CARDIOVASCULAR 2009 No1

news
THE ESAOTE MAGAZINE
Focus on:
Quantification
and
The daily work and outcome of a Cardiovascular Lab goes through a state-
of-the-art technology which must be capable of helping and supporting physicians (no matter
Prevention
what is their skill level), providing tools usable in all patient conditions and manageable with simple, in Cardiovascular Ultrasound
effective interactions in order to always reach diagnostic confidence.
The above concept is the strategic objective of Esaote Cardiovascular Ultrasound, a fundamental
assumption in the development of such an important theme like Quantification
and Prevention of CV Diseases.

Quantification
1. Ultrasound Transducers The First Element of the Chain
The transducer is the primary component in the Signal Processing Chain that leads to the final ultrasound diagnostic image. Even though much effort has been made to optimize scan converters, post processing
algorithms and sophisticated speckle reduction technologies, the first and the main interface between the patient and the user of the ultrasound scanner still remains the ultrasound transducer.
The design of the material and the manufacturing technology of an ultrasound transducer is a fundamental determinant of the system image quality. The iQProbe represents state of the art Esaote Technology due
to the innovation of Quality gold standard ultrasound transducers. Designed to improve performance and ergonomics, iQProbe Technology is based on the following project developments:

iQProbe Active Matrix Multiple Adaptive Geometric Lens

Ergonomics
The iQProbe Technology has applied to
dimensions, size and weight design projects
an extremely important special focus on the
availability of light material and a revolutionary
manufacturing scheme which avoids the use of
a heavy anti-interference protection capsule.
The combination of iQProbe technology and
the appleprobe design represents a terrific
improvement in innovation allowing the user
optimal comfort while providing unparalleled
clinical results and customer satisfaction.
Composite Material
Reduces the high electric impedance (conse-
quent loss of the transmission power), mini-
mizes the extremely high acoustic impedance
of PZT material (20 times greater than hu-
man tissue) and improve the ultrasound wave
propagation generated within the PZT material
through the tissue.
Microscopic view of the Active Matrix Composite Material
Layers
The Multiple Adaptive Layers Technology
reinforces the target achievement with a
further improvement of sensitivity based on an
extraordinary pure pulse signal and an extended
bandwidth greater than 100%.
Microscopic view of the Multiple Adaptive Layers Technology
and Filling Material
The iQProbe Technology is based on an
extraordinarily low-absorption silicone-based
material used in the Geometric Lens Manufacturing
Process, thus obtaining a homogeneous high
sensitivity within the whole bandwidth.
The iQProbe Technology has introduced in the
manufacturing process a Structure Filling Material
with the objective to provide stronger stability of
the array structure, maximising the highest level
of decoupling between array elements.
The silicone-based material used for the
geometric lenses has extreme importance to the
efficiency of the overall transducer sensitivity.

2. Imaging Process Algorithms

Ultrasound suffers from an intrinsic imaging artefact called speckle. Speckle is the random grainy texture that obscures anatomy in ultrasound images and is usually described as “noise”, in order to indicate something that dirties the image. Speckle
is created by a complex interference of ultrasound echoes made by reflectors spaced closer than the ultrasound system’s resolution limit, degrading spatial and contrast resolution and obscuring the underlying anatomy.
The algorithm of processing the ultrasound signal to obtain extraordinary results in diagnostic confidence improvement is fundamental. It needs to perfectly combine the power of the technology with “easy to use” and “user configurable” settings;
therefore, it must have a real time effect involving all available functions in the scanner from the probe to the screen.

A Deeper Look into XView Technology

XView Technology is a real-time algorithm that
provides a significant reduction in speckle. It
achieves speckle reduction during each one of
the stages that covers all the ultrasound image
formation process.
The algorithm function gives the user the option
to choose between three different levels of
image optimization in order to obtain the best
possible image depending on the application.
In addition to the settings provided by the
system, the operator can make use of the
User Optimization “C” Setting, which operates
on three parameters of the image: XSmooth,
XDetail and XEnhancement. For each of these
parameters it is possible to set the level within
a certain range. By modifying these levels the
user will change the characteristics of the
image displayed on the screen according to the
following guideline:
> XSmooth regulation flattens the “noise” that
affects the image.
> XDetail enhances the details of the
contours, curves, edges and structures present
in the information that constitutes the image,
enabling the end user to view even the minimum
characteristics and particulars.
> XEnhancement maximizes the information that
enables the end user to visualize in the best possible
way the information related to the structures
already emphasized with the previous steps.

www.esaote.com
 news

3. Quantification in Echocardiography

In the last twenty years the continuous progress
of technology has helped the diffusion of this
technique for diagnosis, staging and follow up
of cardiac diseases. In many cases, the first
diagnosis is based on the simple visualization
of valvular lesions or of anatomical changes of
cardiac structures.
Then, in the quantification stage, the
echocardiographic software offers the
possibility of measuring diameters, thicknesses,
areas, volumes and related indices as well as
getting a flow quantification using color flow
and spectral Doppler. All these parameters
offer many cardiac function indices but in most
cases there are only indirect, quantifying just
the consequences of myocardial dysfunctions
and cardiac defects. A first attempt of getting a
direct quantification of the myocardial function
has been made using modified Pulsed Wave
Doppler to measure myocardial velocities. After
AHS - Aided Heart Segmentation
more than 20 years since its first publication,
Doppler Myocardial Imaging is still called “new
technology” and hasn’t entered yet the tool box
of the great majority of cardiologists in spite of
being relatively cheap and easy to use. This is
because of its major limitation which is intrinsic
of being a Doppler based quantification system,
thus angle dependent. As a matter of fact, it is
useful only to quantify the myocardial velocity on
the basal segment of the ventricles. The advent
of digitized echocardiography from this simple
Doppler based quantification of myocardial
velocity enabled the development of different
TDI (Tissue Doppler Imaging) techniques. All
of them have had a limited impact on clinical
echocardiography, this once again due to angle,
signal noise and measurement variability. When
the angle between the velocity direction and
the ultrasound beam is > 20°, the real velocity
is underestimated. Since the ventricular
geometry doesn’t
always allow a correct
alignment, TDI derived
measures will show a
lower validity especially
in a dilated heart, i.e.
in all cases where we
need a myocardial
quantification. Recently,
improvements in 2D
echocardiographic image
resolution have enabled
the detection of tissue displacement of myocardial structures over stage systolic dysfunction. One of the major
pixels and tracking of these acoustic markers time and in any direction. The most commonly problems encountered by operators that begin
from frame to frame. The tissue velocity is studied parameters are myocardial velocity, using this kind of software is the learning curve
estimated from the local frame-to-frame myocardial deformation (strain) and its velocity and repeatability difficulty in point selection
displacement; the automatic evaluation of the (strain rate). Esaote has developed a specifically that may result in an unacceptable variability
velocity in a certain point is determined by designed tissue tracking software, called of the values, thereby repeating the same
comparing the displacement of the image data XStrainTM , to derive values for longitudinal, measurement in the same videoclip. In the latest
around that point in two consecutive frames. circumferential and radial velocities, Strain version of XStrain TM Esaote introduced a new
These methods have been used, in several and Strain Rate. The processing system of this tool called AHS (Advanced Heart Segmentation).
different formulations, in many research fields
and fall into the category known as Optical
algorithm is based on a mono-dimensional This system is based on standard ASE heart
technology and seems to be very accurate. In segmentation and has dedicated methods for
Flow, commonly humans, reference values for children and adults apical and short axis views, along with help for
referred to as have recently been published (Bussadori, Moreo the operator in point selection, maintaining the
Speckle Tracking et al. 2009)1. In this study, high applicability and same proportion of segmental size regardless of
in ultrasound repeatability of the measurements have been the dimensions of the ventricle to be examined.
imaging. These exhaustively demonstrated. The use of XStrainTM This resulted in a dramatic reduction in time
systems are technology in human cardiology is getting wider of processing and inter- and intra- operator
totally angle and wider to assess congenital heart defects variability. In a recent repeatability study,
independent. and many acquired myocardial diseases. This the intraoperator variability was of 4% among
By tracking rapid and user friendly layout is now the most expert operators and of 7% among absolutely
myocardial preferred software for evaluation of myocardial inexperienced operators, 7%. At this stage,
selected points synchronicity in cardiac resynchronization XStrain TM software can satisfy all needs of an
during the cardiac therapy. The direct quantification of global echocardiographist looking for a reliable, fast
cycle it is possible and segmental myocardial systolic function in and easy tool for direct quantification of the
to get a precise humans has been demonstrated to be more ventricular function.
quantification of specific and sensitive in identification of early

Prevention
1. A new 2D-Based method for myocardial velocity, strain and strain rate quantification in a normal and paediatric population: assessment
of reference value – CV Ultrasound 2009, 7:8 February 2009

The RF-data technology innovation as developed by Esaote makes it possible to measure automatically and accurately the positions of the anterior and posterior blood vessel wall, providing
blood vessel wall diameter, change in diameter and blood vessel wall thickness of an artery as a continuous function of time. These measured basic blood vessel wall properties provide, by
calculation, access to all major CVD related vascular stiffness parameters, e.g. pulse wave velocity.

Why RF-data technology?

Ultrasonic waves have an intimate and strong
interaction with propagating media, only the
radio frequency (RF) signal received preserves
100% of the informative content collected. A
B-Mode ultrasound image is a non-linear gray-
scale representation of the RF signals received.
The non-linear character of the B-mode
image processing necessary for optimal image
quality makes the B-mode image unsuitable
for measuring blood vessel wall properties.
Therefore, by obtaining RF-data technology
for the measurement of blood vessel wall
properties Esaote uses 100% of the available
information in the data received, solving the
traditional compromise between image quality
and measurement quality.

Assessment of Blood Vessel Wall Properties by means of Ultrasound

Cardio Vascular Disease (CVD) is the most
common cause of death in adults worldwide.
CVD is not only a major threat to individuals
and their “quality” and “durability” of life, but
is also a major economic burden.
Early detection and monitoring of progression
can provide the opportunity for early medication
therapy rather than surgery at a later and more
critical phase. Early indications of CVD are:
> Thickening of the blood vessel wall
> Stiffening of the blood vessel wall
> High blood pressure
> High-level of cholesterol
Thickening of the blood vessel wall
Clinical studies have shown that an increased
vessel wall thickness (IMT) was associated
with an increased risk of incident myocardial
infarction. Therefore, IMT has been used as an
important atherosclerosis surrogate in clinical
practice and in many clinical studies.
Healthy vessel
Diseased vessel
Stiffening of the blood vessel wall
Stiffening of the blood vessel wall is the result
of a long, but steady process and is accelerated
Driving Pressure Blood vessel
Health vessel response
The progression of CVD will result in plaque for-
mation with consequent reduction in blood flow
possibly leading to cardiovascular problems in-
cluding hearth failure, myocardial infarction and
stroke. Heart failure can be the consequence of
a diseased and stiff arterial tree, transferring
too much load on the heart itself and yielding
consequent remodeling of the ventricles. Myo-
cardial infarction is usually related to myocar-
dial ischemia because of reduced blood flow.
Stroke is mostly caused by plaque rupture that
by life style (food, smoking, lack of exercise and e.g. high systolic blood pressure, myocardial
increased weight). In its final phase people are infarction and stroke
confronted with the disastrous consequences,
Change in diameter
Driving Pressure Blood vessel Change in diameter
(distension)
(distension)
Distension 8% of diameter Stiff vessel response
Distension 4% of diameter
generates emboli reaching and blocking the cer-
ebral circulation. CVD is the result of a long, but
steady process and is accelerated by life style.
In its final phase people are confronted with the
disastrous consequences. Today no direct feed- Plaque
back can be provided to subjects about the qual-
ity of their vascular condition, with the conse-
quence that no early treatment or early follow-
up is initiated to prevent further degradation of
the vascular condition and to delay the moment
that the disease causes serious troubles.

www.esaote.com

The cardiology workflow management
in One Powerful Solution
RF
QAS and RFQIMT Technologies
Quality Arterial Stiffness (RFQAS) and Quality Intima media Thickness (RFQIMT) are based on the Esaote RF-data technology for the accurate assessment of arterial stiffness and vessel wall thickness. They are the first step to early detection and early
follow-up of CVD, preventing further degradation of the vascular condition and to delay the moment that the disease causes serious troubles. The RFQAS and RFQIMT measurements are taken at the Common Carotid Artery, which represents a critical
point in the vascular system.
Assessment of blood vessel thickness
RF
QIMT targets the measurement of the blood
vessel wall thickness of a subject in a selected
area of investigation. The ease of use combined
with the real time quality feedback helps the
operator to achieve accurate and reproducible
Healthy vessel
Diseased vessel
For a properly carry out of the IMT measurement
it is recommended to follow the Mannheim pro-
tocol which describes very clearly the proce-
dure. The software of the system supports the
Mannheim protocol in the measurement process
and in the reporting structure.
During the scanning of the carotid artery the
doctor gets real-time feedback on measurement
quality via quality indicators overlaid on the
For any other information please visit our site www.esaote.com
www.esaote.com
Plan & Execute
Enterprise-wide information
systems to streamline
clinical and administrative
workflow
results. The measures (even taken at different
examination times) can be reported on a nor-
malised graph represented as plot indicators to
assist physicians in their diagnostic and thera-
peutically procedures.
Diameter: 5.93 mm
IMT: 324 µm
Diameter: 6.61 mm
IMT: 976 µm
ultrasound image at the position of the vessel
wall (organge lines) and the far wall intima layer
(green line).
This real time feedback gives the doctor the
possibility to optimize his probe position to
have the best perpendicular position of the scan
plane in respect to the far wall of the common
carotid artery.
Quantification
and
Prevention
in Cardiovascular Ultrasound
Image and data management
for all cardiology modalities
Estensa is a dedicated information all administrative and clinical proce- expiration dates and disposables. Any
system for the management of all dures and exams in a single interface, procedure/exam can be documented
Cardiologic Department activities: Estensa becomes essential for data and statistically analyzed for a com-
Interventional Cardiology, Electro- management, statistics, report crea- plete scientific data extraction and
Cardiography, EchoCardiography, tion, imaging and recording signal cost-saving optimization. Thanks to
Electrophysiology. Based on Smart- management, order entry and work- DICOM 3.0, HL7 and FDA-XML stand-
Client technology, it merges the ben- list distribution. The automatic real- ard communication protocols, Es-
efits of typical Client Server solutions time stock and inventory manage- tensa connects to all modalities, sup-
with the simple distribution method ment, with barcode reader support, porting systems interoperability and
of the Web based solutions. Unifying allows for a timely control of costs, avoiding data duplication.
Report & Review Archive & Record Distribute
Professional Workstations PACS & publishing Image distribution
for Cardiologic image systems for small, over Intranet/Internet
visualization, elaboration distributed & enterprise
& reporting film-less hospitals
Assessment of arterial stiffness
RF
QAS targets the measurement of the blood ves- What is diameter?
sel stiffness of a subject in a selected area of
investigation. The blood vessel wall stiffness is
Diameter: 7.04 mm
expressed as pulse wave velocity obtained from
brachial blood pressure and the accurate meas-
urements of diameter and change in diameter. Vessel parameters
Diameter: 7.04 mm
Moreover, the local blood pressure at the site of
What is distension?
Distension: 610 µm
the ultrasound measurement is given. Stiffness PWV: 5.7 m/s
Local blood pressure and stiffness is derived as
quantification results based on sophisticated Distension: 610 µm
clinical studies.
Stiffness measurements
During the scanning of the carotid artery Age: 24 Age: 45 Patient
the doctor gets real-time feedback on
measurement quality via quality indicators
overlaid on the ultrasound image at the
position of the vessel wall (orange lines) and
an indication of distension (green lines).
This real time feedback gives the doctor the
possibility to optimize his probe position to
have the best perpendicular position of the
scan plane in respect to the far wall of the
common carotid artery.
D: 7.0 mm
D: 605 µm
D: 7.5 mm
D: 281 µm
D: 6.3 mm
D: 124 µm
PWV: 5.3 m/s PWV: 8.1 m/s PWV: 11.3 m/s
QAS is not available for sales in the USA
 CARDIOVASCULAR 2009 No.1

Focus on:
Quantification
and
Prevention
in Cardiovascular Ultrasound

10.000 Portable
Ultrasound Installed
Leader in
Premium Performance

Main events Committed to Education

ACC 2009 - American College of Cardiology
Orlando, FL - USA on 29/03/2009 - 31/03/2009
ASE 2009 - American Society of Echocardiography
Washington, DC - USA on 06/06/2009 - 10/06/2009
19th European Meeting on Hypertension International
Milan, Italy on 12/06/2009 - 16/06/2009 School
ESC 2009 - European Congress of Cardiology
Advanced
Cardiovascular
Barcelona, Spain on 29/08/2009 - 02/09/2009
At ESC: Advanced RF-based Vascular Ultrasound
Symposium Tuesday, September 1st, 2009
Ultrasound
AHA 2009 - American Heart Association
Orlando, FL - USA on 14/11/2009 - 18/11/2009
MEDICA 2009
Dusseldorf, Germany on 18/11/2009 - 21/11/2009
EUROECHO 2009 - 13th Annual meeting of European
Association of Echocardiography
Madrid, Spain on 09/12/2009 - 12/12/2009

Esaote S.p.A. www.esaote.com

International Activities: Via di Caciolle, 15 - 50127 Firenze, ITALY Tel. +39 055 4229 1 - Fax +39 055 4229 208 - E-mail: info@esaote.com
Domestic Activities: Via A. Siffredi, 58 - 16153 Genova, ITALY Tel. +39 010 6547 1 - Fax +39 010 6547 275 - E-mail: info@esaote.com
FRANCE GERMANY SPAIN THE NETHERLANDS AND BELGIUM UK USA
Esaote France S.A.R.L. Esaote Biomedica Deutschland GmbH Esaote España S.A. Pie Medical Benelux B.V. Esaote Europe BV Biosound Esaote Inc.
22, rue Pierre Grange, 94124 Fontenay-sous-Bois Max-Planck-Straße 27a, 50858 Köln Avda San Sebastian, s/n 08960 Sant Just Desvern, Barcelona P.O. Box 1132, 6201 BC Maastricht UK Branch Office, 400 Thames Valley Park Drive, 8000 Castleway Drive,
Tel. +33 1 4871 2525, Fax +33 1 4871 3630 Tel. +49 221 9268 00 00, Fax +49 2234 9679 628 Tel. +34 93 473 2090, Fax +34 93 473 2042 Tel. +31 43 3824650, Fax +31 43 3824651 Reading, Berkshire. RG6 1PT P.O. Box 50858, Indianapolis, IN 46250
esaote.france@wanadoo.fr esaote@esaote.de info@esaote.es benelux@pie.nl Tel. +44 118 965 3500, Fax +44 709 288 0231 Tel. +1 317 813 6000, Fax +1 317 813 6600
ukinquiries@esaote.nl info@biosound.com
833 0904 000 (MA Rev. A)

BRASIL ARGENTINA INDIA CHINA RUSSIAN FEDERATION AND CIS

Brasilian Direct Office
Rua Tomas Carvalhal, 711, 04006-001 São Paulo SP
Tel. +55 11 2589 0533 Fax +55 11 2589 0527
edson.lopes@esaote.com
Esaote Latinoamérica S.A.
San Martín 551, Cuerpo ‘C’, Piso 8, (C1004AAK) Buenos Aires
Tel. +54 11 4326 1832, Fax: +54 11 4328 1245
info@esaote.com.ar
Esaote Asia Pacific Diagnostic Private Limited
F-1, Level 1, Global Arcade, Near Global Business Park
M.G. Road, Gurgaon (Haryana)-122002
Tel. +91 124 4775600, Fax +91 124 4775699
info@esaote.in
Esaote China Ltd
18/F, 135 Bonham Strand Trade Centre,
135 Bonham Strand, Sheung Wan, Hong Kong
Tel. +852 2545 8386, Fax +852 2543 3068
esaote@esaotechina.com
Esaote S.p.A.
18 Leningradsky prospekt, off. 5 and 6, Moscow 125040
Tel. +7 495 232 0205, Fax +7 495 232 1833
esaotemoscow@yandex.ru

Specifications subject to change without notice