Measurement of viscoelastic properties of in vivo swine myocardium using lamb wave dispersion ultrasound vibrometry (LDUV)

Cardiac 2-D Shear Wave Imaging Using a New Dedicated Clinical Ultrasound System: A Phantom Study

OBJECTIVE

The purpose of this study was to assess cardiac shear wave imaging implemented in a new MACH 30 ultrasound machine (SuperSonic Imaging, Aix-en-Provence, France) and interfaced with a linear probe and a phased array probe, in comparison with a previously validated Aixplorer system connected to a linear probe (SuperSonic Imaging) using Elasticity QA phantoms (Models 039 and 049, CIRS Inc., Norfolk, VA, USA).

METHODS

Quantile-quantile plots were used for distribution agreement. The accuracy of stiffness measurement was assessed by the percentage error and the mean percentage error (MPE), and its homogeneity, by the standard deviation of the MPE. A p value <0.01 was considered to indicate statistical significance.

RESULTS

The accuracy of dedicated cardiac sequences for linear probes was similar for the two systems with an MPE of 8 ± 14% versus 20 ± 21% (p = not significant) with the SuperSonic MACH 30 and Aixplorer, respectively, and was influenced by target stiffness and location of the measurement in the field of view, but without drift over time. The optimal transthoracic cardiac probe workspace was located between 4 and 10 cm, with an MPE of 29.5 ± 25% compared with 93.3 ± 130% outside this area (p < 0.0001). In this area, stiffness below 20 kPa was significantly different from the reference (p < 0.0001). The sectorial probe revealed no MPE difference in any of the measurement areas, with no significant lateral or axial gradient.

CONCLUSION

The new Supersonic MACH 30 system upgraded with a sectorial probe and specific cardiac settings provided homogenous stiffness measurements, especially when operating at depths between 4 and 10 cm. These phantom results may be useful in designing future in vivo studies.

Ultrasound Viscoelastography by Acoustic Radiation Force: A State-of-the-Art Review

Ultrasound elastography (USE) is a promising tool for tissue characterization as several diseases result in alterations of tissue structure and composition, which manifest as changes in tissue mechanical properties. By imaging the tissue response to an applied mechanical excitation, USE mimics the manual palpation performed by clinicians to sense the tissue elasticity for diagnostic purposes. Next to elasticity, viscosity has recently been investigated as an additional, relevant, diagnostic biomarker. Moreover, since biological tissues are inherently viscoelastic, accounting for viscosity in the tissue characterization process enhances the accuracy of the elasticity estimation. Recently, methods exploiting different acquisition and processing techniques have been proposed to perform ultrasound viscoelastography. After introducing the physics describing viscoelasticity, a comprehensive overview of the currently available USE acquisition techniques is provided, followed by a structured review of the existing viscoelasticity estimators classified according to the employed processing technique. These estimators are further reviewed from a clinical usage perspective, and current outstanding challenges are discussed.

Ultrasound Shear Wave Elastography in Cardiology

The advent of high-frame rate imaging in ultrasound allowed the development of shear wave elastography as a noninvasive alternative for myocardial stiffness assessment. It measures mechanical waves propagating along the cardiac wall with speeds that are related to stiffness. The use of cardiac shear wave elastography in clinical studies is increasing, but a proper understanding of the different factors that affect wave propagation is required to correctly interpret results because of the heart's thin-walled geometry and intricate material properties. The aims of this review are to give an overview of the general concepts in cardiac shear wave elastography and to discuss in depth the effects of age, hemodynamic loading, cardiac morphology, fiber architecture, contractility, viscoelasticity, and system-dependent factors on the measurements, with a focus on clinical application. It also describes how these factors should be considered during acquisition, analysis, and reporting to ensure an accurate, robust, and reproducible measurement of the shear wave.

[Echocardiography with high frame rates in the clinical practice : Principles, applications and perspectives]

Continuous developments in cardiovascular imaging, software and hardware have led to technological advancements that open new ways for assessing myocardial mechanics, hemodynamics, and function. Through new scan modalities, echocardiographic scanners can nowadays achieve very high frame rates up to 5000 frames s-1 which enables a wide variety of new applications, including shear wave elastography, ultrafast speckle tracking, the visualization of intracardiac blood flow and myocardial perfusion imaging. This review provides an overview of these advances and demonstrates possible applications and their potential added value in the clinical practice.

Possible depth-resolved reconstruction of shear moduli in the cornea following collagen crosslinking (CXL) with optical coherence tomography and elastography

Corneal collagen crosslinking (CXL) is commonly used to prevent or treat keratoconus. Although changes in corneal stiffness induced by CXL surgery can be monitored with non-contact dynamic optical coherence elastography (OCE) by tracking mechanical wave propagation, depth dependent changes are still unclear if the cornea is not crosslinked through the whole depth. Here, phase-decorrelation measurements on optical coherence tomography (OCT) structural images are combined with acoustic micro-tapping (AµT) OCE to explore possible reconstruction of depth-dependent stiffness within crosslinked corneas in an ex vivo human cornea sample. Experimental OCT images are analyzed to define the penetration depth of CXL into the cornea. In a representative ex vivo human cornea sample, crosslinking depth varied from ∼100 µm in the periphery to ∼150 µm in the cornea center and exhibited a sharp in-depth transition between crosslinked and untreated areas. This information was used in an analytical two-layer guided wave propagation model to quantify the stiffness of the treated layer. We also discuss how the elastic moduli of partially CXL-treated cornea layers reflect the effective engineering stiffness of the entire cornea to properly quantify corneal deformation.

Possible depth-resolved reconstruction of shear moduli in the cornea following collagen crosslinking (CXL) with optical coherence tomography and elastography

Corneal collagen crosslinking (CXL) is commonly used to prevent or treat keratoconus. Although changes in corneal stiffness induced by CXL surgery can be monitored with non-contact dynamic optical coherence elastography (OCE) by tracking mechanical wave propagation, depth dependent changes are still unclear if the cornea is not crosslinked through the whole depth. Here, phase-decorrelation measurements on optical coherence tomography (OCT) structural images are combined with acoustic micro-tapping (A$\mu$T) OCE to explore possible reconstruction of depth-dependent stiffness within crosslinked corneas in an ex vivo human cornea sample. Experimental OCT images are analyzed to define the penetration depth of CXL into the cornea. In a representative ex vivo human cornea sample, crosslinking depth varied from $\sim 100\mu m$ in the periphery to $\sim 150\mu m$ in the cornea center and exhibited a sharp in-depth transition between crosslinked and untreated areas. This information was used in an analytical two-layer guided wave propagation model to quantify the stiffness of the treated layer. We also discuss how the elastic moduli of partially CXL-treated cornea layers reflect the effective engineering stiffness of the entire cornea to properly quantify corneal deformation.

Full waveform inversion for arterial viscoelasticity

Objective. Arterial viscosity is emerging as an important biomarker, in addition to the widely used arterial elasticity. This paper presents an approach to estimate arterial viscoelasticity using shear wave elastography (SWE).Approach. While dispersion characteristics are often used to estimate elasticity from SWE data, they are not sufficiently sensitive to viscosity. Driven by this, we develop a full waveform inversion (FWI) methodology, based on directly matching predicted and measured wall velocity in space and time, to simultaneously estimate both elasticity and viscosity. Specifically, we propose to minimize an objective function capturing the correlation between measured and predicted responses of the anterior wall of the artery.Results. The objective function is shown to be well-behaving (generally convex), leading us to effectively use gradient optimization to invert for both elasticity and viscosity. The resulting methodology is verified with synthetic data polluted with noise, leading to the conclusion that the proposed FWI is effective in estimating arterial viscoelasticity.Significance. Accurate estimation of arterial viscoelasticity, not just elasticity, provides a more precise characterization of arterial mechanical properties, potentially leading to a better indicator of arterial health.

Estimation of anisotropic properties of CMR patient-specific left ventricle using the virtual field method

Left ventricle (LV) myocardial dysfunction has been recently investigated using the estimation of isotropic myocardial stiffness from magnetic resonance imaging (MRI). However, Myocardium is known to have a 3D complex geometry with anisotropic stiffness. The assessment of the anisotropy properties characterizes structural changes in myocardium as a consequence of heart failure (HF). From image data, the virtual field method (VFM) can determine material stiffness in a non-invasive manner. In the present work, the objective is to compare two inverse identification methods, given the isotropic and anisotropic models in the characterization of properties of myocardium in acute lymphoblastic leukemia (ALL) survivors using VFM and MRI. Two types of VFM approach are presented. Using the first, the virtual displacements (VFs) allow whole-field LV to be imposed into VFM formulation and caused to directly estimate two independent parameters from isotropic constitutive relation. With the second, anisotropic parameters are estimated using piece-wise (Finite element-based) VFM. The resulting values showed significant differences between the subjects in comparative study of leukemia survivors, and variance in estimated parameters by two different VFM approach. This approach would be an efficient tool to characterize early cardiac dysfunction. This work elucidates the benefits and shortcomings of using VFM to determine anisotropic parameters of LV myocardium in linear elastic and of using the FEM application to generate meshes of patient-specific LVs from MRI images.

The influence of acoustic radiation force beam shape and location on wave spectral content for arterial dispersion ultrasound vibrometry

Objective. Arterial dispersion ultrasound vibrometry (ADUV) relies on the use of guided waves in arterial geometries for shear wave elastography measurements. Both the generation of waves through the use of acoustic radiation force (ARF) and the techniques employed to infer the speed of the resulting wave motion affect the spectral content and accuracy of the measurement. In particular, the effects of the shape and location of the ARF beam in ADUV have not been widely studied. In this work, we investigated how such variations of the ARF beam affect the induced motion and the measurements in the dispersive modes that are excited. Approach. The study includes an experimental evaluation on an arterial phantom and an in vivo validation of the observed trends, observing the two walls of the waveguide, simultaneously, when subjected to variations in the ARF beam extension (F/N) and focus location. Main results. Relying on the theory of guided waves in cylindrical shells, the shape of the beam controls the selection and nature of the induced modes, while the location affects the measured dispersion curves (i.e. variation of phase velocity with frequency or wavenumber, multiple modes) across the waveguide walls. Significance. This investigation is important to understand the spectral content variations in ADUV measurements and to maximize inversion accuracy by tuning the ARF beam settings in clinical applications.

Ex Vivo Evaluation of Mechanical Anisotropic Tissues with High-Frequency Ultrasound Shear Wave Elastography

The use of imaging devices to assess directional mechanics of tissues is highly desirable. This is because the directional mechanics depend on fiber orientation, and altered directional mechanics are closely related to the pathological status of tissues. However, measuring directional mechanics in tissues with high-stiffness is challenging due to the difficulty of generating localized displacement in these tissues using acoustic radiation force, a general method for generating displacement in ultrasound-based elastography. In addition, common ultrasound probes do not provide rotational function, which makes the measurement of directional mechanics inaccurate and unreliable. Therefore, we developed a high-frequency ultrasound mechanical wave elastography system that can accommodate a wide range of tissue stiffness and is also equipped with a motorized rotation stage for precise imaging of directional mechanics. A mechanical shaker was applied to the elastography system to measure tissues with high-stiffness. Phantom and ex vivo experiments were performed. In the phantom experiments, the lateral and axial resolution of the system were determined to be 144 μm and 168 μm, respectively. In the ex vivo experiments, we used swine heart and cartilage, both of which are considered stiff. The elastography system allows us to acquire the directional mechanics with high angular resolution in the heart and cartilage. The results demonstrate that the developed elastography system is capable of imaging a wide range of tissues and has high angular resolution. Therefore, this system might be useful for the diagnostics of mechanically anisotropic tissues via ex vivo tests.

Assessing cardiac stiffness using ultrasound shear wave elastography

Shear wave elastography offers a new dimension to echocardiography: it measures myocardial stiffness. Therefore, it could provide additional insights into the pathophysiology of cardiac diseases affecting myocardial stiffness and potentially improve diagnosis or guide patient treatment. The technique detects fast mechanical waves on the heart wall with high frame rate echography, and converts their propagation velocity into a stiffness value. A proper interpretation of shear wave data is required as the shear wave interacts with the intrinsic, yet dynamically changing geometrical and material characteristics of the heart under pressure. This dramatically alters the wave physics of the propagating wave, demanding adapted processing methods compared to other shear wave elastography applications as breast tumor and liver stiffness staging. Furthermore, several advanced analysis methods have been proposed to extract supplementary material features such as viscosity and anisotropy, potentially offering additional diagnostic value. This review explains the general mechanical concepts underlying cardiac shear wave elastography and provides an overview of the preclinical and clinical studies within the field. We also identify the mechanical and technical challenges ahead to make shear wave elastography a valuable tool for clinical practice.

Viscoelasticity Imaging of Biological Tissues and Single Cells Using Shear Wave Propagation

Changes in biomechanical properties of biological soft tissues are often associated with physiological dysfunctions. Since biological soft tissues are hydrated, viscoelasticity is likely suitable to represent its solid-like behavior using elasticity and fluid-like behavior using viscosity. Shear wave elastography is a non-invasive imaging technology invented for clinical applications that has shown promise to characterize various tissue viscoelasticity. It is based on measuring and analyzing velocities and attenuations of propagated shear waves. In this review, principles and technical developments of shear wave elastography for viscoelasticity characterization from organ to cellular levels are presented, and different imaging modalities used to track shear wave propagation are described. At a macroscopic scale, techniques for inducing shear waves using an external mechanical vibration, an acoustic radiation pressure or a Lorentz force are reviewed along with imaging approaches proposed to track shear wave propagation, namely ultrasound, magnetic resonance, optical, and photoacoustic means. Then, approaches for theoretical modeling and tracking of shear waves are detailed. Following it, some examples of applications to characterize the viscoelasticity of various organs are given. At a microscopic scale, a novel cellular shear wave elastography method using an external vibration and optical microscopy is illustrated. Finally, current limitations and future directions in shear wave elastography are presented.

Concepts and applications of ultrafast cardiac ultrasound imaging

The concept of ultrafast echocardiographic imaging has been around for decades. However, only recent progress in ultrasound machine hardware and computer technology allowed to apply this concept to echocardiography. High frame rate echocardiography can visualize phenomena that have never been captured before. It enables a wide variety of potential new applications, including shear wave imaging, speckle tracking, ultrafast Doppler imaging, and myocardial perfusion imaging. The principles of these applications and their potential clinical use will be presented in this manuscript.

A direct comparison of natural and acoustic-radiation-force-induced cardiac mechanical waves

Natural and active shear wave elastography (SWE) are potential ultrasound-based techniques to non-invasively assess myocardial stiffness, which could improve current diagnosis of heart failure. This study aims to bridge the knowledge gap between both techniques and discuss their respective impacts on cardiac stiffness evaluation. We recorded the mechanical waves occurring after aortic and mitral valve closure (AVC, MVC) and those induced by acoustic radiation force throughout the cardiac cycle in four pigs after sternotomy. Natural SWE showed a higher feasibility than active SWE, which is an advantage for clinical application. Median propagation speeds of 2.5-4.0 m/s and 1.6-4.0 m/s were obtained after AVC and MVC, whereas ARF-based median speeds of 0.9-1.2 m/s and 2.1-3.8 m/s were reported for diastole and systole, respectively. The different wave characteristics in both methods, such as the frequency content, complicate the direct comparison of waves. Nevertheless, a good match was found in propagation speeds between natural and active SWE at the moment of valve closure, and the natural waves showed higher propagation speeds than in diastole. Furthermore, the results demonstrated that the natural waves occur in between diastole and systole identified with active SWE, and thus represent a myocardial stiffness in between relaxation and contraction.

Local myocardial stiffness variations identified by high frame rate shear wave echocardiography

BACKGROUND

Shear waves are generated by the closure of the heart valves. Significant differences in shear wave velocity have been found recently between normal myocardium and disease models of diffusely increased muscle stiffness. In this study we correlate in vivo myocardial shear wave imaging (SWI) with presence of scarred tissue, as model for local increase of stiffness. Stiffness variation is hypothesized to appear as velocity variation.

METHODS

Ten healthy volunteers (group 1), 10 hypertrophic cardiomyopathy (HCM) patients without any cardiac intervention (group 2), and 10 HCM patients with prior septal reduction therapy (group 3) underwent high frame rate tissue Doppler echocardiography. The SW in the interventricular septum after aortic valve closure was mapped along two M-mode lines, in the inner and outer layer.

RESULTS

We compared SWI to 3D echocardiography and strain imaging. In groups 1 and 2, no change in velocity was detected. In group 3, 8/10 patients showed a variation in SW velocity. All three patients having transmural scar showed a simultaneous velocity variation in both layers. Out of six patients with endocardial scar, five showed variations in the inner layer.

CONCLUSION

Local variations in stiffness, with myocardial remodeling post septal reduction therapy as model, can be detected by a local variation in the propagation velocity of naturally occurring shear waves.

Detection of Tissue Fibrosis using Natural Mechanical Wave Velocity Estimation: Feasibility Study

In the feasibility study described here, we developed and tested a novel method for mechanical wave velocity estimation for tissue fibrosis detection in the myocardium. High-frame-rate ultrasound imaging and a novel signal processing method called clutter filter wave imaging was used. A mechanical wave propagating through the left ventricle shortly after the atrial contraction was measured in the three different apical acquisition planes, for 20 infarct patients and 10 healthy controls. The results obtained were correlated with fibrosis locations from magnetic resonance imaging, and a sensitivity ≥60% was achieved for all infarcts larger than 10% of the left ventricle. The stability of the wave through several heart cycles was assessed and found to be of high quality. This method therefore has potential for non-invasive fibrosis detection in the myocardium, but further validation in a larger group of subjects is needed.

Parasternal Versus Apical View in Cardiac Natural Mechanical Wave Speed Measurements

Shear wave speed measurements can potentially be used to noninvasively measure myocardial stiffness to assess the myocardial function. Several studies showed the feasibility of tracking natural mechanical waves induced by aortic valve closure in the interventricular septum, but different echocardiographic views have been used. This article systematically studied the wave propagation speeds measured in a parasternal long-axis and in an apical four-chamber view in ten healthy volunteers. The apical and parasternal views are predominantly sensitive to longitudinal or transversal tissue motion, respectively, and could, therefore, theoretically measure the speed of different wave modes. We found higher propagation speeds in apical than in the parasternal view (median of 5.1 m/s versus 3.8 m/s, , n = 9 ). The results in the different views were not correlated ( r = 0.26 , p = 0.49 ) and an unexpectedly large variability among healthy volunteers was found in apical view compared with the parasternal view (3.5-8.7 versus 3.2-4.3 m/s, respectively). Complementary finite element simulations of Lamb waves in an elastic plate showed that different propagation speeds can be measured for different particle motion components when different wave modes are induced simultaneously. The in vivo results cannot be fully explained with the theory of Lamb wave modes. Nonetheless, the results suggest that the parasternal long-axis view is a more suitable candidate for clinical diagnosis due to the lower variability in wave speeds.

Reproducibility of Natural Shear Wave Elastography Measurements

For the quantification of myocardial function, myocardial stiffness can potentially be measured non-invasively using shear wave elastography. Clinical diagnosis requires high precision. In 10 healthy volunteers, we studied the reproducibility of the measurement of propagation speeds of shear waves induced by aortic and mitral valve closure (AVC, MVC). Inter-scan was slightly higher but in similar ranges as intra-scan variability (AVC: 0.67 m/s (interquartile range [IQR]: 0.40-0.86 m/s) versus 0.38 m/s (IQR: 0.26-0.68 m/s), MVC: 0.61 m/s (IQR: 0.26-0.94 m/s) versus 0.26 m/s (IQR: 0.15-0.46 m/s)). For AVC, the propagation speeds obtained on different day were not statistically different (p = 0.13). We observed different propagation speeds between 2 systems (AVC: 3.23-4.25 m/s [Zonare ZS3] versus 1.82-4.76 m/s [Philips iE33]), p = 0.04). No statistical difference was observed between observers (AVC: p = 0.35). Our results suggest that measurement inaccuracies dominate the variabilities measured among healthy volunteers. Therefore, measurement precision can be improved by averaging over multiple heartbeats.

A computational model of open-irrigated radiofrequency catheter ablation accounting for mechanical properties of the cardiac tissue

Radiofrequency catheter ablation (RFCA) is an effective treatment for cardiac arrhythmias. Although generally safe, it is not completely exempt from the risk of complications. The great flexibility of computational models can be a major asset in optimizing interventional strategies if they can produce sufficiently precise estimations of the generated lesion for a given ablation protocol. This requires an accurate description of the catheter tip and the cardiac tissue. In particular, the deformation of the tissue under the catheter pressure during the ablation is an important aspect that is overlooked in the existing literature, which resorts to a sharp insertion of the catheter into an undeformed geometry. As the lesion size depends on the power dissipated in the tissue and the latter depends on the percentage of the electrode surface in contact with the tissue itself, the sharp insertion geometry has the tendency to overestimate the lesion obtained, which is a consequence of the tissue temperature rise overestimation. In this paper, we introduce a full 3D computational model that takes into account the tissue elasticity and is able to capture tissue deformation and realistic power dissipation in the tissue. Numerical results in FEniCS-HPC are provided to validate the model against experimental data and to compare the lesions obtained with the new model and with the classical ones featuring a sharp electrode insertion in the tissue.

Two Point Method For Robust Shear Wave Phase Velocity Dispersion Estimation of Viscoelastic Materials

Ultrasound shear wave elastography (SWE) is an imaging modality used for noninvasive, quantitative evaluation of tissue mechanical properties. SWE uses an acoustic radiation force to produce laterally propagating shear waves that can be tracked in spatial and temporal domains in order to obtain the wave velocity. One of the ways to study the viscoelasticity is through examining the shear wave velocity dispersion curves. In this paper, we present an alternative method to two-dimensional Fourier transform (2D-FT). Our unique approach (2P-CWT) considers shear wave propagation measured in two lateral locations only and uses wavelet transformation analysis. We used the complex Morlet wavelet function as the mother wavelet to filter two shear waves at different locations. We examined how the first signal position and the distance between the two locations affect the shear wave velocity dispersion estimation in 2P-CWT. We tested this new method on a digital phantom data created using the local interaction simulation approach (LISA) in viscoelastic media with and without added white Gaussian noise to the wave motion. Moreover, we tested data acquired from custom made tissue mimicking viscoelastic phantom experiments and ex vivo porcine liver measurements. We compared results from 2P-CWT with the 2D-FT technique. 2P-CWT provided dispersion curves estimation with lower errors over a wider frequency band in comparison to 2D-FT. Tests conducted showed that the two-point technique gives results with better accuracy in simulation results and can be used to measure phase velocity of viscoelastic materials.

Imaging Heart Dynamics With Ultrafast Cascaded-Wave Ultrasound

The heart is an organ with highly dynamic complexity, including cyclic fast electrical activation, muscle kinematics, and blood dynamics. Although ultrafast cardiac imaging techniques based on pulsed-wave ultrasound (PUS) have rapidly emerged to permit mapping of heart dynamics, they suffer from limited sonographic signal-to-noise ratio (SNR) and penetration due to insufficient energy delivery and inevitable attenuation through the chest wall. We hereby propose ultrafast cascaded-wave ultrasound (uCUS) imaging to depict heart dynamics in higher SNR and larger penetration than conventional ultrafast PUS. To solve the known tradeoff between the length of transmitted ultrasound signals and spatial resolution while achieving ultrafast frame rates (>1000 Hz), we develop a cascaded synthetic aperture (CaSA) imaging method. In CaSA, an array probe is divided into subapertures; each subaperture transmits a train of diverging waves. These diverging waves are weighted in both the aperture (i.e., spatial) and range (i.e., temporal) directions with a coding matrix containing only +1 and -1 polarity coefficients. A corresponding spatiotemporal decoding matrix is designed to recover backscattered signals. The decoded signals are thereafter beamformed and coherently compounded to obtain one high-SNR beamformed image frame. For CaSA with M subapertures and N cascaded diverging waves, sonographic SNR is increased by 10× log ₁₀ (N ×M) (dB) compared with conventional synthetic aperture (SA) imaging. The proposed uCUS with CaSA was evaluated with conventional SA and Hadamard-encoded SA (H-SA) methods in a calibration phantom for B-mode image quality and an in vivo human heart in a transthoracic setting for the quality assessment of anatomical, myocardial motion, and chamber blood power Doppler images. Our results demonstrated that the proposed uCUS with CaSA (4 subapertures, 32 cascaded waves) improved SNR (+20.46 dB versus SA, +14.83 dB versus H-SA) and contrast ratio (+8.44 dB versus SA, +7.81 dB versus H-SA) with comparable spatial resolutions to and at the same frame rates as benchmarks.

Naturally Occurring Shear Waves in Healthy Volunteers and Hypertrophic Cardiomyopathy Patients

We apply a high frame rate (over 500 Hz) tissue Doppler method to measure the propagation velocity of naturally occurring shear waves (SW) generated by aortic and mitral valves closure. The aim of this work is to demonstrate clinical relevance. We included 45 healthy volunteers and 43 patients with hypertrophic cardiomyopathy (HCM). The mitral SW (4.68 ± 0.66 m/s) was consistently faster than the aortic (3.51 ± 0.38 m/s) in all volunteers (p < 0.0001). In HCM patients, SW velocity correlated with E/e' ratio (r = 0.346, p = 0.04 for aortic SW and r = 0.667, p = 0.04 for mitral SW). A subgroup of 20 volunteers were matched for age and gender to 20 HCM patients. In HCM, the mean velocity of 5.1 ± 0.7 m/s for the aortic SW (3.61 ± 0.46 m/s in matched volunteers, p < 0.0001) and 6.88 ± 1.12 m/s for the mitral SW(4.65 ± 0.77 m/s in matched volunteers, p < 0.0001). A threshold of 4 m/s for the aortic SW correctly classified pathologic myocardium with a sensitivity of 95% and specificity of 90%. Naturally occurring SW can be used to assess differences between normal and pathologic myocardium.

A Review of in vitro Platforms for Understanding Cardiomyocyte Mechanobiology

Mechanobiology—a cell's interaction with its physical environment—can influence a myriad of cellular processes including how cells migrate, differentiate and proliferate. In many diseases, remodeling of the extracellular matrix (ECM) is observed such as tissue stiffening in rigid scar formation after myocardial infarct. Utilizing knowledge of cell mechanobiology in relation to ECM remodeling during pathogenesis, elucidating the role of the ECM in the progression—and perhaps regression—of disease is a primary focus of the field. Although the importance of mechanical signaling in the cardiac cell is well-appreciated, our understanding of how these signals are sensed and transduced by cardiomyocytes is limited. To overcome this limitation, recently developed tools and resources have provided exciting opportunities to further our understandings by better recapitulating pathological spatiotemporal ECM stiffness changes in an in vitro setting. In this review, we provide an overview of a conventional model of mechanotransduction and present understandings of cardiomyocyte mechanobiology, followed by a review of emerging tools and resources that can be used to expand our knowledge of cardiomyocyte mechanobiology toward more clinically relevant applications.

Natural Shear Wave Imaging in the Human Heart: Normal Values, Feasibility, and Reproducibility

Left ventricular myocardial stiffness could offer superior quantification of cardiac systolic and diastolic function when compared to the current diagnostic tools. Shear wave elastography in combination with acoustic radiation force has been widely proposed to noninvasively assess tissue stiffness. Interestingly, shear waves can also result from intrinsic cardiac mechanical events (e.g., closure of valves) without the need for external excitation. However, it remains unknown whether these natural shear waves always occur, how reproducible they can be detected and what the normal range of shear wave propagation speed is. The present study, therefore, aimed at establishing the feasibility of detecting shear waves created after mitral valve closure (MVC) and aortic valve closure (AVC), the variability of the measurements, and at reporting the normal values of propagation velocity. Hereto, a group of 30 healthy volunteers was scanned with high-frame rate imaging (>1000 Hz) using an experimental ultrasound system transmitting a diverging wave sequence. Tissue Doppler velocity and acceleration were used to create septal color M-modes, on which the shear waves were tracked and their velocities measured. Overall, the methodology was capable of detecting the transient vibrations that spread throughout the intraventricular septum in response to the closure of the cardiac valves in 92% of the recordings. Reference velocities of 3.2±0.6 m/s at MVC and 3.5±0.6 m/s at AVC were obtained. Moreover, in order to show the diagnostic potential of this approach, two patients (one with cardiac amyloidosis and one undergoing a dobutamine stress echocardiography) were scanned with the same protocol and showed markedly higher propagation speeds: the former presented velocities of 6.6 and 5.6 m/s; the latter revealed normal propagation velocities at baseline, and largely increased during the dobutamine infusion (>15 m/s). Both cases showed values consistent with the expected changes in stiffness and cardiac loading conditions.

In Vivo Open- and Closed-chest Measurements of Left-Ventricular Myocardial Viscoelasticity using Lamb wave Dispersion Ultrasound Vibrometry (LDUV): A Feasibility Study

Diastolic dysfunction causes close to half of congestive heart failures and is associated with increased stiffness in left-ventricular myocardium. A clinical tool capable of measuring viscoelasticity of the myocardium could be beneficial in clinical settings. We used Lamb wave Dispersion Ultrasound Vibrometry (LDUV) for assessing the feasibility of making in vivo non-invasive measurements of myocardial elasticity and viscosity in pigs. In vivo open-chest measurements of myocardial elasticity and viscosity obtained using a Fourier space based analysis of Lamb wave dispersion are reported. The approach was used to perform ECG-gated transthoracic in vivo measurements of group velocity, elasticity and viscosity throughout a single heart cycle. Group velocity, elasticity and viscosity in the frequency range 50-500 Hz increased from diastole to systole, consistent with contraction and relaxation of the myocardium. Systolic group velocity, elasticity and viscosity were 5.0 m/s, 19.1 kPa, 6.8 Pa·s, respectively. In diastole, the measured group velocity, elasticity and viscosity were 1.5 m/s, 5.1 kPa and 3.2 Pa·s, respectively.

[Antagonistic function of the heart muscle : Part II: Clinical implications]

In the hypertrophic heart the myostructural afterload in the form of endoepicardial networks is predominant, which enhances myocardial hypertrophy. The intrinsic antagonism is derailed. Likewise, the connective tissue scaffold, i.e. the stromatogenic afterload, is enriched in the response to the derailment of antagonism in a hypertrophic heart up to regional captivation of the heart musculature. Due to the selective susceptibility of the auxotonic, contracting oblique transmural myocardial network for low dose negative inotropic medication, this promises to attenuate progress in myocardial hypertrophy. Volume reduction surgery is most effective in reducing wall stress as long as the myocardium is not critically fettered by fibrosis. The use of external mechanical circulatory support is then effective if the heart is supported in its resting mode, which means around a middle width and at minimal amplitude of motion. The takotsubo cardiomyopathy might possibly reflect an isolated, extreme stimulation of the intrinsic antagonism as a response to hormonally induced sensitization of the myocardium to catecholamine. A particular significant conclusion with respect to the diseased heart is that clinical diagnostics need new impulses with a focus on the analysis of local motion patterns and on myocardial stiffness reflecting disease-dependent antagonistic intensity. This would become a relevant diagnostic marker if corresponding (noninvasive) measurement techniques would become available.

An in silico framework to analyze the anisotropic shear wave mechanics in cardiac shear wave elastography

Shear wave elastography (SWE) is a potential tool to non-invasively assess cardiac muscle stiffness. This study focused on the effect of the orthotropic material properties and mechanical loading on the performance of cardiac SWE, as it is known that these factors contribute to complex 3D anisotropic shear wave propagation. To investigate the specific impact of these complexities, we constructed a finite element model with an orthotropic material law subjected to different uniaxial stretches to simulate SWE in the stressed cardiac wall. Group and phase speed were analyzed in function of tissue thickness and virtual probe rotation angle. Tissue stretching increased the group and phase speed of the simulated shear wave, especially in the direction of the muscle fiber. As the model provided access to the true fiber orientation and material properties, we assessed the accuracy of two fiber orientation extraction methods based on SWE. We found a higher accuracy (but lower robustness) when extracting fiber orientations based on the location of maximal shear wave speed instead of the angle of the major axis of the ellipsoidal group speed surface. Both methods had a comparable performance for the center region of the cardiac wall, and performed less well towards the edges. Lastly, we also assessed the (theoretical) impact of pathology on shear wave physics and characterization in the model. It was found that SWE was able to detect changes in fiber orientation and material characteristics, potentially associated with cardiac pathologies such as myocardial fibrosis. Furthermore, the model showed clearly altered shear wave patterns for the fibrotic myocardium compared to the healthy myocardium, which forms an initial but promising outcome of this modeling study.

Cardiac Shear Wave Velocity Detection in the Porcine Heart

Cardiac muscle stiffness can potentially be estimated non-invasively with shear wave elastography. Shear waves are present on the septal wall after mitral and aortic valve closure, thus providing an opportunity to assess stiffness in early systole and early diastole. We report on the shear wave recordings of 22 minipigs with high-frame-rate echocardiography. The waves were captured with 4000 frames/s using a programmable commercial ultrasound machine. The wave pattern was extracted from the data through a local tissue velocity estimator based on one-lag autocorrelation. The wave propagation velocity was determined with a normalized Radon transform, resulting in median wave propagation velocities of 2.2 m/s after mitral valve closure and 4.2 m/s after aortic valve closure. Overall the velocities ranged between 0.8 and 6.3 m/s in a 95% confidence interval. By dispersion analysis we found that the propagation velocity only mildly increased with shear wave frequency.

Investigating Shear Wave Physics in a Generic Pediatric Left Ventricular Model via In Vitro Experiments and Finite Element Simulations

Shear wave elastography (SWE) is a potentially valuable tool to noninvasively assess ventricular function in children with cardiac disorders, which could help in the early detection of abnormalities in muscle characteristics. Initial experiments demonstrated the potential of this technique in measuring ventricular stiffness; however, its performance remains to be validated as complicated shear wave (SW) propagation characteristics are expected to arise due to the complex non-homogenous structure of the myocardium. In this work, we investigated the (i) accuracy of different shear modulus estimation techniques (time-of-flight (TOF) method and phase velocity analysis) across myocardial thickness and (ii) effect of the ventricular geometry, surroundings, acoustic loading, and material viscoelasticity on SW physics. A generic pediatric (10-15-year old) left ventricular model was studied numerically and experimentally. For the SWE experiments, a polyvinylalcohol replicate of the cardiac geometry was fabricated and SW acquisitions were performed on different ventricular areas using varying probe orientations. Additionally, the phantom's stiffness was obtained via mechanical tests. The results of the SWE experiments revealed the following trends for stiffness estimation across the phantom's thickness: a slight stiffness overestimation for phase speed analysis and a clear stiffness underestimation for the TOF method for all acquisitions. The computational model provided valuable 3-D insights in the physical factors influencing SW patterns, especially the surroundings (water), interface force, and viscoelasticity. In conclusion, this paper presents a validation study of two commonly used shear modulus estimators for different ventricular locations and the essential role of SW modeling in understanding SW physics in the pediatric myocardium.

Shear-wave elasticity measurements of three-dimensional cell cultures for mechanobiology

Studying mechanobiology in three-dimensional (3D) cell cultures better recapitulates cell behaviors in response to various types of mechanical stimuli in vivo. Stiffening of the extracellular matrix resulting from cell remodeling potentiates many pathological conditions, including advanced cancers. However, an effective tool for measuring the spatiotemporal changes in elastic properties of such 3D cell cultures without directly contacting the samples has not been reported previously. We describe an ultrasonic shear-wave-based platform for quantitatively evaluating the spatiotemporal dynamics of the elasticity of a matrix remodeled by cells cultured in 3D environments. We used this approach to measure the elasticity changes of 3D matrices grown with highly invasive lung cancer cells and cardiac myoblasts, and to delineate the principal mechanism underlying the stiffening of matrices remodeled by these cells. The described approach can be a useful tool in fields investigating and manipulating the mechanotransduction of cells in 3D contexts, and also has potential as a drug-screening platform.

Summary: Use of a non-direct-contact platform for measurement of the spatiotemporal dynamics of matrix elasticity when remodeled by cells cultured in three-dimensional contexts.

Quantitative Assessment of Left Ventricular Diastolic Stiffness Using Cardiac Shear Wave Elastography: A Pilot Study

OBJECTIVES

The purpose of this study was to systematically investigate the feasible echocardiographic views for human transthoracic cardiac shear wave elastography (SWE) and the impact of myocardial anisotropy on myocardial stiffness measurements.

METHODS

A novel cardiac SWE technique using pulse inversion harmonic imaging and time-aligned sequential tracking was developed for this study. The technique can measure the quantitative local myocardial stiffness noninvasively. Ten healthy volunteers were recruited and scanned by the proposed technique 3 times on 3 different days.

RESULTS

Seven combinations of echocardiographic views and left ventricular (LV) segments were found to be feasible for LV diastolic stiffness measurements: basal interventricular septum under parasternal short- and long-axis views; mid interventricular septum under parasternal short- and long-axis views; anterior LV free wall under parasternal short- and long-axis views; and posterior LV free wall under a parasternal short-axis view. Statistical analyses showed good repeatability of LV diastolic stiffness measurements among 3 different days from 70% of the participants for the basal interventricular septum and posterior LV free wall short-axis views. On the same LV segment, the mean diastolic shear wave speed measurements from the short-axis view were statistically different from the long-axis measurements: 1.82 versus 1.29 m/s for the basal interventricular septum; 1.81 versus 1.45 m/s for mid interventricular septum; and 1.96 versus 1.77 m/s for the anterior LV free wall, indicating that myocardial anisotropy plays a substantial role in LV diastolic stiffness measurements.

CONCLUSIONS

These results establish the preliminary normal range of LV diastolic stiffness under different scan views and provide important guidance for future clinical studies using cardiac SWE.

Investigation of the effects of myocardial anisotropy for shear wave elastography using impulsive force and harmonic vibration

The myocardium is known to be an anisotropic medium where the muscle fiber orientation changes through the thickness of the wall. Shear wave elastography methods use propagating waves which are measured by ultrasound or magnetic resonance imaging (MRI) techniques to characterize the mechanical properties of various tissues. Ultrasound- or MR-based methods have been used and the excitation frequency ranges for these various methods cover a large range from 24-500 Hz. Some of the ultrasound-based methods have been shown to be able to estimate the fiber direction. We constructed a model with layers of elastic, transversely isotropic materials that were oriented at different angles to simulate the heart wall in systole and diastole. We investigated the effect of frequency on the wave propagation and the estimation of fiber direction and wave speeds in the different layers of the assembled models. We found that waves propagating at low frequencies such as 30 or 50 Hz showed low sensitivity to the fiber direction but also had substantial bias in estimating the wave speeds in the layers. Using waves with higher frequency content (>200 Hz) allowed for more accurate fiber direction and wave speed estimation. These results have particular relevance for MR- and ultrasound-based elastography applications in the heart.

Cardiac shear-wave elastography using a transesophageal transducer: application to the mapping of thermal lesions in ultrasound transesophageal cardiac ablation

Heart rhythm disorders, such as atrial fibrillation or ventricular tachycardia can be treated by catheter-based thermal ablation. However, clinically available systems based on radio-frequency or cryothermal ablation suffer from limited energy penetration and the lack of lesion's extent monitoring. An ultrasound-guided transesophageal device has recently successfully been used to perform High-Intensity Focused Ultrasound (HIFU) ablation in targeted regions of the heart in vivo. In this study we investigate the feasibility of a dual therapy and imaging approach on the same transesophageal device. We demonstrate in vivo that quantitative cardiac shear-wave elastography (SWE) can be performed with the device and we show on ex vivo samples that transesophageal SWE can map the extent of the HIFU lesions. First, SWE was validated with the transesophageal endoscope in one sheep in vivo. The stiffness of normal atrial and ventricular tissues has been assessed during the cardiac cycle (n = 11) and mapped (n = 7). Second, HIFU ablation has been performed with the therapy-imaging transesophageal device in ex vivo chicken breast samples (n  =  3), then atrial (left, n = 2) and ventricular (left n = 1, right n = 1) porcine heart tissues. SWE provided stiffness maps of the tissues before and after ablation. Areas of the lesions were obtained by tissue color change with gross pathology and compared to SWE. During the cardiac cycle stiffness varied from 0.5   ±   0.1 kPa to 6.0   ±   0.3 kPa in the atrium and from 1.3   ±   0.3 kPa to 13.5   ±   9.1 kPa in the ventricles. The thermal lesions were visible on all SWE maps performed after ablation. Shear modulus of the ablated zones increased to 16.3   ±   5.5 kPa (versus 4.4   ±   1.6 kPa before ablation) in the chicken breast, to 30.3   ±   10.3 kPa (versus 12.2   ±   4.3 kPa) in the atria and to 73.8   ±   13.9 kPa (versus 21.2   ±   3.3 kPa) in the ventricles. On gross pathology, the size of the lesions ranged from 0.1 to 1.5 cm(2) in the imaging plane area. Elasticity-estimated depths and widths of the lesions differed respectively with a median of 0.2 mm (first quartile Q1:  -0.8 mm; third quartile Q3: 2.6 mm) for a mean squared error (MSE) of 5.1 mm(2) and a median of 0.2 mm (Q1:  -2.7 mm; Q3: 2.7 mm) for a MSE of 11.1 mm(2) from gross pathology. We have demonstrated the feasibility of the HIFU thermal ablation monitoring using a dual therapy and imaging transesophageal device. The combination of HIFU, ultrasound imaging and SWE on the same transesophageal system could lead to a new clinical device for a safer and controlled treatment of a wide variety of cardiac arrhythmias.

Quantitative evaluation of atrial radio frequency ablation using intracardiac shear-wave elastography

PURPOSE

Radio frequency catheter ablation (RFCA) is a well-established clinical procedure for the treatment of atrial fibrillation (AF) but suffers from a low single-procedure success rate. Recurrence of AF is most likely attributable to discontinuous or nontransmural ablation lesions. Yet, despite this urgent clinical need, there is no clinically available imaging modality that can reliably map the lesion transmural extent in real time. In this study, the authors demonstrated the feasibility of shear-wave elastography (SWE) to map quantitatively the stiffness of RFCA-induced thermal lesions in cardiac tissues in vitro and in vivo using an intracardiac transducer array.

METHODS

SWE was first validated in ex vivo porcine ventricular samples (N = 5). Both B-mode imaging and SWE were performed on normal cardiac tissue before and after RFCA. Areas of the lesions were determined by tissue color change with gross pathology and compared against the SWE stiffness maps. SWE was then performed in vivo in three sheep (N = 3). First, the stiffness of normal atrial tissues was assessed quantitatively as well as its variation during the cardiac cycle. SWE was then performed in atrial tissue after RFCA.

RESULTS

A large increase in stiffness was observed in ablated ex vivo regions (average shear modulus across samples in normal tissue: 22 ± 5 kPa, average shear-wave speed (ct): 4.5 ± 0.4 m s(-1) and in determined ablated zones: 99 ± 17 kPa, average ct: 9.0 ± 0.5 m s(-1) for a mean shear modulus increase ratio of 4.5 ± 0.9). In vivo, a threefold increase of the shear modulus was measured in the ablated regions, and the lesion extension was clearly visible on the stiffness maps.

CONCLUSIONS

By its quantitative and real-time capabilities, Intracardiac SWE is a promising intraoperative imaging technique for the evaluation of thermal ablation during RFCA.

Parametric imaging of viscoelasticity using optical coherence elastography

We demonstrate imaging of soft tissue viscoelasticity using optical coherence elastography. Viscoelastic creep deformation is induced in tissue using step-like compressive loading and the resulting time-varying deformation is measured using phase-sensitive optical coherence tomography. From a series of co-located B-scans, we estimate the local strain rate as a function of time, and parameterize it using a four-parameter Kelvin-Voigt model of viscoelastic creep. The estimated viscoelastic strain and time constant are used to visualize viscoelastic creep in 2D, dual-parameter viscoelastograms. We demonstrate our technique on six silicone tissue-simulating phantoms spanning a range of viscoelastic parameters. As an example in soft tissue, we report viscoelastic contrast between muscle and connective tissue in fresh, ex vivo rat gastrocnemius muscle and mouse abdominal transection. Imaging viscoelastic creep deformation has the potential to provide complementary contrast to existing imaging modalities, and may provide greater insight into disease pathology.

Viscoelastic properties of normal and infarcted myocardium measured by a multifrequency shear wave method: comparison with pressure-segment length method

Our aims were (i) to compare in vivo measurements of myocardial elasticity by shear wave dispersion ultrasound vibrometry (SDUV) with those by the conventional pressure-segment length method, and (ii) to quantify changes in myocardial viscoelasticity during systole and diastole after reperfused acute myocardial infarction. The shear elastic modulus (μ1) and viscous coefficient (μ2) of left ventricular myocardium were measured by SDUV in 10 pigs. Young's elastic modulus was independently measured by the pressure-segment length method. Measurements made with the SDUV and pressure-segment length methods were strongly correlated. At reperfusion, μ1 and μ2 in end-diastole were increased. Less consistent changes were found during systole. In all animals, μ1 increased linearly with left ventricular pressure developed during systole. Preliminary results suggest that μ1 is preload dependent. This is the first study to validate in vivo measurements of myocardial elasticity by a shear wave method. In this animal model, the alterations in myocardial viscoelasticity after a myocardial infarction were most consistently detected during diastole.

Wideband dispersion reversal of lamb waves

Ultrasonic guided waves have been widely acknowledged as the most promising tools for nondestructive evaluation (NDE). However, because of the multimodal dispersion, the received guided modes usually overlap in both time and frequency, which highly complicates the mode separation and signal interpretation. The time-reversal technique can be used to realize the time recompression of the Lamb waves, but because of the multimode excitation and reception, it still may not be able to remove the mode ambiguity and achieve the pure pulse compression. With the goal of overcoming this limitation, a wideband dispersion reversal (WDR) technique is proposed. The technique makes use of a priori knowledge of the guided dispersion characteristics to synthesize the corresponding dispersion reversal excitations, which are able to selectively excite the self-compensation pure mode pulse. The theoretical basis of the technique is thoroughly described. A two-dimensional finite-difference time-domain (2D-FDTD) method is employed to simulate the propagation of two fundamental Lamb modes, the symmetrical S0 and antisymmetrical A0 modes in a steel plate. The proposed method was verified through experimental investigation. Finally, the advantages and potential applications of the method are briefly discussed.

Improved Shear Wave Motion Detection Using Pulse-Inversion Harmonic Imaging With a Phased Array Transducer

Ultrasound tissue harmonic imaging is widely used to improve ultrasound B-mode imaging quality thanks to its effectiveness in suppressing imaging artifacts associated with ultrasound reverberation, phase aberration, and clutter noise. In ultrasound shear wave elastography (SWE), because the shear wave motion signal is extracted from the ultrasound signal, these noise sources can significantly deteriorate the shear wave motion tracking process and consequently result in noisy and biased shear wave motion detection. This situation is exacerbated in in vivo SWE applications such as heart, liver, and kidney. This paper, therefore, investigated the possibility of implementing harmonic imaging, specifically pulse-inversion harmonic imaging, in shear wave tracking, with the hypothesis that harmonic imaging can improve shear wave motion detection based on the same principles that apply to general harmonic B-mode imaging. We first designed an experiment with a gelatin phantom covered by an excised piece of pork belly and show that harmonic imaging can significantly improve shear wave motion detection by producing less underestimated shear wave motion and more consistent shear wave speed measurements than fundamental imaging. Then, a transthoracic heart experiment on a freshly sacrificed pig showed that harmonic imaging could robustly track the shear wave motion and give consistent shear wave speed measurements of the left ventricular myocardium while fundamental imaging could not. Finally, an in vivo transthoracic study of seven healthy volunteers showed that the proposed harmonic imaging tracking sequence could provide consistent estimates of the left ventricular myocardium stiffness in end-diastole with a general success rate of 80% and a success rate of 93.3% when excluding the subject with Body Mass Index higher than 25. These promising results indicate that pulse-inversion harmonic imaging can significantly improve shear wave motion tracking and thus potentially facilitate more robust assessment of tissue elasticity by SWE.

Ultrasound vibrometry using orthogonal- frequency-based vibration pulses

New vibration pulses are developed for shear wave generation in a tissue region with preferred spectral distributions for ultrasound vibrometry applications. The primary objective of this work is to increase the frequency range of detectable harmonics of the shear wave. The secondary objective is to reduce the required peak intensity of transmitted pulses that induce the vibrations and shear waves. Unlike the periodic binary vibration pulses, the new vibration pulses have multiple pulses in one fundamental period of the vibration. The pulses are generated from an orthogonal-frequency wave composed of several sinusoidal signals, the amplitudes of which increase with frequency to compensate for higher loss at higher frequency in tissues. The new method has been evaluated by studying the shear wave propagation in in vitro chicken and swine liver. The experimental results show that the new vibration pulses significantly increase tissue vibration with a reduced peak ultrasound intensity, compared with the binary vibration pulses.