Unleashing the power of echocardiography: can we get closer to maximally exploiting all embedded information from the image?

Ultrasonic imaging has become a widespread clinical tool in almost all medical specialties. While the current generation of equipment provides excellent image quality, the principle of imaging is still very simple: send out an ultrasound pulse, receive the reflections from different tissues, and display the amplitude of the reflected signal on a monitor. In case of echocardiography, this provides high-quality scans of the beating heart, enabling the visual interpretation of morphology and contraction. But what else can we do? Obviously, cardiac ultrasound can also assess (blood and tissue) velocity information using Doppler techniques, but what other information, besides visualization of structures (thus also enabling geometrical measurement), is contained in the image and could be exploited to obtain complementary information?Recently, there is a lot of attention in analysing the typical speckle patterns present in all ultrasound images, by tracking their displacement over time in order to quantify overall tissue motion and segmental deformation. The clinically available tools that use this approach have shown to provide regional and global deformation assessment, which contains a wealth of information on cardiac mechanics and remodelling.1But besides visualization of structures (mainly based on highly reflective boundaries) and tracking speckle patterns for motion/deformation, the power of the reflected ultrasound, from a specific site, should contain complementary information, since the intensity of the signal is determined by the structure and acoustical properties of the tissue that is reflecting it. In the past decades, several authors have attempted to use ultrasound reflectivity for characterizing different tissue types and tissue remodelling and damage in cardiovascular diseases.2 While several analysis methodologies have been proposed and assessed, some even embedded in clinical echocardiographic systems, they have proven to be difficult to use and interpret and have not found a place in clinical practice. Why would this be?To …