Impact of apical foreshortening on deformation measurements: a report from the EACVI-ASE Strain Standardization Task Force

Aims

Foreshortening of apical views is a common problem in echocardiography. It results in an abnormally thick false apex and a shortened left ventricular (LV) long axis. We sought to evaluate the impact of foreshortened (FS) on LV ejection fraction (LVEF) and layer-specific 2D speckle tracking based segmental (S) and global (G) longitudinal strain (LS) measurements.

Methods and results

We examined 72 participants using a GE Vivid E9 system. FS apical views were collected from an imaging window one rib-space higher than the optimal images. Ejection fraction as well as layer-specific GLS and SLS measurements were analysed by GE EchoPAC v201 and TomTec Image Arena 4.6 and compared between optimal and FS images. On average, LV long axis was 10% shorter in FS images than in optimal images. FS induced a relative change in LVEF of 3.3% and 6.9% for GE and TomTec, respectively (both, P < 0.001). Endocardial GLS was 9.0% higher with GE and 23.2% with TomTec (P < 0.001). Midwall GLS measurements were less affected (7.8% for GE and 14.1% for TomTec, respectively, both P < 0.001). Segmental strain analysis revealed that the mid-ventricular and apical segments were more affected by foreshortening, and endocardial measurements were more affected than midwall.

Conclusion

Optimal image geometry is crucial for accurate LV function assessment. Foreshorhening of apical views has a substantial impact on longitudinal strain measurements, predominantly in the apex and in the endocardial layer. Our data suggest that measuring midwall strain might therefore be the more robust approach for clinical routine use.

Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging

Recognizing the critical need for standardization in strain imaging, in 2010, the European Association of Echocardiography (now the European Association of Cardiovascular Imaging, EACVI) and the American Society of Echocardiography (ASE) invited technical representatives from all interested vendors to participate in a concerted effort to reduce intervendor variability of strain measurement. As an initial product of the work of the EACVI/ASE/Industry initiative to standardize deformation imaging, we prepared this technical document which is intended to provide definitions, names, abbreviations, formulas, and procedures for calculation of physical quantities derived from speckle tracking echocardiography and thus create a common standard.

Circumferential and longitudinal strain in 3 myocardial layers in normal subjects and in patients with regional left ventricular dysfunction

BACKGROUND

The left ventricle is not homogenous and is composed of 3 myocardial layers. Until recently, magnetic resonance imaging has been the only noninvasive technique for detailed evaluation of the left ventricular (LV) wall. The aim of this study was to analyze strain in 3 myocardial layers using speckle-tracking echocardiography.

METHODS

Twenty normal subjects and 21 patients with LV dysfunction underwent echocardiography. Short-axis (for circumferential) and apical (for longitudinal strain) views were analyzed using modified speckle-tracking software enabling the analysis of strain in 3 myocardial layers.

RESULTS

In normal subjects, longitudinal and circumferential strain was highest in the endocardium and lowest in the epicardium. Longitudinal endocardial and mid layer strain was highest in the apex and lowest in the base. Epicardial longitudinal strain was homogenous over the left ventricle. Circumferential 3-layer strain was highest in the apex and lowest in the base. In patients with LV dysfunction, strain was lower, with late diastolic or double peak.

CONCLUSIONS

Three-layer analysis of circumferential and longitudinal strain using speckle-tracking imaging can be performed on a clinical basis and may become an important method for the assessment of real-time, quantitative global and regional LV function.

A New Tool for Automatic Assessment of Segmental Wall Motion Based on Longitudinal 2D Strain

Background— Identification and quantification of segmental left ventricular wall motion abnormalities on echocardiograms is of paramount clinical importance but is still performed by a subjective visual method. We constructed an automatic tool for assessment of wall motion based on longitudinal strain.

Methods and Results— Echocardiograms of 105 patients (3 apical views) were blindly analyzed by 12 experienced readers. Visual segmental scores (VSS) and peak systolic longitudinal strain were assigned to each of 18 segments per patient. Ranges of peak systolic longitudinal strain that best fit VSS (by receiver operating characteristic analysis) were used to generate automatic segmental scores (ASS). Comparisons of ASS and VSS were performed on 1952 analyzable segments. There was agreement of wall motion scores between both methods in 89.6% of normal, 39.5% of hypokinetic, and 69.4% of akinetic segments. Correlation between methods was r =0.63 ( P <0.0001). Interobserver and intraobserver reliability using interclass correlation for scoring segmental wall motion into 3 scores by ASS was 0.82 and 0.83 and by VSS 0.70 and 0.69, respectively. Compared with VSS (majority rule), ASS had a sensitivity, specificity, and accuracy of 87%, 85%, and 86%, respectively. ASS and VSS had similar success rates for correct identification of wall motion abnormalities in territories supplied by culprit arteries. VSS had greater specificity and positive predictive values, whereas ASS had higher sensitivity and negative predictive values for identifying the culprit artery.

Conclusions— Automatic quantification of wall motion on echocardiograms by this tool performs as well as visual analysis by experienced echocardiographers, with a greater reliability and similar agreement to angiographic findings.

In vivo validation of a novel method for regional myocardial wall motion analysis based on echocardiographic tissue tracking

The objective of this study was to validate a recently developed tissue tracking (TT) method for cardiac motion, by comparing it with precise invasive measurements of motion and to prove its capability to reflect moderate hemodynamic changes induced by asynchronous activation. In four open-chest sheep, sono-crystals measured the left ventricle(LV) equator's diameters simultaneously with 2D ultrasound acquisition. The LV was paced either from the posterior or from the lateral wall, just prior to the normal LV activation. Global functional indices were calculated based on the regional motions extracted by the TT method. The correlation coefficient between the shortening of the diameters and the global circumferential strain (GCS) was 0.99 +/- 0.004. The peak GCS differentiated between the pacing modes (paired t test, P < 0.05). The GCS, a measurement closely based on the TT method, followed the precise sono-crystals measurements and reflected moderate hemodynamic changes, thus providing a substantial proof of the TT method's accuracy and clinical value.

Effect of medical therapy for heart failure on segmental myocardial function in patients with ischemic cardiomyopathy

The adjustment of medications and dosages to the needs of individual patients with heart failure is mostly intuitive, but even when their effect on global myocardial function is measured by classic indexes, their effect on segmental function is overlooked. This study was conducted to assess the feasibility of using echocardiographic myocardial strain imaging to evaluate the effect of medication on global and segmental function in 21 ambulatory patients with heart failure (mean age 65+/-11 years) who had echocardiographic studies performed before and 2 hours after ingesting their regular morning medications. The ejection fraction, global and regional strain, and time to regional peak strain were compared between the 2 examinations. Medication induced no significant changes in mean ejection fraction (28.6+/-7.8% to 27.5+/-9.9%) and mean global strain (-9.5+/-3.6% to -9.8+/-3.2%). Changes in segmental strain depended on baseline function: normal segments (peak strain more negative than -12%) deteriorated (-15.5+/-2.7% to -13.7+/-4.6%, p<0.0001), but dysfunctional segments (peak strain less negative than -8%) improved (-5.3+/-2.0% to -7.4+/-4.3%, p<0.0001). Medication also improved segmental synchronization: average time to peak strain of segments in which peak strain was attained before aortic valve closure increased (325+/-69 to 375+/-100 ms, p<0.0001), but that of segments with postsystolic shortening at baseline decreased (451+/-93 to 435+/-93 ms, p<0.006). Thus, the time interval between time to peak strain of segments with systolic and post-systolic shortening at baseline was halved after medication. In conclusion, medications for heart failure induced an increase in the echocardiographically determined peak strain of myocardial segments with impaired function at baseline but decreased the peak strain of normally contracting segments. Medications also improved the synchronization of myocardial contraction. Neither the global ejection fraction nor global strain reflected these changes. Thus, medication tended to improve the homogeneity of left ventricular contraction.

The contribution of left ventricular muscle bands to left ventricular rotation: assessment by a 2-dimensional speckle tracking method

BACKGROUND

Torsion is an essential component of left ventricular (LV) function. Systolic rotation, as a component of torsion, winds the heart muscle up like a spring, setting up recoil for early diastole. We used a new 2-dimensional speckle tracking strain method to study differences in twisting in subendocardial and subepicardial layers of the LV in open-chest pigs. Our aim was to identify the relative contributions of the inner or outer layers of the LV wall to rotation and, hence, systole.

METHODS

A total of 23 juvenile pigs were imaged in the short axis, epicardially, to obtain images at a level just below the papillary muscles with high-frequency (14 MHz) ultrasound. Speckle tracking software using scanline files was used to measure the torsional contribution of septum, anterior, posterior, and inferior LV wall segments. Two zones on the septum were evaluated separately: one with apparent circumferential fiber orientation in the inner layer and one with a speckle pattern suggesting longitudinal fiber orientation on the right ventricular aspect of the septum. Pressure rate changes (dP/dt) during the cardiac cycle were measured as an index of LV function and correlated with the regional torsion.

RESULTS

Mean peak rotations measured by speckle tracking echocardiography at the apex showed counterclockwise rotation of LV septal wall (10.68 +/- 2.67 degrees for the inner layer and 8.27 +/- 1.73 degrees for the outer layer). The time difference for time to peak rotation was 213.22 +/- 77.95 and 241.17 +/- 54.67 milliseconds for inner and outer layers, respectively. Significant differences were shown between the inner and outer layer of the LV for both rotation (P = .000) and timing of rotation (P = .02). The dP/dt measurements correlated well with the inner rotation magnitude of the LV and with the difference of short-axis rotation between inner and outer layers of the LV wall.

CONCLUSIONS

Inner and outer layers of the LV wall, especially at the septum, have different rotational behaviors. When used with very high-resolution imaging, this method could contribute to the understanding of functional contributions of the LV wall and their relative contribution to cardiac segmental twisting.

Detection of the cardiac activation sequence by novel echocardiographic tissue tracking method

Asynchronous cardiac activation leads to decreased pumping efficiency. Quantifying the activation sequence may optimize both the selection of patients for cardiac resynchronization therapy (CRT) and its efficacy. The feasibility of assessing the directivity and the degree of synchronous activation with ultrasound was examined. A tissue tracking method (CEB, GE-Ultrasound, AFI, GE Healthcare Inc., Wauwatosa, WI, USA) provided the regional strain profiles. The first maxima in systole of the regional circumferential strains were considered as the activation times. An integrative vector (SDV) describes the activation synchrony and directivity. In six open-chest sheep, activation maps and SDV were calculated in short-axis planes of the left ventricle for normal activation and induced pacings from the anterior and lateral free walls. Both magnitude and angle of the SDV were statistically different (p < 0.05) for the different pacings. Localization of the pacing site was 3 degrees +/- 18 degrees from true position. Conclusions were that motion analysis in echocardiograms provides insightful information regarding the activation process and may enhance procedures such as CRT.

Real-time quantitative automatic assessment of left ventricular ejection fraction and regional wall motion by speckle imaging

BACKGROUND

Echocardiographic assessment of left ventricular function includes calculation of ejection fraction and regional wall motion analysis. Recently, speckle imaging was introduced for quantification of left ventricular function.

OBJECTIVES

To assess LVEF by speckle imaging and compare it with Simpson's method, and to assess the regional LV strain obtained by speckle imaging in relation to conventional echocardiographic scores.

METHODS

Thirty consecutive patients, 28 with regional LV dysfunction, underwent standard echocardiographic evaluation. LV end-diastolic volume, LV end-systolic volume and EF were calculated independently by speckle imaging and Simpson's rule. The regional peak systolic strain presented by speckle imaging as a bull's-eye map was compared with the conventional visual estimate of echo score.

RESULTS

Average EDV obtained by speckle imaging and by Simpson's method was 85.1 vs. 92.7 ml (P = 0.38), average ESV was 49.4 vs. 48.8 ml (P = 0.94), calculated EF was 43.9 vs. 50.5% (P = 0.08). The correlation rate with Simpson's rule was high: 0.92 for EDV, 0.96 for ESV, and 0.89 for EF. The peak systolic strain in two patients without wall motion abnormality was 17.3 +/- 4.7; in normal segments of patients with regional dysfunction, peak systolic strain (13.4 +/- 4.9) was significantly higher than in hypokinetic segments (10.5 +/- 4.5) (P < 0.000001). The strain in hypokinetic segments was significantly higher than in akinetic segments (6.2 +/- 3.6) (P < 0.000001).

CONCLUSIONS

Speckle imaging can be successfully used for the assessment of LV volumes and EF. Bull's-eye strain map, created by speckle imaging, can achieve an accurate real-time segmental wall motion analysis.

Delineation of cardiac twist by a sonographically based 2-dimensional strain analysis method: an in vitro validation study

OBJECTIVE

Normal left ventricular contraction involves a twisting component that helps augment stroke volume, the unwinding of which also very usefully contributes to early diastolic filling. Abnormalities of cardiac twist have been related to abnormal cardiac function. We sought to quantify the twisting action using a new sonographically based angle-independent motion-detecting echo method.

METHODS

A twist model was developed with a variable-speed motor to rotate a wheel in water bath. A freshly harvested pig heart was mounted on it as a twist phantom. Short axis views were acquired with a GE/VingMed Vivid 7 system (GE Healthcare, Milwaukee, WI) at 3.5 MHz and more than 100 frames/s. Eight different speeds (30-100 cycles/min of winding and unwinding) were studied at 5 degrees of rotation (10 degrees , 20 degrees , 30 degrees , 40 degrees , and 50 degrees ). Data were analyzed off-line for twist analysis with a new 2-dimensional speckle-tracking-based program (2-dimensional strain rate method [2DSR]) embedded in EchoPac software (GE Healthcare). Ten freshly harvested pig hearts were studied in this model.

RESULTS

The 2DSR program tracked the twist well (mean determination at 10 degrees = 16.88 degrees +/- 1.81 degrees [SD]; at 20 degrees = 26.5 degrees +/- 1.05 degrees ; at 30 degrees = 36.47 degrees +/- 1.31 degrees ; at 40 degrees = 44.03 degrees +/- 1.39 degrees ; and at 50 degrees = 54.1 degrees +/- 1.96 degrees ).

CONCLUSIONS

The 2DSR program can be used to study twisting action of the heart.

Assessment of myocardial regional strain and strain rate by tissue tracking in B-mode echocardiograms

To date, established ultrasonic methods for myocardial regional deformation recovery are based on the Doppler effect, which has inherent limitations restricting its accuracy and use. The reported time domain methods show in vivo insufficient accuracy. A novel approach is elaborated mimicking the human observer who reaches robust diagnosis upon the B-mode data. In a region-of-interest (ROI), acoustic markers stable for tracking are selected. A weighting index presenting the quality of tracking of each marker is used for spatial polynomial fitting. For the feasibility study, a simple straight ROI was selected, which matches the septum. A thorough proof of concept is provided by comparing with a gold standard method and by applying the method to clinical datasets. The peak systolic longitudinal strains of 12 normals were -15% + -2.3% and, of 12 patients with a light-to-mild dysfunction of the apical-septal segment, they were -9% + -0.8% (p < 0.05). Enhancements of the method using spline fitting are introduced.

Two-dimensional acoustic pattern derived strain parameters closely correlate with one-dimensional tissue Doppler derived strain measurements

BACKGROUND

Two-dimensional strain echocardiography (2D-SE) calculates tissue velocities via frame-to-frame tracking of unique acoustic markers within the image and provides strain parameters in two dimensions. Novel 2D-SE software allows semi-automated strain measurements and increased averaging capabilities optimizing signal-noise ratio.

AIM

We tested whether 2D-SE and the currently used and well-validated tissue Doppler derived strain echocardiography (TD-SE) yield similar information in the clinical setting.

METHODS AND RESULTS

We performed 2D-SE and TD-SE on 17 patients with amyloid cardiomyopathy and 10 age-matched healthy volunteers. Single walls from standard apical views (2- and 4-chamber) were acquired at high frame rates ( approximately 200fps). Offline analysis was performed by observers blinded to clinical data using the EchoPAC program with custom 2D-SE software. Longitudinal strain rate and strain from the basal, mid and apical segments of the septal and lateral walls were determined by each method (TD-SE and 2D-SE). Ejection fraction was >0.55 in healthy volunteers and ranged from 0.30 to 0.80 in cardiomyopathy group. A total of 54 walls (162 segments) were examined. Acceptable quality strain data was available in 92% and 85% segments by 2D-SE and TD-SE, respectively. Two-dimensional strain echocardiography values correlated closely with TD-SE values (r=0.94 and 0.96 for strain rate and strain, respectively).

CONCLUSIONS

Deformation analysis by 2D-SE is feasible in a clinical setting and 2D-SE values correlate closely with TD-SE measurements over a wide range of global systolic function. Two-dimensional strain echocardiography may help to facilitate the routine clinical implementation of deformation analysis.

Measurement of ventricular torsion by two-dimensional ultrasound speckle tracking imaging

OBJECTIVES

We sought to examine the accuracy/consistency of a novel ultrasound speckle tracking imaging (STI) method for left ventricular torsion (LVtor) measurement in comparison with tagged magnetic resonance imaging (MRI) (a time-domain method similar to STI) and Doppler tissue imaging (DTI) (a velocity-based approach).

BACKGROUND

Left ventricular torsion from helically oriented myofibers is a key parameter of cardiac performance but is difficult to measure. Ultrasound STI is potentially suitable for measurement of angular motion because of its angle-independence.

METHODS

We acquired basal and apical short-axis left ventricular (LV) images in 15 patients to estimate LVtor by STI and compare it with tagged MRI and DTI. Left ventricular torsion was defined as the net difference of LV rotation at the basal and apical planes. For the STI analysis, we used high-frame (104 +/- 12 frames/s) second harmonic two-dimensional images.

RESULTS

Data on 13 of 15 patients were usable for STI analysis, and LVtor profile estimated by STI strongly correlated with those by tagged MRI (y = 0.95x + 0.19, r = 0.93, p < 0.0001, analyzed by repeated-measures regression models). The STI torsional velocity profile also correlated well with that by the DTI method (y = 0.79x + 2.4, r = 0.76, p < 0.0001, by repeated-measures regression models) with acceptable bias.

CONCLUSIONS

The STI estimation of LVtor is concordant with those analyzed by tagged MRI (data derived from tissue displacement) and also showed good agreement with those by DTI (data derived from tissue velocity). Ultrasound STI is a promising new method to assess LV torsional deformation and may make the assessment more available in clinical and research cardiology.

Two-dimensional strain-a novel software for real-time quantitative echocardiographic assessment of myocardial function

OBJECTIVES

We sought to assess the feasibility of 2-dimensional strain, a novel software for real-time quantitative echocardiographic assessment of myocardial function.

METHODS

Conventional and a novel non-Doppler-based echocardiography technique for advanced wall-motion analysis were performed in 20 patients with myocardial infarction and 10 healthy volunteers from the apical views. Two-dimensional strain is on the basis of the estimation that a discrete set of tissue velocities are present per each of many small elements on the ultrasound image. This software permits real-time assessment of myocardial velocities, strain, and strain rate. These parameters were also compared with Doppler tissue imaging measurements in 10 additional patients.

RESULTS

In all, 80.3% of infarct and 97.8% of normal segments could be adequately tracked by the software. Peak systolic strain, strain rate, and peak systolic myocardial velocities, calculated from the software, were significantly higher in the normal than in the infarct segments. In the 10 additional patients, velocities, strain, and strain rate obtained with the novel software were not significantly different from those obtained with Doppler tissue imaging.

CONCLUSION

Two-dimensional strain can accomplish real-time wall-motion analysis, and has the potential to become a standard for real-time automatic echocardiographic assessment of cardiac function.

Improving motion estimation by accounting for local image distortion

Cardiac elastography is a useful diagnostic technique for detection of heart function abnormalities, based on analysis of echocardiograms. The analysis of the regional heart motion allows assessing the extent of myocardial ischemia and infarction. In this paper, a new two-stage algorithm for cardiac motion estimation is proposed, where the data is taken from a sequence of 2D echocardiograms. The method combines the advantages of block-matching and optical flow techniques. The first stage employs a standard block-matching algorithm (sum of absolute differences) to provide a displacement estimate with accuracy of up to one pixel. At the second stage, this estimate is corrected by estimating the parameters of a local image transform within a test window. The parameters of the image transform are estimated in the least-square sense. In order to account for typical heart motions, like contraction/expansion, translation and rotation, a local affine model is assumed within the test window. The accuracy of the new algorithm is evaluated using a sequence of 500 grayscale B-mode images, which are generated as distorted, but known copies of an original ROI, taken from a real echocardiogram. The accuracy of the motion estimation is expressed in terms of errors: maximum absolute error, root-mean-square error, average error and standard deviation. The errors of the proposed algorithm are compared with these of the known block-matching technique with cross-correlation and interpolation in the sub-pixel space. Statistical analysis of the errors shows that the proposed algorithm provides more accurate estimates of the heart motion than the cross-correlation technique with interpolation in the sub-pixel space.

Global longitudinal strain: a novel index of left ventricular systolic function

BACKGROUND

Echocardiographic estimation of global left ventricular (LV) function is subjective and time consuming. Our aim was to develop a novel approach for assessment of global LV function from 2-dimensional echocardiographic images

METHODS

Novel computer software for tissue tracking was developed and applied as follows: digital loops were acquired from apical 2-, 3-, and 4-chamber views and a line was loosely traced along the LV endocardium at the frame wherein it was best defined. Around this line, the software selected natural acoustic markers moving with the tissue. Automatic frame-by-frame tracking of these markers during the heart cycle yielded a measure of contractility along the selected region of interest. Global longitudinal strain (GLS) and GLS rate (GLSR) were calculated for the entire U-shaped length of LV myocardium (basal, mid, and apical segments of 2 opposite walls in each view). To test this software, computer-derived GLS and GLSR were analyzed by a nonechocardiographer, blinded to the echocardiographic interpretation, in 27 consecutive patients after myocardial infarction (MI) (age 64.4 +/- 12.9 years; 19 men; mean wall-motion score index of 1.79 +/- 0.44) and compared with those obtained in 12 consecutive control patients (age 59.0 +/- 9.7 years; 8 women), with a normal echocardiographic study.

RESULTS

GLS and GLSR, averaged from the 3 apical views, differed significantly in patients post-MI compared with control patients (GLS -14.7 +/- 5.1% vs -24.1 +/- 2.9% and GLSR -0.57 +/- 0.21/s vs -1.02 +/- 0.09/s for patients post-MI vs control patients, respectively; both P <.0001). There was a good linear correlation between the wall-motion score index and the GLS and GLSR (R = 0.68 and R = 0.67, respectively; both P <.0001). A cut-off value for GLS of -21% had 92% sensitivity and 89% specificity and a cut-off value for GLSR -0.9/s had 92% sensitivity and 96% specificity for the detection of patients post-MI.

CONCLUSIONS

GLS and GLSR are novel indices for assessment of global LV function from 2-dimensional echocardiographic images. Early validation studies with the method are suggestive of high sensitivity and specificity in the detection of LV systolic dysfunction in patients post-MI.

The combined effect of nonlinear filtration and window size on the accuracy of tissue displacement estimation using detected echo signals

In cardiac elastography, the regional strain and strain rate imaging is based on displacement estimation of tissue sections within the heart muscle carried out with various block-matching techniques (cross-correlation, sum of absolute differences, sum of squared differences, etc.). The accuracy of these techniques depends on a combination of ultrasonic imaging parameters such as ultrasonic frequency of interrogation, signal-to-noise ratio, size of a kernel used in a block-matching algorithm, type of data and speckle decorrelation. In this paper, we discuss the possibility to enhance the accuracy of the displacement estimation via nonlinear filtering of B-mode images before block-matching operation. The combined effect of a filter algorithm and a kernel size on the accuracy of the displacement estimation is analyzed using a 36-frame sequence of grayscale B-mode images of a human heart acquired by an ultrasound system operating at 1.77 MHz. It is shown that the nonlinear filtering of images enables to obtain the desired accuracy (less than one pixel) of the displacement estimation with smaller kernels than without filtering. These results are obtained for two filters--an adaptive anisotropic diffusion filter and a nonlinear Gaussian filter chain.

The instantaneous measurement of multiple Doppler spectra in the investigation of ovarian masses

The use of Doppler indices of tumor vascularity as markers for malignancy has been a subject of debate, with inconsistencies in specificity and sensitivity as well as in the diagnostic cut-off values. Part of the discrepancy might be explained by the limited number of vessels selected within the tumor for Doppler evaluation. A typical sample of three or four vessels may not be sufficiently large for correct representation of the vasculature of the tumor, which may contain many vessels. The existing conventional Doppler (color and spectral) techniques clearly have limitations. We present here a novel Doppler modality, namely two-dimensional spectral Doppler imaging (SDI), which allows the acquisition of many Doppler spectra within a few seconds. The operator selects a region of interest within a color Doppler image. The Doppler sequence is initiated and the entire selected region is automatically scanned for about 20 s until all spectral Doppler data have been acquired and processed. The system computer generates a color-coded map of the desired Doppler indices overlaid on the gray-scale image. The system also displays a cumulative histogram or a table of the requested Doppler index from all the sections in the tissue. The whole process is automatically performed by the system computer, without any need for operator intervention. The system provides the examiner with a 'fishing net' for Doppler indices, instead of the 'fishing hook' used in current techniques.