A clinical feasibility study of atrial and ventricular electromechanical wave imaging

Long-term atrial arrhythmia characterization and treatment efficacy evaluation using non-invasive echocardiography-based electromechanical cycle length mapping: a case series

Background

Atrial fibrillation (AF) is a prevalent cardiac condition characterized by irregular heart rhythm. Conventional non-invasive diagnostic techniques, while useful, have limitations in providing comprehensive information for treatment planning. To address this gap, electromechanical cycle length mapping (ECLM), a non-invasive echocardiography-based technique, has emerged as a promising approach. Electromechanical cycle length mapping offers quantitative and spatially specific insights into atrial electromechanical activation rate mapping, thereby enhancing our understanding of arrhythmia disease progression in AF patients.

Case summary

In this case series, we present two patient cases demonstrating the potential utility of ECLM in monitoring and evaluating treatment responses in atrial arrhythmia. The 1st case involved a 61-year-old male with persistent AF who underwent multiple procedures, including direct current cardioversion (DCCV) and radiofrequency ablation. Over three different DCCV encounters, pre- and post-procedure ECLM scans were performed, and the results showed the localization and incomplete elimination of arrhythmic triggers post-DCCV, which were used as early indicators of AF recurrence. The 2nd case involved a 71-year-old male with paroxysmal AF who also underwent cardioversion and ablation procedures. Electromechanical cycle length mapping imaging demonstrated a progressive reduction and elimination of arrhythmia triggers after each encounter, resulting in long-term maintenance of sinus rhythm.

Discussion

The findings from this case series highlight the potential of ECLM as a non-invasive imaging tool for long-term monitoring and evaluating immediate and long-term treatment responses in AF patients. The integration of ECLM with standard echocardiograms holds promise in guiding clinical decisions and improving patient outcomes in managing atrial fibrillation.

Electromechanical Cycle Length Mapping for atrial arrhythmia detection and cardioversion success assessment

BACKGROUND

Direct current cardioversion (DCCV) is an established treatment to acutely convert atrial fibrillation (AF) to normal sinus rhythm. Yet, more than 70% of patients revert to AF shortly thereafter. Electromechanical Cycle Length Mapping (ECLM) is a high framerate, spectral analysis technique shown to non-invasively characterize electromechanical activation in paced canines and re-entrant flutter patients. This study assesses ECLM feasibility to map and quantify atrial arrhythmic electromechanical activation rates and inform on 1-day and 1-month DCCV response.

METHODS

Forty-five subjects (30 AF; 15 healthy sinus rhythm (SR) controls) underwent transthoracic ECLM in four standard apical 2D echocardiographic views. AF patients were imaged within 1 h pre- and post-DCCV. 3D-rendered atrial ECLM cycle length (CL) maps and spatial CL histograms were generated. CL dispersion and percentage of arrhythmic CLs≤333ms across the entire atrial myocardium were computed transmurally. ECLM results were subsequently used as indicators of DCCV success.

RESULTS

ECLM successfully confirmed the electrical atrial activation rates in 100% of healthy subjects (R2=0.96). In AF, ECLM maps localized the irregular activation rates pre-DCCV and confirmed successful post-DCCV with immediate reduction or elimination. ECLM metrics successfully distinguished DCCV 1-day and 1-month responders from non-responders, while pre-DCCV ECLM values independently predicted AF recurrence within 1-month post-DCCV.

CONCLUSIONS

ECLM can characterize electromechanical activation rates in AF, quantify their extent, and identify and predict short- and long-term AF recurrence. ELCM constitutes thus a noninvasive arrhythmia imaging modality that can aid clinicians in simultaneous AF severity quantification, prediction of AF DCCV response, and personalized treatment planning.

Ultrasound Visualization and Recording of Transient Myocardial Vibrations

OBJECTIVE

A new visualization and recording method used to assess and quantitate autogenic high-velocity motions in myocardial walls to provide a new description of cardiac function is described.

METHODS

The regional motion display (RMD) is based on high-speed difference ultrasound B-mode images and spatiotemporal processing to record propagating events (PEs). Sixteen normal participants and one patient with cardiac amyloidosis were imaged at rates of 500-1000/s using the Duke Phased Array Scanner, T5. RMDs were generated using difference images and spatially integrating these to display velocity as function of time along a cardiac wall.

RESULTS

In normal participants, RMDs revealed four discrete PEs with average onset timing with respect to the QRS complex of -31.7, +46, +365 and +536 ms. The late diastolic PE propagated apex to base in all participants at an average velocity of 3.4 m/s by the RMD. The RMD of the amyloidosis patient revealed significant changes in the appearance of PEs compared with normal participants. The late diastolic PE propagated at 5.3 m/s from apex to base. All four PEs lagged the average timing of normal participants.

CONCLUSION

The RMD method reliably reveals PEs as discrete events and successfully allows reproducible measurement of PE timing and the velocity of at least one PE. The RMD method is applicable to live, clinical high-speed studies and may offer a new approach to characterization of cardiac function.

Cardiopulmonary capacity is reduced in children with ventricular arrhythmia

BACKGROUND

Premature ventricular contractions (PVCs) are frequently seen in children and are considered benign. A substantial group of adolescents with PVCs complain about a broad range of clinical symptoms, including low exertion tolerance.

OBJECTIVE

The purpose of this study was to evaluate prospectively whether ventricular arrhythmia affects physical performance in adolescents with normal left ventricular function, using a cardiopulmonary exercise test (CPET) and evaluating the electrocardiographic (ECG) characteristics of patients with PVCs with regard to exercise capacity.

METHODS

The study group consisted of 49 children with PVCs and normal left ventricular function. The control group consisted of 36 healthy volunteers. Standard ECG, 24-hour Holter ECG, and CPET were performed. PVCs were analyzed for QRS duration, bundle branch block pattern, QRS axis, and coupling interval (CInt). For CPET, heart rate (HR), oxygen uptake (VO_2max), predicted VO_2max, and VO_2max expressed as a percentage of the predicted value (%VO₂) were measured.

RESULTS

In 37 patients (76%), arrhythmia subsided during exercise. Patients achieved lower VO_2max (32.9 ± 6.3 mL/min/kg) than controls (40.4 ± 6.7 mL/min/kg; P <.01). %VO₂ was 71.0 ± 13.7 in patients and 79.3 ± 12.2 in controls (P <.01). Exercise HR at which PVCs subsided correlated with VO_2max (r = 0.3; P = .07). Patients with persisting arrhythmia performed worse than those in whom arrhythmia subsided during exercise (VO_2max, P <.01; %VO_2,P <.01). No correlation between QRS and CInt parameters and VO_2max was observed.

CONCLUSION

Patients with PVCs have lower aerobic capacity than their healthy peers. Further worsening of exercise capacity is present when PVCs are preserved during effort.

A new Electromechanical Wave Imaging dispersion metric for the characterization of ventricular activation in different Cardiac Resynchronization Therapy pacing schemes

Conventional biventricular (BiV) pacing cardiac resynchronization therapy (CRT) is an established treatment for heart failure patients. Recently, multiple novel CRT delivering technologies such as His-Bundle pacing have been investigated as alternative pacing strategies for optimal treatment benefit. Electromechanical Wave Imaging (EWI), a high frame-rate echocardiography-based modality, is capable of visualizing the change from dyssynchronous activation to resynchronized BiV-paced ventricles in 3D. This proof-of-concept study introduces a new EWI-based dispersion metric to further characterize ventricular activation. Patients with His-Bundle device implantation (n=4), left-bundle branch block (n=10), right-ventricular (RV) pacing (n=10), or BiV pacing (n=15) were imaged, as well as four volunteers in normal sinus rhythm (NSR). EWI successfully mapped the ventricular activation resulting from His-Bundle pacing. Additionally, very similar activation patterns were obtained in the NSR subjects, confirming recovery of physiological activation with His pacing. The dispersion metric was the most sensitive EWI-based metric that identified His pacing as the most efficient treatment (lowest activation time spread), followed by BiV and RV pacing. More specifically, the dispersion metric significantly (p 0.005) distinguished His pacing from the other two pacing schemes as well as LBBB. The initial findings presented herein indicate that EWI and its new dispersion metric may provide a useful resynchronization evaluation clinical tool in CRT patients under both novel His-Bundle pacing and more conventional BiV pacing strategies.

From Anatomy to Functional and Molecular Biomarker Imaging and Therapy: Ultrasound Is Safe, Ultrafast, Portable, and Inexpensive

Ultrasound is the most widely used medical imaging modality worldwide. It is abundant, extremely safe, portable, and inexpensive. In this review, we consider some of the current development trends for ultrasound imaging, which build upon its current strength and the popularity it experiences among medical imaging professional users.Ultrasound has rapidly expanded beyond traditional radiology departments and cardiology practices. Computing power and data processing capabilities of commonly available electronics put ultrasound systems in a lab coat pocket or on a user's mobile phone. Taking advantage of new contributions and discoveries in ultrasound physics, signal processing algorithms, and electronics, the performance of ultrasound systems and transducers have progressed in terms of them becoming smaller, with higher imaging performance, and having lower cost. Ultrasound operates in real time, now at ultrafast speeds; kilohertz frame rates are already achieved by many systems.Ultrasound has progressed beyond anatomical imaging and monitoring blood flow in large vessels. With clinical approval of ultrasound contrast agents (gas-filled microbubbles) that are administered in the bloodstream, tissue perfusion studies are now routine. Through the use of modern ultrasound pulse sequences, individual microbubbles, with subpicogram mass, can be detected and observed in real time, many centimeters deep in the body. Ultrasound imaging has broken the wavelength barrier; by tracking positions of microbubbles within the vasculature, superresolution imaging has been made possible. Ultrasound can now trace the smallest vessels and capillaries, and obtain blood velocity data in those vessels.Molecular ultrasound imaging has now moved closer to clinic; the use of microbubbles with a specific affinity to endothelial biomarkers allows selective accumulation and retention of ultrasound contrast in the areas of ischemic injury, inflammation, or neoangiogenesis. This will aid in noninvasive molecular imaging and may provide additional help with real-time guidance of biopsy, surgery, and ablation procedures.The ultrasound field can be tightly focused inside the body, many centimeters deep, with millimeter precision, and ablate lesions by energy deposition, with thermal or mechanical bioeffects. Some of such treatments are already in clinical use, with more indications progressing through the clinical trial stage. In conjunction with intravascular microbubbles, focused ultrasound can be used for tissue-specific drug delivery; localized triggered release of sequestered drugs from particles in the bloodstream may take time to get to clinic. A combination of intravascular microbubbles with circulating drug and low-power ultrasound allows transient opening of vascular endothelial barriers, including blood-brain barrier; this approach has reached clinical trial stage. Therefore, the drugs that normally would not be getting to the target tissue in the brain will now have an opportunity to produce therapeutic efficacy.Overall, medical ultrasound is developing at a brisk rate, even in an environment where other imaging modalities are also advancing rapidly and may be considered more lucrative. With all the current advances that we discuss, and many more to come, ultrasound may help solve many problems that modern medicine is facing.

Parameter variations in personalized electrophysiological models of human heart ventricles

The objectives of this study were to evaluate the accuracy of personalized numerical simulations of the electrical activity in human ventricles by comparing simulated electrocardiograms (ECGs) with real patients’ ECGs and analyzing the sensitivity of the model output to variations in the model parameters. We used standard 12-lead ECGs and up to 224 unipolar body-surface ECGs to record three patients with cardiac resynchronization therapy devices and three patients with focal ventricular tachycardia. Patient-tailored geometrical models of the ventricles, atria, large vessels, liver, and spine were created using computed tomography data. Ten cases of focal ventricular activation were simulated using the bidomain model and the TNNP 2006 cellular model. The population-based values of electrical conductivities and other model parameters were used for accuracy analysis, and their variations were used for sensitivity analysis. The mean correlation coefficient between the simulated and real ECGs varied significantly (from r = 0.29 to r = 0.86) among the simulated cases. A strong mean correlation (r > 0.7) was found in eight of the ten model cases. The accuracy of the ECG simulation varied widely in the same patient depending on the localization of the excitation origin. The sensitivity analysis revealed that variations in the anisotropy ratio, blood conductivity, and cellular apicobasal heterogeneity had the strongest influence on transmembrane potential, while variation in lung conductivity had the greatest influence on body-surface ECGs. Futhermore, the anisotropy ratio predominantly affected the latest activation time and repolarization time dispersion, while the cellular apicobasal heterogeneity mainly affected the dispersion of action potential duration, and variation in lung conductivity mainly led to changes in the amplitudes of ECGs and cardiac electrograms. We also found that the effects of certain parameter variations had specific regional patterns on the cardiac and body surfaces. These observations are useful for further developing personalized cardiac models.

Cardiac Resynchronization Therapy Response Assessment with Electromechanical Activation Mapping within 24 Hours of Device Implantation: A Pilot Study

BACKGROUND

Cardiac resynchronization therapy (CRT) response assessment relies on the QRS complex narrowing criterion. Yet one third of patients do not improve despite narrowed QRS after implantation. Electromechanical wave imaging (EWI) is a quantitative echocardiography-based technique capable of noninvasively mapping cardiac electromechanical activation in three dimensions. The aim of this exploratory study was to investigate the EWI technique, sensitive to ventricular dyssynchrony, for informing CRT response on the day of implantation.

METHODS

Forty-four patients with heart failure with left bundle branch block or right ventricular (RV) paced rhythm and decreased left ventricular ejection fraction (LVEF; mean, 25.3 ± 9.6%) underwent EWI without and with CRT within 24 hours of device implantation. Of those, 16 were also scanned while in left ventricular (LV) pacing. Improvement in LVEF at 3-, 6-, or 9-month follow-up defined (1) super-responders (ΔLVEF ≥ 20%), (2) responders (10% ≤ ΔLVEF < 20%), and (3) nonresponders (ΔLVEF ≤ 5%). Three-dimensionally rendered electromechanical maps were obtained under RV, LV, and biventricular CRT pacing conditions. Mean RV free wall and LV lateral wall activation times were computed. The percentage of resynchronized myocardium was measured by quantifying the percentage of the left ventricle activated within 120 msec of QRS onset. Correlations between percentage of resynchronized myocardium and type of CRT response were assessed.

RESULTS

LV lateral wall activation time was significantly different (P ≤ .05) among all three pacing conditions in the 16 patients: LV lateral wall activation time with CRT in biventricular pacing (73.1 ± 17.6 msec) was lower compared with LV pacing (89.5 ± 21.5 msec) and RV pacing (120.3 ± 17.8 msec). Retrospective analysis showed that the percentage of resynchronized myocardium with CRT was a reliable response predictor within 24 hours of implantation for significantly (P ≤ .05) identifying super-responders (n = 7; 97.7 ± 1.9%) from nonresponders (n = 17; 89.9 ± 9.9%).

CONCLUSION

Electromechanical activation mapping constitutes a valuable three-dimensional visualization tool within 24 hours of implantation and could potentially aid in the timely assessment of CRT response rates, including during implantation for adjustment of lead placement and pacing outcomes.

Contractile Fronts In The Interventricular Septum: A Case For High Frame Rate Echocardiographic Imaging

The real time high frame rate (HFR) 2-dimensional ultrasound system, T5, at Duke University is capable of imaging at up to 1000 images per second for adult cardiac imaging. A method for detecting and visualizing the mechanical contraction fronts using HFR echocardioagraphy-derived Strain Rate Image (SRI) was described in 26 patients. The Tissue Shortening Onset front durations for echocardiographic normal patients were significantly shorter than conduction disorder patients with left bundle branch block (LBBB) with intrinsic conduction and conduction disorder patients without LBBB (non-LBBB) with simulated LBBB (sLBBB). Echocardiographic normal patients had significantly higher correlation coefficients between their SRIs and spatially inverted versions of themselves compared to non-LBBB patients with intrinsic conduction and sLBBB. In conclusion, SRIs could spatially resolve contractile event fronts in patients.

Noninvasive localization of cardiac arrhythmias using electromechanical wave imaging

Cardiac arrhythmias are a major cause of morbidity and mortality worldwide. The 12-lead electrocardiogram (ECG) is the current noninvasive clinical tool used to diagnose and localize cardiac arrhythmias. However, it has limited accuracy and is subject to operator bias. Here, we present electromechanical wave imaging (EWI), a high-frame rate ultrasound technique that can noninvasively map with high accuracy the electromechanical activation of atrial and ventricular arrhythmias in adult patients. This study evaluates the accuracy of EWI for localization of various arrhythmias in all four chambers of the heart before catheter ablation. Fifty-five patients with an accessory pathway (AP) with Wolff-Parkinson-White (WPW) syndrome, premature ventricular complexes (PVCs), atrial tachycardia (AT), or atrial flutter (AFL) underwent transthoracic EWI and 12-lead ECG. Three-dimensional (3D) rendered EWI isochrones and 12-lead ECG predictions by six electrophysiologists were applied to a standardized segmented cardiac model and subsequently compared to the region of successful ablation on 3D electroanatomical maps generated by invasive catheter mapping. There was significant interobserver variability among 12-lead ECG reads by expert electrophysiologists. EWI correctly predicted 96% of arrhythmia locations as compared with 71% for 12-lead ECG analyses [unadjusted for arrhythmia type: odds ratio (OR), 11.8; 95% confidence interval (CI), 2.2 to 63.2; P = 0.004; adjusted for arrhythmia type: OR, 12.1; 95% CI, 2.3 to 63.2; P = 0.003]. This double-blinded clinical study demonstrates that EWI can localize atrial and ventricular arrhythmias including WPW, PVC, AT, and AFL. EWI when used with ECG may allow for improved treatment for patients with arrhythmias.

3D-rendered Electromechanical Wave Imaging for Localization of Accessory Pathways in Wolff-Parkinson-White Minors

Arrhythmia localization prior to catheter ablation is critical for clinical decision making and treatment planning. The current standard lies in 12-lead electrocardiogram (ECG) interpretation, but this method is non-specific and anatomically limited. Accurate localization requires intracardiac catheter mapping prior to ablation. Electromechanical Wave Imaging (EWI) is a high frame-rate ultrasound modality capable of non-invasively mapping the electromechanical activation in all cardiac chambers in vivo. In this study, we evaluate 3D-rendered EWI as a technique for consistently localizing the accessory pathway (AP) in Wolff-Parkinson-White (WPW) pediatric patients. A 2000 Hz EWI diverging sequence was used to transthoracically image 13 patients with evidence of ECG pre-excitation, immediately prior to catheter ablation and after successful ablation whenever possible. 3D-rendered activation maps were generated by co-registering and interpolating the 4 resulting multi-2D isochrones. A blinded electrophysiologist predicted the AP location on 12-lead ECG prior to ablation. Double-blinded EWI isochrones and clinician assessments were compared to the successful ablation site as confirmed by intracardiac mapping using a segmented template of the heart with 19 ventricular regions. 3D-rendered EWI was shown capable of consistently localizing AP in all the WPW cases. Clinical ECG interpretation correctly predicted the origin with an accuracy of 53.8%, respectively 84.6% when considering predictions in immediately adjacent segments correct. Our method was also capable of assessing the difference in activation pattern from before to after successful ablation on the same patient. These findings indicate that EWI could inform current diagnosis and expedite treatment planning of WPW ablation procedures.

Detection of Regional Mechanical Activation of the Left Ventricular Myocardium Using High Frame Rate Ultrasound Imaging

We have investigated the feasibility of noninvasive mapping of mechanical activation patterns in the left ventricular (LV) myocardium using high frame rate ultrasound imaging for the purpose of detecting conduction abnormalities. Five anesthetized, open-chest dogs with implanted combined sonomicrometry and electromyography (EMG) crystals were studied. The animals were paced from the specified locations of the heart, while crystal and ultrasound data were acquired. Isochrone maps of the mechanical activation patterns were generated from the ultrasound data using a novel signal processing method called clutter filter wave imaging (CFWI). The isochrone maps showed the same mechanical activation pattern as the sonomicrometry crystals in 90% of the cases. For electrical activation, the activation sequences from ultrasound were the same in 92% of the cases. The coefficient of determination between the activation delay measured with EMG and ultrasound was R ² = 0.79 , indicating a strong correlation. These results indicate that high frame rate ultrasound imaging processed with CFWI has the potential to be a valuable tool for mechanical activation detection.

Localization of Accessory Pathways in Pediatric Patients With Wolff-Parkinson-White Syndrome Using 3D-Rendered Electromechanical Wave Imaging

OBJECTIVES

This study sought to demonstrate the feasibility of electromechanical wave imaging (EWI) for localization of accessory pathways (AP) prior to catheter ablation in a pediatric population.

BACKGROUND

Prediction of AP locations in patients with Wolff-Parkinson-White syndrome is currently based on analysis of 12-lead electrocardiography (ECG). In the pediatric population, specific algorithms have been developed to aid in localization, but these can be unreliable. EWI is a noninvasive imaging modality relying on a high frame rate ultrasound sequence capable of visualizing cardiac electromechanical activation.

METHODS

Pediatric patients with ventricular pre-excitation presenting for catheter ablation were imaged with EWI immediately prior to the start of the procedure. Two clinical pediatric electrophysiologists predicted the location of the AP based on ECG. Both EWI and ECG predictions were blinded to the results of catheter ablation. EWI and ECG localizations were subsequently compared with the site of successful ablation.

RESULTS

Fifteen patients were imaged with EWI. One patient was excluded for poor echocardiographic windows and the inability to image the entire ventricular myocardium. EWI correctly predicted the location of the AP in all 14 patients. ECG analysis correctly predicted 11 of 14 (78.6%) of the AP locations.

CONCLUSIONS

EWI was shown to be capable of consistently localizing accessory pathways. EWI predicted the site of successful ablation more frequently than analysis of 12-lead ECG. EWI isochrones also provide anatomical visualization of ventricular pre-excitation. These findings suggest that EWI can predict AP locations, and EWI may have the potential to better inform clinical electrophysiologists prior to catheter ablation procedures.

Non-invasive Characterization of Focal Arrhythmia with Electromechanical Wave Imaging in Vivo

There is currently no established method for the non-invasive characterization of arrhythmia and differentiation between endocardial and epicardial triggers at the point of care. Electromechanical wave imaging (EWI) is a novel ultrasound-based imaging technique based on time-domain transient strain estimation that can map and characterize electromechanical activation in the heart in vivo. The objectives of this initial feasibility study were to determine that EWI is capable of differentiating between endocardial and epicardial sources of focal rhythm and, as a proof-of-concept, that EWI could characterize focal arrhythmia in one patient with premature ventricular contractions (PVCs) before radiofrequency (RF) ablation treatment. First, validation of EWI for differentiation of surface of origin was performed in seven (n = 7) adult dogs using four epicardial and four endocardial pacing protocols. Second, one (n = 1) adult patient diagnosed with PVC was imaged with EWI before the scheduled RF ablation procedure, and EWI results were compared with mapping procedure results. In dogs, EWI was capable of detecting whether pacing was of endocardial or epicardial origin in six of seven cases (86% success rate). In the PVC patient, EWI correctly identified both regions and surface of origin, as confirmed by results from the electrical mapping obtained from the RF ablation procedure. These results reveal that EWI can map the electromechanical activation across the myocardium and indicate that EWI could serve as a valuable pre-treatment planning tool in the clinic.

Spatiotemporal matrix image formation for programmable ultrasound scanners

As programmable ultrasound scanners become more common in research laboratories, it is increasingly important to develop robust software-based image formation algorithms that can be obtained in a straightforward fashion for different types of probes and sequences with a small risk of error during implementation. In this work, we argue that as the computational power keeps increasing, it is becoming practical to directly implement an approximation to the matrix operator linking reflector point targets to the corresponding radiofrequency signals via thoroughly validated and widely available simulations software. Once such a spatiotemporal forward-problem matrix is constructed, standard and thus highly optimized inversion procedures can be leveraged to achieve very high quality images in real time. Specifically, we show that spatiotemporal matrix image formation produces images of similar or enhanced quality when compared against standard delay-and-sum approaches in phantoms and in vivo, and show that this approach can be used to form images even when using non-conventional probe designs for which adapted image formation algorithms are not readily available.

Electromechanical wave imaging and electromechanical wave velocity estimation in a large animal model of myocardial infarction

Echocardiography is often used in the clinic for detection and characterization of myocardial infarction. Electromechanical wave imaging (EWI) is a non-invasive ultrasound-based imaging technique based on time-domain incremental motion and strain estimation that can evaluate changes in contractility in the heart. In this study, electromechanical activation is assessed in infarcted heart to determine whether EWI is capable of detecting and monitoring infarct formation. Additionally, methods for estimating electromechanical wave (EW) velocity are presented, and changes in the EW propagation velocity after infarct formation are studied. Five (n  =  5) adult mongrels were used in this study. Successful infarct formation was achieved in three animals by ligation of the left anterior descending (LAD) coronary artery. Dogs were survived for a few days after LAD ligation and monitored daily with EWI. At the end of the survival period, dogs were sacrificed and TTC (tetrazolium chloride) staining confirmed the formation and location of the infarct. In all three dogs, as soon as day 1 EWI was capable of detecting late-activated and non-activated regions, which grew over the next few days. On final day images, the extent of these regions corresponded to the location of infarct as confirmed by staining. EW velocities in border zones of infarct were significantly lower post-infarct formation when compared to baseline, whereas velocities in healthy tissues were not. These results indicate that EWI and EW velocity might help with the detection of infarcts and their border zones, which may be useful for characterizing arrhythmogenic substrate.

Noninvasive Imaging of the Coronary Vasculature Using Ultrafast Ultrasound

Objectives

The aim of this study was to investigate the potential of coronary ultrafast Doppler angiography (CUDA), a novel vascular imaging technique based on ultrafast ultrasound, to image noninvasively with high sensitivity the intramyocardial coronary vasculature and quantify the coronary blood flow dynamics.

Background

Noninvasive coronary imaging techniques are currently limited to the observation of the epicardial coronary arteries. However, many studies have highlighted the importance of the coronary microcirculation and microvascular disease.

Methods

CUDA was performed in vivo in open-chest procedures in 9 swine. Ultrafast plane-wave imaging at 2,000 frames/s was combined to an adaptive spatiotemporal filtering to achieve ultrahigh-sensitive imaging of the coronary blood flows. Quantification of the flow change was performed during hyperemia after a 30-s left anterior descending (LAD) artery occlusion followed by reperfusion and was compared to gold standard measurements provided by a flowmeter probe placed at a proximal location on the LAD (n = 5). Coronary flow reserve was assessed during intravenous perfusion of adenosine. Vascular damages were evaluated during a second set of experiments in which the LAD was occluded for 90 min, followed by 150 min of reperfusion to induce myocardial infarction (n = 3). Finally, the transthoracic feasibility of CUDA was assessed on 2 adult and 2 pediatric volunteers.

Results

Ultrahigh-sensitive cine loops of venous and arterial intramyocardial blood flows were obtained within 1 cardiac cycle. Quantification of the coronary flow changes during hyperemia was in good agreement with gold standard measurements (r² = 0.89), as well as the assessment of coronary flow reserve (2.35 ± 0.65 vs. 2.28 ± 0.84; p = NS). On the infarcted animals, CUDA images revealed the presence of strong hyperemia and the appearance of abnormal coronary vessel structures in the reperfused LAD territory. Finally, the feasibility of transthoracic coronary vasculature imaging was shown on 4 human volunteers.

Conclusions

Ultrafast Doppler imaging can map the coronary vasculature with high sensitivity and quantify intramural coronary blood flow changes.

Human ventricular activation sequence and the simulation of the electrocardiographic QRS complex and its variability in healthy and intraventricular block conditions

Aims

To investigate how variability in activation sequence and passive conduction properties translates into clinical variability in QRS biomarkers, and gain novel physiological knowledge on the information contained in the human QRS complex.

Methods and results

Multiscale bidomain simulations using a detailed heart-torso human anatomical model are performed to investigate the impact of activation sequence characteristics on clinical QRS biomarkers. Activation sequences are built and validated against experimentally-derived ex vivo and in vivo human activation data. R-peak amplitude exhibits the largest variability in terms of QRS morphology, due to its simultaneous modulation by activation sequence speed, myocardial intracellular and extracellular conductivities, and propagation through the human torso. QRS width, however, is regulated by endocardial activation speed and intracellular myocardial conductivities, whereas QR intervals are only affected by the endocardial activation profile. Variability in the apico-basal location of activation sites on the anterior and posterior left ventricular wall is associated with S-wave progression in limb and precordial leads, respectively, and occasional notched QRS complexes in precordial derivations. Variability in the number of early activation sites successfully reproduces pathological abnormalities of the human conduction system in the QRS complex.

Conclusion

Variability in activation sequence and passive conduction properties captures and explains a large part of the clinical variability observed in the human QRS complex. Our physiological insights allow for a deeper interpretation of human QRS biomarkers in terms of QRS morphology and location of early endocardial activation sites. This might be used to attain a better patient-specific knowledge of activation sequence from routine body-surface electrocardiograms.

Cardiac Strain Imaging With Coherent Compounding of Diverging Waves

Current methods of cardiac strain imaging at high frame rate suffer from motion matching artifacts or poor lateral resolution. Coherent compounding has been shown to improve echocardiographic image quality while maintaining a high frame rate, but has never been used to image cardiac strain. However, myocardial velocity can have an impact on coherent compounding due to displacements between frames. The objective of this paper was to investigate the feasibility and performance of coherent compounding for cardiac strain imaging at a low and a high myocardial velocity. Left-ventricular contraction in short-axis view was modeled as an annulus with radial thickening and circumferential rotation. Simulated radio-frequency channel data with a cardiac phased array were obtained using three different beamforming methods: single diverging wave, coherent compounding of diverging waves, and conventional focusing. Axial and lateral displacements and strains as well as radial strains were estimated and compared to their true value. In vivo feasibility of cardiac strain imaging with coherent compounding was performed and compared to single diverging wave imaging. At low myocardial velocities, the axial, lateral, and radial strain relative error for nine compounded waves (16.3%, 40.4%, and 18.9%) were significantly lower than those obtained with single diverging wave imaging (19.9%, 80.3%, and 30.6%) and closer to that obtained with conventional focusing (16.7%, 43.7%, and 16%). In vivo left-ventricular radial strains exhibited higher quality with nine compounded waves than with single diverging wave imaging. These results indicate that cardiac strain can be imaged using coherent compounding of diverging waves with a better performance than with single diverging wave imaging while maintaining a high frame rate, and therefore, has the potential to improve diagnosis of myocardial strain-based cardiac diseases.

Technical Note: A 3-D rendering algorithm for electromechanical wave imaging of a beating heart

PURPOSE

Arrhythmias can be treated by ablating the heart tissue in the regions of abnormal contraction. The current clinical standard provides electroanatomic 3-D maps to visualize the electrical activation and locate the arrhythmogenic sources. However, the procedure is time-consuming and invasive. Electromechanical wave imaging is an ultrasound-based noninvasive technique that can provide 2-D maps of the electromechanical activation of the heart. In order to fully visualize the complex 3-D pattern of activation, several 2-D views are acquired and processed separately. They are then manually registered with a 3-D rendering software to generate a pseudo-3-D map. However, this last step is operator-dependent and time-consuming.

METHODS

This paper presents a method to generate a full 3-D map of the electromechanical activation using multiple 2-D images. Two canine models were considered to illustrate the method: one in normal sinus rhythm and one paced from the lateral region of the heart. Four standard echographic views of each canine heart were acquired. Electromechanical wave imaging was applied to generate four 2-D activation maps of the left ventricle. The radial positions and activation timings of the walls were automatically extracted from those maps. In each slice, from apex to base, these values were interpolated around the circumference to generate a full 3-D map.

RESULTS

In both cases, a 3-D activation map and a cine-loop of the propagation of the electromechanical wave were automatically generated. The 3-D map showing the electromechanical activation timings overlaid on realistic anatomy assists with the visualization of the sources of earlier activation (which are potential arrhythmogenic sources). The earliest sources of activation corresponded to the expected ones: septum for the normal rhythm and lateral for the pacing case.

CONCLUSIONS

The proposed technique provides, automatically, a 3-D electromechanical activation map with a realistic anatomy. This represents a step towards a noninvasive tool to efficiently localize arrhythmias in 3-D.

Evaluation of Coronary Artery Disease Using Myocardial Elastography with Diverging Wave Imaging: Validation against Myocardial Perfusion Imaging and Coronary Angiography

Myocardial elastography (ME) is an ultrasound-based technique that can image 2-D myocardial strains. The objectives of this study were to illustrate that 2-D myocardial strains can be imaged with diverging wave imaging and differ, on average, between normal and coronary artery disease (CAD) patients. In this study, 66 patients with symptoms of CAD were imaged with myocardial elastography before a nuclear stress test or an invasive coronary angiography. Radial cumulative strains were estimated in all patients. The end-systolic radial strain in the total cross section of the myocardium was significantly higher in normal patients (17.9 ± 8.7%) than in patients with reversible perfusion defect (6.2 ± 9.3%, p < 0.001) and patients with significant (-0.9 ± 7.4%, p < 0.001) and non-significant (3.7 ± 5.7%, p < 0.01) lesions. End-systolic radial strain in the left anterior descending, left circumflex and right coronary artery territory was found to be significantly higher in normal patients than in CAD patients. These preliminary findings indicate that end-systolic radial strain measured with ME is higher on average in healthy persons than in CAD patients and that ME has the potential to be used for non-invasive, radiation-free early detection of CAD.

Imaging the dynamics of cardiac fiber orientation in vivo using 3D Ultrasound Backscatter Tensor Imaging

The assessment of myocardial fiber disarray is of major interest for the study of the progression of myocardial disease. However, time-resolved imaging of the myocardial structure remains unavailable in clinical practice. In this study, we introduce 3D Backscatter Tensor Imaging (3D-BTI), an entirely novel ultrasound-based imaging technique that can map the myocardial fibers orientation and its dynamics with a temporal resolution of 10 ms during a single cardiac cycle, non-invasively and in vivo in entire volumes. 3D-BTI is based on ultrafast volumetric ultrasound acquisitions, which are used to quantify the spatial coherence of backscattered echoes at each point of the volume. The capability of 3D-BTI to map the fibers orientation was evaluated in vitro in 5 myocardial samples. The helicoidal transmural variation of fiber angles was in good agreement with the one obtained by histological analysis. 3D-BTI was then performed to map the fiber orientation dynamics in vivo in the beating heart of an open-chest sheep at a volume rate of 90 volumes/s. Finally, the clinical feasibility of 3D-BTI was shown on a healthy volunteer. These initial results indicate that 3D-BTI could become a fully non-invasive technique to assess myocardial disarray at the bedside of patients.

Imaging the Propagation of the Electromechanical Wave in Heart Failure Patients with Cardiac Resynchronization Therapy

BACKGROUND

Current electrocardiographic and echocardiographic measurements in heart failure (HF) do not take into account the complex interplay between electrical activation and local wall motion. The utilization of novel technologies to better characterize cardiac electromechanical behavior may lead to improved response rates with cardiac resynchronization therapy (CRT). Electromechanical wave imaging (EWI) is a noninvasive ultrasound-based technique that uses the transient deformations of the myocardium to track the intrinsic EW that precedes myocardial contraction. In this paper, we investigate the performance and reproducibility of EWI in the assessment of HF patients and CRT.

METHODS

EWI acquisitions were obtained in five healthy controls and 16 HF patients with and without CRT pacing. Responders (n = 8) and nonresponders (n = 8) to CRT were identified retrospectively on the basis of left ventricular (LV) reverse remodeling. Electromechanical activation maps were obtained in all patients and used to compute a quantitative parameter describing the mean LV lateral wall activation time (LWAT).

RESULTS

Mean LWAT was increased by 52.1 ms in HF patients in native rhythm compared to controls (P < 0.01). For all HF patients, CRT pacing initiated a different electromechanical activation sequence. Responders exhibited a 56.4-ms ± 28.9-ms reduction in LWAT with CRT pacing (P < 0.01), while nonresponders showed no significant change.

CONCLUSION

In this initial feasibility study, EWI was capable of characterizing local cardiac electromechanical behavior as it pertains to HF and CRT response. Activation sequences obtained with EWI allow for quantification of LV lateral wall electromechanical activation, thus providing a novel method for CRT assessment.

Electromechanical wave imaging (EWI) validation in all four cardiac chambers with 3D electroanatomic mapping in canines in vivo

Characterization and mapping of arrhythmias is currently performed through invasive insertion and manipulation of cardiac catheters. Electromechanical wave imaging (EWI) is a non-invasive ultrasound-based imaging technique, which tracks the electromechanical activation that immediately follows electrical activation. Electrical and electromechanical activations were previously found to be linearly correlated in the left ventricle, but the relationship has not yet been investigated in the three other chambers of the heart. The objective of this study was to investigate the relationship between electrical and electromechanical activations and validate EWI in all four chambers of the heart with conventional 3D electroanatomical mapping. Six (n  =  6) normal adult canines were used in this study. The electrical activation sequence was mapped in all four chambers of the heart, both endocardially and epicardially using the St Jude's EnSite 3D mapping system (St. Jude Medical, Secaucus, NJ). EWI acquisitions were performed in all four chambers during normal sinus rhythm, and during pacing in the left ventricle. Isochrones of the electromechanical activation were generated from standard echocardiographic imaging views. Electrical and electromechanical activation maps were co-registered and compared, and electrical and electromechanical activation times were plotted against each other and linear regression was performed for each pair of activation maps. Electromechanical and electrical activations were found to be directly correlated with slopes of the correlation ranging from 0.77 to 1.83, electromechanical delays between 9 and 58 ms and R ² values from 0.71 to 0.92. The linear correlation between electrical and electromechanical activations and the agreement between the activation maps indicate that the electromechanical activation follows the pattern of propagation of the electrical activation. This suggests that EWI may be used as a novel non-invasive method to accurately characterize and localize sources of arrhythmias.

Validation of electromechanical wave imaging in a canine model during pacing and sinus rhythm

BACKGROUND

Accurate determination of regional areas of arrhythmic triggers is of key interest to diagnose arrhythmias and optimize their treatment. Electromechanical wave imaging (EWI) is an ultrasound technique that can image the transient deformation in the myocardium after electrical activation and therefore has the potential to detect and characterize location of triggers of arrhythmias.

OBJECTIVES

The objectives of this study were to investigate the relationship between the electromechanical and the electrical activation of the left ventricular (LV) endocardial surface during epicardial and endocardial pacing and during sinus rhythm as well as to map the distribution of electromechanical delays.

METHODS

In this study, 6 canines were investigated. Two external electrodes were sutured onto the epicardial surface of the LV. A 64-electrode basket catheter was inserted through the apex of the LV. Ultrasound channel data were acquired at 2000 frames/s during epicardial and endocardial pacing and during sinus rhythm. Electromechanical and electrical activation maps were synchronously obtained from the ultrasound data and the basket catheter, respectively.

RESULTS

The mean correlation coefficient between electromechanical and electrical activation was 0.81 for epicardial anterior pacing, 0.79 for epicardial lateral pacing, 0.69 for endocardial pacing, and 0.56 for sinus rhythm.

CONCLUSION

The electromechanical activation sequence determined by EWI follows the electrical activation sequence and more specifically in the case of pacing. This finding is of key interest in the role that EWI can play in the detection of the anatomical source of arrhythmias and the planning of pacing therapies such as cardiovascular resynchronization therapy.

Improvement of penetration of modified amplitude and phase estimation beamformer

PURPOSE

High-frame-rate ultrasound is the predominant technique for the measurement of tissue dynamics. It enables an imaging frame rate of over 1 kHz using unfocused transmit beams and parallel receive beamforming. On the other hand, the spatial resolution is degraded compared to the conventional method based on sequential transmissions of focused beams. For improvement of the spatial resolution of high-frame-rate ultrasound, we have investigated a kind of adaptive beamformer, i.e., amplitude and phase estimation (APES) beamformer.

METHOD

In our previous study, it was shown that the APES beamformer realized a significantly better spatial resolution than the conventional delay and sum (DAS) beamformer without sub-array averaging and diagonal loading by considering the directivity of each transducer element. By omitting sub-array averaging and adding sub-aperture beamforming, the computational load could also be reduced significantly. One shortcoming of the proposed APES beamformer with element directivity, i.e., modified APES beamformer, is the degradation of penetration compared with the conventional APES beamformer with sub-array averaging and diagonal loading. In the present study, sub-array averaging and diagonal loading were applied to the modified APES beamformer for the improvement of the penetration.

RESULTS

The conventional and modified APES beamformers realized similar performances when used with sub-array averaging and diagonal loading. Furthermore, the modified APES beamformer realized better spatial resolution and improved penetration when used with sub-aperture beamforming and diagonal loading. The modified APES beamformer with diagonal loading at 0.025 of the received power realized a penetration similar to that of the conventional APES beamformer with sub-array averaging and diagonal loading. The lateral spatial resolutions achieved with the conventional and modified APES beamformers were 0.36 and 0.31 mm, respectively. In addition, the modified APES beamformer could reduce the dimension of the covariance matrix to [Formula: see text], versus [Formula: see text] of the conventional APES beamformer, resulting in a computation time of only 1.1 %.

CONCLUSION

Penetration of the modified APES beamformer could be improved significantly by diagonal loading, which hardly increases the computational complexity.

Ultrafast Harmonic Coherent Compound (UHCC) Imaging for High Frame Rate Echocardiography and Shear-Wave Elastography

Transthoracic shear-wave elastography (SWE) of the myocardium remains very challenging due to the poor quality of transthoracic ultrafast imaging and the presence of clutter noise, jitter, phase aberration, and ultrasound reverberation. Several approaches, such as diverging-wave coherent compounding or focused harmonic imaging, have been proposed to improve the imaging quality. In this study, we introduce ultrafast harmonic coherent compounding (UHCC), in which pulse-inverted diverging waves are emitted and coherently compounded, and show that such an approach can be used to enhance both SWE and high frame rate (FR) B-mode Imaging. UHCC SWE was first tested in phantoms containing an aberrating layer and was compared against pulse-inversion harmonic imaging and against ultrafast coherent compounding (UCC) imaging at the fundamental frequency. In vivo feasibility of the technique was then evaluated in six healthy volunteers by measuring myocardial stiffness during diastole in transthoracic imaging. We also demonstrated that improvements in imaging quality could be achieved using UHCC B-mode imaging in healthy volunteers. The quality of transthoracic images of the heart was found to be improved with the number of pulse-inverted diverging waves with a reduction of the imaging mean clutter level up to 13.8 dB when compared against UCC at the fundamental frequency. These results demonstrated that UHCC B-mode imaging is promising for imaging deep tissues exposed to aberration sources with a high FR.

Assessing the atrial electromechanical coupling during atrial focal tachycardia, flutter, and fibrillation using electromechanical wave imaging in humans

Minimally-invasive treatments of cardiac arrhythmias such as radio-frequency ablation are gradually gaining importance in clinical practice but still lack a noninvasive imaging modality which provides insight into the source or focus of an arrhythmia. Cardiac deformations imaged at high temporal and spatial resolution can be used to elucidate the electrical activation sequence in normal and paced human subjects non-invasively and could potentially aid to better plan and monitor ablation-based arrhythmia treatments. In this study, a novel ultrasound-based method is presented that can be used to quantitatively characterize focal and reentrant arrhythmias. Spatio-temporal maps of the full-view of the atrial and ventricular mechanics were obtained in a single heartbeat, revealing with otherwise unobtainable detail the electromechanical patterns of atrial flutter, fibrillation, and tachycardia in humans. During focal arrhythmias such as premature ventricular complex and focal atrial tachycardia, the previously developed electromechanical wave imaging methodology is hereby shown capable of identifying the location of the focal zone and the subsequent propagation of cardiac activation. During reentrant arrhythmias such as atrial flutter and fibrillation, Fourier analysis of the strains revealed highly correlated mechanical and electrical cycle lengths and propagation patterns. High frame rate ultrasound imaging of the heart can be used non-invasively and in real time, to characterize the lesser-known mechanical aspects of atrial and ventricular arrhythmias, also potentially assisting treatment planning for intraoperative and longitudinal monitoring of arrhythmias.

3-D ultrafast Doppler imaging applied to the noninvasive mapping of blood vessels in vivo

Ultrafast Doppler imaging was introduced as a technique to quantify blood flow in an entire 2-D field of view, expanding the field of application of ultrasound imaging to the highly sensitive anatomical and functional mapping of blood vessels. We have recently developed 3-D ultrafast ultrasound imaging, a technique that can produce thousands of ultrasound volumes per second, based on a 3-D plane and diverging wave emissions, and demonstrated its clinical feasibility in human subjects in vivo. In this study, we show that noninvasive 3-D ultrafast power Doppler, pulsed Doppler, and color Doppler imaging can be used to perform imaging of blood vessels in humans when using coherent compounding of 3-D tilted plane waves. A customized, programmable, 1024-channel ultrasound system was designed to perform 3-D ultrafast imaging. Using a 32 × 32, 3-MHz matrix phased array (Vermon, Tours, France), volumes were beamformed by coherently compounding successive tilted plane wave emissions. Doppler processing was then applied in a voxel-wise fashion. The proof of principle of 3-D ultrafast power Doppler imaging was first performed by imaging Tygon tubes of various diameters, and in vivo feasibility was demonstrated by imaging small vessels in the human thyroid. Simultaneous 3-D color and pulsed Doppler imaging using compounded emissions were also applied in the carotid artery and the jugular vein in one healthy volunteer.

Atrial electromechanical cycle length mapping in paced canine hearts in vivo

Atrial arrhythmias affect millions of people worldwide. Characterization and study of arrhythmias in the atria in the clinic is currently performed point by point using mapping catheters capable of generating maps of the electrical activation rate or cycle length. In this paper, we describe a new ultrasound-based mapping technique called electromechanical cycle length mapping (ECLM) capable of estimating the electromechanical activation rate, or cycle length, i.e., the rate of the mechanical activation of the myocardium which follows the electrical activation. ECLM relies on frequency analysis of the incremental strain within the atria and can be performed in a single acquisition. ECLM was validated in a canine model paced from the left atrial appendage, against pacing rates within the reported range of cycle lengths previously measured during atrial arrhythmias such as atrial fibrillation. Correlation between the global estimated electromechanical cycle lengths and pacing rates was shown to be excellent (slope = 0.983, intercept = 3.91, r(2) = 0.9999). The effect of the number of cardiac cycles on the performance of ECLM was also investigated and the reproducibility of ECLM was demonstrated (error between consecutive acquisitions for all pacing rates: 6.3 ± 4.3%). These findings indicate the potential of ECLM for noninvasively characterizing atrial arrhythmias and provide feedback on the treatment planning of catheter ablation procedures in the clinic.

2-D arterial wall motion imaging using ultrafast ultrasound and transverse oscillations

Ultrafast ultrasound is a promising imaging modality that enabled, inter alia, the development of pulse wave imaging and the local velocity estimation of the so-called pulse wave for a quantitative evaluation of arterial stiffness. However, this technique only focuses on the propagation of the axial displacement of the artery wall, and most techniques are not specific to the intima-media complex and do not take into account the longitudinal motion of this complex. Within this perspective, this paper presents a study of two-dimensional tissue motion estimation in ultrafast imaging combining transverse oscillations, which can improve motion estimation in the transverse direction, i.e., perpendicular to the beam axis, and a phase-based motion estimation. First, the method was validated in simulation. Two-dimensional motion, inspired from a real data set acquired on a human carotid artery, was applied to a numerical phantom to produce a simulation data set. The estimated motion showed axial and lateral mean errors of 4.2 ± 3.4 μm and 9.9 ± 7.9 μm, respectively. Afterward, experimental results were obtained on three artery phantoms with different wall stiffnesses. In this study, the vessel phantoms did not contain a pure longitudinal displacement. The longitudinal displacements were induced by the axial force produced by the wall's axial dilatation. This paper shows that the approach presented is able to perform 2-D tissue motion estimation very accurately even if the displacement values are very small and even in the lateral direction, making it possible to estimate the pulse wave velocity in both the axial and longitudinal directions. This demonstrates the method's potential to estimate the velocity of purely longitudinal waves propagating in the longitudinal direction. Finally, the stiffnesses of the three vessel phantom walls investigated were estimated with an average relative error of 2.2%.

Effect of element directivity on adaptive beamforming applied to high-frame-rate ultrasound

High-frame-rate ultrasound is a promising technique for measurement and imaging of cardiovascular dynamics. In high-frame-rate ultrasonic imaging, unfocused ultrasonic beams are used in transmit and multiple focused receiving beams are created by parallel beamforming using the delay and sum (DAS) method. However, the spatial resolution and contrast are degraded compared with conventional beamforming using focused transmit beams. In the present study, the minimum variance beamformer was examined for improvement of the spatial resolution in high-frame-rate ultrasound. In conventional minimum variance beamforming, the spatial covariance matrix of ultrasonic echo signals received by individual transducer elements is obtained without considering the directivity of the transducer element. By omitting the element directivity, the error in estimation of the desired signal (i.e., the echo from the focal point) increases, and as a result, the improvement of the spatial resolution is degraded. In the present study, the element directivity was taken into account in estimation of the spatial covariance matrix used in minimum variance beamforming. The effect of the element directivity on adaptive beamforming was evaluated by computer simulation and basic experiments using a phantom. In parallel beamforming with the conventional DAS beamformer, the lateral spatial resolution, which was evaluated from the lateral full width at half maximum of the echo amplitude profile in the basic experiment, was 0.50 mm. Using conventional amplitude and phase estimation (APES) beamforming, the lateral spatial resolution was improved to 0.37 mm. The lateral spatial resolution was further improved to 0.30 mm using the modified APES beamforming by considering the element directivity. Image contrast and contrast-to-noise ratios, respectively, were -12.3 and 6.5 dB (DAS), -32.8 and -11.3 dB (APES), and -7.0 and 3.1 dB (modified APES).

3D ultrafast ultrasound imaging in vivo

Very high frame rate ultrasound imaging has recently allowed for the extension of the applications of echography to new fields of study such as the functional imaging of the brain, cardiac electrophysiology, and the quantitative imaging of the intrinsic mechanical properties of tumors, to name a few, non-invasively and in real time. In this study, we present the first implementation of Ultrafast Ultrasound Imaging in 3D based on the use of either diverging or plane waves emanating from a sparse virtual array located behind the probe. It achieves high contrast and resolution while maintaining imaging rates of thousands of volumes per second. A customized portable ultrasound system was developed to sample 1024 independent channels and to drive a 32  ×  32 matrix-array probe. Its ability to track in 3D transient phenomena occurring in the millisecond range within a single ultrafast acquisition was demonstrated for 3D Shear-Wave Imaging, 3D Ultrafast Doppler Imaging, and, finally, 3D Ultrafast combined Tissue and Flow Doppler Imaging. The propagation of shear waves was tracked in a phantom and used to characterize its stiffness. 3D Ultrafast Doppler was used to obtain 3D maps of Pulsed Doppler, Color Doppler, and Power Doppler quantities in a single acquisition and revealed, at thousands of volumes per second, the complex 3D flow patterns occurring in the ventricles of the human heart during an entire cardiac cycle, as well as the 3D in vivo interaction of blood flow and wall motion during the pulse wave in the carotid at the bifurcation. This study demonstrates the potential of 3D Ultrafast Ultrasound Imaging for the 3D mapping of stiffness, tissue motion, and flow in humans in vivo and promises new clinical applications of ultrasound with reduced intra--and inter-observer variability.

Images as drivers of progress in cardiac computational modelling

Computational models have become a fundamental tool in cardiac research. Models are evolving to cover multiple scales and physical mechanisms. They are moving towards mechanistic descriptions of personalised structure and function, including effects of natural variability. These developments are underpinned to a large extent by advances in imaging technologies. This article reviews how novel imaging technologies, or the innovative use and extension of established ones, integrate with computational models and drive novel insights into cardiac biophysics. In terms of structural characterization, we discuss how imaging is allowing a wide range of scales to be considered, from cellular levels to whole organs. We analyse how the evolution from structural to functional imaging is opening new avenues for computational models, and in this respect we review methods for measurement of electrical activity, mechanics and flow. Finally, we consider ways in which combined imaging and modelling research is likely to continue advancing cardiac research, and identify some of the main challenges that remain to be solved.

High-contrast ultrafast imaging of the heart

Noninvasive ultrafast imaging of intrinsic waves such as electromechanical waves or remotely induced shear waves in elastography imaging techniques for human cardiac applications remains challenging. In this paper, we propose ultrafast imaging of the heart with adapted sector size by coherently compounding diverging waves emitted from a standard transthoracic cardiac phased-array probe. As in ultrafast imaging with plane wave coherent compounding, diverging waves can be summed coherently to obtain high-quality images of the entire heart at high frame rate in a full field of view. To image the propagation of shear waves with a large SNR, the field of view can be adapted by changing the angular aperture of the transmitted wave. Backscattered echoes from successive circular wave acquisitions are coherently summed at every location in the image to improve the image quality while maintaining very high frame rates. The transmitted diverging waves, angular apertures, and subaperture sizes were tested in simulation, and ultrafast coherent compounding was implemented in a commercial scanner. The improvement of the imaging quality was quantified in phantoms and in one human heart, in vivo. Imaging shear wave propagation at 2500 frames/s using 5 diverging waves provided a large increase of the SNR of the tissue velocity estimates while maintaining a high frame rate. Finally, ultrafast imaging with 1 to 5 diverging waves was used to image the human heart at a frame rate of 4500 to 900 frames/s over an entire cardiac cycle. Spatial coherent compounding provided a strong improvement of the imaging quality, even with a small number of transmitted diverging waves and a high frame rate, which allows imaging of the propagation of electromechanical and shear waves with good image quality.

Ultrafast imaging in biomedical ultrasound

Although the use of ultrasonic plane-wave transmissions rather than line-per-line focused beam transmissions has been long studied in research, clinical application of this technology was only recently made possible through developments in graphical processing unit (GPU)-based platforms. Far beyond a technological breakthrough, the use of plane or diverging wave transmissions enables attainment of ultrafast frame rates (typically faster than 1000 frames per second) over a large field of view. This concept has also inspired the emergence of completely novel imaging modes which are valuable for ultrasound-based screening, diagnosis, and therapeutic monitoring. In this review article, we present the basic principles and implementation of ultrafast imaging. In particular, present and future applications of ultrafast imaging in biomedical ultrasound are illustrated and discussed.