Advances in 3D Speckle Tracking:

Activation Imaging

John Gorcsan III, MD

University of Pittsburgh, Division of Cardiology, Pittsburgh, USA

Activation Imaging is an exciting new 3D mechanical i­nclude LV lead placement for cardiac resyn­chro­ n­ ormalizing all the 3D strain waveforms, a specified
activation mapping tool using echocardio­graphy. nization therapy (CRT), mechanical activation for threshold is set and defined as the start of mechani-
Activation Imaging was developed because of ablation and evaluation of the effects of cardiac cal activation. Each segment is then identified and
a particular interest in the electrophysiology com- pacing. color coded according to the time it takes for it to
munity to localize the onset of electroanatomical cross this threshold. Clinicians have the ability to
­activation non-invasively with ultrasound. When the heart is not functioning properly, set the color coding, starting with red or blue, for
­different segments activate at different moments additional customization.
Activation Imaging in time. Activation Imaging, in conjunction with
During cardiac electrical activation, the impulse Toshiba’s comprehensive 3D Wall Motion Tracking Activation Imaging provides a 3D color overlay
travels down the heart, from the septum to the software, allows clinicians to evaluate dyssyn­chrony of the mechanical activation and is defined using
apex, and then back up to the ventricular walls at the onset of the heart’s contraction and strain values. The activated regions are detected
with a very predictable activation sequence. Before to properly identify the left ventricle’s pumping frame by frame. In the figure below, regions
Activation Imaging, electroanatomical mapping strength and timing. ­activated in the first frame are colored red. Areas
could only be done using catheter-based systems, activated in subsequent frames are colored orange,
such as the CARTO system. Activation Imaging Activation Imaging utilizes color coding to track yellow and green. This sequence of Activation
is the first non-invasive 3D mechanical activation the mechanical activation of the heart, focusing ­Imaging in the 3D display shows clinicians the
mapping tool. Potential clinical applications on the early part of the cardiac cycle. After ­entire range of activation (Figure 1).

Activation Imaging: Normal Study

Figure 1: Activation Imaging – Frame by frame color coding.

In a normal patient, the activation starts in the p­ lastic-bag orientation and a polar map to quantify patient activates early and uniformly, starting
apex (denoted by red) and then moves along with the activation times. The timing is shown in at the apex. The patient with left bundle branch
sequential colors. The activation mechanically ­milliseconds for this normal subject (Figure 4). block has very late segments in the posterior
starts in the apex, moving rapidly up the ventri­cular region. The activation of 229 milliseconds is later
walls, similar to squeezing a tube of toothpaste The orientation of the images can be manipulated than the 92 milliseconds in the normal subject.
from the bottom (Figure 2). for different views. In this example, the activation Also, the activation in the anteroseptal r­ egion is
images are in an apex-up orientation. A normal earlier than normal (Figure 6).
In patients with abnormal electrical activation, this patient is being compared to one with left bundle
new technology holds great promise for clinicians branch block, with late-activating regions shown Evaluating the Effects of CRT
to diagnose issues more accurately and non-­ in orange and red in the posterior LV wall. These One of the most interesting potential clinical appli-
invasively. In this example, the patient has a left images clearly demonstrate the left bundle branch cations of Activation Imaging is tracking changes
bundle branch block as indicated by the large block in the patient on the right (Figure 5). The before versus after CRT. In the patient with left
area of green in the lateral LV wall (Figure 3). polar maps of these same patients show quantita- bundle branch block, the site of latest activation
Activation Imaging can be shown in both 3D tive measurements of the activation. The normal is clearly defined (Figure 7). Following electrical

Figure 2: Activation Imaging showing normal study. Figure 3: Cardiac study showing Left Bundle Branch Block (LBBB).

Figure 4: Activation Imaging can be shown in plastic bag and/or polar map view. Figure 5: Normal study (left) and LBBB (right).
 Advances in 3D Speckle Tracking: Activation Imaging 3

lead placements and proper pacing, there is base to the mid-septum was visualized, resulting Conclusion
­re-synchronization, or re-coordination, of the in increased dyssynchrony and a decreased Activation Imaging is an exciting new technology
­activation of the mechanical sequence. The polar ­ejection fraction. Among patients with a low that holds great promise in quantifying the effects
maps also demonstrate more uniform activation, ­ejection fraction, it ­became even lower with of cardiac pacing and the mechanical activation
and provide quantification of the physiology of ­dyssynchrony. This was uniquely shown with for ablation in tachyarrhythmias.
­activation ­( Figure 8). ­Activation Imaging. These and other latest
­advances and clinical ­applications were recently
Research Applications presented at a special symposium during the
Activation Imaging was recently used in a study 2013 American Society of Echocardiography
to determine the differences in RV pacing for ­National Scientific Sessions (Figure 9).
heart failure patients with left bundle branch block
versus native conduction. After performing RV
pacing on patients with left bundle branch block,
a shift of the earliest activation point from the

Figure 6: Polar maps of normal study (left) and LBBB (right). Figure 7: Before (left) and after (right) CRT.

Figure 8: Polar maps of before (left) and after (right) CRT. Figure 9: Activation Imaging showing increased dysynchrony and decreased ejection
fraction in patients with LBBB after RV pacing.
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