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Tissue Doppler at 25�A learning journey
George Thomas 
Department of Cardiology
Saraf Hospital
Sreekandath Road
Kochi 682 016, India
Tel: +91-484-2363949, Fax: +91-484-2370595
E-mail: HYPERLINK "mailto:gthomas@doctor.com"gthomas@doctor.com
Short title: Tissue Doppler lessons
Key words: Echocardiography, Doppler, Tissue Doppler, principles, lessons




Abstract
          Tissue Doppler is completing 25 years in the year 2014. In spite of the large number of published papers in reputed journals, this has been a specious modality. This is because of the flawed data collection. In tissue Doppler both the measurement and Doppler principles are compromised making the modality totally unacceptable. The beautiful play of colors, the impressive waveforms and numbers have misguided us. But the silver lining is that we could learn many lessons from the study of tissue Doppler. Apart from echocardiographic lessons we could learn lessons in mensuration, mathematics, technology, philosophy, linguistics and even spirituality! Most of the errors are very basic but were unfortunately missed in our excitement for implementing a new technology.  This article is all about this learning journey.










INTRODUCTION
�It doesn�t matter how beautiful your experiment is, it doesn�t matter how carefully you collect your data - if it is based upon a faulty understanding of what is being tested, it�s most likely useless�-      L.D. Hosford 

          25 years ago, in 1989 Isaaz et al published the first paper on the use of Doppler to study cardiac tissue.[1] However it was only 6 years later (1995) that the modality was called �Tissue Doppler�.[2] Since then several papers have been published. A PubMed search for �Tissue Doppler�, �Tissue Velocity� and �Doppler Tissue� yielded a total of 4959 results.  A similar search on Google yielded 391800 results. Such is the interest in this modality.
          I started doing research in tissue Doppler in 1997. In the course of my research, I found very inconsistent results. I attributed it to my research inadequacies. But on deeper enquiry I realized that the data acquisition was not based on sound principles. By using tissue Doppler we were barking up the wrong tree. Most of the errors are very basic but unfortunately missed in our excitement for implementing a new technology. I expressed my concerns about tissue Doppler in 2003[3] and later in 2004[4]. It is now 10 years since this article debunking the very basis of tissue Doppler was published. But the silver lining is that we could learn a many lessons from the study of tissue Doppler. Apart from echocardiographic lessons we could learn lessons in mensuration, mathematics, technology, philosophy, linguistics and even spirituality! This article is all about this learning journey.


ECHOCARDIOGRAPHIC LESSONS
          In the course of the study of tissue Doppler we come to learn that echocardiography consists of 2 components: 1 Ultrasound imaging 2 Doppler studies. The primary purpose of echocardiography is imaging and Doppler is supplementary. The question raised here is why should there be Doppler studies? This is because ultrasound imaging in the present form cannot analyse fast moving blood particles. Spontaneous echo contrasts and contrast echocardiography allows imaging of blood flow. On the other hand Doppler can be used for imaging as in colour flow mapping and Doppler tissue imaging by using the colour Doppler technology. Doppler imaging is an indirect method and is useful in imaging blood flow, but it becomes redundant in imaging the myocardium. While imaging studies permit linear measurements, Doppler studies permit velocity measurement. Theoretically we can derive velocity measurements from imaging studies and linear measurements from Doppler studies by mathematical calculations. 
          The steps in performing Doppler studies were taken for granted. By studying the erroneous tissue Doppler methodology we come to realize the correct method of Doppler studies. To make a meaningful Doppler study the following steps are required: 
1. You must know the line of motion of the object to apply the Doppler beam in alignment.
2. Next, you will know the direction of motion �whether it is moving away or towards the transducer. 
3. After these 2 steps you will be able to measure the velocity properly. 
          Thus the following information can be obtained by Doppler: 
1. Is the target moving? This is one application of tissue Doppler but the information is redundant because we can see the motion better by direct imaging. 
2. What is the direction of movement? In tissue Doppler the information is redundant and deceptive because the direction is the vector resultant of many different motions. This is because of the complexity of myocardial motion. 
3. To measure the clinically significant velocity we must know the unique line of motion. Application of the Doppler beam in that alignment will give us the correct velocity.

          Thus the primary requisite is to know the unique line of motion. This is clear in flow Doppler but unknown in tissue Doppler. For example we know that the blood moves into the left ventricle from the left atrium through the mitral valve. At a point in the mitral valve there is a free linear motion towards the apex. That is why we place the sample volume at the mitral valve directing the beam from the apical views to align with the anticipated line of flow. That is also why we do not interrogate the mitral valve from the parasternal views (Fig 1). Next we learn the direction of motion following which we measure the velocity. In tissue Doppler we can measure  velocities in any direction which would be meaningless. 

          Even in flow Doppler we may err if we do not know the line of motion. For example in mitral stenosis with multiple jets we may not be able to find the proper alignment. This could explain the errors in calculating the mitral valve area by the pressure half time method.[5] Similarly, the sample volume should be placed nearest to the outflow orifice where the flow  is not dispersed. This is also the reason why it is better to place the sample volume under guidance of colour flow maps. 
          The methodological fallacy of tissue Doppler has also crept into the American Society of Echocardiography recommendations for quantification of Doppler echocardiography. In flow Doppler it rightly states that �the Doppler sound beam should be oriented as parallel as possible to the flow guided guided both by the 2D image (sometimes assisted by colour flow imaging) and the quality of the Doppler recording�. Whereas in tissue Doppler the recommendations are �longitudinal velocities within the myocardium can be recorded with tissue Doppler from the apical window with the PW mode. A small (<5 mm) sample volume is placed within a myocardial segment and a spectral recording of velocities within the segment obtained� [6] Here nothing is mentioned about the alignment of the Doppler beam. Besides, the conflicting velocities to the supposedly �longitudinal� velocity are not considered.
         The existing literature presents Doppler as primarily to study velocities.  But in reality the primary function of Doppler is to study the direction of motion. This can be explained by an example. Suppose we see a thickened mitral valve on imaging, we know the valve is stenotic. Then the Doppler velocity estimation will give us incremental information about the degree of stenosis. This will again depend on various other factors. But if there is an abnormal flow it will indicate additional incompetence. This is more important in a �normal� looking (non-thickened) valve. Here an abnormal Doppler flow will be the only indication of an incompetent valve. The flow through the mitral valve occurs in diastole. If there is a flow in systole it becomes abnormal. 
          By studying tissue Doppler we could get a different perspective of aliasing. Tissue Doppler is mainly to study hypofunctioning myocardial segments by analysing lower velocities. Lower velocities do not have indicators like aliasing and variance making them difficult to analyse. This helps us understand aliasing better. The present literature describe aliasing as an undesirable property and a limitation.[7,8] However when we study tissue Doppler we realize that aliasing is a useful phenomenon. Aliasing and variance make it easier to identify higher velocities. Low velocities have no such indicators. Thus aliasing is a useful phenomenon to rapidly identify hyperfunction. This is especially true of colour Doppler. If there is aliasing it means there is hyperfunction at the aliasing frequency.
          The best echocardiographic lessons are learnt by comparing tissue and flow Doppler. Colour Doppler allows us to visualize what we cannot see by ultrasound imaging hence its value is great. A compromised image is obtained by colour tissue Doppler hence its value is marginal. Colour Doppler retains the anatomic landmarks as it is superimposed on the ultrasound image. In tissue Doppler the B-mode image is eliminated and the entire display is Doppler data. It is difficult to determine the anatomic regions because low velocity blood flow is also displayed. The blood-endocardial boundary becomes blurred.
          Blood flow is suitable for Doppler study due to the simplicity of motion. In flow Doppler linear free moving blood particles are studied. Another learning point here is that it is not just red cells as mentioned in the literature that is analysed. Blood particles include intrinsic blood constituents and extrinsic material like contrast agents. At the current interrogation locations there is a unidirectional flow in systole or diastole. For example at the mitral valve the flow recording occurs in diastole. If there is a recording in systole it is abnormal and of great value. In tissue Doppler a systolic and diastolic recording is obtained. This can be even otherwise seen and analyzed by ultrasound imaging. But this is described as an advantage to study the complete cardiac cycle when in reality it is meaningless due to the faulty measurement methodology and is non-discriminatory. 
        There are definite targets for interrogation in flow Doppler. These are the normal and abnormal orifices. Tissue Doppler has no such unique targets. Flow Doppler derivations are based on hydrodynamic formulae and allow us to get pressure gradients and orifice size which are of great clinical importance. The derivations from tissue Doppler are of no value. The audio output in flow Doppler is very useful while in tissue Doppler it becomes an irritant. Thus Doppler is suitable to study flow only.
 LESSONS IN MENSURATION
          The important lesson in measurements was that the measurement tool has to be the right one and the measured object has to be properly placed. You cannot measure the abdominal girth with a rigid ruler. Similarly you do not use a theodolite to indirectly measure the height of a person. Doppler is a right tool for flow but a wrong tool for tissue. 
          Although we can measure everything, all measurements are not useful. We must have a purpose of measurement. Seth Godin states this concept as �measuring nothing (with great accuracy)�:  An example is the weight of a television set has nothing at all to do with the clarity of its picture. Even if you measure to a microgram, this precise data is useless. In echocardiography we can interrogate several points in the heart by flow Doppler. But all this would be a futile exercise and the information derived would be useless. So we interrogate the orifices. Such a purposeful measurement gives very useful information. In the case of tissue Doppler, placing the sample volume on the different parts of the myocardium would be an exercise in futility. Even in the case of mitral annulus there are an indeterminate number of points of interrogation around the ring (Fig 2).
          We have taken measurements for granted. By studying tissue Doppler we understand that measurements follow a proper sequence (Fig 3). This is especially true of linear measurement. For example to measure the height of a person the following steps need to be taken:
1. We should know where the person is. We cannot place the measuring scale in a proper alignment in a dark room! (In tissue Doppler we are in the dark about the movement of the point of interrogation)
2. The person has to stand straight. An un-erect position would not be acceptable. (In tissue Doppler the movement is in twist and turns [9])
3. The measuring scale should be applied in the proper alignment � perpendicular to the floor and parallel to the person. Any other alignment would be unacceptable. (The line of sight Doppler beam cannot be aligned to the myocardial motion - It is like measuring the length of a twisted rod with a straight ruler). 
"The way you measure is more important than what you measure." - Art Gust.
LESSONS IN MATHEMATICS
          Tissue Doppler is a great number factory! In fact cursor positions can be manipulated to �dial in� the desired numbers.[10] Numbers are great only if they are properly derived and meaningful. Improperly derived numbers can give misleading conclusions especially when analyzed statistically. These improperly derived numbers produce �nonsense� or �spurious� correlations. �Not everything that can be counted counts, and not everything that counts can be counted� - Albert Einstein
         The fact that velocity is a vector quantity was forgotten in the case of tissue Doppler. Strain calculations treat velocities as scalar quantities. In the formula for strain calculation, the modulus of a vector quantity (velocity) is incorrectly substituted for a scalar quantity (length) in the original equation. The much hyped E/E� ratio has all the issues related to tissue Doppler and also goes against the principle of parsimony [11,12].

LESSONS IN TECHNOLOGY
            We use technology to improve the applications of echocardiography. The use of technology in echocardiography can be for demonstration (like color flow mapping),   documentation (like systolic anterior motion in M-mode), quantification (like valve stenosis), simplification (like software for calculations and reports), display (like 3D, Google glass, hologram, 3D modeling), dissemination (like telemedicine and cloud computing), miniaturization (hand held or pocket machines) and impression (like producing colors and graphs). Tissue Doppler is a spin-off of colour Doppler technology. In colour Doppler flow signals are analysed after suppressing the noise which are tissue signals. In tissue Doppler the tissue signals consisting of noise from the myocardium and adjacent tissues are analysed after suppressing the flow signals. Here the useful flow signals are eliminated and the �noise� is analyzed. In fact when Doppler was first used for cardiac applications, the Doppler recordings were thought to come from the heart tissues and no signals were attributed to blood flow.[13] Consequently the Doppler technique did not interest the cardiologists then! Tissue Doppler is a retrograde development in echocardiographic technology. It is like eating the peel and discarding fruit.  
          The concept of low-tech and hi-tech should be abandoned. What we need is apt-tech. Tissue Doppler is a good case of inappropriate and misuse of technology. Inappropriate because of the basic flaws as mentioned earlier and also because it is too sensitive giving false positive data. Here lower velocities are analyzed compromising the specificity. An akinetic segment correctly displayed by M-mode is not documented as 0 velocity by tissue Doppler. This would also affect the temporal data. The situation is like magnifying a printed photo when all you can see would be a set of dots. It is also a case of misuse of technology where indirect data collection is favored over direct methods. This could be akin to talking to a person face to face over mobile phone!
PHILOSOPHICAL LESSONS
          Any scientific enquiry should be based on the a priori knowledge. If not, the new phenomenon would be a �paradigm shift�. In tissue Doppler the basic principles of measurement and Doppler are compromised. If tissue Doppler is to be accepted as valid then we must discard the existing principles of measurement and Doppler. Taking such a view, tissue Doppler is epistemologically unacceptable.           
LINGUISTIC LESSONS
          Another problem with tissue Doppler is the terminology. In fact, the word 'tissue Doppler' is a misnomer and this is one of the reasons for the prevailing confusion. It gives the impression that only myocardial tissues can be studied. The appropriate term would have been low velocity Doppler. Any movement in the low velocity range will be detected by 'tissue Doppler'. Myocardial tissue movement is just one among them. There is no such thing as �tissue� Doppler. It is just low velocity Doppler. So now we have 2 types of Doppler studies: High velocity Doppler and low velocity Doppler. When we use such a terminology the application of low velocity Doppler (tissue Doppler) becomes broader. We can properly apply it to flow and study low velocity flow.[14]
LESSONS IN SPIRITUALITY
         In flow Doppler we cannot �see� the target (blood) but we can accurately place the interrogating signal in line with the flow. This is because we know by �faith� in the accepted hydrodynamic laws the expected line of motion.  In tissue Doppler although we can �see� the target (myocardium) we do not know the line of motion. This gives credence to the Biblical principle �For we walk by faith and not by sight� (2 Corinthians 5:7 King James Version) and �Faith is the evidence of things not seen� (Hebrews 11:1 King James Version). In flow Doppler we can confidently place the sample volume at the tip of the mitral valve knowing well that the line of blood flow is from left atrium to the left ventricle. In tissue Doppler although we can see the apparent motion, the actual motion in 3 dimensions is more complex. This also proves the adage �appearances can be deceptive�. 
CONCLUSION
          Any echocardiographic development should improve our understanding of the cardiac structure and function. Or the development should facilitate operation and documentation. Tissue Doppler speciously appears to fulfil these. But in reality Tissue Doppler as advancement fails miserably on all counts. Many papers on tissue Doppler talk about the �limitations� of this modality [15]. Limitations exist if the experiments are done according to the accepted conventions. When data is wrongly collected, it becomes a �blunder�. In tissue Doppler both the measurement and Doppler principles are compromised making it a scientific blunder. The beautiful play of colors, the impressive waveforms and numbers have misguided us. 
          �Science is the belief in the ignorance of the experts� - Richard Feynman. Tissue Doppler is not the only blunder in science.[16] The belief in the geocentric solar system was challenged by Galileo. Similarly the Concorde aircraft which was an amazing technology was abandoned due to flaws in application and practicality.[17] Tissue Doppler is a Sisyphean modality that needs to be relegated to echocardiographic mythology. �Science, my lad, is made up of mistakes, but they are mistakes which it is useful to make, because they lead little by little to the truth.�- Jules Verne in Journey to the Center of the Earth END

DECLARATION OF INTEREST
The author declares that he has no competing interests.

FUNDING
This paper did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.



REFERENCES

Isaaz K, Thompson A, Ethevenot G, Cloez JL, Brembilla B, et al.(1989) Doppler echocardiographic measurement of low velocity motion of left ventricular posterior wall. Am J Cardiol 64:66-75
Miyatake K, Yamagishi M, Tanaka N, Uematsu M, Yamazaki N,et al.(1995) New method for evaluating left ventricular wall motion by color-coded tissue Doppler imaging: in vitro and in vivo studies. J Am Coll Cardiol 25(3):717-24.
Thomas G. (2003) Tissue Doppler echocardiography: a need for review. Indian Heart J 55(1):92-3
Thomas G. (2004)  Tissue Doppler Echocardiography � A case of right tool, wrong use. Cardiovascular Ultrasound 2:12�
House CM, Nelson WB, Nickele GA, Ahmed I, Dahiya R.(2011) Mitral valve area by the pressure half-time method does not correlate with mean gradient in mitral valve repair patients. Eur J Echocardiogr 12:124�130
Qui�ones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA. (2002) Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr 15(2):167-84.
Bom K, de Boo J, Rijsterborgh H. (1984) On the aliasing problem in pulsed Doppler cardiac studies. J Clin Ultrasound 12(9):559-67.
William F Armstrong, Thomas Ryan. (2010) Doppler echocardiography in  Feigenbaums Echocardiography 7th edition. Lippincott Williams and Wilkins. Philadelphia 
Taber LA, Yang M, Podszus WW.(1996) Mechanics of ventricular torsion.J Biomech. 29(6):745-52
Abraham TP, Dimaano VL, Liang HY. (2007) Role of tissue Doppler and strain echocardiography in current clinical practice. Circulation 116(22):2597-609.
Arques S, Roux E, Luccioni R. (2007) Current clinical applications of spectral tissue Doppler echocardiography (E/E' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved left ventricular systolic function (Reader�s comment) Cardiovasc Ultrasound 5:16.
Tsch�pe C, Paulus WJ. (2009) Is echocardiographic evaluation of diastolic function useful in determining clinical care? Doppler echocardiography yields dubious estimates of left ventricular diastolic pressures. Circulation 120(9):810-20.
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Christopher Orlebar. (2004) The Concorde Story. Osprey Publishing. Oxford 

FIGURE LEGENDS

Figure 1
The prime requisite for Doppler studies is the prior knowledge of the line of motion. In flow we know the line of motion is from the atrium to ventricle through the mitral valve. That is why we measure mitral valve velocities from the apical views (a). We cannot measure the flow from the parasternal views as the interrogating beam cannot be aligned to the flow (b).

Figure 2
 In flow Doppler we can measure velocities at several points in the left ventricular cavity (a). But at all these points we do not know the precise direction of movement to direct the Doppler beam. There can be no standardization of measurement points. Same is true of tissue Doppler. Here we can have any number of meaningless interrogation points in the myocardial walls (b) or the mitral annulus (c). Besides in the septal and medial annulus measurements we have to factor in the right ventricular influences. 

Figure 3
To measure the length of a door we must first know the alignment of the side ab to properly place the measurement scale AB. Any other alignment like XY would not be acceptable for the purpose. 








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