Intracardiac Vortex Dynamics by High-Frame-Rate Doppler Vortography-In Vivo Comparison With Vector Flow Mapping and 4-D Flow MRI

Cardiac stasis imaging, stroke, and silent brain infarcts in patients with nonischemic dilated cardiomyopathy

Cardioembolic stroke is one of the most devastating complications of nonischemic dilated cardiomyopathy (NIDCM). However, in clinical trials of primary prevention, the benefits of anticoagulation are hampered by the risk of bleeding. Indices of cardiac blood stasis may account for the risk of stroke and be useful to individualize primary prevention treatments. We performed a cross-sectional study in patients with NIDCM and no history of atrial fibrillation (AF) from two sources: 1) a prospective enrollment of unselected patients with left ventricular (LV) ejection fraction <45% and 2) a retrospective identification of patients with a history of previous cardioembolic neurological event. The primary end point integrated a history of ischemic stroke or the presence intraventricular thrombus, or a silent brain infarction (SBI) by imaging. From echocardiography, we calculated blood flow inside the LV, its residence time (TR) maps, and its derived stasis indices. Of the 89 recruited patients, 18 showed a positive end point, 9 had a history of stroke or transient ischemic attack (TIA) and 9 were diagnosed with SBIs in the brain imaging. Averaged TR, [Formula: see text] performed well to identify the primary end point [AUC (95% CI) = 0.75 (0.61-0.89), P = 0.001]. When accounting only for identifying a history of stroke or TIA, AUC for [Formula: see text] was 0.92 (0.85-1.00) with odds ratio = 7.2 (2.3-22.3) per cycle, P < 0.001. These results suggest that in patients with NIDCM in sinus rhythm, stasis imaging derived from echocardiography may account for the burden of stroke.NEW & NOTEWORTHY Patients with nonischemic dilated cardiomyopathy (NIDCM) are at higher risk of stroke than their age-matched population. However, the risk of bleeding neutralizes the benefit of preventive oral anticoagulation. In this work, we show that in patients in sinus rhythm, the burden of stroke is related to intraventricular stasis metrics derived from echocardiography. Therefore, stasis metrics may be useful to personalize primary prevention anticoagulation in these patients.

Enhanced echocardiographic assessment of intracardiac flow in congenital heart disease

BACKGROUND

4D flow magnetic resonance imaging (4D flow MRI) can assess and measure the complex flow patterns of the right ventricle (RV) in congenital heart diseases, but its limited availability makes the broad application of intracardiac flow assessment challenging. Color Doppler imaging velocity reconstruction from conventional echocardiography is an emerging alternative, but its validity against 4D flow MRI needs to be established.

OBJECTIVE

To compare intracardiac flow parameters measured by color Doppler velocity reconstruction (DoVeR) against parameters measured from 4D flow MRI.

METHODS

We analyzed 20 subjects, including 7 normal RVs and 13 abnormal RVs (10 with repaired Tetralogy of Fallot, and 3 with atrial-level shunts). Intracardiac flow parameters such as relative pressure difference, vortex strength, total kinetic energy, and viscous energy loss were quantified using DoVeR and 4D flow MRI. The agreement between the two methods was determined by comparing the spatial fields and quantifying the cross-correlation and normalized difference between time-series measurements.

RESULTS

The hemodynamic parameters obtained from DoVeR and 4D flow MRI showed similar flow characteristics and spatial distributions. The time evolutions of the parameters were also in good agreement between the two methods. The median correlation coefficient between the time-series of any parameter was between 0.87 and 0.92, and the median L2-norm deviation was between 10% to 14%.

CONCLUSIONS

Our study shows that DoVeR is a reliable alternative to 4D flow MRI for quantifying intracardiac hemodynamic parameters in the RV.

Spatially segmented SVD clutter filtering in cardiac blood flow imaging with diverging waves

Ultrafast ultrasound imaging enables the visualization of rapidly changing blood flow dynamics in the chambers of the heart. Singular value decomposition (SVD) filters outperform conventional high pass clutter rejection filters for ultrafast blood flow imaging of small and shallow fields of view (e.g., functional imaging of brain activity). However, implementing SVD filters can be challenging in cardiac imaging due to the complex spatially and temporally varying tissue characteristics. To address this challenge, we describe a method that involves excluding the proximal portion of the image (near the chest wall) and divides the reduced field of view into overlapped segments, within which tissue signals are expected to be spatially and temporally coherent. SVD filtering with automatic selection of cut-off singular vector orders to remove tissue and noise signals is implemented for each segment. Auto-thresholding is based on the coherence of spatial singular vectors, delineating tissue, blood, and noise subspaces within a spatial similarity matrix calculated for each segment. Filtered blood flow signals from the segments are reconstructed and then combined and Doppler processing is used to form a set of blood flow images. Preliminary experimental results suggest that the spatially segmented approach improves the separation of the tissue and blood subsets in the spatial similarity matrix so that automatic thresholding is significantly improved, and tissue clutter can then be rejected more effectively in cardiac ultrafast imaging, compared to using the full field of view. In the case studied, spatially segmented SVD improved the rate of correct automatic selection of thresholds from 78% to 98.7% for the investigated cases and improved the post-filter power of blood signals by an average of more than 10 dB during a cardiac cycle.

Ultrafast Ultrasound Vector Doppler for Small Vasculature Imaging

Ultrafast Doppler has been accepted as a novel modality for small vasculature imaging with high sensitivity, high spatiotemporal resolution, and high penetration. However, the conventional Doppler estimator adopted in studies of ultrafast ultrasound imaging is only sensitive to the velocity component along the beam direction and has angle-dependent limitations. Vector Doppler has been developed with the goal of angle-independent velocity estimation but is typically employed for relatively large vessels. In this study, combining multiangle vector Doppler strategy and ultrafast sequencing, ultrafast ultrasound vector Doppler (ultrafast UVD) is developed for small vasculature hemodynamic imaging. The validity of the technique is demonstrated through experiments on a rotational phantom, rat brain, human brain, and human spinal cord. A rat brain experiment shows that compared with the ultrasound localization microscopy (ULM) velocimetry, which is widely accepted as an accurate flow velocimetry technique, the average relative error (ARE) of the velocity magnitude estimated by ultrafast UVD is approximately 16.2%, with a root-mean-square error (RMSE) of the velocity direction of 26.7°. It is demonstrated that ultrafast UVD is a promising tool for accurate blood flow velocity measurement, especially for the organs, including brain and spinal cord with vasculature typically exhibiting tendential alignment of vascular trees.

Assessment of Blood Flow Transport in the Left Ventricle Using Ultrasound. Validation Against 4-D Flow Cardiac Magnetic Resonance

Four-dimensional flow cardiac magnetic resonance (CMR) is the reference technique for analyzing blood transport in the left ventricle (LV), but similar information can be obtained from ultrasound. We aimed to validate ultrasound-derived transport in a head-to-head comparison against 4D flow CMR. In five patients and two healthy volunteers, we obtained 2D + t and 3D + t (4D) flow fields in the LV using transthoracic echocardiography and CMR, respectively. We compartmentalized intraventricular blood flow into four fractions of end-diastolic volume: direct flow (DF), retained inflow (RI), delayed ejection flow (DEF) and residual volume (RV). Using ultrasound we also computed the properties of LV filling waves (percentage of LV penetration and percentage of LV volume carried by E/A waves) to determine their relationships with CMR transport. Agreement between both techniques for quantifying transport fractions was good for DF and RV (Ric [95% confidence interval]: 0.82 [0.33, 0.97] and 0.85 [0.41, 0.97], respectively) and moderate for RI and DEF (Ric= 0.47 [-0.29, 0.88] and 0.55 [-0.20, 0.90], respectively). Agreement between techniques to measure kinetic energy was variable. The amount of blood carried by the E-wave correlated with DF and RV (R = 0.75 and R = 0.63, respectively). Therefore, ultrasound is a suitable method for expanding the analysis of intraventricular flow transport in the clinical setting.

Requirements and Hardware Limitations of High-Frame-Rate 3-D Ultrasound Imaging Systems

The spread of high frame rate and 3-D imaging techniques has raised pressing requirements for ultrasound systems. In particular, the processing power and data transfer rate requirements may be so demanding to hinder the real-time (RT) implementation of such techniques. This paper first analyzes the general requirements involved in RT ultrasound systems. Then, it identifies the main bottlenecks in the receiving section of a specific RT scanner, the ULA-OP 256, which is one of the most powerful available open scanners and may therefore be assumed as a reference. This case study has evidenced that the “star” topology, used to digitally interconnect the system’s boards, may easily saturate the data transfer bandwidth, thus impacting the achievable frame/volume rates in RT. The architecture of the digital scanner was exploited to tackle the bottlenecks by enabling a new “ring“ communication topology. Experimental 2-D and 3-D high-frame-rate imaging tests were conducted to evaluate the frame rates achievable with both interconnection modalities. It is shown that the ring topology enables up to 4400 frames/s and 510 volumes/s, with mean increments of +230% (up to +620%) compared to the star topology.

Full-volume three-component intraventricular vector flow mapping by triplane color Doppler

Objective. Intraventricular vector flow mapping (iVFM) is a velocimetric technique for retrieving two-dimensional velocity vector fields of blood flow in the left ventricular cavity. This method is based on conventional color Doppler imaging, which makes iVFM compatible with the clinical setting. We have generalized the iVFM for a three-dimensional reconstruction (3D-iVFM). Approach. 3D-iVFM is able to recover three-component velocity vector fields in a full intraventricular volume by using a clinical echocardiographic triplane mode. The 3D-iVFM problem was written in the spherical (radial, polar, azimuthal) coordinate system associated to the six half-planes produced by the triplane mode. As with the 2D version, the method is based on the mass conservation, and free-slip boundary conditions on the endocardial wall. These mechanical constraints were imposed in a least-squares minimization problem that was solved through the method of Lagrange multipliers. We validated 3D-iVFM in silico in a patient-specific CFD (computational fluid dynamics) model of cardiac flow and tested its clinical feasibility in vivo in patients and in one volunteer. Main results. The radial and polar components of the velocity were recovered satisfactorily in the CFD setup (correlation coefficients, r  = 0.99 and 0.78). The azimuthal components were estimated with larger errors ( r  = 0.57) as only six samples were available in this direction. In both in silico and in vivo investigations, the dynamics of the intraventricular vortex that forms during diastole was deciphered by 3D-iVFM. In particular, the CFD results showed that the mean vorticity can be estimated accurately by 3D-iVFM. Significance. Our results tend to indicate that 3D-iVFM could provide full-volume echocardiographic information on left intraventricular hemodynamics from the clinical modality of triplane color Doppler.

Computational Methods for Fluid-Structure Interaction Simulation of Heart Valves in Patient-Specific Left Heart Anatomies

Given the complexity of human left heart anatomy and valvular structures, the fluid–structure interaction (FSI) simulation of native and prosthetic valves poses a significant challenge for numerical methods. In this review, recent numerical advancements for both fluid and structural solvers for heart valves in patient-specific left hearts are systematically considered, emphasizing the numerical treatments of blood flow and valve surfaces, which are the most critical aspects for accurate simulations. Numerical methods for hemodynamics are considered under both the continuum and discrete (particle) approaches. The numerical treatments for the structural dynamics of aortic/mitral valves and FSI coupling methods between the solid Ωs and fluid domain Ωf are also reviewed. Future work toward more advanced patient-specific simulations is also discussed, including the fusion of high-fidelity simulation within vivo measurements and physics-based digital twining based on data analytics and machine learning techniques.

A Pipeline for the Generation of Synthetic Cardiac Color Doppler

Color Doppler imaging (CDI) is the modality of choice for simultaneous visualization of myocardium and intracavitary flow over a wide scan area. This visualization modality is subject to several sources of error, the main ones being aliasing and clutter. Mitigation of these artifacts is a major concern for better analysis of intracardiac flow. One option to address these issues is through simulations. In this article, we present a numerical framework for generating clinical-like CDI. Synthetic blood vector fields were obtained from a patient-specific computational fluid dynamics CFD model. Realistic texture and clutter artifacts were simulated from real clinical ultrasound cineloops. We simulated several scenarios highlighting the effects of 1) flow acceleration; 2) wall clutter; and 3) transmit wavefronts, on Doppler velocities. As a comparison, an "ideal" color Doppler was also simulated, without these harmful effects. This synthetic dataset is made publicly available and can be used to evaluate the quality of Doppler estimation techniques. Besides, this approach can be seen as a first step toward the generation of comprehensive datasets for training neural networks to improve the quality of Doppler imaging.

Physics-constrained intraventricular vector flow mapping by color Doppler

Color Doppler by transthoracic echocardiography creates two-dimensional fan-shaped maps of blood velocities in the cardiac cavities. It is a one-component velocimetric technique since it only returns the velocity components parallel to the ultrasound beams. Intraventricular vector flow mapping (iVFM) is a method to recover the blood velocity vectors from the Doppler scalar fields in an echocardiographic three-chamber view. We improved ouriVFM numerical scheme by imposing physical constraints. TheiVFM consisted in minimizing regularized Doppler residuals subject to the condition that two fluid-dynamics constraints were satisfied, namely planar mass conservation, and free-slip boundary conditions. The optimization problem was solved by using the Lagrange multiplier method. A finite-difference discretization of the optimization problem, written in the polar coordinate system centered on the cardiac ultrasound probe, led to a sparse linear system. The single regularization parameter was determined automatically for non-supervision considerations. The physics-constrained method was validated using realistic intracardiac flow data from a patient-specific computational fluid dynamics (CFD) model. The numerical evaluations showed that theiVFM-derived velocity vectors were in very good agreement with the CFD-based original velocities, with relative errors ranged between 0.3% and 12%. We calculated two macroscopic measures of flow in the cardiac region of interest, the mean vorticity and mean stream function, and observed an excellent concordance between physics-constrainediVFM and CFD. The capability of physics-constrainediVFM was finally tested within vivocolor Doppler data acquired in patients routinely examined in the echocardiographic laboratory. The vortex that forms during the rapid filling was deciphered. The physics-constrainediVFM algorithm is ready for pilot clinical studies and is expected to have a significant clinical impact on the assessment of diastolic function.

Evaluation of intraventricular flow by multimodality imaging: a review and meta-analysis

Background

The aim of this systematic review was to evaluate current inter-modality agreement of noninvasive clinical intraventricular flow (IVF) assessment with 3 emerging imaging modalities: echocardiographic particle image velocimetry (EPIV), vector flow mapping (VFM), and 4-dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR).

Methods

We performed a systematic literature review in the databases EMBASE, Medline OVID and Cochrane Central for identification of studies evaluating left ventricular (LV) flow patterns using one of these flow visualization modalities. Of the 2224 initially retrieved records, 10 EPIV, 23 VFM, and 25 4D flow CMR studies were included in the final analysis.

Results

Vortex parameters were more extensively studied with EPIV, while LV energetics and LV transport mechanics were mainly studied with 4D flow CMR, and LV energy loss and vortex circulation were implemented by VFM studies. Pooled normative values are provided for these parameters. The meta- analysis for the values of two vortex morphology parameters, vortex length and vortex depth, failed to reveal a significant change between heart failure patients and healthy controls.

Conclusion

Agreement between the different modalities studying intraventricular flow is low and different methods of measurement and reporting were used among studies. A multimodality framework with a standardized set of flow parameters is necessary for implementation of noninvasive flow visualization in daily clinical practice. The full potential of noninvasive flow visualization in addition to diagnostics could also include guiding medical or interventional treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00269-8.

Intraventricular Vector Flow Imaging with Blood Speckle Tracking in Adults: Feasibility, Normal Physiology and Mechanisms in Healthy Volunteers

This study examines the feasibility of blood speckle tracking for vector flow imaging in healthy adults and describes the physiologic flow pattern and vortex formation in relation to the wall motion in the left ventricle. The study included 21 healthy volunteers and quantified and visualized flow patterns with high temporal resolution down to a depth of 10-12 cm without the use of contrast agents. Intraventricular flow seems to originate during the isovolumetric relaxation with a propagation of blood from base to apex. With the E-wave, rapid inflow and vortex formation occurred on both sides of the valve basally. During diastasis the flow gathers in a large vortex before the pattern from the E-wave repeats during the A-wave. In isovolumetric contraction, the flow again gathers in a large vortex that seems to facilitate the flow out in the aorta during systole. No signs of a persistent systolic vortex were visualized. The geometry of the left ventricle and the movement of the AV-plane is important in creating vortices that are favorable for the blood flow and facilitate outflow. The quantitative measurements are in concordance with these findings, but the clinical interpretation must be evaluated in future clinical studies.

On the Depth-Dependent Accuracy of Plane-Wave-Based Vector Velocity Measurements With Linear Arrays

High-frame-rate vector Doppler methods are used to measure blood velocities over large 2-D regions, but their accuracy is often estimated over a short range of depths. This article thoroughly examines the dependence of velocity measurement accuracy on the target position. Simulations were carried out on flat and parabolic flow profiles, for different Doppler angles, and considering a 2-D vector flow imaging (2-D VFI) method based on plane wave transmission and speckle tracking. The results were also compared with those obtained by the reference spectral Doppler (SD) method. Although, as expected, the bias and standard deviation generally tend to worsen at increasing depths, the measurements also show the following. First, the errors are much lower for the flat profile (from ≈ -4 ± 3% at 20 mm to ≈ -17 ± 4% at 100 mm) than for the parabolic profile (from ≈ -4 ± 3% to ≈ -38 ±%). Second, only part of the relative estimation error is related to the inherent low resolution of the 2-D VFI method. For example, even for SD, the error bias increases (on average) from -0.7% (20 mm) to -17% (60 mm) up to -26% (100 mm). Third, conversely, the beam divergence associated with the linear array acoustic lens was found to have a great impact on the velocity measurements. By simply removing such lens, the average bias for 2-D VFI at 60 and 100 mm dropped down to -9.4% and -19.4%, respectively. In conclusion, the results indicate that the transmission beam broadening on the elevation plane, which is not limited by reception dynamic focusing, is the main cause of velocity underestimation in the presence of high spatial gradients.

Tapered Vector Doppler for Improved Quantification of Low Velocity Blood Flow

A new vector velocity estimation scheme is developed, termed tapered vector Doppler (TVD), aiming to improve the accuracy of low velocity flow estimation. This is done by assessing the effects of singular value decomposition (SVD) and finite impulse response (FIR) filters and designing an estimator which accounts for signal loss due to filtering. Synthetic data created using a combination of in vivo recordings and flow simulations were used to investigate scenarios with low blood flow, in combination with true clutter motion. Using this approach, the accuracy and precision of TVD was investigated for a range of clutter-to-blood and signal-to-noise ratios. The results indicated that for the investigated carotid application and setup, the SVD filter performed as a frequency-based filter. For both SVD and FIR filters, suppression of the clutter signal resulted in large bias and variance in the estimated blood velocity magnitude and direction close to the vessel walls. Application of the proposed tapering technique yielded significant improvement in the accuracy and precision of near-wall vector velocity measurements, compared to non-TVD and weighted least squares approaches. In synthetic data, for a blood SNR of 5 dB, and in a near-wall region where the average blood velocity was 9 cm/s, the use of tapering reduced the average velocity magnitude bias from 26.3 to 1.4 cm/s. Complex flow in a carotid bifurcation was used to demonstrate the in vivo performance of TVD, and it was shown that tapering enables vector velocity estimation less affected by clutter and clutter filtering than what could be obtained by adaptive filter design only.

Reconstruction for Diverging-Wave Imaging Using Deep Convolutional Neural Networks

In recent years, diverging wave (DW) ultrasound imaging has become a very promising methodology for cardiovascular imaging due to its high temporal resolution. However, if they are limited in number, DW transmits provide lower image quality compared with classical focused schemes. A conventional reconstruction approach consists in summing series of ultrasound signals coherently, at the expense of frame rate, data volume, and computation time. To deal with this limitation, we propose a convolutional neural network (CNN) architecture, Inception for DW Network (IDNet), for high-quality reconstruction of DW ultrasound images using a small number of transmissions. In order to cope with the specificities induced by the sectorial geometry associated with DW imaging, we adopted the inception model composed of the concatenation of multiscale convolution kernels. Incorporating inception modules aims at capturing different image features with multiscale receptive fields. A mapping between low-quality images and corresponding high-quality compounded reconstruction was learned by training the network using in vitro and in vivo samples. The performance of the proposed approach was evaluated in terms of contrast ratio (CR), contrast-to-noise ratio (CNR), and lateral resolution (LR), and compared with standard compounding method and conventional CNN methods. The results demonstrated that our method could produce high-quality images using only 3 DWs, yielding an image quality equivalent to that obtained with compounding of 31 DWs and outperforming more conventional CNN architectures in terms of complexity, inference time, and image quality.

4-D Echo-Particle Image Velocimetry in a Left Ventricular Phantom

Left ventricular (LV) blood flow is an inherently complex time-varying 3-D phenomenon, where 2-D quantification often ignores the effect of out-of-plane motion. In this study, we describe high frame rate 4-D echocardiographic particle image velocimetry (echo-PIV) using a prototype matrix transesophageal transducer and a dynamic LV phantom for testing the accuracy of echo-PIV in the presence of complex flow patterns. Optical time-resolved tomographic PIV (tomo-PIV) was used as a reference standard for comparison. Echo-PIV and tomo-PIV agreed on the general profile of the LV flow patterns, but echo-PIV smoothed out the smaller flow structures. Echo-PIV also underestimated the flow rates at greater imaging depths, where the PIV kernel size and transducer point spread function were large relative to the velocity gradients. We demonstrate that 4-D echo-PIV could be performed in just four heart cycles, which would require only a short breath-hold, providing promising results. However, methods for resolving high velocity gradients in regions of poor spatial resolution are required before clinical translation.

Comparison Between Multiline Transmission and Diverging Wave Imaging: Assessment of Image Quality and Motion Estimation Accuracy

High frame rate imaging is particularly important in echocardiography for better assessment of the cardiac function. Several studies showed that diverging wave imaging (DWI) and multiline transmission (MLT) are promising methods for achieving a high temporal resolution. The aim of this study was to compare MLT and compounded motion compensation (MoCo) DWI for the same transmitted power, same frame rates [image quality and speckle tracking echocardiography (STE) assessment], and same packet size [tissue Doppler imaging (TDI) assessment]. Our results on static images showed that MLT outperforms DW in terms of resolution (by 30% on average). However, in terms of contrast, MLT outperforms DW only for the depth of 11 cm (by 40% on average), the result being reversed at a depth of 4 cm (by 27% on average). In vitro results on a spinning phantom at nine different velocities showed that similar STE axial errors (up to 2.3% difference in median errors and up to 2.1% difference in the interquartile ranges) are obtained with both ultrafast methods. On the other hand, the median lateral STE estimates were up to 13% more accurate with DW than with MLT. On the contrary, the accuracy of TDI was only up to ~3% better with MLT, but the achievable DW Doppler frame rate was up to 20 times higher. However, our overall results showed that the choice of one method relative to the other is therefore dependent on the application. More precisely, in terms of image quality, DW is more suitable for imaging structures at low depths, while MLT can provide an improved image quality at the focal point that can be placed at higher depths. In terms of motion estimation, DW is more suitable for color Doppler-related applications, while MLT could be used to estimate velocities along selected lines of the image.

Coupling Myocardium and Vortex Dynamics in Diverging-Wave Echocardiography

Echocardiography is widely used to provide critical left ventricular indices describing myocardial motion and blood inflow velocity. Tissue motion and blood flow are strongly connected and interdependent in the ventricle. During cardiac relaxation, rapid filling leads to the formation of a vortical blood flow pattern. In this paper, we introduce a high-frame-rate method to track vortex dynamics alongside myocardium motion, in a single heartbeat. Cardiac triplex imaging (B-mode + tissue Doppler + color Doppler) was obtained by insonating the left ventricle with diverging waves. We used coherent compounding with integrated motion compensation to obtain high-quality B-mode images. Tissue Doppler was retrieved and the septal and lateral velocities of the mitral annulus were deduced. A rate of ~80 triplex images/s was obtained. Vortex dynamics was analyzed by Doppler vortography. Blood vortex signature maps were used to track the vortex and compute core vorticities. The sequence was implemented in a Verasonics scanner with a 2.5-MHz phased array and tested in vivo in 12 healthy volunteers. Two main peaks appeared on the vorticity curves. These peaks were synchronized with the mitral inflow velocities with a small delay. We observed a relationship between the tissue and vortex waveforms, though also with a delay, which denoted the lag between the wall and the flow motion. Clinical diastolic indices combining basal and mitral inflow velocities (E/A ratio and E/ e' ratio) were determined and compared with those measured using a conventional ultrasound scanner; a good correlation was obtained ( r² = 0.96 ). High-frame-rate Doppler echocardiography enabled us to retrieve time-resolved dynamics of the myocardium and vortex flow within the same cardiac cycle. Coupling wall-flow analysis could be of clinical relevance for early diagnosis of filling impairment.

Atrial and ventricular ejection force of the fetal heart: Which of the four chambers is the dominant?

Background/Aim:

This study aimed to measure and compare the ejection force of the cardiac chambers in healthy singleton fetuses and to investigate the relationship of ejection force of cardiac chambers with gestational age, fetal sex, and fetal heart rate.

Patients and Methods:

A prospective study was performed on 68 singleton fetuses with a gestational age of 17–34 weeks. Atrial and ventricular ejection force was measured. Measurements were repeated in 18 of the fetuses to assess intraobserver reliability.

Results:

The right atrium had the highest ejection force of all the cardiac chambers. Ejection force of both atria and ventricles increased with gestational age.

Conclusion:

The right atrium is the dominant chamber of the fetal heart in 17–34 weeks of gestation. Comparison of our values with previous studies indicates that left atrial ejection force almost doubles in the 1^st month after birth. This study highlights the crucial role of the right atrium in the fetal cardiac function during 17–34 weeks of gestation.

High-Frame-Rate Contrast Echocardiography Using Diverging Waves: Initial In Vitro and In Vivo Evaluation

Contrast echocardiography (CE) ultrasound with microbubble contrast agents has significantly advanced our capability for assessment of cardiac function, including myocardium perfusion quantification. However, in standard CE techniques obtained with line by line scanning, the frame rate and image quality are limited. Recent research has shown significant frame-rate improvement in noncontrast cardiac imaging. In this work, we present and initially evaluate, both in vitro and in vivo, a high-frame-rate (HFR) CE imaging system using diverging waves and pulse inversion sequence. An imaging frame rate of 5500 frames/s before and 250 frames/s after compounding is achieved. A destruction-replenishment sequence has also been developed. The developed HFR CE is compared with standard CE in vitro on a phantom and then in vivo on a sheep heart. The image signal-to-noise ratio and contrast between the myocardium and the chamber are evaluated. The results show up to 13.4-dB improvement in contrast for HFR CE over standard CE when compared at the same display frame rate even when the average spatial acoustic pressure in HFR CE is 36% lower than the standard CE. It is also found that when coherent compounding is used, the HFR CE image intensity can be significantly modulated by the flow motion in the chamber.

Evaluation of Peak Reflux Velocities with Vector Flow Imaging and Spectral Doppler Ultrasound in Varicose Veins

Purpose Spectral Doppler ultrasound (SDUS) is used for quantifying reflux in lower extremity varicose veins. The technique is angle-dependent opposed to the new angle-independent Vector Flow Imaging (VFI) method. The aim of this study was to compare peak reflux velocities obtained with VFI and SDUS in patients with chronic venous disease, i. e., pathological retrograde blood flow caused by incompetent venous valves. Materials and Methods 64 patients with chronic venous disease were scanned with VFI and SDUS in the great or the small saphenous vein, and reflux velocities were compared to three assessment tools for chronic venous disease. A flow rig was used to assess the accuracy and precision of the two methods. Results The mean peak reflux velocities differed significantly (VFI: 47.4 cm/s vs. SDUS: 62.0 cm/s, p<0.001). No difference in absolute precision (p=0.18) nor relative precision (p=0.79) was found. No correlation to disease severity, according to assessment tools, was found for peak reflux velocities obtained with either method. In vitro, VFI was more accurate but equally precise when compared to SDUS. Conclusion Both VFI and SDUS detected the pathologic retrograde flow in varicose veins but measured different reflux velocities with equal precision. VFI may play a role in evaluating venous disease in the future.

Accuracy and Precision of a Plane Wave Vector Flow Imaging Method in the Healthy Carotid Artery

The objective of the study described here was to investigate the accuracy and precision of a plane wave 2-D vector flow imaging (VFI) method in laminar and complex blood flow conditions in the healthy carotid artery. The approach was to study (i) the accuracy for complex flow by comparing the velocity field from a computational fluid dynamics (CFD) simulation to VFI estimates obtained from the scan of an anthropomorphic flow phantom and from an in vivo scan; (ii) the accuracy for laminar unidirectional flow in vivo by comparing peak systolic velocities from VFI with magnetic resonance angiography (MRA); (iii) the precision of VFI estimation in vivo at several evaluation points in the vessels. The carotid artery at the bifurcation was scanned using both fast plane wave ultrasound and MRA in 10 healthy volunteers. The MRA geometry acquired from one of the volunteers was used to fabricate an anthropomorphic flow phantom, which was also scanned using the fast plane wave sequence. The same geometry was used in a CFD simulation to calculate the velocity field. Results indicated that similar flow patterns and vortices were estimated with CFD and VFI in the phantom for the carotid bifurcation. The root-mean-square difference between CFD and VFI was within 0.12 m/s for velocity estimates in the common carotid artery and the internal branch. The root-mean-square difference was 0.17 m/s in the external branch. For the 10 volunteers, the mean difference between VFI and MRA was -0.17 m/s for peak systolic velocities of laminar flow in vivo. The precision in vivo was calculated as the mean standard deviation (SD) of estimates aligned to the heart cycle and was highest in the center of the common carotid artery (SD = 3.6% for velocity magnitudes and 4.5° for angles) and lowest in the external branch and for vortices (SD = 10.2% for velocity magnitudes and 39° for angles). The results indicate that plane wave VFI measures flow precisely and that estimates are in good agreement with a CFD simulation and MRA.

CColor and Vector Flow Imaging in Parallel Ultrasound with Sub-Nyquist Sampling

RF acquisition with a high-performance multi-chan-nel ultrasound system generates massive datasets in short periods of time, especially in "ultrafast" ultrasound when digital receive beamforming is required. Sampling at a rate four times the carrier frequency is the standard procedure since this rule complies with the Nyquist-Shannon sampling theorem and simplifies quadrature sampling. Bandpass sampling (or undersampling) outputs a band-pass signal at a rate lower than the maximal frequency without harmful aliasing. Advantages over Nyquist sampling are reduced storage volumes and data workflow, and simplified digital signal processing tasks. We used RF undersampling in color flow imag-ing (CFI) and vector flow imaging (VFI) to decrease data volume significantly (factor of 3 to 13 in our configurations). CFI and VFI with Nyquist and sub-Nyquist samplings were compared in vitro and in vivo. The estimate errors due to undersampling were small or marginal, which illustrates that Doppler and vector Doppler im-ages can be correctly computed with a drastically reduced amount of RF samples. Undersampling can be a method of choice in CFI and VFI to avoid information overload and reduce data transfer and storage.

Spiral Flow Phantom for Ultrasound Flow Imaging Experimentation

As new ultrasound flow imaging methods are being developed, there is a growing need to devise appropriate flow phantoms that can holistically assess the accuracy of the derived flow estimates. In this paper, we present a novel spiral flow phantom design whose Archimedean spiral lumen naturally gives rise to multi-directional flow over all possible angles (i.e., from 0° to 360°). Developed using lost-core casting principles, the phantom geometry comprised a three-loop spiral (4-mm diameter and 5-mm pitch), and it was set to operate in steady flow mode (3 mL/s flow rate). After characterizing the flow pattern within the spiral vessel using computational fluid dynamics (CFD) simulations, the phantom was applied to evaluate the performance of color flow imaging (CFI) and high-frame-rate vector flow imaging. Significant spurious coloring artifacts were found when using CFI to visualize flow in the spiral phantom. In contrast, using vector flow imaging (least-squares multi-angle Doppler based on a three-transmit and three-receive configuration), we observed consistent depiction of flow velocity magnitude and direction within the spiral vessel lumen. The spiral flow phantom was also found to be a useful tool in facilitating demonstration of dynamic flow visualization based on vector projectile imaging. Overall, these results demonstrate the spiral flow phantom's practical value in analyzing the efficacy of ultrasound flow estimation methods.

Vector velocity estimation of blood flow - A new application in medical ultrasound

Vector flow techniques in the field of ultrasound encompass different pulse emission and estimation strategies. Numerous techniques have been introduced over the years, and recently commercial implementations usable in the clinic have been made. A number of clinical papers using different vector velocity approaches have been published. This review will give an overview of the most significant in vivo results achieved with ultrasound vector flow techniques, and will outline some of the possible clinical applications for vector velocity estimation in the future.