ACUSON Juniper

Ultrasound System
syngo® Velocity Vector Imaging™ Technology
VB10 SW Release

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Objectives

• Review cardiac strain principles and

relevance
• Explain image acquisition for cardiac
strain
• Discuss syngo VVI workflow
• Evaluate cardiac strain analysis

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What is cardiac strain?

• Strain is a noninvasive technique which

quantifies myocardial mechanics
• Strain is the change (deformation) in
shape of a material (myocardium) 1

• Tracked via speckle-tracking

echocardiography (STE)
• Expressed as percentage (%)
𝐿1 − 𝐿0
• Strain (€) =
𝐿0
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Three strain principles

• Radial or Transverse (47 ± 15%)1

Global Radial Strain (GRS)
• Circumferential (-23 ± 3%)1
Global Circumferential Strain (GCS)
• Longitudinal (-20 ± 3%)1
Global Longitudinal Strain (GLS)

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Sources | 1. Yingchoncharoen, Teerapat, et al., JASE (2013) 26: 185-91 Unrestricted © Siemens Healthineers 2020
Parameters of myocardial function

• Displacement: distance that a certain feature, such as a

speckle, has moved between two consecutive frames (cm)
• Velocity: reflects displacement per unit of time, or how fast
the location of a feature changes (cm/s)
• Strain: describes myocardial deformation, or the fractional
change in length of a myocardial segment (%)
• Strain Rate: is the rate of change in strain and is expressed
as 1/sec or sec-1

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Global longitudinal systolic strain (GLS)
Clinical relevance

• Studies suggest reduced

strain is associated with
mortality due to
cardiovascular events
• GLS adds prognostic value
in prediction of adverse
cardiovascular outcomes

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Sources | 2. Ashish, Kumar, et al., IJC Heart & Vasculature (2019) 22: 48-49 Unrestricted © Siemens Healthineers 2020
Objectives

• Review cardiac strain principles and

relevance
• Explain image acquisition for cardiac
strain
• Discuss syngo VVI workflow
• Evaluate cardiac strain analysis

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syngo VVI

• syngo VVI is a clinical software

application used to visualize,
measure and assess myocardial
motion and mechanics using
acquired 2D clips
• Tracks and estimates tissue
velocity and deformation along
a user-defined outline (contour)
of the myocardium

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Cardiac strain acquisition configuration
Acquisition Rate (frame rate)

1. Select System Configuration

on touch screen 1
2

2. Select Clip Store

3. Under Acquisition Rate,
select High (60Hz)

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Cardiac strain acquisition “on the fly”
Acquisition Rate (frame rate)

1. Select Clip Settings

2. Press Acquisition Rate until
60Hz is shown (enables clip
capture of 60 fps)
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Cardiac strain image acquisition

• Ensure entire area of

interest is maintained in
field of view (FOV)
• Optimize 2D image settings
• A full R-R wave must be
contained in data set for
quality analysis
• Clips should not exceed 10
heart cycles or 10 seconds

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Cardiac strain image acquisition

Acquisition with ECG (physio) Acquisition without ECG (physio)

• Use a beat capture • Use a timed capture
• Multiple heart cycles are • Limited to 700 frames
allowed
• Recommended clips should
contain 6 frames minimum to
700 frames maximum

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Cardiac strain image acquisition

• 60 – 90 frames per second (fps) is

ideal for optimal tracking results
• 40 fps is the minimum frame rate
and 150 is the maximum frame
rate
70 – 90 frame rate range is
• 40 – 80 fpsfor
recommended areoptimal
widely used in
clinical literature 3
tracking results
40 frames per second is the
minimum frame rate
150 frames per second is the
maximum
Sources frame
| 3. Voigt, Jens-Uwe, et al.,rate
J Am Soc Echocardiography (2015) 28: 183-193 Unrestricted©
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Global longitudinal strain (GLS) acquisition

Apical 4 Chamber Apical 2 Chamber Apical 3 Chamber

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Global circumferential strain (GCS) acquisition

PSAX MV PSAX PM PSAX APEX

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Cardiac strain acquisition

syngo VVI does not support the following acquisition types:

• 2D color Doppler clips
• Secondary capture images or clips
• M-mode of Doppler images
• Static captures
• 2D live dual clips
• 2D dual clips

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Objectives

• Review cardiac strain principles and

relevance
• Explain image acquisition for cardiac
strain
• Discuss syngo VVI workflow
• Evaluate cardiac strain analysis

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syngo VVI workflow

1. Press Review on left

side of control panel
and select desired 2

images 1
3
2. Select Show Selected
3. Select syngo VVI

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syngo VVI workflow

• For Global Longitudinal Strain (GLS)

select A4C, A2C and A3C images
• Chosen clips will be outlined in white

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syngo VVI workflow

• For Global Circumferential Strain (GCS)

PSAX MV, PSAX PM and APEX images
• Chosen clips will be outlined in white

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syngo VVI workflow

Assign thumbnail images

accordingly
• Use SET key to place images
• To delete an image, select the
‘X’ in upper right of image in
thumbnail image box
• Select the gray arrow
displayed in lower right corner
of screen to proceed

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syngo VVI

syngo VVI supports strain analysis

on the following views
• Apical
 Complete apical analysis
provides full bull’s eye map
• Short axis (SAX)
 Complete short axis analysis
provides full bull’s eye map
• Left atrium (Atrium)
• Right ventricle (RV)
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Gamma slider gain control (dB)

If necessary, to modify the gain setting, click and drag

the Gamma slider to the right or left to adjust the
overall gain
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syngo VVI workflow
Three-point method

• Identify placement guide for

positioning contour markers 3

• See trackball controls for

positioning contour markers 2
1
• Press SET key to place first
and second marker at annuli
• Press UPDATE key to “End”
trace at the apex

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syngo VVI workflow
Manual trace method

• Using SET key, place markers

in a clockwise pattern starting
at basal septum
• To complete the trace, press
UPDATE key to anchor
• To process trace, double-click
SET key or select Start
Analysis icon for systole and
then diastole
Recommend at least 7-11 markers for apical traces
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syngo VVI workflow
Performing endocardial and epicardial trace

1. Select Endo+Epi box

1
2. Select green arrows on right
side of image to increase or
decrease thickness 3
between endocardial and 2
epicardial traces
3. To process trace, double-
click SET key or select Start
Analysis icon for systole
and then diastole
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syngo VVI workflow
Edit marker placement

• Edit the desired marker using

SET key to drag and reposition
Red markers adjust a larger
portion of the contour
Blue markers adjust a smaller
portion of the contour

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syngo VVI workflow
Delete a contour

1. Select X next to view

2. Select OK

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syngo VVI workflow
Modify cardiac timing markers

• Select Sequence/M-mode
icon under MMode in control
settings
 eD marker should align with
peak on red Volume curve
 eS marker should align with
trough on red Volume curve
• Note that any curve on
graphs can be hidden by
toggling its colored box
*continued on next slide
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syngo VVI workflow
Modify cardiac timing markers referencing Cine 2D clip

• Freeze 2D reference image

• Press SET key to select and
drag ED then the ES red
bar to desired location
 Watch cine behavior of
2D image to align marker
placement
• Press in the top right
corner to proceed

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syngo VVI workflow
Modify cardiac timing markers referencing M-mode display

• Freeze 2D reference image

• Press SET on 2D clip to
enable drawing M-line
• Press SET key to select and
drag ED then the ES red
bar to desired location
• Press in the top right
corner to proceed

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syngo VVI workflow
Toggle the M-mode display off / on curve graph analysis

• When M-mode display

is used for editing
cardiac timing markers,
M-mode display also
appears on curve
graph analysis
• To toggle M-mode
display off of curve
graphs, select Bkg
MMode display icon
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syngo VVI workflow
Modify cardiac timing markers

To analyze a clip without an

ECG or with a poor ECG:
• Set R-R interval using SET
key to select and drag R1
then R2 blue bar markers
• Press SET key to select and
drag ED and ES red bar
markers to desired location
• Press in the top right
corner to proceed
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Objectives

• Review cardiac strain principles and

relevance
• Explain image acquisition for cardiac
strain
• Discuss syngo VVI workflow
• Evaluate cardiac strain analysis

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syngo VVI workflow

Gamma Slider
Endo+Epi
Go to End Systole
or End Diastole Zoom In/Out

Sequence / M-mode Pictures Mirroring

Selection
Contours or Vectors
Segmental Bkg MMode display
Analysis
New Trace
Swap 3D/2D Correct ES Border
Border Correct ED Border
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Global longitudinal strain (GLS) analysis
Apical 4 chamber
1. 2D Clip with 4. Global
Contour 1 longitudinal /
4
circumferential
2. End-systolic strain curves
border and
end-diastolic 5. Change in LV
border shell 5 volumes over
time
3. Graph display
3 6
between LVEF, 2 6. Bull’s eye
GLS and shape results
function
analysis

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Global longitudinal strain (GLS) analysis
Apical 2 chamber
1. 2D Clip with 4. Global
Contour 1 longitudinal /
4
circumferential
2. End-systolic strain curves
border and
end-diastolic 5. Change in LV
border shell 5 volumes over
time
3. Graph display
3 6
between LVEF, 2 6. Bull’s eye
GLS and shape results
function
analysis

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Global longitudinal strain (GLS) analysis
Apical 3 chamber
1. 2D Clip with 4. Global
Contour 1 longitudinal /
circumferential
4
2. End-systolic strain curves
border and
end-diastolic 5. Change in LV
border shell 5 volumes over
time
3. Graph display 2
3 6
between LVEF, 6. Bull’s eye
GLS and shape results
function
analysis

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syngo VVI workflow

If necessary, toggle
between the contour’s
border, vector, trajectory
or B-mode icons

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Global longitudinal strain (GLS) analysis
Bull’s eye map
1. Bull’s eye map for
strain results
1
2. Numerical result
2
for the segment
of the selected
parameter

3. Color bar for

the selected
parameter
3

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LV EF, GLS, and shape function analysis

The 3D volume
model is a display
of the shape of
the LV at end
diastole and end
systole.

The graph
displays the
relationship
between EF, GLS,
and the shape
function of the
left ventricle (LV).
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EF and GLS relationship

• EF is the change in LV volume

• GLS is the change in LV perimeter
• EF and GLS have a linear
relationship, which is
represented by the blue line

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EF and GLS relationship

-10
Abnormal

?
GLS

-20

Normal

-30

0 50 100

EF

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LV shape function

• The shape of the LV plays

a part in LV function
• Shape is represented by
green curvilinear graph

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LV shape function

Subtle variations of shape, or shape dynamics, with preserved or slight

changes of volumes (generally not detectable using e.g. EF) are often
sensitive precursors of the macroscopic changes of overt disease.4

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Sources | 4. Pedrizzetti, Gianni, et al., Journal of Biomechanics (2014) 47.3: 746-749 Unrestricted © Siemens Healthineers 2020
LV shape function

• Above green curve: shape is

normal (conical) as LV
contracts
• On green curve: no significant
change in shape
• Below green curve: LV shape
became more round
(spherical) in systole Note: EF and GLS may still be normal, even
though the shape is abnormal. This is due
to the LV working harder to compensate for
abnormal shape mechanics.
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syngo VVI analysis

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Perform GCS

• If EF is normal, but GLS

is decreased, GCS
should be performed
• GCS should be elevated
in this scenario
• GCS can compensate for
GLS, which keeps the EF
within normal range

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Global circumferential strain (GCS)

1. 2D clip with 4. Global

contour circumferential
1
strain curve
4

2. End-systolic 5. Rotation of
border and end- endocardial layer
diastolic border 5

3 6. Bull’s eye results

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2
3. Analysis results
for the
displayed clip

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syngo VVI analysis
Segmental analysis

• Quantitative results from

syngo VVI are represented as
parametric curve graphs, M-
mode graphs, and segmental
diagrams
• Results are dependent on the
view used to draw the contour
and the parameter selected
such as velocity, displacement,
strain or strain rate
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Global longitudinal strain (GLS)
Segmental analysis
1. Radial or 4
4. Displays velocity,
transverse displacement,
segmental strain strain, strain rate
data 1

2 5 5. Radial or
2. Contour analyzed transverse
segmental timing
curves
3. Longitudinal or
circumferential 6. Longitudinal
3
segmental data 6 segmental timing
curves

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Global circumferential strain (GCS)
Segmental analysis
1. Radial strain 4
4. Displays for velocity,
data displacement,
strain, and strain
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1 rate

2. Contour
analyzed 5. Radial strain
2
segmental timing
curves

3. Circumferential 6
6. Circumferential
data
3 segmental timing
curves

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Exporting images

To export an image:
• Choose required clip
• To change clip frame, use CINE
control
• Select Export Image
• Select available media

Note: A DICOM video clip cannot be exported

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Exporting clips

To export a clip:
• Choose required clip
• Select Export Clip
• Select available media

Note: A DICOM video clip cannot be exported

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Exporting images and clips

To export data as TXT

and XML files:
• Select view to display
analysis for export
• Select Export Data
• Select available media

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Saving analysis results or image to report

To save data to a report

To save image of report

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Key workflow reminders

• For Acquisition Rate, ensure High is selected under Clip Store before
acquiring images for strain
• GLS calculation is compliant with taskforce guidelines
• Very similar syngo VVI workflow as ACUSON Sequoia and ACUSON
Redwood ultrasound systems, providing harmony across systems
• A dynamic clip capture of VVI package analysis results cannot be
performed; a static clip can be acquired

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Summary

• Review cardiac strain principles and

relevance
• Explain image acquisition for cardiac
strain
• Discuss syngo VVI workflow
• Evaluate cardiac strain analysis

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 Thank you for your enthusiasm!

Questions?

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