6±3.81 and 32.4±3.81 mm Hg, respectively; p=0.0201).

CONCLUSION

Decreases in LV basal, apical and resulting twist may lead to elevated PASP in patients with idiopathic LBBB during exercise.

Role of Speckle Tracking Echocardiography in Dilated Cardiomyopathy: A Review

Dilated cardiomyopathy (DCM) is an important cause of the heart failure. Timely diagnosis and optimal management decrease morbidity and mortality in heart failure patients. Although transthoracic echocardiography is used as the diagnostic test of choice in these patients, new modalities like speckle tracking echocardiography (STE) have promising results in diagnosing these patients in the earlier course of the disease. Advancements in cardiac imaging are expected as more clinical studies on the role of STE in different cardiac diseases that emerge. In this review article, we will discuss the basics of STE and its role in diagnosing DCM.

Evaluation of left ventricular strain in patients with dilated cardiomyopathy

Objective Dilated cardiomyopathy (DCM) can cause structural and functional changes in the left ventricle (LV). In this study, we evaluated whether cardiac magnetic resonance tissue-tracking (MR-TT) can be applied to the detection of LV abnormalities in patients with DCM. Methods We used MR-TT to analyze the global peak radial strain (GPRS), global peak circumferential strain (GPCS), and global peak longitudinal strain (GPLS) in every segment of the LV in 23 patients with DCM and 25 controls. The LV ejection fraction was also measured as a function indicator. Results Compared with the controls, the GPRS, GPCS, and GPLS were significantly reduced in patients with DCM, indicating global LV function impairment in all directions. We also identified a significant linear correlation between the GPRS, GPCS, and GPLS and the LV ejection fraction, indicating that LV function relies on coordinated wall motion from all directions. Moreover, we found that patients with DCM had a significantly reduced magnitude of the PRS, PCS, and PLS in most segments at different levels, indicating impaired myocardial function in most LV regions. Conclusions Our results demonstrate that LV myocardial strain in patients with DCM can be sensitively detected by MR-TT (not only the global LV function changes but also the segmental strain), which can help to identify the injured segment at an early stage and guide clinical treatment.

Three-Dimensional Left Ventricular Torsion in Patients With Dilated Cardiomyopathy - A Marker of Disease Severity

BACKGROUND

LV twist has a key role in maintaining left ventricular (LV) contractility during exercise. The purpose of this study was to investigate LV torsion instead of twist as a surrogate marker of peak oxygen uptake (peak V̇O₂) assessed by cardiopulmonary exercise testing (CPET) in patients with non-ischemic dilated cardiomyopathy (DCM).Methods and Results:We evaluated 45 outpatients with DCM (50±12 years, 24% females) with 3D speckle-tracking electrocardiography prior to CPET. LV torsion, LV ejection fraction (EF), LV diastolic function, LV global longitudinal (GLS) and circumferential (GCS) strain were quantified. A reduced functional capacity (FC) was defined as a peak V̇O₂<20 mL/kg/min. LV torsion correlated most strongly with peak V̇O₂(r=0.76, P<0.001). LV torsion instead of twist was an independent predictor of peak V̇O₂(B: 0.59 to 0.71, P<0.001) in multivariable analyses. Impaired LV torsion <0.61 degrees/cm was able to predict a reduced FC with higher sensitivity and specificity (0.91 and 0.81; area under the curve (AUC): 0.88, P<0.001) than LV EF, GLS or GCS (AUC 0.64, 0.63 and 0.66; P<0.05 for differences in AUC).

CONCLUSIONS

Peak V̇O₂correlated more strongly with LV torsion than with LV diastolic function, LV EF, GLS or GCS. LV torsion had high accuracy in identifying patients with a reduced FC.

Mechanical effects of left ventricular midwall fibrosis in non-ischemic cardiomyopathy

BACKGROUND

Left ventricular (LV) mid-wall fibrosis (MWF), which occurs in about a quarter of patients with non-ischemic cardiomyopathy (NICM), is associated with high risk of pump failure. The mid LV wall is the site of circumferential myocardial fibers. We sought to determine the effect of MWF on LV myocardial mechanics.

METHODS

Patients with NICM (n = 116; age: 62.8 ± 13.2 years; 67% male) underwent late gadolinium enhancement cardiovascular magnetic resonance (CMR) and were categorized according to the presence (+) or absence (-) of MWF. Feature tracking (FT) CMR was used to assess myocardial deformation.

RESULTS

Despite a similar LVEF (24.3 vs. 27.5%, p = 0.20), patients with MWF (32 [24%]) had lower global circumferential strain (Ɛcc: -6.6% vs. -9.4 %, P = 0.004), but similar longitudinal (Ɛll: -7.6 % vs. -9.4 %, p = 0.053) and radial (Ɛrr: 14.6% vs. 17.8% p = 0.18) strain. Compared with - MWF, + MWF was associated with reduced LV systolic, circumferential strain rate (-0.38 ± 0.1 vs. -0.56 ± 0.3 s(-1), p = 0.005) and peak LV twist (4.65 vs. 6.31°, p = 0.004), as well as rigid LV body rotation (64 % vs. 28 %, P <0.001). In addition, +MWF was associated with reduced LV diastolic strain rates (DSRcc: 0.34 vs. 0.46 s(-1); DSRll: 0.38 vs. 0.50s(-1); DSRrr: -0.55 vs. -0.75 s(-1); all p <0.05).

CONCLUSIONS

MWF is associated with reduced LV global circumferential strain, strain rate and torsion. In addition, MWF is associated with rigid LV body rotation and reduced diastolic strain rates. These systolic and diastolic disturbances may be related to the increased risk of pump failure observed in patients with NICM and MWF.

Left Ventricular Dyssynchrony by Three-Dimensional Echocardiography: Current Understanding and Potential Future Clinical Applications

Left ventricular mechanical dyssynchrony is an important prognostic factor for patients with symptomatic systolic heart failure and has emerged as a therapeutic target for cardiac resynchronization therapy (CRT). However, approximately one-third of patients fail to improve after CRT based on current guideline recommendations and electrocardiographic criteria. Two-dimensional echocardiography and tissue Doppler-based techniques have shown variable results in assessment of left ventricular (LV) dyssynchrony and have limited value in clinical practice. Three-dimensional echocardiography (3DE) is an appealing novel imaging modality that has been recently used in quantitative evaluation of global and regional LV function. There is accumulating evidence that 3DE measurement of LV systolic dyssynchrony index may potentially play a role in predicting the short- and long-term response to CRT and further improve patient selection for CRT. New developments in 3DE speckle tracking technique and strain analysis may further improve the accuracy of LV mechanical dyssynchrony assessment in this population. In addition, recent studies suggest that mechanical dyssynchrony is present in patients with LV hypertrophy and diastolic heart failure. Three-dimensional echocardiographic assessment of dyssynchrony may aid in diagnosis and in predicting long-term outcome in these patients. We will summarize current understanding of 3DE techniques and parameters in assessment of LV mechanical dyssynchrony in the population of patients with systolic heart failure, LV hypertrophy, and diastolic heart failure. A number of the novel 3DE techniques described in this review are early in their stage of development, and they will continue to evolve and need further testing in large multicenter studies.

Role of echocardiographic dyssynchrony parameters in predicting response to cardiac resynchronization therapy

AIMS

In the present study, we compare different echocardiographic cardiac dyssynchrony parameters, both of intraventricular and interventricular dyssynchrony, in order to predict response to cardiac resynchronization therapy (CRT).

METHODS AND RESULTS

In a population of 77 heart failure patients scheduled for CRT, we measured the interventricular mechanical delay (IVMD) and we analyzed six different parameters of intraventricular dyssynchony: the tissue Doppler imaging (TDI) septum-lateral wall delay, the systolic dyssynchrony index; the three-dimensional SD of the time to reach minimum systolic volume for 16 left ventricular segments (3D-SDI); the speckle-tracking radial, circumferential and longitudinal dyssynchrony. At 6 months of follow-up, 61 (79%) patients were responders (≤15% in left ventricular end-systolic volume). On baseline analysis, 3D-SDI, radial strain, longitudinal strain and circumferential strain and IVMD were significantly higher in responder group (10.8 ± 3.9 vs. 7.6 ± 1.8% for 3D-SDI; P = 0.003; 212 ± 91 vs. 125 ± 36 ms for radial strain, P = 0.0003; 185 ± 83 vs. 134 ± 53 ms for longitudinal strain, P = 0.02; 190 ± 80 vs. 130 ± 54 ms for circumferential strain, P = 0.006; 45 ± 21 vs. 30 ± 20 ms for IVMD; P = 0.01). On univariate and multivariate analysis, only IVMD was significantly associated with a complete echocardiographic response to CRT. 3D-SDI and radial strain present the better values of sensitivity and specificity, overall if associated to an evaluation of IVMD (sensitivity 76%, specificity 88%, for 3D-SDI + IVMD; sensitivity 80% and specificity 85% for radial strain + IVMD).

CONCLUSION

The novel parameters, such as 3D-SDI and speckle-tracking (particularly radial strain), offer better diagnostic accuracy in identifying patients who are responders to CRT. The addition of the contemporary parameter of IVMD improves the diagnostic accuracy.

New three-dimensional speckle-tracking echocardiography identifies global impairment of left ventricular mechanics with a high sensitivity in childhood cancer survivors

BACKGROUND

The aim of this case-control study was to assess the usefulness of three-dimensional (3D) speckle-tracking echocardiography in the evaluation of global left ventricular (LV) myocardial performance in adolescent and adult survivors of childhood cancers.

METHODS

Fifty-three anthracycline-treated survivors of childhood cancers (mean age, 18.6 ± 5.1 years) and 38 controls were studied. Three-dimensional speckle-tracking echocardiography was performed to assess LV 3D global and segmental strain, time to peak segmental 3D strain, LV torsion, and ejection fraction. LV systolic dyssynchrony index (SDI) was calculated as the percentage of the standard deviation of times to peak strain of the 16 segments divided by the RR interval. A global performance index (GPI) was calculated as (global 3D strain × torsion)/SDI. The area under the receiver operating characteristic curve was calculated to determine the capability of various echocardiographic indices to discriminate between patients and controls.

RESULTS

Compared with controls, patients had significantly reduced LV global 3D strain (P < .001), torsion (P < .001), and GPI (P < .001) and greater SDI (P < .001). All except the basal anteroseptal segment in patients had reduced regional 3D strain compared with controls (P < .05 for all). Global 3D strain (P = .018), SDI (P = .003), and GPI (P = .02) were correlated with cumulative anthracycline dose. The areas under the curves for GPI, global 3D strain, 1/SDI, torsion, and ejection fraction were 0.92, 0.79, 0.79, 0.79, and 0.78, respectively. A GPI cutoff of 10.6°/cm had sensitivity of 84.9% and specificity of 81.6% of differentiating patients from controls.

CONCLUSIONS

Three-dimensional speckle-tracking echocardiography enables the derivation of an index of LV global performance that incorporates LV 3D strain, dyssynchrony, and torsion for the sensitive detection of altered LV mechanics in childhood cancer survivors.

Current state of three-dimensional myocardial strain estimation using echocardiography

With the developments in ultrasound transducer technology and both hardware and software computing, real-time volumetric imaging has become widely available, accompanied by various methods of assessing three-dimensional (3D) myocardial strain, often referred to as 3D speckle-tracking echocardiographic methods. Indeed, these methods should provide cardiologists with a better view of regional myocardial mechanics, which might be important for diagnosis, prognosis, and therapy. However, currently available 3D speckle-tracking echocardiographic methods are based on different algorithms, which introduce substantial differences between them and make them not interchangeable with each other. Therefore, it is critical that each 3D speckle-tracking echocardiographic method is validated individually before being introduced into clinical practice. In this review, the authors discuss differences and similarities of the currently available 3D strain estimation approaches and provide an overview of the current status of their validation.

Three-dimensional speckle-tracking echocardiography – a further step in the non-invasive three-dimensional cardiac imaging

Three-dimensional speckle-tracking echocardiography is a new cardiac imaging methodology, which allows three-dimensional non-invasive evaluation of the myocardial mechanics. The aim of this review is to present this new tool emphasizing its diagnostic potentials and demonstrating its limitations, as well. Orv. Hetil., 2012, 153, 1570–1577.

The role of 3D wall motion tracking in heart failure

Heart failure is a major health problem in developed countries and a growing one in developing countries. Cardiac remodeling in heart failure affects myocardial mechanics, which requires comprehensive evaluation in three dimensions. The novel technique of 3D wall motion tracking applies speckle tracking technology to full volume, 3D echocardiographic datasets. Quantification of conventional and novel left ventricular (LV) parameters including volumes, ejection fraction, global and regional 3D strain, endocardial area strain, twist, and dyssynchrony, and identification of the site of latest mechanical activation are feasible on the basis of a single acquisition of a full-volume dataset. Clinical applications of 3D wall motion tracking include the assessment of global and regional LV performance in ischemic and nonischemic heart diseases, evaluation of mechanics in cardiomyopathies and congenital heart disease, potential selection of patients for cardiac resynchronization therapy and prediction of their response, and detection of subclinical cardiac dysfunction in diseases with likelihood of progression to heart failure. Technological advances with improvement in spatial and temporal resolution of this novel imaging modality are expected. Although 3D wall motion tracking is still in its infancy, this method has begun to provide new insights into LV mechanics and has already found clinical applications. Future developments in 3D assessment of right ventricular and myocardial layer-specific mechanics are awaited.

Perturbed voltage-gated channel activity in perturbed bilayers: implications for ectopic arrhythmias arising from damaged membrane

The ceaseless opening and closing of the voltage-gated channels (VGCs) underlying cardiac rhythmicity is controlled, in each VGC, by four mobile voltage sensors embedded in bilayer. Every action potential necessitates extensive packing/repacking of voltage sensor domains with adjacent interacting lipid molecules. This renders VGC activity mechanosensitive (MS), i.e., energetically sensitive to the bilayer's mechanical state. Irreversible perturbations of sarcolemmal bilayer such as those associated with ischemia, reperfusion, inflammation, cortical-cytoskeleton abnormalities, bilayer-disrupting toxins, diet aberrations, etc, should therefore perturb VGC activity. Disordered/fluidized bilayer states that facilitate voltage sensor repacking, and thus make VGC opening too easy could, therefore, explain VGC-leakiness in these conditions. To study this in membrane patches we impose mechanical blebbing injury during pipette aspiration-induced membrane stretch, a process that modulates VGC activity irreversibly (plastic regime) and then, eventually, reversibly (elastic regime). Because of differences in sensor-to-gate coupling among different VGCs, their responses to stretch fall into two major categories, MS-Speed, MS-Number, exemplified by Nav and Cav channels. For particular VGCs in perturbed bilayers, leak mechanisms depend on whether or not the rate-limiting voltage-dependent step is MS. Mode-switch transitions might also be mechanosensitive and thus play a role. Incorporated mathematically in axon models, plastic-regime Nav responses elicit ectopic firing behaviors typical of peripheral neuropathies. In cardiomyocytes with mild bleb damage, Nav and/or Cav leaks from irreversible MS modulation (MS-Speed, MS-Number, respectively) could, similarly, foster ectopic arrhythmias. Where pathologically leaky VGCs reside in damaged bilayer, peri-channel bilayer disorder/fluidity conditions could be an important "target feature" for anti-arrhythmic VGC drugs.

Three-dimensional speckle-tracking echocardiography: methodological aspects and clinical potential

Speckle-tracking echocardiography (STE) is an advanced echocardiographic technique that allows a novel approach to the assessment of cardiac physiology through the study of myocardial mechanics. In its three-dimensional (3D) modality, it overcomes the drawbacks inherent to other echocardiographic techniques, namely two-dimensional echocardiography and tissue Doppler imaging. Several research studies and software improvements have led 3D-STE to become a promising tool for accurate evaluation of global and regional cardiac function. This article addresses the image acquisition, analytical methods, and parameters of myocardial mechanics that could be derived from 3D-STE. This systematic guidance may help to establish its usefulness in the global and regional evaluation of cardiac function, and to facilitate its clinical application.