A dual-chamber, thick-walled cardiac phantom for use in cardiac motion and deformation imaging by ultrasound

Use of 3D anatomical models in mock circulatory loops for cardiac medical device testing

INTRODUCTION

Mock circulatory loops (MCLs) are mechanical representations of the cardiovascular system largely used to test the hemodynamic performance of cardiovascular medical devices (MD). Thanks to 3 dimensional (3D) printing technologies, MCLs can nowadays also incorporate anatomical models so to offer enhanced testing capabilities. The aim of this review is to provide an overview on MCLs and to discuss the recent developments of 3D anatomical models for cardiovascular MD testing.

METHODS

The review first analyses the different techniques to develop 3D anatomical models, in both rigid and compliant materials. In the second section, the state of the art of MCLs with 3D models is discussed, along with the testing of different MDs: implantable blood pumps, heart valves, and imaging techniques. For each class of MD, the MCL is analyzed in terms of: the cardiovascular model embedded, the 3D model implemented (the anatomy represented, the material used, and the activation method), and the testing applications.

DISCUSSIONS AND CONCLUSIONS

MCLs serve the purpose of testing cardiovascular MDs in different (patho-)physiological scenarios. The addition of 3D anatomical models enables more realistic connections of the MD with the implantation site and enhances the testing capabilities of the MCL. Current attempts focus on the development of personalized MCLs to test MDs in patient-specific hemodynamic and anatomical scenarios. The main limitation of MCLs is the impossibility to assess the impact of a MD in the long-term and at a biological level, for which animal experiments are still needed.

Segmentation Enhanced Elastic Image Registration for 2D Speckle Tracking Echocardiography-Performance Study In Silico

Although the two dimensional Speckle Tracking Echocardiography has gained a strong position among medical diagnostic techniques in cardiology, it still requires further developments to improve its repeatability and reliability. Few works have attempted to incorporate the left ventricle segmentation results in the process of displacements and strain estimation to improve its performance. We proposed the use of mask information as an additional penalty in the elastic image registration based displacements estimation. This approach was studied using a short axis view synthetic echocardiographic data, segmented using an active contour method. The obtained masks were distorted to a different degree, using different methods to assess the influence of the segmentation quality on the displacements and strain estimation process. The results of displacements and circumferential strain estimations show, that even though the method is dependent on the mask quality, the potential loss in accuracy due to the poor segmentation quality is much lower than the potential accuracy gain in cases where the segmentation performs well.

A Realistic and Inexpensive Ultrasound Phantom for Teaching M-Mode Measurement of Fetal Heart Rate

BACKGROUND

M-mode ultrasound is frequently used to measure a fetal heart rate. Phantoms are used to simulate clinical conditions for teaching ultrasound-related skills. This is particularly important in the case of early pregnancy, when it is not ethical to use a live fetus in utero for teaching purposes.

OBJECTIVES

To date, no phantom has been created to model the beating heart of an intrauterine pregnancy. Our goal was to create such a model for use in teaching M-mode ultrasound.

MATERIALS AND METHODS

The phantom is constructed using a toy fish, several balloons, and water-absorbing gel crystals.

RESULTS

We have created a novel phantom for use in teaching M-mode measurements. The cost per phantom is around $20 and the phantom can be constructed in about 20 min.

CONCLUSION

This phantom is easily constructed and cost-effective. It gives learners the opportunity to practice measuring an intrauterine fetal heart rate in a learning environment without exposing a live fetus to unnecessary ultrasound.

Design of heart phantoms for ultrasound imaging of ventricular septal defects

PURPOSE

Ventricular septal defects (VSDs) are common congenital heart malformations. Echocardiography used during VSD hybrid cardiac procedures requires extensive training for image acquisition and interpretation. Cardiac surgery simulators with heart phantoms have shown usefulness for such training, but they are limited in visualization and characterization of complex VSD. This study explores a new method to build patient-specific heart phantoms with VSD, with proper tissue echogenicity for ultrasound imaging.

METHODS

Heart phantoms were designed from preoperative imaging of three patients with complex VSDs. Each whole heart phantom, including atrial and ventricular septums, was obtained by manual segmentation and by surface reconstruction, then by molding and by casting in different materials. Heart phantoms in silicone and polyvinyl alcohol cryogel (PVA-C) were considered, and they were reconstructed in 3-D using 2-D freehand ultrasound imaging.

RESULTS

An electromagnetic measurement system was used to measure the mean VSD diameters from the heart phantoms. Errors were evaluated below 1.0 mm for mean VSD diameters between 6.2 and 7.5 mm.

CONCLUSION

Patient-specific heart phantoms promise for representing complex heart malformations such as VSDs. PVA-C showed better tissue echogenicity than silicone for VSDs visualization and characterization.

Cardiac Tissue-Mimicking Ballistic Gel Phantom for Ultrasound Imaging in Clinical and Research Applications

Ballistic gel was investigated as a tissue-mimicking material in an anthropomorphic cardiac phantom for ultrasound imaging. The gel was tested for its acoustic properties and its compatibility with conventional plastics molding techniques. Speed of sound and attenuation were evaluated in the range 2-12 MHz. The speed of sound was 1537 ± 39 m/s, close to typical values for cardiac tissue (∼1576 m/s). The attenuation coefficient was 1.07 dB/cm·MHz, within the range of values previously reported for cardiac tissue (0.81-1.81 dB/cm·MHz). A cardiac model based on human anatomy was developed using established image segmentation processes and conventional plastic molding techniques. Key anatomic features were observed, captured and identified in the model using an intracardiac ultrasound imaging system. These favorable results along with the material's durability and processes that allow for repetitive production of detailed whole-heart models at low cost are promising. There are numerous applications for geometrically complex phantoms in research, training, device development and clinical use.

A left ventricular phantom for 3D echocardiographic twist measurements

Traditional two-dimensional (2D) ultrasound speckle tracking echocardiography (STE) studies have shown a wide range of twist values, also for normal hearts, which is due to the limitations of short-axis 2D ultrasound. The same limitations do not apply to three-dimensional (3D) ultrasound, and several studies have shown 3D ultrasound to be superior to 2D ultrasound, which is unreliable for measuring twist. The aim of this study was to develop a left ventricular twisting phantom and to evaluate the accuracy of 3D STE twist measurements using different acquisition methods and volume rates (VR). This phantom was not intended to simulate a heart, but to function as a medium for ultrasound deformation measurement. The phantom was made of polyvinyl alcohol (PVA) and casted using 3D printed molds. Twist was obtained by making the phantom consist of two PVA layers with different elastic properties in a spiral pattern. This gave increased apical rotation with increased stroke volume in a mock circulation. To test the accuracy of 3D STE twist, both single-beat, as well as two, four and six multi-beat acquisitions, were recorded and compared against twist from implanted sonomicrometry crystals. A custom-made software was developed to calculate twist from sonomicrometry. The phantom gave sonomicrometer twist values from 2.0° to 13.8° depending on the stroke volume. STE software tracked the phantom wall well at several combinations of temporal and spatial resolution. Agreement between the two twist methods was best for multi-beat acquisitions in the range of 14.4–30.4 volumes per second (VPS), while poorer for single-beat and higher multi-beat VRs. Smallest offset was obtained at six-beat multi-beat at 17.1 VPS and 30.4 VPS. The phantom proved to be a useful tool for simulating cardiac twist and gave different twist at different stroke volumes. Best agreement with the sonomicrometer reference method was obtained at good spatial resolution (high beam density) and a relatively low VR. 3D STE twist values showed better agreement with sonomicrometry for most multi-beat recordings compared with single-beat recordings.

Ultrasonic sensor concept to fit a ventricular assist device cannula evaluated using geometrically accurate heart phantoms

Future left ventricular assist devices (LVADs) are expected to respond to the physiologic need of patients; however, they still lack reliable pressure or volume sensors for feedback control. In the clinic, echocardiography systems are routinely used to measure left ventricular (LV) volume. Until now, echocardiography in this form was never integrated in LVADs due to its computational complexity. The aim of this study was to demonstrate the applicability of a simplified ultrasonic sensor to fit an LVAD cannula and to show the achievable accuracy in vitro. Our approach requires only two ultrasonic transducers because we estimated the LV volume with the LV end-diastolic diameter commonly used in clinical assessments. In order to optimize the accuracy, we assessed the optimal design parameters considering over 50 orientations of the two ultrasonic transducers. A test bench was equipped with five talcum-infused silicone heart phantoms, in which the intra-ventricular surface replicated papillary muscles and trabeculae carnae. The end-diastolic LV filling volumes of the five heart phantoms ranged from 180 to 480 mL. This reference volume was altered by ±40 mL with a syringe pump. Based on the calibrated measurements acquired by the two ultrasonic transducers, the LV volume was estimated well. However, the accuracies obtained are strongly dependent on the choice of the design parameters. Orientations toward the septum perform better, as they interfere less with the papillary muscles. The optimized design is valid for all hearts. Considering this, the Bland-Altman analysis reports the LV volume accuracy as a bias of ±10% and limits of agreement of 0%-40% in all but the smallest heart. The simplicity of traditional echocardiography systems was reduced by two orders of magnitude in technical complexity, while achieving a comparable accuracy to 2D echocardiography requiring a calibration of absolute volume only. Hence, our approach exploits the established benefits of echocardiography and makes them applicable as an LV volume sensor for LVADs.

Patient-specific cardiac phantom for clinical training and preprocedure surgical planning

Minimally invasive mitral valve repair procedures including MitraClip^® are becoming increasingly common. For cases of complex or diseased anatomy, clinicians may benefit from using a patient-specific cardiac phantom for training, surgical planning, and the validation of devices or techniques. An imaging compatible cardiac phantom was developed to simulate a MitraClip^® procedure. The phantom contained a patient-specific cardiac model manufactured using tissue mimicking materials. To evaluate accuracy, the patient-specific model was imaged using computed tomography (CT), segmented, and the resulting point cloud dataset was compared using absolute distance to the original patient data. The result, when comparing the molded model point cloud to the original dataset, resulted in a maximum Euclidean distance error of 7.7 mm, an average error of 0.98 mm, and a standard deviation of 0.91 mm. The phantom was validated using a MitraClip^® device to ensure anatomical features and tools are identifiable under image guidance. Patient-specific cardiac phantoms may allow for surgical complications to be accounted for preoperative planning. The information gained by clinicians involved in planning and performing the procedure should lead to shorter procedural times and better outcomes for patients.

Small Rodent Cardiac Phantom for Preclinical Ultrasound Imaging

Imaging phantoms play a valuable role in the quality control and quality assurance of medical imaging systems. However, for use in the relatively new field of small-animal preclinical imaging, very few have been described in the literature, and even less or none at all are available commercially. Yet, preclinical small animal phantoms offer the possibility of reducing the need for live animals for test and measurement purposes. Human scale cardiac phantoms, both reported in the literature and available commercially, are typically complex devices. Their designs include numerous flow control valves, pumps, and servo motors. These devices are coupled to tissue mimicking materials (TMMs) shaped to replicate the form of cardiac chambers and valves. They are then operated in such a way as to cause the replica TMM heart to move in a lifelike manner. This paper describes the design and construction of a small rodent preclinical cardiac phantom, which is both of a simple design and construction. Using only readily available materials and components, it can be manufactured without the use of workshop facilities, using only hand-tools. Drawings and pictures of the design are presented along with images of the phantom in operation, using a high-frequency preclinical ultrasound scanner.

Effect of Transmural Extent of the Simulated Infarction in a Left Ventricular Model on Displacement and Strain Distribution Estimated from Synthetic Ultrasonic Data

The identification of a sub-endocardial infarction is of major interest in cardiology. This study evaluates the sensitivity of selected measures to the thickness of such an infarction. Synthetic ultrasonic data (long-axis view) of left ventricular models with inclusions were generated using Field II and meshes obtained from finite-element simulations, which also provided the reference for the estimates obtained from ultrasonic data. The displacements, the first and second component of the principal strain (ε₁ and ε₂), and several measures derived from these quantities were estimated. All estimates, except for the poorly estimated ε₂, exhibited sensitivity to the presence and transmurality of the inclusion. The most sensitive was the gradient of the averaged transmural profiles of ε₁, and ε₁ averaged over the area corresponding to the transmural inclusion. The inflection point of the ε₁ profile shifted toward the outer wall with increasing thickness of the non-transmural inclusion.

Optimal Acquisition Settings for Speckle Tracking Echocardiography-Derived Strains in Infants: An In Vitro Study

The purpose of this study was to investigate the effect of frame rate and probe frequency on the accuracy of speckle tracking echocardiography-derived strain measurements in infants. An infant-sized left ventricle phantom with sonomicrometer crystals was made from polyvinyl alcohol. The examined stroke rates were 60, 120 and 180 strokes per min (SPM). Longitudinal strain and circumferential strain measurements were analyzed from a total of 1860 cine loops. These cine loops were acquired using two pediatric probes of different frequencies at both fundamental and harmonic imaging modes. Both probes were examined at different settings (in total, 30 different frame rate-frequency combinations). At optimal settings, both longitudinal and circumferential strain displayed high accuracy. Frequency settings did not have a consistent effect on accuracy, while low frame rates led to less accurate measurements. We recommend a frame rate/heart ratio >1 frame per second/beats per min, especially for circumferential strain.

A Pipeline for the Generation of Realistic 3D Synthetic Echocardiographic Sequences: Methodology and Open-Access Database

Quantification of cardiac deformation and strain with 3D ultrasound takes considerable research efforts. Nevertheless, a widespread use of these techniques in clinical practice is still held back due to the lack of a solid verification process to quantify and compare performance. In this context, the use of fully synthetic sequences has become an established tool for initial in silico evaluation. Nevertheless, the realism of existing simulation techniques is still too limited to represent reliable benchmarking data. Moreover, the fact that different centers typically make use of in-house developed simulation pipelines makes a fair comparison difficult. In this context, this paper introduces a novel pipeline for the generation of synthetic 3D cardiac ultrasound image sequences. State-of-the art solutions in the fields of electromechanical modeling and ultrasound simulation are combined within an original framework that exploits a real ultrasound recording to learn and simulate realistic speckle textures. The simulated images show typical artifacts that make motion tracking in ultrasound challenging. The ground-truth displacement field is available voxelwise and is fully controlled by the electromechanical model. By progressively modifying mechanical and ultrasound parameters, the sensitivity of 3D strain algorithms to pathology and image properties can be evaluated. The proposed pipeline is used to generate an initial library of 8 sequences including healthy and pathological cases, which is made freely accessible to the research community via our project web-page.

Design of anthropomorphic flow phantoms based on rapid prototyping of compliant vessel geometries

Anatomically realistic flow phantoms are essential experimental tools for vascular ultrasound. Here we describe how these flow phantoms can be efficiently developed via a rapid prototyping (RP) framework that involves direct fabrication of compliant vessel geometries. In this framework, anthropomorphic vessel models were drafted in computer-aided design software, and they were fabricated using stereolithography (one type of RP). To produce elastic vessels, a compliant photopolymer was used for stereolithography. We fabricated a series of compliant, diseased carotid bifurcation models with eccentric stenosis (50%) and plaque ulceration (types I and III), and they were used to form thin-walled flow phantoms by coupling the vessels to an agar-based tissue-mimicking material. These phantoms were found to yield Doppler spectrograms with significant spectral broadening and color flow images with mosaic patterns, as typical of disturbed flow under stenosed and ulcerated disease conditions. Also, their wall distension behavior was found to be similar to that observed in vivo, and this corresponded with the vessel wall's average elastic modulus (391 kPa), which was within the nominal range for human arteries. The vessel material's acoustic properties were found to be sub-optimal: the estimated average acoustic speed was 1801 m/s, and the attenuation coefficient was 1.58 dB/(mm·MHz(n)) with a power-law coefficient of 0.97. Such an acoustic mismatch nevertheless did not notably affect our Doppler spectrograms and color flow image results. These findings suggest that phantoms produced from our design framework have the potential to serve as ultrasound-compatible test beds that can simulate complex flow dynamics similar to those observed in real vasculature.

3D strain assessment in ultrasound (Straus): a synthetic comparison of five tracking methodologies

This paper evaluates five 3D ultrasound tracking algorithms regarding their ability to quantify abnormal deformation in timing or amplitude. A synthetic database of B-mode image sequences modeling healthy, ischemic and dyssynchrony cases was generated for that purpose. This database is made publicly available to the community. It combines recent advances in electromechanical and ultrasound modeling. For modeling heart mechanics, the Bestel-Clement-Sorine electromechanical model was applied to a realistic geometry. For ultrasound modeling, we applied a fast simulation technique to produce realistic images on a set of scatterers moving according to the electromechanical simulation result. Tracking and strain accuracies were computed and compared for all evaluated algorithms. For tracking, all methods were estimating myocardial displacements with an error below 1 mm on the ischemic sequences. The introduction of a dilated geometry was found to have a significant impact on accuracy. Regarding strain, all methods were able to recover timing differences between segments, as well as low strain values. On all cases, radial strain was found to have a low accuracy in comparison to longitudinal and circumferential components.

Accuracy of real-time single- and multi-beat 3-d speckle tracking echocardiography in vitro

With little data published on the accuracy of cardiac 3-D strain measurements, we investigated the agreement between 3-D echocardiography and sonomicrometry in an in vitro model with a polyvinyl alcohol phantom. A cardiac scanner with a 3-D probe was used to acquire recordings at 15 different stroke volumes at a heart rate of 60 beats/min, and eight different stroke volumes at a heart rate of 120 beats/min. Sonomicrometry was used as a reference, monitoring longitudinal, circumferential and radial lengths. Both single- and multi-beat acquisitions were recorded. Strain values were compared with sonomicrometer strain using linear correlation coefficients and Bland-Altman analysis. Multi-beat acquisition showed good agreement, whereas real-time images showed less agreement. The best correlation was obtained for a heart rate 60 of beats/min at a volume rate 36.6 volumes/s.

A biventricular multimodal (MRI/ultrasound) cardiac phantom

A cardiac phantom can be of crucial importance in the development and validation of ultrasound and cardiac magnetic resonance (MR) imaging and image analysis methods. A biventricular multimodal cardiac phantom has been manufactured in-house that can simulate normal and pathologic hearts with different degrees of infarction. The two-chamber structure can simulate the asymmetric left ventricular motion. Poly Vinyl Alcohol (PVA) is utilized as the basic material since it can simulate the shape, elasticity, and MR and ultrasound properties of the heart. The cardiac shape is simulated using a two-chamber acrylic mold. An additional pathologic heart phantom has been built to simulate aneurysm and infarction. Segmental dyskinesis is modeled based on three inclusions of different shapes and different degrees of elasticity. The cardiac elasticity is adjusted based on freeze-thaw cycles of the PVA cryogel for normal and scarred regions.

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.

Assessment of myocardial elastography performance in phantoms under combined physiologic motion configurations with preliminary in vivo feasibility

Myocardial elastography (ME) is a non-invasive, ultrasound-based strain imaging technique, which can detect and localize abnormalities in myocardial function. By acquiring radio-frequency (RF) frames at high frame rates, the deformation of the myocardium can be estimated, and used to identify regions of abnormal deformation indicative of cardiovascular disease. In this study, the primary objective is to evaluate the effect of torsion on the performance of ME, while the secondary objective is to image inclusions during different motion schemes. Finally, the phantom findings are validated with an in vivo human case. Phantoms of homogeneous stiffness, or containing harder inclusions, were fixed to a pump and motors, and imaged. Incremental displacements were estimated from the RF signals, and accumulated over a motion cycle, and rotation angle, radial strain and circumferential strain were estimated. Phantoms were subjected to four motion schemes: rotation, torsion, deformation, and a combination of torsion and deformation. Sonomicrometry was used as a gold standard during deformation and combined motion schemes. In the rotation scheme, the input and estimated rotation angle agree in both the homogeneous and inclusion phantoms. In the torsion scheme, the estimated rotation angle was found to be highest, closest to the source of torsion and lowest farthest from the source of torsion. In the deformation scheme, if an inclusion was not present, the estimated strain patterns accurately depicted homogeneity, while if an inclusion was present, abnormalities were observed which enabled detection of the inclusion. In addition, no significant rotation was detected. In the combined scheme, if an inclusion was not present, the estimated strain patterns accurately depicted homogeneity, while, if an inclusion was present, abnormalities were observed which enabled detection of the inclusion. Also, torsion was separated from the combined scheme and was found to be similar to the pure torsion findings. This study shows ME to be capable of accurately depicting and distinguishing between different types of motion schemes, and to be sensitive to stiffness changes in localized regions of tissue-mimicking phantoms under physiologic cardiac motion configurations, while strains estimated in the combined motion scheme were noisier than in individual motion schemes. Finally, ME was shown to be capable of distinguishing between deformation and rotation in a normal human heart in vivo.

Development and characterization of rodent cardiac phantoms: comparison with in vivo cardiac imaging

The increasing availability of rodent models of human cardiovascular disease has led to a need to translate noninvasive imaging techniques such as magnetic resonance imaging (MRI) from the clinic to the animal laboratory. The aim of this study was to develop phantoms simulating the short-axis view of left ventricular motion of rats and mice, thus reducing the need for live animals in the development of MRI.

Cylindrical phantoms were moulded from polyvinyl alcohol (PVA) Cryogel and attached via stiff water-filled tubing to a gear pump. Pulsatile distension of the phantoms was effected by suitable programming of the pump. Cine MRI scanning was carried out at 7 T and compared with in vivo rodent cardiac imaging.

Suitable pulsatile performance was achieved with phantoms for which the PVA material had been subjected to two freeze–thaw cycles, resulting in T1 and T2 relaxation time constants of 1656±124 ms and 55±10 ms, respectively. For the rat phantom operating at 240 beats per min (bpm), the dynamic range of the outer diameter was from 10.3 to 12.4 mm with the wall thickness varying between 1.9 and 1.2 mm. Corresponding figures for the mouse phantom at 480 bpm were outer diameter range from 5.4 to 6.4 mm and wall thickness from 1.5 to 1.2 mm.

Dynamic cardiac phantoms simulating rodent left ventricular motion in the short-axis view were successfully developed and compared with in vivo imaging. The phantoms can be used for future development work with reduced need of live animals.

Regional cardiac motion and strain estimation in three-dimensional echocardiography: a validation study in thick-walled univentricular phantoms

Automatic quantification of regional left ventricular deformation in volumetric ultrasound data remains challenging. Many methods have been proposed to extract myocardial motion, including techniques using block matching, phase-based correlation, differential optical flow methods, and image registration. Our lab previously presented an approach based on elastic registration of subsequent volumes using a B-spline representation of the underlying transformation field. Encouraging results were obtained for the assessment of global left ventricular function, but a thorough validation on a regional level was still lacking. For this purpose, univentricular thick-walled cardiac phantoms were deformed in an experimental setup to locally assess strain accuracy against sonomicrometry as a reference method and to assess whether regions containing stiff inclusions could be detected. Our method showed good correlations against sonomicrometry: r(2) was 0.96, 0.92, and 0.84 for the radial (ε(RR)), longitudinal (ε(LL)), and circumferential (ε(CC)) strain, respectively. Absolute strain errors and strain drift were low for ε(LL) (absolute mean error: 2.42%, drift: -1.05%) and ε(CC) (error: 1.79%, drift: -1.33%) and slightly higher for ε(RR) (error: 3.37%, drift: 3.05%). The discriminative power of our methodology was adequate to resolve full transmural inclusions down to 17 mm in diameter, although the inclusion-to-surrounding tissue stiffness ratio was required to be at least 5:2 (absolute difference of 39.42 kPa). When the inclusion-to-surrounding tissue stiffness ratio was lowered to approximately 2:1 (absolute difference of 22.63 kPa), only larger inclusions down to 27 mm in diameter could still be identified. Radial strain was found not to be reliable in identifying dysfunctional regions.

New microembolus size estimator for peripheral blood vessels

Several factors affecting the power of Doppler scattered signal and, consequently, microembolus size estimation, may be eliminated when assessing the microembolus size via multiple measurements. A new microembolus size estimator is proposed based on the ratio of microembolus scattering cross-section in two directions and for two emission frequencies. Theoretical considerations indicate that the estimation of size of microembolic elements should be independent of the spatial distribution of the wave intensity, tissue attenuation and hardware factors. The simulation results indicate that this estimation only slightly depends on the material of the microembolus and acoustic properties of blood. The experimental results indicate that the accuracy of median size estimation increases with microembolus size. The measurement error is less than 27% for microemboli with median diameter larger than 360 μm. The method is constrained to the estimation of microembolus size in the vessels of extremities.