Tissue Doppler Imaging in Echocardiography: Value and Limitations

Tissue Doppler imaging (TDI) is a useful echocardiographic technique to evaluate global and regional myocardial systolic as well as diastolic function. It can also be used to quantify right ventricular and left atrial function. Recent studies have demonstrated its utility as a diagnostic as well as prognostic tool in different cardiac conditions including coronary artery disease, heart failure (both systolic and diastolic), valvular heart disease, cardiomyopathies as well as constrictive pericarditis. TDI measurements are also helpful to identify patients who will benefit from cardiac resynchronisation therapy. Even though it is reproducible and relatively easy to obtain, it is underutilised in routine clinical practice. TDI is readily available on most commercially available echocardiographic systems, and we recommend that TDI be used for routine clinical echocardiographic evaluation of patients. Tissue Doppler imaging (TDI) is a useful echocardiographic technique to evaluate global and regional myocardial systolic as well as diastolic function. It can also be used to quantify right ventricular and left atrial function. Recent studies have demonstrated its utility as a diagnostic as well as prognostic tool in different cardiac conditions including coronary artery disease, heart failure (both systolic and diastolic), valvular heart disease, cardiomyopathies as well as constrictive pericarditis. TDI measurements are also helpful to identify patients who will benefit from cardiac resynchronisation therapy. Even though it is reproducible and relatively easy to obtain, it is underutilised in routine clinical practice. TDI is readily available on most commercially available echocardiographic systems, and we recommend that TDI be used for routine clinical echocardiographic evaluation of patients. Tissue Doppler imaging (TDI) for echocardiographic evaluation of myocardial function was first described in 1989, [[1]Isaaz K. Thompson A. Ethevenot G. Cloez J.L. Brembilla B. Pernot C. Doppler echocardiographic measurement of low velocity motion of the left ventricular posterior wall.The American Journal of Cardiology. 1989; 64: 66-75Abstract Full Text PDF PubMed Scopus (360) Google Scholar] and has revolutionised the quantitative evaluation of myocardial function. Doppler ultrasound relies on detection of a frequency shift of ultrasound signals reflected from moving objects. In the heart, both blood flow and myocardial contraction result in velocity changes. Blood flow causes high frequency, low amplitude signals that are obtained using traditional Doppler. Tissue Doppler imaging is designed to characterise low velocity, high amplitude signals from myocardial motion [[2]Isaaz K. Munoz del Romeral L. Lee E. Schiller N.B. Quantitation of the motion of the cardiac base in normal subjects by Doppler echocardiography.Journal of the American Society of Echocardiography. 1993; 6: 166-176Abstract Full Text PDF PubMed Scopus (176) Google Scholar], and are obtained by inverting the low pass filter used in traditional Doppler to a high pass filter. The myocardium has subendocardial and epicardial layers, with the former having longitudinally arranged myofibres [[3]Rushmer R.F. Crystal D.K. Wagner C. The functional anatomy of ventricular contraction.Circulation Research. 1953; 1: 162-170Crossref PubMed Scopus (221) Google Scholar]. During ventricular contraction, various layers exert varying tension with the endocardium moving greater distances. Tissue Doppler imaging examines the longitudinal component of myocardial contraction throughout the cardiac cycle. Tissue Doppler imaging is obtained using pulsed wave tissue Doppler or colour tissue Doppler imaging (CTDI). Pulsed wave TDI measures peak longitudinal myocardial velocity from a single segment, but has to be performed ‘on line’. Colour tissue Doppler imaging is performed ‘off line’, and can interrogate velocities from multiple sites simultaneously [[4]Ho C.Y. Solomon S.D. A clinician's guide to tissue Doppler imaging.Circulation. 2006; 113: e396-e398Crossref PubMed Scopus (236) Google Scholar]. However, CTDI represents the mean peak velocity, and are ∼25% lower than pulsed wave Doppler [[5]Abraham T.P. Dimaano V.L. Liang H.Y. Role of tissue Doppler and strain echocardiography in current clinical practice.Circulation. 2007; 116: 2597-2609Crossref PubMed Scopus (256) Google Scholar]. The two methods are therefore not interchangeable. The major disadvantage of TDI is its angle dependence i.e. if the angle of incidence exceeds 15 degrees, there is ∼4% underestimation of velocity [[6]Heimdal A. Stoylen A. Torp H. Skjaerpe T. Real-time strain rate imaging of the left ventricle by ultrasound.Journal of the American Society of Echocardiography. 1998; 11: 1013-1019Abstract Full Text Full Text PDF PubMed Scopus (718) Google Scholar]. Accurate TDI imaging additionally requires high frame rates (>100fps) for image acquisition with excellent temporal resolution. The TDI signal over a cardiac cycle has three peaks, a positive systolic peak and two negative diastolic peaks (Fig. 1A & B). The positive systolic wave (s’ velocity, Sa or Sm) represents myocardial contraction. The negative waves represent the early diastolic myocardial relaxation (e’ velocity, Ea or Em) and active atrial contraction in late diastole (a’ velocity, Aa or Am) (Fig. 1 A & B). The time to peak s’ velocity can be measured and segmental heterogeneity can be ascertained using CTDI [[7]Bax J.J. Bleeker G.B. Marwick T.H. Molhoek S.G. Boersma E. Steendijk P. et al.Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy.Journal of the American College of Cardiology. 2004; 44: 1834-1840Abstract Full Text Full Text PDF PubMed Scopus (936) Google Scholar] (Fig. 2). Additionally, isovolaemic contraction and relaxation periods can also be identified. (Fig. 3) Pulsed wave TDI velocity measurements are obtained by placing the sample volume at the mitral annular level (denoted Sa/s’ or Ea/e’ or Aa/a’) or within the basal LV myocardial segment (denoted Sm or Em or Am). Tissue Doppler imaging velocities can be measured either from the septal or lateral annulus, but the current recommendation is that e’ velocity is expressed as the average of septal and lateral measurements [[8]Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.European Journal of Echocardiography. 2009; 10: 165-193Crossref PubMed Scopus (1717) Google Scholar]. The current accepted nomenclature favours denoting TDI velocities as s’, e’ and a’, although the other abbreviations are also commonly used. Normal pulsed TDI values are given in Table 1.Figure 2Colour tissue Doppler image from the apical 4 chamber view sampling from the septal and lateral mitral annulus illustrating dyssynchronous contraction of the LV.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3IVCT and IVRT measurements from pulsed wave TDI trace. IVCT = isovolumetric contraction time; IVRT = isovolumetric relaxation time.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table 1Normal reference range of TDI values in healthy adults (mean ± SD).s’(cm/s)e’ (cm/s)a’ (cm/s)E/e’e’/a’Septal velocity8.1 ± 1.58.6 ± 1.99.5 ± 2.48.7 ± 2.21 ± 0.7Lateral velocity10.2 ± 2.412.2 ± 311.3 ± 2.96.3 ± 1.91.5 ± 0.6Average septal + lateral9.2 ± 1.710.4 ± 2.210.4 ± 2.77.5 ± 1.91.3 ± 0.7Adapted from Chahal N.S, Lim T.K et al. Eur J Echocardiogr 2010, Garcia, M. J, Rodriguez L et al AHJ 1996, Pai R.G and Gill K.S JASE 1998. Open table in a new tab Adapted from Chahal N.S, Lim T.K et al. Eur J Echocardiogr 2010, Garcia, M. J, Rodriguez L et al AHJ 1996, Pai R.G and Gill K.S JASE 1998. Normal ageing can alter TDI derived myocardial velocities. There is a decrease in s’ and e’ velocities with ageing, with a corresponding increase in a’ velocity [[8]Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.European Journal of Echocardiography. 2009; 10: 165-193Crossref PubMed Scopus (1717) Google Scholar]. Nagueh and colleagues have reported age-based normal cut-off values for basal septal and lateral segments [[8]Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.European Journal of Echocardiography. 2009; 10: 165-193Crossref PubMed Scopus (1717) Google Scholar] (Table 2)Table 2Normal age related values for Doppler-derived diastolic measurements.16-20(yrs.)21-40 (yrs.)41-60 (yrs.)>61(yrs.)Septal é (cm/s)14.9 ± 2.415.5 ± 2.712.2 ± 2.310.4 ± 2.1Septal é/á ratio2.41.6 ± 0.51.1 ± 0.30.85 ± 0.2Lateral é (cm/s)20.6 ± 3.819.8 ± 2.916.1 ± 2.312.9 ± 3.5Lateral é/á ratio3.11.9 ± 0.61.5 ± 0.50.9 ± 0.4Modified from Nagueh, S. F., C. P. Appleton, et al. 2009. Eur J Echocardiogr 10(2): 165-193. Open table in a new tab Modified from Nagueh, S. F., C. P. Appleton, et al. 2009. Eur J Echocardiogr 10(2): 165-193. TDI measurements are reported in varying cardiac conditions with validation as a marker of LV systolic dysfunction [9Nikitin N.P. Loh P.H. Silva R. Ghosh J. Khaleva O.Y. Goode K. et al.Prognostic value of systolic mitral annular velocity measured with Doppler tissue imaging in patients with chronic heart failure caused by left ventricular systolic dysfunction.Heart. 2006; 92: 775-779Crossref PubMed Scopus (113) Google Scholar, 10Wang M. Yip G. Yu C.M. Zhang Q. Zhang Y. Tse D. et al.Independent and incremental prognostic value of early mitral annulus velocity in patients with impaired left ventricular systolic function.Journal of the American College of Cardiology. 2005; 45: 272-277Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar], diastolic dysfunction [8Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.European Journal of Echocardiography. 2009; 10: 165-193Crossref PubMed Scopus (1717) Google Scholar, 11Garcia M.J. Thomas J.D. Klein A.L. New Doppler echocardiographic applications for the study of diastolic function.Journal of the American College of Cardiology. 1998; 32: 865-875Abstract Full Text Full Text PDF PubMed Scopus (884) Google Scholar], LV dyssynchrony [12Yu C.M. Fung W.H. Lin H. Zhang Q. Sanderson J.E. Lau C.P. Predictors of left ventricular reverse remodeling after cardiac resynchronization therapy for heart failure secondary to idiopathic dilated or ischemic cardiomyopathy.The American Journal of Cardiology. 2003; 91: 684-688Abstract Full Text Full Text PDF PubMed Scopus (622) Google Scholar, 13Yu C.M. Lin H. Zhang Q. Sanderson J.E. High prevalence of left ventricular systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration.Heart. 2003; 89: 54-60Crossref PubMed Scopus (541) Google Scholar, 14Bax J.J. Abraham T. Barold S.S. Breithardt O.A. Fung J.W. Garrigue S. et al.Cardiac resynchronization therapy: Part 1.Journal of the American College of Cardiology. 2005; 46: 2153-2167Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar], right ventricular [[15]Meluzin J. Spinarova L. Bakala J. Toman J. Krejci J. Hude P. et al.Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion; a new, rapid, and non-invasive method of evaluating right ventricular systolic function.European Heart Journal. 2001; 22: 340-348Crossref PubMed Scopus (572) Google Scholar] and atrial function [[16]Yamamoto T. Oki T. Yamada H. Tanaka H. Ishimoto T. Wakatsuki T. et al.Prognostic value of the atrial systolic mitral annular motion velocity in patients with left ventricular systolic dysfunction.Journal of the American Society of Echocardiography:. 2003; 16: 333-339Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar]. It is useful in the evaluation of coronary artery disease [[17]Agarwal R. Gosain P. Kirkpatrick J.N. Alyousef T. Doukky R. Singh G. et al.Tissue Doppler imaging for diagnosis of coronary artery disease: a systematic review and meta-analysis.Cardiovascular Ultrasound. 2012; 10: 47Crossref PubMed Scopus (21) Google Scholar] and has prognostic implications [15Meluzin J. Spinarova L. Bakala J. Toman J. Krejci J. Hude P. et al.Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion; a new, rapid, and non-invasive method of evaluating right ventricular systolic function.European Heart Journal. 2001; 22: 340-348Crossref PubMed Scopus (572) Google Scholar, 18Dini F.L. Galderisi M. Nistri S. Buralli S. Ballo P. Mele D. et al.Abnormal left ventricular longitudinal function assessed by echocardiographic and tissue Doppler imaging is a powerful predictor of diastolic dysfunction in hypertensive patients: the SPHERE study.International Journal of Cardiology. 2013; 168: 3351-3358Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 19Pieroni M. Chimenti C. Ricci R. Sale P. Russo M.A. Frustaci A. Early detection of Fabry cardiomyopathy by tissue Doppler imaging.Circulation. 2003; 107: 1978-1984Crossref PubMed Scopus (217) Google Scholar, 20Song Y. Lee S. Kwak Y.L. Shim C.Y. Chang B.C. Shim J.K. Tissue Doppler imaging predicts left ventricular reverse remodeling after surgery for mitral regurgitation.The Annals of Thoracic Surgery. 2013; 96: 2109-2115Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 21Yu C.M. Sanderson J.E. Marwick T.H. Oh J.K. Tissue Doppler imaging a new prognosticator for cardiovascular diseases.Journal of the American College of Cardiology. 2007; 49: 1903-1914Abstract Full Text Full Text PDF PubMed Scopus (482) Google Scholar]. Tissue Doppler imaging measurements are more sensitive than conventional echocardiography for detecting early myocardial alterations in primary myocardial (eg hypertrophic and dilated cardiomyopathies) and secondary myocardial disorders (eg ischaemia) [18Dini F.L. Galderisi M. Nistri S. Buralli S. Ballo P. Mele D. et al.Abnormal left ventricular longitudinal function assessed by echocardiographic and tissue Doppler imaging is a powerful predictor of diastolic dysfunction in hypertensive patients: the SPHERE study.International Journal of Cardiology. 2013; 168: 3351-3358Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 19Pieroni M. Chimenti C. Ricci R. Sale P. Russo M.A. Frustaci A. Early detection of Fabry cardiomyopathy by tissue Doppler imaging.Circulation. 2003; 107: 1978-1984Crossref PubMed Scopus (217) Google Scholar, 22Ho C.Y. Sweitzer N.K. McDonough B. Maron B.J. Casey S.A. Seidman J.G. et al.Assessment of diastolic function with Doppler tissue imaging to predict genotype in preclinical hypertrophic cardiomyopathy.Circulation. 2002; 105: 2992-2997Crossref PubMed Scopus (198) Google Scholar, 23Kitaoka H. Kubo T. Hayashi K. Yamasaki N. Matsumura Y. Furuno T. et al.Tissue Doppler imaging and prognosis in asymptomatic or mildly symptomatic patients with hypertrophic cardiomyopathy.European Heart Journal Cardiovascular Imaging. 2013; 14: 544-549Crossref PubMed Scopus (38) Google Scholar, 24Madler C.F. Payne N. Wilkenshoff U. Cohen A. Derumeaux G.A. Pierard L.A. et al.Non-invasive diagnosis of coronary artery disease by quantitative stress echocardiography: optimal diagnostic models using off-line tissue Doppler in the MYDISE study.European Heart Journal. 2003; 24: 1584-1594Crossref PubMed Scopus (139) Google Scholar, 25Nagueh S.F. Bachinski L.L. Meyer D. Hill R. Zoghbi W.A. Tam J.W. et al.Tissue Doppler imaging consistently detects myocardial abnormalities in patients with hypertrophic cardiomyopathy and provides a novel means for an early diagnosis before and independently of hypertrophy.Circulation. 2001; 104: 128-130Crossref PubMed Scopus (505) Google Scholar, 26Pauliks L.B. Vogel M. Madler C.F. Williams R.I. Payne N. Redington A.N. et al.Regional response of myocardial acceleration during isovolumic contraction during dobutamine stress echocardiography: a color tissue Doppler study and comparison with angiocardiographic findings.Echocardiography. 2005; 22: 797-808Crossref PubMed Scopus (22) Google Scholar, 27Richartz B.M. Werner G.S. Ferrari M. Figulla H.R. Comparison of left ventricular systolic and diastolic function in patients with idiopathic dilated cardiomyopathy and mild heart failure versus those with severe heart failure.The American Journal of Cardiology. 2002; 90: 390-394Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 28Wang M. Yip G.W. Wang A.Y. Zhang Y. Ho P.Y. Tse M.K. et al.Tissue Doppler imaging provides incremental prognostic value in patients with systemic hypertension and left ventricular hypertrophy.Journal of Hypertension. 2005; 23: 183-191Crossref PubMed Scopus (166) Google Scholar]. Hence TDI is useful for screening and detection of subclinical myocardial dysfunction, and for evaluating the efficacy of therapeutic interventions [23Kitaoka H. Kubo T. Hayashi K. Yamasaki N. Matsumura Y. Furuno T. et al.Tissue Doppler imaging and prognosis in asymptomatic or mildly symptomatic patients with hypertrophic cardiomyopathy.European Heart Journal Cardiovascular Imaging. 2013; 14: 544-549Crossref PubMed Scopus (38) Google Scholar, 29Correale M. Totaro A. Ieva R. Ferraretti A. Musaico F. Di Biase M. Tissue Doppler imaging in coronary artery diseases and heart failure.Current Cardiology Reviews. 2012; 8: 43-53Crossref PubMed Scopus (16) Google Scholar]. s’ velocity measures longitudinal LV contraction and is a surrogate of LV systolic function. s’ velocity (average of four basal segments) demonstrated good correlation with LV ejection fraction (LVEF) [[30]Alam M. Wardell J. Andersson E. Samad B.A. Nordlander R. Effects of first myocardial infarction on left ventricular systolic and diastolic function with the use of mitral annular velocity determined by pulsed wave Doppler tissue imaging.Journal of the American Society of Echocardiography. 2000; 13: 343-352Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar]; s’ ≥7.5 cm/s had a sensitivity of 79% and a specificity of 88% in predicting LVEF ≥ 50%. Similarly, s’ (average of six basal segments) > 5.4 cm/sec, had a sensitivity of 88% and specificity of 97% for identifying normal LVEF [[31]Gulati V.K. Katz W.E. Follansbee W.P. Gorcsan 3rd., J. Mitral annular descent velocity by tissue Doppler echocardiography as an index of global left ventricular function.The American Journal of Cardiology. 1996; 77: 979-984Abstract Full Text PDF PubMed Scopus (366) Google Scholar]. Endocardial longitudinal fibre contraction is largely responsible for long axis function, which is susceptible in a variety of cardiac conditions with either resultant LV hypertrophy or dilatation. Early myocardial damage often involves the subendocardial fibres, particularly in myocardial ischaemia, with impairment in long-axis contraction evident before changes in short-axis function. Hypertension, coronary artery disease (CAD), cardiomyopathies and heart failure have all been shown to alter subendocardial fibre function with a reduction in s’ velocity [18Dini F.L. Galderisi M. Nistri S. Buralli S. Ballo P. Mele D. et al.Abnormal left ventricular longitudinal function assessed by echocardiographic and tissue Doppler imaging is a powerful predictor of diastolic dysfunction in hypertensive patients: the SPHERE study.International Journal of Cardiology. 2013; 168: 3351-3358Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 29Correale M. Totaro A. Ieva R. Ferraretti A. Musaico F. Di Biase M. Tissue Doppler imaging in coronary artery diseases and heart failure.Current Cardiology Reviews. 2012; 8: 43-53Crossref PubMed Scopus (16) Google Scholar], despite preserved LVEF. Fang and colleagues screened 101 asymptomatic patients with diabetes mellitus who underwent detailed evaluation including echocardiography and exercise stress testing, excluding those with cardiac dysfunction or ischaemia. Subclinical LV systolic dysfunction with a reduced s’ was noted in 24% [[32]Fang Z.Y. Schull-Meade R. Leano R. Mottram P.M. Prins J.B. Marwick T.H. Screening for heart disease in diabetic subjects.American Heart Journal. 2005; 149: 349-354Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar]. In primary cardiomyopathic conditions like hypertrophic cardiomyopathy (HCM), s’ velocity was reduced in mutation positive individuals without LVH [[25]Nagueh S.F. Bachinski L.L. Meyer D. Hill R. Zoghbi W.A. Tam J.W. et al.Tissue Doppler imaging consistently detects myocardial abnormalities in patients with hypertrophic cardiomyopathy and provides a novel means for an early diagnosis before and independently of hypertrophy.Circulation. 2001; 104: 128-130Crossref PubMed Scopus (505) Google Scholar]. Ischaemic heart disease constitutes a significant proportion of patients reviewed in routine cardiology practice. The s’ velocity is reduced in ischaemic and infarcted segments [[33]Pasquet A. Armstrong G. Beachler L. Lauer M.S. Marwick T.H. Use of segmental tissue Doppler velocity to quantitate exercise echocardiography.Journal of the American Society of Echocardiography:. 1999; 12: 901-912Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar]. Tissue Doppler imaging has been utilised in dobutamine stress echocardiography (DSE), to objectively quantify ischaemia and will be addressed in the stress echocardiography section. [34Altinmakas S. Dagdeviren B. Uyan C. Keser N. Gumus V. Pektas O. Prediction of viability by pulsed-wave Doppler tissue sampling of asynergic myocardium during low-dose dobutamine challenge.International Journal of Cardiology. 2000; 74: 107-113Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 35Marwick T.H. Case C. Leano R. Short L. Baglin T. Cain P. et al.Use of tissue Doppler imaging to facilitate the prediction of events in patients with abnormal left ventricular function by dobutamine echocardiography.The American Journal of Cardiology. 2004; 93: 142-146Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar]. However, TDI is limited by its inability to differentiate active myocardial contraction from the tethering effects of adjacent myocardium (i,e. TDI measures tissue velocity in relation to the transducer rather than to adjacent myocardium), thus lacking site specificity.[[36]Voigt J.U. Nixdorff U. Bogdan R. Exner B. Schmiedehausen K. Platsch G. et al.Comparison of deformation imaging and velocity imaging for detecting regional inducible ischaemia during dobutamine stress echocardiography.European Heart Journal. 2004; 25: 1517-1525Crossref PubMed Scopus (82) Google Scholar] Aging, even in healthy adults, results in altered LV diastolic relaxation [[8]Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.European Journal of Echocardiography. 2009; 10: 165-193Crossref PubMed Scopus (1717) Google Scholar]. Tissue Doppler imaging e’ velocity is a measure of LV relaxation in early diastole and is relatively load independent [[37]Agmon Y. Oh J.K. McCarthy J.T. Khandheria B.K. Bailey K.R. Seward J.B. Effect of volume reduction on mitral annular diastolic velocities in hemodialysis patients.The American Journal of Cardiology. 2000; 85 (A11): 665-668Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar]. e’ velocity can be measured from the septal or lateral annulus in the apical four chamber view [2Isaaz K. Munoz del Romeral L. Lee E. Schiller N.B. Quantitation of the motion of the cardiac base in normal subjects by Doppler echocardiography.Journal of the American Society of Echocardiography. 1993; 6: 166-176Abstract Full Text PDF PubMed Scopus (176) Google Scholar, 8Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.European Journal of Echocardiography. 2009; 10: 165-193Crossref PubMed Scopus (1717) Google Scholar]. However, there is regional variation, and e’ is higher in the lateral, inferior and posterior basal segments compared to anterior and septal segments. e’ velocity correlates inversely with early diastolic pressure (dP/dt) or tau (time constant of LV relaxation) [[38]Oki T. Tabata T. Yamada H. Wakatsuki T. Shinohara H. Nishikado A. et al.Clinical application of pulsed Doppler tissue imaging for assessing abnormal left ventricular relaxation.The American Journal of Cardiology. 1997; 79: 921-928Abstract Full Text Full Text PDF PubMed Scopus (455) Google Scholar] thereby reflecting LV relaxation and elastic recoil. In adults, a lateral e’ velocity > 12 cm/s represents normal LV diastolic function [[39]Yamada H. Oki T. Mishiro Y. Tabata T. Abe M. Onose Y. et al.Effect of aging on diastolic left ventricular myocardial velocities measured by pulsed tissue Doppler imaging in healthy subjects.Journal of the American Society of Echocardiography:. 1999; 12: 574-581Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar] and < 8 cm/s indicates impaired LV diastolic function[[5]Abraham T.P. Dimaano V.L. Liang H.Y. Role of tissue Doppler and strain echocardiography in current clinical practice.Circulation. 2007; 116: 2597-2609Crossref PubMed Scopus (256) Google Scholar], while a septal e’ of > 8 cm/s is considered normal [[40]Chahal N.S. Lim T.K. Jain P. Chambers J.C. Kooner J.S. Senior R. Normative reference values for the tissue Doppler imaging parameters of left ventricular function: a population-based study.European Journal of Echocardiography:. 2010; 11: 51-56Crossref PubMed Scopus (97) Google Scholar]. In normal subjects, transmitral E velocity is higher than A velocity; this pattern reverses in early diastolic dysfunction (DD). However, in advanced DD, E velocity again becomes higher than the A wave (pseudonormal pattern), making it difficult to use mitral inflow pattern to evalute DD [[41]Oh J.K. Park S.J. Nagueh S.F. Established and novel clinical applications of diastolic function assessment by echocardiography.Circulation Cardiovascular Imaging. 2011; 4: 444-455Crossref PubMed Scopus (119) Google Scholar]. However, e’ velocity is reduced even in subjects with early DD, occurring almost 10-15 years prior to reduction of mitral E velocity [[42]Sohn D.W. Chai I.H. Lee D.J. Kim H.C. Kim H.S. Oh B.H. et al.Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function.Journal of the American College of Cardiology. 1997; 30: 474-480Abstract Full Text Full Text PDF PubMed Scopus (1385) Google Scholar]. Its utility is evident from its inclusion in the EAE/ASE guidelines for assessment of diastolic dysfunction [[8]Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.European Journal of Echocardiography. 2009; 10: 165-193Crossref PubMed Scopus (1717) Google Scholar]. Late diastolic TDI a’ (a’/Aa/Am) velocity is useful in assessing atrial function. The a’ velocity is a marker of global atrial function [[43]Thomas L. Levett K. Boyd A. Leung D.Y. Schiller N.B. Ross D.L. Changes in regional left atrial function with aging: evaluation by Doppler tissue imaging.European Journal of Echocardiography. 2003; 4: 92-100Crossref PubMed Google Scholar]. a’ velocity increases with age [[8]Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.European Journal of Echocardiography. 2009; 10: 165-193Crossref PubMed Scopus (1717) Google Scholar], with no significant regional variation in a’ velocity (septum or lateral wall) [[44]Lindstrom L. Wranne B. Pulsed tissue Doppler evaluation of mitral annulus motion: a new window to assessment of diastolic function.Clin Physiol. 1999; 19: 1-10Crossref PubMed Scopus (61) Google Scholar]. a’ velocity correlates with other measures of left atrial function including transmitral peak A velocity, atrial fraction and atrial ejection force [43Thomas L. Levett K. Boyd A. Leung D.Y. Schiller N.B. Ross D.L. Changes in regional left atrial function with aging: evaluation by Doppler tissue imaging.European Journal of Echocardiography. 2003; 4: 92-100Crossref PubMed Google Scholar, 45Hesse B. Schuele S.U. Thamilasaran M. Thomas J. Rodriguez L. A rapid method to quantify left atrial contractile function: Doppler tissue imaging of the mitral annulus during atrial systole.European Journal of Echocardiography. 2004; 5: 86-92Crossref PubMed Scopus (67) Google Scholar]. Colour tissue Doppler imaging a’ velocity permits evaluation of segmental atrial function [[43]Thomas L. Levett K. Boyd A. Leung D.Y. Schiller N.B. Ross D.L. Changes in regional left atrial function with aging: evaluation by Doppler tissue imaging.European Journal of Echocardiography. 2003; 4: 92-100Crossref PubMed Google Scholar]. s’ velocity has been investigated in a variety of cardiac conditions, including heart failure, cardiomyopathies, valvular as well as coronary artery disease [9Nikitin N.P. Loh P.H. Silva R. Ghosh J. Khaleva O.Y. Goode K. et al.Prognostic value of systolic mitral annular veloc